Every finding on record at Chisolm Trail Nursing and Rehabilitation Center

Based on interview and record review the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preference for 1 of 17 residents (Resident #3) reviewed for pain management. The facility failed to consistently and accurately monitor Resident #3's pain levels beginning 05/25/2026 until she was hospitalized on [DATE]. On 08/04/2026 Resident #3's nursing note by LVN B reflected that she was in pain. Resident #3's increased pain was documented in nursing notes by RN A, RN B, and LVN C. Resident #3 was sent to the hospital on [DATE] when she was in excruciating pain and diagnosed with bilateral sacral fractures. These failures could place residents at risk of severe, uncontrolled pain, severe mental anguish or emotional distress that could have led to serious harm, injury, impairment, or death. Findings Included: Record review of Resident #3's face sheet, dated 08/11/2026, revealed a seventy-six-year-old female who was admitted to the facility on [DATE], re-admitted on [DATE] with a diagnosis that included vascular dementia, moderate, with agitation (middle-stage decline in thinking and memory caused by reduced blood flow to the brain, paired with behavioral symptoms like pacing, restlessness, irritability, or verbal and physical distress), generalized anxiety disorder (a long-term mental health condition marked by constant, extreme worry and fear about everyday things like work, health, and money), and chronic atrial fibrillation (a continuous, irregular heart rhythm where the upper chambers of the heart quiver instead of pumping blood normally). Record review of Resident #3's care plan, undated, revealed a focus dated 07/01/2026 Resident #1 was on pain medication therapy related to breakthrough pain with intervention dated 07/01/2026 revealed review for pain medication efficacy, assess whether pain intensity was acceptable to resident, no treatment regimen or change in regimen required; controlled adequately by therapeutic regimen no treatment regimen or change in regimen required but continue to monitor closely, controlled when therapeutic regimen followed, but not always followed as ordered; therapeutic regimen followed, but pain control not adequate, changes required. Focus dated 08/11/2026 the resident has had actual falls related to gait instability and increased restlessness and Resident #3 did not call for assistance. Focus dated 04/21/2026 Resident #3 had impaired cognitive function related to Alzheimer's Dementia (a specific brain disorder and the most common cause of dementia). Focus dated 04/21/2026 discharge from the facility is not feasible as evidenced by the resident needing 24 hours a day, 7 days a week nursing care in a secure care unit. Record review of Resident #3's MDS (clinical assessment to determine resident's strength and needs) dated 05/19/2026 Nursing Home Comprehensive Section C - Cognitive Patterns reflected a BIMS score of 2 indicating severe cognitive impairment and J0100 Pain Management resident received scheduled pain medication regimen, resident received prn pain medications or was offered and declined, J0200 - Pain Assessment Interview to be Conducted, J0300 - Pain Presence resident answered no to Have you had pain or hurting at any time in the last 5 days. Record review of Resident #3's order dated 03/27/2026 reflected Lidocaine External Patch (a local anesthetic that numbs the skin and nerves in a specific area to relieve localized nerve or muscle pain) 5% apply to right rib topically one time a day for pain. Record review of Resident #3's order dated 04/04/2026 reflected Tylenol 8 Hour Oral Tablet Extended Release (commonly marketed for Arthritis Pain or Muscle Aches and Pain) contains 650 mg of acetaminophen (widely used over-the-counter medicine that treats minor aches, pains, and reduces fever) per caplet. Its unique bi-layer design delivers fast-acting relief through the first layer and sustained relief through the second layer for up to 8 hours) 650 MG (Acetaminophen) give one tablet by mouth three times a day for pain. Record review of Resident #3's order dated 04/21/2026 reflected Gabapentin Capsule (prescription oral medications used to treat nerve pain from shingles, manage partial seizures, and calm overactive nerve signals) 300 MG give two capsules by mouth three times a day for pain. Record review of Resident #3's order dated 07/07/2026 reflected tramadol HCI Oral Tablet (a prescription opioid medicine used to treat moderate to moderately severe pain in adults when other non-opioid treatments are not enough) 50 MG give one tablet by mouth two times a day for pain management for fourteen days. Record review all of Resident #3's eMar Pain levels (0 means no pain, and 10 means the worst pain) charted in PCC beginning date 05/25/2026 ending date 08/09/2026 resident assessed by numerical (verbally asked the resident if they were in pain) or PAINAD (observational tool used to evaluate pain levels in patients who cannot verbally communicate). 05/25/2026 Level 0 8:10 AM LVN B numerical05/26/2026 Level 0 8:14 AM LVN B numerical05/26/2026 Level 0 8:15 AM LVN B numerical05/27/2026 Level 0 12:01 AM CMA/CNA A numerical05/27/2026 Level 0 6:18 AM CMA/CNA A numerical05/28/2026 Level 0 5:34 PM CMA/CNA A numerical05/29/2026 Level 0 6:17 PM CMA/CNA A numerical05/31/2026 Level 0 7:03 PM RN B numerical06/01/2026 Level 0 8:29 AM LVN B numerical06/01/2026 Level 0 8:32 AM LVN B numerical06/03/2026 Level 0 2:05 PM LVN B numerical06/06/2026 Level 1 5:35 PM LVN D PAINAD06/08/2026 Level 0 9:16 AM LVN B numerical06/08/2026 Level 0 10:26 AM DON numerical06/10/2026 Level 0 7:54 AM MA D numerical06/10/2026 Level 0 5:46 PM MA D numerical06/15/2026 Level 0 9:36 AM DON numerical06/17/2026 Level 7 10:52 PM RN A numerical06/18/2026 Level 2 3:02 AM RN A numerical06/19/2026 Level 0 8:10 AM MD A numerical06/19/2026 Level 0 2:39 PM MD A numerical06/19/2026 Level 0 5:52 PM MD A numerical06/20/2026 Level 0 1:15 PM LVN C numerical06/20/2026 Level 0 9:17 PM RN B numerical06/22/2026 Level 0 8:05 AM LVN B numerical06/22/2026 Level 0 8:17 AM LVN B numerical06/22/2026 Level 0 1:12 PM LVN B numerical06/23/2026 Level 0 12:25 PM MA E numerical06/23/2026 Level 4 3:20 PM LVN B numerical06/23/2026 Level 0 5:38 PM CMA/CNA A numerical06/23/2026 Level 2 9:21 PM RND numerical06/24/2026 Level 0 9:10 AM LVN B numerical06/29/2026 Level 0 8:46 AM LVN B numerical06/29/2026 Level 0 9:16 AM LVN B numerical06/30/2026 Level 0 5:58 PM CMA/CNA A numerical06/30/2026 Level 7 7:00 PM RN D numerical06/30/2026 Level 2 8:04 PM RN D numerical07/01/2026 Level 0 9:39 AM MA F numerical07/01/2026 Level 0 12:47 PM MA F numerical07/01/2026 Level 0 5:43 PM MA F numerical07/03/2026 Level 0 7:44 PM CMA/CNA A numerical07/03/2026 Level 0 12:25 PM CMA/CNA A numerical07/03/2026 Level 0 5:43 PM CMA/CNA A numerical07/04/2026 Level 0 7:48 AM LVN C numerical07/04/2026 Level 2 8:27 PM RN B numerical07/05/2026 Level 4 7:58 AM (employee not listed in employee roster, unknown if nurse or MT) numerical07/05/2026 Level 4 :19 PM (employee not listed in employee roster, unknown if nurse or MT) numerical07/05/2026 Level 1 5:39 PM (employee not listed in employee roster, unknown if nurse or MT) numerical07/05/2026 Level 0 6:48 PM RN B numerical07/06/2026 Level 0 12:02 AM DON numerical07/07/2026 Level 0 7:59 AM CMA/CNA A numerical07/07/2026 Level 0 9:27 PM CMA/CNA A numerical07/08/2026 Level 0 9:07 AM MA F numerical07/08/2026 Level 0 9:10 AM MA F numerical07/08/2026 Level 0 3:27 PM MA F numerical07/08/2026 Level 0 3:27 PM MA F numerical07/09/2026 Level 0 7:41 AM CMA/CNA A numerical07/09/2026 Level 0 7:41 AM CMA/CNA A numerical07/09/2026 Level 0 12:01 PM CMA/CNA A numerical07/09/2026 Level 0 5:33 PM CMA/CNA A numerical07/09/2026 Level 0 5:33 PM CMA/CNA A numerical07/10/2025 Level 0 7:35 AM CMA/CNA A numerical07/10/2025 Level 0 07:36 AM CMA/CNA A numerical07/10/2025 Level 0 12:28 PM CMA/CNA A numerical07/10/2025 Level 0 5:41 PM CMA/CNA A numerical07/11/2026 Level 0 7:39 PM CMA/CNA A numerical07/11/2026 Level 0 7:39 PM CMA/CNA A numerical07/12/2026 Level 0 6:53 AM CMA/CNA A numerical07/12/2026 Level 0 6:55 AM CMA/CNA A numerical07/12/2026 Level 0 12:09 PM CMA/CNA A numerical07/12/2026 Level 0 12:38 PM CMA/CNA A numerical07/12/2026 Level 0 12:38 PM CMA/CNA A numerical07/13/2026 Level 5 3:36 AM RN A PAINAD07/14/2026 Level 0 6:25 AM CMA/CNA A numerical07/14/2026 Level 0 6:25 AM CMA/CNA A numerical07/14/2026 Level 0 12:05 PM CMA/CNA A numerical07/14/2026 Level 0 5:50 PM CMA/CNA A numerical07/14/2026 Level 0 5:51 PM CMA/CNA A numerical07/15/2026 Level 0 7:58 AM MA E numerical07/15/2026 Level 0 7:58 AM MA E numerical07/15/2026 Level 0 12:34 AM MA E numerical07/15/2026 Level 0 5:33 PM MA E numerical07/15/2026 Level 0 5:33 PM MA E numerical07/16/2026 5:53 PM Level 1 RN B numerical07/16/2026 7:15 PM Level 7 RN A numerical07/17/2026 4:30 AM Level 9 (employee not listed in employee roster, unknown if nurse or MT) PAINAD07/17/2026 5:24 AM Level 0 (employee not listed in employee roster, unknown if nurse or MT) PAINAD07/17/2026 9:52 AM Level 4 (employee not listed in employee roster, unknown if nurse or MT) PAINAD07/17/2026 6:00 PM Level 0 CMA/CNA A numerical07/18/2026 7:59 AM Level 0 CMA/CNA A numerical07/18/2026 7:59 AM Level 0 CMA/CNA A numerical07/18/2026 12:00 PM Level 0 CMA/CNA A numerical07/19/2026 12:15 AM Level 10 RN B PAINAD 07/19/2026 1:44 AM Level 0 RN B numerical07/19/2026 6:50 AM Level 0 CMA/CNA A numerical07/19/2026 6:52 AM Level 0 CMA/CNA A numerical07/19/2026 12:03 PM Level 0 CMA/CNA A numerical07/20/2026 8:37 AM Level 0 MA G numerical07/20/2026 8:40 AM Level 0 MA G numerical07/20/2026 10:26 AM Level 4 LVN B numerical07/20/2026 5:38 PM Level 0 MA G numerical07/20/2026 5:39 PM Level 0 MA G numerical07/20/2026 11:00 PM Level 5 (employee not listed in employee roster, unknown if nurse or MT) PAINAD07/21/2026 4:52 AM Level 6 (employee not listed in employee roster, unknown if nurse or MT) PAINAD07/21/2026 6:38 AM Level 0 CMA/CNA A numerical07/21/2026 6:40 AM Level 0 CMA/CNA A numerical07/21/2026 12:46 AM Level 0 CMA/CNA A numerical07/21/2026 5:47 PM Level 0 CMA/CNA A numerical07/22/2026 5:46 PM Level 0 CMA/CNA A numerical07/23/2026 9:22 AM Level 0 LVN E numerical07/27/2026 8:51 AM Level 0 CMA/CNA A numerical07/27/2026 12:12 PM Level 0 CMA/CNA A numerical07/27/2026 12:53 PM Level 0 LVN B numerical07/27/2026 5:50 PM Level 0 CMA/CNA A numerical07/28/2026 8:24 AM Level 0 CMA/CNA A numerical07/28/2026 12:09 AM Level 0 CMA/CNA A numerical07/29/2026 12:08 PM Level 0 CMA/CNA A numerical07/29/2026 5:32 PM Level 0 CMA/CNA A numerical07/30/2026 7:36 AM Level 0 CMA/CNA A numerical07/30/2026 12:09 PM Level 0 CMA/CNA A numerical08/03/2026 9:09 AM Level 0 LVN B numerical08/03/2026 1:12 PM Level 0 DON numerical08/05/2026 7:11 AM Level 4 LVN B numerical08/06/2026 7:56 AM Level 10 CMA/CNA A Numerical08/06/2026 12:21 PM Level 0 CMA/CNA A Numerical08/07/2026 9:09 AM Level 0 MA G Numerical 08/07/2026 12:09 PM Level 0 MA G Numerical08/07/2026 5:34 PM Level 0 MA G Numerical08/08/2026 1:12 PM Level 0 MA G Numerical 08/08/2026 5:57 PM Level 0 MA G Numerical08/09/2026 Level 10 RN B Numerical Record review of Resident #3's order dated 07/21/2026 reflected Methocarbamol Oral Tablet (a prescription muscle relaxer used short-term alongside rest and physical therapy to ease pain and stiffness from acute muscle injuries) 500 MG give one tablet by mouth three times a day for pain management until 08/11/2026. Record review of Resident #3's order dated 07/21/2026 reflected Tylenol with Codeine #3 Tablet 300-30 MG (a prescription combination opioid medication used to manage mild to moderate pain) give one tablet by mouth three times a day for pain until 08/04/2026. Record review of Resident #3's progress notes dated 08/04/2026 7:36 AM by LVN B reflected Resident #3 complained of right butt cheek pain, difficulty standing and walking, notified NP B and obtained orders for Right hip X-ray. Record review of Resident #3's progress notes dated 08/04/2026 7:36 AM LVN B reflected Resident #3 complained of right butt cheek pain, difficulty standing and walking, notified NP B and obtained orders for Right hip X-ray. Record review of Resident #3's order dated 08/07/2026 reflected Norco Tablet 5-325 MG (5-325 mg tablet contains 5 mg of hydrocodone bitartrate and 325 mg of acetaminophen as active ingredients) give one tablet by mouth as needed for pain one tab twice a day PRN for pain. Record review of Resident #3's progress note dated 08/09/2026 6:02 AM RN B reflected Resident #3 continued with extreme levels of pain when moving lower extremities, current analgesic (a medication or substance used to relieve pain without causing a loss of consciousness) ordered was unable to decrease her level of pain, she had not slept all night and continued with episodes of screaming in pain, she had a nickel size light purple color bruise noted above left [NAME] area, X-rays performed were negative for any fractures, possible tissue injury, will continue to monitor and report as necessary. Record review of Resident #3's progress note dated 08/09/2026 4:09 PM LVN C reflected CNA staff (name of CNA not listed) reported Resident #3 on floor next to wheelchair. CNA staff member explained that she was attempting to take Resident #3 to the bathroom. Resident #3 leaned forward and went to floor abruptly and area from previous fall to left head reopened. Resident #3's cognitive status poor, staff assisted Resident #3 back into bed. Neuro checks initiated. area to left head cleansed and treatment administered per previous wound orders. Proper notifications made. Neuro checks continue per protocol. continue to monitor. Record review of Resident #3's progress note dated 8/09/2026 4:30 PM LVN C reflected Resident #3 had a fall in her rest room and hit head, cognition/behavior at time of event - agitated, restless, cognitive impairment. Resident #3 leaned forward out of wheelchair and reopened area to left head related to previous fall, area cleansed and treatment administered per orders. Resident #3 appeared and/or stated to be in pain, describes the pain as: unable to describe. location of pain: unable to describe, pain relieving intervention used at this time: received routine and prn medications, initial treatment/new orders by NP A: SED rate (a simple blood test that measures how fast red blood cells sink to the bottom of a test tube. It detects inflammation in the body, but it does not treat pain or pinpoint the exact cause of discomfort) to evaluate for inflammation, neuro checks per protocol, and notify on call if any changes. Resident statement - resident hollering in pain, previous to fall, pain unable to be managed, pain to be addressed with SED Rate NP A notified 08/09/2026 3:45 PM. Interventions in place prior to fall: none and interventions initiated in response to fall: none. Record review of Resident #3's nurses progress note dated 08/09/2026 11:51 PM RN A Resident #3 was awake and lying on right side and refused to put any pressure on left hip/sacral area due to excruciating pain. Resident #3 had Tramadol (prescription opioid pain medicine used to treat moderate to moderately severe pain when non-opioid options are not enough) which had little effective relief and was moaning in pain. She had made attempts at getting up to go to bathroom, but she was unable to put weight on the left leg and was a fall risk. She has an order for Norco (prescription opioid pain medication containing hydrocodone and acetaminophen), but the medication had not been delivered yet. At this time, she was given Hydroxyzine (a prescription antihistamine used to treat short-term anxiety, relieve allergic skin itching, and provide sedation before or after surgery) for anxiety with expectation for some sleep. Record review of Resident #3's progress note, Administration note dated 08/10/2026 1:22 AM LVN A reflected hydroxyzine HCI (hydrochloric acid) oral tabled 23 MG (a prescription antihistamine used to treat short-term anxiety, relieve allergic skin itching (hives and eczema), and provide sedation before or after surgery) PRN administration was not effective. Record review of Resident #3's progress note dated 08/10/2026 1:45 AM RN A late entry reflected Resident #3 had unwitnessed fall in the bathroom. Resident #3 attempted to toilet self and discovered on the floor next to toilet. Cognition/behavior at time of event - agitated, resident had cognitive Impairment, CNA (name of CNA not listed) reported that Resident #3 was on bathroom floor apparently having crawled there. Resident #3 appeared and/or stated to be in pain. Resident #3 not able to describe the pain. The location of pain was left hip area and pain-relieving intervention used at the time was Tramadol. Resident #3, unable to say what happened when asked 'what happened kept saying I hurt, help me continued to scream out in pain. NP Date/time of notification: 08/10/2026 2:00 AM. Interventions in place prior to fall: Low bed, CNA regular rounds. Interventions initiated in response to fall: Low bed. Note that in an earlier report, there was an existing small bruise on the left sacral/ hip area from a previous fall.Record review of Resident #3's progress note dated 08/10/2026 2:26 AM RN A reflected CNA (name of CNA not listed) reported that Resident #3 was on bathroom floor apparently having crawled there. Resident #3 had been complaining continuously the whole shift of high-level pain in left sacral/hip area. Ordered pain medications had no effect on relief. On call for facility doctor was notified of falls and pain. NP ordered transfer out to hospital for evaluation and treatment. Record review of Resident #3's hospital progress notes dated 08/10/2026 reflected bilateral sacral fractures (breaks on both sides of the sacrum, the triangular bone at the base of the spine). Record review of facility in-services: Transfer Bed to Chair by the RCN to the Administrator and DON date conducted 08/10/2026 end date 08/11/2026 Event Reporting Competing Events in PCC (an electronic health record designed primarily for long-term and post-acute care facilities) Nurses Only by the RCN to the Administrator and DON date conducted 08/10/2026 end date 08/11/2026 Provider Letter (an official policy communication issued by the Texas Health and Human Services Commission to instruct licensed or certified health and human services providers on mandatory incident-reporting rules, timeframes, and procedures) by the RCN to the Administrator and DON date conducted 08/10/2026 end date 08/11/2026 Transfer Bed to Chair by the DON to nursing and CNA staff date conducted 08/10/2026 end date ongoing Safe Patient Handling (transfers) by the DON to nursing and CNA staff date conducted 08/10/2026 end date ongoing Notifying the Physician of Change of Status by the DON to nursing staff date conducted 08/10/2026 end date ongoing Pain Management by DON to nursing and CNA staff date conducted 08/10/2026 end date ongoing Baseline Care Plan by RCN to nursing staff date conducted 08/10/2026 no end date Fall Prevention by DON to nursing and CNA staff date conducted 08/10/2026 end date ongoing Abuse and Neglect by Administrator to all staff date conducted 08/10/2026 end date ongoing Reporting Guidelines (Provider Letter) by Administrator to all staff 08/10/2026 end date ongoing Pain Management (Nursing Response Uncontrolled Pain) by RCN to nursing and CNA staff date 08/12/2026 no end date During an interview on 08/11/2026 at 2:17 pm with the DON he said because the pain medications were not effective for Resident #3 the nurses should have been more aggressive and painted a clearer picture to both him and the NPs that Resident #3 was in pain and needed to go to the hospital. The DON said when Resident #3 fell the 2nd time, the nurses should have requested another x-ray. The DON said the nurses should have called him and told him about the situation if they were not getting what they wanted from the on-call NPs. The DON said the nurses failed to advocate for the resident and the resident was in pain for a long time. During an interview on 08/12/2026 at 10:24 AM with LVN C she said Resident #3's was in pain, and she discussed with NP A about sending Resident #3 to the hospital and NP A told her to order a SED rate (can indicate the presence of conditions such as infections, autoimmune diseases, arthritis, or certain cancers). LVN C said she called Resident #3's RP and asked him if he wanted to send her to the hospital but he did not request Resident #3 to go to the hospital. LVN C said it was breaking her heart that Resident #3 was in so much pain, and the pain medication was not helping her. LVN C said Resident #3 was screaming in pain and kept all the other residents awake. LVN C said she would not have hesitated to send Resident #3 to the hospital if she had received orders from an NP or the RP said he wanted her to be sent. Attempted to interview RN B on 08/12/2026 at 11:33 AM. Phone call made to RN B but unable to leave a VM, the VM box was full and left a text message with no reply. Attempted to interview RN A on 08/12/2026 at 11:58 AM. Phone call made to RN A and left a VM and sent a text message with no reply. During an interview by phone on 08/12/2026 at 12:10 PM with NP B she said she was not on call the weekend of 08/08/2026. NP B said she knew that Resident #3 had been having pain in her hips for a while and the pain got worse over the weekend of 08/08/2026. NP B said she trusted the judgment of the nurses and the nurse had the resident in front of them. NP B said if a nurse said she thought a resident should be sent to the hospital, she generally agreed for the resident to be sent to the hospital. During an interview by phone on 08/12/2026 at 12:15 PM with CNA B she said she worked with Resident #3 on 08/09/2026 and CNA B said Resident #3 was screaming in pain. CNA B said all night Resident #3 was hollering and Resident #3's voice was hoarse and she sounded like a man because she had been screaming in pain for so long. CNA B said she did not know why Resident #3 was not sent to the hospital. During an interview by phone on 08/12/2026 at 12:52 PM with CNA C she said that Resident #3 was yelling in pain a lot throughout the past week. CNA C said Resident #3's voice was hoarse because Resident #3 had been crying in pain. CNA C said she wondered why Resident #3 was not at the hospital because it was clear she was in pain. During an interview on 08/12/2026 at 1:26 PM with RNC she said a nurse needed to tell a doctor or an NP if they felt a resident needed to go to the hospital. She said nurses needed to use their nursing judgment and if the nurse knew a resident was in excruciating pain and pain medication interventions were not working, they needed to tell the doctor or NP the resident needed to go to the hospital. RN C said the nurses needed to document that they told the doctor or the NP that they felt the resident needed to go to the hospital. RN C said if the nurse felt that the resident needed to go to the hospital they needed to reach out to the DON and let him know that they felt the resident was in pain, interventions were not working and the resident needed to go to the hospital. RN C said the nursing staff needed to document any conversations had with the medical doctor, the NP, and the DON. During an interview on 08/22/2026 at 2:56 PM with MT G she said if a resident was given a scheduled pain medication, she did not ask the residents' level of pain, and the MAR did not prompt them to enter a pain level. She said if the MAR asked for an input of the residents' pain level, she put zero if the resident was not in pain. MT G said she did not work in the secure unit. She said if a resident had any indication that they were in terrible pain, she would go to a nurse directly to speak with them about the resident's pain. She said if she was working with a resident who was non-verbal, she would go by the resident's facial expression to determine if the resident was in pain. During an interview on 08/22/2026 at 3:37 PM with CMA/CNA A she said she remembered administering Resident #3 pain medications. CMA/CNA A said Resident #3 complained a lot about pain and sometimes she cried out in pain. CMA/CNA A said some of Resident #3's pain was not pain, but anxiety about pain. CMA/CNA A said she did not have a way to figure out Resident #3's level of pain. CMA/CNA A said she just based it upon her background of working with Resident #3. During an interview on 08/22/2026 at 4:00 PM with MA H said he has administered residents pain medication. He did not remember giving Resident #3 pain medication before she went to the hospital. MA H said he did not like working on the secure unit and avoided working there. MA H said he could not assess if residents were in pain. He said if the MAR required him to enter a pain level, he entered either zero or NA. MA H said no one at the facility told him to do that, but it was how he was trained. During an interview on 08/22/2026 at 4:05 PM with the DON he said since the surveyor's visit beginning 08/11/2026, the facility had been checking resident pain levels twice a day. The DON said before this time, residents' pain levels were checked daily, and some were checked weekly. The DON said they did not have an accurate level of Resident #3's pain because it was not being recorded. The DON said the picture of Resident #3's pain was incomplete. He said it was also difficult to monitor because of her compromised cognition due to Resident #3's dementia. He said if they had pain numbers in place, they would have had a lot more information to assess her pain levels. The DON said it was his expectation that a licensed nurse recorded resident pain levels. During an interview on 08/22/2026 at 4:45 PM the MDS Coordinator said for the month of August 2026, Resident #3's TAR was not triggered to prompt nursing staff to record any of Resident #4's vital signs or Resident #3's pain level. The MDS Coordinator said the nursing staff who cared for the residents were responsible for noticing this was not included in Resident #3's TAR and should have brought it to the attention of the nursing management. The MDS Coordinator said this was something she should have caught. The MDS Coordinator said a possible negative effect of vitals and pain not being triggered in PCC for documentation was Resident #3 was not assessed or treated in a timely manner. She said the nursing staff would not know if any PRN medications were working for resident's pain and there was not an accurate record of Resident #3's pain. The MDS Coordinator said if an MT or CMA automatically entered either an NA or a zero in a Residents' MAR for pain a pain level, it would be inaccurate. She said this inaccurate record of pain would be recorded in the residents' eMAR. The MDS Coordinator said MTs were not supposed to enter a zero and not to enter an NA because that was no information. Record review of Job Description Certified Medication Aide the following is a non-exhaustive criteria that relates to the job of a Certified Medication Aide, and it is consistent with the business needs of the facility. These are legitimate measures of the qualifications for a Certified Medication Aide and are related to the functions that are essential to the job of a Certified Medication Aide. Ability to record information and perform technical procedures. Responsible for appropriately administering resident's prescribed PO, topical (unbroken skin) and rectal medication according to the physician's orders and Medication Administration policies.Monitors adverse effects of administered medications and reports them immediately to Charge Nurse.Records all medication administration according to company policy.Reports any medication errors immediately to Charge Nurse.Responsible for properly monitoring assigned administration of resident medication.Responsible for notifying the Charge Nurse of complaints, reactions or any change in resident statusRecord review of facility Pain Management, Assessment Scale dated 03/25/2016 reflected pain is a subjective sensation of discomfort derived from multiple sensory nerve interactions generated by physical, chemical, biological, or psychological stimuli. Policy - Complaints of pain will be assessed accordingly by the nurse and effectively managed through prescribed medications, and comfort measures, and all available resources of the facility. Goals - Cognitively impaired residents will demonstrate actions of pain relief. Procedure - Assess resident's physical symptoms of pain, physical complaints, and daily activities, pain questions based on a resident's communication ability were included in the, Admission/readmission and Weekly Nursing Summary, if a resident is verbal, the new questions will be identical to the questions asked on the MDS. If a resident is non-verbal, the questions will be a PAINAD assessment. If the MDS QM Pain criteria is met, a Pain SBAR (a structured communication tool used by nurses to share concise, critical resident data with physicians, nurse practitioners, or transferring hospitals) will be triggered. There is no quality measure criteria for a resident who is non-verbal. If a resident scores 7-10 on the PAINAD scale, then a PAINAD SBAR will be triggered. It is directed toward residents who are non-verbal or cannot communicate. Administer pain medications as prescribed. Monitor and record medication's effectiveness and side effects. PRN - if the resident complains of pain the nurse will assess, implement relief measures as ordered and/or care planned. Monitor for effectiveness of pain interventions.Review of facility Uncontrolled Pain policy, undated reflected a main goal of keep the resident safe, relieve pain, get a clear medical plan, and use the chain of command when the concern is not resolved. What is uncontrolled pain - Pain stays severe or gets worse after ordered pain medication or comfort measures, pain is new, sudden, or very different from the resident's usual pain, pain causes a major change, such as inability to walk, move, eat, sleep, breathe comfortably, or participate in care. Pain occurs with concerning symptoms or a change in condition. What should the nurse do first - 1. Assess the resident, ask where the pain is, when it started, what it feels like, and the pain level or observed pain behaviors.2. Check vital signs and complete a focused assessment based on the complaint.3. Look for a recent fall, injury, wound, procedure, infection, swelling, change in movement, or change from baseline. 4. Review pain orders, the last medication given, and whether it helped.5. Give ordered pain medication and approved contort measures. Do not change doses or frequency without an order.6. Reassess the resident after the intervention and document the response.When should the nurse call MD or the on-call provider? Severe or new painPain not relieved by current ordersPain after a fall or possible injuryNew weakness, confusion, shortness of breath, chest pain, bleeding, inability to bear weight, or other significant change.Any time the nurse believes the resident needs additional evaluation or a higher level of care.Tell the provider: what is happening now, important background, information, your assessment findings, what has already been tried and exactly what you are requesting. If the on-call MD does not agree to send the resident out if the nurse remains concerned after speaking with the on-call MD/provider the concern should not stop with one phone call. Follow the facility chain of command.Repeat the concern clearly - state the resident's current condition and why you believe the resident need hospital/emergency department evaluation. Ask for a clearer plan - If the provider says not to transfer, ask what should we do now? When should the resident be reassessed? Call the DON/designee - notify the DON or nurse leader right away that the pain remains uncontrolled and may need a higher level of care. Call the Medical Director - If the concern remains unresolved, contact the medical director. Important - The DON and the medical director are part of the chain of command to make sure an unresolved safety concern receives timely review. The nurse should continue bedside care and reassessment while escalation is occurring. What should be documented - Pain/behavior findings, vital signs, focused assessment, and change from baseline, medication/comfort measures given and the resident's respons[TRUNCAT

Based on interview and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services by failing to appropriately assess, manage, and respond to acute, extreme levels of pain for 1 of 8 residents (Resident #3). The facility failed to ensure nurses caring for Resident #3 accurately documented her long-term pain levels in PCC (electronic health record). After a fall on 07/13/2026 a nursing note by LVN B dated 08/04/2026 reflected Resident #3 began complaining of pain. Nurses' notes reflected that Resident #3's pain increased and her ADLs declined. Resident #3 was sent to the hospital on [DATE] and diagnosed with bilateral sacral fractures. These failures could place residents at risk of needless agony, fear, trauma, emotional damage, or death.Findings included: Record review of Resident #1's face sheet, dated 08/11/2026, revealed a seventy-six-year-old female who was admitted to the facility on [DATE], re-admitted on [DATE] with a diagnosis that included vascular dementia, moderate, with agitation (middle-stage decline in thinking and memory caused by reduced blood flow to the brain, paired with behavioral symptoms like pacing, restlessness, irritability, or verbal and physical distress), generalized anxiety disorder (a long-term mental health condition marked by constant, extreme worry and fear about everyday things like work, health, and money), and chronic atrial fibrillation (a continuous, irregular heart rhythm where the upper chambers of the heart quiver instead of pumping blood normally). Record review of Resident #1's care plan, undated, revealed a focus dated 07/01/2026 Resident #1 was on pain medication therapy related to breakthrough pain with intervention dated 07/01/2026 revealed review for pain medication efficacy, assess whether pain intensity was acceptable to resident, no treatment regimen or change in regimen required; controlled adequately by therapeutic regimen no treatment regimen or change in regimen required but continue to monitor closely, controlled when therapeutic regimen followed, but not always followed as ordered; therapeutic regimen followed, but pain control not adequate, changes required. Focus dated 08/11/2026 the resident has had actual falls related to gait instability and increased restlessness. Resident #3 did not call for assistance. Focus dated 04/21/2026 Resident #3 had impaired cognitive function related to Alzheimer's Dementia (a specific brain disorder and the most common cause of dementia). Focus dated 04/21/2026 discharge from the facility is not feasible as evidenced by the resident needing 24 hours a day, 7 days a week nursing care in a secure care unit. Record review of Resident #1's MDS (clinical assessment to determine resident's strength and needs) dated 05/19/2026 Nursing Home Comprehensive Section C - Cognitive Patterns reflected a BIMS score of 2 indicating severe cognitive impairment and J0100 Pain Management resident received scheduled pain medication regimen, resident received prn pain medications or was offered and declined, J0200 - Pain Assessment Interview to be Conducted, J0300 - Pain Presence resident answered no to Have you had pain or hurting at any time in the last 5 days. Record review of Resident #3's order dated 03/27/2026 reflected Lidocaine External Patch (a local anesthetic that numbs the skin and nerves in a specific area to relieve localized nerve or muscle pain) 5% apply to right rib topically one time a day for pain. Record review of Resident #3's order dated 04/04/2026 reflected Tylenol 8 Hour Oral Tablet Extended Release (commonly marketed for Arthritis Pain or Muscle Aches and Pain) contains 650 mg of acetaminophen (widely used over-the-counter medicine that treats minor aches, pains, and reduces fever) per caplet. Its unique bi-layer design delivers fast-acting relief through the first layer and sustained relief through the second layer for up to 8 hours) 650 MG (Acetaminophen) give one tablet by mouth three times a day for pain. Record review of Resident #3's order dated 04/21/2026 reflected Gabapentin Capsule (prescription oral medications used to treat nerve pain from shingles, manage partial seizures, and calm overactive nerve signals) 300 MG give two capsules by mouth three times a day for pain. Record review of Resident #3's order dated 07/07/2026 reflected tramadol HCI Oral Tablet (a prescription opioid medicine used to treat moderate to moderately severe pain in adults when other non-opioid treatments are not enough) 50 MG give one tablet by mouth two times a day for pain management for fourteen days. Record review all of Resident #3's eMar Pain levels (0 means no pain, and 10 means the worst pain) charted in PPC beginning date 05/25/2026 ending date 05/09/2026 resident assessed by numerical (verbally asked the resident if they are in pain) or PAINAD (observational tool used to evaluate pain levels in patients who cannot verbally communicate). 05/25/2026 Level 0 8:10 AM LVN B numerical05/26/2026 Level 0 8:14 AM LVN B numerical05/26/2026 Level 0 8:15 AM LVN B numerical05/27/2026 Level 0 12:01 AM CMA/CNA A numerical05/27/2026 Level 0 6:18 AM CMA/CNA A numerical05/28/2026 Level 0 5:34 PM CMA/CNA A numerical05/29/2026 Level 0 6:17 PM CMA/CNA A numerical05/31/2026 Level 0 7:03 PM RN B numerical06/01/2026 Level 0 8:29 AM LVN B numerical06/01/2026 Level 0 8:32 AM LVN B numerical06/03/2026 Level 0 2:05 PM LVN B numerical06/06/2026 Level 1 5:35 PM LVN D PAINAD06/08/2026 Level 0 9:16 AM LVN B numerical06/08/2026 Level 0 10:26 AM DON numerical06/10/2026 Level 0 7:54 AM MA D numerical06/10/2026 Level 0 5:46 PM MA D numerical06/15/2026 Level 0 9:36 AM DON numerical06/17/2026 Level 7 10:52 PM RN A numerical06/18/2026 Level 2 3:02 AM RN A numerical06/19/2026 Level 0 8:10 AM MD A numerical06/19/2026 Level 0 2:39 PM MD A numerical06/19/2026 Level 0 5:52 PM MD A numerical06/20/2026 Level 0 1:15 PM LVN C numerical06/20/2026 Level 0 9:17 PM RN B numerical06/22/2026 Level 0 8:05 AM LVN B numerical06/22/2026 Level 0 8:17 AM LVN B numerical06/22/2026 Level 0 1:12 PM LVN B numerical06/23/2026 Level 0 12:25 PM MA E numerical06/23/2026 Level 4 3:20 PM LVN B numerical06/23/2026 Level 0 5:38 PM CMA/CNA A numerical06/23/2026 Level 2 9:21 PM RND numerical06/24/2026 Level 0 9:10 AM LVN B numerical06/29/2026 Level 0 8:46 AM LVN B numerical06/29/2026 Level 0 9:16 AM LVN B numerical06/30/2026 Level 0 5:58 PM CMA/CNA A numerical06/30/2026 Level 7 7:00 PM RN D numerical06/30/2026 Level 2 8:04 PM RN D numerical07/01/2026 Level 0 9:39 AM MA F numerical07/01/2026 Level 0 12:47 PM MA F numerical07/01/2026 Level 0 5:43 PM MA F numerical07/03/2026 Level 0 7:44 PM CMA/CNA A numerical07/03/2026 Level 0 12:25 PM CMA/CNA A numerical07/03/2026 Level 0 5:43 PM CMA/CNA A numerical07/04/2026 Level 0 7:48 AM LVN C numerical07/04/2026 Level 2 8:27 PM RN B numerical07/05/2026 Level 4 7:58 AM (employee not listed in employee roster, unknown if nurse or MT) numerical07/05/2026 Level 4 :19 PM (employee not listed in employee roster, unknown if nurse or MT) numerical07/05/2026 Level 1 5:39 PM (employee not listed in employee roster, unknown if nurse or MT) numerical07/05/2026 Level 0 6:48 PM RN B numerical07/06/2026 Level 0 12:02 AM DON numerical07/07/2026 Level 0 7:59 AM CMA/CNA A numerical07/07/2026 Level 0 9:27 PM CMA/CNA A numerical07/08/2026 Level 0 9:07 AM MA F numerical07/08/2026 Level 0 9:10 AM MA F numerical07/08/2026 Level 0 3:27 PM MA F numerical07/08/2026 Level 0 3:27 PM MA F numerical07/09/2026 Level 0 7:41 AM CMA/CNA A numerical07/09/2026 Level 0 7:41 AM CMA/CNA A numerical07/09/2026 Level 0 12:01 PM CMA/CNA A numerical07/09/2026 Level 0 5:33 PM CMA/CNA A numerical07/09/2026 Level 0 5:33 PM CMA/CNA A numerical07/10/2025 Level 0 7:35 AM CMA/CNA A numerical07/10/2025 Level 0 07:36 AM CMA/CNA A numerical07/10/2025 Level 0 12:28 PM CMA/CNA A numerical07/10/2025 Level 0 5:41 PM CMA/CNA A numerical07/11/2026 Level 0 7:39 PM CMA/CNA A numerical07/11/2026 Level 0 7:39 PM CMA/CNA A numerical07/12/2026 Level 0 6:53 AM CMA/CNA A numerical07/12/2026 Level 0 6:55 AM CMA/CNA A numerical07/12/2026 Level 0 12:09 PM CMA/CNA A numerical07/12/2026 Level 0 12:38 PM CMA/CNA A numerical07/12/2026 Level 0 12:38 PM CMA/CNA A numerical07/13/2026 Level 5 3:36 AM RN A PAINAD07/14/2026 Level 0 6:25 AM CMA/CNA A numerical07/14/2026 Level 0 6:25 AM CMA/CNA A numerical07/14/2026 Level 0 12:05 PM CMA/CNA A numerical07/14/2026 Level 0 5:50 PM CMA/CNA A numerical07/14/2026 Level 0 5:51 PM CMA/CNA A numerical07/15/2026 Level 0 7:58 AM MA E numerical07/15/2026 Level 0 7:58 AM MA E numerical07/15/2026 Level 0 12:34 AM MA E numerical07/15/2026 Level 0 5:33 PM MA E numerical07/15/2026 Level 0 5:33 PM MA E numerical07/16/2026 5:53 PM Level 1 RN B numerical07/16/2026 7:15 PM Level 7 RN A numerical07/17/2026 4:30 AM Level 9 (employee not listed in employee roster, unknown if nurse or MT) PAINAD07/17/2026 5:24 AM Level 0 (employee not listed in employee roster, unknown if nurse or MT) PAINAD07/17/2026 9:52 AM Level 4 (employee not listed in employee roster, unknown if nurse or MT) PAINAD07/17/2026 6:00 PM Level 0 CMA/CNA A numerical07/18/2026 7:59 AM Level 0 CMA/CNA A numerical07/18/2026 7:59 AM Level 0 CMA/CNA A numerical07/18/2026 12:00 PM Level 0 CMA/CNA A numerical07/19/2026 12:15 AM Level 10 RN B PAINAD 07/19/2026 1:44 AM Level 0 RN B numerical07/19/2026 6:50 AM Level 0 CMA/CNA A numerical07/19/2026 6:52 AM Level 0 CMA/CNA A numerical07/19/2026 12:03 PM Level 0 CMA/CNA A numerical07/20/2026 8:37 AM Level 0 MA G numerical07/20/2026 8:40 AM Level 0 MA G numerical07/20/2026 10:26 AM Level 4 LVN B numerical07/20/2026 5:38 PM Level 0 MA G numerical07/20/2026 5:39 PM Level 0 MA G numerical07/20/2026 11:00 PM Level 5 (employee not listed in employee roster, unknown if nurse or MT) PAINAD07/21/2026 4:52 AM Level 6 (employee not listed in employee roster, unknown if nurse or MT) PAINAD07/21/2026 6:38 AM Level 0 CMA/CNA A numerical07/21/2026 6:40 AM Level 0 CMA/CNA A numerical07/21/2026 12:46 AM Level 0 CMA/CNA A numerical07/21/2026 5:47 PM Level 0 CMA/CNA A numerical07/22/2026 5:46 PM Level 0 CMA/CNA A numerical07/23/2026 9:22 AM Level 0 LVN E numerical07/27/2026 8:51 AM Level 0 CMA/CNA A numerical07/27/2026 12:12 PM Level 0 CMA/CNA A numerical07/27/2026 12:53 PM Level 0 LVN B numerical07/27/2026 5:50 PM Level 0 CMA/CNA A numerical07/28/2026 8:24 AM Level 0 CMA/CNA A numerical07/28/2026 12:09 AM Level 0 CMA/CNA A numerical07/29/2026 12:08 PM Level 0 CMA/CNA A numerical07/29/2026 5:32 PM Level 0 CMA/CNA A numerical07/30/2026 7:36 AM Level 0 CMA/CNA A numerical07/30/2026 12:09 PM Level 0 CMA/CNA A numerical08/03/2026 9:09 AM Level 0 LVN B numerical08/03/2026 1:12 PM Level 0 DON numerical08/05/2026 7:11 AM Level 4 LVN B numerical08/06/2026 7:56 AM Level 10 CMA/CNA A Numerical08/06/2026 12:21 PM Level 0 CMA/CNA A Numerical08/07/2026 9:09 AM Level 0 MA G Numerical 08/07/2026 12:09 PM Level 0 MA G Numerical08/07/2026 5:34 PM Level 0 MA G Numerical08/08/2026 1:12 PM Level 0 MA G Numerical 08/08/2026 5:57 PM Level 0 MA G Numerical08/09/2026 Level 10 RN B Numerical Record review of Resident #3's order dated 07/21/2026 reflected Methocarbamol Oral Tablet (a prescription muscle relaxer used short-term alongside rest and physical therapy to ease pain and stiffness from acute muscle injuries) 500 MG give one tablet by mouth three times a day for pain management until 08/11/2026. Record review of Resident #3's order dated 07/21/2026 reflected Tylenol with Codeine #3 Tablet 300-30 MG (a prescription combination opioid medication used to manage mild to moderate pain) give one tablet by mouth three times a day for pain until 08/04/2026. Record review of Resident #3's progress notes dated 08/04/2026 7:36 AM LVN B reflected Resident #3 complained of right butt cheek pain, difficulty standing and walking, notified NP B and obtained orders for Right hip X-ray. Record review of Resident #3's order dated 08/07/2026 reflected Norco Tablet 5-325 MG (5-325 mg tablet contains 5 mg of hydrocodone bitartrate and 325 mg of acetaminophen as active ingredients) give one tablet by mouth as needed for pain one tab twice a day PRN for pain. Record review of Resident #3's progress note dated 08/09/2026 6:02 AM RN B reflected Resident #3 continued with extreme levels of pain when moving lower extremities, current analgesic (a medication or substance used to relieve pain without causing a loss of consciousness) ordered was unable to decrease her level of pain, she had not slept all night and continued with episodes of screaming in pain, she had a nickel size light purple color bruise noted above left [NAME] area, X-rays performed were negative for any fractures, possible tissue injury, will continue to monitor and report as necessary. Record review of Resident #3's progress note dated 08/09/2026 4:09 PM LVN C reflected CNA staff (name of CNA not listed) reported Resident #3 on floor next to wheelchair. CNA staff member explained that she was attempting to take Resident #3 to the bathroom. Resident #3 leaned forward and went to floor abruptly and area from previous fall to left head reopened. Resident #3's cognitive status poor, staff assisted Resident #3 back into bed. Neuro checks initiated. area to left head cleansed and treatment administered per previous wound orders. Proper notifications made. Neuro checks continue per protocol. continue to monitor. Record review of Resident #3's progress note dated 8/09/2026 4:30 PM LVN C reflected Resident #3 had a fall in her rest room and hit head, cognition/behavior at time of event - agitated, restless, cognitive impairment. Resident #3 leaned forward out of wheelchair and reopened area to left head related to previous fall, area cleansed and treatment administered per orders. Resident #3 appeared and/or stated to be in pain, describes the pain as: unable to describe. location of pain: unable to describe, pain relieving intervention used at this time: received routine and prn medications, initial treatment/new orders by NP A: SED rate (a simple blood test that measures how fast red blood cells sink to the bottom of a test tube. It detects inflammation in the body, but it does not treat pain or pinpoint the exact cause of discomfort) to evaluate for inflammation, neuro checks per protocol, and notify on-call if any changes. Resident statement - resident hollering in pain, previous to fall, pain unable to be managed, pain to be addressed with SED Rate NP A notified 08/09/2026 3:45 PM. Interventions in place prior to fall: none and interventions initiated in response to fall: none. Record review of Resident #3's nurses progress note dated 08/09/2026 11:51 PM RN A Resident #3 was awake and lying on right side and refused to put any pressure on left hip/sacral area due to excruciating pain. Resident #3 had Tramadol (prescription opioid pain medicine used to treat moderate to moderately severe pain when non-opioid options are not enough) which had little effective relief and was moaning in pain. She had made attempts at getting up to go to bathroom, but she was unable to put weight on the left leg and was a fall risk. She has an order for Norco (prescription opioid pain medication containing hydrocodone and acetaminophen), but the medication had not been delivered yet. At this time, she was given Hydroxyzine (a prescription antihistamine used to treat short-term anxiety, relieve allergic skin itching, and provide sedation before or after surgery) for anxiety with expectation for some sleep. Record review of Resident #3's progress note, Administration note dated 08/10/2026 1:22 AM LVN A reflected hydroxyzine HCI (hydrochloric acid) oral tabled 23 MG (a prescription antihistamine used to treat short-term anxiety, relieve allergic skin itching (hives and eczema), and provide sedation before or after surgery) PRN administration was not effective. Record review of Resident #3's progress note dated 08/10/2026 1:45 AM RN A late entry reflected Resident #3 had unwitnessed fall in the bathroom. Resident #3 attempted to toilet self and discovered on the floor next to toilet. Cognition/behavior at time of event - agitated, resident had cognitive Impairment, CNA (name of CNA not listed) reported that Resident #3 was on bathroom floor apparently having crawled there. Resident #3 appeared and/or stated to be in pain. Resident #3 not able to describe the pain. The location of pain was left hip area and pain-relieving intervention used at the time was Tramadol. Resident #3, unable to say what happened when asked 'what happened kept saying I hurt, help me continued to scream out in pain. NP Date/time of notification: 08/10/2026 2:00 AM. Interventions in place prior to fall: Low bed, CNA regular rounds. Interventions initiated in response to fall: Low bed. Note that in an earlier report, there was an existing small bruise on the left sacral/ hip area from a previous fall.Record review of Resident #3's progress note dated 08/10/2026 2:26 AM RN A reflected CNA (name of CNA not listed) reported that Resident #3 was on bathroom floor apparently having crawled there. Resident #3 had been complaining continuously the whole shift of high-level pain in left sacral/hip area. Ordered pain medications had no effect on relief. On call for facility doctor was notified of falls and pain. NP ordered transfer out to hospital for evaluation and treatment. Record review of Resident #3's hospital progress notes dated 08/10/2026 reflected bilateral sacral fractures (breaks on both sides of the sacrum, the triangular bone at the base of the spine). Record review of facility in-services: Transfer Bed to Chair by the RCN to the Administrator and DON date conducted 08/10/2026 end date 08/11/2026 Event Reporting Competing Events in PCC (an electronic health record designed primarily for long-term and post-acute care facilities) Nurses Only by the RCN to the Administrator and DON date conducted 08/10/2026 end date 08/11/2026 Provider Letter (an official policy communication issued by the Texas Health and Human Services Commission to instruct licensed or certified health and human services providers on mandatory incident-reporting rules, timeframes, and procedures) by the RCN to the Administrator and DON date conducted 08/10/2026 end date 08/11/2026 Transfer Bed to Chair by the DON to nursing and CNA staff date conducted 08/10/2026 end date ongoing Safe Patient Handling (transfers) by the DON to nursing and CNA staff date conducted 08/10/2026 end date ongoing Notifying the Physician of Change of Status by the DON to nursing staff date conducted 08/10/2026 end date ongoing Pain Management by DON to nursing and CNA staff date conducted 08/10/2026 end date ongoing Baseline Care Plan by RCN to nursing staff date conducted 08/10/2026 no end date Fall Prevention by DON to nursing and CNA staff date conducted 08/10/2026 end date ongoing Abuse and Neglect by Administrator to all staff date conducted 08/10/2026 end date ongoing Reporting Guidelines (Provider Letter) by Administrator to all staff 08/10/2026 end date ongoing Pain Management (Nursing Response Uncontrolled Pain) by RCN to nursing and CNA staff date 08/12/2026 no end date During an interview on 08/11/2026 at 2:17 pm with the DON he said because the pain medications were not effective for Resident #3 the nurses should have been more aggressive and painted a clearer picture to both him and the NPs that Resident #3 was in pain and needed to go to the hospital. The DON said when Resident #3 fell the 2nd time, the nurses should have requested another x-ray. The DON said the nurses should have called him and told him about the situation if they were not getting what they wanted from the on-call NPs. The DON said the nurses failed to advocate for the resident and the resident was in pain for a long time. During an interview on 08/12/2026 at 10:24 AM with LVN C she said Resident #3's pain was in pain, and she discussed with NP A about sending Resident #3 to the hospital and NP A told her to order a SED rate. LVN C said she called Resident #3's RP and asked him if he wanted to send her to the hospital but he did not request Resident #3 to go to the hospital. LVN C said it was breaking her heart that Resident #3 was in so much pain, and the pain medication was not helping her. LVN C said Resident #3 was screaming in pain and kept all the other residents awake. LVN C said she would not have hesitated to send Resident #3 to the hospital if she had received orders from an NP or the RP said he wanted her to be sent. Attempted to interview RN B on 08/12/2026 at 11:33 AM. Phone call made to RN B but unable to leave a VM, the VM box was full and left a text message with no reply. Attempted to interview RN A on 08/12/2026 at 11:58 AM. Phone call made to RN A and left a VM and sent a text message with no reply. During an interview by phone on 08/12/2026 at 12:10 PM with NP B she said she was not on call the weekend of 08/08/2026. NP B said she knew that Resident #3 had been having pain in her hips for a while and the pain got worse over the weekend of 08/08/2026. NP B said she trusted the judgment of the nurses and the nurse had the resident in front of them. NP B said if a nurse said she thought a resident should be sent to the hospital, she generally agreed for the resident to be sent to the hospital. During an interview by phone on 08/12/2026 at 12:15 PM with CNA B she said she worked with Resident #3 on 08/09/2026 and CNA B said Resident #3 was screaming in pain. CNA B said all night Resident #3 was hollering and Resident #3's voice was hoarse and she sounded like a man because she had been screaming in pain for so long. CNA B said she did not know why Resident #3 was not sent to the hospital. During an interview by phone on 08/12/2026 at 12:52 PM with CNA C she said that Resident #3 was yelling in pain a lot throughout the past week. CNA C said Resident #3's voice was hoarse because Resident #3 had been crying in pain. CNA C said she wondered why Resident #3 was not at the hospital because it was clear she was in pain. During an interview on 08/12/2026 at 1:26 PM with RNC she said a nurse needed to tell a doctor or an NP if they felt a resident needed to go to the hospital. She said nurses needed to use their nursing judgment and if the nurse knew a resident was in excruciating pain and pain medication interventions were not working, they needed to tell the doctor or NP the resident needed to go to the hospital. RN C said the nurses needed to document that they told the doctor or the NP that they felt the resident needed to go to the hospital. RN C said if the nurse felt that the resident needed to go to the hospital they needed to reach out to the DON and let him know that they felt the resident was in pain, interventions were not working and the resident needed to go to the hospital. RN C said the nursing staff needed to document any conversations had with the medical doctor, the NP, and the DON. During an interview on 08/22/2026 at 2:56 PM with MT G she said if a resident was given a scheduled pain medication, she did not ask the residents' level of pain, and the MAR did not prompt them to enter a pain level. She said if the MAR asked for an input of the residents' pain level, she put zero if the resident was not in pain. MT G said she did not work in the secure unit. She said if a resident had any indication that they were in terrible pain, she would go to a nurse directly to speak with them about the resident's pain. She said if she was working with a resident who was non-verbal, she would go by the resident's facial expression to determine if the resident was in pain. During an interview on 08/22/2026 at 3:37 PM with CMA/CNA A she said she remembered administering Resident #3 pain medications. CMA/CNA A said Resident #3 complained a lot about pain and sometimes she cried out in pain. CMA/CNA A said some of Resident #3's pain was not pain, but anxiety about pain. CMA/CNA A said she did not have a way to figure out Resident #3's level of pain. CMA/CNA A said she just based it upon her background of working with Resident #3. During an interview on 08/22/2026 at 4:00 PM with MA H said he has administered residents pain medication. He did not remember giving Resident #3 pain medication before she went to the hospital. MA H said he did not like working on the secure unit and avoided working there. MA H said he could not assess if residents were in pain. He said if the MAR required him to enter a pain level, he entered either zero or NA. MA H said no one at the facility told him to do that, but it was how he was trained. During an interview on 08/22/2026 at 4:05 PM with the DON he said since the surveyor's visit beginning 08/11/2026, the facility had been checking resident pain levels twice a day. The DON said before this time, residents' pain levels were checked daily, and some were checked weekly. The DON said they did not have an accurate level of Resident #3's pain because it was not being recorded. The DON said the picture of Resident #3's pain was incomplete. He said it was also difficult to monitor because of her compromised cognition due to Resident #3's dementia. He said if they had pain numbers in place, they would have had a lot more information to assess her pain levels. The DON said it was his expectation that a licensed nurse recorded resident pain levels. During an interview on 08/22/2026 at 4:45 PM the MDS Coordinator said for the month of August 2026, Resident #3's TAR was not triggered to prompt nursing staff to record any of Resident #4's vital signs or Resident #3's pain level. The MDS Coordinator said the nursing staff who cared for the residents were responsible for noticing this was not included in Resident #3's TAR and should have brought it to the attention of the nursing management. The MDS Coordinator said this was something she should have caught. The MDS Coordinator said a possible negative effect of vitals and pain not being triggered in PCC for documentation was Resident #3 was not assessed or treated in a timely manner. She said the nursing staff would not know if any PRN medications were working for resident's pain and there was not an accurate record of Resident #3's pain. The MDS Coordinator said if an MA automatically entered either an NA or a zero in a Residents' MAR for pain a pain level, it would be inaccurate. She said this inaccurate record of pain would be recorded in the residents' eMAR. The MDS Coordinator said MTs were not supposed to enter a zero and not to enter an NA because that was no information. During an interview on 08/23/2026 at 11:59 PM with RN P she said she had worked at the facility for about one month. RN P said MTs cannot assess residents' pain because it was out of their scope of practice. RN P said MTs and CMAs should not enter NA or 0 for residents' pain level because it was inaccurate. RN P said MTs and CMAs did not know how pain assessment for residents who are not cognitive. RN P said that pain. RN P thought any medication administered to residents for pain needed to be listed in the TAR because the TAR was for nurses and nurses could assess resident pain. RN P said the MAR should be reserved for non-pain medication administrator for the MTs and CMAs to administer. RN P said she had only been at the facility a month, but she had not had a MT or a CMA ask her about assessing a resident's level of pain. RN P said residents should always be asked if they have pain. RN P said all nurses should be recording all resident vital signs and resident pain levels in the residents eMAR each shift. RN P said if the PCC TAR did not automatically populate for the nurse to take and record the vitals and pain, the nurse should take it upon themselves to record it in the resident eMAR. RN P said a prudent nurse action would be to record residents' level of pain every shift. RN P said pain was like taking a resident temperature. If a resident had a temperature the nurse would re-check the temperature and if a resident was in pain, pain needed to be rechecked. RN P said you could not just [NAME] nilly pass out pain medications and not document and track the level of the resident's pain. She said tracking resident pain was a way to effectively treat the resident. RN P said MTs and CMAs could not assess the pain of residents with dementia behaviors who might not be able to communicate. RN P said that residents need to be evaluated to confirm that the behavior exhibited was not simply behavior but might express discomfort or pain. She said a resident might take off their clothing and that might appear to be simply a behavior or it could be behavior for expressing pain. RN A said nursing staff would not know if scheduled pain medications were effective if pain levels were not monitored or if pain was not accurately assessed. During an interview on 08/23/2026 at 1:14 PM with LVN C she said it was prudent nursing practice that once a shift a nurse should document the resident's vitals. LVN C said that pain was a supplementary item to be clicked and included when documenting resident vitals in the eMAR and the pain assessment documentation was not activated in PCC. If a nurse did not assess Resident #3's pain, it did not get recorded in her pain assessment because there was no documentation entry for it in the TAR vitals. LVN C said knowing if a resident had pain was imperative to figure out what was going on with the resident. LVN C said recording pain was important even if the residents did not currently have chronic pain. LVN C said a resident could have a change of condition that caused pain and that would help the nurse begin to find out what was going on with the resident. She said it was a problem for the MTs or CMAs to enter either NA or a 0 for residents' pain because it was not accurate. LVN C said the TAR was for nurse documentation and the MAR was for MT or CMA medication administration documentation. LVN C said she felt that any narcotics or pain medications should be listed in the TAR because those are the medications that involve evaluating pain assessment and pain levels. LVN C said she felt MTs and CMAs should not evaluate the pain for nonverbal residents. LVN C said there were a lot of behaviors involving dementia residents that will demonstrate they are in pain that are not obvious and nurses received the training to evaluate these possible dementia pain behaviors. During an interview on 08/23/2026 at 2:14 PM the DON said a prudent nurse should document all the vitals including resident pain one time a shift. The DON said the current recorded pain levels still have some systematic issues because the medication technician entries have been entered as NA and 0 and that is not accurate. The DON said the recorded levels of NA and 0 were transferred and documented to the residents' eMAR as pain levels and these pain levels were not accurate. The DON said the lack of documentation from nurses of resident pain level was a nurse competency issue. The DON said the facility was trying to bring staff back to quality focused care. The DON said accurate pain levels were vital to the resident interventions. Record review of Job Description Certified Medication Aide the following is a non-exhaustive criteria that relates to the job of a Certified Medication Aide, and it is consistent with the business needs of the facility. These are legitimate measures of the qualifications for a Certified Medication Aide and are related to the functions that are essential to the job of a Certified Medication Aide. Ability to record information and perform technical procedures. Responsible for appropriately administering resident's prescribed PO, topical (unbroken skin) and rectal medication according to the physician's orders and Medication Administration policies.Monitors adverse effects of administered medications and reports them immediately to Charge Nurse.Records all medication administration according to company policy.Reports any medication errors immediately to Charge Nurse.Responsible for properly monitoring assigned administration of resident medication.Responsible for notifying the Charge Nurse of complaints, reactions or any change in resident statusRecord review of facility Pain Management, Assessment Scale dated 03/25/2016 reflected pain is a subjective sensation of discomfort derived from multiple sensory nerve interactions generated by physical, chemical, biological, or psychological stimuli. Policy - Complaints of pain will be assessed accordingly by the nurse and effectively managed through prescribed medications,[TRUNCATE

Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported, immediately but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or bodily injury, to the administrator of the facility and to other officials, including the State Survey Agency in accordance with State law through established procedures for 1 of 5 residents (Resident #2) reviewed for reporting allegations of abuse. The facility failed to immediately (but no later than 24 hours) report an allegation of abuse to HHSC of Resident #1 putting a pillow over Resident #2's face, reported by Resident 2's RP to RN C on 08/18/26. It was reported 08/21/26. This failure could place residents at risk of not having complaints and concerns reported and investigated for abuse, neglect, and exploitation. Findings included: Record review of Resident #1's face sheet, dated 08/11/2026, revealed a seventy seven year-old female who was admitted to the facility on [DATE] with a diagnosis that included vascular dementia, moderate, with agitation (describes a mid-stage decline in thinking and memory caused by reduced blood flow to the brain, accompanied by behavioral symptoms like restlessness, pacing, or verbal and physical distress), generalized anxiety disorder (a long-term mental health condition marked by constant, extreme worry and fear about everyday things like work, health, and money), and psychophysiologic insomnia (a type of chronic sleep difficulty driven by learned anxiety and physical hyperarousal linked to the bed or bedtime), and major depressive disorder, recurrent (a mental health condition defined by experiencing two or more major depressive episodes separated by a clear period of recovery or remission lasting at least two months). Record review of Resident #1's care plan, undated, revealed a focus 06/09/2026 of Resident #1 resided in the secure care unit related to diagnosis of dementia (or related diagnosis) and risk for elopement and a focus dated 06/09/2026 Resident #1 exhibited aggressive or unsafe behavior toward others on 07/18/2026 when Resident #1 entered another resident's room and was observed on video attempting to place a pillow over another resident's face with intervention dated 07/20/2026 of intervene as necessary to protect the rights and safety of others and approach and speak in a calm manner, divert attention, remove from situation and take to alternate location as needed. Record review of Resident #1's MDS (clinical assessment to determine resident's strength and needs) dated 05/19/2026 Nursing Home Comprehensive Section C - Cognitive Patterns reflected a BIMS score of 3 indicating severe cognitive impairment and E0200 Behavioral Symptom - No behavioral symptoms. Record review of Resident #2's face sheet, dated 08/12/2026, revealed an eighty-three-year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis that included senile degeneration of brain (age-related brain tissue breakdown and cognitive decline), vascular dementia, severe, with agitation (advanced cognitive decline from brain blood flow blockage accompanied by severe behavioral disruptions like restlessness, pacing, shouting, or combativeness), and generalized anxiety disorder (a long-term mental health condition marked by constant, extreme worry and fear about everyday things like work, health, and money). Record review of Resident #2's care plan, undated, revealed a focus dated 03/04/2026 of Resident #2 resided in the secure care unit related to diagnosis of dementia and risk for elopement. Record review of Resident #2's MDS (clinical assessment to determine resident's strength and needs) dated 06/23/2026 Nursing Home Comprehensive Section C - Cognitive Patterns reflected a BIMS score of 3 indicating severe cognitive impairment and E0200 Behavioral Symptom - Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) behavior of this type occurred 1 to 3 days, Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) behavior of this type occurred 1 to 3 days, and Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) behavior of this type occurred 1 to 3 days. Record review of Provider Investigative report to HHSC dated 07/21/2026 reflected that the facility received a report on 07/20/2026 that an incident occurred on 07/18/2026 that Resident #1 struck Resident #2 with a pillow. Record review of statement dated 07/28/2026 of the Administrator's statement reflected on 07/20/2026 Resident #2's RP provided a video to him that showed Resident #1 wandered into Resident #2's room on 07/18/2026 and struck Resident #2 in the face with a pillow. The RP told the Administrator that on 07/18/2026 the RP phoned the facility to check on Resident #1. The Administrator's statement reflected that CNA/CMA A went with RN C to Resident #2's room and Resident #1 was not in Resident #2's room. RN C assessed Resident #2 and noted no injuries. Record review of statement dated 07/28/26 of CMA/CNA A reflected she was working as a CMA in the secure unit on 07/18/2026 and RN C was the charge nurse. CMA/CNA A saw RN C talking on the phone and when RN C hung up the phone, she told CMA/CNA A said Resident #2's RP called and the RP, who had a camera in Resident #2's room, said the resident with all white hair and always yelling was in Resident #2's room and put a pillow over Resident #2's face. Record review of email dated 07/27/2026 from RN C to the Administrator reflected on the morning of the incident, RN C received a phone call from Resident #2's RP that, the lady with the white hair had walked into Resident #2's room and placed a pillow over her Resident #2's face. RN C notified LVN, the nurse responsible for the secured unit, that she had received a report from Resident #2's RP regarding the allegation and that Resident #1 had reportedly been displaying aggressive behavior. During an interview on 08/11/2026 at 10:45 AM, CMA/CNA A said that RN C told her that Resident #2's RP called and said Resident #1 was in Resident #2's room and put a pillow over Resident #2's head. She said Resident #2 was assessed and id Resident #2 was fine. CMA/CNA A said she told the other CNAs on the secure unit to make sure they kept eyes on Resident #1. During an interview by phone on 08/11/2026 at 12:26 PM with the Psych NP she said Resident #1 had not previously had physical aggression towards other residents. The Psych NP said the staff in the secured unit watched residents closely and she felt the residents in the secure unit were safe. The Psych NP said the staff did their best to make sure residents were not wandering into other residents' rooms. The Psych NP said after the incident was reported to the Administrator staff conducted Q checks (scheduled, recurring safety and observation checks) on Resident #1. During an interview on 8/11/26 at 12:43 PM, the Administrator said Resident #1 did not have any previous physical altercations with residents prior to 08/18/2026. He said on 08/18/2026, when RN C received the phone call from Resident #2's RP that Resident #1 was in Resident #2's room and put a pillow over Resident #2's face, RN C had not seen the video obtained by Resident #2's RP. He said Resident #2's RP provided the video by email on Monday, 08/20/2026. The Administrator said when Resident #2's RP told the RN C there was a video of Resident #1 putting a pillow over Resident #2's face, that was an allegation of abuse and neglect from Resident #2's RP regardless of if RN C had seen the video. The Administrator said RN C did not call and tell him about the incident, and he did not learn about it until Monday, 08/20/26 from Resident #2's RP. The Administrator said his staff did not report the incident to him, it was reported by Resident #2's RP and never reported to him by his staff. The Administrator said this was a problem because it could have led to serious injury or harm in general. During an interview on 08/11/2026 at 1:37 PM with CMA/CNA A she said she was in the secure unit on 08/18/2026 when RN C told her Resident #'2 RP called and said she had a video recording of Resident #1 in Resident #2's room and Resident #1 put a pillow over Resident #2's face. CMA/CNA A said she and RN C went to Resident #2's room and Resident #1 was not in Resident #2's room. CMA/CNA A said she did not tell anyone about the incident because RN C said she was going to tell the LVN, the charge nurse. CMA/CNA A said she did not know if RN C told the LVN about the incident. CMA/CNA A said the incident was an allegation of abuse and neglect, and she would normally report any allegations of abuse and neglect to the charge nurse, but because RN C said she was going to tell the charge nurse, she did not. CMA/CNA A said she received abuse and neglect training at the facility, and the Administrator was the abuse and neglect coordinator. During an interview by phone on 08/11/2026 at 4:53 PM, RN C said she was the nurse who received the call from Resident #2's RP reporting that she had video of a resident in Resident #2's room and the resident in Resident #2's room put a pillow over Resident #2's head. She said when she went to Resident #2's room, Resident #1 was not in Resident #2's room. RN C said she told the CNAs to keep an eye on the residents and make sure they did not wander into other residents' rooms and to pay particular attention to any residents wandering into Resident #2's room. RN C said she assessed Resident #2 and Resident #2 was okay. RN C said that on the phone Resident #2's RP told her that Resident #1 put a pillow over Resident #2's face. RN C said that was an allegation of abuse and neglect. RN C said she let the charge nurse, the LVN, know what happened. RN C said she received training from the facility in reporting allegations of abuse and neglect to the charge nurse and the Administrator. RN C said that any allegations of abuse and neglect needed to be reported immediately. RN C said while she did receive the training, she was not sure about all the particulars and the details of reporting abuse and neglect, but she now knows the process. During an interview on 08/12/2026 at 10:24 AM, the LVN said she was not told about the video incident that occurred on 08/18/2026 when Resident #1 was in Resident #2's room and Resident #1 was alleged to have put a pillow over Resident #2's face. The LVN said it was reported to her that Resident #1 was in Resident #2's room but never reported to her that Resident #1 put a pillow over Resident #2's face. The LVN said RN C did not report this to her. The LVN said if this had been reported to her, she would have done a resident to resident contact report and immediately placed the aggressive resident on 1:1 (a dedicated staff member is assigned to continuously monitor and stay within arm's length or direct line of sight of a single resident at all times to prevent severe injury, elopement, or self-harm). The LVN said had she known about the allegation of Resident #1 putting a pillow over Resident #2's head, she would have immediately called the DON. The LVN said she was trained in abuse and neglect, and the Administrator was the abuse and neglect coordinator. The LVN said the possible negative effect of not reporting abuse and neglect as soon as possible was that harm might come to residents. Record review of Facility Abuse/Neglect policy, undated, reflected Reporting: Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse, neglect or exploitation must report this to the DON, administrator, state, and/or adult protective services. State law mandates that citizens report all suspected cases of abuse, neglect, or financial exploitation of elderly and incapacitated persons. When a suspected, abused, neglected, exploited, mistreated or potential victim of misappropriation of property comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse Preventionist and/or designee. If the discovery occurs outside of normal business hours, the Abuse Preventionist and/or designee will be called. Facility employees must report all allegations of abuse neglect, or exploitation mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation.

Based on interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #3) reviewed for use of mechanical lifts. The facility failed to ensure mechanical lifts were always operated by two staff members during transfer of residents for Resident #3 on 04/17/2026 (by CNA A) and 06/14/2026 (by CNA B). This failure placed residents at risk of injury.Findings included: Review of the undated face sheet for Resident #3 reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included dementia, osteoarthritis, bipolar disorder, generalized anxiety disorder, limitation of activities due to disability, history of falling, and senile degeneration of brain. Review of the quarterly MDS for Resident #3 dated 05/22/2026 reflected the staff assessment noted she had severely impaired cognition. It reflected that she was totally dependent on staff to transfer between her bed and her chair. Review of the care plan for Resident #3 dated 10/17/2026 reflected the following: FOCUSI have a physical functioning deficit with transfers and require assistance.GOALI will maintain my current level of functioning.INTERVENTIONSHoyer Total Lift x 2 staff .Transfer/Slide Sheet for moving up in bed. Review of Automated Electronic Monitoring footage for Resident #3 reflected a video dated 04/17/2026 at 3:08 PM in which CNA A transferred Resident #3 from her chair to her bed with no other staff present in the room and assisting her. The transfer was completed without incident. An attempt was made on 07/14/2026 at 4:04 PM to interview CNA A by telephone, but no answer was received as of 07/20/2026. Review of Automated Electronic Monitoring footage for Resident #3 reflected a video dated 06/14/2026 at 4:31 PM in which CNA B transferred Resident #3 from her chair to her bed with no other staff present in the room and assisting her. The transfer was completed without incident. During an interview on 07/14/2026 at 3:55 PM, CNA B stated she had seven residents on her hall who transferred by mechanical lift, and she had transferred residents using a lift by herself when they did not want to wait for a second staff. She declined to describe any of the circumstances of these transfers but said the transfer in the video with Resident #3 was one of them. She stated a resident improperly transferred they could accidentally fall or hit the wall. She stated she was trained to use a mechanical lift with two people. During an interview on 07/14/2026 at 11:35 AM, the RP for Resident #3 stated she had seen the staff transfer Resident #3 by mechanical lift with only one person present while she was in the facility. She stated they had done it right in front of her, but she could not remember which staff it was. She stated she also had video of some of the transfers, but she had not shown the video to management. She stated she was worried Resident #3 would be injured. During an interview on 07/14/2026, anonymous staff member D stated CNAs in the facility were frequently transferring residents by mechanical lift with only one staff present and operating the machine. She stated people called in, and they were often short-staffed, and they operated the lifts by themselves when they had to. She stated there were one or two nurses who helped with transfers, but most of the nurses did not. She stated one of the nurses once said, I went to nursing school so I wouldn't have to do transfers. When asked if management had been notified about the single-person mechanical lift transfers, she stated they know. She could or would not say exactly how they knew. She stated the training she was provided required that a mechanical lift only be operated by two staff when transferring a resident. She stated this had been going on for a few months. During an interview on 07/14/2026, anonymous staff member E stated she never transferred residents without a second staff member assisting, but she knew some of the CNAs did. She stated the management knew this was happening and said they had to know because it was obvious. She stated they received training to only use a mechanical lift with two trained staff members, but that was not always happening. During an interview on 07/14/2026 at 4:11 PM, the DON stated his expectation was there would be two staff members operating a mechanical lift when using it to transfer residents. He stated he had in-serviced about this many times and was preparing to conduct the mechanical skills performance reviews with all the CNAs the following week. He produced a binder with the preparatory materials for the skills checks. He stated it was crucial to operate the mechanical lift with two staff, because they needed one to guide the lift and one to guide the resident. He stated he did not know that CNAs were sometimes conducting lift transfers single-handedly. He stated the person responsible for ensuring transfers were conducted correctly was him. He stated he ensured compliance with the system with return demonstration skills and spot checks. He stated the potential negative impacts on residents of not transferring safely with a mechanical lift were falls, fractures, and skin tears. During an interview on 07/14/2026 at 5:40 PM, the ADM stated his expectation was that staff only transfer with two trained persons, and this was reflected in the corporate written policy. He stated it was also important to review manufacturer's instructions, but the instruction manuals rarely contained information about how many people it took to safely operate the lift. He stated the people responsible for ensuring mechanical lift transfers were conducted safely were himself and the nurse management team. He stated he monitored for compliance by reviewing skills competency checks and providing in-services as needed. He stated the potential negative impact to a resident of only one staff person operating a mechanical lift was injury. Review of in-services from January 2026 through July 2026 reflected an in-service performed on 02/17/2026 on safe transfers with the mechanical lift that included the facility written policy and procedure as follows: All mechanical lift transfers require TWO trained staff members. No exceptions. Neither CNA A's nor CNA B's signatures were on the attendance list. Review of the instruction manual for the facility's mechanical lifts reflected the following: The patient lift should only be operated by qualified personnel who have received specific application guidance or training. There were no instructions related to the number of people required to operate the lift. Review of undated facility policy title Hydraulic Lift reflected the following: The hydraulic lift is a mechanical device used to transfer a resident from and to the bed and chair. It is reserved for those who are paralyzed, obese, or too weak to transfer without complete assistance. The number of staff to provide assistance with the transfer should be determined by the manufacturer's recommendations.Goals1. The resident will achieve safe transfer to bed or chair via a mechanical lift device.2. The caregiver will demonstrate safe and correct transfer of the resident to the bed or chair via the hydraulic lift.3. The resident will verbalize a decrease and anxiety following explanation of the procedure.

Based on observation, interview, and record review the facility failed to ensure the resident's right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 2 of 8 residents (Residents #1 and 2) reviewed for access to their call system. The facility failed to ensure Resident #1 and Resident #2's call button was in reach when they were alone in their rooms on 07/14/2026. This failure could residents at risk of not having their care needs met.Findings included: 1.Review of the undated face sheet for Resident #1 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included dementia, repeated falls, and overactive bladder. Review of the quarterly MDS for Resident #1 dated 06/09/2026 reflected a BIMS score of 10, indicating moderately impaired cognition. It reflected that she was independent with chair-to-bed transfers. Review of the care plan for Resident #1 dated 05/18/2026 reflected the following: FOCUSThe resident has an ADL Self Care Performance Deficit.GOALThe resident will maintain or improve current level of function in (Specify Bed Mobility, Transfers, Eating, Dressing,Toilet Use and Personal Hygiene; ADL Score) through the review date.INTERVENTIONSEncourage the resident to use bell to call for assistance.Observation and interview on 07/14/2026 at 11:53 AM revealed Resident #1 sat in her wheelchair on the side of her bed and could not reach her call button, which was tacked to the wall. She stated she wanted to get in bed, but she needed help because her legs did not work very well and she had a wound on her foot so she could not bear weight on that foot right now. She stated she told the CNA who brought her to her room from the dining room that she wanted to get into bed, but sometimes they get sidetracked. She stated she could not remember exactly who brought her to her room. She stated she felt a little impatient about being able to lie down in her bed, but she was used to having to wait. Observation until 12:37 PM in the hallway outside Resident #1's room revealed no staff entered the room during this time. 2.Review of the undated face sheet for Resident #2 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included healed fracture of left femur, history of falling, and osteoarthritis of hip. Review of the quarterly MDS for Resident #2 dated 07/01/2026 reflected she could or would not participate in the BIMS assessment for cognitive status but had modified independence and no memory problems. It reflected that she was totally dependent on staff to transfer between her bed and her chair. Review of the care plan for Resident #2 dated 07/08/2026 reflected the following: FOCUSThe resident has Hip FractureGOALThe resident will remain free of complications related to hip fracture, such as contracture formation, embolism and immobility through/by review date.INTERVENTIONAnticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. Observation and an interview on 07/14/2026 at 11:54 AM revealed Resident #2 seated in her wheelchair next to a rolling bedside table which was between her and her bed. Her call button was on the bed but out of reach. She leaned forward when asked if she could but still could not reach the call button. She stated she wanted to get in her bed. She did not answer any more questions. Observation until 12:37 PM in the hallway outside Resident #2's room revealed no staff entered the room during this time. During an interview on 07/14/2026 at 2:14 PM, CNA B stated she did not remember that she did not hand call buttons to Residents #1 and #2 when she left them in their rooms. She stated she went back to their rooms and got them in bed within an hour of leaving them there. She stated the residents should have had their call buttons within reach at all times. She stated they could fall or need something and not be able to get help if they did not have their call buttons. During an interview on 07/14/2026 at 4:11 PM, the DON stated the resident call button should have been placed within reach of the residents' hands. He stated everyone in the building was responsible for ensuring residents had access to their call buttons, but ultimately it was his responsibility to ensure it happened. He stated he monitored for compliance ongoing with rounds in the morning and afternoon, q2 and PRN. He stated that potential negative impacts on residents for not having access to their call buttons were anger, incontinence, falls, unhappiness, and pain. During an interview on 07/14/2026 at 5:40 PM, the ADM stated call buttons were placed near to the residents so they could access them when they were in bed or the chair. He stated it was everyone's responsibility to ensure call buttons were accessible to residents. He stated he monitored for compliance with in-services and rounding. He stated the potential negative impact on a resident of not being able to access their call buttons was that they might need assistance to the point where it could be dangerous. He stated the facility had no written policy on reasonable accommodation of needs or call button accessibility.

Based on observation, interviews, and record review the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and determined by considering the number, acuity, and diagnoses of the facility's resident population with accordance for 2 (03/30/2026 and 03/31/2026) of 31 days reviewed for sufficient staffing. The facility failed to provide sufficient CNAs on 03/30/2026 and 03/31/2026 leaving the secured unit without a CNA on the overnight shift of 10 p.m. to 6 a.m., leaving residents without proper supervision and care. This failure could place residents at risk of inadequate supervision and an unsafe environment which could lead to falls, serious harm and injury, exacerbations of disease processes, and abuse and neglect. Findings included: Record review of Resident #1's admission record generated on 04/08/2026 reflected a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of sequelae of cerebral infarction (post-stroke complications affecting physical, cognitive, and emotional health), dementia, chronic pain, chronic pulmonary edema (fluid in the lungs), communication deficit, and history of transient ischemic attack and cerebral infarction (stroke). Record review of Resident #1's significant change MDS dated [DATE] reflected Resident #1 had a BIMS score of 02 which indicated severe cognitive impairment. Further review of the MDS indicated Resident #1 required substantial/maximal assistance with oral and toileting hygiene. Resident #1 was always incontinent with bowel and urine and was at risk of developing pressure ulcers. Record review of Resident #1's care plan last revised on 03/02/2026 reflected supervision was needed for bed mobility, transfers, eating, and toileting. She was an elopement risk with Interventions: Supervise closely and make regular compliance rounds whenever resident is in room. The resident had shortness of breath and interventions included, monitor and document changes in orientation, increased restlessness, anxiety, and air hunger. Record review of Resident #1's POC documentation for the month of March 2026 reflected no documented evidence that Resident #1 had any care on the overnight shift (10 p.m. to 6 a.m.) on 03/30/2026 and 03/31/2026. Required documentation fields were blank, including ADL assistance performed during shift, C.N.A care, bowel incontinence, urine incontinence, Medication Side Effects, report any new skin changes to ADON and/or DON, behaviors, Shortness of breath while lying flat, and Turn/Reposition. Record review of Resident #1 's order summary as of 04/08/2026 reflected she was prescribed morphine sulfate (concentrate) oral solution 20 MG/ML by mouth every two hours as needed for pain. Record review of Resident #2's admission record generated on 04/08/2026 reflected an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of urinary tract infection, gastrointestinal hemorrhage (bleeding in stomach), hyperkalemia (high potassium), vascular dementia, congestive heart failure, chronic kidney disease, and chronic pain syndrome. Record review of Resident #2's admission MDS dated [DATE] reflected Resident #2 had a BIMS score of 02 which indicated severe cognitive impairment. Further review of the MDS indicated Resident #2 required substantial/maximal assistance with toileting hygiene and was totally dependent on personal hygiene, dressing, shower/bathing, rolling, sit to stand, transfers. Resident #2 was occasionally incontinent with bowel and urine and was at risk of developing pressure ulcers. Record review of Resident #2's care plan last revised on 03/04/2026 reflected resident will be monitored for adverse medication effect and behavior monitoring with interventions of each shift monitor for and report any potential medication side effects or behaviors in the kiosk. If noted, also verbally report to a licensed nurse. The resident also had a potential for pressure ulcer development due to moderate to maximum assistant with ADLs and repositioning and interventions included, Ensure heels are floated with the use of pillows; the resident needs assistance to turn/reposition. She was an elopement risk with Interventions: Supervise closely and make regular compliance rounds whenever resident is in room. Record review of Resident #2's POC documentation for the month of March 2026 reflected no documented evidence that Resident #2 had any care on the overnight shift (10 p.m. to 6 a.m.) on 03/30/2026 and 03/31/2026. There are blanks for ADL assistance performed during shift, ADL more assistance, C.N.A care, behaviors, bowel incontinence, Medication Side Effects, report any new skin changes to ADON and/or DON, High Risk for falls, and snack. During an interview on 04/07/2026 at 11:40 a.m., CNA A stated there were 12 residents housed in the secured memory care hallway, which always required at least one CNA due to residents wandering, nighttime wakefulness, and the need for rounding every two hours. She stated staffing was often insufficient and that although there was generally one CNA assigned per hallway, she did not know how many CNAs were assigned to the secured hallway during the night shift. CNA A stated she arrived prior to her scheduled 6:00 a.m. shift on multiple occasions and observed no staff present in the secured memory care hallway. She could not recall any specific dates and stated she did not report it to anyone. She could take care of the residents herself and asked for help when needed. CNA A stated the residents appeared okay and she was not aware of any resident harm related to the lack of staff coverage. During an interview on 04/07/2026 at 2:33 p.m., NA stated that on 03/30/2026, during the 10:00 p.m. to 6:00 a.m. shift, she was the only NA working in the facility. She reported that level of staffing was insufficient to meet residents' care needs. She stated although two additional CNAs were scheduled, they did not report for duty. NA stated she was approved by the ADON and the DON to work only until 4:00 a.m. due to the 16 hour work limit and this left the building without any CNAs until the morning shift came in at 6 a.m. NA stated RN G and RN H were present during the shift but did not assist with resident care. NA stated she rounded on all residents only once during the shift due to limited time and the care needed, except those in the secured unit on hallway six, which she did not enter due to lack of experience and discomfort. NA stated she informed RN G and RN H of her concerns; however, neither nurse checked on residents in the secured unit during the shift. NA reported she was not aware of any resident harm. During an interview on 04/07/2026 at 3:05 p.m., the ADON stated she was responsible for scheduling nurses and CNAs. She stated she was not aware of any facility policy specifying minimum staffing levels or actions required when staff failed to report for duty.The ADON stated she typically scheduled 2-3 CNAs and two RNs for the overnight shift and believed that was adequate for an average resident census of 70 and acuity. She stated that on 03/30/2026, two CNAs called in, and NA offered to cover the shift. The ADON stated she attempted to obtain additional CNA coverage but was unsuccessful. The ADON stated an RN should supervise NA but believed NA could perform all routine CNA duties. She stated that everyone in the building was expected to round on residents every two hours and that there were two seasoned RNs working on 03/30/2026. The ADON stated that NA was the only NA in the building from 10:00 p.m. to 4:00 a.m. and stated NA reported that RN G and RN H were not supportive. There was not a CNA in the building from 4:00 a.m. to 6:00 a.m. The ADON stated that it was the only occurrence of having one CNA for the entire facility and stated she was not aware of any resident harm or neglect during the shift. During an interview on 04/07/2026 at 3:35 p.m., CNA C stated staffing levels were frequently insufficient to provide timely resident care and the overnight shift had it worse with staff frequently calling in or not showing up for their shift. She stated there were often only two CNAs assigned to the entire building, whereas she believed at least three to four CNAs were needed due to the number of residents. She stated that usually she was assigned to one hallway and responsible for 10 residents. CNA C stated she was often asked to work late or pick up additional shifts, and everyone knew about the staff shortages because the schedule was posted and they could look on it daily to see that staff called in or did not show up for their shift. She stated there should always be at least one CNA assigned to the secured unit on hallway six due to dementia and supervision needed. CNA C reported she was not aware of any resident harm related to the staffing levels. CNA C stated did her best to round on residents once every two hours, but it was overwhelming and tough. During an interview on 04/07/2026 at 4:00 p.m., a family member of Resident #1 stated she was aware there was only one CNA working in the entire facility on the overnight shift from 10:00 p.m. to 6:00 a.m. on 03/30/2026, based on information provided by a facility staff member. The family member declined to identify the source. She stated Resident #1 had a camera in her room and that no staff were observed checking on the resident from approximately 9:30 p.m. on 03/30/2026 to 5:30 a.m. on 03/31/2026. She stated Resident #1 was on hospice care, did not get out of bed, had restless behaviors, and could have fallen out of bed. During an interview on 04/08/2026 at 9:55 a.m., CNA D stated the facility was frequently short staffed, primarily on weekends, with only two CNAs assigned to the entire building, when she believed three to four CNAs were needed due to having 65 to 75 residents, with some requiring 2-person assistance transfers, assisting with feeding, and one always needed on the secured unit (hall 6) due to confusion and dementia. She stated insufficient staffing made it difficult to provide timely care and that some nurses refused to assist when asked. CNA D stated she arrived early for work at approximately 5:15 a.m. and on multiple occasions observed the secured unit unattended but could not recall a specific date. CNA D stated that the ADON and the DON knew this because they were always trying to call and get more staff to cover shifts. She stated she believed there should always be two staff members assigned to the secured unit on hallway six. CNA D stated all residents were required to be rounded on every two hours. She reported she was not aware of any resident harm related to the staffing concerns. During an interview on 04/08/2026 at 10:08 a.m., the ADON stated there was no facility policy addressing staffing levels or scheduling. She stated it was the responsibility of the charge nurse on each shift to notify the DON if staffing was inadequate. The ADON stated she did not receive a call from the charge nurse on 03/30/2026 regarding understaffing. The ADON stated NA reported that RN G and RN H were not assisting; however, both RNs told her that everything was under control. She stated there were no behaviors reported on the secured unit on hallway six and that residents slept through the night. The ADON stated she was not aware NA did not round on residents in the secured unit overnight on 03/30/2026 but was not concerned because RN H was responsible for the secured unit and reported that everything was under control. During an interview on 04/08/2026 at 10:38 a.m., RN I stated Resident #1 was on hospice care, bedfast, and nearing end of life. He stated Resident #1 exhibited restless movements and was prescribed lorazepam for those behaviors. RN I stated Resident #1 required monitoring every two hours due to the risk of falling from bed. He further stated he would be very concerned for residents in the secured memory care unit if no staff were present to supervise them because they required rounding on every two hours. During an interview on 04/08/2026 at 10:44 a.m., LVN F stated the facility was understaffed approximately once a week, which affected the ability to provide timely resident care. She stated that on the morning of 03/31/2026, when she arrived prior to her scheduled 6:00 a.m. shift, there was no CNA present in the building and no staff assigned to the secured memory care unit. LVN F stated she reported that to the DON and the ADON, who were responsible for scheduling. LVN F stated she worked in the memory care unit and would never leave residents unattended due to risks of confusion, wandering, restlessness, and falls. She stated that while residents in the secured unit generally slept through the night and she was not aware of adverse behaviors during that time, residents were required to be rounded on every two hours. LVN F stated it was ultimately the charge nurse's responsibility to ensure required rounding occurred. She stated that during the overnight shift of 03/30/2026 to 03/31/2026, there was only one CNA assigned to the entire building, which she believed was inadequate for the residents' level of care. She stated appropriate staffing would include one CNA per 15 residents during the day, one CNA per 20 residents at night, and one dedicated CNA assigned to the memory care unit. During an interview on 04/08/2026 at 10:44 a.m., LVN E stated staffing levels were often insufficient to provide timely resident care, although she reported improvement after recent staff hires. She stated that on more than one occasion when she arrived for her 6:00 a.m. shift, staffing in the building was inadequate, but could not recall a specific date. LVN E stated appropriate staffing included one CNA assigned to each hallway, with hallways three and four combined, and one to two CNAs assigned to the secured memory care unit on hallway six. She stated all residents required rounding every two hours and that residents in the memory care unit had Alzheimer's disease and dementia, with behaviors that included wandering, entering other residents' rooms, and agitation, requiring continuous supervision to ensure safety. LVN E stated she was not aware of a time when the secured memory care unit was left without staff due to the importance of supervision. LVN E stated adequate nursing staffing required at least two nurses on each shift due to residents requiring blood glucose monitoring, tube feedings, medication administration, wound care, and two person transfers using a mechanical lift. During an interview on 04/08/2026 at 12:46 p.m., a family member of Resident #2 stated no staff were observed entering the resident's room during the overnight hours of 03/30/2026 to 03/31/2026, based on electronic camera monitoring. She stated that when she visited Resident #2 on the morning of 03/31/2026, dried urine was observed on the bed sheets, and the resident appeared to have remained in the same position overnight. The family member stated LVN E informed her the facility was short staffed because four staff members had left early or called in and did not report to work. The family member stated she texted the DON regarding her concerns and received a response stating, We are not shorthanded. The 1:10 ratio is good . During an interview on 04/08/2026 at 1:02 p.m., the DON stated he was responsible for preparing the nursing schedule or that charge nurses made assignments in his absence. He stated the state did not mandate CNA or nursing staff to resident ratios. He stated based on an average census of approximately 70 residents and what he described as low acuity, the minimum staffing should include two nurses and three CNAs per shift, with a goal of four to five CNAs. The DON stated it was the responsibility of the charge nurse to notify him if staff failed to report to work and that he would otherwise be unaware of staffing deficits. He stated that if staffing was below what was considered safe, the DON, the ADON, and the ADM would come in to assist. The DON stated it was not unsafe to have two RNs and one CNA assigned to the overnight shift. The DON stated he was not aware that student NA was the only CNA working the overnight shift on 03/30/2026 until the surveyor requested schedules and timesheets on 04/07/2026. He stated having no CNAs in the building would be unsafe and that the two RNs should have requested additional support after NA left at 4:00 a.m. on 03/31/2026. The DON stated inadequate staffing could result in delays in resident care and stated all residents required rounding every two hours due to possible changes in condition. He stated he was not aware residents in the secured memory care unit were not rounded on overnight on 03/30/2026 and stated that it did not meet his expectations. The DON stated memory care residents required supervision for safety due to confusion and call light use. The DON stated he was not aware of any written policies addressing staffing or scheduling. During an interview on 04/08/2026 at 1:28 p.m., the ADM stated the DON and the ADON were responsible for determining staffing levels based on census and acuity. He stated the state did not mandate CNA or nursing staff to resident ratios. He stated that for an average census of 67 to 70 residents, staffing should include two nurses, one medication aide, and four CNAs on day shift, and two nurses with one to two CNAs on night shift. The ADM stated two nurses and one CNA, including a student CNA, would be considered sufficient staffing for the overnight shift. He stated residents were expected to be rounded on frequently or every two to three hours for safety. The ADM stated he became aware on 03/31/2026 that a single student CNA worked the overnight shift after it was discussed during the morning meeting. He stated two RNs covering the facility overnight would still be safe and feasible and that he was not concerned about staffing. The ADM stated he was not aware NA did not round on the secured memory care unit and stated it was RN H's responsibility to ensure rounding occurred. He stated the facility did not have policies addressing staffing or scheduling. During a telephone interview conducted after exit on 04/15/2026 at 12:31 p.m., RN H stated she worked from 6:00 p.m. to 6:00 a.m. shifts four days per week and that staffing was insufficient at least twice per week, but could not recall any specific dates besides 03/30/2026. She stated inadequate staffing made it difficult to complete required tasks and resulted in some residents not receiving showers or being gotten out of bed. RN H stated that based on resident acuity with having residents with feeding tubes, pressure ulcers, diabetes, and 2-person transfers, and census averaging around 70, staffing should include four staff capable of administering medications and at least one CNA assigned to each hallway, including a dedicated CNA for the secured memory care unit. She stated management was aware of low staffing on the overnight shift of 03/30/2026 because NA was asked to stay and pick up an additional shift. RN H stated NA was the only CNA in the facility overnight, had worked a 16 hour shift that day, and left at approximately 4:00 a.m. on 03/31/2026, leaving only RN H and RN G in the building. RN H stated due to low staffing, medications were administered late and residents were not rounded on every two hours. She stated two hour rounding was necessary for resident safety, monitoring for changes in condition, repositioning to prevent skin breakdown, and incontinent care. RN H stated no staff member was assigned to the secured memory care unit overnight on 03/30/2026. She reported she intermittently listened to doors and observed residents from hallways but stated residents were not checked every two hours and rooms were not entered. RN H stated management was aware of the staffing concerns and reported her belief that staffing schedules were intentionally presented as fully staffed when they were not. RN H was not aware of any adverse outcomes for the residents due to lack of staffing. Record review of the Facility Daily Assignment for the overnight shift 10 p.m. to 6 a.m. reflected: 03/30/2026 - NA was scheduled to leave at 4 a.m., no CNA assigned to hall 6 (secured unit), and no CNA scheduled from 4 a.m. to 6 a.m. Record review of the Facility Nurse Aide Daily Sign-In Sheet dated 03/30/2026 reflected NA signed in at 12:29 p.m. and signed out at 4:04 a.m. Record review of the facility time sheets reflected NA was the only NA that clocked in for the overnight shift from 12:24 p.m. on 03/30/2026 to 4:04 a.m. on 03/31/2026. RN H was clocked in from 5:59 p.m. on 03/30/2026 to 8:24 a.m. on 03/31/2026; and RN G was clocked in from 5:48 p.m. on 03/30/2026 to 6:26 a.m. on 03/31/2026. Record review of the facility's census on 03/30/2026 reflected 67 residents, with 11 of those residents on hall 6 (secured unit).

Based on observations, interviews, and record reviews, the facility failed to ensure it formulated, adopted, and enforced policies regarding smoking, smoking areas, and smoking safety for 3 of 5 residents (Residents #5, Resident #20, and Resident #78) reviewed for smoking. The facility failed to keep Residents #5, Resident #20, and Resident #78's cigarettes and lighters in a safe place per their policy. This failure placed all residents at risk for serious injury, harm, and/or death due to possible fire or smoking inside the building. Findings Included: Resident #5 Record review of Resident #5's Face sheet dated 08/06/2025 reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #5 had diagnoses which included end stage renal disease, unsteadiness on feet, limitation of activities due to disability, atrial fibrillation (abnormal heart rhythm), chronic obstructive pulmonary disease (chronic progressive lung disease), dementia (memory, thinking, difficulty), low back pain, hyperlipidemia (high cholesterol), legal blindness, hypertension (high blood pressure), insomnia (difficulty sleeping), and tobacco use. Record review of Resident #5's Annual MDS dated [DATE] reflected he had a BIMS Score of 12, indicating moderate impairment. The MDS revealed Resident #5 was a current tobacco user. Record review of Resident #5's Care Plan dated 06/22/2025 revealed Resident #5 was an everyday smoker. Interventions in place was Keep lighter at nurses' station along with cigarettes in smoking box, maintain appropriate level of supervision as determined by smoking assessment, Resident #5 will only smoke in designated smoking areas and smoking apron as indicated. Record review of Resident #5's Smoking assessment dated [DATE] revealed that resident is safe to smoke unsupervised at this time, and all smoking materials will be kept at the nurses station. Resident #20 Record review of Resident #20's Face sheet dated 08/06/2025 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #20 had diagnoses which included cerebral infraction (stroke), dementia (memory, thinking, difficulty), seasonal allergies, non-ST elevation myocardial infarction (a type of heart attack characterized by reduced blood flow to the heart, leading to heart muscle damage), type 2 diabetes mellitus with unspecified complications (high blood sugar), hyperlipidemia (high cholesterol), and cardiomyopathy (a disease of the heart muscle). Record review of Resident #20's Quarterly MDS dated [DATE] reflected he had a BIMS Score of 09, indicating moderate impairment. The MDS did not indicate Resident #20 was a current tobacco user. Record review of Resident #20's Care Plan dated 05/29/2025 revealed Resident# 20 was an everyday smoker. Interventions in place was Assist to and from designated smoking area, assure smoking material is extinguished prior to patient leaving smoking area, observe patient for unsafe smoking behaviors or attempts to obtain smoking materials from outside sources, patient not to have cigarettes or smoking material on person, provide smoking apron while smoking and place patient in position to assure visualization of ashtray. Record review of Resident #20's Smoking assessment dated [DATE] revealed that resident is safe to smoke unsupervised at this time, and all smoking materials will be kept at the nurses station. Resident # 78 Record review of Resident #78's Face sheet dated 08/06/2025 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #78 had diagnoses which included multiple fractures of the pelvis, protein-calorie malnutrition (inadequate intake of both protein and calories), type 2 diabetes mellitus without complications (high blood sugar), and personal history of transient ischemic attack (a short period of symptoms like those of a stroke). Record review of Resident #78's admission MDS dated [DATE] reflected he had a BIMS Score of 09, indicating moderate impairment. The MDS did not indicate Resident #78 was a current tobacco user. Record review of Resident #78's Care Plan dated 07/31/2025 revealed Resident# 78 smoked. Interventions in place was Ensure smoking occurs in designated smoking areas, ensure that no oxygen is located in the smoking area while the resident is smoking, no smoking materials or igniter's will be stored in the resident rooms, safe smoking assessment every month, and this resident is safe to smoke unsupervised, at this time. Record review of Resident #78's Smoking assessment dated [DATE] revealed that resident is safe to smoke unsupervised at this time, and all smoking materials will be kept at the nurses station. Observation of smoking on 08/05/2025 at 4:08 p.m., revealed there were five residents outside for the smoke break. Resident #20 was observed with a pack of cigarettes in her bra, Resident #5 was observed pulling a pack of cigarettes and a lighter out of his pocket. Resident #78 was observed with a pack of cigarettes in her pocket. During an interview on 08/06/2025 12:00 PM with Resident #5 revealed that he had been given instructions on smoking. He said it covered where he goes to smoke and the times that he can smoke. He said the smoking area is outside of Hall 3. He said staff are available when they smoke. He said that the facility gave all the smoking residents a smoking apron. He said he was able to keep his cigarettes on him until recently. He said that the facility just took them from him yesterday because State was here. He said when he had his cigarettes he would keep them in a drawer in his room. During an interview on 08/06/2025 12:05 PM with Resident #20 revealed that she was given the smoking instructions. She said it covered that she could not smoke inside the facility. She said that she had to go outside to the smoking area to smoke. She said that the smoking area is at the end of Hall 3. She said she does not use an apron when she is in the smoking area. She said that she was able to keep her cigarettes and lighter. She said they took her cigarettes and lighter yesterday. She said that she would keep her cigarettes in her bra or in her drawer. She also said that she had people come in and take things from her room in the past. During an interview on 08/06/2025 2:25 PM with Resident #78 revealed that the facility let her keep her cigarettes until 08/05/2025. She said she wanted to know why the facility took her cigarettes from her. She said the facility let her keep them when she got to the facility. She said that the facility did go over the instructions on smoking today with her. She said the facility told her they would start keeping the cigarettes in a clear box. She said the facility instructed her that the staff would take the residents out to smoke during the designated smoking times. She said the smoking area was at the end of hall 3. She also said when she was able to keep her cigarettes she would put them in her top drawer. During an interview on 08/07/2025 11:50 AM with the AD revealed that she had been trained on the smoking policy. She said the training covered the residents must wear aprons, staff must be present while residents are smoking, and the residents are allowed only two cigarettes during the smoke break. She said that there was a list of staff that take the residents out to smoke. She was not sure how often the residents were assessed for safe smoking. She said that residents were not allowed to keep their cigarettes and lighters on them. She said they have never been able to keep them. She said the smoking material is kept in a box at the nurse's station. She said the residents could burn themselves or another resident could get ahold of the cigarettes if the resident kept them. She said that all staff were responsible for monitoring to ensure that the residents did not keep their cigarettes and lighters. She said the staff monitor it by taking the cigarettes after the smoke breaks. She said that Residents #5, Resident #20, and Resident #78 have not had any smoking accidents. She said she did not know why Residents #5, Resident #20 and Resident #78 had their cigarettes and lighters. During an interview on 08/07/2025 3:46 PM with MA E revealed that he had been trained on smoking policy. He said the policy for smoking was that the resident had to smoke outside in the designated area. He said that the residents had to put the smoking apron on before they smoked. He said that the residents were allowed to have two cigarettes and staff had to be present while the residents smoked. He said that different staff take the residents out at different times. He said the residents were educated daily on the smoking policy because they wanted to go outside to smoke all day long. He said the interventions were that the facility had specific times, aprons and staff were there when residents smoked for interventions. He said the residents are a part of the interventions planning and it is discussed when the facility does the residents care plan. He said that residents are not allowed to keep their smoking materials. He also said the residents have never been allowed to keep their smoking materials. He said if residents kept their smoking materials, they could hurt themselves or others. He said that everyone was responsible for monitoring to ensure residents do not have their smoking materials. He said that he did not know why Residents #5, Resident #20 and Resident #78 had their cigarettes and lighters on them. He said that Residents #5, Resident #20, and Resident #78 have not had any smoking related accidents. During an interview on 08/07/2025 5:05 PM with the DON revealed he had been trained on smoking policy. He said the smoking policy was that the facility did a smoking assessment to ensure they are safe to smoke. He said staff take the residents out to smoke and keep the residents in the line of sight. He said that when the residents are done smoking the staff were to collect all the cigarettes and lighters from the residents. He said that the safe smoking assessments were done quarterly. He said that the residents were educated daily on smoking rules because they want to go outside all day long. He said that the interventions in place were aprons, red cigarette cans, the safe smoking assessments and staff present when residents are smoking. He said that the activity director does include the resident in the decision of the interventions. He said the residents were not allowed to keep their smoking materials on them. He said if residents kept their cigarettes and lighters other residents could get ahold of them. He said that all staff were responsible for ensuring the residents do not have their smoking materials. He said staff monitored it by observations and when the smoking break is over. He said he did not know why Residents #5, Resident #20 and Resident #78 had their smoking materials. He also said that none of the residents have had any smoking accidents. During an interview with the ADM on 08/07/2025 at 5:35pm revealed that he had been trained on smoking policy. He said the policy for smoking was that the resident could smoke during the designated times with staff present. He said that staff were assigned to take the residents out to smoke during the smoking times. He said that residents were assessed for safe smoking monthly. He also said that the residents were educated on the smoking rules at least quarterly. He said that interventions in place were the assessments, the residents wearing the aprons, and staff monitoring the residents. He said residents are a part of the smoking intervention decisions. He said that residents were not allowed to keep their smoking materials on them. He said if residents kept their smoking material they might try to smoke in their room or give cigarettes to other residents. He said all staff were responsible for ensuring that residents did not have their smoking materials. He said that it was monitored through observation and the staff would confiscate it when they see a resident with smoking materials. He said he did not know why Residents #5, Resident #20 and Resident #78 had their smoking material on them. He said Residents #5, Resident #20 and Resident #78 have not had any smoking related accidents. Record review of the Smoking Policy dated 11/1/2017 revealed matches, lighters or other ignition sources for smoking are not permitted to be kept or stored in the resident's room.

Based on interview and record review the facility failed to ensure residents had the right to request, refuse, and/or discontinue treatment, to participate in experimental research, and to formulate advance directives for 3 of 10 residents (Resident #1, #4 and #65) reviewed for advance directives. The facility failed to ensure that Resident #1's out of hospital DNR was uploaded to the electronic health record and the care plan was updated.The facility failed to ensure that Resident #4's out of hospital DNR was signed by the physician and uploaded to the electronic health record on [DATE].The facility failed to ensure that Resident #65's out of hospital DNR was signed by the physician and uploaded to the electronic health record on [DATE]. These failures could place residents at-risk of having their wishes dishonored, and of having CPR performed against their wishes. Findings included: Record review of Resident #1's Face sheet dated [DATE] reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included pneumonia, dysphagia pharyngoesophageal phase (inability to empty from the throat to the esophagus), hypertension (high blood pressure), dementia (memory, thinking, difficulty), history of falling, pain in shoulder, asthma, dependency on wheelchair, chronic obstructive pulmonary disease (chronic progressive lung disease), anemia (not enough healthy red blood cells), hyperlipidemia (high cholesterol), respiratory failure, kidney failure, and urinary tract infection. Record review of Resident #1's admission MDS dated [DATE] reflected she had a BIMS Score of 07, indicating severe impairment (significate limitation of basic work activity).Record review of Resident #1's Care Plan dated [DATE] revealed Resident # 1's advance directive was a full code. Record review of Resident #1's electronic health record on [DATE] at 02:23 PM reflected no Out of Hospital DNR in the electronic health record. Record review of the Out of Hospital DNR revealed an Out of Hospital DNR was signed on [DATE] and uploaded to Resident #1's medical record on [DATE] at 3:45pm.Record review of Resident #1's Doctor's Orders revealed a doctor's order dated [DATE] was signed for a DNR directive. Record review of Resident #4's admission record, dated [DATE], revealed an [AGE] year-old female, admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had diagnoses which included unspecified dementia (a disease that causes a general decline in cognitive abilities that can affect the ability to perform everyday activities, memory loss, and poor judgement), type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar), hyperlipidemia (abnormally high level of fats in the blood), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and chronic obstructive pulmonary disease (a lung disease limiting air flow from the lungs).Record review of Resident #4's Quarterly MDS, dated [DATE], revealed a BIMS of 01, which indicated severe cognitive impairment. Record review of Resident #4's order summary, dated [DATE], revealed Do Not Resuscitate with an order date [DATE]. Record review of Resident #4's electronic health record revealed an out of hospital DNR form dated [DATE]. Review of Resident #4's out of hospital DNR revealed under the section titled Physician's Statement no signature by the physician, no date, no printed name, and no license number. Further review revealed under All persons who have signed above must sign below, acknowledging that this document has been properly completed, no signature by the physician. Record review of Resident #4's care plan, dated [DATE] and last revised on [DATE], revealed Resident #4 had chosen to do not resuscitate with goal Patient's wishes will be honored.Review of Resident #65's face sheet dated [DATE] revealed Resident #65 was admitted on [DATE] and readmitted on [DATE] with a primary diagnosis of cerebral infarction (a stroke occurs when the blood vessels in the brain are blocked). The advance directive listed was DNR. The resident was in the secured unit. Review of Resident #65's care plan dated [DATE] revealed resident selected a DNR code status. Goal listed was patient's wishes will be honored. Review of Resident #65's quarterly MDS dated [DATE], revealed a BIMS score of 09, which indicated moderate cognitive impairment. Review of Resident #65's clinical record revealed an OOH-DNR form dated [DATE]. Further review revealed that under the section all persons who have signed above must sign below, acknowledging that this document has been properly completed there was no signature from the physician. During an interview on [DATE] 03:23 PM with the DON, he stated there was not a central location for DNR forms. He stated all residents' DNRs should be in their electronic health record. During an interview on [DATE] at 03:11 PM with the WC LVN, she stated a physician's signature was required on the out of hospital DNR for it to be valid. She stated medical records was responsible for uploading valid out of hospital DNRs to the electronic health record. The WC LVN stated if a valid out of hospital DNR was not in the electronic health record, then the resident may be given CPR even though their wishes were for do not resuscitate.During an interview on [DATE] at 04:10 PM with the MDS LVN, she stated all out of hospital DNR forms require the physician to sign in 2 separate areas on the form for it to be valid. She stated the SW was responsible for ensuring the DNR form was completed correctly and uploaded to the electronic clinical record. The MDS LVN stated if there was not a valid DNR in the electronic health record then the facility must act as if the resident is a full code, and they are required to start CPR. During an interview on [DATE] at 04:40 PM with the SW, she stated that a valid out of hospital DNR required 2 signatures from the physician for it to be valid. She stated she thought medical records, or the nursing department was responsible for ensuring out of hospital DNRs are completed correctly. The SW stated medical records were responsible for uploading the out of hospital DNRs to the residents' electronic health record. She stated if a valid DNR was not in the electronic health record then that could be a huge situation because [the facility staff] would not know [the resident's] preferences in an emergency.During an interview on [DATE] at 04:49 PM with the MR LVN, she stated the physician must sign an out of hospital form in 2 places for it to be valid. She stated she and the SW were responsible for ensuring out of hospital forms are completed correctly. She stated if there was an order for the resident to have DNR as their code status, then the resident's wish would be honored in the facility, but if the resident were sent out to the hospital, their wishes might not be honored in route to the hospital because of not having a valid DNR. During an interview on [DATE] at 5:06 PM with the DON, he stated a physician's signature is required on the out of hospital DNR form for it to be valid. He stated the SW, and nurses were responsible for ensuring the out of hospital DNRs were completed correctly and were valid. The out of hospital DNR was supposed to be uploaded immediately after obtaining all the necessary signatures. He stated if a valid DNR was not in the electronic health record, then families may get upset because a resident might be revived despite their/the family's wishes. During an interview on [DATE] at 05:35 PM with the ADM, he stated a physician's signature was required on the out of hospital DNR form to make it valid. He stated previously nursing leadership was responsible for ensuring the out of hospital DNR was completed correctly, but with the new company it is the SW's responsibility. He stated the SW was responsible for uploading valid DNR forms to the residents' electronic health record. The ADM stated, if a valid out of hospital DNR is not in the electronic health record, then the resident may get CPR against their wishes. Record review of, undated, facility policy titled, Self Determination End of Life Measures revealed .Competent adults may issue advance directives in accordance with applicable state laws.Upon admission, the facility will provide the individual with a copy of his/her rights under Texas law concerning the right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives.If the resident has already executed an advanced directive, the facility will obtain a copy and place it on the clinical record. The facility will respect the wishes of the resident as outlined in the advance directive. The primary nurse will note the resuscitation status of the resident on all applicable clinical records. Also, document whether the resident has executed the advance directive.The facility will ensure compliance with the requirements of Texas law concerning appropriate health care provisions when a resident has not provided written documentation for his/her advance directive, has not made a decision regarding his/her advance directive, or is incapacitated.Record review of health and safety code 166.083(b)(4)(6) dated [DATE] revealed an OOH-DNR order at minimum must contain statement that the physician signing the document is the attending physician of the person and that the physician is directing health care professionals acting in out-of-hospital settings, including a hospital emergency department, not to initiate or continue certain life-sustaining treatment on behalf of the person and places for the printed names and signatures of the witnesses or the notary public's acknowledgment and for the printed name and signature of the attending physician of the person and the medical license number of the attending physicianFurther review of health and safety code 166.089(3) dated [DATE], revealed an OOH-DNR order form appears valid when it includes the signature or digital or electronic signature of the declarant or persons executing or issuing the order and the attending physician in the appropriate places designated on the form for indicating that the order form has been properly completed.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen and 1 of 1 nourishment room reviewed for food and nutrition services. 1) The facility failed to properly seal food product bags in the walk-in freezer to prevent exposure to air. 2) The facility failed to label and date food items in the walk-in freezer, and the nourishment refrigerator. 3) The facility failed to maintain the proper temperature of the refrigerator in the nourishment room. This failure could have placed residents at risk for food contamination and foodborne illness. Findings included: Observation of the kitchen's walk-in freezer on 08/05/2025 at 09:03 AM revealed several boxes of frozen food stacked on top of each other. The boxes were crushed, smashed, wet from condensation, and ice was piled on top of some of the boxes. Several boxes of frozen food were not properly sealed, exposed to air, and not dated. One box of frozen garlic bread was not properly sealed and exposed to air. One bag of frozen cookie dough was not properly sealed, exposed to the air, not labeled nor dated. The freezer cooling machine was observed with condensation water dripping off and landing on boxes of frozen food and the shelving unit. Observation of the nourishment room's refrigerator on 08/06/2025 at 09:16 AM revealed temperature log for the refrigerator, which listed the temperature at 44 degrees on 08/04/2025, 08/05/2025, and 08/06/2025. The thermostat inside the refrigerator listed the temperature at approximately 47 degrees. The contents included two opened bottles of soda, a pack of unopened canned sodas, an unopened bottle of salad dressing, a few unopened bottles of nourishable shakes, and a plastic bag that contained some type of food, all of which were not labeled nor dated. Observation of the nourishment room's refrigerator on 08/07/2025 at 09:33 AM and 10:57 AM revealed temperature log for refrigerator listed at 48 degrees on 08/07/2025. The thermostat inside the refrigerator listed the temperature at appropriately 48 degrees. The contents included six pudding cups from the kitchen that were dated 08/07/2025. Observation at 12:57 PM revealed thermostat inside the refrigerator listed the temperature at appropriately 49 degrees. In an interview on 08/06/2025 at 09:20 AM, RN F stated that the nourishment refrigerator was used for residents' drinks and food. Residents did not have access to the refrigerator because it was inside the locked medication room. Only the nursing staff had access to the room. The nighttime nurse was responsible for monitoring and checking the temperature and it was posted on the temperature log on the outside of the refrigerator door. RN F did not know what the temperature should be as that was monitored by the night nursing staff. RN F stated that it was the facility's policy to label and date all items that go into the refrigerator to ensure the items were not given to the wrong resident and to ensure the items did not go bad. RN F did not know how long food could stay in the fridge, but stated sodas could stay in the fridge for months. It was the responsibility of whoever put the items in the fridge to label and date them. If items were not labeled and dated, they should be thrown away to avoid germs that could make the residents sick. In an interview and observation on 08/06/2025 at 09:25 AM, the DON stated he did not know the correct temperature range for the refrigerator and would have to check the facility's policy. His expectation if the temperature were out of range, was that the nursing staff would adjust the temperature control in the inside of the refrigerator, retake the temperature, and clean the inside of the fridge. The DON stated it was important to maintain proper temperature to ensure food did not spoil, bacteria did not grow, there were no germs and to keep food therapeutic. He stated serving food to residents out of a fridge with a temperature above the recommended range would cause gastrointestinal symptoms. The DON stated he did not know when the night nurse took the temperature or how long the temperature had been out of range. The DON stated that all items put in the fridge should be labeled and dated. If items were not labeled and dated, they should be thrown away to ensure food was not spoiled or given to the wrong resident. The DON was observed to throw out all the items in the fridge that were not labeled and dated. In an interview on 08/06/2025 at 09:25 AM, MA D stated that she did not know the proper temperature for the refrigerator, but she thought it might be 100 degrees. She stated serving residents food out of a refrigerator that was above the recommended temperature could give the residents food poisoning. She did not know how long the temperature had been out of range because it was the night nurse that monitored the inside refrigerator temperature, and their shift ended at 6 AM. In an interview on 08/06/2025 at 02:58 PM, CK B stated she had been trained on how to label, date, and store food. Once a food item was opened, the policy was to seal the food in a plastic bag, label it with the open date, the use by, or the expiration date, and put it back in the refrigerator or freezer. This avoided potential cross contamination with other foods in the refrigerator or freezer or physical contamination. For foods going into the freezer, it was important to properly seal the food to avoid freezer burn. Freezer burn could make the food bad or cause residents to get sick. CK B stated that ultimately it was the dietary manager's responsibility for checking to ensure that all food was properly labeled, dated, and stored. She stated that she did not store items like that in the freezer and had not noticed the food in the freezer was not properly sealed. CK B stated that food not properly sealed in the freezer could have cross contamination from the condensation from the freezer unit. This did not meet her expectations. If she saw foods not properly labeled, dated, or stored, she would take out the food and properly seal, label, and date the food and put it back if it appeared it was okay. If the food appeared spoiled or had freezer burn, she would throw it away. In an interview on 08/06/2025 at 03:14 PM, the DM stated he had been trained on how to label, date, and store food. Once a food item was opened, the policy was to seal the food in a plastic bag, label it with the open date and date received and put it back in the refrigerator or freezer. For foods going into the freezer, he stated it was important to properly seal in the leftovers to avoid freezer burn. Freezer burn could make the food bad, grow bacteria, and potentially cause residents to get sick. If the food container were open and exposed to the elements and air inside the freezer, that could make the food go bad. The DM stated it was all kitchen staff's responsibility to check to ensure that all food was properly labeled, dated, and stored. Food containers not properly sealed, labeled, and dated would not meet his expectations. The DM stated he did not have a routine or schedule of checking to ensure his staff were properly labeling, dating, and storing food, but he did try to check after every meal. If he saw food in the freezer that was not properly sealed, labeled, and dated, he would have an in-service training with the staff to review policy and expectations. He would ask staff if they knew when the food was opened and if the food looked good, he would properly label, date, and seal the food. If the food appeared to have freezer burn, he would throw it out. The DM did not answer if he was aware of the food containers in the freezer that were not properly sealed, labeled, or dated but stated the freezer was being cleaned out because they were expecting a food delivery and there was little space in the freezer. In an interview and observation on 08/07/2025 at 09:33 AM, the DON stated he did not know how long the temperature of the nourishment refrigerator was out of range or when the temperature was taken, because it was done by a night nurse who was no longer at the facility as her shift ended at 6 AM. The DON stated that the temperature range should be between 35 degrees and 46 degrees, and 48 degrees would be out of range. He could not say if any correction action had been taken by the night nurse, but stated he would turn the inside temperature control knob from 3 to 2 and he would recheck the temperature in one hour. The DON stated he did not have the manufacture's instruction manual, but based on his personal refrigerator at home, the control knob 0 was equal to 0 degrees and the higher numbers were warmer, not colder. The DON was observed to leave the kitchen prepared pudding cups labeled 08/07/2025 in the fridge. In the same interview, the DON stated he did not know what the facility's policy was for labeling, dating, and storing food in the kitchen was as that was the dietary manager's responsibility. The DON stated that food in the freezer that was not properly sealed, labeled, or dated should be throw out because food exposed to air and elements in the freezer could get freezer burn, which would potentially cause food to spoil and cause residents gastrointestinal disturbances. In an interview on 08/07/2025 at 10:24 AM, CK C stated that she had received training on how to label, date, and store food. She stated once food was opened, it needed to be sealed with plastic bag or wrap, labeled and dated with date open and the use by or expiration date. CK C stated it was important to avoid using bad or expired food, which could harm the residents and make them sick. CK C stated that food with freezer burn should be thrown away because the food was bad. CK C stated that everyone was responsible to ensure all food was labeled, dated, and stored properly and she checked the food daily. She had not noticed the food in the freezer was not properly sealed. In an interview on 08/07/2025 at 10:29 AM the CDM stated it was the facility's policy to label, date, and store food to ensure the food was kept safe and to avoid cross contamination. Food should be closed and sealed to avoid it being exposed to air and the elements. If she saw food in the freezer that was not properly labeled, dated, or stored, she would throw it away. The CDM stated the food in the freezer that was opened to the elements had all been thrown away. This would not meet her expectations and could make the residents sick. It was the dietary manager's responsibility to check and ensure all food was properly labeled, dated, and sealed. In an interview on 08/07/2025 at 10:34 AM, DA A stated that she had received training on how to label, date, and store food. She stated once food was opened, it needed to be covered and dated. She could not say why that was important or how it might harm a resident, but stated she would report it to her manager if she saw any food that was not covered or dated in the freezer. DA A stated everyone was responsible to ensure all food was covered. She could not say if she had noticed any food in the freezer that was not properly covered and dated. In an interview on 08/07/2025 at 10:40 AM, LVN G stated that the temperature of the nourishment refrigerator should be 32 degrees. If it were out of range, she would report it to the DON, check the inside temperature control knob and adjust it. LVN G stated she would throw out any food that was not labeled and dated. LVN G stated it was important to monitor the temperature to ensure food did not go bad. Serving food to residents that was kept in a refrigerator that was out of temperature range could cause food poisoning such as e. coli. In an interview and observation on 08/07/2025 at 12:57 PM, the DON stated he thought the temperature of the inside of the nourishment refrigerator read 40 degrees earlier today; however, that was incorrect. He stated the temperature was almost 50 degrees and he would take corrective action by turning the temperature control knob in the opposite direction to see if that lowered the temperature. He was observed to leave the pudding in the fridge. In an interview on 08/07/2025 at 5:41 PM, the ADM stated that he had been trained in on how to label, date, and store food. He stated once food was opened, it needed to be sealed, labeled, and dated with the received date and open date. The ADM stated that it was the dietary manager's responsibility to ensure all food was labeled, dated, and stored properly. The ADM stated that it was important to know how long food had been opened. He also said it was important to use the food in the correct time frame to ensure quality and sanitation. He would expect food not labeled, dated, or properly sealed to be thrown away to avoid residents getting ill. The ADM stated that refrigerators should be kept at 32 degrees. The nursing staff were responsible for monitoring the temperature of the nourishment refrigerator. He stated the nourishment refrigerator held residents' food, and it was important to monitor to ensure food was kept at the proper temperature to avoid food spoiling and making the residents sick. Food should be labeled and dated. He would expect the nursing staff to notify the Assistant Director of Nursing or the DON if the temperature was out of range and to advise the residents their food needed to be disposed of. The ADM stated that the cups of pudding in the nourishment refrigerator would be thrown out. The condition of the boxes of food in the freezer on 08/05/2025 and the nourishment refrigerator temperature would not meet his expectations. Review of facility kitchen in-service trainings revealed kitchen staff were trained on food storage and supplies on 07/22/2025 and 08/06/2025 and food safety on 08/06/2025. Review of the facility policy titled Food Storage and Supplies from the Dietary Services Policy & Procedure Manual 2012 reflected: All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, and insects. Procedure: 4. Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened. 8. On perishable foods, microorganisms such as molds, yeasts, and bacteria can multiply and cause food to spoil. Spoiled foods will develop an off odor, flavor, or texture due to naturally occurring spoilage bacteria. If a food has developed such spoilage characteristics, it should not be eaten. There are two types of bacteria that can be found on food: pathogenic bacteria, which cause foodborne illness, and spoilage bacteria, which causes foods to deteriorate and develop unpleasant characteristics such as an undesirable taste or odor making the food not wholesome, but do not cause illness. Perishable foods have been processed/treated and sealed to eliminate pathogenic bacteria, but spoilage bacteria can multiply, and this is what causes the food to deteriorate in quality and taste. If perishable food items are not stored at the proper temperature,spoilage bacteria can grow faster than anticipated and food becomes spoiled and should not be served. Review of the facility policy titled Food Safety from the Dietary Services Policy & Procedure Manual 2012 reflected: We will ensure all food purchased shall be wholesome and manufactured, processed, and prepared in compliance with all State, Federal, and local laws and regulations. Food shall be handled in a safe manner. Procedure: 2. Food is to be wrapped or sealed and covered in clean containers. Opened food shall be labeled, dated, and stored properly. 4. Potentially hazardous food shall be maintained at:41 degrees F or less, or140 degrees or above. Review of the facility's undated policy titled Information sheet for Food brought into the facility for Families reflected: 4. If the resident does not have a personal refrigerator, then the facility's resident nourishment room will be used to store resident food that needs to remain chilled. This refrigerator will be cleaned by facility staff and will remain at 40 degrees or less at all times. Please be sure to label the food item with the resident's name and the date prepared. Be aware that all foods will be discarded according to Texas Food Establishment Rules for leftovers according to the date on the label or expiration date, whichever comes first This is normally within 7 days of preparation as long as the food has remained in storage at 40 degrees or less.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care that included measurable objectives and timeframes to meet the residents' medical, nursing, and mental and psychological needs that are identified in the comprehensive assessment for 2 of 10 residents (Residents #1 and #7).1. The facility failed to ensure the care plan was updated when Resident #7's code status was changed from full code to DNR on [DATE].2. The facility failed to ensure the care plan was updated when Resident #1's code status was changed from full code to DNR on [DATE].This failure could place residents at-risk of having their wishes dishonored, and of having CPR performed against their wishes.Findings included:Record review of Resident #7's admission record, dated [DATE], reflected a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (a lung disease limiting air flow from the lungs), type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar), and bipolar disorder (a mental illness that causes extreme mood swings). The advance directive listed was DNR. Record review of Resident #7's change of condition MDS, dated [DATE], reflected she had a BIMS of 11, indicating moderate cognitive impairment.Record review of Resident #7's care plan, dated [DATE], dated [DATE], reflected Resident #7 was a full code. Record review OOH revealed an Out of Hospital DNR was signed on [DATE]. Record review of Resident #7's Order Summary, dated [DATE], revealed an order Do Not Resuscitate with a start date [DATE]. Record review of Resident #1's Face sheet dated [DATE] reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included pneumonia, dysphagia pharyngoesophageal phase (inability to empty from the throat to the esophagus), hypertension (high blood pressure), dementia (memory, thinking, difficulty), history of falling, pain in shoulder, asthma, dependency on wheelchair, chronic obstructive pulmonary disease (chronic progressive lung disease), anemia (not enough healthy red blood cells), hyperlipidemia (high cholesterol), respiratory failure, kidney failure, and urinary tract infection. Record review of Resident #1's Quarterly MDS dated [DATE] revealed she had a BIMS Score of 07, indicating severe impairment. Record review of Resident #1's Care Plan dated [DATE] revealed Resident #1 was a full code. Record review of the OOH revealed an Out of Hospital DNR was signed on [DATE] and uploaded to Resident #1's medical record on [DATE].Record review revealed a doctor's order dated [DATE] was signed for a DNR directive. During an interview on [DATE] at 04:10 PM with the MDS LVN, she stated the SW was responsible for updating care plans when the advance directives change. She stated if the care plan did not align with the resident's decision for advance directives, then the resident might get CPR even though they chose DNR. During an interview on [DATE] at 04:40 PM with the SW, she stated when a resident chose to change their advance directives to DNR, then the DNR is uploaded to the electronic health record, and the care plan should be changed. She stated she was unsure if she was supposed to update the care plan or if it was the MDS LVN that was responsible. She stated if the care plan did not reflect the resident chose to be DNR then in an emergency the staff would be unaware of how to proceed and may give the resident CPR against their wishes. During an interview on [DATE] at 04:49 PM with the MR LVN, she stated when a resident chose DNR as their advance directives, then their care plan needed to be updated. She stated the facility had transitioned to new owners and was unsure who was responsible for updating the care plans. The MR LVN stated if the care plans were not updated to reflect the resident's choice for DNR then it might cause confusion in the event of an emergency, and the resident could be given CPR. During an interview on [DATE] at 05:06 PM with the DON, he stated once a resident completes the paperwork to change their code status to DNR, then the paperwork is uploaded into the electronic health record, their title bar is changed and their care plan should be updated. He stated he believed it was the MDS LVN's responsibility to change the care plan, but it could be a shared responsibility. He stated this was checked during the resident's quarterly care plan meeting. He stated if the care plan did not reflect the resident chose DNR, then the resident may be revived with CPR, and it could affect their future quality of life.During an interview on [DATE] at 05:35 PM with the ADM, he stated that once a change in advance directives was received, then it was documented in the electronic health record, the DNR form was uploaded into the chart, and the care plan was updated to reflect the resident's wishes. He stated that all changes in advance directives was reviewed in the morning meetings by management. He stated if the care plan was not updated with the resident's wishes for DNR, then the facility may go against the resident's wishes and start CPR. Record review of undated facility policy titled, Comprehensive Care Planning reflected, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following: .the right to refuse treatment.Through the care planning process, facility staff will work with the resident and his/her representative, if applicable, to understand and meet the resident's preferences, choices, and goals during their stay at the facility.Person-centered care means the facility focuses on the resident as the center of control, and supports each resident in making his or her own choices.Residents' preferences and goal may change throughout their stay, so facilities should have ongoing discussions with the resident and resident representative, if applicable, so that changes can be reflected in the comprehensive care plan.

Based on interview and record review, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing for one of two residents (Resident #4) reviewed for pressure injuries. The facility failed to ensure wound care was performed as ordered by the wound care doctor for Resident #4. Resident #4 missed 6 wound care treatments in July 2025 and August 2025. This failure could place residents at risk of improper wound management, the development of new pressure injuries, deterioration in existing pressure injuries, infection, and pain.Findings included:Record review of Resident #4's admission record, dated 08/06/2025, revealed an [AGE] year-old female, admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had diagnoses which included unspecified dementia (a disease that causes a general decline in cognitive abilities that can affect the ability to perform everyday activities, memory loss, and poor judgement), type 2 diabetes mellitus (a condition that affects the way the body processes blood sugar), hyperlipidemia (abnormally high level of fats in the blood), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and chronic obstructive pulmonary disease (a lung disease limiting air flow from the lungs).Record review of Resident #4's Quarterly MDS, dated [DATE], revealed a BIMS of 01, which indicated severe cognitive impairment. Section M (Skin Conditions) revealed she had one or more pressure ulcers/injuries.Record review of Resident #4's care plan, dated 07/17/2025 and last revised on 07/29/2025, revealed Focus: The resident has a pressure ulcer or potential for pressure ulcer development with Interventions/Tasks: Administer medications as ordered. Monitor/document for side effects and effectiveness.Record review of Resident #4's order summary, dated 08/06/2025, revealed Cleanse stage IV pressure wound to right heel wound with normal saline or wound cleanser, apply collagen and cover with calcium alginate and protective foam secured with kerlix and tape one time a day for right heel wound with an order date of 07/08/2025.Record review of Resident #4's treatment administration record for July 2025 and August 2025 revealed Resident #4 had no wound care treatment signed off on the following dates: 07/19/2025, 07/20/2025, 07/24/2025, 08/02/2025, 08/03/2025, and 08/04/2025. Record review of Resident #4's most recent wound care physician note, dated 07/29/2025, revealed Wound Progress: Improved evidenced by decreased necrotic [dead] tissue, decreased surface area.Attempted phone interview with wound care physician on 08/07/2025 at 02:23 PM, no answer, voicemail was left but no return call prior to exit.During an interview on 08/07/2025 at 03:11 PM with the WC LVN, she stated she was responsible for wound care treatments when she was scheduled to work. She stated when she is off work the charge nurses are responsible for providing wound care to the residents. The WC LVN stated wound care was signed off on the treatment administration record after completion of wound care. She stated Resident #4 had a stage IV (a pressure injury that is characterized by full-thickness tissue loss that exposes underlying muscle, tendon, or bone) pressure wound to the right heel. She stated the wound care for Resident #4 was to clean with saline/wound cleanser, the apply collagen powder, cover with calcium alginate, the secure with a foam dressing. The WC LVN stated wound care was ordered for Resident #4 to be performed daily. She stated Resident #4 had a wound care physician assess the wound on a weekly basis. She stated, after reviewing the treatment administration record, that it appeared no wound care treatments were performed on 07/19/2025, 07/20/2025, 07/24/2025, 08/02/2025, and 08/03/2025. The WC LVN stated she worked on 08/04/2025 and performed wound care but forgot to check it off on the treatment administration record. She stated she was upset after providing wound care on 08/04/2025 because she removed the same dressing that she applied on 08/01/2025. She stated the dressing she removed had her initials and the date of 08/01/2025 indicating that no wound care was provided the two days prior. The WC LVN stated she notified the DON but did not document it in the chart. She stated the wound did not show signs of deterioration from not receiving wound care over the previous two days. The WC LVN stated if wound care was not performed as ordered on a daily basis, then the wound could deteriorate or get worse. During an interview on 08/07/2025 at 04:10 PM with the MDS LVN, she stated the WC LVN was responsible for wound care during the week and the charge nurses were responsible for wound care on the weekends. She stated she thought the ADON did a weekly audit to ensure treatments and medications were administered as ordered. The MDS LVN stated it was policy to sign off on the treatment administration record once the treatment was performed. She stated if wound care was not being performed as ordered, then the wound could deteriorate even with one missed treatment. Attempted a phone interview on 08/07/2025 at 04:49 PM with the charge nurse responsible for wound care on 08/02/2025 and 08/03/2025, but no answer. A voicemail was left but a return call was not received prior to exit. During an interview on 08/07/2025 at 05:06 PM with the DON, he stated the WC LVN was responsible for wound care, but when she was not at work, then the charge nurse was responsible for providing the treatment. The DON stated he and the ADON were responsible for running an audit report to ensure treatments were being performed as ordered. He stated it is policy to sign off in the treatment administration record once the wound care had been performed. He stated the effectiveness of the wound care treatment was determined by the measurements and reports received from the wound care physician provided with their weekly visits. The DON stated the nurse that was responsible for wound care on 07/19/2025 and 07/20/2025 was no longer working at the facility. The DON stated if wound care was not done, the wound could get worse, the resident could get septic (a life-threatening medical emergency caused by the body's extreme response to an infection), or the resident could develop osteomyelitis (an infection in the bone). He stated, even a few days can make it go from good to horrible. During an interview on 08/07/2025 at 05:35 PM with the ADM, he stated the WC LVN or charge nurses were responsible for performing wound care treatments as ordered by the wound care physician. He stated he expected staff to sign off on the treatment administration record once the treatment has been performed. He stated he was unsure of the current wound care being provided to Resident #4. He stated if wound care was not performed daily as ordered then the progression of healing could be reversed, and the wound could get worse. Record review of facility policy titled Wound Treatment Management, dated 2021, revealed Policy:To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders.-Policy Explanation and Compliance Guidelines:1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change.7. Treatments will be documented on the Treatment Administration Record.

Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) (for Resident #8) to meet the needs of each resident for 1 of 1 medication storage room and 1 of 3 (hall 1 nurses' medication cart) medications cart reviewed for pharmacy services. The facility failed to ensure expired medications were removed from the medication storage room and the hall 1 nurses' medication cart on 08/07/2025. The facility failed to ensure that the narcotic count sheet accurately reflected the amount of Resident #8's phenobarbital (a controlled medication used in the treatment of seizures) stored in the hall 5 nurses' medication cart. This failure could place residents at risk of receiving an expired medication, not reaching the intended therapeutic dose, and/or adverse reactions from receiving medications past their expiration date. Findings included: 1. Record review of Resident #8's admission record, dated 08/07/2025, reflected a [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including epilepsy (a long-term neurological disorder characterized by recurrent, unprovoked seizures), cognitive communication deficit (problem with communication caused by cognition rather than a language or speech deficit), and cerebral palsy (a neurological disorder that affects body movement and muscle coordination caused by abnormal brain development or damage to the brain during pregnancy, childbirth, or shortly after birth). Record review of Resident #8's quarterly MDS, dated [DATE], reflected a BIMS was not conducted due to him rarely/never being understood. Section C - Cognitive Patterned reflected Resident #8 had memory problem with short-term and long-term memory. Record review of Resident #8's order summary, dated 08/07/2025, reflected Phenobarbital Oral Elixir 20MG/5ML (Phenobarbital) Give 15 ml via PEG-tube [a tube surgically inserted directly to the stomach for nourishment and medication administration] two times a day for seizures. An observation on 08/07/2025 at 08:26 AM of hall 5 nurses' medication cart with the WC LVN revealed a bottle of phenobarbital that was full, manufacturer label stated 473ml, 2/2 was handwritten on the top of the bottle. The bottle of phenobarbital had a prescription label for Resident #8. The narcotic count sheet revealed under the amount remaining column 1397. Record review of Resident #8's phenobarbital narcotic count sheet reflected 2 bottles of phenobarbital was received from the pharmacy on 07/17/2025 in the amount of 946 ml, but the staff member that received the medication doubled that starting amount to 1892 ml. During an interview on 08/07/2025 at 08:28 AM with the WC LVN, she stated she had just received the keys and did not count with the previous person due to being nervous about medication administration observation. She stated it appeared the staff member who received the medication doubled the amount of medication received because there were two bottles, and everyone had just subtracted the amount taken instead of counting what was there. During an observation and interview on 08/07/2025 at 08:48 AM, the DON was notified of the miscalculation and medication reconciliation (corrected medication count) with 973 ml was completed by the DON and WC LVN together. The DON stated the medication form appeared to be miscalculated due to the first incorrect calculation. He stated it was his expectation that staff count the medication in front of them and not calculate the remaining amount based off previous totals. He stated he would start an in-service for staff related to correctly counting narcotics. An observation on 08/07/2025 at 11:22 AM of the medication storage room (facility had only one) with the ADON revealed three bottles of Oyster Shell Calcium with Vitamin D 500mg-5mcg with an expiration date of 06/2025. During an interview on 08/07/2025 at 11:28 AM with the ADON, she verified the three bottles of medication (Calcium with Vitamin D) were expired. She stated all nursing staff with access to the medication room were responsible for checking for expired medications. The ADON stated there was not a specific staff member or timeline assigned for checking the medication storage room for expired medications. She stated the DON periodically checked to ensure staff were checking the medication storage room for expired medications. The ADON stated medication may lose their effectiveness if given to a resident past the expiration date. An observation on 08/07/2025 at 12:42 PM of the hall 1 nurses' medication cart with LVN G revealed one bottle of Bismuth Subsalicylate 525mg/30ml with an expiration date of 08/2024. During an interview on 08/07/2025 at 12:53 PM with LVN G, she verified the bottle of medication (Bismuth Subsalicylate) was expired. LVN G stated she had worked at the facility for 2 weeks. She stated she was unsure who was responsible for checking for expired medications on the medication carts. She also was unsure of how often the carts were checked for expired medications. LVN G stated if an expired medication was administered to a resident, then the medication may not be as effective, or the resident could develop an illness including an upset stomach. During an interview on 08/07/2025 at 03:11 PM with the WC LVN, she stated all the nurses were responsible for checking the medication storage room for expired medications, and she stated she was unsure how often the medication storage room was being checked. The WC LVN stated she was unsure if anyone verified the medication storage room was being checked for expired medications. She stated the nurses and medication aides assigned to the medication cart were responsible for checking for expired medications daily. The WC LVN stated she was unsure if anyone verified the medication carts were checked for expired medications. The WC LVN stated if an expired medication was administered to a resident, the medication may not be as effective. She stated the off-going and on-coming nurse are responsible for counting the controlled medications anytime the keys to the medication cart changed hands. She stated the resident could negatively be impacted by not counting each time the keys changed hands, because the resident may run out of medication faster than reflected on the count sheet and miss a dose. During an interview on 08/07/2025 at 04:10 PM with the MDS LVN, she stated she was unsure who or how often the medication storage room was checked for expired medications. The MDS LVN stated the nurses were responsible for checking all medication carts for expired medications, but she stated she was unsure how often the medication carts were checked. The MDS LVN stated if an expired medication was administered to a resident, the medication may not have the intended effect. She stated the charge nurse was responsible for counting the controlled medications between each shift. She stated if the medications were not counted correctly, then the resident could run out of medication sooner than expected which could possibly lead to seizures. During an interview on 08/07/2025 at 04:49 PM with the MR LVN, she stated all nursing staff with access to the medication storage room were responsible for checking the medication storage room for expired medication at least one time a month. She stated the nurses and medication aides responsible for the medication carts were responsible for checking the medication carts for expired medications weekly. The MR LVN stated if an expired medication were administered to a resident, then the resident might have an adverse reaction like, diarrhea, stomach pain, or an intolerance to the medication. She stated the nurses were responsible for counting all controlled medications at shift change. She stated she did not think that by not counting the medication accurately, it could negatively affect a resident. During an interview on 08/07/2025 at 05:06 PM with the DON, he stated he expected the central supply person and charge nurses to check the medication storage room daily for expired medications. He stated there was not a process in place for ensuring the medication storage room was checked. The DON stated he expected the nurses and medication aides to check the medication carts every shift for expired medications. He stated there was not a process in place for ensuring the medication carts were checked for expired medications. The DON stated if a resident was given an expired medication, then the resident could have an adverse reaction like anaphylaxis (an allergy to something that can cause the throat to swell and close) and it would also me a medication error. The stated he expected the charge nurses and medications aides to count the controlled medications in the medication carts each shift. He stated he sign off sheets that indicated staff counted together every other day or so. He stated if the controlled medication count sheets were not accurate then the resident might be billed for more medication than is allowed or the resident could possibly miss a dose due to lack of medication. During an interview on 08/07/2025 at 05:35 PM with the ADM, he stated he expected the nursing team to check the medication room for expired medications at least monthly. He stated he expected the nurses to check the medication carts for expired medications daily. The ADM stated the nursing administration team was responsible for verifying expired medications were removed from the medication carts weekly. The ADM stated he was unsure how administering expired medication could negatively impact a resident. He stated the nurses were responsible for counting all controlled medications in their medication cart during shift change. He stated nursing management monitored for the nurses to count the controlled medications daily. The ADM stated if the controlled medications were not counted accurately, then a resident may miss a dose of medication. Record review of facility policy titled Medication Storage in the Facility, dated 2025, revealed: Policy.Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.Procedure.13. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to the procedures for medication destruction, and reordered from the pharmacy, if a current order exits[spelling?]. Record review of facility policy titled Storage of a Controlled Substance, dated 2003, and facility policy titled Medication Storage in the Facility, dated 2025, revealed no mention counting medication.Record review of facility in-service titled Narcotic Count, dated 08/07/2025, revealed .Accurate count when receiving medication and narcotic count each shift is crucial.1. When receiving any type of controlled substances whether it is from pharmacy or an admission, two signatures are required for verification.2. Narcotic count is required at shift change or when another staff member takes over the cart at any time.

Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 of 3 (hall 1 nurse's medication cart) Nurse's medication carts reviewed. 1. The facility failed to ensure the nurses' medication cart for hall 1 was secured by a lock when it was left unattended by LVN G on 08/07/2025.These failures could place residents at risk of illness or injury due to missing medication or if unattended medication were consumed. Findings included:An observation on 08/07/2025 at 10:23 AM on hall 1 revealed the nurses' medication cart for hall 1 was left unattended and unlocked.During an interview on 08/07/2025 at 10:25 AM with LVN G, she stated she was responsible for the hall 1 nurses' medication cart that was left unlocked. She stated she forgot to lock the medication cart when she walked down hall 1. She stated leaving the medication cart unlocked could negatively impact a resident because anyone could get into the medication cart and take something they are not supposed to. During an interview on 08/07/2025 at 03:11 PM with the WC LVN, The WC LVN stated the policy of the facility was to lock the medication cart to secure it any time staff walked away from it. She stated it was the responsibility of the staff member who had the keys to the cart to lock the cart. The WC LVN stated if a medication cart were left unlocked, then a resident could get into the medications, take a medication that was not meant for them, and have an adverse reaction, or a medication may go missing and the resident might miss a dose. During an interview on 08/07/2025 at 04:10 PM with the MDS LVN, The MDS LVN stated the policy for securing the medication carts was to take the keys and lock it anytime staff walk away from the medication cart. She stated the staff member with the keys to the medication cart was responsible for ensuring it was secured when they walk away from it. She stated securing the medication carts was monitored daily during walking rounds by management staff. The MDS LVN stated a resident could take a medication that was not meant for them, or a resident could access an ointment meant for the skin and eat it. During an interview on 08/07/2025 at 04:49 PM with the MR LVN, The MR LVN stated the facility's policy was too close and lock the medication cart anytime the staff member responsible for the cart walked away from it. She stated nursing management did walking rounds two times a day and ensuring the medication carts were closed and locked was included in the rounds. The MR LVN stated, if a medication cart was left unlocked, then a resident could take a medication not meant for them and it could cause adverse reactions like dizziness and falls. During an interview on 08/07/2025 at 05:06 PM with the DON, The DON stated the policy was to lock all medication carts when left unattended. He stated it was the responsibility of the staff member who was signed off responsibility of the cart at the beginning of their shift to keep the cart locked when left unattended. He stated all staff were responsible for monitoring if a cart was left unlocked. The DON stated if a medication cart were left unlocked, then residents could take something out of the medication cart or put something in the medication cart that did not belong there. He stated, it is a serious safety issue. During an interview on 08/07/2025 at 05:35 PM with the ADM, The ADM stated it was his expectation that staff lock the medication carts anytime they walk away from it. He stated all staff monitor for the medication carts to be locked during their rounds. The ADM stated, if a medication cart were left unlocked, then there is a possibility a resident could get into the medication cart and get something that is not theirs and take it, and that could lead to side effects. Record review of facility policy titled Medication Storage in the Facility, dated 2025, revealed Policy.Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.Procedure.2. Only licensed nurses, the Consultant Pharmacist, and those lawfully authorized to administer medications (e.g., medication aides) are allowed unsupervised access to medications. Medication rooms, carts, and medication supplies are locked or attended to by persons with authorized access.

Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of three residents reviewed for quality of care. The facility failed to complete an accurate skin assessment on Resident #1 on 07/17/25 which did not include multiple red small scratches underneath both of her eyes. This failure could place residents at risk of skin integrity issues not being addressed, infection, and hospitalization. Findings included:Review of Resident #1's undated face sheet reflected [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including cognitive communication deficit, history of falling, and dementia. Review of Resident #1's quarterly MDS assessment, dated 05/07/25, reflected a BIMS score of 99, indicating she was unable to complete the interview due to her severe cognitive deficit. Section M (Skin conditions) reflected she was at risk of developing pressure ulcers/injuries. Review of Resident #1's quarterly care plan, dated 04/29/25, reflected she had a self-care deficit related to impaired cognition/dementia with an intervention of observing her skin for alterations in skin integrity. Review of Resident #1's Weekly Skin Assessment, dated 07/17/25 at 9:03 AM and documented by the TN, reflected she had no new skin integrity issues.Observation on 7/17/25 at 9:56 AM revealed Resident #1 in her wheelchair in the hallway. She was not able to be interviewed. She had multiple small red scratch-like marks under each eye.During an observation and interview on 07/17/25 at 10:34 AM, this surveyor brought LVN A to Resident #1 and asked what she saw on her face. She stated there appeared to be little scratch marks under her eyes. She stated she would expect to see them on a skin assessment because anything on the resident such as redness, bruising, or open skin should be documented.During an interview on 07/17/25 at 11:12 AM, the TN stated she completed weekly skin assessments on the residents. She stated she did complete Resident #1's assessment that morning and did not see any skin integrity issues. She stated she had been shown Resident #1's face by LVN A (prior to the interview). She stated she normally would not document something like the teeny openings on her face. She stated she normally only documented something she would need to treat, such as skin tears or open areas. During an interview on 07/17/25 at 11:52 AM, the DON stated skin assessment should include a head-to-toe observation. He stated skin integrity issues he would expect to be on a skin assessment would be redness, wounds, open areas, excoriation, and any abnormalities. He stated he would expect scratches to be documented because they were a break in the skin and could turn into something else. He stated the importance for accurate skin assessments was to ensure the nurses were ensuring skin issues were not worsening. Review of the facility's Skin Assessment Policy, dated 2021, reflected the following: It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter.Note any skin conditions such as redness, bruising, rashes, blisters, skin tears, open areas, ulcers, and lesions.

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect resulted in bodily injury, to other officials (including the State Agency) for 4 of 6 residents (Resident #1, Resident #2, Resident #3 and Resident #4) reviewed for abuse and neglect. 1. The facility failed to report to the State Agency an incident that involved Resident #1 on 05/25/2025 within the allotted timeframe. 2. The facility failed to report to the State Agency an incident that involved Resident #2 and Resident #3 on 04/06/2025. 3. The facility failed to report to the State Agency after x-ray results revealed Resident #4 sustained a fracture after a fall on 03/31/2025 within the allotted timeframe. This failure could place residents at risk for harm to include physical abuse, a diminished quality of life, and psychosocial harm. Findings include: 1. Review of Resident #1 face sheet dated 05/28/2025 reflected a [AGE] year-old man admitted on [DATE] with diagnoses of unspecified dementia (cognitive functioning severe enough to affect daily life where type cannot be determined), depression (mood disorder characterized by persistent sadness), other specified arthritis (multiple sites) (inflammation in multiple joints), primary generalized osteoarthritis (breakdown of cartilage in multiple joints), Spondylosis (ongoing wear and wear on spinal joints and disks), and essential hypertension (high blood pressure). Review of Resident #1 admission MDS dated [DATE] reflected a BIMS score of 2 which indicated severe cognitive impairment. Further review reflected Resident #1 had inattention and had difficulty focusing and being easily distractible. Review of Resident #1 care plan dated 05/22/2025 reflected Resident #1 had little, or awareness of safety or boundaries related to other's personal space and wandered within his living space. Further review revealed care plan dated 05/27/2025 reflected Resident #1 had behaviors that included physical aggression. Review of incident report dated 05/25/2025 reflected an incident occurred between Resident #1 and a FM in which Resident #1 struck the FM and FM struck Resident #1 that resulted in bruising to Resident #1's face. Further review reflected the incident occurred on 05/25/2025. Review of TULIP intake submission reflected the facility first learned of the incident on 05/25/2025 at 6:00 PM but the report was not submitted until 05/26/2025. Review of intake email from the ADM reflected submission was sent into the state agency on 05/26/2025 at 3:58 PM, and not within two hours of incident despite Resident #1 suffering from facial bruising. A telephone interview was attempted to LVN B on 05/28/2025 at 12:44 PM, but there was no answer. During an interview on 05/28/2025 at 1:14 PM, the MCD stated that she was called by LVN B that an incident occurred and involved Resident #1. The MCD stated that she contacted the DON and ADM immediately after speaking with LVN B. During an interview on 05/28/2025 at 1:27 PM, the ADM stated he was made aware of the incident with Resident #1 on 05/25/2025 after 4:00 PM and before 5:00 PM. The ADM stated that LVN B contacted him and LCD reached out as well. The ADM stated that it was reported there was an altercation between FM and Resident #1. The ADM stated that Resident #1's RP was notified as well as the staff that were working to assess and separate FM and Resident #1. The ADM stated that all other residents in memory care were assessed, and a police report was made. The ADM stated that in order to protect other residents, Resident #1 was placed on 1:1 supervision and FM was asked to leave the building and instructed that he was not allowed inside the building. The ADM stated he had a discussions with FM via telephone on 05/27/2025 that visitation could be held outside and would be supervised. The ADM stated FM was informed he was not allowed back in the building at this time in order to protect all the residents. The ADM stated FM was confused initially and FM believed his (FM) actions were justified. The ADM stated there were no concerns with FM's actions or behaviors until 05/25/2025. The ADM stated that prior to the incident Resident #1 had no behavioral concerns or physical aggression prior to the incident. The ADM stated Resident #1 would stay on 1:1 supervision for his safety and the safety of other residents. 2. Review of Resident #2's face sheet dated 05/28/2025 reflected a [AGE] year-old man admitted on [DATE] and discharged on 04/13/2025 with diagnoses of diagnoses of idiopathic epilepsy and epileptic syndromes (group of syndromes characterized by seizures without identified brain abnormalities), chronic pain syndrome (pain lasting longer than three to six months), other specified disorders of the brain (wide range of brain conditions), and dysphagia (difficulty swallowing). Review of Resident #2's discharge MDS dated [DATE] reflected no BIMS score was not completed due to Resident #2 discharged from the facility. Further review reflected there was no physical symptoms directed towards others in the 7 days prior to the assessment. Review of Resident #2's care plan dated 03/06/2025 reflected he had a physical functioning deficit with transfers and required assistance. Interventions reflected to use a Hoyer with transfers. There were no behaviors noted in Resident 2's care plan. Review of skin assessment dated [DATE] for Resident #2 reflected no bruising or open areas noted, there were no reddened areas, open areas (cuts/tears) found. Review of Resident #3 face sheet dated 05/28/2025 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of unspecified dementia (cognitive functioning severe enough to affect daily life where type cannot be determined), other abnormalities of gait and mobility (clumsy, unsteady movements), other lack of coordination (wide range of conditions where there is a disruption in the body's ability to coordinate movements), and unspecified glaucoma (condition of fluid buildup in the eye tat can cause vision loss or blindness). Review of Resident #3 quarterly MDS dated [DATE] reflected Resident #3 had a BIMS score of 7 which indicated severe cognitive impairment. Further review reflected Resident #3 had no physician behavioral symptoms directed toward others 7 days prior to the assessment. Review of Resident #3's care plan dated 04/19/2025 reflected Resident #3 had little or no awareness of safety or no boundaries and went into other resident's rooms. Interventions reflected to re-direct Resident #3 to his room to rummage through items safely, invite him to participate in activities and offer opportunities for social interaction. Review of Resident #3's care plan dated 06/05/2025 reflected he had behaviors which included being aggressive with others. Interventions included help residents avoid situations or people that are upsetting and attempt interventions before behaviors begin. Review of incident report dated 04/06/2025 reflected RN A was outside of Resident #3's room and he kicked open Resident #2's door and entered the doorway of Resident #2's room. Resident #2 asked Resident #3 to leave his room and Resident #2 stated before I kick your [Resident #3's] ass. Resident #3 responded do it and Resident #2 punched Resident #3 in the face. Further review reflected DON, family and NP were notified and RN A separated the residents. Incident report reflected no injuries were noted on either resident. Further review reflected Resident #3 was confused and wandered into other residents' rooms. Review of investigation summary by the ADM dated 04/07/2025 reflected nursing reported an incident that occurred on 04/06/2025 between Resident #2 and Resident #3. Further review reflected Resident #3 wandered into Resident #2's room and a dispute was heard by nursing and intervened and separated both residents. Resident #3 and Resident #2 lived on separate halls and were assessed with no signs of bruising or marks. The ADM stated he spoke with Resident #2 and he stated there was an argument and Resident #3 did not recall. The ADM stated there were no concerns or lasting effects. During an interview on 05/28/2025 at 4:19 PM, RN A stated that Resident #3 tended to wander door to door and kicked the doors open with his foot to other resident rooms. RN A stated she was charting and Resident #3 kicked open Resident #2's door. RN A stated Resident #2 told Resident #3 to quit and get away from the door. RN A stated when she turned she saw Resident #2 was at the door and hit Resident #3. RN A stated that she reported it to the physician, family member and reported it to the DON. RN A stated that she assessed each resident and completed a head-to-toe assessment and there were no injuries. RN A stated that Resident #3 was the only resident who was hit. RN A stated the residents were separated and removed from the area. RN A stated that any resident-to-resident incidents should be reported to the DON and the ADM. RN A stated looking back she saw that resident-to-resident incident could have been abuse and neglect. RN A stated at the time she thought it was just an incident and only did an incident report. Review of TULIP on 05/28/2025 reflected no intakes were submitted by the facility related to incident between Resident #2 and Resident #3. During an interview on 05/28/2025 at 4:33 PM, DON stated the incident occurred prior to his role as DON at the facility. DON stated that all emergencies were reported to him and the ADM. During an interview on 05/28/2025 at 5:07 PM, the ADM stated that he was made aware of the incident with Resident #3 and Resident #2 but could not recall when exactly. The ADM stated that he spoke with nursing and it was stated Resident #3 was going down the hallway and Resident #2 stated Resident #3 to get out of the room. The ADM stated nursing intervened and no injuries were found. The ADM stated he spoke with both residents the next day and they had no concerns. The ADM stated he was not able to confirm Resident #2 struck Resident #3. The ADM stated an investigation was conducted but he was unable to confirm that Resident #2 stuck Resident #3 and he understood from RN A that a commotion was overheard. The ADM stated staff are educated on abuse and neglect at least three or four times a year. During an interview on 06/05/2025 at 12:06 PM, the ADM stated that prior to the incident on 04/06/2025 Resident #3 wandered. The ADM stated Resident #3 would be up and active in activities and during that time he would have an eye on him. The ADM stated that interventions included redirection, trying to keep his mind stimulated and offered activities. The ADM stated Resident #3 would also visit his ex-spouse who was also a resident at the facility and that he enjoyed eating meals with her. The ADM stated that prior to the incident there was nothing reported that Resident #3 had wandered into other residents' rooms just that he wandered in general. The ADM stated potential harm for increased wandering behaviors was that other residents could be startled. 3. Review of Resident #4's face sheet dated 05/28/2025 reflected Resident #4 was admitted on [DATE] and discharged on 04/02/2025 as a hospice respite resident with diagnoses of senile degermation of brain (various neurological disorders that cause ongoing decline in cognitive functioning, memory and reason), essential hypertension (high blood pressure) and pain unspecified (discomfort that does not have a clear cause or a particular area of the body). Review of Resident #4's discharge MDS dated [DATE] reflected Resident #4 was unable to complete the BIMS assessment. Further review reflected Resident #4 had a fall since admission and a major injury from 1 fall. Review of Resident #4's progress note by RN A dated 03/30/2025 reflected Resident #4 was found on floor in his room and had complaints of pain to right hip and an order was received for an x-ray. Review of incident report by RN A dated 03/30/2025 with a time of 7:30 PM reflected Resident #4 was found in his room on the floor. Resident #4 was confused and unable to express how he got onto the floor. Vitals were taken and on-call NP was notified. There were no injuries observed at the time of the incident. Resident #4 had complaints of right hip pain. Pre-disposing factors included non-compliance with care. Review of provider investigation reported dated 04/07/2025 reflected incident was reported to HHSC on 04/02/2025 despite x-ray results being returned to the facility on [DATE]. Review of investigation summary reflected it was unable to determine how the fall occurred and hospice opted to treat in-house. Review of Resident #4's orders reflected he had an order to monitor for pain every shift dated 03/31/2025. Review of Resident #4's March and April 2025 MARS reflected there was no pain indicated during any shift between 03/31/2025 and 04/02/2025. Review of Resident #4's physician orders dated 03/28/2025 reflected he had an order for morphine sulfate .25 ml to give every hour as needed for mild pain and 1 mg to give every hour as needed for severe pain. Resident #4 was administered .25 m1 of morphine one time on 03/30/2025. Review of Resident #4's radiology results report reflected report date was 03/31/2025 at 1:06 AM, with examination date on 03/30/2025 at 10:33 PM. Findings reflected right sub capital impaction fracture with minimal callus and mild displacement. Findings reflected mild degenerative changes were seen. During an interview on 05/28/2025 at 4:19 PM, RN A did not recall Resident #4 or his fall. RN A stated fall interventions included to have the bed in a low position. RN A stated if an x-ray returned with a fracture, family, physician and DON were made aware of any findings. During an interview on 05/28/2025 at 4:36 PM, CNA G stated that if she found a resident had a fall she would let the nurse know and make sure the resident was safe. CNA G stated that residents were not to be moved after a fall until they were assessed. CNA G stated that she prevented falls with residents by clearing clutter, providing resident with a walker if needed and ensure they had proper footwear. During an interview on 05/28/2025 at 4:42 PM, CNA H stated that fall prevention interventions included ensuring a resident had a low bed, a fall mat if the nurse let them know they needed one. During an interview on 05/28/2025 at 4:49 PM, LVN I stated fall interventions included signs to call for help and educating a resident to use the call light for assistance. LVN I stated any x-ray that reveled a fracture would be reported to the doctor or on-call NP, ADM, DON and RP right away. During an interview with 05/28/2025 at 4:55 PM, LVN J stated that after a fall a resident was assessed for injuries and then assisted to the bed or chair. LVN J stated that interventions for falls included keeps residents within eyesight, frequent rounding and to have bed in a low position. LVN J stated that an x-ray that revealed a fracture would be reported to the doctor and DON right away. During an interview on 05/28/2025 at 5:07 PM, the ADM stated after he was made aware of an allegation of abuse or neglect he had 24 hours to report it to the state agency. The ADM stated he expected staff to report any resident-to-resident altercation. The ADM stated that he was made aware of the incident with Resident #2 and Resident #3 and that he spoke with RN A and that she reported Resident #2 stated for Resident #3 to get out of Resident #2's room but nursing intervened and confirmed there were no injuries. The ADM stated he spoke with both Resident #2 and Resident #3 the following day (04/07/2025) and he was unable to confirm that Resident #2 struck Resident #3 and neither resident was able to recall the incident. The ADM stated that the DON at the time did speak with RN B and that RN B stated she overheard the two residents but was out in the hallway. The ADM stated that he did review the incident report for Resident #2 and Resident #3, but ADM was unable to confirm the altercation had occurred and that it was just a commotion. The ADM stated that an investigation was initiated, and he spoke with both residents. The ADM stated only incidents that involved immediate danger were reported within a two hour time frame. The ADM stated he was made aware of the results of Resident #4's x-ray midmorning on 03/31/2025 and that the results were returned late 03/31/2025. The ADM stated that there was no specific facility policy on reporting and that information was included in the facility abuse policy. Review of facility in-service dated 03/31/2025 reflected topic was reviewed over preventing falls with all staff. Review of facility in-service dated 03/31/2025 reflected program content of Elder Justice Act/ Resident Rights/ Reporting guidelines was covered with all staff. In-service included facility policy titled Elder Justice Act Reporting dated 03/13/2020 which reflected employee reporting requirements included employes to report reasonable suspicion of a crime to the state agency within a designated time frame. Further review reflected if the reportable event results in serious bodily injury, the staff member shall report the suspicion immediately, but not later than two (2) hours after forming the suspicion. If t he reportable event does not result in serious bodily injury, the staff member shall report the suspicion not later than 24 hours after forming the suspicion. Review of facility policy titled Abuse, Neglect, Misappropriation, Exploitation Policy dated 01/219 reflected the purpose of the policy was to prevent abuse, neglect and exploitation and to ensure reporting and investigation of alleged violations (which included injuries of unknown source) in accordance with state laws. The policy defined injury of unknown source as source of the injury was not observed or could not be explained by the resident and the injury was suspicious because of the extent of the injury. Reporting and response section of the policy reflected all violations will be reported to the administrator immediately and immediately report all alleged violations to the administrator, state agency and/or law enforcement within specified timeframes. Specified time frames as indicated in policy reflected allegations with serious bodily injury should be reported immediately but not later than 2 hours after forming the suspicion. Allegations with no serious bodily injury should be reported no later than 24 hours.

Based on interview and record review, the facility failed to ensure the residents had the right to be free from physical abuse and neglect for two (Resident #1 and Resident #3) of five residents reviewed for abuse and neglect. 1. The facility failed to ensure Resident #1 was not physically abused by FM on 05/25/2025 when FM hit Resident #1 after Resident #1 became agitated and hit the FM. 2. The facility failed to protect Resident #3 from physical abuse by Resident #2. Resident #3 wandered into Resident #2's room and was hit by Resident #2 after Resident #2 stated I'm going to hit you. These failures placed residents at risk of abuse, neglect, trauma, and psychosocial harm. Findings include: 1. Review of Resident #1's face sheet dated 05/28/2025 reflected a [AGE] year-old man admitted on [DATE] with diagnoses of unspecified dementia (cognitive functioning severe enough to affect daily life where type cannot be determined), depression (mood disorder characterized by persistent sadness), other specified arthritis (multiple sites) (inflammation in multiple joints), primary generalized osteoarthritis (breakdown of cartilage in multiple joints), Spondylosis (ongoing wear and wear on spinal joints and disks), and essential hypertension (high blood pressure). Review of Resident #1's admission MDS dated [DATE] reflected a BIMS score of 2 which indicated severe cognitive impairment. Further review reflected Resident #1 had inattention and had difficulty focusing and being easily distractible. Review of Resident #1's care plan dated 05/22/2025 reflected Resident #1 had little, or awareness of safety or boundaries related to other's personal space and wandered within his living space interventions included invite Resident #1 to participate in activities. Further review revealed care plan dated 05/27/2025 reflected Resident #1 had behaviors that included physical aggression. Review of incident report dated 05/25/2025 by LVN B reflected there was an altercation between Resident #1 and FM. When LVN B walked onto the memory care unit, Resident #1 was pacing and assessed for injury. LVN B spoke with FM and stated that Resident #1 was sitting in a chair beside Resident #5. FM told Resident #1 he had to leave and Resident #1 stood up and said Resident #5 was his (Resident #1's) wife. Resident #1 then punched FM twice in the face. FM punched Resident #1 in the cheek in self-defense. NP was notified, DON, ADM and Resident #1's RP. Review of police report dated 05/25/2025 reflected incident was reported at 5:43 PM. Review reflected police spoke with FM and FM indicated that he went to visit Resident #5 and when FM entered Resident #5's room, Resident #1 was there. FM stated Resident #1 became confrontational and believed Resident #5 was his wife. FM claimed Resident #1 punched FM in the face twice and FM punched Resident #1 back and knocked him to the ground in self-defense. FM declined to press charges and a small mark was observed on FM right cheek. Further review reflected Resident #1 wandered the hallway and swelling was observed with band-aid over Resident #1's left cheek. Police officer attempted to speak with Resident #1 and appeared not fully aware or did not recall the incident. Observation on 05/28/2025 at 10:46 AM, revealed Resident #1 was asleep in his room on his bed. Resident #1 was observed with bruising around his left eye that appeared dark purple. Observation on 05/28/2025 at 11:46 AM, revealed Resident #5 no longer resided on the memory care unit and was non-verbal and non-ambulatory. Observation and interview on 05/28/2025 at 4:41 PM, revealed Resident #1 sitting in his room with 1:1 supervision. Resident #1 stated his eye was fine and stated peanut butter stuff caused the bruise. During an interview on 05/28/2025 at 11:39 PM, CNA E stated she was not at work when the incident with Resident #1 occurred. CNA E stated that Resident #1 appeared the same since he admitted to the facility and had not noticed any changes or pain. CNA E stated she never had concerns with FM's behavior during visits to the facility and he always appeared calm. During an interview on 05/28/2025 at 11:42 AM, CNA F stated that she worked yesterday (05/27/2025) and both yesterday and today (05/28/2025) she was to remain 1:1 with Resident #1. CNA F stated that she was required to keep Resident #1 within eyesight at all times. CNA F stated there have been no issues with his behavior and that she redirected him if he went to another resident's room. CNA F stated that she had not noted any changes in Resident #1 and that his appetite has also remained the same. During an interview on 05/28/2025 at 12:02 PM, CNA C stated that she worked on 05/25/2025. CNA C stated that she started to gather residents for dinner and she asked Resident #1 to make his way to the dining room, but he stayed on the hall. CNA C stated this was before 5:00 pm which was dinner time. CNA C stated that Resident #1 sat in a chair next to Resident #5's bed and rubbed her face and Resident #1 recognized Resident #5 as a relative. CNA C stated she asked Resident #1 to leave the room and he became agitated and she attempted to redirect him, but was not successful. CNA C stated that she left to get LVN B and as she went to do so FM arrived to visit Resident #5. CNA C stated that FM asked Resident #1 to leave the room and Resident #1 stated no this is my dad. CNA C stated when she returned Resident #1 was near a medication cart and had blood on his face and FM came from Resident #5's room. CNA C stated when Resident #1 first walked up he stated two guys beat me up and after ice was applied Resident #1 stated he fell off a train. CNA C stated that FM appeared calm and did not yell and did not sound aggressive and apologized when he spoke with LVN B. CNA C stated that Resident #1 did not recall the event after it occurred and ate 100% of his dinner that evening and had no additional incidents the remainder of her shift. CNA C stated Resident #1 remained on 1:1 the remainder of her shift. During an interview on 05/28/2025 at 1:01 PM, the DON stated that he was made aware of the incident with Resident #1 and FM on Sunday (05/25/2025) when MCD called. The DON stated he instructed MCD to place Resident #1 on 1:1. The DON stated NP ordered a facial x-ray and results were pending. The DON stated the police were called and FM visited supervised and outside the memory care unit. The DON stated that no concerns with FM had been observed or concerns regarding his behavior and he was usually very quiet. The DON stated that there had been no behaviors reported by Resident #1 prior to the incident. The DON stated that Resident #1 wandered throughout the memory care unit and had not had any outburst previously. During an interview on 05/28/2025 at 1:14 PM, the MCD stated that she was called by LVN B and informed that an altercation occurred between Resident #1 and FM on 05/25/2025. The MCD stated that she contacted the DON and ADM immediately after speaking with LVN B. The MCD stated she instructed CNA C and LVN B to remain with Resident #1. The MCD stated she interviewed FM and he stated that he found Resident #1 sitting in Resident #5's room. The MCD stated that FM reported that Resident #1 swung at FM so FM swung back at Resident #1 in reaction. The MCD called the police to make a report and stated the DON instructed MCD to ask FM to leave the facility. The MCD stated that prior to the incident FM would visit from out of state and would visit during meals to feed Resident #5. The MCD described FM's demeanor as calm, respectful and stated he often brought staff food. The MCD denied that FM was harsh or aggressive prior to the incident. The MCD stated that FM was instructed he could not enter the facility and visits had to occur with supervision. The MCD stated that Resident #1 was placed on 1:1 and a staff member was asked to stay on the shift later and remain on 1:1 with Resident #1. MCD stated that Resident #1 had not been physically aggressive or have outburst prior to the incident. MCD stated Resident #1 usually wandered. During an interview on 05/28/2025 at 1:27 PM, the ADM stated he was made aware of the incident with Resident #1 on 05/25/2025 after 4:00 PM and before 5:00 PM. The ADM stated that LVN B contacted him and LCD reached out as well. The ADM stated that it was reported there was an altercation between FM and Resident #1. The ADM stated that Resident #1's RP was notified as well as the staff that was working to assess and separate FM and Resident #1. The ADM stated that all other residents in memory care was assessed, and a police report was made. The ADM stated that in order to protect other residents, Resident #1 was placed on 1:1 supervision and FM was asked to leave the building and instructed that he was not allowed inside the building. The ADM stated he had a discussion with FM via telephone on 05/27/2025 that visitation could be held outside and would be supervised. The ADM stated FM was informed he was not allowed back in the building at this time in order to protect all the residents. The ADM stated the FM was confused initially and FM believed his (FM) actions were justified. The ADM stated there was no concerns with FM's actions or behaviors until 05/25/2025. The ADM stated that prior to the incident Resident #1 had no behavioral concerns or physical aggression prior to the incident. The ADM stated Resident #1 would stay on 1:1 supervision for his safety and the safety of other residents. During an interview on 05/28/2025 at 4:36 PM, CNA G stated she did not work during the incident with FM and Resident #1. CNA G stated that physical abuse included hitting, slapping or punching. CNA G stated that any suspicious or witnessed abuse would be reported to the abuse coordinator who was the ADM. CNA G stated that Resident #1 had to be redirected constantly and wandered into other residents' rooms. During an interview on 05/28/2025 at 4:42 PM, CNA H stated she was on 1:1 with Resident #1 and he just woke up. CNA H stated any incidents that involved a family member to resident would be reported to the charge nurse and ADM. CNA H stated physical abuse was hitting someone or being aggressive. During an interview on 058/28/2025 at 4:55 PM, LVN J stated that an example of physical abuse included hitting or scratching of any kind and would be reported immediately to the ADM and DON and potentially police after the resident was separated. A telephone interview was attempted to LVN B on 05/28/2025 at 12:44 PM, and 06/05/2025 at 12:02 PM, there was no answer. During an interview on 06/11/2025 at 10:01 AM, FM stated that he arrived at the facility on 05/25/2025 it was around 4:00 PM. FM stated that he went to visit Resident #5. FM stated CNA C was at the end of the hall near Resident #5's room and heard CNA C tell Resident #1 that is not your room, come on. FM stated that Resident #1 sat next to Resident #5's bed in a chair and Resident #1 patted Resident #5's head. FM stated that he told Resident #1 that was not his room and Resident #1 was going to have to leave. FM stated Resident #1 jumped up and said you stupid ass this is my wife. FM stated he turned to look for CNA C and Resident #1 hit FM and kicked him in the shin and knocked FM on the floor. FM stated that Resident #1 caused FM's glasses to bend. FM stated he subdued Resident #1 and stated he hit Resident #1. FM stated Resident #1 hit FM and did not back down so FM hit Resident #1. FM stated that Resident #1 then left the room. FM stated he was unsure if CNA C witnessed the incident but stated when he looked around he did not see anyone. FM stated he hit Resident #1 once and Resident #1 fell to the ground and he held Resident #1 because Resident #1 still tried to hit FM. FM stated when Resident #1 relaxed, FM let him up and stated he held him down for about 20-30 seconds. FM stated he reported that Resident #1 hit FM twice to staff and the police. FM stated that Resident #5 had been a resident at the facility since 2016 and he was informed he could only visit Resident #5 outside the facility. FM stated he received a statement from ADM about the visitation restrictions and it was to be ongoing with no end date. FM stated he was not allowed to enter the facility at all and that included the common area. FM stated that he did nothing wrong. FM stated that the day prior to the incident Resident #1 had entered Resident #5's room and touched Resident #5's roommate's feet and then left. Review of in-service dated 05/08/2025 with topic of dealing with aggressive behaviors was completed with all staff and included tips for working with residents who had dementia/Alzheimer's. Review of in-service dated 05/28/2025 completed with staff reflected training was reviewed with the topic of current restricted visitation and 1:1 care. FM was not allowed to visit Resident #5 without supervision and needed to visit outside away from other / minimal residents with nursing team to supervise. Resident #1 was currently on 1:1 supervision until IDT concluded it was safe to discontinue. Review of safety surveys completed with 9 residents dated 05/28/2025 reflected there were no concerns noted from additional residents interviewed. Review of total body skin and body assessment conducted with 11 residents in the memory care unit dated 05/27/2025 reflected there were no new wounds observed. Review of 9 staff questionnaire dated 05/28/2025 reflected staff were aware of who to report abuse to, changes such as a bruise or cut on a resident and to report any incident. Review of letter addressed to FM from ADM dated 05/28/2025 reflected that due to the incident on 05/25/2025, FM was not allowed to enter the facility and any visitation with Resident #5 required supervision outside of he facility. The letter reflected that the facility had a responsibility to assure the residents were safe and supervised visitation was to assure no other resident and the potential of any possible harm. Review of in-service dated 05/26/2025 reflected training was reviewed with staff over abuse policy, report guidelines, resident rights. During an interview on 06/05/2025 at 12:06 PM, the ADM stated that a written letter was going to be sent to FM, but the facility's legal team had not approved it yet. Review of in-service dated 05/26/2025 reflected training was reviewed with staff over abuse policy, report guidelines, resident rights. 2. Review of Resident #2 face sheet dated 05/28/2025 reflected a [AGE] year-old man admitted on [DATE] and discharged on 04/13/2025 with diagnoses of idiopathic epilepsy and epileptic syndromes (group of syndromes characterized by seizures without identified brain abnormalities), chronic pain syndrome (pain lasting longer than three to six months), other specified disorders of the brain (wide range of brain conditions), and dysphagia (difficulty swallowing). Review of Resident #2's discharge MDS dated [DATE] reflected no BIMS score was completed due to Resident #2 discharged from the facility. Further review reflected there was no physical symptoms directed towards others in the 7 days prior to the assessment. Review of Resident #2's care plan dated 03/06/2025 reflected he had a physical functioning deficit with transfers and required assistance. Interventions reflected to use a Hoyer with transfers. There were no behaviors noted in Resident #2's care plan. Review of skin assessment dated [DATE] for Resident #2 reflected no bruising or open areas noted, there were no reddened areas, open areas (cuts/tears) found. Review of Resident #3 face sheet dated 05/28/2025 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of unspecified dementia (cognitive functioning severe enough to affect daily life where type cannot be determined), other abnormalities of gait and mobility (clumsy, unsteady movements), other lack of coordination (wide range of conditions where there is a disruption in the body's ability to coordinate movements), and unspecified glaucoma (condition of fluid buildup in the eye that can cause vision loss or blindness). Review of Resident #3's quarterly MDS dated [DATE] reflected Resident #3 had a BIMS score of 7 which indicated severe cognitive impairment. Further review reflected Resident #3 had no physician behavioral symptoms directed toward others 7 days prior to the assessment. Review of Resident #3's care plan dated 04/19/2025 reflected Resident #3 had little or no awareness of safety or no boundaries and went into other resident's rooms. Interventions reflected to re-direct Resident #3 to his room to rummage through items safely, invite him to participate in activities and offer opportunities for social interaction. Review of Resident #3's care plan dated 06/05/2025 reflected he had behaviors which included being aggressive with others. Interventions included help residents avoid situations or people that are upsetting and attempt interventions before behaviors begin. Review of skin assessment dated [DATE] for Resident #3 reflected no bruising or open areas noted, there were no reddened areas, open areas (cuts/tears) found. During an interview on 05/28/2025 at 4:48 PM, Resident #3 stated he did not recall any incident with another resident. Resident #3 stated he felt safe at the facility. Resident was observed laying in bed in his room. Review of surveys completed with 9 residents date 04/07/2025 reflected there were no concerns noted from any resident and they were aware of who the abuse prevention coordinator was. Review of body audit's completed with 28 residents dated 04/08/2025 through 04/10/2025 reflected there were no suspicious alterations in skin found. Review of incident report dated 04/06/2025 with a time of 10:00 AM reflected RN A was outside of Resident #3's room and he kicked open Resident #2's door and entered the doorway of Resident #2's room. Resident #2 asked Resident #3 to leave his room and Resident #2 stated before I kick your [Resident #3's] ass. Resident #3 responded do it and Resident #2 punched Resident #3 in the face. Further review reflected DON, family and NP were notified and RN A separated the residents. Incident report reflected no injuries were noted on either resident. Further review reflected Resident #3 was confused and wandered into other residents' rooms. Review of investigation summary by ADM dated 04/07/2025 reflected nursing reported an incident that occurred on 04/06/2025 between Resident #2 and Resident #3. Further review reflected Resident #3 wandered into Resident #2's room and a dispute was heard by nursing and intervened and separated both residents. Resident #3 and Resident #2 lived on separate halls and were assessed with no signs of bruising or marks. ADM stated he spoke with Resident #2 and he stated there was an argument and Resident #3 did not recall. ADM stated there were no concerns or lasting effects. Review of 10 staff questionnaires dated 04/07/2025 reflected staff were aware of who to report abuse to, changes such as a bruise or cut on a resident and to report any incident. Review of statement dated 04/06/2025 by CNA K reflected she was writing to report an incident that occurred that involved Resident #2 and Resident #3. CNA K wrote that when she was in the hallway after lunch she observed Resident #3 roaming and entered the room of Resident #2. CNA K's statement reflected Resident #3 proceeded to kick the door and directed a verbal threat at Resident #2 that Resident #3 was going to hit Resident #2. CNA K stated she did not witness Resident #3 strike Resident #2 but she did hear Resident #2 said you hit me upon the nurses entry to the room. During an interview on 05/28/2025 at 4:19 PM, RN A stated that Resident #3 tended to wander door to door and kicked the doors open with his foot to other resident rooms. RN A stated she was charting and Resident #3 kicked open Resident #2's door. RN A stated Resident #2 told Resident #3 to quit and get away from the door. RN A stated when she turned she saw Resident #2 was at the door and hit Resident #3. RN A stated that she reported it to the physician, family member and reported it to the DON. RN A stated that she assessed each resident and completed a head-to-toe assessment and there were no injuries. RN A stated that Resident #3 was the only resident who was hit. RN A stated the residents was separated and removed from the area. RN A stated that any resident-to-resident incidents should be reported to the DON and the ADM. RN A stated looking back she saw that resident-to-resident incident could have been abuse and neglect. RN A stated at the time she thought it was just an incident and only did an incident report. During an interview on 05/28/2025 at 4:33 PM, the DON stated the incident occurred prior to his role as DON at the facility. The DON stated that all emergencies were reported to him and the ADM. During an interview on 05/28/2025 at 4:36 PM, CNA G stated if she observed an incident between two residents, would let the nurse know what was going on. CNA G stated that physical abuse included hitting, slapping or punch . CNA G stated that any suspicious or witnessed abuse would be reported to the abuse coordinator who was the ADM. During an interview on 05/28/2025 at 4:49 PM, LVN I stated that for incidents that involved residents she would separate the individuals and ask someone to assist . LVN I stated she would assess for any injuries and notify the ADM, MD, RP, and DON. LVN I stated that physical abuse was pulling, tugging, or being rough with a resident. LVN I stated any abuse or suspicion of abuse would be reported to the DON as soon as it occurred. During an interview on 05/28/2025 at 5:07 PM, the ADM stated that he was made aware of the incident with Resident #3 and Resident #2. ADM stated that he spoke with nursing and it was stated Resident #3 was going down the hallway and Resident #2 stated for Resident #3 to get out of the room. The ADM stated nursing intervened and no injuries were found. The ADM stated he spoke with both residents the next day and they had no concerns. The ADM stated he was not able to confirm Resident #2 struck Resident #3. The ADM stated an investigation was conducted but he was unable to confirm that Resident #2 stuck Resident #3 and he understood from RN A that a commotion was overheard. The ADM stated staff are educated on abuse and neglect at least three or four times a year. During an interview on 06/05/2025 at 11:25 AM, the SSD stated that she was familiar with Resident #3. The SSD stated that normally Resident #3 was calm, but lately he went into other resident's rooms and kicked the doors open. The SSD stated she knew he had an altercation with Resident #2 but was not sure what happened. The SSD stated that Resident #3 started to wonder recently (last few months). The SSD stated Resident #3 is redirected, taken outside on the patio as interventions. During an interview on 06/05/2025 at 11:39 PM, the AD stated Resident #3 was a very sweet person and liked to listen to music, have snacks and play bingo. The AD stated that Resident #3 never exhibited behavior during activities and was easily directed to activities. The AD stated that she had observed Resident #3 on different halls than his own, but he did not go into other resident's room or kicked doors. The AD stated Resident #3 looked out the window. The AD stated she has not observed increased wandering. The AD stated Resident #2 had no aggressive behavior that was observed and stated he preferred to remain in his room most of the time and he was quiet. During an interview on 06/05/2025 at 11:46 AM, the ADON stated that she started at the facility at the end of April 2025. The ADON stated she had observed Resident #3 as pleasant and had not observed him wandering or going into other resident's rooms and that he was just sitting in his wheelchair. The ADON stated that according to other people he can be aggressive, but was unable to recall anything specific. The ADON stated that interventions for Resident #3 included increased rounding, communication in shift report, discussion in morning meeting of any issues. During an interview on 06/05/2025 at 12:06 PM, the ADM stated that prior to the incident on 04/06/2025, Resident #3 wandered. The ADM stated Resident #3 would be up and active in activities and during that time he would have an eye on him. The ADM stated that interventions included redirection, trying to keep his mind stimulated and offered activities. The ADM stated Resident #3 would also visit his ex-spouse who was also a resident at the facility and that he enjoyed eating meals with her. The ADM stated that prior to the incident there was nothing reported that Resident #3 had wandered into other residents' rooms just that he wandered in general. The ADM stated potential harm for increased wandering behaviors was that other residents could be startled. During an interview on 06/05/2025 at 12:21 PM, the DON stated that Resident #3 was usually a calm guy and moved around the halls and looked for his ex-spouse. The DON stated that he knocked on doors until he found the ex-spouse. The DON stated that he did not consider this wandering because Resident #3 had a purpose and goal to find the ex-spouse. The DON stated that once Resident #3 found the ex-spouse he remained in her room. The DON stated that some resident yelled when Resident #3 opened the door. The DON stated that interventions for Resident #3 were to move him to the secured unit and bring him out to the ex-spouse to prevent him going up and down each hall. The DON stated he was also taken out to the back patio. Review of in-service dated 04/06/2025 reflected abuse policy, reporting guidelines and resident rights was reviewed with all staff. During an interview on 06/05/2025 at 12:06 PM, the ADM stated he prevented abuse and neglect in the facility through education of staff and checking in with residents and families. The ADM stated that the phone number for the abuse coordinator was posted in resident rooms. During an interview on 06/05/2025 at 12:21 PM, the DON stated that abuse and neglect was prevented by rounding and residents, reeducating the team and what abuse and neglect was. The DON stated it was important to continue to educate staff on what they are supposed to do and how to conduct themselves. The DON listed example of abuse as hitting or punching. Review of facility policy titled Abuse Policy dated 02/2017 reflected abuse is the willful (individual acted deliberately, not that they must have intent to injury or harm) infliction of injury that resulted in physical harm, pain or mental anguish. The facility shall take corrective action consistent with the investigation findings and to eliminate any ongoing dangers to the resident or other residents that may be affected. Review of facility policy titled Resident's Rights and Quality of Life dated 05/01/2012 reflected a resident has the right to be free from verbal, sexual, physical and mental abuse.

Based on interview and record review the facility failed to ensure based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of three residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1 had a physician's order for suctioning, and order for monitoring for secretions, or an order for when to replace the suction machine's cannister and tubing. This deficient practice could place residents at risk of aspiration, aspiration pneumonia, or hospitalization . Findings Included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including aspiration (inhaling something into your airway) of fluid as the cause of abnormal reaction, cerebral infarction (stroke), anoxic (lack of oxygen) brain injury, dysphagia (difficulty in swallowing), and hypoxemia (abnormally low level of oxygen in the blood). Review of Resident #1's annual MDS assessment, dated 02/20/25, reflected a BIMS score of 99, indicating he was unable to complete the interview. Section K (Swallowing/Nutritional Status) reflected he had a feeding tube. Section O (Special Treatments, Procedures, and Programs) reflected he did not require suctioning as a respiratory treatment. Review of Resident #1's quarterly care plan, revised 01/28/25, reflected he was dependent on tube feeding/inadequate oral intake due to dysphagia and NPO with an intervention of providing oral care daily or PRN. Review of Resident #1's physician orders in his EMR, on 03/04/25, reflected no orders for suctioning, monitoring for secretions, or when to replace the suction machine's cannister or tubing. Review of Resident #1's physician order, dated 07/16/24, reflected provide oral care every shift. Review of Resident #1's hospital records, dated 02/21/25 - 02/24/25, reflected the following: . admitted with altered mental status and hypoxia. [Resident #1] has a history of recurrent aspiration pneumonia. [Resident #1] was admitted to the floor and started on IV antibiotics . . I do suspect that he still having silent aspiration . During an observation and interview on 03/04/25 at 9:28 AM revealed Resident #1 lying on his bed utilizing continuous oxygen. He was struggling to breathe, there were secretions in his mouth, and was pointing to his suctioning machine on his bedside table. This Surveyor went to the nurses' station and let RN A know Resident #1 was in distress. RN A stated, Oh I am sure he needs me to suction him and went to his room. During an interview on 03/04/25 at 12:08 PM, RN A stated Resident #1 was having secretions because he had a peg tube. He stated he had started having secretions since he recently came back from the hospital with aspiration pneumonia (02/24/25). He stated the order to suction was in his TAR under oral care and he was to be suctioned he believed every shift. During an interview on 03/04/25 at 12:29 PM, the MDSC stated oral care was considered cleaning the residents' mouth with utensils to clean out residue and clean their teeth. She stated it was important to keep their mouths clean and moist. She stated residents that are NPO should receive the same oral care, but the staff needed to ensure the head of their beds were elevated to reduce the risk of aspiration. She stated suctioning would only be considered part of oral care if they needed to suction something from their mouth they could not remove while providing oral hygiene care. She stated if a resident needed regular suctioning to remove secretions, she would expect to see an order for PRN suctioning. She stated it was important because an order was needed for anything that was done for a resident, especially someone who was NPO who may be not able to tell you they needed it. She stated it was the responsibility of the nurses to get physician orders. She stated residents that were NPO did not get fluids through their mouths which could increase excessive secretions which could cause aspiration or aspiration pneumonia. She stated Resident #1 did not have excessive secretions in the past but was not sure if that had changed since his recent hospital visit. She stated she believed he would be a high potential for needing PRN suctioning due to him being a high-risk of aspiration and his history of aspiration pneumonia. She stated there should be an order to assess regularly for secretions, PRN suctioning if the nursing staff were regularly utilizing the suctioning machine, and when to change out the cannister and tubing. Review of the facility's undated Airway Management Policy reflected the following: . 2. Review patient's electronic health record (EHR), including health care provider's order and nurses' notes for patient's normal pulse oximeter values, baseline and trends in respiratory rate and effort for breathing, frequency of suctioning, and response to suctioning.

Based on interview and record review, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing for one (Resident #1) of three residents reviewed for pressure injuries. The facility failed to reinstate Resident #1's wound treatment orders after she was readmitted from the hospital on 07/11/24 until 07/16/24. Her wounds worsened and a new pressure injury was acquired during that timeframe. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 08/30/24 at 1:44 PM. While the IJ was removed on 08/31/24 at 12:55 PM, the facility remained at a level of actual no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of improper wound management, the development of new pressure injuries, deterioration in existing pressure injuries, infection, and pain. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including pressure ulcers, diabetes, history of sepsis (a serious condition in which the body responds improperly to an infection), adult failure to thrive, and muscle wasting and atrophy (wasting away). Review of Resident #1's readmission MDS assessment, dated 07/18/24, reflected a BIMS of 14, indicating she was cognitively intact. (Section M) Skin Conditions reflected she was at risk of developing pressure ulcers/injuries and had one stage II, one stage III, and one stage IV pressure injury. Review of Resident #1's quarterly care plan, dated 07/02/24, reflected she was at risk of developing pressure ulcers with interventions of conducting weekly skin inspections and providing treatments as ordered. Review of Resident #1's hospital discharge paperwork from her hospitalization from [DATE] - 07/11/24, reflected the following: PTWC consulted for management of CAPIs to L buttocks and sacrum. [Resident #1]'s CAPI to L buttocks measures 1x1.5 cm and appears to be a stage 2. Wound consists of 100% red viable tissue. CAPI to coccyx measures 1x0.5 cm and consists of 50% slough and 50% red viable tissue after selective debridement with cotton tip applicator. No drainage or malodor noted from wounds. Wounds appear stable at this time . Review of Resident #1's wound assessments conducted by the WCD, dated 07/16/24, reflected the following: Stage 3 pressure wound of the left buttock full thickness: 6.0 cm x 3.0 cm x 0.2 cm Stage 2 pressure wound of the right buttock partial thickness: 2.3 cm x 1.1 cm x 0.1 cm Stage 4 pressure wound coccyx full thickness: 1.5 cm x 1.0 cm x 0.2 cm Review of Resident #1's physician order, dated 07/16/24, reflected stage 3 pressure wound of left buttock: Cleanse with NS, pat dry, apply alginate calcium with silver, cover with border gauze, one time a day for wound care. Review of Resident #1's physician order, dated 07/16/24, reflected pressure wound to coccyx, full thickness: cleanse with NS, pat dry, apply alginate calcium with silver, cover with border gauze, one time a day for wound care. Review of Resident #1's physician order, dated 07/16/24, reflected pressure wound of the right buttock, partial thickness: cleanse with NS, pat dry, apply zinc one time a day for wound care. Review of Resident #1's TAR, dated July 2024, reflected no treatment orders from 07/11/24 - 07/16/24. The first treatments for the wounds were completed after returning from the hospital on 07/11/24 on 07/17/24. During a telephone interview on 08/15/24 at 12:24 PM, Resident #1's WCD stated he was not aware she went without treatment orders after her readmission from the hospital on 07/11/24 until after his weekly assessment on 07/16/24. He stated he would have expected her old treatment orders to have been reinstated or to implement new treatment orders from the hospital. He stated a negative outcome of not having treatment orders in place would depend on the situation of the wounds and it could just be minimal negative outcomes. He stated he was unaware her wounds worsened after her hospitalization . During an interview on 08/15/24 at 12:36 PM, the DON stated it was the responsibility of the admitting nurse to reinstate all orders when a resident was readmitted from the hospital. She stated they also sat down as an IDT and went over the orders together. She stated going several days without treatment orders could lead to sepsis, worsening of wounds, or rehospitalization . Review of the facility's Skin Care Guidelines Policy, dated July of 2018, reflected the following: Purpose: To provide a system for evaluation of skin to identify risk and identify individual interventions to address risk and a process for care of changes/disruption to skin integrity. Process: - All those admitted will be observed for baseline skin condition and evaluated for risk of skin breakdown within 24 hours of admission. The findings will be documented in the electronic medical record. - Patients/Residents will be observed by the nurse aide team members daily for changes in skin condition. These changes will be reported to the licensed nurse and documented in the electronic medical record. The ADM and DON were notified on 08/30/24 at 1:44 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was approved on 08/30/24 at 6:31 PM: 1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. Completion Date: August 30, 2024 - The DNS and designee(s) conducted skin assessments on all residents by August 30, 2024. - An audit was conducted to ensure all treatments, supplies, and equipment were readily available for ordered wound treatments by Nursing Supervisors and designee on August 30, 2024. - A medical records review was completed on all residents by Nursing Supervisors and designee(s) to ensure weekly skin assessments were completed and treatment recommendations/orders were in place by August 30, 2024. - A care plan audit was conducted by the MDS coordinator to ensure that treatment recommendations/orders were on the care plan and that the care plan was being followed . 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. Completion Date: August 30, 2024. - All facility policies and procedures related to skin care, wound care, and pressure injury prevention were reviewed by the Senior Director of Clinical Operations and revised as needed . - An audit of all pressure relieving devices and support surfaces was conducted by the Nursing Supervisor(s) to ensure proper use according to manufacturer's instructions. - DNS/Director of clinical operations provided education to all licensed nurses present have been educated and any further team members will be educated before working next shift on facility policies and procedures related to skin/wound care, as well as appropriate wound treatment measures. This included ensuring residents had necessary support surfaces and pressure relieving devices, and that staff was following the manufacturer's recommendations for use on August 30, 2024. - DNS/Director of Clinical Operations provided education to all licensed nurses present have been educated and any further team members will be educated before working next shift on appropriate documentation which included transcription and entering of treatment orders on the physician's order sheet in the EHR and the resident's TAR on August 30, 2024. - DNS/ Director of Clinical Operations educated all nurse aides present have been educated and any further team members will be educated before working next shift on preventative skin care on August 30, 2024. - DNS/Director of Clinical Operations conducted daily treatment record and nursing documentation audits to ensure accurate and complete documentation of skin related treatments and preventative measures starting on August 30, 2024. - For residents returning from the hospital, treatment recommendations/orders and wound care appointments will be transcribed and overseen by the treatment nurse and DNS. - A QAPI PIP has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly QAA meeting. Monitoring/auditing and reporting will continue for a minimum of three months. The Surveyor monitored the POR on 08/31/24 as followed: During interviews on 08/31/24 from 11:01 AM - 12:42 PM, five CNAs and one MA from different shifts all stated they were in-serviced prior to their shifts . All were able to give examples as to when they would report to their nurse regarding skin integrity issues such as redness, bruising, discoloration, skin tears, or abrasions. They stated it was important to notify the nurse of any skin changes so they could assess the skin and be aware of any possible issues. They all stated it was important to reposition residents every two hours to help prevent skin breakdown. During interviews on 08/31/24 from 11:01 AM - 12:42 PM, two RNs and three LVNs from different shifts all stated they were in-serviced prior to their shifts . They all stated that a head-to-toe assessment was to be conducted immediately upon every new admission and any wounds were to be documented and the NP , DON, and WCD should be notified. They all stated if the resident was admitted without treatment orders, they would enter a standard order until the WCD gave them alternate orders. They all stated negative outcomes of a resident missing wound care treatments could be wounds deteriorating and risk of infection. All nurses stated their expectations were that nursing aides notify them immediately of any new skin issues such as discoloration, redness, open areas, bruising, rashes, or anything abnormal. The Nurses all stated if the WCN was not working it was their responsibility to provide wound care. Review of the facility's QAPI meeting, dated 08/30/24, reflected the ADM, AIT, DON, ICP, WCN, and MD were in attendance. Review of an in-service entitled Wound Care, dated 08/30/24 - 08/31/24 and conducted by the DON, reflected all nurses were in-serviced on pressure injury staging, protocols for wound care, entering wound care orders immediately upon admission, and their Skin Care Guidelines policy. Review of an in-service entitled Caring for Skin, dated 08/30/24 - 08/31/24 and conducted by the DON, reflected all nursing assistants were in-serviced on ensuring pressure relieving devices were being used properly and the following: Skin Changes In Elderly o Normal skin functions decline o Elderly more prone to skin disease, infection, problems in wound healing. o Pigmentation(color). Skin is of pale color o Moisture. Skin becomes dry, flaky&rough Pressure Ulcer Prevention o Change position frequently o Use positioning devices to float heels & relieve skin pressure o Pressure reducing cushions in wheelchairs o Keep skin clean and dry o Encourage fluids, hydration o Lotion and use barrier cream as needed o Report to charge nurse any bruise, red or broken skin o Report to charge nurse any refusals of care What To Report To Charge Nurse o Any bruise or discoloration of skin o Any rash or raised skin area o Any cut or laceration o Any red or open area o Any warm or cool skin area. o Any unusual bumps o Any report of pain Procedure For Reporting o Look and touch skin during AM and PM cares everyday. o Report anything unusual to charge nurse right away or as soon as possible after cares o Charge nurse to assess resident, measure and document. Review of all residents' skin assessments, completed 08/30/24 by the DON, reflected no new skin integrity issues. Review of all residents' EMRs who required pressure relieving devices, on 08/31/24, reflected they all had appropriate physician orders and were care planned for the devices. Review of three residents' EMRs that had recently been readmitted from the hospital, on 08/31/24, reflected their wound treatment orders had been reinstated the same day as their readmission. Review of two residents' EMRs that had current wounds, on 08/31/24, reflected no wound care treatments had been missed during the month of August 2024. While the IJ was removed on 08/31/24 at 12:55 PM, the facility remained at a level of actual no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observations, interviews, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 4 of 6 residents (Residents #10, Resident #60, Resident#131, and Resident #39) reviewed for the usage of wrist blood pressure monitor. LVN C and LVN D did not clean and disinfect the wrist blood pressure monitor while using it on Resident #10, Resident # 39, Resident #60, and Resident #131. This failure could place the residents at the facility at risk of transmission of disease and infection. Findings included: Review of Resident #10's face sheet dated 07/10/24 reflected, Resident #10 admitted to the facility on [DATE]. She was an [AGE] year-old female diagnosed with hypertension, atherosclerotic heart disease (plaque buildup in the artery walls), anemia, coronary artery disease (insufficient supply of blood to heart), peripheral vascular disease (a slow and progressive circulation disorder caused by narrowing, blockage or spasms), chronic obstructive pulmonary disease (breathing difficulty), dysphagia (difficult to swallow), urinary tract infection, and arthritis (swelling and tenderness of one or more joints). Record Review of Resident #10's MDS dated [DATE], reflected she was admitted on [DATE] and the MDS was still in progress. Record Review of Resident #10's care plan dated 07/10/24 revealed she had impaired cardiovascular status related to coronary artery disease, hypertension, and peripheral vascular disease and the relevant intervention was observing for abnormal vital signs and report. Review of Resident # 10's MAR for July 2024, reflected: Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate): Give 0.5 tablet by mouth two times a day for blood pressure. Hold medication for BP below 110/55 or pulse below 55. Review of Resident #39's face sheet, dated 07/10/24, reflected Resident #39 initially admitted to the facility on [DATE] and readmitted on [DATE]. He was a [AGE] year-old male diagnosed with hypertensive heart disease, cerebral palsy (conditions that affects posture and movements), dysphagia (difficult to swallow), speech disturbances, cognitive communication deficit, muscle wasting, slurred speech, abnormalities of gait and mobility, lack of coordination, hyperlipidemia (high fat level), unsteadiness on feet, and hypothyroidism (low thyroid hormones). Record Review of Resident #39's annual MDS assessment dated [DATE], reflected he had a BIMS score of 13, indicating his cognition was intact. Record Review of Resident #39's care plan dated 07/10/24 revealed, impaired cardiovascular status related to hypertension, hypothyroidism, and hyperlipidemia and relevant intervention was observing for abnormal vital signs and report. Review of Resident # 39's MAR for July 2024 reflected: Propranolol HCl Tablet 40 MG: Give 1 tablet by mouth two times a day for BP. An observation of taking blood pressure using a wrist blood pressure monitor on 07/10/24 at 9:20 am revealed LVN C failed to sanitize the wrist blood pressure monitor after using it on Resident #10 and before using it on Resident #39. LVN C took the blood pressure of Resident #10 with the wrist blood pressure monitor and without sanitizing the monitor she kept it on the top of the medication cart. After administering the medications to Resident #10, she moved on to Resident #39 and used the same blood pressure monitor on him without sanitizing it. During an interview on 07/10/24 at 10:05 am LVN C stated she was aware of the necessity of sanitizing the blood pressure wrist monitor after every use on the residents. LVN C said she practiced this her whole career as a nurse however forgot to do it on that day. She stated there was a danger of transmitting diseases from one resident to another if the equipment was not sanitized properly. LVN C stated she received trainings on infection control quite often however could not remember if there was any in-services specifically related to sanitation of medical equipment. Review of Resident #60's face sheet, dated 07/10/24, reflected Resident #60 initially admitted to the facility on [DATE] and readmitted on [DATE]. She was an [AGE] year-old female diagnosed with dementia, chronic obstructive pulmonary disease (difficulty to breath), hypertension, peripheral vascular disease (a slow and progressive circulation disorder caused by narrowing, blockage or spasms), cardiac murmur, cognitive communication deficit. and hyperlipidemia, Record Review of Resident #60's Quarterly MDS assessment dated [DATE], reflected he had a BIMS score of 06, indicating severe cognitive impairment. Record Review of Resident #60's care plan dated 07/10/24 revealed she had impaired coronary artery disease, hypertension, and peripheral vascular disease and the relevant intervention was observing for abnormal vital signs and report. Review of Resident # 60's MAR for July 2024 reflected: 1.Carvedilol Oral Tablet 25 MG (Carvedilol) Give 1 tablet by mouth two times a day related to Essential (primary) Hypertension hold SBP < 110 DBP <60 HR <60. 2. Amlodipine Besylate Oral Tablet 10 MG (Amlodipine Besylate): Give 1 tablet by mouth one time a day related to Essential. (primary) Hypertension, Hold SBP < 110 DBP <60 HR <60. Review of Resident #131's face sheet, dated 07/10/24, reflected Resident #131 admitted to the facility on [DATE]. She was an [AGE] year-old female diagnosed with dementia, type 2 diabetes, chronic obstructive pulmonary disease (disease causes labored breathing) , hypertension, congestive heart failure ( Heart fails to function properly) , rheumatoid arthritis (autoimmune disease that affects mostly the joints) , and major depressive disorder. Record Review of Resident #131's Initial MDS assessment dated [DATE], reflected he had a BIMS score of 03, indicating severe cognitive impairment. Record Review of Resident #131's care plan dated 07/10/24 revealed she had impaired congestive heart failure, coronary artery disease, and hypertension and the relevant intervention was observing for abnormal vital signs and report. Review of Resident # 131's MAR for July 2024, reflected: Amlodipine Besylate Oral Tablet 10 MG (Amlodipine Besylate): Give 1 tablet by mouth one time a day for HTN hold for SBP less than 110 or DBP less than 55. HR less than 55. An observation on 07/10/24 at 10:40 AM revealed, while taking blood pressure using a wrist blood pressure monitor LVN D failed to sanitize the wrist blood pressure monitor before and after using it on Resident #60 and Resident #131. LVN D took the blood pressure of Resident #60 with the wrist blood pressure monitor. She did not sanitize the monitor prior to using it on Resident #60. After the completion of taking blood pressure and medication administration to Resident #60, she moved on to Resident #131 and took blood pressure with the unsanitized blood pressure cuff. During an interview on 07/10/24 at 1:15PM, LVN D stated sanitizing blood pressure cuffs in between the residents was important. She continued, mistakes could happen with anyone and the best way to resolve it was learning from their mistakes. LVN D stated following infection control protocol was important to minimize spreading diseases from one resident to another. LVN D stated she received trainings on infection control two weeks ago and there were no in-services on sanitizing medical equipment. During an interview on 07/11/24 at 11:00AM the DON stated she started working as the DON at the facility on 07/09/24. She stated her expectation was the nursing staff following facility policy/procedure for handwashing and sanitization of medical equipment that included sanitizing the blood pressure monitor every time after the use on residents. She added, this was essential to stop spreading transmittable diseases. During an interview on 07/11/24 at 11:00AM the IP stated she did audit rounds quarterly covering all the activities at the facility and based on the observed deficiency the training programs developed. She stated sanitizing medical equipment in between residents was mandatory since a compromise in this would spread diseases. She stated she conducted most of the in-services and did not remember if any inservice specific to sanitizing medical equipment was conducted. Review of facility's policy titled Equipment and department cleaning/Maintenance Policy dated April,2020 reflected: Each piece of equipment used for patient/resident care is to be cleaned with a center approved surface disinfectant before and after each patient use. This includes, but not limited to wheelchairs, blood pressure cuffs, glucometers, temperature probes, lifts, all therapy equipment, shower chairs, bedside tables, and scales Equipment should not be used between patients without being appropriately disinfected .

Based on observations, interviews, and record review the facility failed to ensure resident rights for personal privacy for 4 of 6 residents (Resident # 6, Resident # 14, Resident #20, and Resident # 43) residents reviewed for personal privacy. The facility failed to knock on Resident #6, #14, #20, and #43's room when going into the residents' rooms. The deficient practice could affect all residents right to privacy in the facility and cause the resident to feel like their privacy was being invaded or the facility was not their home. Findings included: Review of Resident #6's Face Sheet dated 07/10/2024 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #6's diagnoses included senile degeneration of brain, protein deficiency, COVID, schizophrenia (mental disorder), major depressive disorder, nuclear cataract (hardening of the center part of the eye), mood disorder, abnormalities of gait and mobility, muscle wasting, expressive language disorder, muscle weakness, hypertension (high blood pressure), dysphagia (difficulty swallowing), lack of coordination, vitamin D deficiency, cognitive communication deficit (problems with communication), Asthma (breathing difficulty), type 2 diabetes mellitus with diabetic neuropathy (nerve damage due to diabetes), malaise (feeling of general discomfort), heart disease, bronchitis (inflammation in the lungs causing couch), muscle wasting, psychotic disorder with delusions, neuralgia and neuritis (severe pain due to damaged nerves), dementia (memory, thinking difficulty), type 2 diabetes mellitus with hyperglycemia (high blood sugar), solitary pulmonary nodule (small mass in the lung), anemia (not enough healthy red blood cells), hypothyroidism (too much iodine causing the thyroid to produce too much thyroid hormone), anxiety, insomnia (difficulty sleeping), chronic pain, chronic obstructive pulmonary disease (chronic progressive lung disease), duodenal ulcer (a break in the inner lining of the stomach), gastroparesis (delayed emptying of the stomach), scoliosis (irregular curve of the spine), muscle wasting, kidney disease, difficulty walking, abnormalities of gait and mobility, lack of coordination, and long term drug therapy. Record review of Resident #6's Quarterly MDS revealed Resident #6 has a BIMs score of 9, indicating the resident did not understand or make self-understood most of the time. Review of Resident #14's Face Sheet dated 07/10/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #14's diagnoses included intermediate dry stage (vision loss), open angle with borderline findings low risk (one or more eyes at risk of glaucoma), presence of intraocular lens (clear artificial lens), abnormality of albumin (problems with liver and kidney function), lack of coordination, dementia (memory, thinking difficulty), COVID, depression, dysphagia (difficulty swallowing), need for assistance with personal care, unsteadiness on feet, abnormalities of gait and mobility, hypothyroidism (too much iodine causing the thyroid to produce too much thyroid hormone), muscle weakness, lack of coordination, pain in left knee, type 2 diabetes mellitus without complications (high blood sugar), type 2 diabetes mellitus with chronic kidney disease (kidney disease due to diabetes), cerebral infraction (long term effects of a stroke), hypertension (high blood pressure), osteoarthritis of the knee (joint disease), and spinal stenosis (spaces inside the bones of the spine get too small). Record review of Resident #14's Quarterly MDS revealed Resident #6 has a BIMs score of 2, indicating the resident did not understand or make self-understood. Review of Resident #20's Face Sheet dated 07/10/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #20's diagnoses included acute posthemorrhagic anemia (loss of large amount of blood quickly), hematemesis (vomiting of blood), open angle glaucoma, presence of intraocular lens (clear artificial lens), polyneuropathy (damage affecting the nerves roughly the same area on both sides of the body), COVID, reduced mobility, seizures, physical debility, hyperlipidemia (high cholesterol), lack of coordination, dysarthria and anarthria (severe speech sound disorder), need for assistance with personal care, dysphagia (difficulty swallowing), symbolic dysfunctions (development disorder of speech and language), abnormalities of gait and mobility, neuromuscular dysfunction of bladder (lack of bladder control), altered mental state, unsteadiness on feet, presence of neurostimulator (implanted device to shock the nerves), osteoporosis (skeletal disorder), pain in right shoulder, vitamin B12 deficiency, weakness, expressive language disorder, repeated falls, cognitive communication deficit (problems with communication), type 2 diabetes mellitus without complications (high blood sugar), bipolar disorder (extreme mood swings), major depressive disorder, glaucoma (eye disease), hypertension (high blood pressure), dysarthria following cerebral infraction (speech sound disorder after a stroke), rheumatoid arthritis (long term autoimmune disorder that primary affects joints), muscle wasting, and tremor (involuntary movement). Record review of Resident #20's Quarterly MDS revealed Resident #6 has a BIMs score of 10, indicating the resident could understand or make self-understood. Review of Resident #43's Face Sheet dated 07/10/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #43's diagnoses included disorder of bone density, overactive bladder, lack of coordination, abnormal posture, vitamin D deficiency, age related nuclear cataract (hardening of the center part of the eye), vitamin B12 deficiency, hypothyroidism (too much iodine causing the thyroid to produce too much thyroid hormone), hypertension (high blood pressure), embolism and thrombosis of unspecified vein (blood clots in blood vessels), constipation, pressure ulcer (bed sore), pain in joint, hematopoietic stem cell transplantation (cells that can develop into all types of blood cells ), muscle weakness, heartburn, adverse effect of antifungal antibiotics (antibiotics that don't work), feed for assistance with personal care, connective tissue and disc stenosis (spinal disease), neuromuscular dysfunction of bladder (lack of bladder control), calculus of kidneys (kidney stones), and depressive disorder . Record review of Resident #43's Quarterly MDS revealed Resident #6 has a BIMs score of 15, indicating the resident could understand or make self-understood. Observation of hall trays being passed on 07/09/2024 at 12:00pm revealed CNA C not knocking on Resident #20 or Resident #14's doors before entering the room. Observation of hall trays being passed on 07/10/2024 at 12:09pm revealed CNA C not knocking on Resident #6, Resident #14, Resident #20, and Resident # 43's doors before entering the room. An interview with CNA C on 07/11/2024 at 8:20am revealed that staff were supposed to always knock on a resident's door before entering. She stated that it was important to knock before entering because the resident could be doing something or be by the door. She stated if you do not knock, and the resident was by the door they could get hurt when you open the door. She stated that if staff did not knock on the door before entering it could cause the resident to feel like his or her privacy was being invaded. She stated she was used to saying knock, knock instead of knocking. She stated it was hard to carry a meal tray with one hand and knock on the resident's door. An interview with the AM on 07/11/2024 at 8:35am revealed that she had been trained on resident rights and knocking on a resident's door before entering. She stated the policy was staff were to knock and announce themselves and wait for the resident to tell them to come in. She stated it was important to knock before entering to ensure the resident's right to privacy. She stated that if staff do not knock on the door the resident could get upset or irritated and feel as if staff were invading their privacy. The AM stated that she was not aware that she did not knock on the resident's door before entering. An interview with the DON on 07/11/2024 at 8:43am revealed she had been trained on resident rights and knocking on the resident's door before entering. She stated all staff were required to knock on the resident's door before entering their room. She stated it was important to knock for the resident's rights and privacy. She stated that if staff did not knock on a resident's door the resident could feel like they were not being respected or their privacy was being invaded. She stated that one staff did not knock on the resident's door because she was worried about dumping the tray. She stated the staff still should have knocked on the door. An interview with the ADM on 07/11/2024 at 8:54pm revealed staff were supposed to knock before entering a resident's room. She stated all staff and visitors were supposed to knock before entering a resident's room. She stated that it was important to knock before entering to ensure the resident's right for privacy was not being violated. She stated that if staff did not knock on the door before entering the resident might have felt like staff were not respecting their rights. She stated that some staff would say knock, knock but staff should be knocking. An interview with Resident #43 on 07/11/2024 at 8:58am revealed that most of the time staff knock on the resident's door. She stated it does not bother her. Resident #43 also stated that there are times staff do not know and most the time she does not even notice staff did not knock. An interview with Resident #14 on 07/11/2024 at 9:01am revealed that sometimes staff knock. She stated she would like for staff to knock every time. She stated she did not know how she felt about staff not knocking. Record review of DMS Policy & Procedure Review of Residents' Rights dated 05/01/2012 revealed: When must you knock and ask permission to enter a resident's room? Always to protect their right to privacy. A possible exception may be when the resident is in a life-threatening situation and/or unable to respond.

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #1) reviewed for assistive safety devices (bed sensor alarm). Resident #1 sustained a fracture to the Tibia from an unwitnessed fall on 10/31/2011. The batteries on Resident #1's bed sensor pad were not operable. This failure to monitor assistive safety devices likely caused Resident #1 to sustain an injury from an unwitnessed fall and could cause 1 additional resident identified by the facility as using a bed sensor alarm at risk for falls with injuries. Findings include: Review of Resident #1's Physician order [REDACTED]. The order continued "Change batteries every two weeks on chair and bed alarm. Bed alarm while in bed." Review of Resident #1's quarterly Minimum Data Set ((MDS) dated [DATE] reflected a memory problem, moderately impaired-decisions poor;cues/supervision required. Resident #1's MDS reflected 2 person extensive assistance required for transfer. Walk in corridor; support provided-1 person physical assist Review of Resident #1's Plan of Care dated 04/15/10 reflected: "At risk for falls due to history of falls and poor safety awareness related to need to remain/be independent. Approach: Bed alarm and TABS alarm in place for safety. (8/25/10) At risk for recurring spontaneous fractures related to severe Osteoporosis. Approach: call light in reach;encourage resident to call for assist with each contact." Observation on 11/15/11 at 11:35 AM revealed Resident #1 sitting in a wheel chair in the hall outside of her room. Resident #1's right leg was elevated and extended straight out with an immobilizer. Resident #1 had a tab alarm attached to her chair. At the request of the surveyor, Certified Nurse Aide (CNA) D disengaged the alarm. The alarm sounded loudly. In an interview on 11/15/11 at 11:35 AM, Resident #1 stated her leg "hurt very bad." Resident #1 spoke in jumbled terms and was unable to recall the incident. Review of Resident #1's fall assessment dated [DATE] reflected a score of 20 (a resident who scores a 10 or higher is at risk.). The surveyor requested an updated fall assessment from the Director of Nurses (DON); an assessment dated [DATE] reflected a score of 22. Review of a computer generated report of incidents for Resident #1 reflected falls on 04/12/10, 10/16/10,7/23/11,7/24/11, and 10/30/11. In an interview on 11/15/11 at 9:15 AM, the Administrator stated Resident #1 sustained an unwitnessed fall on 10/30/11. The Administrator stated the bed alarm did not sound, upon investigation it was discovered the batteries in the alarm were dead. The Administrator stated the Maintenance Supervisor is responsible for monitoring the alarms and replacing batteries. Review of Resident #1's Provider Investigation Report dated 10/31/11 reflected the following: Description of the Allegation: fall with fracture. Description of Injury; Fracture Tibia. Investigation Summary; appears resident self transferred to the restroom at which time she had a vagal response causing her to get dizzy and fall from the toilet. The resident does have [DIAGNOSES REDACTED]. Provider Action Taken Post-Investigation: Place resident on toileting program and will provide resident and staff education regarding supervision with toileting. Replaced the bed alarm and placed a chair alarm in the wheelchair. Maintenance will check alarm batteries weekly. Review of Resident #1 Hospital Discharge Final Report dated 11/01/11 reflected "there is a nondisplaced proximal tibial fracture." In an interview on 11/15/11 at 12:20 PM, the Maintenance Supervisor stated he replaces alarm batteries "if staff approach me and tell me." The Maintenance Supervisor stated he gives the staff batteries for the alarm sometimes. The Maintenance Supervisor stated the Administrator asked him 2 or 3 weeks ago to check the oxygen concentrators and try to implement the alarm into those checks. The Maintenance Supervisor stated he checks the alarm once in a while if he is out and about, he will pull the magnet out to see if it works. The Maintenance Supervisor stated he does not have a log or has not documented any alarm checks. The Maintenance Supervisor stated he assumed the nurses check the alarm. The Maintenance Supervisor stated he had not been provided a list of residents with bed sensor alarm and had no way of knowing which residents have them. In an interview on 11/15/11 at 12:30 PM, Licensed Vocational Nurse (LVN) B stated the nurses change the batteries on the alarm. The LVN stated the nurses document on an order to change batteries every two weeks in the Treatment Administration Record (TAR). Review of Resident #1's TAR reflected no order to change alarm batteries. In an interview on 11/15/11 at 12:45 PM, LVN C stated she was unable to find a treatment sheet for battery changes for Resident #1. In an interview on 11/15/11 at 1:00 PM, the DON stated it is the responsibility of maintenance and nursing to monitor and replace the alarm batteries. The DON stated alarm batteries are stored in the front office, her office, and the med room. The DON stated if batteries are needed after hours, the staff would notify her and she would come in and get batteries for them. In an interview on 11/15/11 at 1:50 PM, the Administrator stated the facility did not have a policy for alarms. The Administrator stated he would expect for the alarms to work. The Administrator stated a plan had been established for the Maintenance Supervisor to do rounds and monitor the alarms. The Administrator stated he did not know why it was not being done, "My understanding is that the Maintenance Supervisor was monitoring the alarm batteries. In an interview on 11/16/11 at 9:30 AM, CNA E stated if an alarm did not work, she would report it to the Maintenance Supervisor. CNA E stated she had previously reported a non-functioning alarm to the therapy department and was informed maintenance was responsible. In an interview on 11/16/11 at 10:10 AM, the Director of Rehabilitation stated alarm should be checked every time they are placed on a resident; batteries have to be changed out regularly on schedule and documented. The Director of Rehabilitation stated it is the nurses responsibility to monitor the alarm. Review of the Maintenance Log reflected no requests for alarm checks or batteries for the months of August, September, October, or November. A facility acquired list reflected 2 residents with bed sensor alarm.

Based on observation, record review and interview, the facility failed to maintain acceptable parameters of nutritional status, such as body weight, and failed to provide interventions for severe, unplanned weight loss for 2 of 10 residents observed and reviewed for weight loss (#11 and 13). 1. The facility failed to implement physician's orders [REDACTED]. Resident #11 had a unplanned weight loss of 11 pounds over a 6 month period of time, resulting in a severe weight loss of 12.35%. 2. The facility failed to assess and provide interventions to attempt to prevent weight loss for Resident #13. Resident #13 had a severe unplanned weight loss of 19 pounds (11.9%) during a 10 week period. This deficient practice could affect all 71 residents in the facility who were monitored for weight loss and could result in unplanned weight loss. The findings were: A. Review of the consolidated physician orders [REDACTED]. Review of the facility weight records provided by the facility on 03/16/11 for resident #11 revealed the following: -October 2010 - 89 pounds -November 2010 - 86 pounds -December 31, 2010 - 84 pounds -January 04, 2011 - 81 pounds -February 25, 2011 - 76 pounds -March 03, 2011 - 78 pounds. Review of the initial Minimum Data Set, dated dated dated (04/09/10) revealed an admission height of 60 inches and a weight of 81 pounds. Review of the Dietitian assessment notes dated 04/19/10 revealed that this resident was currently at 81% of her ideal body weight of 100 pounds with a goal for no weight loss. Review of a letter of communication between the Dietitian and Attending Physician dated 01/11/11 revealed that the consultant dietitian had recommended the provision of 2 calorie dietary supplement, 90 cc TID with medication pass, to address "9% weight loss x 3 months". The attending physician had signed and dated this recommendation in agreement on 01/13/11. On 03/17/11 at 4:00 PM, the Director of Nurses stated in an interview that when the physician signed the communication letter in agreement with the dietary recommendation, the letter became an official physician's orders [REDACTED]. Review of the dietary consultant's clinical note dated 02/15/11 revealed the dietitian identified this resident with an additional five pound weight loss in a one month period of time (January to February 2011) and again recommended for the provision of the 2 calorie supplement, 90 cc TID with the medication pass and identified that this resident was at an increased risk for [MEDICAL CONDITION] and skin breakdown. Review of the Comprehensive Metabolic Panel laboratory record dated 02/15/11 revealed a low [MEDICATION NAME] level of 3.0 g/dl (protein level in the blood); Normal range (3.3 - 4.8 g/dl) (laboratory reference guide dated 02/15/11). physician progress notes [REDACTED]. Review of the care plan for this resident, dated 2/18/11 revealed the facility identified the problem of "loss of 5% body weight in the last 30 days..." as a problem and recommended "2 cal & med pass supplement" and "fortified food plan" as approaches to address the problem. Review of the dietary consultation clinical note dated 03/10/11 identified that the response was still pending on the 2 calorie supplement recommended on 02/15/11 (originally ordered by the physician on 1/13/11 - 56 days earlier). Review of the medication administration records for the months of January 2011 through March 2011 revealed no documentation of the provision of this physician prescribed dietary supplement. Observation of Resident #11 during the evening meal on 3/16/11 at 6:05 PM revealed the resident feeding herself and being cued by facility staff. The resident was observed to consume 50% of her meal. Observation of Resident #11 during the morning meal on 3/17/11 at 7:45 AM revealed the resident again fed herself and consumed 50% of her meal. She was given a house shake and she consumed 100% of the shake. On 03/17/11 at 10:00 AM, the Director of Nursing stated in an interview that this resident became bedfast in January 2011 due to a fracture to her knee. She stated that this resident refused to eat and experienced decreased socialization, increased pain, and marked changes in her lifestyle at the facility. She stated that the ADON had the responsibility to place the physician order [REDACTED]. On 03/18/11 at 10:15 AM, the Food Service Director stated in an interview this resident had not been placed on a fortified meal plan or on a physician ordered supplement during this period of weight loss. B. Resident #13 was admitted to the facility on [DATE] with a readmission date of [DATE] according to the face sheet dated 5/12/10. A review of the weight records provided by the facility on 3/16/11 for resident #13 revealed the following: January 2011 - 159 pounds February 2011 - 143 pounds March 2011 - 142 pounds March 17, 2011 - 140 pounds A review of resident #13's annual MDS, dated [DATE], and quarterly MDS dated [DATE], revealed the dates of review were prior to the weight loss recorded for February 2011. A review of resident #13's care plan, dated as reviewed 1/28/11, revealed no identification of the weight loss in February 2011 nor any goals or interventions listed to prevent further weight loss. A review of the dietary progress notes dated 12/7/10 revealed the last entry made was on that date. Resident #13's weight was listed at 153 pounds (a loss of 1 pound in one month and a loss of 3 pounds over the last six months). No other entries were found to address the current weight loss. During an interview on 3/17/2011 at 9:45 AM the DON confirmed resident #13's 16 pound (10%) weight loss, from January 2011 thru February 2011 (4 weeks), should have triggered an evaluation by the facility dietitian. During an interview with the PCP on 3/17/11 at 2:45 PM he stated he had no notes or communications from the facility about resident #13's weight loss. During an interview with the DON on 3/18/11 at 9:55 AM she concurred the facility missed identifying resident #13 as having a significant weight loss in the month of February 2011. During an interview with the Food Service Director on 3/18/11 at 10:05 AM he indicated weight loss was tracked on a 1 month, 3 month, and 6 month basis. The Food Service Director stated for the month of February 2011, when the 16 pound weight loss occurred, resident #13's weight was left blank on his report. The facility was unaware of the weight loss and dietary intervention was not initiated. During an interview with the facility Consultant Dietitian on 3/18/11 at 10:55 AM, she stated an "operator error" occurred on the computer program used to track residents weight loss at the facility. She indicated that each month's weights for each resident were entered on a computer program that tracked weight losses at monthly intervals. She revealed resident 13's weight input had a blank space for the month of February 2011 and therefore the resident did not trigger for severe weight loss. A review of the facility's policy and procedures titled Weight Variance, dated as reviewed 2/22/11, revealed "Calculate weight loss or gain every time a resident is weighed. Significant weight variance must be brought to the attention of the Dietitian. The nurse will report significant weight variances to the physician". Based on the 2011 Weight Report provided by the facility on 3/16/11, there were 9 residents who had experienced weight loss of greater than 7% in three months.