Every finding on record at Harlingen Nursing and Rehabilitation Center

Based on interviews, and record reviews the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. The facility failed to ensure LVN C completed Resident #1's neurological checks correctly on 08/11/26.This failure could put residents at risk of having skin breakdowns that could go unidentified and untreated.Findings included: Record review of Resident #1's admission record, dated 08/19/26, reflected a [AGE] year-old female with a re-admission date of 07/20/2026 and an original admission date of 02/20/2026. Her relevant diagnoses included aftercare following joint replacement surgery, displaced fracture of epiphysis (separation) (upper) left femur (medical term for hip injury where the upper growth of the thighbone slips or breaks), abnormalities of gait and mobility (any noticeable change or disruption in normal walking pattern and ability to move freely), cognitive communication deficit (breakdown in communication caused by impaired thinking skills (like attention, memory, or problem solving), unsteadiness on feet (losing your balance or feeling unstable while walking), and Alzheimer's disease (progressive brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple daily tasks).Record review of Resident #1's quarterly MDS assessment, dated 07/24/26,Reflected the BIMS score was left blank, which indicated her cognition was severely impaired. Resident #1 had a yes to questions: Did the resident have a fall any time in the last month prior to admission/entry or reentry, did resident have any fracture related to a fall in the 6 months prior to admission/entry or reentry questions. Record review of Resident #1's quarterly care plan, dated 06/18/26, reflected: Problem: [Resident #1] is a risk for falls r/t cognitive deficit, incontinence, hx. Of recent fall with fracture. Date initiated 07/23/26 and revised on 07/29/26. Interventions included ensure that the [Resident #1] is wearing appropriate footwear, non-skid socks when ambulating or mobilizing in w/c, date initiated 08/11/26 Problem: Unwitnessed fall. Date initiated/revised 07/23/26. Interventions included non-skid mat to w/c and nuero checks 08/11/26 fall. Date initiated 08/11/26. Record review of the facility's Incident by incident log, dated 08/19/26, reflected Resident #1 had an unwitnessed fall on 08/11/26 at 1:15 p.m. Record review of Resident #1's neurological checks initiated on 08/11/26 at 1:15 p.m., authored by LVN A, reflected Resident #1 was in the facility and had not refused neuro checks and 6. Q30#2 on 08/11/26 at 3:00 p.m., vital signs (blood pressure, pulse, respirations, and temperature were not entered. 7. Q1H#1 on 08/11/26 at 4:00 p.m., vital signs (blood pressure, pulse, respirations, and temperature were not entered. 8. Q1H#2 on 08/11/26 at 5:00 p.m., vital signs (blood pressure, pulse, respirations, and temperature were not entered. 9. Q4H#1 on 08/11/26 at 9:00 p.m., vital signs (blood pressure, pulse, respirations, and temperature were not entered. In an attempted telephone interview on 08/19/26 at 11:15 a.m. and 4:00 p.m., LVN A did not answer, a voice message was left. During an interview on 08/19/26 at 2:53 p.m., The DON said Resident #1 was a long-term resident and a fall risk. She said Resident #1 had an unwitnessed fall on 08/11/26 in the dining room. She said Resident #1's NP was notified and ordered neurological checks for 72 hours which were initiated right after her fall. She said Resident #1 had not sustained any injuries. The DON was observed as she reviewed Resident #1's electronic medical record and said LVN A should have documented Resident #1 vital signs for neuro check #6, #7, #8, and #9 since Resident #1 was in the facility and had not refused the neuro checks. She was observed as she reviewed Resident #1's progress notes in her electronic medical record and said she had not found any documentation in progress notes from LVN A pertaining to neuro checks #6, #7, #8, and #9. She said she was not sure if LVN A checked Resident #1's vital signs for neuro checks #6, #7, #8, and #9 or if he had just forgotten to document them. The DON said Resident #1 had not negative findings reported in the rest of her neuro checks on 08/11/26. The DON said a negative outcome to Resident #1 not having her vital signs documented maybe not catching a neurological change. The DON said all nursing staff were regularly in-serviced on the topic of documentation and falls (which included neuro checks). Record review of the facility's Incident and Accident policy, dated 08/15/22, reflected:Policy: It is the policy of this facility for staff to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. Compliance Guidelines.9. In the event of an unwitnessed fall or a blow to the head, the nurse will initiate neurological checks as per protocol and document on the neurological flow sheet.

Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance to prevent an accident for one (Resident #1) of 3 residents reviewed for supervision, in that:The facility failed to ensure CNA B and CNA C placed a non-skid mat to Resident #1's wheelchair on 08/19/26.This failure could place residents at risk of serious injury when care was not provided correctly. Finding included: Record review of Resident #1's admission record, dated 08/19/26, reflected a [AGE] year-old female with a re-admission date of 07/20/2026 and an original admission date of 02/20/2026. Her relevant diagnoses included aftercare following joint replacement surgery, displaced fracture of epiphysis (separation) (upper) left femur (medical term for hip injury where the upper growth of the thighbone slips or breaks), abnormalities of gait and mobility (any noticeable change or disruption in normal walking pattern and ability to move freely), cognitive communication deficit (breakdown in communication caused by impaired thinking skills (like attention, memory, or problem solving), unsteadiness on feet (losing your balance or feeling unstable while walking), and Alzheimer's disease (progressive brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple daily tasks). Record review of Resident #1's quarterly MDS assessment, dated 07/24/26,Reflected the BIMS score was left blank, which indicated her cognition was severely impaired. Resident #1 had a yes to questions: Did the resident have a fall any time in the last month prior to admission/entry or reentry, did resident have any fracture related to a fall in the 6 months prior to admission/entry or reentry questions. Record review of Resident #1's quarterly care plan, dated 06/18/26, reflected: Problem: [Resident #1] is a risk for falls r/t cognitive deficit, incontinence, hx. Of recent fall with fracture. Date initiated 07/23/26 and revised on 07/29/26. Interventions included ensure that the [Resident #1] is wearing appropriate footwear, non-skid socks when ambulating or mobilizing in w/c, date initiated 08/11/26 Problem: Unwitnessed fall. Date initiated/revised 07/23/26. Interventions included non-skid mat to w/c and nuero checks 08/11/26 fall. Date initiated 08/11/26. Record review of the facility's Incident by incident log, dated 08/19/26, reflected Resident #1 had an unwitnessed fall on 08/11/26 at 1:15 p.m. Record review of CNA B and CNA C's Transfer Skills Checklist, dated 09/25/25, reflected both had successfully met all procedures to include #17. which indicated applies all safety devices in appropriate. During an observation on 08/19/26 at 1:15 p.m., Resident #1 was observed sitting in her wheelchair in the hallway next to her room. Resident #1 was observed wearing her non-skid socks, was sitting on a white draw sheet. Resident #1 was not interviewable. During an interview on 08/19/26 at 1:36 p.m., CNA B said Resident #1 was a fall risk and required frequent monitoring. She said Resident #1 had an assigned wheelchair to ambulate. CNA B said Resident #1 required a non-skid mat that was placed on her wheelchair's seat to prevent her from slipping. CNA B said Resident #1's assigned wheelchair was taken to the back to be cleaned, and the non-skid mat remained on the wheelchair. She said earlier today (08/19/26) she and CNA C transferred Resident #1 to a different wheelchair and placed a white draw sheet underneath her instead of the required non-skid mat. She said she and CNA C had placed a while sheet underneath Resident #1 to make it easier for them to reposition. CNA B said a negative outcome for Resident #1 not having a non-skid mat on her wheelchair's seat would be that she might slip off the chair and fall. CNA B said she had been in-serviced on the topics of fall prevention regularly. During an interview on 08/19/26 1:42 p.m., CNA C said Resident #1 was a fall risk and required frequent monitoring. He said Resident #1 required a non-skid mat on her wheelchair's seat, to prevent her from sliding off and falling. He said Resident #1 had an assigned wheelchair which had the non-skid mat but it had been taken to the back to be cleaned and the non-skid mat remained on the seat. He said earlier today (08/19/26), he and CNA B had transferred Resident #1 to a different wheelchair and had placed a white draw sheet on the seat instead of her non-skid mat. CNA C was not able to say if there were any negative outcomes to Resident #1 for not having a non-skid mat while sitting on the wheelchair. He said he was regularly in-serviced on the topic of fall prevention. During an interview and observation on 08/19/26 at 1:54 p.m., the ADON said Resident #1 sustained an unwitnessed fall on 08/11/26. She said one of her interventions was to have a non-skid mat on wheelchair's seat to prevent her from slipping off and falling. During an observation, the ADON said she was not able to see if Resident #1 was sitting on a non-skid mat, she said the only thing she saw was a white sheet underneath her. The ADON said if Resident #1 did not have a non-skid mat underneath her, she may have another fall. The ADON said CNAs were regularly in-serviced on the topics of fall prevention. During an interview on 08/19/26 at 2:53 p.m., the DON said Resident #1 was a long-term resident and was considered a fall risk. She said Resident #1 had an unwitnessed fall on 08/11/26 and one of her interventions for that fall was to have a non-skid mat on her wheelchair's seat to prevent her from slipping off. The DON said CNAs in Resident #1's hall were aware they needed to place a non-skid mat on her wheelchair's seat before being transferred to the wheelchair. The DON said CNA B or CNA C should have gone to get the non-skid mat from Resident #1's assigned wheelchair before she was transferred to another wheelchair. The DON said a negative outcome for Resident #1 not having a non-skid mat on her wheelchair's seat, she could be that she could slip off and fall. The DON said CNAs were regularly in-serviced on the topics of fall prevention and neglect.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation in that: The facility failed to ensure the juicer's dispenser gun was clean. This failure could place residents at risk of foodborne illnesses. Findings included: During the initial tour of the kitchen on 02/22/26 at 8:30 a.m., the juice dispenser gun revealed a reddish slimy substance adhered to it and brownish stains on one side of the nozzle. Record review of the facility's kitchen Daily Cleaning Schedule for the month of February 2026 revealed the juicer had been cleaned every day from the 1st to the 21st. In an interview on 02/22/26 at 8:36 a.m., the DM said the juicer had been used earlier in the morning for breakfast. He said the juicer and its nozzle would be cleaned daily. The DM refused to say if the slimy substance found on the nozzle was a result of that day usage or if it was an accumulation of several days. He was not able to say what the negative outcome to residents was if the juicer nozzle was not clean. In an interview on 02/24/26 at 3:15 p.m. DA C said all kitchen staff were responsible to clean their assigned area at the end of their shift. He said after they cleaned their assigned areas, they assisted in cleaning all equipment which included the juicer and its nozzle. He said the DM had a daily cleaning schedule where they each had to initial what they had cleaned. In an interview on 02/24/26 at 3:25 p.m., DA D said all kitchen staff were responsible to clean their assigned area at the end of their shift. He said after they cleaned their assigned areas, they assisted in cleaning all equipment which included the juicer and its nozzle. He said the DM had a daily cleaning schedule where they each had to initial what they had cleaned. In an interview on 02/24/26 at 4:00 p.m., the Administrator said the kitchen staff would clean all appliances on a daily basis. He was not able to say what the negative outcomes to residents would be if the juicer nozzle was not clen. Record review of the facility's General Kitchen Sanitation policy dated 10/01/18 reflected:Policy: The facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All Nutrition & Foodservice employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness. Procedure: 1. Clean and sanitize all food preparation areas, food-contact surfaces, dining facilities, and equipment. After each use, clean and sanitize all tableware, kitchenware, and food-contact surfaces of equipment, except cooking surfaces of equipment and pots and pans that are not used to hold or store food and are not used solely for cooking purposes.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 3 of 4 medication carts (Hall 400 Med-Aide cart, Hall 300 Med-Aide cart, and Hall 100 Nurse Med-Cart) reviewed for pharmacy services.1. The facility failed to ensure medications in Hall 400 Med-Aide cart, Hall 300 Med-Aide cart, and Hall 100 Nurse Med-cart were labeled with an Open Date on 2/23/2026.2. The facility failed to ensure medication in Hall 300 Med-Aide cart were free of loose pills on 2/23/2026.These deficient practices could place residents at risk for adverse effects and not receiving the therapeutic effects of the medication or treatment. The Findings included: 1. An observation on 2/23/2026 at 2:11 PM of the Hall 400 Med-Aide medication cart, revealed that two boxes of Cyclosporine Ophthalmic emulsion 0.05% for two different residents did not have an Open Date label. Both boxes contained open pouches which included eye drop vials.An observation on 2/23/2026 at 2:28 PM of the Hall 300 Med-Aide medication cart, revealed a box of Xiidra 5% ophthalmic solution did not have an Open Date. The box contained an open pouch which included eye drop vials. An opened box of Sevelamer Carbonate 2.4 g pouches did not have an Open Date.An observation on 2/23/2026 at 3:04 PM of Hall 100 Nurse medication cart, revealed two opened boxes of Ipratropium/Albuterol 2.5 MG Inhalation Solution did not have an Open Date and an open box of Fluticasone Propionate nasal spray did not have an Open Date.In an interview on 2/23/2026 at 2:26 PM with CMA G, he said he checked his cart daily at the beginning of his shift for expired medications and dates on medication. He said he was in a hurry and did not label a box of eye drops that he had just opened. He said he overlooked the date not written on the other boxes of medications. He said the nurses and the DON gave him daily reminders to check for open dates and to label when opening a new medication. He said it was the responsibility of all the medication aides to check the medications carts. He said the medications can expire by not having an Open Date written.In an interview on 2/23/2026 at 3:04 PM with LVN H, he said that all shifts and nurses were responsible for checking medication labels, Open Dates, and expiration dates. He said he had just started his shift and was supposed to check for labels. He said management provided weekly reminders to check medications. LVN H said negative outcomes were not knowing if the medication was new or old. He said if a medication was old, it would not be as effective and it would not provide the therapeutic effect to the resident.In an interview on 2/23/2026 at 3:41 PM with the DON, she said that the nurses and medication aides were responsible for dating when opening a new medication. She said that every time a nurse or medication aide opens a medication, they were to label it. She said every shift is responsible for labeling the medication. The DON said that by not having an Open Date, a resident may have possible negative effects.2. An observation on 2/23/2026 at 2:28 PM of Hall 300 Med-Aide medication cart, revealed five loose pills identified as sertraline 25 mg, memantine 5 mg (2 pills), losartan 5 mg, and furosemide 40 mg, inside the medication cart.In an interview on 2/23/2026 at 2:24 PM with CMA G, said, he said losartan was for blood pressure, memantine was used for dementia. He said if a resident did not receive the medication their blood pressure can go up and was not sure what would happen to the resident if medication for dementia was not given. He said he had been a CMA for two months and had training last month regarding labeled and checked open dates on medication.In an interview on 2/23/2026 at 3:41 PM with the DON, she said medication aides were responsible for cleaning the medication carts. She said if CMAs found loose pills, they notified the nurse, and the medications were destroyed. She said if pills were accidentally dropped inside the medication cart, they would notify the nurse and pulled the medication again. The DON said there was always a backup in the E kit. She said a negative outcome of having loose pills in the medication cart would be that the medication count could be off. She said another possible negative outcome was that the residents did not get their medication and therapeutic effects were not available.Record review of the facility's policy and manual titled: Pharmacy Provider Requirements with a revision date:10/01/2019 indicated .E. Labeling all medications dispensed in accordance with the medication labeling policy with state and federal requirements.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 (Resident #106) residents reviewed for respiratory care.The facility failed to ensure Resident #106's oxygen was being administered on 02/22/26 as ordered by the physician.This deficient practice could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care.The findings included:Record review of Resident # 106's admission record dated 02/23/26 revealed a [AGE] year-old female with an original admission date of 02/19/24 along with a recent admission date of 01/12/26. The diagnosis for Resident #106 included: Hemiplegia (paralysis that affects only one side of your body) and Hemiparesis (one-sided muscle weakness) following cerebral infarction (occurs as a result of disrupted blood flow to the brain) affecting the left non-dominant side, Acute respiratory failure with hypoxia (low levels of oxygen in your body tissues), pneumonia, muscle wasting, and atrophy (wasting away of a part of the body).Record review of Resident #106's Quarterly BIMS assessment dated [DATE] revealed resident had a score of 00 which indicated severe cognitive impairment.Record review of Resident #106's Quarterly MDS dated [DATE] revealed Resident #106 had functional limitation in range of motion with impairment to both upper extremities. The MDS also revealed Resident #106's speech pattern was identified as no speech. The MDS assessment also revealed Resident #106 had an active diagnosis of respiratory failure therefore was on respiratory treatment: oxygen therapy. Record review of Resident #106's Care Plan dated 01/30/26 revealed: Problem: [Resident #106] has oxygen therapy r/t respiratory failure. Interventions: Oxygen at every shift related to acute respiratory failure with hypoxia.Record review of Resident #106's active Order Summary Report revealed an order dated 02/07/26 for Oxygen at 2 LPM via NC every shift related to moderate persistent asthma.During an observation of Resident #106 on 02/22/26 at 3:50 pm revealed the nasal cannula (a lightweight, flexible tube with two prongs inserted into the nostrils to deliver supplemental oxygen) was on resident's left cheek, therefore not properly placed into the nostrils. The oxygen concentrator machine (a medical device that filters ambient air to deliver oxygen) was on at the level of 2 LPM. Resident #106 was in bed, with the head of the bed slightly elevated. No signs of respiratory distress were noted.During an observation and interview on 02/22/26 at 3:51 pm LVN L observed that Resident 106's nasal cannula was not placed into her nostrils. LVN L checked Resident 106's oxygen saturation (measures the percentage of oxygen in the blood) level and it was at 94%. LVN then placed the nasal cannula into the resident's nostrils, and the oxygen saturation level quickly rose to 96%. LVN L stated she had to adjust the nasal cannula because the resident is unable to move her arms due to contractures (shortening of muscles, tendons, skin, and nearby soft tissues that cause the joints to shorten and become very stiff, preventing normal movement). LVN L stated she entered Resident 106's room at the start of her shift which was 2:00 pm but had not gone in again to check on resident. LVN L stated that the negative outcome for Resident #106 not having the nasal cannula in place was that resident could have desatted (medical term for a patient's blood oxygen saturation level dropping below normal) or she could have had shortness of breath.In an interview on 02/22/26 at 4:02 pm CNA M stated she was the CNA for Resident #106's hall. CNA M stated she was instructed to look into every room as she walked down the hallway. CNA M stated that if a resident has the nasal cannula out of place, she was able to correctly place it into a resident's nostrils. CNA M stated she then informs the nurse in case the resident needed to be assessed. CNA M stated that she had not entered Resident 106's room yet since her arrival in the hall, which was around 2:00 pm. CNA M stated she had passed by Resident #106's room several times but did not notice the nasal cannula was out of place. She stated that she is also instructed to check in more often on residents that have oxygen.In an interview on 02/23/26 at 4:10 pm the DON stated Resident #106 was on continuous oxygen due to a recent order on 02/07/26. DON stated that nurses and CNAs were to round on residents every 2 hours and as needed. The rounding might be sooner if residents required treatment. DON stated that oxygen was considered a treatment and therefore should have been checked more frequently. DON stated she instructed the CNAs to look into the resident's rooms while walking through the halls. The DON stated a negative outcome for Resident #106 not having the nasal cannula placed properly was that the resident could have gone into respiratory distress or shortness of breath.In an interview on 02/23/26 at 4:20 pm, the DON stated the facility did not have a policy on oxygen.

Based on observation, interviews, and record reviews, the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized for 1 (Resident #70) of 5 residents.LVN J documented changing of Resident #70's oxygen tubing on 2/15/2026, however, she did not carry out the order due to lack of tubing.The failure could place residents at risk for errors by staff when reading information in the clinical record that was inaccurate or incomplete.The Findings included:Record review of Resident #70's admission Record, indicated an admission date of 12/30/2025, an [AGE] year-old female with a Principle Diagnosis of Hypertensive Urgency (high blood pressure), and a diagnosis of Chronic Obstructive Pulmonary Disease (progressive, long-term lung disease that makes it hard to breathe by damaging and narrowing the airways).Record review of Resident #70's MDS Assessment, dated 1/1/2026 and signed as completed on 1/12/2026 by the RN Assessment Coordinator, reflected assessment observation end date of 1/1/2026. Resident #70 had a BIMS score of 11 which indicated moderate cognitive impairment.Record review of resident #70's Order Summary dated 2/22/2026, indicated an order to Change O2 tubing Q week on Sunday and PRN every night shift every Sunday for change tubing. Order Date:12/30/2025.Record review of resident #70's Medication Administration Record for the month of February 1, 2026-February 28, 2026 indicated Change O2 tubing Q week on Sunday and PRN every night shift every Sunday for change tubing was initialed on 2/15/2026 by LVN J.In an observation on 2/22/2026 at 9:20 AM, Resident #70's O2 tubing was labeled 2/9/26.In an interview on 2/22/2026 at 9:25 AM with Resident #70, she said she did not recall the date the tubing was changed out by the nurse. She said the nurses had been in her room earlier to check the O2 concentrator because it was making a loud noise and the problem was resolved.In an interview on 2/23/2026 at 2:54 PM with the ADON, she said daily rounds were conducted by Resident Ambassadors that checked O2 tubing and equipment. She said she saw the tubing was due to be changed and did not know how the tubing was overlooked. She said that there should have been documentation on the MAR when the tubing was changed. She said if the tubing was not changed there may not be effective oxygenation to the resident. She said medication administration in-services were done yearly which included oxygen and oxygen supplies.In an interview on 2/23/2026 at 3:04 PM with LVN K, he said that he had checked the O2 setting but did not notice the date on the tubing. He said the night nurses were the ones that changed the O2 tubings. He said the tubing gets dirty and were scheduled to be changed every week and as needed. He said the oxygen tubing could collect water and form condensation which would affect the resident by having possible aspiration. He said weekly reminders were given to change out the tubing for oxygen and nebulizers.In an interview on 2/24/2026 at 4:27 PM with LVN J, she said she had signed the MAR by mistake on 2/15/2026. She said she had been changing out the oxygen tubing for other residents and when she got to Resident #70, she ran out of the tubing wrap and did not change the tubing on 2/15/2026. She said once an order was carried, the MAR was supposed to be signed.Record review of the facility's policy titled: Medication Administration with s Date Implemented: 10/24/22 indicated .17. Sign MAR after administered . 20. Correct any discrepancies and report to nurse manager.

Based observations, interviews, and record reviews the facility failed to ensure no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident agrees to this meal span for residents eating meals in their rooms, for 2 (Resident #4 and Resident #69) of 8 residents reviewed for food and nutrition services. 1.The facility failed to ensure that no more than 14 hours lapsed between a substantial evening meal and breakfast the following day and provide a nourishing snack to Resident #84 who ate in her room. 2. The facility failed to ensure that no more than 14 hours lapsed between a substantial evening meal and breakfast the following day and provide a nourishing snack to Resident #69 who ate in her room. These failures could affect all residents who received meals served from the facility's only kitchen by placing residents at risk for unplanned weight loss, and side effects from medication given without food, and diminished quality of lifeFindings included: 1.Record review of Resident #84's admission record dated 02/22/26, reflected a [AGE] year-old female with an admit date of 05/20/23 and an initial admission date of 05/27/23. Her relevant diagnoses included type 2 diabetes (a chronic condition characterized by insulin resistance and high blood sugar levels), legal blindness (severe visual impairment or low vision), adult failure to thrive (syndrome characterized by intended weight loss, poor appetite, malnutrition, inactivity, and functional decline), and dysphagia (difficulty swallowing, causing food or liquid to get stuck in the throat or chest). Record review of Resident #84's quarterly MDS assessment dated [DATE], reflected a BIMS score of 10, which indicated her cognition was moderately impaired. Her functional abilities for eating had been scored a 1, which indicated she was dependent helper does all of the effort. Record review of Resident #84's quarterly care plan date02/24/26/26, reflected a focus of [Resident #84] has an ADL self-care performance deficit r/t failure to thrive, muscle atrophy and wasting. Her interventions in part included functional performance: Eating: The resident dependent for eating. Record review of Resident #84's Nutrition-Snacks history reflected she had not received a snack the evening of 02/21/26. Record review of Resident #84's order summary dated reflected the following medications for her diagnosis of type 2 diabetes: Lantus Subcutaneous Solution 100 unit/ml (insulin Glargine) inject 20 units subcutaneously one time a day for DM related to Type 2 diabetes mellitus with hyperglycemia, effective 01/08/26. Farxiga Oral Tablet 10 mg (Dapagliflozin Propanediol) Give 1 tablet by mouth one time a day related to Type 2 diabetes mellitus with hyperglycemia. Record review of Resident #84's February 2026 eMAR reflected that she had been administered Farxiga Oral Tablet 10 mg, 1 tablet on 02/22/26 at 6:00 a.m. and her blood sugar was 99. Record review of Resident #84's February 2026 eMAR reflected that she had been administered Lantus subcutaneous solution 100 unit/ml, 20 units on 02/22/26 at 6:43 a.m. During an observation on 02/22/26 at 9:47 a.m., this surveyor observed as CNA A as she delivered Resident #84 her breakfast tray and started feeding her. In an interview on 02/22/26 at 10:11 a.m., Resident #84 said she had received her breakfast later than usual that day. She said by the time her breakfast was served it was still warm, she had no concerns with the temperature, and the food was still palatable. In an interview on 02/22/26 at 10:14 a.m., CNA A said the kitchen staff had delivered the food cart to hall (hall 300) at about 7:45 a.m. She said there were usually three CNAs assigned to that hall, but that day one CNA was called to cover another hall. She said of the two CNAs left, one was assigned to go assist with residents in the dining hall, so she was left alone to cover the hall. She said there were 6 residents who stayed in their rooms that required assistance with their meals. CNA A stated the reason she fell behind in assisting Resident #89 with her breakfast was because she was left alone to feed all six residents. CNA A said when three CNAs were in the hall, one would help out in the dining room during meals and the two left feed the resident stayed in their rooms and required assistance. CNA A said management normally would not pull CNAs from her hall and residents who stayed in their room and required assistance with their meals received their breakfast by 8:30 a.m.2. Record review of Resident #69's admission record dated 02/22/26, reflected an [AGE] year-old female with an admit date of 04/09/21. Her relevant diagnoses included heart failure (a chronic serious condition where the heart cannot pump enough blood and oxygen to meet the body's needs, often causing fluid backup in the lungs and legs), dysphagia (difficulty swallowing, causing food or liquid to get stuck in the throat or chest), and bipolar disorder ( a chronic mental health condition causing extreme intense mood swings). Record review of Resident #69's annual MDS assessment dated [DATE], reflected a BIMS score of 14, which indicated her cognition was intact. Her functional abilities for eating had been scored a 2, which indicated helper does more than half the effort.Record review of Resident #69's comprehensive care plan dated 02/24/26, reflected a problem of [Resident #69] has an ADL self-performance deficit r/t limited mobility, date initiated 07/11/22 and revised on 02/24/26. Her interventions in part included Functional performance: Eating: The resident requires sub/max for eating, date initiated/revised 02/24/26.Record review of Resident #69's Nutrition-Snack history reflected she had not received an evening snack on 02/21/26.During an observation on 02/22/26 at 9:43 a.m., Resident #69 was observed in a sitting position in her bed. Resident #69 was heard making a request for her food to CNA B. Resident #69 asked this surveyor to leave her room.In an observation on 02/22/26 at 9:45 a.m., CNA B delivered Resident #69's breakfast tray and assisted her with her breakfast meal. In an interview and observation on 02/22/26 at 10:20 a.m., CNA B said there were usually three CNAs assigned to hall 300, but that day one CNA was called to cover another hall. She said of the two CNAs left in the hall, she had been assigned to go assist with residents with their breakfast in the dining hall and only one stayed in the hall. She said she returned to hall 300 at about 9:40 a.m. and had immediately assisted CNA A in assisting residents with their breakfast. She said by that time she returned to her hall only Resident #69's tray was left in the food cart and immediately delivered it to her room and assisted her with her breakfast. She said Resident #69 was able to verbalize her needs and if her food was cold or not palatable, she would voice her concerns. She said Resident #69 had not voiced any concerns regarding her breakfast. In an interview on 02/23/26 at 11:15 a.m., the DM said the facility's protocol was for a dietary aide to deliver the food carts to the halls for residents that preferred to eat in their rooms. He said the dietary aide would leave the food cart in its corresponding hall for the CNAs to deliver to the residents. He said the morning of 02/22/26, a dietary aide delivered the breakfast food cart to hall 300 no later than 7:45 a.m. The DM said on 02/21/26, the dinner food cart had been delivered to hall 300 at 5:45 p.m. He said the facility offered evening snacks for residents who wanted one or were scheduled to receive one. In an interview on 02/23/26 at 11:31 a.m., the Dietician said meals should have been served with no more than 14 hours between the evening meal and breakfast the following day. He was observed as he reviewed Resident #84 and Resident #69's electronic medical record. He said Resident #84 had a diagnosis of diabetes and had 2 scheduled medications (orally and an injection) daily at 6:00 a.m. He said Resident #84's had been administered her scheduled diabetes medications on 02/22/26 at 6:00 a.m., and her sugar level at the time was 99 which was normal. The Dietician said Resident #84 did not have an order for an evening snack. He said Resident #84's snack history showed she had not received an evening snack on 02/21/26. The dietician said Resident #69 did not have a diagnosis of diabetes and did not have an order for an evening snack. He said Resident #69's snack history did not show she received an evening snack on 02/21/26. The Dietician said there were several negative outcomes to Resident #89 who had more than 14 hours between the evening meal and breakfast the following day and that would be the possibility of her sugar level dropping especially since she had been administered her diabetes medications at 6:00 a.m. He said another negative outcome for both Resident #84 and Resident #69 would be the food temperature, the fact that both residents expected their meal(s) by a certain time and the food's palatability. In an interview on 02/23/26 at 11:45 a.m., the DON said the morning of 02/22/26, 3 CNAs had been scheduled to hall 300. She said 1 CNA from hall 100 called in sick and she had to reassign 1 CNA from hall 300 to hall 100. She said that was an isolated case. The DON said a negative outcome for Resident #84 and Resident #69 having to wait over 14 hours between their evening meal and breakfast the following day could be the possibility of Resident #84's sugar level dropping because she had not had anything to eat for that long and a negative outcome for Resident #69 could be that she was going to be hungry. Record review of the facility's Meal Times policy dated 10/02018, reflected:Policy: The facility provides three meals daily at regular times which are comparable to meal times in the community setting. Meals are served at the specified times except in emergency situations. Procedures: 1. Meals will be served according to the state and federal regulations, with no more than fourteen hours between the evening meal and breakfast the following day.

Number of residents sampled: Number of residents cited: Based on interview, observation, and record review, the facility failed to provide an ongoing activities program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 1 of 3 residents (Resident #1) reviewed for activities.The facility failed to provide Resident #1 with in-room activities.This failure could place residents at risk for boredom, depression, and diminished quality of life.Findings included:Record review of Resident #1's admission Record dated 02/23/26 revealed a [AGE] year-old-female, admitted to facility on 01/02/26 with diagnoses of Metabolic Encephalopathy (brain dysfunction causing confusion, delirium), Tracheostomy (surgically opening a hole in neck to provide alternate airway for breathing), Cognitive Communication Deficit (impairment in communication), Muscle Weakness (Generalized), Down Syndrome (genetic condition resulting in mild to moderate intellectual disability), and Mixed Receptive-Expressive Language Disorder (struggle to understand and use language).Record review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS of 00 indicating his cognition was severely impaired and functional abilities also revealed resident was dependent (helper does all of the effort, resident does none to complete the activity) on sit to lying on bed, chair/bed to chair transfer, and oral hygiene.Record review of Resident#1's Comprehensive Care Plan with an initiation date of 01/02/26 reflected no goals/interventions for Activities for Resident #1. Resident has an ADL self-care performance deficit r/t impaired cognition/down syndrome and requires total x2 staff assistance for dressing, oral care, and transferring.Record review of Activities - Initial Review effective date 01/05/26 for Resident #1 revealed Instructions: Complete on admission. Use this data to design an activities program that meets the residents needs and preferences. Update the care plan upon completion. Resident #1 likes to watch cartoons and movies on tv and be close to her family. Resident is appropriate for in-room visits and would benefit from in-room visits.Record Review of Resident #1's hard copy document titled Activity Department dated February 2026 revealed no activity entries for Resident #1.Observation of Resident #1 on 02/22/26 at 10:24 a.m. in bed, alert, non-verbal, non-responsive. Television is off, no other forms of stimulation observed in room.Observation of Resident #1 on 02/23/26 at 2:13 p.m. in bed, alert, non-verbal, non-responsive. Television is off, no other forms of stimulation observed in room.In an interview on 02/23/26 at 4:40 p.m., the AD said that she had done activities with Resident #1 but had not been documenting because she had been busy with new staff. She said she would turn on the television and played movies for Resident #1. She said Resident#1's father had been spending more time with her so she had not been doing as many activities with her. AD said she hadn't added activities in Resident #1's care plan because she was not required to do that, it was MDS who was responsible for that task.In a follow-up interview on 02/24/26 at 1:20 p.m. the AD said she had received training from the previous Activity Director and also had done online classes.In an interview on 02/24/26 at 2:32 p.m. the DON said she may have benefited from stimulation activities but could not answer for certain.In an interview on 02/24/26 at 3:16 p.m. the Administrator said the AD works closely with MDS. They work together to create activities for residents. He said AD had been trained by the previous activity director. he said if a resident is not receiving any type of activities they would have lack of stimulation, involvement.Facility provided no policy for Resident Activities.

Based on interviews and record reviews, the facility failed to review and revise the comprehensive care plan for 1 (Resident #106) of 5 residents reviewed for comprehensive care plan revisions.The facility failed to review and revise Resident #106's comprehensive person - centered care plan's oxygen interventions to reflect current order of 2 LPM.This failure could affect residents and place them at risk of not receiving appropriate interventions to meet their current needs.The findings were: Record review of Resident # 106's admission record dated 02/23/26 revealed a [AGE] year-old female with an original admission date of 02/19/24 along with a recent admission date of 01/12/26. The diagnosis for Resident #106 included: Hemiplegia (paralysis that affects only one side of your body) and Hemiparesis (one-sided muscle weakness) following cerebral infarction (occurs as a result of disrupted blood flow to the brain) affecting the left non-dominant side, Acute respiratory failure with hypoxia (low levels of oxygen in your body tissues), pneumonia, muscle wasting, and atrophy (wasting away of a part of the body).Record review of Resident #106's Quarterly MDS assessment dated [DATE] revealed resident had a BIIMS score of 00 which indicated severe cognitive impairment. The MDS assessment also revealed Resident #106 was on a respiratory treatment, oxygen therapy. Record review of Resident #106's active Order Summary Report revealed an order dated 02/07/26 for Oxygen at 2 LPM via NC every shift related to moderate persistent asthma Record review of Resident #106's Care Plan dated 01/30/26 revealed: Problem: [Resident #106] has oxygen therapy r/t respiratory failure. Date initiated: 07/28/25. Interventions: Oxygen settings: Oxygen at 5 LPM via NC every shift related to acute respiratory failure with hypoxia. Date initiated: 07/28/25 Revised on 07/30/25. In an interview on 02/23/26 at 4:10 pm, the DON stated care plans are revised quarterly or when there is a change in condition. The DON stated she and MDS were in charge of implementing and revising the care plans. The DON stated Resident #106 had changes in July that required revision but the revision in the care plan was not done. She stated the resident had recently been placed on oxygen again but failed to update the care plan. The DON stated she was not aware the care plan had not been revised stating, It was overlooked. In an interview on 02/24/26 at 3:49 pm, MDS E stated she was in charge of care plan revisions. MDS E stated she would revise care plans quarterly. If a care plan needed to be revised between quarters, then the DON would do those revisions. MDS E stated she took responsibility for Resident #106's care plan not being updated during the quarterly revision. Record review of the facility's policy: Care Plan Revisions Upon Status Change dated 10/24/22 revealed: 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change.2. Procedure for reviewing and revising the care plan when a resident experiences a status change:d. The care plan will be updated with the new or modified interventions.

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 9 residents (Resident #1 and Resident #69) reviewed for comprehensive person-centered care plans.1.The facility failed to ensure Resident #69's care plan included her level of care for ADLs.2.The facility failed to ensure Resident #1's comprehensive care plan included activities to be done with resident.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. Findings included: Record review of Resident #1's admission Record dated 02/23/26 revealed a [AGE] year-old-female, admitted to facility on 01/02/26 with diagnoses of Metabolic Encephalopathy (brain dysfunction causing confusion, delirium), Tracheostomy (surgically opening a hole in neck to provide alternate airway for breathing), Cognitive Communication Deficit (impairment in communication), Muscle Weakness (Generalized), Down Syndrome (genetic condition resulting in mild to moderate intellectual disability), and Mixed Receptive-Expressive Language Disorder (struggle to understand and use language). Record review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS of 00 indicating her cognition was severely impaired and functional abilities also revealed resident was dependent (helper does all of the effort, resident does none to complete the activity) on sit to lying on bed, chair/bed to chair transfer, and oral hygiene. Record review of Resident#1's Comprehensive Care Plan with an initiation date of 01/02/26 reflected no goals/interventions for Activities for Resident #1. Resident had an ADL self-care performance deficit r/t impaired cognition/down syndrome and required total x2 staff assistance for dressing, oral care, and transferring. Record review of Activities – Initial Review effective date 01/05/26 for Resident #1 revealed Instructions: Complete on admission. Use this data to design an activities program that meets the residents needs and preferences. Update the care plan upon completion. Resident #1 likes to watch cartoons and movies on tv and be close to her family. Resident is appropriate for in-room visits and would benefit from in-room visits. In an interview on 02/23/26 at 4:40 p.m., the AD said she had not added activities in Resident #1's care plan because she was not required to do that, it was MDS who was responsible for that task. The AD said she would update the MDS on resident activities and they would be the ones to add it to the care plan. In an interview on 02/24/26 at 2:19 p.m. MDS F said MDS is responsible for updating resident care plans. She said the AD discusses activities for each resident and she updates the care plans. She said it was an oversight on her part and had not added activities to Resident #1's care plan. In an interview on 02/24/26 at 2:32 p.m. the DON said Resident #1 not having activities done could possibly would have had negative outcomes but was not sure. Record review of the facility's Comprehensive Care Plan Policy dated 10/24/22 reflected: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental psychosocial needs that are identified in the resident's comprehensive assessment. 2. Record review of Resident #69's admission record dated 02/22/26, reflected an [AGE] year-old female with an admit date of 04/09/21. Her relevant diagnoses included heart failure (a chronic serious condition where the heart cannot pump enough blood and oxygen to meet the body's needs, often causing fluid backup in the lungs and legs), dysphagia (difficulty swallowing, causing food or liquid to get stuck in the throat or chest), and bipolar disorder ( a chronic mental health condition causing extreme intense mood swings). Record review of Resident #69's annual MDS assessment dated [DATE], reflected a BIMS score of 14, which indicated her cognition was intact. Her functional abilities reflected she required substantial/maximal assistance (helper does more than half the effort. with eating. Record review of Resident #69's comprehensive care plan dated 12/31/25, reflected no falls or incidents. In an interview on 02/22/26 at 10:14 a.m., CNA A said she had cared for Resident #69 for over 2 years. She said Resident #69 required a 1 person assist for all ADLs as she was able to assist the helper. She said resident #69 required assistance with all meals. In an interview on observation on 02/22/26 at 10:20 a.m., CNA B said she had care for Resident #69 for a long time. She said Resident #69 required a 1 person assist for all ADLs as she was able to assist the helper. She said Resident #69 required assistance with all meals. In an interview on 02/24/26 at 2:21 p.m., MDS E was observed as she reviewed Resident #69's electronic medical record and said her most recent MDS included her level of care for all ADLs. She said Resident #69's care plan had not included her level of care for her ADLS since 09/01/25. She said, someone had resolved the section which included the level of care for ADLs in error. MDS E said a negative outcome to Resident #69 not having her level of care included in her care plan would be that staff would not know the level of care she required. In an interview on 02/24/26 at 2:45 p.m., the DON said a resident's care plan should include their level of care for their ADLs. She said resident's care plans were updated quarterly by IDT and she was not sure why they did not see that Resident #69's care plan did not include her lever of care for ADLs. She said there were no negative outcomes to Resident #69 because the CNAs assigned to her hall were tenured and were familiar with her level of care. Record review of the facility's Comprehensive Care Plans policy dated 10/24/22, reflected: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with 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 resident's comprehensive assessment. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain the resident's highest practicable, physical, mental, and psychosocial well-being.

Number of residents sampled: Number of residents cited: Based on observation and interview, the facility failed to post in a place readily accessible to residents, family members, and legal representatives of residents, the results of the most recent survey and post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public for 1 of 1 facility in that: The facility failed to post the most recent surveys in a place viewable and readily accessible to residents, family members, and legal representatives of residents.This failure could place residents at risk of not being able to fully exercise their rights and at risk of not being aware of the facility's past deficiencies.The findings were:In an observation on 02/23/26 at 3:00 p.m. of the facility's front door area, near the receptionist desk revealed there was a survey binder on top of a desk that was set towards a back corner wall. The binder was covered by 2 other binders and it did not have visible lettering stating that it was a Survey binder. It contained the last survey.In a confidential interview on 02/23/26 at 2:17 p.m. 6 residents stated they did not know where or how to access survey results in the facility and they would like to know what previous survey and investigation results were. The residents stated they had never seen a binder labeled with that information anywhere in the facility.In an observation and interview on 02/23/26 at 3:06 p.m. the Administrator stated the survey binder had always been located in the front area by the receptionist desk. He said residents were aware of its location. He said he was responsible for updating the binder.The facility did not provide a policy for survey results.

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 5 residents (Resident #1) reviewed for quality of care.The nurse practitioner failed to recognize and place orders for treatment for Resident #1 who was experiencing significant increased glucose levels. Resident #1 did not have orders in place for glucose checks and had an episode of high blood sugar beginning on 02/04/26 through 02/13/26 that required her to be hospitalized . An IJ was identified on 02/17/26. The IJ began on 02/04/26 and removed 02/14/26. The facility took action to remove the IJ before survey began. While the IJ was removed on 02/14/26, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm because staff failed to ensure, recognize, evaluate and advocate for resident experiencing change in condition.Resident #1 did not have orders in place for glucose checks and had an episode of high blood sugar beginning on 02/04/26 through 02/13/26 that required her to be hospitalized .This failure could affect residents by placing them at risk of delay medical treatment, hospitalization, decline in condition, and death.Findings included: Record review of Resident #1's admission Record dated 02/19/26 revealed a [AGE] year-old-female, admitted to facility on 06/19/23 with diagnoses of Alzheimer's Disease Unspecified (brain disorder that slowly destroys memory and thinking skills), Moderate Protein-Calorie Malnutrition, Type 2 Diabetes Mellitus with Mild Nonproliferative Diabetic Retinopathy without Macular Edema, Bilateral (early stage of eye disease), Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease (high blood sugar and blood pressure damage the kidney's filtering units), Type 2 Diabetes Mellitus with Diabetic Cataract (increase risk of developing cataracts sooner than non-diabetics), Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy without Gangrene (high blood sugar causing poor circulation on legs and feet), and Chronic Kidney Disease Stage 3A (mild to moderate kidney damage).Record review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS of 00 indicating his cognition was severely impaired.Record review of Resident#1's care plan with an initiation date of 07/06/23 reflected Resident #1 had a history of Diabetes Mellitus, DM with CKD. Monitor, document, report signs and symptoms of hyperglycemia such as sweating, confusion, and lack of coordination.Record review of Resident #1's Laboratory Comprehensive Metabolic Panel dated 02/04/26 revealed glucose levels were at 310 mg/dL indicating a high level.Record review of Resident #1's Laboratory Comprehensive Metabolic Panel dated 02/06/26 revealed glucose levels were at 336 mg/dL indicating a high level.Record review of Resident #1's Laboratory Comprehensive Metabolic Panel dated 02/13/26 revealed results of glucose levels were at 625 mg/dL indicating a high level.Record review of Resident #1's nursing notes revealed no new orders were requested for treatment of high glucose levels for lab work that had been done on 02/04/26, 02/06/26 or 02/13/26.Record review of Resident #1's Medication Orders revealed no orders for monitoring glucose levels or orders for glucose checks.Record review of Resident #1's electronic medical record progress note dated 02/05/26 revealed laboratory results being communicated to nurse practitioners with no new orders for high glucose levels.Record review of Resident #1's electronic medical record progress note dated 02/09/26 revealed laboratory results being communicated to nurse practitioners with no new orders for high glucose levels.Record review of Resident #1's electronic medical record progress note dated 02/13/26 revealed critical lab results were communicated to the nurse practitioner with no new orders.Record review of Resident #1's electronic medical record progress note dated 02/14/26 revealed Resident #1 was sent to hospital for glucometer indicating high and weakness.During an interview with hospital nurse LVN A on 02/17/26 at 3:44 p.m. she stated resident #1 had been admitted to hospital with a diagnosis of hyperglycemia which was critically high glucose levels, COVID -19 and a UTI. LVN A stated Resident #1 was given an IV insulin drip. She also stated that Resident #1 was confused but was stabilized.During an interview with LVN B on 02/18/26 at 3:31 p.m. she stated Resident #1's lab work results were reported to the nurse practitioner and no new orders for treatment of glucose were given. LVN B said she had followed the nurse practitioner's orders but they had not included any treatment for Resident #1's high glucose levels. She said they follow doctor's orders. She said if a diabetic patient is left untreated with high blood sugar levels, they can go into diabetic ketoacidosis.During a telephone interview with the Nurse Practitioner on 02/18/26 at 4:04 p.m. she stated she had reviewed Resident #1's labs and was aware of her increasing glucose levels and said she had been treating Resident #1 for hydration and weight loss issues. She also said she had been ordering labs because she suspected Resident #1 had an infection but was unsure what it could be. She said she was focused on the other medical issues and did not place any new orders to address the residents increase in glucose levels. The Nurse Practitioner said kidney injury can be caused but only if exposed to chronically high levels of glucose. During an interview with LVN C on 02/18/26 at 4:36 p.m. she stated Resident #1 did not have orders for blood sugar checks. She said Resident #1 had never had any issues with her glucose. LVN C said she had communicated the critical labs on 02/13/26 to the nurse practitioner but received no orders for treatment. She said she did not make any recommendations to treat the critical labs because she said she followed doctor/nurse practitioner orders. LVN C said something could have happened to a Resident #1 with high blood sugar levels but she said she followed doctor orders.During an interview with the DON on 02/18/26 at 5:44 p.m. she stated Resident #1 was being treated for weight loss and other medical conditions but had not received orders for her high glucose levels. She said resident had had a fall as well but had no injuries. DON said Resident #1 had a possible infection that the nurse practitioner was trying to identify and had ordered antibiotics for Resident #1 on 02/13/26. DON said Resident #1 was admitted to the hospital with a diagnosis of hyperglycemia and COVID - 19. DON said since the nurse practitioner had not given orders for Resident #1 the facility staff did not ask if anything should be ordered for her. She said had Resident #1's glucose levels continued to be high she would have eventually been sent to the hospital.At the time of the investigation, Resident #1 was at the hospital.Facility did not provide a policy for Quality of Care.

Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #69, and Resident #1) of eight residents observed for infection control. 1. LVN A touched multiple surfaces and did not perform hand hygiene prior to checking Resident #69's blood sugar. 2. LVN A placed an insulin pen inside his scrub top pocket prior to administering Resident #69's insulin. 3. RN B failed to perform hand hygiene in between glove changes during a g-tube feeding administration for Resident #1. These failures place residents at risk for healthcare associated cross contamination and infections. Findings included: 1. Record review of Resident #69's electronic facility face sheet dated 11/07/24, revealed he was a [AGE] year-old male admitted to the facility on [DATE], original admitted [DATE] with diagnoses of Type 2 Diabetes Mellitus, Unspecified Dementia (group of thinking and social symptoms that interferes with daily functioning), Hypertension (high blood pressure), and Carcinoma in Situ of Colon (cancer in the large intestine). Record review of Resident #69's quarterly MDS assessment dated [DATE] revealed he scored a 01 on his BIMS which indicated he was severely cognitively impaired. During an observation on 11/06/24 at 08:45 a.m. revealed LVN A applied gloves right outside Resident #69's room. He then walked towards Resident #69's room holding a medication tray with the diabetic supplies, he then turned back to the medication cart, took his keys out of his pocket, unlocked the medication cart, and then proceeded to check Resident #69's blood sugar using the same pair of gloves. LVN A stepped out of Resident #69's room, sanitized his hands, applied gloves, closed the privacy curtain, then proceeded to check Residents #69's blood sugar a second time. LVN A then took out Resident #69's insulin pen from his scrub top pocket and administered insulin. During an interview on 11/06/24 at 09:00 a.m. with LVN A, he stated he did not think he did anything wrong during his medication administration but maybe that he dropped the insulin pen cap on the floor. LVN A stated that it was important not to keep the insulin pen in his pocket, to remove his gloves and sanitize his hands prior to touching other surfaces to protect the resident from cross contamination. He stated that the last in-service he had on infection control was about a month ago and the topics were on handwashing, sanitizing, and enhanced barrier precautions. 2. Record review of Resident #1's electronic facility face sheet dated 11/07/24, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Cerebral Infarction (stroke), Gastrostomy Status (placement of feeding tube in stomach), Dysphagia (difficulty swallowing), Unspecified Dementia (group of thinking and social symptoms that interferes with daily functioning), and Hypertension (high blood pressure). Record review of Resident #1's BIMS assessment dated [DATE] revealed he scored a 07 which indicated he was severely cognitively impaired. During an observation on 11/06/24 at 11:30 a.m. revealed RN B administered a bolus feeding to Resident #1 via g-tube when he removed his gloves and applied a new pair without sanitizing hands. During an interview on 11/06/24 at 11:45 a.m. with RN B, he stated he did not think he did anything wrong during his g-tube feeding administration. RN stated it was important to sanitize his hands in between glove changes to prevent cross contamination. He stated the last in-service he had on infection control was done about a month ago and the topic was on hygiene, and making sure to wash their hands for no less than 20 seconds. During an interview on 11/06/24 at 03:17p.m. with the DON, stated the staff was to change gloves anytime anything was touched besides the resident. THat was to prevent cross contamination. She stated LVN A had been trained and in-serviced in the past on infection control. The DON stated staff was to wash their hands or sanitize prior to putting gloves on and once they were done with patient care. The staff was to remove their gloves, and sanitize their hands if not soiled with BM. If their hands were soiled, then they were to wash hands with soap and water. That was to prevent cross contamination. She stated that the most recent infection control in-service was done about a month ago. During an interview on 11/07/24 at 02:54 p.m. the ADON stated per facility policy the staff should change their gloves when they were visibly soiled and before they rendered patient care. She stated the staff was to sanitize their hands when they removed their gloves and or wash their hands prior to putting on a new pair of gloves. The ADON stated the staff was to sanitize in between glove changes. The ADON stated that hand washing or sanitizing in between glove changes was to prevent the spread of infection of any type of virus or bacteria. She stated infection control was done monthly, randomly, depending on if she saw a certain type of infection, therefore they were ongoing. She stated the most recent infection control in-service was done yesterday, 11/06/24, some in October 2024 and in September 2024. She stated the topic was on the enhanced barrier precautions. She also does monthly spot checks on nurses, housekeeping, CNAs (peri care), and every department for handwashing. Record review of LVN A's Medication Pass Competency assessment dated [DATE] revealed he performed hand hygiene when handling cart/equipment. Injection/Intravenous he performed hand hygiene prior to handling medication(s) and after med administration if resident contact is necessary. [NAME] (put on) gloves for injections, IV infusion/meds, blood glucose checks and other PPE as appropriate. Record review of LVN A's Hand Hygiene Competency assessment dated [DATE] revealed he performed hand hygiene procedures in accordance with the facility's standard of practice. Record review of RN B's Medication Pass Competency assessment dated [DATE] revealed during medication administration via feeding tube, he performed hand hygiene and apply clean gloves prior to med administration. Record review of RN B's Hand Hygiene Competency assessment dated [DATE] revealed he performed hand hygiene procedures in accordance with the facility's standard of practice. Record review of the facility's Infection Prevention and Control Program Policy and procedure dated 05/13/23 revealed Policy: This facility has established and maintains an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standard and guidelines. Definitions: Staff includes all facility staff (direct and indirect care functions), contracted staff, consultants, volunteers, others who provide care and services to residents on behalf of the facility, and students in the facility's nurse aide training programs or from affiliated academic institutions. 2. All staff are responsible for following all policies and procedures related to the program. 4. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. c. All staff shall use personal protective equipment according to established facility policy governing of they of PPE. Record review of the facility's Hand Hygiene policy and procedure dated 10/24/22 revealed Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice.

Based on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standard or food service safety for 1 of 1 kitchen reviewed for food service safety in that: The facility failed to ensure all food items were labeled and dated in freezer. One bag of nuggets was not labeled or dated. This failure could place residents at risk of foodborne illnesses. The findings included: An observation of the facility freezer on 11/05/24 at 8:43 a.m., revealed inside there was a plastic bag with no date or label containing what appeared to be chicken nuggets. In an interview on 11/05/24 at 8:45 a.m. the Dietary Manager said the plastic bag contained chicken nuggets that were leftover, uncooked from the previous day. He said they served nuggets for dinner the night before. The Dietary Manager said they were supposed to be labeled, dated, and stored in a zip top bag. He said the staff has been trained on that. In an interview on 11/07/24 at 3:27 p.m. [NAME] A said they were trained to label and date all food that was in the refrigerator, freezer, or dry storage that had been opened. He said that had to be done so other staff could know when it was opened and determine how long it would be good for or if it needed to be thrown away. In an interview on 11.8.24 at 11:30 a.m. the Administrator said the Dietary Manager oversaw the kitchen staff. He said staff had trainings and should be following policies. Record review of facility's policy titled Policy: Food Storage date revised: June 1, 2019, reflected: .3. Freezers a. Store all frozen meats, poultry, seafood, fruits and vegetables, and some dairy products, such as ice cream, in the freezer at a temperature that maintains the frozen state of the foods. . e. Store frozen foods in moisture-proof wrap or containers that are labeled and dated.

Based on observation, interview and record review, the facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming, and personal hygiene, for one (Resident #16) of 3 residents reviewed for activities of daily living. The facility failed to provide Resident #16 with nasal grooming. This failure could result in decrease in resident self-esteem, embarrassment, and infections. Findings included: Record review or Resident #16's Admission Record dated 11/08/24 revealed a [AGE] year-old male with an Initial admitted [DATE] with diagnoses of Guillain-Barre Syndrome (a condition where body's immune system attacks the nerves. Can cause weakness, numbness), Quadriplegia C1-C4 Incomplete (spinal cord injury that affects the spine and results in some paralysis of arms and legs but allows some movement and sensation to remain), Type 2 Diabetes Mellitus, Muscle Wasting and Atrophy Not Elsewhere Classified, Major Depressive Disorder Recurrent Unspecified. Record Review of Resident#16's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 indicating cognition is intact and was dependent of two or more helpers for all his ADLs. Record Review of Resident#16's Care Plan Revised on 11/08/24 stated Resident #16 had an ADL self-care performance deficit r/t Quadriplegia, Impaired balance, Limited Mobility, Limited ROM. Interventions were Functional Performance: Oral Hygiene; The Resident requires (Dependent Required) for oral hygiene. Date initiated: 04/09/24 and Functional Performance: Personal Hygiene; The resident requires (Dependent Required) for personal hygiene. In an observation and interview on 11/05/24 at 10:59 a.m. it was observed Resident #16 had excessive nasal hair protruding from his nostrils. Resident #16 said he would like to have the nasal hair trimmed but said he never asked staff to do it because he did not think they could do it for him. He said staff never asked him if he would like it trimmed. In an interview on 11/05/24 at 12:24 p.m. CNA L said she showered and groomed Resident #16. She said she did not notice his nasal hairs. She also said she did not do that type of grooming. She said the nurses did that. In an interview on 11/05/24 at 4:35 p.m. LVN X said he had not noticed the excessive nasal hair on Resident #16. He said he had never trimmed nasal hair on a resident, and no one had requested that. He said he had not offered Resident #16 if he would like them to be trimmed. He also said only nurses were supposed to do that kind of trimming. In an interview on 11/06/24 at 2:21 p.m. LVN Y said residents should be groomed after showering. She said CNAs did that with the exception of ear and nose grooming. She said nurses were in charge of doing that. She said staff also offered grooming to residents. LVN Y said she had not noticed that Resident #16 needed nostril hair trimming. She said staff should be asking residents if they would like or need to have it done. She said she did not notice that Resident #16 needed it. LVN Y said that if he needs nasal trimming and it is not done, it could cause allergies or infections. Record review of facility's policy titled Activities of Daily Living (ADL's); date implemented 05/26/24 reflected: Policy: The facility will, based on resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care; Policy Explanation and Compliance Guidelines: .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on interview and record review, the facility failed to ensure adequate supervision was provided for 1 of 3 residents reviewed for accidents and supervision. (Resident #1) The facility failed to ensure Resident#1 received adequate supervision to prevent elopement. Resident #1 eloped from the facility on and was found by the police department approximately 2 miles away from the facility. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 10/08/2023 and ended on 10/08/2023. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of sustaining serious injury, harm and death. Findings included: Record review of Resident #1's electronic facility face sheet dated 09/19/2024, revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Diagnosis of Dementia, Type 2 Diabetes, Depression, and Cerebrovascular Disease (a group of conditions that affect blood flow in the brain). Record review of a Brief Interview for Mental Status dated 10/13/2023 indicated Resident #1 had severely impaired cognition with a score of 03 out of 15. Record review of Resident #1's quarterly MDS dated ,d+[DATE]//2024, revealed his mobility functional abilities for self-care are independent. Resident #1wandering behavior occurred 1 to 3 days ago. Record review of Resident #1's care plan revealed she was an elopement risk/wander, date initiated 10/07/23. Resident #1 eloped facility on 10/8/2023. Interventions included Complete wandering evaluation tool and identify pattern of wandering. Record review of the Incident Report dated 10/08/2023 at 10:05p.m. revealed at 10:05p.m noted resident missing from room. Staff alerted and in facility and surroundings search initiated. At approximately 10:15p.m. police department called and stated Resident #1 had been picked up close to a supply store at 9:42 p.m. No injuries noted to resident but resident noted with confusion. Police department able to contact family via resident cell phone. As per police officer, resident voiced wanting to go home. Immediate Action Taken: MD and RP notified. Full body assessment completed. Vital isgns taken and within normal limits, labs obtained, and one to one initiated. Record review of the Wandering Evaluation dated 10/07/2023, revealed a Score 07 Moderate Risk. Record review of doctors visit records with a History and Physical dated 10/05/23, revealed resident had previously walked out of hospital during a previous visit and had been threatening to leave her home two days before. Record review of progress note dated 10/09/2023, revealed at 10:00 pm noted Resident #1 missing from room. Resident #1 was last seen in room at 9:31pm. Staff alerted, both inside the facility and surroundings search initiated. At approximately 10:15pm law enforcement stated resident had been picked up close to a supply store. No injuries noted to resident, but resident noted with confusion. Police department able to contact family via resident cell phone. As per police department resident in route to facility. At 10:25 pm law enforcement entered building with resident. As per Police officer, resident voiced wanting to go home. MD and RP notified. Full body assessment completed, Vital signs taken and within normal limits, labs obtained. One to One initiated. During an interview on 09/19/2024 at 09:45 a.m., LVN A stated Resident #1 was last seen at approximately 09:31 p.m. when roommates, blood sugar was checked. She stated that as soon as she noticed Resident #1 was not in her room around 10pm and did not know her whereabouts. She came out of the room letting all staff know to start looking. Then other staff started the missing person protocol. LVN A stated she knows that when a resident goes missing to call a code pink right away. She stated the police called at approximately 10:15 a.m. and stated that Resident #1 had been picked up close to the supply store. During an interview on 9/19/2024 at 4:15 p.m. the DON stated, she was not the DON at the time. She stated that Resident #1 was admitted Saturday 10/7/2023 and on Sunday 10/08/2023 at night was when she eloped. She stated she was a moderate risk on the wandering evaluation form on the admission assessment. She stated that the family didn't voice any wandering concerns. Law enforcement used Resident #1's phone, called her family, and then they called the facility. She stated a head count was done. She stated that maybe somebody went out the front door and she walked right behind them. They decided to reeducate everyone on elopement, on accuracy of elopement assessments. She stated they assessed high risk wandering residents for elopement and no scores were modified. Resident #1 was on one-on-one monitoring then she was transferred to a memory care unit for increased supervision. No additional elopement events have been identified since. During an interview on 09/20/2024 at 11:03a.m. the Administrator stated that he ensured that the staff was following the elopement protocol by conducting periodically monthly elopement education and drills. He stated that the drills are unannounced. He stated that the front door code was changed monthly and as needed. Sometimes if they noticed the family member knows the code then they change it right away. Record review of a policy with date implemented of 11/21/2022 titled Elopement and Wandering Residents revealed Policy: The facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Definitions: Elopement occurs when a resident leaves the premises or a safe area without the authorization (i.e. an order for discharge or leave of absence), and/or any necessary supervision to do so. Policy Explanation and Compliance Guidelines: 3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering including identification and assessment of risk evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. The Administrator was notified on 09/20/2024 at 10:55 a.m., that a past non compliance Immediate Jeopardy situation had been identified due to the above failures. It was deternined these failures placed Resident #1 in an Immediate Jeopardy situation on 09/22/2024. The facility had corrected the noncompliance before survey began. The facility had implemented the following interventios. Record review of an In-Service Attendance Record with subject of Elopement Drill and Procedure, dated 10/10/2023, indicated that staff signed the in-service record. During an interview on 9/19/2024 at 4:15 p.m. the DON stated, Resident #1 was placed on a one-to-one monitoring. Resident #1 was transferred to a memory care unit for increase supervision. Assessments of high-risk residents were conducted, and no scores were modified. During interviews on 09/18/2024 at 09:35 a.m. - 09/19/2024 at 11:02 a.m., 3 CNAs were able to identify resident at risk for elopement, she was knowledgeable of the elopement policy and procedure. They were aware of the new expectations to not allow family members to have front door code and to notify the nurse immediately of any resident trying to go outside. During interviews on 09/18/2024 from 10:14 a.m. - 09/19/2024 09:45 a.m., 3 LVNs were able to identify residents at risk for elopement, all were knowledgeable of the elopement policy and procedure, all were aware of the new expectations to not allow any resident outside alone, and to notify the DON/ADON and the Administrator immediately of any resident trying to go outside alone.

Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 2 of 3 residents (R #2 and R #3) reviewed for accuracy of records. The facility did not document R #2 and R #3's wound care treatments in the MAR/TAR on 10/07/23, 10/14/23, 10/15/23, and 10/22/23. This failure could place residents with wound care at risk of not receiving adequate care and services. The findings included: Record review of R #2's face sheet reflected a [AGE] year-old female with original admitted [DATE]. Her diagnosis included: local infection of the skin and subcutaneous tissue, pressure ulcer of sacral region, zoster (shingles) without complications, paraplegia, fibromyalgia, osteoporosis, hyperlipidemia, major depressive disorder, and dysphagia. Record review of R #2's MDS assessment dated [DATE] reflected a BIMS score of 10 (cognitively moderately impaired). Functional abilities for ADLs of bed mobility and personal hygiene required extensive assistance. Record review of R #2's care plan dated 07/21/23 reflected R #2 had a stage 4 pressure ulcer to the sacrum related to immobility, incontinence of bowel, refuses repositioning, ADL care, and getting out of bed. Date initiated: 05/08/23. Interventions included: Administer treatments as ordered and monitor for effectiveness. Record review of R #2's MAR/TAR dated October 2023 reflected; On 10/07/23, 3 orders - Gentamicin Sulfate External Ointment 0.1 % apply to sacral stage 4 topically one time a day (start date- 06/14/23 8:00 AM, discontinue date- 10/10/23 8:37 AM), Collagenase (enzymes that break the peptide bonds in collagen) External Ointment 250 unit apply to sacral stage 4 topically one time a day (start date- 06/27/23 8:00 AM, discontinue date- 10/24/23 at 8:35 AM), and wound care as follows for right heel discoloration, skin prep daily, once a day, until resolved (start date- 10/04/23 at 8:00 AM, discontinue date- 10/18/23 at 4:53 PM) for diagnosis of sacral stage 4 pressure ulcer were not documented as administered or otherwise. On 10/14/23 and 10/15/23, 3 orders - cleanse sacral ulcer with wound cleanser, pat dry with gauze, apply Collagenase with collagen, cover with silicone super absorbent dressing daily (start date- 10/11/23 8:00 AM, discontinue date- 10/24/23 8:36 AM), Collagenase External Ointment 250 unit apply to sacral stage 4 topically one time a day (start date- 06/27/23 8:00 AM, discontinue date- 10/24/23 at 8:35 AM), and wound care as follows for right heel discoloration, skin prep daily, once a day, until resolved (start date- 10/04/23 at 8:00 AM, discontinue date- 10/18/23 at 4:53 PM) for diagnosis of sacral stage 4 pressure ulcer were not documented as administered or otherwise. Record review of R #3's face sheet reflected a [AGE] year-old male with original admitted [DATE]. His diagnosis included: local infection of the skin and subcutaneous tissue, pressure ulcer of left buttock, Guillain-Barre syndrome (disorder in which your body's immune system attacks your nerves), quadriplegia, type 2 diabetes, hyperlipidemia, and dysphagia. Record review of R #3's MDS assessment dated [DATE] reflected a BIMS score of 12 (cognitively intact). Functional abilities for ADLs of bed mobility and personal hygiene were dependent. R #3 had impairment to both sides of upper and lower extremities. Record review of R #3's care plan dated 08/30/23 reflected R #3 had a pressure ulcer stage 3 (left gluteal fold) related to extensive bed immobility and diagnosis of quadriplegia. Date Initiated: 11/11/22. Interventions included: Administer treatments as ordered and monitor for effectiveness. R #3 had an alteration in skin integrity related to the presence of a stage 3 pressure ulcer to the buttock area (left gluteal fold). Date initiated: 12/09/22. Interventions included: Apply treatment per Medical Practitioner's order and monitor for effectiveness of current treatment. Record review of R #3's MAR/TAR dated October 2023 reflected - On 10/07/23, 1 order - wound care for left gluteal fold wound as follows, cleanse with wound cleanser, pat dry with 4x4 apply dressing, cover with sterile dressing daily until resolved (start date- 09/13/23 8:00 AM, discontinue date- 10/09/23 8:47 AM) for left gluteal fold stage 3 pressure ulcer was not documented as administered or otherwise. On 10/15/23, 1 order - wound care for left gluteal fold wound as follows, cleanse with wound cleanser, pat dry with 4x4 apply dressing, cover with sterile dressing daily until resolved (start date- 10/10/23 8:00 AM, discontinue date- 10/16/23 3:45 PM) for unstageable pressure wound was not documented as administered or otherwise. On 10/22/23, 2 orders - Collagenase External Ointment 250 unit, apply to left gluteal fold topically one time a day (start date- 10/17/23 8:00 AM, discontinue date- 10/24/23 11:20 AM), and wound care for left gluteal fold wound as follows, cleanse with wound cleanser, pat dry with gauze, apply Collagenase dressing, cover with sterile dressing daily until resolved (start date- 10/17/23 8:00 AM, discontinue date- 10/24/23 11:23 AM) for diagnosis of unstageable pressure wound were not documented as administered or otherwise. Interview with R #2 on 11/08/23 at 12:45 PM. R #2 said R #2 was doing well and received all the care needed. R #2 said R #2 received wound care daily. R #2 said there had not been a day that R #2 had gone without wound care or that R #2 knew the wound care was missed. R #2 said R #2 had no concerns regarding wound care or treatment. Interview with R #3 on 11/08/23 at 1:30 PM. R #3 said R #3 was doing well. R #3 said R #3 received wound care on certain days but was unsure of the days. R #3 said the wound care might have been daily. R #3 said R #3 was always done and R #3 did not know of any time that the wound care was missed or not completed for R #3. R #3 said R #3 had no concerns regarding wound care or treatment. Interview with LVN B on 11/14/23 at 1:05 PM. LVN B said LVN B worked the 2-10 PM shift. LVN B said R #3 would have been assigned to LVN B to complete R #3's wound care as R #3 was on the left side of the hall. LVN B said LVN B worked with R #3 but did not recall specific dates. LVN B said when there was no treatment nurse working, then the floor nurses, including LVN B, would be responsible to do the wound care. LVN B said there was no time that the wound care was not done for R #3 as ordered. LVN B said the treatments were done, but LVN B possibly forgot to document in the MAR/TAR. LVN B said that should not have happened, but sometimes LVN B got busy and probably forgot to document. Interview with LVN D on 11/14/23 at 3:20 PM. LVN D said R #3 would have been assigned to LVN D to complete R #3's wound care as R #3 was on the left side of the hall and the afternoon shift would complete the left side of the hall for wound care. LVN D said LVN D worked the afternoon, 2-10 PM shift. LVN D said LVN D worked with R #3 a few times. LVN D said LVN D worked with R #3 on 10/07/23 and 10/15/23. LVN D said LVN D would have done the wound care treatments for R #3 on those dates. LVN D said LVN D did not miss any treatments or fail to complete the treatments with R #3. LVN D said perhaps LVN D forgot to mark the check offs on the MAR/TAR. LVN D said maybe LVN D marked it off, but it did not save on the MAR/TAR. LVN D said maybe LVN D forgot to document, but LVN D was sure the treatments were completed. Interview with ADON on 11/14/23 at 3:45 PM. ADON said the team tried to review documentation to ensure proper documentation was done. ADON said for R #3, on 10/07/23, 10/15/23 and 10/22/23, the documentation was missing for wound care in the MAR/TAR. ADON said for R #2, 10/14/23, 10/15/23, and 10/22/23, the documentation was missing for wound care in the MAR/TAR. ADON said the staff and residents did not voice that the treatments were not completed, but the documentation was missing. Interview with DON on 11/14/23 at 5:00 PM. DON said the facility identified the missing documentation for the MAR/TAR when DON initiated an audit on 11/06/23. DON said the plan of correction included to check the documentation at least weekly, however, DON was checking the documentation daily to ensure accuracy. DON said the nurses were also in-serviced to ensure the treatments were checked off on the MAR/TAR. DON said there were no negative outcomes to the residents. DON said for R #3, on 10/07/23, 10/15/23 and 10/22/23, the documentation was missing for wound care in the MAR/TAR. DON said for R #2, 10/14/23, 10/15/23, and 10/22/23, the documentation was missing for wound care in the MAR/TAR. DON said the treatments were done but the nurses failed to document. DON said although there would not be a risk of a negative outcome for the resident, the medical record needed to be accurately documented to ensure the doctors' orders were being followed for the residents. Interview with ADM on 11/15/23 at 4:30 PM. ADM said ADM was aware of the concern regarding that R #2 and R #3 missing documentation in the MAR/TAR. ADM said there were no concerns that the treatments were not done, but the lack of documentation. ADM said the facility addressed this concern with the nurses and the plan of correction was put in place on 11/06/23. Documentation in Medical Record Policy date implemented 10/24/22 reflected; Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Policy Explanation and Compliance Guidelines: 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. Record review of performance improvement plan and Ad Hoc (unplanned meeting focusing on specific problems) meeting dated 11/06/23 reflected upon performing chart audits, noted treatments were not consistently being performed per doctor's orders on weekends and when treatment nurse was not available. Immediate interventions: in-service nurses regarding completion of wound care on weekends and/or when treatment nurse was not available. Systemic changes: DON or designee will conduct weekly audits of TAR.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, for one Resident (R #3) of three residents reviewed for care plans, in that: The facility did not follow R #3's care plan which indicated to keep R #3's fingernails short. This failure could place residents at risk of not receiving the care and services as indicated by their comprehensive care plan. The findings included: Record review of R #3's face sheet reflected a [AGE] year-old male with original admitted [DATE]. His diagnosis included: local infection of the skin and subcutaneous tissue, pressure ulcer of left buttock, Guillain-Barre syndrome (disorder in which your body's immune system attacks your nerves), quadriplegia, type 2 diabetes, hyperlipidemia, and dysphagia. Record review of R #3's MDS assessment dated [DATE] reflected a BIMS score of 12 (cognitively intact). Functional abilities for ADLs of bed mobility and personal hygiene were dependent. R #3 had impairment to both sides of upper and lower extremities. Record review of R #3's care plan dated 08/30/23 reflected R #3 had an actual impairment to skin integrity related to a pressure ulcer. Date initiated: 11/11/22. Interventions included: avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Record review of R #3's progress notes dated 10/09/23-11/07/23 reflected no notes that indicated refusal of nail care. Interview with R #3 on 11/08/23 at 1:30 PM. R #3 said R #3's nails were too long and wanted them cut. R #3 showed HHSC Investigator R #3's nails which were about 0.5 inch long. R #3's nails were clean. R #3 did not allow for photographs to be taken of R #3's nails as he indicated, he was embarrassed. R #3 said had informed the CNAs and nurses about hiss nails being too long but R #3 was unsure of why his nails had not been cut. R #3 said did not remember the staff's names or the days R #3 told them. R #3 said tries to place R #3's hands a certain way to keep his nails from bothering his hands. R #3 said tried to prevent from scratching his body as R #3 knew that could lead to other problems. Observation of R #3 on 11/08/23 at 1:45 PM. R #3's hands were contracted and R #3's fingers and fingernails were facing down and somewhat inward towards R #3's hands (claw hand). There was no hand device or towel roll for R #3's contractures to R #3's hands. Interview with CNA B on 11/08/23 at 2:40 PM. CNA B said if any resident wanted their nails cut, CNA B would check with the nurse to see if the resident was diabetic. CNA B said if the resident was diabetic, then the CNAs could cut the nails, but the nurses could. CNA B said the CNAs usually focused on nail care on Sundays since that was the day there were no scheduled showers. CNA B said there were no residents with their nails too long. Interview with DON on 11/08/23 at 3:30 PM. DON was taken to observe R #3 along with HHSC Investigator. DON asked R #3 to see R #3's nails. DON said R #3's nails were too long. DON asked R #3 if R #3 wanted his nails to be cut, and R #3 responded, [NAME] yeah. DON said to HHSC investigator that maybe R #3 had refused nail care. HHSC Investigator informed DON there were no refusals documented in R #3's file. DON said the nurses would be the ones to cut R #3's nails since R #3 was diabetic, not the CNAs. DON said the CNAs would have informed the nurses about R #3's nails being too long. DON said R #3 could have also voiced R #3's nails being too long to the nurses or staff himself. DON said she was unsure of how R #3's nails went unnoticed, but DON would have them cut. Interview with LVN A on 11/14/23 at 12:35 PM. LVN A said if a resident was diabetic, and they have long nails, the nurses could file their nails. LVN A said if the CNAs noticed that the nails were long or the resident voiced that they wanted their nails cut, the CNAs or the resident could inform the nurses. LVN A said since there were no scheduled showers on Sundays, that was when the CNAs concentrated on nail care. LVN A said LVN A had not been informed that R #3's nails were too long or that R #3 wanted his nails to be cut. LVN A said if R #3's care plan indicated that R #3's fingernails needed to be kept short, then that was what should have been followed. LVN A said the nails were part of the skin. LVN A said R #3's nails should have been kept short for R #3's impairment to skin integrity as R #3 could sustain wounds and infections. Interview with R #3 on 11/15/23 at 12:05 PM. R #3 said he was doing well. R #3 said the nurse trimmed his nails. R #3 showed this investigator R #3's nails which were much shorter, clean, and filed (not sharp). R #3 said he felt much better. Interview with ADM on 11/15/23 at 4:30 PM. ADM said ADM was aware of the concern regarding that R #3's nails were too long. ADM said a nurse had already performed nail care and R #3 was doing well. ADM said the facility addressed this concern with all staff. Interview with DON on 11/15 /23 at 5:10 PM. DON said R #3's care plan indicated to keep R #3's fingernails short related to impairment of skin integrity as R #3 already had wounds. DON said R #3 did not have any skin tears or incidents from R #3's nails being too long. DON said R #3 could have scratched himself although R #3 was calm and not combative. DON said not keeping R #3's fingernails short could have resulted in a scratch or skin tear, and if left untreated or was not noticed, it could have led to an infection.

Based on observations, interviews, and record reviews, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities for 1 of 6 residents (Resident #151) reviewed for activities in that: The facility failed to provide Resident #151 activities designed to meet his interests and promote physical, mental, and psychosocial well-being. This deficient practice could affect residents at the facility who require assistance to activities to decline in mental acuity due to lack of stimulation, boredom, and depression. The findings included: Record review of Resident #151's Order Summary Report dated 08/03/23 reflected Resident #151 was a [AGE] year-old male admitted to facility on 06/28/23 with the diagnosis of major depressive disorder (characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), alcohol dependence with alcohol inducing dementia (damage to the brain, caused by regularly drinking too much alcohol over many years), and anxiety disorder (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Record review of Resident 151's Quarterly MDS assessment dated [DATE] reflected Resident #151 -had unclear speech, -was rarely understood by others -rarely understood others, -severe cognitive impairment and, -required extensive assistance of two plus persons for activities of daily living. Record review of Resident #151's care plan dated 07/06/22 revealed -Resident #151 is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t cognitive deficits. Interventions included: -Establish and record the resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary. -Invite the resident to scheduled activities. -Thank resident for attendance at activity function. -The resident needs assistance/escort to activity functions. Observation on 08/01/23 at 04:45 PM revealed Resident #151 in the dining room. Resident #151 sitting in his wheelchair, did not respond to greeting, has his head back, grabbing the bottom of his shirt with both hands and staring up at the ceiling. Interview on 08/02/23 at 9:28 AM Activity Director said Resident #151 was in the memory unit but was taken out of the memory unit because he does not pose a threat for elopement. AD said Resident #151was walking when he was first admitted to the unit. The AD said Resident #151 does not talk and needs assistance for all his ADLs. The staff assist him with feeding. The AD said Resident #151 does not participate in activities, so he is not taken to activities. The AD said they will play music for him or sit him in the hall or by the nurse's station so he can see people go by. Observation on 08/02/23 at 10: 10 am revealed Resident #151 in the dining room sitting in his wheelchair with a family member. Family member was sitting next to Resident #151 and patting his hand and rubbing his arm. In an interview on 08/02/23 at 10:13 am the Family Member said she would have liked the facility to provide activities to Resident #151 because he would sit in the dining room alone or out in the hall and does not have any sensory stimulation. Observation on 08/02/23 at 10:30 am revealed the AD placing residents in a circle in the dining room and passing out different colored balloons to residents in the circle. Resident #151 saw the balloons and pointed to the balloons. Resident #151 laughed and then said, [NAME], [NAME] (look, look)! Resident #151's family member moved Resident #151 closer to the group. In an interview on 08/03/23 at 9:37 am CNA H said Resident #151 would walk but would not talk, he would only say several words when he was admitted . CNA H said Resident #151 would participate in activities when he first arrived. CNA H said he would dance when they played music, or he would hit the ball or balloon when he first arrived in the unit. Resident declined and stopped participating in the activities. Interview on 08/03/23 at 10:00 am CNA I said Resident #151 would walk in the unit occasionally. Resident #151 was moved to the general population because he could not walk anymore. Resident would participate in activities sometimes. Resident #151 only liked the activity when they passed the balloon and the toy cars that his family member would bring him. Interview on 08/03/23 at 10:37 am CNA J said Resident #151 was walking when he was admitted to the memory unit. CNA said Resident #151 would wander up and down the hall and would go into other resident rooms. Resident would play with his cars and would participate in activities with music or food. Resident declined and stopped playing with his cars, he will only hold the toy car. Observation on 08/03/23 at 12:01 pm revealed Resident #151 at lunch time. Resident #151 was sitting in his wheelchair and a CNA was assisting resident to eat. In an interview on 08/03/23 at 4:00 pm LVN K said Resident #151 is not independent for his ADLs and does not have the strength to move independently. LVN said the Activity Director provides activities to the residents such as Loteria. The Activity Director will call out the cards and that will provide auditory stimulation for residents that are not able to actively participate. In an interview on 08/03/23 at 5:58 PM the Administrator said the Activity Director provides activities to resident #151 such as playing music for him and assisting resident to activities held in the dining room. The Administrator said a family member also brings Resident #151 toy cars because Resident #151 used to like cars. Record review of facility's revised Activity Policy dated 09/2014 reflected: Policy The facility has an on-going program of activities designed to meet the interests and the physical, mental, spiritual, and psychosocial well-being of each resident in accordance with his/her comprehensive assessment. Policy Interpretation and Implementation All residents, particularly bedfast and those residents unable to participate in group activities will be visited by Activity Director, Activity Assistant, and/or volunteers at least 3 times a week.

Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity and care for each resident in a manner and in an environment, that promotes maintenance or enhancement of his or her quality of life, for one Resident (Resident #202) of eight residents reviewed for dignity issues. The facility failed to monitor Resident #202's behavior when resident had her hand with feces while in her wheelchair in the dining room. This failure could place residents at risk of feeling uncomfortable and disrespected and could decrease residents' self-esteem and/or quality of life. Findings included: Record review of Resident #202 admission record dated reflected Resident #202 was a[AGE] year old female and was admitted to the facility on [DATE]. Resident #202's diagnosis included dementia (loss of memory), chronic kidney disease, stage 3 (kidney disease with mild to moderate damage), dysphagia (difficulty in swallowing) and radiculopathy, lumber region (pinched nerve). Record review of Resident #202's care plans, initiated on 08/02/23 reflected Resident #202 had a problem, will place hands inside brief and will grasp BM (feces) with hands. Interventions included to intervene as necessary to protect the rights and safety of others. Remove from situation and take to alternate location as needed. Record review of Resident #202's significant change MDS, dated [DATE] reflected. -resident's cognitive status was severely impaired. -required extensive assistance by two persons for bed mobility, transfer, dressing, toilet use and personal hygiene. -always incontinent of bowel and bladder. Observation on 8/02/23 at 10:05 am revealed Resident #202 in the dining room, in wheelchair. Approximately eighteen residents were in the dining room, participating in activities. Activity Aide was the only staff in the dining room. Other staff were observed bringing in residents into the dining room and they would leave after they brought in the residents. Resident #202 was placed in a table with other residents and observed holding out her hand with feces without any verbal comments. Interview on 08/02/23 at 10:05 with LVN G revealed Resident #202 did have feces all over her right hand while sitting in the dining room. LVN G said she would take Resident #202 to the room to get her cleaned up. LVN G said Resident #202 did have behaviors of placing her hand inside her brief and pulling out feces in her hand. LVN G said the staff had not noticed the feces in her hand. Interview on 08/02/23 at 10:15 am with CNA A revealed hospice staff had come and bathed Resident #202 earlier in the morning. After Resident #202 was showered someone brought the resident to the dining room for activities. CNA A said Resident #202 was in the dining room about forty minutes, with the Activity Aide providing activities to the residents. CNA A said staff had to be checking Resident #202 regularly because she did have the behavior of reaching into her brief and pulling out feces. Interview on 08/02/23 at 10:13 am with Activity Aide revealed her responsibility was to monitor and supervise the residents when they were in the dining room with activities. Activity Aide said Resident #202 did not participate in the activities in the dining room due to her cognitive impairment. The Activity Aide said she was aware of Resident #202's behavior of reaching into her brief and grabbing her feces. The Activity Aide said she was not aware Resident #202 had feces in her hand while she was in the dining room. Interview on 08/03/23 at 8:50 am with the DON revealed that hospice had come and bathed Resident #202 earlier in the morning and then CNAs had taken the resident to the dining room. The DON said CNAs did go and help the Activity Aide with the residents but unfortunately Resident #202 had an episode of getting her feces on her hands and was not observed by any staff. The Activity Aide does ask staff for help if she saw any situation that needed the nurse's attention. Resident #202 is not aware she has this behavior but Resident #202 needs to be monitored so she is not sitting with feces in her hands at any time, especially when Resident #202 was out in the common area. Interview on 08/03/23 at 8:55 am with LVN F revealed Resident #202 had been placed in the dining room on 08/02/23. LVN F said she didn't know who had taken Resident #202 to the dining room. Resident #202 was placed in the dining room to be with other residents. LVN F said there had been several residents in the dining room. LVN F said that the Activity Aide had enough time to monitor all residents for incidents. LVN F said Resident #202's hand had been with feces and there were other residents around her. Record review of facility policy titled Promoting/Maintaining Resident Dignity dated 1/13/23 reflected policy; It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality.

Based on observation, record review, and interview, the facility failed to ensure each resident was free from neglect, for one Resident (R#1) of eight residents reviewed for falls. R#1 required two persons to be transferred. CNA B attempted to perform a one person transfer to a shower chair for R#1. R#1 fell during the transfer to the shower chair and sustained a hematoma to the left calf that required surgical evacuation and debridement of necrotic tissue, and the use of a wound vac. This failure resulted in actual harm to R#1 and could place all 95 residents requiring staff assistance for transfers at risk for additional falls and injuries. The findings were: Record review of R#1's Face Sheet, dated 01/05/17, revealed R#1 was a [AGE] year-old female who was admitted to the facility on [DATE]. R#1's [DIAGNOSES REDACTED]. Record review of an Incident Report, dated 12/05/16 at 6:45 p.m., revealed R#1 was being transferred in her room, from her recliner to the shower chair, by Certified Nurse Aide (CNA) B. While turning R#1 in position to sit in the shower chair, R#1's right knee buckled and she fell to the floor onto her left leg. Record review of Incident Witness Statement, dated 12/05/16, and signed by CNA B, revealed CNA B had been in front of R#1. R#1 told CNA B that she wanted CNA B to go behind the chair to help her into it, and that was when R#1 fell . Record review of the undated, Facility Investigation, revealed that, on 12/05/16 at approximately 6:45 p.m., R#1 asked to be showered. CNA B took R#1 to the shower room. The Facility Investigation indicated that CNA B said she (CNA B) had been in front of R#1 when R#1 stood up from her wheelchair to transfer to the shower chair. CNA B was able to sit R#1 in the shower chair. R#1 was not comfortable in her positioning, and asked CNA B to go behind the shower chair to help R#1 straighten up. R#1 then stood up, but her right leg buckled and she fell to the floor, with her left knee under her. CNA B called the nurse, who noted a discoloration to R#1's left calf. Facility Investigation indicted CNA B was suspended immediately by the Administrator after finding that R#1 was to be assisted by two staff for ADLs. Facility Investigation concluded that, Based on our observation, review of resident's records, and interviews conducted, the facility has found that resident was a X 2 assist and should not have been in the shower room transferring X1. For this reason, the CNA was suspended immediately and will be terminated for not following plan of care. The incident was reported due to the reporting guidelines of the state. Record review of R#1's Tranfer Summary, dated 12/07/16, revealed R#1 was transferred to the hospital on [DATE]. Record review of a History and Physical for R#1, dated 12/07/16, revealed R#1 had fallen two days prior at a nursing home and had pain to her lower extremity. CT scan revealed that there was a hematoma causing mass effect on the surrounding musculature. Record review of Operative Progress Note for R#1, dated 12/14/16, revealed R#1 received a left calf excisional debridement, left calf necrotic skin and subcutaneous tissue retraction, and a wound vac placed. Record review of R#1's Admission Nursing Evaluation, printed 01/05/17, revealed R#1 was readmitted from the hospital on [DATE]. R#1's Admission Nursing Evaluation indicated R#1 had calf debridement on 12/08/16 and skin resection/debridement on 12/14/16. R#1 had a wound vac in place to the left calf on readmission to the facility. Record review of R#1's Significant Change MDS, dated [DATE], revealed R#1: -had moderately impaired cognition, but could make some decisions for herself, -required assistance of two or more staff persons for transfers, and -had range of motion impairment of her lower extremities on one side. Record review of R#1's Care Plan, dated 12/23/17 (sic), revealed R#1 had impaired transfer ability and required assistance from two staff. On 01/05/17 at 11:20 a.m., surveyor observed R#1 in bed in a supine position, with oxygen via nasal cannula, and a wound vac (vacuum) on her left lower leg area. R#1 said that, a few weeks ago, she had been trying to get from her recliner into the shower chair when her right knee gave out, and she fell to the ground onto her left knee and leg. R#1 said that it hurt immediately. R#1 said that, prior to the fall, sometimes one staff member would help her to the shower and sometimes it would be two. R#1 said that she felt okay that day, but looking back, she should have insisted that there be two staff members present to help transfer her. R#1 said that, since that fall, she had to go to the hospital to have surgery to remove a mass she had on the back of her knee/calf area. R#1 said that, after the surgery, she had the wound vac and that she came back to the facility. R#1 said since she returned to the facility she was mostly always in bed because it was extremely painful and difficult to try to get out of bed with the wound vac on her left leg. R#1 said she liked to get up to her recliner prior to the incident and do things with her roommate that she was not currently able to do. In an interview on 01/05/17 at 12:50 p.m., CNA B said that, on 12/05/16, she and her partner (CNA C) were in a resident's room. CNA B said CNA C informed her that R#1 had requested to be showered. CNA C said CNA B should go do that and that she (CNA C) would finish up with the resident they had been working with. CNA B said she asked CNA C if R#1 could be assisted with just one person or if she would need additional help. CNA B said she (CNA B) had been new to the facility and was not familiar with all of the residents. CNA B said CNA C told her at that time that R#1 was very easy and could do most of the work herself, so CNA B could shower R#1 alone. CNA B said CNA C then told her to hurry because R#1 wanted a shower soon. CNA B said that she asked CNA C again if she was sure, and CNA C said it was fine to shower R#1 alone. CNA B said she gathered supplies and went to R#1's room, where R#1 was seated in the recliner next to her bed. CNA B said R#1 asked her to bring the shower chair to the recliner and that she would transfer into that. CNA B said she took the shower chair adjacent to the recliner and locked the wheels. CNA B said R#1 was able to stand, but requested that CNA B go to the back of the shower chair to assist her and ensure that the chair did not slip out from under her. CNA B said that she went to the back of the chair as R#1 had requested. CNA B said that, once she was at the back of the chair, R#1 went to adjust herself to sit down properly in the shower chair and her right knee buckled. R#1 fell to the ground, onto her left knee and leg. CNA B said she immediately called for help. In an interview on 01/05/17 at 2:05 p.m., CNA C said she had worked at the facility for three or four months and was familiar with R#1 and the fall incident that R#1 had in December. CNA C said she had been trained by the facility on how to perform transfers and how to care for residents. CNA C said that, if she did not know how much help a resident needed with care, she would go to the nurse and ask or she could also look it up on the computer. CNA C said the computer had codes to tell staff what kind of help a resident needed. CNA C said that she and her partner, CNA B were both in a resident's room, finishing up, when she told CNA B to go to R#1's room to get R#1 ready for a shower, because R#1 wanted to take a shower. CNA C said she told CNA B she would be in shortly after to help her get R#1 into the shower. CNA C said she did not tell CNA B to do R#1's shower alone. CNA C said she did not say that R#1 was easy. CNA C said she knew that R#1 required a two person transfer and that R#1 had always required a two person transfer as long as R#1 had been a resident at the facility. Record review of In-Service Training Report, dated 12/06/16, revealed staff were trained on transfers for residents who required extensive assistance from two or more staff, which included: -Proper body mechanics involved with extensive assistance by two staff transfers. -Different methods used. -If pt (patient) is too heavy proper protocol to ask for help. -Safety with all transfers. Record review of In-Service Training Report, dated 12/06/16, revealed staff were trained on a topic of, Care Task, using care task as your guide at all times for all ADL care and transfers. On 01/05/17, surveyor observed three different CNAs perform two person transfers of residents residing on the 100 and 200 halls. Surveyor did not observe any problems or concerns with these transfers. The facility's undated CMS Roster/Sample Matrix (802) form, dated 01/05/17, indicated 95 residents required staff assistance with transfers.

Based on observation, record review, and interview, the facility failed to: 1. ensure that one Resident (R#11) of four residents reviewed with pressure ulcers did not develop an avoidable pressure ulcer. R#11 had a history of [REDACTED].#11's left ear in March 2012 when staff observed R#11 tugging on her oxygen mask. 2. ensure R#11 received the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. The facility failed to keep the R#11's Stage 3 pressure ulcer on her left ear covered with a dressing and failed to ensure R#11's nasal cannula was not on the pressure ulcer on R#11's left ear. Failure to monitor R#11 for skin breakdown resulted in R#11 developing a Stage 3 pressure ulcer to the left ear. Failure to protect the pressure ulcer site put R#11 at risk for worsening of the pressure ulcer. These failures could affect all eight residents with pressure ulcers. The findings were: Braden Scale for Predicting Pressure Sores dated 02/08/12 documented R#11 was assessed with [REDACTED]. R#11's care plan dated 02/14/12 indicated R#11 was at risk for skin breakdown related to decreased bed mobility, incontinence, and a history of ulcers. Approaches included weekly skin assessments by a nurse and for staff to monitor R#11 during care and baths for red areas, bruises, and open areas. R#11's computerized physician's orders [REDACTED]. Orders included oxygen at four liters per minute via nasal cannula as needed (order date 02-16-12), oxygen at five liters per minute via face mask as needed (order date 02-26-12), and treatment orders for redness to R#11's left heel. R#11's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R#11: - had a Brief Interview for Mental Status which indicated no cognition or memory problems, - was able to understand others and usually able to make herself understood, - was totally dependent on staff for bed mobility, dressing, and toilet use, - had shortness of breath while sitting and while lying flat, and, - had a pressure ulcer to the heel. Nurses Notes dated 03/23/12 (no time documented) for R#11 indicated, "Upon assessment noted resident pulling on O2 (oxygen) face mask. Noted small Stage 3 ulcer to back of left ear." (Stage 3 ulcer - full thickness tissue loss, subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough (dead tissue in the process of separating from viable tissue) may be present but does not obscure the depth of tissue loss. May include undermining (destruction of tissue extending under the skin edges) or tunneling (passageway of skin destruction under the skin surface.)) R#11's Physician's Telephone Order dated 03/23/12 (no time) indicated to cleanse the back of R#11's left ear with normal saline, pat dry, apply Santyl (ointment to heal skin ulcers), and cover with 4" by 4" gauze every day, for a [DIAGNOSES REDACTED]." R#11's care plan was updated on 03/23/12 and included the following interventions for healing of pressure ulcers: -encourage resident not to reposition or remove oxygen mask by herself - reposition oxygen mask and elastic to be off wound site -use of padding to elastic of oxygen mask R#11's E-Z Graph Wound Assessment Worksheet dated 03/23/12 documented R#11 had a Stage 3 wound behind her left ear, measuring 0.8 cm (centimeter) in length, width of 0.5 cm, and depth of 0.1 cm. The Worksheet indicated the Stage 3 had scant serous (clear, watery fluid) drainage, the wound base was pink and yellow, eschar (dead tissue)/slough was present, and there was no odor. Physician's Telephone Order dated 03/28/12 indicated to discontinue R#11's continuous oxygen at two liters per minute via mask and start continuous oxygen at two liters per minute via nasal cannula. R#11's E-Z Graph Wound Assessment Worksheet dated 03/29/12 documented R#11 had a Stage 3 wound behind her left ear, measuring 0.8 cm in length, width of 0.5 cm, and depth of 0.1 cm. The Worksheet indicated the Stage 3 was unchanged, had scant serous drainage, wound base was pink and yellow, eschar/slough was present, and there was no odor. Treatment order documented on R#11's "Treatment Sheet" sheet dated April 2012 for the pressure ulcer was to cleanse back of left ear with NS (normal saline), pat dry, apply santyl, cover with 4" x 4" gauze OD (once daily). During the initial tour on 04/02/12 at 9:30 a.m. accompanied by Licensed Vocational Nurse (LVN) "A", surveyor observed R#11 lying in bed. R#11 had a nasal cannula in place. LVN "A" informed the surveyor that R#11 had a pressure ulcer to her left ear. On 04/03/12 at 11:55 a.m., surveyor observed R#11 in her room with a nasal cannula in place. The nasal cannula oxygen tubing was resting directly on the pressure ulcer on R#11's left ear. There was no gauze dressing or other protection on R#11's ears and no padding on the nasal cannula tubing. The gauze dressing was lying on the bed next to R#11's left shoulder. R#11 said the gauze fell off when she moved. R#11 said the gauze was for a "scratch" on her ear. R#11 said the "scratch" was not painful. Occupational Therapist Assistant (OTA) "C" was with R#11 in the room at this time. In an interview at this time, OTA "C" said the gauze sometimes fell off. Surveyor observed the OTA pick up the gauze and place it back on R#11's left ear. On 04/03/12 at 4:20 p.m. accompanied by the Director of Nurses (DON), surveyor observed R#11 in her room with a nasal cannula in place. The nasal cannula oxygen tubing was resting directly on the pressure ulcer on R#11's left ear. There was no gauze dressing or other protection on R#11's ears and no padding on the nasal cannula tubing. The gauze dressing was lying on the bed next to R#11's shoulder. Surveyor observed the DON pick up the gauze and place it back on R#11's left ear. The DON said maybe the oxygen tubing could be repositioned away from R#11's ears. The DON said she would check central supply to see if they had the grey tubing to cushion the oxygen tubing on R#11's ears. On 04/03/12 at 4:40 p.m., the DON showed surveyor a package containing "Ear Mates" (cushions for oxygen tubing) and said they would be placed on the oxygen tubing to prevent the tubing from rubbing on R#11's ears. During an interview with Certified Nurse Aide (CNA) "D" on 04/04/12 at 7:50 a.m., CNA "D" said she was assigned to R#11's hall. CNA "D" said she provided care for R#11, but had not noticed the pressure ulcer to R#11's ear prior to 03/23/12. CNA "D" said she would fix R#11's hair but still did not notice the pressure ulcer on R#11's left ear. On 04/04/12 at 9:10 a.m. surveyor observed R#11 in bed with a nasal cannula in place. The nasal cannula oxygen tubing was padded and placed above R#11's ears. There was no gauze dressing on the pressure ulcer on R#11's left ear. At this time, surveyor observed Treatment Nurse/LVN "B" perform the pressure ulcer treatment to R#11's left ear. Treatment Nurse/LVN "B"said this was the first time R#11 had developed a pressure ulcer to her ear. Treatment Nurse/LVN "B" asked R#11 what had happened to the gauze on her left ear. R#11 said she did not know. R#11 complained of stomach pain. Surveyor observed the pressure ulcer to R#11's left ear (in the crease where her ear met her head) to be scabbed over, with no drainage or odor. In an interview with the Treatment Nurse/LVN "B" on 04/04/12 at 9:20 a.m., Treatment Nurse/LVN "B" said R#11's pressure ulcer on her left ear was improving. Treatment Nurse/LVN "B" said she was going to notify the charge nurse that R#11 was complaining of stomach pain. Treatment Nurse/LVN "B" said she would take measurements of R#11's pressure ulcer "later." On 04/04/12 at 1:45 p.m., surveyor asked the Treatment Nurse/LVN "B" if she had taken R#11's pressure ulcer measurements. Treatment Nurse/LVN "B" said that R#11 had been sent to the hospital due to her stomach pain, so she had not been able to take the measurements. Surveyor reviewed the facility's policy on the Prevention of Pressure Ulcers dated 03/12. The policy contained the following policy interpretation and implementation: - "Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area, which destroys the tissue. The most common site of a pressure ulcer is where the bone is near the surface of the body including the back of the head around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles, and toes. Pressure can also come from splints, casts, bandages, and wrinkles in the bed linen. If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident, and often times become infected. -Pressure ulcers are a serious skin condition for the resident. Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of a developing pressure ucler to the supervisor. -The following are additional clinical conditions, treatments and abnormal lab values that indicate that a resident is at risk as listed in survey tag F314: -Continuous urinary incontinence or chronic voiding dysfuction -Severe [MEDICAL CONDITION] -[MEDICAL CONDITION] (paralysis of the lower body)/[MEDICAL CONDITION] (paralysis of all four limbs) -Sepsis (bacterial infection in the bloodstream) -[MEDICAL CONDITION] -Chronic or end stage renal, liver, or [MEDICAL CONDITION] -Head of bed elevated the majority of the day due to medical necessity." During the exit conference on 04/04/12 at 4:55 p.m., the Administrator and DON were given the opportunity to provide additional information regarding pressure ulcers. No additional information was provided. The Centers for Medicare & Medicaid Services (CMS) Resident Census and Conditions of Residents form (672) identified eight residents with pressure ulcers and three receiving respiratory treatments.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well being for one of two residents (SR#10) with Foley catheters (F/C). The facility failed to provide SR#10 with pain medication prior to F/C care and incontinent care. SR#10 had a F/C (tubing placed in the bladder to drain urine) and a slit (tear) to the penis. This area was excoriated (reddened, inflamed, raw area) and painful. During F/C care on 03/22/11 SR#10 made facial frowning expressions, made a loud groaning noise, stiffened his body, and attempted to press his knees together. The facility identified two residents with F/C from a census of 119 residents. Failure to provide pain medication could result in the facility's two residents with urinary catheters experiencing untreated pain. The findings were: On 03/22/11 at 11:03 a.m. surveyor observed F/C care performed by Certified Nurse Aide (CNA) "D" and CNA "E". CNA "D" and CNA "E" washed the area around SR#10's catheter with soap and water. Surveyor observed SR#10 made facial frowning expressions, made a loud groaning noise, stiffened his body, and attempted to press his knees together. Surveyor noticed the anterior skin area of SR#10's penis was excoriated. Surveyor asked CNA "D" and CNA "E" if SR#10 was given pain medication before catheter care and they said, "no." CNA "D" said SR#10 always made a loud groaning noise, and that it was hard to know if he was having pain. CNA "D" said, "Sometimes I think he is having pain because he clenches his knees together and becomes very stiff. I have mentioned it to the nurses." Surveyor interviewed Licensed Vocational Nurse (LVN) "C" on 03/22/11 at 11:25 a.m. LVN "C" said SR#10's Physician had seen him on 02/14/11 and did not make any changes in his care. LVN "C" said, "We were applying [MEDICATION NAME] ointment before on his excoriated area but that was discontinued and the area is washed with soap and water only." Surveyor asked LVN "C" if she assessed SR#10 for pain when performing care. LVN "C" said, "He makes a loud noise, but he makes that noise anyway when no care is provided." Surveyor interviewed the Director of Nurses (DON) on 03/23/11 at 2:45 p.m. related to SR#10's excoriation to the catheter area. The DON said nurses needed to call SR#10's Physician if the area was very sensitive and painful. Surveyor interviewed CNA "F" on 03/24/11 at 10:25 a.m. CNA "F" said, "When I do peri-care he (SR#10) yells like when you're having pain, but he always yells with any movement. I know it has to hurt because of the area where it is at. I have told the nurses how the area is and I have mentioned to them he might be having pain, but I have not actually seen them give him anything for pain. I usually leave after I do the peri care." Surveyor interviewed LVN "G" on 03/24/11 at 10:40 a.m. LVN "G" said, "I took care of (SR#10) about three days ago. I do the Foley catheter care. (SR#10) has a big urethra with that catheter he has had for a long time. I use peri wash to spray the area. When I wash the area he groans, but he always groans. When I flush the catheter he seems like he does have discomfort, I feel he does not need anything for pain. I gave him Tylenol before for high temperatures. When his daughter is here she wants him to have something for pain. He tells her he is having pain. When we ask him he says no. He is able to voice his needs or discomforts." Surveyor interviewed SR#10 on 03/24/11 at 3:00 p.m. Surveyor asked SR#10 if he was having any pain right now, and he answered, "no." Surveyor asked SR#10 if the excoriated area on his penis hurt when it was touched or washed, and he answered, "yes." Surveyor asked SR#10 how strong was his pain, and he answered, "a lot." Surveyor asked SR#10, "When nurses ask you if you are having pain what do you say?" SR#10 answered, "yes." Surveyor asked SR#10 if nurses gave SR#10 medicine for pain. SR#10 said, "They may give me medicine for pain but it still hurts a little." SR#10's Computerized physician's orders [REDACTED]. SR#10's Febuary 2011 and March 2011 Computerized physician's orders [REDACTED]. SR#10's Skilled Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. SR#10's Care Plans revised on 01/21/11 revealed SR#10, "receives Tylenol via G/T (gastrostomy tube/peg tube) PRN, potential for side effects." Care Plan approach included to administer medication as ordered and inform the Physician and Responsible Party of any changes in condition. SR#10's Care Plans did not identify or address pain issues. SR#10's Nurses Notes dated 03/08/11 revealed the following nursing documentation: "patient noted with uncomfortable while up to geri chair (rolling recliner chair) noted abdominal distention as well hypoactive bowel sounds present to all quadrants. Noted sediment to F/C drainage bag. Pt assisted to bed to ease discomfort. Pt noted to moan in pain. Noted pieces of stones to penis area and pad noted scant bleeding patient passed few kidney stones. Abdominal distention decreased gave APAP ([MEDICATION NAME]) for pain. RP (responsible party) at bedside." No follow-up assessment was documented, no documentation of notifying Physician of SR#10's change of condition (passing stones). SR#10's skilled MAR indicated [REDACTED]. During the pre exit conference on 03/24/11 at 7:05 p.m., the facility was given the opportunity to present any additional information related to this deficient practice, facility did not provide additional information. The Centers for Medicare and Medicaid Services (CMS) Resident Census and Conditions form (CMS 672) dated 03/21/11 identified two residents with urinary catheters, from a census of 119 residents.