Every finding on record at Carechoice of Boerne

Based on observation, interview, and record review, the facility failed to ensure that it was free of a medication error rate below 5 percent (%) or greater. The facility had a medication error rate of 100% based on 25 out of 25 opportunities which involved four (4) of four (4) residents (Resident #1, Resident #2, Resident #3, and Resident #4) and three (3) of three (3) staff (LPN A, LPN B, and LPN C) observed for medication administration errors. 1. LPN A administered Namenda (a drug used to treat moderate-to-severe dementia, the impaired ability to remember, think, or make decisions) and Pataday (an eyedrop used to treat eye itching caused by allergies) to Resident #1 on 05/27/2026 at 09:44 a.m., 44 minutes after the scheduled administration window, 07:00 a.m. to 09:00 a.m. 2. LPN B administered Escitalopram Oxalate (a drug used to treat depression and anxiety disorders), Glipizide (a drug used to control high blood sugar in adults), and Metformin HCl (a drug used to manage high blood sugar levels) to Resident #2 on 05/27/2026 at 10:17 a.m., one (1) hour and 17 minutes after the scheduled administration window, 07:00 a.m. to 09:00 a.m. 3. LPN B administered Acetaminophen (a drug used for the short-term relief of minor aches and pains), Allopurinol (a drug used to treat gout, a type of arthritis caused by high levels of uric acid in the blood), Amlodipine Besylate (a drug used to lower blood pressure), Jardiance (a drug used to manage blood sugar levels), Lidoderm (a patch used to relieve nerve pain), Metformin HCl, MiraLax (a drug used to treat occasional constipation, infrequent bowel movements or difficulty passing stool), Pregabalin (a drug used to treat pain), and Senna (a drug used for short-term treatment of constipation) to Resident #3 on 05/27/2026 at 10:28 a.m., one (1) hour and 28 minutes after the scheduled administration window, 07:00 a.m. to 09:00 a.m. 4. LPN C administered Folic Acid (a vitamin B9 supplement used to treat low blood levels of folate), Pepcid (a drug used to reduce stomach acid), Allopurinol, Iron (an iron supplement used to treat low iron levels in the blood), a Multiple Vitamins-Minerals tablet (a supplement used to provide essential vitamins and minerals that are not taken in through the diet), Thiamine (a vitamin B1 supplement used to increase vitamin B1 levels in the blood), Lexapro (a drug used for the treatment of Major Depressive Disorder, a mood disorder that causes a persistent feeling of sadness and loss of interest), Metformin HCl, Magnesium Oxide (a magnesium supplement used to treat low magnesium levels in the blood), Metoprolol Tartrate (a drug used to lower blood pressure), and Zinc (a supplement used to increase zinc levels that are not taken in through the diet) to Resident #4 on 05/27/2026 at 10:18 a.m., 18 minutes after the scheduled administration window, 08:00 a.m. to 10:00 a.m. These failures could place residents at risk of not receiving therapeutic effects of the medications and possible adverse reactions. The findings included: 1. Record review of Resident #1's admission Record, dated 05/27/2026, reflected a [AGE] year-old female. She was admitted on [DATE]. Record review of Resident #1's Medical Diagnosis tab, undated and accessed on 05/27/2026 at 03:39 p.m., reflected diagnoses included unspecified dementia, adjustment disorder with mixed anxiety and depressed mood (a stress-related mental health condition where stressors trigger excessive worry or feelings of fear or dread and sadness or loss of interest), and constipation. Record review of Resident #1's Modification of Quarterly MDS Assessment, dated 04/09/2026, reflected the resident had a BIMS score of 11, which indicated she was moderately cognitively intact. She did not receive pain medications in the last five (5) days, did not receive injections in the last seven (7) days, and received high-risk medications classified as an antidepressant in the last seven (7) days. Record review of Resident #1's Care Plan Report, undated and accessed 05/27/2026 at 03:43 p.m., reflected the following focus and interventions: - Focus: [Resident #1] has dry eyes., date initiated 04/24/2026. - Intervention: [Resident #1] will be administered eye drops as ordered. Notify MD of concerns, date initiated 04/24/2026. - Focus: [Resident #1] has alteration in cognitive status due to Dx of Dementia, date initiated and revised 04/24/2026. - Intervention: Medications as ordered, date initiated 04/24/2026. Record review of Resident #1's Order Summary Report, printed 05/27/2026 with active orders as of 05/27/2026, reflected the following order summaries with order status, order date, start date, and end date if available: - Namenda Oral Tablet 10 MG (Memantine HCl) Give 1 tablet by mouth two times a day related to UNSPECIFIED DEMENTIA., order status Active, order date 01/24/2026, start date 01/29/2026, and no end date. - Pataday Ophthalmic Solution 0.7% (Olopatadine HCl) Instill 1 drop in both eyes one time a day for dry eyes, order status Active, order date 03/26/2026, start date 03/28/2026, and no end date. Record review of Resident #1's 05/01/2026 - 05/31/2026 Medication Administration Record, printed 05/27/2026, reflected the following orders with scheduled administration time ( Hours):- Namenda Oral Tablet 10 MG (Memantine HCl) Give 1 tablet by mouth two times a day related to UNSPECIFIED DEMENTIA., scheduled for administration at 0800 and 1700. - Pataday Ophthalmic Solution 0.7% (Olopatadine HCl) Instill 1 drop in both eyes one time a day for dry eyes, scheduled for administration at 0800. During an observation and interview of medication administration on 05/27/2026 from 09:40 a.m. to 09:44 a.m., LPN A was observed to start preparing Resident #1's medication administration at 09:40 a.m. On LPN A's electronic medication administration record screen, Resident #1's Namenda and Pataday were observed to be highlighted red and scheduled for administration at 08:00 a.m. LPN A was observed to administer Resident #1's medications at 09:44 a.m. LPN A stated Resident #1's medications were late. She stated Resident #1 would often not take her medications until after breakfast, which could result in the medications being administered late. She stated late administration could impact the resident if the medication was scheduled to be administered multiple times a day because it might result in the timeframe between medication administrations having been not far enough apart. She stated if the timeframes were too close, she would have to notify the resident's physician. 2. Record review of Resident #2's admission Record, dated 05/27/2026, reflected a [AGE] year-old female. She was admitted on [DATE]. Record review of Resident #2's Medical Diagnosis tab, undated and accessed on 05/27/2026 at 03:48 p.m., reflected diagnoses included type 2 diabetes mellitus (a condition that develops with the way the body regulates and uses sugar as fuel), anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #2's admission MDS Assessment, dated 04/23/2026, reflected the resident had a BIMS score of 12, which indicated she was moderately cognitively intact. She received scheduled pain medications in the last five (5) days, did not receive injections in the last seven (7) days, and received high-risk medications classified as antidepressant (used to relieve depression), hypoglycemic (used to lower blood sugar levels), and anticonvulsant (used to prevent seizures) in the last seven (7) days. Record review of Resident #2's Care Plan Report, undated and accessed 05/27/2026 at 03:51 p.m., reflected the following focus and interventions: - Focus: [Resident #2] has a dx of Diabetes Mellitus and receives daily medication and therapeutic diet to manage this. , date initiated and revised 04/29/2026. - Intervention: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness., date initiated 04/29/2026. - Focus: [Resident #2] is taking antidepressant medication for a mood disorder.She is at risk for adverse effects., date initiated and revised 04/29/2026. - Intervention: Administer ANTIDEPRESSANT medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT, date initiated 04/29/2026. Record review of Resident #2's Order Summary Report, printed 05/27/2026 with active orders as of 05/27/2026, reflected the following order summaries with order status, order date, start date, and end date if available: - Escitalopram Oxalate Oral Tablet 10 MG (Escitalopram Oxalate) Give 1 tablet by mouth one time a day for Depression/Anxiety, order status Active, order date 04/15/2026, start date 04/16/2026, and no end date. - Glipizide Oral Tablet 5 MG (Glipizide) Give 0.5 tablet by mouth one time a day for DM2, order status Active, order date 04/15/2026, start date 04/16/2026, and no end date.- Metformin HCl Oral Tablet 1000 MG (Metformin HCl) Give 1 tablet by mouth two times a day for DM2, order status Active, order and start date 04/15/2026, and no end date. Record review of Resident #2's 05/01/2026 - 05/31/2026 Medication Administration Record, printed 05/27/2026, reflected the following orders with scheduled administration time ( Hours):- Escitalopram Oxalate Oral Tablet 10 MG (Escitalopram Oxalate) Give 1 tablet by mouth one time a day for Depression/Anxiety, scheduled for administration at 0800. - Glipizide Oral Tablet 5 MG (Glipizide) Give 0.5 tablet by mouth one time a day for DM2, scheduled for administration at 0800. - Metformin HCl Oral Tablet 1000 MG (Metformin HCl) Give 1 tablet by mouth two times a day for DM2, scheduled for administration at 0800 and 1700. During an observation of medication administration on 05/27/2026 from 10:11 a.m. to 10:17 a.m., LPN B was observed to start preparing Resident #2's medication administration at 10:11 a.m. On LPN A's electronic medication administration record screen, Resident #2's Escitalopram Oxalate, Glipizide, and Metformin HCl were observed to be highlighted red and scheduled for administration at 08:00 a.m. LPN A was observed to administer Resident #2's medications at 10:17 a.m. 3. Record review of Resident #3's admission Record, dated 05/27/2026, reflected a [AGE] year-old female. She was admitted on [DATE]. Record review of Resident #3's Medical Diagnosis tab, undated and accessed on 05/27/2026 at 03:53 p.m., reflected diagnoses included constipation, type 2 diabetes mellitus, hypertension (condition of high pressure in the vessels that carry blood from the heart to the rest of the body), and gout (inflammatory arthritis caused by the buildup of uric acid and can lead to sudden and severe attacks of pain). Record review of Resident #3's Quarterly MDS Assessment, dated 05/08/2026, reflected the resident had a BIMS score of 4, which indicated she was severely cognitively impaired. She received scheduled and as needed pain medications in the last five (5) days, did not receive injections in the last seven (7) days, and received high-risk medications classified as an opioid (used to relieve moderate to severe pain), hypoglycemic, and an anticonvulsant in the last seven (7) days. Record review of Resident #3's Care Plan Report, undated and accessed 05/27/2026 at 04:01 p.m., reflected the following focus and interventions: - Focus: [Resident #3] has the potential for complications r/t Hypertension., date initiated and revised 11/12/2025. - Intervention: Adm medication as ordered observing for effectiveness &/or side effects. Notify physician as needed., date initiated and revised 11/12/2025. - Focus: [Resident #3] has the potential for complications r/t Diabetes, date initiated and revised 11/12/2025. - Intervention: Adm related medication as ordered observing for effectiveness &/or side effects. Notify physician as needed., date initiated 11/12/2025. - Focus: [Resident #3] has Dx of Constipation, date initiated and revised 11/12/2025. - Intervention: Monitor for potential side effects of medication and report to MD, date initiated 11/12/2025. - Focus: [Resident #3] has Dx of Gout, date initiated and revised 11/12/2025. - Intervention: Administer medications as ordered and monitor of [sic] effectiveness, date initiated 11/12/2025. - Focus: [Resident #3] is experiencing the presence of frequent pain due to generalized chronic pain., date initiated 01/22/2026 and revised 02/26/2026. - Intervention: Administer pain medication as ordered observing for effectiveness &/or side effects. Notify physician if no relief with use of pain medication &/or side effects noted., date initiated 01/22/2026. Record review of Resident #3's Order Summary Report, printed 05/27/2026 with active orders as of 05/27/2026, reflected the following order summaries with order status, order date, start date, and end date if available: - Acetaminophen Oral Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth three times a day for pain (2 tabs= 650mg), order status Active, order and start date 10/31/2025, and no end date. - Allopurinol Oral Tablet 300 MG (Allopurinol) Give 1 tablet by mouth one time a day for Gout, order status Active, order date 10/31/2025, start date 11/01/2025, and no end date.- Amlodipine Besylate Oral Tablet 5 MG (Amlodipine Besylate) Give 1 tablet by mouth two times a day for HTN *HOLD if SBP < 110 or pulse <60, order status Active, order and start date 10/31/2025, and no end date.- Jardiance Oral Tablet 25 MG (Empagliflozin) Give 1 tablet by mouth one time a day related to Type 2 Diabetes Mellitus with Hyperglycemia, order status Active, order date 11/06/2025, start date 11/07/2025, and no end date.- Lidoderm External Patch 5% (Lidocaine) Apply to Right Hip topically [to the skin] one time a day for pain and remove per schedule, order status Active, order date 10/31/2025, start date 11/01/2025, and no end date.- Metformin HCl Oral Tablet 1000 MG (Metformin HCl) Give 1 tablet by mouth two times a day for DM, order status Active, order and start date 10/31/2025, and no end date.- MiraLax Oral Powder 17 GM/SCOOP (Polyethylene Glycol 3350) Give 1 scoop by mouth two times a day for constipation, order status Active, order and start date 10/31/2025, and no end date.- Pregabalin Oral Capsule 75 MG (Pregabalin) Give 1 capsule by mouth two times a day for pain, order status Active, order and start date 10/31/2025, and no end date.- Senna Oral Tablet 8.6 MG (Sennosides) Give 1 tablet by mouth two times a day for constipation, order status Active, order and start date 10/31/2025, and no end date. Record review of Resident #3's 05/01/2026 - 05/31/2026 Medication Administration Record, printed 05/27/2026, reflected the following orders with scheduled administration time ( Hours):- Acetaminophen Oral Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth three times a day for pain (2 tabs= 650mg), scheduled for administration at 0800, 1400, and 2000. - Allopurinol Oral Tablet 300 MG (Allopurinol) Give 1 tablet by mouth one time a day for Gout, scheduled for administration at 0800. - Amlodipine Besylate Oral Tablet 5 MG (Amlodipine Besylate) Give 1 tablet by mouth two times a day for HTN *HOLD if SBP < 110 or pulse <60, scheduled for administration at 0800 and 1700. - Jardiance Oral Tablet 25 MG (Empagliflozin) Give 1 tablet by mouth one time a day related to Type 2 Diabetes Mellitus with Hyperglycemia, scheduled for administration at 0800. - Lidoderm External Patch 5% (Lidocaine) Apply to Right Hip topically [to the skin] one time a day for pain and remove per schedule, scheduled for administration at Apply 0800 and Remove 2000. - Metformin HCl Oral Tablet 1000 MG (Metformin HCl) Give 1 tablet by mouth two times a day for DM, scheduled for administration at 0800 and 1700. - MiraLax Oral Powder 17 GM/SCOOP (Polyethylene Glycol 3350) Give 1 scoop by mouth two times a day for constipation, scheduled for administration at 0800 and 1700. - Pregabalin Oral Capsule 75 MG (Pregabalin) Give 1 capsule by mouth two times a day for pain, scheduled for administration at 0800 and 1700. - Senna Oral Tablet 8.6 MG (Sennosides) Give 1 tablet by mouth two times a day for constipation, scheduled for administration at 0800 and 1700. During an observation of medication administration on 05/27/2026 from 10:17 a.m. to 10:28 a.m., LPN B was observed to start preparing Resident #3's medication administration at 10:17 a.m. On LPN A's electronic medication administration record screen, Resident #3's acetaminophen, allopurinol, amlodipine besylate, Jardiance, Lidoderm patch, metformin HCl, MiraLax, pregabalin, and senna were observed to be highlighted red and scheduled for administration at 08:00 a.m. LPN A was observed to administer Resident #3's medications at 10:28 a.m. During an interview on 05/27/2026 at 10:28 a.m., LPN B stated most of the residents' medications were scheduled at 08:00 a.m. She stated the nurses had an hour before and after the scheduled time to administer medications. She stated she would start administering some medications at 07:00 a.m., but would then have to stop for breakfast, which she stated took a chunk out of the administration time. She stated she prioritized certain medications that were scheduled to be administered a second time, at 11:00 a.m., to give at 07:00 a.m. because those medications would be too closely administered if the scheduled 08:00 a.m. medication was administered late. She stated the facility was working on addressing the late medications but those observed that were red colored in the electronic administration record were administered late. 4. Record review of Resident #4's admission Record, dated 05/27/2026, reflected a [AGE] year-old female. She was admitted on [DATE]. Record review of Resident #4's Medical Diagnosis tab, undated and accessed on 05/27/2026 at 03:19 p.m., reflected diagnoses included type 2 diabetes mellitus, gout, anemia (low number of red blood cells), hypertension, gastro-esophageal reflux disease (also known as acid-reflux disease or GERD, when the stomach contents flow back into the esophagus and cause discomfort such as heartburn), major depressive disorder, and deficiency of other vitamins. Record review of Resident #4's Quarterly MDS Assessment, dated 05/06/2026, reflected the resident had a BIMS score of 14, which indicated she was cognitively intact. She did not receive pain medications in the last five (5) days, did receive injections in the last seven (7) days, and received high-risk medications classified as an antidepressant, diuretic (medication to help reduce excess fluid from the body which can lower blood pressure and relieve fluid retention), and hypoglycemic in the last seven (7) days. Record review of Resident #4's Care Plan Report, undated and accessed 05/27/2026 at 04:01 p.m., reflected the following focus and interventions: - Focus: [Resident #4] has the potential for complications r/t Diabetes type 2 mellitus with hyperglycemia [high blood sugar level], date initiated and revised 06/14/2021.- Focus: [Resident #4] has the potential for complications r/t Hypertension, date initiated and revised 06/14/2021. - Intervention: [Resident #4] to be administered anti-hypertensive medication as ordered r/t hypotension [low blood pressure], date initiated 06/14/2021 and revised 12/09/2024. - Focus: [Resident #4] has a diagnosis of GERD Digestive disorder, date initiated and revised 06/14/2021. - Intervention: [Resident #4] to be administered medications as ordered and monitor of [sic] effectiveness, date initiated 06/14/2021 and revised 12/09/2024. - Focus: [Resident #4] is at risk for side effects/complications from antidepressant use related to Dx: Depression, date initiated and revised 07/12/2023. - Intervention: [Resident #4] to be administered related medication as ordered observing for side effects &/or adverse reactions. Notify physician if noted &/or as needed., date initiated 07/12/2023 and revised 12/09/2024. - Focus: [Resident #4] has dx of gout, date initiated 12/09/2024. - Intervention: [Resident #4] to be administered medication r/t dx of gout., date initiated 12/09/2024. - Focus: [Resident #4] is at risk due to is prone to elevated Uric Acid levels, date initiated 01/22/2026. - Intervention: Administer medication as ordered, date initiated 01/22/2026. - Focus: [Resident #4] has Dx of anemia, date initiated 09/22/2025. - Intervention: Give medications as ordered, date initiated 09/22/2025 and revised 01/22/2026. Record review of Resident #4's Order Summary Report, printed 05/27/2026 with active orders as of 05/27/2026, reflected the following order summaries with order status, order date, start date, and end date if available: - Folic Acid Tablet 1 MG Give 1 tablet by mouth one time a day for supplement, order status Active, order date 05/11/2021, start date 05/12/2021, and no end date. - Pepcid Oral Tablet 20 MG (Famotidine) Give 1 tablet by mouth one time a day for Acid reflux, order status Active, order date 08/30/2023, start date 08/31/2023, and no end date.- Allopurinol Oral Tablet 100 MG (Allopurinol) Give 1 tablet by mouth one time a day for elevated uric acid level, order status Active, order date 07/05/2023, start date 07/07/2023, and no end date. - Iron (Ferrous Sulfate) Oral Tablet 325 (65 Fe) MG (Ferrous Sulfate) Give 1 tablet by mouth two times a day for supplement per [MD name] office, order status Active, order and start date 08/26/2024, and no end date.- Multiple Vitamins-Minerals Tablet Give 1 tablet by mouth one time a day for supplement, order date 05/11/2021, start date 05/12/2021, and no end date. - Thiamine HCl Tablet 100 MG Give 1 tablet by mouth one time a day for anemia, order status Active, order date 05/11/2021, start date 05/12/2021, and no end date.- Lexapro Oral Tablet 20 MG (Escitalopram Oxalate) Give 1 tablet by mouth one time a day for MDD, order status Active, order date 06/05/2024, start date 06/06/2024, and no end date. - Metformin HCl Tablet 1000 MG give 1 tablet by mouth two times a day for DM, order status Active, order date 09/16/2021, start date 09/17/2021, and no end date.- MagOx 400 Oral Tablet (Magnesium Oxide (Mg Supplement)) Give 1 tablet by mouth two times a day for Supplement, order status Active, order and start date 12/20/2023, and no end date. - Metoprolol Tartrate Tablet 25 MG Give 1 tablet by mouth two times a day for HTN *HOLD if SBP <110 or DBP <60 or HR <60, order status Active, order date 05/11/2021, start date 05/12/2021, and no end date.- Zinc Tablet 50 MG Give 1 tablet by mouth one time a day for supplement, order status Active, order date 05/11/2021, start date 05/12/2021, and no end date. Record review of Resident #4's 05/01/2026 - 05/31/2026 Medication Administration Record, printed 05/27/2026, reflected the following orders with scheduled administration time ( Hours):- Folic Acid Tablet 1 MG Give 1 tablet by mouth one time a day for supplement, scheduled for administration at 0900. - Pepcid Oral Tablet 20 MG (Famotidine) Give 1 tablet by mouth one time a day for Acid reflux, scheduled for administration at 0900. - Allopurinol Oral Tablet 100 MG (Allopurinol) Give 1 tablet by mouth one time a day for elevated uric acid level, scheduled for administration at 0900. - Iron (Ferrous Sulfate) Oral Tablet 325 (65 Fe) MG (Ferrous Sulfate) Give 1 tablet by mouth two times a day for supplement per [MD name] office, scheduled for administration at 0900 and 1700. - Multiple Vitamins-Minerals Tablet Give 1 tablet by mouth one time a day for supplement, scheduled for administration at 0900. - Thiamine HCl Tablet 100 MG Give 1 tablet by mouth one time a day for anemia, scheduled for administration at 0900. - Lexapro Oral Tablet 20 MG (Escitalopram Oxalate) Give 1 tablet by mouth one time a day for MDD, scheduled for administration at 0900. - Metformin HCl Tablet 1000 MG give 1 tablet by mouth two times a day for DM, scheduled for administration at 0900 and 1700. - MagOx 400 Oral Tablet (Magnesium Oxide (Mg Supplement)) Give 1 tablet by mouth two times a day for Supplement, scheduled for administration at 0900 and 1700. - Metoprolol Tartrate Tablet 25 MG Give 1 tablet by mouth two times a day for HTN *HOLD if SBP <110 or DBP <60 or HR <60, scheduled for administration at 0900 and 1700. - Zinc Tablet 50 MG Give 1 tablet by mouth one time a day for supplement, scheduled for administration at 0900. During an observation and interview of medication administration on 05/27/2026 from 10:05 a.m. to 10:18 a.m., LPN A was observed to start preparing Resident #4's medication administration at 10:05 a.m. On LPN A's electronic medication administration record screen, Resident #4's folic acid, Pepcid, allopurinol, iron, multiple vitamin-mineral tablet, thiamine HCl, Lexapro, metformin HCl, magnesium oxide, metoprolol tartrate, and zinc were observed to be scheduled for administration at 09:00 a.m. LPN A was observed to administer Resident #4's medications at 10:18 a.m. LPN A stated she was familiar with the facility's medication administration policy. During an interview on 05/28/2026 at 04:11 p.m., the ADMIN stated, from his understanding, the time the staff had to administer a medication was they had an hour before and after the medication was scheduled, such as if the medication was scheduled at 08:00 a.m., they could administer the medication from 07:00 a.m. to 09:00 a.m. He stated that without knowing what the specific medication was for he could not determine the impact of a late medication administration, but if for example the medication was for pain, the late administration might result in experiencing pain before the pain was leveled off and the resident might become a little perturbed. During an interview on 05/28/2026 at 04:40 p.m., the DON stated the nursing staff had an hour before and after the scheduled administration time to administer a medication per facility procedure. She stated there could be an interruption on the floor that might delay or interrupt administration, but she would usually expect the staff to administer within the two-hour window. She stated the impact of late medication administration would depend on the number of hours between the medications next administration and if the administration was late, it could result in the next administration issued too soon, which could affect the resident. Record review of the facility's policy titled, Administering Medications, dated revised April 2019, revealed, Policy StatementMedications are administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation .4. Medications are administered in accordance with prescriber orders, including any required time frame.5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. Enhancing optimal therapeutic effect of the medication; b. Preventing potential medication or food interactions; and c. Honoring resident choices and preferences, consistent with his or her care plan.7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). Record review of the facility's policy titled, Adverse Consequences and Medication Errors, dated 2001 and revised June 2025, revealed, Medication Errors.2. Examples of medications [sic] errors include:. g. wrong time;.

Based on observations, interviews, and record reviews, the facility failed to protect the confidentiality of personal and medical records for two (2) of three (3) staff (LPN A and LPN B) observed for confidentiality of records. 1. The facility failed to ensure LPN A locked the computer on the 100-Hall medication cart, which exposed 100-Hall resident names and room numbers, so the residents' information could be seen and/or accessed by someone walking by on 05/27/2026 at 09:39 a.m. 2. The facility failed to ensure LPN B locked the computer on the 200-Hall medication cart, which exposed Resident #3's medication list, so the resident's information could be seen and/or accessed by someone walking by on 05/27/2026 at 10:18 a.m. This failure could place residents at risk of having medical information exposed to others and cause residents to feel uncomfortable and disrespected.The findings included: 1. During an observation on 100-Hall on 05/27/2026 at 09:35 a.m., revealed a computer screen on a medication cart (located outside room [ROOM NUMBER], three rooms away from the dining room) was unlocked and unsupervised with 100-Hall resident information, including resident names and room numbers. There were no residents or visitors in the immediate area. LPN A was observed to walk down the hall from the vicinity of the nurses' desk within 30 seconds of the observation and locked the computer. During an interview on 05/27/2026 at 09:39 a.m., LPN A stated the expectation for nursing staff was to usually lock the computer prior to leaving it. She stated, that was me, regarding leaving the computer unlocked. She stated she did not realize she did not lock the computer after she had entered vitals for a resident, noticed she needed to obtain a catheterization tray for an order, and prior to leaving the cart. She stated she had only left the computer and cart unattended during the time it took her to walk from the cart to obtain the catheterization tray and then return. 2. During a medication administration observation on 05/27/2026 from 10:17 a.m. to 10:28 a.m., LPN B was observed to review Resident #3's ordered medications, outside Resident #3's room, 211; and grab a blood pressure cuff from her cart. At 10:18 a.m., she left her computer unlocked and entered Resident #3's room to obtain Resident #3's blood pressure. Resident #3's electronic Medication Administration Record was observed to have been left open and unattended during the time LPN B was in Resident #3's room obtaining Resident #3's blood pressure; approximately 3 minutes. Upon returning to the computer, there were no observed residents or visitors in the immediate area. LPN B was observed to immediately document Resident #3's blood pressure and pulse values in the computer. During an interview on 05/27/2026 at 10:28 a.m., LPN B stated when she entered a resident's room, she would usually hide (lock) the screen. She stated she did not realize she had not locked the computer screen. She stated it was important to hide the screen for HIPAA and to ensure she maintained the residents' privacy. She stated the impact of not hiding the computer screen was that the residents' records would be open, and everyone could see what the resident gets (medications). During an interview on 05/28/2026 at 04:11 p.m., the ADMIN stated his expectation for nursing staff was that the computer should be secured when they were not right in front of the computer. He stated the impact of not locking the computer was that it could be a HIPAA concern, and there was the risk of someone finding out information about the person on the screen that they should not have access to. During an interview on 05/28/2026 at 04:40 p.m., the DON stated her expectation for nursing staff was that they should lock the personal health information before stepping away from their computer. She stated the impact was that other people could see health information that they should not have access to. Record review of the facility's policy titled, Resident Rights, dated revised 2016, revealed, Policy Interpretation and Implementation1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . t. privacy and confidentiality; .3. The unauthorized release, access, or disclosure of resident information is prohibited. All release, access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues. All inquiries concerning the release of resident information should be directed to the HIPAA Compliance Officer.

Based on observations, interviews, and record review the facility failed to ensure all drugs and biologicals were locked in compartments under proper temperature controls and permitted only authorized personnel to have access to the keys, for 1 of 3 medication carts (200-Hall medication cart) reviewed for security. LPN B left the 200-Hall medication cart unsupervised, unattended, and unlocked during a medication administration for approximately two (2) minutes on 05/27/2026 at 10:26 a.m. This failure could place residents at risk for misappropriation of property and or not receiving the therapeutic effects of their medications.The findings included: During a medication administration observation on 05/27/2026 from 10:17 a.m. to 10:28 a.m., LPN B was observed to review and prepare Resident #3's medications for administration. At approximately 10:26 a.m., LPN B picked up Resident #3's prepared medications in a cup, left the 200-Hall cart in the 200-Hall next to Resident #3's room, facing out toward the hallway, and entered Resident #3's room. The 200-Hall medication cart was observed to be unlocked and unattended. There were no residents or visitors in the immediate area. LPN B was observed to administer Resident #3's medications at bedside and returned to the 200-Hall medication cart at 10:28 a.m. During an interview on 05/27/2026 at 10:28 a.m., LPN B stated when she entered a resident's room, she would usually lock the cart. She stated she did not realize she had not locked the cart. She stated the impact of not locking the cart was that if a patient came by, they could open it up. She stated the narcotics would have still been secured since they were locked separately and the punch cards that held most of the resident medications would have been difficult for the residents to get into. During an interview on 05/28/2026 at 04:11 p.m., the ADMIN stated, to his understanding, the medication cart should be secured as soon as the nursing staff pull away from the medication cart. He stated the impact of not locking a medication cart was the safety of someone if they get access to the content of the cart. During an interview on 05/28/2026 at 04:40 p.m., the DON stated her expectation for nursing staff was that they should lock the medication cart anytime they are walking away from the cart. She stated the impact of not locking a medication cart was that medications could be unsecure and potentially accessed by a resident or anyone that should not have access to those medications. Record review of the facility's policy titled, Administering Medications, dated revised April 2019, revealed, Policy StatementMedications are administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation .19. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed.

Based on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedure. In response to allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source for 3 of 5 residents (Resident #2, Resident #33, and Resident #39) whose records were reviewed for abuse and neglect. 1. The facility DON failed to identify a self-inflicted injury as an alleged violation of neglect for Resident #2 on 9/16/2025 resulting in the resident having to be transported to the hospital by emergency medical services for a psych evaluation. 2. The DON failed to report an alleged violation of neglect for Resident #2 on 9/16/2025 to the Administrator of the facility and the Administrator failed to report the violation of neglect not later than 24 hours to other officials (including to the State Survey Agency) in accordance with State law through established procedure. 3. The facility failed to report an incident on 8/31/2025 in which Resident #39 intentionally struck Resident #33 with her walker. 4. The facility failed to report an injury of unknown origin to Resident #39 on 7/25/2025 that resulted in a subdural (the area surrounding the brain inside of the skull) hemorrhage. This deficient practice could place residents at risk of harm by not having their self-inflicted injuries investigated. The findings included: Review of Resident #2's admission record dated 2/11/2026 reflected a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included: dementia (describes a group of symptoms affecting memory, thinking and social abilities), mild cognitive impairment (condition characterized by noticeable memory or thinking problems), major depressive disorder (serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems), generalized anxiety disorder (mental health condition characterized by excessive, uncontrollable worry about everyday issues, affecting daily functioning and quality of life), bipolar disorder (mental health condition characterized by significant mood swings, including manic and depressive episodes), and insomnia (characterized by difficulty falling asleep, staying asleep, or waking up too early and not being able to return to sleep). Review of an incident report titled #3054 Self Inflicted Injury dated 9/16/2025 reflected the following: Incident Description: Nursing Description: [DON] Informed by talk therapist that [Resident #2} had disclosed to here that she wanted to harm herself and yesterday she drank a bottle of eye drops. Resident Description: Upon interview and assessment, [Resident #2] verified that she drank a half bottle of over the counter eye drops because she is struggling with her bipolarism right now. Was the incident witnessed: No Immediate Action Taken: [DON] immediately went to see [Resident #2] and she is alert and oriented to her situation and verified that she drank a half bottle of over the counter eye drops because she is struggling with her bipolarism right now. [DON] informed [Resident #2] that [DON] would be sending her to ER [emergency room] for evaluation and she is agreeable. [DON] asked about symptoms and [Resident #2] states she was a little queasy after taking the drops yesterday and did throw up a little. She states that she is still nauseated now but attributes it to her current mental state. Charge Nurse informed of events reported and instructed to contact Provider for ER eval and inform of self harm attempt. Per talk therapist, PMHNP was contacted with self harm information and [Resident #2] agrees to ER evaluation. Review of Resident #2's EMR hospital encounter note dated 9/16/2025 reflected the following: Risk-Psychiatric Illness Detailed Suicide Risk Overall level suicide risk: high risk Risk Stratification – Suicide – Adult Risk factors reviewed Calculated Suicide Risk: No Risk. Review of Resident #2's care plan dated 9/22/2025 and revised 12/22/2025 reflected the following: [Resident #2] has depression r/t MAJOR DEPRESSIVE DISORDER, RECURRENT MODERATE. [Resident #2] will exhibit indicators of depression, anxiety or sad mood less than daily by review date. Review of Resident #2's quarterly MDS dated [DATE] reflected a BIMS score of 15, indicating little to no cognitive impairment. It reflected Resident #2 completed functional abilities of self-care and mobility independently and without assistance. Resident #2's active diagnoses for psychiatric/mood disorder Section I included: anxiety disorder, depression, bipolar disorder and she was taking antipsychotic, antianxiety, and antidepressant high-risk medications. Review of Resident #2's electronic medical record reflected that the facility comprehensively assessed the resident's physical, mental, and psychosocial needs. Further review of Resident #2's electronic medical record reflected mental health services and medication management were being provided to assist Resident #2 with function and mood. Review of Resident #2's electronic medical record from 2/10/2026 to 2/12/2026 reflected there was no indication the self-inflicted injury incident on 9/16/2025 was reported to the ADM within 24 hours of the event; nor was it reported to the State Survey Agency not later than 24 hours following the event. In an interview on 2/11/2026 at 6:30 PM, the ADM said the facility follows state protocols with reporting incidents of abuse and neglect. He said there are different incidents that require reporting to the state. The ADM said if there is an unwitnessed fall and resident can explain what occurred he would not report. He said witnessed falls would not be reported. The ADM added that unwitnessed falls with injury requiring hospital transport if resident can say what happened he would not report it. He said suicide attempts or self-injury incidents he would report. The ADM said if abuse and neglect are not reported it could be harmful to a resident and their overall health and care at the facility. He said he does not recall the self-harm incident involving Resident #2 and said he was not aware of the incident from 9/16/2025. The ADM called DON to join the interview. In an interview on 2/11/2026 at 6:35 PM, the DON said she was aware of Resident #2's self-harm incident on 9/16/2025 as she was notified immediately and she started interventions immediately. She said Resident #2 had orders for eye drops that were kept in her room. She said the resident had been allowed over the counter eye drops to be kept in her room by her bedside. She said the resident was transported by emergency services to the hospital to undergo a psych evaluation. She said the resident was cleared the same day and discharged back to the facility. She said the over-the-counter eye drops order was discontinued the same day and removed from Resident #2's room. The DON said Resident #2 was placed on one-on-one supervision for three days following her return from the hospital. She said Resident #2 sees therapist weekly and she is stable. The DON said she is being monitored by psych services and the SW, so she did not believe the incident needed to be reported to the state. She said she did not recall if this was reported to the ADM after it occurred. In an interview on 2/12/2026 at 12:11 PM, the SW said she has been working with Resident #2 for numerous years and said she knew this incident was more of a cry for help rather than a self-harm attempt. The SW said the self-harm incident was an acute incident and not part of her baseline, not her day-to-day behavior. She said Resident #2 does have a history of psychiatric hospitalizations in the past, but working with her psychiatrist and therapist she had been stable for some time. In an interview on 2/12/2026 at 12:58 PM, the MDS Coordinator said she was familiar with Resident #2's self-injury incident on 9/16/2025 and recalls the resident was sent to the hospital for an evaluation and psych services and she followed up with resident. She said that Resident #2 was deemed safe by psychiatrist and hospital, so she did not meet criteria for significant change in status. Record review of Resident #33's admission Record dated 2/13/2026 reflected an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included unspecified dementia. Record review of Resident #33's quarterly MDS submitted 12/5/2025 reflected an unassessed BIMS score due to the cognitive status of the resident. Record review of Resident #39's admission Record dated 2/10/2025 reflected a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included unspecified dementia and traumatic subdural hemorrhage without loss of consciousness. Record review of Resident #39's quarterly MDS submitted 10/30/2025 reflected a BIMS score of 03, which indicated severely impaired cognition. Section E0200 (behavioral symptoms) reflected Resident #39 exhibited physical symptoms towards others 4 to 6 days of the lookback period. Section J1800 indicated Resident #39 had experienced 0 falls since previous assessment. Record review of Resident #39's Care Plan Report undated/printed 2/10/2026, revealed the following: 8/31/25- physical aggression initiated, redirected, anticipate needs, encourage resident to talk in a calm manner, listen, follow protocols/policy of facility (date initiat4ed 10/23/2025) 7/25/25- fall w injury, sent to Hosp w hospital admission [DATE]- 7/29/25) . (date initiated 8/11/2025) 7/25/25- x 2 falls, anticipate needs, encourage to call for help, staff to offer assistance as needed (date initiat4ed 10/23/2025). Record review of Resident #39's progress notes reflected the following entry dated 7/25/2025 at 10:29 PM by LVN D: [Radiology] at facility to perform hip x-ray from previous fall. Upon entering resident's room, resident found standing in bathroom washing hands. Resident wearing pajamas and sandals. Resident verbalized that she had fallen. Resident raised bangs and showed this nurse a large contusion to left eyebrow. Resident assisted to bed. Vitals and neuros assessed. On call [provider] notified. New order received to send resident out to ER for eval. DON notified of incident. POA [family member] notified. Record review of the facility incident report dated 2/10/2025 reflected Resident #39 had an incident of physical aggression initiated on 8/31/2025, and Resident #33 had an incident of physical aggression received on 8/31/2025. Record review of the facility incident report titled #3027 Physical Aggression Initiated dated 8/31/2025 at 8:40 AM, reflected the following: I was walking past nurse's station and observed [Resident #39] ram her rolling walker in to [sic] the legs of another resident who was sitting in her w/c in the hallway. [Resident #39] is saying in Spanish that this man is a son of a [expletive]. Resident #39's family member was interviewed on 2/09/2026 at 11:58 AM. She said Resident #39 had numerous falls over the last year that resulted in bone fractures and bleeding in her brain. She said Resident #39 becomes very agitated whenever her family is not present, and she is frequently asked by the staff to come to the facility to monitor Resident #39 for safety. She said Resident #39 is confused and not able to tell her the circumstances of the falls after they happen. Attempted interview on 2/09/2026 at 2:12 PM, Resident #33 was unable to participate due to cognitive decline. In an interview on 2/12/2026 at 10:29 AM, the DON said she did not report the physical aggression incident between Resident #33 and #39 on 8/31/2025 to HHSC because the behavior was common for Resident #39. She said Resident #33 was not injured, and Resident #39 had a known history of physical and verbal aggression. In an interview with the ADM on 2/12/2026 at 10:56 AM, he said the physical aggression incident between Resident #33 and #39 on 8/31/2025 was not reported to HHSC because it did not result in harm. He said he felt that for an incident to be reportable to HHSC, a resident must have intent to harm another resident that is not due to confusion or other cognitive decline. He said he felt that his decision to not report the incident was aligned with the regulatory standards. In a subsequent interview with the DON on 2/13/2026 at 12:32 PM, she said Resident #39 had a witnessed fall on 7/25/2025 at 4:30 PM that was attributed to ambulating without her walker. She said that later that evening, around 10:00 PM, Resident #39 told the nurse that she had fallen again but could not say when or where, and she had a new bruise on her forehead. Resident #39 was sent to the hospital at that time and diagnosed with a pelvic fracture and a subdural hemorrhage. She said that the unwitnessed fall reported by Resident #39 on 7/25/2025 was not reported to HHSC because the resident stated that she fell, and due to the resident's history of frequent falls, she felt the resident's account of the injury was sufficient to explain the head injury. She said the pelvic fracture was likely caused by the falls earlier in the day on 7/25/2025. Record review of Resident #39's admission Record dated 2/10/2025 reflected a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included unspecified dementia and traumatic subdural hemorrhage without loss of consciousness. Record review of Resident #39's quarterly MDS submitted 10/30/2025 reflected a BIMS score of 03, which indicated severely impaired cognition. Section E0200 (behavioral symptoms) reflected Resident #39 exhibited physical symptoms towards others 4 to 6 days of the lookback period. Section J1800 indicated Resident #39 had experienced 0 falls since previous assessment. Record review of Resident #39's Care Plan Report undated/printed 2/10/2026, revealed the following: 8/31/25- physical aggression initiated, redirected, anticipate needs, encourage resident to talk in a calm manner, listen, follow protocols/policy of facility (date initiat4ed 10/23/2025) 7/25/25- fall w injury, sent to Hosp w hospital admission [DATE]- 7/29/25) . (date initiated 8/11/2025) 7/25/25- x 2 falls, anticipate needs, encourage to call for help, staff to offer assistance as needed (date initiat4ed 10/23/2025). Record review of Resident #39's progress notes reflected the following entry dat4ed 7/25/2025 at 10:29 PM by LVN D: [Radiology] at facility to perform hip x-ray from previous fall. Upon entering resident's room, resident found standing in bathroom washing hands. Resident wearing pajamas and sandals. Resident verbalized that she had fallen. Resident raised bangs and showed this nurse a large contusion to left eyebrow. Resident assisted to bed. Vitals and neuros assessed. On call [provider] notified. New order received to send resident out to ER for eval. DON notified of incident. POA [family member] notified. Record review of the facility incident report dated 2/10/2025 reflected Resident #39 had an incident of physical aggression initiated on 8/31/2025, and Resident #33 had an incident of physical aggression received on 8/31/2025. Record review of the facility incident report titled #3027 Physical Aggression Initiated dated 8/31/2025 at 8:40 AM, reflected the following: I was walking past nurse's station and observed [Resident #39] ram her rolling walker in to [sic] the legs of another resident who was sitting in her w/c in the hallway. [Resident #39] is saying in Spanish that this man is a son of a [expletive]. Resident #39's family member was interviewed on 2/09/2026 at 11:58 AM. She said Resident #39 had numerous falls over the last year that resulted in bone fractures and bleeding in her brain. She said Resident #39 becomes very agitated whenever her family is not present, and she is frequently asked by the staff to come to the facility to monitor Resident #39 for safety. She said Resident #39 is confused and not able to tell her the circumstances of the falls after they happen. Attempted interview on 2/09/2026 at 2:12 PM, Resident #33 was unable to participate in due to cognitive decline. In an interview on 2/12/2026 at 10:29 AM, the DON said she did not report the physical aggression incident between Resident #33 and #39 on 8/31/2025 to HHSC because the behavior was common for Resident #39. She said Resident #33 was not injured, and Resident #39 had a known history of physical and verbal aggression. In an interview with the ADM on 2/12/2026 at 10:56 AM, he said the physical aggression incident between Resident #33 and #39 on 8/31/2025 was not reported to HHSC because it did not result in harm. He said he felt that for an incident to be reportable to HHSC, a resident must have intent to harm another resident that is not due to confusion or other cognitive decline. He said he felt that his decision to not report the incident was aligned with the regulatory standards. In an interview with the ADM on 2/12/2026 at 10:56 AM, he said the physical aggression incident between Resident #33 and #39 on 8/31/2025 was not reported to HHSC because it did not result in harm. He said he felt that for an incident to be reportable to HHSC, a resident must have intent to harm another resident that is not due to confusion or other cognitive decline. He said he felt that his decision to not report the incident was aligned with the regulatory standards. In a subsequent interview with the DON on 2/13/2026 at 12:32 PM, she said Resident #39 had a witnessed fall on 7/25/2025 at 4:30 PM that was attributed to ambulating without her walker. She said that later that evening, around 10:00 PM, Resident #39 told the nurse that she had fallen again but could not say when or where, and she had a new bruise on her forehead. Resident #39 was sent to the hospital at that time and diagnosed with a pelvic fracture and a subdural hemorrhage. She said that the unwitnessed fall reported by Resident #39 on 7/25/2025 was not reported to HHSC because the resident stated that she fell, and due to the resident's history of frequent falls, she felt the resident's account of the injury was sufficient to explain the head injury. She said the pelvic fracture was likely caused by the falls earlier in the day on 7/25/2025. Record review of facility document titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating dated September 2022 reflected the following: Policy Statement All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation Reporting Allegations to the Administrator and Authorities 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.

Based on interview and record review the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 kitchen reviewed.The facility failed to employ a qualified dietician or other clinically qualified nutrition professional on a full-time basis or designate a qualified director of nutritional services. A qualified director of nutritional services was last employed February 2025. The facility failed to employ a qualified dietician who designates a person to serve as a full-time director of food and nutrition services for the facility. The person designated to serve as a director of food and nutrition services did not have the qualifications to serve as the director of food and nutrition.These failures could place residents at risk of not having their nutritional needs met.Findings included:In an interview on 2/11/2026 at 11:45 AM, the FSS said she does not have the qualifications to serve as the director of food and nutrition services for the facility. The FSS said she had been working on becoming a certified dietary manager for about a year now. She said she accepted the full-time FSS position over a year back when the former FSS retired after 40 years. She said she was offered the position along with the training to become certified. She said she does have her food safe certification.In an interview on 2/11/2026 at 2:05 PM, the ADM said the facility had been without a qualified director of nutritional services for almost a year. He said he did not know the dietician could not designate the FSS as she does not have qualifications needed and that she is near the end of her training and would be obtaining her director of nutritional services certification within a few weeks. He said he did not see an impact to resident care as he had a dietician on a consultant basis providing resident assessments and guidance to the FSS.Record review of the facility document titled, CONSULT ANT DIETITIAN REPORT dated 11/17/2025, reflected the following: Summary of Consultation Activities: counseled patients on diets.reviewed patients' charts.observed meal preparation/menu followed.discussed general dietetic department admin.resident - problem - recommendation. 1. Completed assessments and MNAs on new admissions. FSS reported she is not completing MNAs due to time constraints.Record review of the facility document titled, CONSULT ANT DIETITIAN REPORT dated 12/23/2025, reflected the following: resident - problem - recommendation. 2. Observed lunch meal service in the dining room. Inadequate portions of pureed foods provided to residents on pureed diets.Limited discussion with cook due to language barrier. Other Dietary staff attempted to translate. Visually showed cook diet spreadsheets and numbers indicated on scoops to serve adequate portions.Recommend: FSS to provide training to cooks on diet spreadsheets and proper portions . 3. Reviewed monthly weights and identified significant weight losses/gains. Completed consults as needed. 4. Received current wound report. No new pressure injuries. 5. Completed assessments and MNAs on new admissions, readmission and annuals due. 6. FSS has submitted no lessons of CDM course for RD review this month.Record review of the facility document titled, CONSULT ANT DIETITIAN REPORT dated 1/26/2026, reflected the following: resident - problem - recommendation. 1. Completed assessments remotely today due to ice storm and icy road conditions. Assessed new admissions, new resident on TF [total fat], significant weight losses/gains, pressure injuries and annuals.Record review of facility document titled, Dietitian dated October 2017 reflected the following: Policy StatementA qualified, competent, and skilled Dietitian will help oversee the food and nutrition services in the facility. Policy Interpretation and Implementation 1. A qualified Dietitian or other clinically qualified nutrition professional will help oversee food and nutrition services provided to the residents.2. A Food and Nutrition Services Manager will oversee the production, storage, and delivery of food. The Dietitian will work closely with the Food and Nutrition Services Manager and clinical staff. 3. The Dietitian or nutrition professional may be a full time or part time consultant or an employee, depending on the current requirements of the facility. These requirements are based on: a. assessments and care plans of resident nutritional needs; and b. the overall facility assessment of the number, acuity and diagnoses of the resident population. 4. The Dietitian will have the qualifications, competency and skills to carry out the functions of the food and nutrition services. 7. If a dietitian is not employed full time (35 or more hours per week) a director of food service management will be designated. This individual will: a. be a certified dietary manager; or b. be a certified food service manager; or c. be nationally certified in food service management and safety; or d. have an associate's (or higher) degree in food service management or hospitality (must be from an accredited institution and include courses in food service or restaurant management); e. Meet any state requirements for food service or dietary managers; and f. Receive frequently scheduled consultations from a qualified dietitian or qualified nutrition profes sional.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 (Resident #4) residents reviewed for infection control. The facility failed to ensure staff utilized proper PPE while providing incontinence care to Resident #4 on 2/11/2026 at 9:36 AM. This failure could lead to the spread of infection and illness. Findings included: Record review of Resident #4's admission Record dated 2/12/2026 revealed an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included pressure ulcer of sacral region [tailbone area on the lower back], stage 3. Record review of Resident #4's quarterly MDS submitted 10/31/2025 revealed a BIMS score of 0 and that the resident is rarely understood. Record review of Resident #4's Order Summary dated 2/12/2026 revealed the following physician's order: Place resident on Enhanced barrier precautions for the following direct care services: Dressing or bathing Transferring Changing linens Assisting with toileting Accessing indwelling medical devices Providing wound care Other high-contact resident care activities, start 1/28/2025 Record review of Resident #4's Care Plan Report, undated/printed 2/12/2026, revealed the following:[Resident #4} is on enhanced barrier precautions r/t wound. Initiation 12/9/2025 In an observation on 2/11/2026 at 9:36 AM, Resident #4's room had a sign posted on the doorway to her room indicating she required EBP precautions. A cart containing PPE supplies were observed in the hallway near Resident #4's doorway. CNA A and CNA B were observed performing incontinence care without donning PPE. In an interview with CNA A and B on 2/11/2026 at 9:45 AM, both staff members said they should have put on gowns prior to entering the room. Both staff members said they were nervous about the observation and forgot, and both had received training from the facility about infection control and isolation precautions. Both staff members said the risk to residents of not donning PPE appropriately was the spread of infection. In an interview with the DON on 2/11/2026 at 10:00 AM, she said her expectation and the facility policy was that staff members would utilize proper PPE when providing care for residents. She said the risk of staff not utilizing PPE properly was the spread of infection.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored the facility must store under proper temperature controls for 1 of 1 medication cart (100 hall cart) reviewed for medication storage. The facility failed to ensure Humalog insulin for Resident #8 was discarded after 28 days of opening. This failure could lead to reduced therapeutic effect of medication. Findings included:In an observation and interview on 2/10/2026 at 8:15 AM with the DON, the medication cart for the 200-hall was observed to contain a Humalog insulin vial for Resident #8 with an opened-on date of 12/29/2025. The DON was unsure what the facility's policy was for insulin storage once opened. In an interview on 2/10/2026 at 8:55 AM, LVN C said the facility policy was to keep insulin for 28 days after opening, and the vial should have been discarded on 1/26/2026. She said the label was folded in a position that obstructed her view, and she did not notice. She said Resident #8 had received medication from the vial. Record review of the facility policy titled Medication Labeling and Storage dated 2001, revealed the following:5. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.

Based on interviews and record reviews, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 2 residents (Resident #2) reviewed for care plans.The facility failed to update or add interventions to Resident #2's care plan regarding a self-inflicted incident that occurred on 9/16/2025.These failures could place residents at risk of not receiving the necessary services or having the appropriate interventions to meet their current needs. The findings included:Review of Resident #2's admission record dated 2/11/2026 reflected a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included: dementia (describes a group of symptoms affecting memory, thinking and social abilities), mild cognitive impairment (condition characterized by noticeable memory or thinking problems), major depressive disorder (serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems), generalized anxiety disorder (mental health condition characterized by excessive, uncontrollable worry about everyday issues, affecting daily functioning and quality of life), bipolar disorder (mental health condition characterized by significant mood swings, including manic and depressive episodes), and insomnia (characterized by difficulty falling asleep, staying asleep, or waking up too early and not being able to return to sleep.)Review of Resident #2's EMR Psychiatric Subsequent Assessment, dated 9/10/2025 reflected the following: Chief Complaint: Doing OK Medical Necessity for visit: Patient seen today for chronic psychiatric conditions not requiring prescription management. Review of Systems Psychiatric: no current episodes Mental Status Examination: Suicidal Ideation: None Assessment/Plan: [Resident #2] Endorses she's doing OK no current symptoms of depression or mood changesReview of an incident report titled #3054 Self Inflicted Injury dated 9/16/2025 reflected the following: Incident Description: Nursing Description: [DON] Informed by talk therapist that [Resident #2} had disclosed to here that she wanted to harm herself and yesterday she drank a bottle of eye drops. Resident Description: Upon interview and assessment, [Resident #2] verified that she drank a half bottle of over the counter eye drops because she is struggling with her bipolarism right now. Was the incident witnessed: No Immediate Action Taken: [DON] immediately went to see [Resident #2] and she is alert and oriented to her situation and verified that she drank a half bottle of over the counter eye drops because she is struggling with her bipolarism right now. [DON] informed [Resident #2] that [DON] would be sending her to ER [emergency room] for evaluation and she is agreeable. [DON] asked about symptoms and [Resident #2] states she was a little queasy after taking the drops yesterday and did throw up a little. She states that she is still nauseated now but attributes it to her current mental state. Charge Nurse informed of events reported and instructed to contact Provider for ER eval and inform of self harm attempt. Per talk therapist, PMHNP was contacted with self harm information and [Resident #2] agrees to ER evaluation.Review of Resident #2's EMR hospital encounter note dated 9/16/2025 reflected the following: Risk-Psychiatric Illness Detailed Suicide Risk Overall level suicide risk: high risk Risk Stratification - Suicide - Adult Risk factors reviewed Calculated Suicide Risk: No RiskReview of Resident #2's EMR Psychiatric Subsequent Assessment, dated 9/22/2025, reflected the following: Top Target Symptoms: Description: Current Rating: Anxiety 6 - Severe Depression 6 - Severe Guilt Feelings 6 - Severe Intervention: Assessed current mood and anxiety symptoms to ascertain current emotional functioning. Addressed trauma triggers and continued verbal No Self Harm contract. Patient's Response to Intervention: [Resident #2] denies any [suicide ideations]and agrees to No Self Harm contract.Plan For Next Session: Continue to address recent [suicide ideation] and trauma.Review of Resident #2's care plan dated 9/22/2025 and revised 12/22/2025 reflected the following: [Resident #2] has depression r/t MAJOR DEPRESSIVE DISORDER, RECURRENT MODERATE. [Resident #2] will exhibit indicators of depression, anxiety or sad mood less than daily by review date. There was no care planning related to suicide risk, self-inflicted injury or suicide ideations.Review of Resident #2's EMR Psychiatric Clinical Treatment Plan Review (Plan of Care) dated 9/09/2025 reflected the following: Psychiatric History: [Resident #2] endorsed long history of mental illness including several months of inpatient psychiatric care 20 years ago and subsequent outpatient therapy and medication maintenance. The Brief Psychiatric Rating Scale: Description: Current Rating: Anxiety 3 - Mild Depression 3 - Mild Guilt Feelings 3 - MildReview of Resident #2's quarterly MDS dated [DATE] reflected a BIMS score of 15, indicating little to no cognitive impairment. It reflected Resident #2 completed functional abilities of self-care and mobility independently and without assistance. Resident #2's active diagnoses for psychiatric/mood disorder Section I included: anxiety disorder, depression, bipolar disorder and she was taking antipsychotic, antianxiety, and antidepressant high-risk medications.Review of Resident #2's electronic medical record from 2/10/2026 to 2/12/2026 reflected that no significant change in status assessment or interdisciplinary review was completed following a self-inflicting injury/self-harm incident, a major deviation from Resident #2's established baseline health on 9/16/2025.Review of Resident #2's electronic medical record from 2/10/2026 to 2/12/2026 reflected that the facility provided Resident #2 with interventions of mental health services and medication management to assist Resident #2 with function and mood.In an interview on 2/11/2026 at 6:30 PM, the DON said she understands accuracy and updates to care plans are necessary to ensure interventions are in place and to give residents the best possible care. She said she does not recall why the care plan was not updated for Resident #2 following her 9/16/2025 self-inflicted injury incident.In an interview on 2/12/2026 at 12:11 PM, the SW said the self-harm incident for Resident #2 on 9/16/2025 was an acute incident and not part of her baseline, not her day-to-day behavior. She said Resident #2 did have a history of psychiatric hospitalizations in the past, but she is working with her psychiatrist and therapist and has been stable for some time.In an interview on 2/12/2026 at 12:58 PM, the MDS Coordinator said significant changes in status assessments and care plans are required to be accurate and submitted on time. She said by not completing assessments or significant change in status could negatively impact care plans and the care provided to a resident. She said that she is required to review 24-hour nursing notes and attend the nursing management daily meetings for resident changes or incidents from the prior shift. She said if an incident occurs that may be a significant change she would reach out to the regional nursing coordinator for assistance and change of condition assessment guidance. She said she was familiar with Resident #2's self-injury incident on 9/16/2025 and recalls the resident was sent to the hospital for an evaluation and psych services followed up with resident. She said that Resident #2 was deemed safe by psychiatrist and hospital, so she didn't meet criteria for significant change in status. MDS Coordinator said the self-injury incident was a one-off occurrence and she did not believe this triggers for a significant change in status assessment. She said Resident #2 would have returned to baseline with staff help. She said the incident should have been updated in Resident #2's care plan and believes there was a communication issue. She said she will work on having the care plan updated immediately.In an interview on 2/11/2026 at 6:30 PM, the ADM said suicide attempts or self-injury incidents are to be investigated. He said he does not recall being informed of this incident and referred me to the DON for more details.In an interview on 2/11/2026 at 6:35 PM, the DON said she was aware of Resident #2's self-harm incident on 9/16/2025 as she was notified immediately and she started interventions immediately. She said the resident was transported by emergency services to the hospital to undergo a psych evaluation. She said the resident was cleared the same day and discharged back to the facility. She said the over-the-counter eye drops order was discontinued the same day and removed from Resident #2's room. The DON said Resident #2 was placed on one-on-one supervision for three days following her return from the hospital. She said Resident #2 sees therapist weekly and she is stable. The DON said that this self-inflicted injury incident should have been care planned for Resident #2 and I would need to speak to the MDS Coordinator for further details.In an interview on 2/12/2026 at 12:11 PM, the SW said she has been working with Resident #2 for numerous years and said she knew this self-inflicted injury on 9/16/2025 was more of a cry for help rather than a self-harm attempt. The SW said the self-harm incident was an acute incident and not part of Resident #2's baseline and not her day-to-day behavior. She said Resident #2 has had other incidents in the past that were acute, many that were brought on from a urinary tract infection. She said Resident #2 does have a history of psychiatric hospitalizations in the past, but she is working with her psychiatrist and therapist, and she had been stable for some time now.In an interview on 2/12/2026 at 5:28 PM, the DON said the self-injury incident with Resident #2 was a significant change to her baseline and was an acute psychiatric episode. She said Resident #2 should have been care planned for psychiatric episode and she doesn't understand why this was not completed and I would need to follow up with the MDS Coordinator for more information.Record review of facility document titled, Care Plans, Comprehensive Person-Centered dated March 2022 reflected the following: Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 2. The comprehensive, person-centered care plan is developed within seven (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. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 7. The comprehensive, person-centered care plan:a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; (2) any specialized services to be provided as a result of PASARR recommendations. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition.Record review of facility document titled, Change in a Resident's Condition or Status dated May 2017 reflected the following: Policy Interpretation and Implementation 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); b.Impacts more than one area of the resident's health status; c. Requires interdisciplinary review and/or revision to the care plan; and d. Ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 9. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA regulations governing resident assessments and as outlined in the MDS RAI Instruction Manual.

Based on interview and record review, the facility failed to complete a Significant Change MDS assessment within 14 days after the facility determined, or should have determined, there had been a significant change in a resident's physical or mental condition for 1 of 8 residents (Resident #2) reviewed for assessments. The facility failed to complete a Significant Change MDS for Resident #2 after a self-injury incident on 9/16/2025. This failure could place residents who had a significant change in condition at risk of not receiving needed services.The findings included:Review of Resident #2's admission record dated 2/11/2026 reflected a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included: dementia (describes a group of symptoms affecting memory, thinking and social abilities), mild cognitive impairment (condition characterized by noticeable memory or thinking problems), major depressive disorder (serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems), generalized anxiety disorder (mental health condition characterized by excessive, uncontrollable worry about everyday issues, affecting daily functioning and quality of life), bipolar disorder (mental health condition characterized by significant mood swings, including manic and depressive episodes), and insomnia (characterized by difficulty falling asleep, staying asleep, or waking up too early and not being able to return to sleep.)Review of Resident #2's quarterly MDS dated [DATE] reflected a BIMS score of 15, indicating little to no cognitive impairment. It reflected Resident #2 completed functional abilities of self-care and mobility independently and without assistance. Resident #2's active diagnoses for psychiatric/mood disorder Section I included: anxiety disorder, depression, bipolar disorder and she was taking antipsychotic, antianxiety, and antidepressant high-risk medications.Review of Resident #2's care plan dated 9/22/2025 and revised 12/22/2025 reflected the following: [Resident #2] has depression r/t MAJOR DEPRESSIVE DISORDER, RECURRENT MODERATE. [Resident #2] will exhibit indicators of depression, anxiety or sad mood less than daily by review date.Review of Resident #2's EMR Psychiatric Subsequent Assessment, dated 9/10/2025 reflected the following: Chief Complaint: Doing OK Medical Necessity for visit: Patient seen today for chronic psychiatric conditions not requiring prescription management. Review of Systems Psychiatric: no current episodes Mental Status Examination: Suicidal Ideation: None Assessment/Plan: [Resident #2] Endorses she's doing OK no current symptoms of depression or mood changesReview of an incident report titled #3054 Self Inflicted Injury dated 9/16/2025 reflected the following: Incident Description: Nursing Description: [DON] Informed by talk therapist that [Resident #2} had disclosed to here that she wanted to harm herself and yesterday she drank a bottle of eye drops. Resident Description: Upon interview and assessment, [Resident #2] verified that she drank a half bottle of over the counter eye drops because she is struggling with her bipolarism right now. Was the incident witnessed: No Immediate Action Taken: [DON] immediately went to see [Resident #2] and she is alert and oriented to her situation and verified that she drank a half bottle of over the counter eye drops because she is struggling with her bipolarism right now. [DON] informed [Resident #2] that [DON] would be sending her to ER [emergency room] for evaluation and she is agreeable. [DON] asked about symptoms and [Resident #2] states she was a little queasy after taking the drops yesterday and did throw up a little. She states that she is still nauseated now but attributes it to her current mental state. Charge Nurse informed of events reported and instructed to contact Provider for ER eval and inform of self harm attempt. Per talk therapist, PMHNP was contacted with self harm information and [Resident #2] agrees to ER evaluation.Review of Resident #2's EMR hospital encounter note dated 9/16/2025 reflected the following: Risk-Psychiatric Illness Detailed Suicide Risk Overall level suicide risk: high risk Risk Stratification - Suicide - Adult Risk factors reviewed Calculated Suicide Risk: No RiskReview of Resident #2's EMR Psychiatric Subsequent Assessment, dated 9/22/2025, reflected the following: Top Target Symptoms: Description: Current Rating: Anxiety 6 - Severe Depression 6 - Severe Guilt Feelings 6 - Severe Intervention: Assessed current mood and anxiety symptoms to ascertain current emotional functioning. Addressed trauma triggers and continued verbal No Self Harm contract. Patient's Response to Intervention: [Resident #2] denies any [suicide ideations]and agrees to No Self Harm contract.Plan For Next Session: Continue to address recent [suicide ideation] and trauma.Review of Resident #2's EMR Psychiatric Clinical Treatment Plan Review (Plan of Care) dated 9/09/2025 reflected the following: Psychiatric History: [Resident #2] endorsed long history of mental illness including several months of inpatient psychiatric care 20 years ago and subsequent outpatient therapy and medication maintenance. The Brief Psychiatric Rating Scale: Description: Current Rating: Anxiety 3 - Mild Depression 3 - Mild Guilt Feelings 3 - Mild.Review of Resident #2's electronic medical record reflected that no significant change in status assessment or interdisciplinary review was completed following a self-inflicting injury/self-harm incident, a major deviation from Resident #2's established baseline health on 9/16/2025.Review of Resident #2's electronic medical record reflected that the facility comprehensively assessed the resident's physical, mental, and psychosocial needs. Further review of Resident #2's electronic medical record reflected mental health services and medication management were being provided to assist Resident #2 with function and mood.In an interview on 2/11/2026 at 6:30 PM, the DON said she does not recall why the MDS assessment, and the care plan was not updated for Resident #2 and understands that accuracy of MDS assessments is needed for any resident to ensure interventions are in place and to give them the best possible care.In an interview on 2/12/2026 at 12:11 PM, the SW said she had been working with Resident #2 for numerous years and said she knew this incident was more of a cry for help rather than a self-harm attempt. SW said the self-harm incident was an acute incident and not part of her baseline, not her day-to-day behavior. She said Resident #2 does have a history of psychiatric hospitalizations in the past, but working with her psychiatrist and therapist she had been stable for some time.In an interview on 2/12/2026 at 12:58 PM, the MDS Coordinator said admission MDS assessments and significant change in status assessments are required to be accurate and submitted on time. She said by not completing MDS assessments or significant change in status assessments could negatively impact care plans and the care provided to a resident. She said that she is required to review 24-hour nursing notes and attend the nursing management daily meetings for resident changes or incidents from the prior shift. She said if an incident occurs that may be a significant change she would reach out to the [NAME] nursing coordinator for assistance and change of condition assessment guidance. She said she was familiar with Resident #2's self-injury incident on 9/16/2025 and recalls the resident was sent to the hospital for an evaluation and psych services followed up with resident. She said that Resident #2 was deemed safe by psychiatrist and hospital, so she didn't meet criteria for significant change in status. The MDS Coordinator said the self-injury incident was a one-off occurrence and she did not believe this triggers for a significant change in status assessment. She said Resident #2 would have returned to baseline with staff help. She said the incident should have been updated in Resident #2's care plan and believes there was a communication issue. She said she will work on having the care plan updated immediately.In an interview on 2/12/2026 at 5:28 PM, the DON said the self-injury incident with Resident #2 was a significant change to her baseline and was an acute psychiatric episode. She said she is not an expert on MDS assessments, but there are certain criteria that are required to lead to a significant change assessment. She said an RAI assessment should have been completed following Resident #2's self-injury incident on 9/16/25. She also added that Resident #2 should have been care planned for psychiatric episode.Record review of facility document titled, Change in a Resident's Condition or Status dated May 2017 reflected the following: Policy Interpretation and Implementation 2. A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); b. Impacts more than one area of the resident's health status; c. Requires interdisciplinary review and/or revision to the care plan; and d. Ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 9. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA regulations governing resident assessments and as outlined in the MDS RAI Instruction Manual.Record review of facility document titled, MDS Completion and Submission Timeframes dated October 2023 reflected the following: Policy Statement Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. 1. The assessment coordinator or designee is responsible for ensuring resident assessments are submitted to CMS' Internet Quality Improvement Evaluation System (iQIES) in accordance with current federal and state guidelines. 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual.Record review of facility document titled, Care Plans, Comprehensive Person-Centered dated March 2022 reflected the following: Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 2. The comprehensive, person-centered care plan is developed within seven (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. 3.The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 7. The comprehensive, person-centered care plan:a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; (2) any specialized services to be provided as a result of PASARR recommendations. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition.

Based on interview and record review the facility failed to, in response to allegations of abuse, neglect, exploitation, or mistreatment, have evidence that all alleged violations are thoroughly investigated and report the results of all investigations to the state survey agency within five working days of the incident for 1 of 2 residents (Resident #2) reviewed for abuse and neglect. The facility failed to investigate when Resident #2 had a self-inflicted injury on 9/16/2025.This deficient practice placed all residents at risk of harm from neglect due to not having a thorough investigation conducted.The findings included:Review of Resident #2's admission record dated 2/11/2026 reflected a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included: dementia (describes a group of symptoms affecting memory, thinking and social abilities), mild cognitive impairment (condition characterized by noticeable memory or thinking problems), major depressive disorder (serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems), generalized anxiety disorder (mental health condition characterized by excessive, uncontrollable worry about everyday issues, affecting daily functioning and quality of life), bipolar disorder (mental health condition characterized by significant mood swings, including manic and depressive episodes), and insomnia (characterized by difficulty falling asleep, staying asleep, or waking up too early and not being able to return to sleep).Review of an incident report titled #3054 Self Inflicted Injury dated 9/16/2025 reflected the following: Incident Description: Nursing Description: [DON] Informed by talk therapist that [Resident #2} had disclosed to here that she wanted to harm herself and yesterday she drank a bottle of eye drops. Resident Description: Upon interview and assessment, [Resident #2] verified that she drank a half bottle of over the counter eye drops because she is struggling with her bipolarism right now. Was the incident witnessed: No Immediate Action Taken: [DON] immediately went to see [Resident #2] and she is alert and oriented to her situation and verified that she drank a half bottle of over the counter eye drops because she is struggling with her bipolarism right now. [DON] informed [Resident #2] that [DON] would be sending her to ER [emergency room] for evaluation and she is agreeable. [DON] asked about symptoms and [Resident #2] states she was a little queasy after taking the drops yesterday and did throw up a little. She states that she is still nauseated now but attributes it to her current mental state. Charge Nurse informed of events reported and instructed to contact Provider for ER eval and inform of self harm attempt. Per talk therapist, PMHNP was contacted with self harm information and [Resident #2] agrees to ER evaluation.Review of Resident #2's EMR hospital encounter note dated 9/16/2025 reflected the following: Risk-Psychiatric IllnessDetailed Suicide Risk Overall level suicide risk: high risk Risk Stratification - Suicide - Adult Risk factors reviewedCalculated Suicide Risk: No Risk.Review of Resident #2's care plan dated 9/22/2025 and revised 12/22/2025 reflected the following: [Resident #2] has depression r/t MAJOR DEPRESSIVE DISORDER, RECURRENT MODERATE. [Resident #2] will exhibit indicators of depression, anxiety or sad mood less than daily by review date.Review of Resident #2's quarterly MDS dated [DATE] reflected a BIMS score of 15, indicating little to no cognitive impairment. It reflected Resident #2 completed functional abilities of self-care and mobility independently and without assistance. Resident #2's active diagnoses for psychiatric/mood disorder Section I included: anxiety disorder, depression, bipolar disorder and she was taking antipsychotic, antianxiety, and antidepressant high-risk medications. There was no indication of self-harm documented.Review of Resident #2's electronic medical record from 2/10/2026 to 2/12/2026 reflected that the facility comprehensively assessed the resident's physical, mental, and psychosocial needs. Further review of Resident #2's electronic medical record reflected mental health services and medication management were being provided to assist Resident #2 with function and mood.Review of Resident #2's electronic medical record from 2/10/2026 to 2/12/2026 reflected there was no indication the self-inflicted injury incident on 9/16/2025 was reported to the ADM within 24 hours of the event; nor was it reported to the State Survey Agency not later than 24 hours following the event and no indication the facility initiated an investigation of alleged violation of abuse or neglect.In an interview on 2/11/2026 at 6:30 PM, the ADM said the facility follows state protocols with investigating incidents of abuse and neglect. He said suicide attempts or self-injury incidents he would report and would undergo an investigation. ADM said if abuse and neglect are not reported it could be harmful to a resident and their overall health and care at the facility. He said he does not recall the self-harm incident on 9/16/2025 involving Resident #2 and he did not investigate. ADM called DON to join the interview.In an interview on 2/11/2026 at 6:35 PM, the DON said she was aware of Resident #2's self-harm incident on 9/16/2025 as she was notified immediately and she started interventions immediately. She said Resident #2 had orders for eye drops that were kept in her room. She said the resident had been allowed over the counter eye drops to be kept in her room by her bedside. She said the resident was transported by emergency services to the hospital to undergo a psych evaluation. She said the resident was cleared the same day and discharged back to the facility. She said the over-the-counter eye drops order was discontinued the same day and removed from Resident #2's room. DON said Resident #2 was placed on one-on-one supervision for three days following her return from the hospital. She said Resident #2 sees therapist weekly and she is stable. DON said she is being monitored by psych services and SW, so she didn't believe the incident needed to be reported to the state and did not require an investigation. She said she did not recall if this incident was reported to the ADM after it occurred.In an interview on 2/12/2026 at 12:11 PM, the SW said she has been working with Resident #2 for numerous years and said she knew this self-inflicted injury on 9/16/2025 was more of a cry for help rather than a self-harm attempt. SW said the self-harm incident was an acute incident and not part of Resident #2's baseline and not her day-to-day behavior. She said Resident #2 does have a history of psychiatric hospitalizations in the past, but she is working with her psychiatrist and therapist, and she had been stable for some time now.In an interview on 2/12/2026 at 12:58 PM, the MDS Coordinator said she was familiar with Resident #2's self-injury incident on 9/16/2025 and recalls the resident was sent to the hospital for an evaluation and psych services and she followed up with resident. She said that Resident #2 was deemed safe by psychiatrist and hospital, so she didn't meet criteria for significant change in status assessment.Record review of facility document titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating dated September 2022 reflected the following: Policy Statement All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation Reporting Allegations to the Administrator and Authorities 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative; d. Adult protective services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's attending physician; and g. The facility medical director. 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. 6. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents. Investigating Allegations I. All allegations are thoroughly investigated. The administrator initiates investigations. 7. The individual conducting the investigation as a minimum: a. reviews the documentation and evidence; b. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; c. observes the alleged victim, including his or her interactions with staff and other residents; d. interviews the person(s) reporting the incident; e. interviews any witnesses to the incident; f. interviews the resident (as medically appropriate) or the resident's representative; g. interviews the resident's attending physician as needed to determine the resident's condition; h. interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; I. documents the investigation completely and thoroughly. 9. The investigator notifies the ombudsman that an abuse investigation is being conducted. The ombudsman is invited to participate in the review process. I 0. The investigator consults daily with the administrator concerning the progress/findings of the investigation. 11. Upon conclusion of the investigation, the investigator records the findings of the investigation on approved documentation forms and provides the completed documentation to the administrator. Follow-Up Report I. Within five (5) business days of the incident, the administrator will provide a follow-up investigation report. 2. The follow-up investigation report will provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified. 3. The follow-up investigation report will provide as much information as possible at the time of submission of the report.

Based on interviews and record reviews, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for one of seven residents (Resident #1) reviewed for care plans. The facility failed to update or add interventions to Resident #1's care plan regarding the loss of her hearing aids that impacted her communication abilities.This failure could place residents at risk of not receiving the necessary services or having the appropriate interventions to meet their current needs.The findings included: Record review of Resident #1's admission Record, dated 10/14/2025, revealed a [AGE] year-old female admitted on [DATE]. Record review of Resident #1's Medical Diagnoses, dated 10/14/2025, revealed diagnoses including unspecified dementia (range of symptoms affecting memory, thinking, and social abilities), Alzheimer's disease (most common type of dementia), nondisplaced fracture of head of left radius, initial encounter for closed fracture (means that the fracture has not caused the bone fragments to shift out of alignment and has not punctured the skin), depression (mental state of low mood and aversion to activity), and muscle weakness. Record review of Resident #1's Significant Change MDS Assessment, dated 09/04/2025, reflected Resident #1 had a BIMS of 00, indicating severe cognitive impairment, which was a significant change upon admission of 08 indicating moderate cognitive impairment. She was noted as having moderate difficulty with hearing when using hearing aids and the speaker had to increase volume and speak distinctly. She was noted for using hearing aids for completing the assessment. She usually made herself understood and had some difficulty communicating some words or finishing thoughts but is able if prompted or given time to respond. She was noted to sometimes understand others and responds adequately to simple, direct communication only. She had no evidence of an acute change in mental status from her baseline. She had no inattention behaviors present; however, she had disorganized thinking behaviors present.Her Significant Change MDS Assessment didn't accurately reflect that Resident #1 did not wear hearing aids as they were lost as of 08/24/2025. Record review of Resident #1's Quarterly MDS Assessment, dated 08/24/2025 reflected sizable differences from the Significant Change MDS Assessment, dated 09/04/2025. Differences included cognitive patterns; she was noted to have evidence of an acute change in mental status from her baseline and behaviors of inattention were present and fluctuated. Her Quarterly MDS Assessment did not include section on preferences for customary routine and activities. Her Quarterly MDS Assessment did not accurately reflect cognitive pattern changes nor was evidence present in Resident #1's EMR of an acute change in mental status from her baseline and behaviors.Record review of Resident #1's Brief Interview for Mental Status (3.0 BIMS) Forms, dated 03/18/2025 to 09/03/2025 reflected:- 09/03/2025, reflected N /A for overall score indicating severe impairment, signed by the MDS- 08/22/2025, reflected N /A for overall score indicating severe impairment, signed by the SW- 05/28/2025, reflected 9 for overall score indicating moderate cognitive impairment, signed by the SW- 03/18/20025, reflected 8 for overall score indicating moderate cognitive impairment, signed by the SWHer Brief Interview for Mental Status (3.0 BIMS) on 08/22/2025 and 09/03/2025 were not accurately performed as Resident #1 was missing one or both hearing aids during these interviews. Record review of Resident #1's care plan, dated 04/02/2025, revealed Resident #1- Had impaired cognitive function related to diagnosis of Dementia/Alzheimer's with the intervention to include ask yes/no questions to determine needs with intervention to include communicating basic needs daily through the review date, initiated, date initiated 09/16/2025.- Had moderate decreased hearing loss in both ears and used hearing aids, date initiated 07/28/2025. - Had a history of choosing not to wear her hearing aids, taking them out, and losing them with the intervention to include assisting resident with putting the hearing aids in each day, facing resident when speaking and speaking in clear simple sentences, and ensuring hearing aids are kept in a safe place, date initiated 07/28/2025.- Her care plan did not include a noted intervention for communication strategies for hearing loss after hearing aids were lost by the resident on 08/24/2025. Record review of Resident #1's EMR on 10/14/2025 and 10/15/2025 did not reveal care plan revision documentation of an update to the loss of hearing aids on 08/24/2025. Record review of Resident #1's EMR on 10/14/2025 and 10/15/2025 did not reveal care plan revision documentation of an update of communication strategies for hearing loss. During an observation and interview on 10/14/2025 at 10:30 AM, Resident #1 was observed in her manual wheelchair sitting near a nursing staff member assigned to hallway 100. The nursing staff member was observed getting at eye level with Resident #1 and speaking loudly and clearly in English and in Spanish to ask her a question about going to her room or going outside. Resident responded to the nursing staff that she wanted to stay put in her chair. Resident #1 appeared groomed well, appropriately dressed ambulating with her manual wheelchair unassisted and without injury. Resident #1 agreed to move the interview to her room for privacy. She revealed in Spanish that her left side hurt, and she pointed to her left elbow. She stated she required total care. She stated she injured herself about two weeks back but doesn't recall where she was in the facility during this injury. She stated she recalls hitting herself on her left elbow, she is given medication for pain, she had x-rays done, and she was taken to the hospital. She stated she doesn't recall what happened, only that she remembers she was standing. She stated the doctor prescribed her medication for pain, she was given an injection for pain, she was offered physical therapy, but she declined. She stated she is administered Tylenol for pain when she asks for it, and it does help to relieve pain. She stated she uses a wheelchair to help her get around. She doesn't go outside often as she has sinus issues and doesn't want to become ill. She stated she cannot recall details of what occurred to hurt herself but knows she didn't fall, and she has no concerns with staff and feels safe.The resident did have minor issues during the interview, such as not being able to answer questions, she couldn't recall timeframes, surveyor had to repeat questions and speak loudly for Resident #1 to understand and respond. Resident's cognitive functions such as memory, attention, and problem-solving skills were delayed during the interview, but when she understood and could hear the question, she was able to respond appropriately. Record review of Resident #1's progress notes, dated 10/15/2025 for progress notes created from 08/18/2025 to 08/24/2025 reflected: Resident #1 had a history of having hearing aids go missing and found by staff with final note of hearing aids remained missing on 08/24/2025. No further notes regarding the loss or recovery of hearing aids were documented for Resident #1.- Orders - Administration Note dated 08/24/2025 at 9:32 AM by nursing department, BILATERAL HEARING AIDES. On in AM and Off at HS. Keep HA secured with Nurse. one time a day for Hearing deficit and remove per schedule h/a missing at this time family aware.- Orders - Administration Note dated 08/23/2025 at 6:47 PM, 08/23/2025 at 7:15 PM, 08/24/2025 at 9:31AM by nursing department, BILATERAL HEARING AIDES. On in AM and Off at HS. Keep HA secured with Nurse. one time a day for Hearing deficit and remove per schedule unable to locate- Orders - Administration Note dated 08/21/2025 at 7:25 AM by nursing department, BILATERAL HEARING AIDES. On in AM and Off at HS. Keep HA secured with Nurse. one time a day for Hearing deficit and remove per schedule Found right hearing aid.- Orders - Administration Note dated 08/20/2025 at 8:25 AM by nursing department, BILATERAL HEARING AIDES. On in AM and Off at HS. Keep HA secured with Nurse. one time a day for Hearing deficit and remove per schedule Unavailable. Family knows.- Orders - Administration Note dated 08/19/2025 at 6:33 AM by nursing department, BILATERAL HEARING AIDES. On in AM and Off at HS. Keep HA secured with Nurse. one time a day for Hearing deficit and remove per schedule Not available. Family was notified.- Orders - Administration Note dated 08/18/2025 at 6:08 AM by nursing department, BILATERAL HEARING AIDES. On in AM and Off at HS. Keep HA secured with Nurse. one time a day for Hearing deficit and remove per schedule Resident lost them. Family and Dr. were notified. During an interview on 10/15/2025 at 2:01 PM, Resident #1 revealed that she can speak to staff when she needs care. She stated sometimes it is hard to hear, and she pointed at her ears. She stated nursing staff need to speak loudly so she can understand them. She stated she did not know where her hearing aids were. She stated that LVN A was very helpful, and she was able to write down questions for her. When asked if writing down questions was helpful, she would smile and nod. She stated she couldn't recall when she misplaced her hearing aids, but it doesn't bother her to not have them. She stated the nursing staff cares for her well and she gets her needs met. During an interview on 10/14/2025 at 1:15 PM, CNA C stated she has been in-serviced on residents rights and knows she can review the electronic care plan when needing to know of a resident's specific care. She stated the electronic care plan provides information on residents' ADLs, and how to care for them. She stated Resident #1 cannot hear very well. She stated that she must speak very loudly to the resident for her to hear, but she can speak in English and Spanish. She can answer questions and tell you if she needs help with care. During an interview on 10/14/2025 at 1:30 PM, LVN A stated Resident #1 requires care with ADLs, transfers, redirection, she gets confused at times and has no behaviors. She stated Resident #1 complains of pain in her left elbow, and she can communicate with her when she needs her PRN Tylenol. She stated it can be a challenge to communicate with the resident at times. During an interview on 10/15/2025 at 10:39 AM, LVN A stated Resident #1 can communicate in English and Spanish. She stated she has some good days and some bad days. She stated Resident #1 usually has more bad days than good ones. She stated on her bad days it takes longer to communicate with the resident, and she will ask more questions to understand her. She stated the DON has a communication tablet and will write a question down for Resident #1, let her read it, and she will respond quickly. She stated this is the first day she was provided with the writing tablet to use with Resident #1. She stated this is good for Resident #1. She stated she is now easily able to communicate with Resident #1. She stated she can write down a question on the whiteboard and the resident excitedly answers with clear understanding. She stated that during Resident #1's admission into the facility she had hearing aids, and her family stated she constantly misplaces her hearing aids. She stated throughout the months she has lost both hearing aids and found them numerous times. She stated the family has made the decision not to order a new pair of hearing aids as they have become costly and she has lost more than 6 pairs over the years. During an interview on 10/15/2025 at 10:50 AM, CNA E stated he has been provided training on Resident Rights and understands if residents are not allowed to exercise their rights it can be frustrating and cause behavior problems. He stated he reviews the electronic care plan, so he is informed of the specific care and ADL assistance each resident requires. During an interview on 10/15/2025 at 11:00 AM, LVN B stated residents have all the rights at the facility, they have the right to refuse care as well. She stated that if residents are not allowed to exercise their rights it can cause anger. She stated the expectation for nursing staff on her shift is to review the electronic care plan to provide the care they need. During an interview on 10/15/2025 at 11:23 AM the DON stated Resident #1 has difficulties hearing, she lost her hearing aids about a month back and family no longer wants to replace as this is the 6th pair lost. She stated she constantly removes her hearing aids, stores them in her purse, napkin, dressers and forgets where they are. She stated she can communicate if she needs assistance. She stated she can read well and will answer questions. The DON stated she began using a whiteboard to write and communicate with Resident #1 about 7-10 days back. She stated she has conveyed the use of the whiteboard to communicate with Resident #1 during an IDT meeting or morning meeting. She wasn't sure when this information was communicated to the nursing management team. She stated she is unsure if the SW or MDS Nurse were aware or received this information. She stated information wasn't communicated to the full nursing staff and Resident #1's care plan had not been revised to include this intervention. [JM17] [SM18] The DON stated she was unsure why this information had not been communicated to all nursing staff, and she could not provide a response. She stated Resident #1 can and does communicate to the nursing staff when she has pain and she is administered PRN pain medication. She stated Resident #1 could benefit from having communication methods care planned. She stated the nursing management team during the morning meetings are responsible for informing the MDS nurse about updates/changes for residents that should be included in the care plan. During an interview on 10/15/2025 at 11:53 AM, OTD stated he had picked up Resident #1 for physical therapy when she had the elbow fracture and she was not to use it at the time. He stated he was trying to work with her on safety and general ADLs. He stated because of her hearing loss she did have hearing aids but was not wearing them. He stated the best way to communicate would be writing, He stated he would write it out and she would verbally respond. He stated he was having somewhat of a hard time engaging with her and the business office manager said the resident does pretty good when you write things down and believes this information was discussed in an IDT meeting but could not recall. He stated that at one time he was able to communicate with her, and she would follow directions. During an interview on 10/15/2025 at 11:52 AM, LVN A stated she has been in-serviced on Resident Rights, but could not recall how long it had been, but it did cover that resident has the right to care, right to tell staff what they like and don't like, refuse their medications/care. She stated that she and the aides review the electronic care plan to confirm the direct care that residents require. The electronic care plan provides information on the residents' ADLs and how staff can approach residents. She stated all nursing staff are to review the electronic care plan as this is a guide for all direct care provided to the residents of the facility. During an interview on 10/15/2025 at 11:57 AM, the SW stated that Resident #1 had extreme hearing concerns, when she conducted the Brief Interview for Mental Status with her, she noticed the lack of hearing and stated that the resident will not use her hearing aids. She stated she would regularly take them out of her ears and put them in multiple places. She stated the hearing aids have been replaced many times, and the family can no longer replace them. She stated Resident #1 was unable to answer questions during the Brief Interview for Mental Status she last conducted on 08/22/2025, which resulted in a score of 0, indicating cognition is severely impaired. She stated the low BIMS score is due to the resident not being able to repeat the words required and given her diagnosis it is difficult for the resident. The surveyor pointed out that there was a significant decline from last quarter, 05/28/2025 Brief Interview for Mental Status rendered a score of 9 and her initial Brief Interview for Mental Status from admission was an 8. SW stated the significantly lower BIMS score could be that Resident #1 couldn't adequately hear the questions and stated she is not sure if the resident was wearing her hearing aids when she scored higher. She stated she has never used the whiteboard to communicate with Resident #1 and didn't know this communication method was being utilized for this resident. She stated she did not receive information from the DON regarding this communication method previously. She stated that moving forward she would be utilizing the whiteboard to communicate with Resident #1 and would work with the MDS Nurse to put this intervention into her care plan. SW stated that she has no doubt if she were to use the whiteboard to communicate with Resident #1, she could answer the first 3 questions of the BIMS. She stated the resident can communicate pain, she will ask her if she needs anything and she can communicate discomfort. She stated Resident #1 may need some prompting but is able to communicate most of the time. During an interview on 10/15/2025 at 11:57 AM, MDS Nurse stated she trained with the corporate nurse July 2022, and she was trained that the MDS sections she is responsible for only require a 7-day look back period, sections B, C, D, E, and Q. She stated she received training verbally, no guides were provided; however, she does have the option to look over the MDS manual. She stated she reviews progress notes, physician notes, therapy and occupational therapy notes and interviews residents to assist her in completing MDS assessments. MDS Nurse stated residents can have a delay in care due to inaccurate assessments. She stated the SW was responsible for the Brief Interview of Mental Status (BIMS). She reviewed Resident #1's progress notes with the surveyor and stated that the resident lost her hearing aids on 08/18/2025. She stated that she believes the significant change in BIMS scores is concerning and would be investigated. She stated that she is aware of Resident #1's hearing loss and hearing aids and stated she has never used the whiteboard to communicate with Resident #1. She stated she didn't know this communication method was being utilized for this resident. She stated she did not receive information from the DON regarding this communication method previously. She stated that moving forward she would be utilizing the whiteboard to communicate with Resident #1 and would work with SW to put this intervention into her care plan. The MDS Nurse stated that the nursing management team during morning meetings determines the interventions that should be placed into a resident's care plan to address a resident's needs and if care plans are not updated with appropriate interventions, it could place residents at risk of not receiving the care they need. During an interview on 10/15/2025 at 1:10 PM, SW stated she received training in care plans and MDS assessments from her corporate officer. She stated she is in constant contact with the corporate officer if she has any specific questions. She stated the care plans include resident ADLS, activities, social services and therapy. She stated any areas or care specific to the resident is listed on their care plan. She stated if something specific occurs it would be updated on the resident's care plan by the next day. She stated if care plans and MDS assessments are not correct or updated it could be a potential risk to the residents. During an interview on 10/15/2025 at 2:03 PM, CNA D stated he was provided with resident rights training last month and stated the training covered the resident's right to be cleaned, changed, repositioned, and to be treated with respect. He stated that if there are new residents or if he is not at the facility for a few days he will review the electronic care plan to know the specific ADLS the resident requires assistance with. He stated the electronic care plan gives detail as to what nursing staff should be doing when working with a specific resident. During an interview on 10/15/2025 at 3:03 PM, DON stated she receives training online and all new employees receive resident rights training upon hire. She stated the residents' rights in-services are provided quarterly or if needed she will create conduct an in-service at that time. She was knowledgeable of resident rights and provided examples. She stated yes, communication would be considered a resident right. She stated if unable to communicate for whatever reason, dementia or memory problems can make the residents very frustrated. She stated she has been provided with care plan training. She stated she and regional staff at corporate level will come in and talk about general responsibilities including care plans. She stated some of her care plan training also derives from HHSC sites. She stated the care plan trainings she's participated in focus on interventions and emphasize that care plans are updated timely depending on what changes the resident is going through, significant changes, follow-up from outside visits. DON stated the MDS Nurse is responsible for completing and updating the care plans. She stated she has a lot of support. She stated during morning meetings the team will discuss any specific concerns or interventions, and this will then be added to the resident's care plan. She stated information is gathered from daily meetings and IDT meetings and will be updated on the same day. She stated if care plans are not completed or revised it delays communication with the rest of the staff and how to provide care to the residents. She stated about a week back she began using the whiteboard to communicate with Resident #1 and the therapist has been using the whiteboard for the last two months. She stated not having her hearing aids would be a barrier but believes Resident #1 does get enough attention from the staff and is able to hear some people very well. She stated nursing staff are expected to review the electronic care plan for resident ADLs. She stated all important information regarding a resident will be in the electronic are plan. During an interview on 10/15/2025 at 4:00 PM, ADM stated the expectation of care plan revisions depend on the scope of care plan change. He stated if the care plan intervention requires an assessment first then this will take place. He stated communication for any change/updates to the care plan takes place in the morning meetings and is updated quickly. He stated the impact of not updating the care plan in a timely manner would delay the care the patient needs. Record review of policy titled, Care Plans, Comprehensive Person-Centered, dated March 2022, revealed: 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.e. reflects currently recognized standards of practice for problem areas and conditions.8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are: a. provided by qualified persons; b. culturally competent; and c. trauma-informed.9. 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.10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers.11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.12. The interdisciplinary team reviews and updates the care plan:a. when there has been a significant change in the resident's condition. Record review of policy titled, Resident Rights, dated February 2021, revealed: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: f. communication with and access to people and services, both inside and outside the facility. jj. equal access to quality care, regardless of source of payment. Record review of policy titled, Change in a Resident's Condition or Status, dated February 2021, revealed: 2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); c. requires interdisciplinary review and/or revision to the care plan.9. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA regulations governing resident assessments and as outlined in the MDS RAI Instruction Manual. Record review of policy titled, Behavioral Assessment, Intervention and Monitoring, dated March 2019, revealed:2. As part of the comprehensive assessment, staff will evaluate, based on input from the resident, family and caregivers, review of medical record and general observations: a. The resident's usual patterns of cognition, mood and behavior; b. The resident's usual method of communicating things like pain, hunger, thirst, and other physical discomforts.3. The nursing staff will identify, document, and inform the physician about specific details regarding changes in an individual's mental status, behavior, and cognition, including: b. Any recent precipitating or relevant factors or environmental triggers.7. Interventions will be individualized and part of an overall care environment that supports physical, functional and psychosocial needs, and strives to understand, prevent or relieve the resident's distress or loss of abilities.

Based on interviews and record reviews, the facility failed to ensure that each resident's MDS assessment accurately reflects the resident's status for one of seven residents (Resident #1) reviewed for accuracy of assessments. The facility failed to ensure the 09/04/2025 MDS assessment accurately reflected Resident #1's cognitive status and the resident's use of hearing aids, which had been lost as of 08/24/2025 This failure could place residents at risk for inaccurate care planning and care delivery. The findings included: Record review of Resident #1's admission Record, dated 10/14/2025, revealed a [AGE] year-old female admitted on [DATE]. Record review of Resident #1's Medical Diagnoses, dated 10/14/2025, revealed diagnoses including unspecified dementia (range of symptoms affecting memory, thinking, and social abilities), Alzheimer's disease (most common type of dementia), nondisplaced fracture of head of left radius, initial encounter for closed fracture (means that the fracture has not caused the bone fragments to shift out of alignment and has not punctured the skin), depression (mental state of low mood and aversion to activity), and muscle weakness. Record review of Resident #1's Significant Change MDS Assessment, dated 09/04/2025, reflected Resident #1 had a BIMS of 00 indicating severe cognitive impairment, which was a significant change upon admission of 08 indicating moderate cognitive impairment. She was noted as having moderate difficulty with hearing when using hearing aids and the speaker had to increase volume and speak distinctly. She was noted for using hearing aids for completing the assessment. She usually made herself understood and had some difficulty communicating some words or finishing thoughts but is able if prompted or given time to respond. She was noted to sometimes understand others and responds adequately to simple, direct communication only. She had no evidence of an acute change in mental status from her baseline. She had no inattention behaviors present; however, she had disorganized thinking behaviors present.Her Significant Change MDS Assessment didn't accurately reflect that Resident #1 did not wear hearing aids as they were lost as of 08/24/2025. Record review of Resident #1's care plan, dated 04/02/2025, revealed Resident #1- Had impaired cognitive function related to diagnosis of Dementia/Alzheimer's with the intervention to include ask yes/no questions to determine needs with intervention to include communicating basic needs daily through the review date, initiated, date initiated 09/16/2025.- Had moderate decreased hearing loss in both ears and used hearing aids, date initiated 07/28/2025.- Had a history of choosing not to wear her hearing aids, taking them out, and losing them with the intervention to include assisting resident with putting the hearing aids in each day, facing resident when speaking and speaking in clear simple sentences, and ensuring hearing aids are kept in a safe place, date initiated 07/28/2025.- Her care plan did not include a noted intervention for communication strategies for hearing loss after hearing aids were lost by the resident on 08/24/2025.Record review of Resident #1's EMR on 10/14/2025 and 10/15/2025 did not reveal care plan revision documentation of an update to the loss of hearing aids on 08/24/2025. Record review of Resident #1's EMR on 10/14/2025 and 10/15/2025 did not reveal care plan revision documentation of an update of communication strategies for hearing loss. Record review of Resident #1's progress notes, dated 10/15/2025 for progress notes created from 08/14/2025 to 08/24/2025 reflected: Resident #1 had a history of having hearing aids go missing and found by staff with final note of hearing aids remained missing on 08/24/2025. No further notes regarding the loss or recovery of hearing aids were documented for Resident #1. - Orders - Administration Note dated 08/24/2025 at 9:32 AM by nursing department, BILATERAL HEARING AIDES. On in AM and Off at HS. Keep HA secured with Nurse. one time a day for Hearing deficit and remove per schedule h/a missing at this time family aware.- Orders - Administration Note dated 08/14/2025 at 9:27 AM BILATERAL HEARING AIDES. On in AM and Off at HS. Keep HA secured with Nurse. one time a day for Hearing deficit and remove per schedule Unable to find right hearing aid this morning.Record review of Resident #1's Quarterly MDS Assessment, dated 08/24/2025 reflected sizable differences from the Significant Change MDS Assessment, dated 09/04/2025. Differences included cognitive patterns; she was noted to have evidence of an acute change in mental status from her baseline and behaviors of inattention were present and fluctuated.Her Quarterly MDS Assessment did not include section on preferences for customary routine and activities. Her Quarterly MDS Assessment did not accurately reflect cognitive pattern changes nor was evidence present in Resident #1's EMR of an acute change in mental status from her baseline and behaviors. Record review of Resident #1's Brief Interview for Mental Status (3.0 BIMS) Forms, dated 03/18/2025 to 09/03/2025 reflected:- 09/03/2025, reflected N /A for overall score indicating severe impairment, signed by the MDS- 08/22/2025, reflected N /A for overall score indicating severe impairment, signed by the SW- 05/28/2025, reflected 9 for overall score indicating moderate cognitive impairment, signed by the SW- 03/18/20025, reflected 8 for overall score indicating moderate cognitive impairment, signed by the SWHer Brief Interview for Mental Status (3.0 BIMS) on 08/22/2025 and 09/03/2025 were not accurately performed as Resident #1 was missing one or both hearing aids during these interviews. Record review of Resident #1's progress notes, dated 10/15/2025 for progress notes created from 09/09/2025 to 09/24/2025 reflected:- Nurses Note dated 09/24/2025 at 12:57 PM by nursing department, Resident's alert, oriented to self. She has episodes of confusion and she is hard of hearing. Needs are anticipated and meet by nursing staff. Resident denies pain or discomfort. No grimaces of pain/discomfort noted.- Nurses Note dated 09/24/2025 at 12:57 PM by nursing department, Resident #1 was unable to hear her RP talking to her on the phone. I spoke to RP and let her know that I would try to put her at ease with info RP gave about coming to see her tomorrow. Resident #1 was able to read note I wrote her letting her know of tomorrow's visit and she calmed down and thanked me for the note.- Nurses Note dated 09/11/2025 at 1:44 PM by nursing department, Resident's alert, oriented to name only. Responsive to verbal and physical stimuli. She is hard of hearing.- Nurses Note dated 09/11/2025 at 1:44 PM by nursing department, Resident's alert, oriented to name only. Responsive to verbal and physical stimuli. Hard of hearing. Administered PRN medication prophylactic for pain/discomfort. She removed split to left arm. Stated that it's uncomfortable and heavy. Able to move left arm without grimaces of pain/discomfort.- Nurses Note dated 09/09/2025 at 21:44 PM by nursing department, I wrote a note for her to read saying that both of her family members were on their way home and safe.Record review of Resident #1's Social Service Progress Review Form, dated 09/04/2025, reflected:Sensory/Communication Status: Resident #1 noted as having hearing limitations that are affecting the resident's ability to function and uses adaptive equipment, Sometimes understands.Usually makes self understood.wheelchair, hearing aids (often lost bc she takes them out). Resident #1 was noted to have independent daily decision-making ability, Res is able to make daily decisions sometimes with prompting/redirection. Her RP is her major decision maker for medical and financial res shown to have a significant decline in BIMS as she was unable to answers any of the questions. Although hearing aids being worn, res still has difficulty hearing and this may be a contributing factor. res is involved at her leisure. She is pleasant and will socialize but due to hearing loss this can be difficult for her.Record review of Resident #1's Multidisciplinary Care Conference Form, dated 09/03/2025, reflected: F. Activities Summary, a. Problems/needs: Resident #1 requires assistance with hearing and some direction to participate in activities. G. Social Work Summary, a.1 Comments on results: BIMS 0 res independently make daily decisions sometimes w prompting. to assist w major decisions. Sometimes difficult for resident to complete assessments independently as res (resident) is hard of hearing and rambles off topic. Record review of Resident #1's Social Service Progress Review Form, dated 08/22/2025, reflected:Sensory/Communication Status: Resident #1 noted as having hearing limitations that are affecting the resident's ability to function and uses adaptive equipment, Sometimes understands.Usually makes self understood.wheelchair, hearing aids (often lost bc she takes them out). Resident #1 was noted to have independent daily decision making ability, Res is able to make daily decisions sometimes with prompting/redirection. Her RP her major decision maker for medical and financial .res is involved at her leisure. She is pleasant and will socialize but due to hearing loss this can be difficult for her.During an observation on 10/14/2025 at 12:30 PM and 4:10 PM, Resident #1 was observed ambulating in her manual wheelchair up and down the hallways from her room to the dining room. She was observed communicating with nursing staff who offered her assistance.During an interview on 10/15/2025 at 11:57 AM, SW stated that Resident #1 had extreme hearing concerns, when she conducted the Brief Interview for Mental Status with her, she noticed the lack of hearing and stated that the resident will not use her hearing aids. She stated she would regularly take them out of her ears and put them in multiple places. She stated the hearing aids have been replaced many times, and the family can no longer replace them. She stated Resident #1 was unable to answer questions during the Brief Interview for Mental Status she last conducted on 08/22/2025, which resulted in a score of 0, indicating cognition is severely impaired. She stated the low BIMS score is due to the resident not being able to repeat the words required and given her diagnosis it is difficult for the resident. The surveyor pointed out that there was a significant decline from last quarter, 05/28/2025 Brief Interview for Mental Status rendered a score of 9 and her initial Brief Interview for Mental Status from admission was an 8. SW stated the significantly lower BIMS score could be that Resident #1 couldn't adequately hear the questions and stated she is not sure if the resident was wearing her hearing aids when she scored higher. She stated she has never used the whiteboard to communicate with Resident #1 and didn't know this communication method was being utilized for this resident. She stated she did not receive information from the DON regarding this communication method previously. She stated that moving forward she would be utilizing the whiteboard to communicate with Resident #1 and would work with the MDS Nurse to put this intervention into her care plan. SW stated that she has no doubt if she were to use the whiteboard to communicate with Resident #1, she could answer the first 3 questions of the BIMS. She stated the resident can communicate pain, she will ask her if she needs anything and she can communicate discomfort. She stated Resident #1 may need some prompting but is able to communicate most of the time. During an interview on 10/15/2025 at 11:57 AM, MDS Nurse stated she trained with the corporate nurse July 2022, and she was trained that the MDS sections she is responsible for only require a 7-day look back period, sections B, C, D, E, and Q. She stated she received training verbally, no guides were provided; however, she does have the option to look over the MDS manual. She stated she reviews progress notes, physician notes, therapy and occupational therapy notes and interviews residents to assist her in completing MDS assessments. MDS Nurse stated residents can have a delay in care due to inaccurate assessments. She stated the SW was responsible for the Brief Interview of Mental Status (BIMS). She reviewed Resident #1's progress notes with the surveyor and stated that the resident lost her hearing aids on 08/18/2025. She stated that she believes the significant change in BIMS scores is concerning and would be investigated. She stated that she is aware of Resident #1's hearing loss and hearing aids and stated she has never used the whiteboard to communicate with Resident #1. She stated she didn't know this communication method was being utilized for this resident. She stated she did not receive information from the DON regarding this communication method previously. She stated that moving forward she would be utilizing the whiteboard to communicate with Resident #1 and would work with SW to put this intervention into her care plan. The MDS Nurse stated that the nursing management team during morning meetings determines the interventions that should be placed into a resident's care plan to address a resident's needs and if care plans are not updated with appropriate interventions, it could place residents at risk of not receiving the care they need. During an interview on 10/15/2025 at 1:10 PM, SW stated she received training in care plans and MDS assessments from her corporate officer. She stated she is in constant contact with the corporate officer if she has any specific questions. She stated the care plans include resident ADLS, activities, social services and therapy. She stated any areas or care specific to the resident is listed on their care plan. She stated if something specific occurs it would be updated on the resident's care plan by the next day. She stated if care plans and MDS assessments are not correct or updated it could be a potential risk to the residents. During an interview on 10/15/2025 at 3:03 PM, DON stated she receives training online and all new employees receive resident rights training upon hire. She stated the residents' rights in-services are provided quarterly or if needed she will create conduct an in-service at that time. She was knowledgeable of resident rights and provided examples. She stated yes, communication would be considered a resident right. She stated if unable to communicate for whatever reason, dementia or memory problems can make the residents very frustrated. She stated she has been provided with care plan training. She stated she and regional staff at corporate level will come in and talk about general responsibilities including care plans. She stated some of her care plan training also derives from HHSC sites. She stated the care plan trainings she's participated in focus on interventions and emphasize that care plans are updated timely depending on what changes the resident is going through, significant changes, follow-up from outside visits. DON stated the MDS Nurse is responsible for completing and updating the care plans. She stated she has a lot of support. She stated during morning meetings the team will discuss any specific concerns or interventions, and this will then be added to the resident's care plan. She stated information is gathered from daily meetings and IDT meetings and will be updated on the same day. She stated if care plans are not completed or revised it delays communication with the rest of the staff and how to provide care to the residents. She stated about a week back she began using the whiteboard to communicate with Resident #1 and the therapist has been using the whiteboard for the last two months. She stated not having her hearing aids would be a barrier but believes Resident #1 does get enough attention from the staff and is able to hear some people very well. She stated nursing staff are expected to review the electronic care plan for resident ADLs. She stated all important information regarding a resident will be in the electronic are plan. During an interview on 10/15/2025 at 4:00 PM, ADM stated accuracy of assessments is necessary as funding and direct care services rely on it. The impact of not accurately completing assessments can cause a delay in resident care Record review of CMS's LTC Resident Assessment Instrument 3.0 User's Manual, dated October 2025, revealed:Section Z0400: Signatures of Persons Completing the Assessment or Entry/Death Reporting: To obtain the signature of all persons who completed any part of the MDS. Legally, it is an attestation of accuracy with the primary responsibility for its accuracy with the person selecting the MDS item response. Each person completing a section or portion of a section of the MDS is required to sign the Attestation Statement. 1.3 Completion of the RAI: In addition, an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment. Record review of policy titled, Care Plans, Comprehensive Person-Centered, dated March 2022, revealed: 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.e. reflects currently recognized standards of practice for problem areas and conditions.8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are: a. provided by qualified persons; b. culturally competent; and c. trauma-informed.9. 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.10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers.11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.12. The interdisciplinary team reviews and updates the care plan:a. when there has been a significant change in the resident's condition. Record review of policy titled, Change in a Resident's Condition or Status, dated February 2021, revealed: If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted. Record review of policy titled, Behavioral Assessment, Intervention and Monitoring, dated March 2019, revealed:2. As part of the comprehensive assessment, staff will evaluate, based on input from the resident, family and caregivers, review of medical record and general observations: a. The resident's usual patterns of cognition, mood and behavior; b. The resident's usual method of communicating things like pain, hunger, thirst, and other physical discomforts.3. The nursing staff will identify, document, and inform the physician about specific details regarding changes in an individual's mental status, behavior, and cognition, including: b. Any recent precipitating or relevant factors or environmental triggers.7. Interventions will be individualized and part of an overall care environment that supports physical, functional and psychosocial needs, and strives to understand, prevent or relieve the resident's distress or loss of abilities. Record review of policy titled, Resident Rights, dated February 2021, revealed: Resident rights to communication with and access to people and services, both inside and outside the facility.

Based on observation, interviews, and record reviews, the facility failed to ensure each resident was treated with respect, dignity, and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for one of seven residents (Resident #1) reviewed for resident rights.The facility failed to ensure. Resident #1 was provided with effective communication strategies to help her convey her daily needs and the nursing staff were not provided with communication strategies to assist Resident #1 to improve effective communication abilities for her day-to-day activities. These failures could place residents at risk of diminished dignity and affect their quality of life.The findings included: Record review of Resident #1's admission Record, dated 10/14/2025, revealed a [AGE] year-old female admitted on [DATE]. Record review of Resident #1's Medical Diagnoses, dated 10/14/2025, revealed diagnoses including unspecified dementia (range of symptoms affecting memory, thinking, and social abilities), Alzheimer's disease (most common type of dementia), nondisplaced fracture of head of left radius, initial encounter for closed fracture (means that the fracture has not caused the bone fragments to shift out of alignment and has not punctured the skin), depression (mental state of low mood and aversion to activity), and muscle weakness. Record review of Resident #1's Significant Change MDS Assessment, dated 09/04/2025, reflected Resident #1 had a BIMS of 00, indicating severe cognitive impairment. She was noted as having moderate difficulty with hearing when using hearing aids and the speaker had to increase volume and speak distinctly. She was noted for using hearing aids for completing the assessment. She usually made herself understood and had some difficulty communicating some words or finishing thoughts but is able if prompted or given time to respond. She was noted to sometimes understand others and responds adequately to simple, direct communication only. She had no evidence of an acute change in mental status from her baseline. She had no inattention behaviors present; however, she had disorganized thinking behaviors present. Record review of Resident #1's care plan, dated 04/02/2025, revealed Resident #1- Had impaired cognitive function related to diagnosis of Dementia/Alzheimer's with the intervention to include ask yes/no questions to determine needs with intervention to include communicating basic needs daily through the review date, initiated, date initiated 09/16/2025.- Had moderate decreased hearing loss in both ears and used hearing aids, date initiated 07/28/2025. - Had a history of choosing not to wear her hearing aids, taking them out, and losing them with the intervention to include assisting resident with putting the hearing aids in each day, facing resident when speaking and speaking in clear simple sentences, and ensuring hearing aids are kept in a safe place, date initiated 07/28/2025. - Her care plan did not include a noted intervention for communication strategies for hearing loss after hearing aids were lost by the resident on 08/24/2025. Record review of Resident #1's EMR on 10/14/2025 and 10/15/2025 did not reveal care plan revision documentation of an update to the loss of hearing aids on 08/24/2025. Record review of Resident #1's EMR on 10/14/2025 and 10/15/2025 did not reveal care plan revision documentation of an update of communication strategies for hearing loss. During an observation and interview on 10/14/2025 at 10:30 AM, [JM1] [SM2] Resident #1 was observed in her manual wheelchair sitting near a nursing staff member assigned to hallway 100. The nursing staff member was observed getting at eye level with Resident #1 and speaking loudly and clearly in English and in Spanish to ask her a question about going to her room or going outside. Resident responded to the nursing staff that she wanted to stay put in her chair. Resident #1 appeared groomed well, appropriately dressed ambulating with her manual wheelchair unassisted and without injury. Resident #1 agreed to move the interview to her room for privacy. She revealed in Spanish that her left side hurt, and she pointed to her left elbow. She stated she required total care. She stated she injured herself about two weeks back but doesn't recall where she was in the facility during this injury. She stated she recalls hitting herself on her left elbow, she is given medication for pain, she had x-rays done, and she was taken to the hospital. She stated she doesn't recall what happened, only that she remembers she was standing. She stated the doctor prescribed her medication for pain, she was given an injection for pain, she was offered physical therapy, but she declined. She stated she is administered Tylenol for pain when she asks for it, and it does help to relieve pain. She stated she uses a wheelchair to help her get around. She doesn't go outside often as she has sinus issues and doesn't want to become ill. She stated she cannot recall details of what occurred to hurt herself but knows she didn't fall, and she has no concerns with staff and feels safe.[JM3] [SM4] The resident did have minor issues during the interview, such as not being able to answer questions, she couldn't recall timeframes, surveyor had to repeat questions and speak loudly for Resident #1 to understand and respond. Resident's cognitive functions such as memory, attention, and problem-solving skills were delayed during the interview, but when she understood and could hear the question, she was able to respond appropriately. During an observation and interview on 10/15/2025 at 2:01 PM, Resident #1 revealed that she can speak to staff when she needs care. She stated sometimes it is hard to hear, and she pointed at her ears. She stated nursing staff need to speak loudly so she can understand them. She stated she did not know where her hearing aids were. She stated that LVN A was very helpful, and she was able to write down questions for her. When asked if writing down questions was helpful, she would smile and nod. She stated she couldn't recall when she misplaced her hearing aids, but it doesn't bother her to not have them. She stated the nursing staff cares for her well and she gets her needs met. Record review of Resident #1's progress notes, dated 10/15/2025 for progress notes created from 09/09/2025 to 09/24/2025 reflected:- Nurses Note dated 09/24/2025 at 12:57 PM by nursing department, Resident's alert, oriented to self. She has episodes of confusion and she is hard of hearing. Needs are anticipated and meet by nursing staff. Resident denies pain or discomfort. No grimaces of pain/discomfort noted.- Nurses Note dated 09/24/2025 at 12:57 PM by nursing department, Resident #1 was unable to hear her RP talking to her on the phone. I spoke to RP and let her know that I would try to put her at ease with info RP gave about coming to see her tomorrow. Resident #1 was able to read note I wrote her letting her know of tomorrow's visit and she calmed down and thanked me for the note.- Nurses Note dated 09/11/2025 at 1:44 PM by nursing department, Resident's alert, oriented to name only. Responsive to verbal and physical stimuli. She is hard of hearing.- Nurses Note dated 09/09/2025 at 21:44 PM by nursing department, I wrote a note for her to read saying that both of her RP were on their way home and safe. Record review of Resident #1's Social Service Progress Review Form, dated 09/04/2025, reflected:Sensory/Communication Status: Resident #1 noted as having hearing limitations that are affecting the resident's ability to function and uses adaptive equipment, Sometimes understands.Usually makes self understood.wheelchair, hearing aids (often lost by she takes them out). Resident #1 was noted to have independent daily decision-making ability, Res is able to make daily decisions sometimes with prompting/redirection. Her RP is her major decision maker for medical and financial res shown to have a significant decline in BIMS as she was unable to answer any of the questions. Although hearing aids being worn, res still has difficulty hearing and this may be a contributing factor. res is involved at her leisure. She is pleasant and will socialize but due to hearing loss this can be difficult for her. Record review of Resident #1's Multidisciplinary Care Conference Form, dated 09/03/2025, reflected: F. Activities Summary, a. Problems/needs: Resident #1 requires assistance with hearing and some direction to participate in activities. G. Social Work Summary, a.1 Comments on results: BIMS 0 res independently make daily decisions sometimes w prompting to assist w major decisions. Sometimes difficult for resident to complete assessments independently as res (resident) is hard of hearing and rambles off topic.Record review of Resident #1's Social Service Progress Review Form, dated 08/22/2025, reflected: Sensory/Communication Status: Resident #1 noted as having hearing limitations that are affecting the resident's ability to function and uses adaptive equipment, Sometimes understands.Usually makes self understood.wheelchair, hearing aids (often lost bc she takes them out). Resident #1 was noted to have independent daily decision-making ability, Res is able to make daily decisions sometimes with prompting/redirection. Her RP is her major decision maker for medical and financial .res is involved at her leisure. She is pleasant and will socialize but due to hearing loss this can be difficult for her.Record review of Resident #1's progress notes, dated 10/15/2025 for progress notes created from 08/18/2025 to 08/24/2025 reflected: Resident #1 had a history of having hearing aids go missing and found by staff with final note of hearing aids remained missing on 08/24/2025. No further notes regarding the loss or recovery of hearing aids were documented for Resident #1. - Orders - Administration Note dated 08/24/2025 at 9:32 AM by nursing department, BILATERAL HEARING AIDES. On in AM and Off at HS[JM9] [SM10] . Keep HA secured with Nurse. one time a day for Hearing deficit and remove per schedule h/a missing at this time family aware.- Orders - Administration Note dated 08/23/2025 at 6:47 PM, 08/23/2025 at 7:15 PM, 08/24/2025 at 9:31 AM by nursing department, BILATERAL HEARING AIDES. On in AM and Off at HS. Keep HA secured with Nurse. one time a day for Hearing deficit and remove per schedule unable to locate- Orders - Administration Note dated 08/21/2025 at 7:25 AM by nursing department, BILATERAL HEARING AIDES. On in AM and Off at HS. Keep HA secured with Nurse. one time a day for Hearing deficit and remove per schedule Found right hearing aid.- Orders - Administration Note dated 08/20/2025 at 8:25 AM by nursing department, BILATERAL HEARING AIDES. On in AM and Off at HS. Keep HA secured with Nurse. one time a day for Hearing deficit and remove per schedule Unavailable. Family knows.- Orders - Administration Note dated 08/19/2025 at 6:33 AM by nursing department, BILATERAL HEARING AIDES. On in AM and Off at HS. Keep HA secured with Nurse. one time a day for Hearing deficit and remove per schedule Not available. Family was notified.- Orders - Administration Note dated 08/18/2025 at 6:08 AM by nursing department, BILATERAL HEARING AIDES. On in AM and Off at HS. Keep HA secured with Nurse. one time a day for Hearing deficit and remove per schedule Resident lost them. Family and Dr. were notified. During an interview on 10/14/2025 at 1:15 PM, CNA C stated she was in-serviced on resident rights and knows she can review the electronic care plan when needing to know of a resident's specific care. She stated the electronic care plan provides information on residents' ADLs, and how to care for them. She stated Resident #1 cannot hear very well. She stated that she must speak very loudly to the resident for her to hear, but she can speak in English and Spanish. She can answer questions and tell you if she needs help with care. During an interview on 10/14/2025 at 1:30 PM, LVN A stated Resident #1 requires care with ADLs, transfers, redirection, she gets confused at times and has no behaviors. She stated Resident #1 complains of pain in her left elbow, and she can communicate with her when she needs her PRN Tylenol. She stated it can be a challenge to communicate with the resident at times because she must ask question numerous times before the resident understood. During an interview on 10/15/2025 at 10:39 AM, LVN A stated Resident #1 can communicate in English and Spanish. She stated she has some good days and some bad days. She stated Resident #1 usually has more bad days than good ones. She stated on her bad days it takes longer to communicate with the resident, and she will ask more questions to understand her. She stated the DON has a communication tablet and will write a question down for Resident #1, let her read it, and she will respond quickly. She stated this is the first day she was provided with the writing tablet to use with Resident #1. She stated this is good for Resident #1. She stated she is now easily able to communicate with Resident #1. She stated she can write down a question on the whiteboard and the resident excitedly answers with clear understanding. She stated that during Resident #1's admission into the facility she had hearing aids, and her family stated she constantly misplaces her hearing aids. She stated throughout the months she has lost both hearing aids and found them numerous times. She stated the family has made the decision not to order a new pair of hearing aids as they have become costly and she has lost more than 6 pairs over the years. She stated the communication with the resident consists of repeating questions and speaking loudly and directly in front of the resident at eye level. During an interview on 10/15/2025 at 10:50 AM, CNA E stated he has been provided training on Resident Rights and understands if residents are not allowed to exercise their rights it can be frustrating and cause behavior problems. During an interview on 10/15/2025 at 11:00 AM, LVN B stated residents have all the rights at the facility, they have the right to refuse care as well. She stated that if residents are not allowed to exercise their rights it can cause them to become angry. During an interview on 10/15/2025 at 11:23 AM the DON stated Resident #1 has difficulties hearing, she lost her hearing aids about a month back and family no longer wants to replace as this is the 6th pair lost. She stated she constantly removes her hearing aids, stores them in her purse, napkin, dressers and forgets where they are. She stated she can communicate if she needs assistance. She stated she can read well and will answer questions. The DON stated she began using a whiteboard to write and communicate with Resident #1 about 7-10 days back. She stated she has conveyed the use of the whiteboard to communicate with Resident #1 during an IDT meeting or morning meeting. She wasn't sure when this information was communicated to the nursing management team. She stated she is unsure if the SW or MDS Nurse were aware or received this information. She stated information wasn't communicated to the full nursing staff and Resident #1's care plan had not been revised to include this intervention. The DON stated she was unsure why this information had not been communicated to all nursing staff, and she could not provide a response. She stated Resident #1 can and does communicate to the nursing staff when she has pain and she is administered PRN pain medication. She stated Resident #1 could benefit from having communication methods care planned. She stated the nursing management team during the morning meetings are responsible for informing the MDS nurse about updates/changes for residents that should be included in the care plan. During an interview on 10/15/2025 at 11:53 AM, OTD stated he had picked up Resident #1 for physical therapy when she had the elbow fracture and she was not to use it at the time. He stated he was trying to work with her on safety and general ADLs. He stated because of her hearing loss she did have hearing aids but was not wearing them. He stated the best way to communicate would be writing. He stated he would write it out and she would verbally respond. He stated he was having somewhat of a hard time engaging with her and the business office manager said the resident does pretty good when you write things down and believes this information was discussed in an IDT meeting but could not recall. He stated that at one time he was able to communicate with her, and she would follow directions. During an interview on 10/15/2025 at 11:52 AM, LVN A stated she has been in-serviced on Resident Rights, but could not recall how long it had been, but it did cover that resident has the right to care, right to tell staff what they like and don't like, refuse their medications/care. She stated that she and the aids review the electronic care plan to confirm the direct care that residents require. The electronic care plan provides information on the residents' ADLs and how staff can approach residents. She stated all nursing staff are to review the electronic care plan as this is a guide for all direct care provided to the residents of the facility. During an interview on 10/15/2025 at 11:57 AM, SW stated that Resident #1 had extreme hearing concerns, when she conducted the Brief Interview for Mental Status with her, she noticed the lack of hearing and stated that the resident will not use her hearing aids. She stated she would regularly take them out of her ears and put them in multiple places. She stated the hearing aids have been replaced many times, and the family can no longer replace them. She stated Resident #1 was unable to answer questions during the Brief Interview for Mental Status she last conducted on 08/22/2025, which resulted in a score of 0, indicating cognition is severely impaired. She stated the low BIMS score is due to the resident not being able to repeat the words required and given her diagnosis it is difficult for the resident. The surveyor pointed out that there was a significant decline from last quarter, 05/28/2025 Brief Interview for Mental Status rendered a score of 9 and her initial Brief Interview for Mental Status from admission was an 8. SW stated the significantly lower BIMS score could be that Resident #1 couldn't adequately hear the questions and stated she is not sure if the resident was wearing her hearing aids when she scored higher. She stated she has never used the whiteboard to communicate with Resident #1 and didn't know this communication method was being utilized for this resident. She stated she did not receive information from the DON regarding this communication method previously. She stated that moving forward she would be utilizing the whiteboard to communicate with Resident #1 and would work with the MDS Nurse to put this intervention into her care plan. SW stated that she has no doubt if she were to use the whiteboard to communicate with Resident #1, she could answer the first 3 questions of the BIMS. She stated the resident can communicate pain, she will ask her if she needs anything and she can communicate discomfort. She stated Resident #1 may need some prompting but is able to communicate most of the time. During an interview on 10/15/2025 at 11:57 AM, MDS Nurse stated she trained with the corporate nurse July 2022, and she was trained that the MDS sections she is responsible for only require a 7-day look back period, sections B, C, D, E, and Q. She stated she received training verbally, no guides were provided; however, she does have the option to look over the MDS manual. She stated she reviews progress notes, physician notes, therapy and occupational therapy notes and interviews residents to assist her in completing MDS assessments. MDS Nurse stated residents can have a delay in care due to inaccurate assessments. She stated the SW was responsible for the Brief Interview of Mental Status (BIMS). She reviewed Resident #1's progress notes with the surveyor and stated that the resident lost her hearing aids on 08/18/2025. She stated that she believes the significant change in BIMS scores is concerning and would be investigated. She stated that she is aware of Resident #1's hearing loss and hearing aids and stated she has never used the whiteboard to communicate with Resident #1. She stated she didn't know this communication method was being utilized for this resident. She stated she did not receive information from the DON regarding this communication method previously. She stated that moving forward she would be utilizing the whiteboard to communicate with Resident #1 and would work with SW to put this intervention into her care plan. The MDS Nurse stated that the nursing management team during morning meetings determines the interventions that should be placed into a resident's care plan to address a resident's needs and if care plans are not updated with appropriate interventions, it could place residents at risk of not receiving the care they need. During an interview on 10/15/2025 at 1:10 PM, SW stated she received training in care plans and MDS assessments from her corporate officer. She stated she is in constant contact with the corporate officer if she has any specific questions. She stated the care plans include resident ADLS, activities, social services, and therapy. She stated any areas or care specific to the resident is listed on their care plan. She stated if something specific occurs it would be updated on the resident's care plan by the next day. She stated if care plans and MDS assessments are not correct or updated it could be a potential risk to the residents. During an interview on 10/15/2025 at 1:40 PM, MDS Nurse stated Resident #1 does have hearing loss, communicating with long conversations can be challenging for her, and short conversations she is all in and can converse. She stated Resident #1 has no significant behaviors, other than keeping her hearing aid in her ears, she engages well with staff and wheels herself around in her wheelchair. During an interview on 10/15/2025 at 2:03 PM, CNA D stated he was provided with resident rights training last month and stated the training covered the resident's right to be cleaned, changed, repositioned, and to be treated with respect. He stated that if there are new residents or if he is not at the facility for a few days he will review the electronic care plan to know the specific ADLS the resident requires assistance with. He stated the electronic care plan gives detail as to what nursing staff should be doing when working with a specific resident. During an interview on 10/15/2025 at 3:03 PM, DON stated she receives training online and all new employees receive resident rights training upon hire. She stated the residents' rights in-services are provided quarterly or if needed she will create conduct an in-service at that time. She was knowledgeable of resident rights and provided examples. She stated yes, communication would be considered a resident right. She stated if unable to communicate for whatever reason, dementia or memory problems can make the residents very frustrated. She stated she has been provided with care plan training. She stated she and regional staff at corporate level will come in and talk about general responsibilities including care plans. She stated some of her care plan training also derives from HHSC sites. She stated the care plan trainings she's participated in focus on interventions and emphasize that care plans are updated timely depending on what changes the resident is going through, significant changes, follow-up from outside visits. DON stated the MDS Nurse is responsible for completing and updating the care plans. She stated she has a lot of support. She stated during morning meetings the team will discuss any specific concerns or interventions, and this will then be added to the resident's care plan. She stated information is gathered from daily meetings and IDT meetings and will be updated on the same day. She stated if care plans are not completed or revised it delays communication with the rest of the staff and how to provide care to the residents. She stated about a week back she began using the whiteboard to communicate with Resident #1 and the therapist has been using the whiteboard for the last two months. She stated not having her hearing aids would be a barrier but believes Resident #1 does get enough attention from the staff and is able to hear some people very well. She stated nursing staff are expected to review the electronic care plan for resident ADLs. She stated all important information regarding a resident will be in the electronic are plan. During an interview on 10/15/2025 at 4:00 PM, ADM stated that the leadership team will provide the nursing staff with resident rights in-services. He stated the nursing staff are expected to adhere to the residents' rights and stated they are in this position to serve. He stated if the nursing staff are not following resident rights, it could impact the residents negatively and become abuse and neglect, which is not tolerated by the company, and they can lose their jobs and can face jail time. During an interview on 10/15/2025 at 4:25 PM, CNA F, stated he has been in-serviced on abuse, neglect, and resident rights. He stated not providing care, going against resident's wishes are examples of abuse and neglect and should be reported immediately. Record review of policy titled, Resident Rights, dated February 2021, revealed: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to: f. communication with and access to people and services, both inside and outside the facility. jj. equal access to quality care, regardless of source of payment.

Based on observation, interview, and record review the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized, for 3 of 8 residents reviewed (Residents #7, #38, and #16) for complete and accurate medical records 1. The facility failed to ensure Resident #7's signed out of hospital do not resuscitation order form was properly uploaded in her medical record and did not contain another residents' (Resident #38's) signed OOH DNR order form; 2. The facility failed to ensure Resident #38's signed OOH DNR order form was properly uploaded in her medical record; 3. The facility failed to ensure Resident #16's signed OOH DNR order form was properly uploaded in her medical record. The findings included: 1. Record review of the Admission Record, dated 11/19/2024, reflected Resident #7 was an [AGE] year-old female, originally admitted [DATE]. Record review of the quarterly MDS assessment dated [DATE], reflected Resident #7 did not have a BIMS conducted due rarely or never being understood, with short and long-term memory problems and had severely impaired cognitive skills for daily decision making. Traumatic brain dysfunction related to unspecified dementia was Resident #7's primary medical condition category for admission. Other active diagnoses included non-Alzheimer's dementia. Resident #7 was coded as not having a prognosis resulting in a life expectancy of less than 6 months. Record review of the Order Summary Report, dated 11/22/2024, reflected Resident #7 had physician orders for a code status of DNR, with an order date of 05/06/2020. Record review of the Care Plan reflected Resident #7 had a focus area of advance directory: Do Not Resuscitate, with an initiated date of 05/12/2020, and revised on 08/14/2024. Record review of the EMR for Resident #7, reviewed on 11/20/2024 at 4:14 PM, revealed a signed OOH DNR order form dated 06/14/2021 but was for Resident #38. There was no signed OOH DNR for Resident #7 in her EMR. Record review of Resident #7's EMR tab entitled Miscellaneous, reflected a signed OOH DNR order form uploaded on 11/20/2024 [after this state agency surveyor alerted facility management of no signed OOH DNR order form for Resident #7 in the EMR, but included the signed OOH DNR order form for Resident #38]. The signed OOH DNR order form for Resident #7 was dated 05/01/2020. In an observation on 11/19/2024 at 11:09 AM, Resident #7 was supine with pillows under her left side with her eyes closed and steady, unlabored respirations. 2. Record review of the Admission Record, dated 11/22/2024, reflected Resident #38 was a [AGE] year-old female, originally admitted [DATE]. Record review of the quarterly MDS assessment dated [DATE], reflected Resident #38 had a BIMS summary score of 12, indicative of moderate cognitive impairment. Traumatic brain dysfunction related to unspecified dementia was Resident #38's primary medical condition category for admission. Other active diagnoses included non-Alzheimer's dementia and depression. Resident #38 was coded as not having a prognosis resulting in a life expectancy of less than 6 months. Record review of the Order Summary Report, dated 11/22/2024, reflected Resident #38 had physician orders for a code status of DNR, with an order date of 07/08/2021. Record review of the Care Plan reflected Resident #38 had a focus area of advance directory: Do Not Resuscitate, with an initiated date of 07/12/2021. Record review of the EMR tab entitled Miscellaneous, reviewed on 11/19/2024, for Resident #38 revealed there was not a signed OOH DNR order form uploaded. Record review of Resident #38's EMR tab entitled Miscellaneous, reflected a signed OOH DNR order form uploaded on 11/20/2024 [after this state agency surveyor alerted facility management that the signed OOH DNR order form in Resident #7's EMR was a signed OOH DNR order form for Resident #38]. The newly uploaded signed OOH DNR order form for Resident #38 was signed 6/14/2021. 3. Record review of the Admission Record, dated 11/22/2024, reflected Resident #16 was a [AGE] year-old female, originally admitted [DATE]. Record review of the annual MDS assessment dated [DATE], reflected Resident #16 had a BIMS summary score of 13, indicative of intact cognition. Other neurological conditions related to schizophrenia was Resident #16's primary medical condition category for admission. Other active diagnoses included cerebrovascular accident, transient ischemic attack or stroke and bipolar disorder. Resident #16 was coded as not having a prognosis resulting in a life expectancy of less than 6 months. Record review of the Order Summary Report, dated 11/22/2024, reflected Resident #16 had physician orders for a code status of DNR, with an order date of 11/08/2019. Record review of the Care Plan reflected Resident #16 had a focus area of advance directory: Do Not Resuscitate, with an initiated date of 11/13/2019. Record review of the EMR tab entitled Miscellaneous reviewed on 11/19/2024 for Resident #16 revealed there was not a signed OOH DNR order form uploaded. Record review of the Resident #16's EMR tab entitled Miscellaneous, reflected a signed OOH DNR order form uploaded on 11/20/2024 [after this state agency surveyor alerted facility management of no signed OOH DNR consent for Resident #16 in the EMR] for Resident #16. The newly uploaded OOH DNR for Resident #16 was signed 11/5/2019 by her legal guardian. In an observation on 11/19/2024 at 10:49 AM, Resident #16 was sitting upright in a WC, dressed appropriately for the weather, including footwear, hair clean and neatly combed. In an interview on 11/21/2024 at 8:10 AM, the DON stated she began as the DON in July 2024 and had recognized the facility had some paper records, for example OOH DNRs, and had developed and implemented a system to scan all paper records into the electronic medical record for each resident. The DON stated the Nurse Case Manager was assigned this duty; the DON stated she (the DON) was responsible for oversight of the system. The DON stated she received a report on 11/20/2024 that Resident #16, Resident #7, and Resident #38 had errors regarding OOH DNR documents. The DON stated she reviewed all residents for accurate records regarding OOH DNR documents and recognized Resident #16, Resident #7, and Resident #38 did not have their OOH DNR scanned into the electronic medical record. The DON stated Resident #38 OOH DNR was erroneously scanned into Resident #7's record. The DON stated she had not previously reviewed Resident #16, Resident #7, and Resident #38 electronic medical record for accuracy regarding the uploading of scanned paper records. The DON stated the failure could affect residents by not having accurate records. In an interview on 11/21/2024 at 2:21 PM, the SW stated it was of upmost importance to have complete and accurate records for advanced directives so that direct care staff know how to honor the residents' end of life wishes. The SW stated that a delay in care, or wrong care provided could happen if accurate advanced directives are not available. The SW stated that either the business office manager [NAME] or she (the SW) would upload signed OOH DNR order forms into the EMR once completed. The SW stated after the signed OOH DNR order form was uploaded in to the EMR, either the DON or the MDS nurse would immediately update the Care Plan and active order sets. The SW stated that she was unaware of any issues with advanced directives. The SW stated she was unsure of who was responsible to ensure EMR documents are uploaded correctly. The SW stated that as a matter of practice, she kept a binder with a copy of the signed OOH DNR order form as a backup copy. The SW stated this binder would not be readily accessible to direct care staff and would not be considered part of the medical records. The SW stated she had not been tasked to verify that the EMR matched the binder she kept in her office. In a group interview on 11/22/2024 at 5:32 PM, with the ADM and the DON, the DON stated that there was the potential to provide incorrect care for the resident due to the wrong OOH DNR being in the EMR, or no OOH DNR being in the EMR. The ADM stated that the issue was an ongoing process improvement plan and he (the ADM) and the DON were responsible for monitoring accuracy of the EMR. The ADM stated he would be holding the appropriate staff accountable and initiate progressive counseling as necessary. Requested facility policy on accurate medical records from the ADM on 11/21/2024 at 5:16 PM; did not receive prior to exit. Record review of Do Not Resuscitate Order policy, revised April 2017, reflected, under the heading Policy Interpretation and Implementation, step 1.) DNR orders must be signed .maintained in the resident's medical record. 2. A signed DNR order form must be completed and signed .placed in the resident's medical record. Review of Lippincott procedures, Long-Term Care Documentation, revised 5/19/2024, accessed 11/27/2024, https://procedures.lww.com/lnp/view.do?pId=4420213&hits=records,record&a=true&ad=false&q=record, reflected under the heading Introduction, long-term care facilities must maintain complete, accurate, readily accessible and systematically organized medical records for each resident.

Based on observations, interviews, and record reviews, the facility failed to ensure residents were free from significant medication errors for 2 of 10 residents (Residents #43 and #47) reviewed for significant medication errors. 1. On 11/21/2024 at 09:45 AM, LVN E administered to Resident #43 memantine (used to treat moderate to severe confusion (dementia) related to Alzheimer's disease) 10mg to Resident #43 late by 45 minutes. 2. On 11/21/2024 at 09:54 AM, LVN E administered to Resident #47: A. Valsartan (used to treat high blood pressure and heart failure. It is also used to improve the chance of living longer after a heart attack.) 160mg late by 54 minutes. B. Levetiracetam (a drug used to suppress seizures) 500mg late by 54 minutes. C. Divalproex 250mg (a drug used to prevent seizures, mood disorders, and migraine headaches) late by 54 minutes . These deficient practices placed residents at risk for not receiving the therapeutic effects of their prescribed medications. The findings include: 1. Resident #43 A record review of Resident #43's admission record dated 11/22/2024 revealed an admitted [DATE] with diagnoses which included Alzheimer's disease (A type of brain disorder that causes problems with memory, thinking and behavior. This is a gradually progressive condition.) A record review of Resident #43's quarterly MDS assessment dated [DATE] revealed Resident #43 was an [AGE] year-old male admitted for long term care and assessed with a BIMS score of 01 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #43's physicians orders dated 11/22/2024 revealed Resident #43 was prescribed to receive daily twice a day memantine 10mg at 08:00 and again at 05:00 PM. A record review of the facilities Medication Admin Audit Report dated 11/21/2024 revealed Resident #43 was administered memantine 10mg at 09:45 AM by LVN E. 2. Resident #47 A record review of Resident #47's admission record revealed an admitted [DATE] with diagnoses which included atherosclerotic heart disease and seizures. A record review of Resident #47's quarterly MDS assessment dated [DATE] revealed Resident #47 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 00 out of a possible 15 which indicated severe cognition impairment. further review revealed Resident #47 could sometimes make herself understood and could sometimes understand others. A record review of Resident #47's care plan dated 11/22/2024 revealed, (Resident #47) has impaired cognitive function related to dementia. administer medication as ordered . (Resident #47) has the potential for altered cardiac output hypertension (high blood pressure) . administer medications as ordered. A record review of Resident #47's physician's orders dated 11/22/2024 revealed the physician ordered Resident #47 to receive daily twice a day at 08:00 AM and at 05:00 PM Valsartan 160mg and levetiracetam 500mg. further review revealed Resident #47 was prescribed to receive three times a day, at 08:00 AM, 02:00 PM, and 08:00 PM, divalproex 250mgs. A record review of the facilities Medication Admin Audit Report dated 11/21/2024 revealed LVN E administered to Resident #47: Valsartan 160mg on 11/21/2024 at 09:54 AM and was scheduled for 08:00 AM. Levetiracetam 500mg on 11/21/2024 at 09:54 AM and was scheduled for 08:00 AM. Divalproex 250mg on 11/21/2024 at 09:54 AM and was scheduled for 08:00 AM. During an observation and interview on 11/21/2024 at 09:20 AM revealed LVN E prepared medications for Residents. LVN E stated she was in the reds for medication administration. LVN E described the electronic medication administration record as being highlighted in red to indicate late medication administration. Observation of Residents MAR revealed the record to be highlighted red. LVN E stated she was assigned medication administration duty for 1/3 of the facility's residents and described her assignment as the Middle Hall. LVN E stated she was late and was complicated by her breakfast safety monitoring assignment this morning (11/21/2024) LVN E stated she began her shift at 06:00 Am this morning and had concluded her Breakfast dining room safety assignment around 08:45 AM and then began her medication administration assignment. LVN E stated if residents prescribed medication time is past 1 hour the electronic medication record would become highlighted in red to indicate a late medication administration. LVN E stated she had more than 3 residents highlighted in red. LVN E stated she had not communicated the potential for late medication administration with her supervisors the ADON and or the DON. LVN E stated residents who received their medications late were at risk for not receiving the therapeutic effects of their medications. During a joint interview on 11/22/24 05:32 PM the Administrator and the DON stated a medication error includes any failure to meet the 5 rights of medication administration to include: 1. The right Resident. 2. The right drug. 3. The right dosage. 4. The right route of administration. 5. And the right time of administration. The DON stated the right time was considered administration to occur within 1 hour of the prescribed time. If a drug prescribed at 08:00 AM was administered at 09:30 AM the administration was late by 30 minutes and the Resident was at risk for not receiving the intended therapeutic effects of the prescribed medication. The administrator stated he agreed with the DON, and stated it was a training vs execution issue, and a skill or will issue and would follow up with medication administration monitoring and would provide accountability measures . A record review of the facility's Adverse Consequences and Medication Errors policy dated February 2023, revealed, Policy heading: the interdisciplinary team monitors medication usage in order to prevent any detect medication related problems such as adverse drug reactions and side effects. Policy interpretation and implementation: . medication errors: a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physicians orders, manufacturer specifications, or accepted professional standards and principles of the professional providing services, examples of medication errors include: . wrong time

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 2 of 3 residents (Residents #20 and #25) reviewed for accidents/hazards, in that: 1. Resident #20 was provided a fall intervention on 05/23/2024 to include an anti-rollback device affixed to his wheelchair. Intermittent observations from 11/19/2024 thru 11/22/2024 revealed Resident #20 was observed ambulating in his wheelchair without a functioning ant-rollback device. 2. Resident #25 was provided a fall intervention on 09/22/2023 to include an anti-rollback device affixed to her wheelchair. Intermittent observations from 11/19/2024 thru 11/22/2024 revealed Resident #25 was observed ambulating in her wheelchair without a functioning ant-rollback device. This deficient practice could place residents at risk for harm. The findings included: 1. Resident #20 A record review of Resident #20's admission and discharge record dated 11/21/2024 revealed an admitted [DATE] with diagnoses which included dementia and COPD (an ongoing lung condition caused by damage to the lungs. The damage results in swelling and irritation, also called inflammation, inside the airways that limit airflow into and out of the lungs) and dementia (group of symptoms affecting memory, thinking and social abilities. In people who have dementia, the symptoms interfere with their daily lives). A record review of Resident #20's quarterly MDS assessment dated [DATE] revealed Resident #20 was a [AGE] year-old male admitted for long term care under hospice services. Resident #20 was assessed with a BIMS score of 03 out of a possible 15 which indicated severe cognition impairment. Resident #20 was assessed as needing substantial / maximal assistance helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort with the following activities of daily life: Sit to stand: the ability to come to a standing position from a sitting in a chair, wheelchair, or on the side of the bed. Chair bed to chair transfer: the ability to transfer to and from a bed to a chair or wheelchair. Toilet transfer: the ability to get on and off a toilet or commode. A record review of Resident #20's fall risk assessment dated [DATE] revealed Resident #20 was a Moderate Risk For Falling. A record review of Resident #20's Multidisciplinary Care Conference dated 10/30/2024 revealed Resident #20 was under hospice services, used a wheelchair. A record review of Resident #20's care plan dated 11/21/2024 revealed Resident #20 was provided an anti-rollback device affixed to his wheelchair in response to falls without injuries on 05/23/2024 . During an observation on 11/19/2024 at 12:22 PM Resident #20 was observed seated in his wheelchair at the lunch table. The wheelchair presented with an antiroll back device. Further observation revealed only 1 safety prong protecting the right wheelchair wheel was in place; the left wheel safety prong was missing. Continued intermittent observations from 11/19/2024 thru 11/22/2024 revealed Resident #20 continued ambulating in his wheelchair without a functioning ant-rollback device. During an observation on 11/21/24 at 02:52 PM revealed Resident #20 was in his room seated in his wheelchair; the wheelchair presented without a functioning anti-rollback device specifically no safety prong protecting the left wheel from rolling backwards. During a joint interview on 11/21/24 at 03:03 PM CNA C and LVN E stated Resident #20 had only 1 spoke covering Resident #20's right wheel on his wheelchair. CNA C and LVN E stated they had no knowledge of how long the spoke was missing and had not noticed how long it had been missing, CNA C stated she was an agency CNA and had worked 2-3 times a week for the past 3 months. LVN E stated she had been employed since July 2024 and had been assigned all residents at 1 point or another but usually was assigned 100-hall where Resident #20 resided. LVN E stated she had not recognized the anti-roll back device was missing a spoke on the left side and stated the risk to Resident #20 was a potential fall. CNA C and LVN E stated the safety device was not functioning without both spokes to brake the wheels when Resident #20 arose from the wheelchair. CNA C stated the wheelchair could roll away to the left if Resident #20 attempted to rise out of the chair. During an interview on 11/21/24 03:12 PM OT F stated Resident #20 was missing the left side portion of the anti-rollback safety device affixed to Resident #20's wheelchair. OT F stated the device would not function as designed and posed a risk for not preventing the wheelchair to rollback when Resident #20 may attempt to rise out of the wheelchair. 2. Resident #25 A record review of Resident #25's admission record dated 11/22/2024 revealed an admitted [DATE] whit diagnoses which included Parkinson's disease (a movement disorder of the nervous system that worsens over time; the disorder also may cause stiffness, slowing of movement and trouble with balance that raises the risk of falls) and dyskinesia (A blanket term to describe uncontrollable and involuntary movements. It's when your body moves in ways you cannot control. It can affect just one part of the body, like the head or an arm, or your entire body.) A record review of Resident #25's quarterly MDS assessment dated [DATE] revealed Resident #25 was a [AGE] year-old female admitted for long term care and assessed with a BIMS score of 15 out of a possible 15 which indicated no cognitive impairment. Resident #25 was assessed with adequate hearing and vision and could understand others and make herself understood. Resident was assessed with the need to use a wheelchair. Resident #25 was assessed with the need for assistance with Chair / bed-to-chair transfer as Supervision or touching assistance - helper provides verbal ques and / or touching / steadying and /or contact guard assistance as Resident completes the activity. Assistance may be provided throughout the activity or intermittently. A record review of Resident #25's fall risk assessment dated [DATE] revealed Resident #25 was a High Risk for Falling. A record review of Resident #25's care plan dated 11/22/2024 revealed, (Resident #25) has high risk for falls related to history of falls, antidepressant medication use and gait balance problems . interventions / tasks . 09/22/2023 resident has had two falls with no injuries in three days, Resident (#25) to use anti rolling device to wheelchair During an observation on 11/19/2024 at 12:40 PM Resident #25 was observed seated in her wheelchair at the lunch table. The wheelchair presented with an anti-roll back device. Further observation revealed only 1 safety prong protecting the left wheelchair wheel was in place; the right wheel safety prong was missing. Continued intermittent observations from 11/19/2024 thru 11/22/2024 revealed Resident #25 continued ambulating in her wheelchair without a functioning ant-rollback device. During an observation on 11/20/24 at 11:15 AM revealed Resident #25 attending the Resident council meeting. Resident #25 was seated in her wheelchair. The wheelchair presented without a safety prong over the left wheel of the wheelchair. During an observation and interview on 11/21/2024 at 03:15 PM revealed Resident #25 in her room laying in her bed. Further observation revealed her wheelchair by her bedside. The wheelchair presented with an anti-rollback device affixed to her wheelchair with the right wheel unprotected with a safety prong. The wheelchair only had a safety prong on the right wheel. Resident #25 communicated the wheelchair did not have a functioning anti-rollback device as evidenced by the lack of a right wheel safety prong. Resident #25 stated the device had been missing for some time and could not recall exactly how long. Resident did respond in the negative when questioned if the safety device was missing longer than weeks and indicated the device was missing longer than months. During a joint interview on 11/21/24 at 03:20 PM OT F and RN D stated Resident #25 was at risk for falling and used a wheelchair with anti-rollback device on her wheelchair. OT F and RN D stated Resident #25's wheelchair had a faulty anti-rollback device with the right wheel safety missing. RN D stated the device could malfunction and would not stop the wheelchair from rolling back and could contribute to a fall. RN D stated Resident #25 was diagnosed with Parkinson's disease and had history of falling. RN D stated she had not noticed the device was faulty and could not state how long the device had been faulty. During a joint interview on 11/21/24 at 04:41 PM the Administrator and the DON stated 3 residents out of the entire census of 47 were provided anti-rollback safety devices for their wheelchair's. The Administrator and the DON stated only residents #20 and #25 had presented with an ineffective anti-rollback device affixed to their wheelchairs. During a joint interview on 11/22/24 05:32 PM the Administrator and the DON stated residents who needed safety devices for fall preventions such as anti-rollback devices for wheelchairs and had faulty safety devices were at risk for falls. The Administrator and the DON stated safety mechanisms needed to be in place and working in order to protect the Resident and the direct care staff should be monitoring the safety devices and reporting if there are problems with safety equipment . The Administrator stated he would get with clinical staff, and address training vs execution issues regarding monitoring of safety equipment and hold staff accountable. A record review of the facility's Accidents and Incidents - Investigating and reporting policy dated July 2017, revealed, policy statement: all accidents or incidents involving residents, employees, visitors, vendors, etcetera, occurring on our premises shall be investigated and reported to the Administrator. Policy interpretation and implementation: the nurse supervisor / charge nurse and or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. this facility is in compliance with current rules and regulations governing accidents and for incidents involving a medical device

Based on observation, interviews, and record reviews the facility failed to ensure its medication error rates were not 5% or greater. The facility had a medication error rate of 8.0% (percent), based on 2 errors out of 25 opportunities which involved 1 of 6 residents (Resident #29) reviewed for medication administration and medication errors. 1. LVN E administered Resident #29's medications: metformin (medication for managing high blood sugar in type 2 diabetes) 1000mg and metoprolol tartrate (an immediate-release tablet that must be taken several times per day) 25mg, scheduled at 08:00 AM, at 09:30 AM thirty minutes late. These deficient practices could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings included: 1. A record review of Resident #29's admission record revealed an admitted [DATE] with diagnoses which included diabetes mellitus (a disorder of carbohydrate metabolism characterized by impaired ability of the body to produce or respond to insulin and thereby maintain proper levels of sugar (glucose) in the blood) and heart failure. A record review of Resident #29's quarterly MDS assessment dated [DATE] revealed Resident #29 was a [AGE] year-old female admitted for long term care and was assessed with a BIMS score of 15 out of a possible 15 which indicated no cognitive impairment. A record review of Resident #29's physicians orders dated 11/22/2024 revealed Resident #29 was prescribed to receive metformin (a drug prescribed to assist with blood sugar levels) 1000mg daily, twice a day, at 08:00 AM and at 05:00 PM for diabetes mellitus. Further review revealed Resident #29 was prescribed to receive metoprolol (a drug prescribed to assist with a normal rhythmic heart beat) 25mg daily twice a day at 08:00 AM and at 05:00 PM for heart failure. A record review of Resident #29's care plan dated 11/22/2024 revealed, (Resident #29) has the potential for complications related to diabetes type 2 mellitus with hyperglycemia (high levels of blood sugar) During an observation and interview on 11/21/2024 at 09:20 AM revealed LVN E prepared medications for Resident #29 to include metformin 1000mg and metoprolol 25mg. LVN E administered the medications at 09:30 AM. LVN E stated she was in the reds for medication administration. LVN E described the electronic medication administration record as being highlighted in red to indicate late medication administration. Observation of Resident #29's medication administration record revealed the record to be highlighted red. LVN E stated she was assigned medication administration duty for 1/3 of the facility's residents and described her assignment as the Middle Hall. LVN E stated she was late and was complicated by her breakfast safety monitoring assignment this morning (11/21/2024) LVN E stated she began her shift at 06:00 Am this morning and had concluded her Breakfast dining room safety assignment around 08:45 AM and then began her medication administration assignment. LVN E stated if residents prescribed medication time is past 1 hour the electronic medication record would become highlighted in red to indicate a late medication administration. LVN E stated she had more than 3 residents highlighted in red. LVN E stated she had not communicated the potential for late medication administration with her supervisors the ADON and or the DON. LVN E stated residents who received their medications late were at risk for not receiving the therapeutic effects of their medications. During a joint interview on 11/22/24 05:32 PM the Administrator and the DON stated a medication error includes any failure to meet the 5 rights of medication administration to include: 1. The right Resident. 2. The right drug. 3. The right dosage. 4. The right route of administration. 5. And the right time of administration. The DON stated the right time was considered administration to occur within 1 hour of the prescribed time. If a drug prescribed at 08:00 AM was administered at 09:30 AM the administration was late by 30 minutes and the Resident was at risk for not receiving the intended therapeutic effects of the prescribed medication. The administrator stated he was in agreement with the DON, and stated it was a training vs execution issue, and a skill or will issue and would follow up with medication administration monitoring and would provide accountability measures. A record review of the facility's Administering Medications policy dated April 2019, revealed, Policy statement: medications are administered in a safe and timely manner, and as prescribed. Policy interpretation and implementation: staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. Medications are administered in accordance with prescriber orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. the heart ministered within one hour of their prescribed time,

44906 Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and prevent the development and transmission of communicable diseases and infection for 1 of 10 residents (Resident #31) reviewed for infection control. The facility failed to ensure hand hygiene was initiated between glove changes during blood glucose monitoring and administration of insulin to Resident #31 on 11/21/2024. This deficient practice could affect all residents by contributing to the bacteria load and/or cross contamination during provision of care. The findings included: Record review of Admission Record, dated 11/22/2024, reflected Resident #31was a [AGE] year-old female, originally admitted [DATE]. Record review of the quarterly MDS assessment dated [DATE], reflected Resident #31 did not have a BIMS assessment conducted due to Resident #31 rarely or never understood. Non-traumatic brain dysfunction related to unspecified dementia was Resident #31's primary medical condition category for admission. Other active diagnoses included Diabetes Mellitus. 7 insulin injections were received during the last 7 days of the MDS look back period. Record review of the Order Summary Report, dated 11/22/2024, reflected Resident #31 had physician orders for Sliding Scale Lispro Insulin [required blood glucose monitoring antecedently] before meals and at bedtime with a start date of 6/25/2024. Record review of the Care Plan reflected Resident #31 had a focus area of potential for complications related to diabetes; with the following associated interventions: perform Accuchecks [blood glucose monitoring] as ordered and prn with an initiated date of 10/21/2020 and revision on 10/30/2024. Record review of the MAR, printed on 11/22/2024, reflected Resident #31 had a blood glucose reading of 270 on 11/21/2024 prior to the noon meal: necessitating administration of 6 units of Lispro insulin by LVN A. In an observation on 11/21/2024 at 11:40 AM, LVN A, prepared the equipment necessary to obtain the blood glucose reading for Resident #31, that included a glucometer, test strip, lancet, alcohol wipes and a 2 by 2-inch gauze pad. LVN A sanitized the glucometer according to manufactures recommendations, by wiping the outside of the glucometer with a disposable sanitizing cloth while wearing disposable gloves. LVN A did not perform hand hygiene after discarding those gloves. LVN A then, entered Resident #31's room to obtain the blood glucose reading for Resident #31. LVN A, washed her hands at the sink in Resident #31's room. LVN A donned gloves prior to lancing the tip of Resident #31 index finger for a drop of blood required for the glucometer. Upon the obtaining the reading, LVN A then determined that Resident #31 would require insulin as per the physicians' orders for sliding scale administration. LVN A, discarded her gloves, and exited the room without performing hand hygiene. LVN A then initiated preparing the sliding scale insulin, whereupon she donned gloves without performing hand hygiene. LVN A, discarded those gloves, and entered Resident #31's room. LVN A, donned gloves without performing hand hygiene and proceeded to administer the sliding scale insulin to Resident #31. LVN A, discarded her gloves, but did not perform hand hygiene and then exited Resident #31's room. In an interview on 11/21/2024 at 11:48 AM, LVN A stated she was very nervous being observed and would forget where she was in the process of obtaining the blood glucose reading and administering insulin. LVN A, stated she thought she had performed hand hygiene at each appropriate step as she had been trained, but stated she was very nervous being observed. In a group interview on 11/22/2024 at 5:32 PM, with the ADM and the DON, the DON stated the appropriate time to perform hand hygiene was prior to doing care with a resident, before you touch a resident. The DON stated that if you use gloves, you need to perform hand hygiene prior to donning gloves, and between glove changes. The DON stated this requirement is trained upon new hire on-boarding process, at annual competency training, and in In-Service trainings as needed. The DON stated that it is not a good practice to skip appropriate hand hygiene in a health care setting. The DON stated that could transmit illness among residents, staff and their homes or families. Review of Handwashing/Hand Hygiene policy, revised October 2023, reflected under the heading Indications for Hand Hygiene, step 1. Hand hygiene is indicated: a) immediately before touching a resident; g.) immediately after glove removal. Under the heading Applying and Removing gloves, step 1. Perform hand hygiene before applying non-sterile gloves; Step 5. [after doffing gloves] Perform hand hygiene. Review of CDC Hands web page, dated 02/27/2024, entitled Clinical Safety: Hand Hygiene for Healthcare Workers, accessed from https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, accessed on 10/07/2024, reflected, under the subheading Know when to clean your hands, immediately after glove removal.

Based on observations, interviews and record reviews the facility failed to ensure 1 (Resident #1) of 7 residents reviewed for mechanical device used by staff received adequate supervision and assistance with devices to prevent accidents. On [DATE] Agency nurse aide A transferred Resident#1 with a mechanical lift by herself. The mechanical lift tipped over causing Resident #1 to obtain a head laceration and a left femur fracture requiring surgery. The non-compliance was identified as past non-compliance (PNC). The PNC IJ began on [DATE] and ended on [DATE]. The facility had corrected the non-compliance before the state's investigation began on [DATE] at 9:30 AM. Failure of facility to provide adequate supervision and assistance with devices could lead to injury or death to residents. Findings included: Record review of Resident #1's face sheet electronically dated [DATE] revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of dementia (the loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities.), contractures to right and left knee(a permanent shortening and tightening of muscle fibers that reduces flexibility and makes movement difficult.), bipolar disorder(A serious mental illness characterized by extreme mood swings. They can include extreme excitement episodes or extreme depressive feelings), and anxiety disorder (intense fear and inability to control moments.) Record review of Resident #1's state optional MDS assessment section C, dated [DATE], reflected Resident #1 had a BIMS score of 01, indicative of cognitively unaware. Section G revealed Resident #1 required extensive assistance with 2 persons for transfers. Record review of Resident #1's care plan dated [DATE], reflected Resident #1 required assistance with ADLs potential for self-care deficit. On [DATE] a revision was made for Resident #1 to be transferred using a Hoyer (mechanical lift) and assistance of two staff members if he is fighting staff. Record reveiw of Resident #1's nursing progress notes dated [DATE] timed at 5:38 pm , {resident on floor,hoyer on top of him. CNA beside him. Has laceration to forehead, complaints of left knee pain during assesment. Laceration to forehead cleansed. He is moving the upper extremeties as usual . No other apparent injuy. Responding to questions as usual , assisted to bed with assistance of 3 staff members. Notified sisiter, and doctor. sent to er.by ems.} Record review of Resident #1's EMR physician progress notes dated [DATE] revealed Resident #1 had a left hip fracture and underrwent cephalomedullary nailing on [DATE] returning to facility on [DATE]. Record review of Agency CNA A's written statement dated [DATE] at 4:45 pm, read I was getting ready to transfer {resident #1} to his chair. I looked around for help, but all the aides were getting up their residents and I was behind, so I went ahead and transferred {res #1} by myself. When I started transferring him, he got agitated and held onto the Hoyer bars and was shaking it. Then before I knew it the Hoyer fell , and resident went to floor. I screamed for help. And pressed his forehead to stop the bleeding then the nurse walked in. Telephone interview attempt with Agency CNA A x3 on [DATE] and [DATE] were unsuccessful. During a telephone interview on [DATE] at 11:36 am the previous DON stated the manufacture recommendations of mechanical lift used during transfer said could be one person usage. She further stated, I don't know if having 2 persons would have made a difference because he (Resident #1) became agitated while in the air. During an interview with current DON on [DATE] at 11:45 am stated 2 staff members were to be used for transfers of residents with a mechanical lift. She further stated this is for the safety of the residents and staff. During a telephone interviw on [DATE] at 12:05 pm Resident #1's Nurse practitioner stated he did not believe that his death on [DATE] was related to his fall on [DATE]. He further stated Resident #1 had multiple commorbidiites that could have contributed to his death. The facility took the following measures on [DATE] after the event and prior to surveyor entrance: Record review of facility in services post incident beginning on [DATE] with competencies and demonstration of mechanical lift transfers were done with 28 of 29 staff members and 4 of 4 agency staff having completed. The facility did not allow Agency CNA A to return to the facility. The facility put a system into place for agency staff to review forms prior to their shift to identify the care needs of each resident. Observations by surveyor on [DATE] at 11:30 am and [DATE] at 2:00 pm and 2:30 pm of 3 mechanical lift transfers of residents(Resident #10, #11, #12) revealed was done with 2 staff members during transfers. During investigation period of [DATE]-[DATE] surveyor interviews with 19 of 29 current nursing staff members on all shifts were done and all said they were to use 2 staff members when doing mechanical lift transfers and can verbalize how to transfer residents. Record review of facility in services post incident with competencies and demonstration of mechanical lift transfers were done with 28 of 29 nursing staff members and 4 of 4 agency staff having completed. Record review of facility's policy titled: Lifting Machine, using a Mechanical dated 2001, Staff will perform mechanical lifts/transfers according to the manufacturer's instructions for use of the device. Manufacturer's operation for mechanical lift states Although [manufacture] recommends two assistants be used for all lifting preparation, transferring from, and transferring to procedures, our equipment will permit proper operation by one assistant. The use of one assistant is based on the evaluation of the health care professional for each individual case.

Based on interview and record review, the facility failed to ensure the resident's right to be free from abuse for 1 of 11 residents (Resident #2) reviewed for abuse, in that: The facility failed to protect Resident #2 from Resident #3 during a resident-to-resident altercation on 09/21/2024. The non-compliance was identified as past non-compliance (PNC). The PNC IJ began on 09/21/2024 and ended on 09/24/2024. The facility had corrected the non-compliance before the state's investigation began on 10/29/2024 at 9:30 a.m. This deficient practice could place residents at risk of physical injury and/or psychosocial harm. The findings were: Record review of Resident #2's face sheet, dated 11/01/2024, revealed the resident was admitted to the facility on [DATE] with diagnoses including: hemiplegia, muscle weakness, low vision in his right eye, and blindness in his left eye. Record review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 4 which indicated severe cognitive impairment. Record review of Resident #2's care plan, initiated 11/01/2021, revealed [Resident #2] is highly visually impaired .may bump into things from not seeing them. [Resident #2] is at moderate risk for falls [related to] Confusion, Gait/balance problems, Paralysis. Record review of Resident #3's face sheet, dated 11/01/2024, revealed the resident was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including: unspecified dementia, generalized anxiety disorder, and impulse disorder. Record review of Resident #3's quarterly MDS, dated [DATE], revealed a BIMS score of 8 which indicated moderate cognitive impairment. Record review of Resident #3's care plan, initiated 04/20/2024, revealed, [Resident #3] has sexual and aggressive behaviors and enters residents' rooms without permission, takes food from other residents in dining room and other resident's refrigerators . he cannot control his impulses . Resident hit another resident. Police came to facility to assess altercation . after resident attempted to punch another resident, he was separated and redirected. Further review of Resident #3's care plan, revised 09/24/2024, revealed an intervention to redirect resident from other resident rooms as a result of the incident on 09/21/2024. Further review revealed a Care Plan meeting occurred on 10/03/2024 which resulted in an increase in medication of trazadone (medication used to treat anxiety disorders). Record review of Resident #3's clinical record, as of 11/01/2024, revealed, a behavior notes, dated 03/14/2024, Flinging snot and phlegm at other residents and the floor in the dining room in the middle of dinner. Parking his wheelchair in the middle of the hall, blocking other residents and continuing to [NAME] phlegm; 03/15/2024, Resident grabbed food out of another resident's hand then attempted to run into another resident with his wheelchair, 06/30/2024, Yelling slurs and shut the fuck up at his roommate whenever he makes a noise. Stealing food items off other residents' tables during mealtimes and flinging phlegm on the floor in the dining room; 07/29/2024, This resident came up to this female resident; both in [wheelchair]. [Resident #3] reached out for her right breast with his [NAME]. This female resident blocked [Resident #3] hand and he laughed. The Occupational Therapist, who witnessed this incident; explained to [Resident #3] that it was inappropriate for him to do that. This nurse redirected him. Resident expressed understanding. Will continue to monitor; 09/28/2024, Attempting to punch another resident for accidentally bumping into him with his wheelchair. Nurse intervened and redirected both residents. Resident very passive aggressive, constantly putting his wheelchair in the middle of the hall, blocking access; 10/03/2024, Yelling at another resident to Shut Up very loudly in front lobby area. Then as he was heading back to his room, he is gesturing angrily at staff and stopped and yelled at another resident to Shut up; 10/17/2024 Behavior: Verbal abuse, cursing, hostility. Incident: Resident outside amongst smokers and asked 2 residents for cigarettes. Both residents denied this residents cigarette. This resident then told other 2 residents to FUCK YOU. Further review of Resident #3's clinical record, as of 11/01/2024, revealed no additional incidents of verbal or physical aggression toward peers or staff since 10/17/2024 (2 weeks after the intervention to increase his Trazadone). Record review of Resident #3's clinical record, as of 11/01/2024, revealed his plan of care had been updated to include additional monitoring and supervision. Further review revealed that after the new intervention of enhanced supervision and redirection of the resident was introduced, on 9/24/24, the number of Resident #3's incidents of aggression decreased. Record review of Resident #3's electronic health record revealed after 9/24/24, his incidents of physical aggression decreased. Incidents consisted of verbal aggression (yelling expletives) only. Record review of the facility incident report, dated 09/21/2024, revealed, An altercation occurred between two residents on 9/21/24 at approximately 7pm. [Resident #3] perpetrator struck [Resident #2]. - Both residents are wheelchair bound, but [Resident #2] resulted on the floor . - The only witness of the event revealed that Resident #2 stood from his wheelchair to hit Resident #3 but Resident #3 pushed Resident #2 away resulting in Resident #2 falling. - The local police department were called in response to the 09/21/2024 incident but Resident #2 did not want to press charges against Resident #3. - The facility had conducted Resident Satisfaction Surveys with none reporting they felt unsafe at the facility. - Record review of the facility in-service, Resident-to Resident, dated 09/24/2024, revealed staff received additional training regarding recognizing and defusing conflicts between residents including methods such as redirecting aggressive residents to calm activities. Record review of Resident #2's clinical record, dated 09/21/2024, revealed a nurse assessment was performed immediately following the incident with no injuries noted. Further review of Resident #2's clinical record revealed he was assessed by a nurse each subsequent day for one week with no injuries noted. During the state's investigation, from 10/29/2024 to 11/01/2024, staff were observed interacting with Resident #3 in a pleasant manner, assisting him to maneuver within the facility, and maintaining close supervision of the resident. Further observations revealed the resident self-propelled slowly and frequently required staff assistance. Observations of Resident #3 on 11/01/2024 between 10:00 a.m. and 4:30 p.m. revealed while sitting in his wheelchair, Resident #3 moved slowly utilizing both feet and one hand/arm to propel himself. His feet would slip when he applied pressure against the floor resulting in several attempts at moving before being successful and going only a very short distance. Staff were observed assisting Resident #3 by pushing his wheelchair. Resident #3 did not exhibit any signs of physical or verbal aggression. During an interview with Resident #3 on 11/01/2024 at 4:32 p.m., Resident #3 stated he was friends with Resident #2 and declined to further converse. During an attempted interview with Resident #2 on 11/01/2024 at 4:36 p.m., Resident #2 was unable to be interviewed. During an interview with Resident #4 on 11/01/2024 at 4:42 p.m., Resident #4 stated she was afraid of Resident #3. She stated Resident #3 hit her during his first admission to facility in 2011, but that he had not done so since his readmission in 2024 and added that Resident #3 often used threatening speech and aggressive mannerisms. Resident #4 further stated that she had not witnessed Resident #3 attempt to strike anyone recently. Resident # 4 further stated she did not inform anyone of her fear. Interviews with nine additional residents on 11/01/2024 between 10:00 a.m. and 4:30 p.m. revealed none who answered affirmatively when asked if Resident #3 had displayed verbal or physical aggression toward them, and none who answered affirmatively when asked if they were afraid of Resident #3. Further interviews with residents revealed Resident #3's incidents of aggression decreased in number and become less physical in nature following the interventions. During an interview with the DOR on 11/01/2024 at 2:56 p.m., the DOR stated that Resident #3 had experienced a decline in physical functioning and lacked the ability to hit or kick peers or staff. The DOR also stated he had been alerted to assist with monitoring and supervising Resident #3 due to the resident's past aggression. Interviews with three CNAs and two LVNs on 11/01/2024 between 10:00 a.m. and 4:30 p.m. revealed they all had been alerted to assist with monitoring and supervising Resident #3 due to the resident's past aggression. Further interviews with staff revealed they had been directed to closely monitor Resident #3, and the resident's incidents of aggression had decreased in number and become less physical in nature following the interventions. Record review of in-service records revealed staff had been provided with training regarding defusing resident-to-resident altercations. Record review of Resident #3's clinical record revealed that in addition to enhanced supervision and monitoring by the staff, the resident was offered psychological services, visited by the facility Social Worker, and his physician ordered medication changes to assist the resident to cope. Further review revealed the incidents of aggression had decreased in number and become less physical in nature following the interventions. During an interview with the Administrator on 11/01/2024 at 5:05 p.m., the Administrator stated that Resident #3 would be involuntarily discharged from the facility due to his aggressive behaviors. Record review of the facility policy, Resident to Resident Altercations, revised September 2022, revealed, All altercations, including those that may represent resident-to-resident abuse, are investigated and reported .