Every finding on record at Caprock Nursing & Rehabilitation

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 1 (Resident #17) of 22 residents reviewed for infection control.The facility failed to ensure Resident #17's catheter bag and catheter tubing were not on the floor on 07/14/26, 07/15/26, and 07/16/26. This failure could place residents at risk of UTIs and spread of bacteria.Findings included:Record review of Resident #17's admission record dated 07/15/26 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, obstructive and reflux uropathy (urine cannot drain through the urinary tract), acute kidney failure (sudden episode of kidney failure that happens in hours or days), unspecified dementia (breakdown of thought process) and urinary tract infection (common infection that can affect any part of urinary system).Record review of Resident #17's admission MDS assessment completed on 05/21/26 revealed a BIMS score of 12 which indicated moderate cognitive impairment. Section GG Functional Abilities revealed Resident #17 required partial to moderate assistance with toileting hygiene. Section H Bladder and Bowel revealed Resident #17 had an indwelling catheter.Record review of Resident #17's care plan dated 05/21/26 revealed he was on enhanced barrier precautions to avoid transmission of infection from or to the resident. The care plan noted Resident #17 had a catheter related to obstructive uropathy secondary to cancer and he would remove the privacy bag from his catheter. One of the tasks related to his catheter was Check tubing for kinds and maintain the drainage bag off the floor.Record review of Resident #17's active orders revealed the following orders with corresponding order start dates:05/14/26 Ensure foley (catheter) bag is in privacy bag while in bed or w/c every shift05/14/26 Foley Catheter: 16F with 10 bulb - change for occlusion, leaking, closed system was compromised05/18/26 Flush Catheter twice a day and PRN.During an observation and attempted interview on 07/14/26 at 10:37 AM Resident #17 was lying fully dressed on his back on top of his made bed. His catheter bag and approximately 2 inches of the tubing were lying on the floor next to his bed. The catheter bag was not in a privacy bag. The tubing was emerging from the bottom of his left pant leg.During an observation on 07/14/26 at 11:50 AM Resident #17 was lying in bed on his right side. His catheter bag was on the floor next to his bed and not in a privacy bag.During an observation on 07/14/26 at 12:26 PM Resident #17 was lying in bed on his back. His catheter bag was on the floor next to his bed and not in a privacy bag.During an observation on 07/15/26 at 10:40 AM CNA A exited Resident #17's room as this surveyor entered his room. He was lying on his back in bed. His catheter bag was on the floor next to this bed and not in a privacy bag.During an interview on 07/15/26 at 10:42 AM CNA A stated Resident #17's catheter bag was often on the floor. She stated, 'I am always getting onto him about that because we (staff) trip over it. CNA A stated she had asked her supervisors for a way to fasten the bag inside Resident #17's pants but he wears tight pants. She stated staff got a smaller catheter bag and fastened it to Resident #17's leg inside his pants but he did not like it. CNA A stated sometimes Resident #17 walked out of his room with his catheter bag dragging behind him on the floor.During an observation and interview on 07/16/26 at 08:43 AM LVN F exited Resident #17's room as this surveyor entered the room. Resident #17 was seated on the edge of his bed putting his socks on. His catheter bag was on the floor with the tubing wrapped around the front left tire of his w/c and several inches of tubing lying on the floor. During an interview on 07/16/26 at 08:53 AM CNA B stated CNAs were responsible for ensuring a resident's catheter bag was not on the floor. She stated she did not know what the facility's policy said about catheters. CNA B stated she was not trained by the facility on catheter care. She stated she was trained when she was getting her certification as a nurse aide. CNA B stated she did not remember why catheter bags were not to be on the floor, only that they were not. She stated she thought it could cause negative health effects for the resident but was unsure what the negative effects would be. She also stated if it was her catheter bag she would not want it on the floor and it might leak.During an interview on 07/16/26 at 09:00 AM CNA C stated CNAs were responsible for emptying and cleaning catheter and nurses were responsible for changing them. She stated she did not know what the facility policy stated about catheters. CNA C stated she was not trained on catheter care by the facility. She stated, I watched YouTube (videos on catheter care) honestly. She stated a catheter bag on the floor could result in infections; somebody stepping on it; it busting or getting pulled out.During an interview on 07/16/26 at 09:07 AM CNA D stated CNAs were responsible to ensure catheter bags were not on the floor. She stated she did not know what the facility policy on catheter care said. She stated she was trained on catheter care when she first started working for the facility in 2021 or when she was certified as a nurse aide but had not been trained since. CNA D stated a catheter bag could rip, it could pull, it could leak, or he (Resident #17) could trip on it.During an interview on 07/16/26 at 09:11 AM CNA E stated CNAs were responsible for ensuring resident catheter bags were not on the floor. She stated she was unfamiliar with the facility catheter care policy. She stated she was not trained by the facility on catheter care. CNA E stated she was trained in CNA school on keeping the catheter bag off the floor. She stated residents could get an infection if their catheter bag was on the floor.During an interview on 07/16/26 at 09:17 AM LVN F stated everyday catheter care was the responsibility of CNAs. She stated the nurse was ultimately responsible for the CNAs actions. She stated the facility catheter care policy directed staff to keep the catheter off the floor, provide a privacy bag, change and empty the catheter bag as needed. She stated she could not remember the last time she was trained on catheter care. She stated having a catheter bag on the floor was an infection control issue. She stated, Indwelling catheters already have a high risk of infection but adding the germs on the floor and it (catheter bag) dragging makes the risk of infection worse. LVN F stated Resident #17's catheter bag was on the floor of his room when she was in his room earlier the morning of 07/16/26 she stated she noticed it needed a new hook and she planned to let his charge nurse know but was distracted by another resident. LVN F stated she tried to prop Resident #17's catheter bag on his bed frame.During an interview on 07/16/26 at 09:36 AM RN G (Resident #17's charge nurse) stated all nursing staff were responsible for ensuring a resident's catheter bag was not on the floor. She stated she was not familiar with the facility policy on catheter care. She stated she was unsure when she was last trained on catheter care. RN G stated having a catheter bag on the floor could result in infections or spread of bacteria if the urine contained bacteria. RN G stated Resident #17 gets up and moves around and his catheter bag will fall on the floor.During an interview on 07/16/26 at 09:43 AM ADON stated all of nursing was responsible for ensuring catheter bags were not on the floor. She stated she did skill checks with all new CNAs at hire and when the facility had UTI outbreaks. She stated she did not know what the facility policy said regarding catheter care. ADON stated she trained staff on catheter care in March and June of 2026. She stated a catheter bag on the floor was an infection control issue.During an interview on 07/16/26 at 09:56 AM DON stated all nursing staff were responsible for ensuring catheter bags were not on the floor. She stated having a catheter bag on the floor could result in infection.During an interview on 07/16/26 at 11:25 AM DON stated the in-services mentioned by ADON did not specifically address keeping a catheter bag off the floor except in the instance of keeping the catheter bag in a privacy bag, which would be keeping it off the floor in principle.Record review of staff in-service dated 06/02/26 and taught by [NAME] revealed the following point: Routine hygiene/care - pericare/cath (catheter) care/. No mention of keeping catheter bags off the floor.Record review of staff in-service dated 06/29/26 and taught by DON revealed the following point: All catheters or drainage bags will be in privacy bag at all times including in bed or out of bed to promote privacy, dignity, and infection control. No mention of keeping catheter bags off the floor.Record review of facility policy titled Catheter Care and dated 02/13/07 revealed the following: . 5.Keep tubing off floor and minimize friction or movement at insertion site. 10. Be sure the catheter tubing and drainage bag are kept off the floor.Record review of an undated facility policy titled Fundamentals of Infection Control Precautions made no mention of urinary catheters except a directive to wash hands after handling urinary catheters.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure freezer, refrigerator, and pantry items were properly stored, labeled, and dated.This failure could place residents at risk of food-borne illnesses.Findings included:Observation of the prep area in the kitchen on 07/14/26 at 9:15 AM revealed the following:1. (12) bowls of cereal sitting on a tray, all bowls were not covered, open to air, not labeled or dated. Observation of the refrigerator on 07/14/26 at 9:17 AM revealed the following:1. (1) package containing what appeared to be cheese, open to air, not labeled or dated.2. (2) individual servings of prune juice, not dated. 3. (1) box containing 12 vanilla shakes, not dated. 4. (1) container of oranges, open to air. 5. (1) box of cucumbers, not dated.6. (1) bag of lettuce, open to air, not dated.Observation of the freezer on 07/14/26 at 9:22 AM revealed the following:1. (2) cups of ice cream, not labeled or dated. 2. (1) opened box of ice cream sandwiches with 3 sandwiches remaining, not labeled or dated.3. (1) bag of meat patties, not labeled or dated.4. (1) bag of some type of meat, not labeled or dated.5. (1) bag of bread, date was unreadable, not labeled. 6. (15) boxes stored on the floor. 7. (3) pesto containers, not dated.8. (1) container of what looked like orange ice cream, not labeled or dated.Observation of the pantry on 07/14/26 at 9:32 AM revealed the following:1. (15) boxes which contained individual oatmeal pies, not dated.2. (10) pudding containers, not dated.In an interview on 07/14/26 at 9:39 AM, [NAME] H stated she had worked at the facility for one month and was trained to label and date food when they were delivered from the truck and that it was everyone's responsibility to label and date the food as it came in. [NAME] H stated if that did not happen, it could make residents sick since they would not know when it had arrived or what was in the containers if they were not labeled. In an interview on 07/14/26 at 9:41 AM, [NAME] I stated he had worked at the facility for 5 1/2 years and everyone who worked in the kitchen was responsible for labeling and dating food. He stated that if it did not happen, residents could become sick and possibly die. In an interview on 07/14/26 at 9:42 AM, [NAME] J stated it was everyone's responsibility to label and date food and if it was not happening, the kitchen could serve bad food since they may not know how old the food was, which could make residents sick.In an interview on 07/14/26 at 9:46 AM, the DM stated she had worked at the facility for 10 months as the DM and that it was everyone's responsibility to label and date food after it was opened and as the food was delivered from the truck. She stated not doing that could put residents at risk of foodborne illnesses, food poisoning, or they could become sick. Record review of facility policy, titled Food Storage and Supplies, undated, revealed the following information in part:1. b. All food and supplies are to be stored six (6) inches above the floor. 3. Dry bulk foods are stored in seamless metal or plastic containers with tight covers or bins. Containers are labeled. 4. Open packages of food are stored in closed containers with covers or in sealed bags and dated as when opened. 7. All food shall be appropriately dated to ensure proper rotation by expiration dates.Record review of facility policy titled, Food Safety, undated, revealed the following in part: 2. Food is to be wrapped or sealed and covered in clean containers. Opened food shall be labeled, dated and stored properly

Based on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided with such care consistent with professional standards of practice for 1 (Resident #11) of 22 residents reviewed for respiratory care. The facility failed to address Residents #11's use of BiPAP therapy in her physician orders. This failure could place resident at risk for complications such as shortness of breath, confusion, respiratory failure, infection, and exacerbation of their condition.Findings included: Record review of Resident #11's face sheet revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include Amyotrophic Lateral Sclerosis (ALS) (a progressive and fatal neurodegenerative disorder) and malaise (a general feeling of discomfort, illness, lack of well-being). Record review of Resident #11's MDS and completed 6/02/2026 listed Resident #11 with a BIMS of 12 indicating she was moderately cognitively impaired, she had a functionality of requiring supervision/touch assistance with minor adl care to activity not attempted due to her medical condition with more complicated adl's such as dressing and showering. Resident #11 was not listed for using any non-invasive mechanical ventilator to include BiPAP therapy. Record review of Resident #11's care plan with admission date of 5/22/2026 revealed no care plans to address Resident #11's BiPAP therapy. Record review of Resident #11's Order Summary Report with Active Orders As Of: 7/14/2026 revealed no orders to address BiPAP therapy. Record review of Resident #11's Respiratory Therapy Assessment Note printed 7/15/2026 revealed the following: Initial admission - 5/22/26Effective Date: 5/24/26Treatment Plan:3. CPAP or BIPAP Therapy 3. BIPAP3a. When is the BIPAP or CPAP to be used? -At night.Signed by: ADON 5/24/2026 During an observation and interview on 07/14/2026 at 10:49 AM Resident #11 was in her room lying in her bed. Resident #11 was unable to speak but was able to type her answers on an iPad. A BiPap machine was observed on her bedside dresser. Resident #11 reported via her iPad that she has had BiPAP therapy for a couple of months. Resident #11 shook her head yes when asked if the staff provided good care and care with her equipment to include her BiPAP therapy. During an interview on 07/15/2026 at 2:54 PM the ADON reported Resident #11 had her BiPAP since she was admitted and Resident #11 used the BiPAP therapy every night. During an interview on 07/16/2026 at 8:05 AM SNA K reported Resident #11 did wear BiPAP (her breathing machine) at night but did not use it during the day. SNA K reported the breathing machine should be addressed in the resident's chart and she (SNA K) would have no idea what kind of problem would occur if the breathing machine was not addressed in the residents' chart. During an interview and observation on 07/16/2026 at 8:08 AM LVN L reported she had not seen Resident #11 wearing BiPAP but was aware Resident #11 had been using BiPAP at night. LVN L did not know for how long. LVN L entered Resident #11's room and verified the BiPAP machine was in the room and Resident #11 again shook her head yes that she was using the BiPAP therapy. LVN L reported that a resident should have orders to address BiPAP therapy. LVN L reviewed Resident #11's chart and reported Resident #11 did have orders for her BiPAP therapy that had been entered into Resident #11 chart on 7/15/2026. LVN L reported if a Resident did not have BiPAP therapy included or addressed in their chart then staff would not be aware of what the resident was receiving, and the resident might not receive their therapy. During an interview on 07/16/2026 at 8:56 AM the ADON reported she was aware Resident #11 did not have orders to address the use of her BiPAP therapy. The ADON reported Resident #11's BiPAP therapy should be addressed in her chart. The ADON reported if the BiPAP was not addressed in the chart then that was not accurate documentation and was a safety issue for the residents and could result in her not getting the right thing, the right treatment. During an interview on 07/16/2026 at 8:59 AM the MDS/LVN reported if a resident's BiPAP therapy was not addressed on the MAR (which was generated from the residents' orders) then she (MDS/LVN) would not know to include that therapy on the resident's MDS assessment. The MDS/LVN checked Resident #11's MDS and reported her BiPAP therapy was not included in the MDS assessment. The MDS/LVN reported if the resident had no orders for the BiPAP therapy then most likely the therapy would not be included in the MDS assessment or the care plans and the nursing staff would not know what to give the resident. The residents may not get what they need. The MDS/LVN reported an inaccurate MDS assessment could affect the facility's reimbursement. During an interview on 07/16/2026 at 10:42 AM the DON reported she was aware of Resident #11 not having her BiPAP therapy addressed in her chart, that the BiPAP therapy was missed due to some confusion with the resident privately paying for the therapy, and she corrected the issue yesterday (7/15/2026) with new orders and adding the therapy to Resident #11's care plans. The DON reported if a resident needs assistance with the required therapy and it was not addressed in the resident's records then staff would not be aware of the resident's needs. The DON reported she was not aware of a policy the facility had for the inclusion of BiPAP therapy in a resident's chart, but she would look. During an interview on 07/16/2026 at 1:48 PM the DON reported the facility did not have a policy pertaining to accuracy of physician orders and what needed to be included.

Based on observation, interview, and record review, the facility failed to ensure that menus were followed, for 3 out of 3 residents that received therapeutic pureed diets (Residents #2, #9, #31), in that: The facility failed to ensure all three residents that received pureed diets received fried chicken on 07/14/2026 which was the posted lunch menu item and instead they were served pureed chicken strips. This failure had the potential to place residents at risk for inadequate nutritional consistency with the planned menu, decreased meal satisfaction, diminished dignity related to receiving a different meal than other residents and failure to receive meals prepared in accordance with the planned menu. Findings included:Resident #2 Record review of Resident #2's Face sheet, dated 07/15/26, reflected at [AGE] year-old female admitted to the facility on [DATE] and with the diagnoses that include but not limited to acute and chronic respiratory failure (failure of lungs to provide oxygen), mild protein-calorie malnutrition (inadequate intake of food and other essential nutrients), mild intellectual disabilities (limitations in adaptive behavior and skills), unspecified dementia (breakdown of thought process), and gastro-esophageal reflux disease (risk of stomach acid going back and forth between the mouth and stomach ).Record review of Resident #2's Quarterly MDS Assessment, dated 06/24/26, indicated a BIMS score of 03 out of 15, reflecting severe impaired cognition. The assessment reflected Resident #2 had a mechanically altered diet (pureed food). Record review of Resident #2's Comprehensive Care Plan, last revised on 07/10/26 reflected Resident #2 had a puree diet texture, with nectar consistency and interventions that included monitoring meal intake and providing supplements when intake was less than 50 percent or meals were refused. Record review of Resident #2's Active Physicians Orders dated 07/15/26 reflected Resident #2 remained on a pureed textured diet. Resident #9Record review of Resident #9's Face sheet, dated 07/15/26, reflected a [AGE] year-old female originally admitted to the facility on [DATE] with the diagnoses that include but not limited dementia (loss of cognitive function), unspecified protein-calorie malnutrition (inadequate intake of food and other essential nutrients), and dehydration (lack of water in body).Record review of Resident #9's Quarterly MDS Assessment, dated 06/09/26, indicated a BIMS score of 99 indicating resident was unable to complete the cognitive interview. The assessment reflected Resident #9 was ordered a mechanically altered (pureed) diet. Record review of Resident #9's Comprehensive Care Plan, last revised on 06/19/26 reflected Resident #9 had a mechanical soft diet with interventions to provide meals as ordered by physician. Record review of Resident #9's Active Physicians Orders dated 07/15/26 reflected Resident #9 received a pureed textured diet. Resident #31Record review of Resident #31's Face sheet, dated 07/15/26, reflected a [AGE] year-old male originally admitted to the facility on [DATE] with the diagnoses that include but not limited Chronic kidney disease (moderate to severe damage to kidneys), dementia (cognitive loss), and gastro-esophageal reflux disease (risk of stomach acid going back and forth between the mouth and stomach ).Record review of Resident #31's admission MDS Assessment, dated 06/08/26, indicated a BIMS score of 11 out of 15 indicating moderately impaired cognition. The assessment reflected Resident #31 had a mechanically altered (pureed) diet. Record review of Resident #31's Comprehensive Care Plan, last revised on 06/19/26 reflected Resident #31 had a mechanical soft diet with interventions to provide meals as ordered. Record review of Resident #31's Active Physicians Orders dated 07/15/26 reflected Resident #31 was ordered a pureed diet. During an observation on 07/14/26 at 11:15 AM the posted weekly menu in the main dining room reflected the lunch entree for that day was fried chicken. During an observation in the kitchen on 07/14/26 at 11:18 AM, revealed fried chicken was being removed from the fryer for the noon meal. During an observation and interview on 07/14/26 at 11:19 AM, [NAME] H was observed placing chicken strips into a mixer to prepare the pureed meals. [NAME] H stated 3 residents received pureed diets and explained she chose chicken strips because she did not want to debone the fried chicken. During an interview on 07/14/26 at 11:21 AM, the DM stated that the night shift failed to thaw the boneless chicken intended for the pureed meals; therefore, chicken strips were used instead. During an observation on 07/14/26 at 12:08 PM in the main dining room, Resident #9 was observed to be assisted by a speech therapist with her pureed meal consisting of chicken strips, mashed potatoes, green beans, and bread. During an observation and interview on 07/14/26 at 12:47 PM, RN G sampled both the regular and pureed test trays with the survey team. RN G stated the pureed chicken tasted different from the fried chicken served on the regular menu, had a different flavor and was saltier. During an interview on 07/15/26 at 1:23 PM, Resident #31 stated he required a pureed diet due to an esophageal condition where he was unable to eat anything sharp. He stated he observed other residents eating fried chicken while his meal did not taste like fried chicken. Resident #31 stated it bothered him that he did not receive the same meal as the other residents. During an interview on 07/15/26 at 3:05 PM, the DM stated the planned menu for both the pureed and regular diets on 07/14/26 for lunch was fried chicken. She stated the original plan was to prepare the boneless chicken by boiling or baking them; however, because the boneless chicken had not been thawed, chicken strips were substituted. The DM stated chicken strips were not nutritionally equivalent to the planned fried chicken and acknowledged she had been educated that menus should remain consistent across diet textures otherwise residents could feel a loss of dignity. The DM further stated that she was responsible for ensuring menus were followed. During an interview on 07/16/26 at 10:02 AM, the DM brought menus and recipes to conference room for the 07/14/26 lunch menu of fried chicken. She stated the recipe allowed breaded chicken as a substitution for fried chicken and clarified the substitution applied to the menu for all residents, not solely those receiving pureed diets. During an interview on 07/16/26 at 10:15 AM, [NAME] H stated she served fried chicken to regular diets and prepared chicken strips for residents receiving pureed diets because deboning fried chicken with the crust was difficult. She stated she believed it was inappropriate for residents who received pureed diet to receive a different menu item than the meal served to other residents and acknowledged the recipe substitution should have been implemented for all residents rather than only those receiving pureed diets. [NAME] H stated that if residents on pureed diets got different menu items from everyone else it could possibly make them feel bad or that they were wronged. During a telephone interview on 07/16/26 at 1:48 PM, the Corporate RD stated staff were expected to follow the written menus and she was not aware substitutions were being made for pureed meals from fried chicken to chicken strips on 07/14/26 until after it happened. The Corporate RD stated a potential negative outcome of not doing so included resident dissatisfaction and residents becoming upset when they did not receive the same menu item as other residents. Record review of Facility Provided Recipe, titled Recipes to Scale dated Tuesday, 07/14/26 -Lunch Fried Chicken 3 oz. reflected under Step 5 that other cuts of chicken or breaded chicken could be substituted. Record review of Facility Provided Menu, titled Weekly Menu for Week 2 - Diet: Regular/Puree, dated 07/14/26 identified fried chicken as the lunch entree. Record review of facility policy titled Consistency Modification dated 2012 reflected the following in part:Policy statement: We will adequately meet nutritional needs of the resident and provide food in a consistency that the resident can tolerate .Guidelines for pureed diets:3. Foods are blended following the regular diet for the day. Record review of facility policy titled Resident Menus, dated 2012 reflected the following in part.Policy Statement: The standard menu will ensure nutritional adequacy of all diets. 3. Alternates for noon and evening meal will be planned and recorded. 4. If any meal served varies from the planned menu, the change and reason for the change shall be noted on the substitution log.5. The menus will be prepared as written using standardized recipes. The Dietary Service Manager and cooks are trained and responsible for the preparation and service of therapeutic diets as prescribed.

Based on interview and record review the facility failed to ensure residents had the right to formulate an advance directive for 1 (Resident #43) of 22 residents reviewed for advance directives.The facility failed to ensure Resident #43's DNR was dated by the two witnesses thereby rendering it invalid.This failure could place residents at risk of not having their end-of-life wishes honored. Findings Included:Record review of Resident #43's admission record dated [DATE] revealed an [AGE] year-old female admitted to the facility on [DATE]. She was noted to be a DNR under the advance directive portion of the admission record.Record review of Resident #43's admission MDS assessment completed on [DATE] revealed a BIMS score of 7 which indicated severely impaired cognition.Record review of Resident #43's care plan initiated on [DATE] revealed the following focus area, goal, and interventions/tasks initiated on [DATE]: Resident is a Full Code.Request for CPR to be initiated will be followed.Initiate BLS CPR if the resident is without a heartbeat or not breathing. Notify EMSNotify the charge nurse immediately if the resident is not breathing or does not have a heart beat [sic].Consult with nursing staff on changes in health.Counsel with resident and family regarding any emotional concern arising from the decision.Record review of Resident #43's OOH-DNR revealed it was signed by the physician and her family member on [DATE]. Two witnesses signed but did not date the OOH-DNR.During an interview on [DATE] at 09:17 AM LVN F stated DON, ADON, MDS LVN, and the floor nurse filling out the DNR were responsible for ensuring it was completely filled out. She stated if a DNR was not completely filled out staff would have to initiate CPR and a resident's end-of-life wishes would not be honored. She stated formulating an advance directive was a resident right and it is not okay not to ensure they were honored.During an interview on [DATE] at 09:36 AM RN G stated DON and MR were responsible for ensuring DNRs were completely/accurately filled out. She stated if the DNR was not completely/accurately filled out staff would have to go against the resident's end-of-life wishes.During an interview on [DATE] at 09:43 AM ADON stated all nursing staff were responsible for ensuring DNRs were accurately/completely filled out. She stated staff should check them during admission and then again during care plan meetings. ADON stated an incomplete DNR would result in staff having to go against resident and family wishes for end-of-life care.During an interview on [DATE] at 09:56 AM DON stated she and MR were responsible for ensuring DNRs were filled out completely. She stated if the DNR was not filled out correctly staff would call EMS and go against resident's end-of-life wishes.During an interview on [DATE] at 10:10 AM MDS LVN stated she has no part in checking advance directives for accuracy. She stated if a DNR was not completely filled out a resident's wishes might not be followed.An interview was attempted with MR on [DATE] at 10:16 AM but was unsuccessful.Record review of an undated facility policy titled Do No Resuscitate Order revealed the following: . Out of Hospital DNR Form . 5. In all cases the form must be signed and dated by two witnesses.Record review of a blank Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) Texas Department of State Health Services Instructions for Issuing an OOH-DNR Order revealed the following: . The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professionals.

Based on observations, interviews, and record reviews, the facility failed to ensure the resident the right to receive written notice, including reason for change, before the resident's room or roommate in the facility is changed for 2 (Resident #5 and Resident #24) of 22 residents reviewed for resident rights.1. The facility failed to provide notice to Resident #5 or her representative before a roommate was moved into her room.2. The facility failed to provide notice to Resident #24 or his representative before he changed rooms.These failures could put residents at risk of being uncomfortable or disoriented in their home.Findings Included:1. Record review of Resident #5's admission record dated 07/15/26 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia (decline in cognitive function), paranoid schizophrenia (a mental illness characterized by episodes of psychosis including hallucinations, delusions, and disorganized thinking), psychotic disorder with delusions (severe mental illness including distorted beliefs), and major depressive disorder recurrent severe (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities). Resident #5 was noted to be on the secure unit.Record review of Resident #5's quarterly MDS assessment completed on 06/09/26 revealed a BIMS score of 7 which indicate severely impaired cognition. Section E Behavior revealed Resident #5 had exhibited physical and verbal behavioral symptoms directed toward others as well as other behavioral symptoms not directed toward others. Record review of Resident #5's care plan completed on 06/19/26 revealed she had agitation and anxiety r/t Dementia as well as delirium or an acute confusional episode.During an observation and interview on 07/14/26 at 11:59 AM Resident #5 was seated in her recliner in her room. During an interview on 07/14/26 at 07:00 PM Resident #5's family member stated Resident #5 got a roommate and she (family member) was not told in advance. She stated she visited Resident #5 and asked the CNAs on the hall when Resident #5 got a roommate and she overheard one of the CNAs say to the other, See, I told you they didn't tell [name of Resident #5's family member]. Resident #5's family member stated there was an altercation between Resident #5 and her roommate where the roommate pushed Resident #5 and after that the roommate was moved to another room. She stated Resident #5 did not have a roommate prior to the new roommate being moved into her room approximately 2-3 weeks ago. She stated she did not have a problem with Resident #5 having a roommate but would have liked to have been consulted.2. Record review of Resident #24's admission record dated 07/15/26 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia (decline in cognitive function), psychotic disorder with delusions (severe mental illness including distorted beliefs), hallucinations (sensory experiences that appear real but are created by your mind), and major depressive disorder recurrent mild (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities). Resident #24 was noted to reside on the secure unit.Record review of Resident #24's admission MDS assessment completed on 07/08/26 revealed a BIMS score of 3 which indicated severely impaired cognition. Section E Behavior revealed he displayed behavioral symptoms not directed at others including disrobing in public. Resident #24 was noted to reject care and to wander 1-3 days of the 7-day look-back period.Record review of Resident #24's care plan completed on 07/10/26 revealed he had impaired cognitive function/dementia or impaired though processes. Staff were to discuss concerns about confusion, disease process, Nursing Home placement with the resident/family/caregivers. He was noted to be at risk for wandering and elopement and therefore he was noted to reside on the secure unit.During an observation on 07/14/26 at 10:14 AM Resident #24 was lying in the extra bed in a room that was not his (his name plate was on a room two doors up the hallway) under the blanket with his eyes closed. He did not respond to knocking or his name being called.During an interview on 07/14/26 at 10:14 AM CNA D stated Resident #24 was often in the bed he was in because he did not like his roommate. She stated she had spoken to management about allowing him to move permanently into the room he was currently sleeping in but had not heard anything back.During an observation on 07/14/26 at 11:52 AM Resident #24 was lying in the same extra bed in the room that was not his under a blanket with his eyes closed. He did not respond to knocking or his name being called.During an interview on 07/14/26 at 11:55 AM of CNA D and CNA M, CNA D stated night shift staff told her Resident #24's roommate keeps him up all night and that is why he has begun to sleep in the other room. CNA M stated Resident #24 had moved so many times he was confused about where his room was. CNA D agreed.During an interview on 07/14/26 at 06:48 PM Resident #24's family member stated she was not informed of his room changes. She stated he had been in several rooms. She stated she found out Resident #24 had changed rooms when she went to visit him and he was no longer in the room he had been in. She stated he was currently sleeping in a room that was not his.During an observation on 07/15/26 at 10:37 AM CNA E attempted to assist Resident #24 to lie down in his room. He resisted when she attempted to steer him from the room he had been sleeping in to his actual room and continued to wander the hallway.During an interview on 07/16/26 at 08:53 AM CNA B stated if a resident and/or their representative were not notified prior to a room or roommate change it could negatively impact the resident. She stated certain personalities should not be placed together on the locked unit because they brought out negative behaviors in one another.During an interview on 07/16/26 at 09:00 AM CNA C stated the resident and their family were notified prior to a room change or a roommate change. She stated not notifying the resident and family could lead to conflicts between roommates over temperature control and television volume and could cause the family distress if they came to visit and could not find their loved one. She stated DON or the nurse on duty was responsible for making the necessary notifications.During an interview on 07/16/26 at 09:07 AM CNA D stated she was not certain who made the decision to change a resident's room, but she knew HSK was involved in some way. She stated if a resident changed rooms or received a new roommate the resident, family, and DON were notified. She stated not giving notification could cause the resident to be confused, agitated, or angry. She stated nurses were responsible for making the notification.During an interview on 07/16/26 at 09:11 AM CNA E stated when a resident changed rooms or received a roommate the resident and the family were notified. She stated no notification could lead to arguments or altercations. She stated she was unsure who was responsible for making the notification and unaware of what the facility policy stated regarding room and roommate changes.During an interview on 07/16/26 at 09:17 AM LVN F stated HSK was involved in the physical part of changing a resident's room or roommate. She stated families and residents were notified of room or roommate changes. LVN F stated, Family is one of the first people that know. She stated not giving notification to residents and families could lead to conflict as the facility was located in a small town and the resident families might have grudges against one another. LVN F stated, It (room and roommate change) is kinda something that needs to be discussed first. She stated the charge nurse was responsible for notifying the family and resident.During an interview on 07/16/26 at 09:36 AM RN G stated the facility administrator decided if a resident was to change rooms or receive a new roommate. She stated the administrator, DON, or charge nurse was responsible for notifying family and the resident. RN G stated she was unsure what the facility policy stated regarding room and/or roommate changes. She stated if residents and/or family were not notified of room and/or roommate changes they could get upset, display worsening behaviors, or have altercations.During an interview on 07/16/26 at 09:43 AM ADON stated the care team decided whether a resident changed rooms or roommates. She stated the resident and family were notified in the event of a room or roommate change. ADON stated if a resident was not given notice of a room change, they could be confused and it could be scary for the resident and the family. She stated everyone was responsible for giving notification to residents and family. ADON stated she was unfamiliar with the facility's policy on room/roommate changes.During an interview on 07/16/26 at 09:56 AM DON stated the care team determined if a resident received a new roommate or room change. She stated the resident representative and the resident were notified. DON stated she was unfamiliar with what the facility policy stated regarding room and/or roommate changes. She stated she did not know what a negative outcome for the resident would be of not having notification of a room/roommate change except confusion on visitation. DON stated the person doing the room change was responsible for notifying residents and family members. She stated there was not one person assigned to do room changes. DON stated, It depends.During an interview on 07/16/26 at 11:07 AM HSK stated Resident #24 started in one room upon admission, was moved to another room for isolation, moved back to the original room, and moved to another room (the one he had been sleeping in) the morning of 07/16/26 following an altercation with his roommate.During an interview on 07/16/26 at 02:30 PM DON stated she had provided notification to Resident #24's family member regarding his room changes. She stated she would provide proof of said notification. No proof was provided.During an interview on 07/16/26 at 02:30 PM ADM stated Resident #24's family member was not provided notice prior to his move the evening of 07/15/26 due to that move being emergent due to altercation between roommates. He stated she was provided notice the morning of 07/16/26 regarding the room change. Record review of facility policy titled Resident Rights and dated 11/28/16 revealed the following: . Respect and Dignity - The resident has the right to be treated with respect and dignity, including: . 14. Notification of changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is - . ii. The facility must also promptly notify the resident and the resident representative, if any, when there is - 1. A change in room or roommate assignment .Record review of an undated facility policy titled Behavior Management revealed the following: . Behavior management includes the management of anger, confusion, hallucinations and other behavior by utilizing techniques such as area limitations, . Behavior changes can be attributed to dementia disorders or psychological conflicts resulting from a loss of control. 8. Avoid unfamiliar situations. 9. Provide structure and routines.Record review of facility policy titled Room Changes and dated 07/11/25 revealed the following: Objective: To ensure that all room changes will be constructive and, in the resident's best interests, whenever possible. Procedure: . The addition of a roommate will take place, whenever possible, after the resident and the family have been given twenty-four (24) hours' notice and prepared for the change. 4. If the resident is asked to relocate to another room, 5 days' notice must be given to the resident or responsible party prior to the move. 5. The notice must be in writing and include the reason for the change. 6. The resident has the right to refuse the change if the change is solely for staff convenience.

Based on observation, interview, and record review the facility failed to, in accordance with professional standards and practices, maintain medical records on each resident that are accurately documented for 1 (Resident #9) of 22 residents reviewed for accuracy of medical records.The facility failed to ensure Resident #9's EHR did not contain active orders and care plan interventions for her to reside on the locked unit when she was residing on a different hall.This failure could place residents at risk of not receiving necessary and accurate care/treatment due to inaccurate medical records.Findings Included:1. Record review of Resident #9's admission record dated 07/15/26 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia severe with psychotic disturbance (a neurological condition marked by profound cognitive decline and psychotic symptoms requiring comprehensive medical management).Record review of Resident #9's quarterly MDS assessment completed on 06/16/26 revealed she had severely impaired cognition based on a staff assessment. Section E Behavior revealed Resident #9 did not exhibit wandering behavior.Record review of Resident #9's care plan completed on 06/19/26 revealed she was at risk for wandering and would reside in the secure unit. The focus area and the interventions including secure unit were initiated on 12/12/23.Record review of Resident #9's active orders dated 07/15/26 revealed the following order with corresponding start date:10/06/25 Admit to secure unit d/t hx of elopement with active exit seeking behavior.During an observation on 07/14/26 at 10:26 AM Resident #9 was observed sleeping in her bedroom on 300 hall, which is not the secure hall.During an interview on 07/14/26 at 06:27 PM Resident #9's emergency contact stated Resident #9 used to reside on the locked hall. She stated Resident #9 was no longer as mobile or exit seeking as she had been previously and was now residing on a regular hall.During an interview on 07/16/26 at 09:17 AM LVN F stated everyone who touched a resident's chart was responsible to ensure the EHR was accurate as far active orders. She stated she thought MDS LVN was ultimately responsible for the EHR's accuracy. She stated if the EHR was not accurate regarding orders the resident might be placed incorrectly within the facility.During an interview on 07/16/26 at 09:36 AM RN G stated if a resident's EHR contained orders for placement on the locked unit and the resident was not on the locked unit the resident might be at risk of elopement.During an interview on 07/16/26 at 09:43 AM ADON stated ensuring a resident's EHR was accurate was a team effort. She stated if a resident had active orders for the locked unit but did not reside on the locked unit it would be improper documentation and inaccurate charting.During an interview on 07/16/26 at 09:56 AM DON stated she was responsible for ensuring resident's active orders accurately reflected their status. She stated she should have removed the order for Resident #9 to reside on the locked unit. She stated if this EHR inaccuracy was not addressed there could be a miscommunication in providing care for the resident.During an interview on 07/16/26 at 10:10 AM MDS LVN stated she was a second set of eyes when it came to ensuring EHR accuracy. She stated there was not really a negative impact if a resident had active orders for the locked unit and resided on a regular hall.Record review of and undated facility policy titled Documentation revealed the following: . Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident. It has legal requirements regarding accuracy and completeness. Special forms in the clinical record are utilized in nursing documentation such as . care plan . 1. The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 (Resident #11, and Resident #43) of 22 residents reviewed for comprehensive care plans. 1. The facility failed to address Residents #11's use of BiPAP therapy in her care plans. 2. The facility failed to ensure Resident #43's care plan reflected her DNR status rather than full code. These failures could place residents at risk of receiving inaccurate/incomplete care.Findings Included: Record review of Resident #11's face sheet revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include Amyotrophic Lateral Sclerosis (ALS) (a progressive and fatal neurodegenerative disorder) and malaise (a general feeling of discomfort, illness, lack of well-being). Record review of Resident #11's MDS and completed [DATE] listed Resident #11 with a BIMS of 12 indicating she was moderately cognitively impaired, she had a functionality of requiring supervision/touch assistance with minor adl care to activity not attempted due to her medical condition with more complicated adl's such as dressing and showering. Resident #11 was not listed for using any non-invasive mechanical ventilator to include BiPAP therapy. Record review of Resident #11's care plan with admission date of [DATE] revealed no care plans to address Resident #11's BiPAP therapy. Record review of Resident #11's Order Summary Report with Active Orders As Of: [DATE] revealed no orders to address BiPAP therapy. Record review of Resident #11's Respiratory Therapy Assessment Note printed [DATE] revealed the following: Initial admission - [DATE]Effective Date: [DATE]Treatment Plan:3. CPAP or BIPAP Therapy 3. BIPAP3a. When is the BIPAP or CPAP to be used? -At night.Signed by: ADON [DATE] During an observation and interview on [DATE] at 10:49 AM Resident #11 was in her room lying in her bed. Resident #11 was unable to speak but was able to type her answers on an iPad. A BiPap machine was observed on her bedside dresser. Resident #11 reported via her iPad that she has had BiPAP therapy for a couple of months. Resident #11 shook her head yes when asked if the staff provided good care and care with her equipment to include her BiPAP therapy. During an interview on [DATE] at 2:54 PM the ADON reported Resident #11 had her BiPAP since she was admitted and Resident #11 used the BiPAP therapy every night. During an interview on [DATE] at 8:05 AM SNA K reported Resident #11 did wear BiPAP (her breathing machine) at night but did not use it during the day. SNA K reported the breathing machine should be addressed in the resident's chart and she (SNA K) would have no idea what kind of problem would occur if the breathing machine was not addressed in the residents' chart. During an interview and observation on [DATE] at 8:08 AM LVN L reported she had not seen Resident #11 wearing BiPAP but was aware Resident #11 had been using BiPAP at night. LVN L did not know for how long. LVN L entered Resident #11's room and verified the BiPAP machine was in the room and Resident #11 again shook her head yes that she was using the BiPAP therapy. LVN L reported that a resident should have care plans to address BiPAP therapy. LVN L reviewed Resident #11's chart and reported Resident #11 did have care plans for BiPAP therapy and the care plans had been entered into Resident #11 chart on [DATE]. LVN L reported if a Resident did not have BiPAP therapy included or addressed in their chart then staff would not be aware of what the resident was receiving, and the resident might not receive their therapy. During an interview on [DATE] at 8:56 AM the ADON reported she was aware Resident #11 did not have care plans to address the use of her BiPAP therapy. The ADON reported Resident #11's BiPAP therapy should be addressed in her chart. The ADON reported if the BiPAP was not addressed in the chart then that was not accurate documentation and was a safety issue for the residents and could result in her not getting the right thing, the right treatment. During an interview on [DATE] at 8:59 AM the MDS/LVN reported if a resident's BiPAP therapy was not addressed on the MAR (which was generated from the residents' orders) then she (MDS/LVN) would not know to include that therapy on the resident's MDS assessment. The MDS/LVN checked Resident #11's MDS and reported her BiPAP therapy was not included in the MDS assessment. The MDS/LVN reported if the resident had no orders for the BiPAP therapy then most likely the therapy would not be included in the MDS assessment or the care plans and the nursing staff would not know what to give the resident. The residents may not get what they need. The MDS/LVN reported an inaccurate MDS assessment could affect the facility's reimbursement. During an interview on [DATE] at 10:42 AM the DON reported she was aware of Resident #11 not having her BiPAP therapy addressed in her chart, that the BiPAP therapy was missed due to some confusion with the resident privately paying for the therapy, and she corrected the issue yesterday ([DATE]) with new orders and adding the therapy to Resident #11's care plans. The DON reported if a resident needs assistance with the required therapy and it was not addressed in the resident's records then staff would not be aware of the resident's needs. The DON reported she was not aware of a policy the facility had for the inclusion of BiPAP therapy in a resident's chart, but she would look. Review of facility provided policy titled Comprehensive Care Planning undated, revealed the following: Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preference and goals, and address the resident's medical, physical, mental, and psychosocial needs.When developing the comprehensive care plan, facility staff will, at a minimum, use the Minimum Data Set (MDS) to assess the resident's clinical condition, cognitive and functional status, and use of services. Record review of Resident #43's admission record dated [DATE] revealed an [AGE] year-old female admitted to the facility on [DATE]. She was noted to be DNR under the advance directive portion of the admission record. Record review of Resident #43's admission MDS assessment completed on [DATE] revealed a BIMS score of 7 which indicated severely impaired cognition. Record review of Resident #43's care plan initiated on [DATE] revealed the following focus area, goal, and interventions/tasks initiated on [DATE]: Resident is a Full Code.Request for CPR to be initiated will be followed.Initiate BLS CPR if the resident is without a heartbeat or not breathing. Notify EMSNotify the charge nurse immediately if the resident is not breathing or does not have a heart beat [sic].Consult with nursing staff on changes in health.Counsel with resident and family regarding any emotional concern arising from the decision. Record review of Resident #43's OOH-DNR revealed it was signed by the physician on [DATE]. During an interview on [DATE] at 09:17 AM LVN F stated everyone who touched a resident's chart was responsible to ensure the EHR was accurate as far as code status. She stated if the EHR was not accurate regarding code status a resident's wishes would not be honored. During an interview on [DATE] at 09:36 AM RN G stated if a resident's EHR was inaccurate as far as code status their wishes might not be honored.During an interview on [DATE] at 09:43 AM ADON stated ensuring a resident's EHR was accurate was a team effort. She stated if a resident's chart was inconsistent regarding code status their end-of-life wishes might not be honored. During an interview on [DATE] at 09:56 AM DON stated she, ADON, and MDS LVN were responsible for ensuring advance directives were accurate throughout a resident's EHR. She stated if these inaccuracies were not addressed there could be a miscommunication in providing care for the residents. During an interview on [DATE] at 10:10 AM MDS LVN stated she has no part in checking advance directives for accuracy. She stated she is a second set of eyes when it came to ensuring EHR accuracy. She stated in the case of code status a resident's wishes might not be followed if the EHR was inaccurate. Record review of and undated facility policy titled Documentation revealed the following: . Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident. It has legal requirements regarding accuracy and completeness. Special forms in the clinical record are utilized in nursing documentation such as . care plan . 1. The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. Record review of an undated facility policy titled Do No Resuscitate Order revealed the following: . Out of Hospital DNR Form . 5. In all cases the form must be signed and dated by two witnesses. 9. the facility will scan a copy into the documents tab of PCC. Based on the completed OOH DNR form, facility staff will enter a physician order for DNR into PCC that will be displayed in the following modules of PCC, the resident chart, EMAR, and POC. These modules will communicate to staff the resident's code status.

Based on interview and record review, the facility failed to ensure an assessment accurately reflected a resident's status for 1 of 22 residents (Resident #11) reviewed for accuracy of MDS assessments. The facility failed to address Residents #11's use of BiPAP therapy in her MDS assessment. This failure to accurately assess a resident could place residents at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services. Findings included: Record review of Resident #11's face sheet revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include Amyotrophic Lateral Sclerosis (ALS) (a progressive and fatal neurodegenerative disorder) and malaise (a general feeling of discomfort, illness, lack of well-being). Record review of Resident #11's MDS and completed 6/02/2026 listed Resident #11 with a BIMS of 12 indicating she was moderately cognitively impaired, she had a functionality of requiring supervision/touch assistance with minor adl care to activity not attempted due to her medical condition with more complicated adl's such as dressing and showering. Resident #11 was not listed for using any non-invasive mechanical ventilator to include BiPAP therapy. Record review of Resident #11's care plan with admission date of 5/22/2026 revealed no care plans to address Resident #11's BiPAP therapy. Record review of Resident #11's Order Summary Report with Active Orders As Of: 7/14/2026 revealed no orders to address BiPAP therapy. Record review of Resident #11's Respiratory Therapy Assessment Note printed 7/15/2026 revealed the following: Initial admission - 5/22/26Effective Date: 5/24/26Treatment Plan:3. CPAP or BIPAP Therapy 3. BIPAP3a. When is the BIPAP or CPAP to be used? -At night.Signed by: ADON 5/24/2026 During an observation and interview on 07/14/2026 at 10:49 AM Resident #11 was in her room lying in her bed. Resident #11 was unable to speak but was able to type her answers on an iPad. A BiPap machine was observed on her bedside dresser. Resident #11 reported via her iPad that she has had BiPAP therapy for a couple of months. Resident #11 shook her head yes when asked if the staff provided good care and care with her equipment to include her BiPAP therapy. During an interview on 07/15/2026 at 2:54 PM the ADON reported Resident #11 had her BiPAP since she was admitted and Resident #11 used the BiPAP therapy every night. During an interview on 07/16/2026 at 8:05 AM SNA K reported Resident #11 did wear BiPAP (her breathing machine) at night but did not use it during the day. SNA K reported the breathing machine should be addressed in the resident's chart and she (SNA K) would have no idea what kind of problem would occur if the breathing machine was not addressed in the residents' chart. During an interview and observation on 07/16/2026 at 8:08 AM LVN L reported she had not seen Resident #11 wearing BiPAP but was aware Resident #11 had been using BiPAP at night. LVN L did not know for how long. LVN L entered Resident #11's room and verified the BiPAP machine was in the room and Resident #11 again shook her head yes that she was using the BiPAP therapy. LVN L reported she was not aware of MDS requirements and therefore would not know if the therapy was included in the MDS. LVN L reported if a Resident did not have BiPAP therapy included or addressed in their chart then staff would not be aware of what the resident was receiving, and the resident might not receive their therapy. During an interview on 07/16/2026 at 8:56 AM the ADON reported she was aware Resident #11 did not have BiPAP therapy addressed on her last MDS assessment. The ADON reported Resident #11's BiPAP therapy should be addressed in her chart. The ADON reported if the BiPAP was not addressed in the chart then that was not accurate documentation and was a safety issue for the residents and could result in her not getting the right thing, the right treatment. During an interview on 07/16/2026 at 8:59 AM the MDS/LVN reported if a resident's BiPAP therapy was not addressed on the MAR (which was generated from the residents' orders) then she (MDS/LVN) would not know to include that therapy on the resident's MDS assessment. The MDS/LVN checked Resident #11's MDS and reported her BiPAP therapy was not included in the MDS assessment. The MDS/LVN reported if the resident had no orders for the BiPAP therapy then most likely the therapy would not be included in the MDS assessment or the care plans and the nursing staff would not know what to give the resident. The residents may not get what they need. The MDS/LVN reported an inaccurate MDS assessment could affect the facility's reimbursement. During an interview on 07/16/2026 at 10:42 AM the DON reported she was aware of Resident #11 not having her BiPAP therapy addressed in her chart, that the BiPAP therapy was missed due to some confusion with the resident privately paying for the therapy, and she corrected the issue yesterday (7/15/2026) with new orders and adding the therapy to Resident #11's care plans. The DON reported if a resident needs assistance with the required therapy and it was not addressed in the resident's records then staff would not be aware of the resident's needs. The DON reported she was not aware of a policy the facility had for the inclusion of BiPAP therapy in a resident's chart, but she would look. During an interview on 07/16/2026 at 10:51 AM the MDS/LVN reported the facility followed the RAI manual for completion of the MDS assessment. Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.20.1, October 2025, revealed the following: O0110: Special Treatments, Procedures, and Programs (cont.)O0110G1, Non-invasive Mechanical VentilatorCode any type of CPAP or BiPAP respiratory support devices that prevent airways from closing by delivering slightly pressurized air through a mask or other device continuously or via electronic cycling throughout the breathing cycle. The BiPAP/CPAP mask/device enables the individual to support their own spontaneous respiration by providing enough pressure when the individual inhales to keep their airways open, unlike ventilators that breathe for the individual. If a ventilator or respirator is being used as a substitute for BiPAP/CPAP, code here. This item may be coded if the resident places or removes their own BiPAP/CPAP mask/device.

Based on interviews and record reviews, the facility failed to ensure residents were free of any significant medication errors for one of seven residents (Resident #1) reviewed for medication administration. LVN A administered Resident #1's short acting insulin, instead of administering her long-acting insulin, which lead to an insulin overdose and hospitalization for observation for 24 hours. The failure could place residents who receive insulin medications at an increased risk for complications such as increased blood glucose levels, change in cognition, and an exacerbation of symptoms and disease process.Findings included: Record review of Resident #1's face sheet, dated 1/20/26, revealed Resident #1 as an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had the following diagnoses: unspecified dementia without behavioral disturbance decline in memory, thinking, and reasoning that disrupts daily life), low back pain, major depressive disorder (serious mood disorder causing persistent sadness, loss of interest and impacting thoughts, feelings and daily life), Parkinson's disease (progressive nervous system disorder affecting movement), disease of pancreas (due to insulin problems or lack of digestive enzymes), moderate protein-calorie malnutrition (reduced protein and energy intake), vitamin D deficiency, hyperlipidemia (high level of fat in the blood), anxiety disorder (excessive persistent fear and worry about everyday problems), idiopathic peripheral autonomic neuropathy (nerve damage affecting involuntary bodily functions - like heart rate, digestion, sweating, blood pressure, where the cause is unknown), overactive bladder common condition causing a sudden, strong urge to urinate), Type 2 diabetes (the body does not use insulin properly or doesn't produce enough of it), gastro-esophageal reflux (symptoms of heartburn or upset stomach), hypothyroidism(thyroid gland does not make enough thyroid hormone- underactive), hypertension (high blood pressure), atherosclerotic heart disease (plaque buildup in arterial walls), Zoster without complications (shingles). Record review of Resident #1's current MDS, resident assessment, dated 11/17/25, documented the resident scored 12 of 15 on a mini-mental exam for cognitive awareness and she was interviewable. Resident #1's functional ability revealed the Resident #1 was independent with all ADL functions. Record review of Resident #1's care plan, last review dated 11/25/25, revealed Resident #1 was care planned for her Diabetes Mellitus. Interventions read that. Diabetes medication as ordered by doctor. Monitor/document side effects and effectiveness. Record review of Resident #1's physician orders, dated 1/1/26 through 1/31/26, revealed Resident #1 has an order for the following insulins: Lantus SoloStar Subcutaneous Solution Pen-Injector 100 units/ml (Insulin Glargine) - inject 42 units subcutaneously one time a day (PM) - long-acting insulin.Lantus Subcutaneous Solution 100 units/ml (Insulin Glargine) - inject 45 units subcutaneously on time a day (AM) - long-acting insulin.Flasp FlexTouch Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Aspart (with Niacinamide)) - inject per sliding scale - short-acting insulin:-if 201 - 250 = 2 units251 - 300 = 4 units301 - 350 = 6 units351 - 400 = 8 units400 - 500 = 10 units Subcutaneously three times a day - 8:00 a.m., 12:00 p.m. and 5:00 p.m. Record review of Resident #1's nurses notes documented the following:1/15/26 at 8:39 a.m. - Resident #1 was transferred to a hospital related to medication error - NP ordered for resident to be transferred out for close evaluation. This is intended to serve as notice of an emergency transfer.1/16/26 at 4:14 p.m. - Resident #1 readmitted /returned from the hospital. Reason for hospital visit: insulin overdose During an interview on 1/20/26 at 9:55 a.m., the Administrator stated LVN A gave Resident #1 her own insulin, but it was the fast-acting insulin, not the long-acting insulin that was ordered for that time of day. During an interview on 1/20/26 at 10:25 a.m., the DON stated on 1/15/26, she was in her office getting ready for a morning meeting when LVN A came to her and said she had given the wrong insulin to Resident #1. The DON stated LVN A meant to give Lantus - a long-acting insulin but gave the short-acting insulin by mistake. The DON stated LVN A realized after about 10 minutes that she had given the wrong insulin to Resident #1 and came directly to her office. The DON stated she immediately went to assess Resident #1 and called the NP to see what she needed to do to get Resident #1 situated. The DON stated the NP said to start an IV for D5, if needed, then the NP called another NP and then the MD and the MD informed her to send the resident to the hospital. The DON stated that very day, they educated LVN A and suspended her, she was still suspended. The DON stated the NP also educated LVN A about searching for medications on Google. The DON stated there were always extra mediations in the Emergency kit if needed. The DON stated LVN A was a new nurse and had been a nurse since [NAME] 2025, when she graduated LVN. The DON stated all the nurses talked very highly of LVN A, but she made a very bad mistake. The DON stated LVN A was still suspended for the time being. During an interview on 1/20/26 at 12:46 p.m., LVN A stated she had gone to her medication cart and had already taken Resident #1's vitals but she always wanted her insulin at a certain time. LVN A stated she was looking for Resident #1's insulin pens as she had two the last time she took care of her, but there was only one pen in the medication cart. LVN A stated afterwards, she had found a vial of Resident #1's insulin but not the pen and it was the long-acting insulin she needed. LVN A stated she contacted ChatGPT, which is like an AI thing the younger generation uses instead of Google, and it said the insulin was the right kind, but she admitted to not reading all of the answer. LVN A asked the State surveyor if she knew what AI was because all the younger generation used it, to which the State surveyor informed LVN A that she was aware of AI. LVN A stated she had gone on to give insulin to another resident, and that resident's insulin was the same as Resident #1's and that was when she knew she had given the wrong medication (short-acting insulin) to Resident #1. LVN A stated she immediately locked her medication cart and went to the Administrator's office and then the DON and told them what happened. LVN A stated Resident #1 was doing good and they gave her two glasses of apple juice and some crackers, and Resident #1 drank both glasses of apple juice and some of the crackers. LVN A stated she checked Resident #1's blood sugar and it was 200 and she checked Resident #1's blood sugar 10 minutes later and her blood sugar was 145. LVN A stated right after that, Resident #1 was sent to the hospital for observation and the resident was not in any distress. LVN A stated the NP wanted her sent to the hospital for further evaluation and treatment. LVN A stated she was terrified by the mistake she made. LVN A stated she would never do that again and instead of contacting ChatGPT, she would go ask the charge nurse or the DON for assistance when she was not sure of the medication she was giving. During an interview on 1/20/26 at 1:54 p.m., Resident #1 stated she remembered getting an IV when she got to the hospital. Resident #1 stated the first thing they did after she got the wrong insulin was give her a glass or two of apple juice and some crackers. Resident #1 wasn't upset about getting the wrong insulin until she found out how serious it could be. Resident #1 stated she usually got insulin from a pen, but she had gotten insulin from a regular insulin syringe. Resident #1 stated she remembered the nurse (LVN A) was scared to death. Resident #1 stated the doctor insisted on sending her to the hospital so she could be monitored closely, and she was just monitored at the hospital and then she was sent back to the facility. Resident #1 stated she did not have any low blood sugars at the hospital. Resident #1 stated those young nurses that were coming to the facility or PRN nurses, she did not understand why the facility used so many of them. Resident #1 stated she was uncomfortable with new nurses, and she trusted the older nurses that had been in the facility for a while. Resident #1 stated she was glad that someone was doing a follow-up on giving her the wrong insulin because that should never have happened. (Resident #1's blood sugars were checked with the medical record on 1/15/26 before being transported to the hospital and all of her blood sugar were in a normal range for her.) During an interview on 1/10/26 at 2:11 p.m., Resident #1's NP stated she was told that the nurse was out of long-acting insulin and googled to see if the other insulin was the same thing and google said it was, so she gave 45 units of short acting insulin in error. The NP stated she was very upset when she was told that because it was a very serious situation. The NP stated she called the doctor and informed him of what happened, and he said to send her to the hospital because they could monitor her better. The NP stated the facility had everything in house to take care of her, but she needed closer monitoring and the resident would be better off in the hospital. The NP stated she was aware that the nurse who made the error was a new nurse and new to the facility but nursing 101 would tell you to look for the DON for any answers that would be needed. The NP state a nurse should never google to make a nursing judgement, a nurse should always ask the DON or ADON, that was what they were there for. The NP stated Luckily, Resident #1 was fine and thought her blood sugar never got below 120. Record review of the facility's, Medication Administration and General Guidelines, undated, documented the following:Policy: Medications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication, monograph of all medications is available in LinkRX otherwise authorized personnel should refer to Drug Reference material provided by facility. -Subcutaneous Injection Administration:-Insulin Injection:1. Assure type of insulin, unit dosage and syringe are correct.-Procedure:2. Read label three times before administering, check with MAR.4. Check label with order. Record review of the facility in-service training, dated 1/15/26, titled Medication Rights, documented the following:-There are 5 rights to medication administration *Right Patient *Right Medication *Right Dose *Right Route *Right Time*Always check you five rights before giving any medication to a resident. It is our responsibility to ensure that safe practice is always followed.*If a medication error occurs, report it immediately to the DON/ADON. While not all medication errors can cause harm, all must be taken seriously and reported.*If you have a question about an order or medication, please get in touch with the DON/ADON or even another seasoned nurse to ensure we are practicing safe practices.*Best practices include: *Clarifying unclear orders *Know what you are administering *Verify allergies *Verifying the 5 rights to medication administration.*If it feels unsafe, stop and clarify. If medication is not available, get with the DON/ADON who can get into contact with the MD/NP and get clarification and new orders.

Based on interviews and record reviews the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment for 1 of 9 residents (Resident #1) reviewed for care plan timing. The comprehensive care plan for Resident #1 was not developed within 7 days after the completion of the comprehensive assessment. The failure could place residents at risk of receiving care that is not person-centered and/or is inadequate to meet the needs identified during the comprehensive assessment.Findings Included: Record review of Resident #1's face sheet, dated 11/24/2025 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, dementia severe with mood disturbances (cognitive decline in memory, reasoning, and the ability to perform daily activities, mood disturbances, which may include symptoms such as depression, anxiety, or irritability), major depressive disorder, type 2 diabetes mellitus without complication, hypertension (elevated blood pressure), generalized anxiety disorder. Record review of Resident #1's annual MDS dated [DATE] revealed a BIMS of 12 which indicated moderate cognitive impairment. Record review of Resident #1's MDS tab in the EHR revealed the following:A Quarterly MDS dated [DATE] Record review of Resident #1's care plan revealed that there was no update or revision to Resident #1's care plan after the completion of the MDS assessment was completed on 10/31/2025.Record review of Resident #1's care plan tab in the HER revealed the following:A care plan with a start date of 09/17/2025, completion date of 09/17/2025. During an interview on 11/24/2025 at 2:24pm with MDS LVN stated it was her responsibility to ensure care plans were timed correctly with MDS assessments. MDS LVN stated she followed the RAI manual as well as facility policies when she was performing care plans and MDS assessments. MDS LVN stated if the care plan was not updated according to the most recent assessments the resident would not receive the correct care. During an interview on 11/24/2025 at 3:39pm with DON stated, the care plan should have be updated within 7 days of completion of the MDS performed on 10/31/2025. DON stated a negative outcome for not updating the care plan does not reflect the needs of the residents, it leads to inaccurate care plans and the residents not receiving the required care it takes to take care of the resident as best as we can. DON stated, It was a team effort to ensure that care plans are revised and updated timely. Record review of the facility's undated policy titled, Comprehensive Care Planning revealed, in part, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.Care planning drives the type of care and services that a resident receives.When developing the comprehensive are plan, facility staff will, at a minimum, use the Minimum Data Set (MDS) to assess the resident's clinical condition, cognitive and functional status, and use of services.A comprehensive care plan will be-Developed within 7 days after completion of the comprehensive assessment.The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Resident #1) of 7 residents and 3 anonymous residents reviewed for resident rights.The facility failed to prevent RN A from referring to residents in the secured unit as feeders when referring to residents that need assistance in feeding.This failure could negatively impact the self-esteem, self-worth, and identity of residents who need assistance with eating.Record review of Resident #1's admission record dated 08/06/2025 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Unspecified dementia(memory loss), neuroleptic induced parkinsonism(tremors), and Vitamin D Deficiency.Record review of Resident #1's quarterly MDS completed on 05/8/25 revealed the following:Section B Hearing, Speech, and Vision: Resident #1 did not require a hearing aid and had the ability to understand others with only missing some/part of the message but comprehends most conversation.Section C Cognitive Patterns: Resident #1 had a BIMS of 3 out of 15 which indicated severe impaired cognition.Section K Nutritional Approaches: Resident #1 required a mechanically altered diet.Record review of Resident #1's care plan updated on 05/07/2025 revealed Resident #1 had a mechanically altered diet as well as a nutritional problem or potential nutritional problem with interventions to monitor/document signs and symptoms of dysphagia: pocketing, choking, couching, drooling, holding food in mouth, several attempts at swallowing. The care plan also stated Resident #1 had a communication problem and to be conscious of the resident when in groups, activities, dining room to promote proper communications with others.Record review of Resident #1's active orders reports as 08/06/2025 revealed the following orders:Regular diet, Mechanical soft texture, regular consistency . with a start date of 03/10/2025.During an observation and interview on 08/06/2025 at 9:15 AM, RN A, who was observed standing near the dining area, approximately 4 feet from 3 residents seated in the dining room on the secured unit. RN A stated lunch time can be busy because there are a several feeders in the unit. RN A said that she and 2 CNAs assist the feeders during dining. RN A continued with saying sometimes physical therapy will come back and help with the feeders.During an interview on 08/06/2025 at 9:20 AM, CNA C stated it was not okay to refer to residents who needed assistance with eating as feeders. She stated, it could be a dignity issue. She stated she had been trained at orientation and during in-services not to refer to residents who needed assistance eating as feeders.During an interview on 08/06/2025 at 9:45, the DON stated referring to residents as feeders could be a dignity issue no matter their cognitive level, all residents should be treated with respect and dignity. The DON stated she was responsible for training her staff on resident rights and dignity.During an interview on 08/06/2025 at 9:57, CNA E was asked about assisting residents during dining times and if it was appropriate to refer to residents that needed assistance with feeding, feeders. CNA E started apologizing and stated she was sorry for calling residents feeders. CNA E stated all residents, no matter their cognition, deserve to be treated with respect. CNA E stated the DON was responsible for in servicing staff on resident rights and dignity.During an interview on 08/06/2025 at 10:24 AM, LVN B stated she was not going to lie and said that she has heard staff using the word feeders when describing residents that need assistance during dining. LVN B stated she did not think using the word feeders was a dignity issue. LVN B then stated, I guess it could be a dignity issue.During an interview on 08/06/2025 at 10:40 AM, Corp RN was in the building due to the Administrator being on vacation, (and not available for an interview) stated it was not okay to refer to residents who needed assistance with eating as feeders as it was a dignity issue. Corp RN stated staff had been trained not to refer to residents who needed assistance eating as feeders.During an observation and interview on 08/06/2025 at 11:20 AM, RN A was standing at her computer and Resident #1 was in her wheelchair sitting directly by RN A. RN A stated she had been a nurse for 10 years and she was taught to call residents that needed assistance during dining full feeders and feels it was appropriate to call residents full feeders. RN A stated she did not feel it was a dignity issue.During an interview on 08/06/2025 at 11:25AM, HA D stated she has working at the facility for about 5 months and was trained during orientation that it was inappropriate to call residents that need assistance with dining as feeders HA D stated she worked on the secured unit and in the main unit and stated it did not matter what level of cognition a resident had it was not appropriate to call them feeders as it was a dignity issue.Record review of facility policy titled Resident Rights and dated 11/28/2016 revealed the following: The resident has a right to a dignified existence. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.

Based on observation, interview and record review, the facility failed to ensure the menu was followed for 1 of 2 lunch meals reviewed for menus and nutritional adequacy on 5/19/25 in that: A. Dietary staff did not serve cherry fried pies to 17 residents on a mechanical soft diet on 5/19/25 (Residents # 2,11,12,15, 19, 22, 26, 32, 38, 40, 43, 45,47, 52, 56, 59, and 64). B. Dietary staff did not serve pureed bread, pureed fried cherry pie, pureed potato salad or pureed bread butter pickles and onion during the noon meal on 5/19/25 for 2 residents reviewed for pureed diets (Resident #s 23 and 53). These failures could place residents who eat mechanical foods and residents who eat pureed foods at risk of not having their nutritional needs met. Findings included: Record Review for the Monday lunch meal for 5/19/25/ revealed the planned menu for the noon meal was BBQ Pork on a bun, baked beans, potato salad, bread and butter pickles and onion, cherry fried pie and iced tea. Record review of the facility diet spreadsheet for the noon meal on 5/19/25 indicated residents on mechanical soft and pureed diets were to receive all foods listed on the menu. During an interview on 5/19/25 at 10:30 AM, the DM stated there were 2 residents in the facility with pureed diets. In an observation on 5/19/25 from 11:55 am to 1:00 pm of the facility lunch meal it was observed that residents with a mechanical soft diet listed on the individual meal ticket did not receive a fried cherry pie. The residents were served applesauce instead. Residents with a pureed diet did not get the fried cherry pie. They were served applesauce. Observations of the pureed meals revealed residents with pureed diets were served BBQ meat and beans with a serving of applesauce. Residents on a pureed diet also did not receive potato salad, bread and butter pickles and onion. In an observation and interview on 5/19/25 at 12:30 pm Resident # 64 's meal tray did not have a fried cherry pie. Resident #64 tray had applesauce instead of the cherry fried pie. Resident # 64 stated she did not like applesauce. She stated she would rather have the fried pie, but no one asked her what she wanted. During an observation and an interview on 5/19/25 at 12:35 pm, Resident #134's meal tray did not have a fried cherry pie. She had apple sauce on her tray. Her family member stated she loves cherry pie and did not get one. He stated he did not know why she did not get a cherry pie for lunch. He stated the resident did not like applesauce but would eat it if presented with it. In an observation on 5/19/25 at 12:37 pm of the pureed meal served to residents in the dining room at lunch, there was no bread, potato salad, bread, pickles and onion or fried cherry pie. Residents on a pureed diet were provided a bowl with a brown substance that smelled like BBQ and a bowl with a brown food that smelled like beans and a serving of applesauce. In an observation on 5/19/25 at 12:39 pm of Resident # 53's pureed meal there was no bread, potato salad, bread, pickles and onion or fried cherry pie. Resident was provided a bowl with a brown substance that smelled like BBQ and a bowl of brown food that smelled like beans and a serving of applesauce. In an interview on 5/19/25 at 12:10 pm the Director of Rehabilitation (OTAG) stated the residents on mechanical soft and pureed diets could have all the menu items listed on the menu. She stated at one point for one person the fried pie was too hard to eat so the kitchen was told not to give him the fried cherry pie but that resident was no longer in the facility. She stated the comment was not meant to be used for all mechanical and pureed diets across the board for the rest of time. She stated the residents need all the calories they can get and need to be offered all foods. She stated she saw the residents got applesauce a lot. In an interview on 5/19/25 at 12:40 pm, [NAME] J stated she had pureed all the food listed for the residents on pureed diets. She stated the residents on pureed and mechanical soft diets did not get the fried cherry pie as the rehab department told them not to give the residents the fried cherry pies. She stated the pie would not puree properly. She stated they were getting applesauce. In an interview on 5/20/25 at 11:50 am, the DM stated she was not aware the residents on pureed diets did not get all the menu items listed. She stated the bread was not pureed but should have been. She stated she did not know why it was not pureed. She stated the residents on a pureed diet did not get the fried pies and were given applesauce instead. She stated the ST told her residents on a mechanical soft and pureed diets could not have the fried pies, so those residents were given applesauce instead. She stated the expected the cook to puree all foods listed. She stated applesauce was not a good nutritional alternative to fried cherry pie. In a confidential interview on 5/21/25 at 8:50 am, one staff member stated every day the staff had to go to the kitchen staff and ask for a roll or other foods the residents did not get. Both residents with mechanical soft and pureed diets did not get what was listed on the menu for most days. The staff member stated the consequences of not getting the correct menu items would be weight loss. In an interview on 5/21/25 at 8:55 am, the ST stated normally she was in the dining room during meals so she could monitor the residents' meals. She stated it had been a battle she had been having for over a year trying to make sure the residents got the foods listed on the menu. She stated the kitchen could have pureed the pies for the residents with pureed diets, but they did not. She stated it was just laziness on the kitchens part. She stated there was no reason the residents with mechanical soft and pureed diets could not have everything on the menu. She stated all residents could have the pureed pies and bread and the mechanical soft diets could have the pies. She stated the consequences of not getting all the foods listed on the menu could result in weight loss. In an interview on 5/21/25 at 9:20 am the DM stated if relish was served, residents on a pureed diet would have been served tomato juice. She stated residents on a pureed diet were not given tomato juice in place of the pickles and onion for the 5/19/25 noon meal. She further stated she was not aware the residents on a pureed diet did not get bread or potato salad. She stated she was a new DM and the previous DM had not trained the cooks for the job. She stated the kitchen had been short staffed. She stated she tried to watch what was going on but the kitchen had been short staffed and she had not been able to watch and train staff as she needed to. She stated [NAME] J was not really on top of things when pureeing foods. The DM stated the corporate person for the dietary department spent 2 days with her when she started. She stated the consequences of not serving all menu items to residents were residents would have weight loss and loss of satisfaction of food. In an interview on 5/21/25 at 1:15 pm, the Regional DON stated she expected all residents to be given all menu items as listed on the menu. She stated the meal tickets for each resident should match the menu. She stated the nurses were supposed to check the trays to ensure accuracy as they go out to the resident. She stated meal monitoring was done by different department heads. She stated the consequences of not getting all the menu items listed were weight loss. Record Review of the facility policy titled, Nutritional assessment and Patient Care Plan Documentation dated 2012 revealed: The DM perform regular meal rounds to observe residents' overall meal acceptance, texture tolerance, positioning and feeding. Record Review of the facility policy titled, Consistency Modification dated 2012 revealed: Guidelines for pureed diets: Foods are blended following the regular diet for the day. Record Review of the facility policy titled, Menu Approval dated 2012 revealed: Policy: Menus will be planned to meet the nutritional needs and preferences of the residents and are in accordance with the recommended daily allowances of the food and Nutritional Board of the National Research Council, National Academy of Sciences. Every attempt will be made to honor resident food preferences. The menus will reflect the religious culture as well as the resident population as well as input received from residents and resident group.

Based on observation, interview, and record review the facility failed to have sufficient nursing staff with the appropriate skills set to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident for 1 of 1 locked unit. The facility failed to have sufficient staff on the locked unit. This failure could place residents at risk of harm due to neglect. Findings Included: During an observation on 05/19/25 beginning at 11:50 AM 15 residents were noted to be residing on the locked unit. 6 residents were in the common area with one staff member. Two other staff members were observed on the locked unit. During an interview on 05/19/25 at 06:47 PM Resident #57's family member stated regarding the locked unit where Resident #57 resided, I don't think they have enough people on that hall. I know they are in compliance with the state, but the state does not spend time on that hall like I do. Recently they have had 2-3 staff on the hall but there have been times there was only one person on the hall. During an interview on 05/20/25 at 07:17 PM Resident #28's family member stated of the locked unit where Resident #28 resided, I think there is just one (staff) person back there most of the time. During a confidential interview Staff Member K revealed they often worked alone on the locked unit. Staff Member K stated they worked on the locked unit alone all the time. Just not this week because you're (state surveyors) here. Staff Member K stated they transferred 2-person transfer residents on the locked unit alone. They stated, A couple of them (residents on the locked unit) are 2-person assists but it is not too much for my body to do it because they are able to stand. I think it is just a fall risk. During a confidential interview Staff Member L stated they often worked alone on the locked unit. Staff Member L stated they transferred residents who needed 2-person assist without help when they were working the locked unit alone. During a confidential interview Staff Member M stated they often worked alone on the locked unit day shift (6 am-6 pm). Staff Member M stated they had been keeping notes on the days they worked alone on the locked unit because I didn't want you guys (state surveyors) to come and me to lose my license. Staff Member M provided a list of 11 days (one day in February 2025, 6 days in March 2025, 4 days in April 2025) in the last two and a half months when they worked the locked unit alone. Staff Member M stated on one of the days they were alone they sent a text to DON asking for help and no help was received. Staff Member M stated working the locked unit alone can be too much. They stated they used to transfer 2-person assist residents alone but do not do so anymore. Staff Member M stated, Last month or the month before the hall (locked unit) was completely full and it was me by myself and a lot of them (residents on the locked unit) are high fall risk and it is hard to manage them when I have to help another resident with something. When there are just 8 (residents on the locked hall) or so it is a lot easier to deal with. They stated when they needed assistance on the locked unit, they had to text DON or another CNA in the facility. They stated CNAs on some shifts were more willing to assist than CNAs on other shifts. During an interview on 05/20/25 at 03:23 PM ADM stated the facility did not have a staffing policy for the locked unit or for the facility as a whole. He stated, We are not a certified unit back there (locked unit). During an interview on 05/21/25 at 08:32 AM SNA C stated transferring a 2-person assist resident alone could result in hurting yourself or hurting the resident. She stated, There could be a fall. During an interview on 05/21/25 at 08:33 AM LVN B stated transferring a 2-person assist resident alone could result in injury to the resident. She stated, That is negligence, they could fall. During an interview on 05/21/25 at 09:11 AM ADM stated it was not safe to transfer a 2-person assist resident alone. He stated, There is a reason for (2-person assist): resident safety. During an interview on 05/21/25 at 09:16 AM DON stated she was responsible for staff schedules on the locked unit. She stated one CNA for 15 residents on the locked unit was sufficient staff, Depending on what is going on back there. We don't have a staffing ratio for the (locked) unit. There are always nurses available and assigned to that hallway. The nurse is assigned to that hallway and one other hallway. DON stated she did not think having one CNA on the locked unit would negatively impact residents. She stated, Their (CNAs') communication is really good. As long as they communicate with us that they need more assistance. DON stated transferring a 2-person assist resident alone might not negatively affect the resident. She stated, Depending on the resident. They (residents) go from 2 (person assist), to 1 (person assist), to ambulatory back there (locked unit) a lot. Record review of facility census on 05/19/25 revealed the locked unit with 15 residents was approximately 23% of the total census of 63. Record review of the last 6 months (from 11/20/24 to 05/20/25) facility reported incidents revealed 9 of the 17 (approximately 53%) facility reported incidents occurred on the locked unit. Eight of the incidents had allegations of resident abuse and neglect due to residents hitting/pulling one another and pulling each other's pants down. The other incident had an allegation of injury of unknown origin. None of the incidents indicated injury of a resident due to inappropriate transfer or mentioned inappropriate transfer. Record review of the 4 months of staffing schedule provided by DON for the locked unit from 01/20/25 to 05/20/25 revealed the month of March was missing as was the schedule for 04/01/25. Of the remaining 89 days, 80 days had portions of the day when only one staff member was scheduled to work on the locked unit. 33 of those days the staff person working alone on the locked unit was not certified or licensed but was a hospitality aide or an uncertified nurse aide.

Based on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 3 (Resident #10, Resident #25, and Resident #34) of 16 residents reviewed for accuracy of assessment. 1. The facility failed to accurately code Resident #10's wound/infection status. 2. The facility failed to accurately code Resident #25's tobacco use status. 3. The facility failed to accurately code Resident #34's IV medication status. These failures could place residents at risk of not receiving necessary care and/or consideration. Findings Included: 1. Record review of Resident #10's admission record dated 05/20/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of: infection following a procedure, deep incisional surgical site, subsequent encounter with an onset date of 01/02/2024. She had a diagnosis of urinary tract infection with an onset date of 11/01/24. Record review of Resident #10's quarterly MDS with an ARD date of 03/26/25 and a completion date of 04/07/25 revealed the following: Section C Cognitive Patterns revealed Resident #10 had a BIMS score of 15 which indicated intact cognition. Section I Active Diagnoses under the Infections section revealed the box next to wound infection was checked. The instructions for this section were Active Diagnoses in the last 7 days - Check all that apply. Record review of Resident #10's care plan completed on 05/12/25 revealed no mention of a wound. Infection was mentioned four times in the care plan. Twice under the interventions for diabetes diagnosis to check with doctor if infection is present and to monitor for signs and symptoms of infection and twice in the list of diagnoses at the end of the care plan for surgical site infection and urinary tract infection. Record review of Resident #10's order summary report dated 05/20/25 revealed no mention of wounds and two mentions of infection located in the list of diagnoses at the beginning of the report for surgical site infection and urinary tract infection. None of Resident #10's active medication/treatment orders mentioned infection or wound. During an observation and interview on 05/19/25 at 03:16 PM Resident #10 was seated in her room. She stated she fell 2 years prior and broke her hip and that was the only time she was hospitalized since she admitted to the facility. She stated she currently did not have any wounds. During an interview on 05/20/25 MDS LVN stated she was responsible for completing MDS assessments. She stated the RAI was the policy she used when completing MDS assessments. MDS LVN stated, Sometimes they (nursing staff) do not take the diagnosis off. She stated that was why Resident #10's MDS indicated a wound infection. She stated, I will modify her MDS right now. MDS LVN stated she did not think residents were negatively affected by an inaccurate MDS. She stated an inaccurate MDS would negatively affect funding for the facility. 2. Record review of Resident #25's admission record dated 05/20/25 revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses that included, but were not limited to, congestive heart failure (a chronic condition in which the heart dose not pump blood as well as it should), nicotine dependence, diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), and history of pneumonia (lung inflammation caused by a bacterial or viral infection). Record review of facility's list of residents who smoke, provided by ADM on 05/19/25 revealed Resident #25's name. Record review of Resident #25's significant change MDS with an ARD of 03/31/25 and completion date of 04/10/25 revealed the following: Section C Cognitive Patterns: Resident #25 had a BIMS score of 6 which indicated severely impaired cognition. Section J Health Conditions: Resident #25 was listed as not having current use of tobacco. Record review of Resident #25's care plan completed on 04/21/25 revealed a focus area of Resident smokes. Date Initiated: 11/08/23. Record review of Resident #25's Safe Smoking Assessment completed 03/18/25 revealed the following: A. Evaluation- 1. Does the resident know the location(s) of the designated areas for smoking? 2. Yes 2. Can the resident get to these areas independently? 2. Yes 3. When observed, can the resident independently light smoking materials safely? 1. No 4. Can the resident extinguish smoking materials completely in an appropriate receptacle? 2. Yes 5. Can the resident dispose of ashes or other tobacco-related residue appropriately? 2. Yes During an interview on 05/20/25 at 03:08 PM MDS LVN verified that Resident #25 did smoke and that she (MDS LVN) missed the tobacco use on the significant change of condition MDS completed 03/31/25. She stated she would complete a corrected MDS immediately. 3. Record Review of Resident #34's admission record dated 05/20/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, squamous cell carcinoma of skin of nose (skin cancer). Record review of Resident #34's quarterly MDS with ARD of 04/22/25 and completion date of 04/25/25 revealed the following: Section C Cognitive Patterns: Resident #34 had a BIMS score of 3 which indicated severely impaired cognition. Section O Special Treatments, Procedures, and Programs: Resident #34 was receiving chemotherapy and IV medications while a resident. Record review of Resident #34's care plan completed on 04/07/25 revealed no mention of IV medication. Record review of Resident #34's order summary report dated 05/20/25 revealed no order for IV medication. Record review of Resident #34's MAR for the month of April 2025 revealed no mention of IV medication. During an observation and interview on 05/20/25 at 03:05 PM MDS LVN stated Resident #34 received an IV infusion at a doctor's office. She searched her computer and stated the name of a cancer treatment center. MDS LVN stated the IV infusion was possibly chemotherapy. She searched her computer again and stated, Yes it was for chemo. MDS LVN stated she was not aware that chemotherapy did not count as IV medication on an MDS assessment. She stated she would correct Resident #34's MDS. She stated the correction would definitely affect the facility's funding. During an interview on 05/21/25 at 09:11 AM ADM stated MDS LVN was responsible for completing MDS assessments. He stated, If it (MDS assessment) is inaccurate we might not be doing what we need to do with that resident. During an interview on 05/21/25 at 09:16 AM DON stated she did not think an inaccurate MDS would affect residents. An interview was attempted with ADON on 05/21/25 at 10:55 AM by phone. The call was not answered or returned. Record review of the Long-Term Care Facility RAI 3.0 User's Manual Version 1.18.11 dated October 2023 revealed the following: . I: Active Diagnoses in the Last 7 Days . There are two look-back periods for this section: Diagnosis identification (Step 1) is a 60-day look-back period. Diagnosis status: Active or Inactive (Step 2) is a 7-day look-back period . 2. Determine whether diagnoses are active: Once a diagnosis is identified it must be determined if the diagnosis is active. Active diagnoses are diagnoses that have a direct relationship to the resident's current functional, cognitive, or mood or behavior status, medical treatments, nursing monitory, or risk of death during the 7-day look-back period. Do not include conditions that have been resolved, do not affect the resident's current status, or do not drive the resident's plan of care during the 7-day look-back period, as these would be considered inactive diagnoses. J: Health Conditions . Current Tobacco Use . 1. Ask the resident if they used tobacco in any form during the 7-day look-back period. 2. If the resident states that they used tobacco in some form during the 7-day look-back period, code 1, yes. If the resident is unable to answer or indicates that they did not use tobacco of any kind during the look-back period, review the medical record and interview staff for any indication of tobacco use by the resident during the look-back period. Special Treatments, Procedures, and Programs . IV medications . Do not include IV medications of any kind that were administered during dialysis or chemotherapy. 46534

Based on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 (Resident #27) of 3 residents reviewed for respiratory care. The facility failed to store Resident #27's nasal cannula properly. This failure could affect residents by placing them at risk for respiratory compromise and associated complications such as shortness of breath, confusion, respiratory failure, infection, and exacerbation of their condition. Findings include: Record review of Resident #27's clinical record revealed an [AGE] year-old female resident admitted to the facility originally on 08/12/22 and readmitted on [DATE] with diagnoses to include chronic obstructive pulmonary disease(a group of lung diseases that block airflow and make it difficult to breath), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), bipolar disease (a disorder associated with episode of mood swings ranging from depressive lows to manic highs), and panic disorder (a disorder characterized by unexpected and repeated episodes of intense fear accompanied by physical symptom that may include chest pian, heart palpitations, and shortness of breath). Record review of Resident #27's clinical record revealed her last MDS was a quarterly completed 3-28-2025 listing her with a BIMS score of 15 indicating she was cognitively intact, and she had a functionality of requiring set-up/clean-up assistance with most of her activities of daily living. Section O-Special Treatments, Procedures, and Programs-Respiratory Programs: Oxygen Therapy-Resident #31 was marked as having oxygen While a Resident. Record review of Resident #27's Order Summary Report with Active Orders as of 05/20/2025 revealed the following orders: - May use oxygen @1-5 l/m via nasal canula two times a day. Active 04/17/2025. - Change nasal canula as needed for maintenance. Active 12/22/2023 Record review of Resident #27's clinical record revealed a care plan with the admitted [DATE], which revealed the following: Focus: The resident has Oxygen Therapy - Ineffective gas exchange. Date Initiated: 10/17/2022. -there were no interventions for respiratory equipment care to include nasal cannula storage. During an observation on 05/19/25 at 10:10 AM Resident #27 was observed in her room sitting in a recliner with no bed present. Resident #27 had her nasal cannula on the floor next to the O2 concentrator that was next to her recliner. Resident #27 reported that she used her oxygen only at night and that she did not need it during the day. There was no date of when the oxygen tubing or nasal cannula had been changed. The nasal prong area of the nasal cannula appeared brownish and discolored from use. There was no storage bag provided for the nasal cannula. During an observation on 05/19/25 at 12:19 PM revealed Resident #27 was not in her room, but her nasal cannula was still on the floor in the same position between her recliner and her oxygen concentrator. During an observation on 05/19/25 at 02:22 PM revealed Resident #27 was not in her room, but her nasal cannula was still on the floor in a slightly different position between her recliner and her oxygen concentrator. During an observation on 05/19/25 at 03:19 PM revealed Resident #27 was in her room sitting in her wheelchair listening to her headphone. Resident #27's nasal cannula was still on the floor between her recliner and her oxygen concentrator in the same position as observed on 05/19/25 at 02:22 PM. During an observation on 05/20/25 at 09:09 AM revealed Resident #27 was in her recliner with her oxygen on. Her nasal cannula was observed to have the same brownish discoloration. Resident #27 was sleeping and did not wake to introduction. During an observation on 05/20/25 at 10:04 AM revealed Resident #27 was not in her room. This observation revealed that the nasal cannula had been replaced and was stored in a bag hanging from the back of the oxygen concentrator. During an interview on 05/21/25 at 07:48 AM LVN B (nurse for the 400 Hall this shift who reported this was her first day to work this week) reported that staff were to make rounds of the resident's room every 2 hours and that they are to check on the resident's oxygen concentrator to ensure that the equipment such as the nasal cannula and tubing are stored correctly. LVN B reported that if a nasal cannula was found on the floor, then it should be replaced, and a bag should be provided so the new nasal cannula could be stored properly off the floor. LVN B reported that if a nasal cannula was left on the floor, then it could become dirty, full of water from the hydration chamber when the machine is on, and it could be an infection problem. During an observation and interview on 05/21/25 at 08:07 AM revealed Resident #27 was in her room sitting in her recliner wearing her headphones resting peacefully. Resident #27 had her oxygen stored correctly in the bag provided behind her O2 concentrator. Resident #27 was asked about her nasal cannula being on the floor on 5/19/25 and Resident #27 reported that she did not really pay attention to that, that she just reached beside her recliner until she feels the tubing and then puts it on. Resident #27 reported that she has not really thought about it being on the floor and didn't really have an opinion either way. During an interview on 05/21/25 at 08:46 AM CNA A (CNA for the 400 Hall this shift) who reported that she was not working on 5/19/25. CNA A reported that staff were to make rounds every two hours, and that they were supposed to check the resident oxygen concentrators, tubing, and nasal cannulas. CNA A reported that the staff should make sure that they have water for the concentrator and that the nasal cannulas were in good shape. CNA A reported that if a nasal cannula was found on the floor, then they throw it away and get a new one because that one could be cross contaminated with whatever was on the floor or someone could have stepped on it, During an interview on 05/21/25 at 11:15 AM the DON reported that staff were to make rounds every 2 hours, they were to check the oxygen concentrators when in the room to make sure they were functioning and have water, and if the nasal cannula was on the floor, then they were to throw the nasal cannula away and replace it. If the nasal cannula was not replaced, then that could be a violation of infection control. During an interview on 05/21/25 at 12:30 PM the CN reported that the facility did not have a policy for care of respiratory equipment.

Based on interview and record review the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 2 (Resident #10 and Resident #57) of 16 residents reviewed for PASRR. 1. The facility failed to refer Resident #10 for PASRR level II assessment, to the state-designated authority, upon receipt of a major depressive disorder recurrent severe diagnosis. 2. The facility failed to refer Resident #57 for PASRR level II assessment, to the state-designated authority, upon receipt of a psychotic disorder with delusions and/or paranoid schizophrenia diagnoses. These failures could place residents at risk of not receiving necessary care and/or services. Findings Included: 1. Record review of Resident #10's admission record dated 05/20/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with a diagnoses that included, but were not limited to, unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), major depressive disorder recurrent severe (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life), brief psychotic disorder (a temporary psychiatric condition characterized by sudden onset of psychotic symptoms, such as delusions and hallucinations, lasting less than one month), and generalized anxiety disorder (inability to control constant worrying). The diagnosis of major depressive disorder recurrent severe had an onset date of 04/05/24. Record review of Resident #10's quarterly MDS completed on 04/07/25 revealed the following: Section C Cognitive Patterns revealed Resident #10 had a BIMS score of 15 which indicated intact cognition. Section I Active Diagnoses revealed Resident #10 had diagnoses of anxiety disorder, depression, and psychotic disorder. Record review of Resident #10's care plan completed on 05/12/25 revealed she had a history of mood problems and depression. She required antidepressant medication. Record review of Resident #10's order summary report dated 05/20/25 revealed the following order: Escitalopram Oxalate Oral Tablet 20 MG . Give 1 tablet by mouth one time a day related to MAJOR DEPRESSIVE DISORDER, RECURRENT SEVERE WITHOUT PSYCHOTIC FEATURES . Record review of Resident #10's most recent PASRR Level 1 Screening revealed an assessment date of 10/03/22. The PASRR was negative for mental illness. 2. Record review of Resident #57's admission record dated 05/19/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), delirium due to know physiological condition (a type of acute confusion that can arise from various factors), paranoid schizophrenia (a mental illness characterized by episodes of psychosis including hallucinations, delusions, and disorganized thinking), psychotic disorder with delusions (severe mental illness including distorted beliefs), and major depressive disorder recurrent severe (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities). The diagnosis of psychotic disorder with delusions had an onset date of 04/04/24. The diagnosis of paranoid schizophrenia had an onset date of 04/22/25. Record review of Resident #57's quarterly MDS completed on 04/21/25 revealed the following: Section C Cognitive Patterns revealed Resident #57 had a BIMS score of 9 which indicated moderately impaired cognition. Section I Active Diagnoses revealed Resident #57 had diagnoses of depression and psychotic disorder. Record review of Resident #57's care plan completed 03/24/25 revealed Resident #57 has mood problem related to vascular dementia and paranoid schizophrenia. Resident #57 required antidepressant and antipsychotic medication. Record review of Resident #57's order summary report dated 05/19/25 revealed the following orders: Donepezil HCI Oral Tablet 5 MG . Give 2 tablet by mouth one time a day related to . PSYCHOTIC DISORDER . risperiDONE Oral Tablet 1 MG . Give 2 tablet by mouth one time a day related to PSYCHOTIC DISORDER WITH DELUSIONS DUE TO KNOWN PHYSIOLOGICAL CONDITION . Sertraline HCI Oral Tablet 100 MG . Give 1 tablet by mouth one time a day related to PSYCHOTIC DISORDER WITH DELUSIONS DUE TO KNOWN PHYSIOLOGICAL CONDITION . Record review of Resident #57's EHR under the miscellaneous tab revealed Resident #57's most recent PASRR Level 1 Screening had an assessment date of 03/19/25. The PASRR was positive for a primary diagnosis of dementia and negative for mental illness. During an interview on 05/20/25 at 10:48 AM MDS LVN stated she was responsible for completing PASRR screening. She stated if a resident received a new mental illness diagnosis after having a negative PASRR I they should have received a new PASRR I to determine if they were eligible for services based on the new diagnosis. MDS LVN stated she should have but did not run new PASRR screenings on Resident #10 and Resident #57. MDS LVN stated she did not think either resident was negatively affected by her failure to run new PASRR screenings due to both residents having a primary diagnosis of dementia (this would cause them to be ineligible for PASRR services). She stated, I don't think it would impact the residents per se because they are long term care, and their care is not going to change. During an interview on 05/20/25 at 10:59 AM ADM stated MDS LVN was responsible for completing PASRR screenings. He stated not doing a new PASRR screening following a new qualifying mental health diagnosis could negatively impact a resident because they might not get services they need. During an interview on 05/21/25 at 09:16 AM DON stated if a resident with a new mental illness did not receive a new PASRR screening they won't receive needed services if they are PASRR positive. Record review of facility policy titled PASRR Level 1 Screen Policy and Procedure and dated 3-6-2019 revealed no mention of re-screening residents following newly qualifying diagnoses.

Based on observations, interviews, and record review, the facility failed to ensure the right to be free from misappropriation of property for 1 (Resident #1) of 8 residents reviewed for misappropriation of property. The facility failed to prevent a diversion (misappropriation) of Resident #1's Tylenol #3 tablets (used to treat pain) for a total of 10 tablets. This failure could place residents at risk for decreased quality of life, misappropriation of property, increased/uncontrolled pain, and dignity. Findings include: Record review of Resident #1's clinical record revealed an [AGE] year-old female resident admitted to the facility originally on 09/25/2019 and readmitted on [DATE] with diagnoses to include malignant neoplasm of unspecified site of the right female breast (a fast-growing cancer of the breast that spreads to other areas of the body), polyneuropathy (a generalized term for peripheral nervous system disorders that impact nerve function in multiple areas of the body), osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), gout (a disease in which defective metabolism of uric acid causes arthritis, especially in the smaller bones of the feet, deposit of chalkstones (a chalky deposit of sedum urate sometimes occurring in the joints of person affected by gout), and episodes of acute pain, and restless leg syndrome (a nervous system problem that causes you to feel an unstoppable urge to get up and pace or walk). Record review of Resident #1's clinical record revealed her last MDS was a quarterly completed 04/08/2025 listing a BIMS score of 11 indicating she was moderately cognitively impaired, and she had a functionality of requiring set-up/clean up assistance for most of her activities of daily living. Resident #1 was listed as having pain Occasionally, that affected her sleep Occasionally, that interfered with therapy activities Occasionally, and interfered with her day-to-day activities Occasionally. Record review of Resident #1's Medication Administration Report with Schedule for April 2025 revealed the following order: - Acetaminophen-Codeine Oral Tablet 300-30 MG (Acetaminophen w/ Codeine) Give 1 tablet by mouth every 6 hours as needed for Pain -D/C Date- 04/24/2025. (Tylenol #3) Record review of Resident #1's clinical record revealed a care plan with the admitted [DATE], which revealed the following: Focus: The resident has a potential for pain r/t osteoarthritis and is on pain medication. Date Initiated: 07/12/2022. Revision on: 04/21/2025 Interventions/Tasks: Administer analgesic medication as per orders. Give 1/2 hour before treatments or care. Date Initiated: 07/12/2022. Revision on: 07/12/2022. During an observation and interview on 4/25/2025 at 10:06 AM Resident #1 was in her room sitting in her recliner wearing her oxygen. Resident #1 reported that she had no issues with her medications and that she was not aware of any missing medications because she has not missed any doses. Resident #1 appeared in good condition, relaxed, and comfortable. During an interview on 04/25/2025 at 08:53 AM LVN A (the witness who discovered the drug diversion incident) reported that she received a call from Hospice for Resident #1 on Thursday 04/17/2025 for a narcotic count and she gave Hospice the information that Resident #1 had 13 Tylenol #3 pills left. LVN A then received another call when she was off on Saturday 04/20/2025 to verify that she had reported a count of 13 Tylenol #3 pills on Thursday 04/17/2025. LVN A reported that this was all she knew of the event in question. During an interview on 4/25/2025 at 01:44 PM the DON reported that the nurse who should have discovered the missing medications for Resident #1 had been suspended and has been tested for narcotics, but the results are still pending. The DON reported that Resident #1's Tylenol #3's medication card was filled on 03/06/2025 for 30 pills and according to the MAR, Resident #1 was given 20 pills, so it looks like 10 pills were unaccounted for. The DON reported that due to the Narcotic count sheet and the Narcotic Medication Blister Pack/Card were both missing, she was not able to exactly identify/make sure what happened. The DON reported that Resident #1 did not miss any doses of her Tylenol #3, that they had the medication in the e-kit and they were able to cover what was needed until Hospice could refill the prescription. The DON reported that only one dose of Tylenol #3 was needed from the E-Kit. The DON reported that nursing staff were immediately in-serviced on training for medication administration records and narcotic counts. The DON reported that if a medication was mishandled or disappears like this one apparently has then a nurse could have misappropriated the resident's medication, that it could affect the resident if they could not get that medication replaced immediately. During an interview on 4/25/2025 at 02:18 PM LVN A (the witness who discovered the drug diversion incident) reported that if resident medications were to disappear then that could be an issue that could affect the resident in which they would not get the treatment they were supposed to and that could make their condition worse. Record review of the facility provided training dated 04/19/25 revealed the following: Signing out PRN's must be done in the Narcotic book and in the computer. You will sign out and count every time you give your cart to next shift or at lunch. This includes med passes as well. A completed Narc sheets to be sent to the DON via under her door or in box immediately. Do not take important nursing documents including report sheets, Narc sheet to hall 200. - signed by 22 nursing staff. Record review of the facility provided training dated 04/22/25 revealed the following: Second signature for signing med in, wasting meds. Sign your count sheets and sign in sheets for Narcs. - Signed by 15 nursing staff. Record review of the facility provided policy titled Abuse/Neglect revised 09/09/2024, revealed the following: The resident has the right to be fee from abuse, neglect, misappropriation of resident property . 9. Misappropriation of resident property: means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident belonging or money without the resident consent.

Based on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, 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, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 (Resident #1) of 5 residents reviewed for abuse and neglect. The facility failed to report the emotional and possible physical abuse of Resident #1 by Resident #2 which occurred on 09/22/24 to administrator and the state survey agency. The noncompliance was found to be Past Non Compliance (PNC). The noncompliance began on 09/22/2024 and ended on 09/26/2024 The facility corrected the noncompliance before the investigation began. This failure could place residents at risk of continued and/or unrecognized abuse or neglect. Findings Included: Record review of Resident #1's admission record dated 10/04/24 revealed an [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses that included, but were not limited to, dementia (a group of thinking and social symptoms that interferes with daily functioning), major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), and psychotic disorder with hallucinations (severe mental illness including seeing things that are not there). Record review of Resident #1's quarterly MDS completed 08/03/24 revealed the following: Section B: Resident #1 was able to understand others sometimes. Section C: Resident #1 was rarely to never understood, therefore had no BIMS. The staff assessment of her mental status revealed she had long and short-term memory problems and moderately impaired cognition. Section E: Resident #1 displayed wandering behavior daily. Section GG: Resident #1 used a wheelchair. She required set up or clean up assistance with eating and upper body dressing; supervision or touching assistance with oral hygiene; partial/moderate assistance with footwear, lower body dressing, and shower/bathing; and substantial/maximal assistance with toileting and personal hygiene. Resident #1 required partial/moderate assistance across all mobility except for walking 10 feet which required supervision or touching assistance and walking 50 feet with two turns and walking 150 feet both of which were not attempted due to medical condition or safety concerns. Section I: Resident #1's primary medical condition was non-traumatic brain dysfunction. Section N: Resident #1 received antidepressant medication during the 7-day look back period. She did not receive anticoagulant medication. Record review of Resident #1's care plan completed on 07/24/24 revealed she had a communication problem. Interventions included monitoring Resident #1 for physical/nonverbal indicators of discomfort or distress, focus on a word or phrase that makes sense, ensure/provide a safe environment, and be conscious of resident's position when in groups, activities, dining room to promote proper communication with others. The care plan indicated Resident #1 had a history of physical aggression received. The corresponding intervention was to keep resident away from any situation that will put resident at risk for situations of physical aggression. Resident #1 was residing in the secure unit related to her diagnosis of dementia and her risk for elopement. Record review of Resident #1's Order Summary Report dated 10/04/24 revealed she had an active order for antidepressant medication Duloxetine HCI 60 mg delayed release capsule once a day with a start date of 08/29/24. Record review of Resident #1's progress notes from 09/04/24 to 10/04/24 revealed no notes from 09/22/24. The progress notes did reveal the following notes: A note written by DON on 09/24/24 at 2:26 PM entered as LATE ENTRY This nurse notified of another resident kissing this resident on forehead. This nurse assessed this resident. No new or worsening injury note at this time. Res (Resident) unable to recall events and states 'No, I'm fine.' Provider notified of incident at this time, no new orders. A note written by DON on 09/24/24 at 4:00 PM This nurse notified [name of psychiatric doctor] office of resident receiving kiss on forehead from another resident. Message left with nurse who stated will notify provider and awaiting call back. A note written by SW on 09/24/24 at 04:16 PM SW met with resident in the unit. She was sitting in her wheelchair in the dining room. She had her head down as she appeared to be sleeping. SW completed PRN Trauma Screen with resident. She denied any trauma at this time. She shook her head yes/no when answering questions. She appeared to be sleepy and did not want to be disturb at this time. No trauma noted. A note written by GVN D on 09/25/24 at 06:18 PM CNA reported major bruise to nurse and ADON immediately [sic]. Nurse and ADON went to assess resident immediately. Purple bruise to right posterior forearm noted, measuring [sic] approximately 14X9.5 cm. Other findings documented in skin assessment. When this nurse asked res what happeneded [sic] res confused and unable to respond due to impaired [sic] mental status. Resident denies any pain or distress at this time. Res taken back to dinning [sic] room, ready to eat dinner. RN compliance nurse and [name of ADM] notified immediately [sic] by nurse and ADON. [Name of physician] and NP notified. [name of Resident #1's family member] emergency contact notified of injury. [name of Resident #1's family member] stated 'the slightest bump makes her bruise very badly, I'm not worried. Just keep me updated.' This nurse notified oncoming shift of injury. Record review of Resident #1's Event Nurses' Note - Bruise completed by DON on 09/25/24 at 05:31 PM revealed the bruise on Resident #1's right posterior forearm was of unknown origin and measured 14 X 9.5 cm. It was blue/purple in color. Resident #1 was unable to recall how she obtained the bruise. Physician and family were notified, and padding was applied to the arm rest of Resident #1's w/c. Record review of Resident #1's Trauma Informed PRN Assessment completed by SW on 09/24/24 at 04:04 PM revealed the following questions with answers in the negative: . 4. Have you (or has the resident) been in a situation that was extremely frightening? 5. Have you (or has the resident witnessed any extremely frightening situations? . Record review of Resident #1's Order Summary Report dated 10/04/24 revealed she was admitted to the secure unit on 08/28/23 due to a high elopement risk. Resident #1 had no order for anticoagulant medication. Record review of Resident #2's admission record dated 10/04/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, dementia (a group of thinking and social symptoms that interferes with daily functioning), generalized anxiety disorder (inability to control constant worrying), and prostate cancer. He was discharged from the facility on 09/26/24 to a behavioral health hospital. Record review of Resident #2's admission MDS completed on 09/13/24 revealed the following: Section B: Resident #2 was able to understand others and make himself understood. Section C: Resident #2 had a BIMS of 3 which indicated severely impaired cognition. Section D: Resident #2 sometimes felt lonely or isolated from those around him. Section E: Resident #2 had no behaviors during the look back period. Section GG: Resident #2 did not use any mobility devices. He needed set up or clean up assistance for eating, oral hygiene, toileting hygiene, dressing, and personal hygiene. Resident #2 was independent across all mobility ADLs except for shower/bath transfer, walking over uneven surfaces, and picking up an object where he needed supervision or touching assistance. Section I: Resident #2's primary medical condition was non-traumatic brain dysfunction. Section K: Resident #2 was 5 feet seven inches tall and weighed 146 pounds. Section N: Resident #2 received antianxiety and antidepressant medications during the 7-day look back period. Record review of Resident #2's care plan completed on 09/16/24 revealed he was taking antianxiety medications and one of the interventions listed was to monitor and record occurrence of target behavior symptoms including violence/aggression towards staff/others and document per facility protocol. Resident #2 was noted to be at risk for wandering. He resided in the secure unit related to his diagnosis of dementia and his risk for elopement. Resident #2 was noted to have potential to demonstrate physical behaviors. He kissed another resident on forehead 09/24/24. [name of behavioral hospital] admission on 09/26/24. Two of the interventions listed was, If the resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately and Notify the charge nurse of any physically abusive behaviors. The care plan noted Resident #2 was placed on 1 on 1 monitoring following his kiss on Resident #1's forehead on 09/24/24. No mention made of incident between Resident #2 and Resident #1 on 09/22/24 in the care plan. Record review of Resident #2's orders prior to his discharge to the behavioral hospital revealed he was started on an antipsychotic medication on 09/23/24 and was receiving antianxiety and antidepressant medications with start dates of 09/04/24. Record review of Resident #2's progress notes from 09/04/24 to 10/04/24 revealed the following notes: A note written by LVN A on 09/22/24 at 07:59 PM Pt was seen going into womans [sic] room and waking her up out of bed and touching her innappropriatly [sic]. Woman pt started to panic and get away from him. Staff transferred [sic] woman pt out of bed and into wc to monitor. This pt began grabbing womans [wic] wc handles and dragging her back. This staff intervened d/t pt woman crying and tryhing [sic] to get away. Pt began hitting staff and chasing after woman pt. At this time, woman has been taken out of secure unit and placed with one staff member for safety. [Hospice] on call called, no response at this time. On call [name of ADON] notifed [sic], stated I am trying to get a hold of SW, but she won't answer me. Awaiting a call back at this time from management [sic] and [Hospice]. Pt is currently standing at secure unit doors trying to pry them open. A note written by LVN A on 09/22/24 at 10:51 PM Pt is now hovering over aide down secure unit touching her cheek and stating, You like this, come on. Aide sternly educated pt to go back to bed. Pt walked in room and is sitting on bed staring out into the hall. A note written by LVN B on 09/23/24 at 12:02 AM Hospice returned call at this time and this nurse explained situation and noting new behavior for resident. Hospice nurse to call her on call provider for orders. Notified ADON. Hospice returned call at approx 2002 (02:02 AM) with new orders for [antipsychotic medication] 0.5mg Q6hrs and to schedule the [antianxiety medication] 0.5mg q4hrs and morphine(20mg/5ml)0.2ml q4hrs. [Antipsychotic medication] will be delivered to facility via hospice pharmacy tomorrow. DON notified of new orders. A note written by LVN F on 09/23/24 at 10:59 PM While this nurse was doing med pass, the aid informed this nurse that the resident would not let her use the restroom. The resident would push the door open and would not allow the aid any privacy. This nurse gave the resident PRN [antianxiety medication] and [antipsychotic medication]. Immediately [sic] after administering [sic] the residents medication, the resident went into another residents room and was messing with her and her bedding. This nurse and a aid had to remove the resident from the other residents room. As per the residents daughter request this nurse notified the residents' daughter about the situation. A note written by LVN G on 09/24/24 at 02: 22 PM This nurse found resident kissing other resident on the forehead in dining area. This nurse removed other resident from the area. Resident is now in room making bed. No distress noted. A note written by DON on 09/24/24 at 02:23 PM This DON notified of incident. Administrator notified. Self report protocol initiated. A note written by DON on 09/24/24 at 02:50 PM This nurse spoke with resident daughter and educated on situation that occurred and facility policy. This nurse also educated resident daughter on interventions put in place such as one on one and referral to inpatient psych. Res daughter verbalizes understanding and appreciative of interventions facility has provided. Res daughter also appreciative on this nurse explaining situation and protocol. Res daughter inquires as to if res will readmit after psych stay, res education on clinical will be reviewed to ensure facility can meet res needs and res or other res will not be at risk of safety if readmitted and facility/inpatient psych assisting with placement if unable to readmit - res daughter verbalizes understanding. A note written by SW on 09/26/24 at 01:36 PM SW has worked with [behavioral hospital] for admission for today. Res was transported to [behavioral hospital]. SW sent ED paperwork to the Judge to be completed. Paperwork was completed and sent to [behavioral hospital]. SW also spoke to resident daughter about him receiving a 30 day notice. Res / daughter also given copy of 30 day notice. Res daughter was appreciative about his care at facility. She reported that they would come Monday and pick up his stuff. Record review of Event Nurses' Note - Behavior written by DON on 09/24/24 at 02:24 PM revealed Resident #2 exhibited physical, resident to resident behavior in the hallway. The behavior was kissing another resident on the forehead, and it was witnessed by LVN on duty. Resident was redirected and provided with 1 on 1 supervision. During an interview on 10/04/24 at 05:30 PM ADM stated he was not sure who the female resident mentioned in Resident #2's progress note written by LVN A on 09/22/24 at 07:59 PM. He stated DON would know. During an interview on 10/04/24 at 05:32 PM DON stated the female resident from Resident #2's progress note written by LVN A on 09/22/24 at 07:59 PM was Resident #1. She stated she had concerns about the wording of the progress note and she called LVN A and got a statement from LVN A stating she put the words touching her inappropriately in the progress note based on what the CNA told her. DON stated the CNA was CNA E. DON stated English is CNA E's second language and confusion had led to the wrong thing being documented. DON stated she would bring me a written copy of CNA E's statement regarding the incident on 09/22/24 between Resident #1 and Resident #2. DON stated after she spoke to CNA E and LVN A she felt Resident #2 only wanted to help/protect the women. DON stated, He was their (female residents') protector and didn't really want us (facility staff) to help. She said this was made very clear after Resident #2 was placed on 1 to 1 supervision following his kiss to Resident #1's forehead when every time a staff member would enter a resident's room he would ask, Who is that? Record review of CNA E's statement revealed it was dated 09/24/24. In the statement CNA E revealed Resident #2 was calling Resident #1 his girl and his girlfriend and patting her on the shoulder. Record review of LVN A's statement regarding why she documented Resident #2 was touching Resident #1 inappropriately on 09/22/24 revealed a photo of a text message which read, I documented the 'inappropriate touching' due to CNA statement.'[sic] During an interview on 10/04/24 at 05:51 PM LVN A stated she wrote Resident #2's progress note on 09/22/24 at 07:59 PM based on what CNA E told her over the phone. (staff in the locked unit often communicate with staff outside the locked unit via phone call) LVN A stated what she saw with her own eyes was Resident #2 grabbing at her (Resident #1's) arms and pulling on her and she was verbally crying and screaming. LVN A said earlier in the night when she assisted Resident #1 to bed Resident #1 said, This is not my room, this is his room. This is his room. He is going to come in here and be fraudulent. LVN A said she did not think anything of it at the time due to Resident #1 having dementia. She said she assured Resident #1 that she would keep her safe. LVN A stated Resident #1 then said, They are going to come in here before you are gone. LVN A stated, Looking back on it, I feel bad because I wonder if she was afraid that night. You know people with dementia say some wild things but in light of what happened, I wonder. LVN A stated that after the incident the nurses took Resident #1 out of the locked unit and had her seated in her w/c at the nurses' station. LVN A said of Resident #1, She stayed up the whole night, I felt so bad for her. LVN A stated the nurses tried putting Resident #1 to bed in an empty room on hall 400 but she would not stay in bed. I think she recognized it was not her room. LVN A stated she knew the staff in the locked unit needed her help when LVN B called her and asked her to open the door of the locked unit so LVN B could push Resident #1 out of the unit without letting Resident #2 out of the unit as well. LVN A stated she opened the door and saw LVN B pushing Resident #1 in her w/c at a slow walk and behind her she saw Resident #2 get away from LVN C and CNA E who were trying to keep him from following and he began to sprint down the hall after Resident #1 and LVN B. LVN A said she told LVN B, Okay, [first name of LVN B] I'm gonna need you to pick it up. LVN A stated LVN B began to walk faster while pushing Resident #1 in her w/c and they got LVN B and Resident #1 out of the locked unit just in time to shut the door and keep Resident #2 in the locked unit. During an observation and interview on 10/04/24 at 06:22 PM Resident #1 was wheeling herself down the hall of the locked unit. When asked if she was [name of Resident #1] she shook her head and continued wheeling herself down the hall. During an interview on 10/04/24 at 06:26 PM SW stated she did interview Resident #1 about trauma following Resident #2 kissing Resident #1 on the forehead. SW stated Resident #1 was alert but not sure what was going on during the interview. When asked if she thought Resident #1 was traumatized by Resident #2 pulling on her and chasing her on the locked unit on 09/22/24 SW said it was hard to tell as the change of venue from the locked unit to the nurses' station for the night might have also been traumatizing. When asked if she thought a reasonable person would have been traumatized by the events that took place between Resident #1 and Resident #2 on 09/22/24, SW stated, It absolutely could be traumatizing. During an interview on 10/04/24 at 06:29 PM LVN A stated she thought Resident #1 was traumatized by the interaction on 09/22/24 with Resident #2 because, she was in bed initially and when I went back, she was out of bed, crying, and trying not to let him (Resident #2) touch her. During an interview on 10/04/24 at 06:31 PM LVN B stated LVN C texted her to please come help in the locked unit as Resident #2 would not let go of Resident #1's w/c. LVN B stated when she got to the locked unit she observed Resident #2 holding onto the handles of Resident #1's w/c and Resident #1 was in the w/c and kept saying, No, you don't want me, I'm too old, I don't want to go with you. LVN B stated she tried to distract Resident #2 and get him to go outside with her to pick weeds as that was one of his favorite pastimes, but he would not let go and kept trying to push Resident #1 in her w/c. LVN B said Resident #2 kept saying Resident #1 was his girl and he was going to go wherever she went. LVN B said she got Resident #1 away from Resident #2 at one point and called LVN A to open the door of the locked unit for her because LVN C and CNA E were holding Resident #2's hands to keep him from following them out. LVN B said during the entire situation she could tell Resident #1 was scared. LVN B stated, We had [name of Resident #1] out here for the night. She was upset. I tried to distract her by giving her a banana, but she was scared. LVN B said after she and Resident #1 exited the locked unit Resident #2 stood on the other side of the locked doors hitting the doors and yelling. LVN B said of Resident #1, We (nursing staff) tried putting her to bed on hall 400 but she kept getting up and she kept saying, 'That guy is going to come get me.' LVN B stated she reported the entire incident to ADON and hospice nurse. LVN B said in her opinion not reporting possible abuse of a resident is just bad. During an interview on 10/04/24 at 06:37 PM LVN C stated that during report at the beginning of her shift on 09/22/24 she found out Resident #2 had been having behaviors all day. She stated she heard CNA E needed help on the locked hall with Resident #2. LVN C said when she got to the locked unit Resident #2 was trying to direct [name of Resident #1] to his room and I could tell she (Resident #1) was afraid. She was saying, 'I'm too old, no you don't want me.' LVN C said Resident #2 was grabbing Resident #1's hands and grabbing the handle of Resident #1's w/c. LVN C stated Resident #1 was crying during part of the interaction. LVN C said Resident #2 became so agitated he was hitting at staff and hitting near Resident #1 but did not hit Resident #1. She said she and CNA E attempted to hold Resident #2's hands to keep him from chasing Resident #1 and LVN B out of the locked unit and because at this point, he was just hitting us. She said Resident #2 got out of their grasp and ran after Resident #1 and LVN B, but they made it out the door before he got to them. LVN C said, I figured if we weren't there, there was going to be abuse going on. During an interview on 10/04/24 at 06:46 PM CNA E stated on 09/22/24 Resident #2 was confused and after [Resident #1]. She said Resident #2 started saying Resident #1 was his girlfriend and his wife and he wouldn't let her go. CNA E said Resident #1 started saying, 'Listen, I don't like you, you're not mine.' CNA E said she had to call the nurses because Resident #2 would not let go of Resident #1's w/c and he got mad. She said Resident #1 kept saying, You don't want to be with me. I don't like you. CNA E did not exhibit any issues with speaking English clearly during this interview. During an interview on 10/04/24 at 07:11 PM DON stated staff are responsible to report to ADM or charge nurse when they notice anything that could constitute resident abuse. When asked what a possible negative outcome of not reporting resident abuse immediately DON said, If a resident did receive abuse possible negative outcome is they wouldn't receive treatment that was necessary. When asked why Resident #2's treatment of Resident #1 on 09/22/24 was not reported as possible abuse she said, I think her case would be different because she does have dementia. When asked what would happen if a reasonable person had endured the same treatment as Resident #1, DON said, If it was somebody else, I'd look at it differently because they were not a dementia patient. During an interview on 10/04/24 at 07:15 PM ADM stated that if the same thing that happened to Resident #1 at the hands of Resident #2 happened to a reasonable person it could be considered abuse. ADM stated it was a no brainer that there could be a negative outcome to residents if possible abuse of residents was not reported timely. During an interview on 10/04/24 at 07:30 PM ADM stated he was not informed of the incident between Resident #1 and Resident #2 on 09/22/24 and that if he had been informed, he would have reported it as possible abuse. During an interview on 10/18/24 at 10:28 AM ADM stated he expected his staff to let him know right away if anything that might constitute resident abuse or neglect took place on the weekend because he is the one who reports such incidents to the state. He stated he was not sure why ADON and DON did not inform him of the incident between Resident #1 and Resident #2 on 09/22/24. He stated, We would have started the process of getting him (Resident #2) out (of the facility). ADM stated the facility started that process on 09/24/24 when Resident #2 was seen kissing Resident #1 on the forehead. He stated to address his staff not informing him of the incident on 09/22/24 all staff were in-serviced on Abuse/Neglect and ADON was in-serviced on what is expected from weekend on-call staff regarding contacting him with concerns. During an interview on 10/18/24 at 10:32 AM DON stated staff did not report any distress on the part of Resident #1 when reporting the incident from 09/22/24 to ADON. During an interview on 10/18/24 at 11:05 AM ADON stated nurses did not indicate any distress on the part of Resident #1 following the incident on 09/22/24. She stated, They (nurses) said he (Resident #2) was going up and down the hallways and walking everywhere and trying to take female residents to their rooms and nurses and CNAs would not let him. They did not report distress to me at all (for Resident #1). I told them to get ahold of Hospice. I called DON and SW. Could not get hold of SW. DON told me we did need to get hold of [name of hospice for Resident #2] They got ahold of hospice, and they were able to take care of him and keep her safe. Record review of facility policy titled Abuse/Neglect and dated March 11, 2013 revealed the following: . Abuse is the willful infliction of . intimidation . with resulting . mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Any person having reasonable cause to believe an elderly or incapacitated adults is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state and/or adult protective services. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 2024-14 dated 08/29/24. a. If the allegations involve abuse or result in serious bodily injury, the report must be made within 24 hours of the allegation. b. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation. Record review of abuse/neglect in-services for the past three months revealed in-services on the following dates: 07/02/24, 07/07/24, 07/08/24, 07/10/24, 07/11/24, 07/16/24, 07/30/24, 08/14/24, 08/13/24, 08/08/24, 08/27/24, 09/24/24, 09/25/24, 09/26/24, 09/29/24, 10/01/24. Each of the in-services included, Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents . If abuse and/or neglect witnessed or suspected, intervene immediately and report to abuse preventionist-the administrator [name of ADM] or immediate supervisor. Record Review of the abuse/neglect in-services for the past three months revealed the following dates: 07/02/24, 07/07/24, 07/08/24, 07/10/24, 07/11/24, 07/16/24, 07/30/24, 08/14/24, 08/13/24, 08/08/24, 08/27/24, 09/24/24, 09/25/24, 09/26/24, 09/29/24, 10/01/24, the ADON and DON participated in said in-service training covering what is abuse and when and to whom it should be reported.

Based on observation, interview, and record review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, for 1 (Resident #1) of 5 residents reviewed for abuse and neglect. The facility failed to report the emotional and possible physical abuse of Resident #1 by Resident #2 as per the facility's Abuse/Neglect policy. The noncompliance was found to be Past Noncompliance (PNC). The noncompliance began on 09/22/24 and ended on 09/26/24. The facility corrected the noncompliance before the investigation began. This failure could place residents at risk of continued and/or unrecognized abuse or neglect. Findings Included: Record review of Resident #1's admission record dated 10/04/24 revealed an [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses that included, but were not limited to, dementia (a group of thinking and social symptoms that interferes with daily functioning), major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), and psychotic disorder with hallucinations (severe mental illness including seeing things that are not there). Record review of Resident #1's quarterly MDS completed 08/03/24 revealed the following: Section C: Resident #1 was rarely to never understood, therefore had no BIMS. The staff assessment of her mental status revealed she had long and short-term memory problems and moderately impaired cognition. Section GG: Resident #1 used a wheelchair. She required set up or clean up assistance with eating and upper body dressing; supervision or touching assistance with oral hygiene; partial/moderate assistance with footwear, lower body dressing, and shower/bathing; and substantial/maximal assistance with toileting and personal hygiene. Resident #1 required partial/moderate assistance across all mobility except for walking 10 feet which required supervision or touching assistance and walking 50 feet with two turns and walking 150 feet both of which were not attempted due to medical condition or safety concerns. Section I: Resident #1's primary medical condition was non-traumatic brain dysfunction. Record review of Resident #1's care plan completed on 07/24/24 revealed she had a communication problem. Interventions included monitoring Resident #1 for physical/nonverbal indicators of discomfort or distress, focus on a word or phrase that makes sense, ensure/provide a safe environment, and be conscious of resident's position when in groups, activities, dining room to promote proper communication with others. The care plan indicated Resident #1 had a history of physical aggression received. The corresponding intervention was to keep resident away from any situation that will put resident at risk for situations of physical aggression. Resident #1 was residing in the secure unit related to her diagnosis of dementia and her risk for elopement. Record review of Resident #1's progress notes from 09/04/24 to 10/04/24 revealed no notes from 09/22/24. The progress notes did reveal the following notes: A note written by DON on 09/24/24 at 2:26 PM entered as LATE ENTRY This nurse notified of another resident kissing this resident on forehead. This nurse assessed this resident. No new or worsening injury note at this time. Res (Resident) unable to recall events and states 'No, I'm fine.' Provider notified of incident at this time, no new orders. A note written by DON on 09/24/24 at 4:00 PM This nurse notified [name of psychiatric doctor] office of resident receiving kiss on forehead from another resident. Message left with nurse who stated will notify provider and awaiting call back. A note written by GVN D on 09/25/24 at 06:18 PM CNA reported major bruise to nurse and ADON immediately [sic]. Nurse and ADON went to assess resident immediately. Purple bruise to right posterior forearm noted, measuring [sic] approximately 14X9.5 cm. Other findings documented in skin assessment. When this nurse asked res what happeneded [sic] res confused and unable to respond due to impaired [sic] mental status. Resident denies any pain or distress at this time. Res taken back to dinning [sic] room, ready to eat dinner. RN compliance nurse and [name of ADM] notified immediately [sic] by nurse and ADON. [Name of physician] and NP notified. [name of Resident #1's family member] emergency contact notified of injury. [name of Resident #1's family member] stated ' the slightest bump makes her bruise very badly, I'm not worried. Just keep me updated.' This nurse notified oncoming shift of injury. Record review of Resident #1's Event Nurses' Note - Bruise completed by DON on 09/25/24 at 05:31 PM revealed the bruise on Resident #1's right posterior forearm was of unknown origin and measured 14 X 9.5 cm. It was blue/purple in color. Resident #1 was unable to recall how she obtained the bruise. Physician and family were notified, and padding was applied to the arm rest of Resident #1's w/c. Record review of Resident #1's Trauma Informed PRN Assessment completed by SW on 09/24/24 at 04:04 PM revealed the following questions with answers in the negative: . 4. Have you (or has the resident) been in a situation that was extremely frightening? 5. Have you (or has the resident witnessed any extremely frightening situations? . Record review of Resident #1's Order Summary Report dated 10/04/24 revealed she was admitted to the secure unit on 08/28/23 due to a high elopement risk. Resident #1 had no order for anticoagulant medication. Record review of Resident #2's admission record dated 10/04/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, dementia (a group of thinking and social symptoms that interferes with daily functioning), generalized anxiety disorder (inability to control constant worrying), and prostate cancer. He was discharged from the facility on 09/26/24 to a behavioral health hospital. Record review of Resident #2's admission MDS completed on 09/13/24 revealed the following: Section B: Resident #2 was able to understand others and make himself understood. Section C: Resident #2 had a BIMS of 3 which indicated severely impaired cognition. Section D: Resident #2 sometimes felt lonely or isolated from those around him. Section E: Resident #2 had no behaviors during the look back period. Section GG: Resident #2 did not use any mobility devices. He needed set up or clean up assistance for eating, oral hygiene, toileting hygiene, dressing, and personal hygiene. Resident #2 was independent across all mobility ADLs except for shower/bath transfer, walking over uneven surfaces, and picking up an object where he needed supervision or touching assistance. Section I: Resident #2's primary medical condition was non-traumatic brain dysfunction. Section K: Resident #2 was 5 feet seven inches tall and weighed 146 pounds. Section N: Resident #2 received antianxiety and antidepressant medications during the 7-day look back period. Record review of Resident #2's care plan completed on 09/16/24 revealed he was taking antianxiety medications and one of the interventions listed was to monitor and record occurrence of target behavior symptoms including violence/aggression towards staff/others and document per facility protocol. Resident #2 was noted to be at risk for wandering. He resided in the secure unit related to his diagnosis of dementia and his risk for elopement. Resident #2 was noted to have potential to demonstrate physical behaviors. He kissed another resident on forehead 09/24/24. [name of behavioral hospital] admission on 09/26/24. Two of the interventions listed was, If the resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately and Notify the charge nurse of any physically abusive behaviors. The care plan noted Resident #2 was placed on 1 on 1 monitoring following his kiss on Resident #1's forehead on 09/24/24. No mention made of incident between Resident #2 and Resident #1 on 09/22/24 in the care plan. Record review of Resident #2's orders prior to his discharge to the behavioral hospital revealed he was started on an antipsychotic medication on 09/23/24 and was receiving antianxiety and antidepressant medications with start dates of 09/04/24. Record review of Resident #2's progress notes from 09/04/24 to 10/04/24 revealed the following notes: A note written by LVN A on 09/22/24 at 07:59 PM Pt was seen going into womans [sic] room and waking her up out of bed and touching her innappropriatly [sic]. Woman pt started to panic and get away from him. Staff transferred [sic] woman pt out of bed and into wc to monitor. This pt began grabbing womans [wic] wc handles and dragging her back. This staff intervened d/t pt woman crying and tryhing [sic] to get away. Pt began hitting staff and chasing after woman pt. At this time, woman has been taken out of secure unit and placed with one staff member for safety. [Hospice] on call called,no response at this time. On call [name of ADON] notifed [sic], stated I am trying to get a hold of SW but she won't answer me. Awaiting a call back at this time from management [sic] and [Hospice]. Pt is currently standing at secure unit doors trying to pry them open. A note written by LVN F on 09/23/24 at 10:59 PM While this nurse was doing med pass, the aid informed this nurse that the resident would not let her use the restroom. The resident would push the door open and would not allow the aid any privacy. This nurse gave the resident PRN [antianxiety medication] and [antipsychotic medication]. Immediately [sic] after administering [sic] the residents medication, the resident went into another residents room and was messing with her and her bedding. This nurse and a aid had to remove the resident from the other residents room. As per the residents daughter request this nurse notified the residents' daughter about the situation. A note written by LVN G on 09/24/24 at 02: 22 PM This nurse found resident kissing other resident on the forehead in dining area. This nurse removed other resident from the area. Resident is now in room making bed. No distress noted. A note written by DON on 09/24/24 at 02:23 PM This DON notified of incident. Administrator notified. Self report protocol initiated. Record review of Event Nurses' Note - Behavior written by DON on 09/24/24 at 02:24 PM revealed Resident #2 exhibited physical, resident to resident behavior in the hallway. The behavior was kissing another resident on the forehead, and it was witnessed by LVN on duty. Resident was redirected and provided with 1 on 1 supervision. Record review of CNA E's statement revealed it was dated 09/24/24. In the statement CNA E revealed Resident #2 was calling Resident #1 his girl and his girlfriend and patting her on the shoulder. Record review of LVN A's statement regarding why she documented Resident #2 was touching Resident #1 inappropriately on 09/22/24s revealed a photo of a text message which read, I documented the 'inappropriate touching' due to CNA statement.'[sic] During interviews on 10/04/24 beginning at 10:04 AM HSK H, HSK K, HSK I, [NAME] J, [NAME] M, COTA L, and CNA N stated they had been trained to recognize abuse, neglect, exploitation, and misappropriation of resident property and to report any suspicion of such to ADM. During an interview on 10/04/24 at 05:30 PM ADM stated he was not sure who the female resident mentioned in Resident #2's progress note written by LVN A on 09/22/24 at 07:59 PM was. He stated DON would know. During an interview on 10/04/24 at 05:32 PM DON stated the female resident from Resident #2's progress note written by LVN A on 09/22/24 at 07:59 PM was Resident #1. She stated she had concerns about the wording of the progress note and she called LVN A and got a statement from LVN A stating she put the words touching her inappropriately in the progress note based on what the CNA told her. DON stated the CNA was CNA E. DON stated English is CNA E's second language and confusion had led to the wrong thing being documented. DON stated she would bring me a written copy of CNA E's statement regarding the incident on 09/22/24 between Resident #1 and Resident #2. DON stated after she spoke to CNA E and LVN A she felt Resident #2 only wanted to help/protect the women. DON stated, He was their (female residents') protector and didn't really want us (facility staff) to help. She said this was made very clear after Resident #2 was placed on 1 to 1 supervision following his kiss to Resident #1's forehead when every time a staff member would enter a resident's room he would ask, Who is that? During an interview on 10/04/24 at 05:51 PM LVN A stated she wrote Resident #2's progress note on 09/22/24 at 07:59 PM based on what CNA E told her over the phone. (staff in the locked unit often communicate with staff outside the locked unit via phone call) LVN A stated what she saw with her own eyes was Resident #2 grabbing at her (Resident #1's) arms and pulling on her and she was verbally crying and screaming. LVN A said earlier in the night when she assisted Resident #1 to bed Resident #1 said, This is not my room, this is his room. This is his room. He is going to come in here and be fraudulent. LVN A said she did not think anything of it at the time due to Resident #1 having dementia. She said she assured Resident #1 that she would keep her safe. LVN A stated Resident #1 then said, They are going to come in here before you are gone. LVN A stated, Looking back on it, I feel bad because I wonder if she was afraid that night. You know people with dementia say some wild things but in light of what happened, I wonder. LVN A stated that after the incident the nurses took Resident #1 out of the locked unit and had her seated in her w/c at the nurses' station. LVN A said of Resident #1, She stayed up the whole night, I felt so bad for her. LVN A stated the nurses tried putting Resident #1 to bed in an empty room on hall 400 but she would not stay in bed. I think she recognized it was not her room. LVN A stated she knew the staff in the locked unit needed her help when LVN B called her and asked her to open the door of the locked unit so LVN B could push Resident #1 out of the unit without letting Resident #2 out of the unit as well. LVN A stated she opened the door and saw LVN B pushing Resident #1 in her w/c at a slow walk and behind her she saw Resident #2 get away from LVN C and CNA E who were trying to keep him from following and he began to sprint down the hall after Resident #1 and LVN B. LVN A said she told LVN B, Okay, [first name of LVN B] I'm gonna need you to pick it up. LVN A stated LVN B began to walk faster while pushing Resident #1 in her w/c and they got LVN B and Resident #1 out of the locked unit just in time to shut the door and keep Resident #2 in the locked unit. During an observation and interview on 10/04/24 at 06:22 PM Resident #1 was wheeling herself down the hall of the locked unit. When asked if she was [name of Resident #1] she shook her head and continued wheeling herself down the hall. During an interview on 10/04/24 at 06:23 PM CNA O stated he had been trained to recognize abuse, neglect, exploitation, and misappropriation of resident property and to report any suspicion of such to the ADM. He stated staff are trained on the above all the time. During an interview on 10/04/24 at 06:26 PM SW stated she did interview Resident #1 about trauma following Resident #2 kissing Resident #1 on the forehead. SW stated Resident #1 was alert but not sure what was going on during the interview. When asked if she thought Resident #1 was traumatized by Resident #2 pulling on her and chasing her on the locked unit on 09/22/24 SW said it was hard to tell as the change of venue from the locked unit to the nurses' station for the night might have also been traumatizing. When asked if she thought a reasonable person would have been traumatized by the events that took place between Resident #1 and Resident #2 on 09/22/24, SW stated, It absolutely could be traumatizing. During an interview on 10/04/24 at 06:29 PM LVN A stated she thought Resident #1 was traumatized by the interaction on 09/22/24 with Resident #2 because, she was in bed initially and when I went back, she was out of bed, crying, and trying not to let him (Resident #2) touch her. LVN A stated she had been trained to recognize abuse, neglect, exploitation, and misappropriation of resident property and to report any suspicion of such to the ADM. During an interview on 10/04/24 at 06:31 PM LVN B stated LVN C texted her to please come help in the locked unit as Resident #2 would not let go of Resident #1's w/c. LVN B stated when she got to the locked unit she observed Resident #2 holding onto the handles of Resident #1's w/c and Resident #1 was in the w/c and kept saying, No, you don't want me, I'm too old, I don't want to go with you. LVN B stated she tried to distract Resident #2 and get him to go outside with her to pick weeds as that was one of his favorite pastimes, but he would not let go and kept trying to push Resident #1 in her w/c. LVN B said Resident #2 kept saying Resident #1 was his girl and he was going to go wherever she went. LVN B said she got Resident #1 away from Resident #2 at one point and called LVN A to open the door of the locked unit for her because LVN C and CNA E were holding Resident #2's hands to keep him from following them out. LVN B said during the entire situation she could tell Resident #1 was scared. LVN B stated, We had [name of Resident #1] out here for the night. She was upset. I tried to distract her by giving her a banana but she was scared. LVN B said after she and Resident #1 exited the locked unit Resident #2 stood on the other side of the locked doors hitting the doors and yelling. LVN B said of Resident #1, We (nursing staff) tried putting her to bed on hall 400 but she kept getting up and she kept saying, 'That guy is going to come get me.' LVN B stated she reported the entire incident to ADON and hospice nurse. LVN B said in her opinion not reporting possible abuse of a resident is just bad. LVN B stated she had been trained to recognize abuse, neglect, exploitation, and misappropriation of resident property and to report any suspicion of such to ADM but she felt that if she told ADON the information would reach ADM and it was a weekend. During an interview on 10/04/24 at 06:37 PM LVN C stated that during report at the beginning of her shift on 09/22/24 she found out Resident #2 had been having behaviors all day. She stated she heard CNA E needed help on the locked hall with Resident #2. LVN C said when she got to the locked unit Resident #2 was trying to direct [name of Resident #1] to his room and I could tell she (Resident #1) was afraid. She was saying, 'I'm too old, no you don't want me.' LVN C said Resident #2 was grabbing Resident #1's hands and grabbing the handle of Resident #1's w/c. LVN C stated Resident #1 was crying during part of the interaction. LVN C said Resident #2 became so agitated he was hitting at staff and hitting near Resident #1 but did not hit Resident #1. She said she and CNA E attempted to hold Resident #2's hands to keep him from chasing Resident #1 and LVN B out of the locked unit and because at this point, he was just hitting us. She said Resident #2 got out of their grasp and ran after Resident #1 and LVN B but they made it out the door before he got to them. LVN C said, I figured if we weren't there, there was going to be abuse going on. LVN C stated she had been trained to recognize abuse, neglect, exploitation, and misappropriation of resident property and to report any suspicion of such to ADM. During an interview on 10/04/24 at 06:46 PM CNA E stated on 09/22/24 Resident #2 was confused and after [Resident #1]. She said Resident #2 started saying Resident #1 was his girlfriend and his wife and he wouldn't let her go. CNA E said Resident #1 started saying, 'Listen, I don't like you, you're not mine.' CNA E said she had to call the nurses because Resident #2 would not let go of Resident #1's w/c and he got mad. She said Resident #1 kept saying, You don't want to be with me. I don't like you. CNA E stated she had been trained to recognize abuse, neglect, exploitation, and misappropriation of resident property and to report any suspicion of such to the ADM. She said staff are trained on recognizing and reporting abuse and neglect almost every day. CNA E did not exhibit any issues with speaking English clearly during this interview. During an interview on 10/04/24 at 07:11 PM DON stated staff are responsible to report to ADM or charge nurse when they notice anything that could constitute resident abuse. When asked what a possible negative outcome of not reporting resident abuse immediately DON said, If a resident did receive abuse possible negative outcome is they wouldn't receive treatment that was necessary. When asked why Resident #2's treatment of Resident #1 on 09/22/24 was not reported as possible abuse she said, I think her case would be different because she does have dementia. When asked what would happen if a reasonable person had endured the same treatment as Resident #1, DON said, If it was somebody else, I'd look at it differently because they were not a dementia patient. During an interview on 10/04/24 at 07:15 PM ADM stated that if the same thing that happened to Resident #1 at the hands of Resident #2 happened to a reasonable person it could be considered abuse. ADM stated it was a no brainer that there could be a negative outcome to residents if possible abuse of residents was not reported timely. During an interview on 10/04/24 at 07:30 PM ADM stated he was not informed of the incident between Resident #1 and Resident #2 on 09/22/24 and that if he had been informed, he would have reported it as possible abuse. During an interview on 10/18/24 at 10:28 AM ADM stated he expected his staff to let him know right away if anything that might constitute resident abuse or neglect took place on the weekend. He stated he was not sure why ADON and DON did not inform him of the incident between Resident #1 and Resident #2 on 09/22/24. He stated to address his staff not informing him of the incident on 09/22/24 all staff were in-serviced on Abuse/Neglect and ADON was in-serviced on what is expected from weekend on-call staff regarding contacting him with concerns that might constitute abuse or neglect. During an interview on 10/18/24 at 10:32 AM DON stated staff did not report any distress on the part of Resident #1 when reporting the incident from 09/22/24 to ADON. During an interview on 10/18/24 at 11:05 AM ADON stated nurses did not indicate any distress on the part of Resident #1 following the incident on 09/22/24. She stated, They (nurses) said he (Resident #2) was going up and down the hallways and walking everywhere and trying to take female residents to their rooms and nurses and CNAs would not let him. They did not report distress to me at all (for Resident #1). I told them to get ahold of Hospice. I called DON and SW. Could not get hold of SW. DON told me we did need to get hold of [name of hospice for Resident #2] They got ahold of hospice and they were able to take care of him and keep her safe. Record review of facility policy titled Abuse/Neglect and dated March 11, 2013 revealed the following: . Any person having reasonable cause to believe an elderly or incapacitated adults is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state and/or adult protective services. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 2024-14 dated 08/29/24. a. If the allegations involve abuse or result in serious bodily injury, the report must be made within 24 hours of the allegation. b. If the allegation does not involved abuse or serious bodily injury, the report must be made within 24 hours of the allegation. Record review of abuse/neglect in-services for the past three months revealed in-services on the following dates: 07/02/24, 07/07/24, 07/08/24, 07/10/24, 07/11/24, 07/16/24, 07/30/24, 08/14/24, 08/13/24, 08/08/24, 08/27/24, 09/24/24, 09/25/24, 09/26/24, 09/29/24, 10/01/24. Each of the in-services included, Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents . If abuse and/or neglect witnessed or suspected, intervene immediately and report to abuse preventionist-the administrator [name of ADM] or immediate supervisor. Record Review of the abuse/neglect in-services for the past three months revealed the following dates: 07/02/24, 07/07/24, 07/08/24, 07/10/24, 07/11/24, 07/16/24, 07/30/24, 08/14/24, 08/13/24, 08/08/24, 08/27/24, 09/24/24, 09/25/24, 09/26/24, 09/29/24, 10/01/24, the ADON and DON participated in said in-service training covering what is abuse and when and to whom it should be reported.

Based on observation, interview, and record review the facility failed to protect each residents right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 (Resident #1) of 5 residents reviewed for abuse and neglect. The facility failed to protect Resident #1 from emotional abuse by Resident #2 on 09/24/24 in spite of Resident #2 emotionally abusing and possibly physically abusing Resident #1 on 09/22/24. The noncompliance was found to be Past Non Compliance (PNC). The noncompliance began on 09/22/2024 and ended on 09/26/2024 The facility corrected the noncompliance before the investigation began. This failure could place residents at risk of continued and/or unrecognized abuse or neglect. Findings Included: Record review of Resident #1's admission record dated 10/04/24 revealed an [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses that included, but were not limited to, dementia (a group of thinking and social symptoms that interferes with daily functioning), major depressive disorder (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), and psychotic disorder with hallucinations (severe mental illness including seeing things that are not there). Record review of Resident #1's quarterly MDS completed 08/03/24 revealed the following: Section B: Resident #1 was able to understand others sometimes. Section C: Resident #1 was rarely to never understood, therefore had no BIMS. The staff assessment of her mental status revealed she had long and short-term memory problems and moderately impaired cognition. Section E: Resident #1 displayed wandering behavior daily. Section GG: Resident #1 used a wheelchair. She required set up or clean up assistance with eating and upper body dressing; supervision or touching assistance with oral hygiene; partial/moderate assistance with footwear, lower body dressing, and shower/bathing; and substantial/maximal assistance with toileting and personal hygiene. Resident #1 required partial/moderate assistance across all mobility except for walking 10 feet which required supervision or touching assistance and walking 50 feet with two turns and walking 150 feet both of which were not attempted due to medical condition or safety concerns. Section I: Resident #1's primary medical condition was non-traumatic brain dysfunction. Section N: Resident #1 received antidepressant medication during the 7-day look back period. She did not receive anticoagulant medication. Record review of Resident #1's care plan completed on 07/24/24 revealed she had a communication problem. Interventions included monitoring Resident #1 for physical/nonverbal indicators of discomfort or distress, focus on a word or phrase that makes sense, ensure/provide a safe environment, and be conscious of resident's position when in groups, activities, dining room to promote proper communication with others. The care plan indicated Resident #1 had a history of physical aggression received. The corresponding intervention was to keep resident away from any situation that will put resident at risk for situations of physical aggression. Resident #1 was residing in the secure unit related to her diagnosis of dementia and her risk for elopement. Record review of Resident #1's Order Summary Report dated 10/04/24 revealed she had an active order for antidepressant medication Duloxetine HCI 60 mg delayed release capsule once a day with a start date of 08/29/24. Record review of Resident #1's progress notes from 09/04/24 to 10/04/24 revealed no notes from 09/22/24. The progress notes did reveal the following notes: A note written by DON on 09/24/24 at 2:26 PM entered as LATE ENTRY This nurse notified of another resident kissing this resident on forehead. This nurse assessed this resident. No new or worsening injury note at this time. Res (Resident) unable to recall events and states 'No, I'm fine.' Provider notified of incident at this time, no new orders. A note written by DON on 09/24/24 at 4:00 PM This nurse notified [name of psychiatric doctor] office of resident receiving kiss on forehead from another resident. Message left with nurse who stated will notify provider and awaiting call back. A note written by SW on 09/24/24 at 04:16 PM SW met with resident in the unit. She was sitting in her wheelchair in the dining room. She had her head down as she appeared to be sleeping. SW completed PRN Trauma Screen with resident. She denied any trauma at this time. She shook her head yes/no when answering questions. She appeared to be sleepy and did not want to be disturb at this time. No trauma noted. A note written by GVN D on 09/25/24 at 06:18 PM CNA reported major bruise to nurse and ADON immediately [sic]. Nurse and ADON went to assess resident immediately. Purple bruise to right posterior forearm noted, measuring [sic] approximately 14X9.5 cm. Other findings documented in skin assessment. When this nurse asked res what happeneded [sic] res confused and unable to respond due to impaired [sic] mental status. Resident denies any pain or distress at this time. Res taken back to dinning [sic] room, ready to eat dinner. RN compliance nurse and [name of ADM] notified immediately [sic] by nurse and ADON. [Name of physician] and NP notified. [name of Resident #1's family member] emergency contact notified of injury. [name of Resident #1's family member] stated ' the slightest bump makes her bruise very badly, I'm not worried. Just keep me updated.' This nurse notified oncoming shift of injury. Record review of Resident #1's Event Nurses' Note - Bruise completed by DON on 09/25/24 at 05:31 PM revealed the bruise on Resident #1's right posterior forearm was of unknown origin and measured 14 X 9.5 cm. It was blue/purple in color. Resident #1 was unable to recall how she obtained the bruise. Physician and family were notified, and padding was applied to the arm rest of Resident #1's w/c. Record review of Resident #1's Trauma Informed PRN Assessment completed by SW on 09/24/24 at 04:04 PM revealed the following questions with answers in the negative: . 4. Have you (or has the resident) been in a situation that was extremely frightening? 5. Have you (or has the resident witnessed any extremely frightening situations? . Record review of Resident #1's Order Summary Report dated 10/04/24 revealed she was admitted to the secure unit on 08/28/23 due to a high elopement risk. Resident #1 had no order for anticoagulant medication. Record review of Resident #2's admission record dated 10/04/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, dementia (a group of thinking and social symptoms that interferes with daily functioning), generalized anxiety disorder (inability to control constant worrying), and prostate cancer. He was discharged from the facility on 09/26/24 to a psychiatric hospital. Record review of Resident #2's admission MDS completed on 09/13/24 revealed the following: Section B: Resident #2 was able to understand others and make himself understood. Section C: Resident #2 had a BIMS of 3 which indicated severely impaired cognition. Section D: Resident #2 sometimes felt lonely or isolated from those around him. Section E: Resident #2 had no behaviors during the look back period. Section GG: Resident #2 did not use any mobility devices. He needed set up or clean up assistance for eating, oral hygiene, toileting hygiene, dressing, and personal hygiene. Resident #2 was independent across all mobility ADLs except for shower/bath transfer, walking over uneven surfaces, and picking up an object where he needed supervision or touching assistance. Section I: Resident #2's primary medical condition was non-traumatic brain dysfunction. Section K: Resident #2 was 5 feet seven inches tall and weighed 146 pounds. Section N: Resident #2 received antianxiety and antidepressant medications during the 7-day look back period. Record review of Resident #2's care plan completed on 09/16/24 revealed he was taking antianxiety medications and one of the interventions listed was to monitor and record occurrence of target behavior symptoms including violence/aggression towards staff/others and document per facility protocol. Resident #2 was noted to be at risk for wandering. He resided in the secure unit related to his diagnosis of dementia and his risk for elopement. Resident #2 was noted to have potential to demonstrate physical behaviors. He kissed another resident on forehead 09/24/24. [name of behavioral hospital] admission on 09/26/24. Two of the interventions listed was, If the resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately and Notify the charge nurse of any physically abusive behaviors. The care plan noted Resident #2 was placed on 1 on 1 monitoring following his kiss on Resident #1's forehead on 09/24/24. No mention made of incident between Resident #2 and Resident #1 on 09/22/24 in the care plan. Record review of Resident #2's orders after the incident with Resident #1 and prior to his discharge to the behavioral hospital revealed the following: An order with start date of 09/23/24 and end date of 09/23/24 for antipsychotic medication Haloperidol Oral Tablet 0.5 MG Give 1 tablet by mouth four times a day related to GENERALIZED ANXIETY DISORDER An order with start date of 09/23/24 and end date of 09/23/24 for antianxiety medication LORazepam Oral Tablet 0.5 MG Give 1 tablet by mouth every 4 hours related to GENERALIZED ANXIETY DISORDER An order with start date of 09/24/24 and end date of 09/27/24 for anticonvulsant medication Divalproex Sodium Oral Tablet Delayed Release 250 MG Give 1 tablet by mouth one time a day related to GENERALIZED ANXIETY DISORDER An order with start date of 09/23/24 and end date of 09/27/24 for anticonvulsant medication Divalproex Sodium Oral Tablet Delayed Release 500 MG Give 1 tablet by mouth one time a day related to GENERALIZED ANXIETY DISORDER An order with start date of 09/23/24 and end date of 09/24/24 for antipsychotic medication Haloperidol Oral Tablet 0.5 MG Give 1 tablet by mouth every 2 hours as needed for Anxiety related to GENERALIZED ANXIETY DISORDER An order with start date of 09/24/24 and end date of 09/24/24 for antipsychotic medication Haloperidol Oral Tablet 0.5 MG Give 1 tablet by mouth three times a day for Anxiety related to GENERALIZED ANXIETY DISORDER An order with start date of 09/24/24 and end date of 09/27/24 for antipsychotic medication Haloperidol Oral Tablet 0.5 MG Give 2 tablet by mouth every 2 hours as needed for Anxiety related to GENERALIZED ANXIETY DISORDER An order with start date of 09/24/24 and end date of 09/27/24 for antipsychotic medication Haloperidol Oral Tablet 0.5 MG Give 2 tablet by mouth every 6 hours for Anxiety related to GENERALIZED ANXIETY DISORDER Record review of Resident #2's progress notes from 09/04/24 to 10/04/24 revealed the following notes: A note written by LVN A on 09/22/24 at 07:59 PM Pt was seen going into womans [sic] room and waking her up out of bed and touching her innappropriatly [sic]. Woman pt started to panic and get away from him. Staff transferred [sic] woman pt out of bed and into wc to monitor. This pt began grabbing womans [wic] wc handles and dragging her back. This staff intervened d/t pt woman crying and tryhing [sic] to get away. Pt began hitting staff and chasing after woman pt. At this time, woman has been taken out of secure unit and placed with one staff member for safety. [Hospice] on call called,no response at this time. On call [name of ADON] notifed [sic], stated I am trying to get a hold of SW but she won't answer me. Awaiting a call back at this time from management [sic] and [Hospice]. Pt is currently standing at secure unit doors trying to pry them open. A note written by LVN A on 09/22/24 at 10:51 PM Pt is now hovering over aide down secure unit touching her cheek and stating You like this, come on. Aide sternly educated pt to go back to bed. Pt walked in room and is sitting on bed staring out into the hall. A note written by LVN B on 09/23/24 at 12:02 AM Hospice returned call at this time and this nurse explained situation and noting new behavior for resident. Hospice nurse to call her on call provider for orders. Notified ADON. Hospice returned call at approx 2002 (02:02 AM) with new orders for [antipsychotic medication] 0.5mg Q6hrs and to schedule the [antianxiety medication] 0.5mg q4hrs and morphine(20mg/5ml)0.2ml q4hrs. [Antipsychotic medication] will be delivered to facility via hospice pharmacy tomorrow. DON notified of new orders. A note written by LVN F on 09/23/24 at 10:59 PM While this nurse was doing med pass, the aid informed this nurse that the resident would not let her use the restroom. The resident would push the door open and would not allow the aid any privacy. This nurse gave the resident PRN [antianxiety medication] and [antipsychotic medication]. Immediately [sic] after administering [sic] the residents medication, the resident went into another residents room and was messing with her and her bedding. This nurse and a aid had to remove the resident from the other residents room. As per the residents daughter request this nurse notified the residents' daughter about the situation. A note written by LVN G on 09/24/24 at 02: 22 PM This nurse found resident kissing other resident on the forehead in dining area. This nurse removed other resident from the area. Resident is now in room making bed. No distress noted. A note written by DON on 09/24/24 at 02:23 PM This DON notified of incident. Administrator notified. Self report protocol initiated. A note written by DON on 09/24/24 at 02:50 PM This nurse spoke with resident daughter and educated on situation that occurred and facility policy. This nurse also educated resident daughter on interventions put in place such as one on one and referral to inpatient psych. Res daughter verbalizes understanding and appreciative of interventions facility has provided. Res daughter also appreciative on this nurse explaining situation and protocol. Res daughter inquires as to if res will readmit after psych stay, res education on clinical will be reviewed to ensure facility can meet res needs and res or other res will not be at risk of safety if readmitted and facility/inpatient psych assisting with placement if unable to readmit - res daughter verbalizes understanding. A note written by SW on 09/26/24 at 01:36 PM SW has worked with [behavioral hospital] for admission for today. Res was transported to [behavioral hospital]. SW sent ED paperwork to the Judge to be completed. Paperwork was completed and sent to [behavioral hospital]. SW also spoke to resident daughter about him receiving a 30 day notice. Res / daughter also given copy of 30 day notice. Res daughter was appreciative about his care at facility. She reported that they would come Monday and pick up his stuff. Record review of Event Nurses' Note - Behavior written by DON on 09/24/24 at 02:24 PM revealed Resident #2 exhibited physical, resident to resident behavior in the hallway. The behavior was kissing another resident on the forehead, and it was witnessed by LVN on duty. Resident was redirected and provided with 1 on 1 supervision. During an interview on 10/04/24 at 05:30 PM ADM stated he was not sure who the female resident mentioned in Resident #2's progress note written by LVN A on 09/22/24 at 07:59 PM. He stated DON would know. During an interview on 10/04/24 at 05:32 PM DON stated the female resident from Resident #2's progress note written by LVN A on 09/22/24 at 07:59 PM was Resident #1. She stated she had concerns about the wording of the progress note and she called LVN A and got a statement from LVN A stating she put the words touching her inappropriately in the progress note based on what the CNA told her. DON stated the CNA was CNA E. DON stated English is CNA E's second language and confusion had led to the wrong thing being documented. DON stated she would bring me a written copy of CNA E's statement regarding the incident on 09/22/24 between Resident #1 and Resident #2. DON stated after she spoke to CNA E and LVN A she felt Resident #2 only wanted to help/protect the women. DON stated, He was their (female residents') protector and didn't really want us (facility staff) to help. She said this was made very clear after Resident #2 was placed on 1 to 1 supervision following his kiss to Resident #1's forehead when every time a staff member would enter a resident's room he would ask, Who is that? Record review of CNA E's statement revealed it was dated 09/24/24. In the statement CNA E revealed Resident #2 was calling Resident #1 his girl and his girlfriend and patting her on the shoulder. Record review of LVN A's statement regarding why she documented Resident #2 was touching Resident #1 inappropriately on 09/22/24s revealed a photo of a text message which read, I documented the 'inappropriate touching' due to CNA statement.'[sic] During an interview on 10/04/24 at 05:51 PM LVN A stated she wrote Resident #2's progress note on 09/22/24 at 07:59 PM based on what CNA E told her over the phone. (staff in the locked unit often communicate with staff outside the locked unit via phone call) LVN A stated what she saw with her own eyes was Resident #2 grabbing at her (Resident #1's) arms and pulling on her and she was verbally crying and screaming. LVN A said earlier in the night when she assisted Resident #1 to bed Resident #1 said, This is not my room, this is his room. This is his room. He is going to come in here and be fraudulent. LVN A said she did not think anything of it at the time due to Resident #1 having dementia. She said she assured Resident #1 that she would keep her safe. LVN A stated Resident #1 then said, They are going to come in here before you are gone. LVN A stated, Looking back on it, I feel bad because I wonder if she was afraid that night. You know people with dementia say some wild things but in light of what happened, I wonder. LVN A stated that after the incident the nurses took Resident #1 out of the locked unit and had her seated in her w/c at the nurses' station. LVN A said of Resident #1, She stayed up the whole night, I felt so bad for her. LVN A stated the nurses tried putting Resident #1 to bed in an empty room on hall 400 but she would not stay in bed. I think she recognized it was not her room. LVN A stated she knew the staff in the locked unit needed her help when LVN B called her and asked her to open the door of the locked unit so LVN B could push Resident #1 out of the unit without letting Resident #2 out of the unit as well. LVN A stated she opened the door and saw LVN B pushing Resident #1 in her w/c at a slow walk and behind her she saw Resident #2 get away from LVN C and CNA E who were trying to keep him from following and he began to sprint down the hall after Resident #1 and LVN B. LVN A said she told LVN B, Okay, [first name of LVN B] I'm gonna need you to pick it up. LVN A stated LVN B began to walk faster while pushing Resident #1 in her w/c and they got LVN B and Resident #1 out of the locked unit just in time to shut the door and keep Resident #2 in the locked unit. During an observation and interview on 10/04/24 at 06:22 PM Resident #1 was wheeling herself down the hall of the locked unit. When asked if she was [name of Resident #1] she shook her head and continued wheeling herself down the hall. During an interview on 10/04/24 at 06:26 PM SW stated she did interview Resident #1 about trauma following Resident #2 kissing Resident #1 on the forehead. SW stated Resident #1 was alert but not sure what was going on during the interview. When asked if she thought Resident #1 was traumatized by Resident #2 pulling on her and chasing her on the locked unit on 09/22/24 SW said it was hard to tell as the change of venue from the locked unit to the nurses' station for the night might have also been traumatizing. When asked if she thought a reasonable person would have been traumatized by the events that took place between Resident #1 and Resident #2 on 09/22/24, SW stated, It absolutely could be traumatizing. During an interview on 10/04/24 at 06:29 PM LVN A stated she thought Resident #1 was traumatized by the interaction on 09/22/24 with Resident #2 because, she was in bed initially and when I went back, she was out of bed, crying, and trying not to let him (Resident #2) touch her. During an interview on 10/04/24 at 06:31 PM LVN B stated LVN C texted her to please come help in the locked unit as Resident #2 would not let go of Resident #1's w/c. LVN B stated when she got to the locked unit she observed Resident #2 holding onto the handles of Resident #1's w/c and Resident #1 was in the w/c and kept saying, No, you don't want me, I'm too old, I don't want to go with you. LVN B stated she tried to distract Resident #2 and get him to go outside with her to pick weeds as that was one of his favorite pastimes, but he would not let go and kept trying to push Resident #1 in her w/c. LVN B said Resident #2 kept saying Resident #1 was his girl and he was going to go wherever she went. LVN B said she got Resident #1 away from Resident #2 at one point and called LVN A to open the door of the locked unit for her because LVN C and CNA E were holding Resident #2's hands to keep him from following them out. LVN B said during the entire situation she could tell Resident #1 was scared. LVN B stated, We had [name of Resident #1] out here for the night. She was upset. I tried to distract her by giving her a banana but she was scared. LVN B said after she and Resident #1 exited the locked unit Resident #2 stood on the other side of the locked doors hitting the doors and yelling. LVN B said of Resident #1, We (nursing staff) tried putting her to bed on hall 400 but she kept getting up and she kept saying, 'That guy is going to come get me.' LVN B stated she reported the entire incident to ADON and hospice nurse. LVN B said in her opinion not reporting possible abuse of a resident is just bad. During an interview on 10/04/24 at 06:37 PM LVN C stated that during report at the beginning of her shift on 09/22/24 she found out Resident #2 had been having behaviors all day. She stated she heard CNA E needed help on the locked hall with Resident #2. LVN C said when she got to the locked unit Resident #2 was trying to direct [name of Resident #1] to his room and I could tell she (Resident #1) was afraid. She was saying, 'I'm too old, no you don't want me.' LVN C said Resident #2 was grabbing Resident #1's hands and grabbing the handle of Resident #1's w/c. LVN C stated Resident #1 was crying during part of the interaction. LVN C said Resident #2 became so agitated he was hitting at staff and hitting near Resident #1 but did not hit Resident #1. She said she and CNA E attempted to hold Resident #2's hands to keep him from chasing Resident #1 and LVN B out of the locked unit and because at this point, he was just hitting us. She said Resident #2 got out of their grasp and ran after Resident #1 and LVN B but they made it out the door before he got to them. LVN C said, I figured if we weren't there, there was going to be abuse going on. During an interview on 10/04/24 at 06:46 PM CNA E stated on 09/22/24 Resident #2 was confused and after [Resident #1]. She said Resident #2 started saying Resident #1 was his girlfriend and his wife and he wouldn't let her go. CNA E said Resident #1 started saying, 'Listen, I don't like you, you're not mine.' CNA E said she had to call the nurses because Resident #2 would not let go of Resident #1's w/c and he got mad. She said Resident #1 kept saying, You don't want to be with me. I don't like you. CNA E did not exhibit any issues with speaking English clearly during this interview. During an interview on 10/04/24 at 07:11 PM DON stated staff are responsible to report to ADM or charge nurse when they notice anything that could constitute resident abuse. When asked what a possible negative outcome of not reporting resident abuse immediately DON said, If a resident did receive abuse possible negative outcome is they wouldn't receive treatment that was necessary. When asked why Resident #2's treatment of Resident #1 on 09/22/24 was not reported as possible abuse she said, I think her case would be different because she does have dementia. When asked what would happen if a reasonable person had endured the same treatment as Resident #1, DON said, If it was somebody else, I'd look at it differently because they were not a dementia patient. During an interview on 10/04/24 at 07:15 PM ADM stated that if the same thing that happened to Resident #1 at the hands of Resident #2 happened to a reasonable person it could be considered abuse. ADM stated it was a no brainer that there could be a negative outcome to residents if possible abuse of residents was not reported timely. During an interview on 10/04/24 at 07:30 PM ADM stated he was not informed of the incident between Resident #1 and Resident #2 on 09/22/24 and that if he had been informed, he would have reported it as possible abuse. During an interview on 10/18/24 at 10:28 AM ADM stated he expected his staff to let him know right away if anything that might constitute resident abuse or neglect took place on the weekend. He stated he was not sure why ADON and DON did not inform him of the incident between Resident #1 and Resident #2 on 09/22/24. He stated, We would have started the process of getting him (Resident #2) out (of the facility). ADM stated the facility started that process on 09/24/24 when Resident #2 was seen kissing Resident #1 on the forehead. He stated to address his staff not informing him of the incident on 09/22/24 all staff were in-serviced on Abuse/Neglect and ADON was in-serviced on what is expected from weekend on-call staff regarding contacting him with concerns. During an interview on 10/18/24 at 10:32 AM DON stated she felt staff kept Resident #1 safe from Resident #2 following the incident on 09/22/24 by removing Resident #1 for the night from the locked unit and calling Hospice to have Resident #2's medications changed to address his behavior. DON stated staff did not report any distress on the part of Resident #1 when reporting the incident to ADON. She stated the next day when Resident #1 was returned to the locked unit she was kept safe by having two staff members in the locked unit with the 8-10 residents. DON stated no other incidents occurred until 09/24/24 when Resident #2 was witnessed kissing Resident #1 on the forehead. During an interview on 10/18/24 at 11:05 AM ADON stated nurses did not indicate any distress on the part of Resident #1 following the incident on 09/22/24. She stated, They (nurses) said he (Resident #2) was going up and down the hallways and walking everywhere and trying to take female residents to their rooms and nurses and CNAs would not let him. They did not report distress to me at all (for Resident #1). I told them to get ahold of Hospice. I called DON and SW. Could not get hold of SW. DON told me we did need to get hold of [name of hospice for Resident #2] They got ahold of hospice and they were able to take care of him and keep her safe. During an interview on 10/18/24 at 01:19 PM DON stated she called CNA E to ask about the date on her statement regarding the incident between Resident #1 and Resident #2 on 09/22/24. CNA E told DON she dated it incorrectly. DON provided a copy of CNA E's working schedule. Record Review of CNA E's work schedule for 09/24/24 revealed she did not work that date but she did work on 09/22/24. Record review of facility policy titled Abuse/Neglect and dated March 11, 2013 revealed the following: . Abuse is the willful infliction of . intimidation . with resulting . mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Any person having reasonable cause to believe an elderly or incapacitated adults is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state and/or adult protective services. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 2024-14 dated 08/29/24. a. If the allegations involve abuse or result in serious bodily injury, the report must be made within 24 hours of the allegation. b. If the allegation does not involved abuse or serious bodily injury, the report must be made within 24 hours of the allegation. Record review of abuse/neglect in-services for the past three months revealed in-services on the following dates: 07/02/24, 07/07/24, 07/08/24, 07/10/24, 07/11/24, 07/16/24, 07/30/24, 08/14/24, 08/13/24, 08/08/24, 08/27/24, 09/24/24, 09/25/24, 09/26/24, 09/29/24, 10/01/24. Each of the in-services included, Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents . If abuse and/or neglect witnessed or suspected, intervene immediately and report to abuse preventionist-the administrator [name of ADM] or immediate supervisor. Record Review of the abuse/neglect in-services for the past three months revealed the following dates: 07/02/24, 07/07/24, 07/08/24, 07/10/24, 07/11/24, 07/16/24, 07/30/24, 08/14/24, 08/13/24, 08/08/24, 08/27/24, 09/24/24, 09/25/24, 09/26/24, 09/29/24, 10/01/24, the ADON and DON participated in said in-service training covering what is abuse and when and to whom it should be reported.

Based on observation, interview, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care for 1 of 1 Resident (Resident #1) during an assisted transfer. CNA A transferred Resident #1 from the bed to wheelchair without 2 persons assist, as care planned, resulting in a fall and injury to resident. Findings include: During an interview on 11/10/2020 at 9:35 AM, Administrator stated that CNA A had been terminated due to not following the rules of a 2 person assist for transferring Resident #1. During an interview on 11/10/2020 at 9:57 AM, ADON confirmed Resident #1 sustained a fractured tibia and fibula from the fall. CNA A was termed due to not following Resident's care plan. During an interview, via telephone, on 11/10/2020 at 11:05 Am, CI stated, Resident #1 had been a resident since 2017. CI was upset, due to this was not the first time Resident #1 had fallen while being transferred by one person. CI confirmed getting a call every 6 months, mostly due to slipping in the shower or getting Resident #1 up from the bed. CI stated Resident #1 had surgery due to her injury and has moved out of the facility to another facility. During an interview on 11/10/2020 at 11:24 AM, CNA A stated she had changed Resident #1's brief and Resident #1 was now in bed. CNA A stated that she had looked for someone to help transfer Resident #1, but CNA's friend (co-worker) was in another room. CNA A stated that Resident #1 had been doing good and had moved her before, on her own. CNA A stated that she would put the wheelchair close to the bed and help Resident #1 stand and then move the chair to Resident #1 and assist her to sit down. This time Resident #1 stood up and her leg folded under and CNA A could not move her to the chair. CNA stated I feel so bad. I am so sorry. CNA confirmed she should have waited for help. Record review of Resident #1's chart revealed she was admitted on [DATE], admitting [DIAGNOSES REDACTED]. Weight recorded prior to injury, showed Resident #1 at 193 lbs. Resident had 3 documented falls since June 2020, all charted as assisted falls. Care plan shows the need for mechanical lift and transfers are assist x2. CNA kiosk stated transfer x2 assist, extensive assist. Nursing progress note of incident stated: This resident was assisted to floor by CNA. Resident was being transferred to w/c from bed and resident slid down. Resident stated, I just guess my legs are weak. Resident was transferred to w/c x2 assist. VS WNL. +2 [MEDICAL CONDITION] RLE, +1 [MEDICAL CONDITION] LLE. No injuries noted at this time. Resident rates pain at an 8 in right extremity. Family notified, voices no concerns at this time. NP notified. New orders for x-ray on pelvis and R Leg. Interview on 11/10/2020 at 1:57 PM, CNA B stated she has used a gait belt to help with transfers of Resident #1, however, in the shower, CNA B normally uses another person, but is known as the Hulk and has the strength to assist by herself when no one else is available. When asked if CNA B had every transferred Resident #1 by herself, CNA B answered yes.

Based on observation, interview, and record review the facility failed to provide specialized rehabilitative services, for 1 of 17 Residents (Resident #63) reviewed for specialized rehabilitative services. The facility failed to ensure the physician's orders [REDACTED].#63 to loose range of motion in her left elbow. This failure could affect 39 Residents receiving rehabilitative services by causing a decline or decrease in their physical capabilities that they may not be able to recover. Findings include: Record review of Resident #63's clinical record revealed an [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #63's Admission MDS dated [DATE], documented a BIMS score of 15 out of 15, indicating she is cognitively intact. Resident required extensive assistance of 2 people for bed mobility, transfers, dressing and toilet use. Record review of Resident #63's Care Plan revealed the following: Alteration in musculoskeletal status r/t (related to) [MEDICAL CONDITION] and shoulder on the left side. Date Initiated: 12/21/17. Revision on: 12/21/17. Goal: I will remain free of complications related to my fracture, such as contracture formation, embolism and immobility through review date. Target Date: 03/08/2018. Record review of the physician's orders [REDACTED].#63, dated 11/27/17, documented the following: WBAT BLE (Weight Bearing As Tolerated Bilateral Lower Extremity) NWB LUE (Non-weight Bearing Left Upper Extremity) Wrist sling to L UE (Left Upper Extremity) to allow elbow to hang free to gravity. Don't prop up elbow. O/T (Occupational Therapy) for ROM (Range of Motion) elbow, wrist, and fingers. Start Pendulum swings L (left) shoulder 1 week post injury. Start gentle ROM L (left) shoulder 4 weeks post injury. Additional note dated 11/29/17 documented: (Note for SNU (Skilled Nursing Unit): Please F/U (Follow Up) with MD D recommendations for PT/OT (Physical Therapy/Occupational Therapy).) Follow up appointment 12/26/17. During an observation and interview on 01/08/18 at 03:13 PM with Resident #63, she was sitting in her wheelchair in her room working on a crossword puzzle. She said she was there for therapy after a fall that broke her humerus. She said she couldn't move her left arm more than a couple of inches and demonstrated this by raising her left arm, which was resting on the arm rest of her wheelchair. She only raised it approximately 2 inches off of the arm rest and said that was as high as it would go. Resident #63 said she started therapy the day after she was admitted to the facility, but it was not the doctor's ordered therapy. Her left arm was also in a sling all the time and shouldn't have been, making rehab slower. Resident #63 said she used to have full range of motion in her left arm before she fell and broke it. During an interview on 01/10/18 at 11:47 AM with Resident #63, she said her orthopedic surgeon sent instructions for therapy to the facility. Resident #63 went for a follow up with her doctor 3 weeks later and the doctor found out the therapy wasn't started as she had ordered. The doctor didn't want the sling on all the time, but it was. Resident #63 didn't have any exercises done with her left arm when she should have been having them. Resident #63 said, It's something that shouldn't have happened. Somebody dropped the ball. It's frustrating and makes me a little mad, too. My family is very upset about it. My elbow got so stiff I can't lift my lower arm at all. The doctor said her elbow froze. It got very, very stiff. I might not get the full use of my arm back. They {Rehab} think they can work it out but who knows, it's just kind of a wait and see actually. Resident #63 said it caused her pain and she is still taking pain pills occasionally. She said it's better than it was, but it was very painful. Resident #63 said, Someone should be held accountable. I don't want this to happen to anyone else. This should be dealt with. During an interview on 01/10/18 at 11:59 AM with LVN E, she said she was the nurse that transcribed the doctor's orders from the hospital to the facility's admission orders [REDACTED]. Record review of the facility's admission orders [REDACTED]. Additional Orders: Sling to LUE (Left Upper Extremity) at all times - Resident may have bed bath. NWB (Non-weight Bearing) to LUE (Left Upper Extremity). Record review of Resident #63's chart revealed a letter from MD D, dated 12/26/17. The letter stated: To whom it may concern: Pt (patient) needs OT/PT for left upper extremity!! I wrote specific orders before patient was discharged from hospital to Caprock for: 1. L elbow and hand ROM out of sling! 2. Pendulum swings L shoulder 1 week s/p (status/post) injury! 3. L wrist sling and no immobilizer; come out of sling to do therapy. 4. Start gentle ROM L shoulder 4 weeks post injury! Pt is now extremely stiff in her elbow and shoulder b/c (because) the lack of therapy by Facility. Caprock never called if they truly did not receive orders. If ever a question, please call!! 1. Aggressive ROM of L elbow 2. ROM passive and active L shoulder 3. D/C sling 4. F/U with me in 3-4 weeks to check ROM. Record review of Physical Therapy Progress Report revealed a start date of 11/30/17. Record review of Occupation Therapy Recertification & Updated Plan of Treatment revealed a start date of 12/1/17. The Certification Period for 12/27/17 - 1/24/18 documented: Pt is now to receive aggressive ROM to her L elbow, ROM passive and active to her L shoulder. During an interview on 01/10/18 at 02:13 PM with CRN and ADM concerning Resident #63's rehab situation, CRN said the doctor (MD D) from the hospital wrote NWB to LUE to hang to gravity. After Resident #63's follow up appointment with MD D, she changed the orders. CRN said MD D was saving face and threw us under the bus trying to blame the facility when the facility followed her orders but the rehab wasn't helping. CRN said the facility was just following the doctor's orders. During an interview on 01/10/18 at 02:58 PM with ST F, she said she was filling in for the Rehab director, who was out sick. ST F went over the OT notes dated 12/8 - 12/14, to explain what therapy Resident #63 received. She said based on her own observations in the therapy room and from what the OT notes said, Resident #63's left arm was always in a sling during exercises and didn't get any therapy. Her right arm got therapy and her lower extremities got therapy. During an interview on 01/10/18 at 04:04 PM with RD, over the phone, she said Resident #63 was non-weight bearing to her left arm when she was admitted but they were now working with the affected hand. Therapy started a week or so after Resident #63 was admitted . RD said they started doing the pendulum swing exercises 2 - 3 weeks ago. During an interview with CRN and ADM at 4:45 p.m. on 01/10/18, CRN said he wished MD D would have notified them sooner about her orders for Resident #63 not being followed. They could have fixed it earlier and been in past non-compliance, instead of SQC now. When the ADM was asked when she first learned of the physician's orders [REDACTED]. Record review of the CMS Form 672 dated 1/8/18 documented 39 Residents were receiving Rehabilitative services.

Based on observation, interview, and record review the facility failed to provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish, based on the comprehensive assessment and consistent with the resident's needs and choices, for 1 of 17 Residents (Resident #63) reviewed for ADLs. The facility failed to ensure the physician's orders [REDACTED].#63 lost function of her left elbow hindering her ability to perform ADLs. This failure could affect 39 Residents receiving rehabilitative services by causing a decline or decrease in their quality of life. Findings include: Record review of Resident #63's clinical record revealed an [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #63's Admission MDS dated [DATE], documented a BIMS score of 15 out of 15, indicating she is cognitively intact. Resident required extensive assistance of 2 people for bed mobility, transfers, dressing and toilet use. Record review of Resident #63's Care Plan revealed the following: Alteration in musculoskeletal status r/t (related to) [MEDICAL CONDITION] and shoulder on the left side. Date Initiated: 12/21/17. Revision on: 12/21/17. Goal: I will remain free of complications related to my fracture, such as contracture formation, embolism and immobility through review date. Target Date: 03/08/2018. Record review of the physician's orders [REDACTED].#63, dated 11/27/17, documented the following: WBAT BLE (Weight Bearing As Tolerated Bilateral Lower Extremity) NWB LUE (Non-weight Bearing Left Upper Extremity) Wrist sling to L UE (Left Upper Extremity) to allow elbow to hang free to gravity. Don't prop up elbow. O/T (Occupational Therapy) for ROM (Range of Motion) elbow, wrist, and fingers. Start Pendulum swings L (left) shoulder 1 week post injury. Start gentle ROM L (left) shoulder 4 weeks post injury. Additional note dated 11/29/17 documented: (Note for SNU (Skilled Nursing Unit): Please F/U (Follow Up) with MD D recommendations for PT/OT (Physical Therapy/Occupational Therapy).) Follow up appointment 12/26/17. During an observation and interview on 01/08/18 at 03:13 PM with Resident #63, she was sitting in her wheelchair in her room working on a crossword puzzle. She said she was there for therapy after a fall that broke her humerus. She said she couldn't move her left arm more than a couple of inches and demonstrated this by raising her left arm, which was resting on the arm rest of her wheelchair. She only raised it approximately 2 inches off of the arm rest and said that was as high as it would go. Resident #63 said she started therapy the day after she was admitted to the facility, but it was not the doctor's ordered therapy. Her left arm was also in a sling all the time and shouldn't have been, making rehab slower. Resident #63 said she used to have full range of motion in her left arm before she fell and broke it. During an interview on 01/10/18 at 11:47 AM with Resident #63, she said her orthopedic surgeon sent instructions for therapy to the facility. Resident #63 went for a follow up with her doctor 3 weeks later and the doctor found out the therapy wasn't started as she had ordered. The doctor didn't want the sling on all the time, but it was. Resident #63 didn't have any exercises done with her left arm when she should have been having them. Resident #63 said, It's something that shouldn't have happened. Somebody dropped the ball. It's frustrating and makes me a little mad, too. My family is very upset about it. My elbow got so stiff I can't lift my lower arm at all. The doctor said her elbow froze. It got very, very stiff. I might not get the full use of my arm back. They {Rehab} think they can work it out but who knows, it's just kind of a wait and see actually. Resident #63 said it caused her pain and she is still taking pain pills occasionally. She said it's better than it was, but it was very painful. Resident #63 said, Someone should be held accountable. I don't want this to happen to anyone else. This should be dealt with. During an interview on 01/10/18 at 11:59 AM with LVN E, she said she was the nurse that transcribed the doctor's orders from the hospital to the facility's admission orders [REDACTED]. Record review of the facility's admission orders [REDACTED]. Additional Orders: Sling to LUE (Left Upper Extremity) at all times - Resident may have bed bath. NWB (Non-weight Bearing) to LUE (Left Upper Extremity). Record review of Resident #63's chart revealed a letter from MD D, dated 12/26/17. The letter stated: To whom it may concern: Pt (patient) needs OT/PT for left upper extremity!! I wrote specific orders before patient was discharged from hospital to Caprock for: 1. L elbow and hand ROM out of sling! 2. Pendulum swings L shoulder 1 week s/p (status/post) injury! 3. L wrist sling and no immobilizer; come out of sling to do therapy. 4. Start gentle ROM L shoulder 4 weeks post injury! Pt is now extremely stiff in her elbow and shoulder b/c (because) the lack of therapy by Facility. Caprock never called if they truly did not receive orders. If ever a question, please call!! 1. Aggressive ROM of L elbow 2. ROM passive and active L shoulder 3. D/C sling 4. F/U with me in 3-4 weeks to check ROM. Record review of Physical Therapy Progress Report revealed a start date of 11/30/17. Record review of Occupation Therapy Recertification & Updated Plan of Treatment revealed a start date of 12/1/17. The Certification Period for 12/27/17 - 1/24/18 documented: Pt is now to receive aggressive ROM to her L elbow, ROM passive and active to her L shoulder. During an interview on 01/10/18 at 02:13 PM with CRN and ADM concerning Resident #63's rehab situation, CRN said the doctor (MD D) from the hospital wrote NWB to LUE to hang to gravity. After Resident #63's follow up appointment with MD D, she changed the orders. CRN said MD D was saving face and threw us under the bus trying to blame the facility when the facility followed her orders but the rehab wasn't helping. CRN said the facility was just following the doctor's orders. During an interview on 01/10/18 at 02:58 PM with ST F, she said she was filling in for the Rehab director, who was out sick. ST F went over the OT notes dated 12/8 - 12/14, to explain what therapy Resident #63 received. She said based on her own observations in the therapy room and from what the OT notes said, Resident #63's left arm was always in a sling during exercises and didn't get any therapy. Her right arm got therapy and her lower extremities got therapy. During an interview on 01/10/18 at 04:04 PM with RD, over the phone, she said Resident #63 was non-weight bearing to her left arm when she was admitted but they were now working with the affected hand. Therapy started a week or so after Resident #63 was admitted . RD said they started doing the pendulum swing exercises 2 - 3 weeks ago. During an interview with CRN and ADM at 4:45 p.m. on 01/10/18, CRN said he wished MD D would have notified them sooner about her orders for Resident #63 not being followed. They could have fixed it earlier and been in past non-compliance, instead of SQC now. When the ADM was asked when she first learned of the physician's orders [REDACTED]. Record review of the CMS Form 672 dated 1/8/18 documented 39 Residents were receiving Rehabilitative services.

Based on observation, interview, and record review the facility failed to ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion, for 1 of 17 Residents (Resident #63) reviewed for range of motion. The facility failed to ensure the physician's orders [REDACTED].#63 to loose range of motion in her left elbow. This failure could affect 39 Residents receiving rehabilitative services by causing a decline or decrease in their physical capabilities that they may not be able to recover. Findings include: Record review of Resident #63's clinical record revealed an [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #63's Admission MDS dated [DATE], documented a BIMS score of 15 out of 15, indicating she is cognitively intact. Resident required extensive assistance of 2 people for bed mobility, transfers, dressing and toilet use. Record review of Resident #63's Care Plan revealed the following: Alteration in musculoskeletal status r/t (related to) [MEDICAL CONDITION] and shoulder on the left side. Date Initiated: 12/21/17. Revision on: 12/21/17. Goal: I will remain free of complications related to my fracture, such as contracture formation, embolism and immobility through review date. Target Date: 03/08/2018. Record review of the physician's orders [REDACTED].#63, dated 11/27/17, documented the following: WBAT BLE (Weight Bearing As Tolerated Bilateral Lower Extremity) NWB LUE (Non-weight Bearing Left Upper Extremity) Wrist sling to L UE (Left Upper Extremity) to allow elbow to hang free to gravity. Don't prop up elbow. O/T (Occupational Therapy) for ROM (Range of Motion) elbow, wrist, and fingers. Start Pendulum swings L (left) shoulder 1 week post injury. Start gentle ROM L (left) shoulder 4 weeks post injury. Additional note dated 11/29/17 documented: (Note for SNU (Skilled Nursing Unit): Please F/U (Follow Up) with MD D recommendations for PT/OT (Physical Therapy/Occupational Therapy).) Follow up appointment 12/26/17. During an observation and interview on 01/08/18 at 03:13 PM with Resident #63, she was sitting in her wheelchair in her room working on a crossword puzzle. She said she was there for therapy after a fall that broke her humerus. She said she couldn't move her left arm more than a couple of inches and demonstrated this by raising her left arm, which was resting on the arm rest of her wheelchair. She only raised it approximately 2 inches off of the arm rest and said that was as high as it would go. Resident #63 said she started therapy the day after she was admitted to the facility, but it was not the doctor's ordered therapy. Her left arm was also in a sling all the time and shouldn't have been, making rehab slower. Resident #63 said she used to have full range of motion in her left arm before she fell and broke it. During an interview on 01/10/18 at 11:47 AM with Resident #63, she said her orthopedic surgeon sent instructions for therapy to the facility. Resident #63 went for a follow up with her doctor 3 weeks later and the doctor found out the therapy wasn't started as she had ordered. The doctor didn't want the sling on all the time, but it was. Resident #63 didn't have any exercises done with her left arm when she should have been having them. Resident #63 said, It's something that shouldn't have happened. Somebody dropped the ball. It's frustrating and makes me a little mad, too. My family is very upset about it. My elbow got so stiff I can't lift my lower arm at all. The doctor said her elbow froze. It got very, very stiff. I might not get the full use of my arm back. They {Rehab} think they can work it out but who knows, it's just kind of a wait and see actually. Resident #63 said it caused her pain and she is still taking pain pills occasionally. She said it's better than it was, but it was very painful. Resident #63 said, Someone should be held accountable. I don't want this to happen to anyone else. This should be dealt with. During an interview on 01/10/18 at 11:59 AM with LVN E, she said she was the nurse that transcribed the doctor's orders from the hospital to the facility's admission orders [REDACTED]. Record review of the facility's admission orders [REDACTED]. Additional Orders: Sling to LUE (Left Upper Extremity) at all times - Resident may have bed bath. NWB (Non-weight Bearing) to LUE (Left Upper Extremity). Record review of Resident #63's chart revealed a letter from MD D, dated 12/26/17. The letter stated: To whom it may concern: Pt (patient) needs OT/PT for left upper extremity!! I wrote specific orders before patient was discharged from hospital to Caprock for: 1. L elbow and hand ROM out of sling! 2. Pendulum swings L shoulder 1 week s/p (status/post) injury! 3. L wrist sling and no immobilizer; come out of sling to do therapy. 4. Start gentle ROM L shoulder 4 weeks post injury! Pt is now extremely stiff in her elbow and shoulder b/c (because) the lack of therapy by Facility. Caprock never called if they truly did not receive orders. If ever a question, please call!! 1. Aggressive ROM of L elbow 2. ROM passive and active L shoulder 3. D/C sling 4. F/U with me in 3-4 weeks to check ROM. Record review of Physical Therapy Progress Report revealed a start date of 11/30/17. Record review of Occupation Therapy Recertification & Updated Plan of Treatment revealed a start date of 12/1/17. The Certification Period for 12/27/17 - 1/24/18 documented: Pt is now to receive aggressive ROM to her L elbow, ROM passive and active to her L shoulder. During an interview on 01/10/18 at 02:13 PM with CRN and ADM concerning Resident #63's rehab situation, CRN said the doctor (MD D) from the hospital wrote NWB to LUE to hang to gravity. After Resident #63's follow up appointment with MD D, she changed the orders. CRN said MD D was saving face and threw us under the bus trying to blame the facility when the facility followed her orders but the rehab wasn't helping. CRN said the facility was just following the doctor's orders. During an interview on 01/10/18 at 02:58 PM with ST F, she said she was filling in for the Rehab director, who was out sick. ST F went over the OT notes dated 12/8 - 12/14, to explain what therapy Resident #63 received. She said based on her own observations in the therapy room and from what the OT notes said, Resident #63's left arm was always in a sling during exercises and didn't get any therapy. Her right arm got therapy and her lower extremities got therapy. During an interview on 01/10/18 at 04:04 PM with RD, over the phone, she said Resident #63 was non-weight bearing to her left arm when she was admitted but they were now working with the affected hand. Therapy started a week or so after Resident #63 was admitted . RD said they started doing the pendulum swing exercises 2 - 3 weeks ago. During an interview with CRN and ADM at 4:45 p.m. on 01/10/18, CRN said he wished MD D would have notified them sooner about her orders for Resident #63 not being followed. They could have fixed it earlier and been in past non-compliance, instead of SQC now. When the ADM was asked when she first learned of the physician's orders [REDACTED]. Record review of the CMS Form 672 dated 1/8/18 documented 39 Residents were receiving Rehabilitative services.