Every finding on record at Capstone Healthcare of Hughes Springs

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen (1 of 1 kitchen) reviewed for food safety requirements. 1. The facility failed to ensure the food mixer was free of a blackish/grey dried substance on the [NAME] head on 06/01/2026. 2. The facility failed to ensure the toaster oven was free of a thick, sticky layer of brown, black and yellow crumbs on 06/01/2026. 3. The facility failed to ensure the plates and trays were appropriately dried before storing on 06/01/2026. 4. The facility failed to ensure the ice machine was free of an orange liquid substance on the interior portion of the top of the cooler on 06/01/2026. These failures could place residents at risk of foodborne illness and food contamination.Findings include: During the initial tour observation and interview on 06/01/2026 at 09:10 AM to 10:00 AM revealed:1. The food mixer had four clumps of dried blackish/grey substance around the sides of the [NAME] head. 2. The toaster oven had a layer of thick, sticky, black, brown and yellow crusty crumbs. 3. The plates and trays were stacked on a kitchen cart against a cabinet/wall with water noted in between the plates and trays.4. The ice machine had a thin line of a runny liquid orange substance with a slow drip into the fresh ice cubes. The Dietary Manager said the food mixer should be cleaned after each use which included the head portion of the [NAME] because of splashing while in use, to prevent the spread of bacteria and food contamination. The Dietary Manager said the plates and trays should remain unstacked to allow air dry to prevent the potential of bacteria growth. The Dietary Manager said the kitchen did not allow enough space for proper air drying. During an interview on 06/03/26 at 10:27 AM, the Dietary Manager said she was not sure how to clean the toaster and would have to figure out how to remove the rollers to remove all the layers of crumbs. The Dietary Manager stated she had not checked the ice machine within the last month or so because she thought that services were contracted out to the ice machine supplier. The Dietary Manager said she monitored the kitchen cleanliness by walk throughs but did not have any documentation of the check offs. The Dietary Manager said ultimately, she was responsible for ensuring the dietary staff and/or herself kept the appliances clean to prevent bacteria and cross contamination, which could make the residents unhealthy. During an interview on 06/03/2026 at 12:14 PM, the Administrator said she expected the cleanliness of the kitchen to meet the requirements. The Administrator said she expected sanitary food practices were followed to prevent food borne illness. The Administrator said she expected the Dietary Manager to monitor the kitchen for cleanliness. The Administrator said she was ultimately responsible for the Dietary Manager oversite and randomly got food out of the kitchen and spot checked while she walked through the kitchen. The Administrator said she needed to educate herself on the ice machine contracts because she had been in the facility for a year and recalled the ice machine being serviced at one time by an outside resource but somehow that was put on the side and not followed up on. The Administrator said it was important for sanitary practices to be followed with food preparation and handling to prevent the residents from getting sick or having any type of weight loss. Record review of the facility's Food Storage/Safety and Supplies policy, implemented on 03/01/2026, indicated It is the policy of this facility to procure food from sources approved or considered satisfactory by federal. Food safety practices will be followed throughout the facility's entire food handling process. E. Equipment used in the handling of food including dishes, utensils, mixers, grinder, toasters .

Based on interview and record review, the facility failed to ensure the resident's drug regimen was free from unnecessary psychotropic drugs and residents who used psychotropic drugs received gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; and PRN orders for psychotropic drugs were limited to 14 days for 2 of 5 residents (Resident #8 and Resident #26) reviewed for unnecessary psychotropic drugs. 1. The facility failed to ensure Resident #8 did not have a PRN order for lorazepam 0.5 mg (a prescription medication used to treat anxiety disorders: feelings of fear, dread, and uneasiness) after 14 days without an evaluation by the physician for continued treatment with a rationale in the resident's medical record. 2. The facility failed to ensure a GDR was attempted for Resident #26's duloxetine medication (a medication used to treat depression) in November 2025 and May 2026. The doctor did not provide an appropriate rationale for not attempting either GDR. These failures could place residents at risk of psychotropic medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications. Findings included: 1. Record review of Resident #8's face sheet, dated 06/01/26, reflected that she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included generalized anxiety disorder (a mental health condition characterized by persistent, excessive, and uncontrollable worry about everyday situations, even when there is little to no cause for concern). Record review of Resident #8's significant change MDS assessment, dated 03/30/26, reflected she had a BIMS score of 08, which indicated moderate cognitive impairment. She was usually able to make herself understood, and she was usually able to understand others. The assessment reflected that she took an antianxiety medication during the 7-day window. Record review of Resident #8's physician's orders, printed on 06/01/26, reflected that she had an order for lorazepam oral tablet 0.5 mg, give 1 tablet by mouth every 8 hours as needed for anxiety/restlessness for 60 days. The start date was 05/06/26, and the end date was 07/05/26. Record review of Resident #8's MAR, dated May 2026, reflected she had an order for lorazepam oral tablet 0.5 mg, give 1 tablet by mouth every 8 hours as needed for anxiety/restlessness for 60 days. The start date was 05/06/26. She received this medication two times on 05/25/26 and 05/29/26, and 1 time on 05/06/26, 05/07/26, 05/11/26, 05/12/26, 05/13/26, 05/14/26, 05/15/26, 05/16/26, 05/20/26, 05/22/26, 05/23/26, 05/26/26, 05/30/26, and 05/31/26. 2. Record review of Resident #26's face sheet, dated 06/02/26, reflected that she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included major depressive disorder (a serious mood disorder characterized by persistent sadness, loss of interest in activities, and an inability to function normally) with an onset date 10/06/25. Record review of Resident #26's quarterly MDS assessment, dated 04/15/26, reflected that she had a BIMS score of 09, which indicated moderate cognitive impairment. She was able to make herself understood, and she was able to understand others. She did take an antidepressant medication during the 7-day window. Record review of Resident #26's physician's orders, printed on 06/02/26, reflected that she had this order:*duloxetine capsule delayed release 30 mg, give 1 capsule by mouth two times a day for depression. The start date was 05/21/25. Record review of a Consultant Pharmacist / Physician Communication form, dated 11/20/25, reflected: .Resident is receiving the following psychoactive medication which is due for review. Per CMS regulations please evaluate the resident for a trial dosage reduction:Medication: Duloxetine 30mg BIDSuggested Change: Duloxetine 30mg QD.If a dosage reduction is contraindicated or resident failed previous attempt, please document below.Physician/Prescriber ResponseNo [change][provider signed and dated 12/02/25] . Record review of a Consultant Pharmacist / Physician Communication form, dated May 2026, reflected: .Resident is receiving the following psychoactive medications that are due for review. Per CMS regulations, please evaluate resident for trial dose reduction.Current order: Duloxetine 30mg BIDProposed change: Duloxetine 30mg QD.If dose reduction is contraindicated for resident failed previous reduction attempt, please document below.Physician/Prescriber Response.Stable no [change][signed by provider but not dated] . During an interview on 06/03/2026 at 11:07 AM, the ADON said Resident #8's order for PRN lorazepam should have been limited to 14 days, but they had a rationale for it being 60 days. She said they attempted to change the dose to scheduled in the past, but the resident did not want it that way. She said she would search the chart to see if they had a rationale from the doctor for 60 days duration. She said she thought an appropriate rationale was provided for not attempting a GDR for Resident #26's duloxetine medication. She said she was a nurse and she was required to follow the physician's orders. She said she did not have a comment on whether the doctor should have provided a different rationale. She said the DON and ADON were responsible for ensuring that GDRs were attempted. She said the process was that they received the GDRs from the pharmacy consultant and then they sent those over to the doctor. She said they then received it back from the doctor and made changes as ordered. During an interview on 06/03/2026 at 11:21 AM, the DON said that Resident #8 could have a PRN order for longer than 14 days if the doctor had given a rationale. She said she had reached out to the doctor to see if it was in his visit note. She said that they had attempted to swap it to scheduled in the past and the resident did not like it. She said she would not go against the rationale provided for not attempting Resident #26's duloxetine GDR. She said if the resident needed anything or if she did not agree with it then she would have a conversation with the provider. She said if she received a piece of paper that said stable no changes then that was what they were going to go with. She said she felt like the GDR rationale was proper. She said she felt that the physician writing stable no changes meant it was clinically contraindicated to do the GDR. During an interview on 06/03/2026 at 12:20 PM, the DON said she did not have a rationale documented for Resident #8's PRN lorazepam. She said she was waiting to hear back from the doctor to see if he had documented it in a doctor's note. A rationale was not provided. During an interview on 06/03/2026 at 12:31 PM, the Administrator said they should have a documented rationale for why Resident #8 had an order for PRN lorazepam extended past 14 days. She said she was not clinical, so she was unsure what the risk was. She said she was unsure on the process for GDRs and was unable to comment on Resident #26's GDRs. Record review of the facility's policy, Use of Psychotropic Medication(s), dated 03/01/26, reflected: .16. Psychotropic medications used on a PRN basis must have a diagnosed specific condition and indication for the PRN use documented in the resident's medical record and is subject to the limitations as noted:a. PRN orders for psychotropic medications, excluding antipsychotics, shall be limited to no more than 14 days, unless the attending physician or prescribing practitioner believes it is appropriate to extend the order beyond 14 days. The medical record should include documentation from the physician or prescriber for the rationale for the extended time period and indicate a specific duration. Record review of the facility's policy, Gradual Dose Reduction of Psychotropic Drugs, dated 03/01/26, reflected: .1. Within the first year in which a resident is admitted on a psychotropic medication or after the prescribing practitioner has initiated a psychotropic medications, the facility will attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated.2. After the first year, a GDR will be attempted annually, unless clinically contraindicated.6. Rationale for clinical contraindications may be documented on the Clinically Contraindicated Dosage Reduction form or other facility designated form or format.

Based on interview and record review, the facility failed to refer all level II residents and 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 1 of 4 residents (Resident #26) reviewed for PASRR. The facility failed to complete an HHSC 1012 form and submit a new PASRR Level 1 form to the local health authority, when Resident #26 received a new diagnosis of major depressive disorder (a serious mood disorder characterized by persistent sadness, loss of interest in activities, and an inability to function normally) on 10/06/25. This failure could place residents at risk for their specialized services not being provided in a timely manner. Findings included:Record review of Resident #26's face sheet, dated 06/02/26, reflected that she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included major depressive disorder (a serious mood disorder characterized by persistent sadness, loss of interest in activities, and an inability to function normally) with an onset date of 10/06/25. Record review of Resident #26's quarterly MDS assessment, dated 04/15/26, reflected that she had a BIMS score of 09, which indicated moderate cognitive impairment. She was able to make herself understood, and she was able to understand others. Record review of Resident #26's PASRR Level 1 Screening, dated 05/21/25, indicated that in Section C, Mental Illness was marked as no, which indicated Resident #26 did not have a mental illness. During an interview on 06/03/2026 at 10:28 AM, the MDS coordinator said she was responsible for reviewing PASRR forms. She said they did not do an HHSC form 1012 or anything to ensure that Resident #26 received a PASRR Evaluation when she received her major depressive disorder diagnosis in October 2025. She said she was not sure if they should have referred Resident #26 for a PASRR Evaluation. She said she did not know they should have referred Resident #26 to the local health authority for a PASRR Evaluation when she received the major depressive disorder diagnosis. She said it was possible Resident #26 may have received PASRR services since she received the diagnosis in October 2025. During an interview on 06/03/2026 at 11:07 AM, the ADON said she did not review PASRR forms. She said the MDS coordinator was responsible for PASRR. During an interview on 06/03/2026 at 11:21 AM, the DON said she did not deal with or review PASRR forms. During an interview on 06/03/2026 at 12:31 PM, the Administrator said she did not know about PASRR forms and did not deal with them. She said she expected the MDS coordinator to fill out the PASRR forms accurately, and ensure that when they received them, they were accurate. Record review of the Facility's policy, Resident Assessment - Coordination with the PASARR Program, dated 03/01/26, reflected: .9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review.

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 2 of 4 residents (Resident #12 and Resident #36) reviewed for PASRR Level I screenings. 1. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #12. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (schizoaffective disorder, bipolar type) was present upon Resident #12's admission date on 09/22/25. 2. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #36. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (major depressive disorder) was present upon Resident #36's admission date on 09/01/24. These failures could place residents at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs. Findings included:1. Record review of Resident #12's face sheet, dated 06/01/26, reflected that she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included schizoaffective disorder, bipolar type (a chronic mental health condition characterized by a combination of schizophrenia symptoms [such as hallucinations or delusions] and severe mood swings) with an onset date of 09/22/25. Record review of Resident #12's quarterly MDS assessment, dated 04/14/26, reflected that she had a BIMS score of 10, which indicated moderate cognitive impairment. She was able to understand others, and she was able to make herself understood. Record review of Resident #12's PASRR Level 1 Screening, dated 09/22/25, indicated that in Section C, Mental Illness was marked as no, which indicated Resident #12 did not have a mental illness. 2. Record review of Resident #36's face sheet, dated 06/01/26, reflected that she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included major depressive disorder (a serious mood disorder characterized by persistent sadness, loss of interest in activities, and an inability to function normally) with an onset date of 09/01/24, and vascular dementia, mild (a decline in thinking and reasoning skills caused by restricted or blocked blood flow to the brain) with an onset date of 09/27/24. Dementia was not marked as her primary diagnosis. Record review of Resident #36's medical diagnosis sheet, printed on 06/02/26, reflected that dementia was not her primary diagnosis during her entire stay at the facility. Record review of Resident #36's annual MDS assessment, dated 04/24/26, reflected that she had a BIMS score of 03, which indicated severe cognitive impairment. She was able to make herself understood, and she was usually able to understand others. Record review of Resident #36's PASRR Level 1 Screening, dated 02/21/25, indicated that in Section C, Mental Illness was marked as no, which indicated Resident #36 did not have a mental illness. Further, in Section C, Primary Diagnosis of Dementia was marked yes, which indicated her primary diagnosis was dementia. This section further reflected .This must be listed in the medical record as the primary diagnosis by the physician. During an interview on 06/03/2026 at 10:28 AM, the MDS coordinator said she was responsible for reviewing PASRR forms. She said she did not correct the PASRR Level 1 form for Resident #12, but she did call the local health authority to get them to conduct a PASRR Evaluation. She said she would look into Resident #12's records and provide a copy of the Evaluation. She said for Resident #36 she did not know major depressive disorder PASRR diagnosis. She said she did not get a PASRR Evaluation completed for Resident #36. She said Resident #36 may have received PASRR services since September 2025 if she was evaluated and considered to be PASRR positive. She said she was responsible for ensuring the PASRR forms were done correctly. She said her corporate consultant checked these behind her. She said the DON and ADON did not check the PASRR forms. She said she was not aware that Resident #36 did not have a primary diagnosis of dementia. She said she would check the PASRR forms on admit more thoroughly from now on. During an interview on 06/03/2026 at 11:07 AM, the ADON said she did not review PASRR forms. She said the MDS coordinator was responsible for PASRR. During an interview on 06/03/2026 at 11:21 AM, the DON said she did not deal with or review PASRR forms. During an interview on 06/03/2026 at 12:13 PM, the MDS coordinator said that she was unable to find a PASRR Evaluation for Resident #12. She said she called the local health authority, and they were also unable to find any evaluation for Resident #12. She said she was going to fill out an HHSC form 1012 and send it to the local health authority for each of these PASRR residents identified in the citation. During an interview on 06/03/2026 at 12:31 PM, the Administrator said she did not know about PASRR forms and did not deal with them. She said she expected the MDS coordinator to fill out the PASRR forms accurately, and ensure that when they received them, they were accurate. Record review of the facility's policy, Resident Assessment - Coordination with the PASARR Program, dated 03/01/26, reflected: .9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 1 of 17 residents (Resident #16) reviewed for comprehensive care plans. The facility failed to ensure Resident #16's refusal to wear her splint for contracture management was included in the comprehensive care plan. This failure could place residents at risk of not having individual needs met and a decreased quality of life. The findings included: Record review of the face sheet, dated 06/03/26, reflected Resident #16 was an [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of hemiplegia (weakness) and hemiparesis (paralysis) following a stroke affecting the right dominant side. Record review of the annual MDS assessment, dated 05/19/26, reflected Resident #16 had clear speech, was understood by others, and was able to understand others. Resident #16 had a BIMS score of 7, which indicated severe cognitive impairment. The MDS reflected Resident #16 had no behaviors or refusal of care. Record review of the comprehensive care plan, dated 03/04/26, reflected Resident #16 had a resting hand splint to be applied to the right upper extremity due to late effects of stroke. The care plan did not address Resident #16's refusal to wear the resting hand splint. Record review of the TAR, dated May 2026, reflected Resident #16 refused her resting hand splint 31 out of 31 days. Record review of the TAR, dated June 2026, reflected Resident #16 refused her resting hand splint 3 out of 3 days. During an observation on 06/01/26 at 10:35 a.m., Resident #16 was lying in the bed with the head of the bed elevated slightly. She did not have a resting hand splint to her right hand. During an observation on 06/01/26 at 3:15 p.m., Resident #16 was lying in the bed on her left side. The head of the bed was elevated slightly. She did not have a resting hand splint to her right hand. During an observation and attempted interview on 06/02/26 at 9:44 a.m., Resident #16 was lying in bed with the head of bed elevated slightly. She had no resting hand splint to her right hand. She was unable to answer questions appropriately related to cognition. During an observation on 06/03/26 at 11:13 a.m., Resident #16 was lying in bed. She had no resting hand splint to her right hand. During an interview on 06/03/26 at 11:33 a.m., RN B stated Resident #16 did not like wearing her resting hand splint to her right hand. She said Resident #16 refused to wear the splint a lot and stated it was uncomfortable. RN B stated the MDS Coordinator, ADON, or DON were responsible for care planning. She said refusal of care should have been included in the care plan. RN B stated she had access to the care plan on the electronic charting system. She stated it was important to ensure refusal of care was included in the care plan so the staff would know. During an interview on 06/03/26 at 1:25 p.m., the MDS Coordinator stated she was responsible for care planning. The MDS Coordinator stated she was aware Resident #16 refused to wear her resting hand splint for contracture management. She said she added Resident #16's refusal of care to the care plan earlier this morning (06/03/26). She stated refusal of care should have been included in the care plan. She said that she was on vacation and was getting things caught up. She stated it was important to ensure a resident's refusal of care was included in the care plan for continuity of care and making sure the staff were aware of the refusal. During an interview on 06/03/26 at 1:46 p.m., the DON stated the MDS Coordinator was responsible for care planning. The DON stated she expected refusal of care to have been included in the care plan. She stated it was important to ensure refusal of care was included in the care plan to ensure residents were getting the proper care and to ensure communication among staff. During an interview on 06/03/26 at 1:49 p.m., the Administrator stated she expected refusal of care to be included in the care plan. She stated nursing management was responsible for monitoring to ensure refusal of care was included in the care plan. She stated it was important to ensure refusal of care was included in the care plan to show the residents needs and honor their rights. Record review of the Comprehensive Care Plans policy, dated 03/01/26, reflected The comprehensive care plan will describe, at a minimum, the following: .b. Any service that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment.

Based on observation, interview and record review, the facility failed to ensure in accordance with State and Federal laws, that all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 2 of 18 residents (Resident #12 and Resident #36) reviewed for storage of medication. 1. The facility failed to securely store Resident #12's dermal wound cleanser on 06/01/26. 2. The facility failed to securely store Resident #36's stomach relief medication (bismuth subsalicylate 525 mg) on 06/01/26, 06/02/26, and 06/03/26. These failures could place residents at risk for adverse reactions to medications or overdose. Findings included:1. Record review of Resident #12's face sheet, dated 06/01/26, reflected that she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included schizoaffective disorder, bipolar type (a chronic mental health condition characterized by a combination of schizophrenia symptoms [such as hallucinations or delusions] and severe mood swings) with an onset date of 09/22/25. Record review of Resident #12's quarterly MDS assessment, dated 04/14/26, reflected that she had a BIMS score of 10, which indicated moderate cognitive impairment. She was able to understand others, and she was able to make herself understood. During an observation on 06/01/2026 at 9:45 AM, Resident #12 was lying in bed resting. There was a bottle of wound cleanser on the dresser at the end of Resident #12's bed. 2. Record review of Resident #36's face sheet, dated 06/01/26, reflected that she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included major depressive disorder (a serious mood disorder characterized by persistent sadness, loss of interest in activities, and an inability to function normally) with an onset date of 09/01/24, and vascular dementia, mild (a decline in thinking and reasoning skills caused by restricted or blocked blood flow to the brain) with an onset date of 09/27/24. Record review of Resident #36's annual MDS assessment, dated 04/24/26, reflected that she had a BIMS score of 03, which indicated severe cognitive impairment. She was able to make herself understood, and she was usually able to understand others. Record review of Resident #36's physician's orders, printed 06/01/26, did not contain an order for the stomach relief medication (an over-the-counter medication used to treat diarrhea, upset stomach, heartburn, nausea, and indigestion). During an observation on 06/01/2026 at 9:33 AM, Resident #36 was sitting in a wheelchair watching TV in her room. The refrigerator on her side of the room had a bottle of stomach relief medication inside it. During an observation on 06/01/2026 at 11:11 AM, Resident #36 was sitting in her wheelchair in the room. There was a bottle of stomach relief medication in the refrigerator. During an observation on 06/02/26 at 03:19 PM, Resident #36 was sitting in a wheelchair in her room watching TV. There was a bottle of stomach relief medication in her refrigerator. During an observation on 06/03/2026 at 9:53 AM, Resident #36 was not in the room at this time. The refrigerator had a bottle of stomach relief medication inside. During an interview on 06/03/2026 at 11:07 AM, the ADON said the wound cleanser should not have been on Resident #12's dresser and should have been secured in the wound care cart. She said a resident could potentially get a hold of it and use it for unintended purposes. She said the medication should not be in Resident #36's refrigerator. She said everybody was responsible for ensuring that medications were not left in the resident's room or fridge. She said anyone had access to the refrigerator and could use it for unintended purposes. During an interview on 06/03/2026 at 11:21 AM, the DON said the wound cleanser should not have been in Resident #12's room, and it should have been on the wound care cart. She said the stomach relief medication should not have been in Resident #36's refrigerator. She said someone could get ahold of it. She said everyone was responsible for checking the fridge. She said housekeeping was responsible for checking the refrigerator daily. During an interview on 06/03/2026 at 11:53 AM, Housekeeper A said she checked the resident refrigerators when she cleaned the rooms. She said she worked on Resident #36's hall on 06/01, 06/02, and 06/03. She said she did not see the stomach medicine in the refrigerator any of those three days. She said it was housekeeping's responsibility to ensure that the refrigerators were checked. She said she checked it this morning sometime between 08:00 AM and 08:30 AM and there was no medication in the refrigerator. She said the risk of the medication being in the refrigerator was that someone could drink it. During an interview on 06/03/2026 at 12:31 PM, the Administrator said the wound cleanser should not have been at Resident #12's bedside. She said it could have a negative impact on her. She said every staff member should be checking for medications at the bedside. She said the stomach relief medication should not have been in Resident #36's refrigerator. She said the risk was that Resident #36 could drink it or use it as lotion. She said everyone should have been checking the fridges and housekeeping was also responsible. Record review of the facility's policy, Medication Storage, dated 03/01/26, reflected: .It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.All drugs and biologicals will be stored in locked compartments.under proper temperature controls.

Based on observation, interview and record review the facility failed to ensure menus met the nutritional needs of residents in accordance with established national guidelines for 1 of 2 meal (the lunch meal) reviewed for food and nutrition services. The facility failed to ensure [NAME] F followed the recipe for pureeing the rice pilaf on 06/02/26 for the lunch meal. This failure could place residents at risk for weight loss, not having their nutritional needs met, and a decreased quality of life.Findings include: During an observation and interview on 06/02/26 at 12:26 PM, [NAME] F was observed on the procedure of pureeing the rice pilaf. [NAME] F appropriately scooped the rice from a pot and placed it into a canister to puree and added water, no were measurements used. [NAME] F said he did not have a recipe for the pureed rice pilaf to follow. He said he used to have one, but he did not know what the Dietary Manager did with it. [NAME] F said he had been doing this (cooking) for a while, so he knew how to puree the food with no recipe or measurements of the additive. [NAME] F said he knew he was supposed to follow the recipe when he pureed food. [NAME] C said he had to use water because the rice pilaf was too dry to puree and would not thin out if water was not used. [NAME] F was unsure why water should not be used as a diluent for pureed food. During an interview on 06/02/26 at 01:13 PM, the Dietary Manager said she was unable to locate the puree rice pilaf recipe. During an interview on 06/02/26 at 2:42 PM, the Dietician said there was a recipe for pureed rice pilaf. The Dietician said water should not be used for pureed rice pilaf or any other pureed food. The Dietician said not following the recipe and by using water, it could diminish the nutritive value of the food and cause weight loss. The Dietician said the dietary manager was responsible to oversee the cooks were using the proper recipe as well as ingredients to maintain the recommended daily caloric intake. During an interview with the Dietician on 06/02/26 at 2:42 PM, the recipe for pureeing the rice pilaf was requested and was not received by the time of exit. During an interview on 06/03/26 at 10:27 AM, the Dietary Manager said [NAME] F was supposed to be following the recipe when pureeing food because water was not ever used to provide a consistency because it had no nutritional value or if not following the recipe adding too much thickener could affect the consistency of the pureed food. The Dietary Manager said she trained all the cooks on how to puree food and tried to observe them making pureed food. The Dietary Manager said if the cooks added too much beef base or water when pureeing, it altered the flavor of the food and it also altered the nutritional value. The Dietary Manager said it was important to follow the menu when pureeing food because if the food did not taste good the residents would not eat it and altering the nutritional value of the food could result in the residents losing weight. The Dietary Manager said [NAME] F not following the recipe to make the pureed rice pilaf was the Dietary Manager's fault for not providing [NAME] F with the recipe. The Dietary Manager said [NAME] F not following the recipe could cause the residents to have weight loss During an interview on 06/03/2026 at 12:14 PM, the Administrator said the Dietary manager was responsible for ensuring the cooks followed the recipes and served the correct food according to the menu. The Administrator said she expected the cooks to follow all the recipes correctly. The Administrator said not following the recipe when pureeing food could make it too thin and could take nutrients away. The Administrator said water should not be used for pureeing due to there being no caloric value. Record review of the Puree Food Preparation policy, implemented on 03/01/26 indicated, .Fundamental Information: A preplanned menu is provided to the facility, which has been planned or reviewed by a Registered Dietitian and includes meals that are adequate to meet the average resident's nutritional needs. 5. Do not use water as an additive to prepare puree food.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 1 facility, 1 of 1 dining room and 7 of 7 residents reviewed for environment. (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6)The facility failed to repair a leaking roof and ensure ceiling tiles were in good repair in the dining room, the area in front of the ice machine leading into the dining room, the rooms for Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7.This failure placed residents at risk of an uncomfortable environment and a decrease in quality of life and self-worth.During an observation on 02/18/26 at 9:35 a.m., in the far back right corner of the dining room above a metal cabinet there were 2 bulging ceiling tiles. There was a large area on both tiles that was discolored. The area were various shades of brown and appeared to be damp. There was another nearby tile that had a smaller brown stain.During an observation on 02/18/26 at 9:37 a.m., in the main area of the dining room there were 4 tiles with various sizes of brown stains. There was one light fixture in the dining room with a brown stain on the inside of the fixture.During an observation on 02/18/26 at 9:38 a.m., near the nurse's station there was one ceiling tile with a brown stain in the corner of the tile. There was another ceiling tile with 2 soft ball sized brown stains. There were 4 tiles in front of the ice machine, in the area leading into the dining room, with brown rings of different sizes.During an observation on 02/18/26 at 9:42 a.m., there was one ceiling tile a little more than halfway down the hall on the right, loose from the ceiling. Insulation was visible.During an interview on 02/18/26 at 9:58 a.m., the previous Maintenance Supervisor said the roof had been an on-going issue. He said he had worked at the facility for three years. He said his last day was 1/23/26. He said he did work to try to resolve the roof issue. He said he had patched the roof with a flexible tar-like substance on numerous occasions. He said there was a structural issue in the ceiling above the ice machine going into the dining room. He said the iron beams were actually starting to rust through in that area. He said corporate had known about this issue since day one. He said he had some of the rooms repaired and they would no longer leak until the patch work at worn off. He said hall three was the one where they would always have to move residents from their rooms due to leaking. He said especially in room [ROOM NUMBER] (Resident #4's room). He said he could never figure out how to repair the leak in the far back of the dining room. He said the rain soaked the insulation down and it would drip for days. He said there were areas where the insulation had been cut away. He said the tiles in the back dining room may have been stained, but he could not say if they were bulging. He said he was told to change the tiles out if they were really bad because that part of the dining room was the activity area and a lot of pictures were taken back there. He said he had changed out those tiles in the past. He said since he could not get the proper ways to fix the roof, the water would leak in and cause the tiles to fall in the area leading into the dining room. He said this area was a high traffic area for residents. He said in the ceiling there was a pan that caught the water from the roof and there was a pipe to drain the water to the outside. He said an ongoing issue was that the facility was planning remodeling but not addressing the roof. He said he did have a roofing company come out and patch the area he thought was causing the issue, but the roof continued leaking, and he felt like the water was funneling from somewhere else.During an observation of room [ROOM NUMBER] and interview on 02/18/26 at 11:05 a.m., Resident #1 was in her bed. Resident #3 was her roommate and in her bed. In the corner above Resident #3's bed was 1 tile that had large brown stain covering most of the tile. Resident #1 said approximately 3 weeks ago the ceiling in her room along the wall to outside was leaking. She said there were multiple tiles that were damaged other than the one still stained in the corner. She said the others had been replaced. She said a man had taken several of them down and replaced them. She said when the tiles were damaged, she could see the water dripping into her room. She said she had also seen the ceiling leaking in front of the ice machine leading into the dining room. She said she had seen water dripping into garbage cans in front of the ice machine.During an interview on 02/18/26 at 10:51 a.m., Resident #2 said the roof had been leaking. He said it leaked in front of the ice machine leading into the dining room. He said the facility had to keep replacing ceiling tiles in front of the ice machine. He said there was a spot in his room too. He said sometimes water dripped into his room from the ceiling.During an observation of room [ROOM NUMBER] on 02/18/26 at 11:01 a.m., in Resident #2's room in the corner near the outside wall at the head of the resident's bed there were two tiles with brown small brown stainsDuring an observation of room [ROOM NUMBER] and interview on 02/18/26 at 11:03 a.m., Resident #3 was in her bed in a room she shared with Resident #1. She said approximately 3 weeks ago the corner of the ceiling in her room was leaking. She said it was leaking in the corner near the head of her bed. She said water was actually dripping into her room. She said at the time it bothered her, but she was ok. There was one tile in the corner with more than half of the tile with a brown stain.During an interview on 02/18/26 at 10:49 a.m., Resident #4 said she had lived in her room, room [ROOM NUMBER], for approximately 1 year. She said the ceiling leaked one time in that year. She said she had to be move to another room while the ceiling was being repaired. She said the leak must have been repaired because during recent rains and ice, it did not leak. She said she had noticed bulging tiles in the corner of the dining room.During an interview on 02/18/26 at 10:55 a.m., a family member of Resident #4 said the facility had an issue with the roof. The family member said when there was a bad rain it leaked in front of the ice machine in the area leading into the dining room. The family member said when this area leaked the facility would use trash cans to catch the water. The family member said in the past ceiling tiles had fallen in this area. The family member said the facility had spent a bunch of money on the new sign out front and they had wondered why that money was not spent on fixing the roof.During an observation and interview on 02/18/26 at 11:49 a.m., Housekeeper A said the tiles in the far corner of the dining room were recently changed along with the ceiling tiles in front of the ice machine leading into the dining room. She said the tiles in the corner of the dining room started bulging after the recent ice storm at the end of January 2026. She said she thought the damage was coming from the roof leaking. She said some of the brown circles on the tiles were huge and an eye sore. She said some tiles fell in the dining room and in front of the ice machine. She said she had seen damaged ceiling tiles in residents' room. In Resident #5's, room [ROOM NUMBER], it was observed there were two missing tiles in one corner along the outside wall. From the opening you could see the roof. In Resident #5's room there was one tile with a brown stain. In Resident #6's room, room [ROOM NUMBER], there were two tiles with a large faint stain on each tile. One of the tiles appeared to still be damp. The housekeeper said all of this was caused during the ice storm at the end of January 2026. She said during the ice storm she had to clean up tiles in the area in front of the ice machine.During an interview on 02/18/26 at 12:00 p.m., CNA B said roof has been leaking since she started working at the facility. She said she had been working at the facility for 6 years. She said the roof had been the whole six years. She said tiles were damaged during storms and they would be fixed. She said the ceiling had actually fallen through in places. She said they did something on the roof in the past and it was good for a while, but it went back to leaking again. She said the tiles in the dining room began bulging during the ice storm at the end of January 2026. She said she had not seen water actually leaking in resident's rooms, but she had seen where ceiling tiles have fallen. She said the area in front of the ice machine was not as bad as the area in the corner of the dining room but during the ice storm it leaked really bad. She said they used trash cans to catch the water and put a floor blanket down to dry the floor. She said if it were her home and the roof was leaking, she would be pretty upset.During an interview on 02/18/26 at 12:08 p.m., the MDS Coordinator said when it rained the roof had leaked at times. She said the maintenance supervisor had been up on the roof several times to get the leaks fixed. She said they had been without a maintenance supervisor a while and someone came in and did work on changing out ceiling tiles. She said she did not know if they did any repairs to the roof. She said it was hard for her to say how long the area had been bulging in the dining room. She said she did not go in there often. She said the area in front of the ice machine had leaked sometimes. She said it had not leaked very often. She said they put caution floor signs around it and the housekeepers got the water up. She said she had not noticed any damaged ceiling tiles in residents' rooms. She said she would be upset if her ceiling tiles were leaking and damaged. She said that was why they tried to fix them as diligently as possible.During an interview on 02/18/26 at 12:15 p.m., the Maintenance Supervisor said he began working at the facility approximately one week ago. He said he did not know how long the roof had been leaking. He said he was told during the winter storm they were having problems with the water leaking into the building. He said he had seen damaged ceiling tiles in the residents' room. He said he had planned to change them out. He said he was going to change the ones in the dining room later on today (02/18/26). He said he needed to spend some time on the roof to see what was going on with it.During an interview on 02/18/26 at 12:21 p.m., the ADON said she began working at the facility in November 2025. She said she had not noticed the ceiling tiles in the dining room. She said she did know that there had been tiles fixed in front of the ice machine, leading into the dining room. She said a few tiles fell and some were taken down to prevent them from falling in this area during the winter storm at the end of January 2026. She said the tiles were repaired the next day. She said with the ice storm there was a leak in Resident #3's room. She said she believed it was dripping water. She said there were wet tiles that had to be replaced in Resident #7's room, room [ROOM NUMBER]. She said leaks and stained tiles could make residents feel like they were not taking care of things. She said it was not very pretty to look at.During an interview on 02/18/26 at 12:27 p.m., the DON said she could not comment on how long the area in the dining room had been leaking. She said she had not noticed that this area was bulging. She said she did not know how long the area in front of the ice machine had been leaking. She said she did know it leaked during the winter storm at the end of January 2026. She said stained ceiling tiles in residents' rooms should have been replaced. She said she did not know anything about repairs on the roof. She said she was not sure what repairs had been made. She said ceiling tiles stained, missing, and leaking could make residents sad and depressed. She said this was their home.During an interview on 02/18/26 at 12:34 p.m., the Administrator said the previous Maintenance Supervisor had gotten up on the roof and done patchwork. She said roofers came out in May 2025 to repair the roof. She said that repair was supposed to have taken care of the issue. She said she was not aware of the bulging tiles in the dining room. She said they had been changed out several times. She said the area in front of the dining room was supposed to have been repaired in May 2025. She said the tiles were replaced after the recent ice storms along with ceiling tiles in residents' rooms. She said leaking, stained, missing, and bulging ceiling tiles could have a negative psychological impact on residents. She said the spots in front of the ice machine were all new, because they had been changed out after the ice storm in January 2026. She said she would expect for the ceiling and roof to be kept in good repair.Record review of an of an invoice dated 05/30/25 indicated roof repair was done. The invoice indicated, .Repair back corner, install flashing and piece of modified bitumen (Roll Roofing) to cover water entry from cinder block. Seal with silicone. The invoice indicated, .Replace general area.with modified bitumen. Limited warranty on repair due to nature of entire roof system. Remove current material and install new. Fix damaged would if any.Replace soffit (the exposed underside of a roof overhang, bridging the gap between siding and the roof edge to provide crucial attic ventilation, protect rafters from weather/pests, and enhance curb appeal) with wood area where soffit is hanging down. Caulk and seal, no paint.Record review of a Resident Rights facility policy last revised in February 2011 indicated, .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the rights to.a dignified existence.Record review of a Homelike Environment facility policy last revised in February 2021 indicated, .Residents are provided with a safe, clean, comfortable and homelike environment.The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike environment. These Characteristics include.clean, sanitary and orderly environment.

Based on observation, interviews and records reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to ensure the comprehensive care plan described the services and interventions to be used to attain and maintain the resident's practicable physical, mental, and psychosocial well-being for 3 of 22 residents reviewed for care plans (Resident #8, Resident #29, and Resident #41). 1. The facility failed to develop a comprehensive person-centered care plan for Resident #29's depression and impaired coping with interventions following aggressive behaviors (scratched roommate on face) on 2/21/2025 and calling the police telling them he was being held hostage at gunpoint on 3/18/2025. 2. The facility failed to develop a comprehensive person-centered care plan for Resident #41's for wounds and enhanced barrier precautions (a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms (MDROs; are bacteria that are resistant to multiple antibiotics and antifungals) implemented. 3.The facility failed to develop a comprehensive person-centered care plan for Resident #8's DNR code status (instruction to not perform life saving measures if a person's heart or breathing stops), diet, anorexia (abnormal loss of the appetite for food), use of a plate guard, mood, anxiety, impaired visual function, and urinary incontinence. These failures could place residents at risk of not having their individualized needs met, and a decline in their quality of care and life. Findings included: 1. Record review of Resident #29's face sheet dated 4/1/2025 indicated Resident #29 was a [AGE] year-old male readmitted to the facility on [DATE]. Resident #29 had diagnoses including unspecified displaced fracture of surgical neck of right humerus (a severe injury where the arm bone (humerus) is broken near the shoulder), fracture of the lower end of right radius (a fracture of the lower end of the right radius (wrist), fracture of unspecified part of neck of right femur (when the ball on top of the femur breaks off at its junction with the neck of the upper thigh bone within the hip joint), Atherosclerotic heart disease of native coronary artery (a buildup of plaque (a waxy, fatty substance) in the arteries), cirrhosis of the liver (is advanced scarring of the liver caused by many diseases and conditions, including hepatitis or alcohol use disorder ) and Major depressive disorder(a mental disorder characterized by a persistent low mood, loss if interest or pleasure in activities). Record review of Resident #29's admission MDS assessment dated [DATE] indicated Resident #29 was usually understood and usually understood others. Resident #29 had a BIMS of 08 which indicated moderate cognitive impairment. Resident # 29 had a diagnosis of Depression and was prescribed antidepressant. Record review of Resident #29's care plan revised on 3/31/2025 indicated Resident #29 had impaired coping with an intervention to monitor the effectiveness of Resident's immediate support system. There was no care plan indicating resident had aggression toward roommate or others, interventions, or effective coping measures to prevent future behaviors. During an interview and observation on 3/31/2025 at 10:39 AM, Resident #29 observed lying in bed with fall mate next to bed. Resident #29 was disheveled in appearance. Resident #29 said he was not eating much because he had a stomachache and he said he was losing weight. Resident said his depression had not been addressed. Resident #29 said he did not want to be here anymore. Resident denied having a plan to harm himself. During an interview on 3/31/2025 at 11:50 AM, the DON was made aware of Resident #29's statement. The DON said he would get the SW and start interventions and a plan for Resident #29's depression. The DON said Resident #29 recently came off isolation and hospice care. During an interview on 3/31/2025 at 12:15 PM, the Social Worker said the resident told her that he has said those things many of times throughout his life and he would not do anything to harm himself. The Social Worker said an outside psychiatric group recently resumed care and the staff are encouraging Resident #29 to participate in activities. During an interview on 3/31/2025 at 1:00 PM, Resident # 29 said he was depressed, not suicidal. The DON came into the room during that time and started conversation with Resident #29. During an interview on 4/1/2025 at 3:35 PM, the Social Worker said Resident #29 should have a Trauma Informed Care assessment, but the Psychiatric group came to the facility while Resident #29 was on Covid restrictions. The Social worker said she had not completed his Trauma Informed care because the facility did not have an official form. The Social worker said she determined if a resident needed a Trauma Informed Care assessment and it was identified if a resident had a diagnosis of depression, other mental illness or behaviors. The Social Worker said she was out when Resident #29 came to the facility. During an interview on 4/1/2025 at 3:50, the Social Worker provided the Trauma Informed Care policy and said she made a referral a couple of weeks ago and the Psychiatric group came in while Resident #29 was on Covid (Coronavirus disease of 2019) restrictions. She said initially Resident #29 was on respite care. The Social Worker said the Psychiatric group would be returning to the facility on [DATE] and she was going to update Resident #29's care plan. During an interview on 4/1/2025 at 4:10 PM, Resident #29's RP said he was a negative person and said he stayed depressed. Resident #29's RP said Resident #29 had multiple losses in his past and past motor vehicle wrecks. Resident #29's RP said the facility was going to resume psychological therapy. 2. Record review of Resident #41's face sheet dated 03/31/2025 indicated Resident #41 was an [AGE] year-old male readmitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (a lung condition caused by damage to the airways and alveoli, usually from smoking or other irritants), Chronic cystitis (infection or inflammation of the urinary bladder or any part of the urinary system cause by a bacteria), Diverticulitis of large intestine without perforation or abscess without bleeding (an inflammation with or without infection of a diverticulum (a pouch-like structure that form in the wall of the large intestine), which causes abdominal pain and can create a collection of pus around the inflamed diverticulum), pressure ulcer of head (an injury to the skin and the tissue below the skin that are due to pressure on the skin for a long time), and abnormal weight loss ( a noticeable drop in your body weight without trying). Record review of Resident #41's comprehensive MDS assessment dated [DATE] indicated Resident #41 understood and was understood by others. Resident #41 had a BIMS score of 12 which indicated moderate cognitive impairment. Resident #41 was at risk of developing pressure ulcer/injuries. Record review of Resident #41's care plan initiated on 3/14/2025 indicated Resident #41 had an incomplete care plan and did not indicate he was on enhanced barrier precautions or had any skin concerns. Record review of Resident #41's treatment administration record dated 3/1/2025-3/31/2025 indicated Resident #41 had multiple abrasions documented as follows: o Abrasion to bridge of nose: Resolved 3/17/2025 o Pressure area to left top of ear: Resolved 3/12/2025 o Left lower knee- Resolved 3/3/2025, 3/17/2025 o Abrasion to left lower hip- Resolved 3/17/2025 o Abrasion to lower left lateral leg- ongoing o Left shoulder wound- Resolved 3/12/2025 o Left upper arm wound- Resolved 3/26/2025 o Right shoulder wound- Resolved 3/7/2025 o Right knee wound- Resolved 3/26/2025 o Right lower shin wound- Resolved 3/12/2025 During an interview on 4/2/2025 at 10:22 AM, RN B said the CNAs know what to do for each resident because they have been there for a while. RN B said the care should be on the care plan. RN B said the care plan was completed by the MDS nurse and the nurses complete the assessments and initiate the care plan along with the MDS nurse. RN B said the ADON, DON and the MDS nurse initiate the care plan. She said the nurse staff would also let the staff know if a resident had a foley catheter. She said the initiation of the care plan should be completed within 24 hours. She said if a resident did not have the proper care plan in place, the staff would know how a resident should be transferred, what medications, oxygen and how they eat. She said if a care plan was not initiated a resident could have a fall if improperly transferred, if foley care was not provided and resident could get an infection. RN B said it was the responsibility of everyone to ensure the care plan was being followed. During an interview on 4/2/2025 at 10:53 AM, the MDS nurse said she completes the care plan. She said the DON completes the baseline care plan and each department completes their part, and the baseline goes into the soft file. The MDS nurse said once the care plan goes into the EMR, it pulls over into the new EMR. She said the DON has a cheat sheet with CNA pocket workbook and they keep it at the front. The MDS nurse said she was responsible for ensuring the care plans were put in. The MDS nurse said the facility changed to a new system and she had to put in new care plans on everyone. The MDS nurse said she was adding new care plans to the new EMR when a new resident was admitted and working on the older residents who had been at the facility for a while as she could get to them. The MDS nurse said the facility has morning meetings and she said she tries to get the 24-hour report and updates the care plan. She said the DON ensured the Care plan was in the system and the staff follow the plan of care. The MDS nurse said she had not been adding the EBP to the care plans and said it was a new policy. During an interview on 4/2/2025 at 11:07 AM, the Social Worker said Resident #29 was on respite in October 2024 then discharged and returned on 11/15/2024 for skilled care, then discharged and returned on 1/9/2025. She said upon readmission, Resident #29 was more agitated due to having to return. The Social worker said there was an incident where the resident called the police. She said she knew Resident #29 prior and the RP was concerned about sundowners. The Social Worker said there were other illnesses that could cause delusions and hallucinations. The Social Worker explained Resident #29 had labs in February 2025 to rule out a medical concern before psychological. She said he had slightly elevated ammonia levels but not enough to trigger for hallucinations. She thought he had a urinary tract infection. The Social Worker said she reviewed a trauma informed care policy, and it says it should be performed but was not clear when it should be done, and the regulations were broad. The Social Worker said the facility turn it over the Psychologist. The Social Worker said Resident #29 does things to get RP's attention and had past behaviors of calling RP and cussing them out. The Social Worker said she felt the behaviors were medical and not psychological. The Social Worker said urinary tract infections can cause hallucinations. She said Resident #29 does have depression and was going to get an assessment and it would need to be care planned. During an interview on 4/2/2025 at 12:13 PM, the ADON said she does not complete the care plans. She said the DON completed the initial baseline care plan and the MDS nurse puts in the care plan. The ADON said the MDS nurse should have the care plans updated. She said the plan of care was for the Aides to know what care to provide to the residents. The ADON said she was not involved in the care plans, but she expected the nurses to follow the plan of care. The ADON said she could not speculate what could happen if a care plan was not available. The ADON said enhance barrier precautions should be on the care plan and a container would be outside the resident's door with a sign. She said she could not speculate on what could happen if enhanced barrier precautions were not care planned and followed. During an interview on 4/2/2025 at 12:34 PM, the DON said he completes the baseline care plan within 48 hours, and he talks to the family and offer them a copy of their orders and have them sign it. The DON said the care plan is used to paint a picture of the resident and guides their care. He said the staff should be following the care plan. The DON said he would have to refer the care plan questions to the MDS nurse on when it needs to be completed. The DON said he could not speculate what could happen if a care plan was not completed. The DON said he would have to review enhanced barrier precautions with the infection preventionist. He said the Infection control nurse determined EBP. He said he could not speculate what could happen if staff was not wearing proper personal protective equipment (PPE). During an interview on 4/2/2025 at 12:59 PM, the Interim Administrator said enhanced barrier precautions should be care planned and PPE should have been worn while providing care to Resident #41. The Interim Administrator said if enhanced barrier precautions were not followed or staff was not wearing proper PPE, it could negatively impact the resident quality of life and puts the resident at risk for infection. During an interview on 4/2/2025 at 1:00 PM, the Administrator said the MDS nurse was responsible for ensuring the care plan are in the computer to ensure proper care was delivered. She said it could potentially decrease the quality of care. The Administrator said she would assume the Care Areas populated from the MDS would need to be placed on the care plan. 3. Record review of Resident #8's face sheet dated 3/31/25 revealed she was [AGE] years old and admitted to the facility on [DATE] with an original admitted [DATE]. Resident #8 had diagnoses including dementia, anxiety, depression, anorexia, and cataracts (clouding of the normal clear lens of the eye). Record review of Resident #8's annual MDS assessment dated [DATE] indicated she had a BIMS of 3, which indicated she had severe cognitive impairment. The MDS indicated Resident #8 had inattention and disorganized thinking. The MDS indicated Resident #8's vision was severely impaired. The MDS indicated Resident #8 was always incontinent of bowel and bladder. The MDS indicated Resident #8 had diagnoses of anxiety disorder, depression, and anorexia. Record review of Resident #8's Order Summary Report dated 4/02/25 reflected an order for a regular diet with soft finger foods with an order and start date of 9/30/24; an order for a DNR Code Status with an order date of 9/30/24; and an order of may use plate guard on plate at mealtimes with an order date of 2/12/25. Record review of Resident #8's undated Care Plan Report reflected the resident had a mood problem, impaired visual function, and bladder incontinence, but there were no interventions for those focus areas. The Care Plan Report reflected there were no focus areas or interventions related to her DNR code status, diet, anorexia, or use of a plate guard. During an observation on 3/31/25 beginning at 12:48 PM, Resident #8 was sitting in her wheelchair at a dining table. Resident #8 was served her meal on a plate with a plate guard and staff told her what foods and where each food was located on the plate. Resident #8 attempted to feed herself and staff sat at the table beside her to assist and give verbal cues during the meal service as needed. During an interview on 4/02/25 at 10:01 AM, the MDS Coordinator said she was still learning the new software since the new company took over the facility in October 2024. The MDS Coordinator said she was responsible for completing the Comprehensive Care Plans. The MDS Coordinator said the purpose of the Comprehensive Care Plan was to show areas including medications, ADL assistance, diagnoses, preferences, Code Status, oxygen, diet, pressure ulcer risks, and fall risks. The MDS Coordinator said if there was a problem care area on the Comprehensive Care Plan then there should be goals and interventions to manage the problem care area. The MDS Coordinator said she would correct Resident #8's Comprehensive Care Plan and did not know how she missed it. The MDS Coordinator said they had to create brand new care plans for each resident when they switched software systems beginning in October 2024 when the new company took over the facility and she could have missed those care areas then. During an interview on 4/02/25 at 10:38 AM, the DON said the MDS Coordinator and himself were responsible for ensuring the Comprehensive Care Plans were complete and included all the care areas pertinent to the resident. The DON said the purpose of the Comprehensive Care Plan was to paint a picture of the resident and to guide the care of the resident. The DON said care areas such as oxygen, diet, vision impairment, DNR code status, ADL assistance, diagnoses, and medications were care areas that should be included in the Comprehensive Care Plan. The DON said each care should include goals and interventions the Comprehensive Care Plan. The DON said he could not speculate what the risk to the resident would be if the Comprehensive Care Plan did not include all the pertinent care areas for the resident. During an interview on 4/02/25 at 12:17 PM with both the ADM and the Interim ADM, the ADM said the purpose of the Comprehensive Care Plan was to have a clear picture of how the team was to care for the resident, so the resident had the best optimum outcomes. The ADM said general quality of care could be impacted if the resident did not have a complete Comprehensive Care Plan with pertinent care areas specific to the resident and could result in a decreased quality of life. The Interim ADM said all areas of care for each resident needed to be addressed in the Comprehensive Care Plan. Record review of a facility's Care Plans, Comprehensive Person-Centered revised March 2022 indicated .A comprehensive, person-centered care plan that includes measurable objectives and timetables .The interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develop and implements a comprehensive .The comprehensive, person-centered care plan is developed within 7 days of the completion of the required MDS assessment (Admission, Annual, or Significant change in status), and no more than 21 days after admission .The care plan interventions are derived from a thorough analysis of the information gathered .Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate .including the right to .participate in the planning process, identify individuals or roles to be included, request meetings, request revisions to the care plan, participate in establishing the expected goals and outcomes of care, and participate in determining the type, amount, frequency and duration of care .Services provided for or arranged by the facility and outlines in the comprehensive care plan are: provided by a qualified person, culturally competent and trauma informed .Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes and relevant clinical decision making . When possible, interventions address the underlying source (s) of the problem area (s), not just symptoms triggers . Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . Record review of a facility's Care Plans, Comprehensive Person-Centered revised March 2022 indicated .A comprehensive, person-centered care plan that includes measurable objectives and timetables .The interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develop and implements a comprehensive .The comprehensive, person-centered care plan is developed within 7 days of the completion of the required MDS assessment (Admission, Annual, or Significant change in status), and no more than 21 days after admission .The care plan interventions are derived from a thorough analysis of the information gathered .Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate .including the right to .participate in the planning process, identify individuals or roles to be included, request meetings, request revisions to the care plan, participate in establishing the expected goals and outcomes of care, and participate in determining the type, amount, frequency and duration of care .Services provided for or arranged by the facility and outlines in the comprehensive care plan are: provided by a qualified person, culturally competent and trauma informed .Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes and relevant clinical decision making . When possible, interventions address the underlying source (s) of the problem area (s), not just symptoms triggers . Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change 46062

Based on observations, interviews, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 10 of 10 residents in a confidential group meeting (Anonymous Resident (AR)1-Anonymous Resident (AR) 10), and 1 of 1 meal (Lunch meal) reviewed for food and nutrition services. The facility failed to ensure on 4/1/25, AR 1through AR 10 were not served hard, burnt dinner rolls at the noon lunch meal. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. Findings included: During an interview and observation, of a confidential resident group meeting on 4/1/25 at 2:30 p.m., AR1-AR 10 were in attendance and wished to remain anonymous. All residents in the confidential meeting said they attended regularly. Anonymous Resident 1 said the facility served burnt rolls today (4/1/25). Anonymous Resident 1 presented a roll wrapped in a paper towel. The roll was dark brown on top and black on the bottom. The roll presented by AR 1 was hard. All residents in the confidential meeting said they had been served burnt bread today and at other mealtimes. The residents said they did not eat the burnt bread or only ate the top portion of the roll. During an interview on 4/2/25 at 10:48 a.m., the Dietary Manager said the rolls served yesterday (4/1/25) were burnt. She said she noticed the rolls were burnt before they were served. She said she did not instruct [NAME] K to discard the rolls and serve something else. She said bread products for the resident's meals had been burnt and served before. She said the oven cooked unevenly. She said no residents, until today, had complained about breads being served burnt. She said it was important not to serve burnt food because it affected the appearance and flavor. She said she was responsible for ensuring food was not served burnt to the residents. She said she should be doing that by inspecting the meals before they were served to the residents. During an interview on 4/2/25 at 11:24 a.m., CNA D said yesterday (4/1/25) a lot of the resident's rolls were burnt. She said none of the residents she served asked for something else. She said on 4/1/25, most of the residents ate the top portion of the roll. She said occasionally the resident's bread has been burnt in the past. She said most of the time, the residents just ate the top portion of the bread. She said serving the residents burnt bread could upset the residents. She said the residents could have been looking forward to eating a nice, soft roll but then were served a burnt one. During an interview on 4/2/25 at 12:00 p.m., CNA J said she noticed the burnt rolls served on 4/1/25. She said several of the residents did not eat the burnt rolls. She said sometimes the resident's bread was served burnt. She said no alternated bread option was offered to the residents on 4/1/25. She said burnt food affected the appearance and flavor. She said the rolls served yesterday were like little rocks! During an interview on 4/2/25 at 12:11 p.m., the DON said he did not know burnt rolls were served on 4/1/25. He said he expected the dietary staff to follow the guidance of the Dietary Manager in what should or should not be served. He said he could not speculate how the burnt rolls affected the residents. He said burnt food was not palatable. He said the Dietary Manager was responsible to ensure palatable food was served. During an interview on 4/2/25 at 12;44 p.m., the Administrator, with the Interim Administrator present said the dietary team and Dietary Manager were responsible for serving palatable and appetizing meals. She said she expected the dietary team to not serve burnt rolls and to substitute something more palatable. She said serving residents burnt food decreased their quality of life. She said the Dietary Manger was overall responsible for ensuring the dietary team served palatable food to the resident. Record review of a facility's Food and Nutrition Services policy revised 10/2017 indicated, .each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs .food and nutrition service staff will inspect food trays .the food appears palatable and attractive .

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 15 residents (Residents #7 and Resident #41) reviewed for infection control practices. 1. The facility failed to ensure CNA D performed hand hygiene and changed gloves appropriately prior to, during, and after providing incontinent care/indwelling urinary catheter care to Resident #7. 2. The facility failed to ensure CNA D did not contaminate Resident #7's clothing, clean brief, bed, bedding, bed remote, positioning wedge, and urinary catheter bag after CNA D had performed bowel incontinent care and incontinent/urinary catheter care. 3. The facility failed to ensure Resident #41 had signage to identify the resident was on Enhance Barrier Precaution (EBP) and the use of personal protective equipment (PPE ) due to open wounds on 4/02/25. 4. The facility failed to ensure Treatment Nurse followed the Enhanced Barrier Precautions (EBP) (interventions to prevent spread of infection in high-risk residents) policy of wearing a gown during Resident #41's wound to left lateral ankle and right mid back wound care to on 4/2/25. These failures could place residents at risk for cross contamination, at an increased risk of infection, and the spread of infection. Findings included: 1. Record review of Resident #7's face sheet dated 4/01/25 revealed he was [AGE] years old and admitted to the facility on [DATE]. Resident #7 had diagnoses including dementia (forgetfulness), senile degeneration of brain (progressive decline in cognitive abilities, such as memory, thinking, and reasoning), diabetes (high blood sugar, places at higher risk of infection), retention of urine, and chronic kidney disease. Record review of Resident #7's annual MDS assessment dated [DATE] indicated he was unable to complete the BIMS, which indicated he had severe cognitive impairment. Resident #7 was dependent on staff assistance for most ADLs. The MDS indicated Resident #7 had an indwelling catheter (urinary catheter inserted into the bladder to drain urine). The MDS indicated Resident #7 was always incontinent of bowel. Record review of Resident #7's undated Care Plan Report indicated he had an indwelling catheter related to retention of urine with interventions including catheter care daily and PRN; he was at risk for self-care deficit with interventions including toileting-dependent x 2 staff; he had bowel incontinence with interventions including to check resident every two hours and assist with toileting as needed, and provide peri (human private area) care after each incontinent episode. Record review of Resident #7's Order Summary Report dated 4/02/25 revealed an order for foley (urinary) catheter care every shift with an order date of 2/06/25. During an observation on 4/01/25 beginning at 3:30 PM of incontinent care and urinary catheter care, surveyor observed an Enhanced Barrier Precautions sign and an isolation cart outside the door of Resident #7. CNA D and CNA E both donned (put on) isolation gowns prior to entering Resident #7's room. Upon entering Resident #7's room, CNA D and CNA E washed their hands and donned gloves. CNA D picked up Resident #7's fall mat off of the floor, folded it, and placed against the wall. Then CNA D pulled Resident #7's bed away from the wall and CNA E went between the wall and Resident #7's bed. CNA D without performing hand hygiene or changing gloves, she proceeded to pull Resident #7's bed sheet back toward his feet, unfastened his brief, then assisted CNA E turn Resident #7 onto his right hip toward CNA E by putting one gloved hand on Resident #7's shoulder and the other gloved hand on his hip and pushed him toward CNA E. CNA D then removed Resident #7's soiled brief and proceeded to cleanse feces (bowel movement) from his buttocks using wipes. CNA D then assisted CNA E assist Resident #7 back on to his back by placing one gloved hand on his shoulder and the other gloved hand on his hip and she did not perform hand hygiene or change her gloves after cleaning feces from his buttocks. CNA D, without performing hand hygiene or changing her gloves, then proceeded to use a wipe to cleanse Resident #7's head of his penis, then used a wipe to cleanse down each side of his testicles, then CNA D used another wipe to cleanse down his urinary catheter tubing and repeated twice. CNA D then assisted CNA E to roll Resident #7 over onto his right hip toward CNA E and placed a new brief on him. CNA D then placed her same gloved hands on his hip and shoulder to turn Resident #7 onto his back. CNA D and CNA E then used a draw sheet to pull Resident #7 up in bed. CNA D placed a positioning wedge under Resident #7's left side, then placed his urinary catheter bag back on the side of his bed, then covered Resident #7 with a bed sheet, then moved his bed back against wall, then CNA D used his bed remote to let Resident #7 down to a low position. CNA D did not perform hand hygiene or change her gloves at any point while providing incontinent care, urinary catheter care, positioning, or arranging Resident #7's furniture, except upon entering Resident #7's room and prior to exiting Resident #7's room. During an interview on 4/01/25 at 3:44 PM, CNA E said she had worked at the facility for approximately six years and normally worked on the 6 AM - 2 PM shift. CNA E said staff should perform hand hygiene and change gloves when a resident has had a bowel movement and before placing clean stuff underneath resident. CNA E said CNA D should have changed her gloves after handling the floor fall mat and prior to providing care to the Resident #7. CNA E said CNA D should have changed gloves and washed her hands after cleaning the bowel movement off Resident #7. CNA E said staff could give the resident an infection, such as a UTI (urinary tract infection), if they use the same gloves used to clean bowel movement and whatever bacteria could have been on the floor fall mat. CNA E said CNA D should have washed her hands and changed gloves prior to handling the residents bedding, bed remote, or anything that was not contaminated. CNA E said CNA D could have given Resident #7 any bacteria that could have been on her gloves onto his urinary catheter, clean brief, clothing, bedding, positioning wedge, bed, and bed remote and then the resident could have touched them and even put his hand in his mouth and given him an infection. CNA E said she had received training on performing incontinent care, urinary catheter care, and infection control, and when to perform hand hygiene and when to change gloves. CNA E said it was an infection control issue when CNA D contaminated Resident #7's urinary catheter, his clothing, clean brief, bed, bedding, bed remote, positioning wedge, and urinary catheter bag. During an interview on 4/01/25 at 3:55 PM, CNA D said she had worked at the facility for a little over a year as a CNA and normally worked the 6 AM - 2 PM shift. CNA D said she should have changed her gloves after picking up the floor fall mat and prior to providing care to Resident #7. CNA D said she should have performed used hand sanitizer and changed her gloves after cleaning bowel movement off Resident #7's back half and then flipped him back to do his front half. CNA D said not sanitizing and changing her gloves after cleaning bowel off Resident #8's back half and then performing incontinent/urinary catheter care and then touching multiple things in Resident #7's room was cross contamination and could cause the resident an infection. CNA D said she had been trained on performing hand hygiene, when to change gloves, incontinent care, urinary catheter care, and infection control and prevention. CNA D said she was just nervous. CNA D said it all was an infection control issue. During an interview on 4/01/25 at 4:02 PM, LVN C said staff should wash hands, put gloves on, change gloves when going from dirty to clean, wash hands, change gloves, and then finish dressing or other things. LVN C said it would be cross contamination if staff did not change their gloves from picking something up off the floor, then performing bowel incontinent care, then urinary catheter care, and then proceeding to touch multiple surfaces and bedding in the resident's room. LVN C said the nursing facility residents had a weaker immune system and it placed them at a higher risk of infection. LVN C said it was cross contamination and an infection control issue. During an interview on 4/02/25 at 9:42 AM, RN B said staff should gather their supplies for incontinent care and/or foley catheter care, then wash their hands, and put on gloves. RN B said staff should perform hand hygiene and change their gloves when going from a dirty area to a clean area. RN B said staff should have removed the resident's fall mat and moved his bed prior to beginning resident care and then washed their hands and applied new gloves. RN B said staff should have changed gloves prior to performing front perineal area care and foley catheter care after cleaning bowel movement from the buttocks of the resident. RN B said it was an infection control issue and it was unsanitary by touching everything around the resident without performing hand hygiene or changing gloves. RN B said residents were on Enhanced Barrier Precautions because they were at a higher risk of infection due to having medical implanted devices such as feeding tubes or urinary catheters. RN B said by staff not changing gloves after cleaning bowel movement and then performing urinary catheter care, there was an increased risk of introducing E-coli (Escherichia coli-bacteria found in feces/bowel movement) into the system and placed the resident at a higher risk of infection. During an interview on 4/02/25 at 10:38 AM, the DON said CNA D should have approached the resident with clean gloves and should have changed gloves and sanitized after performing bowel movement incontinent care and after performing incontinent /urinary catheter care, and again before touching anything clean. The DON said the staff had received training on appropriate hand hygiene, changing gloves, incontinent care, urinary catheter care, and infection control. The DON said he could not speculate what the risk to the resident would be from CNA D not performing hand hygiene or changing her gloves appropriately and then touching multiple surfaces in close proximity of Resident #7. The DON said Resident #7 was on Enhanced Barrier Precautions because he had a urinary catheter because that was the way the Enhanced Barrier Precautions guidelines were written. The DON said he could not speculate if Resident #7 was at a higher risk of infection or urinary tract infections from CNA D not changing her gloves or performing hand hygiene appropriately. During an interview on 4/02/25 at 12:17 PM, the ADM said by the CNA not performing hand hygiene or changing her gloves appropriately, it could be an infection control concern. The ADM said by the CNA touching multiple things in the resident's room, it was cross contamination and could place the resident at a higher risk of infections and UTIs (urinary tract infections). The ADM said she would expect staff to follow the facility's policies related to infection control, hand hygiene, incontinent care, and urinary catheter care. Record review of CNA Orientation/Competency check-off form dated completed on 1/09/25 for CNA D indicated she was evaluated by the DON on 1/09/25 on Incontinent Care to include perineum care and foley catheter care and had a check mark in the Passed column . 2. Record review of Resident #41's face sheet dated 3/31/2025 indicated Resident #41 was an [AGE] year-old male readmitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (a lung condition caused by damage to the airways and alveoli, usually from smoking or other irritants), Chronic cystitis (infection or inflammation of the urinary bladder or any part of the urinary system cause by a bacteria), Diverticulitis of large intestine without perforation or abscess without bleeding (an inflammation with or without infection of a diverticulum (a pouch-like structure that form in the wall of the large intestine), which causes abdominal pain and can create a collection of pus around the inflamed diverticulum), pressure ulcer of head (an injury to the skin and the tissue below the skin that are due to pressure on the skin for a long time), and abnormal weight loss ( a noticeable drop in your body weight without trying). Record review of Resident #41's comprehensive MDS assessment dated [DATE] indicated Resident #41 understood and was understood by others. Resident #41 had a BIMS score of 12 which indicated moderate cognitive impairment. Resident #41 was at risk of developing pressure ulcer/injuries. Record review of Resident #41's care plan initiated on 3/14/2025 indicated Resident #41 had an incomplete care plan and did not indicate he was on enhanced barrier precautions or had any skin concerns. Record review of Resident #41's skin assessment completed on 4/1/2025 indicated Resident #41 had a new sebaceous cyst that opened measuring 0.5 cm x 0.4 cm x 0 with no drainage and wound bed appearance was white. During an observation and interview on 3/31/2025 at 10:18 AM, Resident #41 was sitting up in his wheelchair with observed bruising to bilateral upper arms, and a bandage on his left lower leg. Resident #41 said he had sores all over him and an area on his back that was giving him problems. Resident #41 said the nurse had been keeping his wounds covered. Resident #41 did not have signage and/or PPE outside his door. During an observation on 4/2/2025 at 9:35 AM, Resident #41 did not have signage to identify the resident was on EBP and/or PPE outside his door. The Treatment Nurse performed wound care to Resident #41's left lateral ankle and right mid back without gown. The Treatment Nurse said the wound on Resident #41's back did have some drainage and redness was observed on the peri-wound (skin surrounding the wound). During an interview on 4/2/2025 at 10:10 AM, CNA A said personal protective equipment would be worn while providing care to residents with catheters, wounds, and peg tubes. CNA A said the plan of care would be on the computer and a container would be set up outside a resident's door indicating a resident was on enhanced barrier precautions. CNA A said the enhanced barrier precautions would be documented on the care plan. She said the facility had PPE which included gowns, gloves, and mask. CNA A said the nurse was responsible for ensuring proper PPE was worn. CNA A said the staff could cross-contaminate or get an infection from the resident if PPE was not worn. She said the staff had been in-serviced on EBP precautions. During an interview on 4/2/2025 at 10:22 AM, RN B said the staff had been in-serviced on enhanced barrier precautions. She said anyone providing direct care should wear the proper PPE. RN B said the Infectious Disease nurse was responsible for ensuring PPE was worn. RN B said the care plan indicates what care would be provided to a resident. She said not wearing proper PPE with a resident with wounds could cause infection if not worn properly. During an interview on 4/2/2025 at 11:55 AM, the Treatment Nurse said the Centers for Disease Control (CDC) says PPE should be worn for chronic wounds and Resident #41's has small abrasions when he came into the facility. The Treatment Nurse said she did not place Resident #41 on enhanced barrier precautions because it was not a chronic wound and it was not required with small wounds. She said he was on precautions when he first came to the facility and after he completed an antibiotic, he got much better. The Treatment nurse said the Centers for Disease Control (CDC) leaves things unclear. The Treatment nurse said she had gone over enhanced barrier precautions with the aides on how to properly wear PPE. The Treatment Nurse said enhanced barrier precautions should be worn with Resident's with foley catheters, tracheostomies (a surgical procedure that involves creating an opening through the neck into the trachea (windpipe) to facilitate breathing) , gastrostomy (a medical devices that delivers liquid nutrition directly to the stomach or small intestine through a flexible tube), and wounds. The Treatment nurse said the enhanced barrier precautions were not required for wounds that only required a bandage. During an interview on 4/2/2025 at 12:10 PM, the ADON said enhanced barrier precautions are for residents who have foley catheters, peg tubes and wounds. The ADON said personal protective equipment (PPE) should be worn while providing care for residents with foley catheters, peg tubes and wounds. She said the facility had PPE for staff and she just ordered 400 more gowns. The ADON said if a resident was on enhanced barrier precautions, it should be on the resident's care plan, have a container outside the resident door and a sign on the door. She said she could not speculate what could happen if proper PPE was not worn. During an interview on 4/2/2025 at 12:34 PM, the DON said he would have to review with the Infection Preventionist. He said he did not want to speculate on what could happen if PPE was not worn during care. During an interview on 4/2/2025 at 12:59 PM, the Interim Administrator said the treatment nurse should have worn PPE while providing care to Resident #41. The Interim Administrator said enhanced barrier precautions would be care planned if on precautions and signage should be placed on the door. The Interim Administrator said the facility had in-serviced the staff on enhanced barrier precautions. The Interim Administrator said if a resident was not placed on proper enhanced barrier precautions and the staff was not wearing proper personal protective equipment (PPE), it could place a resident at risk for infection and negatively impact their quality of life. Record review of the facility's policy titled Infection Prevention and Control Program dated revised October 2018 indicated . an infection prevention and control program was established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . important facets of infection prevention include . educating staff and ensuring that they adhere to proper techniques and procedures . implementing appropriate isolation precautions when necessary . following established general and disease specific guidelines such as those of the Centers for Disease Control (CDC) . Record review of the facility's policy titled Perineal Care dated revised February 2018 indicated . the purpose of this procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition . steps in the procedure . wash and dry your hands thoroughly . fold the bedspread or blanket toward the foot of the bed . fold the sheet down to the lower part of the body . put on gloves . for a male resident . wash perineal area (private area) starting with the urethra (opening at head of penis) working outward . if the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about three inches, gently rinse and dry the area . wash and rinse the rectal area thoroughly . remove gloves and discard . wash and dry hands thoroughly . reposition the bed covers, make the resident comfortable . wash and dry your hands thoroughly . Record review of the facility's policy titled Handwashing/Hand Hygiene dated revised August 2019 indicated . the facility considered hand hygiene the primary means to prevent the spread of infections . all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . wash hands with soap and water for the following situations . when hands are visually soiled . use alcohol-based hand rub or soap and water in the following situations . before and after direct contact with residents . before and after handling an invasive device (urinary catheters, intravenous access sites, etc.) . before moving from a contaminated body site to a clean body site during resident care . after contact with objects in the immediate vicinity of the resident . the use of gloves does not replace hand washing/hand hygiene . integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections . Record review of Centers for Medicare and Medicaid Services (CMS ) guideline titled Center for Clinical Standards and Quality/Quality, Safety & Oversight Group dated 3/20/2025 indicated . Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use . used in conjunction with standard precautions and expand the use of personal protective equipment (PPE) to donning of gown and gloves during high-contact resident care activities . indicated for residents with any of the following: . infection or colonization . wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO . Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage . Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies (a surgical procedure that involves creating an opening through the neck into the trachea (windpipe) to facilitate breathing).Facilities should ensure protective personal equipment (PPE) and alcohol-based hand rub are readily accessible to staff. Protective personal equipment PPE for enhanced barrier precautions (EBP) were only necessary when performing high-contact care activities and may not need to be donned prior to entering a resident's room . 49019

Based on record review, observation, and interview , the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 15 residents reviewed for resident rights. (Resident #31) The facility failed to treat Resident #31 with dignity and respect by CNA F denying his request to have food brought by his family reheated on 02/12/2025. This failure could place residents at risk for decreased quality of life, decreased self-esteem and increased anxiety. Findings included: Record review of a face sheet dated 04/01/25 indicated Resident #31 was a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of heart disease, unsteadiness on feet, and generalized weakness. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #31 had a BIMS of 15, which indicated intact cognition. Resident #31 required moderate to maximal assistance for most ADLs. Record review of a care plan dated 03/27/25 indicated Resident #31 had right hemiplegia/hemiparesis (a condition characterized by paralysis on one side of the body) related to a stroke and would maintain optimal status and quality of life within limitations imposed by hemiplegia/hemiparesis. Record review of a Nurse's Note for Resident #31 dated 02/12/25 at 8:00 p.m. indicated, .Res (resident) reports he is upset with CNA staff person due to her declining to heat food brought in by a family member . she made me feel like I didn't need any food. Explained policy of not being able to heat food brought in by family due to infection control, cross contamination and inability to control heat levels of food heated in the microwave. Res voiced understanding but states you know that's BS . The Nurse's Note was signed by RN G. Record review of a Nurse's Note for Resident #31 dated 02/12/25 at 8:30 p.m. indicated, .Res on CL (call light) and CNA went to his aid. She returned to this nurse reporting res had her prepare some snacks for him. She reports res was crying saying he didn't have any supper. This nurse talked with res (resident) and he is calm and having his snacks. Offered crackers or a banana off snack cart and he declines saying he has plenty now . The Nurse's Note was signed by RN G. During an observation and interview on 03/31/25 at 1:55 p.m., Resident #31 said a family member had brought him food from a restaurant. He said the food had been in his refrigerator . There was a refrigerator beside his bed. He said he asked CNA F to reheat the food for him so he could eat it for dinner on 02/12/25. He said she told him it was not their practice to heat up food for residents. He said he had cancelled his supper tray. He said she should have told him that she could not reheat his food before she cancelled his supper for him. He said he was angry and upset that CNA F would not reheat his food for him. He said he skipped supper even though they offered him a sandwich. He said she made him uncomfortable. During an interview on 04/01/25 at 2:12 p.m., CNA F said she went in to Resident 31's room and he asked her to warm up some food that a family member had brought him. She said she carried the food to the kitchen and dietary staff told her they were not allowed to bring it into the kitchen to heat it up due to cross contamination. She said she then went to the nurse and the nurse told her the same thing. She said the nurse also told her she could not heat the food up in the employee breakroom microwave. She said when she went back to tell Resident #31 and he became very upset. She said all she told him was I can only do so much. She said the decision was not up to her. She said he then refused his evening meal tray. She said around 7:15 p.m. she went back in the room to get his roommates bed ready to put him to bed. She said Resident #31 became very upset and began yelling at her. She said he was yelling and hollering. She said again she tried to explain that she had nothing to do with it. That she was not allowed heat up his food. She said she told him to be upset with the nurse and the dietary staff. She said there were no witnesses to the conversation. During an interview on 04/01/25 at 3:18 p.m., RN G said CNA F never came to her and asked her about heating up Resident 31's food. She said staff had been told not to heat up residents' food because they could not regulate the temperature and it was an infection control issue. She said if she were in her home and could not have her food heated up it would make her feel terrible. She said it was Resident 31's right to have his food headed up. She said Resident #31 cried because his food was not heated up for him. During an interview on 04/01/25 at 3:56 p.m., the Social Services Assistant said she met with Resident #31, the DON, and Interim Administrator. She said there were no witnesses to the incident. She said she talked to him about his food not being heated up and he told her it pissed him off. He told her it made him feel like he was fat, and it would not hurt him to miss a meal. He told her that CNA F had not said that to him, but it was how it made him feel. During an interview on 04/02/25 at 9:04 a.m., the Dietary Manager said they did not reheat food that came from outside of the facility. She said this because they cannot prove where it came from or if it is safe or not. She said it would upset her if her food was not reheated but being in the business as long as she had, she would understand the rules and regulations. During an interview on 04/02/25 at 11:07 a.m., the DON said nursing staff could not reheat food for residents. He said food had to be served at a certain temperature and CNAs did not have food preparation training. He said he could not speculate on how not reheating a resident's food could negatively affect a resident. During an interview on 04/02/25 at 11:26 a.m., the Interim Administrator said Resident #31 had requested for CNA F to reheat food his family brought in. She said Dietary staff told CNA F that they could not reheat the food due to cross contamination. She said food brought in by family members was not reheated because they were not able to temp the food and the resident could be burned. She said if the food was old the resident could come in contact with a food borne illness. She said for as much as they were able to do so, she would expect 100% for the resident's preferences to be followed. She said resident preferences not being followed could affect their quality of life and their satisfaction could be negatively affected. Record review of a Foods Brought by Family/Visitors facility policy last revised in 03/2022 indicated, .Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of resident . Record review of a Food and Nutrition Services facility policy last revised in 10/2017 indicated, .Reasonable efforts will be made to accommodate resident choices and preferences . Record review of a Resident Rights facility policy last revised 02/2021 indicated, .Federal and state laws guarantee certain basic rights to all resident of this facility. These rights include the resident's right to .a dignified existence .self-determination .

Based on observation, interviews and record review, the facility failed to ensure a resident with urinary incontinence, based on the resident's comprehensive assessment, received appropriate treatment and services to prevent urinary tract infections (UTI) for 1 of 3 residents (Residents #7) reviewed for urinary catheters. 1. The facility failed to ensure CNA D performed hand hygiene and changed gloves appropriately during and after providing incontinent care to Resident #7. 2. The facility failed to ensure CNA D performed hand hygiene and changed gloves appropriately prior to providing indwelling urinary catheter care to Resident #7. These failures could place residents at an increased risk for urinary tract infections. Findings included: Record review of Resident #7's face sheet dated 4/01/25 revealed he was [AGE] years old and admitted to the facility on [DATE]. Resident #7 had diagnoses including dementia (forgetfulness), senile degeneration of brain (progressive decline in cognitive abilities, such as memory, thinking, and reasoning), diabetes (high blood sugar, places at higher risk of infection), retention of urine, and chronic kidney disease. Record review of Resident #7's annual MDS assessment dated [DATE] indicated he was unable to complete the BIMS, which indicated he had severe cognitive impairment. Resident #7 was dependent on staff assistance for most ADLs. The MDS indicated Resident #7 had an indwelling catheter (urinary catheter inserted into the bladder to drain urine). The MDS indicated Resident #7 was always incontinent of bowel. Record review of Resident #7's undated Care Plan Report indicated he had an indwelling catheter related to retention of urine with interventions including catheter care daily and PRN; he was at risk for self-care deficit with interventions including toileting-dependent x 2 staff; he had bowel incontinence with interventions including to check resident every two hours and assist with toileting as needed, and provide peri (human private area) care after each incontinent episode. Record review of Resident #7's Order Summary Report dated 4/02/25 revealed an order for foley (urinary) catheter care every shift with an order date of 2/06/25. During an observation on 4/01/25 beginning at 3:30 PM to observe incontinent care and urinary catheter care, observed an Enhanced Barrier Precautions sign and an isolation cart outside the door of Resident #7. CNA D and CNA E both donned (put on) isolation gowns prior to entering Resident #7's room. Upon entering Resident #7's room, CNA D and CNA E washed their hands and donned gloves. CNA D picked up Resident #7's fall mat off of the floor, folded it, and placed against the wall. Then CNA D pulled Resident #7's bed away from the wall and CNA E went between the wall and Resident #7's bed. CNA D without performing hand hygiene or changing gloves, she proceeded to pull Resident #7's bed sheet back toward his feet, unfastened his brief, then assisted CNA E turn Resident #7 onto his right hip toward CNA E by putting one gloved hand on Resident #7's shoulder and the other gloved hand on his hip and pushed him toward CNA E. CNA D then removed Resident #7's soiled brief and proceeded to cleanse feces (bowel movement) from his buttocks using wipes. CNA D then assisted CNA E assist Resident #7 back on to his back by placing one gloved hand on his shoulder and the other gloved hand on his hip and she did not perform hand hygiene or change her gloves after cleaning feces from his buttocks. CNA D, without performing hand hygiene or changing her gloves, then proceeded to use a wipe to cleanse Resident #7's head of his penis, then used a wipe to cleanse down each side of his testicles, then CNA D used another wipe to cleanse down his urinary catheter tubing and repeated twice. CNA D then assisted CNA E to roll Resident #7 over onto his right hip toward CNA E and placed a new brief on him. CNA D then placed her same gloved hands on his hip and shoulder to turn Resident #7 onto his back. CNA D and CNA E then used a draw sheet to pull Resident #7 up in bed. CNA D placed a positioning wedge under Resident #7's left side, then placed his urinary catheter bag back on the side of his bed, then covered Resident #7 with a bed sheet, then moved his bed back against wall, then CNA D used his bed remote to let Resident #7 down to a low position. CNA D did not perform hand hygiene or change her gloves at any point while providing incontinent care, urinary catheter care, positioning, or arranging Resident #7's furniture, except upon entering Resident #7's room and prior to exiting Resident #7's room. During an interview on 4/01/25 at 3:44 PM, CNA E said she had worked at the facility for approximately six years and normally worked on the 6 AM - 2 PM shift. CNA E said staff should perform hand hygiene and change gloves when a resident has had a bowel movement and before placing clean stuff underneath resident. CNA E said CNA D should have changed her gloves after handling the floor fall mat and prior to providing care to the Resident #7. CNA E said CNA D should have changed gloves and washed her hands after cleaning the bowel movement off Resident #7. CNA E said staff could give the resident an infection, such as a UTI (urinary tract infection), if they use the same gloves used to clean bowel movement and whatever bacteria could have been on the floor fall mat. CNA E said CNA D should have washed her hands and changed gloves prior to handling the residents bedding, bed remote, or anything that was not contaminated. CNA E said CNA D could have given Resident #7 any bacteria that could have been on her gloves onto his urinary catheter, clean brief, clothing, bedding, positioning wedge, bed, and bed remote and then the resident could have touched them and even put his hand in his mouth and given him an infection. CNA E said she had received training on performing incontinent care, urinary catheter care, and infection control, and when to perform hand hygiene and when to change gloves. CNA E said it was an infection control issue when CNA D contaminated Resident #7's urinary catheter, his clothing, clean brief, bed, bedding, bed remote, positioning wedge, and urinary catheter bag. During an interview on 4/01/25 at 3:55 PM, CNA D said she had worked at the facility for a little over a year as a CNA and normally worked the 6 AM - 2 PM shift. CNA D said she should have changed her gloves after picking up the floor fall mat and prior to providing care to Resident #7. CNA D said she should have performed used hand sanitizer and changed her gloves after cleaning bowel movement off Resident #7's back half and then flipped him back to do his front half. CNA D said not sanitizing and changing her gloves after cleaning bowel off Resident #8's back half and then performing incontinent/urinary catheter care and then touching multiple things in Resident #7's room was cross contamination and could cause the resident an infection. CNA D said she had been trained on performing hand hygiene, when to change gloves, incontinent care, urinary catheter care, and infection control and prevention. CNA D said she was just nervous. CNA D said it all was an infection control issue. During an interview on 4/01/25 at 4:02 PM, LVN C said staff should wash hands, put gloves on, change gloves when going from dirty to clean, wash hands, change gloves, and then finish dressing or other things. LVN C said it would be cross contamination if staff did not change their gloves from picking something up off the floor, then performing bowel incontinent care, then urinary catheter care, and then proceeding to touch multiple surfaces and bedding in the resident's room. LVN C said the nursing facility residents had a weaker immune system and it placed them at a higher risk of infection. LVN C said it was cross contamination and an infection control issue. During an interview on 4/02/25 at 9:42 AM, RN B said staff should gather their supplies for incontinent care and/or foley catheter care, then wash their hands, and put on gloves. RN B said staff should perform hand hygiene and change their gloves when going from a dirty area to a clean area. RN B said staff should have removed the resident's fall mat and moved his bed prior to beginning resident care and then washed their hands and applied new gloves. RN B said staff should have changed gloves prior to performing front perineal area care and foley catheter care after cleaning bowel movement from the buttocks of the resident. RN B said it was an infection control issue and it was unsanitary by touching everything around the resident without performing hand hygiene or changing gloves. RN B said residents were on Enhanced Barrier Precautions because they were at a higher risk of infection due to having medical implanted devices such as feeding tubes or urinary catheters. RN B said by staff not changing gloves after cleaning bowel movement and then performing urinary catheter care, there was an increased risk of introducing E-coli (Escherichia coli-bacteria found in feces/bowel movement) into the system and placed the resident at a higher risk of infection. During an interview on 4/02/25 at 10:38 AM, the DON said CNA D should have approached the resident with clean gloves and should have changed gloves and sanitized after performing bowel movement incontinent care and after performing incontinent /urinary catheter care, and again before touching anything clean. The DON said the staff had received training on appropriate hand hygiene, changing gloves, incontinent care, urinary catheter care, and infection control. The DON said he could not speculate what the risk to the resident would be from CNA D not performing hand hygiene or changing her gloves appropriately and then touching multiple surfaces in close proximity of Resident #7. The DON said Resident #7 was on Enhanced Barrier Precautions because he had a urinary catheter because that was the way the Enhanced Barrier Precautions guidelines were written. The DON said he could not speculate if Resident #7 was at a higher risk of infection or urinary tract infections from CNA D not changing her gloves or performing hand hygiene appropriately. During an interview on 4/02/25 at 12:17 PM, the ADM said by the CNA not performing hand hygiene or changing her gloves appropriately, it could be an infection control concern. The ADM said by the CNA touching multiple things in the resident's room, it was cross contamination and could place the resident at a higher risk of infections and UTIs (urinary tract infections). The ADM said she would expect staff to follow the facility's policies related to infection control, hand hygiene, incontinent care, and urinary catheter care. Record review of CNA Orientation/Competency check-off form dated completed on 1/09/25 for CNA D indicated she was evaluated by the DON on 1/09/25 on Incontinent Care to include perineum care and foley catheter care and had a check mark in the Passed column . Record review of the facility's policy titled Perineal Care dated revised February 2018 indicated . the purpose of this procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition . steps in the procedure . wash and dry your hands thoroughly . fold the bedspread or blanket toward the foot of the bed . fold the sheet down to the lower part of the body . put on gloves . for a male resident . wash perineal area (private area) starting with the urethra (opening at head of penis) working outward . if the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about three inches, gently rinse and dry the area . wash and rinse the rectal area thoroughly . remove gloves and discard . wash and dry hands thoroughly . reposition the bed covers, make the resident comfortable . wash and dry your hands thoroughly . Record review of the facility's policy titled Catheter Care, Urinary dated revised August 2022 indicated . purpose of this procedure was to prevent urinary catheter-associated complications, including urinary tract infections . infection control . use aseptic technique when handling or manipulating the drainage system . Record review of the undated CDC (Centers for Disease Control and Prevention) Indwelling Urinary Catheter Insertion and Maintenance revealed CAUTI (catheter-associated urinary tract infections) were costly and increased morbidity . maintenance catheter care essentials . when an indwelling urinary catheter was indicated, the following interventions should be in place to help prevent infection . use indwelling catheters only when medically necessary . properly secure indwelling catheters to prevent movement and urethral traction . maintain good hygiene at the catheter-urethral interface . maintain unobstructed urine flow . maintain drainage bag below level of bladder at all times . use a catheter securement device to anchor the catheter . perform peri and catheter care per facility policy . assess the patient for any pain or discomfort . inspect for redness, irritation and drainage . once a urinary catheter was inserted, maintaining it according to evidence-based guidelines was crucial to prevent CAUTI . Record review of the facility's policy titled Handwashing/Hand Hygiene dated revised August 2019 indicated . the facility considered hand hygiene the primary means to prevent the spread of infections . all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . wash hands with soap and water for the following situations . when hands are visually soiled . use alcohol-based hand rub or soap and water in the following situations . before and after direct contact with residents . before and after handling an invasive device (urinary catheters, intravenous access sites, etc.) . before moving from a contaminated body site to a clean body site during resident care . after contact with objects in the immediate vicinity of the resident . the use of gloves does not replace hand washing/hand hygiene . integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections .

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 1 medication storage room (medication storage room [ROOM NUMBER]) reviewed for medication storage. The facility failed to ensure Zinc 50mg was not expired in medication storage room [ROOM NUMBER]. The unopened bottle of Zinc expiration date was 3/2025. The facility failed to ensure Acetaminophen Suppositories 650mg were not expired in the medication storage room [ROOM NUMBER]'s medication refrigerator. The suppositories expiration date was 12/10/24. The facility failed to ensure an opened box of Bisacodyl Suppositories 10mg were not expired in the medication storage room [ROOM NUMBER]'s medication refrigerator. The suppositories expiration date was 2/28/25. These failures could place residents at risk for adverse effects and reduced therapeutic effects of medication and supplies. Findings included: During an observation on 4/1/25, starting at 9:40 a.m., this surveyor reviewed 1 of 1 medication storage rooms and found the following medications with expired expiration dates: *One, unopened bottle of Zinc Tablets 50mg with dated expiration of March 2025. *One package of Acetaminophen Suppositories 650 mg with dated expiration of 12/10/24. *One, opened box of Bisacodyl Suppositories 10mg with dated expiration of 2/28/25. During an interview on 4/2/25 at 11:14 a.m., MA H said there was no designated person responsible for checking expiration dates on medications in the storeroom. She said there was also no set day expiration dates were checked on medications. She said expiration dates were checked before the medication ordering was done. She said the ADON ordered the medications in the storeroom. She said the nurse checked expiration dates on the medications stored in the refrigerator. She said the nurses normally gave the medications stored in the refrigerator. She said expired medications should not be in the storeroom because staff could mistakenly grab an expired medication and give it to a resident. She said if an expired medication was given, the resident would not get the full dose of the medication. During an interview on 4/2/25 at 11:47 a.m., the ADON said, the MAs, LVNs, and RNs were responsible for ensuring expired medications were not in the storeroom. She said they had a MA that kept a pretty good track of expired medications being removed. She said she looked at the expiration dates when ordering more medications. She said the Pharmacy Consultant also performed a monthly sweep for expired medications. She said the nurses were responsible for the medications in the storeroom refrigerator. She said expired medications lost effectiveness and changed their chemical makeup. She said she was ultimately responsible for ensuring expired medications were not stored in the medication storeroom. During an interview on 4/2/25 at 12:00 p.m., RN B said MAs and nurses were responsible for ensuring expired medication were not in the storeroom. She said expiration dates were checked randomly. She said if the medication was close to expiring, the nursing staff circled the expiration date. She said there was no designated person responsible for checking expiration dates on medications in the storeroom. She said there was also no set time expiration dates were checked on medications. She said expired medications should not be stored in the medication room because it could be given to the resident, and it would not work. She said the expired medication would not do its job. During an interview on 4/2/25 at 12:11 p.m., the DON said nursing administration was responsible for ensuring expired medications were not stored in the storeroom. He said MAs and nursing staff were also responsible. He said the pharmacy consultant did a sweep for expired medication once or twice a year. He said expired medication should not be stored in the medication room. He said it increased the risk of a resident being administered an expired medication. He said he could not speculate on how an expired medication affected the resident. During an interview on 4/2/25 at 12:44 p.m., the Administrator, with the Interim Administrator present, said nursing was responsible for ensuring expired medications were not stored in the storeroom. She said she did not know the process of how the facility ensured expired medications were not stored in the storeroom. She said when expired medications were stored, they could potential be given to the residents. She said it could negatively impact the health of the resident if they received an expired medication. She said the DON was ultimately responsible for ensuring expired medications were not stored in the medication storeroom. Record review of a facility's Storage of Medications revised 11/2020 indicated, .all drugs and biologicals in a safe, secure, and orderly manner . nursing staff is responsible for maintaining medication storage and preparation . discontinue, outdated or deteriorated drugs .

Based on interviews and record review the facility failed to ensure residents were free from abuse for 4 of 42 residents (Resident #1, #2, #4, and #5) reviewed for resident abuse. The facility did not ensure Resident (Resident #1, #2, #4, and #5) were free from abuse. This failure could place residents at risk of physical harm, mental anguish, or emotional distress. The findings included: 1. Record Review of Resident #1's face sheet dated 1/28/25 at 1:43 p.m., indicated Resident #1 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of COPD-chronic obstructive pulmonary disease with (acute) exacerbation (chronic inflammatory lung disease that causes obstructed airflow from the lungs), atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow), osteoarthritis (degeneration of joint cartilage and the underlying bone), and GERD (gastro-esophageal reflux disease) (stomach acid or bile irritates the food pipe lining). Record Review of Resident #1's MDS assessment dated [DATE] indicated, Resident #1 sometimes understood others and sometimes made herself understood. The MDS assessment indicated Resident #1 had a BIMS score of 11, which indicated Resident #1 was moderately impaired. The MDS assessment indicated Resident #1 had no behaviors of hitting, kicking, pushing, scratching, grabbing, or abusing others sexually. The MDS assessment indicated verbal behavior directed towards others occurred 1 to 3 days (threatening others, screaming at others, cursing at others). The MDS assessment indicated Resident #1's need for assistance with bathing, dressing, using the toilet, or eating was not coded on the MDS assessment. Record Review of Resident #1's care plan, dated on 12/11/24, indicated Resident #1 had impaired physical mobility. The care plan interventions included, encourage use of prescribed assistive devices; evaluate skin for areas of blanching or redness; determine level of needed assistance based on ADLs / IADLs evaluation; and Educate Resident / Representative on safety precautions. Record Review of Resident #2's face sheet dated 1/28/25 at 1:47 p.m., indicated Resident #2 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of dementia without behavioral disturbance (loss of memory, language, problem solving, and other thinking abilities that were severe enough to interfere with daily life), kidney disease unspecified (a progressive decline in kidney function over time), type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), and essential hypertension (high blood pressure). Record Review of Resident #2's MDS assessment dated [DATE] indicated, Resident #2 understood others and made herself understood. The MDS assessment indicated Resident #2 had a BIMS score of 6, which indicated Resident #2 had a severe impairment. The MDS assessment indicated Resident #2 had no behaviors of hitting, kicking, pushing, scratching, grabbing, or abusing others sexually. The MDS assessment indicated Resident #2's need for assistance with bathing, dressing, using the toilet, or eating was not coded on the MDS assessment. Record Review of Resident #2's care plan, dated on 8/14/24, indicated Resident #2 had behavior symptoms. The care plan indicated, Resident #2 had potential for problems related to behaviors: verbal aggression, physical aggression, socially inappropriate behavior, low frustration tolerance, and cursing at staff/other residents. The care plan interventions included approach in a slow calm manner, explain to resident why behaviors were not appropriate, allow resident time to express self, listen closely to reasons for resident actions, record frequency of inappropriate behaviors, administer medication per order, record and report any cognitive changes, notify physician of any physical or cognitive changes, meet physical needs of resident, and remove resident from public area when behavior was unacceptable. Record review of an All Staff Inservice Training for Employees: Resident-To-Resident Altercations, dated 12/16/24, revealed in-service training, which was signed by all employees, on resident-to-resident altercations, behavior awareness, prevention of resident-to-resident abuse, and abuse and neglect policy. Record Review of the intake investigation worksheet dated 8/14/24 at 6:30 p.m. indicated, Narrative of The Incident: Residents #1 and Resident #2 engaged one another in the smoke area over an ash tray. Each resident claims the other slapped them. Staff member laundry aid C was present in smoke area and states both residents slapped one another. Neither resident has any visible marks or injury from altercation. Both residents tell me they are fine mentally, emotionally, and physically. Actions and Notifications: Staff separated the two residents immediately. Notified Admin, DON, physician, and family. Administrator directed Charge Nurse to keep the two separated the rest of the night. Notified ombudsman. Started in service. Record Review of grievance log reviewed on 1/27/25 at 10:01 a.m. Record Review of abuse and neglect policy reviewed on 1/27/25 at 10:26 a.m. Record Review of in-services reviewed on 1/27/25 10:31 a.m. During an interview on1/28/25 at 9:34 a.m., Laundry aid C stated Resident #2 got the ash tray off the table to put her cigarette ashes in and then Resident #1 said to Resident #2 Why did you take that ash tray, how did you know I was done using it. Laundry aid C stated Resident #2 replied and said, Did you pay for it. Laundry aid C stated next Resident #1 said she would come and take the ash tray back. Laundry aid C stated next Resident #2 said, If you do take my ash tray, I will slap you. Laundry aid C stated next Resident #1 tried to take the ash tray from Resident #2. Laundry aid C stated that's when Resident #2 slapped Resident #1 across her head. Laundry aid C stated she was not sure if the slap from Resident #2 went across Resident #1 left or right side of head. Laundry aid C stated she believed the slap from Resident #2 to Resident #1 was made on Resident #1's right side of her head. Laundry aid C stated Resident #1 then slapped Resident #2 back across her hand. Laundry aid C stated she was not sure if the slap from Resident #1 to Resident #2 was made to her left or right hand. Laundry aid C stated Resident #1 started the incident. Laundry aid C stated neither resident occurred any injuries. Laundry aid C stated it was not a hard slap from neither resident. Laundry aid C stated the two residents slapped each other and that was it. Laundry aid C stated, I got a nurse to come help me separate the two residents. Laundry aid C stated she could not remember if any in-services were completed following this incident. Laundry aid C stated this incident occurred around 6 in the evening. Laundry aid C stated she was outside with the residents on the smoking patio when this incident occurred. Laundry aid C stated she reported this incident to LVN D on the night shift. During an interview on 1/28/25 at 10:07a.m., the Administrator stated Resident #2 passed last year on the 21st of August 2024. During an interview on 1/28/25 at 10:12 a.m., Resident #3 stated Resident #2 took the ash tray that Resident #1 was using. Resident #3 stated, It made Resident #1 mad. Resident #3 stated Resident #1 tried to take back the ash tray and that's when Resident #2 hit her. Resident #3 stated next the nursing broke up the fight between the two residents. Resident #3 stated, Resident #1 tried to hit Resident #2 back. Resident #3 stated Resident #2 had grabbed arm to keep her from hitting her back. Resident #3 stated this incident happened so long ago and she was doing her best at remembering this incident. Resident #3 stated, Resident#1 had some bruising on her arm from where Resident #2 grabbed her arm. Resident #3 stated this incident happened on the smoke patio outside. During an interview on 1/28/25 at 10:17 a.m., Resident #1 stated she did not remember the incident. Resident #1 stated, This incident happened so long ago I'm afraid I don't remember. During an interview on 1/28/25 at 10:57 a.m., the Administrator stated he had been employed for 2 years. The Administrator stated the two residents, (Resident #2) and (Resident #1), were roommates for a good year prior to this altercation. The Administrator stated both residents, (Resident #2) and (Resident #1), had strong personalities and were very funny. The Administrator stated eventually they got on each other's nerves when they were out in the smoke area. The Administrator stated usually there was about 3 or 4 ash trays out on the smoke patio. The Administrator stated Resident #2 got one of the ash trays. The Administrator stated Resident #1 did not like that she got the ash tray. The Administrator stated both residents were fussing at each other. The Administrator stated, Resident #1 rolled over and kicked the ash tray then Resident #2 slapped Resident #1. The Administrator stated the staff member interceded and got them apart. The Administrator stated, When Resident #2 slapped Resident #1 that her glasses came off her face. The Administrator stated, Resident #1 had bruising on her arm from when Resident #2 grabbed her arm. The Administrator stated there were no injuries from either resident. The Administrator stated staff separated the residents. The Administrator stated, Resident #2 was put on 15m check to make sure the resident was not re-engaging with Resident #1. The Administrator stated after this incident the residents were not put back in the same room. The Administrator stated, Resident #2 wanted to apologize but Resident #1 did not want her apology. The Administrator stated this resident-to-resident altercation was discussed in QAPI meeting. The Administrator stated the police were not called. The Administrator stated the residents did not want him to call the police. The Administrator stated this was a mutual engagement from both residents. The Administrator stated an in-service on resident-to-resident altercations, awareness and prevention, abuse, and neglect policy was completed following this incident. The Administrator stated the families and physician were notified after this incident. The Administrator stated the interventions that were put in place after the resident-to-resident altercation was Resident #2 was placed on 15m checks for 24 hours and 30m checks thereafter or until he told staff to stop the checks, training was completed, and a referral to for behavior. The Administrator stated the resident-to-resident altercation was discussed in QAPI. The Administrator stated the DON, the ADON, the infection preventionist, the business office manager, social services, the housekeeping supervisor, the diet supervisor, maintenance, CNA, and himself attended QAPI meetings. The Administrator stated the medical director was not able to go to the all the meetings, but he sat down with the medical director and talked about what was discussed in QAPI. The Administrator stated QAPI was completed every month usually the 3rd week of the month. 2. Record Review of Resident #4's face sheet dated 1/28/25 at 1:50 p.m., indicated Resident #4 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of GERD (gastro-esophageal reflux disease) (stomach acid or bile irritates the food pipe lining), hemiplegia (part of the brain controlling movement is damaged) affecting right dominant side), type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), and essential hypertension (high blood pressure). Record Review of Resident #4's MDS assessment dated [DATE] indicated, Resident #4 usually understood others and usually made herself understood. The MDS assessment indicated Resident #4 had a BIMS score of 7, which indicated Resident #4 had a severe impairment. The MDS assessment indicated Resident #4 had no behaviors of hitting, kicking, pushing, scratching, grabbing, or abusing others sexually. The MDS assessment indicated Resident #4's need for assistance with bathing, dressing, using the toilet, or eating was not coded on the MDS assessment. Record Review of Resident #4's care plan, dated on 1/27/25, indicated Resident #4 was at Risk for Harm: Self Directed or Other-Directed due having history of fighting with another resident. The care plan goal indicated; Resident #4 will be free of physically aggressive behaviors. The care plan interventions included administer medications as prescribed, to evaluate and treat as indicated, if resident poses a potential threat to injure self or others notify provider, if wandering or pacing, initiate visual supervision during acute episode, monitor for signs / symptoms of agitation, and utilize calming touch. Record Review of Resident #5's face sheet dated 1/28/25 at 1:47 p.m., indicated Resident #5 was an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (brain chemical imbalance in the blood), hypokalemia (deficiency of potassium in the bloodstream), type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), and essential hypertension (high blood pressure). Record Review of Resident #5's MDS assessment dated [DATE] indicated, Resident #5 understood others and made himself understood. The MDS assessment indicated Resident #5 had a BIMS score of 6, which indicated Resident #5 had a severe impairment. The MDS assessment indicated Resident #5 had no behaviors of hitting, kicking, pushing, scratching, grabbing, or abusing others sexually. The MDS assessment indicated Resident #5's need for assistance with bathing, dressing, using the toilet, or eating was not coded on the MDS assessment. Record Review of Resident #5's care plan, dated on 1/27/25, indicated Resident #5 was at risk for harm: other-directed due to having altercation in the past. The care plan goal indicated; Resident #5 will be free of non-aggressive behaviors. The care plan interventions included administer medications as prescribed, to evaluate and treat as indicated, monitor for cognitive, emotional, or environmental factors that may contribute to violent behaviors, monitor for signs / symptoms of agitation, and provide verbal feedback to resident regarding behavior. Record Review of grievance log reviewed on 1/27/25 at 10:01 a.m. Record Review of abuse and neglect policy reviewed on 1/27/25 at 10:26 a.m. Record Review of in-services reviewed on 1/27/25 10:31 a.m. Record Review of intake investigation worksheet dated 12/6/24 at 4:00 p.m. indicated, Narrative of The Incident: Staff member reports observing Resident #4 approach and slap Resident #5. Staff member states Resident #5 was accusing his roommate Resident #4 of taking his pants immediately before this incident. Altercation was witnessed by CNA B and CNA A. Head to toe assessment shows no injuries, bruising, scratches, related to this incident. Actions and Notifications: Separated residents. Roommates moved to separate rooms. Resident #4 placed on 15-minute checks. Staff directed to keep residents separated. Notified DON, Administrator, Physician, families, and Ombudsman. During observation on 1/27/25 at 3:30 p.m., Resident to Resident interactions were observed in the lounge area of the facility and no issues was observed. During observation on 1/28/25 at 11:00 a.m., Resident to Staff interaction were observed on the smoke patio outside and no issues was observed. During observation on 1/28/25 at 11:00 a.m., Resident to Resident interactions were observed on the smoke patio outside and no issues was observed. During a phone interview on 1/27/25 at 2:32 p.m., CNA A stated she witnessed Resident #4 slap Resident #5 in the face. CNA A stated the residents was separated after the slap to the face in the dining room. CNA A stated after the residents were separated that the two residents were screaming at each other from across room in the dining room. CNA A stated Resident #5 was taken to a separate area to calm down. CNA A stated neither resident had injuries. CNA A stated she reported this incident to the Administrator. During an attempted phone interview on 1/27/25 on 2:36 p.m., CNA B was unavailable to be reached by phone. Record Review of a written statement undated signed by the CNA B indicated, I (CNA B) was coming out of room [ROOM NUMBER] when I was stopped by Resident #5. He asked me did I steal a pair of his pants out of the closet his back was facing the nurses station and my face is facing towards the nurses as Resident #5 and I are talking Resident #4 rolls towards Resident #5 and I and was aggressive, Resident #4 calls Resident #5 a bitch and I stand in between the Resident #5 back is still facing towards Resident #4 as I'm standing between Resident #4 and Resident #5 I push Resident #4 back towards the nurses station he rolls back up takes his left hand and goes across Resident #5 face I separated them CNA A 6/2 shift got the RN E and she took over from there this happened between 3:30 and 4:00 p.m. During an interview on 1/27/25 at 2:55 p.m., Resident #5 stated he did not remember being hit by Resident #4. Resident #5 stated he could not recall what the altercation was about. Resident #5 stated staff was nice to him. Resident #5 stated he did feel safe in the facility but wanted to go home with his. During an interview on 1/27/25 at 2:50 p.m., Resident #4 stated he could not recall the incident. Resident #4 stated he did feel safe. Resident #4 stated staff were nice to him. During an interview on 1/28/25 at 10:47 a.m., the Administrator stated he had been the administrator for 2 years. The Administrator stated the two residents, (Resident #4) and (Resident #5), were roommates. The Administrator stated the aid was trying to help Resident #4 change clothes because he had spilled something on his clothing. The Administrator stated Resident #5 accused the aide of putting his pants on Resident #4. The Administrator stated Resident #4 rolled to Resident #5 and hit him along the face or head area. The Administrator stated there was no injuries or bruising on either resident. The Administrator stated the aide was not sure if Resident #5 made contact to Resident #4's face. The Administrator stated each resident resided on different halls now. The Administrator stated in-services were completed on Behaviors and being aware of behaviors before they escalate to something else. The Administrator stated, I just did an in-service on trying to look for ways to prevent things that frustrated with the residents that leads to altercations. The Administrator stated the police were not notified about this incident. The Administrator stated he asked the resident if they wanted him to call the police and each resident replied that they were fine and not to call the police. The Administrator stated neither resident went to the hospital following this incident. The Administrator stated the family, and the physician were notified about this incident. The Administrator stated the resident-to-resident altercation was discussed in QAPI. The Administrator stated the DON, the ADON, the infection preventionist, the business office manager, social services, the housekeeping supervisor, the diet supervisor, maintenance, CNA, and himself attended QAPI meetings. The Administrator stated the medical director was not able to go to the all the meetings, but he sat down with the medical director and talked about what was discussed in QAPI. The Administrator stated QAPI was completed every month usually the 3rd week of the month. The Administrator stated the interventions that were put in place after the resident-to-resident altercation was Resident #4 was placed on 15m checks for 24 hours and 30m checks thereafter or until he told staff them to stop the checks, training was completed and referral to deer oaks clinic for behavior. Record Review of the facility's abuse and neglect policy dated 2/1/23 indicated, (g) Physical Abuse - includes hitting, slapping, pinching, kicking, or controlling behavior through corporal punishment. (8) All completed Abuse, Neglect, and Misappropriation investigations will be reported to and reviewed by the QAPI committee. The QAPI committee will review and analyze trends and patterns to seek out improved performance opportunities and find ways to prevent future issues.

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements. The facility failed to ensure the ceiling was in good repair in the kitchen. This failure could place residents at risk of foodborne illness and food contamination. Findings included: During initial tour observations in the kitchen on 3/18/24 beginning at 9:08 AM, there was brown staining to approximately six ceiling tiles above to area of the tea maker machine, juice machine, and the food processor (used to make puree and chopped foods). One of the ceiling tiles had a rounded dropped appearance and had loose ceiling tile particles hanging from it directly above the tea maker where there were two uncovered tea filter holders sitting on top of the tea maker and the food processor was beside the tea maker. There was an approximate 1-inch gap in the ceiling tile around half of the fire sprinkler head located above the juice machine. One ceiling tile located directly in front of the tea maker, juice machine and the food processor had a rounded dropped appearance with an approximate 3/4 to 1-inch crack/separation in the ceiling tile on both sides of the air vent, and the air vent was dropped approximately 3/4 of an inch from the ceiling. During an observation on 3/19/24 beginning at 11:26 AM, the DM used the food processor located beside the tea machine and below the damaged ceiling tiles to puree (thick liquid suspension made from cooked food) pork loin, green beans, and black-eyed peas. During an interview on 3/19/24 at 3:11 PM, the DM said the ceiling tiles in the kitchen above the area of the food processor, tea, and juice machines, had been like that since around the first of year or a little before. The DM said the maintenance supervisor had been trying to fix it from leaking. The DM said the maintenance supervisor had put tar on the roof trying to fix the leak. The DM said the area in the kitchen would leak if they had a hard rain, but it did not leak when it rained last month. The DM said it made her a little nervous working in the area where the ceiling tile damage was due to the electrical wiring and ducts. The DM said there could be cross-contamination from the particles hanging from the ceiling tile and/or open areas in the ceiling tiles, but they made sure they washed things down before they used the tea machine, tea filter containers, juice machine, or food processor and kept it as clean as possible. During an interview on 03/19/24 at 3:28 PM, the Maintenance Supervisor said the damaged ceiling tiles in the kitchen had been that way since before he started at the facility in June 2023. The Maintenance Supervisor said he had been on the roof of the building and in the attic trying to patch things and it still leaked when it rained heavy. The Maintenance Supervisor said he did replace the damaged ceiling tiles in the kitchen around the beginning of March, but after the last big rain it was back like it was again. The Maintenance Supervisor said he did not have the repairs documented in his log. The Maintenance Supervisor said he had the ceiling tiles to repair the ceiling in the kitchen, but he had not been able to fix them yet because he would need to schedule the repair when the kitchen was not in use. The Maintenance Supervisor said he had reported the issue to the ADM. The Maintenance Supervisor said the damaged ceiling tiles in the kitchen did not look nice and attic dust and/or insulation could potentially get into the drinks or food with the juicing and tea machines and the food processor being located in the same area. During an interview on 3/20/24 at 2:55 PM, the ADM said he had seen the damaged kitchen tiles and they had been dealing with a leak. The ADM said they had repaired it and sometimes it would leak and sometimes it did not leak. The ADM said he was waiting on a repair quote from a roofing company. The ADM said it seemed like it would be a sanitation issue with the cracks in the ceiling tiles and particles hanging from the ceiling. Record review of the facility's policy titled Food Safety and Sanitation Plan dated revised on 11/28/2017 indicated . it was the policy of the facility to follow an effective, proactive food safety program that was based on preventing food safety hazards before they occurred . residents risk serious complications from foodborne illness as a result of their compromised health status . sanitary conditions must be present in health care food service settings to promote safe food handling .

46062 Based on observation, interviews, and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 5 of 13 residents (Resident #31, Resident #18, Resident #38, Resident #33, and Resident #30) reviewed for resident rights. 1. The facility failed to ensure Resident #31 had a dignified existence by allowing her to use the working bathroom commode in her room. 2.The facility failed to ask Resident #18 to remove a food item from her plate prior to reaching into her plate during her lunch meal. 3.The facility failed to provide Resident #38 with a knife to cut his meat during meals. 4.The facility failed to provide Resident #33 with a requested knife to his cut meat during the lunch meals on [DATE] and [DATE]. 5. The facility failed to ensure CNA G sat in a chair and remained at eye level with Resident #30 while assisting her with her lunch on [DATE]. These failures could place residents at risk of humiliation, diminished quality of life, loss of dignity and loss of self-worth. Findings included: 1. Record review of Resident #31's face sheet dated [DATE] indicated Resident #31 was [AGE] year-old and admitted to the facility on [DATE] with diagnoses including acute pulmonary edema (swelling of the lungs), pneumonia (infection of the lungs), urinary tract infection, hypertension (high blood pressure), cognitive communication deficit, weakness, history of falls, heart failure, major depressive disorder (persistent sadness), and anxiety (nervousness). Record review of Resident #31's annual MDS assessment dated [DATE] indicated Resident #31 was understood and understood others. The MDS indicated Resident #31 had a BIMS score of 15 which indicated she was cognitively intact. Resident #31 had fluctuating inattention and disorganized thinking. Resident #31 did not have behavioral symptoms. Resident #31 used a walker and a wheelchair for mobility. Resident #31 was independent with toilet transfers and required partial assistance with toilet hygiene. The MDS indicated Resident #31 was occasionally incontinent of bowel and bladder. Record review of Resident #31's care plan with a revision date of [DATE] indicated Resident #31 had a problem area of compulsively putting wipes and toilet tissue in commode in bathroom after multiple education and notes put by toilet to not put objects in toilet, resident continued to do, so object had even been denied, but was found to have wipes in her wheelchair where she had taken them off the nurse aide cart, which had caused several plumbing issues and bedside commode was placed in the resident's room. Resident #31 had consults due to gastric (stomach) system issues as evidenced by anal fixation and pain. Resident #31 had infatuation with anal area. During an observation and interview on [DATE] at 10:11 AM, Resident #31 was sitting on the side of her bed with her breakfast tray on her bedside table in front of her. Resident #31 said her breakfast was good and she had eaten most of it. Resident #31 had a bedside commode against the wall at the end of her bed. Resident #31's room had a strong smell of bowel movement. Resident #31 said she had to use a bedside commode because her bathroom commode had not worked since [DATE]. Resident #31 said she wished they would fix her commode, because she did not like using the bedside commode. There was a Sorry Out of Order sign on the outside of bathroom door. There was a sign behind the bathroom commode to not put toilet paper or wipes in toilet. During an observation and interview on [DATE] at 8:25 AM, Resident #31 was sitting on the side of her bed with breakfast tray on her bedside table. Resident #31 said she didn't like having to use the bedside commode and wished they would get the bathroom fixed. Resident #31 said it was embarrassing to use the bedside commode and it did not feel private, even with a curtain. During an observation and interview on [DATE] at 12:48 PM, Resident #31 said she asked the DON about getting the commode fixed because she did not like using the bedside commode and he told her he would look into it. Resident #31 said they were trying to blame her for stopping the commode up, but she said she put the toilet paper and wipes in the trash can, so it wasn't her. Resident #31 said using the bedside commode made her feel uncomfortable due to anyone could walk into her room. Resident #31 said they put the curtain up, but it just did not provide the privacy that a door does in a bathroom. Resident #31 said they just really needed to fix her commode. During an interview on [DATE] at 3:28 PM, the Maintenance Supervisor said they have had to call out the plumbers couple times due to Resident #31 was flushing wipes down the commode and it backed up the entire building septic system. The Maintenance Supervisor said the bathroom toilet in Resident #31's room did work, but they have a sign on the door that it was out of order. The Maintenance Supervisor said Resident #31's bathroom room toilet was fixed approximately a month ago. The Maintenance Supervisor said they have not had an issue with the septic system since they put the bedside commode in Resident #31's room. The Maintenance Supervisor said they were monitoring the situation and there had not been any other issues with the septic system. The Maintenance Supervisor said he did not know what the fix was due to it caused issues with the whole facility's septic system being backed up and residents not being able to flush their toilets. The Maintenance Supervisor said they did not have a specific timeframe to monitor the situation. The Maintenance Supervisor said he knew Resident #31 asked about when her commode would be fixed because the staff told him she asked about it regularly. The Maintenance Supervisor said it was not the ideal situation with an able-bodied person not being able to use their toilet in their room. During an interview on [DATE] at 3:44 PM, CNA A said she had worked at the facility since [DATE] and normally worked the evening and night shifts. CNA A said the kept a plastic bag in Resident #31's bedside commode. CNA A said she would carry Resident #31's bucket of the bedside commode, bag and cover it then transport it to the shower room down the hall and would empty the Resident #31's bedside commode contents in the commode in the shower room. CNA A said she had not heard Resident #31 complain about using the bedside commode. CNA A said if it was her, she would want to go to the bathroom commode with a door. CNA A said she thought they were trying to limit Resident #31's toilet paper, but she was not sure what other interventions they have tried other than bedside commode. During an interview on [DATE] at 01:08 PM, CNA B said she had worked at the facility for approximately 2 years and normally worked the day shift on Resident #31's hall. CNA B said the plumbing had been messed up and Resident 31 had a bedside commode placed in her room. CNA B said she kept a plastic bag in the bedside commode bucket. CNA B said she usually emptied the bedside commode by getting the air out of the plastic bag and tying it up, removed it from the room and then put it in her big trash barrel. CNA B said she did not know if Resident #31's toilet worked, but there was an out of order sign on her bathroom door. CNA B said all the toilets were stopped up at the same time on Resident #31's hall. CNA B said Resident 31 used a lot of toilet paper and sometimes puts it in the trash and sometimes put it in the bedside commode. CNA B said Resident #31 was able to transfer herself and did everything on her own. CNA B said Resident #31 asked for her potty to be fixed almost daily. CNA B said if circumstances warranted the use of a bedside commode, she would be good to use a bedside commode, but if there was a working commode in her room, she would expect to be able to use it. CNA B said Resident #31 did not have a comfortable homelike environment because she had to use a bedside commode and not use the bathroom commode. CNA B said she did not know how it affected Resident #31, but Resident #31 had told her that she did not like having to use the bedside commode. During an interview on [DATE] at 1:37 PM, RN C said she had worked at the facility since 2018 and normally worked the day shift. RN C said they started using the bedside commode in Resident #31's room when the toilets stopped up. RN C said she did not remember how long ago that was and she had not tried to flush Resident #31's toilet to see if it worked. RN C said she believed the bedside commode was a short-term situation. RN C said the maintenance director and the ADM were responsible for monitoring the toilet situation. RN C said a homelike environment should be whatever Resident #31 preferred as her homelike environment. RN C said Resident #31 had not mentioned anything to her about her toilet situation. RN C said it would be a dignity issue if someone came in Resident #31's room and saw her using the bedside. During an interview on [DATE] at 2:29 PM, the DON said he did not think it had been that long since Resident #31 started using the bedside commode due to toilet issues. The DON said he was unaware of the plan related to how long Resident #31 would have the bedside commode. The DON said the ADM would make the final determination when/if the bedside commode would be removed from Resident #31's room and when she would be allowed to use the bathroom commode in her room. The DON said he was unaware if Resident #31's bathroom toilet was working, but to the best of his knowledge it was working. The DON said Resident #31 had not asked him to fix her toilet. The DON said he could not speculate on how Resident #31 felt using a bedside commode. The DON said people use bedside commodes all over the world as a useable tool. The DON said he could not speculate as to what would be reasonable to accommodate her. During an interview on [DATE] at 2:55 PM, the ADM said his plan was to get occupational therapy to work with Resident #31 to not use so much toilet paper. The ADM said Resident #31 had a compulsive personality. The ADM said Resident #31 had an anal fixation and would use an abundance of toilet paper and wipes and would flush down the commode and it would stop up the septic system. The ADM said there was one week he had to call the plumber out three times. The ADM said Resident #31's rights were infringing on the rights of others in the facility. The ADM said they have tried multiple interventions with Resident #31. The ADM said they have done education, signs, redirection, and even got Resident #31 bidet commode training with occupational therapy about six months ago. The ADM said Resident #31 was the only resident with a bidet commode in the facility. The ADM said they tried removing wipes from Resident #31's room, but she was found to have taken wipes off the aides' cart. The ADM said he had spoken to occupational therapy about doing some training with Resident #31, but he had not had a chance to see where they were at with it. The ADM said there were situations where a bedside commode was warranted, and he felt he had taken every step he could take with Resident #31 and the next step was to have occupational therapy work with her. 2. Record review of Resident #18's face sheet dated [DATE] indicated Resident #18 was a [AGE] year-old and admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke-damage to brain tissue due to a loss of oxygen to the area), left hemiplegia/hemiparesis (paralysis/weakness to one side of body), major depressive disorder (persistent sadness), dysphagia (difficulty swallowing), memory deficit, and altered mental status. Record review of Resident #18's admission MDS assessment dated [DATE] indicated Resident #18 was usually understood and usually understood others. The MDS indicated Resident #18 had a BIMS score of 8 which indicated she had moderate cognitive impairment. Resident #18 had fluctuating inattention and disorganized thinking. Resident #18 did not have behavioral symptoms. Resident #18 required setup or clean-up assistance with eating. Record review of Resident #18's undated care plan indicated Resident #18 had a problem area related to taking antidepressant medications (used to treat depression) and antianxiety medications (used to treat anxiety). During an observation on [DATE] at PM, the DON took a napkin and reached onto Resident #18's lunch plate and removed an egg roll and said, You can't have that. During an interview on [DATE] at 2:23 PM, Resident #18 said during lunch today ([DATE]), she was served an egg roll on her meal plate. Resident #18 said because she was on a mechanical soft diet, the DON took the egg roll away from her. Resident #18 said he gave her an extra ice cream for it. Resident #18 said the DON got a napkin and took the egg roll off her plate and did not say anything just that she could not have it. Resident #18 said she felt like a bulldog getting their steak taken away. Resident #18 said her meal plate was sitting in front of her and everyone else at the table. Resident #18 said she would have been fine if the DON had asked her first before putting his hand into her plate and just saying you cannot have that as he was doing it. Resident #18 said they seemed to treat her like a little kid and not explain things. During an interview on [DATE] at 01:08 PM, CNA B said if she saw a resident was served something that was not part of their ordered diet, she would explain to the resident the item was not on their ticket and it did not fit into their ordered diet. CNA B said you should explain the situation to the resident before reaching into their plate, because she would not want someone putting their hands into her plate. During an interview on [DATE] at 1:37 PM, RN C said she assisted in the dining room during mealtimes. RN C said she usually stood at the kitchen door where the meal trays were handed out and would check the tickets versus what was placed on the residents' trays. RN C said she would have the dietary staff to fix or remove a wrong item before it was delivered to the resident. RN C said if an item was mistakenly placed on a resident's meal plate and delivered to the resident, she would go to the resident and explain what was going on prior to removing the item from the resident's plate. RN C said you cannot grab anyone's food off their plate without first letting them know why. RN C said it would never be appropriate to take something off a resident's plate without explaining the reason why first. RN C said, imagine if someone stole your food off your plate. RN C said the resident could be upset and not know why staff took their food and not know staff were just trying to protect them from choking. During an interview on [DATE] at 2:29 PM, the DON said he would explain the reason to a resident if he had to take food items from the resident's plate. The DON said he explained to Resident #18 the egg roll was not part of her mechanical soft diet prior to removing her egg roll from her plate. The DON said he offered Resident #18 ice cream and she said she would like some ice cream. The DON said he brought Resident #18 ice cream and replaced the egg roll with bread, which was the substitute for the egg roll and the DON said she was satisfied at the table. The DON said he did not just yank the egg roll from Resident #18 and throw it away. The DON said he offered her ice cream and gave her the substitution of bread. The DON said Resident #18 had an adequate nutritious meal. The DON said he could not speculate of how it made Resident #18 feel, but she was satisfied at the lunch table. During an interview on [DATE] at 2:55 PM, the ADM said he would expect staff to explain to the resident why something was being removed from the meal plate prior to reaching into the resident's meal plate. The ADM said he was sure it would be upsetting for the resident to have a food item removed from their plate by a staff member and not be explained to of why the item was being removed. 3. Record review of Resident #38's face sheet dated [DATE] indicated Resident #38 was 81-years-old and admitted to the facility on [DATE] with diagnoses including senile degeneration of the brain (mental deterioration associated with old age), severe protein-calorie malnutrition (inadequate intake of protein-calorie foods), altered mental status, cognitive communication deficit, nutritional anemia (results from deficiency in either iron, vitamin B-12, or folic acid), adult failure to thrive, and abnormal weight loss. Record review of Resident #38's MDS assessment dated [DATE] indicated Resident #38 had a BIMS score of 6 which indicated he had severe cognitive impairment. Resident #38 had fluctuating inattention and disorganized thinking. Resident #38 was independent with eating. Record review of Resident #38's undated care plan indicated Resident #38 preferred activities that identified with his prior lifestyle. Resident #38 had a problem area of nutritional status with unintended weight loss and potential for malnutrition. During an observation on [DATE] at 12:42 PM, Resident #38 was sitting at the dining table with 2 other male residents. Resident #31 was served a baked chicken breast and struggled for several minutes to try to cut the chicken breast with his fork. Resident #38 then hollered at CNA G to Go get me a knife! How the hell am I supposed to cut this with a fork? I'm sick of this shit. Resident #38 did not receive a knife, but eventually was able to pull the chicken breast apart with his fork and hands and consumed the chicken breast. During an observation on [DATE] at 12:40 PM, Resident #38 was given plastic eating utensils and stated, what am I supposed to do with plastic utensils, when he received his lunch tray. Resident #38 stated I can't cut meat with plastic. I guess I'm going to have to write my congressman to get a real knife in this place. During an interview on [DATE] at 01:08 PM, CNA B said she had not had any residents ask her for a knife at mealtimes. CNA B said she usually asked the resident if she could help cut the resident's meat for them when she delivered the resident's meal tray. During an interview on [DATE] at 1:37 PM, RN C said she assisted in the dining room during mealtimes. RN C said she had not had residents ask her for a knife, but she would ask the residents if they needed help cutting their meat when she delivered their meals. RN C said there was usually staff in the dining area who could assist the residents with any needs. RN C said the staff had worked at the facility long enough to know what the residents' wanted. During an interview on [DATE] at 2:55 PM, the ADM said he assisted in the dining room during mealtimes when he could, and he had not heard residents ask for a knife to cut their meats. The ADM said he offered to help cut the residents meat if needed. 4.Record review of an undated face sheet revealed Resident #33 was a [AGE] year-old male, admitted to the facility on [DATE] with the diagnoses of dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), depression ( mood disorder that causes a persistent feeling of sadness and loss of interest ), and diabetes type II ( condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). Record review of the quarterly MDS assessment dated [DATE] revealed Resident #33 had a BIMS of 10 which indicated a moderate cognitive impairment. The MDS also indicated Resident #33 required set up/cleanup for eating assistance. Record review of a care plan dated [DATE] revealed Resident #33 had a care plan titled 'Nutritional Status'. The goal for Resident #33 was to gain 1 pound per week to reach his ideal body weight. The care plan intervention revealed to decrease distractions during meals. During an observation and interview of meal service on [DATE] at 12:25 p.m., Resident #33 received a baked chicken breast as the protein for lunch. Resident #33 received a fork and a spoon to eat with and no knife. Resident #33 stated he could not eat the chicken breast because he had no knife and was not going to gnaw it off the bone like a dog. Resident #33 gave his piece of chicken to another resident. He stated he did not want the food to go to waste. During an observation and interview on [DATE] at 12:30 p.m., it was noted Resident #33 received plastic utensils to eat with. Resident #33 said what in the hell am I supposed to do with plastic silverware. Resident #33 said he was sick of not getting the utensils he needed to eat his meal. He stated he never got a knife to cut his meat and no one helped him cut it up. During an interview on [DATE] at 1:45 p.m. CNA G said the kitchen did not pass out knives routinely and it was up to the staff to cut the meat up for the residents. She was not sure how the meat for Residents # 38 and #33 got missed being cut up when their trays were served. CNA G stated if Resident # 38 and Resident #33 were given a knife they could have easily cut up their own meat with no problems. During an interview on [DATE] at 2:00 p.m., the Dietary Manager stated the kitchen never passed out knives with the meal trays. She stated the facility had butter knives, but she stated the residents never asked for a knife that she was aware of. The Dietary Manager stated she could understand how having a knife would make it easier to cut meat. 5.Record review of an undated face sheet revealed Resident # 30 was an 83- year-old female, admitted to the facility on [DATE] with the diagnoses of diabetes type II (condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and anxiety. Record review of a quarterly MDS assessment dated [DATE] revealed Resident #30 had a BIMS of 99, which indicated Resident #30 was unable to complete the interview . The MDS revealed Resident #30 required supervision/ touch assistance with eating. Record review of a care plan dated [DATE], titled 'Nutritional Status', revealed Resident #30 had a goal of gaining or maintain weight over the next 90 days. One of the interventions for this care plan was to observe Resident #30 while eating to monitor for problems. During an observation on [DATE] at 12:40 p.m., Resident #30 was fed by CNA G. CNA G was standing over Resident #30 while feeding her the last half of the lunch meal. During an interview on [DATE] at 1:45 p.m., CNA G said she knew she was supposed to sit down while assisting a resident to eat. CNA G said she knew it was for the resident's dignity that she was supposed to sit and be on eye level with her while assisting. CNA G said not sitting while feeding Resident #30 could have made her feel embarrassed or rushed. During an interview on [DATE] at 1:00 p.m., the ADON stated the CNAs were supposed to sit beside the residents that they assisted feeding and talk with them to help the resident feel comfortable while eating. The ADON stated standing could make the resident feel rushed and uncomfortable. During an interview on [DATE] at 2:00 p.m., the ADM stated it was his expectation for any staff trained to assist in feeding the residents, that they all be seated when assisting. The ADM stated this was for resident's comfort and dignity. Review of an undated policy titled Resident Rights revealed that all residents have the right to a dignified existence.

Based on observation, interviews, and record review, the facility failed to provide a safe, clean, sanitary, comfortable, and homelike environment 4 of 15 residents reviewed for environment. (Resident #1, Resident #41, Resident #29, and Resident #31) 1.The facility failed to ensure Resident #1, Resident #29, and Resident #41's bedroom ceiling tiles did not have brown water stains. 2.The facility failed to ensure Resident #31 was allowed to use the working commode in her room. These failures could place residents at risk of an unsafe, unsanitary, uncomfortable environment, embarrassment due to room not appearing homelike, and a decrease in quality of life and self-worth. Findings included: 1. Record review of Resident #1's face sheet printed [DATE] indicated Resident #1 was a [AGE] year-old, male and was admitted on [DATE] with diagnosis including moderate intellectual disabilities (is a term used when there are limits to a person's ability to learn at an expected level and function in daily life), history of acute respiratory disease (occurs when fluid builds up in the tiny, elastic air sacs (alveoli) in your lungs), and non-pressure chronic ulcer of right calf with fat layer exposed (is defined as a defect in the skin below the level of knee persisting for more than six weeks and shows no tendency to heal after three or more months). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 was understood and understood others. The MDS indicated Resident #1 had clear speech, adequate hearing, and adequate vision. The MDS indicated Resident #1 had a BIMS score of 10 which indicated moderate cognitive impairment. During an interview and observation on [DATE] at 10:16 a.m., Resident #1 was sitting on the side of his bed. Above Resident #1's bed, in the corner of the room were three ceiling tiles with brown water mark stains noted. Underneath the brown water mark stains were two buckets sitting on a shelf. In the corner of Resident #1's room near the closet, one ceiling tile with a brown stain and a container underneath it. Resident #1 said the ceiling used to leak but had not leaked in a couple months after the facility fixed the roof. He said sometimes his room had a mildew smell. He said he did not know why the facility had not changed the tiles since the leak was supposed to be fixed. 2. Record review of Resident #41's face sheet printed [DATE] indicate Resident #41 was a [AGE] year-old, male and admitted on [DATE] with diagnosis including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and history of shortness of breath. Record review of Resident #41's quarterly MDS assessment dated [DATE]indicated Resident #41 was usually understood and usually understood others. The MDS indicated Resident #41 had clear speech, minimal difficulty hearing, and impaired vision with no corrective lenses. The MDS indicated Resident #41 was unable to complete the BIMS assessment due to being rarely/never understood. The MDS indicated Resident #41 had short-and-long term memory recall problem and severely impaired cognitive skills for daily decision making. During an observation on [DATE] at 10:45 a.m., in Resident #41's room in the corner, near his window were three slightly bowing ceiling tile with brown water stains. Two ceiling tiles above the head of his bed were water stained also. During an interview on [DATE] at 10:20 a.m., the maintenance supervisor said he had been employed at the facility since the end of [DATE]. He said the water-stained ceiling tiles in Resident #1 and Resident 41's room were there when he started in [DATE]. He said the roof was damaged by some storms but was fixed in [DATE]. He said he did not know why the water-stained ceilings were not changed after the roof was fixed. He said he meant to change the ceiling tiles since he started but had not gotten to it. He said he did not know why buckets were underneath the water-stained ceilings. He said he did not place the buckets there. He said the water-stained tiles and bucket were not a homelike environment and was tacky. He said the water buckets were also hazardous. He said if the ceiling tiles were wet, they could potentially collapse. During an interview on [DATE] at 1:43 p.m., the DON said he did not know about the water-stained ceiling tiles in Resident #1 and Resident #41's rooms. He said he expected staff members to put maintenance issues in the maintenance log. He said he expected the maintenance supervisor to fix the issues in timely manner. He said he could not speculate how the water-stained ceiling tiles made the residents feel. He said he could not speculate what risks the water-stained ceiling tiles posed to the residents. During an interview on [DATE] at 2:33 p.m., the ADM said the maintenance director was responsible for the upkeep of the facility. He said staff members had a logbook to place maintenance issues in. He said maintenance issue had priority level decided on by him and the maintenance director. He said he was not aware of Resident #1 and Resident #41's water-stained ceiling tiles in their rooms. He said he imagined the water-stained ceiling tiles in the resident's rooms was unpleasant to look at. 3. Record review of a face sheet dated [DATE] revealed Resident #29 was an [AGE] year-old male, admitted to the facility on [DATE] with the diagnoses of cerebral infarction (damage to tissue in the brain due to lack of oxygen in the area), portal vein thrombosis (a narrowing or blocking of the portal vein by a blood blot), and depression (feelings of sadness, emptiness, and hopelessness). Record review of Resident #29's annual MDS dated [DATE] revealed Resident #29 had a BIMS of 13, which indicated intact cognition. The MDS also indicated Resident #29 was independent for ADL such as mobility and toileting. Record review of a care plan dated [DATE], titled 'Psychological Well Being', indicated Resident #29 had a potential for adjustment to the nursing facility and the intervention was listed to encourage Resident #29 to express his feelings and concerns. Record review of the maintenance log dated [DATE] showed no work order for Resident #29's ceiling tiles. During an observation on [DATE] at 9:45 a.m., the ceiling to the left of the door when entering the room of Resident #29 was noted to have an 18-to-20-inch semicircular brown water stain. During an observation on [DATE] at 2:15 p.m., the stain remained to the ceiling tiles in Resident #29's room. The brown stain was approximately 18-to-20 inches at the widest point. During an interview on [DATE] at 9:47 a.m., Resident #29 stated the water stain on the ceiling had been there for a few months and the ceiling would leak if a hard rain came through. Resident #29 stated it was just a few days prior the ceiling had leaked. Resident #29 stated the leaking ceiling and dirty tile made his anxiety worse because it made him worry about black mold. Resident #29 stated he reported the tiles to the maintenance man several weeks prior, but no one had replaced them. During an interview on [DATE] at 1:20 p.m., the Maintenance Director stated he was aware there were a few rooms that had ceiling tiles that needed to be replaced. He stated he just replaced most of the tiles less than 6 weeks ago. He stated he replaced the ceiling tiles in Resident #29's room around that time. The Maintenance Director stated he did not always make a formal request document or log everything he did. He stated sometimes an issue was reported to him and he just took care of it then. During an interview on [DATE] at 1:30 p.m., the DON stated he could not speculate on how ceiling tiles showing water leakage could impact a resident. During an interview on [DATE] at 2:00 p.m., the Administrator stated it was important for physical health, as well as mental health to have clean and well-kept rooms, including no stained ceiling tiles in the resident's rooms. The Administrator stated he could not speculate on what ill outcomes could occur from a stained ceiling. 4. Record review of Resident #31's face sheet dated [DATE] indicated Resident #31 was [AGE] year-old and admitted to the facility on [DATE] with diagnoses including acute pulmonary edema (swelling of the lungs), pneumonia (infection of the lungs), urinary tract infection, hypertension (high blood pressure), cognitive communication deficit, weakness, history of falls, heart failure, major depressive disorder (persistent sadness), and anxiety (nervousness). Record review of Resident #31's annual MDS assessment dated [DATE] indicated Resident #31 was understood and understood others. The MDS indicated Resident #31 had a BIMS score of 15 which indicated she was cognitively intact. Resident #31 had fluctuating inattention and disorganized thinking. Resident #31 did not have behavioral symptoms. Resident #31 used a walker and a wheelchair for mobility. Resident #31 was independent with toilet transfers and required partial assistance with toilet hygiene. The MDS indicated Resident #31 was occasionally incontinent of bowel and bladder. Record review of Resident #31's care plan with a revision date of [DATE] indicated Resident #31 had a problem area of compulsively putting wipes and toilet tissue in commode in bathroom after multiple education and notes put by toilet to not put object in toilet, resident continued to do, so object had even been denied, but was found to have wipes in her wheelchair where she had taken them off the nurse aide cart, which had caused several plumbing issues and bedside commode was placed in the resident's room. Resident #31 had consults due to gastric (stomach) system issues as evidenced by anal fixation and pain. Resident #31 had infatuation with anal area. During an observation and interview on [DATE] at 10:11 AM, Resident #31 was sitting on the side of her bed with her breakfast tray on her bedside table in front of her. Resident #31 said her breakfast was good and she had eaten most of it. Resident #31 had a bedside commode against the wall at the end of her bed. Resident #31's room had a strong smell of bowel movement. Resident #31 said she had to use a bedside commode because her bathroom commode had not worked since [DATE]. Resident #31 said she wished they would fix her commode, because she did not like using the bedside commode. There was a Sorry Out of Order sign on the outside of bathroom door. There was a sign behind the bathroom commode to not put toilet paper or wipes in toilet. During an observation and interview on [DATE] at 8:25 AM, Resident #31 was sitting on the side of her bed with breakfast tray on her bedside table. Resident #31 said she did not like having to use the bedside commode and wished they would get the bathroom fixed. Resident #31 said it was embarrassing to use the bedside commode and it did not feel private, even with a curtain. During an observation and interview on [DATE] at 12:48 PM, Resident #31 said she asked the DON about getting the commode fixed because she did not like using the bedside commode and he told her he would look into it. Resident #31 said they were trying to blame her for stopping the commode up, but she said she put the toilet paper and wipes in the trash can, so it wasn''t her. Resident #31 said using the bedside commode made her feel uncomfortable due to anyone could walk into her room. Resident #31 said they put the curtain up, but it just did not provide the privacy that a door does in a bathroom. Resident #31 said they just really need to fix her commode. During an interview on [DATE] at 3:28 PM, the Maintenance Director said they have had to call out the plumbers couple times due to Resident #31 was flushing wipes down the commode and it backed up the entire building septic system. The Maintenance Director said the bathroom toilet in Resident #31's room did work, but they have a sign on the door that it was out of order. The Maintenance Supervisor said Resident #31's bathroom room toilet was fixed approximately a month ago. The Maintenance Director said they have not had an issue with the septic system since they put the bedside commode in Resident #31's room. The Maintenance Director said they were monitoring the situation and there had not been any other issues with the septic system. The Maintenance Director said he did not know what the fix was due to it caused issues with the whole facility's septic system being backed up and residents not being able to flush their toilets. The Maintenance Director said they did not have a specific timeframe to monitor the situation. The Maintenance Director said he knew Resident #31 asked about when her commode would be fixed because the staff told him she asked about it regularly. The Maintenance Director said it was not the ideal situation with an able-bodied person not being able to use their bathroom toilet in their room. During an interview on [DATE] at 3:44 PM, CNA A said she had worked at the facility since [DATE] and normally worked the evening and night shifts. CNA A said the kept a plastic bag in Resident #31's bedside commode. CNA A said she would carry Resident #31's bucket of the bedside commode, bag and cover it then transport it to the shower room down the hall and would empty the Resident #31's bedside commode contents in the commode in the shower room. CNA A said she had not heard Resident #31 complain about using the bedside commode. CNA A said if it was her, she would want to go to the bathroom commode with a door. CNA A said she thought they were trying to limit Resident #31's toilet paper, but she was not sure what other interventions they have tried other than the bedside commode. During an interview on [DATE] at 01:08 PM, CNA B said she had worked at the facility for approximately 2 years and normally worked the day shift on Resident #31's hall. CNA B said the plumbing had been messed up and Resident #31 had a bedside commode placed in her room. CNA B said she kept a plastic bag in the bedside commode bucket. CNA B said she usually emptied the bedside commode by getting the air out of the plastic bag and tying it up, removed it from the room and then put it in her big trash barrel. CNA B said she did not know if Resident #31's toilet worked, but there was an out of order sign on her bathroom door. CNA B said all the toilets were stopped up at the same time on Resident #31's hall. CNA B said Resident 31 used a lot of toilet paper and sometimes puts it in the trash and sometimes put it in the bedside commode. CNA B said Resident #31 was able to transfer herself and did everything on her own. CNA B said Resident #31 asked for her potty to be fixed almost daily. CNA B said if circumstances warranted the use of a bedside commode, she would be good to use a bedside commode, but if there was a working commode in her room, she would expect to be able to use it. CNA B said Resident #31 did not have a comfortable homelike environment because she had to use a bedside commode and not use the bathroom commode. CNA B said she did not know how it affected Resident #31, but Resident #31 had told her that she did not like having to use the bedside commode. During an interview on [DATE] at 1:37 PM, RN C said she had worked at the facility since 2018 and normally worked the day shift. RN C said they started using the bedside commode in Resident #31's room when the toilets stopped up. RN C said she did not remember how long ago that was and she had not tried the Resident #31's toilet to see if it worked. RN C said she believed the bedside commode was a short-term situation. RN C said the maintenance director and the ADM were responsible for monitoring the toilet situation. RN C said a homelike environment should be whatever Resident #31 preferred as her homelike environment. RN C said Resident #31 had not mentioned anything to her about her toilet situation. During an interview on [DATE] at 2:29 PM, the DON said he did not think it had been that long since Resident #31 started using the bedside commode due to toilet issues. The DON said he was unaware of the plan related to how long Resident #31 would have the bedside commode. The DON said the ADM would make the final determination when/if the bedside commode would be removed from Resident #31's room and when she would be allowed to use the bathroom commode in her room. The DON said he was unaware if Resident #31's bathroom toilet was working, but to the best of his knowledge it was working. The DON said Resident #31 had not asked him to fix her toilet. The DON said he could not speculate on how Resident #31 felt using a bedside commode. The DON said people use bedside commodes all over the world as a useable tool. The DON said he could not speculate as to what would be reasonable to accommodate her. During an interview on [DATE] at 2:55 PM, the ADM said his plan was to get occupational therapy to work with Resident #31 to not use so much toilet paper. The ADM said Resident #31 had a compulsive personality. The ADM said Resident #31 had an anal fixation and would use an abundance of toilet paper and wipes and would flush down the commode and it would stop up the septic system. The ADM said there was one week he had to call the plumber out three times. The ADM said Resident #31's rights were infringing on the rights of others in the facility. The ADM said they have tried multiple interventions with Resident #31. The ADM said they have done education, signs, redirection, and even got Resident #31 bidet commode training with occupational therapy about six months ago. The ADM said Resident #31 was the only resident with a bidet commode in the facility. The ADM said they tried removing wipes from Resident #31's room, but she was found to have taken wipes off the aides' cart. The ADM said he had spoken to occupational therapy about doing some training with Resident #31, but he had not had a chance to see where they were at with it. The ADM said there were situations where a bedside commode was warranted, and he felt he had taken every step he could take with Resident #31 and the next step was to have occupational therapy work with her. On [DATE] at 11:00 AM, a policy on Safe, Comfortable Home like environment was requested and the ADM said they did not have a policy related to Safe, Comfortable, Home-like environment. 44933 44596

Based on interviews and record review, the facility failed to ensure dialysis service were provided consistently with professional standards of practice for 1 of 1 resident reviewed for dialysis services. (Resident #11) The facility failed to document vital signs and an assessment of the access site after Resident #11 returned from dialysis. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs. Findings included: Record review of Resident #11's face sheet printed 03/18/24 indicated Resident #11 was a [AGE] year-old, male and admitted on [DATE] with diagnoses including end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), cerebral infarction (stroke), acute kidney failure (occurs when your kidneys suddenly become unable to filter waste products from your blood), hypotension of hemodialysis (occurs because a large volume of blood water and solutes are removed over a short period of time), and arteriovenous fistula (is an irregular connection between an artery and a vein). Record review of Resident #11's quarterly MDS assessment dated [DATE] indicated Resident #11 had clear speech, minimal difficult hearing, and impaired vision with corrective lenses. The MDS indicated Resident #11 was usually understood and understood others. The MDS indicated Resident #11 had a BIMS score of 15 which indicated intact cognition. The MDS indicated Resident #11 required partial/moderate assistance for shower/bathe self, dressing, and putting on footwear, supervision for toileting and personal hygiene, and setup for oral hygiene. The MDS indicated Resident #11 was on dialysis. Record review of Resident #11's care plan dated 03/15/22, edited 01/05/23, indicated Resident #11 had dialysis related to renal failure. Interventions included assist resident in preparing for transport to dialysis, listen for bruit (a sound heard over an artery or vascular channel, reflecting turbulence of flow) over shunt site every shift, monitor access site every shift, and palpate shunt for thrill (An abnormal vibration that is felt on the skin overlying a loud cardiac murmur or an arteriovenous fistula) site every shift. Record review of an undated, blank facility's dialysis communication form indicated .day of dialysis (pre dialysis) .Resp .Temp .examine shunt site .Dialysis .BP .Pulse .Resp .Temp . The facility's dialysis communication form did not indicate post dialysis vital signs and assessment of access site. Record review of Resident #11's dialysis communication form dated 03/18/24, 03/15/24, 03/13/24, 03/11/24, 03/09/24, 02/23/24, 02/26/24, and 02/23/24 did not indicate post dialysis vital signs and assessment of access site. Record review of Resident #11's progress notes dated 12/05/23-03/18/24 did not reveal post dialysis assessment documentation. Record review of Resident #11's vital report dated 03/04/24-03/18/24 indicated blood pressure and pulse at the beginning of each shift. During an interview on 03/18/24 at 2:30 p.m., Resident #11 said he went to dialysis three times a week. He said when he returned from dialysis, nursing staff did not check his blood pressure or pulse. During an interview on 03/20/24 at 1:18 p.m., RN C said the nurse was responsible for filling out the dialysis form when the resident went to dialysis. She said before dialysis, the nurse checked the resident's vital signs and thrill and bruit of the shunt. She said when the resident returned from dialysis, a bandage was over the site and left on for a couple hours before its removed. She said the nurse normally documented post dialysis vital signs in the vital signs section or progress notes. She said it was important to do a post dialysis assessment to make sure there was no abnormal bleeding, monitor vital signs, and make sure the resident tolerated dialysis. She said if a post dialysis assessment was not done, bleeding could be missed, fistula malfunction could occur, or miss the resident having problems. She said the facility did not have a guideline to specify where to document the post dialysis assessment done at the facility. During an interview on 03/20/24 at 1:43 p.m., the DON said the facility used a dialysis communication form to document vital signs and thrill and bruit. He said the nursing staff should review the documentation from the dialysis center when the resident returned. He said he did not know if nursing staff had to check vital signs after the resident returned from dialysis. He said he had to review the dialysis form and policy. He said the post dialysis assessment was important to ensure the patient was stable. He said he could not speculate how not obtaining the post dialysis assessment affected the resident. He said if staff documented post dialysis assessments, a progress note, or vital signs section would be adequate. Record review of https://www.mayoclinic.org/tests-procedures/hemodialysis/about/pac-20384824 dated 08/05/23 and accessed on 04/04/24 indicated .hemodialysis treatment can be efficient at replacing some lost kidney function, you may experience some of the related conditions .low blood pressure .muscle cramps .sleep problems .anemia .high/low potassium levels .access site complications .it's extremely important to take care of your access site to reduce the possibility of infection and other complications . Record review of the facility's Outpatient Dialysis Service Agreement effective date 02/06/23 which indicated .whereas, the provision of hemodialysis services to ESRD Residents deemed appropriate for such care is consistent with ESRD Residents' rights, community standards of care, public policy, and the efficient and economic delivery of care . Record review of a facility's End-Stage Renal Disease, Care of a Resident with policy dated 09/10 indicated .residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care .

Based on interviews and record review, the facility failed to ensure each residents' drug regimen was free from unnecessary psychotropic drugs (without adequate behavior monitoring) for 4 (Resident # 2, Resident # 11, Resident # 16, and Resident # 41) of 13 residents whose medications were reviewed in that: 1.The facility failed to ensure Resident #2 had behavior monitoring for his prescribed Zoloft (is an antidepressant used to treat major depression). 2.The facility failed to ensure Resident #11 had behavior monitoring for his prescribed Lexapro (is an antidepressant used to treat depression). 3.The facility failed to ensure Resident #16 had behavior monitoring for his prescribed Ativan (is used to treat anxiety), Buspirone (is used to treat anxiety disorders) and Lexapro (is an antidepressant used to treat depression). 4.The facility failed to ensure Resident #41 had behavior monitoring for his prescribed Depakote (is used to treat seizure disorders, certain psychiatric conditions (manic phase of bipolar disorder), and to prevent migraine headaches) and Sertraline (is an antidepressant used to treat major depression). This deficient practice could place residents at risk of not receiving the intended therapeutic benefits of their psychotropic medications. Findings included: 1. Record review of Resident #2's face sheet printed 03/18/24 indicated Resident #2 was a [AGE] year-old, male and admitted on [DATE] with diagnosis including other bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) without behavioral disturbance, and other recurrent depressive disorders (a depressed mood or loss of pleasure or interest in activities for long periods of time). Record review of Resident #2's MDS assessment dated [DATE] indicated Resident #2 usually understood and usually understood others. The MDS indicated Resident #2 had a BIMS score of 10 which indicated moderate cognitive impairment. The MDS indicated Resident #2 had inattention and disorganized thinking that fluctuated. The MDS indicated Resident #2 required partial/moderate assistance for oral, personal, and toilet hygiene, shower/bathe self and lower body dressing. The MDS indicated Resident #2 had an active diagnosis of bipolar disorder and depression. The MDS indicated Resident #2 had received an antidepressant during the 7 days assessment period. Record review of Resident #2's care plan dated 02/08/23 indicated Resident #2 was at risk for adverse consequence related to receiving Zoloft for diagnosis of depressive disorder. Intervention included monitor resident's behavior and response to medication. Record review of Resident #2's consolidated physician order dated 03/01/24-03/20/24 indicated an order for Zoloft (Sertraline), 100 mg, 1 tablet, oral, DX: other recurrent depressive disorders, at bedtime, start date 01/24/23, no end date. No order for behavior monitoring noted. Record review of Resident #2's Side Effects/Behavior Administration history dated 03/01/24-03/20/24 indicated Anti-depressant Medication Use, observe resident closely for significant side effects, every shift, start date 09/26/23, no end date. No administration record for behavior monitoring noted. 2. Record review of Resident #11's face sheet printed 03/18/24 indicated Resident #11 was a [AGE] year-old, male and admitted on [DATE] with diagnosis including other history of recurrent depressive disorders. Record review of Resident #11's quarterly MDS assessment dated [DATE] indicated Resident #11 had clear speech, minimal difficult hearing, and impaired vision with corrective lenses. The MDS indicated Resident #11 was usually understood and understood others. The MDS indicated Resident #11 had a BIMS score of 15 which indicated intact cognition. The MDS indicated Resident #11 required partial/moderate assistance for shower/bathe self, dressing, and putting on footwear, supervision for toileting and personal hygiene, and setup for oral hygiene. The MDS indicated Resident #11 had received an antidepressant during the 7 days assessment period. Record review of Resident #11's care plan dated 03/15/22, edited 01/05/23 indicated Resident #11 was at risk for adverse consequences related to receiving Lexapro 10mg an antidepressant for depression. Intervention included monitor resident's behavior and response to medication. Record review of Resident #11's consolidated physician order dated 03/01/24-03/20/24 indicated an order for Lexapro, 10mg, 1 tablet, oral, DX: other recurrent depressive disorders, once a day. Start date 05/22/23, no end date. No order for behavior monitoring noted. Record review of Resident #11's Side Effects/Behavior Administration history dated 03/01/24-03/20/24 indicated Anti-depressant Medication Use, observe resident closely for significant side effects, twice a day, start date 07/25/23, no end date. No administration record for behavior monitoring noted. 3. Record review of Resident #16's face sheet printed 03/18/24 indicated Resident #16 was a [AGE] year-old, male and admitted on [DATE] and 04/20/22 with diagnoses including depression (is a common and serious medical illness that negatively affects how you feel, the way you think and how you act), alcohol abuse with alcohol-induced anxiety disorder, generalized anxiety disorder (a constant state of worry, fear, and dread), and other recurrent depressive disorders (depression). Record review of Resident #16's quarterly MDS assessment dated [DATE] indicated Resident #16 was understood and understood others. The MDS indicated Resident #16 had a BIMS score of 15 which indicated intact cognition. The MDS indicated Resident #16 required supervision for shower/bathe self and personal hygiene, setup for oral hygiene, independent for toileting hygiene, dressing, and putting on footwear. The MDS indicated Resident #16 an antidepressant and antianxiety during the 7 days assessment period. Record review of Resident #16's care plan dated 09/27/28, edited 02/08/23 indicated Resident #16 received antidepressant medication related to major depressive and disorder and insomnia. Intervention included monitor resident's behavior and response to medication. Record review of Resident #16's care plan dated 11/23/20, edited 02/08/23 indicated Resident #16 received antianxiety medication related to anxiety, Lorazepam. Intervention included monitor resident's mood and response to medication. Record review of Resident #16's consolidated physician order dated 03/01/24-03/2024 indicated an order for: *Lorazepam, 0.5mg, 1 tab, oral, twice a day, DX: Generalized anxiety disorder. Start date 04/14/23, no end date. *Lexapro, 10mg, 1 tablet, oral, DX: Depression, once a day. Start date 05/11/23, no end date. *Buspirone, 5mg, 1 tablet, oral, DX: Generalized anxiety disorder, twice a day. Start date 10/25/23, no end date. No order for behavior monitoring noted. Record review of Resident #11's Side Effects/Behavior Administration history dated 03/01/24-03/20/24 indicated: * Anti-depressant Medication Use, observe resident closely for significant side effects, every shift, start date 02/06/23, no end date. *Anti-anxiety Medication Use, observe resident closely for significant side effects, twice a day, start date 07/25/23, no end date. *Target Behavior: (Angry). At the end of each shift mark frequency, intervention, and effectiveness, twice a day, start date 05/23/22, no end date. No administration record for behavior monitoring noted. 4. Record review of Resident #41's face sheet printed 03/20/23 indicate Resident #41 was a [AGE] year-old, male and admitted on [DATE] with diagnosis including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), dementia, moderate, with anxiety (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and depression (is a common and serious medical illness that negatively affects how you feel, the way you think and how you act). Record review of Resident #41's quarterly MDS assessment dated [DATE]indicated Resident #41 was usually understood and usually understood others. The MDS indicated Resident #41 had clear speech, minimal difficulty hearing, and impaired vision with no corrective lenses. The MDS indicated Resident #41 was unable to complete the BIMS assessment due to being rarely/never understood. The MDS indicated Resident #41 had short-and-long term memory recall problem and severely impaired cognitive skills for daily decision making. The MDS indicated Resident #41 an antidepressant and antianxiety during the 7 days assessment period. Record review of Resident #41's care plan dated 11/15/23 indicated Resident #41 received antidepressant medication. Intervention included monitor resident's mood and response to medication. Record review of Resident #41's consolidated physician order dated 03/01/24-03/2024 indicated order for the following: *Depakote Sprinkle capsules, 125mg, 1 tablet, oral, DX: Dementia in other diseases classified elsewhere, severe, with other behavioral disturbance, twice a day. Start date 11/02/23, no end date. *Sertraline, 25mg, 1/2 tablet, oral, DX: Depression, unspecified, once a day. Start date 02/28/24, no end date. No order for behavior monitoring noted. Record review of Resident #41's Side Effects/Behavior Administration history dated 03/01/24-03/20/24 indicated: * Anti-depressant Medication Use, observe resident closely for significant side effects, every shift, start date 11/03/23, no end date. *Anti-anxiety Medication Use, observe resident closely for significant side effects, every shift, start date 11/03/23, no end date. *Anticonvulsant Medication Use, observe resident closely for significant side effects, every shift, start date 11/03/23, no end date. *Target Behavior: Increase anxiety, restlessness, panic attacks, At the end of each shift mark frequency, intervention, and effectiveness, every shift, start date 11/03/22, no end date. No administration record for behavior monitoring noted. During an interview on 03/20/24 at 12:50 p.m., the ADON said she had been employed at the facility since July 2023. She said target behavior was to monitor the behaviors the resident received the medication for. She said only antipsychotic and antianxiety medications needed behavior monitoring. She said she believed the state only required those two drug classes. She said all psychotropic medication needed side effect monitoring. She said resident did not need orders for behavior monitoring for it to be done. She said using nursing judgement let you know to look for behaviors on all residents. She said she did not feel like the behavior monitoring done by nurses needed to always be documented because you always did not see what the previous nurse charted. She said if a nurse wanted to document behaviors, a progress note, report between nurse, and the 24-hour report was sufficient. During an interview on 03/20/24 at 1:18 p.m., RN C said she had been employed at the facility since 2018. She said the behavior monitoring was under the side effects area. She said behaviors were increased agitation, confusion, or sleepiness. She said behavior monitoring should include intensity, intervention, and effectiveness of intervention. She said behavior monitoring was important to know if the medication was not working and if it needed to be changed. She said if behavior monitoring was not done, residents could hurt themselves or other residents, fall, elope, and wander. During an interview on 03/20/24 at 1:43 p.m., the DON said behavior monitoring was in the side effects/behaviors administration. He said behavior monitoring was to monitor if the resident had behaviors related to what the medication was prescribed to treat. He said behavior monitoring was not the side effects of taking the medication. He said he thought the side effects area had a frequency and intervention section for behavior monitoring. During a phone interview on 03/20/24 at 3:10 p.m., the pharmacy consultant said the facility was not required to do behavior monitoring on antidepressants or anticonvulsants. She said this was per the State. At that time, a request was made to the pharmacy consultant to email the DON the information from the State stating behavior monitoring was not required for certain drug classifications. No information received before or after exit. Record review of an undated facility's Medical Utilization and Prescribing policy indicated .the physician and staff will adjust existing medication based on their efficacy and the continued presence of relevant conditions and risk .monitoring .the staff and physician will periodically re-evaluate the conditions and symptoms for which each resident is receiving medications to ensure that the medication and dosage are still relevant and are not causing undesired complications .this may be reviewed in care plan or other routine assessments .

Based on interview, observation, and record review the facility failed to ensure residents were free from abuse for 1 of 6 residents reviewed for abuse. (Resident #2) The Hospice aide abused Resident #2 by hitting her in the head resulting in a bruise her left temple. This failure could place residents at risk for physical abuse, mental abuse, emotional abuse' and harm. Findings included: A review of a face sheet that indicated Resident #2 was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's annual MDS dated [DATE] indicated her cognitive skills for daily decision-making was moderately impaired, with decisions making poor, cues required, and supervision. The MDS indicated the resident had behaviors of rejection of care that occurred 1 to 3 days a week. The MDS listed Resident #2's bed mobility and transfer requirements as extensive assist with one person. Review of Resident #2's Care Plan indicated Resident #2's the responsible party requested a palliative plan of care. The Goal was Resident #2 would be comfortable, pain controlled, and dignity maintained dated 10/18/21. A Care Plan problem indicated Resident #2 had a potential for decline in ADL function related to terminal illness. A Care Plan problem indicated Resident #2 had behavioral symptoms and she refused to be changed or assisted with any kind of care. Resident #2 would be angry with staff for attempting to help her. Resident #2 tried to keep staff out of her room. One of the approaches was to show kindness dated 10/18/21. A Care Plan problem indicated Resident #2 had behavioral symptoms of socially inappropriate disruptive behaviors as evidenced by refusing medication, hygiene, and bathing. An approach was to allow Resident #2 control over situations if possible, and to assess whether her behaviors were a danger to self or others. Review of Resident #2's physician orders did not indicate an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #2's Hospice Care Plan was signed by her Case Manager on 4/14/22. The Care Plan indicated her mental, psychosocial, and cognitive status was forgetful, disoriented with occasional agitation. The Aides responsibilities was to assist with ADL care. The skilled nurse was to assess the patient for safety and environmental hazards, cognitive status and sensory limitations and impairment. Review of Resident #2's Wound Management Report dated 6/8/22 at 11:54 AM indicated a 4.2 x 3.0 cm bruise to the right lower arm. Wound Management Report dated 6/8/22 at 11:14 AM indicated a bruise to the right hand of 4.5x2.8 cm a Wound Management Report dated 6/8/22 at 11:13 AM indicated a bruise to the left wrist that measured 3.6x2.0 cm. Completed by LVN C. Review of an Events Report indicated on 6/9/22 at 10:00 a.m. Resident #2 was observed to have dark purple areas on the left temple with redness around the area. The activity occurred during bathing. The report indicated a CNA reported Resident #2 had a discolored area on the left side of the forehead. Resident #2 was outside on the patio when assessed. There were no open areas of swelling noted. Vital signs were within normal limits for the resident. Resident #2 alleged that a woman hit me. A hospice CNA was in the room during a.m. care this morning. This was not witnessed resident has a history of being combative during care. Completed by LVN C. Review of a wound management information sheet dated 6/9/22 at 10:00 a.m. indicated Resident# 2 had a bruise to the left side of her forehead that measure 1.30 x1.0 cm. Review of the Hospice Aides statement dated 6/9/22 indicated she provided care to Resident #2 on the morning of 6/9/22 around 10:00 a.m. In her statement she said facility staff told her things as she walked down the hall like, Good Luck, I will be praying for you, I hope you keep all your body parts. When she went into the room the resident was very vocal in cursing her and telling her she did not want to do things. She said during care Resident # 2 hit her, scratched her, threw water on her. She said she held her hands while rolling the resident over and attaching her brief. She said she held her hands two times in the statement to get her to calm down. She said Resident #2 was yelling and cursing her out. When CNA A came in the room, she asked him to help her get the resident dressed. During an interview on 6/9/22 at 11:20 a.m. CNA B said Resident #2 was sweet sometimes, and staff needed to introduce themself or Resident #2 could be combative. CNA B said if Resident #2 started to become combative it was better to walk away. CNA B said if Resident #2 said someone hit her, she believed Resident #2. According to her Resident #2 would call staff all kinds of names but had not accused anyone of hitting her. During an interview on 6/9/22 at 4:12 p.m. LVN C said CNA A and CNA B asked her to come look at the bruise on Resident #2's forehead. Right after Resident # 2 left the room on 6/9/22 the Hospice Aide was still in her room. The left side of temple had a red area about the size of a ping pong ball, she had a large blood vessel in her forehead and two bruises close to the blood vessel. The LVN said Resident #2 had tears in her eyes and appeared to be upset. LVN A said the first time saw the Hospice Aide on 6/9/22d she was going down to provide care to Resident #2. After she saw the bruise on Resident #2, the LVN told the DON. He talked to the Hospice Aide. LVN C said Resident #2 was usually combative during ADL care. During an interview and observation on 6/9/22 at 4:14 p.m. Resident #2 was noted to be coming out from smoking. She had a purple raised area to the left side of her forehead. She said she got the bruise because that gal hit her. She said it was today but could or would not answer any other questions. During an interview on 6/9/22 at 4:19 p.m. the DON said he looked at Resident #2's head and she did say the person that was changing her hit her. The Hospice Aide told him Resident #2 was very active. He said he was informed by the nurse Resident #2 was crying and upset. He asked the Hospice Aide to write a statement and leave the building. During an interview on 6/10/22 at 9 30 a.m. CNA A said on the morning od 6/9/22 he was passing ice and went into Resident #2's room. The Hospice Aide asked him to help put Resident #2's shirt on and transferred her to the wheelchair. He said usually if anyone walked into Resident #2's room she cursed at them. CNA A said he was hesitant to help because Resident #2 would not allow him to provide care to her (because he was a man). He said Resident #2 would not allow the Hospice Aide to put her shirt on. He noticed Resident #2 had some discoloration on the side of her head. CNA A said Resident #2 was different in that she always cursed out the staff and would fuss about anything. Resident #2 would call the staff dirty and vulgar names every day. She was quite that morning. He said he noticed the Hospice Aides pants were wet. He also said he had never tried to hold Resident #2's hands to keep her from hitting him. During an interview on 6/0/22 at 9:20 a.m. the Clinical Director of the Hospice agency said the hospice aide was a new employee. The agency expected the aide to deescalate the situation and ask for help. She said they had problems in the past with Resident #2 being aggressive with aides and nurses. The Director said she did not know if anyone informed the Hospice aide Resident #2 could be aggressive. She also said she did not know why she was holding Resident #2's hands that would be something only the aide would know. She said their priority was the safety of the patient first and try and calm the resident. During an interview on 6/10/22 at 9:40 a.m. CNA D said on 6/7/22 the Hospice [NAME] came to the facility. She and another aide helped her that day. They knew it was her first day. They told her if she needed any help with Resident #2 to let them know because Resident #2 would fight. During a telephone interview on 6/10/22 at 9:58 a.m. the Hospice Aide said she had been a CNA since 2013 however she had not worked for the Hospice agency but a few weeks. She was not oriented about Resident #2 prior to assuming her responsibility. She said her first visit with Resident #2 went great. She was a little mouthy that first day but one of the facility aides helped her. That aide said Resident #2 could be a bit rowdy. The Hospice Aide said on 6/9/22 a nurse at the front desk said good luck to her when she asked where Resident #2's room was. She said as she walked down all three people down the hall said things like, good luck,. I am going to pray for you, and I hope you keep all your body parts. The Hospice aide said she did not know the Resident #2 was combative and the statements the staff made did not give her any indication. The Hospice aide said if she had known Resident #2 was combative, she would have gotten help. When the Resident #2 started to fight, and kick. She was trying to secure the patient first, then get help. She said she held her hands to keep her from doing more damage. Resident #2 had slapped her across the face twice, pinched, her kicked her, and threw water on her. All the while Resident #2 was yelling to the top of her lungs while cursing her out. The Hospice aide said she was able to complete the bed bath. Resident #2 was not rowdy the hole time. The aide said she did not know how Resident #2 received the bruise to her head, she might have bumped herself. The aide said she did not hit Resident #2, all she did was hold her hands. The aide said she stepped back and Resident #2 calmed down long enough to put on her pants. The Hospice aide said when CNA A came into the room Resident #2 was completely calm. He put her shirt on she and assisted her with transferring her to the chair. The Hospice Aide said Resident #2 was not crying or upset. The Hospice Aide said no one from Hospice or from the nursing home told her Resident #2 was a fighter. She said the Hospice aide that took care of Resident #2 before had no contact with her. They did not tell me that she was a fighter. During an interview on 6/13/22 at 9:28 a.m. CNA F said on 6/9/22 while the Hospice Aide was in the room with Resident #2, she was across the hall providing care to another resident. CNA F said she did not hear any hollering from the Resident #2. CNA F said she told the Hospice Aide if she needed any help to pull the call light. She said the light was never pulled. During an interview on 6/13/22 at 9:45 a.m. the ADON said when she came in the facility door on 6/9/22 the Hospice Aide walked up to the desk and said Resident #2 beat her up. The Hospice Aide said no one at the agency told her Resident #2 fought. She said the prior Hospice aide did not tell her anything. The ADON said it is was their policy if a resident was combative, leave them alone, tell the nurse, and or call for help. The ADON said CNA F asked the Hospice Aide why did she did not pull the light. The ADON said she sat outside quite a bit with Resident #2 (smoker). She had never seen any bruise on her head prior to today. Resident #2 often had bruises on her arms because she is wheels herself around and bums into doors. The ADON said Resident repeated all day, that the gal hit me. During an interview on 6/13/22 at 10:00 a.m. CNA A said he did not see the hospice aide holding Resident #2's hands when he went into the room on 6/9/22. He said he did not hear Resident #2 yelling out either. He was on the hall passing ice. During an interview on 6/13/22 at 11:08 a.m. the DON said he asked the Hospice Aide if she had any issues with Resident #2. The aide told him she held Resident #2's hands while she changed a brief. She denied that she hit her. She was asked for a statement and asked her to leave the building. LVN C asked him to go outside and in the smoking area and look at Resident #2's head. The DON said at that time it looked like a raised blood vessel. You could tell it looked fresh, it was still red. Through the day it started to look like a bruise. Resident #2 said the person that just changed her hit her in the head. No one said they saw any bruising previously to. Whatever it was had just happened as the day progressed the discoloration came up and was more pronounced. During an interview on 6/13/22 at 12:12 p.m. the Hospice Case Manager said the Hospice Aide had just started to work for them. She had not met her. The Case Manager said she knew Resident #2 fought. The Case Manager said Resident #2 had refused assessments from her in the past. She said that Hospice Aide would not be back to the facility. She said the aides would be educated on aggressive residents. It is her practice if the resident refused care to leave them alone. Review of the Hospice Aides skills competency checklist indicated the Aide received training on 6/1/22. The training provided consisted was bathing, hair care. skin care, infection control, toilet elimination, making the bed ,assist with dressing, and transfers. There was no information provided regarding abuse or neglect. Review of the facility Abuse and Neglect Policy with no date: indicated abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm. Training staff- employees must be trained through orientation and ongoing in services about appropriate intervention to deal with aggression.

Based on interview, observation, and record review the facility failed to ensure residents were free from accident hazards for 1 of 6 residents reviewed for accidents. (Resident #1) The facility failed to ensure shower chairs were maintained and in working order. A shower chair broke while Resident #1 was sitting in the chair. Resident #1 sustained a laceration to the right side of the head with hematoma (a serious condition where blood collects between the skull and the surface of the brain) and rib fractures. This failure could place residents at risk for accident hazards. Findings included: Review of Resident #1's Face Sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE]. She had diagnoses of [CONDITION(S)] (damage or disease that affects the brain), multiple fractures of ribs, left side, age related cognitive decline, malignant neoplasm of breast (cancerous tumor), and history or falling. Review of a significant change MDS [DATE] indicated her cognitive skills for daily decision making was modified independence with decisions poor, cures or supervision required. Resident #1 was totally dependent for bed mobility and transfer status was extensive assist of one person. Review of Resident #1's Care Plan indicated a problem of. a history of falls as evidenced by an actual fall. The Goal was Dignity will be maintained and free of injury related to falls through the next review. The approach was she had a fall on [DATE]. The shower chair disposed of a new shower chair put in place, though there was no signs of cracking or damage related to the brake. Staff in-service on reporting any type of equipment damage to maintenance supervisor. Another approach was encouraging the resident to use assistive walker and continue to ask for help from staff with ambulation resident does not want to comply with waiting and wanting to get up by herself. Review of Facility Provider Investigation Report dated [DATE] at 9:20 a.m. indicated CNA B said she was giving Resident #1 a shower and the chair broke. When inspecting the broken chair, it was noted that the right back Tee (a connection that forms a T is used to connect pipes at a 90-degree angle) Fitting on the shower chair was broken off in a U shape. Resident #1 weighed 174 pounds, and the maximum capacity for chair was 500 pounds. The shower chair was broken at the base. All staff were interviewed (16 statements accompanied the report), and they voiced no noted concerns that the chair had cracks. The supplier was notified, and new chairs were ordered from a different supplier. Resident#1 had a laceration to the right side of the head with hematoma and rib fractures. Review of Resident #1's nursing notes indicated on [DATE] at 9:39 a.m. the CNA assisted Resident #1 with a shower and getting dressed. When she turned to get the wheelchair to transfer the resident and the shower chair broke. Resident # 1 fell to the floor, caused a laceration to the right side of her head with hematoma. The resident was taken to the hospital. Review of hospital records dated [DATE] indicated Resident #1 was a [AGE] year-old female admitted to the trauma level due to a transfer from another hospital. Resident # 1 was sitting in a shower chair when it gave way, she fell , and struck her forehead. On arrival she was stable, and alert. She was oriented to self and able to follow commands. Resident #1 was confused to place. A list of her injuries were subdural hematoma and forehead laceration. Review of Resident #1's hospital records dated [DATE] at 1:20 p.m. indicated a CT of the head without contrast showed an acute subdural hemorrhage adjacent to the right hemisphere is stable and measured 5mm. A scalp hematoma was stable. There was no fracture with mild atrophy and mild chronic ischemic microvascular disease there is no evidence of mass, mass effect, or a midline shift. The impression was a stable thin acute subdural hemorrhage and stable scalp hematoma. Review of a hospital chest x-ray date [DATE] 1:25 PM indicated left lower rib fractures possibly involving the seventh and eighth through the ninth ribs on the left side with minimal subpleural hematoma or possible small infusion (fluid). Review of a nursing note dated [DATE] at 12:00 p.m. indicated Resident #1 was readmitted to the facility with a diagnosis of subdural hematoma, lower left rib fracture, for head laceration and spine degeneration. Hematoma right forehead with small laceration orbital bruising a couple of bruises on the right lower arm and wrist. Resident #1 was assisted from the stretcher to the recliner in her room. Review of a nursing note dated [DATE] at 1:06 p.m. indicated the Resident #1's condition declined, she was unable to stand with walker. She usually slept in recliner and it was difficult for resident to get out of the recliner. The resident was transferred to bed per to staff. The resident was incontinent of bowel and bladder in the chair. She was assisted with a shower per staff. Her vital signs were taken. The physician and family were notified of the change of condition and EMS transported the resident to the hospital. Review of facility purchase order form dated [DATE] indicated a wide showered chair with a weight capacity of 500 pounds was order by ADON. A purchase order dated [DATE] for a shower chair with a weight capacity of 700 pounds was order by the ADON. A purchase order dated [DATE] indicated a shower chair was ordered and 2 bariatric oversized shower chairs were ordered by ADON. Review of the Maintenance Inspection sheet dated [DATE] indicated one shower chair was inspected on hall 1 and 2 and one shower chair on hall 3 and 4. The form indicated the chairs were inspected there were no other notations. During an interview with the Administrator on [DATE] at 10:00 a.m. she said Resident #1 had a fall from the shower chair. It was a bad chair, there was no indication from staff interviews the chair had any cracks or loose areas prior to the fall. During an interview on [DATE] at 11:04 a.m. CNA A said the shower chair that broke was not a good brand. That shower chair was hard to maneuver; when someone sat in the chair it was hard to roll. During an interview on [DATE] at 11:20 a.m. CNA B said she had worked at the facility since 2014. She said on [DATE] she gave Resident #1 a shower and the resident was completely dressed. CNA B said she sat Resident #1 down in the shower chair. She turned and reached for Resident #1's wheelchair and the shower chair just broke. During an interview on [DATE] at 11:38 a.m. the Maintenance Man said he had worked at the facility since [DATE]. He said he checked the shower chairs once a month to make sure they are functional. According to him they have only two shower chairs in the building. One chair was replaced after the incident with Resident #1. The Maintenance Man said the ADON ordered all medical equipment, and she had the requisition forms the new chair. During an interview on [DATE] at 11:50 a.m. the ADON said the shower chair was placed in the dumpster. She did not want anyone trying to reassemble them. The ADON said the shower chair that broke was over a year old. During an interview on [DATE] at 8:11a.m. CNA D said she had worked at the facility for 3 years. She said she gave showers and the shower chair that broke was hard to roll. If empty it was easy to roll, but if a Resident was in the chair it was hard to roll. CNA D said she told the nurse the chair was had to push, and the maintenance man had worked on the chair in the past. She said she never saw any cracks or breaks on the chair. CNA D said Resident #1 was a one person assist prior to the fall on [DATE]. Resident #1 could get up and go to the bathroom. After the incident she changed, she required more assistance with everything, and she became a two person assist with transfers. During an interview on [DATE] at 8:23 a.m. LVN E said she was working the day Resident #1 fell in the shower. She said CNA B had given her a shower. When she arrived in the shower room one of the wheels broke, and part of the PVC pipe that held the chair together was broken. Resident #1 had she fallen face down. LVN E said she immediately called 911. She knew Resident #1 had hit her head bad because it was a lot of blood. LVN E said no one ever told her the chair was hard to push. During an interview on [DATE] at 9:30 a.m. CNA A said yes, the shower chair that broke was hard to push when there was weight in the chair. He said he told a nurse; he could not remember who. He knew someone had reported it to the Maintenance Man because he had changed out the wheels a few times, and the chair was still hard to roll. During an interview on [DATE] at 9:51 a.m. CNA B said when you placed weight on the shower chair it as hard to move. It was reported to Maintenance Man. He replaced the wheels on the shower chair that broke at least once. She said on the day Resident #1 fell from the shower chair she did not move the chair very far because it was hard to move it just collapsed. During an interview on [DATE] at 12:40 p.m. Staff G said he had worked at the facility for about 5 years, he worked in the laundry, he worked as a part time Maintenance Man and he did transport on occasion. He said he conducted facility equipment checks in the past. He said he had never been instructed to check shower chairs. He was unable to find any Maintenance Inspection sheets. During an interview on [DATE] at 1:00p.m. the Administrator and BOM said they could not find any additional Maintenance Inspection sheets. The BOM searched the computer. The Administrator said they had only been doing them since [DATE]. (No April, or [DATE]) Observation of a picture provided by the Administrator on [DATE] at 2:59 p.m. showed the shower chair was made of PVC ([MEDICATION(S)] chloride- a thermoplastic used in pipes and construction materials) pipe. It was sitting up straight but the whole side of the chair facing the camera was missing. The armrest was curved and connected to a wheel and was seen laying on the grown with the wheel still attached. At the bottom of the chair there were Tee joints that held the PVC pipe in place. The Tee joint on the back close to the wheel was broken on the side facing the camera. There appeared to be another part of the chair that was broken from the bottom of the chair that was not in the picture. During an interview on [DATE] at 8:16 a.m. the maintenance man Maintenance Man said the staff were confused. He had never put any wheels on the shower chair that broke. There was a new wheelchair ordered and there was no reason for him to put wheels on it. It was only two or three weeks old. He had replaced some wheels in the past but not on the wheelchair that broke. He said the facility only had two wheelchairs and they were both new. During an interview on [DATE] at 9:45 a.m. the ADON said the shower chair that broke was purchased in 2020. She said the aides did say it was hard to push and the Maintenance Man was aware. The ADON said she knew the Maintenance Man had replaced wheels because she ordered them. She was not sure if he replaced wheels on the broken chair. When she ordered another shower chair it was ordered from a different supplier. The threw away the broken shower chair and they may have one of the old brand chairs still in the facility. Resident # 1 was sent back from the hospital and she had a decline after she returned. Resident #1 would not feed herself. She would not get out of bed. She was discharged back to the hospital due to a change in condition and died . During an interview on [DATE] at 11:08 a.m. the DON said Resident # 1 had a fall in the shower room from the shower chair. CNA B was with her, the chair broke, she fell out forward, and hit her head. The chair detached the whole frame broke. The DON said he was aware that the chair did not move easily when there was weight on the chair. After the incident they audited all the chairs. Resident #1 was diagnosed with a small brain bleed, and rib fractures. Sent out later and she did not have rib fractures. During an interview and observation on [DATE] with Staff G the shower room on hall 4 was observed. There was one chair sitting in the actual shower with a weight capacity was 400 pounds. It had a sticker from the new company. There were two shower chairs sitting against the wall. One was a reclining shower chair, and it had a weight capacity of 325 pounds. There was an extra wide chair sitting against the wall, it had a weight capacity of 700 pounds. Both those chairs were noted to be from the old company (where the broken chair was purchased from.) Staff G brought out another chair and he said it was from the shower room on the other hall. It had a weight capacity of 300 pounds. It had a sticker from the new company. He said they had a total of 4 shower chairs in the facility. During an interview and record review on [DATE] at 12:45 p.m. with the ADON. the facility reacquisition forms were reviewed. The ADON said in [DATE] she ordered the 500-pound shower chair that broke with Resident #1 in [DATE]. The ADON said in February 2022 she ordered a 700-pound shower chair from the same company. After the [DATE] incident she order one 300-pound shower chair and two 450- pound chairs from the new company. They sent one of the 450-pound chairs back. They currently have 4 shower chairs in the building.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision to prevent accidents was provided for 1 of 4 residents reviewed for elopement. (Resident #1) The facility did not supervise Resident #1 to prevent his elopement from the facility on 6/2/19. Resident #1 was found by local law enforcement on the side of a road approximately a half mile from the facility. An Immediate Jeopardy situation was identified that existed on 06/02/19. This was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents at risk of severe injury/death. Findings included: A face sheet dated 4/17/19 indicated Resident #1 had an admission of 4/17/19-4/29/19. The sheet indicated Resident #1 had [DIAGNOSES REDACTED]. Physician orders [REDACTED].#1 readmitted on [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The clinical record for Resident #1 from 05/29/19 through 06/11/19 indicated there was no elopement assessment completed for Resident #1. The baseline care plan dated 5/29/19 indicated Resident #1 was confused, wandered with no exit seeking behaviors, and was an elopement risk. An intervention listed was .lock doors of the facility . The order on the MAR indicated [REDACTED] The nursing notes for Resident #1indicated the following: *5/31/19 an elopement risk and a high fall risk; *5/30/19 frequently wandered through out the facility. The resident was alert and oriented, with forgetfulness; *5/29/19 arguing with his spouse because he did not want to be left in the facility; *4/23/19 pacing and wandering up and down hallway. The resident was redirected but quickly forgot. *4/21/19 resident was an elopement risk; and *4/19/19 assessed for elopement risk and determined to be at high risk for elopement and all facility doors had been armed and codes are required to exit. An elopement assessment for Resident #1 dated 4/19/19 indicated the resident was at risk for elopement. A nursing note dated 06/02/19 indicated Resident #1 eloped without permission. The note indicated staff was unable to find the resident anywhere in the facility. The note indicated the nurse notified the DON, ADON, administrator, and called 911 at 7:00 a.m. The note indicated the fire department and first responders searched for Resident #1 until the sheriff called to report the resident was found down the road from the nursing home and was transported to the hospital. An incident report dated 6/2/19 at 01:30 p.m., indicated Resident #1 left the facility without permission. The resident was found down the street ½ miles from the facility at approximately 8:55 a.m. The report indicated the sheriff who found the resident sent the resident to the emergency room for evaluation because it appeared the resident had a fall. The report indicated there were no elopement behaviors prior to Resident #1's elopement, and listed possible contributing factors of [MEDICAL CONDITION], dementia, depression, absence of personal contact with family/friends. The report also indicated Resident #1 did not adjust easily to change in routines. A provider investigation report dated 6/2/19 at 7:30 p.m. indicated Resident #1 left the facility without signing out and was noticed missing at 7:30 a.m. and remained missing until 8:48 a.m. The report indicated there was no injury to the resident. The report noted police and family were called, and staff searched the facility and the neighborhood. The report indicated Resident #1 was located in a housing addition within a mile of the facility. The report indicated after the elopement, maintenance tested all doors to the facility and found them in working condition. The report stated it was apparent the resident left through the window in his room, based on the footprints outside of his window. A window alarm was placed on the resident's window after the elopement. The report concluded that the resident had no major injuries, but was taken to a hospital for evaluation, and went home with his wife the same day. During an interview on 6/11/19 at 11:47 a.m. the DON said an elopement risk assessment was not completed for Resident #1 when he readmitted from home. The DON said he completed a baseline care plan that showed the resident wandered, was an elopement risk, and confused, but had no behaviors of exit seeking. During an interview on 6/12/19 at 11:30 a.m. the MDS coordinator indicated Resident #1 did not have an MDS due to Resident #1 being respite stay only. During an interview on 6/11/19 at 3:16 p.m., CNA A said on 6/2/19 at 5:28 a.m., she answered Resident # 1's call light. CNA A said the resident was wearing blue jeans and a shirt that morning but did not have on his belt or shoes. She said Resident #1 told her he was nauseated and had a headache. CNA A said the resident appeared fidgety and anxious. She said she notified LVN B of the resident's nausea and headache. During a telephone interview on 6/11/19 at 11:12 a.m., CNA [NAME] said on the morning of 06/02/19 around 7:00 a.m., CNA [NAME] entered Resident #1's room and announced she had breakfast for the resident, but there was no response. CNA [NAME] said she checked the bathroom, but no one was in there. CNA [NAME] said she asked CNA D about Resident #1's whereabouts and CNA D told her Resident #1 sometimes ate breakfast in the dining room or sat in the lobby area. CNA [NAME] said she could not find Resident #1 anywhere, so she notified LVN C. CNA [NAME] said they searched every inch of the building and the resident was gone. CNA [NAME] said Resident #1 was found approximately two hours later. During a telephone interview on 6/11/19 at 3:27 p.m., CNA F said when she answered Resident #1's call light on 6/2/19 between 5:30 a.m. and 5:40 a.m. he was fumbling around and standing in front of his bed with clothing laid out on top of it. She said he was fully dressed, but CNA F could not remember what clothing Resident #1 was wearing. During a telephone interview on 6/11/19 4:18 p.m., LVN B said on 6/2/19, she saw Resident #1 between 5:30 a.m. and 5:40 a.m. when she administered his medication. LVN B said the resident was in the bed at that time. During a telephone interview on 6/11/19 at 11:01 a.m. CNA D said he worked the morning of 6/2/19. CNA D said as he was passing trays that morning, CNA [NAME] asked him if he had seen Resident #1because he was not in his room. CNA D said CNA [NAME] helped him search for the resident. CNA D said Resident #1 was found by a police officer down the road near the train tracks (approximately a half mile from the facility). CNA D said he had not seen Resident #1 on 6/2/19. During an interview on 6/11/19 at 9:55 a.m., LVN C said Resident #1 went missing on 6/2/19 at 6:45 a.m. LVN C said Resident #1 was able to walk and he had no exit seeking behaviors. LVN C said while staff were serving breakfast on the morning of 06/02/19, she was notified Resident #1 was missing. LVN C said staff searched bathrooms, rooms, closets, outside but were unable to find Resident #1. LVN C said she called the ADON, DON, the administrator and 911. LVN C said when she went to Resident #1's room and saw the curtain was pulled back, the window was unlocked, opened a little, and there was no screen on the window. LVN C said she felt Resident #1 left the facility by going out of his window. LVN C said the sheriff notified her he found Resident #1 and said the resident fell just as the sheriff found him. LVN C said the resident was transferred to the hospital and did not return to the facility. During a telephone interview on 6/11/19 at 11:50 a.m., the sheriff said he found Resident #1 walking up a hill on the edge of the road. The sheriff said Resident #1 lost his balance and fell . The sheriff said the resident appeared to be dehydrated and had a few cuts and scrapes on the resident's which appeared as if the resident may have fallen before he was found. The sheriff said the resident was scared and started crying when he realized the sheriff was there to assist him. The sheriff said Resident #1 was wearing shoes, pants with a Texas belt buckle, and a sweat shirt. The sheriff said he had called an ambulance to take the resident to the hospital to be evaluated. During an observation on 6/11/19 at 8:37a.m., prior to entrance the facility was located near a 2 lane paved road with the speed limited of 55 miles per hour. (MPH) During an observation on 6/121/19 at 1:12p.m. where the resident was said to be found on the shoulder of where two highways met with the speed limited of 45 and 55 next to an apartment complex. During an observation and interview on 6/11/19 at 1:45 p.m., the maintenance director said on 06/02/19, he saw the curtain in Resident #1's room was pulled back a little and the window was not closed. He said the screen was on the ground. The maintenance director pointed the ground outside of the window of Resident #1 and indicated there was a shoe print in the mud. There was no shoe print noted outside of the window at this time. The window was closed with a screen on it. During an interview on 6/11/19 at 9:08 a.m., the administrator said on 6/2/19 when Resident #1 was missing, staff searched the facility for Resident #1 and LVN C called the police and the fire department. The administrator said they believed Resident #1 left the facility through the window of his room because the window was found unlocked and the maintenance man found a shoe print outside of the resident's window. The DON said he went to the scene where the resident was found and said the resident did not appear to have any injuries. The DON said the police called an ambulance and sent the resident to the hospital for evaluation because the resident had fallen. The DON said Resident #1 had no history of elopement but wandered around the facility when he was previously admitted . The DON said the facility doors were coded and alarmed and Resident #1 never set off the door alarms. During an interview on 6/11/19 at 10:10 a.m., CNA G said prior to Resident #1s elopement on 6/2/19, the resident exhibited exit seeking behaviors. CNA G said the resident would attempt to leave when visitors were leaving the facility. CNA G said Resident #1 would ask to leave and try to bribe people to let him out. During an interview on 6/11/19 at 1:18 p.m., the ADON said prior to 6/2/19, Resident #1 would go to the doors and look out and say, I need to go and jiggle the door handle. A weather report accessed on 6/24/19 from https://weather.com indicated the temperature for 6/02/19, the day of the incident, ranged from a low of 72 degrees Fahrenheit to a high of 92 degrees Fahrenheit. The elopement policy dated (MONTH) 2014 indicated: .1. Residents who wander are considered an elopement risk, and the facility will ensure that the safety of residents who wander is maintained, and that elopement is prevented. 2. The MDS nurse will: a. complete an assessment for wandering residents at admission . The administrator, DON, and ADON were notified on 06/12/19 at 10:42 a.m., that a past non-compliance situation had been identified due to the above failures. It was determined these failures placed Resident #1 in an Immediate Jeopardy (IJ) situation on 6/2/19 to 6/3/19. After Resident #1 was found missing from the facility on 6/02/19. The facility implemented the following interventions: *Resident #1 was found and sent to the hospital for evaluation on 6/2/19. *an order was received for a window alarm and staff were to check the window alarm every shift for placement and function effective 6/2/19. *All staff were in-serviced on missing residents on 6/3/19. *All staff were in-serviced on abuse on 6/3/19. *All residents had an elopement assessment completed and care plans updated on 6/3/19. *Residents at risk for elopement had an alarm placed on their bedroom window on 6/2/19. These interventions were completed based on 7 staff (5 CNAs and 2 LVNs) interviewed to ensure the interventions had been completed. The maintenance director check all window alarms and placement, all were functional. Staff were able to appropriately answer the procedure for abuse and neglect, missing resident/ elopement. Chart reviews were completed and all care plans and elopement assessments were completed.

Based on observation, interview, and record review, the facility failed to ensure the right to be free from chemical restraints was provided for 2 of 5 residents reviewed for medications. (Resident #s 1 and 6) The facility did not prevent Resident #1 from being chemically restrained with [MEDICATION NAME] (antipsychotic used to treat [MEDICAL CONDITION] and the manic symptoms of [MEDICAL CONDITION] disorder). The resident was administered [MEDICATION NAME] for wandering and agitation. Resident #1 was administered [MEDICATION NAME] IM (intramuscular) for wandering, and was found unresponsive four hours later. She was transferred to the hospital in cardiopulmonary arrest and died the following day. The facility did not prevent Resident #6 from being chemically restrained with [MEDICATION NAME] (used to treat [MEDICAL CONDITION] disorders or panic disorder) and [MEDICATION NAME]. The resident ambulated and was independent with ADLs. The resident was administered [MEDICATION NAME] (Klonopin) for restlessness and [MEDICATION NAME] after an altercation with his roommate. Resident #6 had a decline in ADLs, was difficult to arouse, ambulated with a shuffled gait and barely moved his left foot/leg. The resident was admitted to the hospital 1 month later and expired. The failure likely contributed to the death of Resident #s 1 and 6. This failure created an Immediate Jeopardy situation identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 27 residents with behavioral symptoms at risk for injury, abuse, adverse drug reactions, and death. Findings included: 1. admission orders [REDACTED]. Physician orders [REDACTED].#1, admitted [DATE], was [AGE] years old. Resident #1 was to receive [MEDICATION NAME] 20 mg IM every 12 hours as needed (prn) for agitation (start date [DATE]), [MEDICATION NAME] 20 mg by mouth twice a day (start date [DATE]), [MEDICATION NAME] 0.5 mg by mouth at night time (start date [DATE]) and [MEDICATION NAME] 0.5 mg by mouth twice a day (start date [DATE]). <http://labeling.pfizer.com/ShowLabeling.aspx?id=584> accessed on [DATE] indicated "[MEDICATION NAME] prescribing information- this is the actual black box warning. WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED [MEDICAL CONDITION] Elderly patients with dementia-related [MEDICAL CONDITION] treated with antipsychotic drugs are at an increased risk of death. Analyses of seventeen placebo-controlled trials (modal duration of 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients of between 1.6 to 1.7 times the risk of death in placebo-treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was about 4.5%, compared to a rate of about 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. Observational studies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear. [MEDICATION NAME] (ziprasidone) is not approved for the treatment of [REDACTED].<http://labeling.pfizer.com/ShowLabeling.aspx?id=584>))..." Nursing notes dated [DATE] (no time) indicated the physician was at the facility and gave a new order of [MEDICATION NAME] 20 mg by mouth twice a day and as needed for anxiety and wandering. A psychoactive medication quarterly evaluation dated [DATE] indicated Resident #1 received [MEDICATION NAME] 20 mg twice a day and as needed for anxiety and wandering. The evaluation noted Resident #1 received [MEDICATION NAME] 0.5 mg twice a day and at hour of sleep as needed. The evaluation did not document a [DIAGNOSES REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #1's cognitive skills for decision making was severely impaired. She exhibited physical and verbal behaviors toward others, resisted care and wandered throughout the facility. The assessment documented the resident did not have behaviors related to [MEDICAL CONDITION]. An undated nursing care plan indicated Resident #1 had a problem of challenging behaviors that included: combative, cursing, yelling, elopement attempt, disrupting living environment, and going into other resident's rooms. Approaches included: redirect, praise for good effort, approach in calm manner, wanderguard, administer medications as ordered and encourage exercise. Nursing notes dated [DATE] indicated the following for Resident #1: *8:30 p.m., Resident #1 was wandering in and out of other residents rooms. Two CNAs and a nurse attempted to get the resident undressed for bed and she became combative with the staff and kicked another resident's door. *8:45 p.m., physician orders [REDACTED]. *9:03 p.m., the nurse and 3 CNAs administered [MEDICATION NAME] 20 mg IM. *9:20 p.m., the resident was sleeping soundly. Nursing notes dated [DATE] at 12 noon, indicated Resident #1 was administered [MEDICATION NAME] IM for anxiety and fighting staff. Resident #1 was taken to the dining room for noon meal and then put to bed. Nursing notes dated [DATE] indicated the following for Resident #1: *2:00 a.m., Resident #1 was wandering throughout facility, exit seeking. When redirected was attempted, she started to get combative with staff. [MEDICATION NAME] 20 mg IM administered. *10:30a.m., resident awake, combative with male staff assisting her to the dining room. 6:00p.m., physician orders [REDACTED]. 6:30 p.m., when the CNA attempted to take Resident #1 to her room to provide care the resident attempted to slap the CNA. [MEDICATION NAME] 20 mg IM was administered. Nursing notes dated [DATE] indicated the following for Resident #1: *11:15 p.m., Resident #1was wandering around the nurse station. When staff attempted to redirect, she became argumentative and aggressive. [MEDICATION NAME] 20 mg IM administered. *11:45 p.m., resident asleep. Nursing notes dated [DATE] indicated the following for Resident #1: *11:45 p.m., Resident #1 was wandering around the facility, going into other residents rooms. A staff member passed by the resident who was sitting in a chair in the dining room and the resident jumped up like she was going to hit her. [MEDICATION NAME] 20 mg IM was administered. *1:00 a.m., resident asleep. Nursing notes dated [DATE] indicated the following for Resident #1: *10:00 a.m., waiting for Resident #1 to wake up to eat meals. Resident #1 slept through breakfast and lunch meals. *1:30p.m., resident awake taken to the dining room for meal. Nursing notes [DATE] at 1:00 p.m., indicated Resident #1 slept all day after being up most of the night. Nursing notes dated [DATE] at 12:45 a.m., another resident reported to the nurse that Resident #1 was hitting her roommate. The staff intervened and saw Resident #1 standing over her roommate, threatening to spank her because she thought she was her daughter. Staff attempted to redirect, but Resident #1 was persistent on spanking her roommate. [MEDICATION NAME] 20 mg IM was given. Nursing notes [DATE] at 2:00 p.m., indicated Resident #1 slept all day except to take medications. Nursing notes [DATE] at 1:00 a.m., Resident #1 walking around the facility, trying to go into other resident's rooms. She became increasingly aggressive when staff attempted to redirect her. [MEDICATION NAME] 20 mg IM was administered and Resident #1 attempted to pull her roommate out of the bed. Resident #1 was assisted to the living area to visit with staff. At 2:30 a.m., resident was asleep on the couch in the living area. Nursing notes [DATE] at 12:45 a.m., Resident #1was wandering and attempting to go into residents rooms. [MEDICATION NAME] 20 mg IM was administered. The PRN MAR indicated [REDACTED]. Nursing notes [DATE] at 7:30 p.m., indicated Resident #1 was sitting on "peoples laps" in front lobby. She became combative when staff attempted to redirect. [MEDICATION NAME] 20 mg IM was administered. Nursing notes dated [DATE] indicated the following for Resident #1: *10:20 p.m., Resident #1 wandering at nursing station and tearing papers out of the charts. Resident #1 was taken to her room and administered [MEDICATION NAME] 20mg IM. *12:30 a.m., Resident #1 continued to wander in her room. CNA assisted her to bed. *2:30 a.m., Resident #1 was found lying in bed unresponsive, unable to obtain vital signs. CPR was initiated and 911 called. The Injection MARs dated [DATE]-26. 2014 indicated Resident #1 was administered [MEDICATION NAME] IM injection on ,[DATE] (,[DATE] shift) and ,[DATE] (,[DATE] shift). A hospital report dated [DATE] indicated Resident #1 was in [MEDICAL CONDITION]. Resident #1 was unstable and her various labs were abnormal. She was transferred to another higher level care hospital on [DATE] where she was admitted with acute hypoxemic [MEDICAL CONDITION], status [REDACTED]. Resident #1 died on [DATE] in the hospital. During an interview on [DATE] at 3:40 p.m., LVN C said Resident #1 wandered throughout the facility at night, waking up other residents and exit seeking. LVN C said they placed carts in front of the exit doors so she would not attempt to go out. LVN C said on [DATE] Resident #1 was at the nursing station ripping papers out of the charts. She said she had the CNAs assisted her to her room and she administered [MEDICATION NAME] 20 mg IM, for agitation. LVN C said she checked on Resident #1 a little later and she was still up in her room. She said she instructed the CNAs to put Resident #1 on her bed. She said the CNA went back later to check on Resident #1 and found her unresponsive. LVN C said cardiopulmonary resuscitation (CPR) was initiated and 911 called. She said staff was to attempt to redirect Resident #1 prior to administering prn anti-psychotic medications. During an interview on [DATE] at 10:00 p.m., CNA F said on [DATE] at the beginning of her shift (10 p.m. - 6 a.m.) Resident # 1 was wandering throughout the facility. She said LVN C told her to assist Resident #1 to her room. She and two other CNAs walked with Resident #1 to her room without difficulty. CNA F said Resident #1 was not combative or aggressive. She said LVN C gave Resident #1 an injection. CNA F said she stayed with Resident #1 for a few minutes and Resident #1 was in the bed when she left the room. She said she checked on Resident #1 again a little later and she was asleep. CNA F said on her last round at approximately 2:30 a.m., she found Resident #1 not breathing. She said she notified LVN C who initiated CPR and called 911. During an interview on [DATE] at 7:49 p.m., CNA E said on [DATE] CNA F asked her to assist her with taking Resident #1 to her room for LVN C. She said Resident #1 went to her room without difficulty. CNA E said LVN C gave Resident #1 a shot. She said she did not check on Resident #1 anymore because she was on the other hall. During an interview on [DATE] at 11:40 a.m., the DON said Resident #1 wandered throughout the facility, was exit seeking, and would resist care. She said Resident #1 was not combative unless staff attempted to redirect her. The DON said [MEDICATION NAME] was used for agitation. She said the staff was to attempt to redirect residents before administering as needed anti-psychotic medications. She said the facility was aware Resident #1 had a history of [REDACTED]. She said the ADON, administrator and social worker discussed her history prior to accepting the resident. The DON said the only interventions used for Resident #1 were IM [MEDICATION NAME] and redirection. During an interview on [DATE] at 12:10 p.m., LVN A said Resident #1 was administered [MEDICATION NAME] for agitation and restlessness. She said Resident #1 wandered throughout the facility and became combative at times when staff attempted to provide care. She said she usually could redirect her, but she required constant redirection. LVN A said when a resident displayed confusion or an increase in behaviors, assessments were conducted to rule out underlying illnesses or they were referred to a behavior unit to monitor behaviors and medications. She said Resident #1 was not assessed for underlying illnesses, referred to a behavior unit or monitored for medications. During an interview on [DATE] at 3:14 p.m., LVN B said Resident #1 was pleasantly confused most of the time. She said Resident #1 stayed up all night wandering throughout the facility. LVN B said [MEDICATION NAME] was administered for agitation. She said [MEDICATION NAME] was administered when Resident #1 became combative with staff. During an interview on [DATE] at 12:09 p.m., CNA D said Resident #1 resisted care and talked ugly to the staff. She said Resident #1 was usually easy to redirect. CNA D said Resident #1 sometimes slept all day and missed breakfast and lunch meals. During an interview on [DATE] at 1:00 p.m., the administrator said the facility accepted Resident #1 knowing she had "sun downers." She said they were unaware Resident#1 was combative with ADLs. The administrator said Resident #1 would sit in the lobby and visit with family. She said Resident #1 usually exhibited behavior in the evenings. The administrator said Resident #1 was hard to redirect at times. She said she was unaware of any discussions regarding Resident #1 needing possible psychological evaluation or other non-pharmacological interventions. 2. Physician orders [REDACTED].#6, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED].#6 received [MEDICATION NAME] 20 mg every night, [MEDICATION NAME] 1 mg twice a day as needed, and [MEDICATION NAME] 15 mg every night. The orders indicated Resident # 6 received [MEDICATION NAME] 0.5 mg at night for leg cramps as needed. The psychoactive medication quarterly evaluation dated [DATE] indicated Resident #6's [DIAGNOSES REDACTED]. The psychoactive medication quarterly evaluation dated [DATE] for Resident #6's [DIAGNOSES REDACTED]. Resident #6's [DIAGNOSES REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #6 exhibited physical/verbal behaviors, wandered, and resisted care at times. He was independent with ambulation and all ADLs except bathing which required limited assistance. The assessment documented the resident did not have behaviors of [MEDICAL CONDITION] and he wandered daily. Nursing notes dated [DATE] indicated the following for Resident #6: *10:30 a.m., Resident #6 was admitted to the facility. He was alert and oriented. He walked with a steady gait, very friendly and talkative. *7:44 p.m., The resident ambulated up and down hall, stops and talks to staff and wanders in other residents rooms looking for his room. Nursing note dated [DATE] at 12:00 p.m., indicated Resident #6 had not been sleeping at night. The physician ordered Tylenol PM at hour of sleep. Nursing notes [DATE] at 1:25 a.m., indicated Resident # 6 continued to walk the hallway and go into other residents rooms. Attempts to get resident to stay in his room were unsuccessful. Resident # 6 was administered [MEDICATION NAME] 1 mg for restlessness (no time noted). The resident continues to ambulate up and down halls, in and out of residents rooms. Resident #6 was administered Tylenol PM. Nursing notes dated [DATE] at 9:00 p.m., indicated Resident #6 ambulated up and down hallways, but was easily redirected. Nursing notes dated [DATE] at 5:00 p.m., indicated a new physician order [REDACTED]. Nursing notes dated [DATE] indicated the following for Resident #6: *2:15 a.m., staff heard yelling coming from Resident #6's room. Resident #6 was trying to hit his roommate with a shoe because his roommate said he had his clothing on. *5:30 p.m., physician ordered Resident #6 [MEDICATION NAME] 10 mg every night and increased his [MEDICATION NAME] to 1 mg twice a day as needed. A Physician telephone order dated [DATE] indicated an increase of Resident #6's [MEDICATION NAME] to 20 mg every night. Nursing notes dated [DATE] indicated the following for Resident #6: *7:50 p.m., Resident #6 found sitting on the floor. He returned from the hospital with new orders for a walker and pain medication related to the fall. *3:00 a.m., Resident #6 found on the floor by his bathroom door. He "soiled" himself. The MARs dated [DATE] indicated Resident #6 was administered an initial dose of [MEDICATION NAME] 10 mg at night on [DATE]. On [DATE] Resident #6's [MEDICATION NAME] was increased to 20 mg at night. Nursing notes dated [DATE] at 4:30 p.m., indicated Resident #6 rolled out of his bed. Nursing notes dated [DATE] (,[DATE] shift) indicated Resident #6 was in bed, incontinent of bowel and bladder, turned and repositioned every two hours and fed by the staff. Nursing note dated [DATE] 9:00 a.m., indicated Resident #6 was showing decline in mental and physical status daily. Staff was to assist with all ADLs. A pharmacy consultant report dated [DATE] indicated Resident #6 had no history or [DIAGNOSES REDACTED]. A physician progress notes [REDACTED].#6's "condition has deteriorated significantly." The note indicated Resident #6 was "difficult to arouse, ambulated with a shuffle gait and barely moving left foot/leg" The note documented Resident # 6 "mumbles to self, but did not speak." Physician orders [REDACTED]." A telephone order dated [DATE] to transport Resident #6 to the hospital for nausea and vomiting. A hospital record dated [DATE] indicated Resident # 6 was admitted to the hospital with [REDACTED]. He expired during his hospitalization . During an interview on [DATE] at 3:14 p.m., LVN B said Resident #6 wandered through out the facility when first admitted . She said Resident #6 was independent with ADLs. LVN B said he was one of the four residents that wandered up and down the halls and into other resident rooms. She said Resident #6 and his roommate got into an altercation one night because Resident #6 was wearing his roommates clothes. LVN B said Resident #6 was prescribed [MEDICATION NAME]. LVN B said Resident #6's mental and physical status declined rapidly after that incident. She said she was unsure of the reason Resident #6 was prescribed [MEDICATION NAME]. LVN B said Resident #6 was easily redirected most of the time, but would become combative at times. She said Resident #6 had a couple of falls and became dependent on staff to assist him with all ADL's. During an interview on [DATE] at 10:00 p.m., CNA F said upon admission Resident #6 was alert and independent with ADLs. She said he wandered throughout the facility, but was easily redirected. She said Resident #6 was incontinent and very confused when he was discharged . The facility drug book, 23rd Edition 2010 Mosby's Nursing Drug Reference, pgs 1139 and 1140 indicated "[MEDICATION NAME] was an anti-psychotic medication, used for [MEDICAL CONDITION] and acute agitation..." "...To be used with precaution in the elderly..." The black box warning indicated "to monitor the elderly closely because heart failure and sudden death had occurred ..." The facility policy revised ,[DATE], Antipsychotic Drug Use indicated "...antipsychotic drug therapy shall be used only when it is necessary to treat a specific condition: residents who have not used antipsychotic drugs will not be given unless to treat specific condition. Antipsychotic medications should not be used if they are the only indications: wandering, poor self-care, restlessness, impaired memory, anxiety, depression, [MEDICAL CONDITION], unsociability, fidgeting, nervousness, uncooperativeness or agitated behaviors which do not represent danger to the resident or others. Nursing staff shall monitor and report side effects ..." http://www.rxlist.com/[MEDICATION NAME]-drug.htm accessed [DATE] for [MEDICATION NAME] patient information with side effects indicated " ...WARNING INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED [MEDICAL CONDITION] Elderly patients with dementia-related [MEDICAL CONDITION] treated with antipsychotic drugs are at an increased risk of death ..." "...Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature ..." "... [MEDICATION NAME] (ziprasidone) is not approved for the treatment of [REDACTED]. The administrator and DON were notified on [DATE] at 2:25 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal (POR) was accepted on [DATE] at 4:20 p.m. and included: " ...1.Resident (#1) is no longer a resident in the facility. Resident (#6) is no longer a resident in the facility. 2. All residents currently receiving antipsychotic have the potential to be affected by this alleged deficient practice. Every resident in the building including new admissions currently receiving antipsychotic medications and those with challenging behaviors will be reviewed by the Nursing Staff, led by regional staff, to determine appropriate measures, assessments, Care Plans, and obtain consents. 3. The Primary Physician will be contacted for justification for antipsychotic medications and gradual dose reduction. 4. For the next seven (7) days, all nursing staff will call or contact the Director of Nursing Services before administering any PRN medications for behaviors. 5. All Nursing Staff will be in serviced on techniques and non? pharmacological interventions in handling residents with challenging behaviors. 6. All Nursing Staff will be in serviced on the CMS regulations for Reducing Antipsychotics In Nursing Homes and chemical restraints. 7. Residents will be assessed and Care Plans updated as necessary to ensure resident needs are being met. 8. Chemical Restraints will not be allowed in the facility. 9. The Pharmacy Consultant will review all Residents for medication necessity This plan was initially implanted [DATE], and will be monitored closely by Regional Director of Operations, and Regional Nurse ... " The surveyors confirmed the POR had been implemented sufficiently to remove the Immediate Jeopardy by: Three CNAs were interviewed and said they had been in-serviced on dealing with residents who exhibited behaviors including residents who wander and were combative. Three nurses were interviewed and said nurses were not to administer medications as a chemical restraint, they had been in-serviced on anti-psychotic medications, drug reductions, notification of DON prior to as needed medication administration, assessment of behaviors, care plan and attempt non pharmacologic interventions. The physician had assessed residents on anti-psychotic medications for appropriate diagnoses, assessed their behaviors and initiated drug reduction. The DON initiated a log of residents behaviors including times and what interventions were implemented. Three resident's clinical records were reviewed and drug reduction had been initiated. The pharmacy consultant was scheduled to review all residents' medications beginning on [DATE] for potential interactions and necessity. The CMS 672 dated [DATE] indicated 27 residents had behavioral symptoms.

Based on interview and record review, the facility failed to ensure the drug regimen was free from unnecessary medication for 2 of 5 residents reviewed for medications. (Resident #s1 and 6) The facility did not prevent Resident # 1 from receiving medications that she did not have indications for use. The resident was administered [MEDICATION NAME] (antipsychotic used to treat [MEDICAL CONDITION] and the manic symptoms of [MEDICAL CONDITION] disorder) and [MEDICATION NAME] (used to treat [MEDICAL CONDITION] disorders or panic disorder). Resident #1 was administered [MEDICATION NAME] IM (intramuscular) for wandering , and was found unresponsive four hours later. She was transferred to the hospital in cardiopulmonary arrest and died the following day. The facility did not prevent Resident #6 from receiving medications that he did not have indications for use. The resident ambulated and was independent with ADLs. The resident was administered [MEDICATION NAME] (Klonopin) for restlessness and [MEDICATION NAME] after an altercation with his roommate. Resident #6 had a decline in ADLs, was difficult to arouse, ambulated with a shuffled gait and barely moved his left foot/leg. The resident was admitted to the hospital 1 month later and expired. The failure likely contributed to the death of Resident #s 1 and 6. This failure created an Immediate Jeopardy situation identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 27 residents with behavioral symptoms at risk for injury, abuse, adverse drug reactions, and death. Findings included: 1. admission orders [REDACTED]. Physician orders [REDACTED].#1, admitted [DATE], and was 80. Resident #1 was to receive [MEDICATION NAME] 20 mg IM every 12 hours as needed (prn) for agitation (start date [DATE]), [MEDICATION NAME] 20 mg by mouth twice a day (start date [DATE]), [MEDICATION NAME] 0.5 mg by mouth at night time (start date [DATE]) and [MEDICATION NAME] 0.5 mg by mouth twice a day (start date [DATE]). <http://labeling.pfizer.com/ShowLabeling.aspx?id=584> accessed on [DATE] indicated "[MEDICATION NAME] prescribing information- this is the actual black box warning. WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED [MEDICAL CONDITION] Elderly patients with dementia-related [MEDICAL CONDITION] treated with antipsychotic drugs are at an increased risk of death. Analyses of seventeen placebo-controlled trials (modal duration of 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients of between 1.6 to 1.7 times the risk of death in placebo-treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was about 4.5%, compared to a rate of about 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. Observational studies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear. [MEDICATION NAME] (ziprasidone) is not approved for the treatment of [REDACTED].<http://labeling.pfizer.com/ShowLabeling.aspx?id=584>))..." Nursing notes dated [DATE] (no time) indicated the physician was at the facility and gave a new order of [MEDICATION NAME] 20 mg by mouth twice a day and as needed for anxiety and wandering. A psychoactive medication quarterly evaluation dated [DATE] indicated Resident #1 received [MEDICATION NAME] 20 mg twice a day and as needed for anxiety and wandering. The evaluation did not document a [DIAGNOSES REDACTED]. A psychoactive medication quarterly evaluation dated [DATE] indicated Resident #1 received [MEDICATION NAME] 0.5 mg twice a day and at hour of sleep as needed. The evaluation did not document a [DIAGNOSES REDACTED]. An Informed Consent for psychoactive medications dated [DATE] indicated Resident #1 received Klonopin for anxiety. An Informed Consent for psychoactive medications dated [DATE] indicated Resident #1 received [MEDICATION NAME] for psychotic behavior. The most recent MDS assessment dated [DATE] indicated Resident #1's cognitive skills for decision making was severely impaired. She exhibited physical and verbal behaviors toward others, resisted care and wandered throughout the facility. The assessment documented the resident did not have behaviors related to [MEDICAL CONDITION]. An undated nursing care plan indicated Resident #1 had a problem of challenging behaviors that included: combative, cursing, yelling, elopement attempt, disrupting living environment, and going into other resident's rooms. Approaches included: redirect, praise for good effort, approach in calm manner, wanderguard, administer medications as ordered and encourage exercise. Nursing notes dated [DATE] indicated the following for Resident #1: *8:30 p.m., Resident #1 was wandering in and out of other residents rooms. Two CNAs and a nurse attempted to get the resident undressed for bed and she became combative with the staff and kicked another resident's door. *8:45 p.m., physician orders [REDACTED]. *9:03 p.m., the nurse and 3 CNAs administered [MEDICATION NAME] 20 mg IM. *9:20 p.m., theresident was sleeping soundly. Nursing notes dated [DATE] at 12 noon, indicated Resident #1 was administered [MEDICATION NAME] IM for anxiety and fighting staff. Resident #1 was taken to the dining room for noon meal and then put to bed. Nursing notes dated [DATE] indicated the following for Resident #1: *2:00 a.m., Resident #1was wandering throughout facility, exit seeking. When redirected was attempted, she started to get combative with staff. [MEDICATION NAME] 20 mg IM administered. *10:30a.m., resident awake, combative with male staff assisting her to the dining room. 6:00p.m., physician orders [REDACTED]. 6:30 p.m., when the CNA attempted to take Resident #1 to her room to provide care the resident attempted to slap the CNA. [MEDICATION NAME] 20 mg IM was administered. Nursing notes dated [DATE] indicated the following for Resident #1: *11:15 p.m., Resident #1 was wandering around the nurse station. When staff attempted to redirect, she became argumentative and aggressive. [MEDICATION NAME] 20 mg IM administered. *11:45 p.m., resident asleep. Nursing notes dated [DATE] indicated the following for Resident #1: *11:45 p.m., Resident #1 was wandering around the facility, going into other residents rooms. A staff member passed by the resident who was sitting in a chair in the dining room and the resident jumped up like she was going to hit her. [MEDICATION NAME] 20 mg IM was administered. *1:00 a.m., resident asleep. Nursing notes dated [DATE] indicated the following for Resident #1: *10:00 a.m., waiting for Resident #1 to wake up to eat meals. Resident #1 slept through breakfast and lunch meals. *1:30p.m., resident awake taken to the dining room for meal. Nursing notes [DATE] at 1:00 p.m., indicated Resident #1 slept all day after being up most of the night. Nursing notes dated [DATE] at 12:45 a.m., another resident reported to the nurse that Resident #1 was hitting her roommate. The staff intervened and saw Resident #1 standing over her roommate, threatening to spank her because she thought she was her daughter. Staff attempted to redirect Resident #1, but resident was persistent on spanking her roommate. [MEDICATION NAME] 20 mg IM was given. Nursing notes [DATE] at 2:00 p.m., indicated Resident #1 slept all day except to take medications. Nursing notes [DATE] at 1:00 a.m., Resident #1 was walking around the facility, trying to go into other resident's rooms. She became increasingly aggressive when staff attempted to redirect her. [MEDICATION NAME] 20 mg IM was administered and Resident #1 attempted to pull her roommate out of the bed. Resident #1 was assisted to the living area to visit with staff. At 2:30 a.m., resident was asleep on the couch in the living area. Nursing notes [DATE] at 12:45 a.m., Resident #1was wandering and attempting to go into residents rooms. [MEDICATION NAME] 20 mg IM was administered. The PRN MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. There was no indication Resident #1 was administered [MEDICATION NAME] at 1 p.m. or 9 p.m. as ordered. Nursing notes [DATE] at 7:30p.m., indicated Resident #1 was sitting on "people's laps" in front lobby. She became combative when staff attempted to redirect. [MEDICATION NAME] 20 mg IM was administered. Nursing notes dated [DATE] indicated the following for Resident #1: *10:20 p.m., Resident #1 wandering at nursing station and tearing papers out of the charts. Resident #1 was taken to her room and administered [MEDICATION NAME] 20mg IM. *12:30 a.m., Resident #1 continued to wander in her room. CNA assisted her to bed. *2:30 a.m., Resident #1 was found lying in bed unresponsive, unable to obtain vital signs. CPR was initiated and 911 called. The Injection MARs dated [DATE]-26, 2014 indicated Resident #1 was administered [MEDICATION NAME] IM injection on ,[DATE] (,[DATE] shift) and ,[DATE] (,[DATE] shift). The MARs dated [DATE]-26, 2014 indicated Resident #1 was administered [MEDICATION NAME] 20 mg twice daily at 9 a.m. and 5 p.m. The MARs dated [DATE]-26, 2014 indicated Resident #1 was administered [MEDICATION NAME] 0.5 mg two times a day and at night at 9 a.m.; 1p.m.; and 9 p.m. A discharge summary dated [DATE] indicated Resident #1 was in [MEDICAL CONDITION]. Resident #1 was unstable and her various labs were abnormal. She was transferred to another higher level care hospital on [DATE] where she was admitted with acute hypoxemic [MEDICAL CONDITION], status [REDACTED]. Resident #1 died on [DATE] in the hospital. During an interview on [DATE] at 3:40 p.m., LVN C said Resident #1 wandered throughout the facility at night, waking up other residents and exit seeking. LVN C did not indicated Resident # 1 exhibited psychotic behaviors. She indicated she was not afraid of the resident. LVN C said they placed carts in front of the exit doors so she would not attempt to go out. LVN C said on [DATE] Resident #1 was at the nursing station ripping papers out of the charts. She said she had the CNAs assisted her to her room and she administered [MEDICATION NAME] 20 mg IM, for agitation. LVN C said she checked on Resident #1 a little later and she was still up in her room. She said she instructed the CNAs to put Resident #1 on her bed. She said the CNA went back later to check on Resident #1 and found her unresponsive. LVN C said cardiopulmonary resuscitation (CPR) was initiated and 911 called. She said staff was to attempt to redirect Resident #1 prior to administering prn anti-psychotic medications. During an interview on [DATE] at 10:00 p.m., CNA F said on [DATE] at the beginning of her shift (10 p.m. - 6 a.m.) Resident # 1 was wandering throughout the facility. She said LVN C told her to assist Resident #1 to her room. She said two other CNAs and herself walked with Resident #1 to her room without difficulty. CNA F said Resident #1 was not combative or aggressive. She said LVN C gave Resident #1 an injection. CNA F said she stayed with Resident #1 for a few minutes and Resident #1 was in the bed when she left the room. She said she checked on Resident #1 again a little later and she was asleep. CNA F said on her last round at approximately 2:30 a.m., she found Resident #1 not breathing. She said she notified LVN C who initiated CPR and called 911. CNA F said resident #1 usually resisted care and wandered around the facility. CNA F said the resident did not appear to hear voices or see things that were not there. She indicated she was not afraid of the resident. During an interview on [DATE] at 7:49 p.m., CNA E said on [DATE] CNA F asked her to assist her with taking Resident #1 to her room for LVN C. She said Resident #1 went to her room without difficulty. CNA E said LVN C gave Resident #1 a shot. She said she did not check on Resident #1 anymore because she was on the other hall. During an interview on [DATE] at 11:40 a.m., the DON said Resident #1 wandered throughout the facility, was exit seeking, and would resist care. She said Resident #1 was not combative unless staff attempted to redirect her. The DON said [MEDICATION NAME] was used for agitation. She said the staff was to attempt to redirect residents before administering as needed anti-psychotic medications. She said the facility was aware Resident #1 had a history of [REDACTED]. She said the ADON, administrator and social worker discussed her history prior to accepting the resident. The DON said only interventions used for Resident #1 were IM [MEDICATION NAME] and redirection. During an interview on [DATE] at 12:10 p.m., LVN A said Resident #1 was administered [MEDICATION NAME] for agitation and restlessness. She said Resident #1 wandered throughout the facility and became combative at times when staff attempted to provide care. She said she usually could redirect her, but she required constant redirection. LVN A said when a resident displayed confusion or an increase in behaviors, assessments were conducted to rule out underlying illnesses or they were referred to a behavior unit to monitor behaviors and medications. She said Resident #1 was not assessed for underlying illnesses, referred to a behavior unit or monitored for medications. During an interview on [DATE] at 3:14 p.m., LVN B said Resident #1 was pleasantly confused most of the time. She said Resident #1 stayed up all night wandering throughout the facility. LVN B said [MEDICATION NAME] was administered for agitation. She said [MEDICATION NAME] was administered when Resident #1 became combative with staff. During an interview on [DATE] at 12:09 p.m., CNA D said Resident #1 resisted care and talked ugly to the staff. She said Resident #1 was usually easy to redirect. CNA D said Resident #1 sometimes slept all day and missed breakfast and lunch meals. During an interview on [DATE] at 1:00 p.m., the administrator said the facility accepted Resident #1 knowing she had "sun downers." She said they were unaware Resident#1 was combative with ADLs. The administrator said Resident #1 would sit in the lobby and visit with family. She said Resident #1 usually exhibited behavior in the evenings. The administrator said Resident #1 was hard to redirect at times. She said she was unaware of any discussions regarding Resident #1 needing possible psychological evaluation or other non-pharmacological interventions. 2. Physician orders [REDACTED].#6, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED].#6 received [MEDICATION NAME] 20 mg every night, [MEDICATION NAME] 1 mg twice a day as needed, and [MEDICATION NAME] 15 mg every night. The orders indicated Resident # 6 received [MEDICATION NAME] (0.5 mg at night for leg cramps as needed. The psychoactive medication quarterly evaluation dated [DATE] indicated Resident #6's [DIAGNOSES REDACTED]. The psychoactive medication quarterly evaluation dated [DATE] for Resident #6's [DIAGNOSES REDACTED]. The evaluation indicated Resident #6's [DIAGNOSES REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #6 exhibited physical/verbal behaviors, wandered, and resisted care at times. He was independent with ambulation and all ADLs except bathing which required limited assistance. The assessment documented the resident did not have behaviors of [MEDICAL CONDITION] and he wandered daily. Nursing notes dated [DATE] indicated the following for Resident #6: *10:30 a.m., Resident #6 was admitted to the facility. He was alert and oriented. He walked with a steady gait, very friendly and talkative. *7:44 p.m., The resident ambulated up and down hall, stops and talks to staff and wanders in other residents rooms looking for his room. Nursing note dated [DATE] at 12:00 p.m., indicated Resident #6 had not been sleeping at night. The physician ordered Tylenol PM at hour of sleep. Nursing notes [DATE] at 1:25 a.m., indicated Resident # 6 continued to walk the hallway and go into other residents rooms. Attempts to get resident to stay in his room were unsuccessful. Resident # 6 was administered Klonopin 1 mg for restlessness (no time noted). The resident continues to ambulate up and down halls, in and out of residents rooms. Resident #6 was administered Tylenol PM. Nursing notes dated [DATE] at 9:00 p.m., indicated Resident #6 ambulated up and down hallways, but was easily redirected. Nursing notes dated [DATE] at 5:00 p.m., indicated a new physician order [REDACTED]. Nursing notes dated [DATE] indicated the following for Resident #6: *2:15 a.m., staff heard yelling coming from Resident #6's room. Resident #6 was trying to hit his roommate with a shoe because his roommate said he had his clothing on. *5:30 p.m., physician ordered Resident #6 [MEDICATION NAME] 10 mg every night and increase his Klonopin to 1 mg twice a day as needed. A Physician telephone order dated [DATE] indicated an increase of Resident #6's [MEDICATION NAME] to 20 mg every night. Nursing notes dated [DATE] indicated the following for Resident #6: *7:50 p.m., Resident #6 found sitting in the floor. He was taken to the hospital with new orders for a walker and pain medication related to the fall. *3:00 a.m., Resident #6 found on the floor by his bathroom door. He had "soiled" on himself. Nursing notes dated [DATE] at 4:30 p.m., indicated Resident #6 rolled out of his bed. Nursing notes dated [DATE] (,[DATE] shift) indicated Resident #6 was in bed, incontinent of bowel and bladder, turned and repositioned every two hours and fed by the staff. Nursing note dated [DATE] 9:00 a.m., indicated Resident #6 showing decline in mental and physical status daily. Staff to assist with all ADLs. A pharmacy consultant report dated [DATE] indicated Resident #6 had no history or [DIAGNOSES REDACTED]. A physician progress notes [REDACTED].#6's condition had deteriorated significantly. He was difficult to arouse, ambulated with a shuffle gait and barely moving left foot/leg. He mumbles to self, but does not speak. Physician orders [REDACTED]. During an interview on [DATE] at 3:14 p.m., LVN B said Resident #6 wandered through out the facility when he first came. He was independent with ADLs. He was one of the four residents that wandered up and down the halls and into other resident rooms. She said he and his roommate had gotten into an altercation one night because Resident #6 was wearing his roommates clothes. LVN B said Resident #6 was placed on [MEDICATION NAME]. She said she was unsure of the reason Resident #6 received [MEDICATION NAME]. She said Resident #6 was easily redirected most of the time, but would become combative at times. LVN B said Resident #6's mental and physical status declined rapidly after that incident. She said Resident #6 had a couple of falls and became dependent on staff to assist him with all ADL's. During an interview on [DATE] at 10:00 p.m., CNA F said upon admission Resident #6 was alert and independent with ADLs. She said he wandered throughout the facility, but was easily redirected. She said Resident #6 was incontinent and very confused when he was discharged . A telephone order dated [DATE] to transport Resident #6 to the hospital. A Physician Emergency Department Form dated [DATE] documented Resident # 6 was admitted to the hospital with [REDACTED]. He expired during his hospitalization . The facility drug book, 23rd Edition 2010 Mosby's Nursing Drug Reference, pgs 1139 and 1140 indicated " [MEDICATION NAME] was an anti-psychotic medication, used for [MEDICAL CONDITION] and acute agitation... " " ..To be used with precaution in the elderly... " The black box warning indicated " ...to monitor the elderly closely because heart failure and sudden death had occurred ... " The facility policy revised ,[DATE], Antipsychotic Drug Use indicated " ...antipsychotic drug therapy shall be used only when it is necessary to treat a specific condition: residents who have not used antipsychotic drugs will not be given unless to treat specific condition. Antipsychotic medications should not be used if they are the only indications: wandering, poor self-care, restlessness, impaired memory, anxiety, depression, [MEDICAL CONDITION], unsociability, fidgeting, nervousness, uncooperativeness or agitated behaviors which do not represent danger to the resident or others. Nursing staff shall monitor and report side effects ... " <http://www.rxlist.com/[MEDICATION NAME]-drug.htm accessed on [DATE]> for [MEDICATION NAME] patient information with side effects indicated " ...WARNING INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED [MEDICAL CONDITION] Elderly patients with dementia-related [MEDICAL CONDITION] treated with antipsychotic drugs are at an increased risk of death ... " " ...Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature [MEDICATION NAME] (ziprasidone) is not approved for the treatment of [REDACTED]. The CMS 802 dated [DATE] indicated there were 27 residents who exhibited behaviors. The administrator and DON were notified on [DATE] at 2:25 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 4:20 p.m. and included: 1. Resident #1 is no longer a resident in the facility. Resident # 6 is no longer a resident in the facility. 2. All residents currently receiving antipsychotic have the potential to be affected by this a alleged deficient practice. Every resident in the building including new admissions currently receiving antipsychotic medications and those with challenging behaviors will be reviewed by the Nursing Staff, led by regional staff, to determine appropriate measures, assessments, Care Plans, and obtain consents. 3. The Primary Physician will be contacted for justification for antipsychotic medications and gradual dose reduction. 4. For the next seven (7) days, all nursing staff will call or contact the Director of Nursing Services before administering any PRN medications for behaviors. 5. All Nursing Staff will be in serviced on technique s and non? pharmacological interventions in handling residents with challenging behaviors. 6. All Nursing Staff will be in serviced on the CMS regulations for Reducing Antipsychotics In Nursing Homes and chemical restraints. 7. Residents will be assessed and Care Plans updated as necessary to ensure resident needs are being met. 8. Chemical Restraints will not be allowed in the facility. 9. The Pharmacy Consultant will review all Residents for medication necessity. This plan was initially implanted [DATE], and will be monitored closely by Regional Director of Operations, and Regional Nurse. The surveyor confirmed the POR had been implemented sufficiently to remove the IJ by: Three CNAs were interviewed and said they had been in-serviced on dealing with residents who exhibited behaviors including residents who wander and were combative. Three nurses were interviewed and said nurses were not to administer medications as a chemical restraint, they had been in-serviced on anti-psychotic medications, drug reductions, notification of DON prior to as needed medication administration, assessment of behaviors, care plan and attempt non pharmalogic interventions. The physician had assessed residents on anti-psychotic medications for appropriate diagnoses, assessed their behaviors and initiated drug reduction. The DON had initiated a log of residents behaviors including times and what interventions were exhibited. Three residents' clinical records were reviewed with drug reduction initiated. The CMS 672 dated [DATE] indicated 27 residents had behavioral symptoms.

Based on interview and record review, the facility failed to consult with the physician for 1 of 4 residents reviewed for significant change in condition. (Resident #3) Resident #3, who had a history of [REDACTED]. The nurse did not consult with the physician regarding this change for over 9 hours. Resident #3 was hospitalized with [MEDICAL CONDITION] and GI bleeding requiring a blood transfusion and was placed on a ventilator. This failure contributed to the hospitalization of Resident #3. This failure could place the census of 45 residents at risk for a delay in medical evaluation and treatment. Findings included: Physician orders [REDACTED]. There were no labs ordered to monitor for GI bleed. A patient transfer form dated 7/06/13 indicated Resident # 3 vomited large amounts of dark brown emesis with coffee ground texture and was transferred to the hospital. A hospital history & physical dated 7/7/13 indicated Resident #3 was admitted with an acute GI bleed. A nursing care plan dated 10/30/13 indicated Resident # 3 had a problem of history of GI bleed. The care plan noted staff was to monitor the resident for signs and symptoms of GI bleed and monitor labs as ordered. The most recent MDS assessment dated [DATE] indicated Resident #3 had long and short term memory problems and impaired ability to make decisions. Resident # 3 ' s nursing notes dated 10/24/13 at 3:30 a.m. indicated LVN A observed coffee ground emesis to Resident # 3's face, pillow and gown. During an interview on 11/12/13 at 11:22 a.m., LVN A said Resident # 3 vomited a small amount of coffee ground emesis. LVN A said she did not consider it a change of condition and did no further assessment because Resident # 3 had done it before. LVN A said she did not consult with the physician or notify the family. Resident # 3 ' s nursing notes dated 10/24/13 at 7:00 a.m. indicated Resident # 3 was pale in color with no nausea/vomiting noted. Resident # 3 ' s nursing notes dated 10/24/13 at 11:00 a.m. indicated Resident # 3 was pale with no shortness of breath. Resident # 3 ' s nursing notes dated 10/24/13 at 1:30 p.m., indicated Resident #3 was short of breath, pale in color, blood pressure (B/P) 97/50, pulse 112, Respirations 50. Her pulse oximeter reading was 94% on room air. The physician was notified and the nurse received orders to transfer to the emergency room . During an interview on 11/12/13 at 11:30 a.m., LVN B said she was unaware Resident #3 had vomited coffee ground emesis on the 10p-6a shift. LVN B said if she had known that, she would have notified the physician earlier and would have considered that to be a change in condition. LVN B said Resident #3 should have been assessed, the physician consulted, and the family notified. During an interview on 11/12/13 at 11:00 a.m., the DON said he was unaware Resident # 3 had coffee ground emesis on 10/24/13 at 3:30 a.m. The DON said that was a change of condition and the physician should have been notified. The 24 hour/change of condition report dated 10/24/13 for the night shift indicated Resident # 3 had " ...dark emesis noted ..." The hospital history and physical dated 10/24/13 indicated Resident #3 was sent to a local hospital but had to be transferred to another hospital that was better equipped to treat her. The resident's white blood count was 30.4 (normal 3.6-11.1), Hemoglobin 6.8 (normal 11.4-14.4), hematocrit 21.5 (normal 33.3-41.4). Resident # 3 was admitted with acute [MEDICAL CONDITION], acute GI bleed,[MEDICAL CONDITION], possible pneumonia and urinary tract infection. The resident was placed on a ventilator and received two units of blood. An in-service training report dated 10/15/13 indicated anytime there was a change in a resident's condition the physician and family were to be notified. The Change in a Resident's Condition or Status policy dated April 2006 indicated " ...the facility was to promptly notify the resident's physician and family with changes in condition... " The CMS 672 dated 11/12/13 indicated a census was 45.

Based on observation, interview and record review the facility failed to accurately assess to provide the necessary care and services in accordance with the comprehensive assessment and plan of care for 1 of 4 residents reviewed for change in condition. (Resident #3) LVN A did not assess Resident #3, who had a history of [REDACTED]. Resident #3 was hospitalized with [MEDICAL CONDITION] and GI bleeding requiring a blood transfusion and was placed on a ventilator. This failure contributed to the hospitalization of Resident #3. This failure could place the census of 45 residents at risk for a delay in medical evaluation and treatment. Findings included: Physician orders [REDACTED]. There were no labs ordered to monitor for GI bleed. A patient transfer form dated 7/06/13 indicated Resident # 3 vomited large amounts of dark brown emesis with coffee ground texture and was transferred to the hospital. A hospital history & physical dated 7/7/13 indicated Resident #3 was admitted with an acute GI bleed. A nursing care plan dated 10/30/13 indicated Resident # 3 had a problem of history of GI bleed. The care plan noted staff was to monitor the resident for signs and symptoms of GI bleed and monitor labs as ordered. The most recent MDS assessment dated [DATE] indicated Resident #3 had long and short term memory problems and impaired ability to make decisions. Resident # 3 ' s nursing notes dated 10/24/13 at 3:30 a.m. indicated LVN A observed coffee ground emesis to Resident # 3's face, pillow and gown. During an interview on 11/12/13 at 11:22 a.m., LVN A said Resident # 3 vomited a small amount of coffee ground emesis. LVN A said she did not consider it a change of condition and did no further assessment because Resident # 3 had done it before. LVN A said she did not consult with the physician or notify the family. Resident # 3 ' s nursing notes dated 10/24/13 at 7:00 a.m. indicated Resident # 3 was pale in color with no nausea/vomiting noted. Resident # 3 ' s nursing notes dated 10/24/13 at 11:00 a.m. indicated Resident # 3 was pale with no shortness of breath. Resident # 3 ' s nursing notes dated 10/24/13 at 1:30 p.m., indicated Resident #3 was short of breath, pale in color, blood pressure (B/P) 97/50, pulse 112, Respirations 50. Her pulse oximeter reading was 94% on room air. The physician was notified and the nurse received orders to transfer to the emergency room . During an interview on 11/12/13 at 11:30 a.m., LVN B said she took care of Resident #3 on 10/24/13. She indicated she took Resident #3's temperature and that was normal, LVN B said she took Resident #3 ' s oxygen saturation and it was 96% on room air. She said she did no further assessment. During an interview on 11/12/13 at 11:30 a.m., LVN B said she was unaware Resident #3 had vomited coffee ground emesis on the 10p-6a shift. LVN B said if she had known that, she would have notified the physician earlier and would have considered that to be a change in condition. LVN B said Resident #3 should have been assessed, the physician consulted, and the family notified. During an interview on 11/12/13 at 11:00 a.m., the DON said he was unaware Resident # 3 had coffee ground emesis on 10/24/13 at 3:30 a.m. The DON said that was a change of condition and the physician should have been notified. The 24 hour/change of condition report dated 10/24/13 for the night shift indicated Resident # 3 had " ...dark emesis noted ..." The hospital history and physical dated 10/24/13 indicated Resident #3 was sent to a local hospital but had to be transferred to another hospital that was better equipped to treat her. The resident's white blood count was 30.4 (normal 3.6-11.1), Hemoglobin 6.8 (normal 11.4-14.4), hematocrit 21.5 (normal 33.3-41.4). Resident # 3 was admitted with acute [MEDICAL CONDITION], acute GI bleed,[MEDICAL CONDITION], possible pneumonia and urinary tract infection. The resident was placed on a ventilator and received two units of blood. An in-service training report dated 10/15/13 indicated anytime there was a change in a resident's condition the physician and family were to be notified. The Change in a Resident's Condition or Status policy dated April 2006 indicated " ...the facility was to promptly notify the resident's physician and family with changes in condition... " The CMS 672 dated 11/12/13 indicated a census was 45.