Every finding on record at Grand Terrace Rehabilitation and Healthcare

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #1) of 3 residents reviewed for care plans. The facility failed to ensure Resident #1's care plan reflected an aggressive behavior he displayed towards a CNA on 5/30/26.This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs. The findings include:Record review of Resident #1's face sheet dated 6/17/26 reflected Resident #1 was admitted on [DATE] with an initial admission date of 5/19/24. Resident #1 was a [AGE] year-old male with diagnoses of hemiplegia (paralysis affecting only one side of the body caused by brain or spinal cord injury) and hemiparesis (partial weakness, numbness, or reduced motor control affecting only one entire side of the body) of left non-dominant side, alcoholic cirrhosis (late stage of progressive liver scarring caused by long-term liver diseases or injuries) of liver, depression (common, serious mood disorder that causes persistent sadness, loss of interest and physical or emotional fatigue), and cognitive communication disorder.Record review of Resident #1's Quarterly MDS dated [DATE] reflected the resident:had a BIMS score of 7 which indicated his cognition was severely impaired.Resident #1 required partial/moderate assistance with oral hygiene and was dependent on staff for all other self-care. Resident #1 had no behaviors. Record review of Resident #1's undated comprehensive care plan did not reflect an update of Resident #1's aggressive behavior towards a CNA on 5/30/26. In an interview on 6/17/26 at 2:00 p.m. MDS A said Resident #1's aggressive behavior in a previously reported incident on 5/30/26 which was investigated should have been care planned. MDS A said usually resident behaviors were care planned by SSS, so she assumed it had been care planned. MDS A said usually Monday mornings she printed out orders, discussed them during morning meetings and then care planned needed items. MDS A said she recalled being off the Monday after Resident #1 displayed the aggressive behavior. MDS A said if aggressive behaviors were not care planned nurses and staff would still have received the information during morning meetings, or they usually reviewed documentation of the previous day to get informed. MDS A said if staff were not informed, they would not know interventions needed, such as to be more patient or look out for aggressive behaviors from the residents.In an interview on 6/17/26 at 2:10 p.m. SSS said the facility normally updated care plans when a resident displayed aggressive behavior. SSS said the MDS department usually updated the care plans. SSS said it was her understanding the facility was going to further investigate and were pending MD orders for possible nursing interventions. In an interview on 6/17/26 at 2:15 p.m. the DON said he looked through the resident's care plan and Resident #1's aggressive behavior on 5/30/26 was not care planned. The DON said the aggressive behavior should have been care planned. The DON said even isolated events of aggressive behaviors should be care planned. The DON said they held a care plan meeting with IDT and family, but they missed it probably due to the nature of the incident which was aggressive behavior towards staff and not towards a resident. The DON said during morning meetings they reviewed progress notes and care planned due to documentation and it was documented on the progress notes. The DON said the care plan could have been edited by any of us. The DON said in the future, they must assign one member of staff to be responsible for ensuring care plans were completed. The DON said CNAs go based off on what the nurses report to them. The DON said an adverse outcome of not care planning aggressive behaviors would be employee safety. Record review of facility's Comprehensive Person-Centered Care Planning reflected, Policy:It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.5. The resident has the right to refuse or discontinue treatment. In the event that a resident refuses certain services posing a risk to resident's health and safety, the comprehensive care plan will identify care or service declined, the associated risks, IDT's effort to educate the resident and resident representative and any alternate means to address risk. 6. The resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment including both the comprehensive and quarterly review assessments.

Based on interviews, and record review, the facility failed to ensure nurse staffing data was posted and readily accessible to residents and visitors with all required information for 1 (6/16/26) of 2 days reviewed for nurse staffing information. The facility failed to ensure the current daily staffing information was posted on 6/16/26. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts. The findings include:Record Review on 6/16/26 of the facility's daily staffing information form revealed the form was dated 6/15/26. In an interview on 6/16/26 at 4:00 p.m. HR said she was in charge of updating and posting their daily staffing information. HR said she obtains the information she needs from the actual schedules. HR said she was informed by the facility that daily staffing should be updated and posted daily. HR said she was never informed by the facility, daily staffing must be posted by a specific time. HR said she normally posted daily staffing between 10:00 a.m. and her lunch time. HR said her lunch was at different times every day. HR said she left for lunch today at 11:30 a.m. and when she returned, she began assisting giving out plates for CNA Week activities. HR said the reason for posting daily staffing information was so the facility and family of residents would know how many staff members were on floor per shift. HR said daily staffing postings were important information in case a family stated there were not enough staff on the floors, so they could show them the staffing information and/or the schedule. HR said if daily staffing were not posted, there would be no negative outcomes that she was aware of other than it was a required posting and it was not done. In an interview on 6/17/26 at 12:24 p.m. the Administrator said there was no answer to justify why the updated daily staffing was not posted on 6/16/26. The Administrator said he did not know what happened because daily staffing was usually posted daily and must be posted at the beginning of the shift. The Administrator said medical records worked on the information for daily staffing and HR was responsible for ensuring accurate information was posted daily. The Administrator said daily staffing information must be posted to inform staff, visitors, and family about census and staffing information and they were able to refer to it if they felt there were not enough staff.In an interview on 6/17/26 at 1:08 p.m. the DON said HR was responsible for updating and posting the daily staffing information. The DON said daily staffing information should be updated and posted daily as soon as possible in the morning. The DON said HR's practice was posting daily staffing information as soon as she got into work in the morning. The DON said they reviewed the information first thing in the morning due to census. The DON said the importance of reviewing and posting daily staffing information was to make everyone aware census and staffing were appropriate. The DON said they were looking into designating a secondary staff member to ensure the information was posted. Record review of facility's Nursing Administration policy dated 5/2024 reflected, Policy:It is the policy of this facility to provide adequate staffing to meet the needs of the resident population.4. Staffing PostingThe facility shall post daily nurse staffing information in a visible location including staff type, shifts, and hours worked. Required postings per Texas HHSC shall be maintained.

Based on observation, interview and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preference for one (Resident #2) of three residents reviewed for call lights.The facility failed to ensure Resident #2's call light was within reach while in bed.This failure could place residents at risk of being unable to obtain assistance or help when needed and in the event of an emergency.Findings included:Record review of Resident #2's Face Sheet dated 05/08/26 revealed an [AGE] year-old male with an admission initial date of 08/21/24, diagnoses included Type 2 Diabetes Mellitus with Hyperglycemia (high blood sugar levels), Chronic Respiratory Failure with Hypercapnia (high levels of carbon dioxide in lungs, Epistaxis (nosebleed) and Gastrotomy Status (surgical opening in stomach for nutritional and medication administration).Record review of Resident #2's Quarterly MDS assessment dated [DATE], reflected a BIMS score of 4 indicating severe cognitive impairment. Section GG - Functional Abilities and Goals indicated Resident used a manual wheelchair and was dependent requiring two or more helpers for the resident to complete the activities of upper and lower body dressing, rolling left and right side on bed, and toileting hygiene. He required partial/moderate assistance when sitting to lying position on bed.Record review of Resident #2's Care Plan dated 03/30/26, reflected a focus on Resident #2's risk for falls. The interventions included to ensure the call light was within reach and encourage to use it to call for assistance as needed.During an observation and interview on 05/07/26 at 10:18 a.m., Resident #2 was in his room sitting upright on his bed and was alert. Resident #2's call light was not observed near him. When asked where his call light was, Resident #2 did not respond. During an interview on 05/07/26 at 10:30 a.m., the ADON entered Resident #2's room and located his call light on the floor behind Resident #2's headboard. The ADON said Resident #2's call light should have been clipped to his bed within his reach. She said both nurses and CNA's round frequently. She said staff were in serviced frequently on resident call lights being within reach and to be answered timely.During an interview on 05/07/26 at 2:11 p.m., CNA B said she went into Resident #2's room in the morning (05/07/26) but did not remember exactly what time. She said she changed his clothing and brief and also changed his bedding. She said she did not recall if she made sure his call light was near him. She said Resident #2 was supposed to have the call light near him. She said if he needed help, he was not able to call for help. CNA B said they were given in services on resident call lights every week. During an interview on 05/08/26 at 6:41 p.m., the DON said Resident #2 was supposed to have the call light within his reach. He said Resident #2 was frequently checked on and staff were also in serviced frequently on ensuring residents' call light was within reach. He said if Resident #2 needed assistance, he could have had a delay in care if he was unable to reach for the call light for help.Record review of the facility's Policy/Procedure - Nursing Clinical revised date May 2023 reflected in part: Subject: Call Light/BellPolicy: It is the policy of this facility to provide the resident a means of communication with nursing staffProcedures:Answer the light/bell within a reasonable time5. Leave the resident comfortable. Place the call device within resident's reach before leaving room.

Based on interviews, and record review the facility failed to ensure the residents right to be informed of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers, for 3 of 10 residents (Resident #1, Resident #2, and Resident #5) reviewed for consent for antipsychotic medications in that: 1. The facility failed to obtain prior consent based on information of the benefits and risks and options available before the administration of Zyprexa (an antipsychotic) for Resident #37. 2. The facility failed to obtain prior consent based on information of the benefits and risks and options available before the administration of Haldol (an antipsychotic) for Resident #61. 3. The facility failed to obtain proper consent before the administration of Zyprexa and had accepted a consent signed by Resident #5 who had severely impaired cognitive skills to make decisions for himself. This failure could affect the right to self-determination of all facility residents who receive medication by allowing them to receive medication without their prior knowledge or consent, or that of their responsible party or emergency contacts. The findings included: 1. Record review of Resident #37's admission record dated 02/18/26, reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia (a group of thinking and social symptoms that interferes with daily functioning) with agitation, hemiplegia and hemiparesis (neurological conditions causing motor impairment on one side of the body due to brain injury) following cerebral infarction (stroke), hypertension (high blood pressure), heart failure, generalized anxiety disorder (a mental health condition characterized by chronic, excessive, and uncontrollable worry about everyday events, activities, or potential disasters), and emotional lability (rapid, exaggerated, and often uncontrollable mood swings, characterized by intense outbursts of crying, laughing, or anger that are disproportionate to the situation). Record review of Resident #37's Quarterly MDS, dated [DATE], revealed a BIMS score of 03, indicating severe cognitive impairment. There were no potential indicators of psychosis and no behavioral symptoms indicated. Active diagnoses included: dementia, hemiplegia and hemiparesis following a cerebral infarction, heart failure, anxiety disorder, depression, and lability. Resident #37 was dependent (Helper did ALL of the effort. Resident did none of the effort to complete the activity. Or, the assistance of 2 or more helpers was required for the resident to complete the activity) for eating, toileting, and personal hygiene. Resident #1 was not receiving an antipsychotic. Record review of Resident #37's Care Plan dated 01/16/26 revealed the focus (Resident #37) is on a Anti psychotic medication r/t psychosis Date Initiated: 01/26/2026. [sic] Record review of Resident #37's Physician's Order dated 01/19/26, revealed Order Summary: ZyPREXA Oral Tablet 5 MG (Olanzapine). Give 1 tablet by mouth at bedtime for Psychosis. Record review of Resident #37's Order Summary dated 01/19/2026 revealed Zyprexa Oral Tablet 5 mg (Olanzapine) Give 1 tablet by mouth at bedtime for Psychosis. Record review of Resident #37's January 2026 MAR revealed Zyprexa 5 mg tablet was administered nightly from 01/20/26 through 01/31/26. Record review of Resident #37's February 2026 MAR revealed Zyprexa 5 mg tablet was administered nightly from 02/01/26 through 02/17/26. Record review of Resident #37's Progress Note written on 01/20/26 at 03:24 pm by LVN G Resident was seen by (NP G) (pysch), Appetit increased, remains depressed (crying spells), Stop Namenda 5mg, stop Aricept. Start Zyprexa 5mg PO HS Unspec psychosis dementia aggression. Please keep (NP G) posted. [sic] Record review on 02/18/26 of Resident #37's medical record did not reveal a consent signed by the RP for the antipsychotic Zyprexa 5 mg tablet. 2. Record review of Resident #61's admission record dated 02/17/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included hypertension (high blood pressure), hemiplegia and hemiparesis (neurological conditions causing motor impairment on one side of the body due to brain injury) following cerebral infarction (stroke), chronic respiratory failure, heart disease, seizures, alcoholic cirrhosis of liver (a chronic advanced liver disease caused by long-term alcohol misuse, characterized by significant, irreversible scarring of the liver tissue), and depression. Record review of Resident #61's Annual MDS, dated [DATE], revealed a BIMS score of 06, indicating severe cognitive impairment. There were no potential indicators of psychosis and no behavioral symptoms indicated. Active diagnoses included: hemiplegia and hemiparesis following a cerebral infarction, heart disease, depression, and alcoholic cirrhosis of the liver. Resident #61 was dependent (Helper did ALL of the effort. Resident did none of the effort to complete the activity. Or, the assistance of 2 or more helpers was required for the resident to complete the activity) for eating, toileting, and personal hygiene. Resident #61 was not receiving an antipsychotic. Record review of Resident #61's Care Plan dated 12/02/25 revealed the focus (Resident #61) is on Anti psychotic medication use r/t altered mental status Date Initiated: 02/12/2026. Record review of Resident #61's Physician's Order 02/11/26 (Discontinued on 02/14/26) revealed Order Summary: Haloperidol Tablet 5 MG Give 1 tablet by mouth one time a day for alter mental status for 30 Days. [sic] Record review of Resident #61's Physician's Order dated 02/14/26 (Discontinued on 02/16/26) revealed Order Summary: Haloperidol Tablet 5 MG Give 1 tablet by mouth in the evening for alter mental status for 30 Days [sic] Record review of Resident #61's February 2026 MAR revealed Haldol 5 mg tablet was administered 02/12/26 and 02/13/26 in the morning and on 02/15/26 Haldol 5 mg tablet was administered in the evening. Record review on 02/18/26 of Resident #61's medical record did not reveal a consent signed by the RP for the antipsychotic Haldol 5 mg tablet. 3. Record review of Resident #5's face sheet, dated 02/19/26, reflected an [AGE] year-old male who was initially admitted to the facility on [DATE]. Resident #5 had diagnoses which included: paranoid schizophrenia (mental health disorder with intense irrational delusions and vivid auditory hallucinations), cerebral infarction, unspecified (blocked blood supply to the brain causing lack of oxygen and damage to the brain), anoxic brain damage, unspecified (occurs when the brain is completely deprived of oxygen), aphasia following cerebral infarction, (language disorder after a stroke causing difficulty or inability to communicate), and cognitive communication deficit (difficulty with verbal and non-verbal communication caused by underlying cognitive impairment). Record review of Resident #5's care plan, with an initiation date of 04/10/25 reflected a focus of [Resident #5] is on a Anti-psychotic medication use r/t for [sic] schizophrenia with an initiation date of 05/16/25. Record review of Resident #5's MDS assessment, dated 04/29/25, reflected Resident #5 was rarely or never able to be understood and was rarely or never able to understand. Resident #5 was categorized as severely impaired for cognitive skills for daily decision making and did not have a BIMS completed due to being rarely or never understood. Record review of Resident #5's consent for antipsychotic or neuroleptic medication treatment reflected Resident #5 signed the consent form on 05/16/25. Record review of Resident #5's order summary report reflected an order for Zyprexa 5mg via peg tube two times a day related to paranoid schizophrenia was started on 05/16/25 and was discontinued on 01/19/26. During an interview and record review with the DON on 02/19/26 at 9:07am the DON stated they were required to get consent in person by either the residents if they are able to consent or their responsible party for any antipsychotic medication such as Zyprexa. The DON stated Resident #5 was his own responsible party and did not have any other contacts for him. The DON stated when Resident #5 admitted he was able to make his own decisions such as signing consents for Zyprexa but stated he had recently been declining. The DON reviewed Resident #5's admission MDS and stated Resident #5 had a BIMS of 0 and was marked as severely impaired for his cognitive skills for daily decision making. The DON stated based on Resident #5's MDS documentation he would not be able to give consent for Zyprexa. The DON stated Resident #5 was allowed to sign for consent because based upon visual assessment he was able to follow commands. The DON stated the facility's interdisciplinary team was responsible for reviewing consents to ensure they were completed accurately and stated they would discuss the consents and review them upon admission and weekly and would review any new orders. The DON stated Resident #5 was on Zyprexa from 05/16/25 until 01/19/26 for his diagnosis of paranoid schizophrenia. The DON stated it was important to ensure proper consents were granted prior to administration of an antipsychotic such as Zyprexa because of the side effects and stated these were also potential negative impacts if consents were not in place. The DON stated Resident #5 did not experience any adverse effects related to his antipsychotic use. During an interview and record review on 02/19/2026 at 09:25 am, the DON stated either DON, ADON or the nurse on admission was responsible for getting the consent (for an antipsychotic medication). The DON stated Resident #37 did not have the consent for Zyprexa. The DON stated Resident #61 had not had a consent for the Haldol that he received. He stated an antipsychotic should not be given before consent was signed. He stated that if the consent was not given for an antipsychotic, the family had not agreed to the resident getting the antipsychotic and the family had the right to either accept or refuse medication. During an interview on 02/19/2025 at 03:11 pm, LVN A stated the nurse who received the order for an antipsychotic was the one who would get the consent signed. She said an antipsychotic was not given until the consent was signed. LVN A stated if the antipsychotic was given without consent, the family may get very upset because their loved one would be getting an antipsychotic they did not want them to get. Record review of the facility's, undated, policy titled, Psychotropic Drug Use reflected a section titled, procedures stated, 7. Upon change of condition or initiation of a new order for psychoactive medications, the License Nurses shall complete the verification of Informed Consent form prior to the initiation of the new medication.

Based on interview and record review, the facility failed to ensure that the residents were free from chemical restraints not required to treat the resident's medical symptoms for 2 (Resident #1 and Resident #2) of 8 residents reviewed for unnecessary medications. 1.The facility failed to have an adequate indication for the use of the medication Zyprexa (an antipsychotic) for Resident #37 before administering the medication with a black box warning. 2.The facility failed to have an adequate indication for the use of the medication Haldol (an antipsychotic) for Resident #61 before administering the medication with a black box warning. This failure could put residents at risk of harm from adverse reactions or harmful side effects. The findings included: 1. Record review of Resident #37's admission record dated 02/18/26, reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia (a group of thinking and social symptoms that interferes with daily functioning) with agitation, hemiplegia and hemiparesis (neurological conditions causing motor impairment on one side of the body due to brain injury) following cerebral infarction (stroke), hypertension (high blood pressure), heart failure, generalized anxiety disorder (a mental health condition characterized by chronic, excessive, and uncontrollable worry about everyday events, activities, or potential disasters), and emotional lability (rapid, exaggerated, and often uncontrollable mood swings, characterized by intense outbursts of crying, laughing, or anger that are disproportionate to the situation). Record review of Resident #37's Quarterly MDS, dated [DATE], revealed a BIMS score of 03, indicating severe cognitive impairment. There were no potential indicators of psychosis and no behavioral symptoms indicated. Active diagnoses included: dementia, hemiplegia and hemiparesis following a cerebral infarction, heart failure, anxiety disorder, depression, and lability. Resident #37 was dependent (Helper did ALL of the effort. Resident did none of the effort to complete the activity. Or, the assistance of 2 or more helpers was required for the resident to complete the activity) for eating, toileting, and personal hygiene. Resident #37 was not receiving an antipsychotic. Record review of Resident #37's Care Plan dated 01/16/26 revealed the focus (Resident #37) is on a Anti psychotic medication r/t psychosis Date Initiated: 01/26/2026. Record review of Resident #37's Physician's Order dated 01/19/26, revealed Order Summary: ZyPREXA Oral Tablet 5 MG (Olanzapine). Give 1 tablet by mouth at bedtime for Psychosis. Record review of Resident #37's Order Summary dated 01/19/2026 revealed Zyprexa Oral Tablet 5 mg (Olanzapine) Give 1 tablet by mouth at bedtime for Psychosis. Record review of Resident #37's January 2026 MAR revealed Zyprexa 5 mg tablet was administered nightly from 01/20/26 through 01/31/26. Record review of Resident #37's February 2026 MAR revealed Zyprexa 5 mg tablet was administered nightly from 02/01/26 through 02/17/26. Record review of Resident #37's Progress Note written on 01/20/26 at 03:24 pm by LVN G Resident was seen by (NP G) (pysch), Appetit increased, remains depressed (crying spells), Stop Namenda 5mg, stop Aricept. Start Zyprexa 5mg PO HS Unspec psychosis dementia aggression. Please keep (NP G) posted. 2. Record review of Resident #61's admission record dated 02/17/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included hypertension (high blood pressure), hemiplegia and hemiparesis (neurological conditions causing motor impairment on one side of the body due to brain injury) following cerebral infarction (stroke), chronic respiratory failure, heart disease, seizures, alcoholic cirrhosis of liver (a chronic advanced liver disease caused by long-term alcohol misuse, characterized by significant, irreversible scarring of the liver tissue), and depression. Record review of Resident #61's Annual MDS, dated [DATE], revealed a BIMS score of 06, indicating severe cognitive impairment. There were no potential indicators of psychosis and no behavioral symptoms indicated. Active diagnoses included: hemiplegia and hemiparesis following a cerebral infarction, heart disease, depression, and alcoholic cirrhosis of the liver. Resident #61 was dependent (Helper did ALL of the effort. Resident did none of the effort to complete the activity. Or, the assistance of 2 or more helpers was required for the resident to complete the activity) for eating, toileting, and personal hygiene. Resident #61 was not receiving an antipsychotic. Record review of Resident #61's Care Plan dated 12/02/25 revealed the focus (Resident #61) is on Anti psychotic medication use r/t altered mental status Date Initiated: 02/12/2026. Record review of Resident #61's Physician's Order 02/11/26 (Discontinued on 02/14/26) revealed Order Summary: Haloperidol Tablet 5 MG Give 1 tablet by mouth one time a day for alter mental status for 30 Days. Record review of Resident #61's Physician's Order dated 02/14/26 (Discontinued on 02/16/26) revealed Order Summary: Haloperidol Tablet 5 MG Give 1 tablet by mouth in the evening for alter mental status for 30 Days. Record review of Resident #61's February 2026 MAR revealed Haldol 5 mg tablet was administered 02/12/26 and 02/13/26 in the morning and on 02/15/26 Haldol 5 mg tablet was administered in the evening. During an interview and record review on 02/19/26 at 09:00 am, the DON stated altered mental status should not be an indication for an antipsychotic order for a resident. He said antipsychotics could not be prescribed with a diagnosis of dementia. He said psychosis should not be an indication for an antipsychotic order for a resident who has dementia. The DON stated when an incorrect diagnosis was written for an antipsychotic, they would call the doctor or NP and clarify, but most times, the NP will not change the diagnosis. During an interview on 02/19/25 03:11 pm LVN A stated antipsychotics needed a correct diagnosis for the residents to get them. She said she sometimes had to call and confirm/clarify the order with the doctor or NP. She said orders for an antipsychotic without a proper diagnosis or especially with the diagnosis for Alzheimer's or dementia are not proper orders. She said an antipsychotic cannot have a diagnosis of Alzheimer's or dementia. During an interview on 02/19/26 at 03:29 pm, RN B stated an antipsychotic order cannot have an indication as Alzheimer's or dementia. RN B stated they needed a proper diagnosis and consent signed before administering an antipsychotic. Record review of the facility's, undated, policy titled, Psychotropic Drug Use reflected a section titled, procedures stated: Policy: It is the policy of this facility to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. 6a. Psychotropic medication was prescribed to treat a specific diagnosed condition, as documented in the clinical record. 6c. Behavior is not related to delirium or other reversible conditions.

Based on observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial need that were identified in the comprehensive assessment for 2 of 6 residents (Resident #18 and Resident #46) reviewed for comprehensive person-centered care plans.1.The facility failed to ensure Resident #46's care plan included his code status of full code.2.The facility failed to ensure Resident #18's care plan included she was a 2 person assist for ADLs.These deficient practices could place residents at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs.The findings included:1.Record review of Resident #46's admission record dated [DATE], reflected a [AGE] year-old male with an admit date of [DATE]. His relevant diagnoses included myasthenia gravis with (acute) exacerbation (chronic autoimmune disorder causing fluctuating weakness of voluntary muscles), acute respiratory failure (a life-threatening emergency occurring when the lungs cannot properly oxygenate the blood or remove carbon dioxide), tracheostomy ( a surgical procedure creating an opening (stoma) in the neck into the trachea), and dependence on respirator (a serious, chronic, or acute state where a person cannot sustain spontaneous breathing on their own).Record review of Resident #46's Medicare 5-day MDS assessment dated [DATE], reflected a BIMS score of 14, which indicated his cognition was intact. Record review of Resident #46's comprehensive care plan dated [DATE], did not reflect his code status of full code.Record review of Resident #46's order summary reflected an active order of full code: use AED (automated external defibrillator) with CPR during sudden cardiac arrest effective [DATE].In an observation and interview on [DATE] at 3:42 p.m., RN E said Resident #46 had been admitted on [DATE] and had a code status of full code. He was observed as he reviewed Resident #46's electronic medical record and said his profile reflected he was a full code. RN E said he also had an order (effective [DATE]) which reflected he was a full code. RN E said his code status was not reflected on his care plan. He said there would be no negative outcomes to Resident #46 for not having his code status reflected on his care plan because nursing staff checked a resident's profile and order in case of an emergency. In an interview on [DATE] at 3:38 p.m., MDS D said Resident #46 had been admitted on [DATE]. She said his profile reflected a code status of full code and had an active order effective [DATE]. MDS D said Resident's code status had not been included in his care plan. MDS D said there was no negative outcomes to Resident #46 because if case of an emergency, nursing staff would check his profile and order. She said even though nursing staff would not check a resident's care plan in case of an emergency, a resident's code status needed to be reflected on their care plan. In an interview on [DATE] at 3:02 p.m., the DON said a resident's code status needed to be reflected on their profile, have an order, and an Out-of-hospital DNR form if they opted to have a code status of DNR. He said there were no negative outcomes to Resident #46 if his code status had not been included on his care plan because in case of an emergency, nursing staff would check his profile and order(s). The DON said, even though nursing staff would not check a resident's care plan in case of an emergency, code status needed to be reflected on their care plan. 2. Record review of Resident #18's admission record dated [DATE], reflected a 73- year-old female with an admit date of [DATE]. Her relevant diagnoses included schizophrenia (a severe, chronic brain disorder that distorts reality through hallucinations, delusions, and disordered thinking), cognitive communication deficit (an impairment in communication due to underlying issues with cognitive processes like memory, attention, and executive function), need for assistance with personal care, and lack of coordination. Record review of Resident #18's quarterly MDS assessment dated [DATE], reflected a BIMS score of 5, which indicated her cognition was severely impaired. Resident #18 had been coded as dependent for her functional abilities which included oral hygiene, toileting hygiene, shower/bathe self, upper/lower body dressing, putting on/taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, and chair/bed-to-chair transfer. A code of dependent indicated helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity.Record review of Resident #18's quarterly care plan dated [DATE], reflected a focus of [Resident #18] has ADL self-care performance deficit r/t limited mobility and generalized weakness. Date initiated [DATE] Interventions for toilet use, transfer (chair/bed to chair transfer, toilet transfer), bed mobility (roll left/right, sit to lying, lying to sitting on side of bed), dressing (lower/upper body dressing, putting on taking off footwear), and transfer (chair/bed to chair transfer, toiler transfer) required a 1 person assist.In an interview on [DATE] at 8:03 a.m., CNA F said CNA F said she had provided care to Resident #18 while she was in the memory unit. She said Resident #18 required a 1 person assist with her ADLs; however, during episodes of aggression, she required a 2 person assist. She said if she needed to check or verify what a Resident #18's level of assistance, she would check her electronic medical record or ask the charge nurse. In an observation and interview on [DATE] at 9:45 a.m., MDS D said Resident #18's most recent MDS assessment (dated [DATE]) reflected she was dependent on all ADLs except for eating. She was observed as she reviewed Resident #18's electronic medical record/care plan and said her care plan indicated she was a 1 person assist for all ADLs with the exception of eating. MDS D said if Resident #18's MDS had her coded as dependent on ADLs then her care plan should have reflected a 2 person assist for ADLs also. MDS D said a negative outcome to Resident #18 not having her care plan match the level of care her MDS assessment reflected would be she would not receive the appropriate level of care for her ADLs. In an interview on [DATE] at 3:02 p.m., the DON said a resident's care plan should reflect the same level of care their MDS assessment reflected. He said a negative outcome to Resident #18 not having the correct level of care on her care plan would be she would not receive the appropriate level of care for her ADLs. Record review of the facility's Comprehensive Person-Centered Care Planning policy revised on 04/2025 reflected:Policy It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.Procedure:4. the facility IDT will develop and implement a comprehensive person-centered, culturally competent, and trauma-informed care plan for each resident within 7 day of completion of the MDS and will include resident's needs identified in the comprehensive assessment.the resident's goals and desired outcomes.

Based on observation, interview and record review, the facility failed to ensure residents received care in accordance with professional standards of practice for 1 (Resident #1) of 2 residents observed for Quality of Care. The facility failed to ensure that CNA A asked for help when she performed incontinent care and dressed a resident who required 2-person assistance for these tasks. This failure could place residents at risk for potential harm or injury during tasks that require 2-person assistance.The findings included:Record review of Resident #1's admission record dated 10/13/25 reflected a [AGE] year-old man who was admitted to the facility on [DATE]. The resident's diagnosis included non-traumatic intracerebral hemorrhage in hemisphere (a stroke caused by bleeding within the brain's cerebral hemispheres, most commonly due to chronic high blood pressure), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (a condition where blood flow to the brain is interrupted, leading to brain tissue damage) affecting the left non-dominant side, need for assistance with personal care, and muscle weakness.Record review of Resident #1's MDS dated [DATE] indicated a BIMS score 06 reflected severe cognitive impairment. The MDS indicated that Resident #1 was totally dependent on two or more staff for toileting hygiene, upper and lower body dressing, putting on/taking off footwear, personal hygiene, and eating. Record review of Resident #1's care plan reflected that Resident #1 had ADL Self Care Performance Deficit related to generalized weakness with interventions of TOILET USE (toilet transfer, toilet hygiene): requires assistance x2 and DRESSING (lower and upper body dressing) requires x2 to dress. On 10/13/25 at 11:00pm observation revealed CNA A performed incontinent care and re-dressed Resident #1 with no assistance from another staff member. It was observed that CNA A did not request assistance from another staff member for this task. On 10/13/25 at 11:10pm, CNA A was interviewed. CNA A stated that she was ok with providing incontinent care alone on Resident #1. CNA A admitted she did not request assistance for this task. CNA A stated that Resident #1's RP, who was present today, usually assisted with incontinent care and dressing. CNA A stated that during the night shift, at times, it was difficult to find another staff member to assist with tasks that required 2-person assistance. CNA A stated that other staff members had their own tasks to perform. CNA A stated that she was aware that Resident #1 had the intervention for 2 persons assist but felt confident in her ability to change the resident on her own. CNA A stated that a negative outcome for not having another staff member assist her could have resulted in the resident being positioned incorrectly or maybe even being injured with a wrong movement. On 10/13/25 at 11:18pm, Resident #1's RP was interviewed. The RP stated that he usually assists the CNAs when they have performed incontinent care or dressed the resident. The RP stated that this was the second time he had seen CNA A perform incontinent care on Resident #1 The RP stated CNA A was not often assigned to Resident #1.On 10/13/25 at 11: 22pm, an attempt was made to interview Resident #1 however resident was too sleepy to answer any questions. When asked a question, Resident #1 kept his eyes closed and did not respond. Resident #1's RP stated that once resident falls asleep, it is difficult to wake him up.On 10/13/25 at 11:41pm CNA B was interviewed. CNA B stated that generally when a new resident arrived at the facility, she looked into the facility's computer system called Kardex which informed her whether a resident required 1- or 2-person assistance on tasks. CNA B stated if she needed assistance from another staff member, she did not rely solely on another, CNA. CNA B stated that nurses have assisted her with resident tasks such as incontinent care or dressing a resident. CNA B stated that CNA A did not ask her to assist her with incontinent care on Resident #1. On 10/13/25 at 11:56pm RN C was interviewed. RN C stated that nurses have the responsibility to inform the CNAs about specific interventions such as whether the residents required 1- or 2-person assistance for tasks. RN C stated that care plans were written by the ADON or the DON and not by the floor nurses. RN C stated that RNs were responsible for overseeing that CNAs followed interventions according to the care plan. RN C stated that CNAs could not access the care plans therefore it was important to communicate with the CNAs on any changes. RN C stated that she was not approached by CNA A to assist with incontinent care for Resident #1. RN C stated she was not aware CNA A had performed incontinent care on Resident #1 alone. On 10/14/25 at 12:04 am RN D was interviewed. RN D stated that she did not write care plans. RN D stated that the DON or the ADON were responsible for implementing care plans and then letting nurses know of any changes. RN D stated that floor nurses were to oversee CNAs and to make sure interventions were performed as written. RN D stated she was not aware CNA A had performed incontinent care on Resident #1 alone. RN D stated CNA A did not ask for her assistance with Resident #1. On 10/14/25 at 12:24 am ADON was interviewed. ADON stated that the facility had implemented two computer-generated systems for resident care: care plans for nurses and Kardex for CNAs. The ADON stated that both systems showed whether the residents required 1- or 2-person assistance for tasks. The ADON stated that she or the DON were responsible for implementing care plans. The ADON stated that the floor nurses were responsible for overseeing that the CNAs had done the interventions according to the care plan. On 10/14/25 at 12:30 am the DON was interviewed. The DON stated that anytime there has been a change in condition, that he or the ADON are responsible for notifying the nurses. The DON stated that the nurses were then responsible for notifying the CNAs. The DON stated that he or the ADON would be informed of any resident that has had a change in condition. He or the ADON will have then changed the care plan and updated the Kardex system. The DON stated that the CNAs were given 1 to 1 verbal communication on changes. The DON stated that he or the ADON would follow up with the CNAs to ensure they are performing the interventions correctly. On 10/14/25 at 12:42 am the Administrator was interviewed. The Administrator stated that the DON and the ADON were responsible for implementing and carrying out the care plans. The administrator stated that when there are changes, the DON or ADON were to follow through to ensure all staff were familiar with resident changes and performing the interventions correctly.

Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 2 residents (Resident #1) reviewed for medication storage.The facility did not ensure a medication named Normal Saline flush was not stored at the bedside for Resident #1 on 10/3/2025.This failure could place all residents at risk of misuse of medication and decreased quality of life. Findings included: Record review of Resident #1 face sheet dated 10/3/2025 revealed an [AGE] year-old male admitted to facility on 9/29/2025 with diagnosis of infection of amputation stump, left lower extremity, acquired absence of other left toes.Record Review of Resident #1s comprehensive care plan dated 09/30/2025 revealed Resident #1 is on intravenous medications related to left wound infection, with interventions flush intravenous site as per doctor orders.During an observation and interview on 10/3/2025 at 5:03 pm Resident # 1 was observed with a normal saline flush on his television stand. He stated the nurse that administered the antibiotic left the normal saline flush on top of the television stand.During an interview on 10/3/2025 at 9:10am with LVN A said no residents should have medications or the normal saline flush at their bedside. She said a resident could take the normal saline, other residents or visitors. She said residents could have an allergic reaction or the normal saline flush could get contaminated.During an interview 10/4/2025 at 2:25 pm with DON said no resident should have medication of any kind at their bedside. He said another resident could go into the room and take the medication. He said Resident #1 could get an adverse reaction.Record Review of facility policy titled Storing and Controlling Medications revealed: It is the policy of this Facility to store medications safely, securely, and properly following manufacturer's recommendations or those of the supplier, and in accordance with federal and state laws and regulations. The medication supply is accessible only to authorized personnel. Ensure maximum safety for residents and wellness personnel.

Based on observations interview, and record review the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 (1 and 2 hallway cart) of 5 medication carts. The facility failed to ensure that the nurses medication cart for 1 and 2 hallway was secured by a lock when it was left unattended by LVN A. The failure could place residents at risk of injury to other residents if medication left unsecured were consumed. Findings included: During an observation on 11/17/2025 from 02:51 PM revealed the 1 and 2 nurse's medication cart was left unlocked and unattended against the nurse's station. During the observation LVN A was called by surveyor and informed her that the medication cart was unlocked. LVN A secured the cart by locking it. During an interview on 11/17/2025 at 02:52 PM with LVN A revealed she was responsible for the nurse's medication cart that was left unlocked. She stated she was expected to lock the nurse's medication cart when she walked away from it. She stated if it was left unlocked then a resident could open a drawer and take a medication that was not for them. She stated she had left the cart unlocked because she just went to answer a call. During an interview on 11/18/2025 at 05:20 PM with the DON revealed numerous staff, including he and the ADON, were responsible for ensuring medications carts were locked. The DON stated his expectation of staff when they walked away from the medication cart was to lock it. The DON stated that the negative outcome for leaving the cart unlocked was that a resident or visitor could grab the medication from the cart, and it could harm them. He stated he had provided in-services to the staff, and he visually monitored daily. Record review of undated facility policy Storing and Controlling Medications dated 7/2017, revealed: Medications of those residents who do not self-administer, will be stored in a locked cabinet, (such as a medication cart). Only authorized personnel will have a key/access to the locked cabinet.

Based on observations, interviews, and record review the facility failed develop a comprehensive person-centered care plan for each resident, consistent with resident needs, that included measurable objectives and time frames to meet residents' physical needs for 1(Resident #66) of 6 residents reviewed for care plans. The facility failed to develop a comprehensive person-centered care plan for Resident #66. The comprehensive care plan failed to address the antibiotic medication ordered by the physician. This failure could place the residents at risk of not receiving appropriate interventions to meet their current needs. Findings included: 1. Record review of Resident #66's electronic facility face sheet dated 11/19/24, revealed she was an [AGE] year-old female admitted to the facility on [DATE], original admitted [DATE] with diagnoses of pneumonia, end stage renal disease (final stage of kidney disease), type 2 diabetes mellitus, pleural effusion (excess fluid buildup in the space between the lung and chest), and acute on chronic diastolic congestive heart failure (heart failure in the left ventricle muscle). Record review of Resident #66's quarterly MDS assessment dated [DATE] revealed she scored a 13 on the BIMS assessment which indicated he was cognitively intact. Record review of Resident #66's physician order summary revealed order date 11/16/24 for Azithromycin tablet 250mg by mouth at bedtime for pneumonia for 4 days with an end date of 11/20/24. During an interview on 11/19/24 at 03:11 p.m. with MDS A, she stated she was not the only one responsible for care planning. She stated that the nurses, the ADON, and the DON were also responsible for care planning. She stated that if she sees that the order was not care planned then she will care plan it at that time. MDS A stated that the antibiotic order came in on Saturday and that she did not work on Saturdays or Sundays. She stated that the antibiotic order got overlooked. MDS A stated that it was important for the antibiotics to be care planned because that was how the nurses knew what signs and symptoms to monitor. The care plan will also have information stating when to contact the doctor if the antibiotic was not working, and also if labs needed to be drawn. During an interview on 11/19/24 at 03:18 p.m. with ADON, she stated that the MDS was responsible for care planning. Then she said they should check it in the morning meetings. She stated that they put out the list of antibiotics to review at the time. The ADON stated that maybe the antibiotic order was missed or overlooked since it came in over the weekend. She stated the antibiotics should be care planned so all of the staff can be on the same page as far as care management. During an interview on 11/19/24 at 03:27 p.m. with the DON, stated the MDS and nursing were responsible for care planning. They audit the physician orders as frequent as possible. He stated they have their morning meetings weekly and they look at the physician orders from the previous week. He stated that he was training the ADON to help him with the stewardship and surveillance. He stated Resident #66 was being treated empirically, then was switched. They audit as a team, and they have clinical resources that do remote audits. He stated that the MDS check physician orders on Monday that came in on Friday that will need to be care planned. The MDS then check the physician orders on Tuesday that came in on Monday. The DON stated that the plan of care for the residents were important for the clinical team to have access to follow the care plan interventions. Record review of Comprehensive Person-Centered Care Planning Policy Revision/Review dated on 01/2022, revealed the following: Policy: It is the policy of this facility that the interdisciplinary team shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a residents medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment .

Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 (room [ROOM NUMBER]) of 5 rooms reviewed for environment. The facility failed to ensure the facility was in good repair as the facility did not repair gaps/holes on the restroom door frame in room [ROOM NUMBER]. This failure could affect all residents, staff, and the public by placing them at risk for diminished quality of life due to the lack of a well-kept environment. The findings included: Observation on 11/01/24 at 10:35 AM revealed room [ROOM NUMBER] in hall 3 had 2 holes on the door frame for the restroom. There was a gap/hole on the outer part of the door frame about 5 inches wide x 4 inches long x 4 inches deep and another gap/hole on the inner part of the door frame about 5 inches wide x 4 inches long x 4 inches deep. The holes were not connected and not able to see to the inside of the restroom through the holes. Observation on 11/08/24 at 10:50 AM revealed room [ROOM NUMBER] still had the holes on the restroom door frame. There were fragments of wood/materials in both holes. The door frame was tapped/hit and nothing came out of the holes. Interview with MN C on 11/08/24 at 11:20 AM revealed MN C said if the staff saw something that they needed to fix, the staff told the maintenance staff or wrote it in the maintenance binder at the nurse's station. MN C said MN D checked the binder daily and if it was something they could not fix, MN D called the contracted companies to fix the issue. MN C said he was not informed of a hole needed to be fixed in room [ROOM NUMBER]. Interview with MN D on 11/08/24 at 12:00 PM revealed MN D said the staff told him of anything that needed to get fixed. MN D said they tried to fix the issue that same day and if it was something he could not fix, he called the companies the facility used. MN D said the staff told him verbally and if not documented the issue on the binder at the nurse's station. MN D said he checked the binder daily. MN D said he had not been informed about anything needed to get fixed in room [ROOM NUMBER]. MN D said it was important to keep the building safe and functional in order to ensure the residents were safe. MN D said they tried to maintain the facility as best as they could to provide a nice, odor free, home environment for the residents, family, and staff, but most importantly for the residents, because the facility was their home. Interview with CNA A on 11/08/24 at 12:15 PM revealed CNA A said if she noticed something wrong with the room or something was broken, not working correctly, she let maintenance know. CNA A said she also documented on the binder at the nurse's station if maintenances staff were not available, but she usually saw maintenance staff walking around, so she let them know and they fixed it. Interview with HK B on 11/08/24 at 2:05 PM revealed HK B said if there was anything that needed to get fixed, like a crack on the wall, or something was broken, she told the maintenance staff. HK B said she documented on the maintenance log, but she usually told the maintenance staff verbally because they were always available. HK B said she cleaned halls 3 and 4. HK B said she had seen the gap/hole at the bottom of the restroom doorway in room [ROOM NUMBER] in hall 3. HK B said she reported the issue to MN D a long time ago, but she did not remember how long ago or when. HK B said she was not sure if she documented in the binder or told MN D verbally. HK B said the holes had been like that for some time but she was not sure how long. HK B said the maintenance staff were good about fixing things, but she was not sure why the holes had not been fixed. Observation on 11/08/24 at 2:20 PM revealed MN C fixed the gaps/holes on the restroom door frame of room [ROOM NUMBER]. MN C used joint compound and a putty knife to repair the holes. Interview with RN F on 11/08/24 at 4:00 PM revealed RN F said if she saw anything wrong with the room, if something was broken, toilet was not working, sink was not working properly, etc., she told the maintenance staff. RN F said she also documented in the binder in the nurse's station. RN F said the maintenance staff followed up and tried to fix the issue. RN F said she did not notice any holes or issues that needed to be fixed in room [ROOM NUMBER] and she did not report anything to maintenance staff for room [ROOM NUMBER]. Interview with the ADM on 11/08/24 at 5:15 PM revealed the ADM said when the staff saw something that needed to be fixed, the staff knew to document in the binder for maintenance or tell the maintenance staff. The ADM said they also had morning meetings, which included all department heads such as the maintenance director, MN D. The ADM said MN D had worked here for almost [AGE] years and was very good at keeping the building in good shape despite the building being built since 1950. The ADM said he did not know there was an issue in room [ROOM NUMBER] until it was brought up today. The ADM said no one had voiced that there were gaps/holes in that room, as far as he was aware. The ADM said it was important to maintain the building in good repair for the safety of the residents and to provide better service to the residents. Record review of the Maintenance Log binder reflected from 06/01/24-11/08/24 there was no service documented for room [ROOM NUMBER] or the gaps/holes on the doorframe. Record review of the Physical Environment/Facility Maintenance Policy date revised 05/2007 reflected Policy: It is the policy of this facility to establish procedures for routine and non-routine care of the facility/building to ensure that the facility remains in good working order for resident and staff safety. Work orders: 1. Work request must be in form of work orders or verbal.

Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 2 of 8 residents (Resident #54 and Resident #11) reviewed for ADLs. 1. The facility failed to ensure Resident # 54 was provided a shower as scheduled. 2. The facility failed to ensure Resident #11 was provided shower or bed bath as scheduled. These failures could place residents at risk for discomfort, and dignity issues. Findings included: 1.Record review of Resident #54's admission record dated 8/31/23 reflected Resident #54 was readmitted to the facility on [DATE] and was a [AGE] year-old female with diagnosis that included schizophrenia (mental disorder characterized by continuous or relapsing episodes of psychosis) and dysphagia (difficulty in swallowing). Record review of Resident #54's quarterly MDS dated [DATE] reflected Resident # 54 -was cognitive independent -required total dependence on two persons for bathing. -required total dependence on two persons for transfers. -required extensive assistance by two persons for dressing, and toilet use. Interview on 8/28/23 at 2:33 pm with CNA K revealed Resident #54 was bathed on Thursdays and per the schedule. CNA K said she would document the task provided in the computerized ADLs tasks. Interview and observation on 08/28/23 at 2:33 pm with Resident #54 revealed Resident #54 in her bed. Resident #54 stated she had not been showered since last Thursday (08/24/23). Resident #54 was dressed in her gown, clean and hair combed. On 08/29/23 at 2:48 pm CNA G and CNA H said they showered the residents in their hall during their shift at 6:00 am to 2:00 pm on rooms 1 to 7 on Monday, Wednesdays, and Fridays. The second shift from 2:00 pm to 10:00 pm showered the rest of the rooms. Resident #54' s room was in this same hall but on their shift. Record review of the shower schedule (undated) reflected Resident #54's bathing schedule was Monday, Wednesdays, and Fridays in the afternoon shift, 2:00 pm to 10:00 pm. Record review of the computerized ADL tasks dated 08/18/23 to 08/31/23 reflected Resident #54 had not received a shower on Friday, 08/18/23, Monday 08/21/23 and Friday, 08/25/23 and Wednesday 08/08/23 as scheduled. 2. Record review of admission record for Resident #11 reflected Resident #11 had been readmitted to the facility on [DATE], was an [AGE] year-old female with diagnosis that included need for assistance with personal care and cognitive communication deficit (difficulties with thinking.) Record review of the quarterly MDS dated [DATE] for Resident #11 reflected -was cognitively impaired -required total dependence on two persons for bathing. Record review of the care plans for Resident #11 reflected Resident #11 had impairment to skin integrity r/t rash to upper back and all affected areas, date initiated, 08/18/23. Interview on 08/30/23 at 1:35 pm revealed Resident #11's RP L was visibly upset that no one had bathed Resident #11 since the previous week. Resident #11's RP L said she had told a staff member that she wanted Resident #11 to be bathed in the morning and not in the afternoon as she had been scheduled previously. Interview on 08/30/23 at 1:32 pm with CNA A revealed she worked from 6:00 am to 2:00 pm. CNA A said no one had told her to bathe Resident #11 in the mornings. Resident #11 was a Hoyer lift for transfers and had to be assisted by two persons. CNA A said if she was working by herself, she had to find another staff from another hall to assist with showers. CNA A said she might have not provided baths to Resident #11 and when she did, she would document in the computerized ADL tasks. Record review of the shower schedule for Resident #11 reflected Resident #11 was to be bathed on Mondays, Wednesdays, and Fridays in the afternoon shift, from 2:00 pm to 10:00 pm. Record review of the computerized ADL tasks for Resident #11 from 08/17/23 to 08/30/23 reflected Resident #11 had not been provided with a bath on Friday 08/18/23, Wednesday 08/23/23, Friday 08/25/23 and Wednesday 08/30/23 as of 08/30/23 at 3:04 pm as scheduled. Resident #11 had received a sponge bath on Monday 08/28/23. Record review of Grievance Resolution Forms for Resident #11 reflected three grievances had been completed by Resident #11's RP L. -grievance form dated 03/14/23 reflected RP concerned resident had not been showered. Resolution reflected the shower days would be moved to morning shift, signed by the facility Administrator. -grievance form dated 05/09/23 reflected RP L concerned that resident was not being showered. Resolution reflected the resident showered. The grievance form was signed by the facility Administrator. -grievance form dated 06/12/23 reflected RP L concerned resident not showered and questioned the cream application. Resolution reflected a shower aide program initiated, resident showered, shower schedule moved to mornings as requested by RP. The grievance form was signed by facility Administrator. Interview on 08/31/23 at 9:57 am with the DON revealed he had several conversations with Resident #11's RP L about the resident not getting any showers. The DON said he implemented a shower aides' program that was not effective in that shower aides quit recently, and the program had been discontinued. The DON said as of 08/09/23, the CNAs on the floor were responsible to provide showers to the residents in their halls according to the shower schedule. The CNAs should document on the computerized ADLs tasks when they provide showers or residents refuse. The DON said the charge nurses were responsible to ensure CNAs provided showers to residents as scheduled. The DON said that Resident #11's RP L had requested to provide showers to Resident #11 and had not been scheduled as she requested. The DON said he was responsible to ensure the charge nurses checked to see if residents were getting their scheduled showers. Record review of the facility policy titled Quality of Care dated July 2017 reflected It is the policy of this facility that residents are given the appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care. If a resident is unable to carry out activities of daily living, the necessary services to maintain good nutrition, grooming, toileting, and personal oral hygiene will be provided by qualified staff.

Based on observation, interview, and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' mental and psychosocial needs; and services that were to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for one (Resident #54) of eight residents reviewed for care plans. The facility failed to develop a care plan for slurred speech for Resident # 54. This failure could place residents at risk for not receiving necessary care and services. Findings included: Record review of the admission record dated 8/31/23 for Resident #54 reflected Resident #54 was readmitted to the facility on [DATE] and was a [AGE] year-old female with diagnosis that included schizophrenia (mental disorder characterized by continuous or relapsing episodes of psychosis) and dysphagia (difficulty in swallowing). Record review of Resident #54's quarterly MDS dated [DATE] reflected Resident # 54 -was cognitive independent -had unclear speech (slurred or mumbled words). Record review of Resident #54's care plans reflected Resident #54 had a focus area indicating resident was dependent on staff for social interaction related to cognitive deficits, date initiated, 06/23/23. Interventions included to engage in simple, structured activities such as (Socialization and watch TV), date initiated 06/23/23. Resident # #54's care plans did not address the resident's slurred speech. Observation and interview on 08/28/23 at 11:40 am with Resident #54 revealed Resident #54 in bed and speech not understood, unclear and mumbled. Interview on 08/29/23 at 2:21 pm with LVN/MDS F revealed Resident #54 did have slurred speech as per her most recent assessment. LVN/MDS F said she had overlooked developing a care plan for this communication area of concern. LVN/MDS F said Resident #54 communicated very well, but this area of care should have been care planned. New staff or visitors might not be able to understand her speech and could cause misinformed communication with Resident #54. Interview on 08/29/23 at 2:25 pm with CNA G and CNA H revealed Resident #54 did have slurred and unclear speech but they were able to understand her because they had assisted her with care for a long time and they understood her when she verbalized her needs to them. CNA G and CNA H said if they didn't understand sometimes, they would ask her to repeat her words. Both CNA G and CNA H staff said that if a new staff would come and provide her with care, they might not be able to understand her. Sometimes other staff from other halls would come to replace them if they were out for some reason. Interview on 08/29/23 at 2:30 pm with LVN E revealed the CNAs that worked regularly with the resident understood Resident #54 better than anyone. LVN E said Resident #54 did have slurred speech and was difficult to understand what she was saying. If a new staff came to assist Resident #54, they would have trouble understanding her slurred speech. The care plans are developed to provide interventions to address the concern. Interview on 08/31/23 at 9:57 am with the DON revealed care plans needed to be developed and interventions implemented to address areas of care concerns. The DON said not developing care plans with interventions for focused areas of concern would place residents at risk of not receiving the necessary care for their individual needs. The IDT team would meet to address areas of concerns as assessed by their MDS assessment. It was his responsibility to ensure the care plans needed to be developed and implemented as needed based on the assessments. The DON said he did not know why the care plan for Resident'#54's focus area of slurred speech had not been developed. Record review of the facility policy titled Comprehensive Person-Centered Care Planning dated January 2022 reflected The facility IDT will develop and implement a comprehensive person-centered care plan for each resident within seven (7) days of completion of the Resident Minimum Data Set (MDS) and will include resident's needs identified in the comprehensive assessment, any specialized services as a result of PASARR recommendation, and residents goals and desired outcomes, preferences for future discharge and discharge plans. The resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment, including both the comprehensive and quarterly review assessments.

Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision for one Resident (Resident #218) of three residents reviewed for supervision. The facility failed to ensure Resident #218 received two-person assist when providing incontinent care. This failure could place residents at risk for accidents and injury. The findings were: Record review of Resident #218's face sheet dated 8/30/23 revealed a [AGE] year-old female with an admitted [DATE] and diagnoses which included: Stroke, peripheral vascular angioplasty status (a procedure to help blood flow better), and chronic kidney disease (longstanding disease of the kidneys leading to renal failure). Record review of Resident #218's Admission MDS assessment dated [DATE] revealed she required extensive assistance/two person physical assistance for bed mobility, dressing, and toilet use. Resident #218 was always incontinent of bowel and bladder. Record review of Resident #218's Care Plan dated 08/21/23 revealed she required assistance extensive to: wash hands, adjust clothing, clean self, transfer onto toilet, transfer off toilet, to use toilet. Resident #218 required 1-2 staff participation to reposition and turn in bed. Observation on 08/28/23 at 10:10 a.m., revealed Resident #218 requested to be changed. CNA B came in to change the resident. In an interview on 08/30/23 at 08:55 a.m., Resident #218 stated 2 people would get her up to put her in her wheelchair. Resident #218 stated sometimes two people would come in to change her and sometimes only one person would come in to change her. Resident #218 stated she needed changed at this time, and pressed her call light (09:07 AM). Observation on 08/30/23 at 09:07 a.m., revealed CNA A answered Resident #218's call light and Resident #218 told CNA A she needed changed (her brief was soiled). CNA A left Resident #218's room to gathered the supplies needed to change the resident. Observation on 08/30/23 at 09:09 a.m., revealed CNA A entered Resident #218's room to change Resident #218. Resident #218 asked surveyor to leave the room so she had privacy during incontinent care. Observation on 08/30/23 at 09:14 a.m., revealed CNA B entered Resident #218's room where CNA A was changing Resident #218's brief. Observation on 08/30/23 at 09:18 a.m., revealed CNA A and CNA B left Resident #218's room. In an interview on 08/30/23 at 09:20 a.m., CNA B stated one person could change Resident #218. CNA B stated on Monday (August 28, 2023) when the surveyor was talking with Resident #218 and Resident #218 had asked CNA B to change her soiled brief, CNA B stated she changed her by herself. CNA B stated Resident #218 can move so she (CNA B) can change Resident #218 by herself. CNA B stated the CNAs can find in Tracker (CNAs computer system where they check for care and document care) how many persons had to assist a resident for changing. Surveyor observed Tracker as showing 2 person assistance required for toileting Resident #218. CNA B stated she just went into Resident #218's room to help CNA A pull Resident #218 up in the bed, but CNA A was the one who changed Resident #218. CNA B stated if a resident was a 2 person assist for changing and 1 person only changed a resident, either the CNA or the resident could get hurt. In an interview on 08/31/23 at 12:43 p.m., CNA A stated yesterday (08/30/23), she changed Resident #218 by herself, and CNA B had come to help at the end of the care. CNA A stated if a resident was dirty she would clean them and not leave them dirty. CNA A said lots of times she was on the hall by herself and would not have help. CNA A stated she sometimes will call for someone to help her if she sees them in the hall. CNA A stated if a resident was a two person assist and only one person assisted, either the CNA or the resident could get hurt. CNA A stated Resident #218 was able to move in the bed, so she (CNA A) had changed Resident #218 by herself. In an interview on 08/31/23 at 02:04 p.m., LVN E stated when a CNA would come to say they need help, LVN E stated if he was not in the middle of something, his cart was locked, and everything was good, he would go with the CNA to assist with whatever they needed. LVN E stated for mornings, like today (08/31/23), there were eight CNAs and one CNA in training working on the floor. LVN E stated he thought that was enough staff to be working at that time. In an interview on 08/31/23 at 02:50 p.m., the DON stated CNAs would come ask him for help if they needed it and he would go assist them. The DON stated he told CNAs to ask for help if they would have a heavy resident. The DON stated CNAs could also go to their kiosk or POC (computer used by the CNAs) to check how many people would be needed to assist the resident. The DON said nurses would look first at the MDS for how much assist a resident needed for ADLs. The DON stated they would then check the resident's care plan, but the first check would be MDS. DON stated the negative outcome for a CNA or resident using a one person assist on a resident instead of two person assist could be improper care, falls or injury. Review of facility's policy titled Nursing Services Quality of Care, revised 07/2015, revealed: Policy: It is the policy of this facility that residents are given the appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care. Procedures: 1. Maintenance and restorative programs will be provided to residents in accordance with the resident's comprehensive assessment 6. ADL care, including personal hygiene, oral care, transfers, grooming, dressing, mobility, ambulation, etc. provided according to resident's assessed needs and level of support.

Based on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 1 (Resident #267) of 6 residents reviewed for enteral nutrition, in that: The facility failed to appropriately label the formula bag for Resident #267 per the facility's policy. This failure could affect residents receiving enteral nutrition/hydration and place them at risk of health complications and decline in health. Findings included: Record review of Resident #267's face sheet revealed the resident was [AGE] year-old female admitted on [DATE] with a diagnosis that including unspecified sequelae of cerebral infarction, heart failure, and gastrostomy status. Record review of Resident #267's quarterly MDS dated [DATE], revealed a BIMS at not able to conduct interview. The assessment reflected Resident #267's required total dependence with eating, and is bed bound. Resident #267's the resident's nutritional approach was feeding tube. Record review of Resident #267's care plan revised dated 08/27/2023 revealed requires tube feeding r/t dysphagia aphasia. Goal: Will be free of s/sx of infection through the review date. Care plan created 08/22/2023 revealed potential nutritional problem r/t gastrostomy status. Goal: Will maintain adequate nutritional status as evidenced by maintaining weight with no s/sx of malnutrition through review date. Record review of Resident #267's physician's order revealed Jevity 1.5 @ 50ml/hr and H2O 150ml every 6 hrs. Observation 08/28/23 at 2:28 PM revealed Resident #267 was asleep, lying-in bed. Observed a feeding pump next to Resident #267. The feeding pump was infusing at 50ml/hr and flush is set at 150ml every 6 hrs. A bag of enteral feeding was hanging from the pole with no formula name, time, date, and initials of who administered the feeding. The surveyor observed the formula bag had about less than half left inside. A bag of water was hanging on the other side of the pole with a label. Interview on 08/28/23 at 2:35 PM with LVN I, he stated he was the nurse for Resident #267. LVN I was informed the formula bag had no formula name, time, date, or initials. LVN I was unaware Resident #267's formula bag was not labeled. LVN I stated he had just came on shift 45 minutes ago. He stated LVN J was the previous nurse. LVN I stated they did bedside report during shift change. LVN I stated he did not go into Resident #267 room today, 08/28/23. Interview on 08/28/23 at 2:50 PM with LVN J, he stated he was nurse for Resident #267. LVN J was informed the formula bag had no formula name, time, date, or initials. LVN J stated she had clarified with the DON and ADON, that since bags came together as a dual bag with only one label then it was okay to put label only on one bag. LVN , stated that one label would have both information for water and feeding. Observation on 08/28/23 at 02:58 PM revealed LVN I held the completed label up which included, formula name, date, and initials. He showed it to LVN J and LVN I proceeded to walk into Resident #267's room to apply label on formula bag. Interview on 08/30/23 at 02:00 PM the DON stated the formula bag and water bag should be labeled individually. The DON stated formula bags were labeled as a precaution. The DON stated the double bags also needed to be labeled individually. Interview on 08/31/23 at 11:50 AM ADON L stated she had been working at the facility for [AGE] years. ADON L stated she monitors staff every morning. She also does the annual skill checks on nurses. ADON L stated she does rounds with new hires. She stated the feeding formula bags come with one sticker but are now encouraging nursing staff to label both the formula bag and water bag individually. The surveyor asked when did the facility start to encourage this, and the ADON stated she was not sure of when it was initiated. Record review of the Enteral Feeding Administration Pump facility policy revised 05/2007 revealed #2 Label bag with formula, residents name, amount, date, time and initials.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for one resident (Resident #126) observed for incontinent care, in that: CNA C did not use one wipe per swipe on the perineal and buttock area during incontinent care on Resident #126. CNA C did not change her gloves during incontinent care for Resident #126. CNA C did not wash her hands before leaving Resident #126's room after performing incontinent care. These failures could place residents at risk for infections and cross contamination. The findings included: Record review of Resident #126's Face Sheet dated 08/31/23, reflected a [AGE] year old male admitted to the facility on [DATE], with diagnoses that included local infection of the skin and subcutaneous tissue (layer of tissue that underlies the skin), Extended Spectrum Beta Lactamase (ESBL) Resistance (enzymes that are resistant to most beta-lactam antibiotics including penicillin, cephalosporins, and the monobactam aztreonam), resistance to vancomycin (vancomycin is an antibiotic used for abscesses, wounds, or peritonitis), sacral stage 4 pressure ulcer (full thickness skin loss with extensive destruction; tissue death); or damage to muscle, bone, or supporting structure such as tendon, or joint capsule below the lumbar spine and above the tailbone), right hip stage 4 pressure ulcer, and left hip stage 4 pressure ulcer, feeding tube, colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon), tracheostomy (an opening surgically created through the neck into the windpipe to allow air to fill the lungs). Record review of Resident #126's Quarterly MDS dated [DATE], revealed Resident #126's cognitive status was severely impaired, he was totally dependent with two-person assistance for bed mobility, dressing, and toilet use, was totally dependent on one person assistance for eating and personal hygiene. Record review of Resident #126's Care Plan dated 08/13/23, revealed Resident #126 had ADL (Activities of Daily Living) self-care performance deficit related to totally dependent on staff secondary to anoxic brain injury (caused by a complete lack of oxygen to the brain, which resulted in the death of brain cells after approximately four minutes of oxygen deprivation). Resident #126 was totally dependent on 1 -2 staff for personal hygiene and oral care. Resident #126 was on hospice. Record review of Resident #126's Weekly Skin assessment dated [DATE] revealed Sacral Stage 4 Pressure Ulcer measurements: 13cm (L) x 11cm (W) 30% slough 30% red skin to bone. Right hip Stage 4 pressure ulcer measurements: 6cm (L) x 8 cm (W) x 1.5cm (D) 70% red 30% yellow, undermining 2.5 cm. Left hip Stage 4 Pressure Ulcer measurements: 7cm (L) x 6.5cm (W) x 2cm (D) undermining 2cm. Observation on 08/31/23 at 03:46 p.m., during incontinent care on Resident #126, revealed CNA C washed her hands for 45 seconds when she entered the resident's room and put on gloves. During incontinent care CNA C used one wipe, wiping twice on the area between Resident #126's scrotum and left leg. CNA C then used one wipe, wiping four times on Resident #126's left buttock area wiping over the dressing of the left hip pressure ulcer. CNA C used one pair of gloves for incontinent care, not changing her gloves. CNA C removed her gloves after performing incontinent care on Resident #126 and left the room. CNA C did not wash her hands before leaving Resident #126's room. In an interview on 08/31/23 at 04:30 p.m., CNA C stated one wipe should be used for one swipe. CNA C stated she used new gloves two times, when she went in the room and when she left Resident #126's room for incontinent care. CNA C stated she was supposed to change her gloves because if she did not change her gloves during pericare, she could contaminate more. CNA C stated she was supposed to wash her hands when she entered the room and when she left the room. CNA C stated she washed her hands in another room after she left the resident's room. In an interview on 08/31/23 at 04:36 p.m., CNA D stated one wipe for each swipe should be used during incontinent care. CNA D stated when one removed their gloves, one should use hand sanitizer, and then put new gloves on. CNA D stated when gloves are soiled one should wash their hands and one should wash their hands when entering the room, if gloves are visibly soiled, and before one exits the room. CNA D stated if one did not do those things, one could cause cross contamination. In an interview on 08/31/23 at 06:00 p.m., the DON stated when performing incontinent care one wipe was to be used for each swipe. The DON stated gloves are to be removed when dirty or visibly soiled and hands are to be washed when entering the room, when gloves/hands are visibly soiled, and before leaving the room. The DON stated when that was not done, there was a risk for infection or cross contamination. When surveyor asked DON for policies on incontinent care and hand hygiene, surveyor was given the following policy: Review of the facility's policy/procedure - Nursing Clinical Routine Procedures Incontinent Care (not dated) revealed: Procedure: 4.D. Cleanse perennial/rectal area and doff gloves. E. Wash hands/perform hand hygiene, don gloves and then apply a new brief. F. Remove gloves and perform hand hygiene.

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment, were reported immediately to the State Survey Agency, within two hours, for 2 residents (Resident #1 and Resident #2) of 2 residents reviewed for abuse/neglect, in that: The facility did not report the allegation of resident abuse to the State Survey Agency within the allotted time frame for Resident #1 and Resident #2 who had a resident to resident altercation. This failure could place all residents at risk for injuries, abuse, and/or neglect. Record review of Resident #1's Admission Record, dated 01/12/23, revealed Resident #1 was a [AGE] year-old male, who was admitted to the facility on [DATE]. Diagnoses included: Type 2 Diabetes Mellitus, hypertension (high blood pressure), Bipolar Disorder (a mental illness that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks), dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), psychotic disturbance (people lose contact with reality and experience a range of extreme symptoms that usually includes: hallucinations - hearing or seeing things that are not real, such as voices. Delusions - believing things that are not true), mood disturbance (can be feelings of distress, sadness or symptoms of depression, and anxiety), anxiety disorder, heart failure. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed Resident #1: -had clear speech -was able to make himself understood -was able to understand others -had a BIMS of 04 (severely impaired cognition) -required extensive assistance on two staff for bed mobility, transfers, dressing, and personal hygiene -required limited assistance by one staff for toileting -required supervision with setup help only for eating. Record review of Resident #1's Nurse's Progress Note dated 08/04/22 at 05:30 p.m., written by LVN E, revealed, notified by CMA resident punched resident (#2) (room #) in the face. resident (#2) (room #) was passing through looking for room, resident (#1) upset and punched (room # of Resident #2) in the face. both resident were separated by CMA (MA) (unknown CMA)(MA). resident redirected and explained that resident (room # of Resident #2) is HOH (hard of hearing) and needs the assistant of handle bars along the hallway. SN placed call to NP, new order for UA, Ammonia level and Psych evaluation. order carried out. unable to contact RP, will forward to incoming SN. Record review of Resident #1's Care Plan updated 08/05/22 to address Potential for a behavior problem r/t verbal aggression towards other residents 8/4/22 - resident had physical agresssion towards another resident (punched). Goals and interventions/tasks applied. Record review of Resident #1's Section 28 dated 08/05/22 revealed Section 28 was signed by judge on 08/05/22. Record review of Resident #2's Admission Record, dated 01/12/23, revealed Resident #2 was a [AGE] year-old male, who was admitted to the facility on [DATE]. Diagnoses included: Dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), muscle weakness, and lack of coordination. Record review of Resident #2's Quarterly MDS, dated [DATE], revealed Resident #2: -had moderate difficulty hearing -had clear speech -was usually able to make himself understood -was usually able to understand others -had a BIMS of 02 (severely impaired cognition) -required extensive assistance on two staff for bed mobility, transfers, dressing, and toileting -required extensive assistance with one staff assisting -required supervision with one staff for assisting -required supervision with setup help only for locomotion on unit. Record review of Resident #2's Nurse's Progress Note dated 08/04/22 at 05:30 p.m., written by LVN E, revealed, notified by CMA (MA)(unknown CMA) resident (#2) was passing through looking for room, resident (#1) (Resident #1's room #) upset and punched [Resident #2] in the face. both resident were separated by CMA (MA). SN explained to resident (#1) that resident (#2) in room (Resident #1's room #) did not like the way he was talking to him. pain medication given a prescribed by MD. SN placed call to [Doctor] new order for X-Ray to facial cranial bones, psych evaluation, orders carried out, RP aware. Record review of Resident #2's x-ray results dated 08/05/22 revealed negative results of facial bones. Record review of Resident #2's Care Plan updated 08/05/22 to address reported to staff physical behaviors by striking another resident unwitnessed. 08/05/22 resident noted being physically aggressive towards staff 8/11/22 aggressive/physical behavior during ADL care. Goals and interventions/tasks applied. Record review of Resident #2's Section 28 dated 08/05/22 revealed for signed by judge on 08/05/22. In an interview on 01/11/23 at 03:43 p.m., LVN E stated when two residents are arguing/fighting she will try to figure out what is going on and separate them right away. LVN E would try to redirect the residents and then tell the DON right away. LVN E would notify the doctor, DON, and get orders from the doctor, and also notify the RP. If the residents get into a physical altercation, residents are assessed. LVN E stated also there is the documentation they do. LVN E stated if she witnessed or was reported abuse allegations, she would tell the DON and Administrator right away. She stated that (Administrator) was the Abuse Coordinator. In an interview on 01/12/23 at 08:57 a.m., DON was asked the resident's name in (Room #) who Resident #1 struck in the face on 08/04/22. DON stated there was no incident report filed on the incident that occurred on 08/04/22. DON stated she did not know who was in (Room #) at that time and was not aware another resident was struck. DON stated she would find out and let surveyor know. In an interview on 01/12/23 at 01:05 p.m., MA A stated she was crossing the hallway and heard Resident #1 and Resident #2 were yelling and cussing at each other. MA A stated she did not see anyone hit anyone. MA A removed Resident #2 from the area (08/02/22 altercation). MA A stated she reported it to ADON. MA A had not seen that ADON in a while and did not think he worked at the facility any longer. MA A stated she did not witness another altercation between Resident #1 and Resident #2 (08/04/22). MA A stated the other MA (MA B) for 2 - 10 shift may have witnessed the other altercation. MA A stated when there was a resident to resident altercation, they try to separate the residents and remove them (from the area). She stated they try to figure out what was going on, try to calm them (the residents) down, and report it (the altercation) to the nurse and ADON. In an interview on 01/12/23 at 01:27 p.m., LVN D stated she could not remember the incident (Resident #1 to Resident #2 altercation on 08/04/22) that occurred five months ago. She stated she could not remember who Resident #1 was. She stated that if she documented it, it had to have happened, but she could not remember. LVN D stated if there were a resident to resident altercation, LVN D would separate, assess, notify doctor, family, ADON, DON, Administrator (Abuse Coordinator), and document. In an interview on 01/12/23 at 01:46 p.m., SW stated there were several altercations with Resident #1 so they (Administrator, former DON, and SW) talked to the son and they decided to transfer Resident #1 to another facility. SW filed a Section 28 on both Resident #1 and Resident #2. SW stated Behavior stated they were full and if they had an opening, they would call SW. So far, they have not called. SW stated she would call a nurse or CNA to separate the residents in a resident to resident altercation. In an interview on 01/12/23 at 02:00 p.m., Administrator stated he does not remember there being another altercation between Resident #1 and Resident #2 (two altercations - one altercation on 08/02/22 and the other on 08/04/22). He said he did not know why it was not reported. Administrator acknowledged concern of not reporting second resident to resident altercation. Administrator stated the staff or even families were to report allegations of abuse to him immediately. Administrator stated he is the Abuse Coordinator for the facility. He said he is the one who reports to State. In an interview on 01/12/23 at 02:33 p.m., MA B stated she did not witness an altercation between Resident #1 and Resident #2 in August (08/04/22). In an interview on 01/12/23 at 02: 39 p.m., MA C stated she did not witness an altercation between Resident #1 and Resident #2 in August (08/04/22). MA C stated when there is an allegation of abuse or abuse witnessed, she notifies the nurse, and also, the Abuse Coordinator, (Administrator) immediately. Record review of facility's Abuse/Neglect policy Centers for Medicare and Medicaid Services. (2017). State operations manual appendix PP - Guidance to surveyors for long term care facilities. (https://www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/downloads/appendix-pp-state-operations-manual.pdf ) Abuse: Prevention of and Prohibition Against ROP Section: 483.12 Freedon From Abuse,Neglect,& Exploitatation Original Date: 11.2017 Revision/Review Date(s) 4.2019; 1.2021; 1.2022 Policy It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Facility staff are prohibited from taking, keeping, using or distributing photographs or video recordings of Facility residents in any manner that would demean or humiliate a resident, regardless of whether the resident provided consent and regardless of the resident's cognitive status. This includes using any type of equipment (e.g., cameras, smart phones, or other electronic devices) to take, keep, or distribute inappropriate photographs or recordings on social media. The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, and exploitation. This policy applies to all Facility staff including, but not limited to, employees, consultants, contractors, volunteers, students, and other caregivers who provide care and services to residents on behalf of the Facility. Purpose: Residents also have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Nursing home residents have a right to personal privacy and confidentiality of their physical body and personal space, including accommodations and personal care. The purpose of this policy is to ensure that nursing Facility staff do not violate these resident rights and to ensure Facility staff are not taking, keeping, using or distributing photographs or video recordings that would demean or humiliate Facility residents, including by sharing such images through social media. Definitions: To assist the Facility's staff members in recognizing incidents of possible abuse, neglect, misappropriation of resident property, or exploitation, the following definitions are provided: Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse includes but is not limited to hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. E. Identification 1. Facility staff with knowledge of an actual or potential violation of this policy must report the violation to his or her supervisor or the Facility administrator immediately. The Facility will assist staff in identifying abuse, neglect, and exploitation of residents, and misappropriation of resident property. This includes identifying the different types of abuse-mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. H. Reporting / Response 1. All allegations of abuse, neglect, misappropriation of resident property, or exploitation should be reported immediately to the Administrator. 2. Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the Facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations.

Based on observation and interview, the facility failed to post the daily nurse staffing data at the beginning of each shift in a prominent place, readily accessible to residents and visitors that included the facility name; the total number of hours worked per shift by the registered nurses, the licensed vocational nurses, and the certified nurse aides directly responsible for resident care for the facility for 1 of 2 days reviewed for staffing postings. The facility did not post the required staffing with hours worked daily. This failure could place the residents, families, and visitors at risk of not having access to information regarding the daily nurse staffing data. Findings included: During an observation on 09/14/22 at 11:00 am, accompanied by ADON A revealed there was no staffing sheet for 09/14/22 posted in the lobby, halls, halls to resident's rooms or at the nurse's station with the total hours worked for RNs, LVNs and CNAs. During an interview on 09/14/22 at 11:00 am with ADON A, he stated HR staff was responsible to post the daily staffing sheet. ADON A said the HR staff had just been hired recently. During an interview on 09/14/22 at 11:05 am with HR staff, she stated she had not been instructed as part of her responsibility to post the staffing sheet since she had just been hired in June 2022. Interview on 09/14/22 at 11:20 am with the Administrator revealed the HR staff had recently been hired in June 2022 and he had not been aware the daily staffing sheet had not been posted since the new HR staff had been hired. The HR staff was responsible to post the daily staffing sheet in a visible place for all visitors, residents, staff, and family members to see. The Administrator said there was no policy provided for daily staff posting. Interview on 09/14/22 at 2:42 pm with LVN B revealed she had not seen the daily staffing sheet posted in the facility for several weeks. Interview on 09/14/22 at 1:52 pm with LVN C revealed he had not seen the daily staffing sheet posted in the facility for several weeks.

Based on observations, interviews and record review, the facility failed to ensure 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 they were unavoidable for 1 (Resident #1) of 7 residents reviewed for pressure ulcers, in that: Resident #1 did not have bilateral heel protectors in place as indicated in the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure could place residents with fragile skin at risk for injury. The findings included: Record review of Resident #1's Face Sheet dated 08/05/22 documented a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Medicare 5 Day MDS dated [DATE] revealed Resident #1's cognitive status was severely impaired, he required extensive assistance with two person assistance for bed mobility and dressing. He required total dependence with two person assistance for transfers and toileting, extensive assistance with one person assistance for eating, and total dependence with one person assistance for personal hygiene. He was at risk of developing ulcers/injuries, and was always incontinent of bowel and bladder. Record review of Resident #1's comprehensive physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Apply heel boot protector to bilateral foot every shift for to prevent wound to heels, start date, 04/15/22. Review of wound measurements for Resident #1, dated 08/05/22 revealed: Left foot dorsal (of, on, or relating to the upper side or back) prox (proximal - a part of the body that is closer to the center of the body than another part) 8.0cm x 6.0cm 50% slough 50% eschar (dead tissue that falls off or sheds from healthy skin) Left 2nd toe 4.5cm x 6.0cm gangerous (gangrenous - The death of tissue often occurs in the extremities or skin from loss of blood supply. The condition often affects toes, fingers, and limbs, but can affect muscles and organs) Left 4th toe 4.0cm x 6cm gangerous New - Left small toe 4.0cm x 5.0cm gangerous Left great toe 2.0cm x 2.0cm Right foot dorsal distal (a part of the body that is farther away from the center of the body than another part) 3.0cm x 2.5cm black eschar Right 2nd toe 1.0cm x 0.5cm red pink Right Great toe anterior 1cm x 1cm black eschar Right lateral foot 0.5cm x 1cm black eschar Observation on 08/04/22 at 12:12 p.m. revealed, Resident #1 was lying in bed on right side with pillows off-loading on left side. Head of the bed was inclined. Fall mats to sides of bed. Scoop mattress was on bed. One heel boot protector was sitting on chair beside bedside table. There was not another heel boot protector observed in the room or on Resident #1. Resident was Nonverbal. Observation on 08/05/22 at 9:10 a.m. revealed, Resident #1 was sitting in wheelchair in the dining room. His left foot was bandaged and right foot had a sock. Resident was not wearing heel protectors. In an interview on 08/05/22 at 9:16 a.m., WCN E stated, The wound care doctor (WCP G) comes in once a week to see the resident. (Resident #1) has arterial wounds to his feet which turned to gangrene quickly within a few days. (WCP G) spoke to the resident's family and told them there was nothing they could do since they were arterial wounds, resident was diabetic, and has PVD. There was no circulation to the lower extremities. The (WCP G) suggested hospice. The family was discussing whether to put (Resident #1) on hospice. WCN E stated that diet, treatment, and repositioning were the three main components of wound care healing. Observation on 08/05/22 at 10:10 a.m., incontinent care on Resident #1 was observed with CNA A and CNA B. Resident #1 was brought to room from dining room. Resident #1 was not wearing heel boot protectors. The heel boot protectors were not observed in the room. The CNAs did not place heel boot protectors on Resident #1 after incontinent care. Observation on 08/05/22 at 10:42 a.m., revealed wound care observation with WCN E. Resident #1 was not wearing bilateral heel protectors. The bilateral heel protectors were not put on Resident #1 after wound care was completed. Interview on 08/05/22 at 12:54 p.m., the CRRN (facility without a DON) stated there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . If they were not worn, heels will not be protected, and doctor's order was not being followed. Interview on 08/05/22 at 1:50 p.m., CNA A stated Resident #1 does have heel protectors and it was the CNAs responsibility to put the heel protectors on the resident. CNA A stated she does not remember if Resident #1 had the heel protectors on or not. CNA A stated the nurse was the one who tells them when heel protectors need to be put on resident or if anything other than the normal was supposed to be done for the resident. CNA A did not know the heel protectors were ordered by the doctor and did not know what could happen if the heel protectors were not worn. In an interview on 08/05/22 at 2:00 p.m., CNA C stated she was assigned to Resident #1's and Resident #1 had heel protectors, but he did not have them on this morning. She stated it was the CNA's responsibility to put heel protectors on the resident. She said the nurses will tell her what the resident needs like the heel protectors. CNA C did not know what negative outcome could happen if the resident did not have the heel protectors on. In an interview on 08/05/22 at 2:05 p.m., CNA B stated she did not notice if Resident #1 had the heel protectors on this morning during pericare. She said sometimes the CNAs who shower remove them and do not put them back on. CNA B stated the CNAs were responsible for putting the heel boots on. CNA B did not know what negative outcome could occur if resident did not wear the heel protectors. In an interview on 08/05/22 at 2:15 p.m., WCN E stated he did not see the resident wearing the heel protectors during wound care and he did not see them in his room. WCN E stated they were all responsible for making sure Resident #1 wore the heel protectors. He stated he did not see the heel protectors in the resident's room. He stated the doctor's order was not followed because the resident was to wear the heel protectors and he did not have them in his room or on his feet. WCN E stated Resident #1's feet would not be protected if he were not wearing the heel protectors. In a telephone interview on 08/05/22 at 2:44 p.m. WCP G for Resident #1 stated Resident #1 was an elderly patient. WCP G stated resident has PAD (Peripheral Artery Disease - a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) in both legs. WCP G stated that he (Resident #1) could not be healed. Resident #1's legs do not have enough blood to heal. Turning to gangrene could occur very quickly within hours or days. WCP G stated it was unavoidable and the resident's condition would progress. WCP G stated he talked to the family explaining the situation and recommended hospice because at this point it would be the most humane thing. He has not heard back on their decision yet. In an interview on 08/05/22 at 3:21 p.m., the CRRN stated they did not have any policies concerning CNAs responsibility of putting on heel boot when ordered by the doctor. The CRRN stated they did not have any policy pertaining to following doctor's order. She stated the only thing she had was the policy on Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . In a telephone interview on 08/05/22 at 4:57 p.m., RN H stated he worked at the facility as the weekend wound care nurse. RN H stated this past weekend (07/30/22 - 07/31/22) he did wound care on Resident #1 with the family in the roomRN H stated Resident #1's toes were necrotic (the death of most or all of the cells in an organ or tissue due to disease, injury, or failure of the blood supply) and smelled bad and the wound up higher toward the ankle looked really bad where the tendon could be seen. The weekend before his foot was bad, but last weekend it was worse. RN H stated he called the wound care doctor and labs were ordered. RN H suggested the hospital, but the doctor stated they would get the labs first. The doctor told him that there was nothing they could do. RN H stated, The wound care doctor had told me that (Resident #1) was not a good candidate for amputation due to his age and comorbidities. We keep the wounds clean and make sure he gets pain medication. RN H stated, The wound care doctor suggested hospice to the family because hospice would make him comfortable. I don't know what decision the family made about hospice.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for one resident (Resident #1) of one resident observed for incontinent care, in that: CNA A and CNA B did not perform hand hygiene between donning and doffing gloves when performing incontinent care for Resident #1. This failure could place residents at risk for infections and cross contamination. The findings included: Record review of Resident #1's Face Sheet dated 08/05/22 documented a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Medicare 5 Day MDS dated [DATE] revealed Resident #1's cognitive status was severely impaired, he required extensive assistance with two person assistance for bed mobility and dressing. He required total dependence with two person assistance for transfers and toileting, extensive assistance with one person assistance for eating, and total dependence with one person assistance for personal hygiene. He was at risk of developing ulcers/injuries, and was always incontinent of bowel and bladder. Observation on 08/05/22 at 10:10 a.m., during incontinent care on Resident #1, CNA B lowered blankets and pajama bottoms. CNA B removed tabs on adult brief. CNA B removed gloves. CNA B washed hands for 25 seconds and put on new gloves. CNA B handed CNA A clean wipes. CNA A wiped front with 6 wipes using 1 wipe for each swipe. CNA A wiped head of penis downward. CNA B removed gloves and put on new gloves without using hand sanitizer. CNA A wiped buttock area front to back using 1 wipe. CNA A removed right glove and put on new right glove using left gloved hand, without using hand sanitizer. CNA A used 5 wipes for each swipe on backside front to back. In an interview on 08/05/22 at 10:30 a.m., CNA A stated, We are supposed to use hand sanitizer when you change gloves. We use hand sanitizer or wash our hands when they are dirty, if we are touching the resident or any of his items. I did not use hand sanitizer when I changed my gloves today. I do every time except today. It is cross contamination if we don't wash our hands or use hand sanitizer when we put on new gloves. It is not facility policy to use hand sanitizer when changing gloves. We were nervous. In an interview on 08/05/22 at 10:35 a.m., CNA B stated, I made a mistake when I changed my gloves and didn't wash my hands or use hand sanitizer. CNA B stated every time she took off her gloves, she either washed her hands or used hand sanitizer. CNA B stated, Today I forgot because I was nervous. It is infection control to either wash hands for 20-30 seconds or use hand sanitizer between glove changes. It is facility policy to wash hands or use hand sanitizer between glove changes. In an interview on 08/05/22 at 12:26 p.m., the CRRN stated staff were trained all the time on hand washing (in-services). CRRN stated there was a policy on handwashing, gloves were not a permanent barrier, and handwashing was necessary for infection control or cross-contamination (of staff and residents). Review of Hand Hygiene Policy ([NAME] Green - IP Resources) (TypeSHEA/ISDA Practice Recommendation. Strategies to Prevent Healthcare-Associated Infections through Hand Hygiene [August 2014] Infection Control and Hospital Epidemiology 35(8): 937-60.) (World Health Organization. WHO Guidelines on Hand Hygiene in Health Care [2009] CDC Guideline for Hand Hygiene in Health-Care Settings [2002]. Morbidity and Mortality Weekly Report [http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf] here) revealed: This facility considers hand hygiene the primary means to prevent the spread of infections. 1.All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 4.Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; m. After removing gloves. 6.The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.