Every finding on record at Brownsville Nursing and Rehabilitation Center

Based on observation, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for 1 of 2 residents (Resident #1) reviewed for infection control. The facility failed to ensure CNA A and CNA B performed proper hand hygiene and used one wipe per swipe during peri care (incontinent care) for Resident #1 on 07/23/26. These deficient practices could place residents at risk of infections, healthcare associated with cross contamination, and the spread of infection. Findings include: Record review of Resident #1's electronic face sheet, dated 07/23/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Cerebral infarction (a type of ischemic stroke that occurs when a blocked or narrowed blood vessel cuts off blood flow to a region of the brain), muscle wasting and atrophy (the shrinking and loss of muscle tissue), Hemiplegia (a medical condition that causes total or partial paralysis on one side of the body, affecting the face, arm, and leg). Record review of Resident #1's comprehensive person-centered care plan, dated on 07/16/2026, reflected Focus [Resident #1] has an ADL self-care performance deficit r/t Hemiplegia, Limit Mobility, Stroke. Interventions: Toilet use: The resident requires assistance by 2 staff to move between surfaces. During an observation on 07/23/2026 at 10:50 a.m. revealed CNA A during incontinent care, CNA A entered Resident #1's room and placed supplies on the bedside table. CNA A washed her hands and put on gloves. CNA A removed the soiled brief and placed it in the trash can. CNA A removed the gloves from her hands and donned gloves sanitized her hands before donning new gloves. CNA A then cleaned peri area using one wipe for 2 swipes. CNA A washed her hands before and after the procedure and lathered her hands for 12 seconds, and CNA B lathered her hands for 8 seconds. During an interview on 07/23/2026 at 11:15 a.m., CNA A stated she should have lathered her hands for at least 20 seconds. CNA stated that she was nervous. CNA A stated the potential negative outcome was infection. CNA A stated that the correct way to clean was one wipe per swipe. CNA A stated that she did not notice that she used one wipe for multiple swipes. During an interview on 07/23/2026 at 11:20 a.m., CNA B stated she should have lathered her hands for at least 20 seconds. CNA stated that she was nervous. CNA A stated the potential negative outcome was infection. CNA B stated that she counted and she thought it was 20 seconds. During an interview on 07/23/2026 at 4:00 p.m., the DON stated the proper handwashing was to lather hands for at least 20 seconds. The DON stated if CNA A and CNA B did not lather for at least 20 seconds this would put Resident #1 at risk for infections. The DON stated that the proper way to do incontinent care was to use one wipe per swipe to prevent spread contamination to other areas. The DON stated that this practice could place residents at risk for infection. Record review of the facility's Infection Prevention and Control Program, dated 05/13/23, reflected: Policy: this facility has established and maintains an infection prevention and control program designed to provide a safe, comfortable environment and to help prevent the development and transmission of communicable diseases and infection as per accepted national stands and guidelines. Record review of the facility's policy titled Hand Hygiene with an implemented date 10/24/22 reflected: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility.4. Hand hygiene technique when using soap and water.c. rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs and biologicals to meet the needs of each resident for 1 of 2 residents observed during incontinent care. (Residents #2) The facility failed to have a physician order in place for the administration of Zinc cream (topical skin protectant containing zinc oxide that is used to soothe, heal, and protect irritated or damaged skin) to Resident #2. This failure could place residents at risk for receiving drugs without an order and put them at risk for an adverse reaction to unprescribed medications and use of unnecessary medications. The findings included: Record review of Resident #2 admission Record dated 07/23/26 revealed a 76 -year -old male admitted on [DATE] with diagnoses Spinal Stenosis, Cervical Region (a narrowing of the spinal canal in the neck that can press on the spinal cord and nerves), and need for assistance with personal care. Record review of Resident #2's comprehensive person-centered care plan, dated on 04/18/2024, reflected Focus [Resident #2] has a potential impairment to skin integrity r/t incontinence, decrease mobility. Goal: The resident will maintain ordevelop clean and intact skin by the review date Record review of Resident #2's Quarterly MDS dated [DATE] reflected a BIMS score of 14 indicating intact cognition. Record review of Resident #2's physician order on 07/23/26 did not include an order for Zinc cream. An observation of CNA C during incontinent care of Resident #2 on 07/23/2026 at 09:45 a.m., revealed, CNA C entered Resident #2's room and placed supplies on the bedside table. CNA C washed her hands, CNA C put gloves. CNA C removed the soiled brief and placed it in the trash can. CNA C removed the gloves from her hands and put gloves sanitized her hands before donning new gloves. CNA C then cleaned peri area using one wipe for one swipe. CNA C had a hard time for removing a white cream from Resident#2's buttocks. CNA C washed her hands before and after the procedure. During an interview on 07/23/2026 at 10:15 a.m., CNA C stated Resident #2 had zinc cream on his buttocks. CNA C stated that he had redness to his buttocks and Resident #2 wanted zinc cream to be applied to his buttocks. During an interview on 7/23/26 at 10:25 a.m., WCN stated she did a skin assessment to Resident #2 on 7/21/26 and he did not have any skin issues. WNC stated that a zinc order needed to be on Resident #2 electronic chart before applied to Resident #2. WCN stated that she thought Resident #2 had the order for zinc cream because he had redness to his buttocks. WCN stated that the negative outcome could be that if WCN was not in the facility the staff could not continue with the care for Resident #2. During an interview on 07/23/2026 at 4:00 p.m., the DON stated the zinc cream had to have an order in Resident #2's electronic chart before applied. DON stated that he did not think there was a negative outcome. Record review of the facility's Physician Visits and Physician Delegation with an implemented date 10/24/22, reflected: Policy: It is the policy of this facility to ensure the physician takes an active role in supervising the care of residents.

Based on interview and record review, the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 4 Residents (Resident #1) reviewed for medical records.1. The facility failed to ensure Resident #1's medical records were complete. 2. The facility failed to ensure staff documented the complete assessment, treatment, and outcome of a possible skin injury to Residents 1's right foot on 6/9/26.These deficient practices could place residents at risk for errors in care and treatment.The findings include: Record review of Resident #1's face sheet, dated 7/16/26, reflected an [AGE] year-old male who was admitted to the facility on [DATE] with an original admission date of 9/21/24. Resident #1's diagnoses included: atherosclerotic heart disease of native coronary artery without angina pectoris (occurs when plaque [buildup of fats, cholesterol, calcium, and other substances in artery walls] narrows the heart's original arteries without causing chest pain, peripheral vascular disease (slow progressive circulation disorder characterized by narrowing, blockage, or spasms in blood vessels outside the heart and brain), chronic kidney disease, stage 4 (severe - kidneys were severely damaged and operating at 15-29% capacity), and type 2 diabetes mellitus (chronic condition where the body could not effectively use insulin or produce enough of it, leading to persistently high blood sugar). Record review of Resident #1's comprehensive Minimum Data Set assessment, dated 6/17/26, reflected Resident #1 had a BIMS score of 8 which indicated a moderate impaired cognition. Resident #1 rejected care and behavior occurred 1 to 3 days. Resident #1 required supervision or touching assistance with eating and was dependent on assistance for all other self-care. Record review of Resident #1's care plan, with a closed date of 7/9/26, reflected Resident #1 had a problem of Peripheral Vascular Disease (PVD) r/t Diabetes Date Initiated: 11/05/2024 Revision on: 07/09/2026. Interventions included: Monitor the extremities for s/sx of injury, infection, or ulcers. Date Initiated: 11/05/2024 Revision on: 07/09/2026. Monitor/document/report PRN any s/sx of skin problems related to PVD: Redness, Edema, Blistering, Itching, Burning, Bruises, Cuts, other skin lesions. Date Initiated: 11/05/2024 Revision on: 07/09/2026.Record review of Resident #1's progress notes from 6/4/26 - 6/15/26 revealed no documentation related to the skin assessment on 6/9/26. Record review of Resident #1's skin assessment, dated 6/9/26, reflected a skin assessment with a foot evaluation was completed, but it did not reflect the reason for the assessment, the location of the foot that was assessed, the type of treatment if any provided, the outcome of the assessment, such as if the NP was notified of the assessment and if any new orders were provided or not. During an interview on 7/16/26 at 2:30 pm, the RN / Treatment Nurse verbalized there was a day when Resident #1 left the facility to a doctor's appointment and returned with dried blood on the right outer side of the ankle, closer towards the back of the ankle. The RN said the family thought Resident #1 might have hit his leg on the wheels of his wheelchair. The family member pointed out the location to her. The RN said the NP C told her to clean the area and address it as needed. The RN said staff held up Resident #1's leg for her, she cleansed the area with dried blood with a generic wound cleanser, dried the area with gauze, and placed a bandage on it. The RN said there was dried blood, but when she cleaned it there was no active bleeding. The RN said she thought the skin injury must have been a very superficial wound. The RN said Resident #1's family member was there, and she thanked her for taking care of it. The RN said she removed the bandage the next day and there was nothing there, no discoloration, not even a scab, so no new orders were needed. The RN said she should have documented the above information in a progress note. The RN said if it was not there, she must have forgotten. The RN said she should have documented Resident #1 had dried blood to the right ankle when he returned from an MD appointment, the treatment the NP requested, what she assessed and what treatment she provided. The RN said a negative outcome of not documenting the information onto a progress note would be no one knew what care was provided which could lead to side effects like infection. During an interview on 7/17/26 at 8:48 a.m. with NP C, she said she was called by Resident #1's family member. NP C said she was out of town and did not have access to her notes. NP C said she told the nurse to assess, clean, and address the area the family was concerned about. NP C said she did not recall what nurse she told and did not recall if Resident #1 actually had an injury, cut, or abrasion or not. NP C said she was covering for Resident #1's primary nurse practitioner, NP B, and provided NP B with a hand off of everything when she returned 2 weeks later. NP C said the nurses should follow the facility's protocols on documenting orders received. NP C said she did not feel the lack of documenting the skin issue would have had a negative effect because the interventions had been done.During an interview on 7/17/26 at 11:22 a.m. with ADON A, he said there were no skin issues reported regarding Resident #1's right leg. ADON A said staff were pretty good at reporting any issues. ADON A said Resident #1 was being seen so frequently, if there was a skin issue the wound care nurse would have done an inspection, then notified the NP, and they would have placed treatment orders in PCC. ADON A said ideally the information should go onto a progress note in PCC. ADON A said he knew the wound care nurse inspected Resident #1's skin regularly and if there was anything notable, there would have been documentation, but it would have depended on the extent of the skin issue. If the wound care nurse cleaned it up and nothing was there or the wound care nurse did not note anything, she would not have documented anything. ADON A said he felt because it was not significant, it would not need follow up especially since the wound care nurse was the one who assessed Resident #1 frequently. ADON A said Resident #1 received all the treatments and care he needed and requested and, in this situation, staff followed policies and procedures.During an interview on 7/17/26 at 12:07 p.m. with the Administrator, she said staff in general knew any bruising, blood, or discoloration must be reported to a nurse. The administrator said best practice would be to document if an abrasion was there or not, any NP orders and any provided care. The administrator said she did not believe there would be a negative outcome if the alleged skin issue was superficial and there was not even a scab noted the next day after the bandage was removed. The administrator said she knew the resident was seen frequently by the wound care nurse so the area was being assessed and any issues would have been documented. She said staff did identify the skin issue, reported it, and provided treatment, however there was not a progress note in the medical record. The Administrator said according to the facility's policy the information should have been documented.Record review of the facility policy titled, Documentation in Medical Record with an implemented date of 10/24/2022 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 assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. 3. Principles of documentation include, but are not limited to:a. Documentation shall be factual, objective, and resident centered.ii. Record descriptive and objective information based on first-hand knowledge of the assessment, observation, or service provided.b. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care.c. Documentation shall be timely and in chronological order.

Based on observation, and interview, the facility failed to provide a safe, clean, and sanitary environment for 2 (room [ROOM NUMBER] and room [ROOM NUMBER]) of 10 rooms. The facility failed to maintain a lighting fixture, and AC ducts from dripping water and water damage in rooms [ROOM NUMBERS]. These failures could place residents at risk for exposure to an unclean, unsanitary environment, risk of falls and other injuries due to an unsafe environment. The findings included: During an observation of rooms [ROOM NUMBERS] on 07/10/26 at 3:30 p.m. revealed there was a lighting fixture in the ceiling above between beds that were dripping water. Observation and re-visit to the rooms on 07/10/26 at 7:15 p.m. revealed the lighting fixture in the ceiling above between beds that were dripping water. During an interview and observation 07/10/26 at 7:45 p.m. the Maintenance Director stated the leak, and lighting fixture had been dripping condensation for about 2 weeks. He said he tried to fix it up and was not aware the water continued to drip. He said if he filled in the holes, condensation would continue to collect in the electrical conduit box and have nowhere to drain. He said the condensation could make a staff or resident fall. During an interview on 07/10/26 at 8:00 p.m., the ADM stated one of the AC ducts had a leak. She said the company came to the facility and said they ordered the parts to fix the AC conduct. The ADM said that the AC duct made condensation and that was why water was dripping. The ADM stated that she did not see a negative impact on the residents. The ADM stated the facility did not have a policy on environment.

Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, for 1 resident (Resident #1) of 5 residents reviewed for quality of care, in that: The facility failed to consult with Resident #1's physician concerning the discontinuation of Depakote at RP's request. These failures placed residents in the facility at risk for not receiving care according to professional standards.The findings were:Record review of Resident #1's admission Record, dated [DATE], revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), and dementia, unspecified (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems. Symptoms may also include personality changes). Record review of Resident #1's [DATE] Quarterly MDS revealed Resident #1 had a BIMS score of 99, indicated Resident could not complete the assessment. Resident #1 had unclear speech, was rarely/never understood others and was rarely/never able to be understood by others. Resident #1 was always incontinent of his bowels and bladder. Resident #1 required substantial/maximal assistance with eating. Resident #1 was dependent on toileting hygiene, showers/baths, and personal hygiene requiring the assistance of two or more helpers. Review of Resident #1's [DATE] MAR revealed he received Depakote 250 mg Oral Tablet Delayed Release two times a day from [DATE] through [DATE]. The morning dose on [DATE], was refused by Resident #1 and the evening dose was not taken due to Resident #1's unresponsiveness and his being sent to the hospital where he expired. Review of Resident #1's progress note dated [DATE] at 03:46 pm revealed DON A wrote I contacted PCP's office to obtain discontinuation orders; however, the office was closed for the weekend. We will await further orders from PCP on Monday ([DATE]). Review of Resident #1's progress notes dated [DATE] revealed DON A had no follow-up note concerning the discontinuation orders for Depakote at the RP's request. During an interview on [DATE] at 11:32 am, OM I stated she believed she called to follow-up with the facility on [DATE] concerning Resident #1 because she had not heard from DON A and was notified at that time Resident #1 was found unresponsive on [DATE], CPR was initiated, then he had been sent out to the hospital, and expired on [DATE]. Record review of facility's Charge Nurse job description not dated revealed:Essential functions: Communicate with resident's point of contact when they ask for a status update or if there is a change in condition.

Based on observation, interview and record review the facility failed to ensure the right for a resident to refuse or discontinue treatment for 1 of 5 Residents (Resident #1) whose records were reviewed for resident rights. The DON, failed to stop Depakote after Resident #1's RP requested the medication be stopped immediately on [DATE]. This deficient practice could affect any resident and could result in residents believing their right to refuse a medication does not matter. The findings were: Record review of Resident #1's admission Record, dated [DATE], revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), and dementia, unspecified (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems. Symptoms may also include personality changes). Record review of Resident #1's [DATE] Quarterly MDS revealed Resident #1 had a BIMS score of 99, which indicated Resident #1 could not complete the assessment. Resident #1 had unclear speech, was rarely/never understood others and was rarely/never able to be understood by others. Resident #1 was always incontinent of his bowels and bladder. Resident #1 required substantial/maximal assistance with eating. Resident #1 was dependent on toileting hygiene, showers/baths, and personal hygiene requiring the assistance of two or more helpers. Review of Resident #1's physician orders for [DATE] revealed the following orders: Start Date [DATE] End Date [DATE] Depakote Oral Tablet Delayed Release 250 MG (Divalproex Sodium) Give 1 tablet by mouth two times a day for MOOD [AFFECTIVE] DISORDER. Review of Resident #1's physician order for Start Date [DATE] End Date [DATE] revealed the following order: Start Date [DATE] End Date [DATE] Depakote Oral Tablet Delayed Release 250 MG (Divalproex Sodium) Give 1 tablet by mouth two times a day for MOOD [AFFECTIVE] DISORDER. Review of Resident #1's [DATE] MAR revealed he received Depakote 250 mg Oral Tablet Delayed Release two times a day from [DATE] through [DATE]. The morning dose on [DATE], was refused by Resident #1 and the evening dose was not taken due to Resident #1's unresponsiveness and his being sent to the hospital where he expired. Review of Resident #1's progress note dated [DATE] at 03:46 pm revealed DON A wrote Nursing Note Skilled nurse received a call from Resident #1's RP, who stated she never gave consent for Depakote and expressed concern that Resident #1 appears very sleepy. She requested that the medication be discontinued immediately. After reviewing the chart, I explained to her that verbal consent had been obtained from her over the phone. RP further stated that she does not want any physician other than PCP to prescribe medications for Resident #1 and that she had not given consent for any other providers to see him. I reminded her that she had previously provided consent to myself and the facility administrator, and that due to the patient's behaviors, psychiatric services were initiated with consent on file. The medication in question is Depakote 250 mg PO BID for mood disorder. I contacted PCP's office to obtain discontinuation orders; however, the office was closed for the weekend. I then called the on-call line and spoke with NP J, who advised that the medication is helping manage the patient's documented behaviors and recommended not discontinuing until PCP is consulted directly. This information was communicated to RP, who has been informed of the plan. We will await further orders from PCP on Monday. continue poc. During an interview on [DATE] at 09:05 am DON B stated when the RP told them to stop a medication, they would stop the medication even if they could not reach the physician to notify. DON B stated the resident or RP's wishes would be honored and they would put the medication on hold. She said the nurses were alerted to the medication hold and also notified during their daily meeting of the hold on the medication. She said the medication would show as on hold on the MAR. The DON stated she had not seen a policy for what to do when a resident or RP told them to stop a medication. During an interview on [DATE] at 10:13 am ADON E stated if the RP requested the medication be stopped, they would notify the RP they had to notify the doctor, and the doctor had to stop the medication. He said if the doctor said it was ok to stop the medication, they would stop it, but the doctor may say to leave the medication in place and the resident could refuse. ADON E stated if the doctor said to continue the medication, they would continue the medication and relay that information to the family. ADON E stated he did not think there was a policy on stopping medication at RP request. During an interview on [DATE] at 10:33 am Administrator D stated they did not have a policy on stopping medications when an RP requested a medication be stopped. During an interview on [DATE] 01:32 pm Resident #1's RP stated in August there was a Care Plan meeting that she and two family members attended. She said at the meeting the three of them told the administrator C and DON A they did not want Resident #1 on Depakote to stop giving it to him. She said they did not want Resident #1 on anything that sedated. RP stated she did not give verbal consent for Depakote in July and even if she did, it should have been stopped after that Care Plan meeting in August. RP stated she called DON A on [DATE]. She said she had found out Resident #1 was still being given the Depakote. She said she told DON A they did not want Resident #1 to take Depakote, and wanted it stopped immediately. She said DON A told her she had given verbal consent back in July for Resident #1 to get Depakote. RP stated she told DON A that she had never given consent for Depakote, and she wanted it stopped immediately. She said DON A stated he would have to talk to the doctor first and he would let her know what the doctor said. RP stated she was pretty sure they had to stop the medication when the family said stop the medication, but DON A said he had to talk to the doctor first. She said he told her that since it was Friday ([DATE]) and the doctor was not in the office, he would talk to the doctor on Monday ([DATE]). She said DON A had said he talked to NP J and NP J stated not to stop Depakote and talk to the doctor. RP stated she called the doctor's office because she felt she had a good relationship with the doctor so the Depakote could be stopped, so she called the doctor's office and spoke to OM I. RP stated the OM I told her DON A did not speak to the NP but had spoken to her. RP stated she tried to get in touch with DON A to ask him about it, but he did not respond to her texts or phone calls. During an interview on [DATE] at 02:30 pm MDS H stated she was the one who wrote the notes for the Care Plan meeting [DATE] for Resident #1. She said the RP attended in person and the two Family Members attended by Teams. She said she could not remember the meeting. She said she probably would not have put in the notes if the family requested the Depakote to be stopped. She said if the family wanted to stop a medication, she would have notified the ADON and the ADON would have taken care of it. During an interview on [DATE] at 03:48 pm APNP L for psychiatric services stated DON A sent the referral for services for Resident #1 on [DATE]. She said DON A put on the intake that PCP had made the referral. APNP L stated she had ordered Depakote for him. She said her name would be on the order because she was the one who ordered it. APNP L stated she went back on [DATE] to see Resident #1 again and she wanted to add Seroquel. She said she told DON A if the family agreed to the Seroquel she would see the resident again, but she never heard back from DON A so she did not see Resident #1 again. During an interview on [DATE] at 11:32 am PCP's Office Manager stated Resident #1's RP called on [DATE] asking about a medication (Depakote). OM told her she was the Office Manager and not a nurse, but she would let the doctor know. OM I stated RP asked if the facility had called to let them know the family wanted the medication stopped. OM I stated RP told her she had never given consent to have her father on that medication (Depakote) and the family had not wanted Resident #1 on it. OM I stated she told RP that DON A called and spoke to her, but she had not given any orders. She said she explained to the RP she was just the Office Manager, not a doctor or NP, and could not order medications to be started or stopped. OM I stated she had the SNF phone and was answering the calls when DON A called on [DATE]. She said she explained to DON A, NP J was out of town and not working when he called. She said that she told him that NP J did not answer her phone on weekends, but she would give her the message on Monday ([DATE]). OM I stated she checked with NP J on [DATE] to see if any orders were given [DATE] through [DATE] for Resident #1. She said NP J told her she had been out of town and did not answer her phone on weekends. OM I stated NP J denied writing any orders or speaking with DON A. During an interview on [DATE] at 03:54 pm RN F stated if an RP or resident wants a medication stopped, they would document in the Progress Notes the RP's request, place the medication on hold, and notify the doctor. She said the request would go on the 24-hour report and it would also be passed on at shift report by the nurse who received the request and the discontinuation order by the doctor if one was received. She said sometimes the doctor would say to leave the medication on and obtain the resident refusal, but usually the doctor would discontinue the order. During an interview on [DATE] at 08:40 am, the Administrator stated there was not a policy concerning a family's request to stop medication or treatment. Review of facility policy, Exercising Your Rights as a Nursing Facility Resident State Long-Term Care Ombudsman Program dated [DATE] revealed, The Resident has the right: * To be treated with dignity and respect also means you have the right to make decisions about your life and care. Your facility must respect your choices and preferences. * To make choices about your care. You have the right to participate in your care and make choices about your care. This includes the right to:- Refuse any care or treatment.- Choose people to help you make decisions or make decisions for you when you are unable to.

Based on interviews and record reviews, the facility failed to ensure review and revision of comprehensive care plans for 1 resident (Resident #1) of 5 residents reviewed for comprehensive care plan revisions in that: The facility failed to review and revise Resident #1's comprehensive person-centered care plan to address the initiation of Depakote, an antiseizure medication used for mood disorder. This deficient practice could affect residents and place them at risk of not receiving appropriate interventions to meet their current needs.The findings were: Record review of Resident #1's admission Record, dated 11/26/2025, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), and dementia, unspecified (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems. Symptoms may also include personality changes). Record review of Resident #1's 07/22/2025 Quarterly MDS revealed Resident #1 had a BIMS score of 99, indicated Resident #1 could not complete the assessment. Resident #1 had unclear speech, was rarely/never understood others and was rarely/never able to be understood by others. Resident #1 was always incontinent of his bowels and bladder. Resident #1 required substantial/maximal assistance with eating. Resident #1 was dependent on toileting hygiene, showers/baths, and personal hygiene requiring the assistance of two or more helpers. Record review of Resident #1's psychiatric note dated 07/26/2025 at 09:00 am written by APNP L revealed an order for Depakote 250 mg twice a day. Record review of physician's orders revealed on 07/26/2025 at 10:20 am an order given by PCP for Depakote Oral Tablet Delayed Release 250 MG (Divalproex Sodium) Give 1 tablet by mouth two times a day for MOOD [AFFECTIVE] DISORDER. Order was discontinued on 08/02/2025. Record review of physician's orders revealed on 08/02/2025 at 05:40 am an order given by PCP for Depakote Oral Tablet Delayed Release 250 MG (Divalproex Sodium) Give 1 tablet by mouth two times a day for MOOD [AFFECTIVE] DISORDER. Order was discontinued on 10/07/2025. Record review of Progress Note for Resident #1 written by LVN G on 07/26/2025 at 10:16 am revealed APNP L ordered Depakote 250 mg twice a day by mouth. Record review of Progress Note for Resident #1 written by MDS H on 08/21/2025 at 05:46 pm revealed NURSING - Plan of Care Note Note Text : CARE PLAN MEETING HELD WITH RP, (and family members) VIA TEAMS MEETING. ADMINISTRATOR, DON, ADON'S AND CARE MANAGEMENT PRESENT. DISCUSSED WTIH FAMILY DECREASE IN BEHAVIORS. DISCUSSED MEDICATION INTERVENTIONS IN PLACE FOR MOOD DISORDER (DEPAKOTE)FAMILY AWARE PATIENT 1 TO 1 WITH RESIDENT WILL BE DISCONTINUED TOMORROW. FAMILY ALSO AWARE THAT PATIENT DOES CONTINUE TO REFUSE ADL CARE AND BECOMES AGITATED WITH INCONTINENT CARE. During an interview on 12/05/2025 at 04:45 pm ADON E stated if a medication needed a consent, it would be care planned. He said Depakote did not need labs since it was being given therapeutically for mood. ADON E stated best practice would be the nurse who gets the order for a medication (Depakote for mood disorder), would be the one who put it in the care plan, but any nurse could do that. During an interview on 12/05/2025 at 04:50 pm DON B stated Depakote would not need labs to check levels if the Depakote was being given for moods. She said if the Depakote were being given for seizures, there would be labs also ordered by the doctor. DON B stated if Depakote were ordered on a Saturday, the nurse who received the order would be the one who care planned the medication after the consent was signed. She said on Monday, the medication would be discussed at the morning meeting with the IDT. Record review of facility's Care Plan Revisions Upon Status Change Policy, dated 10/24/22, revealed:Policy:The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change.Policy Explanation and Compliance Guidelines:1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change.2. Procedure for reviewing and revising the care plan when a resident experiences a status change:c. The team meeting discussion will be documented in the nursing progress notes.d. The care plan will be updated with the new or modified interventions. Record review of facility's Psychoactive Medication Management Policy, not dated, revealed:Upon noting an order for psychoactive medication on admission or initiation of therapy:5. Care plan the targeted behavior and for why the resident is receiving the medicationForms and Timing of Completion:5. Care Plan - upon initiation of medication.

Based on interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with the professional standards of practice of practice, the comprehensive person-centered care plan, and the residents' choices 1 of 3 residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1 had orders in place for wound care for arterial wounds to his left dorsum foot, right dorsum foot, left plantar foot, right plantar foot, right palm, right dorsum hand and surgical wound with 12 sutures to left plantar 3rd digit - amputation site until 08/19/25, after the resident was readmitted on [DATE], This deficient practice could place residents at risk for receiving inadequate treatments which could result in the worsening of the wounds. The findings include: Record review of Resident #1's face sheet, dated 08/31/25, reflected a [AGE] year-old male who was originally admitted to the facility on [DATE] and initially admitted to the facility on [DATE]. Resident #1 had diagnoses which included: idiopathic aseptic necrosis (a condition where bone tissue dies without a clear identifiable cause) of unspecified toe (s), complete traumatic metacarpophalangeal amputation (complete removal of the finger at the joint connecting the metacarpal bone and phalangeal bone) of unspecified finger, subsequent encounter, type 2 diabetes mellitus (insufficient production of insulation causing high blood sugar) without complications, chronic systolic (congestive) (left ventricle lose ability to contract normally and the heart cant with enough force to push enough blood into circulation) heart failure. Record review of Resident #1's admission MDS assessment, dated 08/19/25, reflected Resident #1 had a BIMS score of 11, which indicated his cognition was moderately impaired. Resident #1's section M - skin conditions reflected the resident was at risk for developing pressure ulcers/injuries, had a total of 6 venous and arterial ulcers present and other problems of selected as surgical wounds. Record review of Resident #1's care plan, with an initiation date of 07/24/25, reflected problems such as, [Resident #1] has an arterial of the left dorsum foot, left plantar foot, right dorsum foot, right plantar foot, right dorsum hand, right palm, left dorsum hand, left palm with an initiation date of 08/01/25. Record review of Resident #1's hospital documents, dated 08/14/25, and titled Physician-Discharge Med (medications) Rec Order Landsc (definition unknown) did not include any orders for impaired skin integrity management. Record review of Resident #1's nursing note, dated 08/15/25 at 8:40 PM and written by LVN A reflected Resident #1 was admitted with gangrene (Death of body tissue) affecting the left fingers and toes and stated, Wound care orders include 0-foam dressing with betadine cast on left hand wrapped with kerlix and betadine with kerlix wraps on the right hand and both feet.Plan included continuation of current medications, wound care regimen. Record review of Resident #1's initial nursing evaluation, with a date of 08/15/25, completed by LVN A, had yes marked off which indicated Resident #1 had skin impairments and documented the sites as, right hand (palm), left hand (palm), right hand (back), right toe(s), left toe(s), amputated left fingers and left hand (back) which was documented twice. Record review of Resident #1's skin/wound note, dated 08/18/25 at 6:08 PM, written by the Treatment Nurse, stated Resident has necrosis (Death of most or all of the cells in an organ or tissue due to disease, injury or failure of the blood supply) to right hand, bilateral feet, and amputation to left hand 3rd, 4th, and 5th digits. [Wound care MD] gave treatment orders. Sx (surgical) site has 12 sutures in place site cleansed with generic wound cleanser, dry with gauze, apply xeroform, cover with dry dressing, secure with tape. Extremities with necrosis, cleanse with generic wound cleanser, dry with gauze, apply betadine cast, wrap with rolled gauze secure with tape. Resident tolerated treatment well, no complaints of pain or discomfort. Record review of Resident #1's skin assessments, with an effective date of 08/18/25, reflected Resident #1 had arterial wounds to his left dorsum foot, right dorsum foot, left plantar foot, right plantar foot, right palm, right dorsum hand and surgical wound with 12 sutures to left plantar 3rd digit - amputation site, all were marked as present on admission. Record review of Resident #1's order summary report reflected he had no treatment orders for his identified skin impairments when admitted on [DATE] until 08/19/25, which include the following: 1. Cleanse arterial to left dorsum foot with generic wound cleanser, dry with gauze, apply betadine cast, wrap with rolled gauze, secure with tape. as needed for soiled/disloged [SIC] with an order and start date of 08/19/25.2. Cleanse arterial to left dorsum foot with generic wound cleanser, dry with gauze, apply betadine cast, wrap with rolled gauze, secure with tape. one time a day for arterial with an order date of 08/19/25 and a start date of 08/20/25.3. Cleanse arterial to left plantar foot with generic wound cleanser, dry with gauze, apply betadine cast, wrap with rolled gauze, secure with tape. as needed for soiled/dislodged with an order and start date of 08/19/25.4. Cleanse arterial to left plantar foot with generic wound cleanser, dry with gauze, apply betadine cast, wrap with rolled gauze, secure with tape. One time a day for arterial with an order date of 08/19/25 and start date of 08/20/25.5. Cleanse arterial to right dorsum foot with generic wound cleanser, dry with gauze, apply betadine cast, wrap with rolled gauze, secure with tape. as needed for soiled/dislodged with an order and start date of 08/19/25.6. Cleanse arterial to right dorsum foot with generic wound cleanser, dry with gauze, apply betadine cast, wrap with rolled gauze, secure with tape. One time a day for arterial with an order date of 08/19/25 and start date of 08/20/25.7. Cleanse arterial to right plantar foot with generic wound cleanser, dry with gauze, apply betadine cast, wrap with rolled gauze, secure with tape. as needed for soiled/dislodged with an order and start date of 08/19/25.8. Cleanse arterial to right plantar foot with generic wound cleanser, dry with gauze, apply betadine cast, wrap with rolled gauze, secure with tape. One time a day for arterial with an order date of 08/19/25 and start date of 08/20/25.9. Cleanse arterial to right dorsum hand with generic wound cleanser, dry with gauze, apply betadine cast, wrap with rolled gauze, secure with tape. as needed for soiled/dislodged with an order and start date of 08/19/25.10. Cleanse arterial to right dorsum hand with generic wound cleanser, dry with gauze, apply betadine cast, wrap with rolled gauze, secure with tape. One time a day for arterial with an order date of 08/19/25 and start date of 08/20/25.11. Cleanse arterial to right palm with generic wound cleanser, dry with gauze, apply betadine cast, wrap with rolled gauze, secure with tape. as needed for soiled/dislodged with an order and start date of 08/19/25.12. Cleanse arterial to right palm with generic wound cleanser, dry with gauze, apply betadine cast, wrap with rolled gauze, secure with tape. One time a day for arterial with an order date of 08/19/25 and start date of 08/20/25.13. Cleanse left hand amputation of 3rd, 4th, and 5th finger sx (surgical) incision with generic wound cleanser, dry with 4x4 gauze, apply xeroform, cover with dry gauze, secure with tape. as needed for soiled/dislodged with an order and start date of 08/19/25.14. Cleanse left hand amputation of 3rd, 4th, and 5th finger sx (surgical) incision with generic wound cleanser, dry with 4x4 gauze, apply xeroform, cover with dry gauze, secure with tape. One time a day for amputation sx (surgical) incision with an order date of 08/19/25 and start date of 08/20/25. Record review of Resident #1's August Treatment Administration Record (TAR) reflected Resident #1 was first provided his ordered treatment on 08/19/25. During an interview with Resident #1 on 08/31/25 at 3:15 PM, he stated he did not recall the exact date he most recently came back to the facility from the hospital but stated he knew he arrived in the evening and stated the following day was a weekend and he had not received his wound care for those 2 days. The resident stated someone told him it was because the wound care nurse only worked Monday through Friday. Resident #1 stated he received his wound care on the Monday (08/18/25) after he returned to the facility. Resident #1 stated he did not experience any negative impact or outcomes due to not receiving wound care over the weekend for 2 days. During an interview and record review with LVN A on 08/31/25 at 4:00 PM, he stated he was the admitting nurse for Resident #1 on 08/15/25. LVN A stated Resident #1 had gangrene to bilateral hands and feet and some amputation to his left hand and stated he identified this on his initial nursing assessment. LVN A stated he was given wound care orders for Resident #1 over the phone when he received admission report from the hospital. LVN A stated he verified the orders with the PA but did not recall if he discussed his findings with the PA. LVN A stated he did not discuss wound care orders for Resident #1 with the PA. LVN A stated he should have discussed wound care orders with the PA. LVN A reviewed Resident #1's chart and stated he did not see any wound care orders he had put in at admission on [DATE] and he probably forgot. LVN A stated he was trained over verification of orders and inputting orders and he was trained during his orientation in June 2025. LVN A stated their policy and procedure was to get the hospital paperwork and send to the provider and asked if there were any changes they would make and continue with their orders. LVN A stated the order should be input into the system and he was responsible for inputting the order on 08/15/25 for Resident #1. LVN A stated he followed the policy and procedures in this situation. LVN A stated we were not sure but thought the ADONs reviewed the resident charts the following day to ensure residents had the correct orders in place. LVN A stated a resident who did not have wound care orders in place and did not receive wound care and could have a negative outcome of infection. During an interview with RN B on 08/31/25 at 4:45 PM, she stated she was the weekend supervisor on 08/16/25 and 08/17/25. RN B stated it was her responsibility to review new admission charts to ensure they had the appropriate orders. RN B stated she recalled reviewing Resident #1's chart and had just reviewed it again at that time and she did not see any betadine order on Resident #1's chart for 08/16/25 or 08/17/25. RN B stated she saw LVN A's note regarding wound care but did not see any orders for wound care. RN B stated she did not like to go into the chart and put in orders specifically related to treatment because that was the wound care nurses responsibility. RN B stated she spoke to LVN C, who was the wound care nurse on the weekend of 08/16/15 and stated she spoke to him about seeing Resident #1 and she assumed he would see him and put in the related orders. RN B stated it was her responsibility to get clarification on any orders in question and she should have followed up with the provider. RN B stated LVN A should have put in the wound care orders because it's the admitting nurse's responsibility to do so and anything that was in question could have been let in a queue to be confirmed at a later date or report could have been given to the following nurse to get clarification. RN B stated she was trained over reviewing orders, ensuring all the correct orders were input and contacting the MD for any clarification. RN B stated she was recently trained in early August. RN B stated she reviewed Friday admission on Saturday and Saturday admissions on Sunday and on Monday the entire leadership staff would also review all of the admissions as a double check after her. RN B stated she felt like she followed her facility policy and procedure in this situation. RN B stated not having wound care orders and not having wound care could negatively impact residents by causing worsening or deteriorating wounds. RN B stated Resident #1 had no deterioration to his wounds that she knew of. Attempted interview on 08/31/25 at 5:05 PM, 5:15 PM and 5:16 PM with LVN C, who was the wound care nurse on 08/16/25 and 08/17/25, were unsuccessful. Voicemails were left with each call, however no communication with LVN C was made. During an interview with the DON on 08/31//25 at 6:55 PM, he stated when a resident was admitted to the facility the nurse should get report from the hospital and ask about any orders or treatment they had and wait for the accompanying orders that came with the resident and then verify those orders and any reports provided by the hospital with the physician. After verification, the nurse should then input the orders. The DON stated the charge nurse who admitted the resident was responsible for ensuring orders were clarified with the provider and input into their chart. The DON stated LVN A was responsible for verification and input of the orders for Resident #1 and RN B, who was the weekend supervisor, was also responsible for reviewing the orders and chart to ensure the appropriate orders were in place for treatment and LVN C who was the wound care nurse should have also verified. The DON stated during the weekday, he, the ADONs and the Treatment nurse were responsible for ensuring the orders were clarified and input into resident charts. The DON stated as far as he knew LVN A did verify the orders with a provider. The DON stated he reviewed Resident #1's chart and saw LVN A documented a progress note regarding wound care orders but it was not under his physician orders. The DON stated these orders should have been input by LVN A and according to LVN A he forgot to put them in. The DON stated was not able to get a hold of LVN C who was the wound care nurse on the weekend on 08/16/25 to see if he provided Resident #1 wound care on 08/16/25 and 08/17/25. The DON stated it was his understanding now that Resident #1 had not received wound care on those 2 days. The DON stated he spoke to Resident #1 who stated he did not get wound on the day in question. The DON stated RN B should have gotten clarification on Resident #1's wound care orders and he did not know why RN B did not get clarification on the orders and RN B told him she told LVN C to make sure to check on Resident #1. The DON stated as per their policy any time they got a physician order they had to input the order and had to verify all orders. The DON stated staff had not followed this policy and LVN A, RN B and LVN C had been trained multiple times over getting clarification for orders and inputting the orders by himself, the ADONs and their Regional. The DON stated Resident #1 went without wound care for 2 days. The DON stated the negative impact if inputting orders and not getting wound care would depend on the wound, the order and the extent of the wound and Resident #1 had no negative outcome or deterioration. During an interview with the Wound Care Physician on 08/31/25 at 7:37 PM, he stated Resident #1 would not have any negative outcome for not having wound care for a weekend on 08/16/25 and 08/17/25. The Wound Care Physician stated the treatment was just to maintain the areas of necrosis as dry and contained as possible. The Wound Care Physician stated no intervention would has been able to resolve his case and Resident #1 had severe peripheral artery disease (condition were plaque narrows arteries reducing blood flow to the arms, legs and abdomen). The Wound Care Physician stated the plan for Resident #1 was to at some point have more amputations. The Wound Care Physician stated he was following Resident #1 at the nursing home and would continue to see him when he returned to the hospital. The Wound Care Physician stated the orders on 08/15/25 were to continue the same treatment from the hospital which was betadine. The Wound Care Physician stated the order should have been sent from the hospital but sometimes orders got lost. The Wound Care Physician stated he thought he told them the orders verbally on the day of discharge from the hospital but did recall who he spoke to.,Record review of the facility's Inservice training report dated 07/01/25, revealed LVN A, RN B and LVN C were trained on charge nurse must follow the admission process and can use admission binder at nurses station to input an confirm orders for all residents from new admissions to new order for PCP which included but not limited to phone services. Record review of the facility's policy, with an implementation date of 04/10/23, and titled Medication Reconciliation included section titled, Policy Explanation and Compliance Guidelines: which stated, .4. admission Processes:Verify resident identifiers on the information received.Compare orders to hospital records, etc. Obtain clarification orders as needed.Transcribe orders in accordance with procedures for admission orders.Order medications from pharmacy in accordance with facility procedures for ordering medications.Verify medications received match the medication orders.5. Daily Processes:a. Address any clinically significant medication irregularities reported by pharmacy consultant.Verify medication labels match physician orders and consider rights of medication administration each time a medication is given.Obtain and transcribe any new orders in accordance with facility procedures. Obtain clarification as needed.Order medications from pharmacy in accordance with facility procedures for ordering medications.Verify medications received match the medication orders. During an interview with ADON D on 08/31/25 at 8:31pm he stated they did not have a policy related to wounds.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 3 of 5 residents (Resident #97, Resident #111 , ) reviewed for infection control practices. 1.The facility failed to ensure proper contact precautions for infections of ESBL and MRSA were followed for Resident #97 to prevent cross-contamination and possible infection. 2.The facility failed to ensure proper contact isolation precautions were followed for Resident #9 to prevent cross-contamination and spread of infection. 3.The facility failed to ensure proper Enhanced Barrier Precautions (EBP) were followed for Resident #111 when checking blood sugar and administering insulin. These failures could place residents at risk for cross contamination, infection, and improper wound healing. Findings included: 1.Record review of Resident #97's face sheet, dated 08/12/25, revealed a [AGE] year-old-male with an original admission date of 07/29/25. Current diagnoses included Encounter for Surgical Aftercare Following Surgery on the Skin and Subcutaneous Tissue, Abscess of Tendon Sheath (typically occurs due to an infection within the sheath surrounding a tendon), and Cellulitis of the Left Lower Limb (a bacterial infection which affects the skin and soft tissues underneath). Record review of Resident #97’s admission MDS assessment dated [DATE], revealed a BIMS score of 15, intact cognition. MDS also revealed Active Diagnoses: Encounter for Surgical Aftercare Following Surgery on the Skin, Cellulitis of Left Lower Limb, and Abscess of Tendon Sheath. Record review of Resident #97’s active physician orders with a start date of 08/12/25 revealed an order for wound care to surgical incision and drainage wound to left lateral lower leg. Another physician order with a start date of 08/10/2025 revealed monitor peripheral IV site for redness, as well as an order for contact isolation for ESBL and MRSA to left lower extremity. Record review of Resident #97’s progress note dated 08/01/25 revealed Resident #97 left on pass; Progress note dated 08/02/25 at 1:12 PM revealed Resident #97 left on pass; Progress note dated 08/02/25 at 7:09 PM revealed Resident #97 left on pass; Progress note dated 08/05/25 at 4:16 PM revealed continued to invite Resident #97 to activities; Progress note dated 08/07/25 at 8:33 PM revealed Resident #97 returned from being out on pass; Progress note dated 08/11/25 at 8:03 AM revealed Resident #97 continued to receive IV antibiotics for infection; Progress note dated 08/11/25 at 9:34 AM revealed Resident #97 continued to remain on contact isolation, but he could be out of his room as wound was contained within dressing. Progress note dated 08/11/25 at 9:51 AM revealed resident was re-educated on the importance of contact isolation to prevent the spread of infection, but wound was contained so he was allowed to step out of room but try and limit constant entering and exiting room. Progress note dated 08/12/25 at 7:57 AM revealed Resident #97 was re-educated on the importance of contact isolation. In an observation on 08/11/25 9:35 AM Resident #97 was observed entering and leaving his room twice within a 10-minute time period. He was also seen taking down his own IV antibiotic bag and carrying it across the room. Unsure what he did with it. In an interview on 08/11/25 at 3:45 PM, ADON-A stated a resident on contact isolation should not be going in and out of their room and exposing other residents to cross-contamination and infection, even if the wound was contained and covered. ADON-A stated Resident #97 was educated regarding this. He stated it was also not recommended to share a room with another resident, especially if the resident was not on any precautions at all, and there were available rooms, so he was not sure why the contact isolation Resident #97 was sharing a room with another resident who was not on any precautions or isolation. In an interview on 08/11/2025 at 5:35 PM the Administrator stated ADON-B was the new ICP and was still learning as the infection control nurse. The Administrator stated Resident #97 was on contact isolation and was allowed to come and go as he pleased since his wound was contained, and he was not considered a danger to other residents. He also stated regarding CDC and best practice, Resident #97 should probably not be coming and going as he pleased, and it would be best if he was placed in a room on his own instead of exposing someone else to his infection. In regard to a specific contact isolation policy, the Administrator stated the facility did not have one, and they followed CDC guidelines and recommendations. In an interview on 08/12/2025 at 8:01 AM ADON-B stated he had been in the ICP role for approximately 1 month. He stated contact precautions included draining wounds which cannot be contained, and just because a resident had a wound with a specific organism in it did not specifically qualify them for contact precautions. He stated Resident #97’s wounds did not necessarily constitute contact precautions, and he technically could have just been placed on EBP, but ADON-B placed him on contact precautions because he had MRSA to both wounds on his leg, and he felt like he took this extra step to be cautious. ADON-B stated patients had rights, so he was allowed to come and go as he pleased, but according to CDC recommendations, the facility tried to limit how much he was coming and going in and out of his room. ADON-B stated Resident #97 was not putting other residents at risk for cross-contamination or infection because the wound was contained. ADON-B stated regarding a specific contact isolation policy, the facility did not have one, and they just followed CDC guidelines and recommendations. In an interview on 08/12/25 at 11:04 AM the DON stated they did not have a specific contact isolation policy but followed CDC guidelines and recommendations. He also stated Resident #97’s wound was contained, and they tried to limit his coming and going so as to not cause any cross-contamination. 2. Record review of Resident #9’s face sheet dated 04/12/25, revealed a [AGE] year-old-female. Diagnoses included Atherosclerosis (the buildup of fats, cholesterol and other substances in and on the artery walls causing arteries to narrow and blocking blood flow) of native arteries of extremities with gangrene (when body tissue dies because it does net enough blood flow or because of a serious bacterial infection) of the right leg, need for assistance with personal care, acquired absence of the left leg below the knee, Alzheimer’s, and Diabetes. Record review of Resident #9’s quarterly MDS dated [DATE] revealed a BIMS score of 08, indicating moderate cognitive impairment. She was dependent on staff for all ADLs except eating and oral hygiene which required moderate assistance. She was always incontinent of bladder and bowel. She was receiving antidepressants, antibiotics, and opioid medications for pain control. Record review of Resident #9’s care plan dated 04/12/25 indicated she was on EBP for wound care Date initiated and revised: 06/03/25. The resident has infection of the urine Date Initiated: 07/27/25. Goal: The resident will be free from complications related to infection through the review date of 10/15/25. Interventions: Contact Isolation precautions for MRSA to urine; Wear gowns and masks when changing contaminated linens. Place soiled linens in bags marked biohazard. …Educate the resident/family/caregivers regarding the importance of hand washing. Use antibacterial soap and disposable towels. Wash hands immediately after ADLs, care tasks, and activities. Date Initiated 08/06/25. Administer antibiotic Macrobid x7 days for UTI. Date initiated: 07/27/25. Record review of Resident #9’s progress notes dated 08/11/25 at 9:36 am revealed patient remains on contact isolation when dealing direct contact/and or in room. Patient is bedbound so ok to be with another resident since patient does not use shared toilet. Note written by ADON B. Record review of Resident #9’s progress notes dated 08/11/25 at 11:25 am revealed patient has had 6 days of antibiotic therapy for UTI MRSA to urine with one left as well as no complaints of painful urination…ok to remove contact isolation and continue on EBP. Note written by ADON B. Record review of Resident #9’s lab results for urine cultures dated 07/21/25 indicated she had e. coli and was placed on the antibiotic Cipro. Urine cultures done on 08/03/25 indicated she had MRSA and was placed on the antibiotic Macrobid. Record review of Resident #9’s physician orders dated 07/22/25 indicated she received Cipro 500 mg by mouth every 12 hours for 7 days for UTI. Macrobid 100 mg by mouth every 12 hours for MRSA for 7 days from 08/12/25-08/12/25. Observation and interview with CNA G on 08/11/25 at 9:10 am in a contact isolation room, CNA G was wearing no PPE. CNA G was wearing a short- sleeved scrub shirt. He was sitting in a chair, contacting Resident #9’s bedrail with the underside of his right arm. He said he removed her oxygen (nasal cannula) for her so she could eat better. He said he did not use gloves to remove the oxygen. He said he did not wash his hands after removing the oxygen. CNA G was observed folding his arms, touching the resident’s bedcovers, and the utensils she was using that were on her tray. CNA G was asked by this surveyor why he was not wearing PPE. He said he was not touching the patient. He said he thought she had a wound infection. Then he said he did not know. He said the last time he had training on isolation was 2 weeks ago. He said he washed his hands 20 seconds or more, before & after contacting a resident. He said he knew he should have been wearing PPE. He said his arm was leaning on the side rail and he was touching where the patient touched. During the interview, he touched his face. In an interview with HA on 08/11/25 at 9:29 am, she said she donned PPE because she was going to help CNA G turn Resident #9. HA said staff wore PPE for wound infections and for “other things” she could not elaborate about. She said she got training 2 weeks ago on isolation. She said the process for proper hand washing was 2-3 minutes then said 2-3 seconds then said 20 minutes “or something like that”. HA used ABHR and donned gloves prior to entering the contact isolation room. In an interview with the DON on 08/11/25 at 4:19 pm, he said the last infection control in-service held was last month and today. He said today’s in-service was “just for continuing education”. He said CDC recommendations were to limit their (residents’) movements, and the facility could not force a resident to stay in their room if they were in isolation. He said it was preferrable to not have contact isolation patients rooming with someone without contact isolation. He said his expectations were for staff to wear PPE for all necessary precautions. In an interview with ADON B on 08/12/2025 at 8:05 am, he said the reason for PPE was to prevent the spread of infection. He said PPE was required for feeding residents in contact isolation. He said in-services and 1:1 education were enforced for staff who did not follow protocol. He said administrative staff knew if the staff was adhering to isolation precautions by consistent rounding or if it was brought to his attention. He said PPE policy education was done monthly and as needed. He said he did not say “policy”. He said the last in-service was yesterday and the one before that was 2 weeks ago. He said he did a 1:1 with CNA G and said CNA G told him he did not wear PPE because he thought he was not in direct contact with Resident #9. He said he told CNA G that PPE and handwashing was required on contact isolation when entering and exiting every single time to prevent spread of infection. PPE Policy was requested at that time. 3. Record review of Resident #111’s electronic face sheet dated 08/12/2025 reflected a [AGE] year-old-female with an admission date of 06/23/2025. Pertinent diagnoses included Cholecystectomy Drain (a drain placed after gallbladder surgery), Type 2 Diabetes Mellitus, Chronic Kidney Disease Stage 3A (damage to your kidneys and they aren't working as well as they should), Dependence on Renal Dialysis (dependent on a life sustaining treatment that replaces the function of failing kidneys), Absence of Right Leg Above Knee (above the knee amputation). Record review of Resident #111's MDS assessment, dated 06/23/2025, reflected she scored a 14 on her BIMS which reflected cognitively intact. Record review of Resident #111’s person-centered care plan-initiated date 07/04/2025 reflected Resident #111 had the need for Enhanced Barrier Precautions due to:… cholecystectomy tube. Intervention included Place on Enhanced Barrier Precautions…. Record review of Resident #111’s active physician orders with a start date of 08/10/2025 reflected an order for Enhanced Barrier Precautions: Use gown and gloves for high contact resident care activities for those with ……as well as those residents with wounds or indwelling medical devices every shift for cholecystectomy drain. During an observation of medication administration on 08/11/2025 at 4:16 p.m. revealed that LVN L wore gloves but did not put on a gown when she checked Resident #111’s blood sugar and administered insulin who had a drain. There was an Enhanced Barrier Precaution (EBP) (an infection control intervention designed to reduce transmission of drug-resistant organisms) sign posted on Resident #111’s door. In an interview on 08/11/2025 at 4:30 p.m. LVN L stated that the residents who meet the EBP criteria were residents with IV’s, infection, or those who have wounds. She stated Resident #111 was on EBP due to having a gallbladder drain. LVN L stated that it was to her understanding that the staff was to wear gloves and gowns only when having direct contact to the site. She stated that it was important to put on proper PPE to prevent the spread of infection. She stated she received in-services for enhanced barrier precautions upon hire. In an interview on 08/11/2025 at 4:51 p.m. the DON stated EBP was ordered for residents who meet the criteria such as residents with G-Tubes, open wounds, wounds that are draining, central lines, a tracheostomy, foley catheters, or central lines. The DON stated LVN L was supposed to put on a gown and gloves when checking blood sugar and administering insulin to Resident #111. He stated that proper PPE was to be worn to make sure they did not contaminate the area and to prevent the spread of infection. The DON stated LVN L was fairly new, and training was provided on infection control and EBP. Record review of the facility’s Infection Prevention and Control Program policy, dated 05/13/23, revealed “This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection as per accepted national standards and guidelines. 5.a. A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC guidelines.” Record review of CDC: Transmission Based Precautions: Contact precautions are used for patients with known or suspected infections that represent an increased risk for contact transmission. Ensure appropriate patient placement in a single patient room if room was available and make room placement decisions balancing risks to other patients. Limit transport and movement of patients outside of the room to medically necessary purposes. When transport or movement in any healthcare setting was necessary, ensure that infected or colonized areas of the patient’s body are contained and covered. Remove and dispose of contaminated PPE and perform hand hygiene prior to transporting patients on contact precautions. DON clean PPE Website reviewed 08/12/25 at 12:35 PM https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html Record review of the facility's policy, titled Enhanced Barrier Precautions, revised 04/5/24, reflected: 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.” Policy Explanation and Compliance Guidelines: 1. “Prompt recognition of need: a. All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions. 2. “Initiation of Enhanced Barrier Precautions: b. indwelling medical devices (e.g. central lines, urinary catheters, feeding tubes )”

Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for storage, preparation and sanitation. 1.The facility failed to ensure the juice gun nozzle, coffee maker, cabinets, drinking glasses, pitchers, and utensils were clean. 2.The facility failed to ensure the area under a prep sink was free from water damage and debris. 3.The facility failed to ensure the underside of the shelf on the stove, directly above cooking food, was kept clean. 4.The facility failed to ensure dirty utensils were not kept in a clean drawer. 5.The facility to ensure dry storage items were not left on the floor. 6.The facility failed to ensure spices were not left open to air when not in use. 7.The facility failed to ensure leftovers in refrigerator #2 were labeled and dated. These failures could place residents who received meals and/or snacks from the kitchen at risk for food contamination and food borne illness. Findings included: Observation and initial tour of the kitchen on 08/10/25 at 11:10 am revealed the inner nozzle of the juice gun was clogged with a thick, red substance. The dripper of the coffeemaker had a thick, layered dark brown substance coating the opening. The cabinets below and in front of the coffee maker was stained from the countertop to the floor with a thin brown substance. 75 of 120 drinking glasses (4 full trays) and 7 plastic pitchers were stained and/or caked on the inside bottoms and up the sides with a removable white and/or light brown substance. The drinking glasses and pitchers were on clean racks. The drinking glasses did not have a dry mat between them and the trays. The area under a prep sink appeared to have water damage and a large amount of small, round, black fuzzy spots, dirt, stains, and debris. There were 2 metal spatulas with deep crevasses in the melted handles and a dirty hand-held lime juicer in a clean utensil drawer. The underside of the shelf above the stove was covered with a dark brown/black gritty substance that was directly over cooking food. Five sleeves of Styrofoam cups were on the floor near a large working water purifier in the dry storage room. There were 5 of 12, 16-ounce containers of spices open to air. There was a covered half-size holding pan with leftovers in refrigerator #2 that was not labeled or dated. In an interview with DA-1 on 08/10/25 at 11:10 am, she said the plastic glasses and pitchers were dry and on clean racks to be used for service. She said the substance in the drinking glasses was removable and could be stained by lemonade, tea, juice, or milk. She said the removable substance in the glasses could cause cross contamination and make residents sick. She said she would not drink from the glasses. She said she had been trained on sanitation and cleanliness of the kitchen but could not remember the last training or in-service she had. She said the juice gun was cleaned every shift. She said she had not cleaned the juice gun, did not know who was responsible for cleaning it, or when it was last cleaned. In an interview with DA-2 on 08/10/25 at 11:15 am, she said the plastic glasses and pitchers were dry and on clean racks to be used for service. She said the substance inside the drinking glasses was humidity. She said she would not drink from the glasses after removing some of the white substance with her finger. She said she did not know what the substance was. She said it could come off in the drinks and make residents sick. She said she had been trained on sanitation and cleanliness of the kitchen but could not remember the last training or in-service she had. She said she did not know how often the juice gun was cleaned or supposed to be cleaned, or who was responsible for cleaning it. In an interview with the FPS on 08/10/25 at 11:30 am, she said she had worked at the facility for 4 years. She said all the drinking glasses and pitchers were clean and dry. She said the white substance inside the glasses did not come off. When asked to try to remove some of the white substance by this surveyor, she did so with her fingernail then flicked it aside. She said she was not sure what the white substance was and today was the first time she had ever seen it (the heavy white build-up) before. She said they served juice, tea, lemonade, and milk to the residents in the same glasses. She said she would drink from the glasses and proceeded to do so but was stopped by this surveyor before the glass touched her lips. She said she did not know what the stuff was under the prep sink, and she had never looked there before. She said the spices were open to air because they (the cooks) used them for breakfast service. She said spices should not be left open to air because debris or anything in the air could contaminate them and if consumed, could make residents sick and alter the flavor of the food. She said she held an in-service last week on the topics of labeling and storage. In-services, the registered dietician, cleaning schedules, and facility policies for cleaning schedules and sanitization were requested at this time. In an interview with the CK on 08/10/25 at 11:45 am, she said all items in the refrigerators and freezers should be labeled and dated. She said she should have closed the spices when she was done cooking. She said she put the unlabeled leftovers that were in the holding pan in the refrigerator because she was in a hurry that morning and meant to label it later. She said undated leftovers and open spices could make residents sick if consumed due to cross contamination. Record Review of the facility's kitchen monthly cleaning schedules dated 05/01/25-08/10/25 indicated the vent hood and filters, ice machine, refrigerators, freezers, and floor were cleaned without fail. Record Review of the facility's kitchen daily cleaning schedules dated 05/01/25-08/10/25 included the coffee area and coffee machine were cleaned after each meal. Doors, walls, stove, and oven were cleaned on Saturdays or Sundays. All dates and times were initialed as having been cleaned. The different initials were written-in by what appeared to be the same writer. Record Review of the facility's kitchen weekly cleaning schedules dated 05/01/25-08/10/25 revealed all dates and times were initialed as having been cleaned. The different initials were written-in by what appeared to be the same writer. Record Review of the facility's kitchen policy dated 10/01/18, titled, Cleaning Schedules revealed under Policy: The facility will maintain a cleaning schedule prepared by the Nutrition & Foodservice Manager and followed by employees as assigned in order to ensure that the kitchen is clean and free of hazards. 3. The cleaning list will be posted weekly and initialed off and dated by each employee upon completion of the task. The Nutrition & Foodservice Manager or designee will verify that the tasks were completed as assigned. Record Review of the facility's kitchen policy approved 10/01/18, titled, Manual Cleaning and Sanitizing of Utensils and Portable Equipment revealed under Policy: The facility will follow the cleaning and sanitizing requirements of the state and US Food Codes for manual cleaning in order to ensure that all utensils and equipment are thoroughly cleaned and sanitized to minimize the risk of food hazards. Under Procedure: 5. Prior to washing, pre-flush or pre-scrape all equipment and multi-use utensils. When necessary, presoak to remove gross food particles and soil. 8. Sanitize all multi-use eating and drinking utensils and the food-contact surfaces of other equipment in the third compartment by one of the following methods: a. Immerse for at least 30 seconds in clean, hot water at a temperature of 170 F or above. b. Immerse for at least 60 seconds in a clean sanitizing solution.c. Be sure to cover all surfaces of the utensils and/or equipment with hot water or the sanitizing solution and keep them in in contact for the appropriate amount of time. 11. Air-dry the utensils or equipment, since wiping can re-contaminate equipment and can remove the sanitizing solution from the surfaces before it has finished working. Make certain all equipment is dry before putting it into storage. Record Review of the facility's kitchen policy approved 10/01/18, titled, General Kitchen Sanitation revealed under Policy: The facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All Nutrition & Foodservice employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness. Under Procedure: 1. Clean and sanitize all food preparation areas, food-contact surfaces, dining facilities and equipment. After each use, clean and sanitize all tableware, kitchenware and food-contact surfaces of equipment, except cooking surfaces of equipment and pots and pans that are not used to hold or store food and are used solely for cooking purposes. 3. Keep food-contact surfaces of all cooking equipment free of encrusted grease deposits and other accumulated soil. 4. Clean and sanitize all multi-use utensils and food-contact surfaces of equipment used in the preparation or storage of potentially hazardous food prior to each use. Clean and sanitize food-contact surfaces of equipment and multi-use utensils used for preparation of potentially hazardous foods on a continuous or production line basis at scheduled intervals throughout the preparation period based on food temperature, type of food and amount of food particle accumulation. 6. Clean non-food-contact surfaces of equipment at intervals as necessary to keep them free of dust, dirt, and food particles and otherwise in a clean and sanitary condition. References: FDA Food Code 2022 Ch. 2-102.20 Food Protection Manager Certification 2-103 Duties 2-103.11 Person in Charge. The person in charge shall ensure that: Ch. 4-202 Cleanability 4-202.11 Food-Contact Surfaces. (A)Multiuse food-contact surfaces shall be: (1) Smooth; (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; (3) Free of sharp internal angles, corners, and crevices; (4) Finished to have smooth welds and joints 4-5 Maintenance and Operation 4-501 Equipment 4-501.11 Good Repair and Proper Adjustment. (A) Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Part 4-2. 4-602 Frequency 4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) Equipment food-contact surfaces and utensils shall be cleaned: (5) At any time during the operation when contamination may have occurred. Equipment food-contact surfaces and utensils shall be cleaned throughout the day at least every 4 hours.

Based on observation, interview, and record review, the facility failed to ensure that the residents' environment remained free of accidents or hazards as possible for 1 of 5 residents' (Resident #29 and Resident #70) bathrooms reviewed for environment.The facility failed to maintain and ensure all chemicals were labeled appropriately and put away appropriately out of Resident #29 and #70's shared bathroom.This failure could place residents at risk for injury.The findings included:1. Record review of Resident #29's face sheet dated 08/12/25 revealed she was a [AGE] year-old female with an admission date of 09/16/2019. Pertinent diagnoses included Alzheimer's Disease (progressive decline in memory, thinking, and behavior), cognitive communication deficit (difficulty in communication which arises from impaired cognitive functions), and Unspecified Dementia (a group of symptoms affecting memory, thinking, and social abilities).Record review of Resident #29's Annual MDS assessment dated [DATE] revealed a BIMS score of 03, indicating severely impaired cognition.Record review of Resident #29's care plan initiated 07/10/25 revealed Resident #29 needed a structured environment in a secure unit related to cognitive deficit.2. Record review of Resident #70's face sheet dated 08/12/25 revealed she was an [AGE] year-old female with an admission date of 01/29/25. Pertinent diagnoses included Unspecified Dementia (a group of symptoms affecting memory, thinking, and social abilities) and Depression (a mood disorder described as feelings of sadness, loss, or anger which interfere with a person's everyday activities). Record review of Resident #70's Quarterly MDS dated [DATE] revealed a BIMS score of 06, indicating severely impaired cognition. Record review of Resident #70's care plan initiated 06/30/25 revealed Resident #70 needed a structured environment in a secure unit related to cognitive deficit.In an observation on 08/10/25 at 11:25 AM an unlabeled bottle with a clear liquid in the bottom of it was observed hanging on the handrail of Resident #29 and Resident #70's bathroom. The liquid had a very strong, chemical like odor. In an interview on 08/10/25 at 11:26 AM HA-I stated she had not known where the bottle came from or how it got there. She stated she was unsure if it belonged to the residents or the housekeeping staff. HA-I stated she did not think there should be a bottle with chemicals in the residents' rooms or bathrooms, especially unlabeled bottles. In an interview on 08/10/23 at 11:27 AM LA-J, who was assisting with housekeeping that day, stated she had not known what was in the bottle or where it came from. She stated she had not left it there and was not sure who had. She stated it smelled strong and if it was chemicals, it could have harmed the residents if they had ingested it or gotten it on their skin. In an interview on 08/10/23 at 11:31 AM ES stated he was unsure where the bottle came from, but he thought a resident's family member may have brought it in. He opened the bottle and stated it had a very strong chemical scent like bleach. He stated chemicals in the facility were supposed to have a label on them, and they were not supposed to be left in residents' rooms or bathrooms because if a resident was to drink it, it could harm them. He stated the facility did not have a specific policy on labeling chemicals or keeping them out of residents rooms.Record review of the facility's Safety Data Sheet, Disinfectant/Detergent Cleaner, no date identified, revealed 2. Hazards Identification: Hazard Statement: causes severe skin and eye burns; Harmful if swallowed; Harmful in contact with skin. Precautionary Statement: Store locked up.

Based on observation, interview and record review revealed based on a resident's comprehensive assessment, the facility must ensure that a resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 1 of 5 Residents (Resident #35 ) whose records were reviewed for weight loss. Nursing staff failed to follow physician orders to weigh Resident #35 weekly for four weeks, effective 07/17/25. This deficient practice could affect residents at risk for losing weight and result in unplanned weight loss and a decline in the resident's overall health.The findings were:Record review of Resident #35's admission record dated 08/12/25 reflected a [AGE] year-old-female with an admit date of 07/17/25. Her relevant diagnoses included pneumonia (an infection that inflames air sacs in one or both lungs, which may fill with fluid), dysphagia-oropharyngeal phase (difficulty swallowing that originates in the mouth and throat), sepsis (when chemicals released in the bloodstream to fight an infection trigger inflammation throughout the body), and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Record review of Resident #35's initial MDS assessment dated [DATE] reflected a BIMS score of 10, which indicted her cognition was moderately intact. Record review of Resident #35's care plan assessment indicated:Problem: [Resident #35] had a nutritional problem or potential nutritional problem r/t diet restrictions.Interventions: in part included to monitor/record/report to MD prn s/sx of malnutrition, muscle wasting, significant weight loss (date initiated 07/31/25). Record review on 08/11/25 at 1: 20 p.m., of Resident #35's physician order effective 07/17/25 reflected weigh weekly for 4 weeks, then monthly and PRN one time a day every 7 day(s), and Med Plus 2.0 (nutritional drink) effective 08/09/25 three times a day for supplement to meet caloric intake, give 90 ml.Record review on 08/11/2025 at 1:22 p.m., of Resident #35's weight history on her electronic medical record reflected:07/18/2025 107.4 lbs.08/02/2025 102.0 lbs. In an interview on 08/10/25 at 1:15 p.m., Resident #35 said she liked the food being served in the facility and for the most part would eat all that was served. She said she would get assistance with her meals. During an interview on 08/11/25 at 2:43 p.m., RN D said Resident #35 had been admitted for IV therapy due to pneumonia. She said Resident #35 had an order for weekly weights due to being a new admit and the facility's restorative aide was responsible to take her weights. She said Resident #35 also had an order for a nutritional supplement Med Pass 2 which was given to her 3 times a day. She said it was to meet her caloric intake. During an interview and observation on 08/11/25 at 3:12 PM, the ADON A said it was the facility's policy to monitor new admits weight for 4 weeks upon admission and monthly or PRN thereafter. He said it was his responsibility as a ADON to ensure all residents who required daily, weekly, or monthly weights were weighed. He said Resident #35 was a new admit and had an order for weekly weights effective 07/17/25. He said the facility's restorative aide was tasked with the responsibility to weigh residents. ADON said once a week, he would provide the restorative aide with a paper list of residents that needed to be weighed. He said the restorative aide would log the resident's weight on the paper list and at the end of the week, she would give it back to him. He said at that time he would review their weights, make necessary changes, and enter their weight on the resident's electronic medical record. He said Resident #35 was supposed to have been weighed on 07/18/25, 07/25/25, 08/01/25, and on 08/08/25. The ADON A was observed as he checked a binder he had on his desk with paper list provided by the restorative aide and said the only weights recorded for Resident #35 were for 07/18/25 and 08/01/25. ADON A said the negative outcome for Resident #35 not being weighed per physician's order could have been that the facility might have missed if she had lost weight and possibly not meeting her nutritional and diuretics needs. During an interview on 08/11/2025 at 3:30 p.m., CNA E said she was responsible to weigh all residents. She said newly admitted residents were weighed weekly for 4 weeks after admission and monthly or as needed. CNA E said it was ADON A's responsibility to give her a weekly list of residents that required to be weighed. She said once she was done weighing the residents, she would give the list back to ADON A. She said once she handed over the list to ADON A, she did not know what he did with the list. She said she did not recall if Resident #35 was supposed to be weighed weekly. An interview on 08/12/2025 at 8:45 a.m., the DON, said new admits were supposed to be weighed weekly for 4 weeks and monthly or prn thereafter. He said it the responsibility of ADON A to ensure all residents were weighed according to their physician's order. He said a negative outcome for any resident not being weighed according to their physician order would be that the facility would not know if the resident had any weight loss or gain. Record review of the facility's policy on Weight Monitoring (undated) reflected:Policy: Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise.Compliance Guidelines:Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem.5. A weight monitoring schedule will be developed upon admission for all residents:a. Weights should be recorded at the time obtained. b. Newly admitted residents-monitor weight weekly for 4 weeks.

Based on observation, interview and record review the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 1 of 5 residents (Resident#2) reviewed for oxygen in that: The facility failed to ensure Resident #2's oxygen was administered at the correct setting of 2 liters per minute on 08/10/2025 as ordered by the physician. This deficient practice could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care. The findings included: Record review of Resident 2's electronic admission record dated 08/10/2025 reflected an [AGE] year-old male with an admission date of 04/15/2025 and with an initial admit date of 04/24/2024. Pertinent diagnoses included Nonspecific Abnormal Findings of Lung Field, Dementia, Congestive Heart Failure, Chronic Kidney Disease, Muscle Wasting and Atrophy (loss of muscle tissue), Type 2 Diabetes Mellitus, Dysphagia (difficulty swallowing), and Hypertension (high blood pressure). Record review of Resident #2's Quarterly MDS assessment, dated 06/12/2025 reflected BIMS score of 11, which indicated his cognition was moderately impaired. Record review of Resident #2's person-centered care plan, revised date 05/08/2025 reflected Resident #2 had risk for altered respiratory status/difficulty breathing related to. hypoxia. Intervention included Oxygen settings: O2 as ordered. Record review of Resident #2's physician order dated 06/23/2025, reflected oxygen at 2 LPM via nasal cannula every shift for shortness of breath. During an observation of Resident #2 on 08/10/2025 at 12:28 p.m. the oxygen level setting on the oxygen concentration machine was at 3 LPM via nasal cannula. Observed Resident #2 with O2 tubing via nasal cannula in bed with head of the bed slightly elevated. No signs of respiratory distress noted. In an interview on 08/10/2025 at 12:29 p.m. with Resident #2, he stated that he did not know what the oxygen level settings was supposed to be at. He stated that he was feeling well. He stated he did not remember seeing the nurse checking the oxygen machine, but that she had been in his room that morning. Resident #2 stated if he needed anything, he used his call light. In an interview on 08/10/2025 at 12:30 p.m. LVN K, stated she was the nurse for Resident #2. LVN K confirmed that the O2 setting was set at 3 LPM. She stated the oxygen setting was supposed to be at 2 LPM per physician orders. She stated that she checked Resident #2's oxygen setting that morning, and it was at 2 LPM. LVN K stated that he had a nebulizer treatment that morning, and did not know who might have moved it. She stated that she checked the oxygen setting periodically throughout her shift. LVN K stated the negative outcome of the oxygen setting being high was that it could increase the CO2 and cause respiratory distress. In an interview on 08/10/2025 at 5:08 p.m. with the DON, stated that the charge nurses assigned to that hall were responsible for checking the O2 setting. He stated that the nurses were to check the setting once per shift. The DON stated they were to follow oxygen settings on physician orders. The DON stated that the negative outcome depended on the patient's diagnosis but for Resident #2 it would be hyperoxygenation (excessive oxygen in the lungs or other body tissues). He stated that they did not have an Oxygen Administration Policy. Record review of the facility's policy subject titled, Medication Administration, date implemented 10/24/22 revealed:Policy Explanation and Compliance Guidelines:14. Administer medications as ordered in accordance with manufacturer specifications. Record review of the Respiratory Care Critical Element Pathway revealed:Oxygen: Oxygen machine set at the correct Liters.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were secured and stored in accordance with currently accepted professional principles and standards for 1 of 4 medication carts (400 Hall Med-Aide Medication Cart) reviewed for storage. The facility failed to ensure the 400 Hall Med-Aide medication cart was locked and secured. This failure could place the residents at risk of gaining access to unlocked medications that were not prescribed to them. Findings included: In an observation on 08/10/25 at 11:34 AM, the med-cart which belonged to the 400 Hall Med-Aide was noted to be unlock, and the Med-Aide was noted to be off the unit. In an interview on 08/10/25 at 11:37 AM Med-Aide-C stated she knew she was supposed to lock her medication cart when she was away from it. She stated if the cart was left unlocked anyone could have gotten into it and taken medication which did not belong to them, and it could have made them sick, or even caused death. In an interview on 08/12/25 at 11:04 AM the DON stated nurses and med-aides should always lock their med-carts when they walk away from them. If a med-cart was left unlocked anyone could have taken anything out of it creating a drug diversion or causing possible harm to the resident if ingested. In an interview on 08/12/2025 at 3:04 PM ADON-B stated nurses were supposed to lock the med-carts when they were not in use, and med-carts should not be left unlocked because residents could get into it and ingest medications which did not belong to them. Depending on the medication ingested, the resident could have had side effects of dizziness, lethargy or even death. In a record review of the facility's Medication Administration: Medication Carts and Supplies for Administering Med policy, dated 10/01/19, revealed 2. The medication cart is locked at all times when not in used. 3. Do not leave the medication cart unlocked or unattended in the resident care areas.

Based on observation, interview, and record review, the facility failed to ensure each resident received food prepared in a form designed to meet individual needs for 1 of 8 residents (Resident #100) reviewed for pureed diet needs. The facility failed to provide Resident #100 with her regular pureed diet (that was prescribed for individuals who have difficulty chewing or swallowing food) as designated on her meal ticket on 08/10/25. This deficient practice could place residents at risk for poor food intake, weight loss, and not having their nutritional needs met. Record review of Resident #100‘s face sheet dated 11/23/21 reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Diagnoses included Stroke, Muscle wasting, and dysphasia (difficulty swallowing). Record review of Resident #100‘s quarterly MDS assessment dated [DATE] reflected the resident had active diagnoses including non-traumatic brain dysfunction, Alzheimer’s, Aphasia (difficulty speaking), dysphasia (difficulty swallowing), and disturbances of salivary secretion (dry mouth). Resident #100‘s BIMS score of 99 indicated severe cognitive impairment. She was dependent on staff or required maximal assistance for all ADL’s and required moderate assistance with eating. She utilized a manual wheelchair and could not self-propel. She was always incontinent of bladder and bowel. Record review of Resident #100' s Order Summary Report revealed Dietary Order for Regular Diet, Pureed texture, Nectar Thickened Liquids consistency, Fortified Foods with all meals. Order date 10/29/2024 and Start date 10/20/2024. Record review of Resident #100‘s care plan reflected a problem as “The resident has potential nutritional problem r/t current diet: Regular diet, Pureed texture, Nectar thickened liquids consistency, Fortified foods with all meals. Date initiated: 10/10/21 Revision on: 08/10/25. Goal: The resident will maintain adequate nutritional status through review date. Date initiated: 12/10/21. Revision on: 10/02/23. Target date: 10/09/25. Interventions included Monitor/document/report as needed and s/sx of dysphagia: Pocketing, choking, coughing, drooling, holding food in mouth…Date initiated: 06/18/25. Provide and serve diet as ordered. Date initiated: 06/18/25. Provide, served diet as ordered. Monitor intake and record every meal. Date initiated: 12/10/21. Problem: The resident has unplanned/unexpected weight loss r/t Poor food intake. Date initiated: 08/10/25. Goal: The resident will consume (100%) two of three meals/day. Date Initiated: 08/10/25 Revision on: 08/10/25 Target Date: 10/09/25. Interventions: Give the resident supplements as ordered. Alert nurse/ dietitian if not consuming on a routine basis. Date Initiated: 08/10/2025. Monitor and evaluate any weight loss. Determine percentage lost and place interventions for weight loss per dietician/physician. Date Initiated: 08/10/25. Monitor and record food intake at each meal. Date Initiated: 08/10/25. Offer substitutes as requested or indicated. Date Initiated: 08/10/25. Revision on: 08/10/25. Observation and interview on 08/10/25 at 12:24 pm in the dining room revealed Resident #100 was coughing after taking bites of her food. Her meal plate had chopped carrots, mashed potatoes, and cut up chicken. Her tray ticket indicated Regular Diet, Pureed Texture, Fluids-Nectar. RN F reviewed her meal ticket and said Resident #100 was provided the wrong food texture. RN F said Resident #100 required a regular diet with pureed texture and nectar thick liquids and not mechanical altered. She said Resident #100‘s plate had mechanical altered food. She said she checked the resident’s tray on the cart prior to delivering it to her. She said she saw “regular” (diet) on the tray card but overlooked where it read “pureed” texture. She said she should have taken the tray of mechanical textured food back to the kitchen immediately. She said she should have had an “order listing” (a list of all resident’s tray cards) to go by. She said the kitchen had the same one (list). She said Resident #100 should have a refusal form in her chart in the electronic health record under “miscellaneous”. RN F said Resident #100 had been refusing her pureed diet. She said Resident #100 was edentulous (no teeth) and did not want to wear dentures. She said the diet, refusal, having no teeth and not wanting dentures should all be in Resident #100‘s care plan. RN F said nurses were responsible for getting the refusal forms signed, verbally or a physical signature by the resident. She said if the resident was not able to sign or verbalize, then a nurse signed the form to verify with families or the resident, if the resident had a BIMS score of 10 or greater but was not sure about the BIMS score. In an interview with ADON-A, on 08/10/25 at 12:27 pm, he said Resident #100’s tray card showed pureed but Resident #100 had a mechanical altered plate she was choking on. He said meal trays were checked by the nurses. He would not say what the outcome or dangers could be if a resident had the wrong texture diet. In an interview with CK on 08/12/25 at 11:45 am, she said the “tray line” was responsible for getting the food correct on the trays from the kitchen. She said once the trays went on the carts, the nurses were responsible to check the trays before serving the residents. She said if there was a tray that did not have the right diet on it, she would correct it right away. She said sometimes the trays were mixed up on the carts. Kitchen policies, in-services, and the RD’s presence was requested at this time. The RD was not available for interview throughout the survey. In-services were not received. Record Review of the facility’s kitchen policy revised 06/01/19, titled, “Tray Service” revealed under “Policy: The facility believes that accurate tray service and adequate portion sizes are essential to the residents' well-being and safety. The facility will ensure that diets are served accurately and in the correct portions and that resident preferences are met. Under Procedure: 3. For tray line service, Nutrition & Foodservice staff will check each resident's tray card prior to service to ensure that preferences and dislikes are honored, the correct diet is served, portion sizes are accurate and appropriate substitutions provided. 6. The Nutrition & Foodservice Manager or consultant (RD) will conduct in-services with the Nutrition, Foodservice as needed to ensure all serving staff are familiar with portion sizes and therapeutic and mechanically altered diets.

Based on observations, interviews, and record review, the facility failed to ensure residents remained free from accidents, hazards and each resident received adequate supervision and assistance while providing care for 1 of 5 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure Resident #1 received supervision when outside in his wheelchair. Resident #1 wheeled his way down the parking lot to the road, flipping his wheelchair where the parking lot met the roadway pinning Resident #1 on the roadway where he was unable to get up. The non-compliance was identified as past non-compliance. The Immediate jeopardy began on 12/31/2024 and ended on 01/02/2025. The facility had corrected the noncompliance before the survey began. This deficient practice has the potential to affect all residents in the building by causing resident injuries, such as falls, fractures, and even death due to improper supervision. The findings included: Record review of Resident #1's admission record dated 06/17/2025 revealed he was a [AGE] year-old male with an admission date of 12/27/2024. Diagnoses included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), and osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time). Record review of Resident #1's Care Plan dated 12/31/2024 revealed: FOCUS: o CANCELLED: Resident #1 is an elopement risk/wanderer r/t Dementia Date Initiated: 01/02/2025 Revision on: 01/31/2025 Cancelled Date: 01/31/2025 GOALS: o CANCELLED: The resident's safety will be maintained through the review date. Date Initiated: 12/31/2024 Revision on: 01/31/2025 Target Date: 01/15/2025 Cancelled Date: 01/31/2025 INTERVENTIONS/TASKS: o CANCELLED: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: Date Initiated: 12/31/2024 Revision on: 01/31/2025 Cancelled Date: 01/31/2025 ACTA CNA LN RN SS 01/31/2025 o CANCELLED: Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. Date Initiated: 12/31/2024 Revision on: 01/31/2025 Cancelled Date: 01/31/2025 ACTA CNA 01/31/2025 o CANCELLED: Pt Wandering seeking to exit. Wander guard placed for safety and monitoring. Date Initiated: 12/31/2024 Revision on: 01/31/2025 Cancelled Date: 01/31/2025 LN RN SS 01/31/2025. Record review of Resident #1's admission MDS dated [DATE] revealed Resident #1 had severe cognitive impairment with a BIMS of 03. Wandering impact was blank. Resident #1 was substantial/maximal assistance (Helper does more than half the effort) for ADLs. Record review of Resident #1's Wandering Evaluation dated 12/27/2024 revealed Resident #1 was not a wandering risk. Record review of Resident #1's Progress Notes revealed on 12/31/24 at 01:15 PM, Resident #1 had an unwitnessed fall from his wheelchair outside the facility. Record review of 12/31/24 at 03:45 PM Progress Notes for Resident #1 revealed on assessment, Resident #1 sustained a 1-inch abrasion to his right elbow when he fell. Observation on 06/19/25 at 08:15 AM revealed from the front door of the facility to the road in front of the facility where Resident #1 fell out of his wheelchair, while unsupervised on 12/31/24 at 01:15 PM, is approximately 150 feet. The road outside the facility is a busy road with a hospital across the street with cars parked on both sides of the roadway making visibility difficult for oncoming cars. Review of the weather on 12/31/24 at 01:15 PM revealed it was 72 degrees and clear. Record review of Resident #1's Progress Notes dated 12/31/24 at 03:45 PM written by LVN F revealed Resident #1 had an unwitnessed fall outside. Resident #1 was assessed. The Doctor and RP were notified. The Doctor ordered STAT x-ray of skull, shoulders bilaterally, femur bilateral, hip bilaterally, humerus bilaterally, ankles bilaterally, elbows bilaterally, and wrist bilaterally. Results negative for fracture or injury. Resident #1 had no complaints of pain and verbalized refusal to take pain medication. Record review of Resident #1's Progress Notes dated 01/01/2025 at 05:55 AM written by LVN C revealed LVN C reported x-ray results to doctor. LVN C notes there were no new orders given. Record review of Resident #1's Progress Notes dated 12/31/2024 at 08:29 PM written by LVN C revealed S/P Fall 24 hours: Resident in his bedroom without complain of pain or discomfort. Resident continues with wander guard placed on the right ankle. No seeking behaviors noted at this time. Record review revealed between 12/31/2024 - 01/02/2025, staff and residents were interviewed, in-services on Abuse/Neglect, Elopement, Notifying Nurses of Residents Going Outside re-education for all staff was initiated and ongoing. Record review of Resident #1's Care Plan was updated on 01//02/2024 to include elopement risk/wanderer/ related to dementia with intervention of a wander guard. Record review of Resident #1's Progress Notes dated 01/06/2025 at 02/27 PM written by LVN W revealed Resident #1's wander guard to his right ankle was removed due to resident was not exit seeking. Resident #1's wander guard was removed, and a nonskid placement pad applied to the resident's wheelchair. Record review on 06/20/2025 revealed Receptionist JJ was not trained on Notifying Nurses of Residents Going Outside prior to the incident on 12/31/2024. In an interview on 06/1920/25 at 11:24 AM a visitor stated on 12/31/24 around 01:15 PM she was arriving at the facility to visit another resident. She said she was trying to find a parking spot when she noticed a resident in a wheelchair trying to escape down the parking lot. The visitor stated the resident reached the road, and his wheelchair hit the pothole between the parking lot and the road. She said the wheelchair tipped over and threw the resident out of the wheelchair, and it landed on top of him. She said she ran to him and took the wheelchair off him and helped him back into his wheelchair. The visitor stated she asked the resident where he was going, and he told her he was going downtown. She said at that time staff started coming down to help the resident. She did not know how the staff found out the resident had fallen. In an interview on 06/19/2025 at 01:08 PM BOM G stated the receptionist was the one who told her a resident had fallen outside. BOM G stated she when she went out, Resident #1 was on the ground with his wheelchair next to him. She said at the time, the visitor, the receptionist, ADON H, ADON I, and the Interim Administrator were there. BOM G stated Resident #1 said he was moving, tripped, and he was fine. In an interview on 06/19/2025 at 01:15 PM LVN F stated on 12/31/2024 he was at the nurse's station when he was told Resident #1 had fallen outside. LVN F stated he stayed at the nurse's station when the other nurses ran outside. LVN F stated he remembers when the resident came back in, and LVN F stated the resident was assessed by him and ADON I who was no longer working at the facility. LVN F stated he thinks he remembers a skin tear, but he was unsure. LVN F stated if a resident had a BIMS of 13 or more, they could sign themselves out of the building, but if the BIMS was less than 13, a family member, nurse, or CNA had to sign or take them out. He said sometimes Activities would take a resident out, but they had to clear it with the nurse before they would take them out. In an interview on 06/19/25 at 09:35 AM The DON stated Receptionist JJ was terminated on 01/14/2025 for taking Resident #1 outside and leaving him unsupervised. Termination papers along with file reviewed by surveyor. In an interview on 06/19/2025 at 04:55 PM, the DON stated if a resident wanted to go outside, the DON could take the resident outside. He said if a family member, with the RP's permission, could take their resident outside, or a CNA could, or a nurse could. The DON stated if the resident had a good BIMS of 13 or above, they could go outside alone and if the BIMS is less than 13, they would have to be supervised. The DON stated the door at the front was always locked so the receptionist had to screen before opening the door. The DON stated Code Yellow was announced for missing residents. He said the last in-services on elopement, residents going outside were last Monday (06/16/25) and they are on-going. In an interview on 06/19/2025 at 05:17 PM The Administrator stated a resident could go outside by themselves would depend on their BIMS. He said for a BIMS of 13 or above they can sign themselves out. If their BIMS was 13 or below, they cannot go outside unsupervised. The Administrator stated they had to be signed out by a family member, but the RP had to agree to a family member signing the resident out, by a nurse. The Administrator stated Code Yellow was announced to the facility if a resident was missing. He said they had monthly drills on elopement so everyone would know what to do in the event a resident was missing. The Administrator stated last Friday, 06/13/2025, he had an all staff meeting and went over elopements, residents going out by themselves (who can and who cannot), and abuse/neglect. The facility had corrected the noncompliance before the survey began as followed: Record review of the following interventions put into place: 1. Record review of Resident #1's medical record revealed Resident #1 was assessed by the nurse, findings reported to doctor, and x-rays ordered. 2. Record review of Resident #1's Wandering Evaluation dated 12/31/2024 revealed he was a wander risk. 3. Record review of Resident #1's skin assessment dated [DATE] revealed abrasion to right elbow with slight bleeding and a skin tear to his left knee details. 4. Record review of Resident #1's neurological checks dated 12/31/2024 revealed were started at 01:20 PM. 5. Record review of Resident #1's medical record showed wander guard was placed on 12/31/2024. 4. Record review of in-service education dated 12/31/2024-01/02/25 revealed all staff including direct care staff were in-serviced on Abuse/Neglect, Elopement, and Notifying Nurses of Residents Going Outside. 5. Record review of questionnaires dated 12/31/2024-01/02/2025 reflected all staff were quizzed on Abuse/Neglect, Elopement, and Notifying Nurses of Residents Going Outside. 6. Record review of Resident #1's Care Plan was updated to include wandering risk, wander guard, and injuries sustained with interventions. 7. Record review of revealed the facility investigated the incident and Receptionist JJ was terminated for taking and leaving Resident #1 outside unsupervised. 8. Record review revealed facility reported the incident to State within the correct timeframe. On 06/19/2025, 2 Receptionists, 1 Activity Aide and 1 Activity Director, 1 Human Resource Coordinator, 1 Housekeeper, 1 Medication Aide, 1 Hospitality Aide, 9 CNAs, 1 MDS LVN, 12 LVNs, 1 RN, the DON, and the Administrator were interviewed on policy/procedures on Abuse/Neglect, Elopement, and for residents going outside supervised and unsupervised, Code Yellow for missing residents, and in-services. All staff were able to state the correct policy/procedures. In an interview on 06/19/25 at 05:17 PM the Administrator stated they had an all staff meeting on Friday, 06/13/25, in-servicing on Abuse/Neglect, Elopement, and Notifying Nurses of Residents Going outside and the in-services were ongoing. He said they had monthly Elopement Drills with the staff. Record review of facility's policy titled Going Outside Policy undated, revealed The resident's stay with the facility is voluntary. The resident may leave the facility temporarily on therapeutic leave at any time. The resident or responsible party shall follow the facility rules regarding signing in and out of the facility whenever he or she leaves the facility. Record review of facility's policy Elopements and Wandering Residents dated 11/21/2022 revealed: Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Policy Explanation and Compliance Guidelines: 1.The facility may be equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 4.Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering d. Adequate supervision will be provided to help prevent accidents or elopements.

Based on observations, interviews and record review, the facility failed to ensure the residents had the right to be free from abuse, neglect, and misappropriation of property for 6 of 8 residents (Residents #6, #9, #7, and R#10) reviewed for abuse. 1.The facility failed to ensure Resident #6 was free from abuse when Resident #7 dug her nails on Resident #6's left forearm that resulted with multiple skin tears with serosanguineous drainage on 01/02/2025. 2.The facility failed to ensure Resident #9 was free from abuse when Resident #6 hit Resident 9 on her upper left arm with a closed hand on 03/25/2025.3.The facility failed to ensure Resident #7 was free from abuse when Resident #2 slapped Resident #7 on the left side of the face with a closed hand on 03/25/2025. 4.The facility failed to ensure Resident #7 was free from abuse when Resident #6 grabbed Resident #7 by the hair and arm on 04/11/2025. 5.The facility failed to ensure Resident #10 was free from abuse when Resident #6 rolled his wheelchair towards her and hit her left knee and caused a skin tear on 03/28/2025. The findings included: Resident #6Record review of Resident #6's admission record dated 07/15/2025 reflected a [AGE] year-old-male with an admission date of 09/06/2024. His relevant diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), dementia (a group of thinking and social symptoms that interferes with daily functioning), unspecified mood (affective) disorder (a serious mental illness that causes persistent and intense changes in a person's mood, energy, and behavior) , and cognitive communication deficit ( difficulties in communication that arise from impairments in cognitive processes like attention, memory, problem-solving, and executive functions). Record review of Resident #6's quarterly assessment dated [DATE] reflected a BIMS score of 06, which indicated his cognition was severely impaired. Further review reflected Resident #6 had behavioral problems with physical behavioral symptoms directed towards others (e.g., hitting kicking, pushing, scratching, grabbing, abusing others sexually) that occurred 1 to 3 days. Verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) that occurred 4 to 6 days, but less than daily. Record review of Resident #6's quarterly care plan dated 05/12/2025 reflected the following: Problem: [Resident #6] is/has potential to be physically aggressive r/t dementia (date initiated 04/21/2025 and revised on 07/11/2025). Goal: [Resident #6] will not harm self or others through the review date (date initiated 04/21/2025). Interventions: Administer medications as ordered, monitor/document for side effects and effectiveness (date initiated: 04/21/2025), communication, provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated (date Initiated 04/21/2025), give the resident as many choices as possible about care and activities (date initiated 04/21/2025), monitor/document/report PRN any s/sx (signs and symptoms) of resident posing danger to self and others (date initiated 04/21/2025) Resident #9Record review on 07/12/2025 of Resident #9's admission sheet dated 07/14/2025 reflected an [AGE] year-old female with an admission date of 08/14/2023 and an original admit date of 02/06/2023. Her relevant diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), dementia (a group of thinking and social symptoms that interferes with daily functioning), mood disorder, and obsessive-compulsive personality disorder (a personality disorder characterized by an intense focus on order, perfectionism, and control).Record review on 07/12/2025 of Resident #9's change of condition MDS assessment dated [DATE] reflected a BIMS score of 06, which reflected her cognition was severely impaired. Record review on 07/12/2025 of Resident 9's quarterly care plan dated 05/22/2025 reflected no behavioral problems and the resident to resident on 03/25/2025 had not been care planned. Resident #7Record review of Resident #7's face sheet dated 07/14/2025 reflected a [AGE] year-old-female with an admission date of 09/16/2019. Her relevant diagnoses included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), emotional lability (a sign or symptom exaggerated changes in mood or affect in quick secession), mood disorder, and dementia(a group of thinking and social symptoms that interferes with daily functioning) . Record review of Resident #7's annual MDS assessment dated [DATE] reflected a BIMS score of 03, which reflected her cognition was severely impaired. Record review of Resident #7's comprehensive care plan dated 06/19/2025 reflected:Problem: [Resident #7] does tend to get verbally/physically abusive with staff and residents. She isn't easily redirected at time. Resident #10Record review of Resident #10's admission sheet dated 07/14/2025 reflected a [AGE] year-old-female with an admission date of 03/25/2025 and a discharge date of 04/16/2025. Her relevant diagnoses included chronic kidney disease (longstanding disease of the kidneys leading to renal failure), anemia (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin), unsteadiness on feet, and diabetes (too much sugar in the blood). Record review of Resident #10's admission MDS dated [DATE] reflected a BIMS score of 08, which reflected her cognition was moderately intact. Record review of Resident #10's comprehensive care plan dated 03/25/2025 reflected no behavior problems and resident-to-resident on 04/11/2025 had not been care planned. Resident #2Record review of Resident #2's admission sheet dated 07/14/2025, reflected [AGE] year-old male with an admission date of 07/06/2021. His relevant diagnoses w included Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), dementia (a group of thinking and social symptoms that interferes with daily functioning) without behavioral disturbance, psychotic disturbance (delusions and hallucinations), mood disturbance, and anxiety (feelings of worry, nervousness, or unease, often about an anticipated event. Record review on 07/12/2025 of Resident #2's quarterly MDS, dated [DATE], revealed a blank BIMS, which indicated his cognition was severely impaired. Record review on 07/12/2025 of Resident #2's quarterly care plan dated 06/13/2025 reflected a problem the resident has a behavior problem related to vascular dementia, mood disorder, delusional disorder. Resident #2's resident-to-resident altercation with Resident #7 on 03/25/2025 had not been care planned and no interventions were set in place. Record review on 07/11/2025 of the facility's incident reports from 01/02/2025 through 07/11/2025 reflected the following: Resident #6 had a resident-to-resident altercation (victim) on 01/02/2025 with Resident #7. 1. Record review of Resident #6's progress note dated 01/02/2025 at 6:19 p.m. authored by LVN P reflected sn (skilled nurse) noted resident trying to get passed another resident and bumped her chair and they exchanged words asking female resident to move and that is when the female resident responded and grabbed resident l fa and pierced the skin and caused multiple skin tears. SN (skilled nurse) witnessed and intervened immediately. SN (skilled nurse) assessed resident and noted serosanguineous drainage coming from site. SN (skilled nurse) cleansed sited with n/s (normal saline) and pat dried and applied steri-strips. Resident denies any discomfort at this time. Up to w/c (wheelchair) waiting for dinner. SN (skilled nurse) continues to monitor resident for any type of changes in condition.NP, RP and administrator made aware. Plan of care ongoingRecord review of Resident #6's change in condition dated 01/02/2025 at 5:30 p.m., reflected:Signs/symptoms details: skin tears to left forearm, started 01/02/2025, since started it has gotten stayed the same.Assessment/suggestion: cleanse with normal saline, pat dry and apply steri strips.Notifications: RP on 01/02/2025 at 5:35 p.m., NP on 01/02/2025 at 5:30 p.m. Record review on 07/11/2025 of Resident #6's skin and wound-total body skin assessment dated [DATE] at 5:09 p.m. Authored by LVN P reflected the following:Turgor: good elasticitySkin color: normal for ethic groupTemperature: warm (normal)Moisture: normalCondition: normalEnter the # of new wounds: 1 Record review of the facility's incident reports from 01/02/2025 through 07/11/2025 reflected the following: Resident #6 had the following resident-to-resident altercations (aggressor) on 03/25/2025 with Resident #9. 2. Record review on 07/11/2025 of Resident #9 progress note dated 03/25/2025 at 5:07 p.m., authored by LVN K reflected: resident (Resident #9) sitting at dining room table interacting with other residents when male resident (Resident #6) at sitti8ng [sitting] at the [NAME] [corner] of the dining room table attempts to take a jacket away from resident. Resident able to stay with a jacket. at this point sn (skilled nurse) noted male resident strike resident on left upper arm with closed hand. Sn (skilled nurse) immediatly [immediately]removed resident. SN (skilled nurse) assessed resident and no discoloration or erythema noted to site. v/s (vital signs) 126/74, 78,98%ra,18,97.8. resident stating that has discomfort to l upper extremity. resident noted with same rom (range of motion) as per baseline. When asked what happened, the resident stated [NAME] el [NAME] me golpio. (the man hit me) contacted dr pending callback with any new orders. administered prn (as needed). contacted rp and understanding verbalized. don made aware.Record review on 07/11/2025 of Resident #9's skin and wound-total body skin assessment dated [DATE] at 7:08 p.m., by LVN P reflected no new wounds.Record review of the facility's incident reports from 01/02/2025 through 07/11/2025 reflected the following: Resident #2 had the following resident-to-resident altercations (aggressor) on 03/25/2025 with Resident #7. 3. Record review on 07/11/2025 of Resident #7 progress note dated, authored by LVN P reflected: resident (Resident #7) in the middle of the hallway when cna (no name) was trying to move her out of the way from the exit door. as cna is maneuvering the resident out of the way of the exit door entrance a male resident (Resident #2) noted to close hand and strike resident in the face on the left cheek. Residentnoted to yell and attempt to strike back. sn intervene immediatly. sn assessed resident noted with no discoloration or erythema to left cheek. resident (Resident #7) denies any discomfort at this time. v/s (vital signs) 128/72,70,98%ra,18,97.3 resident (Resident #7) stating i don't know why he did that. contacted np (nurse practitioner) n/o (new orders) for xr t(x-ray) to left mandible, nasal and nose. RP made aware understanding verbalized. DON made aware. Record review of Resident #7's skin and wound-total body assessment dated [DATE] at 5:26 p.m., authored by LVN P reflected no new wounds. Record review of Resident #7's x-ray results reflected no fractures or other bony abnormalities. Record review of the facility's incident reports from 01/02/2025 through 07/11/2025 reflected the following: Resident #6 had the following resident-to-resident altercations (aggressor) on 04/11/2025 with Resident #7 at 3:15 p.m 4. Record review on 07/11/2025 of Resident #7's progress notes dated 04/11/2025 at 4:50 p.m., authored by LVN K reflected Upon my rounds CNA (no name) notified me of an altercation that occurred between this resident and other resident having her hair pulled and grabbed on her arm. Upon arriving to wandering unit both residents were already separated and performed whole body assessment resident finding no abnormalities. resident complained of no pain VS (vital signs) 123/89 BP, P 89, T 97.6, O297, RR 18. Neuro checks normal notified family and practitioner. Will continue to monitor for deviations of baseline and separate residents in facility.Record review of the facility's risk management report dated 04/11/2025 at 12:25 p.m., authored by LVN K reflected :Incident description: Upon my rounds CNA (no name) notified me of an altercation that occurred between this resident and other resident having her hair pulled and grabbed on her arm. Upon arriving to wandering unit both residents were already separated and performed whole body assessment resident finding no abnormalities. resident complained of no pain VS (vital signs) 123/89 BP, P 89, T 97.6, O297, RR 18. Neuro checks normal notified family and practitioner. Will continue to monitor for deviations of baseline and separate residents in facility. Injury type: no injuries observed at time of incidentLevel of pain: 0Resident description: Resident unable to answer Record review on 07/11/2025 of the Resident #7 skin and wound-total body skin assessment dated [DATE] at 3:18 p.m. reflected no new wounds.Record review of the facility's incident reports from 01/02/2025 through 07/11/2025 reflected the following: Resident #6 had the following resident-to-resident altercations (aggressor) on 03/28/2025 with Resident #10 at 3:15 p.m 5. Record review on 07/11/2025 of the facility's risk management report for Resident #6 (altercation with Resident #10) dated 03/28/2025 at 3:15 p.m., authored by LVN A reflected: aides reported to this nurse resident was hit with a wheelchair in the left knee by [Resident #6], resident has a small skin tear noted to left knee, wound care nurse assessed and treated skin tear, admin and don notified and aware, md at 1546 tx [treatment] order for , Rp notified at 1545. Immediate action taken: resident has small skin tear to left knee that was assessed and treated by wound care nurse. Left skin tear: clean with wound cleanser, pat dry; apply clean gauze dssg [dressing] and monitor for s/s infection. MD notified and tx[treatment] order for. no pain or discomfort noted, resident got herself up and started walking around hallway. Record review on 07/11/2025 of Resident #10's progress notes dated 03/28/2025 at 4:21 p.m., authored by LVN A reflected: aides reported to this nurse resident was hit with a wheelchair in the left knee by [Resident #6], resident has a small skin tear noted to left knee, wound care nurse assessed and treated skin tear, admin and DON notified and aware, md at 13:46 tx [treatment] order for , Rp notified .Record review on 07/11/2025 of Resident #10's change in condition dated 03/25/2025 at 4:26 p.m., reflected the following: The change in condition, symptom, or signs to report: resident was hit with a wheelchair in the left knee by [Resident #6], small skin tear noted to left knee, wound care nurse skin tear.In an interview on 07/11/2025 at 1:00 p.m., CNA KK said Resident #6 for the past couple of months had not displayed any aggressiveness towards staff or residents. She said he was much calmer and would spend more time in his room. She said his health had declined, and he was under palliative care. She said she had been present during his altercation with Resident #7 on 01/02/2025. She said LVN P was sitting in the nurse station facing both residents; she was in the hallway in proximity of where the altercation had taken place. She said Resident #6 had not shown any aggression prior to striking Resident #6 on her face. She said both she and LVN P immediately intervened and separated them. She said she removed Resident #6 while LVN P assessed Resident #6. She said all residents in the memory unit need constant redirecting. She said out of the 21 residents in the memory unit only 3 are bedbound, and the rest are able to ambulate on their own or wheelchairs. She said the unit had enough staff to monitor and redirect residents when needed. She said she was regularly trained in the topics of abuse, neglect, and exploitation. An interview on 07/14/2025 at 4:05 p.m., LVN P said she was the charge nurse in the memory unit during the resident-to-resident involving Resident #6 with Resident #7, and Resident #9. LVN P said on 01/02/2025 (day shift), Resident #7's wheelchair was parked in the middle of the entry of the dining room when Resident #6's wheelchair accidentally bumped into Resident #7's wheelchair. She said, as soon as he bumped her, Resident #7 started making a motion to grab his arm and that's when she immediately went towards them and removed Resident #7's hand from Resident #6's wrist. She said both Resident #6 and Resident #7 have dementia, and they have good and bad days and can be both physically and verbally aggressive. She said Resident #6 sustained multiple skin tears. She said she had immediately cleansed his wounds and notified his NP and RP. She said she was sitting at the nurse's station and always had eyes on them, that's why she was able to immediately intervene. She said Resident #6 and Resident #7 both resumed their normal activities.LVN P said on 03/25/2025 at 2:30 p.m., she was sitting in the nurse's station and had full visual of all the residents in the dining room. She said she saw Resident #7 sitting in the dining room and was approached by Resident #2. She said as Resident #2 tried to remove Resident #7's jacket that was in the back of her wheelchair, Resident #7 quickly grabbed it preventing him from taking it. She said at that time Resident #6 got upset and immediately striked her on her arm. She said she witnessed the entire incident and as soon as Resident #2 raised his hand, she quickly walked towards them, but he still managed to hit Resident #7. She said she and other staff quickly approached both residents and separated them. She said she assessed Resident #7 and saw no injuries. She said she notified their RP's, NP's, and the DON. LVN P said on 03/25/2025 at 3:00 p.m., while sitting in the nurse's station and having full visual of the dining room and hallway, she observed Resident #7 sitting on her wheelchair close to the exit door. She said she then saw Resident #2 walking in the same direction and as a CNA (no name given) tried to move Resident #7 out of the way, Resident #2 was seen closing his hand and what appeared to have striked Resident #7 on her left cheek. She said both were immediately separated and she rendered care to Resident #7. She said she notified her NP (nurse practitioner) who ordered an x-ray of her face area. She said Resident #7 had no visible marks after her skin assessment and denied any pain. LVN P said she was regularly in-service on the topic of abuse and neglect. She said Resident #6, #7, #9 and #2 all had behavior problems related to their diagnoses of Alzheimer's. She said the unit had enough staff to care for all 21 residents. She said Resident #6's resident-to-resident altercations would be considered abuse. She said the Administrator had always been notified of all the resident-to-resident altercations.In an interview on 07/11/2025 at 2:30 p.m., the DON said he was informed of all resident-to-resident altercations. He said all resident-to-resident altercations needed to be care planned and interventions set in place. He said the Administrator was also notified al all resident-to-resident altercations as he was the Abuse Coordinator. He said he was responsible for reporting to the state. The DON said the memory unit had enough staff to care for all 21 residents. He said there were always a minimum of 2 CNAs, 1 charge nurse, 1 activity aide, and the MDS nurse was housed in the unit. He said if a resident needed to be on a 1:1 then they would get another staff member from the facility to cover. The DON said all staff were in-service on the topic of abuse, neglect, and exploitation regularly. The DON could not say if Residents # 2, #6, #7, #9, and #10 had any negative outcomes due to the resident-to-resident altercations they had. In an interview on 07/11/2025 at 2:45 p.m., the Administrator said he would be notified of all resident-to-resident altercations. He said he did not consider the resident-to-resident altercations in the memory unit as abuse because of their mental status. He said all suffered from dementia and to him there was no ill intent when they would strike another resident. He said that was the reason he had not reported the resident-to-resident altercations. Record review of the facility's Abuse, Neglect and Exploitation policy dated 07/11/25 reflected the following: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 property. Definitions: Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. 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, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the resident, 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 a conflict or neglect. IV: Identification of abuse, neglect, and exploitationB. Possible indicator of abuse includes, but are not limited to: 6. physical abuse of a resident observed

Based on observations, interviews, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment, were reported immediately to the State Survey Agency, within two hours if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for 3 (Resident #5, Resident #3, and Resident #2) of 4 residents reviewed for neglect. The facility failed to report allegations of resident neglect for Resident #5 to the State Survey Agency within the allotted time frame of 2 hours on 05/24/25 when Resident #5 had a fall at around 7:30 AM and sustained a serious bodily injury (distal fibular diametaphyseal fracture). The facility failed to report two Resident – to – Resident altercations. One on 11/15/24 between Resident #3 and Resident #2. The other occurred on 03/25/25 with Resident #2 and an unknown resident. The facility failed to report unwitnessed injury for Resident #2 on 11/11/24, 11/13/24, 12/17/24, 01/07/25, 02/04/2025, and 03/19/25. The facility failed to report an unwitnessed fall with skin tear to Resident #2 ' s nose. These failures could place all residents at increased risk for potential abuse/neglect due to unreported allegations of abuse and neglect. The findings included: 1.Record review of Resident #5 ' s admission sheet reflected a [AGE] year-old female with an admission date of 03/18/25 and an original admission date of 03/02/24 and a discharge date of 03/22/25). Her relevant diagnoses included dementia (a group of symptoms affecting memory, thinking, and social abilities, which interfere with daily life), abnormalities of gait and mobility (any deviations from typing walking pattern, often indicating underlying neurological, musculoskeletal, or other medical conditions), unsteadiness on feet. Record review of Resident #5 ' s quarterly MDS assessment dated [DATE] reflected she had a BIMS score of 12, which indicated her cognition was moderately intact. Record review of Resident #5 ' s quarterly care plan dated 03/04/24 reflected Resident #5 was at risk for falls related to impaired mobility and history of falls. Her interventions in part included to anticipate and meet her needs, call light within reach, and to ensure [Resident #5] wore appropriate footwear (when ambulating or mobilizing in wheelchair. Record review on 06/17/25 of Resident #5 ' s progress note dated 01/18/25 at 11:09 a.m., authored by LVN T reflected reported to NP purple skin discoloration to right dorsal foot and right inner extremity .Order x-ray, arterial scan to extremity and consult with Dr. Orders in place. Record review on 06/17/25 of Resident #5 ' s radiology result report dated 01/18/25 signed at 6:52 p.m., reflected Resident #5 had an acute distal fibular diametaphyseal fracture with soft tissue swelling. Record review on 06/17/25 of Resident #5 ' s progress note dated 01/18/25 at 10:50 p.m., authored by LVN C reflected charge nurse reported .foot right 2 views results serviced 01/18/25 to NP T. As per NP T repeat foot 2 views x-ray, tibia-fibula right 2 views x-ray . Record review on 06/17/25 of Resident #5 ' s intake reflected the facility reported her injury on 01/19/25 at 3:57 p.m. In a telephone interview on 06/17/25 at 02:45 p.m., LVN C said he did not remember much of Resident #5 ' s 01/18/25 incident. He said the only thing he remembered was that he had been given report by the outgoing nurse that Resident #5 had complained her ankle being discolored. An interview on 06/19/25 at 10:30 a.m., LVN U said on 01/18/25 (did not remember the time), Resident #5 had complained to her of having purple skin discoloration to her lower right inner extremity. She said while she assessed her, Resident #5 had voiced that she had not fallen or injured her right leg in any way. LVN U said she immediately notified Resident 4 ' s NP and received order for a scan and x-ray. In an interview on 06/19/25 at 10:55 p.m., the DON said Resident #5 had complained her lower right leg was discolored, purple in color on 01/18/25 around 11:00 a.m. He said the charge nurse had conducted a head-to-toe assessment and notified Resident #5 ' s NP. He said NP ordered a duplex and an x-ray to right tibia-fibula and to right foot. The DON said the facility had received confirmation from the mobile X-ray company on 01/18/25 at 6:52 p.m. that Resident #5 had a fracture. He said staff must have not read the report until 10:48 p.m. He said Resident #5 ' s NP was notified, and he had ordered a repeat x-ray to confirm fracture. The DON said the reason the NP had ordered a repeat x-ray was because Resident #5 had not complained of pain or reported any injury. The DON said Resident #5 had a repeated x-ray on 01/19/25 and the findings confirmed Resident #5 had an acute distal fibular diametaphyseal fracture. The DON said since Resident#4 ' s NP had requested a repeated x-ray; they did not considered Resident #5 having a fracture until the results from the second x-ray came in. He said Resident #5 ' s NP had not deemed it a fracture yet because he had ordered a second x-ray that was the reason the facility had reported the incident to state on 01/19/25 after the results from the second x-ray confirmed the findings from the first x-ray taken on 01/18/25. The DON said the facility would not call a fracture, until the NP/Dr. called it a fracture. An interview on 06/19/25 at 11:00 a.m., the Administrator the facility had received Resident #4 ' s x-ray results of a fracture on 01/18/25 at 7:00 p.m., but her NP had ordered a repeat to confirm the finding. The Administrator said the repeated x-ray was done and confirmed on 01/19/25 that Resident #4 had sustained an acute right distal fibular diametaphyseal fracture. He said he reported the fracture within 2 hours of confirming fracture. The Administrator said he did not report the fracture to state on 01/18/25 because Resident #4 ' s NP had not confirmed the fracture. A telephone interview on 06/19/25 at 12:48 p.m., NP T said he had ordered a repeated x-ray for Resident #4 to confirm the findings of the first x-ray which indicated she had a distal fibular diametaphyseal fracture. He said the second x-ray would serve as a confirmation only and he would go with the first x-ray findings to diagnose her as having a fracture. 2. Record review of Resident #3's admission record dated 06/17/2025, revealed an [AGE] year old male with an admission date of 08/15/2024, and a re-admission date on 11/25/2024, with a diagnoses which included dementia (a group of thinking and social symptoms that interferes with daily functioning) without behavioral disturbance, psychotic disturbance (delusions and hallucinations), mood disturbance, and anxiety, and traumatic subdural hemorrhage (a type of bleeding near the brain that can happen after a head injury) with loss of consciousness of 30 minutes or less. Record review of Resident #3's admission MDS, dated [DATE], revealed a BIMS of 01, indicating severe cognitive impairment. There were no potential indicators of psychosis, and no behavioral symptoms were indicated. Active diagnoses included: traumatic brain dysfunction (an impairment in the normal functioning of the brain caused by an outside force, usually a violent blow to the head), and dementia. 3. Record review of Resident #2's admission record dated 06/17/2025, revealed a [AGE] year old male with an admission date of 07/06/2021,with a diagnoses which included Alzheimer ' s Disease (a progressive disease that destroys memory and other important mental functions), dementia (a group of thinking and social symptoms that interferes with daily functioning) without behavioral disturbance, psychotic disturbance (delusions and hallucinations), mood disturbance, and anxiety. Record review of Resident #2's Change in Condition MDS, dated [DATE], revealed a blank BIMS, indicating severe cognitive impairment. There were no potential indicators of psychosis, verbal behavioral symptoms occurred 1 – 3 days, and other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily waste, or verbal/vocal symptoms like screaming, disruptive sounds) occurred 1 – 3 days. Active diagnoses included: Alzheimer ' s Disease and dementia. Record review of Resident #2 ' s Care Plan dated 04/02/2025 revealed: FOCUS: · The resident is potential to be physically aggressive with staff when redirected. Physically aggresive with staff during showers, dressing, adl care UPSET WHEN REDIRECTED FROM OTHER PATIENTS BED. APT TO SLEEP IN OTHER'S ROOMS. AND ON SOFA. Date Initiated: 09/09/2021 Revision on: 11/11/2024 GOALS: · The resident will not harm self or others through the review date. Date Initiated: 09/09/2021 Revision on: 12/26/2024 Target Date: 07/01/2025 INTERVENTIONS/TASKS: · Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 11/11/2024 LN RN · COMMUNICATION: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. Date Initiated: 09/09/2021 CNA LN RN SS · Monitor/document/report PRN any s/sx of resident posing danger to self and others. Date Initiated: 09/09/2021 CNA LN RN SS · When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Date Initiated: 11/11/2024 CNA LN RN FOCUS: · The resident has a behavior problem r/t Vascular Dementia, Mood disorder, Delusional disorder: RP REFUSES PSCHIATRIC SERVICES. ONLY WANTS PRIMARY MD TO FOLLOW UP WITH BEHAVIORS. Bangs on exit doors Wanders into other residents rooms Rummages through other residents personal belongings Takes other residents seeing eye glasses and puts them on Removes nurses items behind nurses station Urinates in trash cans, hallway, other residents rooms Defecates in trash cans urinates in closets at times likes to eat meals on sofa with bedside table 4/9/24 combative during adl care causing skin tear. RESIDENT NOTED EATING CRAYONS DURING ACTIITY TIME. APT TO PUT ACTIVITY OBJECTS IN MOUTH 9/3/24 ALTERCATION WITH ANOTHER RESDIENT punches, scratches, kicks staff during care Date Initiated: 07/09/2021 Revision on: 11/11/2024 GOALS: · The resident will have fewer episodes by review date. Date Initiated: 07/09/2021 Revision on: 12/26/2024 Target Date: 07/01/2025 INTERVENTIONS/TASKS: · 4/9/24 Administer wound care to skin tear as ordered-patient removes dressing Date Initiated: 04/11/2024 Revision on: 04/11/2024 LN RN · 9/3/24 MEDICATON REVIEW Date Initiated: 09/04/2024 Revision on: 09/04/2024 LN RN SS · Anticipate and meet The resident's needs. Psychiatric consult 12/15/21 with medication recommendations- RP refused. Date Initiated: 07/09/2021 Revision on: 12/30/2021 CNA LN RN · Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by. Date Initiated: 07/09/2021 CNA LN RN SS · Explain all procedures to the resident before starting and allow the resident to adjust to changes. Date Initiated: 03/17/2022 Revision on: 03/17/2022 CNA LN RN · If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Date Initiated: 07/09/2021 CNA LN RN SS · Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Date Initiated: 07/09/2021 CNA LN RN SS · Praise any indication of The resident's progress/improvement in behavior. Date Initiated: 03/17/2022 CNA LN RN SS · Reward the resident for appropriate behavior by (OFFERINC SNACKS, ICE ACTACREAM-PER FAMILY REQUEST)- ATTEMPTED FOOD, SNACKS AND ICE CREAM. Date Initiated: 04/11/2024 Revision on: 04/11/2024 CNA LN RN SS. Record review of Resident #2 ' s CPS Report dated 11/11/2024 revealed Today is 11/11/24. 77 yo has significant injuries to his face that may have been caused by another resident. There are concerns about the level of care that 77yo is receiving if another resident has assaulted him and caused these injuries. 77 yo has an injury to his mouth and was described as having a swollen lip. 77 yo has a bruise near his eye. Staff are unable to explain how this occurred. Staff did not seem to be aware of the injuries until concerns were voiced to them. There was not believed to be physical abuse by staff personnel at the facility. Record review of Resident #2 ' s Progress Notes dated 11/11/2024 at 11:25 AM written by LVN W revealed, head to toe assessment performed. residents affected areas measured. purplish discoloration to left forearm measured at 2cm (0.787 inches) in length and 2cm (0.787 inches) in in height. purplish discoloration to left side of 52w9chin measured at 1/2 cm in height. resident denies any pain when affected areas are assessed. no skin tears or abnormal skin breakage noted. Record review of Resident #2 ' s Progress Notes dated 11/13/2024 at 09:06 AM written by LVN P revealed LVN P assessed Resident #3 with reddened discoloration to bilateral (left and right) forearms. Record review of Resident #3 ' s Progress Notes on 11/15/24 at 12:06 PM written by LVN W revealed Resident #3 displayed physical behaviors toward Resident #2. Verbal comments were made by Resident #3 to Resident #2. Resident #3 pushed Resident #2 away from him. Record review of Resident #3 ' s Progress Notes on 11/15/24 at 12:07 PM written by LVN W revealed the interaction between both residents was stopped by staff. Residents were separated from each other. Residents PCP made aware of the incident. Order received to increase clonazepam 1mg BID scheduled (Resident #3), and psych consult. orders carried out. The residents ' behavior was to be monitored continuously. Record review of Resident #2 ' s Progress Notes on 11/15/2024 at 12:26 PM written by LVN W revealed Resident #2 was seen interacting with Resident #3. Resident #2 approached Resident #3 in their face. Resident #3 struck Resident #2 which caused Resident #2 to stumble back. Resident #2 proceeded to push Resident #3. Record review of Resident #2 ' s Progress Notes on 11/15/2024 at 12:26 PM written by LVN W revealed Resident #2 and Resident #3 were separated immediately by nursing staff. Resident #2 continued walking down the hallway. Resident #2 ' s behavior was to be monitored continuously. Record review of Resident #2 ' s Progress Notes dated 12/17/2024 at 09:06 AM written by LVN X revealed Monitor discoloration to the left arm and to the left side of the chin. every shift. Record review of Resident #2 ' s Progress Notes dated 01/07/2025 at 12:00 PM written by LVN J revealed CNA alerted this SN of resident having discoloration to bilateral upper extremities (left arm and right arm) and discoloration to right side of scalp. Upon assessment, red discoloration to bilateral arms noted, no skin tears to bilateral arms noted, and no swelling to bilateral arms noted. Purplish discoloration to scalp noted, approximately 2x2cm. Record review of Resident #2 ' s Change in Condition Note dated 02/04/2025 at 04:28 PM written by LVN J revealed Resident observed with a bump to forehead and was reported to physician. A new order was given to monitor Resident #2 for 24 hours for any changes. Record review of Resident #2 ' s Progress Note dated 03/10/2025 at 09:30 PM written by LVN B revealed LVN B was made aware by CNA that Resident #2 was found in supine position next to the bed. Resident #2 was assessed, and a skin tear was noted to bridge of his nose. Record review of Resident #2 ' s Change in Condition Note dated 03/10/2025 at 09:33 PM written by LVN B revealed Type: Change of Condition Signs/Symptoms Details: unwitnessed fall, started 03/10/2025. Record review of Resident #2 ' s Orders - Administration Note dated 03/19/2025 at 10:01 AM written by RN V revealed Monitor discoloration to the left arm and to the left side of the chin. every shift. Record review of Resident #2 ' s Progress Note dated 03/25/2025 at 08:48 PM written by LVN C revealed S/P 1/3 Resident to Resident, Vital signs BP 124/68, pulse 67, Respiration 18, oxygen saturation 97 Room air and temperature 97.8F. Record review of Resident #2 ' s Progress Note dated 03/25/2025 at 11:52 AM written by LVN J revealed Resident (#2) is S/P Day 2/3 of Resident to Resident. Interview on 06/16/2025 at 02:30 PM Resident #2 ' s FM stated Resident #2 always had bruises, but it was nothing like what it was that time with a swollen lip and bruised eye in November 2024. He said the facility told him it was unwitnessed, and they did not know what happened. He said he had not heard anything back from the facility. Interview on 06/18/2025 at 02:10 PM CNA Z stated she had been a CNA since August 2024 and had worked at the facility the entire time. She said if she would see a resident fall or found a resident on the floor, she would tell the nurse right away. CNA Z stated she would not move or leave the resident until the nurse said they could get them up. CNA Z stated she would stay with the resident until the nurse said it was ok to leave. CNA Z stated they try to keep the residents busy. They offer snacks, puzzles, and some watch television. CNA Z stated if there was a resident-to-resident altercation, they try to separate residents, and they call for the nurse. She said there was a nurse in the unit at all times. CNA Z stated CNAs reported any changes to a resident immediately to the nurse. CNA Z stated she would abuse/neglect the administrator because he is the Abuse Coordinator. Interview on 06/25/2025 at 04:00 PM LVN X stated he had not worked at the facility for over two months. LVN X stated he could not remember the progress note he wrote on 12/17/2024 which said, Monitor discoloration to left arm and left side of chin. He said he thought it was already reported by the prior shift. Interview on 06/26/2025 at 01:14 PM LVN P stated she could not remember why she completed a Skin and Wound Assessment on Resident #2 on 03/25/2025. LVN P stated Resident #2 was not a faller. She said he paced the hall and has Alzheimer/Dementia. LVN P stated Resident #2 self-ambulated and was an assisted feeding. LVN P stated Resident #2 had unexplained bruising and they did not know why. LVN P stated for discoloration out of nowhere, it should be reported to the doctor, RP, and DON. LVN P stated for changes of a resident either a CNA reported or assessed by the nurse, the doctor would be notified, she would follow through with orders, notify family, complete a Change in Condition form, and let all the team members know what was going on including the DON. LVN P stated if a CNA told her a resident had fallen or was on the floor or if she saw a resident on the floor or a resident fell she would assess the resident, make sure they were safe, contact doctor, follow through with orders, contact family, notify DON, and put in Incident Report. LVN P stated if there was a Resident – to – Resident altercation (verbally or physically) she would immediately separate residents, assess the residents, contact doctor, make sure residents were safe, contact family, complete an Incident /accident report, monitor for 72 hours, and notify DON. Interview on 06/26/2025 at 05:33 PM the DON stated he would have to look at Resident #2 ' s chart to know if he fell a lot because he had not been at the facility long and did not know all the residents yet. The DON stated he was not sure if Resident #2 had a history of a lot of unexplained bruising. He said all incidents are reported to the doctor (bruising, skin tears, change in condition, etc.). The DON stated all changes a CNA would report or if he would see to a resident are reported. He said if a CNA would tell him a resident had fallen or was on the floor or if he saw a resident on the floor or he had seen the resident fall, he would assess, notify doctor and RP, and follow all orders given. He said if it was safe to put the resident in bed, he would help put them in bed. He said if the fall were unwitnessed, he would get an x-ray, and report to State if needed. The DON stated if there were a Resident – to – Resident altercation (verbally or physically), first thing would be to separate them, safety first, assess, notify doctor and RP. He said if orders were given, he would follow through with the orders. Interview on 06/26/2025 at 06:42 PM the Administrator stated Resident #2 had a few falls since he had been at the facility. He said he had been at the facility since 02/03/2025. He said he was not aware of any unexplained bruising on Resident #2. He stated that no one had reported any unexplained bruising on Resident #2 to him. The Administrator stated abuse/neglect, injuries of unknown origin, and falls with major injuries were to be reported to State. Record review of the facility ' s Abuse, Neglect and Exploitation policy dated 08/15/22 reflected: Policy: It is a policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing policies and procedures that prohibit and prevent, neglect, exploitation, and misappropriation of property. IV. Identification of Abuse, Neglect and Exploitation A. The facility will have written procedures to assist staff in identifying the different types of abuse – mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations. B. Possible indicators of abuse include, but are not limited to: 2. Physical marks such as bruises or patterned appearances such as a handprint, belt or ring mark on a resident ' s body. 3. Physical injury of a resident, of unknown source. VII. Reporting/Response: The facility will have written procedures that include: 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: Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on observations, 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 3 (Resident #2, Resident#3, Resident #4) of 5 residents reviewed for accuracy and completeness of clinical records. 1.The facility failed to ensure LVN A and LVN F correctly completed Resident #4's neuro checks between 05/24/25 and 05/27/25. 2. The facility failed to ensure LVN A documented on Resident #4's electronic medical record; he had a nosebleed after the fall he sustained on 05/24/25. 3. The facility failed to ensure Resident #4's left inferior orbital wall fracture was documented on his electronic medical record. 4. The facility failed to ensure two Resident-to-Resident altercations were documented thoroughly. One altercation between residents on 11/15/2024 between Resident #3 and Resident #2, and the other altercation occurred on 03/25/2025 with Resident #2 and Resident #6.5. The facility failed to ensure the bruising of unknown origin for Resident #2 on 11/11/2024, 11/13/2024, 12/17/2024, 01/07/2025, 02/04/2025, and 03/19/2025 was thoroughly documented in the Progress Notes.6. The facility failed to ensure the unwitnessed fall on 03/10/2025 with skin tear to the bridge of Resident #2's nose was thoroughly documented.These failures could place residents at risk of not receiving adequate care and services due to inaccurate reflection of the care provided. Findings included: Record review of Resident #4's admission sheet dated 06/18/25 reflected an [AGE] year-old male with an admission date of 04/19/23 with pertinent diagnoses that included dementia (a group of symptoms affecting memory, thinking, and social abilities, which interfere with daily life), history of falling, difficulty walking, abnormalities of gait and mobility, and presence of intraocular (anything that is situated within the eyeball) lens . Record review of Resident #4's quarterly MDS assessment dated [DATE] reflected a BIMS score of 04, which indicated his cognition was severely impaired. Record review of Resident #4's quarterly care plan dated 05/26/25 reflected he was at risk for falls related to confusion and poor safety awareness (date initiated 04/19/23 and revised on 05/26/23). Resident #4's interventions in part included a safe environment with even floors free from spills and/or clutter, adequate flare free light, a working and reachable call light, and personal items within reach. Record review of Resident #4's progress notes on his electronic medical record dated 05/24/25 at 7:35 a.m., authored by LVN C reflected aide reported to this nurse resident had fell lying on left side on the floor in hallway. resident has redness to left side of cheek and skin tear to left hand. resident stated his foot caught his other foot while walking pushing wheelchair and fell. redness noted to left side of cheek, skin tear noted to back of left hand, NP notified. vs 130/74, 77, 18, 97.4 at time of assisting resident. skin tear cleansed with wound cleanser, and dry dressing applied. Record review of Resident #4's progress notes on his electronic medical record dated 05/24/25 at 9:12 a.m., authored by LVN C reflected NP gave order to send to ER for CT of head to rule out brain bleed from fall, EMS notified at 9:01 a.m. called ER and gave report to RN at 9:08 a.m. Record review on 06/19/25 of Resident #4's hospital record dated 05/24/25 reflected, he had presented to their emergency room via EMS due to a fall. His stated complaint: fall/nosebleed/left hand skin tear. The impression of cat scan performed on 05/24/25 was a left maxillary sinus anterior, medial, and lateral walls, and a left inferior orbital wall fracture which is minimally to nondisplaced. Record review of Resident #4's neuro checks on her electronic medical record reflected they were done from 05/24/25 to 05/26/25. Record review of Resident #4, 13th neuro checks on his electronic medical record were not dated, or time stamped by LVN C. Record review of Resident #4's, 16th and 17th neuro check was left blank by LVN F. In an observation and interview on 06/18/25 at 9:00 a.m., Resident #4 was observed sitting in his wheelchair in the memory unit's dining room. He did not have any visible bruising or any facial grimacing. Resident #4 closed his eyes when this surveyor started speaking to him. An interview on 06/18/25 at 9:15 a.m., LVN A said Resident #4 had sustained a fall on 05/24/25 at around 7:35 a.m., while walking down the hall of the memory unit. She said she was also in the hallway when a nurse aide reported to her Resident #4 had fallen. She said she found Resident #4 lying on his left side. She said she had immediately assessed him and the only injuries he had were a red mark on his cheek and a skin tear to his left hand. LVN A said Resident #4 told her, his foot caught his other foot while walking pushing his wheelchair and fell. She said she immediately notified his NP (no new order given) and proceeded to cleanse his wounds. She said she then proceeded to cleanse his wounds and checked his vitals. She said after his vitals were checked; she initiated the neuro checks. LVN A said during one of the 30-minute neuro checks, she noticed Resident #4 had a nosebleed. She said she called his NP again at 9:12 a.m., to let him know of the nosebleed and gave ordered for Resident #4 to be sent out to the ER to rule out brain bleed from the fall. LVN A said Resident #4 came back the same day with a diagnosis of a left sinus fracture. LVN A said she had contacted Resident #4's NP twice the morning of 05/24/25. She said she had documented Resident #4's fall and nosebleed on his electronic medical record under progress notes and on the neuro check where his nosebleed had been noticed. In an interview on 06/19/25 at 2:00 p.m., LVN A said she had completed Resident #4's neuro check #13. She said she had forgotten to enter the date and time but had answered the rest of the questions. LVN A said she thought she had documented Resident #4's nosebleed on the neuro check but did not know why there was no record of it. She said there were no negative outcomes to Resident #4 not having his neuro check #13th dated/timed, or his nosebleed documented on his electronic medical record. In an interview on 06/19/25 at 2:45 p.m., LVN F said he was supposed to complete Resident #4's neuro checks # 16 and 17 on 05/26/25. He said he did not remember why neuro checks #16 and #17 were blank. He said he did not remember if it was because Resident #4 had refused or if it had been a computer error that the information had not populated. This surveyor asked him what he meant by a computer error and his response was band width issues. LVN F said there were no negative outcomes to Resident #4 not having neuro checks #16 and #17 completed because Resident #4 had been stable that night. An interview on 06/19/25 at 3:00 p.m., the DON said on 05/24/25, Resident #4 had reported he was walking towards the dining area in the memory unit when he fell. The DON said Resident #4 was found lying to his left side in the hallway, he had redness to the left side of the cheek and a skin tear to left hand. He said Resident #4 had given a description of how he had fallen. The DON said after he had been assessed head-to-toe, his NP had been notified. The DON said what he thought had happened was that the NP had not answered the first time, and he later called back and had given orders to send to the ER for treatment, evaluation, and a CT scan. He said the neuro checks were initiated at 7:10 am on 05/24/25 and continued after Resident #4 returned from the hospital. He said neuro check #13, was not dated or timed on 05/25/25 and neuro checks #16 and #17 had been left blank. The DON said it was his responsibility to check on a daily basis any assessments to include neuro checks were done by his nursing staff to ensure they were completed correctly. The DON said when he checked any assessment and did any corrections, his name populated as signed by. He said he missed Resident #4's neuro check 13th had not been dated or signed by LVN C. The DON said on 05/26/25 which he checked Resident #4's neuro checks completed on 05/26/25, he noticed neuro check #16 and #17 had been left blank by LVN F. The DON said he ensured, Resident #4 had his vitals checked on 05/26/25 and that they were within normal range. The DON said no negative outcome to Resident #4 for not having his neuro checks #13, #16, and #17 completed correctly. This Surveyor read LVN A's interview back to the DON. He said he was not aware that LVN C had gotten a hold of Resident #4's NP the first time she called him on 05/24/24, that during a neuro check, Resident #4 had a nosebleed, or that the NP had been called a second time and given orders to send to the ER. The DON said he did not find that information on Resident #4's electronic medical records (progress notes or neuro checks). The DON said Resident #4 had sustained a fracture to the left maxillary sinus. This Surveyor asked the DON to review Resident #4's page 3 of his discharge form from the ER department where it reflected, he had sustained a fracture to the left maxillary sinus anterior, medial, and lateral walls and a left inferior orbital wall fracture which was minimally to nondisplaced. The DON said he had not read about the fracture to the left inferior orbital wall but that it did not matter because it was all the same area. He said both fractures would heal on their own therefore, there were no negative outcome to Resident #4 not having his second fracture (left inferior orbital wall) documented on his electronic medical record. 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 doing documentation. Record review of Resident #2's admission record dated 06/17/2025, revealed a [AGE] year old male with an admission date of 07/06/2021, with a diagnoses which included Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), dementia (a group of thinking and social symptoms that interferes with daily functioning) without behavioral disturbance, psychotic disturbance (delusions and hallucinations), mood disturbance, and anxiety. Record review of Resident #2's Change in Condition MDS, dated [DATE], revealed a blank BIMS, indicating severe cognitive impairment. There were no potential indicators of psychosis, verbal behavioral symptoms occurred 1 - 3 days, and other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily waste, or verbal/vocal symptoms like screaming, disruptive sounds) occurred 1 - 3 days. Active diagnoses included: Alzheimer's Disease and dementia. Record review of Resident #2's Care Plan dated 04/02/2025 revealed: FOCUS: o The resident is potential to be physically aggressive with staff when redirected. Physically aggresive with staff during showers, dressing, adl care UPSET WHEN REDIRECTED FROM OTHER PATIENTS BED. APT TO SLEEP IN OTHER'S ROOMS. AND ON SOFA. Date Initiated: 09/09/2021 Revision on: 11/11/2024 GOALS: o The resident will not harm self or others through the review date. Date Initiated: 09/09/2021 Revision on: 12/26/2024 Target Date: 07/01/2025 INTERVENTIONS/TASKS: o Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 11/11/2024 LN RN o COMMUNICATION: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. Date Initiated: 09/09/2021 CNA LN RN SS o Monitor/document/report PRN any s/sx of resident posing danger to self and others. Date Initiated: 09/09/2021 CNA LN RN SS o When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Date Initiated: 11/11/2024 CNA LN RN FOCUS: o The resident has a behavior problem r/t Vascular Dementia, Mood disorder, Delusional disorder: RP REFUSES PSCHIATRIC SERVICES. ONLY WANTS PRIMARY MD TO FOLLOW UP WITH BEHAVIORS. Bangs on exit doors Wanders into other residents rooms Rummages through other residents personal belongings Takes other residents seeing eye glasses and puts them on Removes nurses items behind nurses station Urinates in trash cans, hallway, other residents rooms Defecates in trash cans urinates in closets at times likes to eat meals on sofa with bedside table 4/9/24 combative during adl care causing skin tear. RESIDENT NOTED EATING CRAYONS DURING ACTIITY TIME. APT TO PUT ACTIVITY OBJECTS IN MOUTH 9/3/24 ALTERCATION WITH ANOTHER RESDIENT punches, scratches, kicks staff during care Date Initiated: 07/09/2021 Revision on: 11/11/2024 GOALS: o The resident will have fewer episodes by review date. Date Initiated: 07/09/2021 Revision on: 12/26/2024 Target Date: 07/01/2025 INTERVENTIONS/TASKS: o 4/9/24 Administer wound care to skin tear as ordered-patient removes dressing Date Initiated: 04/11/2024 Revision on: 04/11/2024 LN RN o 9/3/24 MEDICATON REVIEW Date Initiated: 09/04/2024 Revision on: 09/04/2024 LN RN SS o Anticipate and meet The resident's needs. Psychiatric consult 12/15/21 with medication recommendations- RP refused. Date Initiated: 07/09/2021 Revision on: 12/30/2021 CNA LN RN o Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by. Date Initiated: 07/09/2021 CNA LN RN SS o Explain all procedures to the resident before starting and allow the resident to adjust to changes. Date Initiated: 03/17/2022 Revision on: 03/17/2022 CNA LN RN o If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Date Initiated: 07/09/2021 CNA LN RN SS o Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Date Initiated: 07/09/2021 CNA LN RN SS o Praise any indication of The resident's progress/improvement in behavior. Date Initiated: 03/17/2022 CNA LN RN SS o Reward the resident for appropriate behavior by (OFFERINC SNACKS, ICE ACTACREAM-PER FAMILY REQUEST)- ATTEMPTED FOOD, SNACKS AND ICE CREAM. Date Initiated: 04/11/2024 Revision on: 04/11/2024 CNA LN RN SS. Record review of Resident #2's Progress Notes dated 11/11/2024 at 11:25 AM written by LVN W revealed, head to toe assessment performed. residents affected areas measured. purplish discoloration to left forearm measured at 2cm (0.787 inches) in length and 2cm (0.787 inches) in in height. purplish discoloration to left side of 52w9chin measured at 1/2 cm in height. resident denies any pain when affected areas are assessed. no skin tears or abnormal skin breakage noted. Record review of Resident #2's Progress Notes dated 11/13/2024 at 09:06 AM written by LVN P revealed LVN P assessed Resident #3 with reddened discoloration to bilateral (left and right) forearms. Record review of Resident #2's Progress Notes dated 12/17/2024 at 09:06 AM written by LVN X revealed Monitor discoloration to the left arm and to the left side of the chin. every shift. Record review of Resident #2's Progress Notes dated 01/07/2025 at 12:00 PM written by LVN J revealed CNA alerted this SN of resident having discoloration to bilateral upper extremities (left arm and right arm) and discoloration to right side of scalp. Upon assessment, red discoloration to bilateral arms noted, no skin tears to bilateral arms noted, and no swelling to bilateral arms noted. Purplish discoloration to scalp noted, approximately 2x2cm (about 0.79 inch by 0.79 inch). Record review of Resident #2's Change in Condition Note dated 02/04/2025 at 04:28 PM written by LVN J revealed Resident observed with a bump to forehead and was reported to physician. new order to monitor resident for 24 hours for any changes. Record review of Resident #2's Progress Note dated 03/10/2025 at 09:30 PM written by LVN B revealed LVN B was made aware by CNA that Resident #2 was found in supine position next to the bed. Resident #2 was assessed, and a skin tear was noted to bridge of his nose. Record review of Resident #2's Change in Condition Note dated 03/10/2025 at 09:33 PM written by LVN B revealed Type: Change of Condition Signs/Symptoms Details: unwitnessed fall, started 03/10/2025. Record review of Resident #2's Orders - Administration Note dated 03/19/2025 at 10:01 AM written by RN V revealed Monitor discoloration to the left arm and to the left side of the chin. every shift. Record review of Resident #2's Progress Note dated 03/25/2025 at 08:48 PM written by LVN C revealed S/P 1/3 Resident to Resident, Vital signs BP 124/68, pulse 67, Respiration 18, oxygen saturation 97 Room air and temperature 97.8F. Record review of Resident #2's Progress Note dated 03/25/2025 at 11:52 AM written by LVN J revealed Resident (#2) is S/P Day 2/3 of Resident to Resident. Interview on 06/18/2025 at 02:10 PM CNA Z stated if she would see a resident fall or found a resident on the floor, she would tell the nurse right away. CNA Z stated she would not move or leave the resident until the nurse said they could get them up. CNA Z stated she would stay with the resident until the nurse said it was ok to leave. CNA Z stated they try to keep the residents busy. They offer snacks, puzzles, and some watch television. CNA Z stated if there was a resident-to-resident altercation, they would try to separate residents, and they would call the nurse. She said there was a nurse in the unit at all times. CNA Z stated CNAs reported any changes to a resident immediately to the nurse. Interview on 06/25/2025 at 04:00 PM LVN X stated he had not worked at the facility for over two months. LVN X stated he could not remember the progress note he wrote on 12/17/2024 which said, Monitor discoloration to left arm and left side of chin. He said he thought it was already reported by the prior shift. Interview on 06/26/2025 at 01:14 PM LVN P stated she could not remember why she completed a Skin and Wound Assessment on Resident #2 on 03/25/2025. LVN P stated Resident #2 was not a faller. She said he paced the hall and has Alzheimer/Dementia. LVN P stated Resident #2 self-ambulated and was an assisted feeding. LVN P stated Resident #2 had unexplained bruising and they did not know why. LVN P stated for discoloration out of nowhere, it should be reported to the doctor, RP, and DON. LVN P stated for changes of a resident either a CNA reported or assessed by the nurse, the doctor would be notified, she would follow through with orders, notify family, complete a Change in Condition form, and let all the team members know what was going on including the DON. LVN P stated if a CNA told her a resident had fallen or was on the floor or if she saw a resident on the floor or a resident fell she would assess the resident, make sure they were safe, contact doctor, follow through with orders, contact family, notify DON, and put in Incident Report. LVN P stated if there was a Resident - to - Resident altercation (verbally or physically) she would immediately separate residents, assess the residents, contact doctor, make sure residents were safe, contact family, complete an Incident /accident report, monitor for 72 hours, and notify DON. Interview on 06/26/2025 at 05:33 PM the DON stated he would have to look at Resident #2's chart to know if he fell a lot because he had not been at the facility long and did not know all the residents yet. The DON stated he was not sure if Resident #2 had a history of a lot of unexplained bruising. He said all incidents are reported to the doctor (bruising, skin tears, change in condition, etc.). The DON stated all changes a CNA would report or if he would see to a resident are reported. He said if a CNA would tell him a resident had fallen or was on the floor or if he saw a resident on the floor or he had seen the resident fall, he would assess, notify doctor and RP, and follow all orders given. He said if it was safe to put the resident in bed, he would help put them in bed. He said if the fall were unwitnessed, he would get an x-ray, and report to State if needed. The DON stated if there were a Resident - to - Resident altercation (verbally or physically), first thing would be to separate them, safety first, assess, notify doctor and RP. He said if orders were given, he would follow through with the orders. Interview on 06/26/2025 at 06:42 PM the Administrator stated Resident #2 had a few falls since he had been at the facility. He said he had been at the facility since 02/03/2025. He said he was not aware of any unexplained bruising on Resident #2. He stated that no one had reported any unexplained bruising on Resident #2 to him. Record review of the facility's Documentation in Medical Record policy dated 10/24/22 revealed: 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 doing documentation. Policy Explanation and Compliance Guidelines: 1.Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy 2.Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. 3.Principles of documentation include, but are not limited to: e. record date and time of entry

Based on interviews, and record reviews the facility failed to ensure the residents right to be informed of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers, for 1 of 5 residents (Resident #3, Resident #6 ) reviewed for consent for antipsychotic medications in that: 1. Resident #3 was prescribed and administered Haldol (an antipsychotic) without prior consent based on information of the benefits, risks, and options available. 2. The facility failed to ensure psychoactive medication consents for Resident #6's were signed and dated by his guardian for the use of Zyprexa (antipsychotic medication), Buspirone (anxiolytic medication), lorazepam (benzodiazepine medication), and Risperidone (antipsychotic medication). These failures could affect the right to self-determination of all facility residents who receive medication by allowing them to receive medication without their prior knowledge or consent, or that of their responsible party or emergency contacts. The findings included: 1. Record review of Resident #3's admission record dated 06/17/2025, revealed an admission date of 08/15/2024, and a re-admission date on 11/25/2024, with a diagnoses which included dementia (a group of thinking and social symptoms that interferes with daily functioning) without behavioral disturbance, psychotic disturbance (delusions and hallucinations), mood disturbance, and anxiety, and traumatic subdural hemorrhage (a type of bleeding near the brain that can happen after a head injury) with loss of consciousness of 30 minutes or less. Record review of Resident #3's admission MDS, dated [DATE], revealed a BIMS of 01, indicating severe cognitive impairment. There were no potential indicators of psychosis, and no behavioral symptoms were indicated. Active diagnoses included: traumatic brain dysfunction (an impairment in the normal functioning of the brain caused by an outside force, usually a violent blow to the head), and dementia. Resident #3 was not receiving an antipsychotic.Record review of Resident #3's Progress Note written by LVN J, dated 10/28/2024 at 11:18 AM revealed, As per NP (S), new order for Haldol Deconate 50mg IM Q month for aggression behavior. Record review of Resident #3's Progress Note Orders - Administration Note on 10/28/2024 written by LVN J revealed This order is outside of the recommended dose or frequency. Haldol Decanoate Intramuscular Solution 50 MG/ML (Haloperidol Decanoate) Inject 50 mg intramuscularly one time a day every 1 month(s) starting on the 28th for 1 day(s) for 50mg IM Q month - The frequency of monthly is below the usual frequency of every 28 days.Record review of Resident #3's Progress Note dated 10/29/2024 at 08:18 PM written by LVN K, revealed Administered monthly haloperidol.Record review of resident #3's care plan, dated 11/19/2024, revealed:FOCUS: The resident uses antipsychotic medications (HALDOL) r/t AGITATION Date Initiated: 11/19/2024 Revision on: 11/19/2024.GOALS: Resident will have no injuries related to medication usage Date Initiated: 11/19/2024 Target Date: 12/31/2024.INTERVENTIONS/TASKS: o psych consult Date Initiated: 11/19/2024 Revision on: 11/19/2024 LN o Discuss side effects of medications with resident/RP Date Initiated: 11/19/2024 LN o Keep environment free of clutter and safety hazards Date Initiated: 11/19/2024 LN o Monitor behaviors. Notify MD of new or worsening behaviors Date Initiated: 11/19/2024 LN SS o Monitor vital signs as ordered by MD and PRN Date Initiated: 11/19/2024 LN o 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: 11/19/2024 LN. Record review of Resident #3's medical record did not reveal consent for the antipsychotic Haldol until 02/22/2025.During an interview on 06/25/2025 at 03:38 PM Resident #3's RP stated she had gone to the facility sometime around February to sign a consent for a medication they wanted to give Resident #3. The RP stated she could not remember the name of the medication. She said they told her it was for sleep because he woke up in the night and because he walked around. During an interview on 06/26/2025 at 01:14 PM LVN P stated for an antipsychotic to be given to a resident, the LVN needed to make sure she had a consent form, the correct diagnosis, the right reason, the right time, the right route, the right patient, and the right documentation. During an interview on 06/26/2025 at 01:48 PM LVN K stated he could not recall if he had administered the Haldol injection to Resident #3 on 10/29/2024 or not. He stated he had just started working as a nurse at the facility (October 2024). LVN K stated Resident #3 did not have behavior. In an interview on 06/26/25 at 05:33 PM the DON stated to administer an antipsychotic; consent must be signed prior to giving an antipsychotic. The DON stated he had seen the consent for the Haldol for Resident #3 had been signed in February 2025. The DON stated the consent should have been signed by the RP and checked by the nurse before the Haldol was administered. 2. Record review of Resident #6’s admission record dated 09/06/24, revealed a [AGE] year-old male with diagnoses which included: Alzheimer’s disease, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety and cognitive communication deficit. Record review of Resident #6’s quarterly MDS assessment dated [DATE] revealed resident had a BIMS score of 6 indicating moderately impaired cognition and that Resident #6 was taking antipsychotic and antianxiety medications. Record review of Resident #6’s physician orders revealed orders which included the following: Zyprexa 2.5MG tablet Give 1 tablet by mouth two times a day for mood disorder effective 09/14/24; Zyprexa 5MG tablet Give 1 tablet by mouth three times a day for agitation effective 12/17/24; Buspirone 5MG tablet Give 1 tablet by mouth two times a day for mood disorder effective 03/19/25; Lorazepam 0.5MG tablet Give 1 tablet by mouth every 12 hours as needed for mood disorder effective 01/08/25; Risperidone 0.25MG tablet Give 1 tablet by mouth one time a day for mood disorder effective 04/04/25. Record review of Resident #6’s MAR revealed Zyprexa, Buspirone, and Lorazepam had been administered on dates prior to have received the signed consents. Record review of Resident #6’s “Informed Consent for Psychoactive Medications” for Zyprexa 2.5MG and Zyprexa 5MG revealed both forms were signed and dated by the doctor and resident’s RP on 05/22/25. Record review of Resident #6’s “Informed Consent for Psychoactive Medications” for Buspirone revealed the form was signed by the doctor but was not dated. The same form revealed resident’s RP signed and dated on 05/21/25. Record review of Resident #6’s “Informed Consent for Psychoactive Medications” for Buspirone revealed a second consent form was signed and dated by the doctor and resident’s RP on 06/25/25. Record review of Resident #6’s “Informed Consent for Psychoactive Medications” for lorazepam revealed the form was signed and dated by the doctor and resident’s RP on 06/27/25. Record review of informed consents revealed there was no actual consent form for Risperidone. Interview was attempted with Resident #6 on 07/14/25 at 9:35 am but resident was unable to answer any medication questions. During an interview on 07/14/25 at 10:28 am, LVN F stated that when a doctor gave an order for an antipsychotic medication, the nurse was to verify the order and make sure it was correct. Once the order was verified that it was correct, then the consent is needed from the family, either verbally or signed on paper. LVN F stated that verbal orders that were obtained by the phone, were to be verified with another nurse present during the phone call. Once the family gave consent, LVN F stated both nurses were to sign the form and then hand the form off to the medical records office. LVN F stated that the ADON H, ADON I, or the DON were responsible for reviewing the consents that were submitted for the new orders that were received. During an interview on 07/14/25 at 3:37 pm, MDS D stated that when a psychotropic medication was ordered by a doctor, the nurse that received the order had to obtain the family’s consent before the medication was given. MDS D stated that consents, either verbal or in person, are signed off on a paper form. MDS D verified which one of Resident #6’s medications needed a consent. MDS D stated that Zyprexa 2.5MG and Zyprexa 5MG, Buspirone, Lorazepam, and Risperidone all needed consents. The consents for Zyprexa, Buspirone and lorazepam had been uploaded to their computer system however the consent form for Risperidone was not found. MDS D stated those were the only consents she was able to find in the system for Resident #6. During an interview on 07/15/25 at 10:39 am, the DON stated that when a doctor gave an order for an antipsychotic, consent from the family was required. The DON stated that the family was informed of the new order and the family was allowed to give consent or refuse. If the family gave consent over the phone, then two nurses received the verbal consent and both nurses signed the actual consent form. The DON stated that consents were monitored every morning during the reports from the morning meeting. The DON stated that new medications or new orders were discussed in every morning meeting. The DON stated that ADON H, ADON I, or he himself would review that the forms have been signed correctly. If the consent had not been done, there would be a hold on medication administration and notify the doctor that the medication was not administered. The DON reviewed Resident #6’s medication administration record and stated the medications had been administered on dates prior to have received the written consent forms. The DON states he was unaware the consent forms had not been signed by RP nor by the doctor. A record review of the facility's policy Nursing Facility Residents' Rights, dated November 2021, revealed, Participation in Your Care You have the right to: -Have any psychoactive medications prescribed and administered in a responsible manner as mandated by the Texas Health and Safety Code, 242.505, and refuse to consent to the prescription of psychoactive medications. A record review of the facility's policy Use of Psychotropic Medication(s), dated 03/05/25, revealed, Policy Explanation and Compliance Guidelines: 9. Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase. 10. The resident has the right to accept or decline the initiation or increase of psychotropic medication. 11. The facility will document that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and the preferred option to accept or decline in a format the facility deems to use (e.g., written consent form, narrative note, etc.).

Based on interview, and record review the facility failed to have physician orders for the resident's immediate care at time of admission for 1 of 4 residents (Resident #2) reviewed for physician admission orders. 1.Resident #2 was readmitted to the facility on [DATE] and did not have orders in place for blood sugar checks and had an episode of low blood sugar on 04/08/25 that required him to be sent to hospital. 2.Resident #2 was readmitted to the facility on [DATE] and did not have wound care orders in place for identified impaired skin intergrity until 04/07/25. An IJ was identified on 05/06/25. The IJ template was provided to the facility on [DATE] at 5:18PM . While the IJ was removed on 05/08/25, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These deficient practices could affect residents by placing them at risk of not having orders for the staff to follow in order to provide care and treatment for identified health needs. The findings included: 1.Record review of Resident #2's face sheet, dated 04/16/25, revealed the resident was an [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnoses that included: type 2 diabetes mellitus (insufficient production of insulation causing high blood sugar) without hypoglycemia (low blood sugars) without coma, chronic systolic (congestive) (left ventricle lose ability to contract normally and the heart cant with enough force to push enough blood into circulation) heart failure, hyperlipidemia (abnormally high levels of lipids (fat) in the blood) and essential (primary) hypertension (high blood pressure). Record review of Resident #2's Medicare 5-day MDS assessment, dated 02/27/25, revealed Resident #2 had a BIMS score of 11, indicating his cognition was moderately impaired. Record review of Resident #2's care plan with an initiation date of 04/16/25 reflected problems such as, [Resident #2] has Diabetes Mellitus and included a goal of the resident will have no complication related to diabetes and interventions including, Monitor/document/report PRN (as needed) any s/sx (signs and symptoms) of hypoglycemia: Sweating, Tremor, Increased heart rate (Tachycardia), Pallor (Pale), Nervousness, Confusion, slurred speech, lack of coordination and Staggering gait. with initiation dates of 04/16/25. Record review of Resident #2's hospital document titled, Physician - Discharge Med Rec Order Lansc (Definition unknown) dated 04/03/25 stated to stop Resident #2's order for insulin sliding scale and did not include any orders related to blood sugar checks. Record review of Resident #2's hospital document titled; Discharge Medication dated 04/03/25 did not include any orders related to blood sugar checks. Record review of Resident #2's order summary report from his admission on [DATE] indicated he had no orders for blood sugar checks. Record review of Resident #2's order summary report from his admission on [DATE] indicated he had an order for dapagliflozin propanediol oral tablet 5MG 1 time a day every day and glipizide-metformin HCI oral tablet 5-500MG 2 times a day every day both with a start date of 04/04/25 and a discontinue date of 04/10/25. Record review of Resident #2's nursing note dated 04/03/25 at 7:41 p.m., written by LVN A reflected he had returned to the facility at that time after a hospital stay and stated LVN A had verified medication list with the NP. Record review of Resident #2's order audit report revealed he had previously had blood sugar checks ordered on 03/05/25 and discontinued on 03/15/25 when resident was sent to the hospital prior to re-admitting to facility on 04/03/25. Record review of Resident #2's blood sugar summary revealed his last blood sugar check was completed on 03/15/25 and was 174. Record review of Resident #2's change in condition completed by LVN A dated 04/08/25 stated Resident #2 complained of shortness of breath, O2 saturation was at 98% and had a blood sugar reading of 50. Resident #2 was alert at all times, had no signs and symptoms of hypoglycemia or distress, had even and unlabored breathing, and was given glucose gel and a cup of orange juice. Resident #2 was transferred to hospital. Record review of Resident #2's hospital admission dated 04/08/25 revealed he was admitted for episodes of hypoglycemia. During an interview with the NP on 04/16/25 at 9:02 a.m., he stated residents with diabetes and history of low of fluctuating blood sugars would absolutely have to have blood sugar checks. The NP did not recall the specific phone call with LVN A when Resident #2 returned to the facility on [DATE]. The NP stated he usually continues the hospital orders and resume hospital orders and the resident's orders. The NP did not recall saying specifically to check his blood sugars but stated Resident #2 has had episode of fluctuating blood sugars and would imagine the facility would be checking his blood sugar. The NP clarified that Resident #2 would require blood sugar checks. The NP did not know why he did not have any blood sugar checked from 04/03/25-04/08/25 and stated it would not make any sense to discontinue the glucometer checks on a diabetic and stated he was not aware of an order like that being given. The NP stated if a resident did not have their blood sugar checked there was a possibility of hyperglycemic (high blood sugar) or hypoglycemic (low blood sugar) episodes. During a telephone interview with LVN A on 04/16/25 at 12:36 p.m., she stated she went over the orders with the NP and stated there was no communication to the NP asking if he needed blood sugar checks and LVN A stated she did not ask if Resident #2 needed them because usually they would come on the medication list. LVN A stated there was not a reason why she did not ask for blood sugar checks for Resident #2 and stated she just did not and stated she just followed the order from the hospital. LVN A stated some people who had type 2 diabetes had to have blood sugar and stated some people do not check their blood. LVN A stated Resident #2 did not have blood sugar checks for a total of 5 days during his stay from 04/03/25-04/08/25. LVN A stated she did not know why Resident #2 did not have blood sugar checks. LVN A stated not having blood sugar checks could impact a resident negatively by their sugar dropping or going too high. LVN A stated she had not been trained in requesting or inputting orders for blood sugar checks and stated she just put in whatever orders were on the paper. LVN A did not know the facility policy regarding blood sugar checks or diabetic procedures. LVN A stated the only negative outcome Resident #2 had was on 04/08/25 he was complaining of shortness of breath and had his blood sugar was at 50. LVN A stated Resident #2 was sent out to the hospital. During an interview on 04/16/25 at 4:12 p.m. ADON E stated normally when a resident is on diabetic PO (by mouth) medication they will do blood sugar checks on them and stated they reviewed the hospital medication list that Resident #2 came in with on 04/03/25 and stated they had discontinued his sliding scale insulin. ADON E stated she did not know if LVN A thought his blood sugar checks were discontinued because the sliding scale was discontinued. ADON E stated LVN A did document that she verified the medications with the NP but she did not know exactly what LVN A verified and did not know why the glucose checks were dropped. ADON E was not sure if there was any communication about getting blood sugar checks for Resident #2 and stated it was not documented on LVN As note. ADON E did not know why LVN A did not ask for blood sugar checks for Resident #2 and stated residents with type 2 diabetes should be on blood sugar checks. ADON E stated she spoke with the NP today who said if they would have addressed it with him he would have given the blood sugar checks. ADON E stated Resident #2 was without blood sugar checks for 5 days from 04/03/25-04/08/25. ADON E stated herself and ADON G had trained staff over requesting and in putting orders and about checking blood sugar for diabetics. ADON E stated they did not have a facility policy for diabetic procedures or blood sugar checks and stated it was just nursing 101 to check diabetics blood sugars before meals. ADON E stated LVN A did not follow procedure in this situation. ADON E stated not getting blood sugar checks could negatively impact a resident by causing them to go hypoglycemic (low blood sugar). ADON E stated she believed Resident #2 was sent out due to him becoming hypoglycemic on 04/08/25 and stated she did not see him during that time. During an interview with the DON on 05/02/25 at 6:11pm he stated there was a progress note from LVN A on 04/03/25 that stated she went over Resident #2's orders with the NP. The DON stated that progress note did not include communication regarding blood sugar checks. The DON stated some physicians did not have residents on blood glucose checks and would instead check their A1C. The DON stated if a resident's blood glucose is controlled with diet and oral medication, they can be taken off blood glucose checks and if they are uncontrolled then you really cannot take them off blood glucose checks. The DON was asked if there was a reason why LVN A did not ask the NP for blood glucose checks for Resident #2 and he stated it depended on the order that came in with the resident from the hospital, and stated it they were on insulin they are on glucose checks regardless but stated sometimes they went in with PO (oral) medication and would use an A1C to check their glucose. The DON stated Resident #2 did not have any order from blood sugar checks during his stay from 04/03/25 through 04/08/25. The DON stated Resident #2 had no negative outcomes from not having his blood glucose checked during that time that he knew of. The DON stated he was not sure if staff had been trained prior to Resident #2 over blood glucose checks but stated they had been trained since and stated the training occurred prior to him starting to work at the facility. The DON stated yes, the facility had a policy regarding diabetic procedures and blood glucose checks but had to read it to give me information regarding what it stated. The DON stated LVN A followed the admission process. The DON stated if someone had a history of hypoglycemia and did not have blood glucose checks it could put their life in danger. The DON reviewed Resident #2's blood sugar summary and stated he only identified 1 episode of Resident #2's blood sugar at 50 on 02/16/25. During a follow up interview on 05/06/25 at 12:14pm The DON stated if a resident was responsive they could decompensate within 5 to 30 minutes if their blood glucose was at 50 and was not being monitored. Record review of facility Inservice training report dated 04/11/25 revealed LVN A and ADON E had been trained on glucose checks, admissions and notifying the doctor. Record review of LVN A's orientation and skills competency revealed a section titled, Physician Orders and a subsection titled, acquisition that indicated she had been evaluated over this area on 01/02/24 by a previous DON. There was no additional comments on comment section and was signed and dated by both LVN A and a previous DON on 01/02/24 Record review of facility in services revealed LVN A had been trained over medication reconciliation and verifying medication on 04/17/25. Record review of facility Ad HOC QAPI dated 04/11/25 revealed, blood glucose as an agenda item. During an interview on 04/16/25 at around 4:00pm the Regional Clinical Specialist stated they did not have a facility policy for diabetic procedures or blood sugar checks. During an interview on 04/16/25 at 4:12pm ADON E stated they did not have a facility policy for diabetic procedures or blood sugar checks. During an interview on 04/16/25 at 5:16pm the Administrator stated they did not have a facility policy for diabetic procedures or blood sugar checks. Record review of facility policy with an implementation date or 10/24/22 and titled Notification of Changes stated, the purpose of this policy is to ensure the facility prompt informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. and 3. Circumstances that require a need to alter treatment. This may include a. a new treatment. 2.Record review of Resident #2's face sheet, dated 04/16/25, revealed the resident was an [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnoses that included: type 2 diabetes mellitus (insufficient production of insulation causing high blood sugar) without hypoglycemia (low blood sugars) without coma, chronic systolic (congestive) (left ventricle lose ability to contract normally and the heart cant with enough force to push enough blood into circulation) heart failure, hyperlipidemia (abnormally high levels of lipids (fat) in the blood) and essential (primary) hypertension (high blood pressure). Record review of Resident #2's Medicare 5-day MDS assessment, dated 02/27/25, revealed Resident #2 had a BIMS score of 11, indicating his cognition was moderately impaired. Resident #2's section M - skin conditions reflected Resident #2 was at risk for developing pressure ulcers/injuries, had no unhealed pressure ulcers/injuries, 1 venous and arterial ulcer present, had diabetic foot ulcer(s), moisture associated skin damage (MASD), had a pressure reducing device for bed and had application of non-surgical dressings (with or without topical medications) other than to feet. Record review of Resident #2's care plan with an initiation date of 04/16/25 reflected problems such as, [Resident #2] has an arterial of the left dorsum foot, [Resident #2] has a stage 2 pressure injury to left gluteus and unstageable pressure injury to left heel and [Resident #2] has actual impairment to skin integrity of the sacrum r/t (related to) MASD and impairment to skin integrity of the penis r/t (related to) surgical wound. All 3 problem areas had an intervention of, Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Record review of Resident #2's hospital documents dated 04/03/25 and titled Physician-Discharge Med (medications) Rec Order Landsc (definition unknown) and Discharge - Patient Medication Report did not include any orders for impaired skin integrity management. Record review of Resident #2's nursing note dated 04/03/25 at 7:41 p.m., written by LVN A reflected he had returned to the facility at that time after a hospital stay and stated LVN A had verified medication list with the NP. Record review of Resident #2's nursing note dated 04/03/25 at 7:41 p.m., written by LVN A reflected he had returned to the facility at that time after a hospital stay. Nursing note also stated Resident #2 present with Discoloration noted to bilateral arms. Multiple scabs noted to posterior left arm . Red discoloration noted to sacrum area .Surgical incision to penis area d/t (due to) circumcision. Swelling noted to groin area. Scab noted to top of left foot and left heel. Record review of Resident #2's initial nursing evaluation dated 04/03/25 completed by LVN A had yes marked off indicating Resident #2 had skin impairments but did not mark anything on body diagram or site and description table that detailed location or measurement. Record review of Resident #2's skin assessments with an effective date of 04/07/25 revealed Resident #2 had the following: a diabetic wound to left dorsum foot that measured an area of 3.1 cm² with a length of 3.3 cm, width of 1.4 cm, depth of 0.1 cm. A diabetic would to left heel that measured an area of 1.8 cm² with a length of 2.2 cm, width of 1.0 cm, depth of 0.1 cm, MASD specifically incontinence associated dermatitis to sacrum that measured an area of 2.2 cm² with a length of 3.8 cm, width of 0.7 cm, depth of 0.1 cm. and an abrasion to penis that measured an area of 8.7 cm² with a length of 4.6 cm, width of 4.4 cm, depth of 0.1 cm. All areas of skin impairments were listed as present on admission on [DATE] and 01/26/25 and were all marked as resolved. Record review of Resident #2's order summary report revealed he had no treatment orders for his identified skin impairments when admitted on [DATE] until 04/07/25, which include the following: 1. Penile wound: clean with dakin's, dab dry with gauze, apply Mupirocin topically, LOTA (leave open to air) one time a day with an order date of 04/07/25 and a start date of 04/08/25. 2. Sacral MASD (moisture associated skin damage): clean with Dakin's, apply Medihoney and optifoam patch. one time a day with an order date of 04/07/25 and a start date of 04/08/25. 3. Lt (left) heel wound: clean with Dakin's, apply Betadine cast followed by kerlix. one time a day with an order date of 04/07/25 and a start date of 04/08/25. 4. Lt (left) dorsum foot: clean with Dakin's, apply Silvadene, cover with gauze dssg. (dressing) one time a day with an order date of 04/07/25 and a start date of 04/08/25. Record review of Resident #2's change in condition completed by LVN A and dated 04/08/25 stated Resident #2 complained of shortness of breath, O2 saturation was at 98% and had a blood sugar reading of 50. Resident #2 was alert at all times, had no signs and symptoms of hypoglycemia or distress, had even and unlabored breathing, and was given glucose gel and a cup of orange juice. Resident #2 was transferred to hospital. During a telephone interview on 04/10/25 at 4:19 p.m., LVN A who was the admitting nurse for Resident #2 on 04/03/25 stated she recalled Resident #2 on 04/03/25 and recalled she did the initial nursing evaluation. LVN A stated she did not recall wounds too well and just put redness and discoloration. LVN A stated she did see redness on the sacrum and did not do anything, she stated she did not ask the doctor for any orders for the redness and stated it was more just on the sacrum. LVN A stated she did not know why she did not ask the doctor for any order. LVN A stated she just verified the medication list, LVN A stated they did not have an order for zinc and stated it was not on his medication list. LVN A stated LVN G assisted with the assessment of Resident #2. LVN A stated usually the wound care nurse would evaluate the resident the following day in the morning and stated if residents had wounds they usually came with order. During a follow up interview on 05/01/25 at 7:14pm with LVN A she stated when a resident arrived to the facility she would go and assess them, take vitals, verify orders and would complete a skin assessment that would be documented on a nursing note and stated she would complete a diagram as a reminder if they had things like a bruise. LVN A stated she did not open a new form for skin wound assessment when Resident #2 was admitted and stated she had since been educated to complete a wound form for new admissions. During an interview with the NP on 04/16/25 at 9:02 a.m., he stated to determine skin or wound care orders the nurse would discuss any skin impairments with him or request orders from him which he would give if they were requested. The NP stated he did not recall if LVN A informed him of any skin impairments identified on Resident #2 when he was admitted on [DATE]. The NP stated not having wound care orders could potentially impact Resident #2 negatively due to being fragile elderly patient and could potentially have worsening wounds. During an interview on 04/16/25 at 4:12 p.m., ADON E stated when a resident or new admission is identified with skin impairments or wounds the admitting nurse was responsible for doing a full head to toe and going over the medication with the doctor. ADON E stated the admitting nurse had to do a skin evaluation and document any skin impairment and if they came in without orders from the hospital then the admitting nurse needed to review any findings with the doctor. ADON E stated when Resident #2 admitted on [DATE], LVN A was the nurse who completed the initial nursing evaluation. ADON E stated the initial nursing evaluation did include a skin assessment but stated the model on the nursing evaluation did not have anything documented. ADON E confirmed that staff marked yes that skin impairments were identified but stated there was nothing documented on the model and stated there should be something documented on there. ADON E stated she is assuming LVN A did not communicate any skin impairment findings to the doctor because there was no order in place for wound care upon admission of Resident #2 on 04/03/25. ADON E stated identified skin impairments and wounds are something they needed to call the doctor about and see what changes he wanted to make and stated the NP was very accessible and if staff would have addressed the skin impairment with him then he would have given orders. ADON E did not know why staff did not communicate Resident #2's skin impairment findings from 04/03/25 with the doctor. ADON E stated it was important to communicate any findings to make sure they were not left untreated. ADON E stated staff had recently been trained by her and ADON G on making notifications to the doctor and requesting orders from the doctor. ADON E stated LVN A did not follow the facility policy which stated anything out of the norm should be reporting for monitoring or treatment. ADON E stated Resident #2 went without wound care for 5 days and stated she did not believe Resident #2 was receiving wound care during those days and stated she did not have a baseline from 04/03/25 to say if there was any deterioration to his wounds during that time and stated there was not any negative impact that she knew of. ADON E stated not having wound care could negatively impact residents by causing wounds to get bigger or infected or go septic. During a follow up interview on 04/16/25 at 6:52 p.m., LVN A stated when a new admission is identified with skin impairments or wounds they would either get order from the medication list or the treatment nurse would assess the resident the following day. LVN A confirmed that she completed Resident #2's initial nursing evaluation when he admitted on [DATE]. She stated she thought the initial nursing evaluation included a skin assessment. LVN A stated she identified skin impairments to include redness to sacrum and scabs to feet. LVN A stated she did not communicate these findings to the NP and did not ask for orders based on her skin assessment and stated she only verified orders with the NP. LVN A stated skin impairments and wounds are something she should communicate with the doctor and stated that she knew of it being the treatment nurse who would communicate that but stated no one told her she was out. LVN A stated she did not communicate her findings with the doctor because she thought the treatment nurse would. LVN A stated it was important to communicate skin and wound findings to the doctor to make sure it would not get worse. LVN A stated she did not remember a training over reporting skin impairments or changes in condition but stated they had to report it to the DON and doctor. LVN A did not know her facility policy regarding communicating findings with the doctor. LVN A stated she did not know how many days Resident #2 went without wound care and stated she was off that following weekend and was not sure if he was receiving any kind of wound care and did not know if there was any deterioration to his wounds during that time. LVN A stated not getting wound care for 4 days could negatively impact the resident by causing the wounds to get infected. LVN A stated she should have notified the doctor if she had seen any signs or symptoms of infection and stated she should have asked him for wound care orders as time of assessment. During an interview and record review with the DON on 05/02/25 at 6:11pm he stated he started working at the facility on 04/21/25. The DON stated LVN A completed Resident #2's initial nursing evaluation on 04/03/25. The DON reviewed Resident #2's initial nursing evaluation from 04/3/25 and stated there was a section for skin integrity on there and stated LVN A marked yes to skin impairments but did not identify them on that form and instead did so on her progress note. The DON stated a skin form was not completed until 04/07/25. The DON stated that LVN A did communicate findings with the NP based off a note that stated she verified medications with NP. The DON stated LVN A's note did not include if she asked for orders based on her skin assessment and stated he would have to ask the LVN A or the NP. The DON stated staff should communicate any findings that warranted an order with the NP. The DON did not know why LVN A had not communicate her findings with the NP. The DON stated communicating findings with the NP and getting order for wound care and skin impairments was important because wounds and skin impairments could get worse, go septic or get infected. The DON stated he knew staff had been trained on making notifications to the NP and getting orders for wound care and skin impairments prior to him starting to work at the facility. The DON stated the facility policy stated to notify the NP of any change in condition and anything to the skin. The DON stated LNV A followed the admission process and stated he didn't know if she actually asked the NP about the wounds or scans. The DON stated Resident #2 was without wound care orders from day of readmission on [DATE] until they were put in on 04/07/25. The DON stated not having wound care treatment in place could negatively impact a resident by causing deterioration of the wound, going septic or getting an infection and having pain. The Treament Nurse was attempted to be contacted via telephone for an interview on 05/05/25 at 3:59pm with no success. The Treament Nurse was attempted to be contacted via telephone for an interview on 05/05/25 at 4:00pm, the call was answered, reason for call was explained, however while explaining the reason for call the person who answered the phone hung up the phone. The Treatment Nurse was attempted to be contacted via telephone for an interview on 05/05/25 at 4:01pm with no success. During an interview with ADON E on 05/05/25 at 4:08pm stated she stated the Treatment Nurse would have been the nurse who completed Resident #2's skin assessment on 04/07/25. ADON E reveiwed the skin assessments from 04/07/25 and stated the Treatment Nurse was indicated as the staff memeber who created the skin assessments on 04/07/25 for Resident #2. Record review of facility Inservice training report dated 04/11/25 (after incident occurred) revealed LVN A and ADON E had been trained on glucose checks, admissions and notifying the doctor. Record review of facility policy with an implementation date or 10/24/22 and titled Notification of Changes stated, the purpose of this policy is to ensure the facility prompt informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. and 3. Circumstances that require a need to alter treatment. This may include a. a new treatment. This was determined to be an Immediate Jeopardy (IJ) on 05/06/25 at 4:55 PM. The administrator and the DON were notified. The Administrator and the DON were provided with the IJ template on 05/06/25 at 5:18pm The following Plan of Removal (POR) submitted by the facility was accepted on 05/07/25 at 11:30 PM: [Facility] [Address] [Phone Number] LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY May 6, 2025 Attention Sir or Madam: On May 6, 2025, the facility was notified by the surveyor that an Immediate Jeopardy had been called and the facility needed to submit a letter of removal. The Facility respectfully submits this Letter for a Plan of Removal pursuant to Federal and State regulatory requirements. The immediate jeopardy is as follows: Issue: F 635 admission Orders LVN A failed to obtain clarification orders for glucose checks upon readmission despite having a diagnosis of diabetes. R#2 complained of shortness of breath and suffered hypoglycemic episode with a blood glucose of 50 on 04/08/25. Actions for Resident Involved On 4/16/25, Resident #2 returned to the facility and orders were reviewed. Resident #2 was readmitted with Blood Glucose Check orders and was carried out as ordered. Identification of Others: On 4/10/25 and 5/6/2025 the DON/Designee conducted an audit of admissions/readmissions in the last 30 days to ensure that orders have been reconciled and reviewed by Medical Providers and carried out as ordered. On 4/10/25 and 5/6/2025, residents with diagnosis of type 2 diabetes mellitus were identified and referred to medical providers to review if additional orders are needed related to management of diabetes. Systemic Changes/ Education On 4/10/25 and 5/6/2025, the Director of Nursing/Designee initiated and completed 100% education with licensed staff. Comprehension of training was verified by having nurses voice understanding of the training and repeat back training contents. Those that are PRN and/ or out on FMLA/ LOA will be taken off schedule and have the education completed prior to accepting assignment for their next scheduled shift. Licensed Nurses were educated on the following: Admission/readmission order review process: o Medication reconciliation for admission/readmissions. Nurses to ensure all medications and orders upon admit/readmit have been verified with Medical Providers and carried out as ordered. o Compare Hospital Transfer orders to hospital records including review of diagnosis. The License nurse will contact the medical provider and obtain clarification orders as needed based on order review and nursing assessment. Diabetes Mellitus and Blood Glucose Checks Beginning 5/6/25 and ongoing, newly hired licensed nurses will receive this training during orientation prior to providing care to the residents. The training will include the above-stated educational components. Admission/readmission/ER (emergency room) visits orders will be reviewed during the morning clinical meeting to ensure orders have been reconciled with hospital record and orders and the Medical Provider is notified of any orders requiring clarifications based on record review and/or nurse's assessment. Weekend RN Supervisor and/or ADON will complete and review Medication reconciliation for admission/readmissions over the weekend. Charge Nurses will ensure all medications and orders upon admit/readmit have been verified with Medical Providers and carried out as ordered. Monitoring Beginning 5/6/25 and going forward, The Director of Nursing/ designee will review new admissions /readmissions to ensure order reconciliation is completed and hospital records including the diagnosis are reviewed and medical provider is contacted if needed for clarifications based on order review and nursing assessment. Beginning 5/6/25 and going, the Director of Nursing or designee will

Based on interview, and record review the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for 1 of 4 residents (Resident #2) reviewed for quality of care. 1.Resident #2 was readmitted to the facility on [DATE] and did not have orders in place for wound care for MASD to sacrum, diabetic wound to left heel and left dorsum foot or abrasion to penis until 04/07/25. 2. Resident #2 was readmitted to the facility on [DATE] and did not have orders in place for blood sugar checks and had an episode of low blood sugar on 04/08/25 that required him to be sent to hospital. An IJ was identified on 05/06/25. The IJ template was provided to the facility on [DATE] at 5:18PM . While the IJ was removed on 05/08/25, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These deficient practices could affect residents who receive wound care treatments by placing them at risk for receiving inadequate treatments resulting in the worsening of the wounds. The findings included: Record review of Resident #2's face sheet, dated 04/16/25, revealed the resident was an [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnoses that included: type 2 diabetes mellitus (insufficient production of insulation causing high blood sugar) without hypoglycemia (low blood sugars) without coma, chronic systolic (congestive) (left ventricle lose ability to contract normally and the heart cant with enough force to push enough blood into circulation) heart failure, hyperlipidemia (abnormally high levels of lipids (fat) in the blood) and essential (primary) hypertension (high blood pressure). Record review of Resident #2's Medicare 5-day MDS assessment, dated 02/27/25, revealed Resident #2 had a BIMS score of 11, indicating his cognition was moderately impaired. Resident #2's section M - skin conditions reflected Resident #2 was at risk for developing pressure ulcers/injuries, had no unhealed pressure ulcers/injuries, 1 venous and arterial ulcer present, had diabetic foot ulcer(s), moisture associated skin damage (MASD), had a pressure reducing device for bed and had application of non-surgical dressings (with or without topical medications) other than to feet. Record review of Resident #2's care plan with an initiation date of 04/16/25 reflected problems such as, [Resident #2] has an arterial of the left dorsum foot, [Resident #2] has a stage 2 pressure injury to left gluteus and unstageable pressure injury to left heel and [Resident #2] has actual impairment to skin integrity of the sacrum r/t (related to) MASD and impairment to skin integrity of the penis r/t (related to) surgical wound. All 3 problem areas had an intervention of, Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Record review of Resident #2's hospital documents dated 04/03/25 and titled Physician-Discharge Med (medications) Rec Order Landsc (definition unknown) and Discharge - Patient Medication Report did not include any orders for impaired skin integrity management. Record review of Resident #2's nursing note dated 04/03/25 at 7:41 p.m., written by LVN A reflected he had returned to the facility at that time after a hospital stay and stated LVN A had verified medication list with the NP. Record review of Resident #2's nursing note dated 04/03/25 at 7:41 p.m., written by LVN A reflected he had returned to the facility at that time after a hospital stay. Nursing note also stated Resident #2 present with Discoloration noted to bilateral arms. Multiple scabs noted to posterior left arm . Red discoloration noted to sacrum area .Surgical incision to penis area d/t (due to) circumcision. Swelling noted to groin area. Scab noted to top of left foot and left heel. Record review of Resident #2's initial nursing evaluation dated 04/03/25 completed by LVN A had yes marked off indicating Resident #2 had skin impairments but did not mark anything on body diagram or site and description table that detailed location or measurement. Record review of Resident #2's skin assessments with an effective date of 04/07/25 revealed Resident #2 had the following: a diabetic wound to left dorsum foot that measured an area of 3.1 cm² with a length of 3.3 cm, width of 1.4 cm, depth of 0.1 cm. A diabetic would to left heel that measured an area of 1.8 cm² with a length of 2.2 cm, width of 1.0 cm, depth of 0.1 cm, MASD specifically incontinence associated dermatitis to sacrum that measured an area of 2.2 cm² with a length of 3.8 cm, width of 0.7 cm, depth of 0.1 cm. and an abrasion to penis that measured an area of 8.7 cm² with a length of 4.6 cm, width of 4.4 cm, depth of 0.1 cm. All areas of skin impairments were listed as present on admission on [DATE] and 01/26/25 and were all marked as resolved. Record review of Resident #2's order summary report revealed he had no treatment orders for his identified skin impairments when admitted on [DATE] until 04/07/25, which include the following: 1. Penile wound: clean with dakin's, dab dry with gauze, apply Mupirocin topically, LOTA (leave open to air) one time a day with an order date of 04/07/25 and a start date of 04/08/25. 2. Sacral MASD (moisture associated skin damage): clean with Dakin's, apply Medihoney and optifoam patch. one time a day with an order date of 04/07/25 and a start date of 04/08/25. 3. Lt (left) heel wound: clean with Dakin's, apply Betadine cast followed by kerlix. one time a day with an order date of 04/07/25 and a start date of 04/08/25. 4. Lt (left) dorsum foot: clean with Dakin's, apply Silvadene, cover with gauze dssg. (dressing) one time a day with an order date of 04/07/25 and a start date of 04/08/25. Record review of Resident #2's change in condition completed by LVN A and dated 04/08/25 stated Resident #2 complained of shortness of breath, O2 saturation was at 98% and had a blood sugar reading of 50. Resident #2 was alert at all times, had no signs and symptoms of hypoglycemia or distress, had even and unlabored breathing, and was given glucose gel and a cup of orange juice. Resident #2 was transferred to hospital. During a telephone interview on 04/10/25 at 4:19 p.m., LVN A who was the admitting nurse for Resident #2 on 04/03/25 stated she recalled Resident #2 on 04/03/25 and recalled she did the initial nursing evaluation. LVN A stated she did not recall wounds too well and just put redness and discoloration. LVN A stated she did see redness on the sacrum and did not do anything, she stated she did not ask the doctor for any orders for the redness and stated it was more just on the sacrum. LVN A stated she did not know why she did not ask the doctor for any order. LVN A stated she just verified the medication list, LVN A stated they did not have an order for zinc and stated it was not on his medication list. LVN A stated LVN G assisted with the assessment of Resident #2. LVN A stated usually the wound care nurse would evaluate the resident the following day in the morning and stated if residents had wounds they usually came with order. During a follow up interview on 05/01/25 at 7:14pm with LVN A she stated when a resident arrived to the facility she would go and assess them, take vitals, verify orders and would complete a skin assessment that would be documented on a nursing note and stated she would complete a diagram as a reminder if they had things like a bruise. LVN A stated she did not open a new form for skin wound assessment when Resident #2 was admitted and stated she had since been educated to complete a wound form for new admissions. During an interview with the NP on 04/16/25 at 9:02 a.m., he stated to determine skin or wound care orders the nurse would discuss any skin impairments with him or request orders from him which he would give if they were requested. The NP stated he did not recall if LVN A informed him of any skin impairments identified on Resident #2 when he was admitted on [DATE]. The NP stated not having wound care orders could potentially impact Resident #2 negatively due to being fragile elderly patient and could potentially have worsening wounds. During an interview on 04/16/25 at 4:12 p.m., ADON E stated when a resident or new admission is identified with skin impairments or wounds the admitting nurse was responsible for doing a full head to toe and going over the medication with the doctor. ADON E stated the admitting nurse had to do a skin evaluation and document any skin impairment and if they came in without orders from the hospital then the admitting nurse needed to review any findings with the doctor. ADON E stated when Resident #2 admitted on [DATE], LVN A was the nurse who completed the initial nursing evaluation. ADON E stated the initial nursing evaluation did include a skin assessment but stated the model on the nursing evaluation did not have anything documented. ADON E confirmed that staff marked yes that skin impairments were identified but stated there was nothing documented on the model and stated there should be something documented on there. ADON E stated she is assuming LVN A did not communicate any skin impairment findings to the doctor because there was no order in place for wound care upon admission of Resident #2 on 04/03/25. ADON E stated identified skin impairments and wounds are something they needed to call the doctor about and see what changes he wanted to make and stated the NP was very accessible and if staff would have addressed the skin impairment with him then he would have given orders. ADON E did not know why staff did not communicate Resident #2's skin impairment findings from 04/03/25 with the doctor. ADON E stated it was important to communicate any findings to make sure they were not left untreated. ADON E stated staff had recently been trained by her and ADON G on making notifications to the doctor and requesting orders from the doctor. ADON E stated LVN A did not follow the facility policy which stated anything out of the norm should be reporting for monitoring or treatment. ADON E stated Resident #2 went without wound care for 5 days and stated she did not believe Resident #2 was receiving wound care during those days and stated she did not have a baseline from 04/03/25 to say if there was any deterioration to his wounds during that time and stated there was not any negative impact that she knew of. ADON E stated not having wound care could negatively impact residents by causing wounds to get bigger or infected or go septic. During a follow up interview on 04/16/25 at 6:52 p.m., LVN A stated when a new admission is identified with skin impairments or wounds they would either get order from the medication list or the treatment nurse would assess the resident the following day. LVN A confirmed that she completed Resident #2's initial nursing evaluation when he admitted on [DATE]. She stated she thought the initial nursing evaluation included a skin assessment. LVN A stated she identified skin impairments to include redness to sacrum and scabs to feet. LVN A stated she did not communicate these findings to the NP and did not ask for orders based on her skin assessment and stated she only verified orders with the NP. LVN A stated skin impairments and wounds are something she should communicate with the doctor and stated that she knew of it being the treatment nurse who would communicate that but stated no one told her she was out. LVN A stated she did not communicate her findings with the doctor because she thought the treatment nurse would. LVN A stated it was important to communicate skin and wound findings to the doctor to make sure it would not get worse. LVN A stated she did not remember a training over reporting skin impairments or changes in condition but stated they had to report it to the DON and doctor. LVN A did not know her facility policy regarding communicating findings with the doctor. LVN A stated she did not know how many days Resident #2 went without wound care and stated she was off that following weekend and was not sure if he was receiving any kind of wound care and did not know if there was any deterioration to his wounds during that time. LVN A stated not getting wound care for 4 days could negatively impact the resident by causing the wounds to get infected. LVN A stated she should have notified the doctor if she had seen any signs or symptoms of infection and stated she should have asked him for wound care orders as time of assessment. During an interview and record review with the DON on 05/02/25 at 6:11pm he stated he started working at the facility on 04/21/25. The DON stated LVN A completed Resident #2's initial nursing evaluation on 04/03/25. The DON reviewed Resident #2's initial nursing evaluation from 04/3/25 and stated there was a section for skin integrity on there and stated LVN A marked yes to skin impairments but did not identify them on that form and instead did so on her progress note. The DON stated a skin form was not completed until 04/07/25. The DON stated that LVN A did communicate findings with the NP based off a note that stated she verified medications with NP. The DON stated LVN A's note did not include if she asked for orders based on her skin assessment and stated he would have to ask the LVN A or the NP. The DON stated staff should communicate any findings that warranted an order with the NP. The DON did not know why LVN A had not communicate her findings with the NP. The DON stated communicating findings with the NP and getting order for wound care and skin impairments was important because wounds and skin impairments could get worse, go septic or get infected. The DON stated he knew staff had been trained on making notifications to the NP and getting orders for wound care and skin impairments prior to him starting to work at the facility. The DON stated the facility policy stated to notify the NP of any change in condition and anything to the skin. The DON stated LNV A followed the admission process and stated he didn't know if she actually asked the NP about the wounds or scans. The DON stated Resident #2 was without wound care orders from day of readmission on [DATE] until they were put in on 04/07/25. The DON stated not having wound care treatment in place could negatively impact a resident by causing deterioration of the wound, going septic or getting an infection and having pain. The Treament Nurse was attempted to be contacted via telephone for an interview on 05/05/25 at 3:59pm with no success. The Treament Nurse was attempted to be contacted via telephone for an interview on 05/05/25 at 4:00pm, the call was answered, reason for call was explained, however while explaining the reason for call the person who answered the phone hung up the phone. The Treatment Nurse was attempted to be contacted via telephone for an interview on 05/05/25 at 4:01pm with no success. During an interview with ADON E on 05/05/25 at 4:08pm stated she stated the Treatment Nurse would have been the nurse who completed Resident #2's skin assessment on 04/07/25. ADON E reveiwed the skin assessments from 04/07/25 and stated the Treatment Nurse was indicated as the staff memeber who created the skin assessments on 04/07/25 for Resident #2. Record review of facility Inservice training report dated 04/11/25 (after incident occurred) revealed LVN A and ADON E had been trained on glucose checks, admissions and notifying the doctor. Record review of facility policy with an implementation date or 10/24/22 and titled Notification of Changes stated, the purpose of this policy is to ensure the facility prompt informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. and 3. Circumstances that require a need to alter treatment. This may include a. a new treatment. 2. Record review of Resident #2's face sheet, dated 04/16/25, revealed the resident was an [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnoses that included: type 2 diabetes mellitus (insufficient production of insulation causing high blood sugar) without hypoglycemia (low blood sugars) without coma, chronic systolic (congestive) (left ventricle lose ability to contract normally and the heart cant with enough force to push enough blood into circulation) heart failure, hyperlipidemia (abnormally high levels of lipids (fat) in the blood) and essential (primary) hypertension (high blood pressure). Record review of Resident #2's Medicare 5-day MDS assessment, dated 02/27/25, revealed Resident #2 had a BIMS score of 11, indicating his cognition was moderately impaired. Record review of Resident #2's care plan with an initiation date of 04/16/25 reflected problems such as, [Resident #2] has Diabetes Mellitus and included a goal of the resident will have no complication related to diabetes and interventions including, Monitor/document/report PRN (as needed) any s/sx (signs and symptoms) of hypoglycemia: Sweating, Tremor, Increased heart rate (Tachycardia), Pallor (Pale), Nervousness, Confusion, slurred speech, lack of coordination and Staggering gait. with initiation dates of 04/16/25. Record review of Resident #2's hospital document titled, Physician - Discharge Med Rec Order Lansc (Definition unknown) dated 04/03/25 stated to stop Resident #2's order for insulin sliding scale and did not include any orders related to blood sugar checks. Record review of Resident #2's hospital document titled; Discharge Medication dated 04/03/25 did not include any orders related to blood sugar checks. Record review of Resident #2's order summary report from his admission on [DATE] indicated he had no orders for blood sugar checks. Record review of Resident #2's order summary report from his admission on [DATE] indicated he had an order for dapagliflozin propanediol oral tablet 5MG 1 time a day every day and glipizide-metformin HCI oral tablet 5-500MG 2 times a day every day both with a start date of 04/04/25 and a discontinue date of 04/10/25. Record review of Resident #2's nursing note dated 04/03/25 at 7:41 p.m., written by LVN A reflected he had returned to the facility at that time after a hospital stay and stated LVN A had verified medication list with the NP. Record review of Resident #2's order audit report revealed he had previously had blood sugar checks ordered on 03/05/25 and discontinued on 03/15/25 when resident was sent to the hospital prior to re-admitting to facility on 04/03/25. Record review of Resident #2's blood sugar summary revealed his last blood sugar check was completed on 03/15/25 and was 174. Record review of Resident #2's change in condition completed by LVN A dated 04/08/25 stated Resident #2 complained of shortness of breath, O2 saturation was at 98% and had a blood sugar reading of 50. Resident #2 was alert at all times, had no signs and symptoms of hypoglycemia or distress, had even and unlabored breathing, and was given glucose gel and a cup of orange juice. Resident #2 was transferred to hospital. Record review of Resident #2's hospital admission dated 04/08/25 revealed he was admitted for episodes of hypoglycemia. During an interview with the NP on 04/16/25 at 9:02 a.m., he stated residents with diabetes and history of low of fluctuating blood sugars would absolutely have to have blood sugar checks. The NP did not recall the specific phone call with LVN A when Resident #2 returned to the facility on [DATE]. The NP stated he usually continues the hospital orders and resume hospital orders and the resident's orders. The NP did not recall saying specifically to check his blood sugars but stated Resident #2 has had episode of fluctuating blood sugars and would imagine the facility would be checking his blood sugar. The NP clarified that Resident #2 would require blood sugar checks. The NP did not know why he did not have any blood sugar checked from 04/03/25-04/08/25 and stated it would not make any sense to discontinue the glucometer checks on a diabetic and stated he was not aware of an order like that being given. The NP stated if a resident did not have their blood sugar checked there was a possibility of hyperglycemic (high blood sugar) or hypoglycemic (low blood sugar) episodes. During a telephone interview with LVN A on 04/16/25 at 12:36 p.m., she stated she went over the orders with the NP and stated there was no communication to the NP asking if he needed blood sugar checks and LVN A stated she did not ask if Resident #2 needed them because usually they would come on the medication list. LVN A stated there was not a reason why she did not ask for blood sugar checks for Resident #2 and stated she just did not and stated she just followed the order from the hospital. LVN A stated some people who had type 2 diabetes had to have blood sugar and stated some people do not check their blood. LVN A stated Resident #2 did not have blood sugar checks for a total of 5 days during his stay from 04/03/25-04/08/25. LVN A stated she did not know why Resident #2 did not have blood sugar checks. LVN A stated not having blood sugar checks could impact a resident negatively by their sugar dropping or going too high. LVN A stated she had not been trained in requesting or inputting orders for blood sugar checks and stated she just put in whatever orders were on the paper. LVN A did not know the facility policy regarding blood sugar checks or diabetic procedures. LVN A stated the only negative outcome Resident #2 had was on 04/08/25 he was complaining of shortness of breath and had his blood sugar was at 50. LVN A stated Resident #2 was sent out to the hospital. During an interview on 04/16/25 at 4:12 p.m. ADON E stated normally when a resident is on diabetic PO (by mouth) medication they will do blood sugar checks on them and stated they reviewed the hospital medication list that Resident #2 came in with on 04/03/25 and stated they had discontinued his sliding scale insulin. ADON E stated she did not know if LVN A thought his blood sugar checks were discontinued because the sliding scale was discontinued. ADON E stated LVN A did document that she verified the medications with the NP but she did not know exactly what LVN A verified and did not know why the glucose checks were dropped. ADON E was not sure if there was any communication about getting blood sugar checks for Resident #2 and stated it was not documented on LVN As note. ADON E did not know why LVN A did not ask for blood sugar checks for Resident #2 and stated residents with type 2 diabetes should be on blood sugar checks. ADON E stated she spoke with the NP today who said if they would have addressed it with him he would have given the blood sugar checks. ADON E stated Resident #2 was without blood sugar checks for 5 days from 04/03/25-04/08/25. ADON E stated herself and ADON G had trained staff over requesting and in putting orders and about checking blood sugar for diabetics. ADON E stated they did not have a facility policy for diabetic procedures or blood sugar checks and stated it was just nursing 101 to check diabetics blood sugars before meals. ADON E stated LVN A did not follow procedure in this situation. ADON E stated not getting blood sugar checks could negatively impact a resident by causing them to go hypoglycemic (low blood sugar). ADON E stated she believed Resident #2 was sent out due to him becoming hypoglycemic on 04/08/25 and stated she did not see him during that time. During an interview with the DON on 05/02/25 at 6:11pm he stated there was a progress note from LVN A on 04/03/25 that stated she went over Resident #2's orders with the NP. The DON stated that progress note did not include communication regarding blood sugar checks. The DON stated some physicians did not have residents on blood glucose checks and would instead check their A1C. The DON stated if a resident's blood glucose is controlled with diet and oral medication, they can be taken off blood glucose checks and if they are uncontrolled then you really cannot take them off blood glucose checks. The DON was asked if there was a reason why LVN A did not ask the NP for blood glucose checks for Resident #2 and he stated it depended on the order that came in with the resident from the hospital, and stated it they were on insulin they are on glucose checks regardless but stated sometimes they went in with PO (oral) medication and would use an A1C to check their glucose. The DON stated Resident #2 did not have any order from blood sugar checks during his stay from 04/03/25 through 04/08/25. The DON stated Resident #2 had no negative outcomes from not having his blood glucose checked during that time that he knew of. The DON stated he was not sure if staff had been trained prior to Resident #2 over blood glucose checks but stated they had been trained since and stated the training occurred prior to him starting to work at the facility. The DON stated yes, the facility had a policy regarding diabetic procedures and blood glucose checks but had to read it to give me information regarding what it stated. The DON stated LVN A followed the admission process. The DON stated if someone had a history of hypoglycemia and did not have blood glucose checks it could put their life in danger. The DON reviewed Resident #2's blood sugar summary and stated he only identified 1 episode of Resident #2's blood sugar at 50 on 02/16/25. During a follow up interview on 05/06/25 at 12:14pm The DON stated if a resident was responsive they could decompensate within 5 to 30 minutes if their blood glucose was at 50 and was not being monitored. Record review of facility Inservice training report dated 04/11/25 revealed LVN A and ADON E had been trained on glucose checks, admissions and notifying the doctor. Record review of LVN A's orientation and skills competency revealed a section titled, Physician Orders and a subsection titled, acquisition that indicated she had been evaluated over this area on 01/02/24 by a previous DON. There was no additional comments on comment section and was signed and dated by both LVN A and a previous DON on 01/02/24 Record review of facility in services revealed LVN A had been trained over medication reconciliation and verifying medication on 04/17/25. Record review of facility Ad HOC QAPI dated 04/11/25 revealed, blood glucose as an agenda item. During an interview on 04/16/25 at around 4:00pm the Regional Clinical Specialist stated they did not have a facility policy for diabetic procedures or blood sugar checks. During an interview on 04/16/25 at 4:12pm ADON E stated they did not have a facility policy for diabetic procedures or blood sugar checks. During an interview on 04/16/25 at 5:16pm the Administrator stated they did not have a facility policy for diabetic procedures or blood sugar checks. Record review of facility policy with an implementation date or 10/24/22 and titled Notification of Changes stated, the purpose of this policy is to ensure the facility prompt informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. and 3. Circumstances that require a need to alter treatment. This may include a. a new treatment. 2.Record review of Resident #2's face sheet, dated 04/16/25, revealed the resident was an [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnoses that included: type 2 diabetes mellitus (insufficient production of insulation causing high blood sugar) without hypoglycemia (low blood sugars) without coma, chronic systolic (congestive) (left ventricle lose ability to contract normally and the heart cant with enough force to push enough blood into circulation) heart failure, hyperlipidemia (abnormally high levels of lipids (fat) in the blood) and essential (primary) hypertension (high blood pressure). Record review of Resident #2's Medicare 5-day MDS assessment, dated 02/27/25, revealed Resident #2 had a BIMS score of 11, indicating his cognition was moderately impaired. Resident #2's section M - skin conditions reflected Resident #2 was at risk for developing pressure ulcers/injuries, had no unhealed pressure ulcers/injuries, 1 venous and arterial ulcer present, had diabetic foot ulcer(s), moisture associated skin damage (MASD), had a pressure reducing device for bed and had application of non-surgical dressings (with or without topical medications) other than to feet. Record review of Resident #2's care plan with an initiation date of 04/16/25 reflected problems such as, [Resident #2] has an arterial of the left dorsum foot, [Resident #2] has a stage 2 pressure injury to left gluteus and unstageable pressure injury to left heel and [Resident #2] has actual impairment to skin integrity of the sacrum r/t (related to) MASD and impairment to skin integrity of the penis r/t (related to) surgical wound. All 3 problem areas had an intervention of, Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Record review of Resident #2's hospital documents dated 04/03/25 and titled Physician-Discharge Med (medications) Rec Order Landsc (definition unknown) and Discharge - Patient Medication Report did not include any orders for impaired skin integrity management. Record review of Resident #2's nursing note dated 04/03/25 at 7:41 p.m., written by LVN A reflected he had returned to the facility at that time after a hospital stay and stated LVN A had verified medication list with the NP. Record review of Resident #2's nursing note dated 04/03/25 at 7:41 p.m., written by LVN A reflected he had returned to the facility at that time after a hospital stay. Nursing note also stated Resident #2 present with Discoloration noted to bilateral arms. Multiple scabs noted to posterior left arm . Red discoloration noted to sacrum area .Surgical incision to penis area d/t (due to) circumcision. Swelling noted to groin area. Scab noted to top of left foot and left heel. Record review of Resident #2's initial nursing evaluation dated 04/03/25 completed by LVN A had yes marked off indicating Resident #2 had skin impairments but did not mark anything on body diagram or site and description table that detailed location or measurement. Record review of Resident #2's skin assessments with an effective date of 04/07/25 revealed Resident #2 had the following: a diabetic wound to left dorsum foot that measured an area of 3.1 cm² with a length of 3.3 cm, width of 1.4 cm, depth of 0.1 cm. A diabetic would to left heel that measured an area of 1.8 cm² with a length of 2.2 cm, width of 1.0 cm, depth of 0.1 cm, MASD specifically incontinence associated dermatitis to sacrum that measured an area of 2.2 cm² with a length of 3.8 cm, width of 0.7 cm, depth of 0.1 cm. and an abrasion to penis that measured an area of 8.7 cm² with a length of 4.6 cm, width of 4.4 cm, depth of 0.1 cm. All areas of skin impairments were listed as present on admission on [DATE] and 01/26/25 and were all marked as resolved. Record review of Resident #2's order summary repo[TRUNCATED]

Based on observation, record review, and interview, the facility failed to: -ensure the resident environment remained as free of accident hazards as is possible, and -ensure each resident received adequate supervision and assistance devices to prevent accidents, for two residents (R#2 and R#1) of six residents reviewed for accident hazards and falls. 1) The facility failed to remove a mattress placed on the floor next to R#2's bed by an unknown person. R#2 got out of bed to go to the restroom, and fell due to the mattress on the floor. R#2 sustained fractures to both of her wrists. 2) The facility did not provide the type and amount of supervision necessary to prevent R#1 from falling 10 times in less than four months. These failures could place residents at risk of additional falls and injuries. The findings were: 1) Record review of R#2's admission record, dated 08/21/19, revealed R#2 was admitted to the facility on [DATE]. R#2's [DIAGNOSES REDACTED]. Record review of R#2's Order Summary Report, dated 08/21/19, did not show any orders for a mattress to be placed alongside R#2's bed for fall precautions. Record review of R#2's baseline care plan, dated 08/17/19, revealed R#2: -could communicate easily with staff, -had adequate vision, -had an ADL self-care performance deficit related to generalized weakness, -required limited to moderate assist by staff with bathing/showering, -was able to perform own personal and oral care with limited assist and tray set up, -was able to transfer to toilet with limited assist x1, and -required limited assistance by one staff member to move between surfaces as necessary. R#2's baseline care plan indicated: -Is the resident at risk for falls: No -Is the resident an elopement risk: No [NAME] Special Treatments & Cognition -Level of consciousness: Alert -Cognitive status: Cognitively impaired [NAME] Functional Status -Set up only for: eating, bed mobility -One-person physical assist: personal hygiene, toilet use, dressing, bathing, transfers walk in room, and locomotion. There was no mention of R#2 being a fall risk or the implementation of the mattress next to her bed for fall precautions. Record review of R#2's Fall Risk Evaluation, dated 08/17/19, scored R#2 at a 9, indicating R#2 was a Low Risk for falls. The evaluation indicated: .B. History of falls (past 3 months) 1. No falls in past 3 months C. Ambulation/Elimination status 2. Requires use of assistive devices (i.e. cane, w/c, walker, furniture). Scoring: If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. Record review of R#2's progress note and incident report #1161, dated 08/18/19 at 7:30 a.m. revealed: 08/18/19 at 12:41 - Note Text: informed by CNA (Certified Nurse Aide) resident was laying on side bed mattress. Assessed resident noted resident was lying on her right side. asked resident what happened. Resident stated she was trying to go to the restroom. Encourage resident to use the call light. No redness noted at this time. no [MEDICAL CONDITION] noted c/o (complaint of) pain to back right side and both hands. v/s (vital signs) 105/58 66 16 97.6 ax. Called np (Nurse Practitioner) to made aware. New orders given. Portable x ray to right scapula 2v (view) right clavicle 2v right humerus 2v right forearm 2v right wrist 3v right hand 3v left hand 3v d/t dementia dx (diagnosis): pain. Neurochecks initiated. Orders carried out. rp (Responsible Party) made aware. Incoming nurse made aware. Signed by Licensed Vocational Nurse (LVN) C. Record review of the facility's, Provider Self-Reporting of Incidents form, dated 08/19/19, revealed Xrays showed non-displaced fractures to both of R#2's wrists. Record review of R#2's progress note and incident report #1165, dated 08/19/19 at 4:15 revealed: Advised by CNA's that resident had been found on the ground, upon entering room resident was sitting on floor, facing her bed, feet planted on the floor, and hands around knees .resident stated to have lost her balance .no obvious signs of trauma, has discoloration to bilateral wrists r/t previous fall. In an interview on 08/20/19 at 3:52 p.m., R#2 said she did not remember how the fall (on 08/18/19) occurred. R#2 said she thought the fall occurred in the bathroom when she was washing her hands. R#2 said she put her hands on the sink bowl and her hands slipped and she fell to the floor. R#2 said she had pain to her wrists. R#2 had splints and ace bandages wrapped around both wrists. The tops of R#2's hands had purple discolorations. R#2's RP D was in the room at the time of the interview. RP D said she was told the fall occurred in R#2's room, on the morning after R#2's admission. RP D said that, for some unknown reason, a mattress had been placed next to R#2's bed. When R#2 tried to get up to go to the restroom, R#2 tried to stand on the mattress that was on the floor and fell forward. RP D said R#2 probably put her arms out to break her fall and ended up breaking both of her wrists. RP D said R#2 used to be very independent and was able to walk and feed herself. RP D said that, after this incident, R#2 required more assistance with all of her ADLs, including dressing, toileting, and eating. In an interview on 08/20/19 at 11:00 a.m., LVN C said she was the Charge Nurse when R#2 fell in her room on 08/18/19. LVN C said she was called into the room by CNA E. LVN C said, when she walked into the room, R#2 was on a mattress that was on the floor, on her right side. LVN C said R#2 said she had been trying to go to the restroom when she fell . LVN C said she notified the MD of R#2 complaining of pain to her back and right shoulder. LVN C said she obtained an order for [REDACTED]. LVN C said she did not place the mattress next to the resident's bed. LVN C said when she came on her shift, the mattress was already on the floor. In an interview on 08/21/19 at 3:00 p.m., LVN F said he was the nurse who admitted R#2 to the facility. LVN F denied implementing a floor mattress as a fall precaution. LVN F said R#2 did not qualify as a fall precaution resident according to her Fall Risk assessment. In an interview on 08/21/19 at 4:07 p.m., LVN H said he was the nurse who worked the date R#2 was admitted to the facility and worked on hall 400 (the secured unit) where R#2 was admitted . LVN H denied implementing a floor mattress as a fall precaution. In an interview on 08/21/19 at 4:40 p.m., Registered Nurse (RN) G said she was the nurse for the secured unit (hall 400) on 08/17/19 - 08/18/19 on the 10:00 p.m. - 6:00 a.m. shift. RN G said she did not implement the fall mattress next to R#2's bed because she did not have a need to. RN G said R#2 was asleep all night. In an interview on 08/22/19 at 2:29 p.m., the Director of Nurses (DON) said that, according to R#2's family, R#2 was able to ambulate unassisted at home, was able to feed herself and was independent with most of her ADLs. The DON said R#2 was able to walk short distances but was encouraged to ask for assistance by staff to get to the restroom. The DON said R#2 was new to the facility and they were not familiar with her needs. The DON said that, based on her investigation of the incident, R#2 fell on the mattress that was put down on the floor next to her bed when she attempted to get up to go to the bathroom. The DON said she had interviewed several staff and had not determined who put the mattress down on the floor next to R#2's bed. The DON said R#2 did not meet the criteria to be a fall risk and the mattress should not have been placed next to her bed. The DON said a mattress should not be placed beside the bed of a resident who was weak and could trip on it because it could cause the resident to fall. The DON said the mattress was probably left in the room from the previous resident who was there. The DON said none of the staff had admitted to putting the fall mattress on the floor. 2) Record review of R#1's Admission Record dated 08/12/19 indicated R#1 was admitted to the facility on [DATE] and re-admitted on [DATE]. R#1's [DIAGNOSES REDACTED]. Record review of R#1's care plan, dated 05/10/18 revealed, Problem: The resident is risk for falls r/t Gait/balance problems r/t [MEDICAL CONDITION] poor communication, wandering. Interventions: 05/10/18 - Anticipate and meet the resident's needs 05/10/18 - Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. 05/10/18 - Pt (physical therapy) evaluate and treat as ordered or PRN (as needed). Record review of R#1's care plan, dated 05/10/18 revealed, Problem: The resident is resistive to care r/t Alzheimer's Med (medication) administration refuses to use w/c (wheel chair) Refuses staff to assist when poor balance. Becomes agitated when corrected. Interventions: 10/15/18 Educate resident/family/caregivers of the possible outcome(s) of not complying with treatment or care. Record review of R#1's care plan, initiated on 06/10/18 revealed: Problem: Resident with actual unwitnessed fall on 06/10/2018 Resident with an actual unwitnessed fall on 06/29/2018 Resident with actual unwitnessed fall on 12/09/2018 Resident with witnessed fall on 12/22/18 . Interventions: 12/10/18 - Resident received re education on asking for assistance when needed to ambulate to and from room. 12/22/18- Staff received education on providing assistance while ambulating down the hallway. Record review of R#1's Minimum Data Set (MDS) assessment, dated 08/01/19, revealed R#1: -had unclear speech -was sometimes able to make himself understood, -was sometimes able to understand others, -had impaired vision, -did not use corrective lenses, -was not able to give a response to any of the items on the Brief Interview for Mental Status (BIMS), -exhibited no behavioral symptoms, -required limited assistance of one staff for walking in room/corridor and locomotion on/off unit, - was not steady, and only able to stabilize with staff assistance when moving from seated to standing position, and -was not steady, but able to stabilize without staff assistance when walking. Record review of the facility incident log/reports revealed the following fall incidents involving R#1: -#908 - Witnessed fall dated 05/03/19 at 6:40 p.m. revealed R#1 lost his balance and fell to the floor in the hallway. R#1 sustained no injuries. -#952 - Witnessed Fall dated 05/19/19 at 2:50 p.m. revealed R#1 was seen losing balance and falling to the floor as R#1 attempted to enter another resident's room. R#1 sustained a scratch to his left elbow. Record review of R#1's care plan, dated 05/10/18 revealed, Problem: The resident is resistive to care r/t Alzheimer's Med (medication) administration refuses to use w/c (wheel chair) Refuses staff to assist when poor balance. Becomes agitated when corrected. Interventions: 05/21/19 Remind resident to use w/c when needed 05/21/19 reorient and redirect as needed. -#981 - Un-witnessed dated 05/31/19 at 3:15 p.m. revealed R#1 was found in his room on the floor on his knees and hands. R#1 sustained no injuries. -#1043 - Un-witnessed dated 06/27/19 at 2:25 p.m. revealed R#1 had an unwitnessed fall in the dining room and got up from the floor by himself. R#1 sustained no injuries. -#1067 - Witnessed fall dated 07/09/19 at 6:10 p.m. revealed R#1 was observed by the charge nurse in the dining room lose balance and fell on his knee to the floor. R#1 sustained redness to both knees, no further injuries. -#1081 - Witnessed fall dated 07/15/19 at 6:05 p.m. revealed R#1 was observed by the charge nurse in the dining room lose balance and fell on his buttocks to the floor. R#1 sustained no injuries. -#1107 Un-Witnessed dated 07/29/19 at 2:35 p.m. revealed R#1 was found in his room with his head on the floor and his body on the bed. R#1 sustained a skin tear to the top of his head. -#1136 - Witnessed Fall dated 08/07/19 at 3:45 p.m. revealed R#1 was walking with his responsible party (RP) in the hall way when he lost balance and fell to the floor on his right knee. R#1 sustained no injuries. -#1140 - Witnessed Fall dated 08/09/19 at 11:30 a.m. revealed R#1 was observed standing from a chair in the living room of the secured unit. R#1 attempted to hold on to the snack cart with his left hand but the cart rolled away and R#1 fell to the floor. X-rays revealed R#1 sustained a fracture to the 5th metacarpal head with displacement and impaction noted with soft tissue swelling. -#1154 - Witnessed Fall dated 08/15/19 at 5:20 p.m. revealed R#1 fell to the floor when he attempted to pick up a piece of fruit from the floor. As R#1 looked up from the floor, a chair was behind him and R#1 hit the back of his head with the chair. R#1 sustained no injuries. Record review of R#1's care plan, initiated on 08/19/19, revealed R#1 had witnessed falls on 08/07/19, and 08/09/19. Interventions: 08/09/19 - Staff received education on never leaving snack cart unattended 08/09/19 - Staff received education on placing snack cart behind nurse's station stored properly 08/09/19 - Staff received education on locking brakes on snack cart when cart is stationary 08/15/19 - Instructed patient on requesting assistance to pick up item from floor and not to try to pick up fallen items on his own. 08/15/19 - Staff received education on providing patient assistance with picking up items from floor should they fall down so patient does not attempt to do so on his own. Observation on 08/21/19 at 2:34 p.m., revealed R#1 was in the secured unit dining area, sitting on a chair and participating in the daily activities. R#1 was not exhibiting any signs or symptoms of distress or discomfort. LVN A and a CNA assisted R#1 up from the chair and ambulated him to his room. R#1 was not able to walk on his own, his gait was unsteady, requiring two staff to ambulate the resident. Surveyor attempted to interview R#1 about the falls, but R#1 was not able to answer surveyor's questions. In an interview on 08/20/19 at 10:47 a.m., LVN B said he was a witness to the fall R#1 suffered on 08/09/19. LVN B said he was standing about arm's length away from R#1 in the secured unit living room when R#1 decided to get up from the sofa and attempted to grab the snack cart by the handle. LVN B said that, as he saw R#1 grab the snack cart handle, the snack cart rolled away and R#1 fell to the floor. LVN B said R#1 was able to ambulate independently in the unit at times. LVN B said R#1 had [MEDICAL CONDITION] and his gait could get very unsteady. In an interview on 08/22/19 at 2:59 p.m., the Director of Nurses (DON) said R#1 was very impulsive and had a strong upper and lower body. The DON said R#1 ambulated independently in the unit until he got tired. The DON said R#1 would suddenly get tired and suffered falls because of it. The DON said the staff tried to supervise R#1 as much as they could. The DON acknowledged R#1 had 10 falls since (MONTH) 2019. The DON said she and the Administrator discussed getting the family involved and possibly getting a sitter for the resident to prevent and/or reduce the number of falls. Record review of the facility's Fall Risk policy, dated (MONTH) (YEAR), revealed: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. The staff will identify appropriate interventions to reduce the risk of falls. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. If underlying causes cannot be readily identified of corrected, staff will try various interventions, based on assessment of the nature or category of falling.

Based on record review and interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being, in accordance with the comprehensive assessment, for one Resident (R#1) of three residents reviewed for the use of indwelling catheters. R#1 had a urinary catheter. Facility staff noted R#1's urine had a strong smell of ammonia, and was dark in color. Urinalysis results were abnormal on [DATE]. R#1 was sent to the hospital for respiratory distress on [DATE]. At the hospital, R#1's urine was noted to be brown and turbid. Urine and blood cultures showed E. coli ESBL. R#1 was found to be in shock, possibly secondary to dehydration, but also possibly secondary [MEDICAL CONDITION] due to UTI. R#1 was diagnosed with [REDACTED]. The facility did not: -ensure that R#1's Primary Physician was informed of the lab results and R#1's symptoms, -observe and record urine appearance every shift and as needed and report any abnormalities to R#1's Physician, as called for in R#1's care plan, -consistently monitor R#1's urine output. R#1 expired less than 24 hours after being sent to the hospital. This failure could place all nine residents with urinary catheters at risk for development or worsening of urinary tract infections (UTIs). The findings were; Record review of R#1's Face Sheet dated [DATE] revealed R#1 was an [AGE] year-old female who was admitted to the facility on [DATE]. Record review of R#1's [DATE] Physician order [REDACTED]. Record review of R#1's Minimum Data Set (MDS) Quarterly review assessment, dated [DATE], revealed R#1: -was rarely/never able to make herself understood or understand others, -had severely impaired cognition (never/rarely made decisions), -was totally dependent on staff assistance for bed mobility, transfers, locomotion, dressing, eating, toilet use, and personal hygiene, -had impaired range of motion to the lower extremities on both sides, -was always incontinent of bowel and bladder, -was at risk of developing pressure ulcers, and -had a Stage 1 (Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.) or higher pressure ulcer. Record review of R#1's care plan dated [DATE] documented R#1 had a toileting self-care deficit, required total assistance with toileting, and was incontinent of bowel and bladder. Care plan indicated R#1 had a urinary catheter as of [DATE]. Record review of R#1's Physician's telephone orders dated [DATE] revealed an order for [REDACTED]. Record review of R#1's Departmental Notes dated [DATE] (late entry for [DATE]) revealed a new order for a urinary catheter due to a Stage 3 to the right buttocks, to promote wound healing. Incoming nurse aware of new order, will insert Foley during night shift. RP notified upon recommendation from wound care center for Foley to be placed. Record review of R#1's care plan dated [DATE] revealed R#1 was at risk for Urinary Tract Infections (UTIs) due to the use of an indwelling urinary catheter for wound healing. Interventions were to observe and record urine appearance every shift and as needed and report any abnormalities to R#1's Physician and Responsible Party (RP). In an interview on [DATE] at 10:10 a.m., the Director of Nurses (DON) said there was no documentation that R#1's urine appearance was recorded every shift, as indicated in the care plan. Record review of R#1's laboratory results of a urinalysis (UA), collected [DATE], revealed: - Urine color was pink (reference range colorless). - Urine appearance was cloud (reference range - clear). - Urine ph was 8.0 (reference range - 5.0 - 7.5). - Urine protein was 600 (reference range - negative). - Urine Leuk Est was large (reference range - negative). - Urine blood was moderate (reference range - negative). - Urine WBC (white blood cells) >182 (reference range ,[DATE]). - Urine RBC (red blood cells) >182 (reference range ,[DATE]). - Urine Squam Epth 11, (reference ,[DATE]). Record review of R#1's laboratory results of a Urine Culture, collected [DATE], revealed: Final report - Mixed flora, 3 or more morphotypes, possible contamination. Correlate results with clinical findings. Record review of a Situation Background Assessment Recommendation (SBAR) Communication Form, dated [DATE], for R#1, revealed R#1's laboratory results were faxed to R#1's Physician, pending call back from staff for new orders to follow up labs, reported to medical director, no new orders for recollection. The SBAR form was electronically signed by Licensed Vocational Nurse (LVN) G. In an interview on [DATE] at 4:20 p.m., LVN G said she called R#1's Physician on [DATE] to request lab work because she noticed R#1's urine had a strong smell of ammonia, and it was dark in color. LVN G said that, after the lab results came back, she called R#1's Physician, but the Physician did not return her call. LVN G said she then called the facility's Medical Director about R#1's lab results, but the Medical Director gave no new orders. LVN G said she did not attempt to call R#1's primary Physician again after the Medical Director gave no new orders. LVN G said she did not take care of R#1 after that date. In an interview on [DATE] at 10:20 a.m., the DON said R#1's [DATE] lab work was, not a recurrent problem and the facility's Medical Director had given no new orders. In an interview on [DATE] at 12:15 p.m., the DON said there was no time frame to call the Medical Director in cases in which the resident's primary physician was not responding to nurses' calls. The DON said the time to call the Medical Director was dependent on each case and severity. In an interview on [DATE] at 12:30 p.m., LVN A said that, if nurse was not able to get hold of a resident's physician, the nurse was to call the facility's Medical Director. LVN A said the nurse should continue to call the resident's primary physician to inform him/her about the orders from the Medical Director. Record review of R#1's Departmental Notes, dated [DATE] at 4:43 a.m., revealed, ,[DATE] shift: Foley catheter changed at 4 a.m., out of place, FR16 balloon filled with 30 millimeters (mls); urine output is clear with small blood clots. No drainage to previous bag. Received report evening nurse had changed it on ,[DATE] shift. Will continue to monitor. In an interview on [DATE] at 2:00 p.m., LVN S said that, on [DATE], she replaced R#1's urinary catheter because it was not placed correctly. LVN S said sometimes small blood clots would be noticed due to trauma replacement. There were no Departmental Notes documented for R#1 from [DATE] at 4:43 a.m., until [DATE] at 3:38 p.m. In an interview on [DATE] at 10:00 a.m., the DON said the facility documented, by exception. Record review of R#1's Departmental Notes, dated [DATE] at 3:38 p.m., revealed, 2:00 p.m. upon doing walking round resident noted with chills with small amount of emesis. ,[DATE] nurse called physician took over resident and assessed her, pending call back with orders. RP aware, will continue to monitor. Note was electronically signed by LVN O. In an interview on [DATE] at 8:40 a.m., LVN O said he worked on [DATE] from 6:00 a.m. to 2:00 p.m. LVN O said when doing his final round, accompanied by the incoming nurse, LVN B, they noticed that R#1 was shaking. In an interview on [DATE] at 10:35 a.m., LVN B said he did not see R#1's [DATE] lab results until [DATE]. LVN B said he called R#1's Physician because he thought R#1 could have a UTI. Record review of R#1's Physician Telephone Order dated [DATE] at 5:20 p.m. revealed, Transfer to emergency hospital for evaluation and treatment. [DIAGNOSES REDACTED]. Record review of R#1's Medical Status Summary, dated [DATE] at 5:52 p.m., revealed R#1 was noted in respiratory distress, with labored breathing. R#1's oxygen (O2) saturation level was ,[DATE] on room air. R#1 was pale with bluish discoloration to her hands. R#1 was placed on an O2 non rebreather at 25 liters per minute (lpm) and R#1's oxygen saturation went up to 90%. R#1's urinary catheter was in place, with no urine noted. R#1's Physician was notified and ordered that R#1 be sent to the emergency room for further treatment and evaluation. R#1's Medical Status Summary indicated that R#1's most recent vital signs taken were dated [DATE] and included Temperature- 97.8, Respiration- 16 per minute. In an interview on [DATE] at 11:30 a.m., the DON said R#1 did not exhibit any signs or symptoms of a change in condition. The DON said nobody noticed any changes in R#1. The DON said nurses documented only when there was a change in condition or abnormality. The DON said residents' vital signs were taken once a month or for a change of condition. The DON said R#1's Medical Status Summary did not document vital signs for [DATE]. DON said there was another document given to EMS that had R#1's vital sign information, however, she was not able to locate the document. Record review of R#1's Departmental Notes, dated [DATE] at 6:18 p.m., revealed that, After receiving the floor ,[DATE] shift, R#1 had a temperature of 98.8 degrees F (Fahrenheit). Tylenol 325 mg (milligrams), two tablets, was administered. Call back pending from the physician. At 4:00 p.m., R#1's temperature elevated up to 100.1 degrees F. R#1's family member arrived and noted R#1 with emesis, and labored breathing. R#1's oxygen saturation level was ,[DATE] on room air. R#1 was pale with bluish discoloration to her hands. R#1 was placed on an O2 non rebreather at 25 lpm and R#1's oxygen saturation went up to 90%. R#1's temperature was 99.1 degrees F. R#1's urinary catheter was in place, with no urine noted. R#1's Physician was notified and ordered that R#1 be sent to the emergency room for further treatment and evaluation. Record review of R#1's Discharge Summary, dated [DATE], revealed R#1 was transferred to the hospital via Emergency Medical Services (EMS). Record review of R#1's Hospital Admission Record dated [DATE] revealed a chief complaint description of Acute [MEDICAL CONDITION] and Severe Dehydration. Record review of R#1's Hospital, Urinalysis Testing report, collection date [DATE] revealed a urinalysis documented: Urine color was - Brown (reference range - yellow), Urine appearance was - Turbid (thick or opaque with matter in suspension : cloudy or muddy in appearance), (reference range - clear). Record review of R#1's Hospital, Microbiology, urine culture report, collection date [DATE], revealed the presence of E. coli ESBL (resistant strain of E. coli). Record review of R#1's Hospital, Microbiology, blood culture report, collection date [DATE], revealed the presence of E. coli ESBL. Record review of R#1's Hospital History and Physical revealed R#1 was admitted on [DATE]. Problem List was: -Acute [MEDICAL CONDITION], -Sepsis (potentially life-threatening complication of an infection.[MEDICAL CONDITION] occurs when chemicals released into the bloodstream to fight the infection trigger [MEDICAL CONDITION] responses throughout the body) with septic shock, secondary to urinary tract infection (bacteria pending to identify), -Metabolic acidosis (condition that occurs when the body produces excessive quantities of acid or when the kidneys are not removing enough acid from the body), -Acute [MEDICAL CONDITION], -Disseminated Intravascular coagulation (condition in which small blood clots develop throughout the bloodstream, blocking small blood vessels), -Elevated Troponin, -[MEDICAL CONDITION] (elevated sodium level in the blood), -Advanced Dementia. History of present illness: .She (R#1) was transferred as per my order to the emergency room at (hospital) yesterday afternoon after that was complaining that the patient was weak, more than her baseline. Also, the patient had an abnormal urinalysis with too many white blood cell count. The nurse from the nursing home ___ for IV antibiotics; however, in view that the patient's saturation was also reported to be 50 at some point, I have recommended to transfer to the emergency room and despite of the nurse notes from the nursing home state that her blood pressure was ,[DATE]. After evaluation in the emergency room , the patient was found to be dehydrated with in shock that possibly secondary to dehydration, but also possibly secondary [MEDICAL CONDITION] due to UTI . Prognosis: minutes to hours. Record review of R#1's Hospital Discharge Summary dated [DATE] revealed a discharge date of [DATE]. Hospital course indicated that, after evaluation in the emergency room , R#1 was found dehydrated, acidotic and R#1's blood cultures and urine cultures came back positive for ESBL Escherichia coli. R#1 was in the intensive care unit. She was on [MEDICAL CONDITION] and family members signed the Do not Resuscitate (DNR) documentation. R#1 was given comfort measures and expired on [DATE]. In an interview on [DATE] at 9:20 a.m., Licensed Vocational Nurse (LVN)/Treatment Nurse C said R#1 had a Stage 3 pressure ulcer on her right buttocks. LVN/Treatment Nurse C said R#1's physician ordered a urinary catheter because of R#1's pressure ulcer. LVN/Treatment Nurse C said urinary catheters helped keep residents dry. LVN/Treatment Nurse C said R#1 required total care for all her activities of daily living, including incontinent care. LVN/Treatment Nurse C said an infection could occur when staff did not properly clean urinary catheters. In an interview on [DATE] at 11:15 a.m., LVN H said R#1 had lab work done on [DATE], however, the facility's Medical Director did not give new orders related to the lab results. LVN H said Certified Nurse Aides (CNAs) did catheter care every time CNAs did peri-care. LVN H said urinary catheter bags were usually changed twice a month. LVN H said urinary catheters were changed every month, or if there was no urine coming out due to not being properly placed. In an interview on [DATE] at 1:30 p.m., LVN B said R#1 was total care, not able to express her needs, and was bed bound or up to a Geri-chair. LVN B said that, on [DATE], R#1 was throwing up. LVN B said he did not notice any changes in R#1's mental status, or skin turgor. LVN B said he had not checked R#1's urinary catheter or observed CNAs do R#1's catheter care. LVN B said he had not checked R#1's fluid intake. In an interview on [DATE] at 8:25 a.m., the Director of Nurses (DON) said CNAs did catheter care, and were trained on catheter care upon hire. DON said urinary catheter bags had to be emptied at least once per shift. DON said approximately 30 cc of urine per hour was normal; approximately 240 cc of urine per eight hours (720 cc per day). Review of website at https://www.nlm.nih.gov/ ./ency/ ./ 5.h ., United States National Library of Medicine, Medline Plus indicated: The normal range for 24-hour urine volume is 800 to 2000 milliliters (cc) per day (with a normal fluid intake of about 2 liters per day). Record review of R#1's, Bladder Roster, revealed outputs were documented from [DATE] until [DATE]: -[DATE] - documented urine output measured once, with a total of 600 cc for the day. -[DATE] - documented urine output measured twice, with a total of 1350 cc for the day. -[DATE] - no documentation urine output was measured on any shift. -[DATE] - no documentation urine output was measured on any shift. -[DATE] - documented urine output measured once, with a total of 250 cc for the day. -[DATE] - no documentation urine output was measured on any shift. -[DATE] - documented urine output measured once, with a total of 250 cc for the day. -[DATE] - documented urine output measured twice, with a total of 1450 cc for the day. -[DATE] - documented urine output measured once, with a total of 300 cc for the day. -[DATE] - documented urine output measured once, with a total of 300 cc for the day. There was no output documentation from [DATE] to [DATE]. Record review of R#1's Completed Care form, printed on [DATE] at 2:45 p.m., documented: -[DATE] - documented urine output measured three times, with a total of 950 cc for the day. -[DATE] - documented urine output measured three times, with a total of 1100 cc for the day. -[DATE] - documented urine output measured three times, with a total of 1150 cc for the day. -[DATE] - documented urine output measured three times, with a total of 900 cc for the day. Record review of R#1's paper record and electronic record revealed no documentation the facility recorded R#1's urine character such as color and odor as indicated in R#1's Comprehensive Care plan dated [DATE]. In an interview on [DATE] at 10:20 a.m., CNA J said R#1 required total care. CNA J said that, in her last days at the facility, R#1 had no appetite. CNA J said R#1's urinary catheter was cleaned every time peri-care was done. CNA J said CNAs had to document in the computer system the amount of urine output every time they emptied the urinary catheter bag. CNA J said any CNA in the hall could input the information, even if they were not the ones that actually emptied the urinary catheter bag and measured the output. CNA J said CNAs could ask another CNA working the same hall and shift to input the information in the system. In an interview on [DATE] at 8:30 a.m., LVN N said that, if a resident had a urinary catheter and was stable, nurses did not look into their urine output documentation. LVN N said CNAs were to report to nurses if they found something different in the urine output, then nurses would check the urinary catheter bag. The facility's undated, Policy on Catheter Care, Urinary, revealed: -The purpose of this procedure is to prevent catheter-associated urinary tract infections. -The following information should be recorded in the resident's medical record; Character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), and odor. The facility's Resident Census and Conditions of Residents form dated [DATE] documented nine residents with indwelling or external catheters.

Based on record review and interview, the facility failed to ensure a resident who was incontinent of bladder received the appropriate treatment and services to prevent urinary tract infection, for one Resident (R#1) of three residents reviewed for the use of indwelling catheters. R#1 had a urinary catheter. Facility staff noted R#1's urine had a strong smell of ammonia, and was dark in color. Urinalysis results were abnormal on [DATE]. R#1 was sent to the hospital for respiratory distress on [DATE]. At the hospital, R#1's urine was noted to be brown and turbid. Urine and blood cultures showed E. coli ESBL. R#1 was found to be in shock, possibly secondary to dehydration, but also possibly secondary [MEDICAL CONDITION] due to UTI. R#1 was diagnosed with [REDACTED]. R#1 expired less than 24 hours after being sent to the hospital. The facility did not: -ensure that R#1's Primary Physician was informed of the lab results and R#1's symptoms, -observe and record urine appearance every shift and as needed and report any abnormalities to R#1's Physician, as called for in R#1's care plan, -consistently monitor R#1's urine output. This failure could place all nine residents with urinary catheters at risk for development or worsening of urinary tract infections (UTIs). The findings were; Record review of R#1's Face Sheet dated [DATE] revealed R#1 was an [AGE] year-old female who was admitted to the facility on [DATE]. Record review of R#1's [DATE] Physician order [REDACTED]. Record review of R#1's Minimum Data Set (MDS) Quarterly review assessment, dated [DATE], revealed R#1: -was rarely/never able to make herself understood or understand others, -had severely impaired cognition (never/rarely made decisions), -was totally dependent on staff assistance for bed mobility, transfers, locomotion, dressing, eating, toilet use, and personal hygiene, -had impaired range of motion to the lower extremities on both sides, -was always incontinent of bowel and bladder, -was at risk of developing pressure ulcers, and -had a Stage 1 (Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.) or higher pressure ulcer. Record review of R#1's care plan dated [DATE] documented R#1 had a toileting self-care deficit, required total assistance with toileting, and was incontinent of bowel and bladder. Care plan indicated R#1 had a urinary catheter as of [DATE]. Record review of R#1's Physician's telephone orders dated [DATE] revealed an order for [REDACTED]. Record review of R#1's Departmental Notes dated [DATE] (late entry for [DATE]) revealed a new order for a urinary catheter due to a Stage 3 to the right buttocks, to promote wound healing. Incoming nurse aware of new order, will insert Foley during night shift. RP notified upon recommendation from wound care center for Foley to be placed. Record review of R#1's care plan dated [DATE] revealed R#1 was at risk for Urinary Tract Infections (UTIs) due to the use of an indwelling urinary catheter for wound healing. Interventions were to observe and record urine appearance every shift and as needed and report any abnormalities to R#1's Physician and Responsible Party (RP). In an interview on [DATE] at 10:10 a.m., the Director of Nurses (DON) said there was no documentation that R#1's urine appearance was recorded every shift, as indicated in the care plan. Record review of R#1's laboratory results of a urinalysis (UA), collected [DATE], revealed: - Urine color was pink (reference range colorless). - Urine appearance was cloud (reference range - clear). - Urine ph was 8.0 (reference range - 5.0 - 7.5). - Urine protein was 600 (reference range - negative). - Urine Leuk Est was large (reference range - negative). - Urine blood was moderate (reference range - negative). - Urine WBC (white blood cells) >182 (reference range ,[DATE]). - Urine RBC (red blood cells) >182 (reference range ,[DATE]). - Urine Squam Epth 11, (reference ,[DATE]). Record review of R#1's laboratory results of a Urine Culture, collected [DATE], revealed: Final report - Mixed flora, 3 or more morphotypes, possible contamination. Correlate results with clinical findings. Record review of a Situation Background Assessment Recommendation (SBAR) Communication Form, dated [DATE], for R#1, revealed R#1's laboratory results were faxed to R#1's Physician, pending call back from staff for new orders to follow up labs, reported to medical director, no new orders for recollection. The SBAR form was electronically signed by Licensed Vocational Nurse (LVN) G. In an interview on [DATE] at 4:20 p.m., LVN G said she called R#1's Physician on [DATE] to request lab work because she noticed R#1's urine had a strong smell of ammonia, and it was dark in color. LVN G said that, after the lab results came back, she called R#1's Physician, but the Physician did not return her call. LVN G said she then called the facility's Medical Director about R#1's lab results, but the Medical Director gave no new orders. LVN G said she did not attempt to call R#1's primary Physician again after the Medical Director gave no new orders. LVN G said she did not take care of R#1 after that date. In an interview on [DATE] at 10:20 a.m., the DON said R#1's [DATE] lab work was, not a recurrent problem and the facility's Medical Director had given no new orders. In an interview on [DATE] at 12:15 p.m., the DON said there was no time frame to call the Medical Director in cases in which the resident's primary physician was not responding to nurses' calls. The DON said the time to call the Medical Director was dependent on each case and severity. In an interview on [DATE] at 12:30 p.m., LVN A said that, if nurse was not able to get hold of a resident's physician, the nurse was to call the facility's Medical Director. LVN A said the nurse should continue to call the resident's primary physician to inform him/her about the orders from the Medical Director. Record review of R#1's Departmental Notes, dated [DATE] at 4:43 a.m., revealed, ,[DATE] shift: Foley catheter changed at 4 a.m., out of place, FR16 balloon filled with 30 millimeters (mls); urine output is clear with small blood clots. No drainage to previous bag. Received report evening nurse had changed it on ,[DATE] shift. Will continue to monitor. In an interview on [DATE] at 2:00 p.m., LVN S said that, on [DATE], she replaced R#1's urinary catheter because it was not placed correctly. LVN S said sometimes small blood clots would be noticed due to trauma replacement. There were no Departmental Notes documented for R#1 from [DATE] at 4:43 a.m., until [DATE] at 3:38 p.m. In an interview on [DATE] at 10:00 a.m., the DON said the facility documented, by exception. Record review of R#1's Departmental Notes, dated [DATE] at 3:38 p.m., revealed, 2:00 p.m. upon doing walking round resident noted with chills with small amount of emesis. ,[DATE] nurse called physician took over resident and assessed her, pending call back with orders. RP aware, will continue to monitor. Note was electronically signed by LVN O. In an interview on [DATE] at 8:40 a.m., LVN O said he worked on [DATE] from 6:00 a.m. to 2:00 p.m. LVN O said when doing his final round, accompanied by the incoming nurse, LVN B, they noticed that R#1 was shaking. In an interview on [DATE] at 10:35 a.m., LVN B said he did not see R#1's [DATE] lab results until [DATE]. LVN B said he called R#1's Physician because he thought R#1 could have a UTI. Record review of R#1's Physician Telephone Order dated [DATE] at 5:20 p.m. revealed, Transfer to emergency hospital for evaluation and treatment. [DIAGNOSES REDACTED]. Record review of R#1's Medical Status Summary, dated [DATE] at 5:52 p.m., revealed R#1 was noted in respiratory distress, with labored breathing. R#1's oxygen (O2) saturation level was ,[DATE] on room air. R#1 was pale with bluish discoloration to her hands. R#1 was placed on an O2 non rebreather at 25 liters per minute (lpm) and R#1's oxygen saturation went up to 90%. R#1's urinary catheter was in place, with no urine noted. R#1's Physician was notified and ordered that R#1 be sent to the emergency room for further treatment and evaluation. R#1's Medical Status Summary indicated that R#1's most recent vital signs taken were dated [DATE] and included Temperature- 97.8, Respiration- 16 per minute. In an interview on [DATE] at 11:30 a.m., the DON said R#1 did not exhibit any signs or symptoms of a change in condition. The DON said nobody noticed any changes in R#1. The DON said nurses documented only when there was a change in condition or abnormality. The DON said residents' vital signs were taken once a month or for a change of condition. The DON said R#1's Medical Status Summary did not document vital signs for [DATE]. DON said there was another document given to EMS that had R#1's vital sign information, however, she was not able to locate the document. Record review of R#1's Departmental Notes, dated [DATE] at 6:18 p.m., revealed that, After receiving the floor ,[DATE] shift, R#1 had a temperature of 98.8 degrees F (Fahrenheit). Tylenol 325 mg (milligrams), two tablets, was administered. Call back pending from the physician. At 4:00 p.m., R#1's temperature elevated up to 100.1 degrees F. R#1's family member arrived and noted R#1 with emesis, and labored breathing. R#1's oxygen saturation level was ,[DATE] on room air. R#1 was pale with bluish discoloration to her hands. R#1 was placed on an O2 non rebreather at 25 lpm and R#1's oxygen saturation went up to 90%. R#1's temperature was 99.1 degrees F. R#1's urinary catheter was in place, with no urine noted. R#1's Physician was notified and ordered that R#1 be sent to the emergency room for further treatment and evaluation. Record review of R#1's Discharge Summary, dated [DATE], revealed R#1 was transferred to the hospital via Emergency Medical Services (EMS). Record review of R#1's Hospital Admission Record dated [DATE] revealed a chief complaint description of Acute [MEDICAL CONDITION] and Severe Dehydration. Record review of R#1's Hospital, Urinalysis Testing report, collection date [DATE] revealed a urinalysis documented: Urine color was - Brown (reference range - yellow), Urine appearance was - Turbid (thick or opaque with matter in suspension : cloudy or muddy in appearance), (reference range - clear). Record review of R#1's Hospital, Microbiology, urine culture report, collection date [DATE], revealed the presence of E. coli ESBL (resistant strain of E. coli). Record review of R#1's Hospital, Microbiology, blood culture report, collection date [DATE], revealed the presence of E. coli ESBL. Record review of R#1's Hospital History and Physical revealed R#1 was admitted on [DATE]. Problem List was: -Acute [MEDICAL CONDITION], -Sepsis (potentially life-threatening complication of an infection.[MEDICAL CONDITION] occurs when chemicals released into the bloodstream to fight the infection trigger [MEDICAL CONDITION] responses throughout the body) with septic shock, secondary to urinary tract infection (bacteria pending to identify), -Metabolic acidosis (condition that occurs when the body produces excessive quantities of acid or when the kidneys are not removing enough acid from the body), -Acute [MEDICAL CONDITION], -Disseminated Intravascular coagulation (condition in which small blood clots develop throughout the bloodstream, blocking small blood vessels), -Elevated Troponin, -[MEDICAL CONDITION] (elevated sodium level in the blood), -Advanced Dementia. History of present illness: .She (R#1) was transferred as per my order to the emergency room at (hospital) yesterday afternoon after that was complaining that the patient was weak, more than her baseline. Also, the patient had an abnormal urinalysis with too many white blood cell count. The nurse from the nursing home ___ for IV antibiotics; however, in view that the patient's saturation was also reported to be 50 at some point, I have recommended to transfer to the emergency room and despite of the nurse notes from the nursing home state that her blood pressure was ,[DATE]. After evaluation in the emergency room , the patient was found to be dehydrated with in shock that possibly secondary to dehydration, but also possibly secondary [MEDICAL CONDITION] due to UTI . Prognosis: minutes to hours. Record review of R#1's Hospital Discharge Summary dated [DATE] revealed a discharge date of [DATE]. Hospital course indicated that, after evaluation in the emergency room , R#1 was found dehydrated, acidotic and R#1's blood cultures and urine cultures came back positive for ESBL Escherichia coli. R#1 was in the intensive care unit. She was on [MEDICAL CONDITION] and family members signed the Do not Resuscitate (DNR) documentation. R#1 was given comfort measures and expired on [DATE]. In an interview on [DATE] at 9:20 a.m., Licensed Vocational Nurse (LVN)/Treatment Nurse C said R#1 had a Stage 3 pressure ulcer on her right buttocks. LVN/Treatment Nurse C said R#1's physician ordered a urinary catheter because of R#1's pressure ulcer. LVN/Treatment Nurse C said urinary catheters helped keep residents dry. LVN/Treatment Nurse C said R#1 required total care for all her activities of daily living, including incontinent care. LVN/Treatment Nurse C said an infection could occur when staff did not properly clean urinary catheters. In an interview on [DATE] at 11:15 a.m., LVN H said R#1 had lab work done on [DATE], however, the facility's Medical Director did not give new orders related to the lab results. LVN H said Certified Nurse Aides (CNAs) did catheter care every time CNAs did peri-care. LVN H said urinary catheter bags were usually changed twice a month. LVN H said urinary catheters were changed every month, or if there was no urine coming out due to not being properly placed. In an interview on [DATE] at 1:30 p.m., LVN B said R#1 was total care, not able to express her needs, and was bed bound or up to a Geri-chair. LVN B said that, on [DATE], R#1 was throwing up. LVN B said he did not notice any changes in R#1's mental status, or skin turgor. LVN B said he had not checked R#1's urinary catheter or observed CNAs do R#1's catheter care. LVN B said he had not checked R#1's fluid intake. In an interview on [DATE] at 8:25 a.m., the Director of Nurses (DON) said CNAs did catheter care, and were trained on catheter care upon hire. DON said urinary catheter bags had to be emptied at least once per shift. DON said approximately 30 cc of urine per hour was normal; approximately 240 cc of urine per eight hours (720 cc per day). Review of website at https://www.nlm.nih.gov/ ./ency/ ./ 5.h ., United States National Library of Medicine, Medline Plus indicated: The normal range for 24-hour urine volume is 800 to 2000 milliliters (cc) per day (with a normal fluid intake of about 2 liters per day). Record review of R#1's, Bladder Roster, revealed outputs were documented from [DATE] until [DATE]: -[DATE] - documented urine output measured once, with a total of 600 cc for the day. -[DATE] - documented urine output measured twice, with a total of 1350 cc for the day. -[DATE] - no documentation urine output was measured on any shift. -[DATE] - no documentation urine output was measured on any shift. -[DATE] - documented urine output measured once, with a total of 250 cc for the day. -[DATE] - no documentation urine output was measured on any shift. -[DATE] - documented urine output measured once, with a total of 250 cc for the day. -[DATE] - documented urine output measured twice, with a total of 1450 cc for the day. -[DATE] - documented urine output measured once, with a total of 300 cc for the day. -[DATE] - documented urine output measured once, with a total of 300 cc for the day. There was no output documentation from [DATE] to [DATE]. Record review of R#1's Completed Care form, printed on [DATE] at 2:45 p.m., documented: -[DATE] - documented urine output measured three times, with a total of 950 cc for the day. -[DATE] - documented urine output measured three times, with a total of 1100 cc for the day. -[DATE] - documented urine output measured three times, with a total of 1150 cc for the day. -[DATE] - documented urine output measured three times, with a total of 900 cc for the day. Record review of R#1's paper record and electronic record revealed no documentation the facility recorded R#1's urine character such as color and odor as indicated in R#1's Comprehensive Care plan dated [DATE]. In an interview on [DATE] at 10:20 a.m., CNA J said R#1 required total care. CNA J said that, in her last days at the facility, R#1 had no appetite. CNA J said R#1's urinary catheter was cleaned every time peri-care was done. CNA J said CNAs had to document in the computer system the amount of urine output every time they emptied the urinary catheter bag. CNA J said any CNA in the hall could input the information, even if they were not the ones that actually emptied the urinary catheter bag and measured the output. CNA J said CNAs could ask another CNA working the same hall and shift to input the information in the system. In an interview on [DATE] at 8:30 a.m., LVN N said that, if a resident had a urinary catheter and was stable, nurses did not look into their urine output documentation. LVN N said CNAs were to report to nurses if they found something different in the urine output, then nurses would check the urinary catheter bag. The facility's undated, Policy on Catheter Care, Urinary, revealed: -The purpose of this procedure is to prevent catheter-associated urinary tract infections. -The following information should be recorded in the resident's medical record; Character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), and odor. The facility's Resident Census and Conditions of Residents form dated [DATE] documented nine residents with indwelling or external catheters.