Every finding on record at Colonial Nursing & Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 2 of 5 residents (Resident #1 and Resident #2) reviewed for resident rights. The facility failed to ensure Resident #1's call light and water were within reach on 7/27/26. The facility failed to ensure Resident #2's call light was within reach on 7/27/26. These failures could place residents at risk for a delay in assistance and a decreased quality of life.Findings included: 1. Record review of the face sheet dated 7/27/26 indicated Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including cerebral infarction (the death of brain tissue caused by a blocked blood vessel that cuts off oxygen and blood flow), hemiplegia and hemiparesis (causes total paralysis and causes partial weakness) following cerebral infarction affecting left non-dominant side, muscle weakness, and lack of coordination. Record review of the admission MDS assessment dated [DATE] indicated Resident #1 sometimes understood others and was sometimes understood by others. The MDS indicated Resident #1 had a BIMS of 03 and was severely cognitively impaired. The MDS indicated Resident #1 required partial/moderate assistance with toileting and transfers and required substantial/maximum assistance with bathing and dressing. During an observation and interview on 7/27/26 at 10:25 a.m. Resident #1 was lying in bed with the call light wrapped around the assist rail on the left side of the bed and hanging down towards floor. Resident #1 said he was not checked on regularly. Resident #1's water was on the nightstand on the left side of the bed and not within reach. Resident #1's bed was positioned with the right side against the wall. During an interview on 7/27/26 at 11:15 a.m. LVN A said Resident #1's call light and water were not within reach. LVN A said Resident #1 was unable to grasp things with his left hand. LVN A said if Resident #1's call light and water were on the bedside table on the left side of his bed he still would not have been able to utilize these items. 2. Record review of the face sheet dated 7/27/26 indicated Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including encephalopathy (any disease, damage, or malfunction of the brain that causes an altered mental status), hypertension (elevated blood pressure), orthostatic hypotension (a sudden drop in blood pressure that happens when you stand up from a sitting or lying position), and atrial fibrillation (irregular and fast heartbeat). Record review of the Entry MDS assessment dated [DATE] indicated Resident #2 admitted to the facility on [DATE] from a short-term general hospital. Record review of the care plan, last revised 7/27/26, indicated Resident #2 was at risk for falls related to gait/balance, poor communication/comprehension, and unaware of safety needs with interventions including be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. During an observation on 7/27/26 at 10:28 a.m. Resident #2's call light was wrapped around the assist rail and hanging down almost touching the floor. During an interview on 7/27/26 at 11:20 a.m. LVN A said Resident #2's call light was not in reach. LVN A said it was all staff's responsibility to ensure call lights and water were within reach of the residents. LVN A said the importance in ensuring call lights and water were within reach was in case a resident had an emergency and for hydration. During an interview on 7/27/26 at 1:05 p.m. the DON said she expected residents to have their call lights and water within reach. The DON said the importance of residents having their call lights and water within reach was for emergencies, if they needed assistance, and hydration. During an interview on 7/27/26 at 1:15 p.m. the Administrator said call lights should be in reach of a resident when they were in their rooms whether they were in bed or up in a chair. The Administrator said water should be in reach of the residents, especially if they were capable of drinking independently. The Administrator said the importance of residents having their call lights and water within reach was dignity and self-worth. Record review of the facility's, Answering the Call Light policy last revised September 2003 indicated, The purpose of this procedure is to respond to the resident's requests and needs.When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on interviews and record review, the facility failed to ensure in accordance with professional standards of practices, the medical records on each resident were accurately documented for 1 of 5 residents (Resident #3) reviewed for medical records. The facility failed to ensure Resident #3's admission Assessment completed on 7/13/26 by LVN B accurately reflected the number of falls she had in the past 3 months. This failure could place residents at risk for not receiving the proper fall precautions and investigation of injuries not being accurate.Findings included: 1. Record review of the face sheet dated 7/27/26 indicated Resident #3 was an [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses including periprosthetic fracture around the internal prosthetic hip joint (a broken bone that happens around an artificial joint replacement), Alzheimer's (is a type of dementia that affects memory, thinking and behavior ), anxiety ( mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation ), repeated falls, dementia ( is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life ), lack of coordination, and muscle weakness. Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #3 rarely/never understood others and was rarely/never understood by others. The MDS indicated Resident #3 did not have a BIMS assessment. The MDS indicated Resident #3 required substantial/maximum assistance with transfers. Record review of the care plan last revised on 7/27/26 indicated Resident #3 was at risk for falls related to confusion, gait/balance problems, incontinence, poor communication/comprehension, and unaware of safety needs. Record review of the admission assessment dated [DATE] indicated Resident #3 had 1-2 falls in the past 3 months. Record review of the Incidents by Incident Type list dated 2/1/26 through 7/27/26 indicated Resident #3 had not had any falls during this time. During an interview on 7/27/26 at 11:09 a.m. the Administrator said Resident #3 had not had any falls in the past 3 months. The Administrator said Resident #3 did not move and mainly sat in a high back wheelchair. During an interview attempt on 7/27/26 at 11:12 a.m. a voicemail was left for LVN B. During an interview on 7/27/26 at 11:26 a.m. the DON said the last fall Resident #3 had been on 1/12/26. During an interview on 7/27/26 at 1:10 p.m. the NP said she was familiar with Resident #3. The NP said Resident #3 had not had a fall since January 2026. During an interview on 7/27/26 at 1:05 p.m. the DON said she expected nursing staff to document in true time and accurately. The DON said the importance of accurate documentation was to assist in the plan of care and meeting the residents' needs. During an interview on 7/27/26 at 1:15 p.m. the Administrator said she expected staff to accurately document. The Administrator said the importance of accurate documentation was continuity of care. Record review of the facility's Charting Errors and/or Omissions policy last revised August 2026 indicated, Accurate medical records shall be maintained by this facility.

Based on observation, interview and record review the facility failed to ensure residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 3 of 8 residents reviewed for nutritional status (Resident #9, #25, and #31). The facility failed to implement the RD's 02/21/2026 nutritional recommendations for Resident #9 who experienced a significant weight loss of 6.5% (6 lbs.) from 01/02/2026 to 02/10/2026. The facility failed to ensure the physician's orders included the amount of liquid nutritional supplement to be administered to Resident #25 and Resident #31. The facility failed to ensure the staff responsible for the delivery and administration of liquid nutritional supplements were clearly identified. These failures could place residents with weight loss at risk for malnourishment, further weight loss, skin breakdown, and a decreased quality of life. Findings included: 1.During an observation on 03/16/2026 at 01:00 PM, Resident #9 was observed to receive lunch on a tray served by a CNA-B. After a couple of minutes of watching Resident #9 not attempt to feed herself, CNA-B attempted to spoon feed Resident #9. Resident #9 was observed closing her mouth and turning her face away from the spoons of food offered by the aid. There was no Health shake noted on Resident #9's lunch tray. Record review of a face sheet dated 03/17/2026 indicated Resident #9 was a [AGE] year-old female who initially admitted to the facility on [DATE]. She had diagnoses which included spastic quadriplegic cerebral palsy (severe form of cerebral palsy caused by brain damage and affects all four limbs, the trunk, and face resulting in extreme muscle stiffness, limited mobility, and causes speech, swallowing, and cognitive impairments), profound intellectual disability, and anorexia (a serious mental health eating disorder).Resident #9 had a hospital stay from 02/06/2026-02/10/2026 where she was treated for Influenza A, pneumonia, and a urinary tract infection. Record review of a quarterly MDS dated [DATE] noted Resident #9 was coded for significant weight loss. The MDS included a BIMS assessment which noted Resident #9 was rarely/never understood and required the supervision and assistance of one person with eating. Record review of an undated care plan indicated Resident #9 had a potential for nutritional problem related to her diagnoses of cerebral palsy and anorexia. The care plan identified interventions to address the concern which included providing Resident #9 with assistance with all meals and serving diet and supplements as ordered. Record review of the medical records indicated Resident #9's weights were as follows: 01/2/2026 92 lbs,02/02/2026 89 lbs, 02/10/2026 86 lbs, 03/04/2026 89 lbs. Record review of the March 2026 physician's orders revealed an order dated 11/18/2025 for Resident #9 to be given a Health Shake twice a day. Record review of the Dietary Supplement List indicated Resident #9 was on the list to receive a Health Shake at lunch daily. Record review of the February and March clinical records did not reveal any documentation of Health Shakes being provided to Resident #9 nor of Resident #9's acceptance or refusal of the nutritional supplements. Record review of a Nutrition/Dietary Note dated 02/21/2026 indicated Resident #9 had experienced significant weight loss and recommended discontinuing the health shakes and adding 90ml of Med Pass twice a day. A review of the nutritional information for Health Shakes and Med Pass indicated the following:1 Health Shake contained 220 calories and 6 grams protein 90ml Med Pass contained 290 calories and 9 grams protein. Record review of Resident #9's February and March physician orders, MARs, and TARs indicated the 02/21/2026 RD's recommendations to discontinue the Health Shakes and start Med Pass 90ml twice a day had not been implemented. During an interview on 03/18/2026 at 09:40 AM, the RD said it was her first visit to the facility and said she was not familiar with Resident #9. After reviewing the previous RD's 02/21/2026 recommendations, she said the previous RD replaced the Health Shakes with Med Pass because the Med Pass offered more nutrition by way of increased calories and protein. During an interview on 03/18/2026 at 09:45 AM, the DM said the previous RD would document her recommendations in the residents' charts and send her recommendations to the ADON. She said the ADON would print the recommendations and give them to the doctor for approval. She said once the recommendations were approved, the ADON would transcribe the physician's orders into the EHR and send the DM a dietary communication form. During an interview on 03/18/2026 at 10:05 AM, the ADON said she was responsible for following up on the RD's recommendations. She said she did not see the RD's 02/21/2026 recommendations for Resident #9 in the progress notes. She said the previous RD did not send her the recommendations as she was supposed to. The ADON said she transcribed the physician's orders for Resident #9 to receive the 2 health shakes daily into the clinical record but failed to assign them to the MAR. She said the MAR would communicate the instructions to give Resident #9 a health shake and the Medication Aide would document the health shake was given. The ADON said there was no documentation to show Resident #9 had received the health shakes. During an interview on 03/18/2026 at 10:50 AM, the DON said there had been problems with receiving communications from the previous RD who was no longer affiliated with the facility. She said the facility had a new RD and she was going to review the communication process with her. The DON 2. Record review of a face sheet dated 03/18/2026 indicated Resident #25 was an [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses which included dementia, dysphagia (difficulty swallowing, vitamin D deficiency, and debility (a state of severe weakness often characterized by frailty, exhaustion, and reduced functional capacity). Record review of a quarterly MDS dated [DATE] noted Resident #25 had a BIMS score of 4 indicating her cognition was severely compromised. The same MDS noted Resident #25 was coded for significant weight loss. Record review of the medical records indicated Resident #25 weighed 117 lbs. on 02/14/2026 and 108 lbs. on 03/04/2026, indicating a 7.5% (9 lbs.) weight loss. Record review of the progress notes dated 02/18/2026 indicated Resident #25 had a weight loss of 7.5% and a new order was received from the Nurse Practitioner to give Resident #25 90ml of Med Pass 2.0 daily with the morning medications. Record review of Resident #25's February and March 2026 physician's orders revealed an order dated 02/19/2026 for Med Pass 2.0 in the morning for weight decrease. The order did not specify the amount of Med Pass to be given. The order did not identify who was responsible for giving Med Pass 2.0 to Resident #25. Record review of Resident #25's 2026 February and March MARs revealed there were no instructions for Resident #25 to be given Med Pass 2.0. There was no documentation of Resident #25 having received Med Pass 2.0 with her morning medications or at any other time. 3. Record review of a face sheet dated 03/17/2026 indicated Resident #31 was a [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses which included dementia, schizoaffective disorder (a mental health condition that is marked by a mix of schizophrenia symptoms and a milder form of mania which is a condition with extreme changes in mood or emotions), bipolar disorder (a mental health condition that causes extreme mood swings), and chronic kidney disease. Record review of an admission MDS dated [DATE] noted Resident #31 had a BIMS score of 12 indicating her cognition was moderately compromised. Record review of the medical records indicated Resident #31 weighed 119 lbs. on 01/23/2026 and 110 lbs. on 02/02/2026, indicating a 7.5% (9 lbs.) weight loss. Record review of the progress notes dated 02/18/2026 indicated Resident #31 had a weight loss of 7.5% and a new order was received from the Nurse Practitioner to give Resident #31 90ml of Med Pass 2.0 daily with the morning medications. Record review of resident #31's February and March physician's orders revealed an order dated 02/19/2026 for Med Pass 2.0 in the morning for weight decrease. The order did not specify the amount of Med Pass to be given. Record review of Resident #31's 2026 February and March 2026 MARs revealed there were no instructions for Resident #31 to be given Med Pass 2.0 daily. There was no documentation of Resident #31 having received Med Pass 2.0 in February and March, 2026. During an interview on 03/17/2026 at 02:35 PM, the ADON said she was responsible for transcribing dietary recommendations into the physician's orders and selecting the appropriate electronic health records such as the MAR or TAR. She said she failed to specify the amount of Med Pass 2.0 that was to be given to Resident #25 and Resident #31 in the physician's orders. She said the orders should have included the specific amount of Med Pass 2.0 to be given and the order should have been assigned to the appropriate EHR for administration. She said if the order was not on the MAR, then the Medication Aide or Nurse administering medications would not know to give it which result in the residents not receiving supplemental nourishment and potentially having further weight loss. The ADON said dietary staff were responsible for providing the dietary supplements which included the liquid Med Pass supplement on the trays of those residents who ate in the dining room. She said the medication aides were responsible for administering the Med Pass supplement to the residents who did not always take their meals in the dining room. Record review of the facility's policy dated 2005 and revised April 2007 and titled Nutrition (Impaired)/Unplanned Weight Loss-Clinical indicated the following: Assessment: 5.The physician will review possible causes of anorexia or weight loss with the nursing staff and/or dietician before ordering interventions. Treatment: 2. The physician will authorize appropriate general or cause-specific interventions, as indicated. A record review of the facility's policy dated 2001 and revised July 2016 and titled Medication and Treatment Orders indicated the following: Orders for medications and treatments will be consistent with principles of safe and effective writing.

Based on observation, interview and record review, the facility failed to ensure medical records, in accordance with accepted professional standards and practices, were complete and accurately documented for 4 of 6 residents (Residents #9, #25, #31,and #55) reviewed for medical records accuracy The facility failed to ensure the administration of nutritional supplements was documented in the clinical records for Resident #55, Resident # 9, Resident #25, and Resident #31. The facility failed to ensure physician orders included complete instructions for the administration of a liquid nutritional supplement (Med Pass) for Resident #9, Resident #25, Resident #31, and Resident #55. The facility failed to ensure the physician's orders for liquid nutritional supplements were transcribed into the MARs. These failures could place residents at risk for incomplete clinical records. Findings included: 1.Record review of a face sheet dated 03/17/2026 indicated Resident #55 was a [AGE] year-old female born 01/13/1934 and admitted on [DATE]. According to a face sheet dated 03/17/2026, she had diagnoses which included cerebral infarction, dementia, and dysphagia ( difficulty swallowing). Record review of a MDS dated [DATE], noted Resident #55 had a BIM's score of 4 which indicated she had severely impaired cognition. Record review of progress notes dated 2/18/2026 revealed the dietitian recommended a nutritional supplement (Med Pass 2.0) to be administered in the morning for Resident #55 due to weight decrease, with instructions to provide 90ml with breakfast. T The dietitian's recommendation was not transcribed onto the February and March 2026 MAR or TAR. There was no documented evidence that the nutritional supplement was administered as recommended and ordered. Record review of the physician's orders dated 3/16/2026 revealed the physician's orders did not specify the amount of Med Pass 2.0 to be provided each morning with meals. During an interview on 3/17/2026 at 1:15p.m., LVN C stated she had been employed at the facility for approximately two weeks and acknowledged there was no documentation on the MAR or TAR to indicate the Med Pass supplement was administered or recorded. LVN C stated she was unable to confirm whether the supplement had been given to the resident. During an interview on 3/17/2026 at 1:20p.m., ADON confirmed the dietitian's recommendation was not reflected or documented on the MAR or TAR. ADON acknowledged the physician order did not specify the exact volume of the Med Pass supplement. She stated the supplement was provided on the resident's breakfast tray and that a communication form had been submitted to the dietary manager to ensure the Med-Pass supplement was included on the resident's breakfast tray. The ADON further acknowledged she was unable to confirm whether the resident had consumed the supplement. Duning an interview on 3/17/2026 at 1:25 p.m., the Dietary Manager stated the dietitian recommendations are communicated thorough the ADON and the physician, then forwarded to the dietary via a communication form. For Resident #55, she identified a 2/18/2026 communication form indicated Med Pass 90 ml daily with breakfast. She stated the supplement was measured and placed on the resident's breakfast tray; however, she was unable to confirm whether the resident consumed the supplement. During an interview on 3/17/2026 at 1:29 p.m., the DON further confirmed that the dietitian's recommendation was not reflected or documented on the MAR or TAR. The DON stated the supplement was provided on the resident's breakfast tray and that a communication form had been submitted to the dietary manager to ensure the Med-Pass supplement was included. The DON further stated that a recent weight review conducted a few days prior showed Resident #55 had gained weight, which was confirmed by a reweigh on 3/17/2026. The DON indicated the dietitian was scheduled to make rounds later that day and would reevaluate the resident in response to the recent weight gain. 2. A record review of a face sheet dated 03/17/2026 indicated Resident #9 was a [AGE] year-old female who initially admitted to the facility on [DATE]. She had diagnoses which included spastic quadriplegic cerebral palsy (severe form of cerebral palsy caused by brain damage and affects all four limbs, the trunk, and face resulting in extreme muscle stiffness, limited mobility, and causes speech, swallowing, and cognitive impairments), profound intellectual disability, and anorexia (a serious mental health eating disorder). A record review of a quarterly MDS dated [DATE] noted Resident #9 was coded for significant weight loss. The MDS included a BIMS assessment which noted Resident #9 was rarely/never understood. A record review of an undated care plan indicated Resident #9 had a potential for nutritional problem related to her diagnoses of cerebral palsy and anorexia. The care plan identified interventions to address the concern which included providing Resident #9 with assistance with all meals and serving diet and supplements as ordered. A record review of the March 2026 physician's orders revealed an order dated 11/18/2025 for Resident #9 to be given a Health Shake twice a day. A record review of the Dietary Supplement List indicated Resident #9 was on the list to receive a Health Shake at lunch daily. A record review of Resident #9's March 2026 MAR indicated there were no physician orders or instructions to give her a Health Shake. There was no documentation of Resident #9 receiving Health Shakes twice daily. 3. A record review of a face sheet dated 03/18/2026 indicated Resident #25 was an [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses which included dementia, dysphagia (difficulty swallowing), vitamin D deficiency, and debility (a state f severe weakness often characterized by frailty, exhaustion, and reduced functional capacity). A record review of a quarterly MDS dated [DATE] noted Resident #25 had a BIMS score of 4 indicating her cognition was severely compromised. The same MDS noted Resident #25 was coded for significant weight loss. A record review of the medical records indicated Resident #25 weighed 117 lbs. on 02/14/2026 and 108 lbs. on 03/04/2026, indicating a 7.5% (9 lbs.) weight loss. A record review of the progress notes dated 02/18/2026 indicated Resident #25 had a weight loss of 7.5% and a new order was received from the Nurse Practitioner to give Resident #25 90ml of Med Pass 2.0 daily with the morning medications. A record review of the February and March physician's orders revealed an order dated 02/19/2026 for Med Pass 2.0 in the morning for weight decrease. The order did not specify the amount of Med Pass to be given. A record review of Resident #25's 2026 February and March 2026 MARs revealed there were no instructions for Resident #25 to be given Med Pass 2.0. There was no documentation of Resident #25 having received Med Pass 2.0 with her morning medications or at any other time. 4. A record review of a face sheet dated 03/17/2026 indicated Resident #31 was a [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses which included dementia, schizoaffective disorder (a mental health condition that is marked by a mix of schizophrenia symptoms and a milder form of mania which is a condition with extreme changes in mood or emotions), bipolar disorder (a mental health condition that causes extreme mood swings), and chronic kidney disease. A record review of an admission MDS dated [DATE] noted Resident #31 had a BIMS score of 12 indicating her cognition was moderately compromised. A record review of the medical records indicated Resident #31 weighed 119 lbs. on 01/23/2026 and 110 lbs. on 02/02/2026, indicating a 7.5% (9 lbs.) weight loss. A record review of the progress notes dated 02/18/2026 indicated Resident #31 had a weight loss of 7.5% and a new order was received from the Nurse Practitioner to give Resident #31 90ml of Med Pass 2.0 daily with the morning medications. A record review of the February and March physician's orders revealed an order dated 02/19/2026 for Med Pass 2.0 in the morning for weight decrease. The order did not specify the amount of Med Pass to be given. A record review of Resident #31's 2026 February and March 2026 MARs revealed there were no instructions for Resident #31 to be given Med Pass 2.0 daily. There was no documentation of Resident #31 having received Med Pass 2.0 in February and March, 2026. During an interview on 03/18/2026 at 09:45 AM, the DM said the previous RD would document her recommendations in the residents' charts and send her recommendations to the ADON. She said the ADON would print the recommendations and give them to the doctor for approval. She said once the recommendations were approved, the ADON would put the physician's orders into the EHR and send the DM a dietary communication form. The DM said the kitchen provided the residents who ate breakfast in the dining room with Med Pass. She said her staff did not monitor the residents to see if they consumed the supplement. She said the dietary staff did not document they gave the Med Pass supplement. During an interview on 03/17/2026 at 02:35 PM, the ADON said she was responsible for transcribing dietary recommendations into the physician's orders and assigning the orders to the appropriate electronic health records such as the MAR and TAR. She said she failed to specify the amount of Med Pass 2.0 that was to be given to Resident #25 and Resident #31 in the physician's orders. She said the orders should have included the specific amount of Med Pass 2.0 to be given and the order should have been assigned to the MAR for administration. She said if the order was not on the MAR, then the Medication Aide or Nurse administering medications would not know to give it and could result in the residents not receiving supplemental nourishment and potentially having further weight loss. The ADON said dietary staff were responsible for providing the dietary supplements which included the liquid Med Pass supplement on the trays of those residents who ate in the dining room. She said the medication aides were responsible for administering the Med Pass supplement to the residents who did not always take their meals in the dining room. She said the dietary staff would put dietary supplements on the residents' meal trays, but they were not responsible for monitoring whether or not the residents consumed the supplements. She said nursing was responsible for monitoring residents for consumption of nutritional supplements. The ADON said there was no documentation of Residents #9, #25, and #31 having received or consumed the nutritional supplements that were ordered by the nurse practitioner or physician. A record review of the facility's policy dated 2001 and revised July 2016 and titled Medication and Treatment Orders indicated the following: Orders for medications and treatments will be consistent with principles of safe and effective writing. A record review of the facility's policy dated 2001 and revised November 2014 and titled Orders, Receiving and Transcribing indicated the following: 7.Commercial Dietary Supplements - When receiving orders for commercial dietary supplements, specify the type, amount, and frequency.

Based on observation, interview, and record review, the facility failed to protect and promote the rights of each resident for 6 of 11 residents (Residents #14, #35, and 4 other unidentified Residents) reviewed for dignity and respect. CNA-A and CNA-B were observed eating their personal lunch in the secure unit dining area where Resident #14, Resident #35, and four unidentified Residents were sitting and waiting for their lunch to be served. This failure could place residents who reside in the secured unit of the facility at risk of not being treated with courtesy, consideration, and respect. Findings included: A record review of a face sheet dated 03/18/2026 indicated Resident #14 was a [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses which included Alzheimer's dementia and major depressive disorder. An elopement risk assessment completed on 02/14/2025 indicated Resident #14 was an elopement risk and was assigned placement on the secured unit of the facility. An annual MDS dated [DATE] noted Resident #14 had a BIMS score of 4 indicating her cognition was severely compromised, was independently ambulatory, and was able to feed herself. A record review of a face sheet dated 03/17/2026 indicated Resident #35 was a [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses which included dementia, depression, and anxiety. An elopement risk assessment completed on 02/24/2025 indicated Resident #35 was an elopement risk and was assigned placement on the secured unit of the facility. An annual MDS dated [DATE] noted Resident #35 had a BIMS score of 14 indicating her cognition was intact, was independently ambulatory, and was able to feed herself. During an observation on 03/16/2026 at 01:00 PM, 6 (six) Residents (Residents #14, #35, and four other unidentified residents) were noted sitting in the dining room area of the secure unit. 2 CNAs (CNA-A and CNA-B) were noted eating their lunch in the area that opened to the dining room and visible to the residents. In response to being told lunch was about to be served, Resident #14 said, Good, I'm hungry. Resident #35 waved her hand toward CNA-A and CNA-B and said, Me too, they're not. During an interview with Resident #14 and Resident #35 on 03/16/2026 at 02:10 PM, Resident #14 said she thought it was rude to eat in front of someone who had not eaten. Resident #35 said, If I did that, my mother would have sent me outside and I wouldn't have gotten another bite of food. During an interview on 03/17/2026 at 11:30 AM, CNA-B said she ate lunch in the area that opened to the dining room so she could keep an eye on the residents in the dining room. She said lunch had not been served to the residents prior to eating her lunch in front of them. She said she heard Resident #14 and Resident #35 say they were hungry. CNA-B said the Residents should not have to watch staff eat when the Residents have nothing to eat. CNA-B said she did not consider how it may have looked to the Residents. CNA-B said the courteous and respectful thing would have been for her and CNA-A to have taken turns eating lunch so they could eat somewhere where the residents would not have seen them. During an interview on 03/17/2026 at 11:35 AM, CNA-A said she usually ate her lunch in the area of the dining room so she could see down the hall and watch for residents who were not in the dining area. She said lunch had not been served prior to eating her lunch in front of them. She said she heard Resident #14 and Resident #35 say they were hungry. She said the Residents should be treated with courtesy, consideration, and respect. She said she and CNA-B should not have been eating their lunch in front of the Residents who had not eaten and were hungry. During an interview on 03/17/2026 at 01:45 PM, the DON said she expected staff to be courteous and respectful of all the residents. She said the aides in the secured unit should not have been eating in view of the residents when the residents had not eaten their lunch and had nothing to eat. Record review of the facility's policy dated as revised August 2009 and titled Resident Rights indicated the following: Policy StatementEmployees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity.

Based on interview and record review, the facility failed to ensure an accurate MDS was completed for 1 of 5 residents (Resident #35) reviewed for MDS assessment accuracy. The facility failed to complete an MDS assessment that accurately reflected Resident #35's health status. This failure could place residents at risk of not receiving appropriate care and services to maintain the highest level of well-being. Findings included: A record review of a face sheet dated 03/17/2026 indicated Resident #35 was a [AGE] year-old female who re-admitted to the facility on [DATE] after being discharged from the hospital where she was treated for Influenza A, bilateral pneumonia, and sepsis (a life-threatening medical emergency caused by the body's response to an infection). A record review of an annual MDS with an assessment reference date (ARD) of 02/09/2026 indicated Resident #35 was coded for dehydration during the 7-day look-back period (the 7 days immediately preceding the ARD).Resident #35 had a BIMS score of 14 indicating her cognition was intact. A record review of the hospital emergency department notes dated 02/02/2026 indicated Resident #35 was admitted to the hospital with a primary diagnosis of Influenza A and sepsis secondary to bilateral pneumonia. The list of co-existing and historical diagnoses did not include a diagnosis of dehydration. A record review of the hospital Discharge summary dated [DATE] noted Resident #35's list of active diagnoses were as follows: Hospital Diagnoses: Active: Influenza A (virus causing seasonal flu), Bilateral pneumonia (infection of the lungs), GERD (gastroesophageal reflux disease - condition where acid flows back into the esophagus causing heartburn, chest pain, and potential damage to the tissue lining of the esophagus), Type 2 diabetes mellitus (chronic condition where the body resists insulin or fails to produce insulin causing high blood sugar levels), Hypertension, Respiratory failure (condition when the lungs cannot adequately supply oxygen to the blood or remove carbon dioxide from the blood), Sepsis (life-threatening emergency caused by the body's extreme reaction to an infection). A diagnosis of dehydration was not listed in the hospital's list of active diagnoses. A record review of the PCP's notes dated 02/05/2026 indicated the PCP performed an in-facility follow-up visit on 02/05/2026 and addressed the diagnoses of hypertension, Influenza A, pneumonia, GERD, and Type 2 diabetes. The physician documented the following visit summary: Assessment: 1. Influenza A/bilateral pneumonia/acute respiratory failure with hypoxemia (low level of oxygen in the blood)/sepsis syndrome: Completing antibiotics. Feeling better. 2. Status post fall: No documented injury 3. Debility: Seems to be close to baseline 4. Diabetes: Sugars are doing well 5. Gastroesophageal reflux disease: Asymptomatic.The PCP's progress notes and history and physical did not include a diagnosis of nor treatment for dehydration. A record review of the hospital and the facility records did not reveal any documentation of intake and output, documentation of clinical signs of dehydration, nor documentation of elevated laboratory values indicative of dehydration. During an interview on 03/18/2026 at 11:15 AM, the MDS Coordinator said she was responsible for coding the MDS assessments. She said she coded Resident #35's MDS assessment for dehydration because she noted Resident #35 received fluids while she was in the hospital and had fever. She said she thought that was sufficient evidence for a dehydration diagnosis. The MDS Coordinator said the facility used the MDS RAI 3.0 Manual as the facility's guidelines for coding the MDS. During an interview with the DON on 03/18/2026 at 11:40 AM, she said her expectations were for the MDS assessments to be coded correctly. A record review of the MDS RAI 3.0 Manual dated October 1, 2025 indicated the following: J1550: Problem Conditions (cont.) Dehydrated: Check this item if the resident presents with two or more of the following potential indicators for dehydration: 1. Resident takes in less than the recommended 1,500 ml of fluids daily (water or liquids in beverages and water in foods with high fluid content, such as gelatin and soups). Note: The recommended intake level has been changed from 2,500 ml to 1,500 ml to reflect current practice standards. 2. Resident has one or more potential clinical signs (indicators) of dehydration, including but not limited to dry mucous membranes, poor skin turgor (the skin's elasticity representing the ability to change shape and snap back quickly, cracked lips, thirst, sunken eyes, dark urine, new onset or increased confusion, fever, or abnormal laboratory values (e.g., elevated hemoglobin and hematocrit, potassium chloride, sodium, albumin, blood urea nitrogen, or urine specific gravity). 3. Resident's fluid loss exceeds the amount of fluids they take in (e.g., loss from vomiting, fever, diarrhea that exceeds fluid replacement).

Based on interview and record review, the facility failed to ensure an MDS was electronically transmitted to the CMS System within 14 days after completion of the assessment for 5 of 24 residents reviewed for assessments. (Residents # 15, 20, 41,42 and 62) The facility did not transmit an admission MDS assessment within 14 days into the CMS system as required. This failure could place residents at risk of not having records completed and submitted in a timely manner as required. Findings include: A review of Resident #15's face sheet dated 03/18/2026 reflected a [AGE] year-old female. She was admitted to the facility on [DATE]. Resident #15 was discharged on 12/4/2025 which reflected that the MDS record was over 120 days old. A review of Resident #20's face sheet dated 03/18/2026 reflected a [AGE] year-old male. He was admitted to the facility on [DATE]. Resident #20 was discharged on 11/17/2025 which reflected that the MDS record was over 120 days old. Review of the electronic MDS tab for Resident #20 revealed the admission MDS was dated 03/18/2026. The admission MDS status reflected incomplete, assessment was never added to a batch, meaning the assessment had not been electronically transmitted to CMS. A review of Resident #41's face sheet dated 03/18/2026 reflected a [AGE] year-old female. She was admitted to the facility on [DATE]. Resident #41 was discharged on 9/26/2025 which reflected that the MDS record was over 120 days old. Review of the electronic MDS tab for Resident #41 revealed the admission MDS was dated 03/18/2026. The admission MDS status reflected incomplete, assessment was never added to a batch, meaning the assessment had not been electronically transmitted to CMS. A review of Resident #42's face sheet dated 03/18/2026 reflected a [AGE] year-old male. He was admitted to the facility on [DATE]. Resident #42 was discharged on 10/22/2025 which reflected that the MDS record was over 120 days old. Review of the electronic MDS tab for Resident #42 revealed the admission MDS was dated 03/18/2026. The admission MDS status reflected incomplete, assessment was never added to a batch, meaning the assessment had not been electronically transmitted to CMS. A review of Resident #62's face sheet dated 03/18/2026 reflected a [AGE] year-old male. He was admitted to the facility on [DATE]. Resident #42 was discharged on 10/7/2025 which reflected that the MDS record was over 120 days old. Review of the electronic MDS tab for Resident #62 revealed the admission MDS was dated 03/18/2026. The admission MDS status reflected incomplete, assessment was never added to a batch, meaning the assessment had not been electronically transmitted to CMS. An interview with the MDS Nurse on 3/17/2026 at 3:12 PM revealed she was responsible for ensuring the MDS was completed and transmitted. The MDS Nurse revealed the Admissions MDS should have been completed and transmitted by the 14th day. The MDS nurse revealed the admission MDS for Residents #15, 20, 41, 42 and 62 had not been completed and transmitted. She stated the reason the MDS had not been completed and transmitted was that she just did not realize that these 5 residents' MDS had not been transmitted, but it was her responsibility to transmit all MDS to CMS. When asked for a policy she said, the policy they use is CMS's RAI Assessment Transmission refers to the electric transmission by state and federal guidelines. An interview with the DON on 03/17/2026 at 3:30 PM revealed she was not aware Residents # 15, 20, 41, 42 and 62's MDSs had not been completed and transmitted. She said it was the responsibility of the MDS nurse to complete and transmit the MDS, and she was indirectly responsible also to make sure that all MDSs are being transmitted in a timely manner. Record Review of the CMS RAI Version 3.0 Manual, dated October 2023, indicated in Chapter 2, page 2-39 09. Discharge Assessment-Return Not Anticipated (A0310F), Must be completed (item Z0500B) within 14 days after the discharge date (A2000 + 14 calendar days). The RAI Manual further revealed the discharge assessment-return not anticipated must be submitted within 14 days after the MDS completion date (Z0500B +14 calendar days) .

Based on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments under proper temperature controls and permitted only by authorized personnel to have access to the keys for 1 of 3 nurse medication storage carts (A Hall) reviewed for storage of medication and biologicals.The facility failed to ensure 15 tablets of APAP/Codeine 300-30mg (medication used for moderate to severe pain) was not, the medication expired on 11/01/25, and had been expired for 10 days, and were not removed from use.This failure could place residents at risk of adverse reactions to medications, misappropriation of medications, and not receiving therapeutic effects of medication.Findings include:Observation of the facility A Hall medication storage cart and interview with RN A on 11/10/25 at 06:45 p.m. revealed in second draw of the cart was an affixed lock box which revealed the following:-an individual medication card with 15 untouched tablets of APAP/Codeine 300-30mg with an expiration date of 11/01/25 and fill date of 11/01/24, the medication had been expired for 10 days and had not been removed from use in the medication cart. RN A stated the APAP/Codeine 300-30mg medication had been expired since 11/01/25 and she said 15 out of 30 tablets were left. RN A said she started working with the facility about 8 months ago. RN A said she was responsible for administering medication out of the A-hall nurse medication cart but had not given any of the expired APAP/Codeine 300-30mg. RN A said she was trained by the facility on medication storage, making sure medications were not expired before giving the medication and keeping the cart stocked, free of expired medications and spills. RN A said if residents were administered expired medications it could lead to medication poisoning or sickness. RN A said she would remove the expired medications from the cart.During an interview on 11/11/25 at 1:10 p.m., the DON said there should be no expired medications inside the medication room or inside the medication carts. The DON said the Nurse working on the medication cart checked the medication cart every time they work on the medication cart. The DON said nurses were to check for expired medications and discharged residents' medication to be removed for disposal during each shift. The DON said she was responsible in ensuring the nurses were checking the medication carts for removal and disposal of expired medications and she said she was not sure how it got overlooked. The DON said if the medication was not given for months, then they could expire and be overlooked on the medication cart. She said the effects of expired medications could range from reduced effectiveness to unfavorable side effects.Record review of the facility's individual control drug record for the APAP/Codeine 300-30mg indicated it was last given 10/26/2025 at 6:47 a.m. with an ending count of 15 tablets.Record review of the facility's pharmacy monthly medication review for storage, dated 7/2025 to 10/2025, reflected no evidence of expired medications on the medication carts needing removal. Record review of the facility's policy, dated 11/2020, titled Storage of Medications reflected in part: .Policy: The facility stores all drugs and biologicals in a safe secure and orderly manner.3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean safe and sanitary manner.4. Drug containers that have missing incomplete improper or incorrect labels are returned to the pharmacy for proper labeling before storing discontinued outdated or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on interview and record review, the facility failed to use the service of an RN for 8 consecutive hours 7 days a week. The facility did not have RN coverage on the following dates: 12/2/24 - 12/9/24, 12/13/24-12/18/24, 12/20/24-12/22/24, 12/25/24, and 12/28/24 - 1/6/2025. This failure has the potential to affect the residents in the facility and place them at risk of not having staff with advance care skills available to assist in their care needs. Finding included: Record review of the RN Coverage for months of December 2024 and January 2025 indicated there were no RN hours on the following dates: * 12/2/24 - 12/9/24 * 12/13/24-12/18/24 * 12/20/24-12/22/24 * 12/25/24 * 12/28/24 - 1/6/2025 During an interview on 1/6/2025 at 8:45 am, Administrator F, said the facility does not have a full time RN for coverage, she stated a possible negative outcome for not having an RN working for 8 hours/day would be that if something bad happened, the staff would not know what to do and would not have anyone to go to. During an interview on 1/7/2025 at 10:25 AM, the BOM stated the facility did not have a full time RN working in the facility. She stated the consequences of not having an RN in the facility would be not having another set of eyes for the residents. She stated she did not know why there was no full time RN working. A record review of the facility's Departmental Supervision policy dated April 2006, revealed, Policy Statement: The Nursing Services department shall be under the direct supervision of a Registered or Licensed Practical/ Vocational Nurse at all times. Policy Interpretation and Implementation: I. A Registered or Licensed Practical/Vocational Nurse (RN/LPN/LVN) is on duty twenty-four hours per day, seven (7) days per week, to supervise the nursing services activities in accordance with physician orders and facility policy. 2. A Registered Nurse (RN) is employed as the Director of Nursing Services (DNS). The DNS is on duty during the day shift Monday through Friday. During the absence of the DNS, a Nurse Supervisor/Charge Nurse is responsible for the supervision of all nursing department activities including the supervision of direct care staff. 47723

Based on interview and record review, the facility failed to designate a registered nurse (RN) to serve as the DON on a full-time basis since 11/3/2024 The facility did not have a DON from 11/3/2024 to currant date. This failure could place residents at risk of lack of nursing oversight and a higher level of care. Findings include: Record review of DON Coverage from Raw Punch Report dated 1/7/2025 indicated last day of DON coverage was 11/3/2024 with punch out time of 2:38pm with a total of 6.70 hours. During Entrance Conference interview on 1/6/2025 at 8:45 AM with the administrator F, she said they currently do not have a DON. ADM F said her first day of employment was 11/25/2024, and there was not a DON. Record Review of offer of employment for ADM F dated 11/16/2024, offer for employment for the administrator position at [facility] with effective start date of 11/25/2024. During an interview on 1/8/2025 at 2:09 p.m. the ADON, said she began employment on 11/11/2024 and there was not a DON at that time. Record review of letter dated 1/6/2025 at 6:50p.m. from ADM F stated: I am letting you know I am no longer at [facility]. Please take my name off that facility as they were wanting me to say I was DON so they would have RN coverage hours. Adm F, RN, DNP LNFA, [email] During an interview on 1/7/2025@ at 9:00 a.m. with Adm G, he said he was now the Administrator of the facility, and they still do not have a DON. He states have been unable to employee a DON and this was his second day of employment. A record review of the facility's Director of Nursing Services policy dated August 2006, revealed, Policy Statement: The Nursing Services department is under the direct supervision of a Registered. Policy Interpretation and Implementation: I. The Nursing Service department is managed by the Director of Nursing Services. The Director is a Registered Nurse (RN), licensed by this state, and has experience in nursing administration, rehabilitation, and geriatric nursing. 2. The Director is employed full time (40-hours per week) and is responsible for, but is not necessarily limited to: a) Developing and periodically updating nursing service objectives and statement of philosophy b) Developing standards of nursing practice c) Developing and maintaining nursing policies and procedure manuals d) Developing and maintaining written job descriptions for each level of nursing personnel etc.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen observed for kitchen sanitation. A 16 oz. bag of tortilla chips was opened and not re-sealed. DA A checked the sanitizing of the dish machine using quaternary ammonia test strips instead of chlorine test strips. The dish machine log [DATE] had been pre-filled with results for the noon check ([DATE]) when the noon meal had not occurred. The results indicated temperatures but no sanitizing conditions for any date. The dish machine log for [DATE] and [DATE] had blanks where washing temperatures and sanitizing results had not been documented. In the walk in cooler ,d+[DATE] oz. nectar thick iced teas, ,d+[DATE] oz. nectar thick orange juice, and ,d+[DATE] oz. honey thick water with lemon had been opened and not labeled with the open date. These failures could place residents who ate food from the kitchen at risk of foodborne illness. Findings included: During observations, interviews and record reviews on [DATE] of the kitchen the following was noted: *at 9:40 AM DA A was washing dishes and was asked to check the sanitizing solution on the dish machine. He took a container of test strips from a wall-mounted storage box above the dish machine and tested the water in the dish machine after the sanitizing cycle. The test strip did not chemically react. The container of test strips was labeled QAC (quaternary ammonia compounds-a sanitizer). The sanitizing solution connected to the dish machine was marked as CL (chlorine). DA A said he had been using the test strips that were in the storage box because those were the strips the dish machine vendor had left. He said he did not know the QAC strips were the incorrect ones. He said he had had the purple chlorine strips before and someone had put the QAC strips in the storage box but he did not know exactly when that happened. DA A said he was to log the wash, rinse and sanitizing results in the logbook that was in the dish room. The DM said, at that time, the dish machine vendor always came when he was not at the facility. He said he did not know the QAC strips were in the storage box. He said the vendor came about a week ago sometime before the first of the year to change out the chemicals. DA A said he had not made any chemical notations in the logbook, only the water temperatures for [DATE]. He had already filled in the noon meal temperatures by 9:00 AM. The DM was asked if he checked the sanitizing logbook on a regular basis and he did not respond to the question. He did not know the logbook had no notations for sanitizing of the dishes in the dish machine for [DATE] through 6, 2025 only the wash and rinse temperatures. The DM said the QAC strips were used to test the sanitizing solution used in the red sanitizing buckets and the 3 compartment sink. The DM left the dish room and returned with a container of test strips labeled chlorine to be used on the dish machine. The DM said the sanitizing solution should test between 50 and 200 ppm. He said the kitchen staff were to check the sanitizer when they washed the dishes for each meal and log it in the Dish Machine Temperature Logbook. The dish machine was tested and the result was 200 ppm which indicated the machine was sanitizing although at a higher concentration noted on the logbook. The DM used liquid paper to erase the temperatures entered for [DATE] noon meal. A copy was made before it was changed. The DM said he did not know the sanitizing results were not entered for all 3 meals for [DATE], [DATE], [DATE], [DATE], [DATE] or for breakfast on [DATE]. *at 10:07 AM in the dry pantry one 16 oz. bag of tortilla chips was opened and the tops\ was rolled down and not secured or placed in a re-sealable bag. After surveyor intervention the DM took the opened bag and placed it in a resealable bag and returned it to the shelf. *at 10:10 AM in the walk in cooler there was one 46 oz. nectar thick orange juice and one 46 oz. honey thick water with lemon, and the packaging indicated May be kept for up to 7 days after opening under refrigeration and two 46 oz. nectar thick iced teas (by another manufacturer) and the packaging indicated Discard if not used within 10 days of opening. The DM said the dates written on the side of the cartons were the truck date when the product came to the facility. He said he did not know the thickened liquid products had an expiration date after opening. He did not do anything with the opened products and they remained in the cooler for service. Record review of the facility's Dish Machine Temperature Logbook at 9:50 AM, dated [DATE], indicated 3 sets of columns which indicated the date, temp/chem and initials of person doing the test. The 3 sets of columns were for the 3 meal times for the day. Day [DATE]) indicated the morning meal and noon meal contained values for the date, temp/chem, and initials for the noon meal that had not occurred. The noon and evening meal values were not recorded on [DATE]. The evening meal values were not recorded for [DATE] and [DATE]. Chem values were not sanitizer values but rinse water temperatures (the values ranged from 50, 59, 69, 70, and 80. Record review of the facility's Dish Machine Temperature Logbook at 9:50 AM, dated [DATE], indicated 3 sets of columns which indicated the date, wash, rinse, chem and initials of the DM. The 3 sets of columns were for the 3 meal times for the day. Day [DATE]) indicated the morning meal and noon meal contained values for the date, temp/chem, and initials for the noon meal that had not occurred. The noon and evening meal values were not recorded on [DATE]. The breakfast values were not recorded for [DATE], [DATE] and [DATE]. The lunch values were not recorded for [DATE], [DATE], and [DATE]. The evening meal values were not recorded for [DATE], [DATE], [DATE], and [DATE]. Chemical values were inaccurately noted as 58, 59, 62, 63, 68, 69, 76, 77, 78, 80, 89, 98, 101, and 102 when the values can only be 0, 50, 100 or 200 per the chemical testing strip for chlorine. The record was not initialed by the DM on any day. Review of undated directions on the front of the Dish Machine Temperature Logbook binder indicated Make sure you are recording temperatures before the start of each meal to ensure all dishes are being properly sanitized. Low Temperature Dish Machine Wash: ,d+[DATE] degrees; Rinse: 140 degrees; Sanitizer: 50 ppm-100 ppm. Record review of the facility's Sanitation policy, dated [DATE], indicated the following: .Low-Temperature Dishwasher (Chemical Sanitization) a. Wash temperature (120 degrees F); b. Final rinse with 50 parts per million (ppm) hypochlorite (chlorine) for at least 10 seconds. Record review of the facility's Dishwashing Machine Use policy, dated [DATE], indicated the following: 4. Dishwashing machine sanitizer concentrations and contact times will be as follows: Chlorine ,d+[DATE] ppm 10 seconds contact time, Quaternary Ammonium ,d+[DATE] ppm per manufacturer's instructions for contact time. 5. A supervisor will check the dishwashing machine for proper concentrations of sanitizer solution after filling the dishwashing machine and once a week thereafter. Concentrations will be recorded in a facility approved log. Record review the facility's Refrigerators and Freezers policy, dated [DATE], indicated the following: .8. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates.

Based on interview and record review the facility failed to ensure accurate assessments were completed for 3 of 15 residents (Residents #16, #52, and #53) reviewed for accuracy of assessments. The facility failed to ensure Residents #16, #52, and #53's MDS assessment was accurately coded for Preadmission Screening and Resident Review (PASRR). These failures could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings included: 1.A review of Resident #16's face sheet for January 2025 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included bipolar disorder and depressive disorder. A review of Resident #16's PASRR Level 1 screening done 10/24/2024 indicated he now had a primary diagnosis of dementia and would not qualify for specialized services. A review of Resident #16's PASRR Evaluation done10/22/2020 indicated he was positive for mental illness but did not meet the PASRR definition for mental illness for specialized services. A review of Resident #16's annual MDS dated [DATE] Section A1500. Preadmission Screening and Resident Review (PASRR) indicated No if resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section I Active Diagnoses under Psychiatric/Mood Disorder indicated the resident had depression and bipolar disorder. 2. A review of Resident #52's face sheet for January 2025 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included psychotic disorder with delusions, pseudobulbar affect (neurological condition that causes sudden and uncontrollable outbursts of crying or laughter), and dementia. A review of Resident #52's PASRR Level 1 screening done 09/26/2024 indicated he was positive for MI. A review of Resident #52's PASRR Evaluation done 10/04/2024 indicated he was positive for MI. The resident was positive for mental illness but did not meet the PASRR definition for mental illness for specialized services. A review of Resident #52's admission MDS dated [DATE] Section A1500. Preadmission Screening and Resident Review (PASRR) indicated No if resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section I Active Diagnoses under Psychiatric/Mood Disorder indicated the resident had depression and psychotic disorder. 3. A review of Resident #53's face sheet for January 2025 indicated he was an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included psychotic disorder with delusions, major depressive disorder, and vascular dementia. A review of Resident #53's PASRR Level 1 screening done 10/24/2024 indicated he had a primary diagnosis of dementia and the local authority determined a PASRR Evaluation would not be done. He would not qualify for specialized services due to his dementia. A review of Resident #53's admission MDS dated [DATE] Section A1500. Preadmission Screening and Resident Review (PASRR) indicated No if resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section I Active Diagnoses under Psychiatric/Mood Disorder indicated the resident had depression and psychotic disorder. During an interview on 01/08/2025 at 9:15 AM, the MDS Coordinator said the facility used the RAI Version 3.0 Manual as the policy for completing MDS assessments. She said if she had any questions regarding the MDS assessment she went directly to the RAI manual. She said she also had a corporate resource person. She said Section A 1500 indicated if the resident was positive for mental illness, intellectual disability or developmental disability. She said she did not realize the Section I Active Diagnoses was related to Section A PASRR screening documentation. She said she had been taught if the local authority had found residents that did not qualify for PASRR services because they did not meet the PASRR definition for mental illness for specialized services and she was told to answer no because they were negative. She said she did not know Section A had to be coded as positive for mental illness, intellectual disability or developmental disability even though they did not qualify for PASRR services. 42190 47723

Based on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications for the facility's only resident with an enteral device (Resident #34). The facility failed to ensure LVN D followed the facility's policy for administration of medications through an enteral tube (gastrostomy tube, G-Tube). This failure could place the resident at risk for clogging and/or damage of the gastrostomy tube and possible leakage of medications, formula, and/or water into the abdominal cavity. Findings include: A record review of a face sheet dated 01/08/2025 indicated Resident #34 was a [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses which included pharyngeal dysphagia (difficulty swallowing due to damage to the throat), erosive esophagitis (inflammation, irritation, or swelling of the lining of the esophagus), irritable bowel syndrome (intestinal disorder causing pain in the belly, gas, diarrhea, and constipation), and gastrostomy tube placement (a feeding tube that is surgically inserted through the abdomen and stomach wall to provide nutrition directly into the stomach - also called enteral tube or G-Tube). A record review of an Admission MDS assessment dated [DATE] noted Resident #34 had a BIMS of 15 which indicated her cognition was intact. The MDS assessment indicated Resident #34 had a feeding tube. A record review of Resident #34's care plan dated 01/08/2024 indicated she was receiving a pureed diet with thin liquids orally with supplementation of liquid feedings via a feeding tube (G-Tube) as needed. The care plan did not include any instructions for administering medications through the G-Tube. A record review of the physician's orders dated 01/07/2025 for Resident #34 included the following: -1 multivitamin with minerals tablet via G-tube one time a day, -1 vitamin C 500mg tablet via G-tube one time a day, -1 zinc 50 mg tablet via G-tube one time a day, - Protonix Oral Packet 40mg (pantoprazole Sodium granules) - give 1 packet via G-tube one time a day - May crush meds/open capsules -Flush enteral tube with 30 mL of water before and after medication administration Further review revealed the physician's orders did not include any other instructions specific for the administration of crushed medications via the G-Tube. During an observation and interview on 01/07/2025 at 08:12 AM, LVN D prepared Resident 34's morning medications consisting of 1 (one) multivitamin with minerals tablet, 1 (one) Vitamin C 500mg tablet, 1 (one) Zinc 50mg tablet and 1 (one) Protonix 40 mg tablet by crushing all the medications together. He placed the crushed medication mixture in a plastic cup and added an unmeasured amount of water. LVN drew the mixture up into a 60 mL syringe. The medications and water mixture measured approximately 25 mL in the syringe. He donned gloves and entered Resident #34's room. After checking the tube for placement and residual, LVN D attached the syringe to Resident #34's G-Tube and used the syringe plunger to push the medication mixture into the tube. After pushing approximately one-half of the mixture into the tube, he said he could not get the rest of the mixture to go in. He withdrew the syringe and said he could see a piece of medication lodged in the tip of the syringe. LVN D was able to dislodge the medication from the tip and back into the syringe barrel. He emptied the contents of the syringe with the uncrushed piece of medication in it back into the medicine cup and used the syringe tip to crush the uncrushed piece. LVN D drew the liquid mixture back up into the syringe, re-connected the syringe to the G-Tube and continued to push the syringe plunger, forcing the mixture into the tube. He disconnected the syringe from the G-Tube, capped the G-Tube, and said he was done. He did not flush the G-Tube with water before nor after administering the medication mixture. During an interview on 01/07/2025 at 10:45 AM, LVN D said the medications were supposed to be crushed and administered separately with water flushes prior to administering any medications, between each medication, and after administering all the medications to reduce the risk of clogging the tube. He said he crushed them all together because he thought Resident #34 might not tolerate the extra water flushes. He said he did not have an order to crush the medications together. He said he forgot to flush the G-Tube with water before and after administering the medications. LVN D said crushing and administering medications together could result in possible tube occlusion. LVN D said he was not supposed to use the syringe plunger to push the medications into the tube. He said he was supposed to remove the plunger from the syringe, pour water for flushes and medications into the syringe barrel, and allow them to drain into the tube via gravity flow. LVN D said forcing medications into and through a G-Tube could result in damage to the tube resulting in possible leakage of medications, formula, and/or water into the abdominal cavity. LVN D said that forcing medications into and through a tube could result in damage to the tube resulting in leakage of medications, formula, and/or water into the abdominal cavity. He said the rationale flushing the tube with water before, between, and after medications was to reduce the risk of clogging the tube resulting in the tube becoming un-usable and possibly requiring surgical replacement. During an interview with the MDS Nurse Coordinator and ADON on 01/07/2025 at 02:12 PM, the MDS Coordinator said medications given via the G-Tube route should be crushed and administered separately. She said the G-Tube should have been flushed with water before, between, and after each medication to reduce the risk of adverse reactions and non-therapeutic responses and possible damage to the tube. The ADON said she expected the nurses to follow the physician's orders and the facility's policy on administering medications through a G-Tube. A record review of the facility's policy dated November 2018 and titled Administering Medications through an Enteral Tube indicated the following: Purpose The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube. General Guidelines 3. Administer each medication separately and flush between medications. Procedure 8. When correct tube placement and acceptable residual volume have been verified, flush tubing with 15-30 mL warm purified water (or prescribed amount). 9. a. Remove plunger from syringe. 9. b. Dilute crushed (powdered) medication with at least 30 mL purified water (or prescribed amount). 10. Administer each medication separately. 12. Administer medication by gravity flow. 12. a. Pour diluted medication into the barrel of the syringe 13. If administering more than one medication, flush with 15mL warm purified water (or prescribed amount) between medications 14. When the last of the medication begins to drain from the tubing, flush the tubing with 15 mL of warm purified water (or prescribed amount).

Based on observation, interview and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 2 of 4 residents (Resident #34 and Resident #50) reviewed for pharmacy services. The facility failed to ensure Resident #34's physician orders included accurate and complete instructions for the administration of medications via the enteral route. The facility failed to ensure Resident #50's Cyanocobalamin (Vitamin B12) Oral Tablet 2500 mcg daily was available for administration resulting in MA B performing mathematical calculations and making substitutions with the doses of the same medication on hand in the facility. These failures could place residents at risk for non-therapeutic responses to medications and receiving the wrong dose of a medication with a possible decline in health status. Findings include: 1.A record review of a face sheet dated 01/08/2025 indicated Resident #34 was a [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses which included pharyngeal dysphagia (difficulty swallowing due to damage to the throat) and gastrostomy tube placement (a feeding tube that is surgically inserted through the abdomen and stomach wall). A record review of the Admission MDS assessment dated [DATE] noted Resident #34 had a BIMS of 15 indicating her cognition to be intact. The MDS assessment indicated Resident #34 had a feeding tube (enteral or G-Tube). A record review of the physician's orders dated 01/07/2025 for Resident #34 included the following: -1 multivitamin with minerals tablet via G-tube one time a day, -1 vitamin C 500mg tablet via G-tube one time a day, -1 zinc 50 mg tablet via G-tube one time a day, - Protonix Oral Packet 40mg (pantoprazole Sodium granules) - give 1 packet via G-tube one time a day - May crush meds/open capsules -Flush enteral tube with 30 ml of water before and after medication administration During an observation and interview on 01/07/2025 at 08:12 AM, LVN D prepared Resident 34's morning medications consisting of 1 (one) multivitamin with minerals tablet, 1 (one) Vitamin C 500mg tablet, 1 (one) Zinc 50mg tablet and 1 (one) Protonix 40 mg tablet by crushing all the medications together. He placed the crushed medication mixture in a plastic cup and added an unmeasured amount of water. LVN drew the mixture up into a 60 mL syringe. The medications and water mixture measured approximately 25 ml in the syringe. He donned gloves and entered Resident #34's room. After checking the tube for placement and residual, LVN D attached the syringe to Resident #34's G-Tube and used the syringe plunger to push the medication mixture into the tube. He then disconnected the syringe from the G-Tube, capped the G-Tube, and said he was done. LVN D did not flush the G-Tube with water before nor after administration of the medications. During an interview on 01/07/2025 at 10:45 AM, LVN D said the medications were supposed to be crushed and administered separately with water flushes between each medication. He said he crushed them all together because he thought Resident #34 might not tolerate the extra water flushes. He said he did not have a specific order to crush the medications together nor how much water to use to dilute each medication nor how much water to flush the tube with between each medication. He said he knew but forgot that Protonix was not supposed to be crushed. He said he did not know Protonix was to be given with applesauce (orally) or apple juice (orally or via tube). LVN D said crushing and administering medications together could result in chemical incompatibilities leading to an altered therapeutic response and possible tube occlusion. During an interview with the MDS Nurse Coordinator and ADON on 01/07/2025 at 02:12 PM, the MDS Coordinator said medications to be given via the G-Tube route should be crushed and administered separately. She said the G-Tube should have been flushed with water before, between, and after each medication to reduce the risk of adverse reactions and non-therapeutic responses and possible damage to the tube. The ADON said the physician's orders should include the procedure to be used to administer medications via an enteral tube including the amount of water to be used to flush the tube and to dilute the crushed tablets with. She said that if a medication required specific instructions such as not to crush or give with apple juice, then it should be included in the physician's orders so staff would have the information available when administering medications. A record review of the facility's policy dated November 2018 and titled Administering Medications through an Enteral Tube indicated the following: Purpose The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube. Preparation 1.Verify that there is a physician's medication order for this procedure. General Guidelines 3. Administer each medication separately and flush between medications. 4. Do not crush or split medications for administration through an enteral tube unless first checking with the pharmacy or facility approved Do Not Crush Medication List. 4.a. Tablets that must be crushed prior to administration through an enteral tube require a specific order related to crushing. 2.A record review of a face sheet dated 01/08/2025 indicated Resident #50 was a [AGE] year-old male who admitted to the facility on [DATE]. He had diagnoses which included Alzheimer's Disease, Cerebral Infarction (stroke caused by blockage of blood flow to the brain), and vitamin deficiency. A record review of a MDS dated [DATE] noted resident #50 to have a BIMS of 6 indicating his cognition was severely impaired. He was continent, ambulatory, and able to voice basic needs. A record review of a care plan dated 01/08/2025 indicated Resident #50 had a concern for short- and long-term memory loss and required minimal supervision for most activities of daily living. A record review of Resident #50's physician orders dated 01/07/2025 indicated he was to receive Cyanocobalamin (Vitamin B12Oral Tablet 2500 mcg daily. During an observation on 01/07/2025 at 08:43 AM, MA B obtained 2 (two) tablets of Vitamin B12 1000 mcg and 1 (one) tablet of Vitamin B12 500 mcg from her medication cart and put them in a medication cup containing some other medications. She handed the cup of medications to Resident #50 who swallowed the medications. A record review of Resident #50's MAR dated 01/07/2025 indicated MA B had administered 1 Vitamin B12 2500mcg tablet. There was no record of Resident #50 being administered 2 Vitamin B12 1000mcg tablets and 1 Vitamin B12 500mcg tablet. During an interview with MA B on 01/07/2025 at 10:45 AM, MA B said the physician's order was for 1 (one) tablet of Vitamin B12 2500mcg. MA B said she did not have any Vitamin B12 vitamins in the 2500mcg strength so she used 2 (two) of the Vitamin B12 1000mcg tablets plus 1 (one) of the Vitamin B12 500mcg tablets to equal the 2500mcg ordered dose. MA B said she told several people she did not have the Vitamin B12 in the strength listed in the physician's orders, but she had never gotten any. MA B said she made the calculations and determined she would need 2 (two) of the Vitamin B 1000mcg tablets plus 1 (one) of the Vitamin B12 500mcg tablets to equal the physician ordered dose. MA B said medication aides were not supposed to perform drug dose calculations. She said the physician's orders were supposed to indicate exactly what the medication aide was supposed to give to prevent medication giving the wrong dose of a medication. During an interview on 01/07/2025 at 11:45 AM, the ADON said the physician's order for Vitamin B12 2500mcg should have been updated to reflect what the facility had on hand. She said there should be 2 (two) physician orders, one order to give 2 Vitamin B12 1000mcg tablets and a second order to give 1 Vitamin B12 500mcg tablet. She said medication aides were not allowed to calculate medication doses nor make changes in how a dose of medication was to be administered. The ADON said that since the medication aides were signing that they were giving 1 Vitamin B12 2500mcg tablet, there was no way of knowing what strength tablets they were giving nor if they were giving the correct dose. The ADON said administering medications according to the physician's instructions reduced the risk for administering the wrong dose of a medication. A record review of the facility's policy dated April 2019 and titled Administering Medications indicated the following: Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders .

Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not 5 percent or greater. The facility had a medication error rate of 7% based on 2 errors out of 26 opportunities which involved 1 of 4 residents (Resident #34) observed for medication administration. LVN D failed to ensure a delayed-release medication (releases the medication in the intestine to prevent break-down of the medication by stomach acids) was not crushed. LVN D crushed and mixed Resident #34's morning medications (and administered them via the gastrostomy tube route in a single administration. These failures could place residents who receive medications via the gastrostomy tube route at risk for non-therapeutic responses and/or potential adverse effects of the mediations with a possible decline in health status. Findings include: A record review of a face sheet dated 01/08/2025 indicated Resident #34 was a [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses which included pharyngeal dysphagia (difficulty swallowing due to damage to the throat), erosive esophagitis (inflammation, irritation, or swelling of the lining of the esophagus), irritable bowel syndrome (intestinal disorder causing pain in the belly, gas, diarrhea, and constipation), and gastrostomy tube placement (a feeding tube that is surgically inserted through the abdomen and stomach wall). A record review of the Admission MDS assessment dated [DATE] indicated Resident #34 had a BIMS of 15 which indicated her cognition was intact. The MDS assessment indicated Resident #34 had a feeding tube (enteral or G-Tube). A record review of Resident #34's physician's orders dated 01/07/2025 indicated an order dated 12/16/2024 for Protonix Oral Packet 40mg (Pantoprazole Sodium granules) - give 1 packet via G-tube one time a day. During an observation on 01/07/2025 at 08:12 AM, LVN D prepared Resident #34's morning medications. He obtained 1 (one) multivitamin with minerals tablet, 1 (one) Vitamin C 500mg tablet, and 1 (one) Zinc 50mg tablet from the medication cart and placed all 3 medications in a plastic cup. He said Resident #34 was supposed to get Protonix but said he did not have any in the cart. He said he would have to obtain the Protonix from the automated medication dispensing cabinet in the medication room. LVN D obtained 1 (one) Protonix 40mg tablet from the cabinet, returned to the cart, added the Protonix tablet to the other medications in the cup, and crushed all the medications together. He placed the crushed medication mixture in a plastic cup, added water, and drew the mixture up into a 60 mL syringe. He donned gloves and entered Resident #34's room. After checking the tube for placement and residual, LVN D attached the syringe to Resident #34's G-Tube and administered the medications through the G-Tube. He disconnected the syringe from the G-Tube, capped the G-Tube, and said he was done. During an interview on 01/07/2025 at 10:45 AM, LVN D said the medications were supposed to be crushed and administered separately. LVN D said Resident #34 was supposed to have been given 1 packet of Protonix 40mg granules. He said he did not have any in his cart and that was why he substituted the Protonix 40mg tablet. LVN D said he knew he was not supposed to crush Protonix tablets but forgot. He said he did not know that Protonix was a delayed release medication and that crushing it would increase the risk of the medication being released prematurely resulting in Resident #34 not receiving the intended therapeutic effect of the medication. During an interview with the ADON on 01/07/2025 at 11:15 AM, she said expected the nurses to follow the facility's policy on administering medications through a G-Tube. She said LVN D should not have substituted the Protonix 40 mg tablet for the ordered packet of Protonix granules, should not have crushed the Protonix tablet, and should not have crushed all the medications together and administered them in a single action. A record review of the facility's policy, Administering Medications, and dated April 2019 indicated the following: Policy Statement Medications are to be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 4. Medications are administered in accordance with prescriber orders, . 8. If a .medication has been identified as having adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's Medical Director to discuss the concerns. A record review of the facility's policy, Administering Medications through an Enteral Tube, dated November 2018 indicated the following: 3. Administer each medication separately and flush between medications. 4. Do not crush or split medications for administration through an enteral tube unless first checking with the pharmacy or facility approved Do Not Crush Medication List. b. Do not crush enteric coated, sustained release, buccal, or sublingual, or enzyme-specific medications. A review of information on Drugs.com at https://www.drugs.com: FDA Prescribing Information: Pantoprazole: Package Insert/prescribing Information, Last updated November 13, 2024: Dosage and Administration indicated the following: Do not split, chew, or crush Pantoprazole sodium delayed-release tablets.

Based on interview and record review, the facility failed to ensure medical records, in accordance with accepted professional standards and practices, were complete and accurately documented for 1 of 5 Residents (Resident #41) reviewed for medical records accuracy. The facility failed to insure Resident #41's OOHDNR code status was accurately reflected in the facility's code status book, on the Resident's face sheet and in the physician orders and care plan. This failure could place residents at risk for receiving resuscitation actions against their declared instructions. Findings include: A record review of Resident #41's face sheet dated [DATE] indicated she was an [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses which included Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), depression (a persistent feeling of sadness and loss of interest in activities), coronary atherosclerosis (condition where plaque builds up in the coronary arteries which can reduce or block blood flow to the heart), communication deficit, and a history of cancer of the colon. The face sheet also indicated Resident #41 had a Full Code status. A record review of Resident #41's Significant Change MDS dated [DATE] noted Resident #41 had a BIMS of 2 which indicated her cognition was severely impaired. She was non-ambulatory, incontinent of bowel and bladder, and dependent on staff for most activities of daily living. A record review of Resident #41's physician orders dated [DATE] noted an order for Full Code dated [DATE]. A record review of Resident #41's care plan dated [DATE] indicated her elected code status was Full Code and the goal was for Resident #41's wishes to be honored and her code status upheld in the event she was found to be without vital signs. A record review of a notebook titled Code Book located at the nurses' station included a green sheet of paper with Resident #41's name on it and the letters DNR on it which indicated Resident #41 was a DNR. A record review of the miscellaneous medical records section indicated Resident #41 had a signed and notarized OOHDNR (Out Of Hospital Do Not Resuscitate) document signed on [DATE] in her chart. During an interview with LVN E on [DATE] at 01:45 PM, LVN E looked in a notebook at the nurse's station and said Resident #41 was a Full Code. An unidentified RN at the nurses' station was sitting at the computer and said Resident #41's face sheet indicated Resident #41 was a Full Code. LVN E said that if Resident #41 was found to be without a pulse, she would initiate cardiopulmonary resuscitation actions. When asked about the OOHDNR document, LVN E said she was a PRN nurse and did not know what was expected. During an interview with the Admission Coordinator on [DATE] at 02:00 PM, she said the facility did not have a DON nor Social Worker and said she helped with the Code Book. She said Resident 41's code status was Full Code. She said Resident #41's family member had gone back and forth regarding code status, but the status was currently a Full Code. When asked about the OOHDNR document, the Admission Coordinator said she would call the family member and verify the status. During an interview on [DATE] at 02:10 PM with Admin 1, she said Resident #41 received hospice services. She said Resident #41's family member changed the Resident's code status and gave the OOHDNR document to hospice. She said hospice did not verbally communicate that change to anyone at the facility. She said hospice should have spoken to the Administrator, DON, Social Worker, or Admission Coordinator about changing Resident #41's code status to DNR code status so a physician's order could have been obtained and Resident #41's medical records updated. During an interview with the Admission Coordinator on [DATE] at 02:40 PM, she said Resident #41's code status was DNR. She said the Resident #41's family member told her he had signed the OOHDNR document with his mother's hospice nurse. She said the hospice nurse faxed the document to the facility but did not verbally communicate the change in code status to anyone at the facility. The Admission Coordinator said evidently the OOHDNR document came by fax and was placed in the tray for items that needed to be scanned into the system. She said it looked like the OOHDNR document was scanned into the system without anybody being made aware of the change in code status. She said if Resident #41 had died , staff would have attempted to resuscitate her. A record review of the facility's policy titled Advance Directives indicated the following: Advance directives will be respected in accordance with state law and facility policy. 5. In accordance with current OBRA definitions and guidelines governing advance directives, our facility has defined advance directives as preferences regarding treatment options and include, but are not limited to: b. Do Not Resuscitate - Indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other lifesaving methods are to be used. 8. Changes or revocation of a directive must be submitted in writing to the Administrator.The Care Plan team will be informed of such changes and/or revocations so that appropriate changes can be made in the resident assessment (MDS) and care plan. 9. The Director of Nursing Services or designee will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. 13. Inquiries concerning advance directives should be referred to the Administrator, Admissions Director, Director of Nursing Services, and/or to the Social Services Director.

Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Residents #34) reviewed for infection control. LVN D failed to don appropriate PPE prior to administering medications through a gastrostomy tube (also called a G-Tube, enteral tube, or feeding tube). This failure could place residents at risk of exposure and/or possible transmission of communicable diseases and infections. Findings include: A record review of a face sheet dated 01/08/2025 indicated Resident #34 was a [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses which included pharyngeal dysphagia (difficulty swallowing due to damage to the throat), necrotizing fasciitis of the neck (serious bacterial infection of the body's soft tissue, also called flesh-eating disease), erosive esophagitis (inflammation, irritation, or swelling of the lining of the esophagus), irritable bowel syndrome (intestinal disorder causing pain in the belly, gas, diarrhea, and constipation), alcoholic cirrhosis of the liver with ascites (a condition where fluid builds up in the abdomen due to liver scarring caused by chronic alcohol consumption), and gastrostomy tube placement (a feeding tube that is surgically inserted through the abdomen and stomach wall to provide nutrition directly into the stomach - also called enteral tube or G-Tube)). A record review of Resident #34's Admission MDS assessment dated [DATE] noted Resident #34 had a BIMS of 15 which indicated her cognition was intact. The MDS assessment indicated Resident #34 had a feeding tube. A record review of the physician's orders dated 01/07/2025 indicated Resident #34 had a gastrostomy tube for administration of medications and supplemental nutrition. During an observation on 01/07/2025 at 08:12 AM, LVN D prepared Resident 34's morning medications for administration through her feeding tube. He donned gloves and entered Resident #34's room. Resident #34 had a sign on the doorway entrance into her room which indicated Enhanced Barrier Precautions were required. The sign also said that all providers and staff must wear gloves and a gown for high-contact activities which included feeding tube care or use. There was a 3-drawer plastic container outside the doorway which contained PPE which included gloves and gowns. LVN D did not put on a gown. LVN D told Resident #34 that he had her medications. LVN D got down on one knee, bringing the lower leg of his uniform into direct contact with the floor. LVN checked tube placement and administered the medications through the feeding tube. LVN D said he was done and left the room. He removed his gloves, disposed of them, and performed hand hygiene. During an interview with the ADON on 01/07/2025 at 10:20 AM, she said Enhanced Barrier Precautions meant the staff were supposed to don gloves and a gown when providing direct patient care to residents with wounds and indwelling medical devices such as urinary catheters, feeding tubes, and tracheostomies. She said the purpose was to prevent and reduce the risk of spreading infections and diseases. During an interview with the MDS Coordinator on 01/08/2025 at 02:30 PM, she said she was the Infection Preventionist as of 01/07/2025. She said nurses were required to wear gloves and a gown when administering medications through a G-tube to reduce the spread of infections and diseases. During an interview on 01/08/2025 at 04:55 PM, LVN D said he did not don a gown because did not think it was necessary since Resident #34 no longer had an infection nor a pressure ulcer. He said he should have donned a gown prior to providing care to Resident #34 because she had a feeding tube which required EBP. A record review of the facility's policy titled Enhanced Barrier Precautions and dated 04/01/2024 indicated the following: It is the policy of this facility to follow CDC guidelines by utilizing Enhanced Barrier Precautions in the care of patients susceptible to multiple drug resistant organisms (MDRO), and to reduce the spread and prevalence of MDRO related infections. Enhanced barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. The use of gown and gloves for high-contact resident care activities is indicated, when Contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. The following situations would warrant Enhanced Barrier Precautions .feeding tubes .

Based on observation, record review and interview the facility failed to ensure residents had the right to be free from abuse and neglect for 5 of 11 residents reviewed for abuse and neglect. (Resident #1 #2, #4, #5, and #8) 1. The facility failed to ensure Resident #2 was free from abuse after Resident #2 indicated MA B physically assaulted her on 11/9/24. The facility failed to address the abuse, report/investigate the allegations of abuse or suspend the alleged perpetrator. 2. The facility failed to provide assistance and supervision for Resident #1 between the hours of 12:20 am and 5:30 am on 6/2/24. Resident #1 rolled out of bed and was not checked on during this time. 3. The facility failed to ensure residents were free from abuse from Resident #7. a. Resident #7 was in Resident #8's room and was found touching Resident #8's genital area. Resident #8 had no pants on. b. Resident #7 pushed Resident #1 down on 10/3/24. c. Resident #7 choked Resident #8 on 10/4/24. d. Resident #7 had additional incidents of aggressive behaviors per nursing notes dated 10/16/24 with no detailed information. 4. The facility failed to ensure residents were free from abuse from Resident #3. a. Resident #3 grabbed a female resident by the wrist and would not let go on 10/28/24. b. Resident #3 hit Resident #4 in the mouth on 10/31/24. c. Resident #3 hit Resident # 5 in the head several times on 11/16/24 and was transferred to a behavioral unit. An Immediate Jeopardy (IJ) situation was identified 12/19/24 at 4:50 p.m. While the IJ was removed on 12/22/24 at 2:32 p.m., 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 a pattern due to the facility's need to evaluate the effectiveness of the corrective systems. The facility failures could have caused residents serious physical injury, and emotional abuse due to neglect and continued abuse. Findings Included: 1. Record review of Resident #2's face sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were unsteadiness on feet, dementia (general memory loss) mild with anxiety (feelings of fear, dread, and uneasiness that may occur as a reaction to stress), nicotine dependence, post-traumatic stress disorder (difficulty recovering after experiencing or witnessing a terrifying event) and borderline personality disorder (mental disorder characterized by unstable moods, behavior, and relationships). Record review of Resident #2's quarterly MDS assessment dated [DATE] indicated her BIMS score was a 13 indicating she was cognitively intact. The MDS indicated Resident #2 required set up assistance only with all ADLs. Record review of Resident #2's care plan indicated a Focused area with an initiation date of 5/15/24 that she was a smoker. She was noncompliant with the safe smoking policy. She hid cigarettes and smoking material in her room and was educated repeatedly on these issues. She became confrontational with other residents, staff and visitors during smoke times for no apparent reason. Resident #2 had a Focused area of behavior problems related to smoking and smoking times. One of the interventions was care givers were to provide an opportunity for positive interaction, and attention. Record review of an incident report dated 11/9/24 at 10:10 p.m. indicated this nurse was called by nurse in the front station to report that Resident #2 had been physically aggressive towards MA B. As per front nurse, MA B was just asking Resident #2 to back up a little bit since she was already inside the nurse's station and was in the way of one of the cabinets she needed to open. When MA B pushed her wheelchair back, that was when the resident grabbed the MA's left arm and caused a scratch. Resident #2 called for police assistance without anyone's knowledge. Both parties were interviewed by the police. The nurse talked to the resident, and she claimed MA B grabbed her arm and assaulted her. Resident #2's mental status was oriented to person, place, time, and situation. There was a section for statements and the comment that indicated there were no statements found. There were no injuries noted post incident. Other information was the residents' smoke schedule changed recently and that did not make her happy. Record review of Resident #2's nursing note dated 11/9/24 at 10:23 p.m. indicated the nurse was called by nurse in the front station to report Resident #2 had been physically aggressive towards the MA B. As per front nurse, MA B was asking resident to back up a little bit since she was already inside the nurse's station and was in the way of one of the cabinets that she needed to open. When MA B pushed her wheelchair back, that was when the resident grabbed the MA's left arm and caused a scratch. This nurse talked to Resident #2 and calmed her down. And she verbalized that the MA had assaulted her. This nurse talked to both sides and agreed amicably and just escalated out of proportion. When the police arrived, the resident was in her room resting. Both parties were interviewed by the police. The Resident was sent to the hospital for an evaluation. Signed by LVN C Record review of Resident #2's nursing notes dated 11/9/24 at 11: 45 p.m. indicated the resident came back from the hospital with no new orders. She was sent out to a psychiatric evaluation due to an earlier incident. The resident is resting in bed with no behaviors. Record review of Resident #2's After Visit Summary dated 11/9/24 indicated the reason for visit was a psychiatric evaluation with a diagnosis of physical assault, left upper arm pain, and speech impairment. There were instructions to schedule an appointment for neurology and a family practitioner. Record review of Resident #2's nursing noted dated 11/12/24 indicated she was transferred to another facility. Record Review of Resident #2's hospital records obtained from the facility on 12/18/24 at 12:31 p.m. indicated Resident #2 was sent to the hospital on 11/9/24 for a psychiatric evaluation. The resident reportedly got into a physical altercation with of the caregiver at the facility. The patient stated she got into an argument with a staff member that she did not get along with. She stated the worker grabbed her left forearm and refused to let go despite the patient asking her to, so she pulled away violently. Resident #2 reported bruising to her left arm and some pain with movement of the left wrist, left elbow, and left shoulder. She remembered the incident fully. She stated she did this to get away from her. She stated they keep telling her that she had dementia, and she did not believe them. She was able to answer the month, year, date of birth, location, and identified the situation without significant difficulty. Comments were mild bruising noted to the left distal bicep, left distal forearm, mild pain with range of motion of the wrist and elbow and shoulder. The Clinical Impression on 11/10/24 at 12:35 a.m. was physical assault and left arm pain. Record review of a Provider Investigation Report indicated HHSC was notified on 12/19/24 at 3:30 p.m. after surveyor intervention. The report contained statements from LVN C (with no date) said LVN M told her she had seen Resident #2 had jumped up and grabbed MA Bs hand causing a skin tear. (There was no statement from LVN M). LVN C said both parties claimed they were grabbed by the arm. She said Resident #2 insisted she was assaulted. LVN C said she checked both of their arms and neither had any visible marks. She said she was preparing to send the resident out to the ER for an evaluation as ordered by her supervisor. Resident #2 had called the police and they showed up. The resident went to the ER for a couple of hours. There were no new orders given to the nurse in report. There was no mention of any injury. When Resident #2 came back from the hospital Resident #2 said she was just tired. A statement dated 12/19/24 from MA B said on the second time she found Resident #2 behind the nursing station on 11/9/24 and told her she was going to move her. MA B said in her statement when she moved Resident #2 back, she jumped up and swung at her barley grazed her. (She did not say she grabbed her.) She said she went and talked to a LVN M who was in the room with a resident. She then said she went and found LVN C and told her Resident #2 was mad about her cigarettes. She said she avoided Resident #2 all night. She said another staff member reported to her that Resident #2 was telling other residents she was going to call the police and tell them she hit her. She said later an officer came and took her statement. Record review of MA B's personnel file indicated she worked double weekends as an MA. Review of her time sheet indicted she last worked Sunday, 12/15/24; her regular scheduled day. During a telephone interview with the hospital ER doctor on 12/18/24 at 11:54 a.m., he said he needed to review the ER notes from 11/9/24. He said the facility had sent Resident #2 to the hospital on 11/9/24. The report he received from the facility was Resident #2 had dementia. He said there was nothing wrong with Resident #2's cognitive recall. She did not have a diagnosis of dementia. He said Resident #2 told him the staff member that abused her did not like her and Resident #2 had words with that staff on several occasions. He said Resident #2 said the staff member grabbed her arm and would not let go despite her asking her to let go. He said they did an assessment of Resident #2 and determined bruising on her left distal forearm and left distal bicep were consistent with her story and she was indeed assaulted. He said again after reviewing Resident #2's chart there was no indication she had dementia from their testing. He said they usually sent the ER report with the resident back to the facility, but he could not be sure. During an interview on 12/18/24 at 12:29 p.m., the Marketing Director said the hospital usually sent the ER records back with the residents when they came from the hospital. She said Resident #2's ER or After Visit Summary records were already uploaded to the facility digital file. However, it took a few days for the physician report to generate. The Hospital records for Resident #2's was uploaded today into the facility's digital system. During a telephone interview on 12/18/24 at 4:00 p.m., LVN C said when she arrived at the nursing station on 11/9/24 Resident #2 was in there in a Wheelchair at the nursing station. She said there may have been another resident that witnessed the incident. She said the facility had cameras. LVN C said when she arrived, she listened to both MA B and Resident #2. She said the MA B said Resident #2 got too close in the nursing station and she asked Resident #2 to move, and the resident would not. She said the aide told her she had pushed Resident #2's wheelchair back. The LVN said the MA B told her Resident #2 had clawed her on the arm. LVN C said Resident #2 said she was assaulted. LVN C said they were arguing back and forth exchanging words and accusations. She said she got them separated and Resident #2 went to her room and apparently called the police. The nurse said she did not call the police. She said the police came and talked to both the MA B and Resident #2. LVN C said she had called the former ADON and was told to send the resident to the hospital for an evaluation. She said she had only looked at Resident #2's hand/ wrist area where she said the aide had grabbed her and she did not see any bruising. She did not do a full body assessment. LVN C said she did not write a statement, and as far as she knew the incident was resolved. She said when the police came, they mentioned the word assault but she had called her supervisor and done what she was told. She said she knew what abuse was and did not believe any abuse had occurred. She said when the resident came from the hospital there were no new orders on her paperwork, and she did not see anything else. During a telephone interview on 12/18/24 at 4:30 p.m. MA B said there were two incidents that occurred with Resident #2 on 11/9/24. She said the first incident Resident #2 was behind the nurse's station in one of the employee bags, and she asked her to back up. MA B said she pulled Resident #2's wheelchair back and the resident was upset. She said Resident #2 grabbed her on the forearm on that occasion. MA B said the second time she came back to the nurse's station again, and Resident #2 was back at the nursing station trying to open the cigarette box. She said she told Resident #2 she was going to have to move her back. MA B said Resident #2 went on about her cigarettes. She said she told her she was going to pull back the wheelchair, and Resident #2 jumped out of the chair and was trying to hit her. She said this happened right at shift change, but she could not say anyone witnessed the incidents. She said she had heard staff saying Resident #2 said she had assaulted her. MA B said that night about an hour and half later, the police came, and she told them what happened. She said she had a scratch on her hand, and they took a picture her hand. She said Resident #2 had swung at her, but she barely scratched her. MA B said Resident #2 was mad at her because, previously, they had words about the cigarettes. She said Resident #2 would want to go and smoke and demand to be smoked. MA B said they sent Resident #2 to the hospital to be evaluated. The MA said she did not touch Resident #2 she only touched her wheelchair. The MA said Resident #2 accused her of assault; she was telling the aides on the floor, and police. MA B said she did feel like she was accused of abuse. MA B said no one asked her questions other than the LVN C at that time and no one asked questions after. She said no one asked her to write a statement. During an interview on 12/19/24 at 2:35 p.m., the Director of Operations said they were not aware Resident #2 had a diagnosis of physical assault. They did not have the hospital records uploaded into the computer until today. He said at the time of the incident the former Administrator had turned in her notice a few days before effective immediately and the DON had left without notice on 11/8/24. During an interview on 12/20/24 at 4:16 p.m., the Administrator said that LVN C and MA B had written their statements on yesterday, 12/19/24. She stated she called the allegation of abuse into the state on 12/19/24 regarding Resident #2 that occurred on 11/9/24. She said MA B had come to the facility long enough for the in service and to write her statement and left on 12/19/24. The Administrator said she was not employed at the facility at the time of the incident. Record review of the facility census report dated 12/17/24 indicated the census on the unit was 13. It also indicated Resident #1, Resident #3, Resident #4, Resident #7, and Resident #8 all resided on the locked unit. 2. Record review of Resident #1 face sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were vascular Dementia (brain damage caused by multiple strokes which caused memory loss), assistance with personal care, unsteadiness on feet, muscle weakness, and lack of coordination. Record review of Resident #1's quarterly MDS dated [DATE] indicated a BIMS score of 2 which indicate severe cognitive impairment. The resident had behaviors of disorganized thinking or incoherent rambling, or irrelevant conversations, which could be unclear or illogical. The MDS indicated she required touching assistance with eating, and putting on and taking off footwear, and dressing. She was independent with transfers, sit to stand, and walking. Record review of Resident #1's care plan with an initiation date 9/6/23 indicated a Focus area of at risk for wandering or elopement. She resided on the secure unit. Resident #1 had a Focused area of communication deficit related to dementia. One of the interventions was to provide a safe environment, with call light within reach, and the bed in the lowest position. Resident #1 had a Focus area of episodes of aggression and resistant with care. The resident preferred her door shut. She kept her door closed and did not like anyone in her space/room. She was very anti-social and preferred to stay to herself in her room. Resident #1 had a Focused care area of ADL self-care performance deficit related to dementia and altered thought process. Record review of Resident #1's computerized physician orders indicted an order to admit to the secured unit for exit seeking behaviors with a revision date of 11/23/24. Record review of a Provider Investigation Report indicated on 7/2/24 indicated CNA A was working the 10p to 6 a shift. She failed to check on Resident #1 between 12:20 a.m. and 5:30 a.m. Resident #1 rolled out of bed and was on the floor close to 4.5 hours. CNA A took her break around 3:00 a.m. and notified the charge that she had checked all residents, however that was not true. The family had 2 cameras in Resident #1's room and were aware of what happened. The report indicated CNA A failed to check on Resident # 1. The report stated if CNA A had rounded frequently, Resident #1 would not have been left on the floor for an extended period without attention. Based upon the film recording of the incident CNA A failed to care for Resident #1. The allegation of neglect was confirmed, and CNA A was terminated. During an observation on 12/17/24 at 10:17 a.m., Resident #1 sitting at the table and did not respond when spoken to but was noted to be ambulatory. During a telephone interview 12/18/24 at 11:17 a.m., LVN H said on 7/2/24, CNA A said she was going on break around 3:00 a.m. LVN H said CNA A said she had just completed rounds on everyone on the unit, and everything was good. LVN H said when CNA A was doing her last round about 5:30 a.m. she found Resident #1 on the floor. She said she was informed by the family the resident had been on the floor for hours. She then asked CNA A if she had checked on Resident #1 at 3:00 a.m. and she said she was not sure. During a telephone interview on 12/18/24 at 2:27 p.m., CNA A said she did not remember if she had checked on Resident #1 on the night of 7/2/24. She said it had been a while and she was not sure. 3. Record review of Resident #7's face sheet indicted he was an [AGE] year-old male admitted to the facility on [DATE]. Some of his diagnoses were dementia (general memory loss), cognitive communication deficit, lack of coordination, and generalized muscle weakness. Record review of Resident #7's quarterly MDS dated [DATE] indicated his BIMS score was 1 indicated severe cognitive impairment. The only behavior he had listed on the MDS was rejection of care which occurred one to three days a week. He required setup and cleaned up help with most ADLs and he was independent with transfers and walking. Review of Resident #7's care plan indicated a Focused area of diagnosis of dementia with agitation and delirium secondary to alcohol abuse with an initiation date of 9/6/23 and a revision date of 12/17/24. Some of the approaches were to acknowledge moods in one-to-one interventions as needed, monitor for changes in mood and behaviors. A Focused area of Resident #7 had the potential to be physically and verbally aggressive related to dementia and poor impulse control. On 5/1/24, he was verbally and physical aggressive to staff. The care plan indicated on 7/28/24, he was physically aggressive a resident tapped on the arm. On 10/3/24, he had physical aggression toward a resident. On 10/4/24, he had physical aggression towards a resident. Some of the interventions were to administer medications, analyze times of day, circumstances, triggers, and de-escalate the behavior and document, send to acute hospital as needed, when he became agitated, intervene before the agitation escalates. (There was no mention of sexually in appropriate behaviors. There was no mention of aggression after 10/4/24.) Record review of Resident #7's physician orders indicated on Order dated 12/7/24 for Lorazepam 0.5 mg to give 1 tablet by mouth every 12 hours as needed for anxiety related to a diagnosis of dementia. An order dated 12/9/24 revealed an order for Depakote 500 mg delayed release. Give 1 tablet by mouth two times a day related to unspecified dementia. Record review of Resident #7's computerized physician's orders indicated an order for medication management may provide psychiatric services dated 9/8/23. Record review of Resident #8's face sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were Alzheimer's Disease (a progressive disease that destroys memory and important mental functions), and adjustment disorder (a mental disorder that involves and intense emotional or behavioral response to a stressful event or life change.) Record review of Resident #8's quarterly MDS dated [DATE] indicated a BIMS score of 9 which indicated moderate cognitive impairment. Resident #8's functional status was she was independent with toileting hygiene and dressing. She was independent with bed mobility, transfers, walking/ambulation. Record review of Resident #8' s care plan indicated a focused area of ADL care performance deficit related to dementia, with an initiation date of 5/10/24. Some of the interventions were the resident required one person assist with bathing, hygiene, dressing and transfers. (No mention of behaviors or an inappropriate relationship) Record review of an incident report dated 6/23/24 at 10:26 a.m. indicated Resident #8 was found lying in her bed without any pants/underwear while being touched in her private area (vaginal) by Resident #7. The residents were unable to give a description. Residents were asked to stop and were separated. There were no injuries at the time of the incident. The residents thought they were married to each other. Record review of a nursing note dated 6/24/24 at 2:35 a.m. indicated the resident was found by nurse doing rounds lying in her bed with no pants/underwear while being touched in her private parts by Resident #7. The residents were told to stop and separated. Notified all parties. Record review of Resident #8's nursing notes dated 6/24/24 at 8:15 a.m. day one of three monitoring due to inappropriate sexual behaviors will continue to monitor. Record review of Resident #8's nursing notes dated 6/25/24 at 8:51 a.m. day two of three monitoring due to inappropriate sexual behaviors will continue to monitor. Record review of Resident #8's nursing notes dated 6/26/24 at 2:24 p.m. day three of three monitoring due to inappropriate sexual behaviors will continue to monitor. Record review of Resident #8's physician's physical examination dated 7/3/24 indicated poor insight, poor judgement, and poor recall. Record review of Resident #7's nursing notes dated 9/23/24 indicated CNA E said Resident #7 was being aggressive with other residents and herself. The nurse went to check on the resident and he was very agitated. PRN Lorazepam was given to calm resident down. He was sitting in the common room using foul language. Record review of a Provider Investigation report dated 11/20/24 indicated on 10/3/24 at 1:30 p.m., Resident # 7 pushed Resident #1 causing her to fall. Resident #1 had no injuries and both residents had dementia. No other Provider Investigation Report was found for Resident #7. Review of Resident #7's nursing notes dated 10/3/24 at 12:35 p.m. said Resident #7 was very upset and was witnessed pushing Resident #1 down. He yelled. She was in my way. Record review of Resident #1's nursing notes dated 10/3/24 at 12:45 p.m. indicated Resident #1 had witnessed fall in the hallway when she was pushed down by Resident #7. Resident #1 was found sitting on the floor. When asked where she hursts she stated all over. The resident received an order for a pelvic x ray. Record review of Resident #1's nursing notes dated 10/4/24 indicated x-rays of pelvis results received indicated no acute fracture or dislocation. Record review of Resident #7's nursing notes dated 10/4/24 at 3:58 a.m. indicated he was placed on Q 15 checks for 72 hours. Review of Resident #7's Q 15-minute monitoring indicated on 10/4/24 he was in another residents room at 12:00 p.m. to 12:30 p.m. and had behaviors of restlessness, wandering, pacing and agitation. On 10/4/24 at 7:45 p.m. he was swinging a cane. He was sent to the hospital. Record review of Resident #7's nursing notes dated 10/4/24 at 10:29 p.m. indicted the nurse was called to the locked unit by CNA, the resident was standing in the hallway with a cane in his hand and swinging at another resident and staff. The CNA told the nurse that the resident choked the other resident involved. The nurse tried to reason with Resident #7 and asked him to release the cane. He became more agitated. The nurse separated the residents by putting the female resident in her room. The nurse then went for help and called 911. The resident was sent to the ER. Record review of Resident #7's Hospital After Visit Summary dated 10/4/24 indicated medications have changed, start taking Haldol 2 mg tablet by mouth every 8 hours as need for agitation. The reason for visit was a psychiatric evaluation. The diagnoses were dementia without behavioral disturbance, psychotic disturbances, mood disturbances, or anxiety. Review of a Resident #7's nursing notes dated 10/5/24 at 12:12 p.m. indicated Resident #7 arrived back at the facility. Record review of Resident #7's Order Audit Report indicated on 10/5/24 an order for Haloperidol oral 3mg give one tablet by mouth every 8 hours as needed for agitation. The order was discontinued on 10/28/24. Record review of Resident #8's nursing note dated 10/5/24 at 7:29 a.m. indicated day one of aggression received from Resident #7. Record review of Resident #8's nursing note dated 10/7/24 at 3:37 p.m. indicated day three of three of aggression received from Resident #7. There were no delayed injuries noted. The resident had no complaints of pain or discomfort at this time. Record review of Resident #7's progress note dated 10/16/24 indicated he had grabbed another resident by the wrist and would not let her go. Staff were able to get him to let her go but he was very agitated. Record Review of Resident #7's Progress Note/History and Physical dated 10/18/24 indicted Resident #7 was sent to the ER earlier this month for agitation and attempting to harm others on the memory care unit. Nursing staff reported he had been redirectable, and they were monitoring him closely. During an observation and interview on 12/17/24 at 10:21 p.m. Resident #7 was sitting in a chair. When staff asked him what he preferred to be called he yelled loudly and said he was fine. During an interview on 12/17/24 at 10:22 a.m., CNA K said she had only been on the unit for 2 days and Resident #7 was had anger issues and was easily agitated. During an observation and interview on 12/17/24 at 10:19 a.m., Resident #8 was sitting at the table in the common area. She talked about her family and how they had dumped her at the facility. The more she talked the more upset she became. She said the facility was okay, but she should not be there. Resident #8 said the staff and residents were fine for the most part. During an interview on 12/18/24 at 11:12 a.m. LVN G said when she was working the floor, she was responsible for the residents on the locked unit. She said on 10/21/24 Resident #7 was in Resident #8's face trying to make her sit down. She said Resident #7 grabbed Resident #8 by the wrist and did not want to let her go. LVN G said most of Resident #7's arguments were with Resident #8. She said Resident #7 thought Resident #8 was his wife and they bickered back and forth. LVN G said Resident #7 tried to tell Resident #8 what to do and insisted that she do it right then. During a telephone interview 12/18/24 at 11:17 a.m., LVN H said she remembered an incident of aggression with Resident #7. She said the incident occurred on 10/4/24 when Resident #7 was swing a cane. LVN H said there was one resident standing in the hallway, Resident # 8, and it was her cane that Resident #7 had. She said she could not remember if another resident was in the hallway She said that was right after it was reported to her that he had choked Resident #8 in the hallway. During an interview on 12/18/24 at 12:58 p.m. LVN J said he was the nurse on the unit on day shift. He said it was an ongoing thing between Resident #7 and Resident #8. He said Resident #7 thought Resident #8 was his wife. He said sometimes Resident #8 was with it and realized Resident #7 was not her husband. LVN J said other times Resident #8 would think Resident #7 was her husband. He said they acted like a married couple that did not get along. LVN J said they fussed at each other, sit together, or walk together. LVN J said, at times, Resident #8 would tell Resident #7 to do something, and he would listen. He said Resident #8's dementia goes and comes. During an interview on 12/18/24 at 2:15 p.m., CNA E said she had seen Resident # 7 get angry and hit at women. She said he mostly had controversy with Resident #8. She said she saw him choke Resident #8. She said she had gone into his room and Resident #8 was sitting on the side of the Resident #7's bed holding his hand. She had asked Resident #8 to leave and Resident #7 wanted her to sleep with him. CNA E said Resident #8 told him she was not going to sleep with him, and Resident # 7 got upset and told Resident #8 she needed to give him his fifteen hundred dollars back. She said Resident #8 told him she did not have his money and left the room. She said Resident #8 was on her way to her room and Resident #7 came behind her yelling. She said Resident #7 was to the back side of Resident #8 and put his hands around her neck as if to choke her. The CNA said she was right there within reaching distance and told him to stop and he removed his hands from Resident #8's neck. She said he did not squeeze or have a chance to choke Resident #8, but he did put his hands around her neck. She said she had written a statement and told the former DON the same thing. During a telephone interview on 12/19/24 at 11:03 a.m., the former DON said Resident #8 could not make her own decisions. She stated she was on the unit for a reason, but she can make some decisions. She said she was aware of the incident when Resident #7 supposedly choked Resident #8. She said she did an investigation into that incident and Resident #7 never put hands around the neck. She said she was told he only touched her on the back of her neck; there were no red marks. She said her assessments did not show that he had harmed her physically, he had only touched her. She said when Resident # 7 came into the facility and was very confused. The former DON said she did not believe he was aggressive toward any of the staff. He was independent and missed his wife. The former DON said no harm occurred. 4. Record review of Resident #3's face sheet indicated he was an [AGE] year-old male admitted to the facility on [DATE]. Some of his diagnoses were Alzheimer's Disease (a progressive disease that destroys memory and important mental functions), dementia (general memory loss), and psychotic disorder (mental illness that cause abnormal thinking and perceptions- a loss of reality.) Record review of Resident #3's admission MDS dated [DATE] indicated a BIMS score of 3 indicating severe cognitive impairment. The MDS indicated Behavioral indicators of psychosis such as delusions, misconceptions or beliefs that are firmly held, but contrary to reality. Resident # 3 also had behaviors that occurred one to three days a week of physical symptoms directed towards others such as hitting, pushing, or grabbing. He also has other behavioral symptoms not dir [TRUNCATED]

Based on observation, record review, and interview the facility failed implement their abuse policy to ensure residents had the right to be free from abuse and neglect, allegations were investigated, 7 of 11 residents reviewed for abuse and neglect. (Resident #1, #2, # 3, #4, #5, #7, and #8) 1. The facility failed to ensure Resident #2 was free from abuse after Resident #2 indicated MA B physically assaulted her on 11/9/24. The facility failed to address the abuse, report/investigate the allegations of abuse or suspend the alleged perpetrator. 2. The facility failed to provide assistance and supervision for Resident #1 between the hours of 12:20 am and 5:30 am on 6/2/24. Resident #1 rolled out of bed and was not checked on during this time. 3. The facility failed to ensure residents were free from abuse from Resident #7. a. Resident #7 was in Resident #8's room and was found touching Resident #8's genital area. Resident #8 had no pants on. This incident was not investigated, and no measures were put in place to protect Resident #8. b. Resident #7 pushed Resident #1 down on 10/3/24. c. Resident #7 choked Resident #8 on 10/4/24. d. Resident #7 had additional incidents of aggressive behaviors per nursing notes dated 10/16/24 with no detailed information. 4. The facility failed to ensure residents were free from abuse from Resident #3. a. Resident #3 grabbed a female resident by the wrist and would not let go on 10/28/24. b. Resident #3 hit Resident #4 in the mouth on 10/31/24. c. Resident #3 hit Resident # 5 in the head several times on 11/16/24 and was transferred to a behavioral unit. This incident was not investigated or reported to HHSC. An Immediate Jeopardy (IJ) situation was identified 12/19/24 at 4:50 p.m. While the IJ was removed on 12/22/24 at 2:32 p.m., 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 a pattern due to the facility's need to evaluate the effectiveness of the corrective systems. The facility failures could have caused residents serious physical injury, and emotional abuse due to neglect and continued abuse. Findings Included: Record review of the facilities, signs and symptoms of abuse and neglect policy revise January 20, 2021. Indicate it was the policy of the facility to prohibit resident abuse or neglect in any form and to report in accordance with the law any incident in which there was cause to believe a resident's physical or mental health or welfare had been adversely after by abuse or neglect cause by another person. Abuse was defined as willful infliction of injury, unreasonable, confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness. The following examples of actual abuse are neglect with signs and symptoms, [NAME] or bruises, sexual exploitation, signs of neglect, caregiver indifference to resident personal care needs, and leaving someone unattended who needs supervision. Sexual abuse was defined as the non-consensual sexual contact of any type with a resident. The policy indicated all residents will be immediately protected from harm. All allegation involving staff will necessitate suspension. If another resident is the alleged perpetrator, they shall immediately be assessed for treatment options. The safety and protection of other residents is the facility's concern. Reporting- indicate all allegations of abuse will be reported to the appropriate state agency and to all other agencies as required by regulation. 1. Record review of Resident #2's face sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were unsteadiness on feet, dementia (general memory loss) mild with anxiety (feelings of fear, dread, and uneasiness that may occur as a reaction to stress), nicotine dependence, post-traumatic stress disorder (difficulty recovering after experiencing or witnessing a terrifying event) and borderline personality disorder (mental disorder characterized by unstable moods, behavior, and relationships). Record review of Resident #2's quarterly MDS assessment dated [DATE] indicated her BIMS score was a 13 indicating she was cognitively intact. The MDS indicated Resident # 2 required set up assistance only with all ADLs. Record review of Resident #2's care plan indicated a Focused area with an initiation date of 5/15/24 that she was a smoker. She was noncompliant with the safe smoking policy. She hid cigarettes and smoking material in her room and was educated repeatedly on these issues. She became confrontational with other residents, staff and visitors during smoke times for no apparent reason. Resident #2 had a Focused area of behavior problems related to smoking and smoking times. One of the interventions was care givers were to provide an opportunity for positive interaction, and attention. Record review of an incident report dated 11/9/24 at 10:10 p.m. indicated this nurse was called by nurse in the front station to report that Resident #2 had been physically aggressive towards MA B. As per front nurse, MA B was just asking Resident #2 to back up a little bit since she was already inside the nurse's station and was in the way of one of the cabinets she needed to open. When MA B pushed her wheelchair back, that was when the resident grabbed the MA's left arm and caused a scratch. Resident #2 called for police assistance without anyone's knowledge. Both parties were interviewed by the police. The nurse talked to the resident, and she claimed MA B grabbed her arm and assaulted her. Resident #2's mental status was oriented to person, place, time, and situation. There was a section for statements and the comment that indicated there were no statements found. There were no injuries noted post incident. Other information was the residents' smoke schedule changed recently and that did not make her happy. Record review of Resident #2's nursing note dated 11/9/24 at 10:23 p.m. indicated the nurse was called by nurse in the front station to report Resident #2 had been physically aggressive towards the MA B. As per front nurse, MA B was asking resident to back up a little bit since she was already inside the nurse's station and was in the way of one of the cabinets that she needed to open. When MA B pushed her wheelchair back, that was when the resident grabbed the MA's left arm and caused a scratch. This nurse talked to Resident #2 and calmed her down. And she verbalized that the MA had assaulted her. This nurse talked to both sides and agreed amicably and just escalated out of proportion. When the police arrived, the resident was in her room resting. Both parties were interviewed by the police. The Resident was sent to the hospital for an evaluation. Signed by LVN C Record review of Resident #2's nursing notes dated 11/9/24 at 11: 45 p.m. indicated the resident came back from the hospital with no new orders. She was sent out to a psychiatric evaluation due to an earlier incident. The resident is resting in bed with no behaviors. Record review of Resident #2's After Visit Summary dated 11/9/24 indicated the reason for visit was a psychiatric evaluation with a diagnosis of physical assault, left upper arm pain, and speech impairment. There were instructions to schedule an appointment for neurology and a family practitioner. Record review of Resident #2's nursing noted dated 11/12/24 indicated she was transferred to another facility. Record Review of Resident #2's hospital records obtained from the facility on 12/18/24 at 12:31 p.m. indicated Resident #2 was sent to the hospital on 11/9/24 for a psychiatric evaluation. The resident reportedly got into a physical altercation with of the caregiver at the facility. The patient stated she got into an argument with a staff member that she did not get along with. She stated the worker grabbed her left forearm and refused to let go despite the patient asking her to, so she pulled away violently. Resident #2 reported bruising to her left arm and some pain with movement of the left wrist, left elbow, and left shoulder. She remembered the incident fully. She stated she did this to get away from her. She stated they keep telling her that she had dementia, and she did not believe them. She was able to answer the month, year, date of birth, location, and identified the situation without significant difficulty. Comments were mild bruising noted to the left distal bicep, left distal forearm, mild pain with range of motion of the wrist and elbow and shoulder. The Clinical Impression on 11/10/24 at 12:35 a.m. was physical assault and left arm pain. Record review of a Provider Investigation Report indicated HHSC was notified on 12/19/24 at 3:30 p.m. after surveyor intervention. The report contained statements from LVN C (with no date) said LVN M told her she had seen Resident #2 had jumped up and grabbed MA Bs hand causing a skin tear. (There was no statement from LVN M). LVN C said both parties claimed they were grabbed by the arm. She said Resident #2 insisted she was assaulted. LVN C said she checked both of their arms and neither had any visible marks. She said she was preparing to send the resident out to the ER for an evaluation as ordered by her supervisor. Resident #2 had called the police and they showed up. The resident went to the ER for a couple of hours. There were no new orders given to the nurse in report. There was no mention of any injury. When Resident #2 came back from the hospital Resident #2 said she was just tired. A statement dated 12/19/24 from MA B said on the second time she found Resident #2 behind the nursing station on 11/9/24 and told her she was going to move her. MA B said in her statement when she moved Resident #2 back, she jumped up and swung at her barley grazed her. (She did not say she grabbed her.) She said she went and talked to a LVN M who was in the room with a resident. She then said she went and found LVN C and told her Resident #2 was mad about her cigarettes. She said she avoided Resident #2 all night. She said another staff member reported to her that Resident #2 was telling other residents she was going to call the police and tell them she hit her. She said later an officer came and took her statement. Record review of MA B's personnel file indicated she worked double weekends as an MA. Review of her time sheet indicted she last worked Sunday, 12/15/24; her regular scheduled day. During a telephone interview with the hospital ER doctor on 12/18/24 at 11:54 a.m., he said he needed to review the ER notes from 11/9/24. He said the facility had sent Resident #2 to the hospital on 11/9/24. The report he received from the facility was Resident #2 had dementia. He said there was nothing wrong with Resident #2's cognitive recall. She did not have a diagnosis of dementia. He said Resident #2 told him the staff member that abused her did not like her and Resident #2 had words with that staff on several occasions. He said Resident #2 said the staff member grabbed her arm and would not let go despite her asking her to let go. He said they did an assessment of Resident #2 and determined bruising on her left distal forearm and left distal bicep were consistent with her story and she was indeed assaulted. He said again after reviewing Resident #2's chart there was no indication she had dementia from their testing. He said they usually sent the ER report with the resident back to the facility, but he could not be sure. During an interview on 12/18/24 at 12:29 p.m., the Marketing Director said the hospital usually sent the ER records back with the residents when they came from the hospital. She said Resident #2's ER or After Visit Summary records were already uploaded to the facility digital file. However, it took a few days for the physician report to generate. The Hospital records for Resident #2's was uploaded today into the facility's digital system. During a telephone interview on 12/18/24 at 4:00 p.m., LVN C said when she arrived at the nursing station on 11/9/24 Resident #2 was in there in a Wheelchair at the nursing station. She said there may have been another resident that witnessed the incident. She said the facility had cameras. LVN C said when she arrived, she listened to both MA B and Resident #2. She said the MA B said Resident #2 got too close in the nursing station and she asked Resident #2 to move, and the resident would not. She said the aide told her she had pushed Resident #2's wheelchair back. The LVN said the MA B told her Resident #2 had clawed her on the arm. LVN C said Resident #2 said she was assaulted. LVN C said they were arguing back and forth exchanging words and accusations. She said she got them separated and Resident #2 went to her room and apparently called the police. The nurse said she did not call the police. She said the police came and talked to both the MA B and Resident #2. LVN C said she had called the former ADON and was told to send the resident to the hospital for an evaluation. She said she had only looked at Resident #2's hand/ wrist area where she said the aide had grabbed her and she did not see any bruising. She did not do a full body assessment. LVN C said she did not write a statement, and as far as she knew the incident was resolved. She said when the police came, they mentioned the word assault but she had called her supervisor and done what she was told. She said she knew what abuse was and did not believe any abuse had occurred. She said when the resident came from the hospital there were no new orders on her paperwork, and she did not see anything else. During a telephone interview on 12/18/24 at 4:30 p.m. MA B said there were two incidents that occurred with Resident #2 on 11/9/24. She said the first incident Resident #2 was behind the nurse's station in one of the employee bags, and she asked her to back up. MA B said she pulled Resident #2's wheelchair back and the resident was upset. She said Resident #2 grabbed her on the forearm on that occasion. MA B said the second time she came back to the nurse's station again, and Resident #2 was back at the nursing station trying to open the cigarette box. She said she told Resident #2 she was going to have to move her back. MA B said Resident #2 went on about her cigarettes. She said she told her she was going to pull back the wheelchair, and Resident #2 jumped out of the chair and was trying to hit her. She said this happened right at shift change, but she could not say anyone witnessed the incidents. She said she had heard staff saying Resident #2 said she had assaulted her. MA B said that night about an hour and half later, the police came, and she told them what happened. She said she had a scratch on her hand, and they took a picture her hand. She said Resident #2 had swung at her, but she barely scratched her. MA B said Resident #2 was mad at her because, previously, they had words about the cigarettes. She said Resident #2 would want to go and smoke and demand to be smoked. MA B said they sent Resident #2 to the hospital to be evaluated. The MA said she did not touch Resident #2 she only touched her wheelchair. The MA said Resident #2 accused her of assault; she was telling the aides on the floor, and police. MA B said she did feel like she was accused of abuse. MA B said no one asked her questions other than the LVN C at that time and no one asked questions after. She said no one asked her to write a statement. During an interview on 12/19/24 at 2:35 p.m., the Director of Operations said they were not aware Resident #2 had a diagnosis of physical assault. They did not have the hospital records uploaded into the computer until today. He said at the time of the incident the former Administrator had turned in her notice a few days before effective immediately and the DON had left without notice on 11/8/24. During an interview on 12/20/24 at 4:16 p.m., the Administrator said that LVN C and MA B had written their statements on yesterday, 12/19/24. She stated she called the allegation of abuse into the state on 12/19/24 regarding Resident #2 that occurred on 11/9/24. She said MA B had come to the facility long enough for the in service and to write her statement and left on 12/19/24. The Administrator said she was not employed at the facility at the time of the incident. Record review of the facility census report dated 12/17/24 indicated the census on the unit was 13. It also indicated Resident #1, Resident #3, Resident #4, Resident #7, and Resident #8 all resided on the locked unit. 2. Record review of Resident #1 face sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were vascular Dementia (brain damage caused by multiple strokes which caused memory loss), assistance with personal care, unsteadiness on feet, muscle weakness, and lack of coordination. Record review of Resident #1's quarterly MDS dated [DATE] indicated a BIMS score of 2 which indicate severe cognitive impairment. The resident had behaviors of disorganized thinking or incoherent rambling, or irrelevant conversations, which could be unclear or illogical. The MDS indicated she required touching assistance with eating, and putting on and taking off footwear, and dressing. She was independent with transfers, sit to stand, and walking. Record review of Resident #1's care plan with an initiation date 9/6/23 indicated a Focus area of at risk for wandering or elopement. She resided on the secure unit. Resident #1 had a Focused area of communication deficit related to dementia. One of the interventions was to provide a safe environment, with call light within reach, and the bed in the lowest position. Resident #1 had a Focus area of episodes of aggression and resistant with care. The resident preferred her door shut. She kept her door closed and did not like anyone in her space/room. She was very anti-social and preferred to stay to herself in her room. Resident #1 had a Focused care area of ADL self-care performance deficit related to dementia and altered thought process. Record review of Resident #1's computerized physician orders indicted an order to admit to the secured unit for exit seeking behaviors with a revision date of 11/23/24. Record review of a Provider Investigation Report indicated on 7/2/24 indicated CNA A was working the 10p to 6 a shift. She failed to check on Resident #1 between 12:20 a.m. and 5:30 a.m. Resident #1 rolled out of bed and was on the floor close to 4.5 hours. CNA A took her break around 3:00 a.m. and notified the charge that she had checked all residents, however that was not true. The family had 2 cameras in Resident #1's room and were aware of what happened. The report indicated CNA A failed to check on Resident # 1. The report stated if CNA A had rounded frequently, Resident #1 would not have been left on the floor for an extended period without attention. Based upon the film recording of the incident CNA A failed to care for Resident #1. The allegation of neglect was confirmed, and CNA A was terminated. During an observation on 12/17/24 at 10:17 a.m., Resident #1 sitting at the table and did not respond when spoken to but was noted to be ambulatory. During a telephone interview 12/18/24 at 11:17 a.m., LVN H said on 7/2/24, CNA A said she was going on break around 3:00 a.m. LVN H said CNA A said she had just completed rounds on everyone on the unit, and everything was good. LVN H said when CNA A was doing her last round about 5:30 a.m. she found Resident #1 on the floor. She said she was informed by the family the resident had been on the floor for hours. She then asked CNA A if she had checked on Resident #1 at 3:00 a.m. and she said she was not sure. During a telephone interview on 12/18/24 at 2:27 p.m., CNA A said she did not remember if she had checked on Resident #1 on the night of 7/2/24. She said it had been a while and she was not sure. 3. Record review of Resident #7's face sheet indicted he was an [AGE] year-old male admitted to the facility on [DATE]. Some of his diagnoses were dementia (general memory loss), cognitive communication deficit, lack of coordination, and generalized muscle weakness. Record review of Resident #7's quarterly MDS dated [DATE] indicated his BIMS score was 1 indicated severe cognitive impairment. The only behavior he had listed on the MDS was rejection of care which occurred one to three days a week. He required setup and cleaned up help with most ADLs and he was independent with transfers and walking. Review of Resident #7's care plan indicated a Focused area of diagnosis of dementia with agitation and delirium secondary to alcohol abuse with an initiation date of 9/6/23 and a revision date of 12/17/24. Some of the approaches were to acknowledge moods in one-to-one interventions as needed, monitor for changes in mood and behaviors. A Focused area of Resident #7 had the potential to be physically and verbally aggressive related to dementia and poor impulse control. On 5/1/24, he was verbally and physical aggressive to staff. The care plan indicated on 7/28/24, he was physically aggressive a resident tapped on the arm. On 10/3/24, he had physical aggression toward a resident. On 10/4/24, he had physical aggression towards a resident. Some of the interventions were to administer medications, analyze times of day, circumstances, triggers, and de-escalate the behavior and document, send to acute hospital as needed, when he became agitated, intervene before the agitation escalates. (There was no mention of sexually in appropriate behaviors. There was no mention of aggression after 10/4/24.) Record review of Resident #7's physician orders indicated on Order dated 12/7/24 for Lorazepam 0.5 mg to give 1 tablet by mouth every 12 hours as needed for anxiety related to a diagnosis of dementia. An order dated 12/9/24 revealed an order for Depakote 500 mg delayed release. Give 1 tablet by mouth two times a day related to unspecified dementia. Record review of Resident #7's computerized physician's orders indicated an order for medication management may provide psychiatric services dated 9/8/23. Record review of Resident #8's face sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were Alzheimer's Disease (a progressive disease that destroys memory and important mental functions), and adjustment disorder (a mental disorder that involves and intense emotional or behavioral response to a stressful event or life change.) Record review of Resident #8's quarterly MDS dated [DATE] indicated a BIMS score of 9 which indicated moderate cognitive impairment. Resident #8's functional status was she was independent with toileting hygiene and dressing. She was independent with bed mobility, transfers, walking/ambulation. Record review of Resident #8' s care plan indicated a focused area of ADL care performance deficit related to dementia, with an initiation date of 5/10/24. Some of the interventions were the resident required one person assist with bathing, hygiene, dressing and transfers. (No mention of behaviors or an inappropriate relationship) Record review of an incident report dated 6/23/24 at 10:26 a.m. indicated Resident #8 was found lying in her bed without any pants/underwear while being touched in her private area (vaginal) by Resident #7. The residents were unable to give a description. Residents were asked to stop and were separated. There were no injuries at the time of the incident. The residents thought they were married to each other. Record review of a nursing note dated 6/24/24 at 2:35 a.m. indicated the resident was found by nurse doing rounds lying in her bed with no pants/underwear while being touched in her private parts by Resident #7. The residents were told to stop and separated. Notified all parties. Record review of Resident #8's nursing notes dated 6/24/24 at 8:15 a.m. day one of three monitoring due to inappropriate sexual behaviors will continue to monitor. Record review of Resident #8's nursing notes dated 6/25/24 at 8:51 a.m. day two of three monitoring due to inappropriate sexual behaviors will continue to monitor. Record review of Resident #8's nursing notes dated 6/26/24 at 2:24 p.m. day three of three monitoring due to inappropriate sexual behaviors will continue to monitor. Record review of Resident #8's physician's physical examination dated 7/3/24 indicated poor insight, poor judgement, and poor recall. Record review of Resident #7's nursing notes dated 9/23/24 indicated CNA E said Resident #7 was being aggressive with other residents and herself. The nurse went to check on the resident and he was very agitated. PRN Lorazepam was given to calm resident down. He was sitting in the common room using foul language. Record review of a Provider Investigation report dated 11/20/24 indicated on 10/3/24 at 1:30 p.m., Resident # 7 pushed Resident #1 causing her to fall. Resident #1 had no injuries and both residents had dementia. No other Provider Investigation Report was found for Resident #7. Review of Resident #7's nursing notes dated 10/3/24 at 12:35 p.m. said Resident #7 was very upset and was witnessed pushing Resident #1 down. He yelled. She was in my way. Record review of Resident #1's nursing notes dated 10/3/24 at 12:45 p.m. indicated Resident #1 had witnessed fall in the hallway when she was pushed down by Resident #7. Resident #1 was found sitting on the floor. When asked where she hursts she stated all over. The resident received an order for a pelvic x ray. Record review of Resident #1's nursing notes dated 10/4/24 indicated x-rays of pelvis results received indicated no acute fracture or dislocation. Record review of Resident #7's nursing notes dated 10/4/24 at 3:58 a.m. indicated he was placed on Q 15 checks for 72 hours. Review of Resident #7's Q 15-minute monitoring indicated on 10/4/24 he was in another residents room at 12:00 p.m. to 12:30 p.m. and had behaviors of restlessness, wandering, pacing and agitation. On 10/4/24 at 7:45 p.m. he was swinging a cane. He was sent to the hospital. Record review of Resident #7's nursing notes dated 10/4/24 at 10:29 p.m. indicted the nurse was called to the locked unit by CNA, the resident was standing in the hallway with a cane in his hand and swinging at another resident and staff. The CNA told the nurse that the resident choked the other resident involved. The nurse tried to reason with Resident #7 and asked him to release the cane. He became more agitated. The nurse separated the residents by putting the female resident in her room. The nurse then went for help and called 911. The resident was sent to the ER. Record review of Resident #7's Hospital After Visit Summary dated 10/4/24 indicated medications have changed, start taking Haldol 2 mg tablet by mouth every 8 hours as need for agitation. The reason for visit was a psychiatric evaluation. The diagnoses were dementia without behavioral disturbance, psychotic disturbances, mood disturbances, or anxiety. Review of a Resident #7's nursing notes dated 10/5/24 at 12:12 p.m. indicated Resident #7 arrived back at the facility. Record review of Resident #7's Order Audit Report indicated on 10/5/24 an order for Haloperidol oral 3mg give one tablet by mouth every 8 hours as needed for agitation. The order was discontinued on 10/28/24. Record review of Resident #8's nursing note dated 10/5/24 at 7:29 a.m. indicated day one of aggression received from Resident #7. Record review of Resident #8's nursing note dated 10/7/24 at 3:37 p.m. indicated day three of three of aggression received from Resident #7. There were no delayed injuries noted. The resident had no complaints of pain or discomfort at this time. Record review of Resident #7's progress note dated 10/16/24 indicated he had grabbed another resident by the wrist and would not let her go. Staff were able to get him to let her go but he was very agitated. Record Review of Resident #7's Progress Note/History and Physical dated 10/18/24 indicted Resident #7 was sent to the ER earlier this month for agitation and attempting to harm others on the memory care unit. Nursing staff reported he had been redirectable, and they were monitoring him closely. During an observation and interview on 12/17/24 at 10:21 p.m. Resident #7 was sitting in a chair. When staff asked him what he preferred to be called he yelled loudly and said he was fine. During an interview on 12/17/24 at 10:22 a.m., CNA K said she had only been on the unit for 2 days and Resident #7 was had anger issues and was easily agitated. During an observation and interview on 12/17/24 at 10:19 a.m., Resident #8 was sitting at the table in the common area. She talked about her family and how they had dumped her at the facility. The more she talked the more upset she became. She said the facility was okay, but she should not be there. Resident #8 said the staff and residents were fine for the most part. During an interview on 12/18/24 at 11:12 a.m. LVN G said when she was working the floor, she was responsible for the residents on the locked unit. She said on 10/21/24 Resident #7 was in Resident #8's face trying to make her sit down. She said Resident #7 grabbed Resident #8 by the wrist and did not want to let her go. LVN G said most of Resident #7's arguments were with Resident #8. She said Resident #7 thought Resident #8 was his wife and they bickered back and forth. LVN G said Resident #7 tried to tell Resident #8 what to do and insisted that she do it right then. During a telephone interview 12/18/24 at 11:17 a.m., LVN H said she remembered an incident of aggression with Resident #7. She said the incident occurred on 10/4/24 when Resident #7 was swing a cane. LVN H said there was one resident standing in the hallway, Resident # 8, and it was her cane that Resident #7 had. She said she could not remember if another resident was in the hallway She said that was right after it was reported to her that he had choked Resident #8 in the hallway. During an interview on 12/18/24 at 12:58 p.m. LVN J said he was the nurse on the unit on day shift. He said it was an ongoing thing between Resident #7 and Resident #8. He said Resident #7 thought Resident #8 was his wife. He said sometimes Resident #8 was with it and realized Resident #7 was not her husband. LVN J said other times Resident #8 would think Resident #7 was her husband. He said they acted like a married couple that did not get along. LVN J said they fussed at each other, sit together, or walk together. LVN J said, at times, Resident #8 would tell Resident #7 to do something, and he would listen. He said Resident #8's dementia goes and comes. During an interview on 12/18/24 at 2:15 p.m., CNA E said she had seen Resident # 7 get angry and hit at women. She said he mostly had controversy with Resident #8. She said she saw him choke Resident #8. She said she had gone into his room and Resident #8 was sitting on the side of the Resident #7's bed holding his hand. She had asked Resident #8 to leave and Resident #7 wanted her to sleep with him. CNA E said Resident #8 told him she was not going to sleep with him, and Resident # 7 got upset and told Resident #8 she needed to give him his fifteen hundred dollars back. She said Resident #8 told him she did not have his money and left the room. She said Resident #8 was on her way to her room and Resident #7 came behind her yelling. She said Resident #7 was to the back side of Resident #8 and put his hands around her neck as if to choke her. The CNA said she was right there within reaching distance and told him to stop and he removed his hands from Resident #8's neck. She said he did not squeeze or have a chance to choke Resident #8, but he did put his hands around her neck. She said she had written a statement and told the former DON the same thing. [TRUNCATED]

Based on interview and record review, the facility failed to ensure a resident received adequate supervision and assistive devices to prevent accidents for 1 of 11 residents reviewed for accidents. (Resident #6) The facility failed to ensure CNA D prevented Resident #6 from failing during a mechanical lift transfer by transferring the resident alone. This facility failure could place residents at risk of injuries including lacerations and bruising to the forehead. Findings included: Record review of Resident #6's face sheet dated 12/16/24 indicated he was a [AGE] year-old male admitted to the facility on [DATE]. Some of his diagnoses were paralysis on the left side due to a stroke, need for assistance with personal care, generalized muscle weakness, and lack of coordination. Record review of Resident #6's quarterly MDS assessment dated [DATE] indicated his cognition was severely impaired. His functional limitation in range of motion was impaired on one side for the upper extremity (shoulder, elbow, wrist, and hand) and Lower extremity (hip, knee, ankle, and foot.) The MDS indicted Resident #6 was dependent on staff for all ADLs including sit to stand and transfers. Record review of Resident #6's care plan with an initiation date of 10/26/22 indicated Resident #6 had an ADL self-care performance deficit related to stroke and contractures. An intervention was Resident #6 required a mechanical lift for transfers with two staff. Record review of Resident #6's nursing notes dated 11/14/24 at 4:53 p.m. indicated an aide notified the nurse that Resident #6 had fallen from the Hoyer lift. An assessment of the incident showed Resident #6 was lying next to the bed with the Hoyer sling still attached to the Hoyer. The right side of his face had facial swelling and a gash in the center. The resident was unable to follow commands and his right eye was more sluggish than the left. Called the NP and received orders to send Resident #6 to the ER for further evaluation. Signed by LVN F. Record review of a nursing note dated 11/15/24 at 12:34 a.m. indicated Resident #6 was back at the facility following a witnessed fall incident. He had no fractures. He received a new order for ointment applied topically three times daily for 7 days to his right brow laceration. No other injures noted. Record review of Resident #6's Skin Observation sheet dated 11/15/24 indicted a new skin issue of a laceration with bruising to the right eye area. Record review of an in-service training dated 11/14/24 indicted when transferring with a Hoyer lift, two persons must be present to assist. An attachment to the in-service titled Transfers and Mechanical Lift Guidelines with no date indicated to make sure all equipment or assistance is available prior to the start of a lift transfer, and there must be two staff members for lifting nonweight bearing residents. Record review of nursing note dated 11/16/24 at 9:59 a.m. indicated Day 3 of 3 days post fall from Hoyer lift and ER visit, day 2 of day 7 of ointment to the right brow. No distress noted at this time and no delayed injuries note, Resident #6 continued with trace edema to the right eye. Record review indicated an Employee Termination Form dated 11/19/24 indicating CNA D was terminated due to failure to meet performance expectations. The reason was she failed to use two people with a Hoyer lift transfer resulting in an incident. Record review of a Provider Investigation Report dated 11/20/24 indicated on 11/14/25 at 5:00 p.m. a staff member transferred a resident with a mechanical lift without assistance and the resident fell to the floor. The employee was suspended immediately, and staff were in-serviced on the protocol for safe transfers using mechanical lift. The facility findings were confirmed. During an interview on 12/17/24 at 12:06 p.m. the ADON said on 11/14/24 she had been ADON for 5 days and they did not have a DON at that time or currently. She said she was told CNA D had allowed Resident #6 to fall during a Hoyer lift transfer. The ADON said CNA D did not ask for assistance and the Hoyer lift pad strap came off the Hoyer lift during the transfer. The ADON said all Hoyer lift transfers required two people. They removed the Hoyer lift from the hall due to the strap holders being small. She said they no longer used that lift. During an interview on 12/17/24 at 12:44 p.m. the Maintenance Supervisor said the incident on 11/14/24 occurred after hours and he was not at the facility at the time. He said what they told him was the lift pad straps came of the Hoyer lift. He said it was a new lift and they had only had it for a few weeks. The Maintenance Supervisor said after he looked at it the hook holders on the lift, he made the determination they were too small. He said they had removed that Hoyer from the hall and gotten a new lift to replace it. He said prior to the incident on 11/14/24, no staff had reported any problems to him about the Hoyer lift. He said he could not remember if he had inspected the lift prior to it being placed on the hall. He said there was no schedule for checking the Hoyer lifts. He stated the company that inspected the facility scales, checked the Hoyer lifts twice a year when they did the scales. During an interview on 12/17/24 at 12:52 a.m. LVN F said she was called to the room by CNA D on 11/14/24. She said when she went into the room, Resident #6 was on the floor on his right side, with his head toward the end of the bed. She said he had some facial swelling with a gash to his right eye. She said she had initiated neuros and he was more sluggish than usual, and he was sent to the ER. LVN F said Resident #6 was nonverbal and could not say what happened or how he felt. She said the Hoyer lift straps were still attached. She said CNA D was in the room without assistance. LVN said the aide did not ask her for assistance prior to transferring the resident. During an interview on 12/17/24 at 1:23 p.m., the Therapy Director said he was not at the facility on 11/14/24 when Resident #6 fell from the Hoyer. He said he had worked at the facility for [AGE] years and conducted regular training on transfers and lift transfers. He said during all the training on Hoyer's, staff were told to always have two people to transfer with Hoyer lift. Therapy Director said CNA D was a seasoned aide that knew what she was doing. He said that he and the Maintenance Supervisor looked at the Hoyer lift the next day and observed the hocks on the Hoyer were smaller than normal. He said they felt the Hoyer was not appropriate for use so, they got rid of the Hoyer and got another one. He said the Hoyer had been at the facility for a week at the most. During a telephone interview on 12/17/24 at 1:46 p.m., CNA D said she had performed a Hoyer lift transfer of Resident #6 on 11/14/24. She said the hooks on the Hoyer lift were not very big. She said she had gone in alone to transfer Resident #6 from the bed to the chair. She said the transfer had gone well until the resident was up in the air from the bed and between the bed and the chair. She said one of the lift pad straps had come off and he went down headfirst. She said it was the first strap on the right side by his head, and then she said it was the strap closer to his right foot. She said she did not panic when it happened. She bent over to his face to see if he was alright. She said he did not speak, but he was grunting. She said she had gone to get the LVN F. CNA D said prior to the transfer she did not ask for help. She said she knew it was supposed to be two people to transfer Resident #6. CNA D said she knew better, but she was not the only one that had transferred Resident #6 unassisted. She said she had done so in the past but had just got caught at that time. CNA D said she was glad the resident was not badly hurt, and she was sorry. During an interview on 12/18/24 at 9:00 a.m., the Administrator said people that checked the weight machine, checked the Hoyer's when they came twice a year. She said she did was not employed by the facility until 11/25/24 and was not aware of the details of the incident involving Resident #6' s fall on 11/14/24. During an interview on 12/19/24 at 1:15 p.m., the Director of Operations said that the facility had purchased a new Hoyer lift after the incident on 11/14/24 with Resident #6 and he provided a receipt. Record review of an invoice statement dated 11/21/24 indicated a power patient lift was purchased by the facility.

Based on interview and record review, the facility failed to ensure adequate supervision was provided to prevent an elopement for 1 of 6 residents reviewed for elopement. (Resident #1) The facility did not implement interventions or monitor Resident #1 when his wife said he did not want to be there. The resident was found lying in the middle of the street that runs beside the facility at 2:06 a.m. approximately 4 hours after he was last seen in the facility. This was determined to be a past non-compliance immediate jeopardy due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents at risk of elopement, severe injury, or death. Findings included: Physician order [REDACTED].#1, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. Resident #1 did not have a completed MDS due to his being a new admission. An Admission Data sheet dated 09/29/19 indicated Resident #1 was evaluated for elopement risk and was determined to be a moderate risk. A nurse's note dated 09/29/19 at 6:58 p.m. indicated Resident #1 was wandering in the halls. A baseline care plan dated 09/29/19 did not address Resident #1 being an elopement risk. A care plan dated 10/01/19 indicated Resident #1 attempted to elope. Interventions included: assess for contributing sensory deficits, maintain a behavior log, notify physician and family/responsible party, remove resident from immediate situation to assure safety, and Watch for Walkers sign. A nurse's note dated 09/30/19 at 6:59 a.m. indicated the police department called the facility to report Resident #1 was in their custody. The resident was found behind the facility laying in the road, and the resident said he was just praying and thinking things over. The police returned the resident to the facility in good humor and cooperative with staff instructions. Resident #1 was assisted from the police car to a wheelchair; his gait was unsteady, but he was able to pivot into the wheelchair. A complete body assessment was completed, and no injuries were found. Resident #1's wife was called, and she said she did not even know the resident could walk that well. The resident talked to his wife. The DON was notified and gave instructions to count all the residents and call the administrator. The administrator was notified along with the resident's NP that the resident had not been seen in the facility for approximately four and a half hours. An Offense/Incident Report from the local police department dated 09/30/19 at 2:01 a.m. indicated on 09/30/19 at 2:06 a.m. Patrol Officer H was dispatched on report of a suspicious person. When he arrived, he noticed an elderly man lying in the middle of the road. He approached the man and asked for his name at which time Resident #1 identified himself. Patrol Officer H asked Resident #1 why he was in the middle of the road at which time the resident told him he was looking for his wife. He talked to the resident for a little while and realized the resident had a mental illness which caused him to be confused. Patrol Officer H had dispatch to see what Resident #1's address was on his driver's license; he then transported Resident #1 to that address. When Patrol Officer H drove up to the given address he noticed the grass to be grown up and the house appeared to be abandoned. He told dispatch to contact the nursing facility to see if Resident #1 resided there, and dispatch told him the nursing facility was where Resident #1 lived. Patrol Officer H transported Resident #1 back to the nursing facility and turned him over to the staff. A nurse's note dated 09/30/19 at 6:59 a.m. indicated Resident #1 was resting quietly in his bed with a CNA at the bedside for one on one monitoring for safety reasons. A nurse's note dated 09/30/19 at 7:29 a.m. indicated at 5:15 a.m. Resident #1 was in the dining room with a CN[NAME] The resident was confused and said, My wife tried to have me slain last night, but it didn't work. An attempt to redirect the resident's thoughts was made but was unsuccessful. A nurse's note dated 09/30/19 at 8:27 a.m. indicated Resident #1 remained in the dining room with a CN[NAME] The resident's wife was called regarding the resident's needs. She said she would come to the facility to discuss alternative placement and the current plan of care for Resident #1. A statement dated 09/30/19 completed by RN A indicated Resident #1 was wandering around the nurse's station after his admission. She said he was monitored closely throughout the shift. RN A said LVN B sat outside with Resident #1 for a little while since he wanted to go outside. She said she last observed him around 8:00 p.m. at the nurse's station on the phone talking to his wife. An undated statement by CNA C indicated he saw Resident #1 around the nurse's station about 9:30 p.m. CNA C said he was told the resident needed to be monitored closely since he was walking around. A statement dated 09/30/19 by LVN D indicated Resident #1 was observed at 10:00 p.m. with CNAs [NAME] and F. She said she told the CNAs to give Resident #1 some space because his wife said he was combative. LVN D said the resident was monitored closely throughout her shift. A statement dated 09/30/19 by CNA G indicated she observed Resident #1 close to the end of her 2:00 p.m. to 10:00 p.m. shift. She said he was walking around with a cane. During an interview on 10/03/19 at 1:18 p.m. Resident #1's wife said she told the admission nurse her husband did not want to be at the facility on 09/29/19 when he was admitted . She said since his elopement, she had church members staying with her husband from 3:00 p.m. to 10:00 p.m. and 10:00 p.m. until she arrived at the facility in the morning. She said the facility was trying to find alternative placement for Resident #1; a place that had a Wander Guard system or a locked unit for his safety. During an interview on 10/03/19 at 1:44 p.m. RN A said she worked 8 a.m. to 8 p.m. and admitted Resident #1 on 09/29/19. She said assessing a resident for elopement risk was part of the admission assessment. She said based upon the questions asked during the elopement risk assessment, Resident #1 was a moderate elopement risk. She said he was not wandering to exit doors or trying to get out of the facility but was wandering. She said Resident #1 would come to the doorway of his room and look left and right for his wife. She said then he walked to the nurse's station and back to his room. She said Resident #1 never told her he wanted to leave the facility. She said his wife did tell her Resident #1 did not want to be at the facility and had a history of [REDACTED]. RN A said Resident #1 wanted to go outside, so LVN B sat with him outside until about 7:45 p.m. on 09/29/19. She said she told LVN D the information she learned about Resident #1 during her admission assessment of him on 09/29/19. She said she told LVN D Resident #1 was a potential to leave and he might leave. During an interview on 10/03/19 at 2:25 p.m. CNA F said she came on shift about 10:00 p.m. on 09/29/19. She said she heard LVN D giving report to LVN I, and she heard LVN D say there was a new resident. She said Resident #1 was not in the room she was told he was assigned to at 10:20 p.m. She said she was not told Resident #1 was an elopement risk. She said the only thing she was told about Resident #1 was he was a new patient. She said she did not see Resident #1 until the police brought him back to the facility at about 6:59 a.m. During an interview on 10/03/19 at 2:40 p.m. the DON said LVN I told her on the evening of 09/29/19, she received report and started her rounds but could not remember if she checked on Resident #1 or not. She said according to interviews she did with the staff, she determined the last time Resident #1 was seen in the facility was at about 10:00 p.m., during shift change. She said Resident #1 was on one on one monitoring since his elopement. She said the facility started looking for Resident #1 alternative placement on the morning of 09/30/19. The DON said the facility doors were locked at night to prevent entry, but they do not lock to prevent exiting. She said all the exit doors have an alarm when they were opened, but after this incident, new ones had been ordered with louder alarms. The DON said the charge nurses have started checking all the exit door alarms to make sure they were working properly and doing walking rounds to see every resident at shift change. She said these two interventions were documented on a log sheet in a red notebook at each nurse's station. She said an elopement risk notebook was kept at each nurse's station with a list of the residents that were an elopement risk along with their face sheet with a picture of them and the elopement policy. The DON said all the residents were reassessed for elopement risk. She said the residents that were elopement risk had their care plans updated and a physician order [REDACTED]. She said the Watch for Walkers program had been started which was a sign outside of the elopement risk residents' room indicating to staff the resident was an elopement risk and needed to be watched closely. During an interview on 10/03/19 at 9:35 p.m. LVN I said she was Resident #1's nurse when he eloped. She said she had clocked in about 9:55 p.m. LVN I said she and CNAs [NAME] and F received report from LVN D. She said she told the CNAs to start their shift by checking on all the residents to make sure their beds were in low position, that they had water, were toileted, and had their call light. She said LVN D told her Resident #1 was a new resident that was confused and combative and said he was asleep in his bed, but LVN D did not tell her Resident #1 was an elopement risk. LVN I said she made a mental note to check on Resident #1 first but got called to give some as needed medications. She said she forgot about Resident #1. She said about 2:00 a.m. the police station called and said Resident #1 was in their custody. She told the officer the resident belonged at the facility. She said the officer told her he had to carry the resident to the vehicle to return him to the facility. She said Resident #1 received a head to toe assessment; Resident #1's vital signs were within normal limits, and no injuries were found. She said the resident went to sleep in his bed. She said she notified the DON and the administrator. LVN I said there was no excuse for her not checking on Resident #1; she just forgot. She said since the incident, the charge nurses started doing walking rounds and making sure all residents were accounted for at shift change along with checking all the exit door alarms to make sure they were working properly. She said at each nurse's station there was an elopement notebook that had a list of the residents that were an elopement risk along with a face sheet that contained a picture. She said they have implemented Watch for Walkers which was a program where a sign was placed outside an elopement risk resident's room, so all staff know the resident was an elopement risk. She said elopement risk residents had to be checked on every 2 hours, and that was documented on the MAR. She said staff are constantly checking on residents because they are up and down the halls throughout the shift. During an interview on 10/04/19 at 9:15 a.m. the DON said there was not a policy indicating how often a new resident would be checked on. An elopement policy dated 06/13 indicated locate and return resident to a safe environment. An immediate investigation and search will be conducted if a resident is considered missing. It was determined the above failures placed Resident #1 in an Immediate Jeopardy situation from 09/29/19 to 09/30/19. The facility took the following actions to correct the non-compliance on 09/30/19: An in-service on rounding and reporting dated 09/30/19 completed by the DON indicated nurses and aides were to do walking rounds at the beginning of each shift to ensure every resident was accounted for. The nurses were to ensure their aides were aware of the needs of new residents. If a resident started to exit seek or if the resident was identified as a moderate risk for elopement, the nursing administration was to be notified to ensure proper interventions were put into place. An in-service on abuse and neglect dated 09/30/19 completed by the DON indicated types and signs of abuse, signs of self-neglect, signs of exploitation, and signs of abandonment. An in-service on caring for residents who wander, code green, and elopement risk binders dated 09/30/19 completed by the DON included information on causes of wandering, measures to help residents who wander, and what to do if a resident is discovered to be missing. An in-service on the Watch for Walkers program dated 10/01/19 completed by the DON indicated any resident that scored higher than an 11 on their elopement risk assessment was to have a Watch for Walkers sign placed on the outside of their door. The nurse doing the assessment was responsible for putting the sign on the door and updating the resident's ADL P[NAME] to include elopement risk. The CNAs were to document any exit seeking behaviors observed during their shift. All exit seeking behaviors needed to be reported to the charge nurse who will then report them to administration for further interventions. An in-service on alarm checks and head count dated 10/02/19 completed by the DON indicated the 8 a.m. to 8 p.m. nurse would check the door alarms on the day and evening shifts to ensure all are activated and functioning properly. The staff who work 10 p.m. to 6 a.m. would check the alarms on their end. The check off sheet needed to be completed each time. At the beginning of each shift the floor nurse would print a 24-hour report sheet. The charge nurse would physically go to each residents' room to ensure all residents are accounted for at the beginning of their shift. The charge nurse would document this information in the red notebook. All residents were reassessed for their elopement risk. The primary physician(s) of the 5 residents found to be elopement risk were notified the resident was an elopement risk, and an order was given for the resident to be checked on every 2 hours, and administration was to be notified if the resident attempted to exit the facility. The 5 residents that were found to be an elopement risk had their care plans updated to indicate they were an elopement risk and would be checked on every 2 hours and administration would be notified if they attempted to exit the building. The 5 residents that were an elopement risk were observed every 2 hours and this was documented on the resident's MAR. All exit door alarms were checked at shift change. The charge nurses did walking rounds at shift change and made sure all the residents were accounted for. On 10/04/19, the surveyor confirmed the non-compliance was removed by: * The DON in-serviced and tested the staff on 09/30/19 through 10/02/19 on rounding, reporting, abuse and neglect, caring for residents who wander, code green, elopement risk binder, the Watch for Walkers program, alarm checks, and head counts. This was confirmed through interviews with staff as follows: * Four CNAs, a SCNA, and a MA were interviewed and said they had received training prior to the surveyor's entrance regarding making sure all residents are accounted for at shift change and all the exit door alarms work properly, checking elopement risk residents every 2 hours, the Watch for Walkers program, abuse and neglect, elopement risk binder, and risks and prevention of elopements. * Four nurses were interviewed and said they received training prior to the surveyor's entrance regarding making sure all exit door alarms are in working condition at shift change, making sure all residents are accounted for at shift change, checking on elopement risk residents at least every 2 hours and documenting it on their MAR, the Watch for Walkers program, abuse and neglect, elopement risk binders, and risks and prevention of elopements. * An Accountability of Residents log indicated all residents were accounted for at every shift change from 09/30/19 to 10/04/19. * A log in the red notebook at each nurse's station indicated all exit door alarms were checked at shift changed from 09/30/19 to 10/04/19. * Seven resident charts indicated an elopement risk assessment was completed on 09/30/19. * The DON said new exit door alarms that were louder than what they currently have had been ordered. * Resident #1 had been placed on and would remain on one on one monitoring until the resident was discharged to alternative placement. During an interview on 10/04/19 at 9:55 a.m., the facility was asked for additional information regarding the elopement incident on 09/29/19 at exit. No additional information was provided.

Based on interview and record review, the facility failed to ensure residents drug regimen were free from unnecessary drugs for 1 of 14 residents reviewed for medications. (Resident #1) Resident #1 received diabetic medication, based on an erroneous transcription, without a [DIAGNOSES REDACTED]. This failure led to Resident #1 being hospitalized for [REDACTED]. (low blood sugar) An Immediate Jeopardy was identified that existed from 11/26/17 to 12/1/17. This was determined to be past non-compliance. The facility implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place 27 new admissions at risk of adverse reactions or death related to receiving incorrect medications. Findings included: A face sheet dated 12/2/17 indicated Resident #1 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. He did not have a [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 was interviewable, but was not interviewed. Staff assessment for Resident #1 indicated he had modified independence in making decisions regarding tasks of daily life. He had no signs of [MEDICAL CONDITION] and no behaviors. A hospital discharge medication list dated 11/26/17 did not include orders for the following medications: [REDACTED]. (oral hypoglycemic) Physician orders [REDACTED].#1 was to receive the following medications: [REDACTED]. During an interview on 12/20/17 at 3:45 p.m., LVN A (evening shift nurse for 11/26/17) said when Resident #1 was admitted , he had both computerized and hand-written orders from the hospital which she put into the system. She said the orders for glimepiride and [MEDICATION NAME] were both on the handwritten orders, along with orders for [MEDICATION NAME] and aspirin which she omitted from Resident #1's orders because he was allergic to them. She said she should have called the hospital to verify the medications herself, but it was shift change and she told LVN B to tell the dayshift nurse to verify the medications because Resident #1's medications were not jiving right. She said it did not make sense to her why his medication list would include two medications he was allergic to. She said the hand-written orders she transcribed Resident #1's medications from could not be located. An attempt was made to contact LVN B (night shift nurse for 11/26/17-11/27/17, relieved LVN A) on 12/21/17 at 7:09 p.m. She did not answer, and her voicemail was full. An attempt was made to contact RN C (dayshift nurse for 11/27/17, relieved LVN B) on 12/21/17 at 12:52 p.m. Her phone went straight to voicemail and a message was left for her to call the surveyor back. During an interview on 12/21/17 at 2:29 p.m., LVN D said Resident #1's laboratory results came in on 11/29/17 and he had a critical glucose level. LVN D said she notified the physician of the critical laboratory tests, and got an order to get a blood sugar check. LVN D said when she checked Resident #1's blood sugar, it was in the 40s. She said she gave Resident #1 some juice, and 15 minutes his blood sugar had still not come up. LVN D said she notified the physician again, and the physician said to hold Resident #1's orders for glimepiride and [MEDICATION NAME]. LVN D said she called the wife to notify her of the lab result and medications being held, and the wife told LVN D that Resident #1 had never been diabetic, never had any previous issues with his blood sugar, and never took diabetic medications before. LVN D said she started reviewing Resident #1's chart and could not find orders for the glimepiride or [MEDICATION NAME]. She said she saw computer generated orders from the hospital, but did not see any handwritten orders. She said she notified the physician at that time, who discontinued Resident #1's entire medication list and the medications were input correctly from the computerized hospital records at that time. She said the physician told LVN D Resident #1 needed to be monitored closely. She said Resident #1 was asymptomatic until the next morning when he was sent out due to a change in condition. A Medication Aide MAR indicated [REDACTED] A laboratory test result report indicated a renal function panel was collected on 11/28/17 and results were received on 11/29/17. This laboratory test result report indicated Resident #1 had critical glucose level of 59. (normal range was 70-110) A nursing note dated 11/29/17 indicated Resident #1's blood sugar was 45 when checked that morning. His blood sugar was re-checked and was 61. The physician and Resident #1's wife were notified. A physician's orders [REDACTED]. A MAR indicated [REDACTED]. A 24 hour report dated 11/29/17 indicated Resident #1's blood glucose was 49 at 4:30 p.m., and increased to 51 after orange juice with sugar was given. A physician order [REDACTED].#1's glimepiride and [MEDICATION NAME] were initiated on 11/26/17 and discontinued on 11/29/17. During an interview on 12/21/17 at 12:56 p.m., LVN E said on 11/30/17 around 7:05 a.m., she heard Resident #1's physician yelling at Resident #1 trying to wake him up. LVN E said Resident #1 was unresponsive. LVN E said Resident #1's physician asked LVN E to check Resident #1's blood sugar. She said Resident #1's blood sugar was 37 at first, he was given a [MEDICATION NAME] injection, then checked the resident's blood sugar again and it was 27. She said after a second injection was given, Resident #'1 blood sugar was over 300. During an interview on 12/22/17 at 12:37 p.m., Resident #1's physician said he was Resident #1's primary care physician prior to Resident #1 being admitted to the nursing facility. He said when he first approved Resident #1's admission orders [REDACTED]. He said he was contacted by the facility regarding Resident #1's critical glucose level, and regarding his blood sugars throughout the day. He said he spoke with Resident #1's wife and learned Resident #1 did not have any issues with his blood sugars while in the hospital. He said at that time, he discontinued Resident #1's diabetic medication and told the facility to monitor Resident #1. He said the next morning, on 11/30/17, around 7:30 a.m., he saw Resident #1 in his room during rounds. The physician said Resident #1 was breathing, but would not wake up. He said a nurse took Resident #1's blood sugar, and it was 40 or 50. He said they administered a [MEDICATION NAME] injection, retook Resident #1's blood sugar after 5 minutes, and Resident #1 had no improvement. He said Resident #1 was given a second injection, and his blood sugar was over 300 approximately 5 minutes later. He said EMS arrived, and asked if the physician still wanted Resident #1 transferred because Resident #1 had opened his eyes. The physician said he ordered for Resident #1 to be transferred to the hospital because, although he was alert, Resident #1 was still not completely with it. The physician said he checked Resident #1's record and saw he had not taken any diabetic medications in over 24 hours, and those medications should have had no effect on Resident #1 24 hours later. A hospital assessment report dated 11/30/17 indicated Resident #1 was admitted to the hospital at 8:27 a.m. A hospital history and physical dated 11/30/17 indicated Resident #1 had altered mental status at the nursing home. His blood sugar was in the low 20s. He was given an [MEDICATION NAME] (amp) (single dose of medication pre-packaged in an injectable glass or plastic vessel) of D50 (25 grams [MEDICATION NAME] in 50 mililiters-a sugar that your body produces naturally, used as treatment of [REDACTED]. In the emergency room , the patients blood sugar dropped again to 26. He was given an amp and was started on D10 intravenously. Resident #1's primary [DIAGNOSES REDACTED]. A hospital discharge summary dated 12/4/17 indicated Resident #1's final [DIAGNOSES REDACTED]. The discharge summary indicated upon admission to hospital, Resident #1 was started on D10, and was slowly weaned off with improvement in his blood sugars. It was determined these failures placed the facility in an Immediate Jeopardy (IJ) situation from 11/26/17 to 12/1/17; however, prior to surveyor entrance the facility took the following actions to correct the non-compliance: On 12/1/17, all charts for patients on oral hypoglycemic medications were audited to ensure a [DIAGNOSES REDACTED]. Starting 12/1/17, all new admissions medications since 11/30/17 were reviewed by nursing management for hospital orders received, whether there were hand-written orders, and whether the orders were entered into the computer system correctly. The following in-services were performed: -11/30/17 - LVN A was in-serviced on transcribing orders and best practice in regards to handwritten admission orders [REDACTED]. -11/30/17 - charge nurses were in-serviced on transcription of new admission orders [REDACTED]. Charge nurses were in-serviced that hand-written orders were to be verified with discharging hospital as well as with facility admitting physician. An Admission/Discharge list dated 11/29/17-12/21/17 indicated there were 27 new admissions since 11/29/17.

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for 1 of 2 residents reviewed for quality of care (Resident #1) and 2 of 4 residents reviewed for urinary catheters. (Residents #3 and #4) The facility did not provide preventative treatments as ordered by the physician to Resident #1's skin and did not implement interventions according to the comprehensive plan of care to keep his skin clean and dry. Resident #1 was incontinent of urine and had a history of [REDACTED]. The resident was not provided incontinent care for more than 4 hours on 11/30/17. He had 9 new open wounds with indistinct edges and no treatment was provided. The facility did not secure Resident #3's catheter to prevent it from pulling at the insertion site. Resident #3 complained of discomfort from the catheter tubing pulling. The facility did not have an appropriate medical indication for Resident #4's catheter and did not secure his catheter to prevent it pulling at the insertion site. The failure could place 19 residents receiving preventative skin care at risk for developing wounds, [MEDICAL CONDITION], infections, and pressure injuries. This failure could place 4 residents with indwelling catheters at risk for urethral tears, infections, discomfort, [MEDICAL CONDITION]. Findings included: 1. A face sheet dated 11/30/17 indicated Resident #1 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. A care plan dated 7/27/17 indicated Resident #1 had a self-care deficit and the interventions included to inspect his skin daily during care and bathing. A care plan dated 8/02/17 indicated Resident #1 was at risk for skin break down. The interventions included to apply a protective or barrier lotion after incontinence, assist the resident to turn and reposition frequently, inspect his skin daily during care and bathing, and report any changes to the charge nurse. Staff were to keep Resident #1's skin clean, dry, and free of irritants. It did not indicate he had break down. An MDS dated [DATE] indicated Resident #1 was cognitively intact and he was understood and he usually understood others. He required extensive assist for bed mobility, toileting and personal hygiene and was dependent for transfers, dressing, and bathing. Resident #1 was frequently incontinent of bladder and at risk for pressure injury development. The MDS reflected he had moisture-associated skin damage and received applications of ointments/medications. A physician order [REDACTED].#1's peri-area then apply [MEDICATION NAME] 90 units-87 mg-788 mg/gram ointment (promotes wound healing) topically to Resident #1's excoriated skin every shift. A TAR dated (MONTH) (YEAR) for Resident #1 indicated zinc oxide was discontinued 11/16/17. The TAR did not indicate the [MEDICATION NAME] (ordered 11/16/17) was applied. A nursing note by LVN H dated 11/22/17 indicated Resident #1 had a skin problem identified to his peri-area, buttocks. The notes did not address if the resident had any open wounds. The most recent skin assessment dated [DATE], completed by the LVN treatment nurse, indicated Resident #1 had rash/redness to buttocks. During an interview on 11/30/17 at 11:14 a.m., RN C said Resident #1 had stained purple excoriated skin on his perineal area and buttocks since admission. RN C said the resident did not have any open wounds on his buttocks area that she was aware of. She said she last assessed his skin on Tuesday 11/28/17 and there were no open areas. She said she did not recall what the treatment was for Resident #1. A Nurse Aide Observation Report by CNA D dated 11/29/17 indicated Resident #1 had redness on his bottom. During an interview on 11/30/17 at 11:50 a.m., CNA D said she notified RN C that Resident #1 had redness on his bottom yesterday (Wednesday 11/29/17) while she was assisting him with his bath. She said Resident #1 was always excoriated, but it was the procedure to report it to the nurse. During an interview on 11/30/17 at 11:58 a.m., RN C said she did not perform Resident #1's skin assessments. She said she did not chart Resident #1's refusal of care or the redness on his bottom reported to her by CNA D. RN C said she did not notify the resident's physician. She said she did not have time. During an observation and interview on 11/30/17 at 10:26 a.m., Resident #1 was lying on his back in bed with a urine saturated brief on. He said his brief had not been changed since 4:00 a.m. He said he requested to be changed at 8:30 a.m., but it was not done. He said he was often left wet for prolonged times and his skin itched and burned from it. He said the staff rarely applied ointment or cream on his buttocks to prevent his skin from breaking down. He said no one had assessed his skin and he did not receive treatments. Resident #1 said he did not know if he had any open areas. During an interview on 11/30/17 at 2:08 p.m., CNA A said she was assigned to Resident #1's hall on the morning shift. She said she did not recall when she last performed incontinent care for Resident #1. She said she did not know if he required barrier ointment. She did not recall if he had open areas to his buttock area. During an observation on 11/30/17 at 10:34 a.m., CNA B and LVN G removed Resident #1's saturated brief. Resident #1 had macerated deep purple and reddened skin from his buttocks and gluteal folds extending to the back of his upper thighs. There were multiple slit-like open wounds on the resident's right and left buttocks and in his left gluteal fold. There was no ointment or cream evident on his perineal area. CNA B and LVN G did not apply any type of ointment or cream during care. During an observation and interview on 11/30/17 at 10:46 a.m., the LVN treatment nurse said she had not assessed Resident #1's skin this week because she was pulled to work the floor. She said the charge nurses were supposed to do the treatments when she worked the floor. She said Resident #1 had [MEDICATION NAME] ointment ordered for his buttocks area to be applied after incontinent care. She said it did not look like the resident had any ointment applied at the time CNA B and LVN G provided incontinent care. The LVN treatment nurse said she did not apply any [MEDICATION NAME] or other cream to Resident #1's buttocks/peri-area this week. She said she did not know he had any open areas. During an interview on 11/30/17 at 10:52 a.m., CNA B said she was not Resident #1's assigned aide. She said she did not have any barrier ointment to apply to his skin and was unsure if he required it. She said she did not know when the resident was last provided incontinent care. During an interview on 12/01/17 at 10:21 a.m., Resident #1 said about fifteen minutes ago the wound care physician assessed his buttocks area, but did not take measurements. He said staff did not apply ointment or cream to his buttocks area after incontinent care. During an interview on 12/01/17 at 10:26 a.m., the wound care physician said Resident #1 had moisture-associated [MEDICAL CONDITION] (moisture-associated skin damage, MASD). He said he recommended the Venelex ointment as ordered. The wound care physician said Resident #1 was a challenge due to he was a young guy with so many issues. A Wound Care Specialist Initial Evaluation dated 12/01/17 indicated Resident #1 had a rash of unknown duration. The treatment ordered was Venelex ointment every shift and as needed. The follow-up indicated an evaluation by the wound care specialist within 7 days with further intervention as indicated. During an observation on 12/01/17 at 11:08 a.m., Resident #1's buttocks, gluteal folds, and the back of his upper thighs was a purplish/red color with multiple small open wounds that did not have distinct wound edges. The wounds measured by the LVN treatment nurse were as listed: *Right buttock- #1 - 0.4cm x 0.9cm, red open area #2 - 0.1cm x 0.3cm, red open area #3 - 0.2cm x 0.5 cm, red open area #4 - 0.1 cm x 0.3 cm, red open area *Left gluteal fold - #5 - 4cm x 1.3cm, red open area #6 - 3.5cm x 1.5cm, red open area #7 - 2cm x 1.3cm, red open area #8 - 1cm x 0.8cm, red open area #9 - 0.5cm x 0.5cm, red open area During an interview on 11/30/17 at 11:20 a.m., the DON said skin assessments were supposed to be done on residents' bath days by the treatment nurse or the charge nurse if she was not available. She said she thought she knew what skin issues the facility had, but she guessed not. She said Resident #1 was noncompliant with care, but she did not assess his skin and was not aware of what it looked like. A Skin Care Policy dated (MONTH) 2012 indicated evaluations will be performed on admission, weekly and on discovery of wounds. The procedures indicated evaluation is a formal process in which wound characteristics, underlying conditions, and contributory medical history are identified/quantified. Evaluation results are communicated to the members of the care team through documentation, case conference, and care planning. According to the website, http://mkt.medline.com/advancing-blog/skincare-talk-how-to-spot-moisture-associated-skin-damage, accessed 12/6/17, MASD is officially defined as inflammation and erosion of the skin caused by prolonged exposure to moisture and its contents, including urine, stool, perspiration, wound exudate, mucus, or saliva. 2. Physician orders [REDACTED].#3 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #3 was ordered a urinary catheter on 10/31/17 with catheter care to be performed every shift. A care plan dated 10/26/17 indicated Resident #3 was incontinent of bowel and staff should provide peri-care after each incontinent episode. Resident #3 was at risk for skin breakdown and staff should keep Resident #3's skin clean and dry. The care plan did not address Resident #3's urinary catheter. An MDS dated [DATE] indicated Resident #3 made herself understood and understood others. She required extensive assistance with toilet use, dressing, transfers, and bed mobility. She was incontinent of bowel and had an indwelling urinary catheter. During an observation and interview on 11/30/17 at 2:18 p.m., the treatment nurse and LVN G provided incontinent care for Resident #3. The treatment nurse pulled down Resident #3's pants and Resident #3's urinary catheter was not secured to her leg. Resident #3 said the urinary catheter was pulling and caused discomfort. The insertion site was bright red with feces on the catheter tubing. During an interview on 11/30/17 at 2:28 p.m., the treatment nurse said Resident #3's urinary catheter should be secured and she would get tape to secure the catheter after she was completed with Resident #3's incontinent care. During an observation and interview on 12/01/17 at 1:20 p.m., Resident #3's urinary catheter tubing was ran down her pants leg. She said the urinary catheter was not secured and was causing her discomfort. 3. Consolidated physician orders, printed 11/30/17, indicated Resident #4 was an [AGE] year old male admitted on [DATE] and most recent readmission on 11/28/17. His [DIAGNOSES REDACTED]. The current MDS dated [DATE] indicated Resident #4 made himself understood and understood others and was cognitively intact. He required extensive assistance with toilet use, dressing, hygiene, and bed mobility and was dependent for transfers. He was frequently incontinent of bladder. A care plan dated 11/21/17 indicated Resident #4 had a urinary catheter and risk of complications included pain and discomfort. The admission orders [REDACTED]. A (MONTH) (YEAR) TAR indicated Resident #4's urinary catheter to have continuous gravity drainage and catheter care every shift for a [DIAGNOSES REDACTED]. During an observation and interview on 11/30/17 at 10:26 a.m., Resident #4 was sitting up in his wheel chair in his room. He had on a gown and CNA A was assisting him to get dressed. Resident #4's urinary catheter was not secured to his leg and he said the urinary catheter was pulling and caused discomfort. During an interview on 11/30/17 at 10:37 a.m., CNA A said she would tell the charge nurse Resident #4's catheter was hurting him. She said she just completed his shower and it was not secured prior to his care. During an observation on 11/30/17 at 1:52 p.m., Resident #4's catheter was unsecured. During an interview and observation on 11/30/17 at 2:25 p.m., Resident #4's catheter was unsecured and he said it still hurt him and pulled. LVN H said all catheters were supposed to be secured to prevent injury. She said no one had reported Resident #4's catheter was unsecured or he complained of pain. During an interview on 11/30/17 at 2:31 p.m., the DON and corporate nurse said Resident #4's catheter was supposed to be secured per facility policy. The DON said she did know why Resident #4 had a catheter but would see about getting it discontinued. During an interview on 11/30/17 at 4:15 p.m., the corporate nurse said the facility only had a policy addressing urinary catheter care. The Catheter Care policy dated (MONTH) 2013 indicated Indwelling or intermittent catheterization will be used for those residents whose medical condition requires intervention for urinary elimination or for those residents whose condition requires alternate urinary elimination techniques in order to protect skin surfaces. The website, http://www.cdc.gov/hicpac/cauti/002_cauti_sumORecom.html, accessed 12/5/17 indicated the following: .Properly secure indwelling catheters after insertion to prevent movement and urethral traction The CMS 672 dated 11/30/17 indicated there were 19 residents receiving preventative skin care and 4 residents had urinary catheters.

Based on observation, interview, and record review, the facility failed to implement interventions based on a comprehensive assessment to promote healing of existing pressure sores and prevent new pressure sores from developing for 1 of 3 residents reviewed for pressure sores. (Resident #1) Resident #1 developed two facility acquired Stage II pressure sores. The facility did not provide the resident with a low air loss mattress for 13 days and did not provide nutritional supplements to address his low protein levels. The resident's existing pressure sores worsened to unstageables and increased in size and he developed 4 more pressure sores on his feet. The MD was not notified of Resident #1's pressure sores worsening and the facility did not develop care plans to address the resident's pressure sores or nutritional decline. These failures contributed to the worsening of existing pressure sores and the development of a new pressure sorefor Resident #1 and placed 2 other residents with existing pressure sores at risk of worsening of their pressure ulcers. Findings included: Current electronic physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The orders indicated he received skin treatments for pressure sores on his left buttock from 7/17/14 - current date; mid back from 10/10/14 - to current date; and bilateral toes from 10/20/14 - to current date. His diet included double meat portions with every meal (ordered 8/23/14), and a house supplement with morning snack pass and as needed. A physician's orders [REDACTED]. The MDS dated [DATE] indicated Resident #1 made himself understood and he understood others. (BIMS-(brief interview for mental status) score was 15 ( = cognitively intact). He required limited assistance for bed mobility, but required extensive to total dependence for his ADL care. He was incontinent of bowel and bladder. A pressure sore care plan updated 9/24/14 for Resident #1 included interventions of: turning and repositioning every two hours, monitoring nutrition/hydration needs, notifying physician of negative findings, monitoring laboratory results, and weekly skin assessments. No additional interventions were added to his care plan or implemented when his pressure sores declined or when he developed new pressure sores. A nutrition care plan dated 9/24/14 indicated he was on a therapeutic diet of regular no added salt and low concentrated sweets. Interventions included: FSS would monitor and discuss food preferences, offer snacks within diet, and monitor weight, and report weight loss to physician. No new interventions were implemented regarding his low [MEDICATION NAME] were on his care plan. Wound care consultant notes for Resident #1 included the following: * Left buttocks (now included coccyx) dated 9/1/14 - 1.5 cm x 1.5 cm -Stage II; 100% red dermal tissue. * 1. Left buttocks (included the coccyx) dated 10/27/14 - 2 cm x 2 cm - Stage II; 100% red dermal tissue. (Resident #1 was on low air loss mattress at this assessment). Date of onset was 7/17/14. 2. Lower mid back - 1 cm x 1 cm -Stage II; * 1. Left buttocks (included the coccyx) dated 11/21/14 - 2 cm x 2 cm, (unstageable) - 100% slough, peri-wound pink fragile tissue. (Resident #1 was not on a low air loss mattress at this assessment) 2. Lower mid back - 1 cm x 1 cm; Stage II During an observation and interview on 12/1/14 at 9:52 a.m., Resident #1 was lying on his back on a Geo-mattress with wings (scooped mattress). Resident #1's heels were not offloaded and he did not have a foot cradle to protect his toes from the pressure of the linens. He said he went to [MEDICAL TREATMENT] 3 days a week. CNA B turned him on his right side and a bandage was noted to his coccyx and upper back. A Medical Equipment letter (undated) indicated they were contacted on 11/19/14 regarding Resident #1's malfunctioning low air loss mattress. The low air loss mattress was not replaced until 12/1/14 (after lunch). Resident #1 was without a low air loss mattress for approximately 13 days. Nursing notes for Resident #1 dated 11/23/14 indicated the pressure sore on his coccyx had a foul odor. Resident #1's treatment records, skin sheets, and/or consultant reports indicated no previous odor to wound. (No documentation that physician was notified). Nursing notes for Resident #1 dated 11/25/14 - 11/27/14 indicated the pressure sores to the resident's mid- back and coccyx with no improvement. Resident #1 complained of back and buttock pain, pain medication was administered, and they would monitor. (no documentation physician was notified, of new increased pain to his back and buttock.) The most recent skin assessment for Resident #1 dated 11/27/14 included the following: 1. Left buttocks (coccyx area) pressure sore - 3 cm x 3 cm, with yellow slough (that adheres to the ulcer bed in strings or thick clumps or mucinous), moderate serosanguineous drainage (clear/bloody). The interventions were effective and continue plan of care. 2. Lower mid back- 1.0 cm x 1.0 cm x 0.1 cm (depth), with [MEDICATION NAME] tissue (new skin grown light pink/shiny in color, scant serosanguieneous drainage, interventions effective, continue plan of care. 3. Left great toe- 1 cm x 1 cm, necrotic tissue, no drainage, interventions effective, continue plan of care. 4. Right great toe- 1cm x 1 cm, necrotic tissue, no drainage, interventions effective, continue plan of care. Nursing notes dated 11/28/14- 12/2/14 for Resident #1 did not indicate the physician was notified of the decline in the resident ' s pressure sores. During an observation and interview on 12/2/14 at 10:12 a.m., Resident #1 was positioned on his right side, lying on a low air loss mattress (placed back on low air loss mattress after survey entry 12/1/14), his feet were not off loaded and a foot cradle was not in use. His bed linens were lying on his feet and toes. The treatment nurse said a wound care consultant usually saw Resident #1 at the beginning of the month and he was last seen in November. She said Resident #1 had not gone to a wound care center. The treatment nurse said Resident #1 was removed from his low air mattress due to faulty equipment and placed on the Geo-mattress for a few weeks. The treatment nurse said she could not measure the wounds at that time since it was time for him to go to [MEDICAL TREATMENT]. The following was noted during wound care: 1. An unstageable pressure sore on Resident #1's coccyx area with 100% greyish/yellow slough in the wound bed. There were 2 open areas each 1 cm in size at the 6 o'clock area of the pressure sore. The skin surrounding the pressure sore (periwound) from 9 o ' clock to 3 o ' clock was red and inflamed extending 6 cm out from the wound bed. 2. A Stage III pressure sore on the resident ' s mid back with yellow slough in the wound bed near the 12 o'clock and the rest of the wound bed was pink. 3. An unstageble pressure sore on the resident ' s left great toe with black eschar covering the wound bed. 4. An unstageable on his right great toe with black eschar covering the wound bed. 5. A Stage I (newly identified pressure sore) on his right heel was dark red and unblanchable (without capillary refill). 6. A Stage I (newly identified pressure sore) on his left heel was dark red and unblanchable. During an observation on 12/3/14 at 1:50 p.m., Resident #1 was lying in bed on his back and his feet were not off-loaded. There was not a foot cradle on his bed and his linens were covering his toes and feet. The treatment nurse turned him on his right side to measure his pressure sores which included the following: 1. An unstageable on his coccyx (left buttocks per skin sheets) measured at 8.7 cm x 3 cm (included new open areas) with 100% grey colored eschar. The treatment nurse said she was measuring from the new opened areas at 6 o ' clock to the top of wound at 12 o ' clock. 2. A Stage III on his mid-back measuring 2.5 cm x 1.5 cm with 100% yellow slough. 3. An unstageable on his left great toe measuring 0.5 cm x 0.5 cm with black eschar. 4. An unstageable on his right great toe measuring 1.5 cm x 1.5 cm with black eschar. 5. A suspected deep tissue injury on his right heel measuring 4.5 cm x 4 cm and purple in color. 6. A suspected deep tissue injury on his left heel measuring 1 cm x 1 cm and purple in color. It was firm to touch. During an interview on 12/3/14 at 11:30 a.m., the physician said when he saw Resident #1 a couple of weeks ago, the pressure sore on Resident #1's coccyx was red and somewhat painful to him. He said he was not aware Resident #1's pressure sores declined and they had not discussed sending the resident to an outpatient wound care clinic. Most recent physician progress notes [REDACTED].#1 was doing well with no new complaints and his condition was stable. During an interview on 12/2/14 at 8:45 a.m., Resident #1 said he did not always get large portions or extra meat during his meals. He said they sometimes gave it to him but not always. He said his appetite had been down recently. Resident #1 said he was given a vanilla health shake daily but he did not like the vanilla flavor. Laboratory (lab) work for Resident #1 dated 9/17/14 indicated: * Total protein (measures the total amount of two classes of proteins found in the fluid portion of your blood) - 4.2 (normal 6.4-8.3) * [MEDICATION NAME] (measures the amount of this protein in the clear liquid portion of the blood) - 1.8 (normal 3.5-5.0) Dietitian progress notes for Resident #1 included the following: * 9/22/14- [MEDICATION NAME] 1.8.....Regular, no added salt diet, large meat/egg portions, house supplement with snacks and as needed. Resident continued on [MEDICAL TREATMENT], continued with skin concerns. Good intake, no new recommendations. * 10/29/14- Weight stable (10/14-156 lbs.), no new labs to assess, continues with skin concerns. No new recommendations. * 11/20/14- Resident continued on [MEDICAL TREATMENT], weight was down a little (150 lbs.), intake decreased a little, started on [MEDICATION NAME] on 11/12/14, intake improved since then, continues with skin concerns. No new recommendations. During an observation on 12/3/14 at 10:15 a.m., Resident #1 sat in his wheelchair in his room with tennis shoes on his feet. He said his bottom and heels were sore. An unopened can of vanilla Nepro was near him. Resident #1 said he did not like the vanilla Nepro shake. During an interview on 12/2/14 at 11:50 a.m., [MEDICAL TREATMENT] Dietitian F said Resident #1 had lab work done on 10/30/14 that was faxed to the facility. She said his last [MEDICATION NAME] was below normal at 2.2 (normal 3.5-5.0). She said the resident could not always tolerate rich type shakes like Nepro and was not currently on any other protein supplement. [MEDICAL TREATMENT] Dietician F said she would order Resident #1 Prostat (liquid protein) to provide him extra protein. During an interview on 12/2/14 a 12:00 p.m., Dietitian H said Resident #1 received large portions of meat every meal (physician order [REDACTED]. She said the resident was started on [MEDICATION NAME] to help his appetite. She said Resident #1 did not have Prostat (liquid protein) ordered, but he should have it to help increase his protein levels. During an interview on 12/3/14 at 10:45 a.m., the FSS said she had not interviewed the resident on food preferences, snacks or new supplements to increase his nutrition and improve protein intake. The website, http://www.spanamerica.com/geomattress, Support Surface Management Algorithm, accessed 12/4/14, indicated " ...if a patient has multiple stage 2 or a single stage 3 or 4 pressure sore other than on heels the Geo-Mattress with Wings should not be used... " The website, https://www.americannursetoday.com</CITE> [MEDICATION NAME] Testing for Early Malnutriton Detection, accessed 12/4/14 said, " ... pre-[MEDICATION NAME] test should be done when residents have a chronic debilitating condition, for serum [MEDICATION NAME] levels below 2.8 g/dl and etc...." The website, http://www.npuap.org/pr2.htm, accessed 12/5/14, indicated "A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction ..." " Pressure Ulcer StagesSuspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Further description:Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Further description: The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable.Unstageable:Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.Further description:Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as "the body's natural (biological) cover and should not be removed." Protein/[MEDICATION NAME] levels: According to the Clinical Practice guideline #15, treatment of [REDACTED]. The state of the wound is correlated with the severity of nutritional deficits, particularly low protein intake or a below-normal serum [MEDICATION NAME]. " The CMS 672 dated 12/1/14 indicated 3 residents had pressure sores.

Based on observation, interview and record review, the facility failed to consult the physician regarding pressure sores at admission and the development of new pressure sores for 1 of 11 residents sampled for pressure sores (Resident #10). Resident #10 was admitted on [DATE] with a Stage II pressure sore on her left buttock and a Stage II pressure sore on her right upper buttock. On 11/17/10, the resident had three new Stage II pressure sores and the pressure sore on her left buttock had increased in size. The facility did not consult with Resident #10's physician to obtain treatment and nutritional support orders until 11/17/10. This failure contributed to the worsening of a Stage II pressure sore and the development of three new Stage II pressure sores for Resident #10. This failure could place 6 residents with pressure sores at risk for delay in treatment, deterioration of current pressure sores and development of new pressure sores. Findings included: Resident #10's November 2010 computerized physician orders [REDACTED]. The resident's [DIAGNOSES REDACTED]. Resident #10's Admission Nursing Assessment, dated 11/10/10, noted she was admitted with two Stage II pressure sores on her sacral/coccyx area. The admission assessment indicated both wounds measured .5 x .5 centimeters. The assessment noted Resident #10 required total assistance with transfers and was non-weight bearing. During an observation and interview on 11/17/10 at 12:15 p.m., LVN F said Resident #10 currently had "one or two" pressure sores on her buttocks. She said she had not assessed or provided any treatment to the pressure sores. She said the CNAs applied [MEDICATION NAME] to the resident's buttocks. LVN F turned Resident #10 to her side and said the resident had four Stage II pressure sores. LVN F said the pressure sores on the resident's sacral area and right buttock were new. Resident #10's entire clinical record contained no information regarding treatment or assessment of Resident #10's wounds from 11/10/10 to 11/17/10. During an interview on 11/17/10 at 11:20 a.m., the DON said Resident #10's physician had not been consulted to initiate treatment for [REDACTED]. During an interview on 11/17/10 at 1:04 p.m., LVN J said she was the nurse that admitted Resident #10. She said Resident #10 was admitted close to change of shift so she completed Resident #10's skin assessment and vital signs and passed the admission to the oncoming nurse. LVN J said Resident #10 had a Stage II pressure sore on her upper right buttock and a Stage II pressure sore on her inner left buttock. She said both pressure sores measured 0.5 cm x 0.5 cm. During an interview on 11/17/10 at 2:58 p.m. LVN S said she had not obtained orders for treatment or nutritional supplements for Resident #10. LVN S said the admitting nurse would assess a new resident's skin, contact the physician to obtain treatment orders, and notify the skin treatment nurse. She said if the admitting nurse failed to complete the process "any nurse could obtain the order." The facility's undated Nutrition Protocol for Pressure Related Wounds for Stage II wounds noted the following: "1. Add a multi-vitamin with minerals if resident is not already on one." During an interview on 11/18/10 at 9:40 a.m., the administrator said Resident #10's pressure sores were present when the resident was admitted to the facility on [DATE]. In an interview on 11/18/10 at 3:20 p.m., LVN T said she provided weekly skin assessments at the facility on Tuesdays and was last at the facility on 11/16/10. LVN T said she found out about Resident #10's pressure sores on 11/17/10. Resident #10's skin assessment sheets dated 11/17/10 noted the following pressure sore measurements (length x width): -Left Buttock - 1.0 cm x 1.2 cm -Proximal Coccyx - 0.5 x 0.5 -Medial Coccyx - 0.7 x 0.5 -Coccyx - 1.2 x 2.0 -Right Buttock - 0.3 x 0.2 The following treatments were written on the assessment sheets: -Pre-[MEDICATION NAME] level, -Multivitamin with minerals every day, -[MEDICATION NAME] every shift and as needed, -Vitamin C 500 mg two times daily, -Turn every two hours from side to side, and -Specialty mattress. The CMS Form 672 dated 11/16/10 noted 6 residents with pressure sores and 70 residents receiving preventative skin care. During the exit conference the facility was given an opportunity to provide additional information. The facility provided copies of in-services completed on 11/17/10 regarding pressure sore assessments, physician notification of change of conditions, initiating treatment and documentation of assessments.

Based on observation, interview, and record review the facility failed to assess, identify and prevent pressure sore development for 1 of 11 residents sampled for pressure sores (Resident #10). Resident #10 was admitted on [DATE] with a Stage II pressure sore on her left buttock and a Stage II pressure sore on her right buttock. On 11/17/10, the resident had three new Stage II pressure sores and the pressure sore on her left buttock had increased in size. The facility did not assess the resident's skin for 10 days, consult Resident #10's physician to obtain treatment and nutritional support orders until 11/17/10, or implement any interventions. These failures contributed to the worsening of a Stage II pressure sore and the development of three new Stage II pressure sores for Resident #10. This failure could place 6 residents with pressure sores at risk for delay in treatment and deterioration of current pressure sores and could place 70 residents who receive preventative skin care at risk for the development of pressure sores. Findings included: Resident #10's November 2010 computerized physician orders [REDACTED]. The resident's [DIAGNOSES REDACTED]. On 11/16/10 at 10:32 a.m., Resident #10 was observed resting on a scoop mattress. She was positioned slightly on her right side. Resident #10's Admission Nursing Assessment, dated 11/10/10, noted she was admitted with two Stage II pressure sores on her sacral/coccyx area. The admission assessment indicated both wounds measured .5 x .5 centimeters. The assessment noted Resident #10 required total assistance with transfers and was non-weight bearing. "Supportive devices used" noted an air mattress. Resident #10's Braden Scale (used to assess pressure sore risk) dated 11/11/10 reflected a score of 17 (score of 12 or less represents high risk). Resident #10's admission care plan dated 11/10/10 did not address her current pressure sores or her risk of developing other pressure sores. During an observation and interview on 11/17/10 at 11:00 a.m., CNA L said Resident #10 had "some" open areas on her buttocks. She said they (CNAs) applied [MEDICATION NAME] to the resident's buttocks. Resident #10 was lying on a scoop mattress on her back . CNA L turned the resident to her side. CNAs L and O donned gloves and removed the resident's soiled brief. Runny, liquid feces was on the resident's buttocks and labial area. CNA O wiped the resident's buttocks and anal area. Without removing her gloves, CNA O applied [MEDICATION NAME] to the resident's buttocks and sacral area. Resident #10 had four Stage II pressure sores on her buttocks and sacral area. CNA L said Resident #10 had the pressure sores "for a while", but she was not sure if any of the pressure sores were new. During an observation and interview on 11/17/10 at 12:15 p.m., LVN F said Resident #10 currently had "one or two" pressure sores on her buttocks. She said she had not assessed or provided any treatment to the pressure sores. She said the CNAs applied [MEDICATION NAME] to the resident's buttocks. LVN F turned Resident #10 to her side and said the resident had four Stage II pressure sores. LVN F said she assisted a CNA to reposition Resident #10 on Friday (11/12/10). She said she "only saw" the resident's pressure sore on her left buttock. LVN F said the pressure sores on the resident's sacral area and right buttock were new. Resident #10's entire clinical record contained no information regarding treatment or assessment of Resident #10's pressure sores from 11/10/10 to 11/17/10. During an interview on 11/17/10 at 11:20 a.m., the DON said Resident #10's physician had not been consulted to initiate treatment for [REDACTED]. In an interview on 11/17/10 at 11:26 a.m., the DON and ADON said Resident #10 was admitted on [DATE] but her weekly skin assessment was not due until 11/20/10. During an interview on 11/17/10 at 1:04 p.m., LVN J said she was the nurse that admitted Resident #10. She said Resident #10 was admitted close to change of shift so she completed Resident #10's skin assessment and vital signs and passed the admission to the oncoming nurse. LVN J said Resident #10 had a Stage II pressure sore on her upper right buttock and a Stage II pressure sore on her inner left buttock. She said both pressure sores measured 0.5 cm x 0.5 cm. LVN J said she had worked with Resident #10 several times since her admission on 11/10/10 and had assisted with Resident #10's care on 11/16/10. She said she did not thoroughly inspect Resident #10's coccyx/sacral area and did not remove the [MEDICATION NAME] that was already on the resident's buttock. She said she "just re-applied some [MEDICATION NAME] over the [MEDICATION NAME] that was already there." During an interview on 11/17/10 at 2:58 p.m., LVN S said she had not obtained orders for treatment or nutritional supplements for Resident #10. LVN S said she had last worked with the resident on 11/15/10. She said she had not checked Resident #10's skin since admission. LVN S said the admitting nurse would assess a new resident's skin, contact the physician to obtain treatment orders, and notify the skin treatment nurse. She said if the admitting nurse failed to complete the process "any nurse could obtain the order." The facility undated Nutrition Protocol for Pressure Related Wounds for Stage II wounds noted the following: "1. Add a multi-vitamin with minerals if resident is not already on one." During an interview on 11/18/10 at 9:40 a.m., the administrator said Resident #10's pressure sores were present when the resident was admitted to the facility on [DATE]. She said the resident's next weekly skin assessment should have occurred on 11/13/10 but was not done. The administrator said Resident #10 "should be on a low air loss mattress." She said she told the staff, "to put Resident #10 on the specialty mattress on admission". She said all residents admitted to the facility with sores should be on a low air loss mattress. During an observation and interview with the DON on 11/18/10 at 9:55 a.m., Resident #10 was on a scoop mattress. The DON said the mattress was not an air loss mattress. In an interview on 11/18/10 at 3:20 p.m., LVN T said she provided weekly skin assessments at the facility on Tuesdays and was last at the facility on 11/16/10. LVN T said she found out about Resident #10's pressure sores on 11/17/10. Resident #10's skin assessment sheets dated 11/17/10 noted the following pressure sore measurements (length x width): -Left Buttock - 1.0 cm x 1.2 cm -Proximal Coccyx - 0.5 x 0.5 -Medial Coccyx - 0.7 x 0.5 -Coccyx - 1.2 x 2.0 -Right Buttock - 0.3 x 0.2 The following treatments were written on the assessment sheets: -Pre-[MEDICATION NAME] level, -Multivitamin with minerals every day, -[MEDICATION NAME] every shift and as needed, -Vitamin C 500 mg two times daily, -Turn every two hours from side to side, and -Specialty mattress. The CMS Form 672 dated 11/16/10 noted 6 residents with pressure sores and 70 residents receiving preventative skin care. During the exit conference the facility was given an opportunity to provide additional information. The facility provided copies of in-services completed on 11/17/10 regarding pressure sore assessments, physician notification of change of conditions, initiating treatment and documentation of assessments.