Every finding on record at Clyde W Cosper Texas State Veterans Home

Based on observation, interview, and record review the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for 3 of 4 residents (Resident #1, Resident #2 and Resident #3) reviewed for range of motion. The facility failed to ensure Resident #1, Resident #2, and Resident #3's referrals for customized wheelchairs were made. These failures could place residents at risk of not having their individualized needs met, decreased range of motion and a decline in their quality of care and life. Findings included: 1. Record review of a face sheet dated 07/28/2026 indicated Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis affects left nondominant side (paralysis of the left upper and lower extremities resulting from damage to the brain and/or spinal cord), chronic pulmonary obstructive disease (lung disease making it difficult to breathe) and muscle weakness. Record review of Resident #1's Quarterly MDS assessment dated [DATE] indicated he was able to make himself understood and was able to understand others. The MDS assessment indicated Resident #1 had a BIMS of 14, which indicated his cognition was intact. The MDS assessment indicated Resident #1 was dependent on staff for walking and standing. The MDS assessment indicated Resident #1 had functional limitations in range of motion to upper and lower extremities of the left side. The MDS assessment indicated Resident #1 was dependent on staff for mobility with a manual wheelchair. Record review of Resident #1's Order Summary Report dated 07/20/2026 did not address the referral made for his customized wheelchair. Record review of Resident #1's care plan revised 08/10/2026 indicated he had an ADL self-care performance deficit related to hemiplegia and hemiparesis on the left non dominant side with interventions to assist with bathing, dressing and grooming as needed. Record review of an email dated 07/15/2026 from the Rehab Director to the Director of Transportation reflected the Rehab Director inquired about the 06/05/2026 requested appointment for Resident #1's power wheelchair assessment scheduled date. The email stated, Was there a response from the transportation? Record review of an email dated 07/16/2026 from the Rehab Director to an outside clinic reflected the Rehab Director inquired about an upcoming power chair evaluation for Resident #1. The outside clinic responded that Resident #1 was not scheduled for a power chair. During an observation and interview on 07/27/2026 at 09:55 AM, Resident #1 said he was aggravated that it was taking so long to get the customized wheelchair evaluation completed. Resident #1 said that therapy said they were working on the appointment, but it had been well over a month and still nothing had transpired. Resident #1 said he could not use his left side to propel the wheelchair very well, and this had resulted in him bumping his right foot on many occasions. Resident #1 was concerned he would get skin lacerations from attempting to propel himself in the manual wheelchair. He reported he was concerned because he does not heal fast or well. Resident #1 said he had been propelling backwards in his manual chair and used a mirror to look behind him. Resident #1 was observed using his right foot to push himself backwards in his manual wheelchair in his room from the side of the bed to the bathroom. During an interview on 07/27/2026 at 12:00 PM, the Rehab Director said she made the request into the EDS on 06/05/2026 and attempted to follow-up by email with the Director of Transportation on 06/18/2026 but never received a response or update regarding Resident #1's power chair evaluation being scheduled. The Rehab Director said she had voiced this concern to the DON and the Administrator during a morning meeting but never received a response from them. The Rehab Director said she was concerned because Resident #1's mobility was limited by his decreased range of motion of the left side of his body and propelling backwards with the mirror was not idealistic or safe. During an interview on 07/28/2026 at 12:30 PM, the Director of Transportation stated she could not locate any scheduled consults for Resident #1. The Director of Transportation said she guessed she was not doing her job correctly because she also had to be a driver for the facility. The Director of Transportation said the Administrator and the DON were aware she could not complete all the tasks assigned to her daily because of doing too many things. The Director of Transportation said it was important for consults to be made timely to prevent any decrease in mobility for the residents. The Director of Transportation said wheelchair consults were very important because it was the residents' only way to be mobile and get from place to place. 2. Record review of a face sheet dated 07/28/2026 indicated Resident #2 was a [AGE] year-old male with a readmission to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis affects left nondominant side (paralysis of the left upper and lower extremities resulting from damage to the brain and/or spinal cord), chronic pulmonary obstructive disease (lung disease making it difficult to breathe) and muscle wasting and atrophy. Record review of Resident #2's Quarterly MDS assessment dated [DATE] indicated he was able to make himself understood and was able to understand others. The MDS assessment indicated Resident #2 had a BIMS of 11 and was moderately cognitively impaired. The MDS assessment indicated Resident #2 was dependent on all ADLS except eating and required set up and clean up assistance. The MDS assessment indicated Resident #2 had functional limitations in range of motion to upper and lower extremities of the left side. The MDS assessment indicated Resident #2 used a manual wheelchair for mobility. Record review of Resident #2's Order Summary Report dated 07/28/2026 indicated Resident #2 needed to be evaluated by an outside clinic for custom standard wheelchair to improve posture, improve comfort in wheelchair, provide specialty cushion with a start date of 01/02/2025. Record review of Resident #2's care plan revised 04/21/2026 indicated he had impaired mobility related to CVA with left sided hemiparesis, and he used a wheelchair by using his right foot and right hand. His care plan included interventions of one person to assist with all transfers, positioning, and ambulation and therapy screens as indicated. Record review of an email dated 07/15/2026 from the Rehab Director to the Director of Transportation reflected the Rehab Director inquired about the 05/14/2026 requested appointment for Resident #2's wheelchair assessment for a new chair related to skin damage caused by Resident #2's current wheelchair. Record review of an email dated 07/16/2026 from the Rehab Director to an outside clinic reflected the Rehab Director inquired about an upcoming wheelchair evaluation with a response of Resident #2 was not scheduled for a wheelchair evaluation. During an observation and interview on 07/27/2026 at 10:15 AM, Resident #2 was slumped down and leaning forward in the wheelchair. Resident #2 was being repositioned by the CNA to an upright angle. Resident #2 said he sure needed another wheelchair due to the curvature of his spine was causing him to lean onto his left arm with pressure. Resident #2 said the staff told him they were getting him a different wheelchair but that had been over a month or more that he could remember. Resident #2 said, maybe they forgot about me. During an interview on 07/27/2026 at 12:00 PM, the Rehab Director said she had made the request into the EDS on 05/14/2026 and attempted to follow-up by email with the Director of Transportation on 7/15/2026 but never received a response or update regarding Resident #2's power chair evaluation date being scheduled. The Rehab Director said she voiced this concern to the DON and the Administrator during a morning meeting but did not receive a response from them. The Rehab Director said she placed another consult request in the EDS on 07/14/2026 because the Treatment Nurse stated concerns regarding potential skin breakdown due to Resident #2's current wheelchair was rubbing his arm. The Rehab Director stated she had not received a response from the Director of Transportation. The Rehab Director stated Resident #2 could experience skin breakdown, infection and decreased, limited mobility due to not having a timely wheelchair evaluation. During an interview on 07/28/2026 at 12:30 PM, the Director of Transportation stated she could not locate any scheduled consults for Resident #2. The Director of Transportation said Resident #2's consult request must have gotten lost or maybe she was waiting to hear back from the outside clinic before she could schedule the consult. The Director of Transportation said it was important for wheelchair consults to be completed timely when received to prevent skin breakdown if the wheelchair was irritating the resident's skin which could lead to infection. 3. Record review of a face sheet dated 07/282026 indicated Resident #3 was an [AGE] year-old male with an admission date of 03/20/2026 with diagnoses which included hemiplegia and hemiparesis affects left nondominant side (paralysis of the left upper and lower extremities resulting from damage to the brain and/or spinal cord), and muscle wasting and atrophy. Record review of Resident #3's Quarterly MDS assessment dated [DATE] indicated he was able to make himself understood and was able to understand others. The MDS assessment indicated Resident #3 had a BIMS of 10 and was moderately cognitively impaired. The MDS assessment indicated Resident #3 was dependent on all ADLS except eating and required set up and clean up assistance. The MDS assessment indicated Resident #3 had functional limitations in range of motion to upper and lower extremities of the left side. The MDS assessment indicated Resident #3 used a manual wheelchair for mobility. Record review of Resident #3's Order Summary Report dated 07/28/2026 indicated Resident #3 was to be evaluated by an outside clinic for a custom wheelchair with a start date of 06/16/2026. Record review of Resident #3's care plan revised 03/23/2026 indicated he had impaired mobility related to weakness and nontraditional posture with the following interventions to allow and encourage resident to perform task and assist only as needed, give verbal cues and reminders as needed. Record review of an email dated 07/22/2026 from the Rehab Director to the Administrator and DON stated, it was brought to my attention another consult for a custom wheelchair request was put in on 06/16/2026 for [Resident #3]. His [family member] is asking about the appointment. I have not heard an answer from the Director of transportation. During an interview on 07/27/2026 at 10:20 AM, Resident #3's family member stated it had been at least a month since the consult was made, and she still had not heard anything about the wheelchair evaluation. Resident #3's family member said she hoped he would be more mobile with a motorized wheelchair throughout the facility so that he was not depending upon others to move him around due to the hemiplegia of the left side. During an interview on 07/27/2026 at 12:00 PM, the Rehab Director said she had not received a response from the Director of Transportation, DON, or the Administrator regarding Resident #3. The Rehab Director stated Resident #3could experience skin breakdown, infection and decreased, limited mobility due to not having a timely wheelchair evaluation. During an interview on 07/28/2026 at 12:30 PM, the Director of Transportation stated she could not locate any scheduled consults for Resident #3. During an interview on 07/28/2026 at 04:00 PM, the ADON said when a consult was made by a discipline it was placed in the EDS, then every morning the Director of Transportation would receive this notice on the EDS dashboard in her workflow. The ADON said once the appointment/consult was scheduled, the dashboard notification went away. The ADON said the dashboard was checked daily by herself and the DON to ensure there were no outstanding notifications. The ADON said she was aware there had been several issues with transportation, but she had not been directly involved with the specifics or the resolutions of those matters. The ADON said she thought the Administrator was working on the transportation issues. The ADON said it was important to ensure that consults were made timely to ensure the residents received proper equipment to meet their needs and so that the residents could remain as mobile as possible and not be limited and dependent upon others. During an interview on07/28/2026, at 5:45 PM, the DON said he had not received any specific emails from the Rehab Director or recalled any specific events regarding transportation issues. The DON stated he was not aware that the consults for Resident #1, Resident #2 or Resident #3 had not been scheduled timely. The DON stated the Administrator was directly over the Director of Transportation. The DON said there are a lot of residents in the facility which resulted in a lot of appointments and transports made daily. The DON said he understood sometimes it was a lengthy process to get all the scheduling completed. The DON said he expected timely consults to be made to prevent any resident from experiencing limited mobility. The DON said the Administrator was not available for interview at the time of exit. The policy for contracture management/limited mobility was requested and not received prior to exit of the facility.

Based on observation and interview, the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel for 1 of 13 medication carts (Treatment cart) reviewed for pharmacy services. The facility failed to ensure the Treatment Cart was properly secured when it was left unattended on 07/23/2026. These failures could place residents at risk for not receiving drugs and biologicals as needed and a drug diversion.Findings include: During an observation on 07/23/2026 at 10:46 AM, the Treatment Cart was observed on 600 Hall unlocked. The Treatment Cart was able to be opened by the surveyor and triamcinolone cream tubes were noted in the top drawer. No staff noticed or attempted to stop the surveyor from opening the cart. During an interview on 07/23/2026 at 11:15 AM, the treatment nurse said she usually locked the treatment cart because it contains items and some medications such as wound cleanser and creams that could be potentially dangerous if ingested by an individual. The Treatment Nurse stated she stepped into a resident's room because a family member had requested help with a resident and did not take the time to lock the treatment cart. During an interview on 07/23/2026 at 5:15 PM, the Administrator stated he expected the Treatment Nurse to keep the treatment cart locked at all times to prevent any accidents from occurring such as a resident drinking or spraying a harmful substance into their eyes resulting in a potential injury. During an interview on 07/23/2026 at 5:35 PM, the DON said he expected the treatment cart to be under the supervision of the Treatment Nurse directly or locked at all times to prevent accidental ingestion of any items that the cart holds such as creams, ointments, and skin cleanser which could result in harm. The DON said the treatment nurse was just nervous with state being in the building because she had never left a treatment cart open before. Record review of the undated facility's policy titled, Medication Storage in Facility, indicated, . 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.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident and determined that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for 1 of 7 medication carts (600 Hall Medication Aide Medication Cart) and 2 of 3 (A Hall Medication Storage Room and Memory Care Medication Storage Room) reviewed for pharmacy services. The facility failed to ensure Resident #118's lorazepam gel with expiration date of 04/14/2026 and acetaminophen 650 mg suppositories with expiration date of 03/2026 were removed from the Memory Care Medication Storage Room. The facility failed to ensure acetaminophen 650 mg suppositories with expiration date of 01/2026 were removed from the A Hall Medication Storage Room refrigerator. The facility failed to ensure 30 tablets of famotidine 10 mg with an expiration date of 11/2025 were removed from the 600 Hall Medication Aide Medication Cart. These failures could place the residents at risk of not having medications available for use.Findings included: Record review of Resident #118's face sheet dated 04/29/2026 indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life) and anxiety disorder (mental illness defined by feelings of uneasiness, worry and fear). Record review of Resident #118's Comprehensive MDS assessment dated [DATE] indicated she was understood by others and understood others. Resident #118 had a BIMS score of 3, which indicated her cognition was severely impaired. Resident #118 required setup or clean-up assistance with eating and toileting and partial/moderate assistance with bathing and personal hygiene. The MDS assessment did not indicate Resident #118 received anxiety medication. Record review of Resident #118's Order Summary Report dated 04/29/2026 indicated:Ativan gel 0.5 mg/ml apply topically to the inner wrist every 6 hours as needed with a start date of 04/24/2026 and end date of 05/08/2026. Record review of Resident #118's care plan reviewed 04/16/2026 indicated she had a potential for alteration in mood as evidenced by a history of anxiety to administer medications as ordered. During an observation and interview on 04/27/2026 starting at 3:56 PM, an observation of the Memory Care Medication Storage Room refrigerator with RN C revealed a box of acetaminophen 650 mg suppositories with 11 suppositories remaining in the box with an expiration date of 03/2026 and 1, 1ml syringe of lorazepam gel 0.5 mg/1 ml with an expiration date of 04/14/2026, which belonged to Resident #118. RN C said the acetaminophen suppositories and lorazepam gel should have been removed from the refrigerator and disposed of properly. RN C said the RN supervisors were supposed to go through the medications every night and discard expired medications. RN C the nurses should also be checking the medications daily for expired medications. RN C said expired medications could cause harm to the residents or be ineffective. During an observation and interview on 04/27/2026 starting at 4:12 PM, an observation of the A Hall Medication Storage Room refrigerator with LVN D, the unit manager, revealed a box of acetaminophen 650 mg suppositories with 7 suppositories remaining in the box with an expiration date of 01/2026. LVN D said the nurses were responsible for checking the medications daily for expiration dates. LVN D said the expired suppositories should not have been removed from the refrigerator. LVN D said expired medications administered to the residents could be ineffective. LVN D said LVN E should have checked the medications that morning. LVN E said she checked the medications in the refrigerator every morning, and she did not notice the acetaminophen suppositories were expired. LVN E said it was important for expired medications to be discarded because if administered they would not have the same effectiveness and to ensure the residents had medications that were not expired available when they needed them. During an observation of the 600 Hall MA Medication Cart and interview with MA K on 04/28/2026 at 3:08 PM, there were 30 tablets of famotidine 10 mg with an expiration date of 11/2025. MA K said she did not notice the famotidine was expired because she did not administer it. MA K said administering expired medications could be ineffective. During an interview on 04/29/2026 at 3:21 PM, ADON T said the MAs, nurses, and unit managers were responsible for checking the medication carts and medication storage rooms and refrigerators for expired medications. ADON T said he expected for the staff administering medications to check for expired medications and discard them when they were giving medications and when they were going in the refrigerator to get medications. ADON T said expired medications were not effective. ADON T said Resident #118's lorazepam was expired and should have been discarded upon its expiration by the nurses. ADON T said the lorazepam gel was a compounded medication and if it was administered expired it would not be effective. During an interview on 04/29/2026 at 3:47 PM, the Administrator said he expected expired medications to be disposed of so they were not administered to the residents. The Administrator said the unit managers and the nurses were responsible for ensuring expired medications were discarded. The Administrator said not discarding expired medications could result in an adverse effect to the resident or the medication being ineffective. During an interview on 04/29/2026 at 4:18 PM, the DON said the nurses should be checking medication when administering them and should ensure no expired medications were on the medication cart and in the refrigerators. The DON said he did not know there had been studies to show what effects expired medications could have on the residents, so it was unknown what effect expired medications could have. Record review of the facility's undated policy titled, Storage of Medications, indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's, provider pharmacy recommendations, or those of the supplier to maintain their integrity. 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 procedures for medication disposal .

Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment for 2 of 2 shower rooms (A Hall and C Hall) reviewed for homelike environment. The facility failed to ensure the shower stalls in the C Hall shower room did not have black grime buildup. The facility failed to ensure the shower stalls in the A Hall shower room did not have yellowish-brownish and pink grime buildup. These failures could place the residents at risk for a decreased quality of life, an uncomfortable, unhomelike environment due to unsanitary conditions. Findings included: During a confidential group interview, the resident group said when they went to take their showers the shower rooms on A Hall and C hall were always dirty, and they did not like taking showers in a dirty shower room. During an observation and interview of the A Hall shower room with LVN D on 04/29/2026 at 1:52 PM, the A Hall shower room had 3 shower stalls. The 3 shower stalls had yellowish-brownish grime from the middle down to the lower part of the tile on the shower walls, and one of the shower stalls also had pink grime built up on it. LVN D said the 3 shower stalls inside the shower room on A Hall appeared clean. LVN D said after giving the residents showers the CNAs ensured the shower stalls were clean by spraying down the shower stalls, but the housekeepers performed a deeper clean. During an observation and interview of the C Hall shower room with RN L on 04/29/2026 at 2:13 PM, the C Hall shower room had 2 stalls. Both stalls had black grime buildup on the lower parts of the shower walls, corners, and scattered on the grout of the tile on the floor of the shower stalls. One of the stalls had a slightly folded over band-aid with illegible writing lying next to some bottles of body wash in a built-in cavity/shelf on the shower wall. RN L said the housekeepers cleaned the shower stalls once a day. RN L said the CNAs should be taking out the trash and should not leave used band aids in the shower stalls. RN L said it appeared like there was mold on the shower stalls inside the C Hall shower room. RN L said it was important for the shower stalls to be clean to prevent the spread of infection and for the shower stalls' appearance to be pleasant for the residents. RN L said CNA M and CNA W provided the residents' showers today, 04/29/2026. During an interview on 04/29/2026 at 2:18 PM, CNA M said she did not leave the used band aid in the shower stall inside the C-Hall shower room. CNA M said she did not know who left it there. CNA M said the CNAs should ensure trash was not left in the shower stalls after giving a resident a shower. CNA M said it was important for trash not to be left in the shower stalls for infection control. CNA M said she had not noticed the shower stalls were dirty or any mold. CNA M said the housekeepers were responsible for cleaning the shower stalls. CNA M said it was important for the shower rooms to be clean so the residents could take a shower in a clean area. During an interview on 04/29/2026 at 2:23 PM, CNA W said she did not know who left the band aid in the shower stall inside the C-Hall shower room. CNA W said trash should be bagged and placed in the bin after giving a resident a shower. CNA W said the housekeepers deep cleaned the shower rooms once a week. CNA W said it was important for trash not to be left in the shower stalls and for the shower rooms to be clean for sanitation, infection control, and to make sure everything was clean for the residents. During an interview on 4/29/26 at 2:32 PM, Housekeeper H said the housekeepers deep cleaned the shower rooms on Sundays, but they could not deep clean the shower rooms last Sunday (4/26/2026) because they did not have enough housekeepers. She said they had not been scrubbing the showers just mopping them, and they had a chemical they could use for the tile to get it clean. She said the shower stalls inside the A-Hall and C-Hall shower rooms were dirty, and they should be cleaner. She said it was important for the showers to be clean because it was the residents' home, and they should not have to take a shower in a dirty shower room. During an observation and interview on 04/29/2026 at 2:42 PM, Housekeeper O said the A-Hall shower room stalls looked dirty and had mold. She said they cleaned the shower stalls every Sunday, but they did not clean them on Sunday, 04/26/2026, because they did not have enough staff. Housekeeper O said the shower stalls should be clean to prevent cross contamination, so the residents did not get sick, and because mold could affect the residents breathing. During an observation and interview with the Housekeeping Supervisor and Housekeeper P on 04/29/2026 at 2:49 PM, the Housekeeping Supervisor said the shower stalls in the A-Hall shower room needed to be scrubbed. She said they looked dirty and had pink grime on them. The Housekeeping Supervisor said they had a tile and grout cleaner to clean the shower stalls. She said the shower stalls in the C-Hall shower room looked dirty and needed to be scrubbed. The Housekeeping Supervisor said she was not sure if the black grime on the shower stalls was mold. She said she was responsible for making sure the showers were cleaned by the housekeepers. The Housekeeping Supervisor said she checked on Mondays to ensure the shower rooms were deep cleaned on Sunday, but lately she had not been monitoring. The Housekeeping Supervisor said the residents should not have to get clean in a dirty shower and the dirty showers could cause cross contamination. She said the showers should be clean to prevent the residents from getting sick. Housekeeper P said the A-hall and C-hall shower stalls could be cleaner. He said the last time he scrubbed the shower stalls was 2-3 weeks ago. Housekeeper P said the showers needed to be clean to prevent the residents from getting sick During an interview on 04/29/2026 at 3:56 PM, the Administrator said he expected for the shower rooms to remain clean and hygienic. The Administrator said he and the housekeeping staff were responsible for ensuring the shower rooms were clean. The Administrator said he rounded daily and had not noticed the shower rooms were not clean. The Administrator said it was important for the shower rooms to be clean to ensure a clean and sanitary environment and so the residents did not get sick. Record review of the facility's policy titled, Resident Rights, dated October 2022, indicated, Safe environment. The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. The facility failed to ensure:The deep fryer was clean and free of food debris.One medium-sized skillet was free from black buildup on the inside and outside.One large-sized skillet with Teflon coating was free from peeling on the inside. These failures could place residents at risk for food contamination and foodborne illness. Findings included: During an observation of the kitchen on 04/26/2026 starting at 10:30 AM, the fryer had crumbs around it, one medium-sized skillet had black carbon built up on the inside and outside and one Teflon coated large-sized skillet had the coating peeling off on the inside. During an observation of the kitchen on 04/27/2026 at 10:18 AM, the fryer had crumbs around it, and hanging off the rack with pots and pans there was one medium-sized skillet with black carbon built up on the inside and outside of it and one Teflon coated large-sized skillet with the coating peeling off on the inside. During an interview on 04/28/2026 at 12:35 PM, [NAME] B said the cook in the evening, [NAME] G, was responsible for cleaning the fryer. [NAME] B said she noticed the medium skillet with the carbon buildup and the large skillet with the Teflon peeling, and the Dietary Manager was aware of this too. [NAME] B said the skillets having carbon buildup and the Teflon peeling could get in the food and make the residents sick. During an interview on 04/28/2026 at 12:49 PM, the Assistant Dietary Manager said the fryer should not have crumbs, and the Dietary Manager or the night crew were responsible for cleaning it. The Assistant Dietary Manager said the fryer having crumbs could lead to cross contamination of food and cause illness. The Assistant Dietary Manager said she had not noticed the large skillet with peeling Teflon, but she had noticed the medium skillet with carbon buildup and it should have gone in the trash a long time ago. The Assistant Dietary Manager said the Dietary Manager was responsible for ensuring the skillets were in good condition and replaced. The Assistant Dietary Manager said the carbon buildup and peeling Teflon could come off and get in the residents' food and this could result in the resident illness. During an interview on 04/28/2026 at 12:53 PM, the Dietary Manager said the deep fryer should be cleaned by the cook who used it after each meal, or he cleaned it too. The Dietary Manger said he tried to make daily rounds in the kitchen to ensure everything was clean, but he had not checked the fryer yesterday, 04/27/2026. The Dietary Manager said it was important for the fryer to be cleaned and not have any crumbs so the residents would not get sick. The Dietary Manager said he was aware the medium and large-sized skillets needed to be replaced, but he had just missed it. The Dietary Manager said he made rounds once a month in the kitchen to see what needed to be replaced, and he did not make it around to replace some of the skillets that needed replacement. The Dietary Manager said the skillet with peeling Teflon and the carbon buildup could get in the residents' food and make them sick. During an interview on 04/28/2026 at 1:07 PM, [NAME] G said the deep fryer was cleaned by the cooks. [NAME] G said after they used the deep fryer they scraped the crumbs off and washed the baskets, but sometimes they did not get around to it or forgot to clean it. [NAME] G said it was important for the fryer to be clean because it could cause issues with bacteria and could cause diseases. [NAME] G said he mentioned to the Dietary Manager that the medium skillet and large skillet needed to be replaced due to the carbon buildup and peeling Teflon, but they still had not been replaced. [NAME] G did not remember when he mentioned it. [NAME] G said the carbon buildup and peeling Teflon on the skillets could lead to health issues because the carbon buildup and Teflon could get in the residents' food. During an interview on 04/29/2026 at 3:53 PM, the Administrator said he conducted walk-throughs in the kitchen at least weekly, if not a couple times a week. The Administrator said he had not noticed the medium-sized skillet with black carbon buildup on the inside and outside and the Teflon coated large-sized skillet with the coating peeling off on the inside or the deep fryer with crumbs. The Administrator said he expected the kitchen to remain clean and hygienic. The Administrator said the Dietary Manager and the Assistance Dietary Manager were responsible for ensuring the kitchen was cleaned and the skillets were in good condition. The Administrator said the deep fryer having crumbs could make the residents sick or cause food poisoning. The Administrator said the skillets having carbon buildup and Teflon coating peeling could make the residents sick. Record review of the facility's undated policy titled Cleaning and Sanitation of Dining and Food Service Areas, indicated, Policy: The food and nutrition services staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. Record review of the U.S. Food and Drug Administration Food Code 2022, indicated, Multiuse FOOD-CONTACT SURFACES shall be: (1) Smooth; (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations.

Based on observation, interview, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 2 of 5 residents (Resident #20, and Resident #161), 2 of 7 medication carts (200 Hall Nurse Medication Cart and 600 Hall Medication Aide Medication Cart), ) medication storage rooms reviewed for drugs and biologicals. 1. The facility failed to ensure UTI-Stat and Pro-Stat on the 600 Hall Medication Aide Medication Cart were dated after opened. 2. The facility failed to ensure a package of budesonide ampules in the 200 Hall Nurse Medication cart was labeled properly. 3. The facility failed to ensure Resident #161's medication labels for his glipizide, finasteride, gabapentin, and metformin matched his physician orders. 4. The facility did not ensure Resident #20's Systane Eye Drops (eye drops) were not left on his nightstand These failures could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion.1. Record review of a face sheet dated 04/28/2026 indicated Resident #161 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included chronic ischemic heart disease (progressive condition characterized by reduced blood flow to the heart muscle due to narrow or blocked coronary arteries), dysphagia pharyngeal phase (difficulty swallowing caused by impaired movement of food or liquid through the throat this phase ensures food and liquids are safely moved from the airway into the digestive tract), and gastrostomy status (creation of an external opening into the stomach to provide nutrition, fluids, or medications). Record review of Resident #161's Quarterly MDS assessment dated [DATE] indicated he understood others and was understood by others. Resident #161 had a BIMS score of 15, which indicated his cognition was intact. Resident #161 required setup or clean-up assistance with eating and showering and was independent for toileting, dressing, and personal hygiene. Resident #161's MDS assessment did not indicate he had difficulty swallowing or presence of a feeding tube. Record review of Resident #161's Order Listing Report dated 04/01/2026-04/30/2026 indicated Glipizide give 5 mg via PEG-tube two times a day with a start date of 04/21/2026 Finasteride 5 mg give 1 tablet via PEG-tube one time a day with a start date of 04/21/2026 Gabapentin 100 mg give 1 capsule via PEG-tube one time a day with a start date of 04/22/2026 Metformin give 1000 mg via PEG-tube two times a day with a start date of 04/21/2026 Record review of Resident #161's care plan reviewed 03/07/2026 did not address administering his medications via PEG tube. During an observation of medication administration and an interview with LVN A on 04/28/2026 starting at 9:06 AM, revealed LVN A halved Resident #161's glipizide 10 mg tablet. LVN A said she had to half the pill because his order had recently changed to glipizide 5 mg when he returned from the hospital. The medication label on Resident #161's glipizide instructed glipizide 10 mg give 1 tablet by mouth twice daily before meals. Resident #161's finasteride indicated 5 mg give 1 tablet by mouth every day. Resident #161's gabapentin indicated give 100 mg 1 capsule by mouth every day. Resident #161's metformin indicated give 1000 mg 1 tablet by mouth twice daily. LVN A administered all of Resident #161's medications via PEG tube. LVN A said Resident #161 returned from a hospitalization about 7 days ago and now required his medications administered via PEG tube. LVN A said a change of direction sticker should have been placed on Resident #161's medications to indicate the route of administration changed and to indicate the glipizide was decreased to 5 mg. LVN A said the nurses were responsible for placing the change of direction sticker on the medications when they received a new order or the pharmacy nurse, ADON T, placed the sticker on the medications. LVN A said she did not know why a change of direction sticker had not been placed on Resident #161's medications. LVN A said not having the correct route of administration on the medication label could result in medications being administered incorrectly or by the incorrect route. LVN A said Resident #161's glipizide not having the correct dose on it could result in him receiving the wrong dose, and his blood sugar dropping. 2. During an observation of the 600 Hall MA Medication Cart and interview with MA K on 04/28/2026 at 3:08 PM, there were 30 tablets of famotidine 10 mg with an expiration date of 11/2025, an opened bottle of UTI-Stat with no open date, and an opened bottle of Pro-Stat with no open date. The bottle of UTI-Stat indicated discard 3 months after opening and record date opened on bottom of container. MA K said they checked the medication carts weekly for expired medications. MA K said she did not notice the famotidine was expired because she did not administer it. MA K said she did not administer the Pro-Stat or the UTI-Stat, so she did not know they were not dated. MA K said the Pro-Stat and UTI-Stat should have been dated when opened by the person who opened them. MA K said administering expired medications could be ineffective. MA K said it was necessary to date bottles when opened because they could only be used for a certain number of days before they went bad. During an observation of the 200 Hall Nurse Medication Cart and interview with LVN F on 04/28/2026 at 3:17 PM, in the top drawer there was a package of budesonide 0.5 mg/2 ml with 5 ampules, and it did not have a pharmacy label on it or resident name. LVN F said he worked as needed, so he did not why the budesonide was not in its original box from the pharmacy. He said he did not know which resident the medication belonged to. LVN F said medications should be kept in the packaging it came from the pharmacy with the pharmacy label with the resident's name on it and directions for administration. LVN F said all medications should be labeled properly to know who the medication belonged to, how to administer it, and how long it had been on the medication cart. During an interview on 04/29/2026 at 3:21 PM, ADON T said medications should not be stored in a drawer without a pharmacy label because they would not know whose medication it was, and they would not be able to see the dosage that needed to be administered. ADON T said the budesonide should have been stored in a box inside the medication cart with the proper labeling from pharmacy. ADON T said the nurse who was responsible for the medication cart should ensure medications were labeled and stored properly. ADON T said not having the proper labels on medications could lead to a medication error. ADON T said a change of direction label should have been placed on Resident #161's medications to indicate there was a change in administration from by mouth to by PEG tube. ADON T said a change of direction label should have been placed on Resident #161's glipizide to indicate the dosage had been decreased to 5 mg. ADON T said the nurse who received the order or any of the nurses that noticed the discrepancy should have placed a change of direction label on Resident #161's medications. ADON T said not having the correct route of administration on Resident #161's medications could result in the medications being administered to him by mouth and cause him to aspirate. ADON T said Resident #161's glipizide not having the correct dosage on it could result in him receiving the wrong dosage, which could cause low blood sugars. During an interview on 04/29/2026 at 3:47 PM, the Administrator said he expected for the nurses to ensure the orders on the medication labels matched what they were doing during medication administration. The Administrator said he expected for the nurses to place a change of order sticker on medications when there was a change in the order. The Administrator said there could have been an adverse effect to the resident if the medication was administered via the incorrect route. The Administrator said the incorrect dosage could be administered if the medication label did not match the orders and it could harm the residents. The Administrator said he expected medications to be labeled as required and for the medications to be stored per the policy. The Administrator said the nurses and unit managers were responsible for ensuring this happened. The Administrator said not having medications properly labeled could result in the medication being given to the wrong resident or in the staff not knowing who to give the medication to. During an interview on 04/29/2026 at 4:18 PM, the DON said ADON T, the pharmacy nurse, should have ensured a change of direction label on Resident #161's medications to reflect there was a dosage change, and the route changed to PEG tube. The DON said Resident #161's medication label indicating to administer his medications by mouth could have resulted in the medications being administered by the wrong route. The DON said there was a potential for the wrong dosage to be administered to Resident #161 because his glipizide did not have the correct dosage on the medication label. 3. Record review of Resident #20's face sheet, dated 04/29/26, reflected Resident #20 was an [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life) and acute conjunctivitis (inflammation of the clear membrane lining the eyelid and eye) of left eye. Record review of Resident #20's admission MDS assessment, dated 04/08/26, reflected Resident #20 made himself understood and understood others. Resident #20's BIMS score was 9, which reflected his cognition was moderately impaired. Record review of Resident #20's undated comprehensive care plan, reflected Resident #20 was at risk for irritation as evidence by complaints of dry eyes. The care plan intervention included: administer eye medication as ordered. Record review of Resident #20's order summary report, dated 04/29/26, reflected an active physician order for Systane Ultra Ophthalmic Solution 0.4 percent-0.3 percent: instill 1 drop in both eyes every 6 hours as needed for dry eyes with a start date 04/27/26. During an observation and interview on 04/26/26 at 12:46 p.m., A bottle of Systane Eye Drops was observed on Resident #20's nightstand. Resident #20's family member was at the bedside when she stated he had brought the eye drops when he was first admitted to the facility. Resident #20's family member stated she did not know if the facility knew or seen the medication. During an observation on 04/27/26 at 9:42 a.m., A bottle of Systane Eye Drops was observed on Resident #20's nightstand. During an observation and interview on 04/27/26 at 9:45 a.m., the state surveyor observed the eye drops on Resident #20's nightstand with LVN R. LVN R removed the medication from the table and stated the medication should be stored in the nurse's cart. LVN R stated if a resident was able to self-administer, he/she must be assessed for competence. LVN R stated Resident #20 could not self-administer his eye drops due to his diagnosis of dementia. LVN R stated his family member had been educated on bringing medications without the physician order to the facility. LVN R stated it was important to ensure medications were not left at bedside for resident safety. During an interview on 04/29/26 at 10:24 a.m., CNA N stated during her rounds she did not see the eye drops on Resident #20's nightstand. CNA N stated all staff were responsible for ensuring items were stored properly and securely. CNA N stated eye drops should be stored in the medication cart. CNA N stated it was important to ensure medications were not left at bedside for resident safety. During an interview on 04/29/26 at 2:03 p.m., RN L stated she did not see eye drops on Resident #20's nightstand when she worked 04/26/26. RN L stated Resident #20's family members tend to bring stuff without telling the nurses. RN L stated the nursing staff were responsible for ensuring medications were stored properly and securely in the nurse's cart. RN L stated during her rounds she looked to see if there were things that should not be in the resident's room. RN L stated Resident #20 was not competent to administer his own medications because he had a diagnosis of dementia. RN L stated it was important to ensure medications were not left at bedside for resident safety. During an interview on 04/29/26 at 2:20 p.m., Unit Manager S stated she just started the position on 04/27/26 but she expected medications to be stored in the nurse's cart not at bedside. Unit Manager S stated CNAs should report to the nurse or unit manager if medications were observed at bedside. Unit Manager S stated if the nurse observed the medication he/she should remove the medication and notify the family that medication should not be brought. Unit Manager S stated it was important to ensure medications were not left at bedside for resident safety. During an interview on 04/29/26 at 3:15 p.m., the DON stated he expected medications to be stored on the medication cart. The DON stated nursing staff were responsible for ensuring medications were not stored at bedside by observing during rounds. The DON stated he was responsible for monitoring and overseeing by entering random residents' rooms and making observations. The DON stated it was important to ensure medications were not at bedside due to the possibility of harm. During an interview on 04/29/26 at 4:17 p.m., the Administrator stated medications should be locked/secured in the nurse's cart or medication room. The Administrator stated nursing staff should be ensuring medications were not left at bedside. The Administrator stated the unit manager, DON and himself responsible for monitoring medications at bedside by spot checks. The Administrator stated it was important to ensure medications were not left at bedside for resident safety. Record review of the undated facility's policy titled Storage of Medications reflected. Medications and biologicals are stored safely, securely, and properly. B. Only licensed nurses. and those lawfully authorized to administer medication such as medication aides are allowed access to medications. Record review of the undated facility's policy titled Bedside Medication Storage reflected. Bedside medication storage is permitted for residents who can self-administer medications upon the written order of the prescriber and when it is deemed appropriate in the judgment of the facility's interdisciplinary resident assessment team. F. All nurses and nursing aides are required to report to the charge nurse on duty any medications found at the beside not authorized for bedside storage and to give unauthorized medications to the charge nurse for return to the family or responsible party. Record review of the facility's undated policy titled, Storage of Medications, indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's, provider pharmacy recommendations, or those of the supplier to maintain their integrity. The provider pharmacy dispenses medications in containers that meet state and federal labeling requirements, including standards set forth by the United States Pharmacopeia (USP) for good manufacturing practices. Medications are kept in these containers and stored in a controlled environment. This storage may include such containers as medication carts, medication rooms, medication cabinets, or other suitable containers. Transfer of medications from one container to another is done only by the pharmacy personnel. 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 procedures for medication disposal . Record review of the facility's undated policy titled, Medication Labels, indicated, Medications are labeled in accordance with facility requirements and state and federal laws. Only the dispensing pharmacy can modify or change prescription labels. Labels are permanently affixed to the outside of the prescription container. Each prescription medication label includes: 1. Resident's name 2. Specific directions for use, including route of administration a. Due to the complexity and length/length/number of instructions, some medications may be labeled use as directed and refer the person administering the medication to the medication administration record for instruction details. If the physician's directions for use change or the label is inaccurate, the nurse may place a change of order—check chart label on the container indicating there is a change in directions for use, taking care not to cover important label information. 2. When such a label appears on the container, the medication nurse checks the resident's medication administration record (MAR) or the physician's order for current information. 3. The dispensing pharmacy is informed prior to the next refill of the prescription so the new container will show an accurate label.

Based on interview and record review, the facility failed to ensure assessments accurately reflected the resident status for 1 of 35 residents (Resident #28) reviewed for MDS assessment accuracy. Resident #28's quarterly MDS, dated [DATE], identified the resident was not receiving oxygen therapy. This failure could place residents at risk of not receiving adequate care and services to meet their needs. Findings include:Record review of Resident #28's face sheet, dated 04/28/26, reflected Resident #28 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnosis which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #28's quarterly MDS assessment, dated 04/08/26, reflected Resident #28 made himself understood and understood others. Resident #28 had a BIMS score of 8, which reflected his cognition was moderately impaired. During the 7-day look-back period the assessment did not reflect Resident #28 was receiving oxygen. Record review of Resident #28's physician order summary report, dated 04/28/26, reflected the following: * an active order for oxygen at 3L via N/C PRN for SOB and to maintain oxygen saturation above 90 percent every shift related to COPD with a start date 04/16/26. *an active order to check, clean, and/or replace oxygen filter every week every night shift Wednesday with a start date 02/04/26. Record review of the TAR dated 04/01/26-04/30/26, reflected Resident #28 wore oxygen at 3L via N/C on 04/02/26, 04/03/26, 04/04/26, 04/05/26, 04/06/26, 04/07/26, and 04/08/26. Record review of Resident #28's undated comprehensive care plan reflected Resident #28 may receive oxygen related to acute respiratory failure with hypoxia (low levels of oxygen in body tissues), hypercapnia (too much carbon dioxide in the blood), and pneumonia (infection that inflames the air sacs in one or both lungs). The care plan interventions included administer oxygen as ordered, change oxygen humidifier bottle and tubing as per facility policy. The care plan did not address oxygen filters. During an interview on 04/29/26 at 11:41 a.m., MDS Coordinator U stated she was responsible for Resident #28's quarterly MDS assessment. After reviewing Resident #28's electronic medical records, MDS Coordinator U stated she misunderstood the physician order and TAR about Resident #28 receiving oxygen. MDS Coordinator U stated she should have coded yes to oxygen use. MDS Coordinator U stated it was important to ensure the assessment was coded correctly because it was a picture of the resident status on how to ensure his needs were being met. During a telephone interview on 04/29/26 at 2:47 p.m., the Director of MDS stated she expected Resident #28's quarterly MDS assessment to be coded accurately. The Director of MDS stated MDS Coordinator U was responsible for ensuring oxygen use was correctly coded. The Director of MDS stated her understanding was MDS Coordinator U misunderstood the order. The Director of MDS stated she monitored by random audits that addressed certain sections of the MDS and weekly team call with the MDS Coordinators that covered common miscoded items. The Director of MDS stated it was important to ensure the correct information was coded to ensure the care plan reflected the care that the resident should be receiving. During an interview on 04/29/26 at 3:15 p.m., the DON stated he expected Resident #28's quarterly MDS to be coded correctly which reflected oxygen use. The DON stated MDS Coordinator U was responsible for coding the assessment correctly. The DON stated the Director of MDS was responsible for monitoring. The DON stated it was important to code the assessment correctly, so the billing was correct and the taxpayer was not taken advantage of. During an interview on 04/29/26 at 4:17 p.m., the Administrator stated he expected Resident #28's quarterly MDS assessment to be coded correctly. The Administrator stated the Director of MDS was responsible for monitoring the MDS Coordinators to ensure accuracy. The Administrator stated it was important to code the assessment correctly to keep accurate records of his current condition. Record review of the facility's policy Clinical Services: Care Plans and Case Management, revised on 04/2025 reflected .1. The Resident Assessment Instrument will be used by the facility in accordance with federal guidelines. Record review of the Resident Assessment Instrument 3.0 Manual, dated 10/2025, reflected . 1. Review the resident's medical record to determine whether or not the resident received or performed any of the treatments, procedures, or programs within the assessment period.

Based on observation, interview, and record review the facility failed to ensure menus met the nutritional needs of residents in accordance with established guidelines and ensure menus were followed for 1 of 2 meals (the lunch meal) reviewed for nutritional adequacy. The facility failed to ensure [NAME] B used a #16 scoop to serve the pureed roll on 04/27/2026. The facility failed to ensure the Assistant Dietary Manager served one cup of the regular chicken cacciatore pasta on 04/27/2026. These failures could place residents at risk of weight loss, not having their nutritional needs met, and a decreased quality of life. Findings included: During an observation and interview of the lunch meal in the kitchen on 04/27/2026 starting at 11:22 AM, [NAME] B said she served the lunch meal for the residents who ate lunch in the halls. [NAME] B used a #20 scoop to serve the pureed bread. A size #16 scoop was required. During an observation and interview of the lunch meal in the main dining room on 04/27/2026 at 11:43 AM, the Assistant Dietary Manager said she was using only 1/2 scoops to serve the lunch meal. The Assistant Dietary Manager served 1/2 a cup of chicken cacciatore to the residents in the main dining room. Record review of the extended menu dated Monday, Week 2, Spring/Summer 2026 indicated:Regular 1 cup Chicken Cacciatore PastaPureed one #16 scoop wheat dinner roll. During an interview on 04/28/2026 at 12:28 PM, [NAME] B said when she got ready to serve, she checked the extended menu to see what scoop sized needed to be used. [NAME] B said yesterday (04/27/2026), she did not check the menu because they usually use the same scoop sizes to serve each meal. [NAME] B said the extended menu should be followed, and she did not notice she used the incorrect scoop size to serve the pureed rolls. [NAME] B said the #20 scoop she used was smaller than the #16 scoop. [NAME] B said not using the correct scoop size resulted in them not meeting the requirements for the residents' nutrition and they may not get full if they were not getting enough food. [NAME] B said using a smaller scoop size could result in weight loss. During an interview on 04/28/2026 at 12:42 PM, the Assistant Dietary Manager said when she served the meals, she looked at the extended menu to verify what scoop sizes should be used to serve each meal. The Assistant Dietary Manager said yesterday, 04/27/2026, she did not check the extended menu for the scoop sizes because she was not supposed to serve the lunch meal. The Assistant Dietary Manager said serving less than what was supposed to be served resulted in the residents being underfed and could lead to malnutrition. During an interview on 04/28/2026 at 12:49 PM, the Dietary Manager said when the cooks prepared the food they were supposed to have the extended menu visible because it provided all the information, they needed to ensure they used the correct scoop sizes. The Dietary Manager said he and the Assistant Dietary Manager were responsible for ensuring the staff served the meals using the correct scoop sizes, and they monitored meals to ensure the correct scoop sizes were served. The Dietary Manager said yesterday, 04/27/2026, he did not notice the incorrect scoop sizes were used by [NAME] B and the Assistant Dietary Manager. The Dietary Manager said if the residents were not served using the correct scoop sizes, they would not be getting the correct portions, they received less nutrition, and this could lead to weight loss. During an interview on 04/28/2026 at 3:53 PM, the Administrator said he expected the dietary staff to use the correct scoop sizes. The Administrator said the Dietary Manager was responsible for ensuring the correct scoop sizes were used. The Administrator said not using the correct scoop sizes could lead to weight loss. Record review of the extended menu dated Monday, Week 2, Spring/Summer 2026 indicated:Regular 1 cup Chicken Cacciatore PastaPureed one #16 scoop wheat dinner roll. Record review of the facility's undated policy titled, Accuracy and Quality of Tray Line Service, indicated, Policy: Tray line positions and set up procedures will be planned for efficient and orderly delivery. All meals will be checked for accuracy by the food and nutrition services staff and by the service staff prior to serving the meal to the individual. Procedure: 1. The menu extensions (food items and amounts for each regular or therapeutic diet) should be displayed where the tray line staff can easily see them. The meal will be checked against the therapeutic diet spread sheet to assure that foods are served as listed on the menu. Each meal tray will be checked for: c. Proper portion sizes.

Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 6 residents (Resident #76) reviewed for resident rights. The facility failed to ensure CNA Z called Resident #76 by his preferred name while providing care on 04/28/26. This failure could place residents at risk for diminished quality of life, loss of dignity, and self-worth.Findings included:Record review of Resident #76's face sheet dated 04/28/26 indicated he was [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses which included adjustment disorder with mixed anxiety and depressed mood (stress-related condition when individual copes with life changes) , and vascular dementia (progressive decline in thinking caused by conditions that reduce blood flow to the brain). Record review of Resident #76's significant change MDS dated [DATE] indicated usually made himself understood and usually understood others. The MDS also indicated he had a BIMS score of 03 which meant he had severe cognitive loss. Record review of Resident #76's care plan dated 11/25/25 indicated he was a male resident and preferred to be called [name] with interventions to respect resident wishes. During an observation and interview on 04/28/26 at 8:55 AM Resident#76 was lying in bed when CNA Z and CNA AA were attempting to provide care for Resident #76. CNA Z called Resident #76 by his last name and he told the two CNAs loudly that they could call him Dickhead, Asshole, or anything else but he did not want them calling him by his last name. Resident #76 said his name was [name] and that was what he wanted to be called. CNA Z called him by his last name again and Resident #76 immediately corrected her and said Dickhead. During an interview on 04/28/2026 at 10:05 AM CNA AA said she had been on floor as CNA for 12-14 days. CNA AA said she always called Resident #76 by his last name, but he has gotten mad, but that's his name. CNA AA said no nurse has ever said anything about him being called anything but his last name. CNA AA said if he wanted to be called something different, she would have called him that because that was his right. CNA AA said CNA Z was her trainer and she had never told her that. During an interview on 04/28/2026 at 10:20 AM CNA Z said no other nurse had said Resident #76 did not like to be called by his last name, but he always responded when they called him by his last name. CNA Z said she had always called Resident #76 by his last name but on 04/28/26 Resident #76 was not his normal self. CNA Z said for Resident #76's dignity and respect all staff should have been calling Resident #76 by his first name instead of his last name. During an interview on 04/29/2026 at 3:17 PM LVN W said she was not aware that Resident #76 preferred to be called by his first name and LVN W said she typically called all residents by their last names out of respect. LVN W said it was Resident #76's right to be called by his first name if he wanted to be called by his first name and what all staff should have been calling him by his first name. LVN W said it was the charge nurse's responsibility to know resident preferences and to notify CNAs. During an interview on 04/29/26 at 4:05 PM the DON said he expected the CNAs to call residents as the resident prefers. The DON said the preference should have been in Resident #76's care plan for triggers. The DON said it was Resident #76's right to be called what he preferred and avoid all triggers. During an interview on 04/29/26 at 4:10 PM the Administrator said he expected the residents to be called by their preferred names. The Administrator said the nursing staff and the leadership staff (the ADON, DON, and Administrator) were responsible for ensuring the residents were called by their preferred names. The Administrator said the failure placed a risk for triggers and upsetting the residents. Record review of the undated facility policy Resident Rights indicated:Purpose: The purpose of this policy is to affirm and protect the fundamental rights of all patients/residents receiving care at [Facility Name], in accordance with federal and state regulations.Dignity and Respect: The right to be treated with consideration, respect, and recognition of individuality.

Based on interview and record review, the facility failed to ensure the coordination and provision of services agreed upon during the IDT meeting for 1 of 5 residents (Resident #12) reviewed for PASARR. 1. The facility failed to provide documentation of Resident #102's psychosocial rehabilitative services (group), psychosocial rehabilitative services (individual), and routine case management services as requested in the PCSP Form.2. The facility failed to refer Resident #86 for PASARR Level ll assessment when a diagnosis of major depressive disorder, was diagnosed after admission on [DATE]. These failures could cause residents with mental health disorders and psychiatric conditions to have a delay in services or not receive specialized services or equipment that may be needed.Findings included: 1. Record review of Resident #102's face sheet, dated 04/29/26, reflected Resident #102 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included Schizophrenia (severe psychiatric disorder is characterized by persistent delusions of persecution, unwarranted suspicion, and often vivid hallucinations), anxiety (excessive worry), and bipolar disorder (extreme mood changes). Record review of Resident #102's quarterly MDS assessment, dated 01/02/26, reflected Resident #102 understood others, and made himself understood. Resident #102 BIMS score was 15, which reflected his cognition was intact. Record review of Resident #102's comprehensive care plan, revised 03/12/26, reflected Resident #102 had identified that he was in need of specialized services due to mental illness. The care plan interventions included: follow up with agency representative to ensure recommendations are fully implemented. Record review of the PASARR Comprehensive Service Plan (PCSP) meeting dated 03/12/26 reflected that group therapy, individual therapy, and routine case management were recommended for Resident #102. Record review of Resident #102's electronic medical record dated 04/26/26 reflected no documentation of group therapy, individual therapy, or routine case management notes. During a telephone interview on 04/29/26 at 2:48 p.m., PASARR Case Manger stated she came to the facility monthly to get a report from Resident #102 to ensure his needs were met. The PASARR Case Manger stated she did not leave any documentation for the monthly visits at the facility. The PASARR Case Manger stated she followed up with the nurses after each visit to see if there were any concerns with his care. During an interview on 04/03/26 at 2:00 p.m., The MDS Coordinator stated she was responsible for ensuring visits were conducted by the PASARR Case Manager. The MDS Coordinator stated she was not aware when the skill trainer came to visit but the PASRR Case Manger came every month. The MDS Coordinator stated she did not coordinate with them after their visits. The MDS Coordinator stated it was important documentation was received after every visit to ensure they were receiving services. During an interview on 04/29/26 at 2:10 p.m., the DON stated he and the corporate nurse would attempt to reach out to obtain evidence of services provided. During an interview on 04/29/26 at 3:45 p.m., the DON stated he could not recall the exact services Resident #102 should be receiving. The DON stated he did not know when the PASRR Case Manger came to the facility until he received an email from the PASRR Case Manger to schedule the quarterly meeting. The DON stated it was important to ensure documentation was provided for continuity of care. During an interview on 04/26/26 at 3:59 p.m., the Administrator stated he did not know what services Resident #102 was receiving until the state surveyor intervention. The Administrator stated he had not received recommendations to know how often Resident #102 should be seen. The Administrator stated in his experience that if the facility ever needed documentation, they would ask that provider to provide the documentation. The Administrator stated there was not a system in place to monitor the MDS Coordinator oversight of needs. The Administrator stated it was important to ensure documentation was provided to ensure Resident #102 was receiving his PASARR services. 2. Record review of a face sheet dated 4/29/26 indicated Resident #86 was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis which included hemiplegia (complete paralysis) and hemiparesis (partial weakness) following cerebral infarction (the death of brain tissue due to a blockage in blood flow, leading to oxygen and nutrient deprivation) affecting left dominant side, anxiety disorder (mental illness defined by feelings of uneasiness, worry and fear), and insomnia (a common sleep disorder that can make it hard to fall asleep or stay asleep). Record review Resident #86's face sheet dated 4/29/26 indicated a new diagnosis of Major Depressive Disorder on 11/26/25. Record review of Resident #86's annual MDS assessment dated [DATE] indicated he was understood by others and understood others. The MDS assessment indicated Resident #86 had a BIMS score of 13, which indicated his cognition was considered intact. The MDS section, Preadmission Screening and Resident Review indicated Resident #86 did not have a serious mental illness. The section named Level II Preadmission Screening and Resident Review Conditions did not reflect a mental illness. Record review of Resident #86's care plan revised 3/7/2026 indicated Resident #86 required anti-depressants (Zoloft and Trazodone) related to a diagnosis of depression and used anti-anxiety medication (Buspar) related to anxiety. Record review of Resident #86's PASRR Level 1 Screening completed on 2/10/2025 indicated in section C0100 no evidence of this individual having mental illness. Record review of the electronic health record accessed on 4/27/2026 did not reveal the facility had completed a Form 1012 for Resident #86 and the new diagnosis of Major Depressive Disorder. During an interview on 4/28/26 at 9:40 a.m., the MDS Nurse stated she has worked for the facility as the MDS nurse for two years. She stated she should have completed a Form 1012 for the new diagnosis of Major Depressive Disorder dated 11/26/2025. She stated she gets the notes emailed to her from Psych Services when the diagnoses are Record review of Preadmission Screening and Resident Review (PASARR) policy revision date 8/29/25 revealed is to ensure each resident in a nursing facility screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that the individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs. Record review of the facility's policy Clinical Services: Care Plans and Case Management, revised on 04/2025 reflected .1. The Resident Assessment Instrument will be used by the facility in accordance with federal guidelines.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs, for 1 of 35 (Resident #28) residents reviewed for care plans. The facility did not ensure Resident #28 had a floor mat on each side of the bed. This failure could place residents at risk of accidents and falls with injuries. Findings include: Record review of Resident #28's face sheet, dated 04/28/26, reflected Resident #28 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnosis which included repeated falls. Record review of Resident #28's quarterly MDS assessment, dated 04/08/26, reflected Resident #28 made himself understood and understood others. Resident #28 had a BIMS score of 8, which reflected his cognition was moderately impaired. Resident #28 was dependent with chair/bed-to-chair transfer, and the activity sit to stand was not attempted. Resident #28 did not have any falls since admission/entry, reentry or prior assessment. Record review of Resident #28's order summary report, dated 04/28/26, reflected an active order to ensure cushioned floor mat on floor, on each side of bed if/when resident was in bed with an order date 12/27/24. Record review of Resident #28's undated care plan reflected Resident #28 had an actual fall. The care plan interventions included cushioned floor mat on floor on each side of bed if/when resident is in bed. During an observation on 04/26/26 at 11:25 a.m., revealed Resident #28 laid in bed. There was a cushioned floor mat only on Resident #28's right side of the bed. During an observation and interview on 04/27/26 at 1:00 p.m., revealed Resident #28 was lying in bed. There was a cushioned floor mat only on Resident #28's right side of the bed. Resident #28 stated he did not know if he should have a cushioned floor mat on his left side of the bed. During an observation on 04/28/26 at 9:00 a.m., revealed Resident #28 was lying in bed. There was a cushioned floor mat only on Resident #28's right side of the bed. During an interview on 04/28/26 at 9:04 a.m., CNA X stated she was Resident #28's aide. CNA X stated she just started working at the facility on 04/07/26. CNA X stated the nursing staff were responsible for ensuring a floor mat was at Resident #28's left side of the bed. CNA X stated she was unaware that Resident #28 should have a floor mat on each side of his bed. After reviewing Resident #28 electronic medical records, CNA X stated he should have a floor mat on each side of the bed. CNA X stated usually there was a sign above resident's bed to indicate if the resident should have a floor mat or go into PCC and look under the Kardex and it will tell you there. CNA X stated it was important to ensure safety measures were put in place to prevent serious injury. During an interview on 04/28/26 at 9:15 a.m., MA Y stated the nursing staff wereresponsible for ensuring a floor mat was at Resident #28's left side of the bed. MA Y stated staff should review the safety precautions in electronic medical records under the Kardex tab every day to ensure all measures were in place. After reviewing Resident #28 electronic medical records, MA Y stated he should have a floor mat on each side of the bed. MA Y stated it was important to ensure safety measures were in place to prevent serious injury. During an interview on 04/28/26 at 9:30 a.m., LVN R the nursing staff wereresponsible for ensuring a floor mat was at Resident #28's left side of the bed. LVN R stated nurses were responsible for educating the aides verbally on safety measures beginning of each shift. After reviewing Resident #28 electronic medical records, LVN R stated he should have a floor mat on each side of the bed. LVN R stated it was important to ensure fall safety interventions were put in place to prevent serious injury. During an interview on 04/29/26 at 2:20 p.m., Unit Manager S stated she just started the management position on Monday (04/27/26) but she expected both floor mats to be in place. Unit Manager S stated CNAs, MA and nurses were responsible for ensuring the fall mats were in place. Unit Manager S stated she would be monitored by daily rounds. Unit Manager S stated it important to ensure that fall safety interventions were put in place to prevent fractures or serious injuries. During an interview on 04/29/26 at 3:15 p.m., the DON stated he expected floor mats on each side while in bed. The DON stated nurses and aides were responsible for ensuring the floor mats were in place. The DON stated he monitored by random spot checks and had not noticed any issues in the past. The DON stated it was important safety measures were in place for precaution intervention. During an interview on 04/29/26 at 4:17 p.m., the Administrator stated he expected Resident #28 to have both floor mats on each side of the bed. The Administrator stated nursing staff were responsible for ensuring the floor mats were in place. The Administrator stated unit managers, DON and himself were responsible for monitoring by spot checks. The Administrator stated it was important to ensure safety measures were in place to ensure his safety. Record review of the facility's Clinical Services: Care Plans and Case Management, revised on 06/2019 reflected . to develop an interdisciplinary resident centered comprehensive care plan to meet the individual needs of each resident.1. An interdisciplinary team develops and maintains a comprehensive care plan for each resident. 2. The comprehensive care plan has been designed to: identify care needs that includes resident's strengths, history, and preferences.

Based on interview and record review the facility failed to provide or obtain laboratory services to meet the needs of its residents for 1 of 7 residents (Resident #12) reviewed for laboratory services. 1. The facility failed to ensure Resident #12's Pre-Albumin (measures the level of a liver-produced protein in the blood to assess nutritional status and monitor for malnutrition) was drawn bi-weekly and Albumin (measures the level of albumin, a protein produced by the liver, in the blood or urine to assess liver/kidney function and nutritional status) was drawn monthly for Resident #12. 2. The facility failed to ensure Vitamin D and Lipid panel test were drawn every year for Resident #12. Vitamin D (measures the levels of vitamin D in your blood. Vitamin D helps your body absorb calcium to build healthy bones and teeth). Lipid panel (a blood test measuring cholesterol and triglycerides to evaluate cardiovascular risk) These failures could place residents at risk of not receiving lab services as ordered, not receiving timely diagnosis and treatment, and not receiving appropriate monitoring for certain diseases. Findings include:Record review of Resident #12's face sheet, dated 02/07/25, reflected an [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted [DATE]. Resident #12 had diagnoses which included stage 4 pressure ulcer (a severe, full-thickness wound extending to exposed muscle, tendon, or bone, often with extensive tunneling or undermining), vitamin d deficiency (occurs when the body lacks sufficient vitamin D, causing fatigue, bone pain, muscle weakness, and mood changes), diabetics (high blood sugars and when your blood sugar is high over a long time, it can damage your internal organs, including your liver), kidney disease (a progressive condition where kidneys are damaged and cannot filter blood properly), and dementia (decline in memory, thinking, and behavior, which impairs daily functioning).Record review of Resident #12's comprehensive care plan, reviewed 04/19/24, reflected Resident #12 was at risk for complications related to diagnosis of Vitamin D Deficiency and at risk for impaired thought process related to liver cirrhosis. The care plan interventions included: labs as ordered, medication as ordered and observe for any complications. Record review of Resident #12's physician's order, dated 07/09/25, reflected: Albumin lab to be drawn monthly, and Prealbumin lab to be drawn biweekly to assist the registered dietitian with nutritional assessment of nutritional needs and pressure wound.Record review of Resident #12's physician's order, dated 07/09/25, reflected: Lipid and Vitamin D level yearly. Record review of Resident #12's electronic medical record did not indicate Resident #12 had a Lipid or Vitamin D level since labs were ordered on 07/09/25.Record review of Resident #12's electronic medical record revealed Resident #12's last Pre-Albumin and Albumin level was drawn on 02/02/26.Record review of Resident #12's comprehensive care plan, revised 03/20/26, reflected Resident #12 was at risk for complications related to wounds. The care plan interventions included: labs as ordered, medication as ordered and observe for any complications.Record review of Resident #12's quarterly MDS, dated [DATE], reflected Resident #12 usually made himself understood and was usually understood by others. Resident #12's BIMS score was 14, which indicated his cognition was intact. Resident #12 required assistance with his activities of daily living. The MDS did not indicate any weight loss.During a phone interview on 4/29/26 at 11:45 a.m., the physician said he expected labs to be done as ordered.He said labs where usually done to check different systems in the body which were important for the well-being of each resident.During an interview on 04/29/26 at 2:29 p.m., LVN W said when labs were ordered the nurses filled out the lab slip and the new order would be placed on the 24-hour report for the nurses to follow up. She said if it was a routine lab the nurses were supposed to check the lab book at the nurse's station daily. She said she was not aware of Resident #12 missing labs any labs. She said failure to follow up on labs could potentially cause the residents to miss a medication or something else they might need.During an interview on 04/29/26 at 3:44 p.m., the DON said he expected labs to be drawn as ordered by the physician order. The DON said he was unaware Residents #12, was missing labs until the state surveyor intervention. The DON said the unit manager was responsible for ensuring labs were done as ordered. The DON said failure to monitor ordered labs for Resident #12 could cause his wounds to worsen and further weight loss. The DON said it was noted that there may not be an effective routine lab monitoring process however the process would be reviewed and revamped to monitor for compliance. The DON said it was important to ensure labs were drawn as ordered by the physician to ensure the resident's health had been monitored by those lab values. During an interview on 04/29/26 at 3:58 p.m., the Administrator said he expected labs to be drawn as ordered. He said the nurses were responsible for filling out the lab slip and the lab company was supposed to draw the lab ordered. He said nurse management was responsible for ensuring labs were drawn as ordered. The Administrator said it was important for labs to be drawn as ordered by the physician for the welfare of the resident's health. Record review of the facility's policy titled Laboratory Services, revised 09/02/25, indicated .Purpose: laboratory services will be performed as ordered by the physician.Policy Explanation and Compliance Guidelines: 1. Laboratory services will be ordered by the physician. 2. Laboratory services will be completed on the date specified by the physician or on the next scheduled lab day, if a specific date is not identified.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 7 residents (Resident #73 and Resident #86) reviewed for infection control.1.The facility failed to ensure LVN E wore PPE (gown and mask) while performing a blood sugar check on Resident #73 on 04/28/26, who was on droplet precautions (Droplet Precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions).2.The facility failed to ensure CNA CC and Nurse DD performed proper glove changes while providing incontinent care to Resident #86 on 4/27/2026.These failures could place residents at risk for cross-contamination and the spread of infection.Finding include:1. Record review of Resident #73's face sheet, dated 04/29/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted [DATE]. Resident #73 had diagnoses which included Myelodysplastic syndromes also known as MDS (a group of blood cancers occurring when immature blood cells in the bone marrow do not mature properly, resulting in low blood cell counts such as anemia, infections, bleeding), pancytopenia (a blood condition where all three major blood cell types [red cells, white cells, and platelets] are abnormally low, leading to symptoms like anemia, infection risk, and bleeding), and Iron deficiency anemia (a common, treatable blood disorder where low iron levels prevent the body from producing enough hemoglobin to carry oxygen).Record review of Resident #73's physician order, dated 01/21/26, indicated droplet precautions related to white blood count of 1.8 every shift.Record review of Resident #73's comprehensive care plan, dated 01/22/26, indicated Resident #73 had droplet precautions related to low white blood count (indicates a weakened immune system, raising the risk of infection) results. The intervention was for staff to follow droplet precautions as indicated. Record review of Resident #73's quarterly MDS assessment, dated 04/03/26, indicated Resident #73 understood and was understood by others. Resident #73's BIMS score was 15, which indicated his cognition was intact. Resident #73 was independent with his daily activities. The MDS did not indicate isolation.During an observation and interview on 04/26/26 at 12:36 p.m., Resident #73 had a droplet sign on his door and a cart outside his door which contained gloves, gowns and mask. He said he was on droplet precautions because he had a low white blood count and was anemic. He said staff had been wearing a gown and mask while in his room.During an observation on 04/28/26 at 4:30 p.m., LVN E was in Resident #73's room taking his blood sugar. LVN E had gloves on but did not have a gown or mask on. During an interview on 04/28/26 at 4:35 p.m., LVN E said she did not know if she was supposed to wear anything in Resident #73's room. She went back and looked at Resident #73's door and said she was supposed to wear gown, gloves, and a mask. She said she was not aware and did not see the sign on his door. She said failure to wear the correct PPE could cause the resident to be transmitted something that could worsen his condition. She said they had in-services on PPE in the past.During an interview on 04/29/26 at 3:58 p.m., the DON said he expected staff to wear PPE such as goggles, gloves, gown, and face mask while in Resident #73's room. He said he expected the unit managers, the ADON and himself to ensure staff were following the droplet precautions. He said if the staff were not following the droplet precautions it placed Resident #73 at risk of infection.During an interview on 04/29/26 at 3:58 p.m., the Administrator said he expected all staff to wear face masks, gowns, and gloves while in Resident #73's room or performing care. He said the unit managers, DON and himself were responsible for ensuring staff wore the proper PPE while in Resident #73's room. He said they had a skills fair in March 2026 where they went over PPE and said staff should also be aware of the signs on the resident's door and or over the resident's bed. He said if staff were not wearing proper PPE, they could contaminate Resident #73 or cause him to become sick. 2. Record review of Resident #86's face sheet, dated 04/29/26, indicated a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #86 had a diagnosis which included hemiplegia (complete paralysis) and hemiparesis (partial weakness) following cerebral infarction (the death of brain tissue due to a blockage in blood flow, leading to oxygen and nutrient deprivation) affecting left dominant side and irritant contact dermatitis due to fecal, urinary or dual incontinence (localized inflammatory skin reaction caused by direct contact with substances or environmental factors that damage the skin barrier). Record review of Resident #86's annual MDS assessment, dated 12/03/25, indicated he was understood by others and understood others. Resident #86 had a BIMS score of 13, which indicated his cognition was considered intact. Resident #86 was dependent for functional abilities which included personal hygiene, putting on/ taking off footwear, lower body dressing, upper body dressing, shower/bathing, and toileting hygiene. Resident #86 was at risk for developing pressure ulcers/injuries. Record review of Resident #86's care plan, revised 03/07/26, indicated he was at risk for skin breakdown related to fragile skin, incontinence of bowel and bladder, and impaired mobility. During an observation and interview on 04/27/26 at 12:30 p.m. revealed CNA CC and Nurse DD provided incontinent care for Resident #86. CNA CC performed hand hygiene and donned gloves. CNA CC unfastened Resident #86's dirty brief, assisted the resident as he rolled onto his side, then CNA CC got a wipe from the package, and wiped the resident's backside. CNA CC placed the dirty wipe into the trash bag and touched Resident #86's pillow and call light cord to move them out of the way, with the dirty gloves. Nurse DD entered to assist and donned gloves without performing hand hygiene. Nurse DD helped hold Resident #86 on his side as CNA CC continued with incontinent care. CNA CC continued to clean Resident #86 using multiple wipes and not changing gloves. CNA CC grabbed the clean brief with the dirty gloves and replaced the dirty brief with the clean one. Nurse DD placed it in the trash bag. Nurse DD arranged Resident #86's blanket back over Resident #86 with the dirty gloves. CNA CC stated she should have changed her gloves when going from dirty to clean. She stated she should not touch the resident's pillow or call light cord without first removing the dirty gloves and performing hand hygiene. CNA CC stated it was important to perform proper hand hygiene to prevent the spread of infection and cross contamination for safety of the resident and for ourselves. Nurse DD stated she forgot to perform hand hygiene because Resident #86 got impatient and she was in a hurry to help. Nurse DD stated she was intimidated by the state surveyors. She stated performing proper hand hygiene was important to prevent the spread of infection. During an interview on 04/29/26 at 2:50 p.m., the DON stated oversight for incontinent care was done with random checks, but did not say by whom. The DON stated the expectation was staff would follow proper protocol and procedures. He stated it was important to avoid possible infection and cross contamination. During an interview on 04/29/26 at 3:10 p.m., the Administrator stated regular in-services and annual skills check offs were performed. The Administrator stated the expectation was for those providing patient care, proper hand hygiene was always practiced. He stated it was important to practice proper hand hygiene to keep residents safe and healthy, and to prevent the spread of infection. Record review of the facility's policy titled, Droplet Precautions, dated 04/25, indicated, Purpose: To provide an environment that protects against droplet disease transmission and is safe for the health care worker. It is the policy of this facility to comply with CDC standards related to infection control practices for the residents requiring droplet precautions. Policy Expectations and Compliance Guidelines: Droplet precautions shall be used in addition to standard precautions for residents. #1 Gloves and handwashing: perform hand hygiene before entering the room [ROOM NUMBER] gloves should be worn when entering the room and while providing care.#4 gloves should be removed before leaving the room and hands should be washed. #5 gowns should be worn by staff upon entering the resident's room and discarded prior to exiting. #6 Eye protection and/or face Shields should be worn upon entering the resident's room and removed prior to exiting the room. #8 a mask should be worn upon entering the resident's room and removed prior to exiting the room.Record review of the policy titled, Incontinent/ Perineal Care, revised on 09/2/25, stated in a step by step process the guidelines for performing care. The steps included:* Washing hands prior to applying gloves to begin care* Removing gloves, washing hands, and applying clean gloves after cleaning the soiled resident * Removing gloves, washing hands, and applying clean gloves after applying barrier cream* Removing gloves, washing hands, and applying new gloves to apply clean brief* Removing gloves, washing hands after exiting room and disposing of supplies and linen.

Based on interview and record review, the facility failed to provide specialized rehabilitative services such as but not limited to physical therapy, speech therapy-language pathology, occupational therapy, respiratory therapy, and rehabilitative services for mental illness and intellectual disability or services of a lesser intensity, as required in the resident's comprehensive plan of care for 1 of 7 residents (Resident #67) reviewed for specialized rehabilitative services. The facility did not ensure Resident #67 received physical therapy after a therapy screening on 03/11/26. This deficient practice could place residents at risk of a decline or decrease in their physical capabilities. Findings include: Record review of Resident #67's face sheet, dated 04/29/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #67 had a diagnosis which included repeated falls. Record review of Resident #67's significant change of status MDS assessment, dated 02/27/26, reflected Resident #67 made himself understood and understood others. Resident #67 had a BIMS score of 13, which reflected his cognition was intact. Resident #67 used a wheelchair, was independent with all self-care abilities and mobility. Resident #67 did not receive any therapy services for at least 15 minutes a day on or more days in the last 7 days. Record review of Resident #67's, undated, comprehensive care plan, reflected Resident #67 was at risk for injury (falls) related to history of falls. The care plan intervention included provide assistance with mobility as needed. Resident #67 was at risk for impaired mobility related to bone density and structure. The care plan interventions included therapy screened as indicated. Record review of Resident #67's therapy post fall screen, dated, 03/11/26 reflected Resident #67 had a fall on 03/10/26 and PT was recommended. Record review of Resident #67's therapy post fall screen, dated, 03/23/26 reflected Resident #67 had a fall on 03/20/26 and PT was recommended. Record review of Resident #67's order summary report, dated 04/29/26, reflected an active physician order for PT/OT/ST screen as needed with a start date 01/30/26. During an interview on 04/26/26 at 1:58 p.m., Resident #67 stated he had been at the facility for two weeks and therapy has not started. During an interview on 04/28/26 at 10:00 a.m. the DOR stated Resident #67 had a Fall on 03/10/26 and was screened on 03/11/26 with recommendations for physical therapy. The DOR stated she called and left a message for Resident #67 regarding the copay assistance. The DOR stated, I dropped the ball and did not follow back up. The DOR stated she was not informed by any of the nursing staff Resident #67 had a decline since the last fall on 03/23/26. The DOR stated it was important residents received therapy services to meet their needs and prevent a decline in ADLs. During an interview on 04/29/26 at 10:24 a.m., CNA N stated Resident #67 had not mentioned therapy services to her. CNA N stated Resident #67 ambulated with a wheelchair and had not had a decline in his ADLs since his last two falls. During a telephone interview on 04/29/26 at 10:46 a.m., Resident #67's family member stated she mentioned therapy services to the Director of admission when Resident #67 first was admitted but she never heard anything back. Resident #67's family member stated she would pay the copay for him to receive therapy services. Resident #67's family member stated she had not noticed a decline since his falls. During an interview on 04/29/26 at 10:54 a.m., the Director of admission stated Resident #67's family member had mentioned she would like some form of therapy when he was first admitted . The Director of admission stated she had taken her PT EE to have him explain the process. The Director of admission stated it was important for residents to receive therapy services to maintain the quality of life and prevent limited mobility. During an interview on 04/29/26 at 11:06 p.m., PT EE stated he did not recall having a conversation with Resident #67's family member about Resident #67 receiving therapy services. PT EE stated he had been waiting on the approval from the DOR to start services. PT EE stated it was important to ensure residents received therapy services to address change in function and retire any loss of function. During an interview on 04/29/26 at 2:03 p.m., Unit Manager S stated Resident #67 ambulated with a wheelchair and required one-person assistance. Unit Manager S stated Resident #67 had not mentioned therapy to her. Unit Manager S stated she had not noticed a decline since the falls. Unit Manager S stated it was important to ensure residents received therapy services to help with muscle strengthening and transfer safety. During an interview on 04/29/26 at 3:15 p.m., the DON stated he expected all services to be available to Resident #67 as requested. The DON stated he expected the DOR to follow up for completion of resident desire pertaining to receiving therapy. The DON stated he had not noticed a decline since his fall. The DON stated it was important residents received therapy to prevent the possibility of decline in abilities. During an interview on 04/29/26 at 4:17 p.m., the Administrator stated he was informed today (04/29/26) by the DOR Resident #67 was not on rehab services. The Administrator stated he expected the DOR to contact Resident #67's family to confirm whether they approved of the copay. The Administrator stated therapy services were brought up for Resident #67 after each fall during morning meetings. The Administrator stated the DOR stated she would consult with the family to get approval for him to start therapy, but he did not follow up to ensure the family was contacted. The Administrator stated it was important for residents to receive therapy to maintain the highest level of independence. Record review of the facility's policy Rehabilitation Services-Texas, dated 08/2021, reflected .Therapy services will be available to assist residents with maintaining their maximum level of independence and enhance quality of life. Therapy may be beneficial for ambulation, activities of daily living (ADLs), positioning, joint range of motion, etc. The community will have therapy services, in the form of physical therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST), available to residents who meet criteria and may benefit from services. 1. Residents will be screened upon admission and as needed to determine if therapy services may be of benefit.3. Residents and/or the resident representative will be involved in the therapy plan.

Based on observation, interview and record review the facility failed to ensure therapeutic diets were prescribed by the attending physician for 1 residents (Resident #2) reviewed for health shakes. The facility failed to ensure Resident #2 received his health shake, as ordered by the physician. This failure could place residents at risk of not maintaining adequate nutritional status including unintentional weight loss. Findings include:Record review of Resident #2 face sheet revealed a male who was admitted to the facility 10/22/2024. Resident #2 had diagnoses which included Parkinson's (difficult movement due to decreased brain function; tremors) and dysphagia of the opharyngeal phase (difficult swallowing food from mouth to throat). Record review of Resident #2 comprehensive MDS, dated [DATE], revealed Resident p#2 had a BIMS of 10, which indicated the resident had moderate cognitive impairment. Resident #2 was dependent on assistance with all eating. Resident #2 had weight loss of 5% or more in one month or 10% or more in 6 months and was on physician-prescribed weight loss regime with a diet of mechanically altered diet and therapeutic diet. Record review of Resident #2 care plan last reviewed, dated 3/19/2026, revealed he was care planned for an actual weight loss related to diet change and decreased intake by mouth. The Care plan listed an intervention as diet as ordered. Record review of Resident #2's physician order, dated 3/20/2026, documented a health shake/supplement [mighty health shake with meals for 60 day every day] as part of a therapeutic diet plan for nutritional support. Resident #2 had an order for regular diet, puree texture, and nectar consistency, dated 3/19/2026. Record review of dietary records and meal service documentation did not consistently reflect delivery or intake of the ordered supplement on [4/26/2026] Sunday noon meal.Observation on 4/26/2026 at 11:38 p.m. during meal service revealed Resident #2 did not receive the ordered health shake with the meal tray. No substitute supplement was observed being offered or provided at that time. Meal ticket was observed with health shake listed. Interview on 4/26/2026 at 12:05 p.m., Resident #2 stated they had not received the ordered health shake as part of his lunch meal. Resident #2 stated that sometimes he gets his shake and sometimes he does not. Interview on 4/26/2026 at 12:09 p.m., the Certified Nursing Assistant (CNA) A stated they were unaware the resident had not received the ordered health shake. The CNA stated the Dietary aid was responsible for putting it on the tray and the LVN checked the trays. Interview on 4/26/2026 at 12:12 p.m., the LVN FF stated dietary orders should have been verified and implemented as written, and residents should receive ordered supplements as part of their therapeutic diet plan. The LVN FF stated she must have missed it when checking the tray. The LVN FF stated Resident #2 was at risk of weight loss. Interview on 4/26/2026 at 12:20 p.m., the Dietary Aid stated the resident had a therapeutic order for a health shake; however, the order was not reflected on the meal delivery tray because she had forgotten to put it on the tray.Interview on 4/26/2026 at 12:23 p.m., the Dietary Manager stated the resident had a therapeutic order for a health shake; however, the shake was forgotten and the dietary aid was responsible for putting it on the tray. The dietary manger stated they were supposed to follow the dietary meal tickets. Interview on 4/29/2026 at 12:45 p.m., the D Unit RN Supervisor stated she expected for Resident #2 to receive his prescribed health shake to prevent weight loss. The RN Supervisor stated the RN on duty was responsible, but she also was responsible because she was in attendance of mealtime for observation of meal tickets. Interview on 4/29/2026 at 3:45 p.m., the DON stated he expected diets to be provided as ordered. The DON stated Resident #2 was prescribed the health shake for weight loss and he was at risk of more weight loss. Interview on 4/29/2026 at 3:50 p.m., the Administrator stated he expected Resident #2 received his health shake with meals. The Administrator stated Resident #2 was at risk of weight loss and clinical decline. The Administrator stated the kitchen staff were responsible for putting the health shake on the tray with each meal, the RN was responsible for checking the trays, and the CNA who assisted with meals were all responsible for ensuring Resident #2 received his health shake with each meal. Record review of the Therapeutic Deits policy, dated 2023, revealed diets will be offered as ordered by the physician.

Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 of 7 residents (Resident #56 and Resident #28) reviewed for respiratory care.1.The facility failed to ensure Resident #56's oxygen concentrator filter was cleaned. 2. The facility failed to ensure Resident #28's oxygen concentrator filter was cleaned.This failure could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory disease.Findings included: 1.Record review of Resident #56's face sheet dated 04/29/26 indicated he was an [AGE] year-old male who admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease also known as COPD (a progressive, incurable lung disease—primarily caused by smoking—that obstructs airflow, causing chronic breathing difficulties),anxiety ( the feeling of fear and worry that is both intense and excessive). Record review of Resident #56's quarterly MDS assessment dated [DATE] indicated he made himself understood and he understood others. The MDS also indicated he had a BIMS score of 15 which meant he was cognitively intact. The MDS did not indicate Resident #56 required oxygen. Record review of Resident #56's comprehensive care plan last revised 02/18/26, indicated Resident #56 had shortness of breath and received oxygen. The interventions were to check oxygen filter, clean and/or replace filter every week. Record review of Resident #56's physician order dated 08/31/23, indicated as follows: *check oxygen filter, clean and/or replace filter every Wednesday night shift. *: Oxygen at 2 Liters per nasal cannula as needed for shortness of breath. Record review of Resident #56's medication administration record indicated LVN C initialed she cleaned Resident #56's filter on 04/22/26. During an observation and interview on 04/26/26 at 12:37 a.m., Resident #56 was lying in bed and had his oxygen on at 2 liters per minute. The oxygen concentrator filter was covered in a gray-like substance. Resident #56 said he wore oxygen but when asked about the filter he would not answer. During an observation on 04/28/26 at 4:51 p.m., Resident #56's was lying in bed and had his oxygen on at 2 liters per minute. The oxygen concentrator filter continued to be covered in a gray-like substance. During an observation and interview on 04/28/26 at 4:42 p.m., LVN E verified Resident # 56 was wearing oxygen at 2 liters per minute and his concentration filter was covered in a gray-like substance. She said it was dirty. She said she thought there was a schedule for oxygen tubing and filters to be cleaned on the night shift, but said nurses were supposed to look at them daily. She said she had not looked at Resident #56's filter today (04/28/26). She said failure to keep the filter clean placed Resident #56 at risk for infection. During an attempted telephone interview on 04/29/26 at 3:28 p.m., with LVN V, the nurse for Wednesday 04/22/26 (responsible for cleaning/changing the oxygen filter), was unsuccessful. During an interview on 04/29/26 at 11:40 a.m., the Business Office Manager said she was responsible for the ambassador rounds for Resident #56. She said she was responsible for checking and ensuring the resident had what he needed, checking for outdated items in the refrigerator or things not allowed in the room, making sure his room was clean, and making sure his oxygen tubing was dated. She said she was not aware of checking the oxygen concentrator filters. During an interview on 04/29/26 at 3:44 p.m., the DON said he expected oxygen concentrator filters to be cleaned. He said the charge nurses and the ambassadors should be checking the filters and he did random spot checks. The DON said dirty concentrator filters placed Resident #56 at an increased risk for respiratory infection. During an interview on 04/29/26 at 3:58 p.m., the Administrator said the nurses should been changing and cleaning the oxygen concentrator filters and the unit managers should be monitoring the cleanliness every Wednesday night. He said Resident #56 should have had an order to clean the oxygen concentrator filter. The Administrator said failure to have Resident #56's oxygen concentrator filter cleaned placed him at risk for infection, such as pneumonia. 2. Record review of Resident #28's face sheet, dated 04/28/26, reflected Resident #28 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnosis which included COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #28's quarterly MDS assessment, dated 04/08/26, reflected Resident #28 made himself understood and understood others. Resident #28 had a BIMS score of 8, which reflected his cognition was moderately impaired. During the 7-day look-back period the assessment did not reflect Resident #28 was receiving oxygen. Record review of Resident #28's undated comprehensive care plan reflected Resident #28 may receive oxygen related to acute respiratory failure with hypoxia (low levels of oxygen in body tissues), hypercapnia (too much carbon dioxide in the blood), and pneumonia (infection that inflames the air sacs in one or both lungs). The care plan interventions included administer oxygen as ordered, change oxygen humidifier bottle and tubing as per facility policy. The care plan did not address oxygen filters. Record review of Resident #28's physician order summary report, dated 04/28/26, reflected an active order for oxygen at 3L via N/C PRN for SOB and to maintain oxygen saturation above 90% every shift related to COPD with a start date 04/16/26. Record review of Resident #28's physician order summary report, dated 04/28/26, reflected an active order to check, clean, and/or replace oxygen filter every week every night shift Wednesday with a start date 02/04/26. During an observation on 04/26/26 at 11:25 a.m., revealed Resident #28's oxygen concentrator filter had a thick, gray, fuzzy material. During an observation and interview on 04/27/26 at 1:00 p.m., revealed Resident #28 was lying in bed. Resident #28's oxygen concentrator filter had a thick, grey, fuzzy material. Resident #41 stated he wore oxygen at night due to SOB. During an observation on 04/28/26 at 9:00 a.m., revealed Resident #28 was lying in bed. Resident #28's oxygen concentrator filter had a thick, grey, fuzzy material. During an interview on 04/28/26 at 9:30 a.m., LVN R stated the nurse staff on Wednesday nights were responsible for changing/cleaning the oxygen filter. LVN R observed Resident #28's oxygen filter and stated, it's dirty. LVN R stated it was important to ensure filters were cleaned to prevent a respiratory infection. An attempted telephone interview on 04/28/26 at 3:30 p.m., with LVN Q, the nurse for Wednesday 04/22/26 (responsible for cleaning/changing the oxygen filter per the 04/22/26 schedule), was unsuccessful. During an interview on 04/29/26 at 11:31 a.m., ADON T stated he was responsible for the ambassador rounds for Resident #28. ADON T stated rounds should be done every day but there were some days he did not have time to complete. ADON T stated his last round was done on 04/27/26 and he did not look at the filter. ADON T stated it was important to ensure filters were cleaned to prevent an infection and ensure proper airflow. During an interview on 04/29/26 at 2:20 p.m., Unit Manager S stated she just started the management position on Monday (04/27/26) but she expected the filters to be cleaned/changed by the nurse on Wednesday nights. Unit Manager S stated she would be monitoring and overseeing by random rounds. Unit Manager S stated it was important to ensure filters were cleaned to prevent a respiratory infection. During an interview on 04/29/26 at 3:15 p.m., the DON stated the nurse on Wednesday night was responsible for cleaning/changing the filter. The DON stated he monitored by random spot checks and ambassador rounds. The DON stated there had not been any issues in the past. The DON stated it was important to cleaned/change the oxygen filter to prevent the possibility of infection. During an interview on 04/29/26 at 4:17 p.m., the Administrator stated he expected the filters to be cleaned/changed on Wednesday nights by the charge nurse. The Administrator stated the unit managers, DON and himself were responsible for monitoring and overseeing by random spot checks and daily ambassador rounds. The Administrator stated it was important to clean/change the oxygen filter to prevent Resident #28 from getting sick. Record review of the facility's Oxygen Administration, revised on 09/02/25 reflected . to administer oxygen to the resident with insufficient oxygen saturation.5 (b). clean the filters daily with soap and water.

Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 6 residents (Resident #1) reviewed for assessments: The facility failed to ensure Resident #1's Quarterly MDS assessment accurately reflected the use of antidepressants. This failure could place residents at risk for inadequate care due to inaccurate assessments. The findings were: Record review of Resident #1's face sheet, dated 04/07/2026, revealed an admission date of 11/26/2024 with diagnoses that included Alzheimer's disease (a progressive disorder that is the common cause of dementia (cognitive loss), anxiety (a group of mental illnesses that cause constant fear and worry), delusional disorder (a chronic condition characterized by the presence of one or more false beliefs), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypertension (high blood pressure), hyperlipidemia (elevated levels of any lipid (fats) in the blood), and osteoarthritis (a joint disease caused by the breakdown of cartilage leading to pain, stiffness and reduced mobility). Review of Resident #1's medication administration record, dated 020126-022826, revealed Resident # 1 received antidepressants daily Mirtazapine Oral Tabled 15MG Give 1 tablet by mouth at bedtime for sadness related to depressive disorders with a start date of 11/19/2025; Trazodone HCl Oral Tablet 50 MG Give 1.5 tablet by mouth at bedtime for sleeplessness related to depression with a start date of 11/19/2025, and Zoloft Oral Tablet Give 100mg by mouth one time a day for sadness related to depressive disorders with a start date of 11/26/2025. Record review of Resident #1's Quarterly MDS assessment, dated 02/25/2026, revealed Section N0415 High-Risk Drug Classes: Use and Indication, Resident #1 was identified as not receiving an antidepressant. During an interview with the MDS Coordinator RN A on 04/07/2026 at 1:25 p.m., the MDS Coordinator RN A stated she had completed the MDS. The MDS Coordinator RN A stated Resident #1's Quarterly MDS was coded as the resident had not received antidepressant medications. The MDS Coordinator RN A stated t Resident #1 received three antidepressant medications. The MDS Coordinator RN A stated she had made an error in data input on the MDS and provided her documentation for her assessment which did indicate Resident #1 was receiving antidepressant medications. The MDS Coordinator RN A stated she utilized the RAI 3.0 User's Manual as her tool for completion of the MDS assessments. During an interview with the DON on 04/07/2026 at 4:25 p.m., the DON stated Resident #1 received antidepressant medications and should have been coded as receiving antidepressant medications in the Quarterly MDS assessment. The DON stated inaccuracy of the MDS assessment could negatively impact care received. The DON stated that the MDS Coordinator is responsible for ensuring accuracy of the MDS assessments. During an interview with the Administrator on 04/07/2026 at 4:25 p.m., the Administrator stated that the accuracy of the MDS is important to ensure resident's needs are accurately reported. Record review of, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.18.11, October 2023, revealed, N0415C1. Antidepressant: Check if an antidepressant medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days).

Based on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for 1 of 10 residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure Resident #1's wheelchair was properly secured in the facility transport van on 12/05/2025. Resident #1 sustained a contusion to his head when the wheelchair tipped over as the van turned a corner during transport. This failure could place residents transported via facility van at risk for accidents resulting in serious injury. The findings were:Record review of Resident #1's face sheet dated 03/12/2026 revealed an [AGE] year-old male admitted [DATE] and readmitted [DATE] with diagnoses that included a cerebral infarction with hemiplegia (a stroke caused by reduced blood flow leading to brain tissue death that limits movement on one side of the body), Osteoarthritis (a joint disease where protective cartilage breaks down, causing bones to rub together), Diabetes Type II (a metabolic disorder where the body develops insulin resistance and cannot properly regulate blood sugar), Major depression disorder (a mental health condition characterized by persistent sadness, low energy and loss of interest) and overactive bladder (a condition characterized by sudden, uncontrollable urge to urinate).Record review of Resident #1's quarterly MDS dated [DATE] revealed no communication or comprehension deficits with a BIMS of 15 which indicated intact cognition. Resident #1 had no upper or lower extremity range of motion impairment, required the use of a wheelchair for mobility, was independent in eating, toileting, upper & lower body dressing, bed mobility, and transfers, required set-up assistance with bathing and supervision with extended gait distance. Resident #1 had hearing loss corrected with the use of a hearing aid, vision corrected with use of prescription glasses.Record review of Resident #1's care plan with target date of 04/25/2026 revealed ADL self-care deficit requiring minimal assistance and no mood or behavior concerns that interfered with daily care management. Record review of facility self-report dated 12/12/2025 revealed that Resident #1 sustained a contusion to back of his head when his wheelchair tipped over during transport in the facility transport van. Record review of Resident #1's EMR for the incident on 12/05/2025 that included Form 3613-A self-report indicated: Resident #1 was returning to the facility after an appointment in the facility wheelchair van when the van turned a corner and the wheelchair tipped over causing resident to hit his head resulting in a contusion. Resident of this incident was in close proximity to the facility and the RN Supervisor assessed, Resident #1 returned to the facility and after notification to the physician, was transported to the hospital for evaluation. Resident #1 was transported to the hospital via ambulance and returned to the facility same day with a head contusion and mild headache and no new orders. Record review of written statement from Van Driver A dated 12/05/2025 revealed she secured Resident #1's wheelchair with the straps and that one of the straps was not at the lowest position. Attempted phone interview with Van Driver A (no longer employed at this facility) was unsuccessful. Record review of Van Driver's A's employee training file revealed she had successfully completed drivers training and safety program on 07/21/2025. Record review of the written statement from the RN Supervisor B dated 12/05/2025 revealed that she was notified by Van Driver A of incident, travelled to van location, assessed Resident #1 for injury, returned resident to the facility and notified the physician. Statement indicates that the physician recommended hospital transfer for evaluation due to resident hitting his head. Attempted phone interview with RN Supervisor B (no longer employed at this facility) was unsuccessful. During an interview on 03/11/2026 at 12:55 p.m., Resident #1 stated that his wheelchair tipped over during transport on 12/05/2025 when the van turned a corner, and he hit his head on the bar. Resident #1 denied that the van was going too fast to maneuver the corner safely. Resident #1 stated he had a bump on [his] head and was transported to the hospital for a CT (a diagnostic procedure that uses x-rays and computer technology to create a detailed image). The resident stated he was told the CT was negative. Resident #1 stated he has no fear or anxiety or other adverse effects because of the fall and has no fear of utilizing the facility transport van and believes the facility did respond promptly and provide adequate nursing care and intervention. During an interview and observation on 03/11/2026 at 1:00 p.m., Van Driver C stated she was hired as a Van Driver on 02/19/2025 and received her certification for wheelchair restraint and procedures as well as hands on training prior to transporting a resident in the wheelchair van. Van Driver B stated that she will pick up the resident from then nurses station or his/her room once the charge nurse states that the resident is ready for transport. Van Driver C stated that in the event of an emergency during transport, she would pull-over and call 911, then call the facility Administrator or Director of Nurses. Observed Van Driver C secure a proxy resident in a standard wheelchair in the transport van and appropriately secure the wheelchair with the restraint straps provided as well as appropriately secure the proxy resident in the wheelchair with approved seat belt restraints. During an interview and observation on 03/11/2026 at 1:00 p.m., Transport Aide D stated that she had received training for the use of the transport van restraints as well as hands on training prior to her first resident transport. Transport Aide D stated that she believes refresher training is done yearly, but that the Administrator will complete spot checks sometimes to ensure the residents are safely secured in the van prior to leaving the facility. Observed Transport Aide D and Van Driver B secured the wheelchair for the proxy resident with no adverse findings. During an interview on 03/11/2026 at 1:00 p.m., Transport Aide E stated she received training by computer for the restraint use and received her certification prior to transferring from her nurse aid position to the Transport Aid position. Transport Aide E stated that she also completed hands on training and had to show the trainer she could properly secure the wheelchairs before she was allowed to complete her first transport ride. During an interview on 03/12/2026 at 10:00 a.m., the DON stated it is the responsibility of the nursing staff to ensure the residents are seated in an appropriately sized wheelchair with footrests prior to transport in facility transport van. The DON stated the transport aid or driver picks up the resident from the nurse's station or their room once the charge nurse verifies that he/she is ready of the transport. The DON stated it is the responsibility of the charge nurses and unit managers to ensure the residents are adequately seated and prepared for the van transport and he is ultimately responsible to ensure the nursing staff are completing their job duties. During an interview on 03/12/2026 at 10:30, the Administrator stated that he and the Regional Maintenance Director complete the training for newly hired staff for both van drivers and transport aides which include watching a video on the proper techniques and use of the wheelchair restraints that are utilized in the facility transport van as well as a hands on, return demonstration training for al drivers and transport aides. The Administrator stated he was not the Administrator at the time of this incident, but that he was aware all transports in the facility van were help for three days to ensure all drivers at that time received training on securing wheelchairs. The Administrator stated that he completes hands on training for both wheelchairs and motorized chairs and that the training is completed quarterly and as needed for any new hires. The Administrator stated that the training encompasses a driver inspection audit and a passenger securement safety audit and that since this incident, the facility requires two staff members (driver and assistant) for all transports. The Administrator stated that he is responsible for ensuring all employees hired a van driver and/or transport aid are properly trained and competent in their job skills to ensure resident's safety. Record review of facility policy titled HMR Veterans Services, Facility Transportation Policy, dated 11/26/2025, revealed Purpose: To provide safe transportation for facility residents to appointments and activities away from the facility grounds.Wheelchair residents must use vehicle lifts and be secured per manufacturer instructions and wheelchair secured using proper tie-downs.

Based on observation, interview, and record review, the facility failed to provide liquids consistent with the residents' needs for 2 of 3 (Resident #1 and Resident #2) residents reviewed for liquid inconsistency. 1. The facility failed to ensure LVN A checked the lunch tray appropriately for Resident #1, who required nectar-thick liquids on 11/10/25. 2.The facility failed to ensure Resident #1, and Resident #2 did not have thin liquids at their bedside on 11/11/25. These failures could affect residents by placing them at risk for aspiration and not receiving appropriate interventions to meet their current needs.Findings included: 1. Record review of Resident #1' face sheet dated 11/12/25, indicated a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included Parkinson's (a progressive brain disorder that affects movement, primarily caused by the death of brain cells that produce dopamine), and dysphagia (difficulty swallowing, where food or liquids cannot move easily from the mouth to the stomach). Record review of Resident #1's quarterly MDS assessment dated [DATE], indicated Resident #1 understood and was understood by others. Resident #1's BIMS score was 06, which indicated he was severely cognitively impaired. The MDS indicated Resident #1 was independent with eating. The MDS assessment indicated Resident #1 required a mechanically altered diet (change in texture of food or liquids, such as pureed food or thickened liquids). Record review of Resident #1's comprehensive care plan, revised on 05/07/25, indicated Resident #1 was at risk for choking/aspiration and dehydration related to his diagnosis of dysphagia. The care plan interventions were for staff to offer additional fluids within diet parameters and serve the diet as ordered. Record review of Resident #1's comprehensive care plan dated 10/27/25, indicated Resident #1's diet consisted of minced and moist ground texture, nectar-thickened liquids, no rice, gravy on all meats, related to his diagnosis of dysphagia for thickened fluids. The care plan intervention was for staff to serve the diet as ordered. Record review of Resident #1's order summary report dated 11/12/25, indicated Resident #1 had the following orders:*Regular diet with minced and moist ground texture, nectar-thickened liquids, no rice, gravy on all meats, with an order start date of 10/24/25. During an observation on 11/10/25 at 12:15 p.m., Resident #1 had a glass of water placed in front of him and was observed drinking twice from the glass. His meal ticket for lunch had a diet order for minced and moist ground texture and nectar-thickened liquids. During an observation and interview on 11/10/25 at 12:21 p.m., CNA B said she did not notice Resident #1's water was not nectar consistency. She said the nurse checked the trays, and she assumed it was correct. She said she thought Resident #1 was supposed to have nectar-thick liquids but went to ask the nurse to clarify it. CNA B came back and said Resident #1 should have had nectar-thick fluids. CNA B took Resident #1's thin liquid and replaced it with nectar-thick liquids. She said that since Resident #1 had thin liquids, it placed him at risk of choking. During an interview on 11/10/25 at 12:42 p.m., RN A said she was the nurse responsible for checking the trays in the dining room. She said she thought Resident #1 was on honey-thick liquids. She said she put the water on his lunch tray. She said she did not read the card correctly and it was an overcite. She said Resident #1 was at risk for aspiration because he received thin liquids. During an observation and interview on 11/11/25 at 9:47 a.m., Resident #1 had a bottle of water at bedside within reach. Resident #1 said, Yeah, I have been drinking it. It is almost empty. Resident #1 said he did not know who gave him the bottle of water or how he got it. During an observation and interview on 11/11/12 at 10:00 a.m., CNA C came into Resident #1's room and verified he had a bottle of water which contained thin liquids at his bedside. She said she was not aware how he received the bottle of water. She asked Resident #1 if he had been drinking the water, and he shook his head Yes. He said, He drank from the bottle yesterday and last night. She said Resident #1 was at risk of choking since he had drunk the thin liquids. She removed the water bottle from his bedside. During an observation and interview on 11/11/12 at 10:10 a.m., RN A said she was Resident #1's nurse. She said she had been in Resident #1's room this morning (11/11/25) but had not seen the water bottle on his bedside table. She said it was everyone's responsibility to ensure he did not have any thin liquids. She said Resident #1 was at risk for aspiration. 2. Record review of a face sheet dated 11/12/25 indicated Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia (deterioration of memory, language, and other thinking abilities), diabetes, and Schizoaffective (mental health condition that combines symptoms of schizophrenia (such as hallucinations and delusions) with mood disorder symptoms like depression or mania). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #2 understood and was understood by others. Resident #2's BIMS score was 06, which indicated he was severely cognitively impaired. The MDS indicated Resident #2 required assistance with eating. The MDS assessment indicated Resident #2 required a mechanically altered diet (change in texture of food or liquids such as pureed food or thickened liquids). Record review of Resident #44's care plan, revised 10/08/25, indicated he was at risk for dehydration (occurs when you don't have enough fluid in your body) related nectar thick liquids . The interventions were for staff to offer the fluids ordered. Record review of the Order Summary Report dated 11/12/25 indicated Resident #2 had an order for a Regular diet, Minced &Moist- Ground texture, Nectar consistency with a start date of 11/07/25. During an observation on 11/11/25 at 9:45 a.m., Resident #2 had thin liquid in a metal cup sitting on his dresser next to his bedside. During an interview on 11/11/25 at 10:17 a.m., Resident #2 said he drank from the metal cup every time he took his medication. During an interview on 11/11/25 at 1:10 p.m., the speech therapist said Resident #1 and Resident #2 were on nectar-thick liquids. She said both had been on the speech therapy case load. During an interview on 11/12/25 at 8:40 a.m., CNA C said that yesterday (11/11/25), after being questioned by the state surveyor, she went into Resident #2's room and looked in his metal cup and saw he had thin liquids in his cup. She said she poured it out and removed the cup. She said she was aware he had the metal cup but had never looked inside the cup. She said Resident #2 should have nectar-thick liquids and not thin liquids. She said he was at risk of choking if he swallowed thin liquids. During an interview on 11/12/25 at 12:16 p.m., the DON said she expected staff to follow the diet ordered. She said whoever served the tray should have ensured they were serving the correct liquid consistency. She said she randomly checked the dining rooms and rooms for the correct diets and liquid consistency. She said all staff were responsible for ensuring residents had the correct liquid consistency, and if they were not aware, they needed to ask. She said if the residents were served the incorrect fluid consistency, it could place them at risk of aspiration. During an interview on 11/15/24 at 12:40 p.m., the Administrator said he expected the staff to follow the diets and the signs for honey and nectar-thick liquids. He said the nurse was responsible for checking the tray cards and ensuring staff were following the prescribed diet for the residents while in the dining room. He said if the staff does not follow or serve the correct liquid consistency, we could place the residents at risk of choking. Review of the facility's policy titled, Thickened Liquids, revised January 2025, indicated, Purpose: to provide thickened liquids per physician's order. Procedure: 1. Speech therapy to screen and evaluate, then screen routinely for advancement 2. Obtain an M.D. order for treatment recommended and with appropriate terminology: nectar-like, honey-like, or pudding thick consistency. 3. Notify family and/or resident of any new liquid consistency or regimen. 4. Notify nursing staff and dietary. 5. Add to dietary list and tray cards. #11 Residents will not be provided with liquids with a thinner consistency than prescribed by the physician.

Based on observation, interviews and record review, the facility failed to ensure the necessary treatment and services, in accordance with comprehensive assessment and professional standards of practice, to prevent development of pressure injuries was provided for 1 of 6 Residents (Resident #74) reviewed for pressure injuries. 1. The facility failed to provide care to prevent pressure ulcer or injury development for Resident #74. Resident #74 broke his right ankle and a soft splint was applied on 07/13/24. The facility failed to obtain a clarification order from the doctor related to Resident #74's splnt care. Resident #74 developed 4 unstageable deep tissue injuries to his right foot and possible osteomyelitis. An IJ was identified on 02/05/25. The IJ template was provided to the facility on [DATE] at 4:57 PM. While the IJ was removed on 02/06/25, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on pressure ulcer prevention and management, cast and splint care, and turning and repositioning . This failure could potentially place residents at risk of development of pressure ulcers, worsening pressure ulcers, and infections. The findings included: Record review of the face sheet, dated 02/07/25, reflected Resident #74 was an [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses of dementia (memory loss) and diabetes mellitus (high blood sugar). The face sheet further revealed two stage 3 pressure ulcers to the right heel and left heel (wound caused from pressure with full-thickness skin loss) developed after admission and a stage 4 pressure ulcer to other site (wound caused from pressure with exposed muscle, tendon, or bone) developed after admission. Record review of the quarterly MDS assessment, dated 01/08/25, reflected Resident #74 had clear speech and was understood by others. The MDS reflected Resident #74 was able to understand others. The MDS reflected Resident #11 had a BIMS score of 11, which indicated moderately impaired cognition. The MDS reflected Resident #74 had no behaviors or refusal of care. The MDS reflected Resident #74 normally used a wheelchair and had impairment to both lower extremities. The MDS reflected Resident #74 required substantial/maximal assistance to partial/moderate assistance with bed mobility and transfers. The MDS reflected Resident #74 had one or more unhealed pressure ulcers/injuries and was receiving treatments that included: pressure reducing device for chair, nutrition or hydration interventions to manage skin problems, pressure ulcer/injury care, and applications of ointments/medications other than to feet. Record review of the comprehensive care plan, initiated on 04/17/24, reflected Resident #74 was at risk for complications related to edema to bilateral lower extremities. The interventions included: encourage elevation of bilateral lower extremities as tolerated. Record review of the comprehensive care plan, revised on 07/16/24, reflected Resident #74 had impaired mobility related to weakness. The interventions included: assist with positioning, transfers and ambulation as necessary and no weight bearing to right lower extremity. Record review of the comprehensive care plan, revised 07/16/24, reflected Resident #74 was at risk for complications related to fracture of right lower leg. The interventions included: no weight bearing to right lower extremity, consult with orthopedic doctor, follow up with orthopedic as ordered/needed, notify physician as needed, observe extremities every shift for signs of complications (redness, swelling, fever, poor circulation, pain) and intervene as appropriate, and provide proper body alignment and safety as possible. An intervention was added on 07/29/24 for right tall CAM boot on at all times; off only for showers. Record review of the discontinued and completed orders, between 04/29/24 and 7/26/24, reflected Resident #74 had no orders for the care of his soft splint that was placed on 07/13/24. Record review of the MAR/TAR, dated July 2024, reflected Resident #74 had no treatment or orders for splint care. The TAR reflected orders were started on 07/26/24 for pressure ulcer wound care. Record review of the body audit form, dated 07/12/25, reflected Resident #74 had redness and discoloration to his right knee, left ear lobe, left upper elbow, left lower forearm and hand, upper elbow, left inner elbow discoloration, left index knuckle, right inner forearm discoloration, and right small discoloration to hip after a fall that occurred on 07/12/24. The body audit form did not reveal any pressure ulcers. Record review of the emergency room records, dated 07/13/24, reflected Resident #74 had an ankle fracture and a soft splint was applied. The care instructions included: do not put weight on the splint, keep leg raised when sitting or lying down, keep cast or splint dry at all times, and place an ice pack over the injured area for no more than 15 to 20 minutes. The follow-up care instructions included: follow up with healthcare provider in 1 week, or as advised, if you were given a splint, it may be changed to a cast or boot after the swelling goes down. The instructions did not specify do not remove. Record review of the body audit form, dated 07/14/24, reflected Resident #74 had skin issues (such as redness, broken areas, darkened or bruised areas) to ears, elbows, lower arms, hands/fingers, and hips. The additional comments section reflected acute mildly displaced distal fibula fracture to right leg. (broken right leg at the ankle) The body audit form did not reveal any pressure ulcers. Record review of the total body skin assessment, dated 07/15/24, reflected Resident #74 had good elasticity, normal skin color, warm skin, normal moisture, and normal condition. The assessment reflected Resident #74 had no new wounds. Record review of the body audit form, dated 07/20/24, reflected Resident #74 had skin issues (such as redness, broken areas, darkened or bruised areas) to lower legs. The additional comments section reflected acute mildly displaced distal fibula fracture (broken right ankle) to the right leg. Cast remains on leg. Record review of the Braden Scale for Predicting Pressure Sore Risk assessment, dated 07/26/24, reflected Resident #74 had a score of 15, which indicated he was at risk for pressure ulcer development. Record review of Resident #74's progress notes from 07/04/24 to 08/03/24, reflected the following: 07/13/24 at 3:20 PM Resident #74 was hurting bad and screaming with pain to his ankle, he was sent to the emergency room . 07/13/24 7:40 PM Resident #74 returned from the hospital with a diagnosis of right ankle fracture. The note did not reflect any orders or care orders for a soft splint. 07/13/24 9:09 PM The NP was notified of Resident #74's return to facility. Verbal orders were obtained for pain medications. The note did not reflect any orders or care orders for a soft splint. The note did not reflect the NP was notified of the soft splint to his ankle. 07/14/24 2:57 PM The note did not mention a soft splint or care to Resident #74's right ankle. 07/14/24 9:39 PM The note did not mention a soft splint or care to Resident #74's right ankle. 07/15/24 3:23 PM Resident #74 was resting in bed with splint in place to right lower leg extremity. No neurovascular assessment was documented. 07/16/24 12:10 AM Resident #74 was lying in bed with splint in place to right leg. No neurovascular assessment was documented. 07/16/24 12:47 PM Resident #74's splint was intact. No neurovascular assessment was documented. 07/16/8:56 PM Resident #74 was in bed, required assistance of 2 person to reposition. The note stated soft cast was noted to right lower leg. No neurovascular assessment was documented. 07/18/24 11:31 PM The responsible party notified facility of the orthopedic doctor attempting to cancel Resident #74's appointment related to insurance information. Unit Manager voiced concerns of pain, resident begin non weight bearing, skin concerns, diet and quality of life with responsible party. 07/19/24 11:05 AM Resident #74 lying in bed with soft cast to right lower extremity. Resident #74 required Hoyer lift for transfers. No neurovascular assessment was documented. 07/19/24 7:16 PM Resident #74 was non-weight bearing to right leg and Resident #74 required a Hoyer lift for all transfers. The note did not mention the soft splint or a neurovascular assessment. 07/20/24 1:57 PM Resident #74 was non-weight bearing to right leg and Resident #74 required a Hoyer lift for all transfers. The note did not mention the soft splint or a neurovascular assessment. 07/21/24 2:26 AM Resident #74 was non-weight bearing to right leg and Resident #74 required a Hoyer lift for all transfers. The note did not mention the soft splint or a neurovascular assessment. 07/23/24 1:20 AM Resident #74 was non-weight bearing and awaiting a walking boot. The note did not mention the soft splint or a neurovascular assessment. 07/25/24 4:59 PM Resident #74's right leg in cast and required a mechanical lift for transfers to wheelchair. No neurovascular assessment was documented. 07/26/24 11:46 AM The director of rehab received clarification for the right lower extremity as non-weight bearing and wear right tall CAM boot at all times, remove only for showers; remove soft splint. 07/26/24 12:45 PM The Treatment Nurse documented the following unstageable wounds: 1. Unstageable deep tissue injury to right mid dorsal foot (top of right foot), which measured 5.5 cm x 2 cm. Unable to determine depth. (Later identified as a stage 4 pressure ulcer.) 2. Unstageable deep tissue injury to right plantar 5th metatarsal area (side of foot near 5th toe) which measured 1 cm x 1.5 cm. Unable to determine depth. (Later healed.) 3. Unstageable deep tissue injury to right heel which measured 1.5 cm x 2 cm. Unable to determine depth. (Later identified as a stage 3 pressure ulcer.) 4. Unstageable deep tissue injury to left heel which measured 2.5 cm x 3 cm. Unable to determine depth. (Later identified as a stage 3 pressure ulcer.) Record review of the Orthopedic progress note, dated 07/22/24, reflected Resident #74 was seen by the doctor with new orders for a right tall CAM walker boot x 99 months . The progress note did not specify do not remove the soft splint. Record review of the nursing progress note, dated 02/04/25, reflected Resident #74 had a vascular appointment in which they were concerned for osteomyelitis (bone infection) and ordered several x-rays to his right foot. Record review of the radiology results report, dated 02/05/25, showed Resident #74 had potential osteomyelitis to the distal second and third metatarsal (bones of the foot). Record review of the e-mailed statement, dated 02/05/25 at 9:22 PM, reflected the NP stated Resident #74 returned to the facility after a short acute hospital stay for a right ankle fracture. The NP stated the staff notified her of his return and were concerned there was no instructions on care for the splinted leg. The NP stated she instructed the staff to follow up with orthopedist for instructions on care, when she was asked about removal of the splint, she instructed them to leave it in place until guidance was received on care from orthopedist. During an interview on 02/03/25 beginning at 11:32 AM, Resident #74 stated he had developed wounds after he broke his leg at the facility. Resident #74 was unable to remember details of the incident as it happened in July 2024. During an observation and interview on 02/05/25 beginning at 8:54 AM, the Treatment Nurse performed wound care on Resident #74 in 3 locations, his left heel, top of his right foot, and his right heel. The Treatment Nurse explained the wound to his left heel started out as unstageable and was later staged at a stage 3 pressure wound. The Treatment Nurse stated the wound to his right heel was also started out as unstageable and was later identified as a stage 3 pressure wound. The Treatment Nurse stated the wound to the top of his right foot was unstageable at first and was later staged at a stage 4 because he had exposed tendon. The wound observed. It was open and tendon was observed. During an interview on 02/05/25 beginning at 2:33 PM, Unit Manager T stated Resident #74 moved to the C wing after he had already developed the pressure ulcers. Unit Manager T stated Unit Manager O would have been the one overseeing Resident #74's care during the month of July 2024. During an interview on 02/05/25 beginning at 2:38 PM, Unit Manager O said she did not remember Resident #74's care back in July 2024. Unit Manger O stated she was unsure she was even the one overseeing his care during that time. Unit Manager O said she was unsure what type of care Resident #74 needed prior to the fall on 07/12/24. Unit Manager O stated if a resident had a splint/cast the nurses should have been assessing the area every shift. Unit Manager O stated the site should have been assessed for redness, warmth, pain, or any rubbing or tightness. Unit Manager O stated it would have depended on the doctors' orders if it was removed or remained in place. Unit Manager O stated if orders were not obtained then the physician should have been contacted and order clarifications received. During an interview on 02/05/25 beginning at 2:43 PM, the Orthopedic doctor stated Resident #74 was seen at the facility after a right ankle fracture. The Orthopedic doctor stated Resident #74 had a soft splint at the appointment. The Orthopedic doctor stated he instructed Resident #74 and the people who accompanied him to the appointment that he was able to remove the splint for showers, therapy, and assessments. The Orthopedic doctor stated if he did not want the splint removed, he would have specified in his notes. During an interview on 02/05/25 beginning at 2:48 PM, LVN XX stated she was unable to remember Resident #74 receiving pressure ulcers or breaking his ankle. LVN XX stated she remembered he was always happy and required help with transfers. LVN XX stated if a resident was at risk for developing pressure ulcers, wound care should have been consulted and involved in the care. LVN XX stated if a resident had a soft splint, it should have been assessed for skin breakdown or redness. LVN XX stated a resident should have been turned and repositioned every 2 hours if they were immobile. LVN XX stated the nurse of the floor should have clarified orders with the physician if it did not specify removal of the splint for showers or assessment. During an interview on 02/05/25 beginning at 3:24 PM, CNA KK stated she remembered Resident #74 when he was on her hallway. CNA KK stated Resident #74 required a one person assistance with his ADLs including dressing, bathing, transfers, and personal hygiene. CNA KK stated when Resident #74 broke his leg, then he required a two person assistance with transfers and use of mechanical lift. CNA KK stated the nurses let them know he had a change of condition and she noticed he stayed in the bed more often. CNA KK stated the staff floated the leg that was hurt and changed his position when he asked. CNA KK stated she remembered he complained of pain to his leg. During an interview on 02/05/25 beginning at 3:56 PM, the Treatment Nurse stated she did not take over Resident #74's care until he developed the wounds. The Treatment Nurse said Resident #74 had a soft cast placed from the hospital and she was told by the nurse not to remove the splint until he followed up with the orthopedic doctor. The Treatment Nurse stated she assumed orders were in place by the nurse who received the orders. The Treatment Nurse stated once the wounds developed, she immediately assessed the wounds, notified the doctor, implemented treatment orders, and updated his care plan. During an interview on 02/05/25 beginning at 5:34 PM, Escort CNA OO stated she remembered taking Resident #74 to his orthopedic appointment on 07/22/24. Escort CNA OO stated the orthopedic doctor did not remove the dressing or splint to his right lower leg because it was fresh. Escort CNA OO said the orthopedic doctor said not to remove the splint until the CAM boot was received by the facility. Escort CNA OO stated she reported the information to LVN XX on the day of the appointment. Escort CNA OO stated LVN XX and the DOR asked for the orders from the orthopedic doctor on 07/26/24 and she told them again. Escort CNA OO stated the DOR then called the orthopedic office for clarification orders. Escort CNA OO stated Resident #74's family member was at the appointment with him and heard the same orders. During an interview on 02/05/25 beginning at 5:44 PM, the DON stated the NP gave the verbal order after Resident #74 returned from the emergency room with the soft splint to not remove it. The DON stated the orders should have been placed in the computer and documented. The DON stated she was looking for the orders. During an interview on 02/07/25 beginning at 12:52 PM, the DON stated she expected the nursing staff to ensure preventable measures were in place to prevent pressure ulcer development. The DON stated she expected orders to have been clarified if they were unclear. The DON stated interventions and order clarifications should have been documented to prove that things were completed and promote continuity of care. During an interview on 02/07/25 beginning at 1:15 PM, the Administrator stated she was not at the facility in July 2024. The Administrator stated she expected pressure ulcers to have been reviewed daily during the clinical stand up meetings. The Administrator stated if actions were needed, she expected the actions to have been completed immediately. The Administrator stated she expected the doctors' orders to have been followed and documented in the clinical record. The Administrator stated if it wasn't documented, it was not done. The Administrator stated it was important to ensure pressure ulcer prevention was implemented because it could affect the outcome of the health of the residents. Record review of the Wound Intervention and Prevention policy, dated 12/2023, reflected identify residents being at risk for alteration in skin integrity .limited transfer and bed mobility; bed/chair bound; unable to reposition self .assure proper tissue load management .reposition resident when in bed or in chair .use proper position technique and positioning device . Record review of the Cast Care policy, dated June 2024, reflected protect from moisture, position the cast to prevent the edge from pinching or pressing into the skin .observe for persistent pain/swelling .circulation checks - observe for warmth, color, edema, and adequate capillary refill to effected extremity every shift .elevate if needed . This was determined to be an Immediate Jeopardy (IJ) on 02/05/25 at 4:45 PM. The Administration and the DON were notified. The Administrator was provided the IJ template on 02/05/25 at 4:57 PM and a plan of removal was requested. The following plan of removal submitted by the facility was accepted on 02/06/25 at 8:26 AM and included the following: Immediate action: On 07/26/24, PT and Charge Nurse removed the soft cast and observed skin impairments. The Treatment Nurse was notified, the areas were evaluated, and the physician was notified. New orders for wound care were initiated. The soft cast remained off and a CAM boot was applied that could be removed for showers allowing skin checks. Care plans were initiated for the skin impairments. 100% of all available direct care staff will be trained on 02/05/25 by the DON or designee and all other direct care staff will be trained before their next scheduled shift on skin check procedures for residents with a splint or cast and wound care prevention. A post-test will be completed at the end of training to ensure effectiveness of training. 100% of all available licensed nurses will be trained on 02/05/25 by the DON/Designee on following physician's orders. All others will be trained before their next scheduled shift. The Wound Nurse received 1:1 (one on one) education on caring for a resident with a cast/splint, following physician's orders and wound care prevention per the Regional Nurse Consultant on 02/05/25. Skin audits were completed on all residents by the DON/Designees on 02/05/25. No new pressure injuries were identified during the audit. Care plans were audited for all residents with pressure ulcers and/or risk for pressure ulcers to ensure interventions were accurate and in place by the DON/Designee on 02/05/25. On 02/05/25, The DON/Designee reviewed current resident care needs for any resident with a device that is not/cannot be removed. No residents currently reside in the facility with devices that cannot be removed. On 02/05/25 100% audit of all residents was completed to ensure weekly skin checks are ordered. No issues identified. Pressure Ulcer QA tool will be completed on 02/06/25 by 11:00 AM, weekly X 4 weeks, the monthly X 2 months, and then quarterly. The results will be presented to the QAPI committee, and any areas of deficiency will be immediately addressed through education. Wound Care Prevention policy was reviewed, and no updates were indicated on 02/05/25 by Director of Clinical Operations. This policy was included in the above noted training. Medical Director was notified of IJ on 02/05/25 at 5:27 PM. Facility QAPI meeting will be held on 02/06/25 at 8AM to discuss POR. This Plan of Removal will be completed by 4PM on 02/06/25. On 02/06/25 the survey team confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: 1. During an interview on 02/06/2025 at 9:25 AM, the Medical Director said he had been notified of the immediate jeopardy. The Medical Director said the facility had sent him the reports to review and the facility was working on monitoring to prevent further issues. 2. Record review of Resident #74's nursing progress notes, dated 07/26/24, reflected the nurse removed the soft splint and noted skin impairments. The Treatment Nurse was notified, and the skin was assessed. 4 new pressure injuries were identified, and the doctor was notified. 3. Record review of Resident #74's TAR, dated July 2024, reflected new treatment orders were initiated and completed for the 4 new pressure injuries. The TAR also revealed a CAM boot was applied after the soft splint was removed . 4. Record review of the comprehensive care plan, dated 07/26/24, reflected Resident #74 had care plans in place for the 4 pressure areas identified after the soft splint was removed. 5. Record review of the shower/bath sheet used for the skin audit, dated 02/05/25, reflected all residents received a skin assessment with no new skin areas identified. 6. Record review of the care plan detail report used for the care plan audit, dated 02/05/25 - 02/06/25 reflected all residents with pressure ulcers or residents at risk for pressure ulcers were reviewed and updated. 7. Record review of the order summary report, dated 02/05/25, reflected all residents had an order for weekly skin reviews. 8. Record review of the Pressure Ulcer QA tool, dated 02/06/25, reflected each resident identified with pressure ulcers, including Resident #74, had no identified issues. 9. Record review of the QAPI sign-in sheet, dated 02/06/25 at 8 AM, reflected the meeting was held with multiple department heads in attendance. 10. Record review of the in-service training on wound intervention, prevention, and turning and repositioning, un-dated, reflected education was provided to the facility staff. There were 64 signatures. 11. Record review of the pressure ulcer prevention post-test, dated 02/05/25 to 02/06/25, reflected CNA X, CNA DD, CNA EE, CNA FF, CNA GG, CNA F, CNA HH, CNA KK, CNA LL, CNA MM, CNA NN, CNA PP, CNA QQ, CNA RR, CNA SS, CNA UU, CNA VV, CNA WW, Escort CNA OO, Escort CNA TT, MA Y, MA Z, MA W, MA BB, MMA CC, LVN H, LVN K, LVN G, LVN L, LVN M, LVN N, LVN P, LVN Q, LVN V, RN AA, Unit Manager O, Unit Manager R, Unit Manager T, Unit Manager U, Unit Manager A, Treatment Nurse, MDS Coordinator D, Quality Assurance Nurse, and ADON S were able to answer all questions appropriately including turning and repositioning residents at risk for pressure ulcers at least every 2 hours, factors that could increase the risk for pressure ulcers, and the purpose of using pressure-reliving devices. 12. Record review of the in-service training on cast care, undated, reflected education was provided to facility staff. There were 64 signatures. 13. Record review of the cast care post-test, dated 02/05/25 to 02/06/25, reflected CNA X, CNA DD, CNA EE, CNA FF, CNA GG, CNA F, CNA HH, CNA KK, CNA LL, CNA MM, CNA NN, CNA PP, CNA QQ, CNA RR, CNA SS, CNA UU, CNA VV, CNA WW, Escort CNA OO, Escort CNA TT, MA Y, MA Z, MA W, MA BB, MMA CC, LVN H, LVN K, LVN G, LVN L, LVN M, LVN N, LVN P, LVN Q, LVN V, RN AA, Unit Manager O, Unit Manager R, Unit Manager T, Unit Manager U, Unit Manager A, Treatment Nurse, MDS Coordinator D, Quality Assurance Nurse, and ADON S were able to answer all questions appropriately including monitoring warmth, color, adequate capillary refill every shift, and notifying the physician or nurse if resident is complaining of severe pain. 14. Record review of the in-service training on physician orders, dated 02/05/25, reflected the nurses were provided education on ensuring clear communication of orders, documentation of orders, verifying orders with care team, implementing orders timely, monitoring, and evaluating outcomes and engaging the family and resident. There were 26 signatures. 15. Record review of the employee counseling form, dated 02/05/25, reflected the Treatment Nurse was provided a verbal warning. The employer statement was a resident returned to the facility on [DATE] with a soft splint. The treatment nurse did not ensure that appropriate treatment orders were in place for splint care to ensure the resident was free from complications. 16. During an interview on 02/06/25 between 1:30 PM and 3:41 PM, CNA X, CNA DD, CNA EE, CNA FF, CNA GG, CNA F, CNA HH, CNA KK, CNA LL, CNA MM, CNA NN, CNA PP, CNA QQ, CNA RR, CNA SS, CNA UU, CNA VV, CNA WW, Escort CNA OO, Escort CNA TT, MA Y, MA Z, MA W, MA BB, MMA CC, LVN H, LVN K, LVN G, LVN L, LVN M, LVN N, LVN P, LVN Q, LVN V, RN AA, Unit Manager O, Unit Manager R, Unit Manager T, Unit Manager U, Unit Manager A, Treatment Nurse, MDS Coordinator D, Quality Assurance Nurse, and ADON S were able to verbalize residents at risk for pressure ulcers, interventions for pressure ulcer preventions, procedure for turning and repositioning, and procedures for cast/splint care. 17. During an interview on 02/06/25 between 1:30 PM and 3:41 PM, LVN H, LVN K, LVN G, LVN L, LVN M, LVN N, LVN P, LVN Q, LVN V, RN AA, Unit Manager O, Unit Manager R, Unit Manager T, Unit Manager U, Unit Manager A, Treatment Nurse, MDS Coordinator D, Quality Assurance Nurse, and ADON S were able to verbalize the correct procedure for obtaining physician orders including when to clarify orders and documentation of the orders. The Administrator and DON were informed the IJ was removed on 02/06/25 at 3:51 PM. The facility remained out of compliance at a scope of pattern and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as possible and provided supervision to prevent avoidable accidents for 1 of 5 residents (Resident #134) reviewed for supervision. The facility failed to ensure Resident #134 received adequate supervision to prevent exiting the facility without facility knowledge on 01/25/2025, when Resident #134 was found outside sitting on the curb of the facility's parking lot with her wheelchair tipped over. The facility failed to ensure adequate interventions were placed for Resident #134 after exit seeking attempts on 11/18/2024 and 01/25/2025. The facility failed to review Resident #134's exit incidents to determine triggers that increased her risk for elopement and develop person centered interventions to prevent elopement. An Immediate Jeopardy (IJ) was identified on 02/04/2025 at 3:20 PM. The IJ template was provided to the facility on [DATE] at 3:40 PM. While the IJ was removed on 02/06/2025, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of unsafe wandering, accidents, and injuries. Findings included: Record review of a face sheet dated 02/04/2025 indicated Resident #134 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance , mood disturbance, and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), chronic obstructive pulmonary disease (chronic inflammatory lung condition that affects the respiratory system), and nicotine dependence (use of tobacco products, cigarettes). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #134 was understood and understood others. The MDS assessment indicated Resident #134's BIMS score was a 3, which indicated her cognition was severely impaired. Resident #134's MDS assessment indicated she did not exhibit wandering. The MDS assessment indicated Resident #134 used a wheelchair. The MDS assessment indicated Resident #134 was dependent on staff for toileting, showering/bathing and lower body dressing and required partial/moderate assistance with personal hygiene and substantial/maximal assistance with upper body dressing. Record review of Resident #134's care plan last reviewed 01/03/2025 indicated, she was at increased risk of confusion and disorientation related to a diagnosis of dementia to assist her with decision making, observe for changes in mental status, and use diversional activities as needed. Resident #134's care plan indicated she required supervision with smoking per the facility policy that she was to be supervised by staff until cigarette was finished and properly disposed of. Resident #134's care plan indicated she exhibited exit seeking behavior with a goal that the resident would not leave the building unattended through the next review date. Interventions included to admit to the special care unit, attempt diversional activities as needed, contact the physician and family of attempts to leave the facility, observe frequently, personal secure alarm as ordered, redirect resident as needed, and routine risk assessment. Record review of Resident #134's Order Summary Report dated 02/06/2025 indicated admit to special care unit (secure unit) with a start date of 01/25/2025. Record review of Resident #134's January 2025 Treatment Administration Record indicated: Check functionality and visualization of wander guard/exit management system through wand or alarmed door every night shift with a start date of 11/18/2024 and discontinued date of 01/27/2024 indicated it was completed 01/01/2025-01/25/2025. Visualization of wander guard/exit management system to right wrist of resident every day shift with a start date of 11/19/2024 and a discontinue date of 01/26/2025 indicated it was completed 01/01/2025-01/26/2025. Record review of Resident #134's Elopement Evaluations indicated: Effective date: 11/18/2024 indicated Resident #134 had a history of elopement or attempted leaving the facility without informing the staff, resident verbally expressed the desire to go home packed belongings to go home or stayed near an exit door, wandering behavior with a pattern, and goal directed (specific destination in mind, going home), there were no clinical suggestions indicated. Effective date: 12/12/2024 indicated Resident #134 had a history of elopement or attempted leaving the facility without informing the staff, resident verbally expressed the desire to go home packed belongings to go home or stayed near an exit door and did not wander. Effective date: 01/25/2025 indicated Resident #134 had a history of elopement or attempted leaving the facility without informing staff, resident wandered aimlessly or non-goal-directed (confused, moves with purpose, may enter others' rooms and explore others' belongings), resident's wandering behavior was likely to affect the privacy or others and likely to affect the safety or well-being of self/others, no clinical suggestions were indicated. Record review of Resident #134's progress notes indicated: 11/18/2024 at 10:15 AM, Called to front lobby for fall. Upon arrival resident was seated on the floor in front of her wheelchair. No staff witnessed the fall. Resident was confused and searching for her family member. Resident will be staying in close proximity to a staff member to ensure safety. No noted injury. Assisted back to wheelchair using gait belt and two staff. Signed by RN OOO 11/18/2024 at 10 15 AM, LATE ENTRY Elopement Evaluation: History of elopement while at home: No. Wandering behavior a pattern or goal-directed: Yes. Wanders aimlessly or non-goal-directed: No. Wandering behavior likely to affect the safety or well-being of self / others: No. Wandering behavior likely to affect the privacy of others: No. Recently admitted or readmitted (within past 30 days) and has not accepted the situation: No. Elopement Score: 3.0 (Score value of 1 or higher indicates Risk of Elopement) Actioned clinical suggestions: (none were listed). Signed by LVN V. 11/18/2024 at 10:15 AM, Date / Time of Fall: 11/18/2024 10:14 AM Fall was not witnessed. Fall occurred elsewhere. Other fall location: Lobby Activity at the time of fall: Attempting to leave The reason for the fall was not evident. Pre-Fall: Fall Risk Score: 2 Post-Fall: Fall Risk Score: 2 Did an injury occur as a result of the fall: No. Did fall result in an ER visit/hospitalization : No. Provider: medical director Time notified: 11/18/2024 Notified of: Unwitnessed fall with no injury and attempt to elope . Signed by LVN V 11/18/2024 at 12:00 PM, Intervention put in place: 1.) Resident added to The Falling Star Program; resident to be monitored and observed by staff for any unsafe practices with staff intervening if/when needed as a part of The Falling Star Program. 2.) Placement of a wanderguard to her wrist as she presents with intermittent confusion - staff will be alerted via system if/when resident leaves facility. This resident's current Fall Care Plan to be reviewed and revised as appropriate. This Quality Assurance Nurse in collaboration with Unit Manager, Charge Nurse and CNA's regarding most recent fall encounter, details of fall encounter and interventions placed for implementation . Signed by RN BBB 11/18/2024 at 1:52 PM, Resident was sitting on the floor with her right knee bent leaning against the bed, grippy socks on call light within reach, wheelchair on opposite side of the bed out of reach, fall mat in place. Resident had pajama's on with housecoat on. Resident was chatting and laughing about fall. Resident stated, I just slid off the bed, I was going to check on my family member. I just slid off the bed, I was going to check on my family member. Signed by LVN V 11/18/2024 at 2:58 PM, Resident was going through the front door in her wheelchair, notified by peer. Resident stated she was looking for I-30, I just need to get home I'm looking for I-30 and my family member brought me here last night. Notified RN Supervisor and assisted in reorienting resident to the present. Resident was assisted back into the facility and taken down to her room, attempted to reinforce this is where she lives now. Showed her the room with her name on it. She acknowledged it was room however she continued to think she would be leaving to go home with her family member. She was offered a snack which she accepted and placed in front of her TV with the show she likes to watch. Resident appeared to be settled at that time. Instructed the CNAs to monitor her whereabouts. Signed by LVN V 11/18/2024 at 3:05 PM, Elopement Evaluation: History of elopement while at home: No. Wandering behavior a pattern or goal-directed: No. Wanders aimlessly or non-goal-directed: No. Wandering behavior likely to affect the safety or well-being of self / others: No. Wandering behavior likely to affect the privacy of others: No. Recently admitted or readmitted (within past 30 days) and has not accepted the situation: No. Elopement Score: 0.0 Actioned clinical suggestions: (none listed). Signed by LVN V. 11/18/2024 at 3:22 PM, Resident was attempting to go through the front doors and fell on the floor when attempting to open the door. Notified by receptionist. Resident has nonslip socks on, pajamas and housecoat on sitting directly in front of the wheelchair. I don't know what happened, I fell . RN Supervisor was present, resident was assessed for injury and had none. Blood pressure 150/96, Pulse 114, Respirations 20, Temperature 97.5, oxygen saturation-97% on room air. A complete body assessment was performed no injuries were noted. Neuro checks initiated and gait belt was placed around the resident, and she was assisted to a standing position and placed back in her chair. A wander guard was placed on her right wrist. Notified the doctor, notified resident responsible party and family member stated they had been with her yesterday and they did not notice increased confusion. Resident is very confused today stating she needs to leave and find her family member. Resident went into the transport office and sat with an employee had some snacks and neuro checks were initiated. Labs ordered and pending. Signed by LVN V 11/18/2024 at 3:24 PM, Elopement Evaluation: History of elopement while at home: No. Wandering behavior a pattern or goal-directed: Yes. Wanders aimlessly or non-goal-directed: No. Wandering behavior likely to affect the safety or well-being of self / others: No. Wandering behavior likely to affect the privacy of others: No. Recently admitted or readmitted (within past 30 days) and has not accepted the situation: No. Elopement Score: 3.0 Actioned clinical suggestions: (none listed). Signed by LVN V 01/25/2025 at 7:48 PM, This nurse was notified by oncoming staff that resident was sitting outside on the front porch curb, upon going to assess resident noted sitting on the curb on her buttocks with her wheelchair tipped over in front of her over the curb. Resident voiced I was going to go have a cigarette Vital signs as follows temperature 97.3 blood pressure 132/89 pulse 62 blood sugar 101 respirations 18 oxygen saturation 93%: Resident noted with no wander-guard on her wrist resident was assisted back to her wheelchair she is able to move all extremities without facial grimacing or pain. No internal or external rotation noted to bilateral lower extremities resident denies any pain and continues to voice that she wants to go smoke. Neuros initiated Full head to toe assessment completed with no injury noted. Environmental assessment completed with noted wander- guard observed intact sitting on her bedside table of her shared room: DON notified, Resident to be transferred to memory support unit (secure unit) for safety at this time. Responsible party notified of room change to memory support unit. Immediate Intervention is to transfer resident to memory support unit related to resident removing her wander-guard Medical Director notified of potential fall and room change. Signed by RN DDD 01/25/2025 at 7:48 PM, Elopement Evaluation: History of elopement while at home: No. Wandering behavior a pattern or goal-directed: No. Wanders aimlessly or non-goal-directed: Yes. Wandering behavior likely to affect the safety or well-being of self / others: Yes. Wandering behavior likely to affect the privacy of others: Yes. Recently admitted or readmitted (within past 30 days) and has not accepted the situation: No. Elopement Score: 5.0 Actioned clinical suggestions: (none listed). Signed by RN DDD During an interview on 02/04/2025 at 9:58 AM, CNA CCC said when Resident #134 was not on the secure unit she wandered, and she tried to go out of the front door. CNA CCC said Resident #134 would just get to the doors. CNA CCC said Resident #134 always tried to get outside the door and she would do it after visiting with her family member. CNA CCC said Resident #134 had a wander guard. CNA CCC said the day Resident #134 was found outside she had left her shift at 6 PM. CNA CCC said when she left Resident #134 was in her room. During an interview on 02/04/2025 at 10:48 AM, Unit Manager U said on 01/25/2025, she was on call and was called in to work. Unit Manager U said that night she parked in the front parking spot when she came in and she could see somebody by the handicap parking space. Unit Manager U said when she went to park, she put her lights on, and she could tell it was Resident #134. Unit Manager U said she called the RN supervisor to tell her they needed a blood pressure cuff to assess Resident #134. Unit Manager U said Resident #134's wheelchair was on the left tipped over. Resident #134 was alert and oriented x2, which was her normal. Unit Manager U said she asked her what she was doing, and Resident #134 said she was going to smoke a cigarette. Unit Manager U said the RN supervisor came out and Resident #134 had no pain, no breaks to her skin. Resident #134 repeated she was going to smoke a cigarette. Unit Manager U said Resident #134 was taken back inside the facility, and they took her to smoke. Unit Manager U said Resident #134 continued to voice she was going back out, so they completed an elopement screen, and she was transferred to the unit. Unit Manager U said Resident #134 had pulled off her wander guard, that it was still snapped together, and it was laying on her over bed table. Unit Manager U said Resident #134 was moved to the secure unit that same night. Unit Manager U said, I want to say I came around 7 PM that night. Unit Manager U said RN DDD was the RN supervisor that night. Unit Manager U said she could not recall who the CNAs were that night. Unit Manager U said she did not recall if Resident #134 had a history of elopement, but she had exhibited exit seeking behaviors in November 2024. Unit Manager U reviewed Resident #134's electronic health record and indicated the incident for Resident #134 on 01/25/2025 was timed at 7:48 PM. Unit Manager U said if a resident was experiencing exit seeking behaviors they would run labs, if they continued they would complete an elopement screen, and they moved them to the memory care unit as applicable. Unit Manager U said if a resident was exit seeking they would bring the resident back in, conduct an assessment, and check if they had a physical need that needed to be addressed, check for urinary tract infections, constipation, if redirection was not effective a wander guard would be applied, and if the exit seeking continued the Resident would be placed on the secure unit. Unit Manager U said typically the wander guard was tried first, and if questionable they would go to the DON and collaborate with her to determine the need for placement on the secure unit vs use of the wander guard. Unit Manager U said the nurses should be actively looking to see that the wander guard was on the residents, and she encouraged them to put it on the resident's wrist, so they did not fall from messing with it if it was on the leg. During an interview on 02/04/2025 at 11:48 AM, the DON said on 11/18/2024 Resident #134 was trying to go through the front door, she fell , a wander guard was placed on her, labs were conduced because that was not normal for her. The DON said Resident #134 usually stayed in her bed and just got up to smoke. The DON said if a resident was having exit seeking behaviors that was out of their normal, they completed an elopement scree. It the resident was exit seeking and had a wander guard then they would go on the secure unit for their safety. The DON said they did a step procedure of putting the wander guard on first to see if they could be controlled. The DON said that was the first defense. If the resident was up and walking that would be considered, they checked for the resident's mobility. Since Resident #134 was wheelchair bound and slow to move in her condition, the wander guard was the best option for her. It depended on the resident's level of mobility and how aggressive they were when trying to leave. If they were truly exit seeking, they always looked at making sure they had a wander guard in place. The DON said to her knowledge Resident #134 did not attempt to exit seek prior to November 2024. The DON said if residents were exit seeking or attempting to elope, they conducted the elopement evaluation. The DON said the wander guard should be checked every shift to ensure it was in place, and the functionality of the wander guard was checked every night. The DON said the nurses should be documenting every shift that the wander guard was in place, one of the checks indicated the wander guard was on and the other indicated the check for the functionality of the wander guard. The DON said on 01/25/2025 Resident #134 went outside and fell at the end of the porch, and that was when they placed her in memory care (secure unit). The DON said Resident #134 was found outside by Unit Manager U. The DON said she did not think Resident #134 had her wander guard on at the time. The DON said she thought at that time was when Resident #134 was staying in the bed all the time, and they had reviewed and assessed to ensure it was no longer required. The DON said she thought she was one of the ones that had a change and did not have it on. The DON said she had asked when the last time Resident #134 was seen on 01/25/2025 and RN DDD said she had seen her 6-7 minutes prior to Unit Manager U finding her outside. The DON said she did not remember if any in-services were conducted related to this incident that she would look and provide them, if they were conducted (none were provided upon exit to the facility). The DON said the residents were not re-evaluated to see if anyone else was at risk of elopement. The DON said they evaluated the residents minute to minute if they had a change. The DON said she remembered Resident #134 had removed her wander guard the night of 01/25/2025 and placed it on her nightstand, and that was why she went to memory care (secure unit). The DON said that night, 01/25/2025, she had the staff check the residents' wander guards to ensure they were in place. During an interview on 02/04/2025 at 12:38 PM, the Administrator said she expected the staff to follow the elopement policy for the need for a wander guard or secure unit placement. The Administrator said this would be completed by the social worker or nursing that they worked together on these things. The Administrator said when Resident #134 was found outside on 01/25/2025, an incident report was completed and the DON took care of it all since she was just an interim administrator. The Administrator said the wander guards should be checked and assessed to ensure the residents did not elope and for the safety of the residents. During an observation and interview on 02/04/2025 at 12:58 PM, Unit Manager U walked outside and indicated to the state surveyor where she found Resident #134 the night of 01/25/2025. Unit Manager U said she had seen Resident #134 sitting on the curb where the handicap parking space was. Unit Manager U said it appeared like Resident #134's wheelchair had rolled down the little ramp and tilted over. The location where Resident #134 was found was approximately 40 feet from the facility's front door entrance. During an interview on 02/04/2025 at 3:48 PM, CNA HHH said the night (01/25/2025) Resident #134 got out, Resident #134 was trying to leave, and they had caught her a couple times that evening at the double doors (the front entrance of the facility). CNA HHH said they brought her back to the hall and tried to watch her. CNA HHH said she knew when Resident #134 got out she was in the shower room. CNA HHH said they kept leaving her at the nurse's desk, and the CNA she was working with tried to lay her down. CNA HHH said she notified RN DDD that Resident #134 was trying to leave, and RN DDD also saw Resident #134 was trying to leave. CNA HHH said they tried to keep an eye on Resident #134 and do one-on-one, but they were short that night. CNA HHH said it was just her and CNA KKK. CNA HHH said since she arrived for her shift Resident #134 was trying to leave. CNA HHH said when a resident was exit seeking, she tried to redirect them and bring them back in and keep them with her. CNA HHH said she tried to figure out what they were wanting so she could give it to them. CNA HHH said she believed Resident #134 was wanting to go smoke, and they were not able to take her to smoke at that moment. CNA HHH said it was important to ensure the residents did not leave the facility without their knowledge, so they did not get out and get hurt. During an interview on 02/04/2025 at 4:01 PM, RN DDD said she did not remember where in the building she was when she received the phone call from Unit Manager U that Resident #134 was outside. RN DDD said Unit Manager U had gone to the facility to relieve someone and she saw Resident #134 close to the parking lot she was sitting on the curb. Unit Manager U said Resident #134 was outside, and RN DDD ran out and Resident #134 was sitting on the curb and the wheelchair was dumped forward. RN DDD said she did not know if Resident #134 had fallen. They assessed Resident #139, and she did not have any injuries. RN DDD said Resident #134 told them she was going to smoke so they brought her back into the facility. RN DDD said she wondered why the doors did not alarm, and when they went back to Resident #134's room to see if she had any bruising, RN DDD noticed Resident #134 did not have her wander guard on. It was sitting on the bedside table like Resident #134 had slipped it off. RN DDD said she notified the DON, and they ended up taking Resident #134 to the memory care (secure) unit. RN DDD said she checked the residents' wander guards, and they were all in place. RN DDD said Resident #134 always went up and down the halls wanting to smoke even if it was not the scheduled time. RN DDD said on 01/25/2025, Resident #134 kept talking about going to smoke up and down the halls, and RN DDD told the staff, Y'all keep an eye on her. RN DDD said they had seen her at the doors exit seeking, and she wanted to go smoke. RN DDD said they just redirected her back. RN DDD said she told the CNAs to watch her until they took her to smoke. RN DDD said she was at the nurse's station the last time she saw Resident #134. RN DDD said she could not remember the timeframe between when she last saw her before Unit Manager U called her. RN DDD said, it was crazy that night. RN DDD said it was important to ensure the residents did not go outside without staff knowledge to keep the residents safe and for nothing to happen to them. During an interview on 02/05/2025 at 7:39 AM, CNA KKK said he remembered Resident #134 tried to go out of the front doors a couple times prior to being found outside the night of 01/25/2025. CNA KKK said Resident #134 kept trying to go out of the doors because she wanted to smoke. CNA KKK said they caught her, but when he went to care for his residents, he guessed at some point Resident #134 ended up getting out. CNA KKK said he was in a patient room when it happened. CNA KKK said he did not remember the timeframe from the last time he saw Resident #134 to when she was found outside. CNA KKK said RN DDD was aware Resident #134 was attempting to leave and wanted to go smoke, and they were trying to keep an eye on her. CNA KKK said he was not assigned to care for Resident #134 that day (01/25/2025), and he could not remember who the CNAs were that night. During an interview on 02/06/2025 at 4:37 PM, LVN V said on 11/18/2024 Resident #134 was exit seeking, and she thought they may have tested her for a UTI. LVN V said that was not Resident #134's normal behavior. LVN V said Resident #134 was trying to go home. LVN V said a wander guard was placed on Resident #134, they called her family member, and LVN V tried to keep Resident #134 close to her, but LVN V was doing treatments and other things. LVN V said they tried to keep Resident #134 at the nurse's station and in LVN V's line of sight, but when they turned their back Resident #134 would shoot out. LVN V said the receptionist alerted them to Resident #134 exit seeking on 11/18/20024. LVN V said she thought her family member came by later that day. LVN V said Resident #134 said if she could smoke, she would lay down. Record review of the facility's policy, Elopement, revised August 2013, indicated, To provide early identification of residents at risk for elopement and provide a secure environment. 1. Upon admission, quarterly, and with significant change, the resident will be screened for elopement risk utilizing the elopement screen form. 2. If the resident is considered to be at risk for elopement, preventative measures will be implemented: a. A care plan problem addressing the risk of elopement with a new preventative measure addressing each elopement. b. Preventative measures such as a door alarm system or other devices may be used taking into account the least restrictive measure necessary to reduce elopement risk. 3. Nursing to check placement of security bracelet each shift and function of bracelet each day. Record both in the clinical record . 5. It is the responsibility of staff members to report to a nurse if a resident attempts to leave facility. 6. Staff members will be trained on the elopement policy and procedures during orientation and ongoing . 5. The facility has an eyes on policy where residents are observed every two hours or more frequently if deemed necessary. 6. The facility completes a care plan on all residents who are at risk for elopement to identify to the staff interventions to attempt to prevent elopement from the facility . This was determined to be an Immediate Jeopardy (IJ) on 02/04/2025 at 3:20 PM. The facility Administrator and the DON were notified. The Administrator was provided with the IJ template on 02/04/2025 at 3:40 PM and a Plan of Removal was requested. The facility's plan of removal was accepted on 02/05/2025 at 10:15 AM and included the following: PLAN OF REMOVAL Facility Date: 2/4/2025 Immediate action: Upon notification the resident was assisted to re-enter the facility and assessed per RN on 1/25/25 at 1948 (7:48 PM) with no injuries noted. The MD and responsible party were notified with new orders for resident to move to the secured memory care unit. The resident's care plan was updated on 2/4/2025 to include personalized interventions and potential triggers for exit seeking behavior by the Director of Nursing and/or Social Worker. The new interventions added include triggers that may cause the resident to exit seek and interventions staff can use to redirect the resident. 100% of available staff that provide care to the resident will be trained on 2/5/2025 by 10:00 a.m. and all others will be trained prior to their next scheduled shift by the Director of Nursing/Designee. 100% of all available staff will be trained on 2/4/2025 and all other staff will be trained before their next scheduled shift on elopement procedures and managing exit seeking behaviors by the Director of Nursing and/or designee. A posttest will be completed at the end of training to ensure effectiveness of training. Social Workers were educated on 2/5/2025 by the DON on resident specific care plan interventions and identifying triggers related to exit seeking behaviors. Elopement drills will be conducted on an ongoing quarterly basis to include all shift beginning with day shift on 2/5/2025 by 4 pm. Elopement Risk book will be reviewed and updated by Social Worker/Designee on 2/5/2025. This book contains identification information on residents at risk for wandering. Picture of resident as well as face sheet are included. Book is available to all staff with copy at receptionist desk and on each nursing unit. 100% of all available staff will be trained on the elopement book by Social Worker/designee on 2/5/2025 by 4 pm. All other staff will be trained before their next scheduled shift on the elopement book. If a resident exit seeks or has an elopement attempt/incident staff have been educated on what interventions to implement as part of the elopement/exit seeking training beginning on 2/4/2025. All doors with the wanderguard system will be checked to ensure proper function on 2/5/2025 by facility maintenance staff. Elopement Risk will be completed on all residents by DON/Designee by 2/5/25. Any resident identified with elopement risk will have interventions in place. These will include but not be limited to Wander Guard, Secure Unit, frequent checks and the Care Plan will be updated. These updates will reflect resident specific interventions. Residents with any risk will have interventions implemented. Elopement policy was reviewed and updated as indicated on 2/4/2025 by Regional Clinical Consultant. This was included in training being provide to staff on Elopement. As a component of the elopement policy, the Electronic Monitoring policy was updated to reflect changes made to the Elopement Risk Assessment. Medical Director was notified of IJ on 2/4/2025 at 5:47 PM. Facility QAPI meeting will be held on 2/5/2025 at 8 AM to discuss POR. This Plan of Removal will be completed by 4:00 PM on 2/5/2025. On 02/06/2025 the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of Resident #134's care plan indicated it was revised on 02/04/2025 to include personalized interventions and triggers for exit seeking behavior. Record review completed on all residents' Elopement Risks, and reviewed the care plan of all residents who were at risk for elopement to ensure their care plans included resident specific interventions. Record review completed of the Elopement Policy and the Electronic Monitoring policy to ensure it was updated. Record review completed of the Elopement Drill Checklist and Elopement Drill Documentation Forms dated 02/05/2025. Record review completed of the Quality Assurance Performance Improvement (QAPI) facility meeting sign in sheet dated 02/05/2025, time 8 AM. Record review completed of the in-service sign in sheet for Elopement/Exit Seeking dated February 4th and 5th, 2025 indicated 148 staff signatures. Record review completed of the in-service sign in sheet for the Elopement Book dated 02/05/2025 indicated 94 staff signatures. Record review completed of all the staffs' post tests Elopement/Exit Seeking Post-Test dated 02/04/2025 and 02/05/2025. During observations made starting at 02/06/2025 at 9:09 AM, confirmed the elopement books were at the receptionist desk and on each nursing unit. During observations made starting at 02/05/2025 at 3:16 PM, all doors with the wander guard system were checked to ensure proper functioning with Maint[TRUNCATED]

Based on interview and record review, the facility failed to implement written policies to prevent abuse, neglect, and exploitation for 1 of 10 (Resident #1) residents reviewed for abuse. The facility failed to follow facility policy of each resident having the right to be free from abuse, corporal punishment, and involuntary seclusion by not protecting Resident #1 from physical abuse by a staff member. The facility failed to implement their policy by providing training to manage residents with behaviors that could lead to abusive behaviors. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 11/15/23 at 4:25 p.m. While the IJ was removed on 11/18/23, the facility remained out of compliance at no actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place the resident at risk for abuse, neglect, and injuries of unknown origin. Findings include: 1. Record review of the facility's Abuse policy dated October 2022 indicated, Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the residents, family members, resident representatives, friends, and other individuals. The resident(s) will be protected from any identified offender during the course of the investigation by removing the alleged perpetrator from the facility. Record review of the facility's Abuse Prevention policy dated October 2022 indicated, .The facility will identify resident whose personal histories, aggressive behaviors, dependency for daily care, and/or communication needs render them at risk for abuse and/or abusing other residents .Supervisory staff will be responsible for identifying and intervening in situations of inappropriate staff/resident behaviors .The facility will provide ongoing oversight and supervision of staff to assure policies are implemented as written to include education and periodic drills. Record review of the Provider Investigation Report dated 12/6/22 indicated Housekeeper CCC witnessed CNA A slap Resident #2 on the back. The Provider Investigation Report indicated Housekeeper CCC also witnessed Resident #2 hit CNA A in the throat. The Provider Investigation Report indicated CNA denied slapping Resident #1 in the back. The Provider Investigation Report indicated CNA admitted to pushing Resident #1 due to Resident #2's aggression. The Provider Investigation Report indicated CNA A was suspended pending investigation. The Provider Investigation report indicated the facility determined the event to be unfounded. Record review of a written statement dated 12/6/22 by CNA A indicated Resident #2 was pulling on the computer wires at the nurse's station. The written statement indicated CNA A tried to take the computer wires from Resident #2. The written statement indicated Resident #2 grabbed CNA A by the throat and then Resident #2 hit CNA A in the throat with his fist. The written statement indicated CNA A pushed Resident #2 to get him off her. Record review of an Investigation Statement/Interview dated 12/6/22 with Housekeeper CCC indicated on 12/5/22 Housekeeper CCC witnessed Resident #2 punch CNA A in the throat. The Investigation Statement/Interview indicated Housekeeper CCC then witnessed CNA A hit Resident #2 on the back with an open hand. The Investigation Statement/Interview indicated Resident #2 became more aggressive with CNA after CNA hit Resident #2. 2. Record review of the face sheet dated 11/22/23 indicated Resident #1 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Alzheimer's, hypertension (elevated blood pressure), repeated falls, delusional disorder, and anxiety disorder. Record review of the MDS dated [DATE] indicated Resident # 1 understood others and was understood by others. The MDS indicated Resident #1 had a BIMS of 03 and was severely cognitively impaired. The MDS indicated Resident #1 required extensive assistance with bed mobility, transfers, dressing, eating, and personal hygiene. The MDS indicated Resident #1 used a wheelchair for mobility. Record review of the care plan last revised 8/18/23 indicated Resident #1 had anticipatory grief and anxiety secondary to expected decline of resident. The MDS indicated Resident #1 required hospice care. The care plan indicated Resident #1 had impaired cognitive function/dementia or impaired thought process related to Alzheimer's. Record review of the nursing progress note dated 5/14/23 at 11:45 p.m. indicated a head-to-toe assessment was completed on Resident #1 with no injuries noted. The nursing progress note indicated Resident #1 did not demonstrate any distress and had no recall of the alleged staff related event. Record review of the Provider Investigation Report dated 5/15/23 indicated on 5/14/23 at 11:20 p.m. a fell ow CNA alleged that CNA A hit Resident #1 in the back of the head with an opened hand. The Provider Investigation Report indicated CNA A was witnessed pushing Resident #1 in his wheelchair aggressively down the hall. The Provider Investigation Report indicated Resident #1 swung his arm back and knocked CNA A's glasses off. The Provider Investigation Report indicated CNA was observed hitting Resident #1 in the back of the head with an open hand and then pushed him to his room. The Provider Investigation Report indicated CNA A denied the allegation and was suspended pending investigation. The Provider Investigation Report indicated on 5/15/23 CNA A notified the facility she would not be returning to work and requested her employment be terminated. The Provider Investigation Report indicated the allegation was unconfirmed due to having no other witnesses and Resident #1 was unable to recall the event. The Provider Investigation Report indicated upon conclusion of this investigation, there were no other witnesses to this event. The Provider Investigation Report indicated Resident (#1) was unable to recall the event and was noted to have no injuries. The Provider Investigation Report indicated with no collaborating evidence this allegation is unconfirmed. The Provider Investigation Report indicated the Provider Action Taken Post investigation was social services would follow for distress and staff education regarding timely reporting. The Provider Action Taken Post investigation did not indicate any other education to staff as a response to the incident. Record review of the nursing progress note dated 5/14/23 at 11:45 p.m. indicated a head-to-toe assessment was completed on Resident #1 with no injuries noted. The nursing progress note indicated Resident #1 did not demonstrate any distress and had no recall of the alleged staff related event. Record revie of the social services progress note dated 5/16/23 at 10:34 a.m. indicated the social worker went down to visit with Resident #1 regarding the staff incident. The social services progress note indicated Resident #1 did not recall the event and showed no signs of distress. Record review of CNA A's schedules indicated she had worked on the secured unit on 12/01/22, 12/05/22, 1/25/23, 3/11/23, 3/12/23, and 5/12/23. Record review of CNA A's time sheet for 5/14/23 indicated she clocked in at 6:00 p.m. and clocked out at 11:50 p.m. Record review of CNA A's Notice of Termination dated 5/19/23 indicated her effective date of termination was 5/15/23, The Notice of Termination indicated the reason for termination was due to CNA A quitting. The Notice of Termination indicated CNA A was eligible for rehire. During an interview on 11/15/23 at 11:55 a.m. the DON said CNA A had been involved in an altercation with Resident #1 and asked to leave the facility. The DON said the facility did a telephone interview with CNA A and the DON was going to terminate CNA A. The DON said CNA A did not return to the facility and said during the phone interview CNA A said she was tired of them. During an interview on 11/15/23 at 12:54 p.m. the DON said CNA A's alleged physical abuse towards Resident #1 was unconfirmed due to being she said, she said and the facility not being able to prove the abuse occurred. The DON said prior to CNA A's resignation the facility had planned on terminating CNA A for this incident because even though they were unable to prove the allegation. The DON said it did not sit well with her and CNA A had a previous allegation of physical abuse on 12/5/22 against Resident #2. During an interview on 11/15/23 at 2:05 p.m. the DON said she sat CNA A down in her office and spoke with her after the incident on 12/5/22 with Resident #2. The DON said she did not have any documentation of a formal one-on-one in-service or counseling with CNA A due to the allegation being unconfirmed by the facility and unsubstantiated by the state agency. The DON said the allegation of abuse from 12/5/22 was unconfirmed due to the witness changing his story. During an interview on 11/15/23 at 3:11 p.m. Housekeeper CCC said he remembered the incident between CNA A and Resident #2. Housekeeper CCC said Resident #2 punched CNA A in the throat and CNA A got mad. Housekeeper CCC said CNA A and Resident #2 got into a scuffle. Housekeeper CCC said Resident #2 was bent over, and CNA A slapped Resident #2 in the back to get him off of her. Housekeeper CCC said Resident #2 was bent over trying to fight with CNA A. During an interview on 11/16/23 at 9:00 a.m. the DON said CNA A denied both allegations of abuse. The DON said the witness to the first allegation changed his story on how the CNA hit Resident #2. The DON said they felt if Resident #2 had been hit as hard as what was alleged, he would have had some kind of mark on his body. The DON was notified on 11/15/23 at 4:40 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The DON was provided the Immediate Jeopardy template on 11/15/23 at 4:50 p.m. The facility's Plan of Removal was accepted on 11/17/23 at 4:04 p.m. and included: 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. In-services on Abuse have been held in facility 11/15/2023 to train on the following process. Upon an allegation of abuse, Resident will be immediately evaluated for any physical, emotional, cognitive changes or signs of injury. Resident will be interviewed. A written statement and interview will be completed by person alleging abuse. The alleged person will also be interviewed and asked to write a statement. The alleged person will be suspended and directed to immediately leave the facility and not return until asked to do so by administration. Other residents will be interviewed related to quality of care provided by alleged person. Any staff assigned to area during time of incident will be interviewed and statements obtained regarding incident. At conclusion of investigation Administrator, DON, and other designated staff will review the evidence and reach a conclusion if abuse has been substantiated. CNA A attended trainings on Abuse and Managing Resident Behaviors 12/14/2022, 1/26/2023, 3/24/2023, and 4/3/2023. CNA A was reassigned from Memory Support Unit to D Unit upon return to work 12/14/2022. D Unit was her primary assignment until suspension 5/14/2023. On 5/14/2023 she did assist with mealtime on MSU and went to D Unit at 6PM. Incident occurred on D Wing at 11:15 PM. On 12/14/2022 CNA A received the training provided to other staff, after the incident, regarding abuse and the incident was reenacted with C. N. A. A and DON. Incident was discussed regarding any potential triggers. Due to allegation being unfounded no additional disciplinary action was warranted. CNA A was immediately suspended from the facility following allegations of abuse on 5/14/2023. CNA A called facility to state she would not be returning on 5/15/2023 during the facility allegation of abuse investigation. All staff is being trained on the de-escalation of aggressive behaviors. This training includes having no physical contact with resident. Regardless of whether it is a reflex reaction or a defensive action on the part of the staff member it is considered abuse. Staff should remove themselves from the Resident and have no contact. This training is being currently completed for all staff at the facility and will be completed by 4:30 PM on 11/17/2023. Training will be ongoing until all staff have attended. Staff will not be permitted to work unless education has been completed. DON did initial training to all administrative staff and department supervisors on 11/17/2023. Department Supervisors are subsequently training their staff. DON and designees educated all staff on facility Abuse policies, Resident Aggression including Management and Prevention. This training commenced on 11/15/2023 and continues 11/16/2023. Training will be ongoing until all staff have attended. Staff will not be permitted to work unless education has been completed. DON has been educated by Regional Nurse on 11/17/2023 that following any staff to resident incidents, staff are to receive 1:1 training and disciplinary action prior to returning to their shift should they be reinstated. Residents with a BIMS score of 10 or greater are being interviewed by facility social workers to identify if they feel safe and if they experienced abuse while living at facility. These interviews will be completed by 5:00PM 11/16/2023. RN House supervisors and LVN Unit Managers are completing physical assessments/ body audits on residents with BIMS score less than 10 to identify any injuries of unknown origin and/or evidence of abuse. These physical assessments/ body audits will be completed by 5:00 PM 11/16/2023. 0. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. 1. CNA A resigned from facility on May 15, 2023, while on suspension. 2. Allegation of Abuse/Neglect Checklist has been implemented 11/15/2023. This includes step by step tasks that are required, including any training that was done with alleged perpetrator and staff. Checklist and file will then be reviewed and signed off by administrator, DON and HR prior to closing file within five days of incident. 3. Staff is being monitored by RN House Supervisors and Unit Managers beginning 11/16/2023 for any signs of potential burnout that could lead to low tolerance. Nurse leadership have received education from Regional Nurse on 11/16/2023 on Nurse Burnout and how to prevent it. A burnout self-test was provided with this training to assist in identifying burnout. 4. Burnout can result not only from working long hours but also caring for demanding and confused residents. Staff is being educated to discuss any concerns regarding a change in their tolerance, becoming easily agitated, feeling overwhelmed with Nurse managers. This training is being currently completed for all staff at the facility and will be completed by 4:30 PM on 11/17/2023. Training will be ongoing until all staff have attended. Staff will not be permitted to work unless education has been completed. 5. Staffing coordinator will not schedule staff for multiple days without time off. The staffing coordinator was re-educated on 11/16/2023 by DON. 6. In the absence of Administrator, Abuse Coordinator is DON. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 11/17/2023. On 11/18/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of a random sample of Safe Surveys dated 11/15/23 through 11/17/23 indicated residents felt comfortable asking staff for assistance, felt they were treated with dignity and respect, felt safe in the facility, felt comfortable telling staff about concerns, felt staff were willing to listen to their concerns and resolve them, and had not ever had staff physically harm them. Record review of a random sample of body audits dated 11/15/23 through 11/16/23 indicated residents assessed did not have an injury of unknown origin or evidence of abuse. Staff interviewed on 11/18/23 between 12:25 PM - 4:52: Medical Records F Administrative Assistant G RN H LVN K Director of Human Resources ADON Housekeeper L Floor Tech M BOM Cook N Dietary Aide P Dietary Aide Q MDS Coordinator Housekeeper R Housekeeper S Housekeeper T Housekeeper V LVN W Laundry Aide X LVN Y CNA Z LVN AA RN BB LVN CC NAIT DD Social Worker EE Admission Coordinator RN FF Director of Rehab Assistant Maintenance Director Housekeeping Supervisor LVN GG Quality Assurance Treatment Nurse Activities Assistant CNA HH AD CNA KK CNA LL Transportation Supervisor LVN MM CNA NN LVN PP Were able to verbalize the different types of abuse, identify the abuse coordinator, and when to report abuse. There were able to verbalize different approaches at de-escalating combative or aggressive residents. They stated if they were unable to de-escalate the situation, they would make sure the resident was safe and walk away. They stated reflexively or defensively hitting a resident was still considered abuse. They were able to identify triggers that may indicate burnout, and all stated if they were feeling that way, they should report it to their immediate supervisor. During an interview with the Staffing Coordinator on 11/18/23 at 1:48 PM she was able to answer all above questions and was also in-serviced on looking at the schedule to identify potential for burnout and try not to schedule multiple days in a row. The Staffing Coordinator stated she always checks on staff and asks if they are doing okay if they exhibit signs of burnout. The Staffing Coordinator stated if they are experiences signs of burnout, she tries to look at the schedule to see what can be done. During an interview with the DON on 11/18/23 at 12:53 p.m. she was able to answer all above questions and was also in-serviced on the abuse allegation and investigation process to include assess resident/interview residents (ensure safety) - obtain statement from the alleged perpetrator and suspend them pending investigation. Notify the state agency and start an investigation. The DON said if any type of abuse was substantiated, she would terminate the employee. The DON said if it was required coming back from suspension, she would provide disciplinary action. The DON said she instructed all managers to monitor for signs of burnout and instructed all employees to notify the manager if there were experiencing burnout. The DON said reflexively or defensively hitting a resident was still considered abuse. While the IJ was removed on 11/18/23, the facility remained out of compliance at no actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure the resident had the right to be free from abuse for 1 of 10 (Resident #1) residents reviewed for abuse. The facility failed to protect Resident #1 from physical abuse by CNA A on 5/14/2023.CNA A had a history of a physical abuse allegation in December 2022 towards Resident #2. The facility failed to implement measures to protect residents from further abuse. The facility failed to train staff on how to manage residents with behaviors that could lead to abusive behaviors. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 11/15/23 at 4:25 p.m. While the IJ was removed on 11/18/23, the facility remained out of compliance at no actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk for physical and verbal abuse, psychosocial harm, and decreased quality of life. Findings Include: 1. Record review of the Provider Investigation Report dated 12/6/22 indicated Housekeeper CCC witnessed CNA A slap Resident #2 on the back. The Provider Investigation Report indicated Housekeeper CCC also witnessed Resident #2 hit CNA A in the throat. The Provider Investigation Report indicated CNA denied slapping Resident #2 in the back. The Provider Investigation Report indicated CNA admitted to pushing Resident #2 due to Resident #2's aggression. The Provider Investigation Report indicated CNA A was suspended pending investigation. The Provider Investigation report indicated the facility determined the event to be unfounded. Record review of a written statement dated 12/6/22 by CNA A indicated Resident #2 was pulling on the computer wires at the nurse's station. The written statement indicated CNA A tried to take the computer wires from Resident #2. The written statement indicated Resident #2 grabbed CNA A by the throat and then Resident #2 hit CNA A in the throat with his fist. The written statement indicated CNA A pushed Resident #2 to get him off her. Record review of an Investigation Statement/Interview dated 12/6/22 with Housekeeper CCC indicated on 12/5/22 Housekeeper CCC witnessed Resident #2 punch CNA A in the throat. The Investigation Statement/Interview indicated Housekeeper CCC then witnessed CNA A hit Resident #2 on the back with an open hand. The Investigation Statement/Interview indicated Resident #2 became more aggressive with CNA after CNA hit Resident #2. 2. Record review of the face sheet dated 11/22/23 indicated Resident #1 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Alzheimer's, hypertension (elevated blood pressure), repeated falls, delusional disorder, and anxiety disorder. Record review of the MDS dated [DATE] indicated Resident # 1 understood others and was understood by others. The MDS indicated Resident #1 had a BIMS of 03 and was severely cognitively impaired. The MDS indicated Resident #1 required extensive assistance with bed mobility, transfers, dressing, eating, and personal hygiene. The MDS indicated Resident #1 used a wheelchair for mobility. Record review of the care plan last revised 8/18/23 indicated Resident #1 had anticipatory grief and anxiety secondary to expected decline of resident. The care plan indicated Resident #1 required hospice care. The care plan indicated Resident #1 had impaired cognitive function/dementia or impaired thought process related to Alzheimer's. Record review of the Provider Investigation Report dated 5/15/23 indicated on 5/14/23 at 11:20 p.m. a fell ow CNA alleged that CNA A hit Resident #1 in the back of the head with an opened hand. The Provider Investigation Report indicated CNA A was witnessed pushing Resident #1 in his wheelchair aggressively down the hall. The Provider Investigation Report indicated Resident #1 swung his arm back and knocked CNA A's glasses off. The Provider Investigation Report indicated CNA was observed hitting Resident #1 in the back of the head with an open hand and then pushed him to his room. The Provider Investigation Report indicated CNA A denied the allegation and was suspended pending investigation. The Provider Investigation Report indicated on 5/15/23 CNA A notified the facility she would not be returning to work and requested her employment be terminated. The Provider Investigation Report indicated the allegation was unconfirmed due to having no other witnesses and Resident #1 was unable to recall the event. The Provider Investigation Report indicated upon conclusion of this investigation, there were no other witnesses to this event. The Provider Investigation Report indicated Resident (#1) was unable to recall the event and was noted to have no injuries. The Provider Investigation Report indicated with no collaborating evidence this allegation is unconfirmed. The Provider Investigation Report indicated the Provider Action Taken Post investigation was social services would follow for distress and staff education regarding timely reporting. The Provider Action Taken Post investigation did not indicate any other education to staff as a response to the incident. Record review of the nursing progress note dated 5/14/23 at 11:45 p.m. indicated a head-to-toe assessment was completed on Resident #1 with no injuries noted. The nursing progress note indicated Resident #1 did not demonstrate any distress and had no recall of the alleged staff related event. Record review of the social services progress note dated 5/16/23 at 10:34 a.m. indicated the social worker went down to visit with Resident #1 regarding the staff incident. The social services progress note indicated Resident #1 did not recall the event and showed no signs of distress. Record review of CNA A's schedules indicated she had worked on the secured unit on 12/01/22, 12/05/22, 1/25/23, 3/11/23, 3/12/23, and 5/12/23. Record review of CNA A's time sheet for 5/14/23 indicated she clocked in at 6:00 p.m. and clocked out at 11:50 p.m. Record review of CNA A's Notice of Termination dated 5/19/23 indicated her effective date of termination was 5/15/23, The Notice of Termination indicated the reason for termination was due to CNA A quitting. The Notice of Termination indicated CNA A was eligible for rehire. During an interview on 11/15/23 at 11:55 a.m. the DON said CNA A had been involved in an altercation with Resident #1 and asked to leave the facility. The DON said the facility did a telephone interview with CNA A and the DON was going to terminate CNA A. The DON said CNA A did not return to the facility and said during the phone interview CNA A said she was tired of them. During an interview on 11/15/23 at 12:54 p.m. the DON said CNA A's alleged physical abuse towards Resident #1 was unconfirmed due to being she said, she said and the facility not being able to prove the abuse occurred. The DON said prior to CNA A's resignation the facility had planned on terminating CNA A for this incident even though they were unable to prove the allegation. The DON said it did not sit well with her and CNA A had a previous allegation of physical abuse on 12/5/22 against Resident #2. During an interview on 11/15/23 at 2:05 p.m. the DON said she sat CNA A down in her office and spoke with her after the incident on 12/5/22 with Resident #2. The DON said she did not have any documentation of a formal one-on-one in-service or counseling with CNA A due to the allegation being unconfirmed by the facility and unsubstantiated by the state agency. The DON said the allegation of abuse from 12/22/22 was unconfirmed due to the witness changing his story. During an interview on 11/15/23 at 3:11 p.m. Housekeeper CCC said he remembered the incident between CNA A and Resident #2. Housekeeper CCC said Resident #2 punched CNA A in the throat and CNA A got mad. Housekeeper CCC said CNA A and Resident #2 got into a scuffle. Housekeeper CCC said Resident #2 was bent over, and CNA A slapped Resident #2 in the back to get him off her. Housekeeper CCC said Resident #2 was bent over trying to fight with CNA A. During an interview on 11/16/23 at 9:00 a.m. the DON said CNA A denied both allegations of abuse. The DON said the witness to the first allegation changed his story on how the CNA hit Resident #2. The DON said they felt if Resident #2 had been hit as hard as what was alleged, he would have had some kind of mark on his body. Record review of the facility's Abuse policy dated October 2022 indicated, Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the residents, family members, resident representatives, friends, and other individuals. The resident(s) will be protected from any identified offender during the course of the investigation by removing the alleged perpetrator from the facility. Record review of the facility's Abuse Prevention policy dated October 2022 indicated, .The facility will identify resident whose personal histories, aggressive behaviors, dependency for daily care, and/or communication needs render them at risk for abuse and/or abusing other residents .Supervisory staff will be responsible for identifying and intervening in situations of inappropriate staff/resident behaviors .The facility will provide ongoing oversight and supervision of staff to assure policies are implemented as written to include education and periodic drills. The DON was notified on 11/15/23 at 4:40 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The DON was provided the Immediate Jeopardy template on 11/15/23 at 4:50 p.m. The facility's Plan of Removal was accepted on 11/17/23 at 4:04 p.m. and included: 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. In-services on Abuse have been held in facility 11/15/2023 to train on the following process. Upon an allegation of abuse, Resident will be immediately evaluated for any physical, emotional, cognitive changes or signs of injury. Resident will be interviewed. A written statement and interview will be completed by person alleging abuse. The alleged person will also be interviewed and asked to write a statement. The alleged person will be suspended and directed to immediately leave the facility and not return until asked to do so by administration. Other residents will be interviewed related to quality of care provided by alleged person. Any staff assigned to area during time of incident will be interviewed and statements obtained regarding incident. At conclusion of investigation Administrator, DON, and other designated staff will review the evidence and reach a conclusion if abuse has been substantiated. CNA A attended trainings on Abuse and Managing Resident Behaviors 12/14/2022, 1/26/2023, 3/24/2023, and 4/3/2023. CNA A was reassigned from Memory Support Unit to D Unit upon return to work 12/14/2022. D Unit was her primary assignment until suspension 5/14/2023. On 5/14/2023 she did assist with mealtime on MSU and went to D Unit at 6PM. Incident occurred on D Wing at 11:15 PM. On 12/14/2022 CNA A received the training provided to other staff, after the incident, regarding abuse and the incident was reenacted with CNA A and DON. Incident was discussed regarding any potential triggers. Due to allegation being unfounded no additional disciplinary action was warranted. CNA A was immediately suspended from the facility following allegations of abuse on 5/14/2023. CNA A called facility to state she would not be returning on 5/15/2023 during the facility allegation of abuse investigation. All staff is being trained on the de-escalation of aggressive behaviors. This training includes having no physical contact with resident. Regardless of whether it is a reflex reaction or a defensive action on the part of the staff member it is considered abuse. Staff should remove themselves from the Resident and have no contact. This training is being currently completed for all staff at the facility and will be completed by 4:30 PM on 11/17/2023. Training will be ongoing until all staff have attended. Staff will not be permitted to work unless education has been completed. DON did initial training to all administrative staff and department supervisors. Department Supervisors are subsequently training their staff. DON and designees educated all staff on facility Abuse policies, Resident Aggression including Management and Prevention. This training commenced on 11/15/2023 and continues 11/16/2023. Training will be ongoing until all staff have attended. Staff will not be permitted to work unless education has been completed. DON has been educated by Regional Nurse on 11/17/2023 that following any staff to resident incidents, staff are to receive 1:1 training and disciplinary action prior to returning to their shift should they be reinstated. Residents with a BIMS score of 10 or greater are being interviewed by facility social workers to identify if they feel safe and if they experienced abuse while living at facility. These interviews will be completed by 5:00PM 11/16/2023. RN House supervisors and LVN Unit Managers are completing physical assessments/ body audits on residents with BIMS score less than 10 to identify any injuries of unknown origin and/or evidence of abuse. These physical assessments/ body audits will be completed by 5:00 PM 11/16/2023. 0. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. 1. CNA A resigned from facility on May 15, 2023, while on suspension. 2. Allegation of Abuse/Neglect Checklist has been implemented 11/15/2023. This includes step by step tasks that are required, including any training that was done with alleged perpetrator and staff. Checklist and file will then be reviewed and signed off by administrator, DON and HR prior to closing file within five days of incident. 3. Staff is being monitored by RN House Supervisors and Unit Managers beginning 11/16/2023 for any signs of potential burnout that could lead to low tolerance. Nurse leadership have received education from Regional Nurse on 11/16/2023 on Nurse Burnout and how to prevent it. A burnout self-test was provided with this training to assist in identifying burnout. 4. Burnout can result not only from working long hours but also caring for demanding and confused residents. Staff is being educated to discuss any concerns regarding a change in their tolerance, becoming easily agitated, feeling overwhelmed with Nurse managers. This training is being currently completed for all staff at the facility and will be completed by 4:30 PM on 11/17/2023. Training will be ongoing until all staff have attended. Staff will not be permitted to work unless education has been completed. 5. Staffing coordinator will not schedule staff for multiple days without time off. The staffing coordinator was re-educated on 11/16/2023 by DON. 6. In the absence of Administrator, Abuse Coordinator is DON. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 11/17/2023. On 11/18/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of a random sample of Safe Surveys dated 11/15/23 through 11/17/23 indicated residents felt comfortable asking staff for assistance, felt they were treated with dignity and respect, felt safe in the facility, felt comfortable telling staff about concerns, felt staff were willing to listen to their concerns and resolve them, and had not ever had staff physically harm them. Record review of a random sample of body audits dated 11/15/23 through 11/16/23 indicated residents assessed did not have an injury of unknown origin or evidence of abuse. Staff interviewed on 11/18/23 between 12:25 PM - 4:52 PM: Medical Records F Administrative Assistant G RN H LVN K Director of Human Resources ADON Housekeeper L Floor Tech M BOM Cook N Dietary Aide P Dietary Aide Q MDS Coordinator Housekeeper R Housekeeper S Housekeeper T Housekeeper V LVN W Laundry Aide X LVN Y CNA Z LVN AA RN BB LVN CC NAIT DD Social Worker EE Admission Coordinator RN FF Director of Rehabilitation Assistant Maintenance Director Housekeeping Supervisor LVN GG Quality Assurance Treatment Nurse Activities Assistant CNA HH AD CNA KK CNA LL Transportation Supervisor LVN MM CNA NN LVN PP Were able to verbalize the different types of abuse, identify the abuse coordinator, and when to report abuse. They were able to verbalize different approaches at de-escalating combative or aggressive residents. They stated if they were unable to de-escalate the situation, they would make sure the resident was safe and walk away. They stated reflexively or defensively hitting a resident was still considered abuse. They were able to identify triggers that may indicate burnout, and all stated if they were feeling that way, they should report it to their immediate supervisor. During an interview with the Staffing Coordinator on 11/18/23 at 1:48 PM she was able to answer all above questions and was also in-serviced on looking at the schedule to identify potential for burnout and try not to schedule multiple days in a row. The Staffing Coordinator stated she always checks on staff and asks if they are doing okay if they exhibit signs of burnout. The Staffing Coordinator stated if they are experiences signs of burnout, she tries to look at the schedule to see what can be done. During an interview with the DON on 11/18/23 at 12:53 p.m. she was able to answer all above questions and was also in-serviced on the abuse allegation and investigation process to include assess resident/interview residents (ensure safety) - obtain statement from the alleged perpetrator and suspend them pending investigation. Notify the state agency and start an investigation. The DON said if any type of abuse was substantiated, she would terminate the employee. The DON said if it was required coming back from suspension, she would provide disciplinary action. The DON said she instructed all managers to monitor for signs of burnout and instructed all employees to notify the manager if they were experiencing burnout. The DON said reflexively or defensively hitting a resident was still considered abuse. While the IJ was removed on 11/18/23, the facility remained out of compliance at no actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure treatment and care was provided based on the comprehensive assessment and in accordance with standards of practice for 1 of 10 residents reviewed for quality of care. (Resident #1) The facility did not: *follow hospital discharge orders and did not administer [MEDICATION NAME] (an antibiotic) after Resident #1 underwent pacemaker replacement surgery. The facility did not notify Resident #1's cardiologist when RN A removed surgical glue holding Resident #1's incision together and placed steri strips over the incision. The facility did not notify Resident #1's cardiologist when Resident #1's pacemaker surgical incision dehisced (partial or total separation of previously approximated wound edges, due to a failure of proper wound healing). Thirteen days later, Resident #1 was sent to the hospital for an infected pacemaker site. This failure could place residents at risk for not receiving necessary care and services to meet their needs, serious impairment, and death. Findings included: 1. A face sheet dated 10/22/20 indicated Resident #1 was [AGE] years old, admitted on [DATE] with diagnosed including: [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #1 had severely impaired cognition, usually made his needs known, and usually understood others. He required extensive assistance with ADLs. He was incontinent of bowel and had a urinary catheter. A hospital discharge summary dated 09/17/20 indicated Resident #1 was transferred to the emergency roiagnom on [DATE] for nausea and vomiting and was found to be constipated and was admitted to the hospital. Resident #1 was given Linzess (a drug used to treat irritable bowel syndrome with constipation and chronic constipation with no known cause) and his symptoms improved. Resident #1's ICD/pacemaker was at the end of device life and was removed on 09/14/20 and replaced with a biventricular pacemaker (special type of pacemaker that paces both sides of the lower chambers of the heart (the right and left ventricles) to help treat heart failure). Resident #1 discharged back to the nursing facility and would follow up with his primary care physician, cardiologist, and pulmonologist. Hospital discharge instructions dated 09/17/20 for Resident #1 included [MEDICATION NAME] 300 mg (antibiotic) every 12 hours for 3 days. A hand-written note on the discharge instructions had a line drawn to the [MEDICATION NAME] order indicated start in a.m., and was scratched out. Another hand-written note with a line drawn to the [MEDICATION NAME] order indicated do not do this one. Resident #1's hospital discharge instructions did not include wound care orders. Resident #1's hospital discharge instructions included to follow up in a week with his cardiologist for a wound check via video telehealth. During an interview on 10/22/20 at 4:49 p.m., LVN B said Resident #1 returned to the facility from the hospital on [DATE]. She said Resident #1 came back with orders for [MEDICATION NAME] but there was no [DIAGNOSES REDACTED]. She said Resident #1's [DIAGNOSES REDACTED].#1's [MEDICATION NAME] order did not meet their antibiotic stewardship and based on their protocol, the physician would not let them start the antibiotic. LVN B said she did not remember if she spoke to Resident #1's facility physician about the hospital ordered antibiotic. A nursing note dated 09/17/20 at 3:43 p.m. indicated Resident #1 returned from the hospital for a paralytic ileus that was resolved. Incision with bruising noted to left upper chest measuring 6.5 cm. Dry dressing removed per discharge instructions and left open to air. Physician orders [REDACTED].#1 indicated to clean incision to left upper chest wall with wound cleanser, pat dry, and leave open to air twice a day. During an interview on 10/19/20 at 2:58 p.m., LVN D said she worked with Resident #1 twice after he returned from the hospital on [DATE], she said he was on the quarantine hall for 14 days. She said Resident #1 had his pacemaker replaced and had an island dressing covering the incision site, she said she was told the hospital nurse who called the report said to remove the dressing upon arrival. LVN D said she removed the dressing and there were no sutures and no steri-strips. She said surgical glue was holding the incision closed and there were no signs of infection. She said she did not see Resident #1's discharge paperwork when he returned to the facility. She said she last worked with Resident #1 about a week later and there were blood droplets on the resident's shirt and the treatment nurse was aware. A skin progress note dated 09/17/20 indicated Resident #1 had a surgical incision to his left chest wall for a pacemaker replacement. Measurements were 5 cm in length across and 3 cm length down (in a 7 shape) and width was 0.5 cm. There was scant amount of serosanguineous exudate (discharge that contains both blood and a clear yellow liquid known as blood serum). The surrounding skin was pink in color. Treatment was initiated and Resident #1's physician and responsible party was notified. A surgical wound assessment dated [DATE] for Resident #1 indicated he had a surgical incision to his left chest wall for a pacemaker replacement. Measurements were 5 cm in length across and 3 cm length down (in a 7 shape) and width was 0.5 cm. There was scant amount of serosanguineous exudate. A nursing note dated 09/19/20 at 10:08 p.m. indicated Resident #1 received a new order for [MEDICATION NAME] 875/125 mg (antibiotic) twice a day for 10 days for pneumonia. A Medication Administration Record [REDACTED]. A nursing note from Resident #1's cardiologist's office dated 09/23/20 indicated nursing at the facility said Resident #1's incision site was well approximated, clean and dry, with no signs of infection, and will call with any concerns. Resident #1's ICD surgical site was viewed by video with minimal amount of dry blood at the pacemaker site with no signs of infection. A late entry nursing note dated 10/16/20, written by LVN B, indicated on 09/23/20, Resident #1's cardiologist called for a virtual follow up on Resident #1's surgical wound to his left chest wall. The wound was shown to the cardiologist's nurse and the nurse said, ok that looks good, that is all we needed. No new orders were received. During an interview on 10/22/20 at 4:49 p.m., LVN B said she was in Resident #1's room on 09/23/20 when the cardiologist's office followed up on Resident #1's surgical incision with a video visit. She said she showed the nurse Resident #1's incision site and the cardiologist nurse said the incision looked good and did not provide any wound care instructions any did not instruct them to call if the incision site worsened. A nursing note dated 09/24/20 indicated Resident #1 had a virtual follow up appointment and no new orders noted. A care plan dated 09/24/20 indicated Resident #1 had a surgical wound to his left chest wall from a pacemaker battery replacement. Interventions included to assess the wound and record measurements routinely, observe for signs of infection, observe for signs of complications, and notify the physician as needed. A surgical wound assessment dated [DATE] indicated Resident #1 had a surgical incision to his left chest wall for a pacemaker replacement. Measurements were 5 cm in length across and 2.5 cm length down (in a 7 shape) and width was 0.5 cm. There was no exudate or odor. A skin progress note dated 09/25/20 indicated Resident #1 had a surgical incision to his left chest wall measuring 5 cm length across and 2.5 cm length down (in a 7 shape) and 0.5 cm width. There was no exudate or odor present. Surrounding skin was pink and the site improved from last assessment. Resident #1's current treatment will be continued. A nursing note dated 09/28/20 at 12:00 p.m., written by RN A, indicated Resident #1 was receiving wound care when the nurse noted a scabbed area and glue that was used to approximate wound edges to be detached from the incision. RN A cleaned the area and removed the scab and surgical glue from Resident #1's left chest where the pacemaker had been replaced. No signs of infection noted, and the resident did not verbalize pain. RN A approximated the wound edges by applying 5 steri-strips to the incision site and left the area open to air. RN supervisor, responsible party, and physician notified. A physician order [REDACTED].#1's incision to left upper chest wall with wound cleanser, pat dry, and leave open to air twice a day and monitor steri-strips in place to incision for signs of infection. A treatment administration record (TAR) dated September 2020 indicated Resident #1 received wound care to his left chest wall incision that included to clean the incision with wound cleanser, pat dry, leave open to air twice daily and monitor steri-strips in place for signs of infection from 09/18/20 to 09/30/20. A nursing note dated 10/01/20 at 12:26 p.m., written by RN A, indicated Resident #1's surgical area to his left chest wall had 3 steri-strips remaining and the wound edges were approximated to the left incision area and the right corner of the incision had partially dehisced. The dehisced area measured 1.0x1.5x0.3 cm and the total incision measured 4.5x3.0 cm. The wound bed had granulation tissue with moderate amount of serous drainage. The wound edges were normal for skin and the peri-wound skin was pink in color with some dry scabbed areas. No signs of infection were noted. The NP was notified and received orders to update treatment order. Treatment order initiated with alginate dressing to wound bed and cover with a dry dressing daily and monitor for signs of infection. Responsible party, RN supervisor, and physician aware. A surgical wound assessment dated [DATE] for Resident #1 indicated he had a surgical incision to his left chest wall for a pacemaker replacement. Measurements were 4 cm in length across and 3 cm length down (in a 7 shape) and width was 0.5 cm. There was an open area to right corner of incision measuring 1.0x1.5x0.3 cm that was partially dehisced. There was moderate amount of serous exudate. Three steri-strips remained intact with wound edges approximated to the left of incision area length wise. Wound skin pink in color with some dry scabbed areas. No complaints of pain or signs of infection. Treatment order was updated. A physician order [REDACTED].#1 indicated to clean left chest wall incision with wound cleanser, pat dry, cut and fit alginate dressing to wound bed and cover with dressing daily and monitor steri-strips in place for signs of infection. A TAR dated October 2020 for Resident #1 indicated he received wound care to clean left chest wall incision with wound cleanser, pat dry, cut and fit alginate dressing to wound bed and cover with dressing daily and monitor steri-strips in place for signs of infection daily from 10/02/20 to 10/13/20. A skin progress note dated 10/02/20 at 3:57 p.m., indicated Resident #1's surgical incision to his left chest wall measured 4.0 cm length across and 3.0 cm length down (in a 7-shape width 0.5cm). There was an open area to the right corner of the incision measuring 1.0x1.5x0.3 cm. There was a small amount of serosanguineous exudate and the surrounding skin was pink in color. Resident #1's incision site deteriorated from previous assessment. The treatment order was changed. A nursing note dated 10/06/20, written by RN A, indicated Resident #1's responsible party was notified his surgical incision and right corner incision dehiscence from his pacemaker replacement site was improving with the current treatment. Resident #1's responsible party said she spoke to the cardiologist after the surgery and was told that Resident #1's skin was so thin that it tore, and they had to use a lot of surgical glue to hold the skin together. Resident #1's dressing remained in place to left chest wall and 3 steri-strips remained in place to the left side of incision. There were no signs of infection noted. A facility physician progress notes [REDACTED].#1 had a pacemaker with skin breakdown around incision site. Resident #1 was receiving daily wound care. A surgical wound assessment dated [DATE] for Resident #1 indicated he had a surgical incision to his left chest wall for a pacemaker replacement. Dehisced area measurements were 2.9x1.4x0.3 cm. Two steri-strips remained intact with wound edges approximated. Area to right side of incision was dehisced. Wound bed with granulation tissue and slough (yellow/white material in the wound bed; it is usually wet but can be dry. It generally has a soft texture. It can be thick and adhered to the wound bed, present as a thin coating, or patchy over the surface of the wound) to outer tissue edges. Moderate amount of serous drainage. Wound edges normal for skin and no signs of infection or pain. During an interview on 10/19/20 at 11:43 a.m., LVN H said she last worked with Resident #1 on 10/11/20. She said she performed the ordered wound care for Resident #1's left chest wall wound. She said there was no swelling to the surrounding tissue and the wound was red and beefy with minimal drainage. LVN H said there was a small area that was open. She said Resident #1 complained of generalized pain and she administered [MEDICATION NAME] and it was effective. A nursing note dated 10/12/20 at 12:27 p.m., written by RN A, indicated Resident #1's incision to the left side of his chest wall had noted improvement to wound bed with less slough to outer edges and granulation tissue to wound bed. There was a small amount of serous drainage, no signs of infection, steri-strips to left side of surgical wound no longer intact, wound edges are well approximated with clean dressing. During an interview on 10/22/20 at 2:07 p.m., LVN G said on 10/12/20 around 6:30 p.m., Resident #1 complained of pain all over and he normally did not complain of pain. She said Resident #1 had an order for [REDACTED].#1 later and his pain improved. During an interview on 10/20/20 at 11:06 a.m., LVN F said she worked 10/12/20 from 6:00 p.m. to 10/13/20 at 6:30 a.m. She said Resident #1 vomited once during the night and he said he thought it was something he ate that made him vomit. She said Resident #1 said he felt better after he vomited. She said he vomited quite a bit and the staff had to change Resident #1's clothing. She said she last saw Resident #1 around 6:15 a.m. because he had medications scheduled for 6:00 a.m. She said she looked at Resident #1's dressing that covered his surgical incision and it was not soiled but there was redness near the bump in his skin that covered the pacemaker. She said she did not see Resident #1's incision because it was covered with a dressing and the treatment was completed during the day. She said she reported to the oncoming nurse that Resident #1 vomited during the night. During an interview on 10/16/20 at 12:38 p.m., CNA E said on 10/13/20 about 9:00 a.m., she was taking Resident #1 to the shower and she noticed the skin around his surgical site was red and swollen. She said she called for LVN C, CNA J, and RN A. She said she saw Resident #1's surgical site on 10/12/20 and did not remember what the incision looked like but there was no redness to the surrounding skin. During an interview on 10/22/20 at 2:16 p.m., CNA J said Resident #1's skin was red around his wound on 10/13/20. He said he was not aware Resident #1's wound was open. He said Resident #1's wound was usually covered when he saw it. During an interview on 10/16/20 at 3:37 p.m., LVN C said on the morning of 10/13/20, she removed Resident #1's dressing that covered his pacemaker incision because the dressing was soiled, and he was about to get a shower. She said she was notified from the night shift Resident #1 vomited once during the night, but she was not sure if it was vomit or drainage that soiled the resident's dressing. She said Resident #1's skin surrounding the incision was red and swollen and Resident #1 complained of shoulder pain. She said they notified RN A and she came to assess Resident #1's incision. LVN C said the last time she saw Resident #1's incision site was on 10/05/20 and there was a small area of dehiscence but there were no signs of infection. A nursing note dated 10/13/20 at 12:25 p.m., written by RN A, indicated she was notified by staff that when assisting Resident #1 up for his shower this morning, the dressing to the left side of his chest was saturated. The night shift reported that Resident #1 had vomited once during the night. Resident #1's left chest wall incision remained dehisced and surrounding area distal to dehisced area showing signs of infection. Resident #1 complained of pain when touching surrounding surgical area and redness and swelling observed. Notified Resident #1's physician and received order for Bactrim antibiotic. Notified Resident #1's wife and wife requested the nurse to call Resident #1's cardiologist. Called Resident #1's cardiologist office and received new order to send Resident #1 to the cardiologist's office as soon as possible. The nurse marked Resident #1's area of redness with a black marker in case reddened area increases in size. Resident #1's blood pressure was 108/54, pulse 72, respirations 24, and temperature 97.8. During an interview on 10/16/20 at 12:18 p.m., RN A said she was the facility's treatment nurse. She said Resident #1 returned from the hospital on [DATE] and had an incision to his left chest wall where he underwent pacemaker replacement surgery. RN A said Resident #1's incision was held together with a large amount of surgical glue and had no drainage. She said Resident #1 had no discharge wound care instructions when he returned to the facility and the incision was left open to air. RN A said Resident #1's incision was healing well and on 09/28/20, she noticed some of the surgical glue had lifted up from Resident #1's incision and she clipped the surgical glue that was not attached to Resident #1's skin. She said she placed steri-strips across the incision site where she removed the surgical glue. She said a few days later, Resident #1's incision began to dehisce where the steri-strips were placed and there was moderate drainage. RN A said she called the NP and Resident #1's wife about the incision dehiscing and the NP ordered daily wound care of alginate to the wound bed and cover with a dressing. She said the NP did not order antibiotics for Resident #1. She said she notified Resident #1's wife. She said she did not call Resident #1's cardiologist to notify him of the incision dehiscence. RN A said Resident #1's incision showed no signs of infection and continued with serosanguineous drainage. She said on 10/12/20, Resident #1's incision showed no signs of infection. She said on 10/13/20, she was summoned to look at Resident #1's incision site by LVN C. RN A said Resident #1's incision looked good, but the surrounding tissue was red and swollen. She said she called Resident #1's physician and he ordered Bactrim (antibiotic). She said she then called Resident #1's wife to notify her of the change in the surgical site and the new antibiotic order. RN A said Resident #1's wife told her to call Resident #1's cardiologist. She said she called Resident #1's cardiologist's office and notified them of the change in the surgical site and they asked why they were not notified of the dehiscence and asked for Resident #1 to be immediately sent to the cardiologist's office. RN A said Resident #1 was sent out to his cardiologist's office. RN A said she was not sure why she did not call Resident #1's cardiologist when the incision dehisced. During an interview on 10/19/20 at 2:22 p.m., the facility NP said RN A called her several weeks after Resident #1 returned to the facility after having his pacemaker replaced and told her the area was red and inflamed, but not really dehisced. She said she ordered daily wound care with alginate. The NP said she was not aware that RN A placed steri-strips on the incision or that there was drainage. She said she did not see Resident #1's incision site. A nursing note from Resident #1's cardiologist office dated 10/13/20 indicated RN A called the cardiologist's office at 11:30 a.m. and notified them that Resident #1's implantable cardioverter defibrillator (ICD) site was severely infected and was red, inflamed, and weeping. The RN A reported that Resident #1's ICD site dehisced over a week ago, glue was coming off in chunks, and she had been doctoring the site. RN A reported that Resident #1 had vomited on himself during the night and soaked the dressing covering his surgical incision and when staff removed the dressing for the resident's morning shower, the site was infected. Resident #1's cardiologist's nurse contacted Resident #1's facility charge nurse (LVN C) said was told that Resident #1's blood pressure had been low, and his respirations had increased. LVN C said Resident #1's blood pressure was 108/54 and his respirations were 24 breaths a minute before he was picked up by transportation to be sent to the cardiologist's office. LVN C said Resident #1 was not acting like himself and complained of hurting all over. During an interview on 10/20/20 at 3:27 p.m., the nurse from the cardiologist's office said Resident #1 was discharged from the hospital back to the nursing facility on 09/17/20 and his orders included to remove the dressing covering the incision after 24 hours, a [MEDICATION NAME] antibiotic from hospital, and wound check in 5 to 7 days. She said Resident #1 was prescribed [MEDICATION NAME] for 3 days. She said the cardiologist's NP saw the resident during the video follow up on 09/23/20 and the NP said the wound looked good, keep the wound open to air, and to let them know if there were any changes. The nurse said the facility did not notify them of any changes until 10/13/20 when RN A called and notified them Resident #1's surgical site appeared infected and it had dehisced over a week ago. She said the facility should have called the cardiologist's office when the incision dehisced, and they would have ordered antibiotics or wanted to see Resident #1 in the clinic. She said RN A should not have removed the surgical glue from Resident #1's incision. The nurse said when RN A called the office on 10/13/20, they requested Resident #1 be sent to the office, but during transport, they decided to send him to the hospital emergency room . She said Resident #1 was admitted to a heart hospital from the emergency room . During an interview on 10/22/20 at 3:51 p.m., the ADON said Resident #1's physician was notified about the hospital order for [MEDICATION NAME] after he returned to the facility on [DATE]. The ADON said Resident #1's order for [MEDICATION NAME] did not meet their criteria for the use of antibiotics and provided an infection signs and symptoms review (McGeer definitions of infections in long term care). A facility infection signs and symptoms review (McGeer definitions of infections in long term care) addressed signs that must be present for respiratory infections, gastrointestinal tract infections, urinary tract infections, and skin/soft tissue/mucosal infections. The review did not address [MEDICATION NAME] use of antibiotics. During an interview on 10/28/20 at 9:55 a.m., Resident #1's physician said he remembered someone calling him about an order for [REDACTED]. Resident #1's physician said he thought the [MEDICATION NAME] order was started in the hospital and continued for a few days when he returned to the facility so he was fine with discontinuing the order. He said he did not remember if he was notified about Resident #1's incision dehiscing but the facility could have called his NP. He said he expected staff to observe the incision site for signs of infection and to complete good wound care. He said an antibiotic did not have to be started because Resident #1's incision dehisced as long as there were no signs of infection. Resident #1's physician said he did not remember if he saw Resident #1's surgical incision. He said he normally would not look at a surgical site unless he was notified of a problem. A hospital infectious disease consult dated 10/14/20 indicated Resident #1 was sent to the emergency roiagnom on [DATE] for the management of a pacemaker site infection. Resident #1 was noted with an open wound to his pacemaker site and the pacemaker pocket was boggy and inflamed. Resident #1 was diagnosed with [REDACTED]. Resident #1 was started on [MEDICATION NAME] and [MEDICATION NAME] antibiotics and will be transferred to a heart hospital for an implant of a new pacemaker. A hospital history and physical dated 10/14/20 for Resident #1 indicated he was transferred to the heart hospital for evaluation of an infected pacemaker pocket. Resident #1's permanent pacemaker (PPM) on his left chest wall had a large area of redness, swelling, increased warmth and tenderness with a large amount of fluctuance from a wound dehiscence at about 2 o'clock on the PPM site. A hospital lab wound culture report dated 10/17/20 indicated Resident #1 had [DIAGNOSES REDACTED] pneumoniae (a Gram-negative, non-motile, encapsulated, lactose-fermenting, facultative anaerobic, rod-shaped bacterium) and [MEDICAL CONDITION] (MRSA) (Gram-positive bacteria that are genetically distinct from other strains of Staphylococcus aureus.[MEDICAL CONDITION] is responsible for several difficult-to-treat infections in humans) in his left chest pacemaker site. An advanced care planning hospital note dated 10/16/20 indicated Resident #1 had a pacemaker infection and was pacemaker dependent. Resident #1 was in need of device and wire removal with external pacer placement until wound cultures were negative. Resident #1 was at high risk for device removal and his wife was considering home with hospice versus home with IV antibiotics. Resident #1's wife was aware that IV home antibiotics wound not cure Resident #1. Resident #1 also had wound dehiscence which would not likely heal due to malnutrition and dementia, regardless of antibiotics. During an interview on 10/19/20 at 2:51 p.m., the DON said when a resident return to the facility from the hospital, the staff are to contact the facility physician or NP for any orders. She said it was not normal protocol to contact Resident #1's cardiologist for orders or changes. She said RN A called Resident #1's physician when she noticed signs of infection at the surgical site on 10/13/20 and he ordered Bactrim. She said RN A called Resident #1's wife, who asked her to call the cardiologist, and she did. The DON said Resident #1 was sent to the cardiologist's office at the request of the cardiologist. The DON said the facility did not have a policy specifically regarding surgical incisions. The facility's change of condition policy dated February 2020 indicated .in the following situations .a sudden or unexpected change or deterioration in the resident's physical, mental, or emotional status .the resident's attending physician, or designee and resident representative will be notified by the licensed nurse .the licensed nurse will follow physician's orders [REDACTED].