Every finding on record at Focused Care at Webster

Based on observation, interview and record review, the facility failed to ensure that residents who are unable to carry out activities of daily living receive the necessary treatment and services, consistent with professional standards of practice, to maintain personal hygiene. Video footage of in room surveillance revealed the facility failed to provide Resident #1, who was totally dependent on staff for ADL care, with timely incontinent care. Resident #1 did not receive incontinent care for more than 15 hours on 5/24/26 and 5/25/26, and on 05/25/26, was subsequently diagnosed with a Stage 3 pressure ulcer to his sacrum. This failure could place residents at risk for skin breakdowns, diminished quality of life, and a decline in personal hygiene. Findings Include:Record review of Resident #1's admission record revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. His admitting diagnoses were cerebrovascular disease (conditions that affect blood circulation to the brain), bacterial pneumonia (an infection of your lungs caused by a certain bacteria), protein calorie malnutrition (insufficient intake of protein and calories), aphasia (impairment of the ability to understand, speak, read, or write), dysphagia (difficulty swallowing), aphonia (the loss or reduction of vocal ability), and lack of coordination, abnormalities of gait and mobility, bilateral hand contractures (tightening and stiffen of hands limiting movement), and atrophy (reduction in muscle mass and strength). At admission, Resident #1 did not have a diagnosis for the Stage 3 sacral pressure ulcerRecord review of Resident #1's comprehensive care plan revealed focus on incontinence of bowel and bladder on 09/12/24 (goal revised on 05/05/26) Resident #1 will remain clean, dry, and odor free with no occurrence of skin breakdown. Interventions noted were to monitor for incontinence as required and prn, change promptly and apply protective skin barrier, monitor for s/s of skin break down and report abnormal findings to MD/RP, assess for causes of incontinence, labs as ordered by MD, monitor for s/s of infection and notify MD/RP promptly. Further review of comprehensive care plan revealed focus on ADL self-care performance deficit r/t disease processes, impaired balance, limited mobility, stroke, and required maximum assistance of staff initiated 09/13/24. The goal was to improve current level of function in bed mobility and transfers through implementation of requirement of maximum assist of two staff members to turn and reposition in bed, provide skin care to keep clean and prevent skin breakdown, total dependence on one staff for personal hygiene, and skin inspection daily to observe for redness, open areas, scratches, cuts, or bruises and report change to the nurse. Review of comprehensive care plan shows on 11/13/24 (revision date 05/05/26) Resident #1 has a potential bladder incontinence and is at risk for skin breakdown r/t incontinence of urine r/t impaired mobility. The goal states Resident #1 will remain free from skin breakdown due to incontinence and brief use. Interventions listed were to clean peri-area with each incontinence episode. Review revealed on 01/31/25, Resident #1 would receive care from hospice by working cooperatively with hospice team to ensure spiritual, emotional intellectual, physical, and social needs are met. In further review of his comprehensive care plan, initiated on 03/02/26 revealed focus on Resident #1's current skin condition of MASD (inflammation and erosion of the skin caused by prolonged exposure to moisture) sacrum and left posterior (back) ear to resolve concerns without complications. Interventions listed were to perform treatments per MD orders, monitor areas for increase breakdown, s/s of infection and report to MD, monitor for pain, give med per order, monitor for relief, keep MD and RP informed of Resident #1's progress and assess skin weekly and record findings in clinical records. Record review of Resident #1's Care Plan Report revealed that the care plan was updated on 05/26/26 to include his injury to the left sacrum r/t immobility, incontinence, and disease process. It includes administering medications/treatments as ordered and monitor for effectiveness, educate Resident #1/FM as to causes of skin breakdown, including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning; weekly treatment documentation to include measurement of each area of skin's breakdown's width, length, depth, type of tissue and exudate. Record review of Resident #1's admission MDS revealed that no BIMS score was recorded. Under section H titled Bladder and Bowel, completed by RN A on 02/25/26 revealed, Resident #1 was always incontinent with urine and bowel. Under section M titled Skin Conditions completed by RN A revealed that Resident #1 was at risk of developing a pressure ulcer/injury. The assessment shows that Resident #1 had no unhealed pressure ulcers/injuries. Under section GG titled functional abilities: Self-Care, Resident #1 was coded as requiring substantial/maximal assistance (helper does more than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides more than half the effort) with toileting, upper and lower body dressing, and personal hygiene. Under section GG titled functional abilities: Mobility, Resident #1 was coded as requiring substantial/ maximal assistance with rolling left and right (the ability to roll from lying on back to left and right side and return to lying on back on the bed). On admission and completion of the MDS, Resident #1 was coded as not attempting, nor did he perform the activity of toilet transfer prior to his current illness. Record review of the video dated 05/24/26 reflectedat 4:36 a.m. after brief change, Resident #1 was lying on his back in the center of the bed with the head of bed elevated and his positioning wedge on his bedside table. Resident #1 received medication from a nurse at 5:47 a.m. At 7:29 a.m. it was observed that he was receiving medication again by a nurse. CNA B entered Resident #1's room at 7:40 a.m. and turned on lights for his roommate and she left. She returned at 8:07 a.m. to administer care to the roommate. Resident #1 was in the same position and positioning wedge on bedside table. CNA B returned at 8:10 a.m. and fed Resident #1 and his roommate simultaneously while wearing the same gloves. CNA B began watching Resident #1 television at 8:17 a.m. and completed feeding Resident #1 and his roommate at 8:18 a.m. CNA B returned to Resident #1's room at 9:09 a.m. to turn off the light over his roommate and stated to Resident #1 I'm doing blood pressures and I'll be back. At 9:30 CNA B returned to Resident #1's room with a plastic bin filled with adult briefs and placed on his roommate's nightstand. CNA B began to provide care to the roommate and at 9:49 a.m. she is seen wheeling Resident #1's roommate. During this time Resident #1 was seen lying on his back with the head of bed elevated. At 9:54 a.m. CNA B returns to the room, and she removes the bin of adult briefs and turns off the lights. 10:19 a.m. housekeeping is seen mopping room. CNA B returns to Resident #1's room at 11:21 a.m. and obtains Resident #1's television remote on his bedside table is seen looking at his television, he is still in the center of the bed lying on his back with the head of the bed elevated. Another staff member enters Resident 1's room is seen and heard talking with CNA B. Both CNA B and the unknown staff member leave the room at 11:21 a.m. At 11:51 a.m. dietary staff member is seen leaving lunch tray for Resident #1. CNA B returns to Resident #1's room at 12:34 p.m. and she proceeds to feed him without wearing gloves. CNA B leaves at 12:34 p.m. and does not return until 4:08 p.m. during this time she watches Resident #1's television and adjusts the window blinds. She then walks out of the view area of the camera. Resident #1 was seen in the center of the bed lying on his back with head of the bed elevated and his positioning wedge was on his right side near his feet not in use. She returns to Resident #1 at 1640 and exchanges towel on his chest. CNA B returns to Resident #1 bedside at 6:09 p.m. and leaves. At 7:54 p.m. Resident #1's brief was changed by CNA C. Record review of video dated 05/25/26 revealed at 4:26 a.m. CNA C changed Resident #1's brief. Resident #1 is lying on his back close to the left side of the bed. The head of his bed is elevated, and positioning wedge is not in sight. He received medication from nursing staff at 5:44 a.m. At 8:03 a.m. CNA B is seen in Resident #1's room turning on the light on his roommate's side. Resident #1 received medication from nurse at 8:30 a.m. CNA B returns to room at 9:26 a.m. but moves out of view of camera, she returns to Resident #1 bedside to feed him. CNA B adjusts blinds on Resident #1 side at 9:56 a.m. and returns at 10:17 a.m. to his bedside and leaves. Resident #1 is seen lying on his back in the same position as earlier. Unknown nursing staff member is seen at Resident #1 bedside at 11:37 looking under his sheets and adjusting his bedside table. CNA B returns to his bedside with a dietary in her hand, draws the curtain between the roommates and walks away. She returns at 1:31 p.m. to feed Resident #1 and leaves at 1:35 p.m. She is seen in view at 1:41 p.m. but leaves again and returns to room at 3:48 p.m. on Resident #1's roommate side. At 4:41 p.m. CNA B returns to Resident #1 bedside to offer a pain pill. He replies but his communication is not easily understandable. CNA B walks out of room. Resident #1 is still lying on his back close to the left side of the bed with no positioning wedge within sight. CNA B returns at 4:47 p.m., placing Resident #1's dinner tray at bedside and is seen walking away. CNA B does not return. At 6:53 p.m. CNA C discovers tray at Resident #1's bedside and walks way to determine if she could still feed him. CNA C returns to Resident #1's bedside at 7:45 p.m. and changes his brief. Record review of Progress Notesdated 5/24/26 revealed no documentation related to incontinent care on this date. Record review of Resident #1's Wound Consultant Follow Up assessment on 05/27/26 revealed Resident #1 was bed bound, with bilateral upper extremity contractures, and bilateral lower extremity muscle weakness. Records revealed that the status of the Pressure Ulcer was new with measurements of 2.2 cm (length) x 1 cm (width) X 0.1 cm (depth). The actual area was noted as 2.2 cm and volume 0.22 cm3. The wound base was 100% granulation (new tissue forming), periwound is fragile (the skin around the wound), exudate (bodily fluid that is discharged from tissue during body response from injury) is moderate amount of clear drainage. Recommendations include implementation of pressure relieving measures and offloading (reducing or removing pressure from a specific area to promote wound healing and prevent further tissue damage). Treatment recommendations are to clean the pressure ulcer with wound cleaner, apply calcium alginate (moist, absorbent dressing for draining wounds) and dry dressing; change dressing daily or as needed if dislodged, saturated or soiled. Record review of Resident #1's Progress Note of Skin/Wound Care note by WCN entered on 05/26/26 at 1:03 pm. WCN noted that Resident #1 had what appears to be a pressure injury noted to right gluteal measuring 1 x 1.1 no obvious s/s of infection nor bleeding present. New order to apply med-honey and cover with dry dressing daily and prn for soilage/dislodgement. RP notified. Air mattress and heel protectors in place. At 1:13 p.m., WCN documented an SBAR (used to convey critical information to care team members) receiving Primary Care Provider Feedback with recommendations of Med-Honey and dry dressing. Record review of Resident #1's Progress Notes from WCN on 05/27/26 at 6:26 p.m. revealed wound care provider rounded on Resident #1. WCN noted Resident #1 has one Stage 3 pressure ulcer to left sacrum, no s/s of infection. Treatment order updated. Resident #1 tolerated well, air mattress in place to facilitate wound healing, wedge in place for offloading while Resident #1 is in bed, heel protectors in place, RP aware, plan of care ongoing. Record review of Progress Notes dated 06/05/26 revealed NP A documented on 06/05/26 at 5:21 p.m. that Resident #1 had a Braden Scale (tool used to assess a resident's risk for developing pressure injuries) score of 14 (score of 13 - 14 per Braden Scale places the patient in the moderate risk category) on 05/26/26, placing the resident at moderate to high risk for pressure injury development. NP A notes continued with stating that Resident #1 was evaluated by the RD on 05/13/26. Per NP A, documentation by the RD at that time stated Goal: Support comfort care by providing adequate nutrition to promote wound healing. The resident is under the care of hospice; weight loss and skin breakdown anticipated related to current medical condition. NP A documented that despite implementation of appropriate preventative measures including routine skin assessments, pressure injury prevention protocols, repositioning as tolerated, nutritional support, hospice oversight, and nursing interventions consistent with the resident's goal of care, Resident #1 developed a Stage 3 pressure injury on 05/26/26. Record review of Resident #1's Physician Orders on revealed that on 03/13/26 an order for a pressure reducing mattress to bed. Records revealon 03/14/26 Resident #1 received an order for admission to hospice d/t CVA. Records showed on 03/17/26, an order to apply zinc oxide to sacrum daily as needed for MASD until healed and to apply one time a day every other day for skin integrity. Records revealed on 05/27/26, order placed to provide wound care to left sacrum pressure by cleansing with wound cleaner/normal saline and pat dry, apply calcium alginate and cover with dry daily and PRN for soilage/dislodgement, one time a day for wound healing/skin integrity to begin on 05/28/26. Record review of Resident #1's MAR/TAR revealed that on 05/21/26 and 05/29/26 zinc oxide to sacrum area for MASD was not documented on days scheduled for administration as ordered. Further review of MAR/TAR reveals on 05/29/26 and 05/31/26 left sacrum pressure ulcer dressing change was not documented as ordered. Observation of Resident #1 on 06/05/26 at 10:30 a.m., noted he was lying on his back with the head of his bed elevated, with pillow to his right of head, arms were contracted and on his chest. Resident #1 was nonverbal. Returned to Resident #1's room at 12:45 p.m., he was still lying on his back and pillow to right side of his head, blood stains on bottom of his sheet. CNA A and RN B were called into the room to change his position of pillow and provide a new sheet for Resident #1. Observation at 2:00 p.m., Resident #1 could be heard moaning at door entry of his room. Resident #1 was moved between 1:00 p.m. and 2:00 p.m.to center of bed, lying on his back with pillow now behind his head. Observation at 4:35 p.m. resident was lying on his back with pillow behind his head. Incontinent care was observed being provided by RN B and CNA A. In interview with DON, she stated that it is excepted for staff to round on resident's every two hours. On 06/05/26 at 5:55 p.m., interview was conducted with NP. During the interview, the NP stated She is not in the facility enough to address the frequency of incontinence care. She discussed other medical treatment being provided to prevent pressure ulcers. She is unsure of how frequent incontinent care is performed. Phone interview was conducted with CNA B on 06/05/26 at 6:24 p.m. During the interview, CNA B stated that she recalled taking care of Resident #1 on 05024/26. She stated on that day, she changed Resident #1's briefs a total of three - four times however she could not list the times. CNA B stated that she enlisted the help of LVN B d/t the resident being a two person assist. When asked how often she changes Resident #1 and why did she enlist the help of LVN B who was not assigned to her hall, CNA B stated he's different from other residents so it depends how often to change. How busy we get every 2 hours they're not coming, so I got the LVN B to get what needs to be done. When CNA B was asked if she would be surprised there was a video of her not providing incontinent care of Resident #1 during her 12-hour shift on 05/24/26, CNA B replied, I wasn't aware. Interview conducted at 6:40 PM with HRN/NCO. When asked to explain the gap of service from 05/22/26 - 05/26/26 provided to Resident #1 by hospice, the HRN/NCO replied care is not provided over the weekends and there was a holiday on 05/25/26 which we do not provide care on those days unless emergency. When speaking with the HRN/NCO she stated that the hospice nursing aide visits daily to provide grooming and bed bath for Resident #1. It was not noted in her daily assessment on Friday, 05/22/26 that Resident #1 had a pressure ulcer. In a telephone interview with Resident #1's FM1 on 06/05/26 at 12:11 p.m., she stated that she had previously notified the DON and Ombudsman by phone of her concerns of not changing Resident #1's brief nor repositioning in bed. She stated that Resident #1 is not moved by staff when she is visiting and requests that his position is changed. FM1 stated last request was on 06/04/26 at around 1:00 p.m. FM1 stated iN no, they don't have anyone to do it. FM1 stated that she would review Resident #1's camera in his room to view days that he was not changed by staff and provide footage. Interview with Resident #1's FM2 was conducted on 06/05/26 at 5:00 p.m. FM2 stated that while visiting Resident #1 he is kept in the same position throughout the duration of his visit despite asking staff to reposition Resident #1. FM2 was able to provide video recording of Resident #1's care on 05/24/26. FM2 stated that after watching the video he noticed that no staff members provided care after 4:36 a.m. to 7:54 p.m. Record review of the requested policy Skin Management revealed that DON submitted a blank sign-in sheet for review of policy by staff with no attached policy.

Based on observation, interview and record review, the facility failed to ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable. Video footage of in room surveillance revealed the facility failed to provide Resident #1, who was totally dependent on staff for ADL care, with timely incontinent care. Resident #1 did not receive incontinent care for more than 15 hours on 5/24/26 and 5/25/26, and on 05/25/26, was subsequently diagnosed with a Stage 3 pressure ulcer to his sacrum. The failure could place residents at risk for worsening skin breakdowns, progression of the ulcer to move to more severe stages, and overall decline in quality of life. Findings Include:Record review of Resident #1's admission record revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. His admitting diagnoses were cerebrovascular disease (conditions that affect blood circulation to the brain), bacterial pneumonia (an infection of your lungs caused by a certain bacteria), protein calorie malnutrition (insufficient intake of protein and calories), aphasia (impairment of the ability to understand, speak, read, or write), dysphagia (difficulty swallowing), aphonia (the loss or reduction of vocal ability), and lack of coordination, abnormalities of gait and mobility, bilateral hand contractures (tightening and stiffen of hands limiting movement), and atrophy (reduction in muscle mass and strength). At admission, Resident #1 did not have a diagnosis for the Stage 3 sacral pressure ulcerRecord review of Resident #1's comprehensive care plan revealed focus on incontinence of bowel and bladder on 09/12/24 (goal revised on 05/05/26) Resident #1 will remain clean, dry, and odor free with no occurrence of skin breakdown. Interventions noted were to monitor for incontinence as required and prn, change promptly and apply protective skin barrier, monitor for s/s of skin break down and report abnormal findings to MD/RP, assess for causes of incontinence, labs as ordered by MD, monitor for s/s of infection and notify MD/RP promptly. Further review of comprehensive care plan revealed focus on ADL self-care performance deficit r/t disease processes, impaired balance, limited mobility, stroke, and required maximum assistance of staff initiated 09/13/24. The goal was to improve current level of function in bed mobility and transfers through implementation of requirement of maximum assist of two staff members to turn and reposition in bed, provide skin care to keep clean and prevent skin breakdown, total dependence on one staff for personal hygiene, and skin inspection daily to observe for redness, open areas, scratches, cuts, or bruises and report change to the nurse. Review of comprehensive care plan shows on 11/13/24 (revision date 05/05/26) Resident #1 has a potential bladder incontinence and is at risk for skin breakdown r/t incontinence of urine r/t impaired mobility. The goal states Resident #1 will remain free from skin breakdown due to incontinence and brief use. Interventions listed were to clean peri-area with each incontinence episode. Review revealed on 01/31/25, Resident #1 would receive care from hospice by working cooperatively with hospice team to ensure spiritual, emotional intellectual, physical, and social needs are met. In further review of his comprehensive care plan, initiated on 03/02/26 revealed focus on Resident #1's current skin condition of MASD (inflammation and erosion of the skin caused by prolonged exposure to moisture) sacrum and left posterior (back) ear to resolve concerns without complications. Interventions listed were to perform treatments per MD orders, monitor areas for increase breakdown, s/s of infection and report to MD, monitor for pain, give med per order, monitor for relief, keep MD and RP informed of Resident #1's progress and assess skin weekly and record findings in clinical records. Record review of Resident #1's Care Plan Report revealed that the care plan was updated on 05/26/26 to include his injury to the left sacrum r/t immobility, incontinence, and disease process. It includes administering medications/treatments as ordered and monitor for effectiveness, educate Resident #1/FM as to causes of skin breakdown, including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning; weekly treatment documentation to include measurement of each area of skin's breakdown's width, length, depth, type of tissue and exudate. Record review of Resident #1's admission MDS revealed that no BIMS score was recorded. Under section H titled Bladder and Bowel, completed by RN A on 02/25/26 revealed, Resident #1 was always incontinent with urine and bowel. Under section M titled Skin Conditions completed by RN A revealed that Resident #1 was at risk of developing a pressure ulcer/injury. The assessment shows that Resident #1 had no unhealed pressure ulcers/injuries. Under section GG titled functional abilities: Self-Care, Resident #1 was coded as requiring substantial/maximal assistance (helper does more than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides more than half the effort) with toileting, upper and lower body dressing, and personal hygiene. Under section GG titled functional abilities: Mobility, Resident #1 was coded as requiring substantial/ maximal assistance with rolling left and right (the ability to roll from lying on back to left and right side and return to lying on back on the bed). On admission and completion of the MDS, Resident #1 was coded as not attempting, nor did he perform the activity of toilet transfer prior to his current illness. Record review of the video dated 05/24/26 reflectedat 4:36 a.m. after brief change, Resident #1 was lying on his back in the center of the bed with the head of bed elevated and his positioning wedge on his bedside table. Resident #1 received medication from a nurse at 5:47 a.m. At 7:29 a.m. it was observed that he was receiving medication again by a nurse. CNA B entered Resident #1's room at 7:40 a.m. and turned on lights for his roommate and she left. She returned at 8:07 a.m. to administer care to the roommate. Resident #1 was in the same position and positioning wedge on bedside table. CNA B returned at 8:10 a.m. and fed Resident #1 and his roommate simultaneously while wearing the same gloves. CNA B began watching Resident #1 television at 8:17 a.m. and completed feeding Resident #1 and his roommate at 8:18 a.m. CNA B returned to Resident #1's room at 9:09 a.m. to turn off the light over his roommate and stated to Resident #1 I'm doing blood pressures and I'll be back. At 9:30 CNA B returned to Resident #1's room with a plastic bin filled with adult briefs and placed on his roommate's nightstand. CNA B began to provide care to the roommate and at 9:49 a.m. she is seen wheeling Resident #1's roommate. During this time Resident #1 was seen lying on his back with the head of bed elevated. At 9:54 a.m. CNA B returns to the room, and she removes the bin of adult briefs and turns off the lights. 10:19 a.m. housekeeping is seen mopping room. CNA B returns to Resident #1's room at 11:21 a.m. and obtains Resident #1's television remote on his bedside table is seen looking at his television, he is still in the center of the bed lying on his back with the head of the bed elevated. Another staff member enters Resident 1's room is seen and heard talking with CNA B. Both CNA B and the unknown staff member leave the room at 11:21 a.m.At 11:51 a.m. dietary staff member is seen leaving lunch tray for Resident #1. CNA B returns to Resident #1's room at 12:34 p.m. and she proceeds to feed him without wearing gloves. CNA B leaves at 12:34 p.m. and does not return until 4:08 p.m. during this time she watches Resident #1's television and adjusts the window blinds. She then walks out of the view area of the camera. Resident #1 was seen in the center of the bed lying on his back with head of the bed elevated and his positioning wedge was on his right side near his feet not in use. She returns to Resident #1 at 1640 and exchanges towel on his chest. CNA B returns to Resident #1 bedside at 6:09 p.m. and leaves. At 7:54 p.m. Resident #1's brief was changed by CNA C.Record review of video dated 05/25/26 revealed at 4:26 a.m. CNA C changed Resident #1's brief. Resident #1 is lying on his back close to the left side of the bed. The head of his bed is elevated, and positioning wedge is not in sight. He received medication from nursing staff at 5:44 a.m. At 8:03 a.m. CNA B is seen in Resident #1's room turning on the light on his roommate's side. Resident #1 received medication from nurse at 8:30 a.m. CNA B returns to room at 9:26 a.m. but moves out of view of camera, she returns to Resident #1 bedside to feed him. CNA B adjusts blinds on Resident #1 side at 9:56 a.m. and returns at 10:17 a.m. to his bedside and leaves. Resident #1 is seen lying on his back in the same position as earlier. Unknown nursing staff member is seen at Resident #1 bedside at 11:37 looking under his sheets and adjusting his bedside table. CNA B returns to his bedside with a dietary in her hand, draws the curtain between the roommates and walks away. She returns at 1:31 p.m. to feed Resident #1 and leaves at 1:35 p.m. She is seen in view at 1:41 p.m. but leaves again and returns to room at 3:48 p.m. on Resident #1's roommate side. At 4:41 p.m. CNA B returns to Resident #1 bedside to offer a pain pill. He replies but his communication is not easily understandable. CNA B walks out of room. Resident #1 is still lying on his back close to the left side of the bed with no positioning wedge within sight. CNA B returns at 4:47 p.m., placing Resident #1's dinner tray at bedside and is seen walking away. CNA B does not return. At 6:53 p.m. CNA C discovers tray at Resident #1's bedside and walks way to determine if she could still feed him. CNA C returns to Resident #1's bedside at 7:45 p.m. and changes his brief. Record review of Progress Notesdated 5/24/26 revealed no documentation related to incontinent care on this date. Record review of Resident #1's Wound Consultant Follow Up assessment on 05/27/26 revealed Resident #1 was bed bound, with bilateral upper extremity contractures, and bilateral lower extremity muscle weakness. Records revealed that the status of the Pressure Ulcer was new with measurements of 2.2 cm (length) x 1 cm (width) X 0.1 cm (depth). The actual area was noted as 2.2 cm and volume 0.22 cm3. The wound base was 100% granulation (new tissue forming), periwound is fragile (the skin around the wound), exudate (bodily fluid that is discharged from tissue during body response from injury) is moderate amount of clear drainage. Recommendations include implementation of pressure relieving measures and offloading (reducing or removing pressure from a specific area to promote wound healing and prevent further tissue damage). Treatment recommendations are to clean the pressure ulcer with wound cleaner, apply calcium alginate (moist, absorbent dressing for draining wounds) and dry dressing; change dressing daily or as needed if dislodged, saturated or soiled. Record review of Resident #1's Progress Note of Skin/Wound Care note by WCN entered on 05/26/26 at 1:03 pm. WCN noted that Resident #1 had what appears to be a pressure injury noted to right gluteal measuring 1 x 1.1 no obvious s/s of infection nor bleeding present. New order to apply med-honey and cover with dry dressing daily and prn for soilage/dislodgement. RP notified. Air mattress and heel protectors in place. At 1:13 p.m., WCN documented an SBAR (used to convey critical information to care team members) receiving Primary Care Provider Feedback with recommendations of Med-Honey and dry dressing. Record review of Resident #1's Progress Notes from WCN on 05/27/26 at 6:26 p.m. revealed wound care provider rounded on Resident #1. WCN noted Resident #1 has one Stage 3 pressure ulcer to left sacrum, no s/s of infection. Treatment order updated. Resident #1 tolerated well, air mattress in place to facilitate wound healing, wedge in place for offloading while Resident #1 is in bed, heel protectors in place, RP aware, plan of care ongoing. Record review of Progress Notes dated 06/05/26 revealed NP A documented on 06/05/26 at 5:21 p.m. that Resident #1 had a Braden Scale (tool used to assess a resident's risk for developing pressure injuries) score of 14 (score of 13 - 14 per Braden Scale places the patient in the moderate risk category) on 05/26/26, placing the resident at moderate to high risk for pressure injury development. NP A notes continued with stating that Resident #1 was evaluated by the RD on 05/13/26. Per NP A, documentation by the RD at that time stated Goal: Support comfort care by providing adequate nutrition to promote wound healing. The resident is under the care of hospice; weight loss and skin breakdown anticipated related to current medical condition. NP A documented that despite implementation of appropriate preventative measures including routine skin assessments, pressure injury prevention protocols, repositioning as tolerated, nutritional support, hospice oversight, and nursing interventions consistent with the resident's goal of care, Resident #1 developed a Stage 3 pressure injury on 05/26/26. Record review of Resident #1's Physician Orders on revealed that on03/13/26 an order for a pressure reducing mattress to bed. Records revealon 03/14/26 Resident #1 received an order for admission to hospice d/t CVA. Records showed on 03/17/26, an order to apply zinc oxide to sacrum daily as needed for MASD until healed and to apply one time a day every other day for skin integrity. Records revealed on 05/27/26, order placed to provide wound care to left sacrum pressure by cleansing with wound cleaner/normal saline and pat dry, apply calcium alginate and cover with dry daily and PRN for soilage/dislodgement, one time a day for wound healing/skin integrity to begin on 05/28/26. Record review of Resident #1's MAR/TAR revealed that on 05/21/26 and 05/29/26 zinc oxide to sacrum area for MASD was not documented on days scheduled for administration as ordered. Further review of MAR/TAR reveals on 05/29/26 and 05/31/26 left sacrum pressure ulcer dressing change was not documented as ordered. Observation of Resident #1 on 06/05/26 at 10:30 a.m., noted he was lying on his back with the head of his bed elevated, with pillow to his right of head, arms were contracted and on his chest. Resident #1 was nonverbal. Returned to Resident #1's room at 12:45 p.m., he was still lying on his back and pillow to right side of his head, blood stains on bottom of his sheet. CNA A and RN B were called into the room to change his position of pillow and provide a new sheet for Resident #1. Observation at 2:00 p.m., Resident #1 could be heard moaning at door entry of his room. Resident #1 was moved between 1:00 p.m. and 2:00 p.m.to center of bed, lying on his back with pillow now behind his head. Observation at 4:35 p.m. resident was lying on his back with pillow behind his head. Incontinent care was observed being provided by RN B and CNA A. In interview with DON, she stated that it is excepted for staff to round on resident's every two hours.On 06/05/26 at 5:55 p.m., interview was conducted with NP. During the interview, the NP stated She is not in the facility enough to address the frequency of incontinence care. She discussed other medical treatment being provided to prevent pressure ulcers. She is unsure of how frequent incontinent care is performed. Phone interview was conducted with CNA B on 06/05/26 at 6:24 p.m. During the interview, CNA B stated that she recalled taking care of Resident #1 on 05024/26. She stated on that day, she changed Resident #1's briefs a total of three - four times however she could not list the times. CNA B stated that she enlisted the help of LVN B d/t the resident being a two person assist. When asked how often she changes Resident #1 and why did she enlist the help of LVN B who was not assigned to her hall, CNA B stated he's different from other residents so it depends how often to change. How busy we get every 2 hours they're not coming, so I got the LVN B to get what needs to be done. When CNA B was asked if she would be surprised there was a video of her not providing incontinent care of Resident #1 during her 12-hour shift on 05/24/26, CNA B replied, I wasn't aware. Interview conducted at 6:40 PM with HRN/NCO. When asked to explain the gap of service from 05/22/26 - 05/26/26 provided to Resident #1 by hospice, the HRN/NCO replied care is not provided over the weekends and there was a holiday on 05/25/26 which we do not provide care on those days unless emergency. When speaking with the HRN/NCO she stated that the hospice nursing aide visits daily to provide grooming and bed bath for Resident #1. It was not noted in her daily assessment on Friday, 05/22/26 that Resident #1 had a pressure ulcer. In a telephone interview with Resident #1's FM1 on 06/05/26 at 12:11 p.m., she stated that she had previously notified the DON and Ombudsman by phone of her concerns of not changing Resident #1's brief nor repositioning in bed. She stated that Resident #1 is not moved by staff when she is visiting and requests that his position is changed. FM1 stated last request was on 06/04/26 at around 1:00 p.m. FM1 stated iN no, they don't have anyone to do it. FM1 stated that she would review Resident #1's camera in his room to view days that he was not changed by staff and provide footage. Interview with Resident #1's FM2 was conducted on 06/05/26 at 5:00 p.m. FM2 stated that while visiting Resident #1 he is kept in the same position throughout the duration of his visit despite asking staff to reposition Resident #1. FM2 was able to provide video recording of Resident #1's care on 05/24/26. FM2 stated that after watching the video he noticed that no staff members provided care after 4:36 a.m. to 7:54 p.m. Record review of the requested policy Skin Management revealed that DON submitted a blank sign-in sheet for review of policy by staff with no attached policy.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs for 1 out of 4 (Resident #1) residents reviewed for pharmacy service in that: The facility failed to ensure MA B did not leave Resident #1 medications on top of the bedside table. This failure could place residents at risk of not receiving their medications, choking and respiratory distress.Findings include: Record review of Resident #1's face sheet dated 4/1/25 revealed she was an [AGE] year-old-female initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included: unspecified dementia (cognitive decline or memory loss), unspecified severity (recognizes a condition exists and causes impairments), without behavioral disturbance (does not exhibit significant agitation), psychotic disturbance (a severe mental state characterized by a loss of contact with reality, manifesting as hallucinations, delusions, and disorganized thinking), anxiety disorder (mental health condition characterized by excessive, persistent, and uncontrollable fear), cognitive communication deficit (an impairment in communication due to underlying cognitive issues like poor memory), essential primary hypertension (chronic high blood pressure with no single, identifiable medical cause), and need for assistance with personal care. Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 03 out of 15, indicating severely impaired cognition. Further review revealed Resident #1 needed extensive assistance with ADL. Record review of Resident #1's care plan dated 04/01/2026 revealed Resident #1 was at Risk for potential side effects due to missed medication. Record review of Resident #1's order summary report dated 04/01/26 read in part, Memantine HCl Oral Tablet 10MG, give one tablet by mouth two times a day for dementia ordered date 03/31/26. Metoprolol Tartrate Tablet 25 MG, give one tablet by mouth two times a day for High Blood Pressure ordered date 01/29/24. During an observation and interview on 04/01/26 at 1:51p.m., surveyor observed two pills in a cup on Resident #1's bedside table. When surveyor asked about the medication, Resident #1 stated she was not taking the pills and reported she did not know what the medication was for. Resident #1 told the surveyor, You can have it because I'm not taking it, and repeated that she was over [AGE] years old and does not believe in continuing tests or medications. During an interview on 04/01/26 at 4:17p.m, Medication Aide (MA B) said that residents in the facility are not permitted to self-administer medications. The MA B described the facility's medication administration protocol as requiring staff to observe the resident taking medications, ensure adequate fluid intake, and confirm Resident #1 swallows each medication prior to leaving the room. The MA B said she prepared Resident #1 medications in a cup and used water from Resident #1's personal cup. The MA B said Resident #1 typically takes medications one at a time or occasionally two at a time, but not all at once. The MA B said she initially observed Resident #1 taking the medications, however, MA B said she turned her back and began preparing for the resident next door. The MA B said she assumed Resident #1 had taken all medications, as this is Resident #1's usual practice. The MA B said she exited the room without confirming all medications were consumed. The MA B said the potential risk to Resident #1's failure to take blood pressure medication could result in elevated blood pressure which could increase the risk of a stroke or a headache. The MA B said the potential risk to Resident #1's failure to take dementia medication could result in increased confusion. The MA B said if another resident ingested the medication there is a risk that residents will have an adverse or allergic reaction. During an interview on 04/01/26 at 4:43 p.m., Director of Nursing (DON) said that medication aides are responsible for administering medications and confirming that each resident has taken their medication. The DON said currently no residents in the facility are permitted to self-administer medications. The DON said the failure to administer high blood pressure medication to Resident #1 could result in an elevated pulse. She said the failure to administer dementia medications may negatively impact Resident #1's cognitive status. She said if medications are left unattended another resident could take the medication and the risk to that resident can result in an adverse reaction. During a telephone interview on 04/01/26 at 5:02 p.m., Nurse Practitioner (NP) said that his expectation for medication administration is that staff follow physician orders exactly as prescribed. The NP said missing high blood pressure mediation could place Resident #1 at risk for elevated blood pressure medication potentially causing adverse health outcomes. During an interview on 04/01/26 at 5:25 p.m., Administrator (ADM) said medications must not be left in a resident's room. The ADM said his expectation of the MA is that they must follow facility policy regarding proper medication administration. The ADM said the risk to Resident #1 missing her blood pressure medication could result in elevated blood pressure or a stroke. He said the risk to Resident #1 not receiving dementia medication could lead to ongoing cognitive issues. The Policy for Medication Administration requested on 04/01/26 at 3:08 p.m., surveyor was not provided with all the documents for the policy requested.

Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys to meet the needs for 1 out of 4 (Resident #1) residents reviewed for pharmacy service in that: The facility failed to ensure MA B did not leave Resident #1 medications on top of the bedside table.MA B failed to ensure that the medication was secure when she walked away and left two pills in the cup unsupervised. This failure could place residents at risk of not getting their medications as ordered. Findings include: Record review of Resident #1's face sheet dated 4/1/25 revealed she was an [AGE] year-old-female initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included: unspecified dementia (cognitive decline or memory loss), unspecified severity (recognizes a condition exists and causes impairments), without behavioral disturbance (does not exhibit significant agitation), psychotic disturbance (a severe mental state characterized by a loss of contact with reality, manifesting as hallucinations, delusions, and disorganized thinking), anxiety disorder (mental health condition characterized by excessive, persistent, and uncontrollable fear), cognitive communication deficit (an impairment in communication due to underlying cognitive issues like poor memory), essential primary hypertension (chronic high blood pressure with no single, identifiable medical cause), and need for assistance with personal care. Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 03 out of 15, indicating severely impaired cognition. Further review revealed Resident #1 needed extensive assistance with ADL. Record review of Resident #1's care plan dated 04/01/2026 revealed Resident #1 was at Risk for potential side effects due to missed medication. Record review of Resident #1's order summary report dated 04/01/26 read in part, Memantine HCl Oral Tablet 10MG, give one tablet by mouth two times a day for dementia ordered date 03/31/26. Metoprolol Tartrate Tablet 25 MG, give one tablet by mouth two times a day for High Blood Pressure ordered date 01/29/24. During an observation and interview on 04/01/26 at 1:51p.m., surveyor observed two pills in a cup on Resident #1's bedside table. When surveyor asked about the medication, Resident #1 stated she was not taking the pills and reported she did not know what the medication was for. Resident #1 told the surveyor, You can have it because I'm not taking it, and repeated that she was over [AGE] years old and does not believe in continuing tests or medications. During an interview on 04/01/26 at 4:17p.m, Medication Aide (MA B) said that residents in the facility are not permitted to self-administer medications. The MA B described the facility's medication administration protocol as requiring staff to observe the resident taking medications, ensure adequate fluid intake, and confirm Resident #1 swallows each medication prior to leaving the room. The MA B said she prepared Resident #1 medications in a cup and used water from Resident #1's personal cup. The MA B said Resident #1 typically takes medications one at a time or occasionally two at a time, but not all at once. The MA B said she initially observed Resident #1 taking the medications, however, MA B said she turned her back and began preparing for the resident next door. The MA B said she assumed Resident #1 had taken all medications, as this is Resident #1's usual practice. The MA B said she exited the room without confirming all medications were consumed. The MA B said the potential risk to Resident #1's failure to take blood pressure medication could result in elevated blood pressure which could increase the risk of a stroke or a headache. The MA B said the potential risk to Resident #1's failure to take dementia medication could result in increased confusion. The MA B said if another resident ingested the medication there is a risk that residents will have an adverse or allergic reaction. During an interview on 04/01/26 at 4:43 p.m., Director of Nursing (DON) said that medication aides are responsible for administering medications and confirming that each resident has taken their medication. The DON said currently no residents in the facility are permitted to self-administer medications. The DON said the failure to administer high blood pressure medication to Resident #1 could result in an elevated pulse. She said the failure to administer dementia medications may negatively impact Resident #1's cognitive status. She said if medications are left unattended another resident could take the medication and the risk to that resident can result in an adverse reaction. During a telephone interview on 04/01/26 at 5:02 p.m., Nurse Practitioner (NP) said that his expectation for medication administration is that staff follow physician orders exactly as prescribed. The NP said missing high blood pressure mediation could place Resident #1 at risk for elevated blood pressure medication potentially causing adverse health outcomes. During an interview on 04/01/26 at 5:25 p.m., Administrator (ADM) said medications must not be left in a resident's room. The ADM said his expectation of the MA is that they must follow facility policy regarding proper medication administration. The ADM said the risk to Resident #1 missing her blood pressure medication could result in elevated blood pressure or a stroke. He said the risk to Resident #1 not receiving dementia medication could lead to ongoing cognitive issues. The Policy for Medication Administration requested on 04/01/26 at 3:08 p.m., surveyor was not provided with all the documents for the policy requested.

Based on observation, interview, and record review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, based on the comprehensive assessment for 1 of 5 residents (Resident #1) reviewed for quality of care in that: Resident #1's skin was not thoroughly assessed on 2/25/26 when he had moisture-associated skin damage behind both ears that was not identified. Resident #1 had moisture-associated skin damage behind both ears that was not being treated between 2/20/26 and 2/27/26. This deficient practice placed residents at risk of delayed treatment and developing avoidable pressure injuries.Findings include:Record review of Resident #1's Order Summary Report generated on 3/10/26 revealed he was admitted to the facility on [DATE] and had diagnoses of hypertension (a chronic condition where blood forcefully pushes against artery walls), hyperlipidemia (condition characterized by elevated levels of lipids (fats), such as LDL cholesterol or triglycerides, in the blood), shortness of breath, pneumonia (causes inflammation and fluid or pus in the air sacs, usually triggered by bacteria, viruses, or fungi), and respiratory failure. He was [AGE] years old. An order for continuous oxygen at a rate of 4 L/min via nasal cannula was initiated on 1/30/25. Record review of Resident #1's annual MDS assessment dated [DATE] revealed ithe was rarely/never understood, and had short-term and long-term memory problems. He required substantial/maximal assistance for personal hygiene and transfers. Record review of Resident #1's Care Plan Report revised on 1/30/26 revealed he was at risk for pressure injuries related to immobility. Interventions included to follow facility policies/protocols for the prevention and treatment of skin breakdown and inform the resident/family of any new area of skin breakdown. Record review of Resident #1's weekly skin assessment completed by the Treatment Nurse dated 2/25/26 at 4:27pm revealed no bruises, skin tears, abrasions, lacerations or moisture-associated skin damage was identified. In the section under 'other skin issues,' the nurse indicated that he had two wounds on his right hand, but no other skin conditions were identified. In an observation on 2/27/26 at 11:45am, Resident #1 was wearing an oxygen nasal cannula, and the concentrator was set at a rate of 4 L/min. In a telephone interview on 2/27/26 at 1:24pm, Resident #1's family member stated that she identified that he had wounds behind his ears and noticed they were not being treated. She said she took pictures and will would send them to the surveyor. Record review of a photo provided by Resident #1's family member dated 2/20/26 at 5:36pm revealed a picture of Resident #1. Resident #1's right ear was raw, and the skin was broken and red where the ear met the scalp at the top of his ear. Record review of a photo provided by Resident #1's family member dated 2/20/26 at 5:36pm revealed a picture of Resident #1's left ear. Resident #1's left ear was raw, and the skin was broken and red where the ear met the scalp at the top of his ear. In an interview on 2/27/26 at 3:30pm, the Treatment Nurse stated she completed weekly skin assessments for all residents. She said she completed skin assessments by looking at residents from head to toe. She said if a new wound or skin issue was identified, she would reach out to the wound care provider and put in any orders they give, then add a progress note. She said Resident #1 had two wounds on his hand and no other wounds. In an interview on 2/27/26 at 4:40pm, RN B said the treatment nurse was providing care for the wounds on his hand. She said she was not aware of Resident #1 having any other skin breakdown. In an interview on 2/27/26 at 4:30pm, CNA L said she had not seen Resident #1 with skin breakdown or rashes. In an observation on 2/27/26 at 5:27pm, LVN R and CNA L assisted with observing Resident #1's skin. Observation of his right ear revealed there was a scabbed area and redness where his ear met his scalp. The skin was raw and red, and some of his skin was peeling. Observation of his left ear revealed it was raw, and red and the skin was peeling where the ear met his scalp. Record review of Resident #1's progress note dated 2/27/26 at 6:33pm revealed LVN R noted blanchable redness behind both ears. She indicated she called a nurse practitioner who gave new orders for Zinc Oxide to both ears daily and ear protectors. Record review of Resident #1's Order Summary Report generated on 3/10/26 revealed an order for Nystatin External Powder 100,000 Unit/GM, apply to bilateral back of ears topically two times a day for moisture associated skin damage (inflammation and skin erosion caused by prolonged exposure to moisture) with a start date of 3/9/26. In a telephone interview on 3/10/26 at 2:49pm, the Hospice RN stated she worked for Resident #1's hospice company and she visited him multiple times in February 2026. She said she noticed Resident #1 had skin breakdown behind both of his ears on 2/24/26. She said she notified the hospice doctor about getting orders for ear protectors. She said she called the facility staff on 2/26/26 and asked if they received any orders for his ears because she had not heard back about any orders. She could not recall who she spoke to. She said irritation behind the ear iswas common for residents with oxygen. Record review of Resident #1's hospice communication binder revealed there was a sign-in sheet that indicated Hospice RN visited on 2/24/26. In an interview on 3/10/26 at 3:15pm, the DON stated the Treatment Nurse was responsible for skin assessments. She said she may do complete have done skin assessments while providing wound care. She said they completed skin assessments weekly and expected the nurse to look at a resident from head to toe. She said nurses and CNAs should report skin issues. When asked about the skin breakdown behind Resident #1's ears, she said it may have just developed, because he did not have anything before the observation on 2/27/26. She said he sweated a lot and that could have caused the skin breakdown. She said she interviewed some of the nursing staff and they did not see any skin issues. She said she did not think it was possible that it was missed during a skin assessment. She said if it was there longer, it would characterize differently. In an interview on 3/10/26 at 4:14pm, the Treatment Nurse stated it was not possible that anything was missed during Resident #1's skin assessment on 2/25/26 .

Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care and services, including oxygen administration, was provided such care, consistent with professional standards of practice for 1 of 5 residents (Resident #1) reviewed for quality of care in that:Resident #1's oxygen humidifier bottle was empty. This failure could place residents at risk of discomfort, anxiety, and decline in quality of life. The findings were:Record review of Resident #1's Order Summary Report generated on 3/10/26 revealed he was admitted to the facility on [DATE] and had diagnoses of hypertension, hyperlipidemia, shortness of breath, pneumonia, and respiratory failure. He was [AGE] years old. An order for continuous oxygen at a rate of 4 L/min via nasal cannula was initiated on 1/30/25. Record review of Resident #1's annual MDS assessment dated [DATE] revealed he was rarely/never understood and had short-term and long-term memory problems. He required substantial/maximal assistance for personal hygiene and transfers. Record review of Resident #1's Care Plan Report dated 2/27/26 revealed he used oxygen therapy. Interventions included, Monitor for (signs and symptoms) of respiratory distress and report to MD. OXYGEN SETTINGS: O2 via nasal cannula @ 4L. In an observation on 3/10/26 at 11:30am, Resident #1 was wearing an oxygen nasal cannula and the concentrator was set at a rate of 4 L/min. The humidifier bottle contained no water. In an observation and interview on 3/10/26 at 11:38pm, LVN E said the bottle on the oxygen concentrator should have water in it. He looked at the bottle on Resident #1's concentrator, and said it was completely out of water. In an interview on 3/10/26 at 2:35pm, LVN E said when a resident was administered oxygen, he checked the resident's pulse oximeter readings to monitor. He said he would look at tubing and make sure it did not need to be changed. He said the humidifier bottle was typically full of water for two days. He said when he changed the water, he knew he had two days to fill it again. When asked about Resident #1's humidifier bottle, he said they worked 12-hour shifts, and he was off for a few days. He said the water was for humidification to prevent nasal irritation. In an interview on 3/10/26 at 3:15pm, the DON stated there should be water in the oxygen concentrator bottle. She said the water humidified a resident's nasal passages and prevented them from drying out. She said nurses should notice when the water was low and add water to the bottle. In a telephone interview on 3/10/26 at 2:21pm, LVN W said she worked with Resident #1 last night and the night before. She said Resident #1's oxygen tubing was checked every Sunday. She said she checked the humidification bottle to ensure there was water in the bottle. She said she put water in it the day before yesterday. She said when she left last night, it was about half full of water. Record review of the facility's policy regarding oxygen therapy dated 4/2021 read, it is the policy of this community to ensure all oxygen administration is conducted in a safe manner. use distilled water for humidification.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in 2 of 17 rooms from hallway 200 affecting 2 of 14 residents (Resident #1 and Resident #2) reviewed for environment. The facility failed to clean food crumbs, and stains from the floor in Resident #1 and Resident #2's rooms that looked like dried coffee. The facility failed to repair the footboard of Resident #2 's bed that had exposed wooden particle board and splintered edges. The facility failed to repair the closet door of Resident #2's closet that was off of the hinges and could not be closed or opened properly. The facility failed to repair the overhead light above Resident #2's bed, which was cracked with jagged edges. These failures could place residents and staff at risk of living, working, and visiting in an unsafe, unsanitary, and uncomfortable environment. Findings included: 1. Record review of Resident # 1's admission record, dated 11/18/2025, revealed an [AGE] year-old female admitted on [DATE], with diagnoses of encephalopathy (disease or damage that affects the brains function or structure causing a change in mental status), dysphagia (difficulty swallowing with an inability to move food or liquids easily from the mouth to the stomach), chronic non-pressure ulcer (chronic non-healing wound of the skin that is not caused by prolonged pressure) of left foot, weakness and falls. Record review of Resident # 1's admission MDS assessment, dated 08/25/2025, revealed a BIMS score of 5 out of 15 indicating severe cognitive impairment. The resident's functional abilities revealed she needed moderate assistance with oral and personal hygiene, and substantial assistance with toileting hygiene, shower, lower body dressing and putting on or taking off footwear and was to remain at the facility long term. 2.Record review of Resident # 2's admission record, dated 11/18/2025, revealed a [AGE] year-old male, admitted [DATE] with diagnoses of cerebral infarction (the death of brain tissue caused by a prolonged lack of blood flow, which leads to stroke), lack of coordination, type II diabetes mellitus (a chronic disease where the body does not use insulin correctly causing blood sugar levels to remain high), hemiplegia (paralysis or weakness of muscles on one side of the body affecting the arm, leg and face), dysphagia (difficulty swallowing with an inability to move food or liquids easily from the mouth to the stomach), chronic obstructive pulmonary disease (a group of progressive lung diseases that block airflow to the lungs, causing breathing problems), alcoholic cirrhosis of the liver (a late stage of liver damage caused by excessive alcohol consumption, where scar tissue replaces healthy liver tissue, leading to liver failure) with ascites (a condition where severe scarring of the liver from chronic alcohol use causes a buildup of fluid in the abdomen) and colostomy (a surgically created opening that connects the colon to the outside of the body, allowing stool and gas to be collected in a pouch). Record review of Resident # 2's admission MDS assessment, dated 02/26/2025, revealed a BIMS score of 13 out of 15 indicating he was cognitively intact. The resident's functional abilities revealed he required maximal assistance with toileting, personal and oral hygiene, showers, lower body dressing and putting on or taking off footwear. In an observation and interview on 11/12/25 at 11:16 a.m. in Resident # 1's room, the floor had stains, food crumbs and plastic wrappers. Resident #1 was seated on her bed and when asked if staff cleaned her room, she said no. Resident #1 said the floors in her room were often dirty, and sticky and rarely swept or mopped. Resident #1 said she had bugs and the pest people would put out traps. Observed several round black disks in all four corners of her room, behind the toilet in the corners of her bathroom and around the entrance of her bifold closet door. During an observation and interview on 11/12/25 at 5:48 p.m. in Resident # 1's room, the floor remained stained with food crumbs and plastic wrappers. Resident #1 was seated to the side of her bed and was eating from a dinner tray. Resident#1's family member was seated in a chair at the bedside. Resident #1 said no one cleaned her room [ROOM NUMBER]/12/25. The family member said they visited Resident # 1 almost daily. The family member said they had not complained or said anything to management because they did not want to cause any trouble and usually when they point out the mess or lack of cleaning in the room to the resident's aide or nurse, someone comes to clean the room shortly thereafter. Resident #1 then said that if she asks someone to clean the room, they usually would l when they got around to it, but no one had on 11/12/25. Resident #1 shrugged her shoulders when asked how it made her feel when her room was not cleaned daily. Resident #1's family member said the facility should clean the residents' rooms daily. In an observation and interview on 11/18/25 at 1:17 p.m. in Resident #2's room, the floor was dirty with food crumbs, and stains that appeared to be dried coffee. The floor felt sticky with surveyor shoes sticking to the floor and the floor making squeaky noises when stepped on. Resident #2 was in bed and said his room was cleaned daily but had not been cleaned yet on 11/18/25. Resident #2 said normally the staff cleaned his room in the mornings, but it could be any time of day because there was no designated cleaner assigned to his hall. Observed the bifold closet door in Resident # 2's room off the top track and hanging forward out of the closet frame. Resident #2 said he complained that the closet doors did not open or close properly but could not remember who he told or when he reported it. Observed the footboard to Resident #2's bed splintered and broken. The resident said he had not noticed. Observed the light fixture above Resident #2's head of bed where he was laying was broken and cracked, with jagged pieces of plastic sticking out. Resident# 2 said a lot of things at the facility were broken or run down but it was home for now, and he was ok because the people treated him well and no place was perfect. Resident #2 said he would prefer if housekeeping cleaned in the morning and again in the evening but would be happy with once daily. Resident #2 said he there were ants crawling on him one time but could not recall when that happened. Resident #2 said it happened once and he had not seen any bugs, pests, insects, or rodents. Interview with DON and Administrator on 11/18/2025 at 1:24 p.m. in Resident # 2's room, the Administrator said he was unsure why Resident #2's room was not cleaned yet for the day. When shown the hanging, inoperable bifold closet doors, the Administrator said they should have reported that, and he would have maintenance fix it. When asked who he meant by the term they, he said the staff and or the resident. When shown the splintered footboard of Resident #2's bed the Administrator said they would have to fix that. When shown the dirty floor, the DON said Resident #2 sometimes threw trash on the floor. When asked when resident rooms should be cleaned both the Administrator and DON said daily. Both the Administrator and DON said Resident #2 notified them of any of the issues in his room. When asked if administrative staff conduct any kind of daily room rounds, the Administrator said yes and said the Central Supply/transport person was the assigned department head for Resident #2's daily room rounds, and he would have to locate her daily rounding sheets. Interview with Housekeeper A on 11/18/2025 at 3:44 p.m. said she worked at the facility for about a month and had completed her assigned hallway for cleaning, which was 100 hallway. Housekeeper A said that 200 Hallway was a hallway they all split because there were only 3 housekeepers and 4 hallways. She said 200 hallway did not have a designated regular daily housekeeper. Housekeeper A said she cleaned the front of 200 hallway, but Housekeeper B signed the sheet that she did it instead. She said the Housekeeping Manager assigned the housekeeper to split 200 hall and each of them had a designated area of that hallway to clean but Resident #1's and Resident #2's rooms were not part of her assignment. Housekeeper A said they had not seen any live bugs or insects but saw bait traps in various resident rooms on all four hallways. Housekeeper A said all the residents' rooms should be cleaned daily because resident deserved a clean room. Interview with Housekeeper C on 11/18/2025 at 3:48 p.m., said she worked at the facility for five years and the housekeeping department was having trouble retaining staff. She said that 200 hallway was the only hallway that did not have a regularly assigned housekeeper and the three housekeepers working that day, including herself, were assigned to split 200 hallway but the back of 200 hall, which included rooms [ROOM NUMBERS] were not her assigned rooms. Housekeeper C said the assignment sheet was in the housekeeping office. Housekeeper C said she saw flies and roaches on 200 hall in the past but not recently. Housekeeper B said she reported any insects to administrator, her supervisor (when they had one) and maintenance so they could contact pest control. Housekeeper C said the rooms can get dirty and floors should be swept and mopped, bathrooms cleaned, and trash emptied at least daily. Interview with Housekeeper B on 11/18/2025 at 3:53pm who was actively cleaning Resident #2's room, Housekeeper A said she worked at the facility since June 2025 and had cleaned on the front of 200 hallway earlier in the day but had not made it to the back of 200 hallway yet. She said that the housekeepers usually split 200 hallway because there was no permanently assigned housekeeper for that hall. Housekeeper B said Resident #2's room was dirty on the floors, but she cleaned it daily whenever she worked. Housekeeper B said that she may not always clean her assigned area on 200 hall in the morning but completed it daily prior to the end of her shift. Housekeeper B said having food debris on the floor was not acceptable because it could attract pests or insects which she said she had seen before all around the facility. Housekeeper B said she saw flies, gnats, and roaches on 200 hall in the past. Housekeeper B said she reported any insects to the administrator, her supervisor and maintenance so they could contact pest control. In an interview with the Administrator on 11/18/25 at 4:03 p.m. the surveyor requested the 200-hallway assignment sheet for 11/18/2025. In an interview on 11/18/2025 at 4:50 p.m., the Maintenance Director said he started working at the facility on 10/31/25 and was not asked to assist with the building's pest control. He said he was asked to notify the pest control company, which he did. He said residents and staff complained about pests, including roaches and rodents, throughout the facility. He said the pest control program was ineffective because some of the pests could have nests in the walls. He said some areas of the building seemed to be worse than others. He said some of the residents' rooms on 200 hall were affected but could not recall which ones. He said since working at the facility, he had mainly been doing painting and touch-ups of rooms and only completed repairs when he had the time to, because the priority seemed to be getting the rooms painted and ready for new admissions. He said there was a repair log located at the central nursing station, and he was not notified about repairs needed in room [ROOM NUMBER]. The Maintenance Director said the facility and resident rooms should be cleaned daily. He said there were a lot of new staff in those departments and they were trying to get things corrected. Record review on 11/18/2025 at 4:52 p.m. of facility maintenance log from October of 2025 through 11/18/2025 revealed no entries for repairs to Resident #2's foot board, closet door, or overhead light. In an interview on 11/18/2025 at 4:53 p.m. the Administrator said he could not locate the daily room rounding sheets for Resident #2's room or the 200-hallway housekeeping assignment sheet. The Administrator said the housekeeping and laundry departments had a recent large turnover with several housekeepers and the former housekeeping supervisor all quitting at the same time. The Administrator said he t hired a new laundry and housekeeping supervisor and was trying to slowly get the department back on track. He said the new supervisor was not at the facility and he would be the person to answer any surveyor questions because the new manager had no information. The Administrator said staff should report any repairs to himself or the maintenance director. The Administrator said the Maintenance Director was also new. He said that all staff were trained and knew how to submit a repair request and where to locate the maintenance repair book for Resident #2's closet door, overhead light, and footboard. The Administrator said he did not know why staff had not reported the need for those repairs. The Administrator said the resident rooms should be cleaned daily to minimize bugs and pests. He said the facility had a pest control program that came in monthly and as needed. Interview with the DON on 11/18/25 at 4:55 p.m. said most of the residents on 200 hallway were more independent and had their own snacks and food items. The DON said she did not know why Resident #2's room was not cleaned for the first time all day until after 1:00 p.m. and was not familiar with the housekeeping schedules. The DON said that Resident #1 could be confused at times and may not have noticed if a housekeeper had cleaned the room. The DON said all of the resident rooms should be cleaned daily and that the Administrator and Housekeeper supervisors were responsible for ensuring the cleanliness of the facility and that the Administrator oversaw the pest control program at the facility. The DON said Resident #2 never told her about having an ant crawling on him and had no other reports about the alleged incident saying she learned about it at the same time the surveyor did. In an interview with LVN A on 11/18/25 at 6:33 p.m. said she worked the 6pm-6am shift fulltime for about one year. LVN A said her regularly assigned hallway was 200 and there were housekeeping issues since she started. LVN A said she was unsure if the housekeeper had adequate supplies or training and the dirty rooms were repeatedly reported to administration, and it would get better for a little while and revert to being dirty. LVN A said none of the residents ever complained to her about dirty rooms, but she would prefer not to work in a dirty environment and usually brought her own cleaning supplies to work including wipes, hand sanitizer and garbage bags. LVN A said she felt sorry for the residents sometimes because they lived there and deserved a clean and healthy environment. LVN A said if the environment was dirty, it could spread bugs and infection. LVN A said she noticed the broken closet in Resident #2's room and reported it in the maintenance log but the facility did not have a maintenance director. LVN A said she had not noticed Resident #2's splintered foot board on his bed or the cracked overhead light. LVN A said the pest control program at the facility was ineffective because she and other staff saw roaches and bugs regularly throughout the facility. Record Review of the facility's policy titled Cleaning and Disinfection of Environmental Services, dated August 2019, revealed in part: 10. Environmental services will be disinfected or cleaned on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. Requested a policy and procedure on Maintenance Services from the Administrator on 11/18/25 at 5:15 p.m. and did not receive one prior to facility exit.

Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for 1 of 4 hallways, (Hall 100) and Resident #4's room. The facility had a live roach and live flies in Resident #4's room. This failure could place residents at risk for decreased residents' health, safety, and quality of life. Findings included: Record review of Resident #4's admission Record dated 11/18/2025 revealed a [AGE] year-old female, admitted [DATE] and readmitted [DATE] with diagnoses of encephalopathy (disease or damage that affects the brains function or structure causing a change in mental status), dysphagia (difficulty swallowing with an inability to move food or liquids easily from the mouth to the stomach), history of falls, ataxic gait (an abnormal clumsy and staggering walk characterized by a lack of balance), atrial fibrillation (a common type of arrythmia[an abnormal heart rate]where the heart's upper chamber beat chaotically and irregularly, often too fast), and intellectual disability. Record review of Resident 4's admission MDS, dated [DATE], revealed a BIMS score of 9 out of 15, which indicated moderate cognitive impairment. The resident's functional abilities in section GG revealed she required maximal assistance with toileting, and personal hygiene, and moderate assistance with showers, lower body dressing and putting on or taking off footwear. Observation and interview with Administrator on 11/18/25 at 1:35 p.m. of an empty resident room # 209 with a live pile of ants or some type of crawling insects in a mound in the corner just inside the door of the room. The Administrator said the room was empty and he would call the pest control company to come out and do an off-schedule treatment. The Administrator said he was doing his best to stay on top of things after returning to the facility and he was just getting up to speed on a lot of things that had fallen through the cracks in his absence. During an observation and interview with the facility Ombudsman on 11/18/2025 at 3:18 p.m., in Resident #4's room with the Ombudsman to show a live roach on the floor in front of her recliner chair and 2 flies flying around in the room. Resident #4 was at an activity and the Ombudsman stepped on the roach killing it. The Ombudsman said the facility had an issue with roaches and other pests and would say they were addressing it but did not feel it was effective because there were pests all over the facility and this was not the first time she had seen or killed a live insect or bug, while visiting with residents at the facility. Observation and interview with Resident #4 on 11/18/25 at 3:27 p.m. in main dining room area. Resident #4 was appropriately dressed and groomed and seated in a chair. When asked if she had ever had any issues with bugs, roaches, flies or pests in her room she said from time to time. When asked what happened when she saw pests in her room, she said she would tell the nurse or aide and someone would kill it. When asked if her room was cleaned daily, she said yes. When asked if she felt like the facility did enough to make sure there were no bugs or pests in her room, she said yes. Resident #4 said she saw the pest control people regularly at the facility at least every few weeks. Interview with Housekeeper B on 11/18/2025 at 3:53 p.m. who was actively cleaning Resident #2's room Housekeeper A said she worked at the facility since June 2025 and had cleaned on the front of 200 hallway earlier in the day but had not made it to the back of 200 hallway yet. She said that the housekeepers usually split 200 hallway because there was no permanently assigned housekeeper for that hall. Housekeeper B said Resident #2's room was dirty on the floors, but she cleaned it daily whenever she worked. Housekeeper B said that she may not always clean her assigned area on 200 hall in the morning but completed it daily prior to the end of her shift. Housekeeper B said having food debris on the floor was not acceptable because it could attract pests or insects which she said she had seen before all around the facility. Housekeeper B said she saw flies, gnats, and roaches on 200 hall in the past. Housekeeper B said she reported any insects to the administrator, her supervisor and maintenance so they could contact pest control. Interview on 11/18/2025 at 4:50 p.m., the Maintenance Director said he started working at the facility on 10/31/25 and was not asked to assist with the building's pest control. He said he was asked to notify the pest control company, which he did. He said residents and staff complained about pests, including roaches and rodents, throughout the facility. He said the pest control program was ineffective because some of the pests could have nests in the walls. He said some areas of the building seemed to be worse than others. He said some of the residents' rooms on 200 hall were affected but could not recall which ones. In an interview on 11/18/2025 at 4:53 p.m. the Administrator said he could not locate the daily room rounding sheets for Resident #2's room or the 200-hallway housekeeping assignment sheet. The Administrator said the housekeeping and laundry departments had a recent large turnover with several housekeepers and the former housekeeping supervisor all quitting at the same time. The Administrator said he t hired a new laundry and housekeeping supervisor and was trying to slowly get the department back on track. He said the new supervisor was not at the facility and he would be the person to answer any surveyor questions because the new manager had no information. The Administrator said the resident rooms should be cleaned daily to minimize bugs and pests. He said the facility had a pest control program that came in monthly and as needed. The Administrator said he felt like they were doing all they could do to minimize and control pests at the facility. Interview with the DON on 11/18/25 at 4:55 p.m. said all of the resident rooms should be cleaned daily and the Administrator and Housekeeper supervisors were responsible for ensuring the cleanliness of the facility and that the Administrator oversaw the pest control program at the facility. The DON said Resident #2 never told her an ant was crawling on him and had no other reports about the ant crawling on Resident #2 and said she learned about the ant crawling on Resident #2 at the same time the surveyor did. In an interview with LVN A on 11/18/25 at 6:33 p.m. said she worked the 6pm-6am shift fulltime for about one year. LVN A said her regularly assigned hallway was 200 and there were housekeeping issues since she started. LVN A said she was unsure if the housekeeper had adequate supplies or training and the dirty rooms were repeatedly reported to administration, and it would get better for a little while and revert to being dirty. LVN A said none of the residents ever complained to her about dirty rooms, but she would prefer not to work in a dirty environment and usually brought her own cleaning supplies to work including wipes, hand sanitizer and garbage bags. LVN A said she felt sorry for the residents sometimes because they lived there and deserved a clean and healthy environment. LVN A said if the environment was dirty, it could spread bugs and infection. LVN A said she noticed the broken closet in Resident #2's room and reported it in the maintenance log but the facility did not have a maintenance director. LVN A said she had not noticed Resident #2's splintered foot board on his bed or the cracked overhead light. LVN A said the pest control program at the facility was ineffective because she and other staff saw roaches and bugs regularly throughout the facility. Record review on 11/18/25 at 6:37 p.m. of facility pest controls logs with an 11/06/2025 entry that read in part: room [ROOM NUMBER]: Resident present during service. Found live German roaches behind the nightstand. Applied roach gel bait and placed Lo-liner monitors, room [ROOM NUMBER]. Significant roach activity observed on glue boards and the floor. Applied roach gel bait and placed Lo-liner monitors. room [ROOM NUMBER]: Live German roach activity found; unit is infested. German roaches clean out service needed for 105/106 and 208. Record Review of the facility's policy titled Cleaning and Disinfection of Environmental Services, dated August 2019, revealed in part: 10. Environmental services will be disinfected or cleaned on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. Record review of the facility's undated pest control policy reflected in part: Our Facility shall maintain an effective pest control program. 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects. 6. Maintenance services assists, when appropriate and necessary, in providing pest control services.

Based on observation, interviews and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 out of 5 residents (Resident #1 and Resident #2) reviewed for adequate supervision.- The facility failed to ensure Resident #1 who was severely cognitively impaired and nonverbal and Resident #2 who was moderately cognitively impaired and had behaviors of inappropriate sexual comments to staff received adequate supervision to prevent abuse after she wandered into Resident #2's room in facility on 9/23/25. Resident #1 was sexually assaulted by Resident #2. An Immediate Jeopardy (IJ) was identified on 10/02/2025 at 4:41 p.m. The IJ template was provided to the Administrator and DON on 10/02/25 at 4:41 p.m. While the IJ was removed on 10/06/25 at 1:28 p.m. the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that was not an immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.This deficiency exposed residents living in the facility to potential harm, injury, or death due to not being adequately monitored. Record review of Resident #1's facility admission record dated 10/1/25 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with most current admission date of 6/26/18. Resident #1 admitted with diagnoses that included anoxic brain damage (a condition where the brain experiences a complete lack of oxygen supply. This deprivation of oxygen can lead to widespread damage to brain cells, resulting in severe neurological impairment or death) and epilepsy and epileptic syndromes (Epilepsy is a brain disorder characterized by recurrent, unprovoked seizures, while an epileptic syndrome is a specific, complex constellation of signs and symptoms that define a unique epilepsy condition. An epileptic syndrome includes specific seizure types, other clinical features).Record review of Residents #1's care plan date Initiated 9/15/21 and revised on 9/24/25 revealed she was care-planned for a high elopement risk/wandering in male residents' room and was at risk for possible injury r/t impaired safety awareness and diagnosis of dementia, Anoxic brain damage. Date Initiated: 09/15/2021. Revision on: 09/24/2025: Goals: Resident #1's safety will be maintained throughout the review date. Date Initiated: 09/15/2021. Revision on: 09/12/2025. Target Date: 10/19/2025 Interventions: Assess for fall risk. Date Initiated: 09/15/2021. Provide structured activities: Toileting, walking inside and outside, reorientation strategies, including signs, pictures, and memory boxes. Date Initiated: 09/15/2021. Wander guard placed for resident's safety, bracelet will alert staff if and when resident attempts to exit doors of facility. Staff to monitor daily. Date Initiated: 09/15/2021. Redirect resident. Date Initiated: 09/24/2025. A care plan to address Resident #1 identifies as a trauma survivor. 1.possible trigger of aggressive vocal stimuli. 2. Childhood trauma memories, Domestic abuse memories , Physical Abuse memories, Sexual Abuse memories. Date Initiated: 11/14/2019. Revision on: 05/07/2020. Goals: SHE will remain stable and adjusted to her environment. Date Initiated: 11/14/2019 Revision on: 09/12/2025. Target Date: 10/19/2025. Interventions: Ask for permission to enter resident's room, perform care, and/or assist with ADLs. Date Initiated: 09/08/2023. Explain all procedures to the resident before starting and allow the resident (X minutes) to adjust to changes when necessary. Date Initiated: 09/08/2023. Reduction of possible triggers in her environment. Date Initiated: 11/14/2019. A care plan to address Resident #1's impaired cognitive function or impaired thought processes r/t ANOXIC BRAIN INJURY. SHE has cognitive loss (loss of memory, time sense and requires assistance with decision making r/t Impaired decision-making abilities, is not always understood or able to understand verbal and non-verbal expression. Date Initiated: 05/07/2020. Revision on: 05/07/2020. Resident #1 will improve current level of cognitive function through the review date. Date Initiated: 02/09/2021. Revision on: 09/12/2025. Target Date: 10/19/2025.Record review of Resident #1's Quarterly MDS dated [DATE] revealed Cognitive Skills for Daily Decision Making (section C1000) were coded at 3, indicating her cognition was severely impaired. Resident #1 was coded to require substantial/maximal assistance with ADLs. She was always incontinent of bowels and bladder and used a wheelchair for mobility.Record review of Resident #1's physician orders dated September 2025 revealed orders with a start date of 9/25/25 to administer Emtricitabine- Tenofovir oral tablet 200-300 MG (Emtricitabine- Tenofovir Disoproxil Fumarate) Give 1 tablet by mouth one time a day for antiviral for 28 days at 9:00 AM. An order for Tivicay Oral (Dolutegravir Sodium) Tablet 50 MG Give 1 tablet by mouth one time a day for antiviral for 28 days at 9:00 AM. An order for Plan B One-Step Oral Tablet 1.5 MG (Levonorgestrel Emergency OC) Give 1 tablet by mouth one time only for contraceptive for 1 day with a start date of 9/24/25. Record review of Resident #1's MAR dated September 2025 revealed that Resident #1 was administered Emtricitabine and tenofovir antiretroviral medication (used to treat and prevent HIV infection) on 9/25/25 through 9/30/25. Resident #1 was administered Tivicay Oral (Dolutegravir Sodium) Tablet 50 MG Give 1 tablet by mouth one time a day for antiviral on 9/25/25 through 9/30/25. Resident #1 was administered Plan B One-Step Oral Tablet 1.5 MG (Levonorgestrel Emergency OC (Oral Contraceptive) 1 tablet by mouth on 9/25/25.Record review of Nurses Note dated 9/23/2025. Note Text: Called to room by CNA A and CNA B reported to staff nurses that resident was having sexual activity with Resident #1. Resident #1 was immediately removed for safety. When male resident questioned by staff nurse what happened male resident began to laugh and stated nothing happened . Female resident is not cognitively intact female resident monitored all safety measures in place. Male resident immediately monitored 1-1 by staff. DON notified of above. MD notified. Family notified by DON awaiting return call. The resident transferred to local hospital.Record review of Nurses Note dated 9/23/2025. Note Text: Spoke with forensic nurse at local hospital who reported that she completed an exam on resident . She stated she was able to get a swab for DNA and STD testing but was unable to do a vaginal exam because the resident closed her legs and would not allow her to examine her. She stated that a pregnancy test was performed and was negative, resident was treated prophylactically with ATBs and will discharge to facility with orders for ATBs to continue. Resident #1 will also return with an order for Plan B . Nurse stated that an official report will be available in 1-2 business days. Called RP to update her on report from the nurse, message left, awaiting call back.Record review of the post hospital discharge instructions and orders dated 9/24/25 revealed that Resident #1 was seen for sexual assault. A SANE (Sexual Assault Nurse Examiner) adult sexual assault exam was performed (a forensic exam was performed (results pending and coordinated with the local police department). Orders for STI Sexually Transmitted Infection Prophylaxis: Ondansetron 4 mg PO x1, Azithromycin 1gm PO x1, Metronidazole 2gms PO x1, Ceftriaxone 500mg IM reconstituted with 1.1 ml of 1% Lidocaine. Lab orders for Pharyngeal Gonorrhea ( a sexually transmitted infection (STI) caused by the Neisseria gonorrhoeae bacteria that infects the pharynx. It is spread through oral sex with an infected person and can be asymptomatic, but symptoms may include a sore throat, difficulty swallowing, swollen lymph nodes in the neck, or redness/swelling in the throat) and Chlamydia (a common sexually transmitted infection (STI) caused by the bacterium Chlamydia trachomatis. It is primarily spread through sexual contact with an infected person).Record review of Nurse Practitioner note dated 9/25/25 for Resident #1: Chief Complaint: Evaluation of patient for alleged sexual assault incident: Hospital Course: She was taken to the ER a few days ago after an incident with another resident of a sexual nature. She was examined for possible sexual assault and started on post-exposure prophylaxis (levonorgestrel single dose; dolutegravir 50 mg daily x28 days; emtricitabine/tenofovir 200/300 mg daily x28 days; PRN ondansetron). Hospital examination results are pending. Today she appears in no distress. History of Present Illness: Resident #1, a [AGE] years old female with history of anoxic brain damage, epilepsy, unsteadiness on the feet, ataxia (poor muscle control that causes clumsy movements), abnormal gait, generalized muscle weakness, dysphagia (swallowing difficulties), mixed receptive/expressive language disorder (is a neurodevelopmental condition that affects a child's ability to both understand and produce language), dysarthria (difficulty speaking because the muscles you use for speech are weak), severe hypoxic ischemic encephalopathy (a brain injury that happens before, during, or shortly after birth when oxygen or blood flow to the brain is reduced or stopped), hyperlipidemia (an elevated level of lipids - like cholesterol and triglycerides - in your blood), hypertensive heart disease (a constellation of structural and functional changes in the left ventricle, left atrium, and coronary arteries resulting from chronic blood pressure elevation), and hypothyroidism (a condition in which the thyroid gland does not make enough thyroid hormone) among other medical problems was seen today upon the request of the Nurse due to a reportable incident that happened between patient and another resident. Patient was examined in the dining room. She is nonverbal and not able to make needs known due to anoxic brain injury. Patient was taken to the ER a few days ago for an examination of an encounter with another resident of a sexual nature. She was examined for sexual assault. Findings were not available at the time of this visit; however, patient was placed on several medications including: Levonorgestrel 1.5 mg tablet 1 time only, dolutegravir 50 mg daily for 28 days, emtricitabine/tenofovir 200/300 mg daily for 28 days and as needed Zofran. The results of the patient's examination at the hospital are still pending. - Additional consultations: Psychiatry and Psychology evaluations requested for psychological support.Record Review of Resident #1's Diagnostic Assessment from Psychological Evaluation and Treatment Services dated 9/29/25 revealed that the referral was made due to possible sexual assault at the facility. Resident #1 was unable to answer assessment questions or questions regarding the alleged events therefore she is not a candidate for psychotherapy. Record review of Resident #1's Initial Psychiatric assessment dated [DATE] revealed that Resident #1 was referred due to recent sexual assault without ability to consent, patient was noted to not be able to respond, trauma screening was unable to be determined due to patient being unable to respond. Resident #2Record review of Resident #2's facility admission record dated 10/2/25 revealed a [AGE] year-old-male, admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side (a stroke damaged the right side of the brain, causing paralysis (hemiplegia) and/or weakness (hemiparesis) on the left side of the body) and Chronic Viral Hepatitis C (a long-term liver infection caused by the hepatitis C virus). Record review of Resident #2's care plan revealed care plans to address areas that included: The resident has a behavior problem r/t inappropriate verbal sexual comments towards staff. Date Initiated: 08/18/2025. Revision on: 09/23/2025 Goals: The resident will have fewer episodes of inappropriate behaviors by review date. Date Initiated: 08/18/2025 Revision on: 09/23/2025 Target Date: 12/18/2025: Interventions: The resident's behavior is de-escalated by redirection. Date Initiated: 08/18/2025. Revision on: 09/23/2025. Medication adjustment by psych Date Initiated: 10/01/2025. Minimize potential for the resident's disruptive behaviors. Date Initiated: 08/18/2025. Revision on: 09/23/2025, Psych consult date initiated: 08/18/2025. A care plan area to address the potential to be physically aggressive r/t Dementia Date Initiated: 09/09/2025. Revision on: 09/24/2025 and a care plan to address uses antidepressant medication r/t Depression. Date Initiated: 06/20/2025. Revision on: 09/24/2025. Interventions included to Administer ANTIDEPRESSANT medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT, Monitor/document/report PRN adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt loss, n/v, dry mouth, dry eyes. Date Initiated: 06/20/2025.Record review Resident #2's Quarterly MDS dated [DATE] revealed a BIMS score of 12 out of 15, indicating he was moderately cognitively impaired. The complete MDS was requested but not received.Record review of Resident #2's physician orders for September 2025 for Depakote Oral Tablet Delayed Release 125 MG (Divalproex Sodium) give 2 tablet by mouth two times a day for mood with a start date of 9/26/25, and a Physician order dated 10/2/25 for Chlamydia and Gonorrhea.Record review of Resident #2's MAR dated September 2025 revealed that Resident #2 was administered Depakote Oral Tablet Delayed Release 125 MG (Divalproex Sodium) on 9/26/25 at 9:00 am and on 9/27 through 9/30 at 9:00 AM and 6 PM. Record Review of Resident #2's lab results dated 10/3/25 for Chlamydia and Gonorrhea revealed they were negative. Record review of lab results dated 10/4/ 25 revealed an abnormal and reactive result to the Hepatitis C Antibody (positive for Hepatitis C).Record review of Resident #2's Psychological Services Progress note dated 9/24/25 read in part.Clinician was notified that this patient was accused of sexually assaulting another resident and requested a crisis session. The clinician worked on developing a therapeutic relationship with the patient as he was new to her. Used supportive listening to validate patient's emotions and encouraged patient to tell their story Related to current difficulties and then focused more narrowly to intervene. Patient's Response to Intervention: Patient reported frustration and stated that a CNA accused him of raping another resident last night. He reported that the resident is frequently in his room because it used to be her room.Clinician then asked him to explain the events of last night. He stated that she was in his room watching TV and wet her clothes. He opened the door to the bathroom for her. She then wheeled to the support bar straight ahead and stood up holding onto the bar. He moved her wheelchair to the side so that he could help her get on the toilet. He acknowledged that her pants and brief were off but denied that his had been pulled down. He reported that he has helped her in the bathroom previously and that CNAs have had to come and assist in the past. He further reportedfrustration about being accused of rape. The clinician stated that if it was consensual there was not issue. He immediately stated that the other resident was not capable of consent, and he was not sure she was even at a five-year-old's level of understanding. Next, he reported the police taking his statement, clothing, and brief as evidence. He reported understanding the collection due to the allegation.Record review of Nurse Practitioner Progress note for Resident #2, dated 9/25/25 read in part.Patient, [AGE] years old male was seen today in his room due to incident involving another resident. According to resident, he was accused of having sex with another resident. Patient is now on one-on-one supervision and is wondering why he is on surveillance. According to the Resident, the female resident wanders into his room and bathroom all the time and he denies doing what he is accused of. However, according to the Nurse and Director of Nursing, there were eyewitnesses who saw what happened. Law enforcement is now involved, and patent {sic} has been made aware of that. Patent was made aware that he will continue to be on close supervision by staff until Law enforcement are done with their investigation. Verbalized understanding. Patient is alert during this assessment and was able to answer all questions appropriately. Patient has history of dementia but is still able to hold normal conversations. Psychological and psychiatric consultation requested. Will continue one-on-one supervision with this patient until incident is resolved.Record review of Resident #2's Psychiatric Subsequent Assessment/note dated 9/30/25 read in part.Reason for Referral: Sexually Inappropriate Behavior, Other: Alleged sexual assault of another resident. Patient seen today for a F/U visit. The last visit was on 9/26/2025. Initiated Depakote 250 mg tablet BID. Assess the Pt's behaviors, monitor the response to Depakote. ON EXAM, the Pt is in the room, w/ 1:1 staff, calm and not in distress. LAST visit: Per nursing staff, [Resident #1] was wandering to [Resident #2's] room on 9/23/25 and the Aid {sic} witnessed inappropriate behavior in [Resident #2's] bathroom. In addition, the Aid {sic} witnessed that [Resident #1] was facing the wall and [Resident #2] was behind her. [Resident #2] was placed to 1:1. [Resident #1] was sent out to the hospital for vaginal examination, however the patient refused to cooperate.Record review of Resident #2's Social Service Note dated 10/1/25. Note: interviewed resident regarding his statement of assisting female residents to the bathroom when they come into his room. Initially in the interview he stated that on the night of the alleged abuse he was assisting the female resident to the bathroom. He also stated that he helped another female resident to the bathroom. As the interview continued, he stated that he assisted the female resident to the bathroom on the night in question, however that was the only female resident he assisted to the bathroom. When asked why he did not report this initially, he stated I did not remember. When asked what did he do with the other female resident he stated that they visit, have conversations on various topics, and watch a tv show together. Resident was educated that if a female resident comes into his room, he should press the call light or go to the Nurse's station to request the assistance of the Charge Nurse but never provide any form of ADL care. Resident verbalized understanding of the conversation.Record Review of Resident #2's Social Services Note dated 10/2/25. Note Text: Director of Social Services informed by IDT that it was determined that resident would be discharged to another facility for safety of the other residents. DRSS met with resident and informed him of impending discharge. He expressed understanding of situation and agreed with discharge. After discussing options, resident stated he would like to explore being admitted to a personal care home. Since resident is his own RP, DRSS inquired if he would like me to contact family members listed on his face sheet to inform them and he stated yes. Afterwards, DRSS contacted residents' families. They expressed understanding of situation and discharge.Record review of Nurse's Note for Resident #2 dated 10/4/2025. Note Text: Resident discharged to a personal care home. Transported out to vehicle via wheelchair. Resident left the facility awake, alert, oriented, without any c/o pain or signs of distress. During an interview on 10/01/25 at 9:56 a.m., the DON said LVN Q called around 8:50 p.m., on 09/23/25, and said CNA A and CNA B called LVN Q to Resident #2's bathroom after they saw Resident #1 and Resident #2 with their clothes pulled down and exposed. Resident #2 was standing behind Resident #1, and his semen was everywhere. The DON said Resident #1 wanders, and the intervention was to redirect, and the facility staff made rounds frequently. She said Resident #1 often wanders to Resident #2's room and to other residents' rooms, and staff would remove her from his room. The DON said Resident #1's BIMS was 0, and she could not consent to having sex. When the surveyor asked what other interventions were put in place after redirecting was ineffective, the DON responded that the facility did not place wandering residents on one-on-one. Still, staff made frequent rounds to check on residents. The DON said Resident #2 was making sexual comments towards staff, but he had not had any physical sexual act until this incident. The DON said Resident #2 denied having any sexual act with Resident #1.During an observation and interview on 10/01/25 at 11:12 a.m., Resident #1 was dressed in her street clothes and was sitting in her wheelchair in the TV room. Resident #1 did not respond to the surveyor's greeting, and she was not able to make her needs known.During an interview on 10/01/25 at 11:18 a.m., Resident #2 said he did not have sex with Resident #1, but he was assisting her to the toilet, and she fell backward, and he had to hold onto her. Resident #2 said the day of the incident was not the first time he had taken Resident #2 to the bathroom and assisted her to the toilet, because Resident #1 often comes to his room, and the staff were aware she comes to his room. He denied having sexual intercourse and said he had not ejaculated in months, and nothing sexual happened.During an interview on 10/01/25 at 2:44 p.m., CNA A said she and CNA B went to Resident #2's room, and the entrance door to Resident #2's room was closed. CNA A said she knocked on Resident #2's room entrance door and announced herself before she opened the room door, and she saw Resident #2 was having sex with Resident #1. CNA A said she shouted what are doing and Resident #2 pulled his penis out of Resident #1 and there was semen coming out of his penis. Then she told CNA B to call LVN Q. CNA A said that Resident #1 and Resident #2 were laughing, and Resident #2 said he was assisting her to the toilet. CNA A said she told Resident #2 to go back to his room, waited for LVN Q, and when she came and assessed Resident #1, she told her to take Resident #1 to her room and not clean her, and she was going to call the DON and the Administrator. CNA A said the police came and took the brief, which had urine and bowel movement. CNA A said she placed a clean incontinent brief on Resident #1 but did not clean her. CNA A said the police officer interviewed her, and she wrote her statement for the incident.During an interview on 10/02/25 at 8:22 a.m., CNA B said she and CNA A went to provide care to Resident #2, and when they got to his room, the entrance door was closed. CNA A knocked on the door, introduced herself, and opened the door, and she was behind her. CNA B said CNA A shouted What are you doing? and when she came from behind CNA A and looked, she saw Resident #2 had only an incontinent pull-up, and his brief was pulled down, and his penis was out, and he had semen everywhere, and he was laughing.During an interview on 10/02/25 at 9:19 a.m., NP said one of the Nurses called and told him CNA A and CNA B found Resident #1 and Resident #2 having a sexual encounter. NP said Resident #1 was sent to the hospital. NP said he made rounds the next day after the Nurse told him, and saw and assessed both Resident #1 and Resident #2. NP said Resident #1 was nonverbal and she could not respond to any question or tell you anything, and could not consent to consensual sex. NP said the hospital staff gave Resident #1 medication to prevent pregnancy and two types of HIV medication. The NP said Resident #2 denied having sex with the resident. NP said the facility staff had not told him Resident # 2 made any sexual comments to staff or to other residents. NP said it is a possibility if Resident #2 had hepatitis C and had unprotected sex with Resident #1, she could contract hepatitis C. He said he was unsure whether Resident #1 had hepatitis C.During a telephone interview on 10/02/25 at 9:41 a.m., FM said Resident #1 could not consent to sexual activity. RP said she would not consent for Resident #1 to have sexual relations at the facility. FM said the facility failed to protect Resident # 1 from sexual assault.During a telephone interview on 10/02/25 at 10:23 a.m., the Detective said he would be investigating the incident, but it has not been assigned to him yet; it would be assigned to him in a couple of days. He said from the report that the officers who came out to the facility read, CNA A said she observed Resident #1 and Resident #2 having sexual intercourse. He said the Forensic Nurse did a sexual assault kit when Resident #1 was in the hospital, and it would take 4 to 6 weeks before the result would be ready.During an interview on 10/02/25 at 12:12 p.m., the DON said she was not aware Resident #2 had hepatitis C, and the NP would see Resident #1 and Resident #2 today, and he would order labs on Resident #2. The DON said Resident #1 could be infected with hepatitis C, and she would follow up with the NP.During an interview on 10/02/25 at 2:28 p.m., the Administrator said he was responsible for in-service training on abuse and neglect. He said the abuse policy was part of the admission paper. The DON, the Corporate Nurse, and the Administrator said they do not have any policy on how to educate the resident about safe consensual sex, but they would contact their corporate office.During an interview on 10/02/25 at 2:43 p.m., the Interim Administrator said he had been the interim at the facility for three weeks, did not have access to the facility computer, and could not recall when he was notified about the incident between Resident #1 and Resident #2. He said he was not aware that the facility had a policy on how residents would be educated on having safe consensual sex. He said they usually made rounds every two hours for residents and wandering residents, and if two hours were not safe for a wandering resident, the resident should be in a locked unit. The Interim Administrator said with regard to sexual abuse in service for the staff, they were educated to separate the residents and notify the Abuse Coordinator. He said it would be an awkward conversation with residents on consensual sex. He said his thoughts about any resident who wanted to be intimate would go to the Nurse or Social Worker, who would advise the resident on what to do.During an interview on 10/02/25 at 1:45 p.m., NP said he saw Resident #1 and Resident #2 today (10/02/25), and they are stable, and labs were ordered: HIV, hepatitis C profile, BMP, and CBC for Resident #2. He said he advised the facility to find another placement for Resident #2 after the investigation because the facility still has other female residents, which could prevent the incident from recurring. He said the facility should have involved Resident #1 in activities to occupy her time and put her to bed early to rest, which would have prevented her wandering, and the incident could have been prevented.Record review of the facility policy and procedure entitled Incident and Accident dated 3-1-17 read in part.Accidents or incidents involving residents shall be investigated and reported to the Executive Director of Operations.Licensed nurse will complete an incident and accident report when staff is aware that an incident occurred. Review each incident report at daily clinical meeting.Licensed nurse will notify physician and responsible party and update resident's care plan.If resident requires one to one supervision, staff will document using the One-on-One Monitoring form.Record review of the facility policy and procedure entitled Elopement dated 11/01/2019, provided by facility DON who referred to this policy as the policy on wandering on 10/5/25 read in part. POLICY: To safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing. Elopement drill will be held quarterly.Once it has been established that a patient/resident is missing, the following staff members are notified immediately: The charge nurse, Executive Director of Operations, Director of Clinical Operations, and social service designee, responsible party and the primary care physician. Conduct a headcount. An Immediate Jeopardy (IJ) was identified on 10/02/2025 at 4:41 p.m. The IJ template was provided to the Administrator and DON on 10/02/25 at 4:41 p.m. F689- Accident and SupervisionThe following Plan of Removal submitted by the facility was accepted on 10/03/2025 at 1:46 p.m.Plan of Removal F689 October 2, 2025.What corrective actions have been implemented for the identified residents? Plan of Removal.Immediate Jeopardy On 10/2/2025 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safetyThe facility failed to ensure Resident #1 received adequate supervision to prevent abuse.F689- Accident and SupervisionImmediate Action Resident #1 sent to hospital for assessment and returned on 9/24/25. Resident placed on one on one 10/2/25 until alternative placement is found on secure unit. Family notified 10/2/2025 of plan for discharge. Resident #1 was placed on 1:1 on 10/2/2025 until alternate placement is found due to wandering into other resident's rooms. Alternate placement will be a secure unit or placement chosen by RP. Resident #2 was placed on 1:1 on 10/2/2025 until evaluated by psychiatrist for further direction on care. Identification of Residents Affected or Likely to be Affected: On 10/2/2025 the DON and Social worker completed the audit for all residents who wander to other residents' room, none was identified. An audit was completed on 10/2/2025.Facility's Plan to ensure compliance quickly #2 will be re-evaluated by the Psychiatry by 10/3/2025. Resident #2 is appropriate for group home as determined by psych services. Referral to group home sent by Social Services on 10.3.25 per family recommendation. The Director of Nurses initiated Inservice on 10/2/25 with all staff. Inservice was on Abuse and neglect, resident rights, Accident and Supervision which was conducted by the Director of Clinical Service. Inservice will be completed by 10/3/2025. The Director of Social Service initiated education with residents on resident rights policy and procedure, notifying staff of unwanted visitors in their rooms to include wandering residents. Resident education was Completed on 10/3/2025. The Director of Clinical Operations and Designee Assessed all wandering residents to determine if they are wandering into other resident rooms and if they are at risk. Resident assessment completed on 10/3/2025, Social worker completed audit on 10/2/2025 on all residents for inappropriate sexual behavior and none was identified. Medical Director notified of alleged facility noncompliance with ensuring supervision of wandering staff. Reviewed staff training on Resident Abuse, Accident and Supervision on 10/2/2025. No changes with policy will be made at this time. Staff are required to make rounds every 2 hours to monitor and supervise residents. All residents that wanders were assessed by DCO and Charge Nurses with their care plan audit completed on 10/2/2025, and no concern noted. Audit performed on 10.3.25 by Social Worker and DCO. No residents with inappropriate sexual behaviors were identified. Any staff member not available for training will not assume any job assignment until training is completed. All new hires will be educated on abuse policy, resident monitoring, and supervision. Ad Hoc QAPI completed to review all IJs, interventions and Plan of care taken with IDT and Medical director, all interventions are effective at this time.Mo

Based on observation, interview and record review, the facility failed to ensure residents were free from abuse for 1 of 5 residents (Resident #1) reviewed for resident abuse.-The facility failed to ensure that Resident #1 was free from sexual abuse when Resident #1 wandered into Resident #2's room in the facility on 9/23/25, and Resident #2 sexually assaulted Resident #1.An Immediate Jeopardy (IJ) was identified on 10/02/2025 at 4:41 p.m. The IJ template was provided to the Administrator and DON on 10/02/25 at 4:41 p.m. While the IJ was removed on 10/06/25 at 1:28 p.m. the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that was not an immediate jeopardy and a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems.This failure could place residents at risk of physical harm, mental anguish, and/or emotional distress. Record review of Resident #1's facility admission record dated 10/1/25 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with most current admission date of 6/26/18. Resident #1 admitted with diagnoses that included anoxic brain damage (a condition where the brain experiences a complete lack of oxygen supply. This deprivation of oxygen can lead to widespread damage to brain cells, resulting in severe neurological impairment or death) and epilepsy and epileptic syndromes (Epilepsy is a brain disorder characterized by recurrent, unprovoked seizures, while an epileptic syndrome is a specific, complex constellation of signs and symptoms that define a unique epilepsy condition. An epileptic syndrome includes specific seizure types, other clinical features).Record review of Residents #1's care plan date Initiated 9/15/21 and revised on 9/24/25 revealed she was care-planned for a high elopement risk/wandering in male residents' room and was at risk for possible injury r/t impaired safety awareness and diagnosis of dementia, Anoxic brain damage. Date Initiated: 09/15/2021. Revision on: 09/24/2025: Goals: Resident #1's safety will be maintained throughout the review date. Date Initiated: 09/15/2021. Revision on: 09/12/2025. Target Date: 10/19/2025 Interventions: Assess for fall risk. Date Initiated: 09/15/2021. Provide structured activities: Toileting, walking inside and outside, reorientation strategies, including signs, pictures, and memory boxes. Date Initiated: 09/15/2021. Wander guard placed for resident's safety, bracelet will alert staff if and when resident attempts to exit doors of facility. Staff to monitor daily. Date Initiated: 09/15/2021. Redirect resident. Date Initiated: 09/24/2025. A care plan to address Resident #1 identifies as a trauma survivor. 1.possible trigger of aggressive vocal stimuli. 2. Childhood trauma memories, Domestic abuse memories , Physical Abuse memories, Sexual Abuse memories. Date Initiated: 11/14/2019. Revision on: 05/07/2020. Goals: SHE will remain stable and adjusted to her environment. Date Initiated: 11/14/2019 Revision on: 09/12/2025. Target Date: 10/19/2025. Interventions: Ask for permission to enter resident's room, perform care, and/or assist with ADLs. Date Initiated: 09/08/2023. Explain all procedures to the resident before starting and allow the resident (X minutes) to adjust to changes when necessary. Date Initiated: 09/08/2023. Reduction of possible triggers in her environment. Date Initiated: 11/14/2019. A care plan to address Resident #1's impaired cognitive function or impaired thought processes r/t ANOXIC BRAIN INJURY. SHE has cognitive loss (loss of memory, time sense and requires assistance with decision making r/t Impaired decision-making abilities, is not always understood or able to understand verbal and non-verbal expression. Date Initiated: 05/07/2020. Revision on: 05/07/2020. Resident #1 will improve current level of cognitive function through the review date. Date Initiated: 02/09/2021. Revision on: 09/12/2025. Target Date: 10/19/2025.Record review of Resident #1's Quarterly MDS dated [DATE] revealed Cognitive Skills for Daily Decision Making (section C1000) were coded at 3, indicating her cognition was severely impaired. Resident #1 was coded to require substantial/maximal assistance with ADLs. She was always incontinent of bowels and bladder and used a wheelchair for mobility.Record review of Resident #1's physician orders dated September 2025 revealed orders with a start date of 9/25/25 to administer Emtricitabine- Tenofovir oral tablet 200-300 MG (Emtricitabine- Tenofovir Disoproxil Fumarate) Give 1 tablet by mouth one time a day for antiviral for 28 days at 9:00 AM. An order for Tivicay Oral (Dolutegravir Sodium) Tablet 50 MG Give 1 tablet by mouth one time a day for antiviral for 28 days at 9:00 AM. An order for Plan B One-Step Oral Tablet 1.5 MG (Levonorgestrel Emergency OC) Give 1 tablet by mouth one time only for contraceptive for 1 day with a start date of 9/24/25. Record review of Resident #1's MAR dated September 2025 revealed that Resident #1 was administered Emtricitabine and tenofovir antiretroviral medication (used to treat and prevent HIV infection) on 9/25/25 through 9/30/25. Resident #1 was administered Tivicay Oral (Dolutegravir Sodium) Tablet 50 MG Give 1 tablet by mouth one time a day for antiviral on 9/25/25 through 9/30/25. Resident #1 was administered Plan B One-Step Oral Tablet 1.5 MG (Levonorgestrel Emergency OC (Oral Contraceptive) 1 tablet by mouth on 9/25/25.Record review of Nurses Note dated 9/23/2025. Note Text: Called to room by CNA A and CNA B reported to staff nurses that resident was having sexual activity with Resident #1. Resident #1 was immediately removed for safety. When male resident questioned by staff nurse what happened male resident began to laugh and stated nothing happened . Female resident is not cognitively intact female resident monitored all safety measures in place. Male resident immediately monitored 1-1 by staff. DON notified of above. MD notified. Family notified by DON awaiting return call. The resident transferred to local hospital.Record review of Nurses Note dated 9/23/2025. Note Text: Spoke with forensic nurse at local hospital who reported that she completed an exam on resident . She stated she was able to get a swab for DNA and STD testing but was unable to do a vaginal exam because the resident closed her legs and would not allow her to examine her. She stated that a pregnancy test was performed and was negative, resident was treated prophylactically with ATBs and will discharge to facility with orders for ATBs to continue. Resident #1 will also return with an order for Plan B . Nurse stated that an official report will be available in 1-2 business days. Called RP to update her on report from the nurse, message left, awaiting call back.Record review of the post hospital discharge instructions and orders dated 9/24/25 revealed that Resident #1 was seen for sexual assault. A SANE (Sexual Assault Nurse Examiner) adult sexual assault exam was performed (a forensic exam was performed (results pending and coordinated with the local police department). Orders for STI Sexually Transmitted Infection Prophylaxis: Ondansetron 4 mg PO x1, Azithromycin 1gm PO x1, Metronidazole 2gms PO x1, Ceftriaxone 500mg IM reconstituted with 1.1 ml of 1% Lidocaine. Lab orders for Pharyngeal Gonorrhea ( a sexually transmitted infection (STI) caused by the Neisseria gonorrhoeae bacteria that infects the pharynx. It is spread through oral sex with an infected person and can be asymptomatic, but symptoms may include a sore throat, difficulty swallowing, swollen lymph nodes in the neck, or redness/swelling in the throat) and Chlamydia (a common sexually transmitted infection (STI) caused by the bacterium Chlamydia trachomatis. It is primarily spread through sexual contact with an infected person).Record review of Nurse Practitioner note dated 9/25/25 for Resident #1: Chief Complaint: Evaluation of patient for alleged sexual assault incident: Hospital Course: She was taken to the ER a few days ago after an incident with another resident of a sexual nature. She was examined for possible sexual assault and started on post-exposure prophylaxis (levonorgestrel single dose; dolutegravir 50 mg daily x28 days; emtricitabine/tenofovir 200/300 mg daily x28 days; PRN ondansetron). Hospital examination results are pending. Today she appears in no distress. History of Present Illness: Resident #1, a [AGE] years old female with history of anoxic brain damage, epilepsy, unsteadiness on the feet, ataxia (poor muscle control that causes clumsy movements), abnormal gait, generalized muscle weakness, dysphagia (swallowing difficulties), mixed receptive/expressive language disorder (is a neurodevelopmental condition that affects a child's ability to both understand and produce language), dysarthria (difficulty speaking because the muscles you use for speech are weak), severe hypoxic ischemic encephalopathy (a brain injury that happens before, during, or shortly after birth when oxygen or blood flow to the brain is reduced or stopped), hyperlipidemia (an elevated level of lipids - like cholesterol and triglycerides - in your blood), hypertensive heart disease (a constellation of structural and functional changes in the left ventricle, left atrium, and coronary arteries resulting from chronic blood pressure elevation), and hypothyroidism (a condition in which the thyroid gland does not make enough thyroid hormone) among other medical problems was seen today upon the request of the Nurse due to a reportable incident that happened between patient and another resident. Patient was examined in the dining room. She is nonverbal and not able to make needs known due to anoxic brain injury. Patient was taken to the ER a few days ago for an examination of an encounter with another resident of a sexual nature. She was examined for sexual assault. Findings were not available at the time of this visit; however, patient was placed on several medications including: Levonorgestrel 1.5 mg tablet 1 time only, dolutegravir 50 mg daily for 28 days, emtricitabine/tenofovir 200/300 mg daily for 28 days and as needed Zofran. The results of the patient's examination at the hospital are still pending. - Additional consultations: Psychiatry and Psychology evaluations requested for psychological support.Record Review of Resident #1's Diagnostic Assessment from Psychological Evaluation and Treatment Services dated 9/29/25 revealed that the referral was made due to possible sexual assault at the facility. Resident #1 was unable to answer assessment questions or questions regarding the alleged events therefore she is not a candidate for psychotherapy. Record review of Resident #1's Initial Psychiatric assessment dated [DATE] revealed that Resident #1 was referred due to recent sexual assault without ability to consent, patient was noted to not be able to respond, trauma screening was unable to be determined due to patient being unable to respond. Resident #2Record review of Resident #2's facility admission record dated 10/2/25 revealed a [AGE] year-old-male, admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side (a stroke damaged the right side of the brain, causing paralysis (hemiplegia) and/or weakness (hemiparesis) on the left side of the body) and Chronic Viral Hepatitis C (a long-term liver infection caused by the hepatitis C virus). Record review of Resident #2's care plan revealed care plans to address areas that included: The resident has a behavior problem r/t inappropriate verbal sexual comments towards staff. Date Initiated: 08/18/2025. Revision on: 09/23/2025 Goals: The resident will have fewer episodes of inappropriate behaviors by review date. Date Initiated: 08/18/2025 Revision on: 09/23/2025 Target Date: 12/18/2025: Interventions: The resident's behavior is de-escalated by redirection. Date Initiated: 08/18/2025. Revision on: 09/23/2025. Medication adjustment by psych Date Initiated: 10/01/2025. Minimize potential for the resident's disruptive behaviors. Date Initiated: 08/18/2025. Revision on: 09/23/2025, Psych consult date initiated: 08/18/2025. A care plan area to address the potential to be physically aggressive r/t Dementia Date Initiated: 09/09/2025. Revision on: 09/24/2025 and a care plan to address uses antidepressant medication r/t Depression. Date Initiated: 06/20/2025. Revision on: 09/24/2025. Interventions included to Administer ANTIDEPRESSANT medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT, Monitor/document/report PRN adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt loss, n/v, dry mouth, dry eyes. Date Initiated: 06/20/2025.Record review Resident #2's Quarterly MDS dated [DATE] revealed a BIMS score of 12 out of 15, indicating he was moderately cognitively impaired. The complete MDS was requested but not received.Record review of Resident #2's physician orders for September 2025 for Depakote Oral Tablet Delayed Release 125 MG (Divalproex Sodium) give 2 tablet by mouth two times a day for mood with a start date of 9/26/25, and a Physician order dated 10/2/25 for Chlamydia and Gonorrhea.Record review of Resident #2's MAR dated September 2025 revealed that Resident #2 was administered Depakote Oral Tablet Delayed Release 125 MG (Divalproex Sodium) on 9/26/25 at 9:00 am and on 9/27 through 9/30 at 9:00 AM and 6 PM. Record Review of Resident #2's lab results dated 10/3/25 for Chlamydia and Gonorrhea revealed they were negative. Record review of lab results dated 10/4/ 25 revealed an abnormal and reactive result to the Hepatitis C Antibody (positive for Hepatitis C).Record review of Resident #2's Psychological Services Progress note dated 9/24/25 read in part.Clinician was notified that this patient was accused of sexually assaulting another resident and requested a crisis session. The clinician worked on developing a therapeutic relationship with the patient as he was new to her. Used supportive listening to validate patient's emotions and encouraged patient to tell their story Related to current difficulties and then focused more narrowly to intervene. Patient's Response to Intervention: Patient reported frustration and stated that a CNA accused him of raping another resident last night. He reported that the resident is frequently in his room because it used to be her room.Clinician then asked him to explain the events of last night. He stated that she was in his room watching TV and wet her clothes. He opened the door to the bathroom for her. She then wheeled to the support bar straight ahead and stood up holding onto the bar. He moved her wheelchair to the side so that he could help her get on the toilet. He acknowledged that her pants and brief were off but denied that his had been pulled down. He reported that he has helped her in the bathroom previously and that CNAs have had to come and assist in the past. He further reportedfrustration about being accused of rape. The clinician stated that if it was consensual there was not issue. He immediately stated that the other resident was not capable of consent, and he was not sure she was even at a five-year-old's level of understanding. Next, he reported the police taking his statement, clothing, and brief as evidence. He reported understanding the collection due to the allegation.Record review of Nurse Practitioner Progress note for Resident #2, dated 9/25/25 read in part.Patient, [AGE] years old male was seen today in his room due to incident involving another resident. According to resident, he was accused of having sex with another resident. Patient is now on one-on-one supervision and is wondering why he is on surveillance. According to the Resident, the female resident wanders into his room and bathroom all the time and he denies doing what he is accused of. However, according to the Nurse and Director of Nursing, there were eyewitnesses who saw what happened. Law enforcement is now involved, and patent {sic} has been made aware of that. Patent was made aware that he will continue to be on close supervision by staff until Law enforcement are done with their investigation. Verbalized understanding. Patient is alert during this assessment and was able to answer all questions appropriately. Patient has history of dementia but is still able to hold normal conversations. Psychological and psychiatric consultation requested. Will continue one-on-one supervision with this patient until incident is resolved.Record review of Resident #2's Psychiatric Subsequent Assessment/note dated 9/30/25 read in part.Reason for Referral: Sexually Inappropriate Behavior, Other: Alleged sexual assault of another resident. Patient seen today for a F/U visit. The last visit was on 9/26/2025. Initiated Depakote 250 mg tablet BID. Assess the Pt's behaviors, monitor the response to Depakote. ON EXAM, the Pt is in the room, w/ 1:1 staff, calm and not in distress. LAST visit: Per nursing staff, [Resident #1] was wandering to [Resident #2's] room on 9/23/25 and the Aid {sic} witnessed inappropriate behavior in [Resident #2's] bathroom. In addition, the Aid {sic} witnessed that [Resident #1] was facing the wall and [Resident #2] was behind her. [Resident #2] was placed to 1:1. [Resident #1] was sent out to the hospital for vaginal examination, however the patient refused to cooperate.Record review of Resident #2's Social Service Note dated 10/1/25. Note: interviewed resident regarding his statement of assisting female residents to the bathroom when they come into his room. Initially in the interview he stated that on the night of the alleged abuse he was assisting the female resident to the bathroom. He also stated that he helped another female resident to the bathroom. As the interview continued, he stated that he assisted the female resident to the bathroom on the night in question, however that was the only female resident he assisted to the bathroom. When asked why he did not report this initially, he stated I did not remember. When asked what did he do with the other female resident he stated that they visit, have conversations on various topics, and watch a tv show together. Resident was educated that if a female resident comes into his room, he should press the call light or go to the Nurse's station to request the assistance of the Charge Nurse but never provide any form of ADL care. Resident verbalized understanding of the conversation.Record Review of Resident #2's Social Services Note dated 10/2/25. Note Text: Director of Social Services informed by IDT that it was determined that resident would be discharged to another facility for safety of the other residents. DRSS met with resident and informed him of impending discharge. He expressed understanding of situation and agreed with discharge. After discussing options, resident stated he would like to explore being admitted to a personal care home. Since resident is his own RP, DRSS inquired if he would like me to contact family members listed on his face sheet to inform them and he stated yes. Afterwards, DRSS contacted residents' families. They expressed understanding of situation and discharge.Record review of Nurse's Note for Resident #2 dated 10/4/2025. Note Text: Resident discharged to a personal care home. Transported out to vehicle via wheelchair. Resident left the facility awake, alert, oriented, without any c/o pain or signs of distress.During an interview on 10/01/25 at 9:56 a.m., the DON said LVN Q called around 8:50 p.m., on 09/23/25, and said CNA A and CNA B called LVN Q to Resident #2's bathroom after they saw Resident #1 and Resident #2 with their clothes pulled down and exposed. Resident #2 was standing behind Resident #1, and his semen was everywhere. The DON said Resident #1 wanders, and the intervention was to redirect, and the facility staff made rounds frequently. She said Resident #1 often wanders to Resident #2's room and to other residents' rooms, and staff would remove her from his room. The DON said Resident #1's BIMS was 0, and she could not consent to having sex. When the surveyor asked what other interventions were put in place after redirecting was ineffective, the DON responded that the facility did not place wandering residents on one-on-one. Still, staff made frequent rounds to check on residents. The DON said Resident #2 was making sexual comments towards staff, but he had not had any physical sexual act until this incident. The DON said Resident #2 denied having any sexual act with Resident #1.During an observation and interview on 10/01/25 at 11:12 a.m., Resident #1 was dressed in her street clothes and was sitting in her wheelchair in the TV room. Resident #1 did not respond to the surveyor's greeting, and she was not able to make her needs known.During an interview on 10/01/25 at 11:18 a.m., Resident #2 said he did not have sex with Resident #1, but he was assisting her to the toilet, and she fell backward, and he had to hold onto her. Resident #2 said the day of the incident was not the first time he had taken Resident #2 to the bathroom and assisted her to the toilet, because Resident #1 often comes to his room, and the staff were aware she comes to his room. He denied having sexual intercourse and said he had not ejaculated in months, and nothing sexual happened.During an interview on 10/01/25 at 2:44 p.m., CNA A said she and CNA B went to Resident #2's room, and the entrance door to Resident #2's room was closed. CNA A said she knocked on Resident #2's room entrance door and announced herself before she opened the room door, and she saw Resident #2 was having sex with Resident #1. CNA A said she shouted what are doing and Resident #2 pulled his penis out of Resident #1 and there was semen coming out of his penis. Then she told CNA B to call LVN Q. CNA A said that Resident #1 and Resident #2 were laughing, and Resident #2 said he was assisting her to the toilet. CNA A said she told Resident #2 to go back to his room, waited for LVN Q, and when she came and assessed Resident #1, she told her to take Resident #1 to her room and not clean her, and she was going to call the DON and the Administrator. CNA A said the police came and took the brief, which had urine and bowel movement. CNA A said she placed a clean incontinent brief on Resident #1 but did not clean her. CNA A said the police officer interviewed her, and she wrote her statement for the incident.During an interview on 10/02/25 at 8:22 a.m., CNA B said she and CNA A went to provide care to Resident #2, and when they got to his room, the entrance door was closed. CNA A knocked on the door, introduced herself, and opened the door, and she was behind her. CNA B said CNA A shouted What are you doing? and when she came from behind CNA A and looked, she saw Resident #2 had only an incontinent pull-up, and his brief was pulled down, and his penis was out, and he had semen everywhere, and he was laughing.During an interview on 10/02/25 at 9:19 a.m., NP said one of the Nurses called and told him CNA A and CNA B found Resident #1 and Resident #2 having a sexual encounter. NP said Resident #1 was sent to the hospital. NP said he made rounds the next day after the Nurse told him and saw and assessed both Resident #1 and Resident #2. NP said Resident #1 was nonverbal and she could not respond to any question or tell you anything and could not consent to consensual sex. NP said the hospital staff gave Resident #1 medication to prevent pregnancy and two types of HIV medication. The NP said Resident #2 denied having sex with Resident #1. NP said the facility staff had not told him Resident # 2 made any sexual comments to staff or to other residents. NP said it is a possibility if Resident #2 had hepatitis C and had unprotected sex with Resident #1, she could contract hepatitis C. He said he was unsure whether Resident #1 had hepatitis C.During a telephone interview on 10/02/25 at 9:41 a.m., FM said Resident #1 could not consent to sexual activity. RP said she would not consent for Resident #1 to have sexual relations at the facility. FM said the facility failed to protect Resident # 1 from sexual assault.During a telephone interview on 10/02/25 at 10:23 a.m., the Detective said he would be investigating the incident, but it has not been assigned to him yet; it would be assigned to him in a couple of days. He said from the report that the officers who came out to the facility read, CNA A said she observed Resident #1 and Resident #2 having sexual intercourse. He said the Forensic Nurse did a sexual assault kit when Resident #1 was in the hospital, and it would take 4 to 6 weeks before the result would be ready.During an interview on 10/02/25 at 12:12 p.m., the DON said she was not aware Resident #2 had hepatitis C, and the NP would see Resident #1 and Resident #2 today, and he would order labs on Resident #2. The DON said Resident #1 could be infected with hepatitis C, and she would follow up with the NP.During an interview on 10/02/25 at 2:28 p.m., the Administrator said he was responsible for in-service training on abuse and neglect. He said the abuse policy was part of the admission paper. The DON, the Corporate Nurse, and the Administrator said they do not have any policy on how to educate the resident about safe consensual sex, but they would contact their corporate office.During an interview on 10/02/25 at 2:43 p.m., the Interim Administrator said he had been the interim at the facility for three weeks, did not have access to the facility computer, and could not recall when he was notified about the incident between Resident #1 and Resident #2. He said he was not aware that the facility had a policy on how residents would be educated on having safe consensual sex. He said they usually made rounds every two hours for residents and wandering residents, and if two hours were not safe for a wandering resident, the resident should be in a locked unit. The Interim Administrator said with regard to sexual abuse in service for the staff, they were educated to separate the residents and notify the Abuse Coordinator. He said it would be an awkward conversation with residents on consensual sex. He said his thoughts about any resident who wanted to be intimate would go to the Nurse or Social Worker, who would advise the resident on what to do.During an interview on 10/02/25 at 1:45 p.m., NP said he saw Resident #1 and Resident #2 today (10/02/25), and they are stable, and labs were ordered: HIV, hepatitis C profile, BMP, and CBC for Resident #2. He said he advised the facility to find another placement for Resident #2 after the investigation because the facility still has other female residents, which could prevent the incident from recurring. He said the facility should have involved Resident #1 in activities to occupy her time and put her to bed early to rest, which would have prevented her wandering, and the incident could have been prevented. Record review of the facility policy and procedure entitled Abuse dated last revised 1/1/23 read in part.The purpose of this policy is to ensure that each resident has the right to be free from any type of Abuse, Neglect, Intimidation, Involuntary Seclusion/Confinement.Abuse is the willful infliction of injury or negligent, unreasonable confinement.resulting in physical or emotional harm or pain to a resident; or sexual abuse involuntary or nonconsensual sexual conduct that would constitute an offense under penal code S 21.08 (indecent exposure) or Penal Code chapter 22 (assaultive offenses) sexual harassment, sexual coercion or sexual assault.Residents will not be subjected to abuse by anyone including, but not limited to, community staff, other residents.This includes physical, verbal, sexual, physical/chemical restraint. An Immediate Jeopardy (IJ) was identified on 10/02/2025 at 4:41 p.m. The IJ template was provided to the Administrator and DON on 10/02/25 at 4:41 p.m.The following Plan of Removal submitted by the facility was accepted on 10/03/2025 at 1:46 p.m.Plan of Removal F600 October 2, 2025.What corrective actions have been implemented for the identified residents? Plan of Removal.Immediate Jeopardy On 10/2/2025 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safetyThe facility failed to ensure Resident #1 was free from sexual abuse.F600 - Sexual abuse Immediate action Resident #1 sent to hospital for assessment and returned on 9/24/25. Resident placed on one on one 10/2/25 until alternative placement is found on secure unit. Family notified 10/2/2025 of plan for discharge Resident #1 was placed on 1:1 monitoring until alternate placement is found due to wandering into other resident's rooms. Alternate placement will be a secure unit or placement chosen by RP. The Regional director of clinical services (RDCO) in-serviced the Executive Director of operations (administrator) and Director of Nursing operation (DON) on abuse policy on 10/2/2025. The DON initiated In-service on Abuse and Neglect for all staff on 10/2/2025 to be completed on 10/3/2025. Residents #1 and #2 were assessed by charge Nurses on 10/2/2025, no concern noted. All residents that wanders were assessed by DCO and Charge Nurses with their care plan audit completed on 10/2/2025, and no concern noted. Resident #2 was placed on 1:1 monitoring until evaluated by psychiatrist for further direction on care. Resident #2 RP was notified of resident current status by social worker on 10/2/2025. Resident # 2 physicians was notified of current status by DCO on 10/2/2025. Resident #1 and #2 care plans were updated by MDS Nurse on 10/2/2025. DON trained all staff on rounding and supervision on residents to be completed on 10/3/2025. The Director of Social Service initiated education with residents on resident rights policy and procedure, notifying staff of unwanted visitors in their rooms to include wandering residents. Resident education was Completed on 10/3/2025.Identification of Residents Affected or Likely to be AffectedOn 10/2/2025 the DON and Social worker completed the audit for all residents who wander to other residents' room, none was identified. An audit was completed on 10/2/2025Facility's Plan to ensure compliance quickly DON will provide in-service to all staff on abuse policy and will be completed on 10/3/2025. Staff will not provide direct care until training is completed. DON will provide training for all staff on redirecting resident that wanders into other resident's room and to notify the charge Nurse immediately. DON trained Charge Nurse to assess the residents, notify the DON and Administrator and to monitor residents. Training to be completed on 10/3/2025. DCO will review residents that wander daily in IDT meetings to determine changes to where they wander to and determine if they need to revise their plan of care. Daily rounds will be conducted by the IDT during focus rounds to identify any concern with residents that wanders and discuss the concern with administrator. Social worker to contact resident #1 Rp to discuss plan of care to be completed 10/3/2025. The medical Director was notified of the immediate jeopardy on 10/2/2025 by the administrator. The medical director reviewed abuse and neglect policy and made no changes to the policy on 10/2/2025. Any staff member not available for training will not assume any job assignment until training is completed. Staff will identify residents with inappropriate behaviors such as sexual comments, wandering that poses a safety concern, or aggression. If a resident experiences inappropriate behaviors we immediately place them on a 1:1. Psych is then consulted to provide guidance on the behavior and to assist with a plan of care. IDT will ensure that proper interventions are in place. DCO and/or designee will communicate with staff. DCO and/or designee will monitor process. Monitoring of the plan of removal from 10/04/2025 through10/06/25 included:Record review of P

Based on observations, interviews, and record review, the facility failed to ensure that S483.55(a)(5) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay for 1 of 10 residents (Residents #70) reviewed for dental services. -The facility failed to assist in providing emergency or routine dental services in a timely manner. -The facility failed to promptly within 3 days, refer Resident #70 for dental services related to lost dentures. -The facility failed to provide documentation of the extenuating circumstances that led to the delay in Resident #70 being seen by a dentist. These failures could place residents at risk of oral complications, dental pain, and diminished quality of life. Findings included: Resident #70 Review of Resident #70's Admission Record revealed she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included effusion of right wrist (condition in which there is an excessive build-up of fluid within the joint of the right wrist), protein calorie malnutrition (condition of nutritional status in which reduced availability of nutrients leads to changes in body composition and function), fracture of lower end of right radius (broken bone of lower right arm near the wrist), and abnormal weight loss (unintentional weight loss). Review of Resident #70's Admission MDS assessment dated [DATE] revealed she had a BIMS score of 14 out of 15 indicating she had intact cognitive function, she used a wheelchair for mobility, required set-up assistance with eating, received a regular diet and had no reported weight loss or gain and there was no documentation of mouth/dental pain or issues and no dental CAA's were triggered at the time of the assessment. Record review on 1/29/25 at 2:12 pm of facility Grievance/Complaint Form for Resident #70 completed by Social Worker and dated 12/2/24 revealed in part: Family member reports that residents' dentures are missing . and listed the date incident occurred as 11/26/24. Recommendations/Corrective Action taken: Resident was placed on dental list to be fitted for new dentures . Record review on 1/29/25 at 2:15pm of facility undated dental Appointment Pull Chart List revealed: Resident #70 had a dental appointment on 2/14/25 at 2:00 pm. Telephone interview followed immediately by an in-person interview with family member of Resident #70 on 1/28/25 at 2:57 pm who said that he requested Resident #70 receive a puree diet back in early December 2024 because Resident #70 could not eat her regular diet without her upper denture which was lost back on 11/26/24. Family member said they spoke with the SW repeatedly immediately after the loss of the upper denture on 11/26/24 and was told that the facility assumed no responsibility for the loss of the dentures and would not pay to replace them. Family member said that he offered to split the cost of dentures 50%/50% with the facility but SW told him Administrator said no. Family member said they never spoke with Administrator or DON. The Family member said they only spoke with the SW and the SW said that Resident #70 needed a payor source to see the dentist. The Family member said that Resident #70 and had just gotten approved for Medicaid in January 2025. The family member said that after about 10 days to two weeks after Resident #70's upper dentures were lost, and Resident #70 still had not seen the dentist and when he asked the SW about this, he had repeatedly been given excuses about the holidays and the winter storm for why Resident #70 had not been seen by the dentist yet. Interview on 1/28/25 at 4:08pm with Administrator who said that SW managed scheduling of dental consultations for residents and was responsible for the facility's dental program. The Administrator said he was advised by corporate oversight that they would not pay for dentures. The Administrator said he was not informed of family member's offer to split costs 50%/50%. The Administrator said that he did not know when Resident #70 was supposed to see the dentist for the first time. The Administrator said he thought the grievance had been resolved and that the SW was also responsible for the grievance follow ups. The Administrator did not respond when asked if he thought waiting from 11/26/24 until 2/14/25 to see a dentist was too long to wait. The Administrator said he was brand new and had only worked at the facility for few months. Interview with the SW on 1/28/25 at 4:24pm he said he was responsible for sending referrals and for scheduling dental services for the facility residents. When asked if he had updated Resident #70 or her family member on the first dental visit being scheduled for 2/14/25, the SW said that he spoke with Resident #70's family member almost every day but could not recall if he told them that the first dental appointment was not until 2/14/25. When asked if he thought waiting from 11/26/24 until 2/14/25 to be seen by a dentist for new dentures was too long of a wait, the SW replied 12/2/24. The SW said that the grievance was on 12/2/24. The SW then said that he initiated the referral process on 12/10/24 and would look to see how he could provide documentation as he could not show surveyor in the facility's EMR or Resident #70's clinical notes, where his documentation of the referral with dental services and communications with Resident #70 or her family members could be located in Resident #70's clinical record. When asked if he had informed the DON and Administrator about any potential delays in Resident #70 being seen by a dentist, the SW huffed and said that he thought he had discussed the situation with everyone and moving forward he would document everything as it happened. Interview on 1/29/25 with RD at 12:29 pm she said that Resident #70 had not triggered for weight loss despite not having her upper dentures, until January 2025. RD said that Resident #70 did not have significant weight loss and that she evaluated all facility residents upon admission and quarterly and as needed when clinically indicated. RD said that Resident #70 admitted to facility with history of significant weight loss but had not had a significant weight loss since admission. RD said that last month in December, it was brought to her attention that Resident #70 was having trouble chewing without her upper denture and the family member requested a pureed diet. RD said IDT and physician agreed with recommendation. RD said she had no updates on Resident #70's denture or dental visit status. Interview and observation with on 1/30/25 at 8:15 am observed staff removing breakfast trays from hallway and observation of Resident #70's breakfast tray revealed she had consumed all of hot cereal on tray for a meal intake of 25%,. 100% of coffee and health shake were consumed. The DON proceeded to bedside with surveyor and had Corporate Clinical Nurse on telephone at the time of the observation and interview. Resident #70 who was seated in bed appropriately groomed and dressed. Resident #70 said she did not have any issue with eating soft foods now but said that if she had her dentures, she would eat regular food. Resident #70 said that she had no pain in her mouth. Resident #70 said that she did not know when she was supposed to see the dentist because her family member kept track of all of those things for her. Resident #70 said she wished she had her teeth but did not feel neglected over not having them because she can eat other things and was not a big eater anyway . Resident #70 said she did not know how long it had been since she lost her teeth and said she did not feel like it was taking too long to get new ones. Resident #70 shrugged her shoulders and stated, what's time in a place like this. Resident #70 said she was [AGE] years old and content for now. Interview on 1/30/25 with DON at 09:00am she said she and her ADON were responsible for monitoring weights at the facility and that Resident #70 had no significant weight loss since the loss of her dentures. The DON said that the SW was responsible for ensuring residents were added to the dental list and that she was not aware of any significant delay in Resident #70 getting a dental referral and actual appointment with the dentist. The DON said that she did not believe Resident #70 had been neglected by having to eat a pureed diet due to not having her upper dentures and said that at one point Resident #70 had a referral to go home with family member on hospice. The DON said that she had not been updated on actual date of Resident #70's first dental appointment. The DON did not respond when asked if she thought waiting from November until February to see a dentist was too long. Telephone interview on 1/30/25 at 11:10 am with MDD A who said that Resident #70 was [AGE] years old and had no bone for her upper denture to fit properly and comfortable. MDD A said that bone loss was a part of the aging process and that most likely once Resident #70 received the new upper dentures, they will not fit her well or be comfortable and Resident #70 will most likely end up not wearing them. MDD A said that waiting from late November until mid-February to be seen by a dentist would not have a negative clinical impact on Resident #70 . Record review on 1/30/25 at 2:33pm of SW text message log revealed he placed calls and text messages to Dental Company A starting on 12/11/24. Requested dental policy and procedure from DON on 1/30/25 at 09:00am and Administrator on 1/30/25 at 11:13 am. At time of survey exit on 1/30/25 at 5:00pm, no policy had been provided to the survey team for review.

Based on Record review and interview, the facility failed to transmit encoded, accurate, and complete MDS data to the CMS System for 2 (Resident #15, Resident #56) of 18 residents reviewed for MDS transmission, in that: -The facility failed to transmit a completed Admission MDS assessment for Resident #15 - The facility failed to ensure Resident #56's Significant change MDS Assessment was completed within 14 days significant change. This failure could place residents at-risk of not having their assessments completed timely, which could result in denial of services and or payment for services. Findings include: Findings include. Record review of Resident #15's face sheet dated 01/29/25 revealed Resident #15 was a [AGE] year-old female, with an original admitted [DATE] and re admitted on [DATE]. Her diagnosis included acute pyelonephritis (A sudden and severe inflammation of kidney due to a bacterial infection). Muscle wasting, Hypothyroidism (a condition where the thyroid gland does not make enough hormone) communication deficit (Difficulty in communication that arises from impairments in cognitive process), unspecified lack of coordination, Unsteady feet. Record review of Resident #15's Admission MDS dated [DATE] was completed 02/13/25 which was 20 days after admission. Resident #56 Record review of Resident #56's face sheet dated 01/27/25 revealed Resident #56 was a [AGE] year-old female, with an original admitted [DATE] and re admitted on [DATE]. Her diagnosis included Respiratory failure, muscle wasting, hypothyroidism, Hypothyroidism (a condition where the thyroid gland does not make enough hormone) and depression. Record review of Resident #56's significant change MDS dated [DATE] was signed as completed on 09/17/24 53 days after significant change MDS. During an interview on 01/29/25 at 2:00PM, the MDS coordinator said she was not present at the facility during the time of the MDS assessment. She said the facility did an audit and was aware of the late MDS and had a plan of correction in place. She said she was responsible for ensuring that all MDS reflected resident's condition and are transmitted within a certain time frame. She said not completing the MDS in a timely manner could result in care plan not being completed and delay in care and services as well as denial of payment for services by payor source. During an interview with the DON on 01/28/24 at 4:00PM , she said she was not trained to sign the MDS and there was a Cooperate staff that signed off on the MDS. Policy on MDS completion and transmission was requested on 01/29/24 at 4:00 PM. MDS coordinator said she follows the RAI manual

Based on observation, interview and record review, the facility failed to maintain medical records on each resident that are accurately documented for 1 (Resident #3) of 5 residents reviewed for resident records. Resident #3's Medication Administration Record showed that Mucinex DM oral tablet extended release 12 Hour 30-600 mg was documented as being given when guaifenesin 400 mg tablet was administered. The failure could place residents who receive medications from facility staff at risk for less than therapeutic benefits, and/or not receiving ordered medications due to inaccurate documentation of administration. Findings include: Record Review of Resident 3's face sheet dated 1/30/25 revealed resident was a [AGE] year old male admitted to the facility on [DATE] with diagnoses including Cerebral Infarction (Stroke), Dysphagia (difficulty swallowing), Type 2 Diabetes Mellitus, Hypertensive Disease with Heart Failure with history of acute upper respiratory infection and acute bronchitis. Record review of Resident's 3's quarterly MDS dated [DATE] revealed a BIMS score of 15 that suggests Resident #3's cognition is intact. Record review of Resident 3's January Medication Administration Record printed on 1/30/25 revealed Mucinex DM Oral Tablet Extended Release 12 Hour 30-600 mg (Dextromethorphan-Guaifenesin) Give 1 tablet by mouth every 12 hours for Cough and congestion for 7 days with a start date of 1/22/25 at 9 a.m. and discontinue date of 1/28/25 at 4:57 p.m. Mucinex DM was documented as being administered from 1/22-1/27/25 at 9 a.m. and 9 p.m. and on 1/28/25 at 9 a.m. Record review of Resident 3's Care Plan provided on 1/30/25 revealed a focus that Resident 3 is at risk for frequent infections related to diabetes mellitus with goal that Resident 3 will have no complications related to diabetes through the review date. Observation of Resident 3's medication administration on 1/28/25 at 8:23 a.m. revealed that Resident 3 was administered guaifenesin 400 mg for order of Mucinex DM Oral Tablet Extended Release 12 Hour 30-600 mg (Dextromethorphan-Guaifenesin) Give 1 tablet by mouth every 12 hours by CMA A. Observation of 100 hallway medication cart on 1/28/25 at 4:55 p.m. with CMA A revealed that no Mucinex DM could be found with either the over the counter medications or with Resident #3's medications from the pharmacy. Interview of CMA A on 1/28/25 at 12:54 p.m. revealed that she notified the charge nurse (LVN B) about three days prior to interview when she could not find the Mucinex DM order and was instructed that she could give the guaifenesin 400 mg. CMA A said that the Mucinex was on order. CMA A said that Resident #3 was previously taking guaifenesin 400 mg and the order was recently changed to Mucinex DM . CMA A said that she normally works on the hall that Resident #3 is currently residing on which shows that CMA A is familiar with Resident #3 and gives his medications frequently. Interview of LVN B on 1/28/25 at 1:02 p.m. revealed that she was not aware that Resident #3 was receiving guaifenesin 400 mg instead of Mucinex DM. LVN B said that Resident #3 had been taking guaifenesin 400 mg for years and it was changed to Mucinex DM for seven days last week when resident got sick. Interview of CMA A on 1/28/25 at 4:47 p.m. revealed that she did not document in the facility's electronic medical record when she notified the nurse regarding needing Mucinex DM for Resident #3. CMA A stated that she does not chart notifications to the nurse in the electronic medical record. CMA A stated she has given Resident #3 guaifenesin 400 mg since she started working at the facility. Interview of LVN C on 1/29/25 at 11:22 a.m. revealed she could not remember administering specific medication to Resident #3 but was not aware of him missing any medications. Per Resident 3's January MAR, LVN C had documented administering Mucinex DM at 9 p.m. 1/23/25, 1/24/25 and 1/25/25. Interview of CMA B on 1/29/25 at 11:45 a.m. revealed that she would have administered medications to Resident #3 as what is documented on Resident 3's medication administration record. Per Resident 3's January MAR, CMA B had documented administering Mucinex DM at 9 a.m. on 1/25/25 and 1/26/25. Record review of facility's policy General Guidelines for Medication Administration revealed that medications are to be administered as prescribed in accordance with good nursing principles and practices. Record review of facility's policy Administration Procedures for All Medications revealed that after administration of a medication that staff should document administration in the MAR or TAR.

Based on observation, interview and record review, the facility failed to provide routine and emergency drugs and biologicals to its residents or obtain them under an agreement described in S483.70(f) for 1 (Resident #3) of 5 residents reviewed for pharmacy services. The facility failed to provide Mucinex DM as ordered for Resident #3. The failure could place residents at risk of receiving less than therapeutic benefits from medications. Findings include: Mucinex DM is a medication that has two ingredients which are guaifenesin and dextromethorphan. Guaifenesin is a medication that helps to clear chest congestion and dextromethorphan is a cough suppressant that relieves cough. Resident #3 was given only guaifenesin instead of Mucinex DM. Record review of Resident 3's Progress Notes dated 1/28/25 at 5:02 p.m. revealed that LVN B spoke to the resident's NP and that new order was received to discontinue Mucinex DM and restart Guaifenesin 400 mg oral twice a day routine for cough and congestion. Record Review of Resident 3's face sheet dated 1/30/25 revealed resident is a [AGE] year old male admitted to the facility on [DATE] with diagnoses including Cerebral Infarction (Stroke), Dysphagia (difficulty swallowing), Type 2 Diabetes Mellitus, Hypertensive Disease with Heart Failure with history of acute upper respiratory infection and acute bronchitis. Record review of Resident 3's quarterly MDS dated [DATE] revealed a BIMS score of 15 that suggests Resident #3's cognition is intact. Record review of Resident 3's January Medication Administration Record printed on 1/30/25 revealed Mucinex DM Oral Tablet Extended Release 12 Hour 30-600 mg (Dextromethorphan-Guaifenesin) Give 1 tablet by mouth every 12 hours for Cough and congestion for 7 days with a start date of 1/22/25 at 9 a.m. and discontinue date of 1/28/25 at 4:57 p.m. Mucinex DM was documented as being administered from 1/22-1/27/25 at 9 a.m. and 9 p.m. and on 1/28/25 at 9 a.m. Record review of Resident 3's Care Plan provided on 1/30/25 revealed a focus that Resident 3 is at risk for frequent infections related to diabetes mellitus with goal that Resident 3 will have no complications related to diabetes through the review date. Observation of Resident 3's medication administration on 1/28/25 at 8:23 a.m. revealed that Resident 3 was administered guaifenesin 400 mg for order of Mucinex DM Oral Tablet Extended Release 12 Hour 30-600 mg (Dextromethorphan-Guaifenesin) Give 1 tablet by mouth every 12 hours by CMA A. Interview of CMA A on 1/28/25 at 12:54 p.m. revealed that the process to order over the counter medications that are needed is to write the medication needed on a paper and give to the person who is over central supply. CMA A stated that over the counter medications are ordered twice a month. Observation of the facility's medication room on 1/28/25 at 1:01 p.m. accompanied by CMA A revealed that no Mucinex DM could be found with the over the counter medications stock. Interview of LVN B on 1/28/25 at 1:02 p.m. revealed that she was not aware that Resident #3 was receiving guaifenesin 400 mg instead of Mucinex DM and that the Mucinex DM was not in stock. LVN B said that when Mucinex DM was first ordered she found a box of Mucinex DM and had given it to the CMA. LVN B said that Resident #3 had been taking guaifenesin 400 mg for years and it was changed to Mucinex DM for seven days last week when resident got sick. Interview of Central Supply/Transportation on 1/28/25 at 1:10 p.m. revealed that staff will notify her when medications are not in stock. Central Supply/Transportation said that orders are placed once a week on Mondays, but she can run to a local pharmacy to purchase medications if needed. Observation of the facility's medication room on 1/28/25 at 1:25 p.m. accompanied by Central Supply/Transportation. No Mucinex DM could be found in the medication room with the assistance of Central Supply/Transportation. Interview of Central Supply/Transportation on 1/28/25 at 1:25 p.m. revealed that Mucinex DM was ordered and was suppose to be delivered last week but was delayed due to the winter storm that occurred on 1/21/25. Observation of 100 hallway medication cart on 1/28/25 at 4:55 p.m. with CMA A revealed that no Mucinex DM could be found with either the over the counter medications or with Resident #3's medications from the pharmacy. Interview of Central Supply/Transportation on 1/29/25 at 9:21 a.m. revealed that she will notify the DON and administrator if the supply truck does not arrive. Central Supply/Transportation said that if the supply truck does not arrive that she will reach out to sister facility for supplies. Central Supply/Transportation said that she makes the orders on Monday and the truck usually comes on Tuesday but she will wait a day before checking on the order. Central Supply/Transportation said she reached out on 1/22/25 regarding the order that should have arrived on 1/21/25 and was told the truck should arrive by 1/23-1/24/25 and by 1/27-1/28/25 at the latest. Central Supply/Transportation said the truck arrived early this morning on 1/29/25. Interview of DON on 1/29/25 at 11:06 a.m. revealed that the central supply person orders the over the counter medication after she is given a list from staff and that they inventory the over the counter stock as well. The DON stated that if there is a new order then the central supply person can go purchase the medication from a local pharmacy if needed. Interview with LVN C on 1/29/25 at 11:22 a.m. revealed she could not remember administering specific medication to Resident #3 but was not aware of him missing any medications. LVN C said she was responsible for refiling missing medications from medication cart if needed. LVN C said she would check the over the counter medication stock and the automated medication dispensing system if she was unable to find a medication that was ordered. Interview of CMA B on 1/29/25 at 11:45 a.m. revealed that if she needs an over the counter medication then she will check the medication room and if she is unable to find the medication that she would notify the charge nurse. CMA B said she would make a list for Central Supply/Transportation and give them the list directly. Record review of facility's policy House Supplied (Floor Stock) Medications revealed that the facility may maintain a supply of commonly used over-the-counter (OTC) medications considered floor stock or house medications (not resident-specific), to be administered only upon receipt of an order from an authorized prescriber. Record review of facility's policy General Guidelines for Medication Administration revealed that the facility is to have a sufficient medication distribution system to ensure safe administration of medications with unnecessary interruptions.

Based on observation, interview and record review, the facility failed to ensure that parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders and consistent with professional standards for 1 (Resident #286) of 2 residents reviewed for intravenous fluids. The facility failed to ensure that the dressing on Resident #286's mid-line intravenous line (a short flexible tube inserted into a vein to administer fluids and medications) was changed according to the doctor's order and facility's standard of care. The failure could place residents at risk of infections. Findings include: Record Review of Resident 286's face sheet dated 1/30/25, revealed resident is a [AGE] year old female admitted to the facility on [DATE] with diagnoses including Unspecified Dementia, Urinary Tract Infection, Type 2 Diabetes and Unspecified Systolic (Congestive) Heart Failure. Record review of Resident 286's quarterly MDS dated [DATE] revealed a BIMS score of 13 that suggests that Resident 286's cognition is intact. Record review of Resident 286's order summary report dated 1/27/25 reflected the following orders: Mid line dressing and cap change weekly using sterile technique per protocol as needed with an order and start date of 01/20/2025. Mid line dressing and cap change weekly using sterile technique per protocol one time a day every Mon for prophylaxis with order date of 1/20/25 and start date of 1/27/25. Record review of Resident 286's care plan with an admitted [DATE] revealed focus that resident is on antibiotic(s) and is at risk for adverse reactions. Record review of Resident 286's January medication and treatment administration record printed on 1/30/25 revealed that there were no mid line dressing and cap changes documented during 1/20-1/26/25. Per treatment administration record Resident 286 was monitored for signs and symptoms of infection every 8 hours from 1/20-1/30/25. Record review of Resident 286's January medication and treatment administration record printed on 1/30/25 revealed that Resident 286 received IV antibiotics (Meropenem) and Metronidazole every 8 hours as from 1/20-1/27/25. Observation of Resident 286 on 1/27/25 at 11:55 a.m., revealed resident was in her room, lying in bed. Resident was observed to have a midline to her right upper arm with dressing dated 1/18/25. Interview with LVA A on 1/27/25 at 11:55 a.m. revealed that she also confirmed that Resident 286's midline dressing was dated 1/18/25. LVA A stated that Resident 286's midline dressing should have been changed around 1/26/25 and that night shift usually changes the IV dressings. Interview with DON on 1/27/25 at 3:36 p.m. revealed that they do not have a policy for midline dressing changes and the competency is the only form they have. The DON confirmed that IV dressing changes should be completed every five to seven days per facility's competency. Interview of DON on 1/29/25 at 11:06 a.m. revealed that IV dressing changes are to be done every five to seven days and the nurse is responsible with the practice being the night shift changes the IV dressings. Record review of the facility's competency assessment for peripheral IV dressing changes revealed that dressings are to be changed at least every 5 to 7 days.

Based on observation, interview, and record review, the facility failed to ensure residents were free from Misappropriation of property for one (Resident #15) of 18 residents reviewed for misappropriation of property. The facility failed to ensure Resident #15 was free from misappropriation of property when an employee used her credit card for personal benefit. The non-compliance was identified as past non-compliance. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of Exploitation/Misappropriation of Property and financial distress. Findings include: Record review of Resident #15's face sheet dated 01/29/25 revealed [AGE] year-old female, with an original admitted [DATE] and re admitted on [DATE]. Her diagnosis included acute pyelonephritis (A sudden and severe inflammation of kidney due to a bacterial infection). Muscle wasting, Hypothyroidism (a condition where the thyroid gland does not make enough hormone) communication deficit (Difficulty in communication that arises from impairments in cognitive process), unspecified lack of coordination, Unsteadiness on feet. Record review of Resident #15's Admission MDS assessment dated [DATE] revealed she had a BIMS score of 12 out of 15, which indicated moderate cognitive impairment. Resident #15 was independent with ADLs for toileting and personal hygiene coded as limited assistant. Record review of PIR (Form 3613-A of Texas Health and Human Services) dated 12/30/24 read in part Resident #15's responsible party reported that there were fraudulent charges on Resident #15's debit card. RP stated that Resident #15's debit card was mission and there were charges on the debit card. Record review of Facility's communication with Resident #15's RP revealed Resident #15's debit card was stolen at the facility and two charges were made on the debit card as $30.66 at a gas station on Hwy 3 and $73.61 for margaritas down in Lake [NAME] Texas. Observation and interview on interview on 01/27/25 at 10:00AM, revealed Resident #15 was present at the facility in her room, in bed, alert and oriented. During an interview she said she was doing well and sleepy. In an interview with Resident #15 on 01/27/25 at 1:00PM, she said she remembered the incident very well. She said she wanted a cup of coffee and the girl (CNA T) said she was on her break and would get her the coffee. Resident #15 said e CNA T sat at the edge of her bed. Resident #15 said she took the $6 from her purse and her debit card might have fallen out and she did not know until her daughter called her to ask if she gave her debit card to anyone. Resident #15 said she told her RP no and explained to her RP that she sent someone out to the store to get her coffee but gave the staff the sum of #$6.00 for the coffee. Resident #15 said she remembered the staff very well and called CNA T by name and described her as golden girl because CNA T had some earrings on her face and nose. Phone call was made to Resident #15's RP on 01/27/25 at 4:00pm, no answer. Second phone call was made on 01/28/24 at 11:00am and at 4:30pm no answer voice message was with a phone #. During an interview with the Facility's Administrator and the DON on 01/28/24 at 2:00pm, the DON said the facility know exactly who the staff was by Resident #15's description of the staff, the schedule and sign in sheet. The DON identified the CNA' as CNA T. The DON said the police was called by Resident #15's RP as soon as she discovered that Resident #15's debit card was stolen and there were charges made on it. The DON said as soon as she received the e-mail, herself, the Administrator, and the Social Worker started an investigation and reported it to the State as required. The DON on said the police walk walked in almost at the same time while she was doing the investigation. She said the police asked for the staff that worked on the 29 and the 30th of December 2024. The DON said CNA T had gone out through the back door out of the facility. The DON said she called CNA T and CNA T told her that she had a ticket in at another county, and she was on her way to pay the ticket. The DON said the police gave a case # and a copy of the video that shows CNA T purchasing goods from the store. The DON said CNA CAN T worked from 12/11/24 through 12/30/24 the day the police showed up for the investigation. The DON provided CNACAN T. signed schedules and timecard that indicated CNA clocked in and out. Phone call placed to CNA T on 01/28/25 at 3:00PM. No answer; message was left with a returned phone #. During a phone interview on 1/29/25 at 2:30PM, CNA T said she worked at the facility for 3 days and she did not work with Resident #15. She said she worked with another CNA, CNA K that worked with Resident #15. She said the CNA K gave her ride to the store because CNA K was going to get coffee for Resident #15. CNA T said she bought some goods and paid for what she bought with her card. She said she does not remember CNA CAN K's full name. She gave a name that did not exist on the employee list provided by the facility. CNA T said she did not clock in at the facility because she did not have a pin # to clock in since she was on orientation. She said she wrote her hours on a paper and submitted it to the DON. She said she did not work at the facility on 12/29/2024 to 12/30/20244 because she lost her son on the 12/29/24. She said she did not go back to the facility to work due to poor working condition of not being trained and not having enough staff. Phone call was made to Local Police department that investigated that investigated the case on 01/30/25 at 3:30pm. Message left with a returned call phone # and case #-2403057. Second attempt was made on 01/30/25 at 5:00pm. Record review of facility's schedules with signatures revealed CNA T was hired on 12/10/24. She had two-day orientation on 12/11/24 and 12/12/24. Record review of signed schedules revealed CNA T worked till 12/30/24. Record review of facility of facility's provided policy on abuse, neglect and exploitation dated 02/01/2017 revised 01/01/2023 read in part The purpose of this policy is to ensure that each resident has the right to be free from any type of Abuse, Neglect, Intimidation, Involuntary Seclusion/Confinement, and or Misappropriation of property.

Based on observation , interview, and record review the facility failed to ensure the resident's had the right to have reasonable access to the use of telephone and a place in the facility where calls can be made without being without being overheard for 1 of 3 (Resident #1) residents reviewed for communication. The facility failed to provide a place for Resident #1 to make telephone calls without being overheard. Observation of Resident #1 using the phone at nursing station while (3) nurses were at the nurse station and (2) other resident's at the nurse station receiving medication. This failure could place residents at risk of conversation being overheard and privacy right's not being respected and could result in a decline in resident's psychosocial well-being and quality of life. Findings include: Record review of Resident #1 admission face sheet dated 01/14/2021 reflected a [AGE] year-old male admitted on [DATE]. Record review of Resident #1's History and Physical dated 01/28/23 revealed diagnosis of depression (a common mental health condition characterized by persistent low mood, loss of interest or pleasure in activities, and other symptoms that interfere with daily functioning.) Record review of Resident #1's MDS dated [DATE] revealed a BIMS of 14 indicating the resident was cognitively intact. During Interview with Resident #1 on 1/28/2025 at 10:30AM. Resident #1 said he called his friends or family on the phone at the nursing station he was told that is the only place to make a telephone call or if you have a cell phone. Resident #1 said the facility does not have a cordless phone to use and most of my conversations are heard by the nurses or anyone walking by. Resident #1 said we only get 15 minutes due to the nursing staff needing to use the phone. Resident #1 said he had not been offered any other phone to use in private. Resident #1 said he knows how to use the phone however staff will call the number for him. Resident #1 said he does not feel secure in his conversations and speaking in an open area, and he knows the nurse can hear his conversation. Resident #1 said it makes him feel like he does not have any privacy. During Interview with DON on 1/28/2025 at 11:20 am the DON said the nurse's station is the only area for residents to use the phone. Many of the alert residents have their own personal cell phones. The DON said unfortunately we do not have an area for the Residents to use for privacy. During Interview with facility Administrator on 1/28/2025 at 12:00 pm the Administrator said the residents are able to use the phone at the nurse station or at the receptionist desk if need be. He stated I have a phone by my office that they can use also but as of now we do not have designated area for the resident to use, we are currently working on that. The Administrator said the facility did not have a policy on resident phone use and privacy.

Based on interview and record review, the facility failed to ensure residents were free from verbal abuse for 1 of 5 residents (Resident # 1) reviewed for abuse. The facility failed to prevent Med Aide A, on 11/18/2024, from verbally abusing Resident # 1 when he used foul language. These failures could place residents at risk of emotional distress, fear, decreased quality of life and further abuse. Findings included: Review of face sheet for Resident # 1, dated 11/21/2024, reflected he was admitted to the facility on [DATE] with diagnoses of : Major Depressive Disorder(is a serious mood disorder that can affect how someone feels, thinks, and acts), Unspecified Osteoarthritis ( is a type of arthritis that affects an unspecified joint), and Anxiety Disorder (a mental health condition that involves persistent and uncontrollable feelings of fear and anxiety that can significantly impact a person's life). Review of the Quarterly MDS Assessment for Resident # 1, dated 11/6/2024 reflected Resident # 1 BIMS score was 15 and he had the ability to express ideas and wants. His physical assessments reflect. He needed extensive assistance with bed mobility, transfers, and ADL's. He needed limited assistance with eating. He was assessed as always incontinent of bladder and bowel. Review of the Care Plan for Resident # 1 revision date 7/2/2024 reflected interventions were in place for: bathing/showering bed mobility and personal hygiene. Provide supportive care, assistance with mobility as needed. Review of the facility investigation reflected the incident was reported on 11/19/2024 and occurred on the evening of 11/18/2024. Review of the incident report reflected Resident # 1 was to by Med Aide A FU Resident # 1. CNA B said Med Aide A said, FU Resident # 1. On interview by the DON Resident # 1 corroborated the statement. Resident # 1 said he has shoulder pain. Assessment of Resident # 1 showed no signs of physical injury. In an interview on 11/21/2024 at 2:00 pm Resident # 1 stated on 11/18/2024 CNA A needed to give him a bed bath. He stated CNA A needed to place a sheet under him. He stated CNA A needed him to turn to his right side. He stated CNA A was new, and she did not know how to handle him. He stated CNA A asked CNA B to assist. He said he was trying to tell CNA A and CNA B how to position him. He stated CNA A said they needed assistance from an aide who was familiar with working with him and CNA A got Med Aide A to assist them. He said Med Aide A arrived at his room and immediately began to be rude. He stated Med Aide A told him Come on Resident # 1 we have things to do, and we cannot be in your room all day. Resident # 1 stated he can turn himself and hold on to the bed rail. He said CNA A and CNA B used a bed sheet to help roll him to the left side. He stated Med Aide A was shrugging and pushing his right shoulder. Resident # 1 said he told Med Aide A to stop because he was too rough. Resident # 1 said he asked Med Aide A to leave his room. He said Med Aide A told him Resident # 1 Ioing to let you have it. F it. He said Med Aide A remained in the room and he asked him to leave again. He stated as Med Aide A was leaving the room he said F you Resident # 1. Resident # 1 stated he felt fine and safe since Med Aide A was removed from the building. He stated Med Aide A had demonstrated a bad attitude on different occasions. He stated that he immediately reported this incident to LVN A and the DON. In an interview on 11/21/2024 at 3:45 pm CNA A stated she and CNA B went to give Resident # 1 a bed bath. She stated Resident # 1was a huge patient, and this was the first time she worked with him. She stated she left the room to get linen and wipes. She stated when she returned to the room, she and CNA B did a comfort bath on Resident # 1. She stated Resident # 1 was disrespectful to her and CNA B. She stated Resident # 1 told her how to properly bathe him. She stated she asked Med Aide A to assist as Med Aide A was Resident # 1's CNA in the past. She stated Resident # 1 seen Med Aide A and said, get the F out my room. She stated Med Aide A continued to assist with the patients care. She stated Resident # 1 had a draw sheet under him and this sheet made it easier to turn Resident # 1. She stated Resident # 1 was holding the bed rail while Med Aide A was positioning the sheets under Resident # 1. She stated she was trying to clean Resident # 1. She stated Resident # 1 yelled again for Med Aide A to get out of his room. She stated Med Aide A was walking out of Resident # 1's room and Med Aide A said, F it. She stated that she continued to provide care to Resident # 1. She stated that Resident # 1 told her that if she wanted to know how to care for him, to ask him. She stated that LVN A and the DON immediately came to Resident # 1's room. She stated she provided a written statement to the DON. Review of a Statement from CNA B dated 11/18/2024 reflected she had overheard Med Aide A tell Resident # 1 FU Resident # 1 In an interview on 11/21/2024 at 4:10 pm CNA B stated she was assisting CNA A with Resident # 1's bed bath. She stated when she arrived at Resident # 1's room both Resident # 1 and CNA A were aggravated. She stated Resident # 1 was trying to tell CNA A how he wanted things done. CNA B stated both she and CNA A were new, therefore, she left the room to find the nurse as she wanted to make certain they were following the proper protocol for Resident # 1's line of care. She stated she could not find the nurse, so she returned to Resident # 1's room. She said Med Aide A offered to assist. She stated Med Aide A entered Resident # 1's room and he said to Resident # 1 let's get this done. She said Med Aide A was a little rough with Resident # 1. She stated she witnessed Med Aide A Grab Resident # 1's arm and pull it up as Med Aide A was trying to force Resident # 1 roll over. CNA B stated she had worked with Resident # 1, and he can roll over he was just a little slow. CNA B stated Resident # 1 told Med Aide A to leave his room. Resident # 1 told Med Aide A he wanted me and CNA A to finish his care. She stated Med Aide A refused to leave Resident # 1's room. She stated Resident # 1 told Med Aide A I told you to leave my room. She stated Med Aide Asaid, F it. She said as Med Aide A was leaving the room he turned around and told Resident # 1 FU Resident # 1 and he walked out the room. She stated Med Aide A should have left the room when first asked. She stated she and CNA finished cleaning Resident # 1. CNA B felt Resident # 1 was verbally abused by Med Aide A. CNA B stated that she immediately reported this abuse to LVN A. In an interview on 11/21/2024 at 3:06 pm LVN A stated Resident # 1 reported that CNA A and CNA B were providing care to him. He stated that the CNA's were completing their care when Med Aide A came in the room to assist them. She stated Resident # 1 reported that Med Aide A was trying to turn him, and Med Aide A pulled his right arm. She said Resident # 1 reported when Med Aide attempted to pull his right arm again, he asked Med Aide A to stop. She stated Resident #1 told her Med Aide A told him FU Resident # 1. LVN A stated Resident # 1 reported Med Aide A hurt his right shoulder when he pulled him. LVN A stated she assessed Resident # 1 and reported the incident to the DON. LVN A stated based on what Resident # 1 reported to her she felt as though Resident # 1 was verbally abused by Med Aide A. In a telephone interview on 11/21/2024 at 3:30 pm, Med Aide said he also worked as a CNA. He stated he has been Resident # 1's CNA. He stated he was working the medication cart on 11/18/2024 when CNA A asked for assistance with Resident # 1. He stated CNA A was new, and she informed him she was trying to give Resident # 1 a bed bath and she asked if I could assist with turning Resident # 1. He stated Resident # 1 can assist with turning as Resident # 1 will grab the bed rail for support and turn. He stated Resident # 1 was turned by scooching over to the left and Resident # 1 will grab the bed rail while he pushed his shoulder with the sheet and tuck the sheet under him. He stated this day Resident # 1 wanted to be pushed by the hip. He stated while the CNA was cleaning Resident # 1, he took the lining and rolled it up so Resident # 1 could turn on the other side. He said Resident # 1 started yelling I'm not clean yet. He stated Resident # 1 had things when it was a new worker, he tried to go above and beyond. He stated Resident # 1 wanted to guide staff through the whole thing by telling them how to clean him. He stated Resident # 1 was turned to side, and he was getting ready to put his diaper on him. He stated Resident # 1 told him Boy you better get out of here. He said Resident # 1 let the rail go and he landed flat on his back. He said Resident # 1 tried to swing at him and told him to leave the room. He said he told Resident # 1 Resident # 1 you got this and he left out the room. He denied speaking to Resident # 1 inappropriately. He denied saying FU or F it. Med Aide said he was trained in Abuse, Neglect and Exploitation. In an interview on 11/21/2024@ 4:27 pm with the DON on 11/18/2024 LVN A informed her the CNA needed to report something that was going on with Resident # 1. She stated she went to Resident # 1's room and Resident # 1 informed her that he was verbally abused by Med Aide A. She stated she immediately asked Med Aide A to get off the floor and to go to her office. The DON stated she spoke with Resident # 1 who informed her that Med Aide A told him FU Resident # 1. She stated she assessed and interviewed Resident # 1. She stated Resident # 1 said Med Aide A was rough with him. He stated Med Aide A pushed him too hard. He stated that Resident # 1 told her he was trying to turn to hold the bar when Med Aide A pushed his shoulder. She stated she called Resident # 1's doctor and he ordered a stat x ray of the shoulder. She stated Resident # 1 told her he told Med Aide A to get out his room and Med Aide A said, FU Resident # 1. The DON stated that skin and pain assessment was performed on Resident # 1. The DON stated at the time of the assessment Resident # 1 reported he was in pain because he had received pain medications. The DON stated Med Aide A was suspended that day and was removed from the floor immediately. The DON stated safety surveys have been conducted to make sure all residents feel safe. The DON stated if Med Aide A said to Resident # 1 FU Resident #1that was verbal abuse. The DON stated interviews were conducted with Resident # 1, Med Aide A, LVN A, CNA A and CNA B. The DON stated all staff have been trained in abuse, neglect, and exploitation. In an interview on 11/21/2024 at 4:56 pm with the Administrator, he said he expected his team to be professional, including no profanity or abuse. The Administrator stated he expected staff to follow rules and regulations passed by the State of Texas. He stated he was notified about the incident between Resident # 1 and Med Aide A on Monday night. He stated the incident report was sent to the state on Tuesday. He stated the investigation has been done to include interviews with Resident # 1, CNA's, Med Aide A and LVN A. He stated Med Aide A was suspended. He stated abuse Inservice and safe surveys were conducted. The Administrator stated all staff have been in serviced on abuse and neglect. Review of Med Aide A's employee record reflected he was hired on 7/23/2024 background check. completed; his last abuse prevention training was done on 7/23/2024. Review of a Statement from LVN A dated 11/18/2024 reflected that Resident # 1 reported that Med Aide A told him FU Resident # 1 FU Review of the Facility Policy on Abuse Neglect dated 2/1/2027 reflected the resident has a right to be free from any type of Abuse, . The facility staff will adhere to the policies and procedure and will follow the guidelines in the written policy and procedure. Examples of verbal abuse threats of harm, saying things that frighten a resident, name calling, bullying, demeaning, intimidating, or controlling.

Based on record review and interview, the facility failed to immediately inform the resident representative(s) of the need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for one (Resident #1) of five residents reviewed for notification of changes. -The facility failed to ensure they reported, to Resident #1's Representative on 09/30/2024, Resident #1's change of condition with moisture associated skin damage (MASD) on the sacrum and buttock to include new orders for zinc oxide (used to treat and prevent diaper rash and other minor skin irritations). - The facility failed to ensure they reported, to Resident #1's Representative on 09/30/2024, when noted blanching redness to the left lateral forefoot and the left heel on Resident#1. These failures could place residents at risk for harm and not allowing the opportunity for consent of care. Findings included: Record review of Resident #1's (undated) face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included cognitive communication deficit (difficulty paying attention to a conversation, staying on topic, remembering information, responding accurately, understanding jokes or metaphors, or following directions), dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage) and cellulitis (a common, potentially serious bacterial skin infection). Further review revealed Resident #1's family member was identified as Resident #1's Medical and Financial Power of Attorney, Responsible Party, and Emergency Contact. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed she had a BIMS score 08 out of 15 which indicated she had moderately impaired cognition. She required partial/moderate assistance with toileting hygiene, shower/bathe self and required substantial/maximal assistance with personal hygiene. Record review of Resident#1's care plan initiated 09/30/2024 and revised on 10/10/2024 revealed the following read in part: . Focus: The resident has potential/actual impairment to skin integrity of the Buttock r/t Incontinence and immobility. Goal: The resident will maintain or develop clean and intact skin by the review date. Target Date: 12/31/2024. The resident will have no complications r/t (SPECIFY skin injury type) of the (SPECIFY location) through the review date. Target Date: 12/31/2024. Interventions: Follow facility protocols for treatment of injury. Reposition resident while in bed every 2 hours to relieve pressure. Educate resident/family/caregivers of causative factors and measures to prevent skin injury . Record review of Resident #1's Physician orders dated 09/30/2024 revealed an order to apply zinc oxide to MASD on the sacrum and buttock area every shift and PRN until healed. Every shift for Skin integrity. Record review of Resident #1's Treatment Administration Record for the month of October 2024 revealed that Resident #1 was receiving zinc oxide on the 6am to 6pm shift and 6pm to 6am shift. Record review of Resident #1's nurse's notes dated 09/30/2024 at 4:19 pm written by the Wound Care Nurse read in part: .Resident has noted MASD to the buttock zinc applied and treatment in place. Resident has blanching redness to the left lateral forefoot and the left heel . Record review of Resident #1's electronic Medical Record revealed no documentation that the family representative was informed about that change in medication/skin impairment. In a telephone interview on 10/21/2024 at 12:12 p.m., Resident #1's representative stated she had not received any communication that her loved one had bed sores until she learned herself by visiting Resident #1 at the hospital on 10/15/2024. In an interview on 10/21/2024 at 4:05 p.m., with the Wound Care Nurse stated she reviewed Resident #1's nurses notes with the Surveyor. The Wound Care Nurse stated that resident's responsible party should have been informed about the new order. The Wound Care Nurse stated that she did not see any documentation that she notified the Responsible party I forgot to notify the family . In an interview on 10/21/2024 at 4:49 p.m., with LVN A, she stated any time a new mediation was ordered or there was a change in condition, family needed to be notified, so that they were aware of the resident's new order and document in the progress notes. In an interview on 10/21/2024 at 5:04 p.m., with the Wound Care Nurse and the DON. The DON stated that nurses were to notify the family at the start of a new medication or change in condition. The DON stated she re-educated the Wound Care Nurse on the change of conditions protocols to include notifications for residents and their representatives any new orders and or treatments in their care. DON stated family/representatives needed to know so they could have ease of mind. Nurses needed to notify plan of care as it prevents the family from feeling their loved ones are not neglected and in the know of any changes in patients. Record Review of the facility's Change in a Resident's Condition or Status policy (Revised May 2017) read in part: .Policy Statement: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: b. There is a significant change in the resident's physical, mental, or psychosocial status; 5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. .

Based on observation, interview, and record review, the facility failed to ensure that residents received the necessary treatment and services, to promote healing, prevent infection for 1 of 5 residents (Resident #2) reviewed for pressure ulcers in that: -The facility failed to ensure Resident #2's right buttock stage 3 wound had a dressing covering the wound on 10/25/24. This failure could affect residents with wounds placing them at risk of infection, a decline in health, pain, and hospitalization . Findings included: Record review of Resident #2's (undated) face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included pressure ulcer of sacral region, stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle), type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) and bed confinement status (which is meant for patients confirmed to be bedridden). Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed he had a BIMS score 10 out of 15 which indicated he had moderately impaired cognition. He required substantial/maximal assistance with toileting hygiene, shower/bathe self, and personal hygiene. Record review of Resident #2's care plan initiated 03/21/2019 and revised on 10/25/2024 revealed the following: Focus: The resident has Stage 3 pressure injury to the Rt. Buttock D/T immobility. Goal: The resident's pressure ulcer will show signs of healing and remain free from infection by/through review date. Target Date: 12/31/2024. Interventions: Monitor dressing daily to ensure it is intact and adhering. Report lose dressing to Treatment nurse. Record review of the Physician's orders for Resident #2 revealed an order to Cleanse stage 3 Pressure Injury to the Rt. buttock with moistened 4x4 gauze with WC/NS, Pat dry, apply Honey and calcium alginate, cover with border gauze dressing daily and PRN for soilage/dislodgement until healed. as needed for soilage/dislodgment Observation and attempted interview on 10/25/24 at 12:13 p.m., revealed Resident #2 was resting in his bed. He was alert and well groomed. The resident mumbled for 5 minutes while being interviewed and could not make himself understood and did not respond appropriately to asked questions about his pressure sore/injuries. Observation on 10/25/24 at 12:18 p.m., revealed the Wound Care Nurse providing wound care for Resident #2. The Wound Care Nurse was assisted by ADON A. An open area of approximately 2.0 centimeters in diameter, was observed without a dressing on the right buttock. The Wound Care Nurse said, WCD did the dressing yesterday it must have come off. In an interview on 10/25/24 at 12:36 p.m., with CNA BB, she stated she provided peri care and got the resident dressed for his appointment that morning around 7:20 am. She stated there was 1 patch on the resident's bottom which was pretty soiled with BM. She stated she did not notify the Wound Care nurse or the floor nurse that the dressing needed to be changed because the transport was already in the room waiting to take the resident. In an interview on 10/25/24 at 12:41 p.m., with the Wound Care Nurse, she confirmed Resident #2's right buttock wound did not have a dressing on it. She said the CNA should have immediately notified her or the floor nurse because there were prn orders if the dressing became soiled or dislodged. The WCN stated it was important to provide dressings on the wound to keep it protected from infections. Wound bed could damage by scaping on brief itself . Feces can get in it and cause delayed healing. In an interview on 10/25/24 at 1:01 p.m., the DON stated the Wound Care Nurse was responsible for wound care Monday through Friday and the floor nurses were responsible for wound care on the weekends. The Surveyor shared the observation from earlier. The DON said her exception was for wound dressings to be changed daily and as needed if soiled or dislodged according to physician's orders. She stated the CNA should have notified the charge nurse/wound care nurse so they could dress the wound. She stated it was important to dress the wound to prevent infection. If the wound was left open it can get germs, delayed wound healing and for patient's comfort . In an interview on 10/25/24 at 2:11 p.m., with LVN Z, she said the CNA did not notify her that Resident #2's dressing had come off. She said the CNAs were supposed to come and tell the nurses right away so the nurse can dress the wound as there were prn orders for dressing change. Record review of the facility's Skin Management policy (Last Revised: 10/06/2022) revealed read in part: .POLICY: The purpose of this procedure is for prevention and treatment of skin breakdown such as pressure injuries, diabetic ulcers, arterial ulcers, and skin wounds. 4. Treatment: Wound care dressings are dated and initialed .

Based on interview and record review the facility failed to provide pharmaceutical services to include procedures that assure the accurate administering of all drugs and biologicals to meet the needs of each resident for 1 of 6 (CR#1) residents reviewed for pharmacy services to meet the needs of each resident in that: 1. The facility failed to ensure physician ordered, Tramadol (an FDA controlled medication for pain) was provided the scheduled or PRN as resident requested for her pain; 2. The facility failed to ensure Nifedipine hypertension medication was provided to CR#1 causing a high systolic pressure and hospital admission. This failure caused CR#1 to have unresolved pain and an increase in her BP and placed all residents in the facility at risk for missed medications. Findings Included: Record review of CR#1's undated face sheet revealed an [AGE] year-old woman who was admitted to the facility on [DATE] with diagnoses of Unspecified Dementia (a general term for a group of thinking and social symptoms that interferes with daily functioning), Hyperlipidemia (a condition in which rthere are high levels of fat particle in the blood) , Hypertensive heart disease(changes in the left ventricle, left atrium as a result of chronic blood pressure elevation) with heart failure and low back pain. Record review of CR#1's MDS dated [DATE] revealed Section C500- Brief interview of mental status (BIMS) score was 13, which meant she was cognitively intact. Record review of CR #1's physician orders dated 1/23/2023 revealed Tramadol HCL oral tablet 100 mg every 12 hours as needed for pain and twice PRN and Nifedipine Oral capsule 10 mg by mouth at bedtime for HTN (hypertension) hold for SBP (systolic blood pressure) <100. Record review of CR#1's MAR dated 1/1/2024-1/31/2024 record revealed no one documented that Tramadol HCL 100 mg oral tablet was given on 1/15, or 1/18 on night shift. Further review revealed Nifedipine 10 mgs was not documented as given on 1/9, 1/15 or 1/18/2024. 1/9/2024- Blood pressure shows N/A in documentation. 1/15/2024 - Blood pressure was documented as 134/78. It should have been given 1/18/2024- Blood pressure was documented as 120/71 .It should have been given. Record review of Disciplinary action record revealed DON wrote a written action notice for LVN A on 1/23/2024. Dates of occurrences were 1/15/2024 and 1/18/2024. Facts regarding incident: LVN A failed to administer scheduled medication to CR#1. LVN A failed to document why medication was not given. Expectations for team member behavior: LVN A will administer resident medications as ordered when unable to she will document accordingly. An interview with CR#1's RP on 1/30/2024 at 2:45 p.m. revealed CR#1 had been admitted to the hospital on 1/19/2024 due to her blood pressure being elevated to 200/67. She said she learned that LVN A had not been administering CR#1's pain or high blood pressure medications. She said she learned about CR#1's missed medications on or about 1/18/2024 when she received a call from an unnamed Nurse. She said she was not sure of the exact date she received the call. She said the doctor decided to send her to the hospital because CR#1's blood pressure was high. She was discharged to the hospital on 1/19/2024 and will not return to the facility. She said was not aware of the exact days CR#1 missed her medications. An interview with Regional Operations Manager on 1/30/2024 at 3:07pm, revealed she stated LVN A failed to ensure CR#1 received her pain or hypertension medications. She could not recall which medication was not administered at the time. She stated she was out of the building and received a call from a former nurse (RN A) who stated she ran a missed medication report and learned that LVN A did not administer medications. She said RN A said told the DON and she instructed the DON to do a written warning of discipline. She said the Regional Nurse had remote access and reviewed the MAR and LVN A had put see progress note by the reason the medication was not given. She stated again that she did not recall which medications but recalled that it was 2 days. She said that LVN A had been educated on Neglect by the DON. She said the physician had been notified. An interview with the DON on 1/30/2024 at 3:21pm revealed she wrote the written disciplinary action for LVN A . She stated former nurse (RN A) ran a missed medication report and verified that LVN A had not given CR#1 her hypertension medication on 1/15/2024 and 1/18/2024. She said it was her understanding on the evening of 1/15/2024 CR#1 had visitors in her room and did not want her pain medication at the time. She said she is not sure what exactly happened. But, LVN A did not document that she had given her the pain or hypertension medication. She said she looked at the schedule and LVN A worked both nights she was supposed to get the night dose of Nifedipine or the scheduled Tramadol. She said her expectation is that all medications will be administered as ordered, document any refusals and notify the physician. She said the physician and family were notified. An interview with the Administrator on 2/1/2024 at 9:23am, revealed she had been employed two days at the facility. She said she wanted to learn more information and called LVN A to interview about the incident. She said LVN A stated CR#1 was in a bad mood on 1/18/2024 and refused her Tramadol although she was complaining about being in pain. She said she questioned why a resident in pain would refuse her pain medication. She said LVN A said CR#1 did not want it on or about 10pm but she later gave CR#1 the medication. She said she was confused about this situation. She said she spoke with two CNA's that said the Resident was agitated. She said she was still looking into the incident. An interview with LVN A on 2/1/24 at 11:15am, states she and CR#1 had a good relationship. She said she attempted to give her medications 1/18/2024/around 10pm but she did not want her melatonin until she had taken her shower. She said Melatonin and all her medications were provided on the 15th and 18th. She said CR#1 had no issues taking her blood pressure medication and her blood pressure was in normal range. LVN A stated CR#1 refused a PRN medication (tramadol) on the 19th around 4 a.m. after complaining of pain . She said the resident got angry saying that she should have offered the medication earlier in the night and she used expletives towards her. She explained that it is a PRN medication, and she has to tell her she needed it for her pain. CR #1 was screaming down the hallway. Aides in room with her. LVN A said she did not pop the medication. It was her understanding that CR#1 told the DON said she had not given CR#1 her medications. She said denied CR#1 used expletives prior to this incident. She said it is her job to provide medications as ordered. She said on the night of 2/18/2024 the computer was glitching and this might be why her documentation was not there, but she did administer all medications as ordered. An interview with CR#1 on 2/1/2024 at 3:30 p.m. revealed LVN A did not give her Tramadol like she requested on 1/15, 1/18 and a night prior but she could not recall the date. She said she requested her Tramadol later during the night when she was ready to sleep due to her back pain. She said she was currently at a local hospital and had a pacemaker put in earlier today (2/1/2024). She said she had no issues getting her medications except the last few days before she left the facility. CR#1 said she was not sure why those nights were a problem for LVN A to give her medications as she requested. She said she never denied her blood pressure or pain medication. She would sometimes ask LVN A to come back to give her the Tramadol. Record review of the medication and orders policy revised 7/2016 did not address missed medications or documentation requirements.

Based on interview and record review, the facility failed to provide services in accordance with the written Plan of Care for 1 of 6 residents (CR #1) reviewed for compliance with physician's orders [REDACTED]. -CR # 1 did not receive laxatives as ordered if there was no bowel movement for 24 hours; - CR #1 was transferred to the hospital on [DATE] with distended abdomen, decreased consciousness, lethargy and unresponsiveness. CR #1 expired [DATE] with immediate cause of death of fecal impaction. This failure affected 1 resident and placed 109 current residents at risk for not receiving the care and services ordered by the physician and a decline in health status. Complaint # 0 Findings include: CR #1 Record review of the facility face sheet revealed CR #1 was a [AGE] year old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. CR #1 expired at a local hospital on [DATE]. Record review of the annual MDS dated , [DATE], revealed in part: CR#1 was cognitively impaired, was total dependent on two staff for transfer and toilet use and was always incontinent of bowel and bladder. Record review of the care plan initiated [DATE] for CR #1 Revealed in part:- "I have a history of constipation and am at risk for impaction and bowel obstructions" . Goals - "will have no signs and symptoms of impaction". - Interventions - Monitor bowel movements for amount and bowel movements. Give enemas/laxatives as ordered by MD. Further record review revealed no information of CR #1's history of ileus. Record review of CR #1's computerized physician orders [REDACTED]. -[MEDICATION NAME] solution 10 mg /15 ml by mouth as needed for No bowel movement in 24 hours up to once daily, -[MEDICATION NAME] suppository 10 mg insert 1 rectally as needed for constipation up to once daily, -[MEDICATION NAME] tablet delayed release give 1 tablet by mouth every 72 hours as needed for constipation (1 tablet=10 mg dose), -[MEDICATION NAME] suppository 10 mg insert 1 suppository rectally one time a day every 3 days related to unspecified constipation, -[MEDICATION NAME] sodium tablet 100 mg give 1 tablet by mouth two times a day related to unspecified constipation and -[MEDICATION NAME] solution 10 mg/15 ml give 45 ml by mouth one time a day related to unspecified constipation. Record review of CR #1's MD progress notes dated [DATE] revealed in part: Physical exam - Gastrointestinal: moderately firm abdomen, non-tender, hypoactive bowel sounds. Record review of CR #1's telephone orders written and signed by MD on [DATE] revealed in part: "Give additional [MEDICATION NAME] 45 cc by mouth X 1, if no results [MEDICATION NAME] suppository per rectal X 1, if no results, fleet enema per rectal X 1, KUB in the morning. Constipation/history of ileus". Record review of CR #1's MAR's for [DATE] revealed that [MEDICATION NAME] 45 cc by mouth X 1 dose was given on [DATE] at 5 p.m. Further review revealed that [MEDICATION NAME] suppository and fleet enema were not given as ordered despite CR #1 not having a bowel movement on [DATE] and [DATE]. Record review of MD progress notes dated [DATE] revealed in part: History of present illness: "Constipation - recent exacerbation, KUB indicating severe, although no obstruction, previous [MEDICATION NAME] and [MEDICATION NAME] orders given, limited effects (?) (sic) abdomen still distended, hypoactive bowel sounds, repeat KUB, onset years ago related to gastroparesis, immobility, decreased fluid intake. [MEDICATION NAME] are scheduled." Record review of CR #1's KUB-abdomen x ray revealed, in part, the following: -[DATE] at 2:14 p.m.: a large amount of air and stool are noted within the distal colon. Severe constipation. -[DATE]: the patient shows evidence of constipation. -[DATE]: moderate amount of stool is still present throughout the colon. Record review of MD progress notes dated [DATE] revealed in part: History of present illness: Constipation-persistent difficulties after recent exacerbation, previous KUB indicating severe constipation. Abdomen still distended, hypoactive bowel sounds. Record review of MD progress note dated [DATE] revealed in part: reported increased somnolence, some concern expressed for decreased by mouth intake. Moderately firm abdomen, non-tender, hypoactive bowel sounds. Record review of CR #1's ADL bowel movement record revealed no bowel movement on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. CR #1 had a small bowel movement in the morning on [DATE] and [DATE]. Further review revealed on [DATE] and [DATE] CR#1 only had small loose bowel movements. Continued review of CR #1's ADL bowel movement record for [DATE] revealed the PRN orders for constipation were not given at all in the month of [DATE]. Record review of CR #1's CT abdomen and pelvis without contrast, dated [DATE] at 10:10 p.m., conducted at a local hospital revealed in part: reason: fever, abdominal distension and altered mental status. Extensive fecal material in the colon is greatest at the rectum. Impression: 1.- Findings compatible with constipation and rectal fecal impaction. 2.- Moderate bilateral hydrouretero[DIAGNOSES REDACTED] (water inside the kidneys and ureters usually caused by obstruction of the free flow of urine from the kidney) likely related to rectal fecal impaction. Record review of CR #1's SBAR communication form dated [DATE] at 5:00 p.m. revealed in part: Abdomen distended, decreased consciousness, sleepy, lethargic and unresponsiveness. New orders to send CR #1 to the ER for evaluation and treatment. In an interview on [DATE] at 3:30 p.m. ADON A stated she was not able to see in the records that on [DATE] [MEDICATION NAME] suppository per rectal X 1 and fleet enema per rectal X 1 were given as ordered after CR #1 had not had a bowel movement on [DATE]. She stated, "I did not find that [MEDICATION NAME] or fleet enema were given on [DATE]". At that time, ADON A was asked if CR #1 had any "as needed" laxatives as ordered for constipation in the month of July and she replied "I did not see it...she (CR #1) was already on routine laxative orders". Continuing this interview, ADON A stated, she did not see where any PRN laxatives had been given to CR #1 as she was looking the MAR's of CR #1. At that time, the facility bowel protocol policy/procedures for following physician orders [REDACTED].#1 if she did not have a bowel movement in 24 hours." In an interview on [DATE] at 4:35 p.m. the DON revealed the facility monitored bowel records on the point click (a computer based) system. She said that the point click system would alert staff when residents had not had a bowel movement for 3 days. She said CR #1 was on routine laxative medications. When the DON was asked specifically about the as needed laxative order for CR #1, if there was no bowel movement in 24 hours, the DON did not respond. She said, "medications are expected to be given as ordered". Record review of CR #1's certificate of death dated [DATE] revealed in part: Immediate cause of death: a) fecal impaction b) acute [MEDICAL CONDITION] c)[MEDICAL CONDITION]. At the time of exit, 5:40 p.m. on [DATE], the facility policy on bowel protocol and physician orders [REDACTED]. According to the CMS 672 dated [DATE], there were 109 residents in the facility.

Based on interview and record review, the facility failed to provide necessary care and services to attain or maintain the highest practicable physical, mental or psycho-social well being according to the plan of care and comprehensive assessment for 2 of 6 residents (CR #1 and CR #2) reviewed for care and services, as evidenced by: -Staff failed to monitor daily bowel record of CR #1 and administer laxatives, if needed, as ordered; - CR #1 was transferred to the hospital on [DATE] with distended abdomen, decreased consciousness, lethargy and unresponsiveness. CR #1 expired [DATE] with immediate cause of death of fecal impaction. -CR #2 developed drainage on [DATE] to his bilateral surgical incisions to his above knee amputation sites. Staff failed to notify the primary physician and surgeon immediately (notification was not made until [DATE]). CR#2 was re-admitted on [DATE] to the hospital for additional surgery to remove 2 additional inches from each limb. -Staff failed to revise and update CR #2's plan of care to address the current condition of his wounds to his bilateral amputation surgical incisions sites. This failure affected 2 residents and placed 109 current residents at risk for experiencing an unrecognized change of condition at risk for delay in medical evaluation and treatment. Findings included: Intake # 0 and 9 CR #1 Record review of the facility face sheet revealed CR #1 was a [AGE] year old female admitted to the facility on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. CR #1 expired at a local hospital on [DATE]. Record review of the care plan initiated [DATE] for CR #1 Revealed in part:- "I have a history of constipation and am at risk for impaction and bowel obstructions" . Goals - "will have no signs and symptoms of impaction". - Interventions - Monitor bowel movements for amount and bowel movements. Give enemas/laxatives as ordered by MD. Further record review revealed no information of CR #1's history of ileus. Record review of the annual MDS dated , [DATE], revealed in part: CR#1 was cognitively impaired, was total dependent on two staff for transfer and toilet use and was always incontinent of bowel and bladder. Record review of CR #1's computerized physician orders [REDACTED]. -[MEDICATION NAME] solution 10 mg /15 ml by mouth as needed for No bowel movement in 24 hours up to once daily, -[MEDICATION NAME] suppository 10 mg insert 1 rectally as needed for constipation up to once daily, -[MEDICATION NAME] tablet delayed release give 1 tablet by mouth every 72 hours as needed for constipation (1 tablet=10 mg dose), -[MEDICATION NAME] suppository 10 mg insert 1 suppository rectally one time a day every 3 days related to unspecified constipation, -[MEDICATION NAME] sodium tablet 100 mg give 1 tablet by mouth two times a day related to unspecified constipation and -[MEDICATION NAME] solution 10 mg/15 ml give 45 ml by mouth one time a day related to unspecified constipation. Record review of CR #1's MD progress notes dated [DATE] revealed in part: Physical exam - Gastrointestinal: moderately firm abdomen, non-tender, hypoactive bowel sounds. Record review of CR #1's telephone orders written and signed by MD on [DATE] revealed in part: "Give additional [MEDICATION NAME] 45 cc by mouth X 1, if no results [MEDICATION NAME] suppository per rectal X 1, if no results, fleet enema per rectal X 1, KUB in the morning. Constipation/history of ileus". Record review of CR #1's MAR's for [DATE] revealed that [MEDICATION NAME] 45 cc by mouth X 1 dose was given on [DATE] at 5 p.m. Further review revealed that [MEDICATION NAME] suppository and fleet enema were not given as ordered despite CR #1 not having a bowel movement on [DATE] and [DATE]. Record review of MD progress notes dated [DATE] revealed in part: History of present illness: "Constipation - recent exacerbation, KUB indicating severe, although no obstruction, previous [MEDICATION NAME] and [MEDICATION NAME] orders given, limited effects (?) (sic) abdomen still distended, hypoactive bowel sounds, repeat KUB, onset years ago related to gastroparesis, immobility, decreased fluid intake. [MEDICATION NAME] are scheduled." Record review of CR #1's ADL bowel movement record revealed no bowel movement on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. CR #1 had a small bowel movement in the morning on [DATE] and [DATE]. Further review revealed on [DATE] and [DATE] CR#1 only had small loose bowel movements. Continued record review of CR #1's ADL bowel movement record revealed review revealed the PRN orders for constipation were not given at all in the month of [DATE]. Record review of CR #1's KUB-abdomen x ray revealed, in part, the following: -[DATE] at 2:14 p.m.: a large amount of air and stool are noted within the distal colon. Severe constipation. -[DATE]: the patient shows evidence of constipation. -[DATE]: moderate amount of stool is still present throughout the colon. Record review of MD progress notes dated [DATE] revealed in part: History of present illness: Constipation-persistent difficulties after recent exacerbation, previous KUB indicating severe constipation. Abdomen still distended, hypoactive bowel sounds. Record review CR #1's MD progress note dated [DATE] revealed in part: reported increased somnolence, some concern expressed for decreased by mouth intake. Moderately firm abdomen, non-tender, hypoactive bowel sounds. Record review of CR #1's CT abdomen and pelvis without contrast, dated [DATE] at 10:10 p.m., conducted at a local hospital revealed in part: reason: fever, abdominal distension and altered mental status. Extensive fecal material in the colon is greatest at the rectum. Impression: 1.- Findings compatible with constipation and rectal fecal impaction. 2.- Moderate bilateral hydrouretero[DIAGNOSES REDACTED] (water inside the kidneys and ureters usually caused by obstruction of the free flow of urine from the kidney) likely related to rectal fecal impaction. Record review of CR #1's SBAR communication form dated [DATE] at 5:00 p.m. revealed in part: Abdomen distended, decreased consciousness, sleepy, lethargic and unresponsiveness. New orders to send CR #1 to the ER for evaluation and treatment. In an interview on [DATE] at 3:30 p.m. ADON A stated she was not able to see in the records that on [DATE] [MEDICATION NAME] suppository per rectal X 1 and fleet enema per rectal X 1 were given as ordered after CR #1 had not had a bowel movement on [DATE]. She stated, "I did not find that [MEDICATION NAME] or fleet enema were given on [DATE]". At that time, ADON A was asked if CR #1 had any "as needed" laxatives as ordered for constipation in the month of July and she replied "I did not see it...she (CR #1) was already on routine laxative orders". Continuing this interview, ADON A stated, she did not see where any PRN laxatives had been given to CR #1 as she was looking the MAR's of CR #1. At that time, the facility bowel protocol policy/procedures for following physician orders [REDACTED].#1 if she did not have a bowel movement in 24 hours." In an interview on [DATE] at 4:35 p.m. the DON revealed the facility monitored bowel records on the point click (a computer based) system. She said that the point click system would alert staff when residents had not had a bowel movement for 3 days. She said CR #1 was on routine laxative medications. When the DON was asked specifically about the as needed laxative order for CR #1, if there was no bowel movement in 24 hours, the DON did not respond. She said, "medications are expected to be given as ordered". Record review of CR #1's certificate of death dated [DATE] revealed in part: Immediate cause of death: a) fecal impaction b) acute [MEDICAL CONDITION] c)[MEDICAL CONDITION]. At the time of exit, 5:40 p.m. on [DATE], the facility policy on bowel protocol and physician orders [REDACTED]. CR #2 Record review of the facility face sheet revealed CR # 2 was a [AGE] year old male admitted to the facility on [DATE] and re-admitted on [DATE]. His [DIAGNOSES REDACTED]. CR #2 was readmitted to the hospital on [DATE] after surgeon assessed surgical incisions to his above knee [MEDICAL CONDITION]. Record review of CR #2's Hospital instructions dated [DATE] at 1750 revealed in part: Notify physician if you have increased drainage from incisions. Record review of the care plan initiated [DATE] for CR #2 Revealed in part:- Resident has current skin concerns: Surgical wound left above knee amputation and right above knee amputation. Goals - "areas will not show signs of infection over next review. Areas will heal without complications over next review". - Interventions - Monitor areas for signs and symptoms of infection, keep MD and responsible party informed of residents progress. Further review revealed no interventions to address the drainage of his wounds to his bilateral amputation surgical incisions sites on [DATE]. Record review of CR #2 re-admission skin assessments dated [DATE] revealed in part: bilateral above knee amputation sites with staples in place. Left above knee amputation site with 28 staples and right above knee amputation site with 31 staples. Record review of CR #2's telephone orders dated [DATE] revealed in part: wound care consult, please contact vascular surgery office to determine follow up visit. Record review of CR #2's skin assessments dated [DATE] revealed in part: Right above knee amputation site with 31 intact staples with moderate drainage. Left above knee amputation site with 28 intact staples with moderate drainage. Continued record review revealed no information on MD notification or any interventions. Record review of the significant change in status MDS dated [DATE] revealed CR#2 required extensive assistance of two persons for bed mobility, transfer, dressing and bathing and extensive assistance for eating and total dependent on staff for personal hygiene. Record review of CR #2's Skin assessments dated [DATE] revealed in part: Right above knee amputation site with 31 intact staples with moderate drainage. MD aware. Follow up with vascular MD appointment. Left above knee amputation site with 28 intact staples with moderate drainage. Follow up with vascular MD appointment. In an interview on [DATE] at 1:40 p.m., WCN B revealed CR #2 had moderate drainage to his bilateral above knee amputation sites on [DATE]. She stated she did not call the surgeon or the primary MD. She stated, "I called the wound care MD and notified them of the orders for CR #2 to be evaluated by a wound care MD". She stated that wound care MD did not see CR #2 after he returned from the hospital on [DATE] with the above knee amputations because CR#2 was admitted to the hospital on [DATE] when he went to see the surgeon to have his surgical incisions evaluated and the wound care MD came after that time. In continued interview at that time, WCN B revealed that changes in condition in a wound would be if the wound increases in size, showed any signs of infection, including drainage, redness, pain and odor. She also stated the facility protocol was to notify the resident's doctor and family if there were any changes. In an interview on [DATE] at 4:05 p.m. with MD C revealed facility notified the doctor's office on [DATE] of the orders to see CR #2. MD C stated her physician assistant was going to see CR #2 on [DATE] but she was not able to do it. She further stated, "there is a global period for the surgery. Within the first 90 days the surgeon is the only one that can give orders, medicare will only pay the surgeon, not us. I did not know who the the surgeon was". She further stated, "the main issue was the surgery sites were getting worse and when I went to see CR #2 he was not there anymore". In an interview on [DATE] at 4:20 p.m. ADON A revealed the facility used the SBAR form to document changes in residents condition. She stated she did not see any SBAR form in CR #2's file. She further stated "CR #2 went to see a vascular MD on [DATE] and [DATE] but it was to have his AV shunt checked, not for the surgical incisions". In an interview on [DATE] at 4:25 p.m. the DON revealed she was not aware that CR #2 was having drainage to his bilateral above knee amputations. She stated she did not know until [DATE] when CR#2 was getting ready to go to the appointment with the surgeon. She stated at that time was when WCN B notified her the wound care MD did not get to see CR #2 and that his wounds had been draining. The DON stated "I would have notified the doctor and documented". In an interview on [DATE] at 1:40 p.m. with the Responsible Party of CR #2 revealed when CR #2 went to see the surgeon on [DATE] the surgical incisions smelled "really bad" and had drainage. He further stated the surgeon sent CR #2 immediately to the hospital and performed surgery again to remove 2 more inches on each of his limbs "because the infection was really bad". He further stated the facility did not notify him of the deterioration in the condition of the surgical incisions. Record review of the facility change in a resident's condition or status policy and procedure, revised [DATE], read in part: ".... Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition." 2.- A "significant change" of condition is a decline or improvement in the resident's status that: a) will not normally resolve itself without intervention by staff b) impacts more than one area of the resident's health status. According to the CMS 672 dated [DATE], there were 109 residents in the facility.