Every finding on record at Heritage Convalescent Center

Based on interview and record review the facility failed to consider the views of a resident group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility for 5 of 7 anonymous residents.The facility failed to address a grievance put forth by the resident council regarding sheets not being changed on beds. This failure could lead to residents feeling unheard and unvalued in their place of residence.Findings Included:During a resident council meeting on 12/03/25 at 2:00 PM 5 of 7 attendees complained that their bed sheets were not being changed weekly while they were getting their showers, which was what was supposed to happened. One of the anonymous residents stated that she was a new admit and had only resided in the facility for one month. She stated that her bed sheets had only been changed one time since she had moved in. Another of the anonymous residents stated that a nurse would bring her the clean sheets and she would put them on herself and make her own bed. All five anonymous residents stated they had raised their concerns for the last couple of months at the resident council meeting and they had not heard anything back from staff on how this issue was being addressed.Record review of grievances from June 2025-December 2025, revealed no grievance about the sheets not being changed.Record review of the June 2025-December 2025 resident council minutes revealed that on dates 10/7/25 & 11/4/2025, beds were not being made. The AD was the staff in attendance.During an interview on 12/04/25 at 9:52 AM, The AD stated she had been working in the facility for 2 years. She stated that if a resident wanted to file a grievance, they would talk to her and then she reported it to the SW. Together they would fill out a form with the resident, and it was her understanding that an investigation was then started. The AD stated that after the Resident Council meeting each month, she presented the issues from Resident Council at morning meeting the next day, where all department heads were present. Then the SW or that department head with the issue would take that grievance from resident council and deal with it. The AD stated she felt like the issues were being dealt with. The AD stated that she had a resident on Tuesday, December 2nd, 2025, after the monthly resident council meeting, tell the AD that her bed sheets had not been changed in a month. She stated she took that resident straight to the DON. The AD stated she was not sure what happened with that issue because she did not follow up on it. She stated a possible negative outcome of residents' grievances not being resolved could be they would not feel heard or issues not getting better when they complained.During an interview on 12/04/25 at 10:04 AM, The DON stated that when there was a grievance filed in resident council, if it involved the nursing staff, it would be brought to her attention. When told that many residents during the resident council meeting had stated that their bed sheets were not being changed, the DON stated that sheets were getting changed to her knowledge, and she had not heard about that in morning meeting. She stated that the protocol was nurses were to change the bed sheets 3 times a week when residents received a shower. The DON again stated she thought sheets were being changed per protocol. She stated a negative outcome for residents' grievances not being followed up on could be that they would feel unheard and sheets not being changed regularly could lead to skin breakdown, infection issues, and dignity issues.During an interview on 12/04/25 at 10:57 AM, ADON A stated the SW was the grievance officer but that she was new and had only been working at the facility for about a week or two. She stated that when any issues were brought up during a resident council meeting, the SW, DON, & ADON would address them and do an investigation to decide what needed to be done and what to change. ADON A stated that she was not aware that sheets were not being changed but she had not been in morning meeting for a few weeks. She stated a possible negative outcome for a resident not having their grievance followed up on could be they would feel unheard. On 12/04/25 at 11:10 AM, attempted phone interview with SW was unsuccessful.During an interview on 12/04/25 at 11:43 AM, CNA C stated that she had worked at the facility for one year and when a resident had a complaint they wanted to report as a grievance, she would go to the DON. She stated she believed then that the DON would go to the SW with the issue and then up the chain from there. CNA C stated that a possible negative outcome of a resident's grievance not being followed up on could result in them not feeling heard or making the resident sad.On 12/04/25 at 12:11 PM, attempted phone interview with SW was unsuccessful.Record review of facility policy titled Resident Rights and dated December 2016 revealed in part: . Federal and state law guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . u. voice grievances to the facility . v. have the facility respond to his or her grievances . Record review of facility policy titled Resident Council and dated December 13, 2016 revealed in part:The facility will consider views of the resident council and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure refrigerated, freezer, and pantry items were properly stored, labeled, and dated.This failure could place residents at risk of food-borne illness. Findings included:Observation of the freezer on 12/02/25 at 8:33 AM revealed the following:1. (1) small Ziploc containing French fries, no label or date.2. (1) small Ziploc containing chicken nuggets, no label or date.3. (4) boxes of juice, no label or date.Observation of the pantry on 12/02/25 at 8:26 AM revealed the following:1. (1) Ziploc bag with open cheese sauce mix bag inside, no label. Date on Ziploc was 5/4-6/4. 2. (1) bag of sloppy joe mix - expired December, 2024. DM threw this item in trash.3. (1) bag opened pork roast gravy mix, not in a sealed container.4. (1) box Jiffy corn bread mix in Ziploc, no label or date. Expiration date of 5/22/24.Observation of the walk-in refrigerator on 12/02/25 at 8:42 AM revealed the following:1. (1) Ziploc containing deli meat, no date or label.In an interview on 12/02/25 at 8:45 AM, [NAME] E stated she had worked at the facility for 8 months and was trained by the RD to label and date everything that comes in. She stated it was everyone's responsibility to label and date food and if this was not happening, staff in the kitchen would not know when food was received or opened and it could make residents sick. In an interview on 12/02/25 at 8:48 AM, [NAME] D stated he had worked at the facility since April of 2025 and everyone who worked in the kitchen was responsible for labeling and dating food. He stated a possible negative outcome was they could possibly serve out of date food which could cause residents to become sick. In an interview on 12/02/25 at 8:52 AM, The DM stated it was everyone's responsibility to label and date food, and that if a staff member opens a box, they are to immediately label and date it. He stated that the RD trained staff so everyone would know how to date/label food and so everyone was on the same page. The DM stated a possible negative outcome for not labeling and dating food could be that residents could get sick.In an interview on 12/02/25 at 12:15 PM, the RD stated she wrote the policy for the facility on labeling and dating food and does in services regularly with kitchen staff based on the policy. She stated this was the only policy for the kitchen that the facility had.Record review of facility policy, titled Labeling and Dating Food not dated, revealed the following information in part:- All food must be dated as to when it was received.- When the food item is removed from the original box, each item must be dated, or container must be dated (i.e. tray or tube or pan).-If a food item does not have its own expiration date, and is shelf stable, it may be kept for a year from receipt. -Once you open a food item, you must date it the day it was opened.

Based on observation, interview and record review, the facility failed to ensure each resident had a right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 18 residents (Resident #15) reviewed for accommodation of needs in that:Resident #15 was not being provided with the correct size of adult brief.This failure could place residents at risk of not having met their needs and a decline in their quality of care and life.Findings included:Record review of Resident #15's face sheet, dated 12/03/2025, revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included, but were not limited to, Chronic Respiratory Failure with Hypoxia (failure of lungs to provide oxygen), Other lack of coordination, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypothyroidism (thyroid underperforming), Type 2 diabetes Mellitus (inability to process sugar), morbid (severe) obesity due to excess calories, anxiety disorder, unspecified (a group of mental illnesses that cause constant fear and worry), myopathy, unspecified (muscle weakness and dysfunction), Essential (Primary) hypertension (abnormally high blood pressure that's not the result of a medical condition), emphysema (sacs in lungs can't switch oxygen and carbon dioxide leaving person breathless), and Chronic obstructive pulmonary disease (COPD refers to a group of diseases that cause airflow blockage and breathing related problems). Record review of Resident #15's quarterly MDS, dated [DATE], revealed a BIMS score of 15 out of 15 which indicated cognition was intact. Resident #15 was dependent and required two-person staff assistance with bed mobility and lower body dressing, total two-person staff dependence with transferring bed to chair, sit to stand and toilet transfer. Resident #15 was always incontinent of bladder and frequently incontinent of bowel.Record review of Resident #15's care plan, dated 10/30/25, revealed, in part, [Resident #15] has bladder incontinence with goal of remaining free from skin breakdown due to incontinence and brief use. Interventions included: prefers to wear 2 briefs and a protective pad for furniture. During an observation on 12/02/25 at 10:03 AM, Resident #15 was lying on her bariatric bed, awake, watching tv. Resident stated that she remembered surveyor from an investigation a few weeks ago. Resident stated that she was wearing 3X briefs, but that the size she needed was 5X. She told the CNAs not to fasten the sides of the 3X briefs because it was too tight and uncomfortable. Resident stated that when surveyor was here last time, the ADM stated she was looking for her 5X briefs but had not heard anything back about it or if they had been ordered. Resident stated that she knew 5X sized briefs were manufactured because she had them at another facility before this one.During an observation on 12/03/25 at 10:29 AM, the supply closet on the hall where Resident #15 resided revealed to have 3X briefs as the largest size.During an interview on 12/03/25 at 10:30 AM, RN F stated she was not sure if the facility had tried to get Resident #15 larger briefs.During an interview on 12/03/25 at 10:33 AM, CNA G stated that he had worked at the facility for 3 1/2 years and was very familiar with Resident #15. He stated that when he changed her, she does not want the sides of the briefs snapped because they are too tight and so CNAs make sure that she was covered but leave the sides unsnapped. CNA G stated that 2 months ago he asked the ADM if they could order her bigger ones, but he stated he was not sure of the status of that, but he stated he had not seen 5X briefs for Resident #15.During an observation and interview on 12/03/25 at 10:52 AM, CNA H was observed during incontinent care for Resident #15. CNA H stated that they had been asking for bigger briefs for Resident #15, but administration had not gotten them for her.During an interview on 12/03/25 at 10:53 AM, RN F stated that she felt Resident #15's bottom area could get aggravated due to the briefs they are using for her being too small. RN F stated that the facility cannot find her larger sized ones on the website they use.During an interview on 12/03/25 at 11:01 AM, ADM was asked for Accommodation of Needs Policy.During an interview on 12/04/25 at 9:15 AM, Resident #15 stated that she had lived here almost 2 years and that the management had talked to her once about getting her a larger sized brief. She stated she did not feel like the facility tried to meet her needs in that regard. Resident #15 stated this made her feel like administration wanted her to leave because she had so many health issues and for the resident to possibly buy her own larger briefs, which she could not afford. She stated that the CNAs have asked management to get her larger briefs on several occasions, which she appreciated.During an interview on 12/04/25 at 9:23 AM, LVN I stated that she had worked at the facility for almost a year and was charge nurse for the hall that Resident #15 resided on. She stated she did not feel like it was a problem for Resident #15 to wear smaller briefs. When surveyor asked LVN I if it would affect her if she had to wear pants 2 sizes too small. LVN I stated it would be a problem, and it could cause pain and issues.During an interview on 12/04/25 at 9:32 AM, CNA C stated she had worked at the facility for 1 year and worked the hall Resident #15 resided on. She stated that ADON A told her about a month ago that they were going to order bigger briefs for Resident #15. CNA C stated she felt the smaller sized briefs bothered Resident #15, and that the resident had told her she was uncomfortable. CNA C stated that a possible negative outcome of residents not having their needs accommodated could be that they could suffer abuse.During an interview on 12/04/25 at 10:43 AM, ADON A stated that she did not feel the size of Resident #15's brief was causing any issues because they did not snap the sides and CNAs leave them open because fastening them made it uncomfortable for her. ADON A stated she would personally not enjoy wearing underwear that was 2 sizes smaller and stated it would be uncomfortable for sure. ADON A stated that she remembered CNAs asking her to order 5X briefs for Resident #15, but she did not order them and she stated that the ADM could not find that size on the company website that they use. She stated a possible negative outcome for not having a residents needs met could be that they would be unhappy which could cause issues with the family or they could get sick.During an observation on 12/04/25 at 11:01 AM, Amazon.com was observed to sell Adult Briefs for women and men in size 4-5XL with stretchable sides.During an interview on 12/04/25 at 11:21 AM, The ADM stated that she had not ordered the 5X briefs for Resident #15 because no one made that large of a size of brief. Surveyor stated that Amazon sold them and observed them online that morning. ADM responded, really? ADM stated that there was not a negative outcome for a resident who was not getting his/her needs met. ADM stated they did not have an Accommodation of Needs Policy.Record Review of the facility's Resident Rights Policy dated December 2016, revealed in part.Policy Statement: Employees shall treat all residents with kindness, respect, and dignity.Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a. A dignified existence.b. Be treated with respect, kindness, and dignity.Record review of the facility's admission packet with Statement of Resident Rights reviewed, not dated, revealed in part.You have a right to:1. All care necessary for you to have the highest possible level of health.4. be treated with courtesy, consideration, and respect.

Based on interview and record review the facility failed to ensure all residents had the right to formulate an advanced directive for 1 (Resident #24) of 24 residents reviewed for advanced directives. Resident #24 had a DNR in her record that was signed incorrectly by the witnesses. The facility's failure to ensure the accuracy of a residents advanced directive could place residents at risk for not receiving healthcare as per their or their legal representatives' wishes.Findings included: Record review of Resident #24's face sheet printed [DATE] revealed she was a [AGE] year-old female resident admitted to the facility originally on [DATE] and readmitted on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interferes with daily functioning), Alzheimer's (a progressive disease that destroys memory and other important mental functions), and renal insufficiency (a condition where the kidneys do not function properly). In the section Advance Directives Resident #24 is listed as a DNR. Resident #24's last MDS was a quarterly assessment completed [DATE] listing her with a BIMS of 05 indicating she was severely cognitively impaired, and she had a functionality from being dependent on staff for assistance with lower body care to requiring supervision/touch assistance with eating and oral hygiene. Resident #24's care plan with admission date of [DATE] revealed the following: Focus:I/responsible family have an order for DNR.Not Resuscitate (DNR). Record review of the clinical record for Resident #24 revealed an Order Summary printed [DATE] with the following order: DNR Active - Revision Date: [DATE]. Record review of the clinical record for Resident #24 revealed a DNR dated [DATE] (signed by Resident #24's MPOA) with the following:Section - Two Witnesses: (See qualification on backside) We have witnessed the above-noted competent adult person or authorized declarant making his/her signature above and, if applicable, above-noted adult person making an OOH-DNR by nonwritten communication to the attending physician. -Witness #1 was the current activity director and signed the form on [DATE]. (two days before the MPOA)-Witness #2 was the former social worker and signed the form on [DATE]. (two days before the MPOA) During an interview on [DATE] at 09:57 AM LVN L (the nurse responsible for Resident #24 this shift) reviewed Resident #24 electronic chart and verified Resident #24 was listed as being a DNR. LVN L reported Resident #24 had cancer and was a DNR so if an employee reported to her Resident #24 was not breathing or did not have a heart beat she (LVN L) would first verify the resident condition, then notify management, the Dr, then call 911 to let them know they had a resident that had passed away and the Resident was a DNR. LVN L reported she would not start CPR for Resident #24. LVN L then reviewed Resident #24 DNR form that was in her electronic chart and noted the responsible party signed the DNR form on [DATE] and both witnesses signed the DNR form on [DATE]. LVN then stated, this is not a legitimate form. Now you do CPR. LVN L reported if the DNR form was not completed correctly then the residents will not get coded correctly and this could result in the residents' wishes not being honored. LVN L reported the social worker was the person responsible in the facility for ensuring the DNRs' were completed correctly. During an interview on [DATE] at 11:12 AM the DON reported Resident #24 was a DNR and Resident #24's FM M (who was the MPOA that signed the form) lived out of state and FM M signed the form on [DATE] and uploaded it on [DATE] so they (the facility) would have it. (the DON was noted having difficulty seeing the DNR form and identifying the correct date the MPOA signed the form). The DON reported the former SW M and the current AD signed as the witnesses on Resident #24's DNR form. The DON reported if a DNR was not completed correctly then the facility would not be following the residents' wishes. Record review of the facility provided policy titled Patient Self Determination Act undated, revealed the following:The Health Care Center recognizes the right of each Resident to utilize those advanced directive recognized under stated law and will honor advanced directives developed in accordance with stated law. Record review of the facility provided policy titled Advanced Directives Policy and Acknowledgment undated, revealed the following:The facility makes every effort to comply with the end-of-life choices made by competent resident or individual with Medical [NAME] of Attorney. Record review of the OUT-OF-HOSPITAL DO-NOT-RESUSCITATE (OOH-DNR) ORDER-TEXAS DEPARTMENT OF STATE HEALTH SERVICES, revised [DATE] revealed the following:-The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professionals -In addition, the OOH-DNR Order must be signed and dated by two competent adult witnesses, who have witnessed either the competent adult person making his/her signature in section A, or authorized declarant making his/her signature in either section B, C, or E,. -Qualified Witnesses: .One of the witnesses must meet the qualifications in HSC 166.003(2), which requires that at least one of the witnesses not: .be an employee of a health care facility in which the person is a patient if the employee is providing direct patient care to the person or is an officer, director, partner, or business office employee of the health care facility.

Based on observation, interview, and record review the facility failed to ensure residents the right to a safe, clean, comfortable, and homelike environment including clean bed linens for 2 (Resident #12 and Resident #78) of 18 residents reviewed for environment.1. The facility failed to ensure Resident #12 had clean sheets.2. The facility failed to ensure Resident #78 had clean sheets and a clean, sanitary room.These failures could lead to residents feeling neglected and/or to infection control issues.Findings Included:1. Record review of Resident #12's admission record dated 12/03/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to cognitive communication deficit (difficulty with one or more of the following: attention, memory, perception, language, problem-solving, and reasoning), weakness, need for assistance with personal care, and muscle weakness.Record review of Resident #12's quarterly MDS assessment completed on 10/13/25 revealed a BIMS score of 15 which indicated intact cognition.Record review of Resident #12's care plan completed 09/12/25 revealed no mention of refusing or resisting care.Record review of Resident #12's bathing schedule for December 2025 revealed she was bathed on 12/01/25 and on 12/03/25.During an observation on 12/02/25 at 09:27 AM Resident #12 was in her bed with HOB raised to seated position. Her bottom sheet was soiled with greenish and tan splotches near her left shoulder.During an observation on 12/02/25 at 12:25 PM Resident #12 was seated in her bed. Her bottom sheet was soiled in the same place near her left shoulder with the same pattern of greenish and tan splotches as previously observed.During an observation on 12/03/25 at 08:43 AM Resident #12 was seated in her bed. Her bottom sheet was soiled in the same place near her left shoulder with the same pattern of greenish and tan splotches as previously observed. She stated staff change her top sheet nearly every day and change her bottom sheet every 4 days.2. Record review of Resident # 78's admission record dated 12/03/25 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, weakness and need for assistance with personal care.Record review of Resident #78's quarterly MDS assessment completed on 09/09/25 revealed a BIMS score of 15 which indicated intact cognition.Record review of Resident #78's care plan completed on 09/05/25 revealed no mention of refusing or resisting care.Record review of Resident #78's bathing schedule for December of 2025 revealed he received a bath on 12/02/25.During an observation and interview on 12/02/25 at 09:31 AM Resident #78 was seated on the edge of his bed. His bottom sheet was soiled with what appeared to be blood on the upper right side of the bed in splotches that formed two vertical parallel lines. There was a bloody tissue on the floor of his room as well as one on the windowsill of his room. He stated the tissues were from his arm. He gestured to his right upper arm. He stated his arm would not quit bleeding.During an observation on 12/02/25 at 12:02 PM Resident #78 was not in his room. The bloody tissue was still on his windowsill,l and the blood stains were still on his bottom sheet in the same pattern as observed previously.During an interview on 12/02/25 at 03:07 PM Resident #78 was seated in his wheelchair in his room. The bloody tissue was still in his windowsill, and the blood stains were still on his bottom sheet in the same pattern as observed previously. He stated the blood on his sheet was from his upper right arm.During an interview on 12/02/25 at 03:11 PM SNA N stated CNAs and SNAs are responsible for changing resident's sheets. She stated they change them all the time and anytime there are crumbs on the sheets.During an observation and interview on 12/03/25 at 08:45 AM Resident #78 was seated on the edge of his bed eating his breakfast from the bedside table. His bottom sheet was still stained with blood in the pattern observed previously and the bloody tissue was still on his windowsill next to his bed. He stated he did not know when staff changed his sheets or how often they were changed. He stated, Whenever I say so I guess.During an observation on 12/03/25 at 11:03 AM Resident #78 was seated in his wheelchair in his room. His bottom sheet was still stained with blood in the pattern observed previously and the bloody tissue was still on the windowsill.During an interview on 12/04/25 at 08:48 AM ADON B stated nurses and CNAs were responsible for changing resident sheets. She stated the sheets were changed on resident shower days. She stated if the sheets were soiled or if a resident just wanted fresh sheets staff were to change them even if it was not a shower day. She stated every time she and DON and ADON A do an in-service they cover sheet changes. ADON B stated she would expect her staff to remove soiled or bloody sheets as soon as they were noticed, clean the mattress with disinfectant spray, let it dry, and apply clean sheets. She stated a possible negative outcome to residents of having soiled or bloody sheets was their dignity of course.During an interview on 12/04/25 at 09:00 AM CNA J stated nurses and aides were responsible for changing resident's sheets. She stated, We change them as needed and also on each shower day. She stated a resident could get skin breakdown if their sheets were left soiled. She stated, It is not sanitary. She stated she had not noticed any blood on Resident #78's sheets.During an interview on 12/04/25 at 09:13 AM HSK K stated if she saw a bloody tissue in a resident's room she would ask a CNA to pick it up. She stated a possible negative outcome of not removing a bloody tissue from a resident's room was Germs would spread.During an interview on 12/04/25 at 09:15 AM RN F stated nurses and CNAs were responsible for changing resident's sheets. She stated sometimes housekeeping staff assisted with sheet changes. She stated sheets were changed every shower day and anytime there was a spill or other issue. RN F stated if she noticed a resident had soiled or bloody sheets she would change their sheets. She stated a possible negative outcome for a resident having dirty sheets was the resident would not feel taken care of. She stated she had seen a bloody tissue in Resident #78's room one time. She stated she had seen blood on his sheets but he refused to have his sheets changed. She stated he picked his skin and that is where the blood on the sheets came from.During an interview on 12/04/25 at 09:56 AM DON stated nurse aides were responsible for changing resident's sheets. She stated the sheets were changed on shower days. DON stated staff had been trained on changing sheets. She stated she and ADONs did rounds to ensure staff were following their training. DON stated she expected her staff to change sheets if they were soiled or bloody. She stated, Of course it is a dignity issue as well as an infection control issue, it is just the decent thing to do.During an interview on 12/04/25 at 10:31 AM HSK SUP stated he expected his staff to clean floors and surfaces when cleaning resident rooms. He stated his staff occasionally helped change resident's sheets when nursing staff let them know they needed assistance. He stated he expected his staff to throw away bloody tissues found in resident rooms. He stated a possible negative outcome of not throwing away bloody tissues was contamination.During an observation on 12/04/25 at 10:38 AM Resident #78 was seated in his wheelchair in his room. His bottom sheet was still stained with blood in the pattern observed previously.Record review of facility policy titled Resident Rights and dated December 2016 revealed the following: . Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence .Record review of facility policy titled, Quality of Life - Homelike Environment and dated May 2017 revealed the following: . Residents are provided with a safe, clean, comfortable and homelike environment . 1. Staff shall provide person-centered care that emphasizes the residents' comfort . 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary and orderly environment; . e. Clean bed and bath linens .Record review of unnumbered page from the facility's admission packet revealed the following: Statement of Resident Rights You, the resident . have a right to: 1. all care necessary for you to have the highest possible level of health 2. safe, decent and clean conditions .

Based observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights and including measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 (Resident #1 and Resident #24) of 18 residents reviewed for comprehensive care plans.1. The facility failed to include Resident #1's oxygen therapy in her care plan.2. The facility failed to include Resident #24's skin lesion in her care plan.These failures could lead to residents not receiving necessary care and/or treatment or receiving inaccurate care/and or treatment.Findings Included:1. Record review of Resident #1's admission record dated 12/04/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, paroxysmal atrial fibrillation (irregular heartbeat) and generalized anxiety disorder (inability to control constant worrying).Record review of Resident #1's admission MDS completed on 09/02/25 revealed a BIMS score of 5 which indicated severely impaired cognition. In section J Health Conditions Resident #1 was coded as having shortness of breath with exertion, when sitting at rest, and when lying flat. Section O Special Treatments, Procedures, and Programs indicated she was receiving oxygen therapy intermittently On Admission and While a Resident.Record review of Resident #1's care plan dated 08/28/25 revealed no mention of oxygen therapy. She was to be monitored for shortness of breath due to heart disease and for difficulty breathing due to high blood pressure.Record review of Resident #1's orders dated 12/04/25 revealed the following order for oxygen therapy with a start date of 12/04/25: Oxygen Via N/C 1-2 L as needed. Code number of liters actively using every day and night shift related to PAROXYSMAL ATRIAL FIBRILLATION.Record review of Resident #1's struck out, discontinued, and completed orders revealed no order for oxygen therapy.Record review of Resident #1's oxygen saturation record revealed 16 entries since her admission to the facility on [DATE]. She was receiving oxygen via NC for the following 8 of those entries: 08/20/25, 08/22/25, 08/23/25, 08/24/25, 08/28/25, 09/02/25, 09/05/25, 09/07/25. The last date of oxygen saturation measurement as of 12/04/25 was 10/31/25.During an observation on 12/02/25 at 10:41 AM Resident #1 was lying on her back in bed with the head of the bed elevated. Her eyes were closed and she was snoring softly. She was receiving oxygen via N/C at 2 L/Min.During an observation and interview on 12/04/25 at 07:38 AM Resident #1 stated regarding her oxygen, I wear it when I need it. When I'm having trouble breathing. Her oxygen concentrator was beside her bed, and the N/C tubing was inside a plastic bag.During an interview on 12/04/25 at 10:11 AM LVN L stated resident #1 received O2 PRN for tachycardia (abnormal heart rhythm and fast heart rate).During an interview on 12/04/25 at 10:44 AM MDS LVN stated she was responsible for care plans. She stated when Resident #1 came to the facility in August she was receiving oxygen therapy due to a respiratory issue, but it was not currently on her care plan because she was not receiving oxygen therapy any longer. When asked why Resident #1 was observed receiving O2 via N/C on 12/02/25, MDS LVN stated, I don't have it documented anywhere that she (Resident #1) is using it (O2). MDS LVN stated an inaccurate care plan would not affect a resident's care because nobody really pays attention to it (care plan).2. Record review of Resident #24's admission record dated 12/04/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and acute kidney failure (sudden episode of kidney failure that happens in hours or days).Record review of Resident #24's quarterly MDS completed on 11/03/25 revealed a BIMS score of 5 which indicated severely impaired cognition. Section M Skin Conditions revealed Resident #24 had an Open lesion(s) other than ulcers, rashes, cuts (e.g., cancer lesion).Record review of Resident #24's care plan completed 10/09/25 revealed no mention of a lesion or sore.Record review of Resident #24's NP progress note dated 06/04/25 revealed the lesion was biopsied prior to that NP visit and results of the biopsy were pending.Record review of Resident #24's NP progress note dated 08/18/25 revealed the following description of the lesion: . She has a mass on the left side of her cheek that is cancerous. Skin lesion to the face-left side of his [sic] face, I can see a dark color pustular ulcerated lesion (a raised open wound that is crater-like with yellowish pus under the skin), around 1 cm diameter, chronic lesion, no bleeding, no purulence (pus).Record review of Resident #24's progress notes revealed a note dated 11/06/25 when nursing staff contacted Resident #24's family member who is also her power of attorney and discussed the lesion on her face. Her family member was in agreement with treatments but specified that he did not want to do anything that would cause Resident #24 to have more health problems. He requested an email from facility following each of Resident #24's appointments with the oncologist.Record review of the most recent NP progress note dated 11/14/25 revealed Resident #24 would continue to follow up with oncology, but family had decided not to proceed with treatment of the lesion.During an observation on 12/02/25 at 12:28 PM Resident #24 was seated at a table in the dining room. She had a large growth (a circle approximately 2.5 to 3 inches in diameter) on her left cheek between her mouth and her ear.During an observation on 12/02/25 at 01:53 PM Resident #24 was lying in bed. She had a large raised, rough, open area to her left cheek. She stated, regarding the area, It is a bad place, and I want it taken off. I have had it for a while. It is getting bigger, and it seeps.During an interview on 12/04/25 at 08:48 AM ADON B stated a resident having an inaccurate care plan could negatively impact the resident's care.During an interview on 12/04/25 at 09:00 AM CNA J stated a resident's care could be negatively impacted by having an inaccurate care plan in many ways depending on the care the resident required. She stated the care plan included a lot of things we need to know about each resident.During an interview on 12/04/25 at 09:15 AM RN F stated, Honestly, I don't give a rat's ass about a care plan. That is something the state makes us do, we are going to care for them (residents) no matter what and probably do a better job than that care plan.During an interview on 12/04/25 at 09:56 AM DON stated MDS LVN is responsible for care plans. She stated nursing staff contacted MDS LVN when something needed to be added to a care plan. DON stated an inaccurate care plan could result in residents' needs not being met and in correct observations not being done.During an interview on 12/04/25 at 10:44 AM MDS LVN stated she was responsible for care plans. She stated she did not know why she had not included Resident #24's facial lesion in her care plan.Record review of facility policy titled Care Plan - Resident and dated 4-2022 revealed the following: . It is the policy of this home that staff must develop a comprehensive care plan to meet the needs of the resident. Concerns and Problems . Sources are, but not limited to: . 10. All problems identified on all assessments. Remember the resident care plan is the tool used to coordinate all care provided to the resident to be sure care is necessary, appropriate and planned to meet the individual needs of the resident consomant [sic] with the physician's plan of care for the resident. The resident care plan must be kept current at all times.

Based on observation, interview, and record review the facility failed to ensure the resident environment remains as free of accident hazards as is possible for 1 (Resident #11) of 18 residents reviewed for accident hazards.The facility failed to ensure Resident #11 did not have a tube of medicated cream and an aerosol can of sanitizing spray in her room.This failure could lead to harm if a resident was to ingest the cream and/or spray their skin with the sanitizing spray.Findings Included:Record review of Resident #11's admission record dated 12/03/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, cognitive communication deficit (difficulty with one or more of the following: attention, memory, perception, language, problem-solving, and reasoning), COPD (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath, and fatigue), and need for assistance with personal care.Record review of Resident #11's quarterly MDS completed on 11/13/25 revealed a BIMS score of 13 which indicated intact cognition. Section GG Functional Abilities revealed Resident #11 was dependent on staff for toileting; bathing and showering; lower body dressing; footwear application and removal; and for all mobility and tranfers. Section H Bladder and Bowel revealed she was always incontinent of urine and frequently incontinent of bowel. Section J Health Conditions indicated Resident #11 had shortness of breath with exertion, when sitting at rest, and when lying flat.Record review of Resident #11's care plan completed on 11/13/25 revealed no mention of self-administration of medication.Record review of Resident #11's orders revealed no order for the medicated ointment found on her bedside table.During an observation on 12/02/25 at 10:25 AM Resident #11 was in her bed with HOB raised to seated position. She had a can of sanitizing spray on one bedside table and a tube of medicated ointment on the other bedside table.During an observation on 12/03/25 at 08:53 AM the can of sanitizing spray and the tube of medicated ointment were still on the bedside tables in Resident #11's room. She was not in the room.During an interview on 12/04/25 at 08:48 AM ADON B stated residents could not have sanitizing sprays or medicated creams in their rooms. She stated a possible negative outcome was possible ingestion of the medicated cream or sanitizing spray.During an observation and interview on 12/04/25 at 09:09 AM Resident #11 was in her bed with HOB raised to seated position. She stated she used the medicated ointment on her bottom. She stated she used the sanitizing spray to spray in the air when it smells like poop.During an interview on 12/04/25 at 09:15 AM RN F stated residents were not to have sanitizing spray in their rooms. She stated if the resident could demonstrate to her that they knew how and where to apply a medicated cream she was fine with them having one in their room. She stated, If they (residents) are cognitively there and can demonstrate proper use of it (medicated cream) I feel that is their right to have it there. She stated there was one resident who wandered on Resident #11's hall. RN F stated if a wandering resident who was not cognitively intact ingested a medicated ointment it could result in anything from bellyache to convulsions. Here she mimed holding a phone in her left hand up to her ear and said, Poison Control?During an interview on 12/04/25 at 09:56 AM DON stated residents were not to have sanitizing sprays or medicated creams in their rooms. She stated a possible negative outcome was, They could apply it where they wanted it instead of where it needed to go and if a wanderer got into their room they could get ahold of it.During an interview on 12/04/25 at 01:57 PM ADM stated the facility did not have an accident hazards policy but that the environment policy she provided addressed accident hazards.Record review of the label of the sanitizing spray revealed the following: Hazardous to Humans and Domestic Animals. Caution: Avoid contact with skin or clothing. If on skin. Call a poison control center or doctor for treatment advice. Store in original container in areas inaccessible to small children.Record review of the Safety Data Sheet of the sanitizing spray with revision date of 10/15/19 revealed the following: . HAZARD IDENTIFICATION . Compressed Gas WARNING . Contains gas under pressure; may explode if heated .Record review of the label of the medicated ointment revealed the following: Keep out of reach of children. In case of accidental ingestion contact a physician or Poison Control Center immediately. Active ingredients were lanolin, menthol, petrolatum, and zinc oxide.Record review of an unnumbered page of the facility's admission packet revealed the following: Items Not Allowed in Resident Room . Medications: (included all prescription and Over-the-Counter drugs. Any medicated creams or powders. NOTE: A good rule of thumb has been established by the Food and Drug Administration whereby any products labeled Keep out of reach of children or carries any type of caution label is merchandise that contains ingredients which are harmful if taken without supervision or used in a way not designated. Many of our residents, due to mental impairments or poor eyesight might inadvertently drink or eat some of the above items causing irreparable harm. SAFETY HAZARDS: Aerosol cans of any product that are combustible.Record review of facility policy titled, Quality of Life - Homelike Environment and dated May 2017 revealed the policy did not mention accident hazards, but it did state, . Residents are provided a safe.environment.Record review of an unnumbered page in the facility's admission packet revealed the following: Statement of Resident Rights . 2. Safe, decent and clean conditions .

Based on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 (Resident #1) of 5 residents reviewed for respiratory care. -Resident #1 was receiving oxygen with no orders for her therapy. This failure could affect residents by placing them at risk for respiratory compromise and associated complications such as shortness of breath, confusion, respiratory failure, infection, and exacerbation of their condition. Findings included: Record review of Resident #1's face sheet dated 12/02/2025 revealed an [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), dementia (a group of thinking and social symptoms that interferes with daily functioning), generalized anxiety disorder (a mental health disorder characterized by feeling of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and seizures (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain). Record review of Resident #1's admission MDS completed 8/27/2025 listed her with a BIMS of 5 indicating she was severely cognitively impaired, she had a functionality of being dependent on staff for most of her activities of daily living and was listed on oxygen therapy on admission and while a resident. Record review of Resident #1's care plan with admission date 8/20/2025 revealed no care plan for oxygen use. Record review of Resident #1's order summary report printed 12/04/2025 revealed the following: Oxygen via N/C 1-2L as needed. Code number of liters actively using. Every day and night shift related to Paroxysmal Atrial Fibrillation (I48.0). Start Date: 12/04/2025 at 6:30 PM. -No other orders for oxygen therapy noted. Record review of Resident 1's MAR for the following revealed:December 2025 (current)-no documentation of oxygen therapy.August 2025 (admission)- no documentation of oxygen therapy. During an observation on 12/02/2025 at 10:41 AM Resident #1 was sleeping in her bed with the HOB elevated. Resident #1 was snoring softly and wearing her O2 via NC at 2L/min. During an observation and interview on 12/04/2025 at 7:38 AM Resident #1 was in bed under her covers with her HOB elevated. Resident #1 was awake and alert. Noted was her O2 concentrator next to her with her tubing stored in a plastic bag. Resident #1 stated. I wear it when I need it, when I'm having trouble breathing and I'm doing good this morning. Resident #1 was unable to remember how long she had been in the facility but stated she had been using oxygen, a while. During an interview on 12/04/2025 10:11 AM LVN L reviewed Resident #1 chart and reported she could not find an order for Resident #1 oxygen therapy. LVN L reported Resident #1 received oxygen currently PRN and could have oxygen continuously if needed for tachycardia (a heart rate that is too fast, generally over 100 beats per minute at rest, caused by problems with the hearts electrical signals, making it less efficient at pumping blood). LVN L reported that administering a medication such as oxygen without an order was a medication error and can be considered practicing medicine without a license. LVN L reported she was the individual responsible for verifying all orders for this unit and she will need to verify all of Resident #1's orders and charting again to make sure she did not miss anything else. During an interview on 12/04/2025 at 11:07 AM the DON reported she had been made aware they had an issue with Resident #1 not having an order for her oxygen therapy and to her understanding Resident #1 was not receiving the medication for respiratory needs, it was being given for poor cardiac function. The DON reported the nurse who took the order for the oxygen therapy was responsible for writing the order and including it in the resident's chart, but it would be impossible to determine the nurse who took Resident #1's oxygen order because she (Resident #1) had been on it a while. The DON reported that the facility does a quarterly review to ensure all orders and resident needs are being met. The DON reported that if a resident was receiving medication, they did not have an order for, they could have a negative reaction that could affect their condition. Record review of the facility provided policy titled, Oxygen Safety effective 4/2022, revealed the following: Policy:It is the policy of this home to ensure all oxygen administration is conducted in a safe manner.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure refrigerated and freezer items were properly stored, labeled, and dated.This failure could place residents at risk of food-borne illness. Findings included:Observation of the freezer on 09/09/25 at 9:54 AM revealed the following:1. (1) bag of unidentified food, no label or date. 2. (1) opened freezer bag of French fries, no label or date.3. (1) bag of hamburger patties, no label or date.4. (1) bag of hashbrowns, open to air, no label or date. 5. (1) bag of meat, no label or date.6. (1) opened, half-eaten ice cream sandwich, open to air, no label or date.7. (2) clear cups with lids, orange substance inside, no label or date. Observation of the walk-in refrigerator on 09/09/25 at 10:03 AM revealed the following: 1. (1) sealed container of vegetable base, no date or label.2. (6) packages of butter, one opened and in a baggie, no date or label.3. (2) bowls of water containing celery and carrots. No date or label. 4. (1) bowl containing whole onions, peppers, and tomatoes. No date or label.5. (1) box of cucumbers, no date or label. In an interview on 09/09/25 at 10:08 AM, [NAME] A stated he had worked at the facility since January 2025 and everyone was responsible for labeling and dating food. He stated a possible negative outcome for not labeling and dating food could be that residents could get sick and they could serve out of date food. In an interview on 09/09/25 at 10:10 AM, the DM stated he had worked at the facility since April of 2025 and everyone who worked in the kitchen was responsible for labeling and dating food. He stated a possible negative outcome for not doing that could be a resident could become sick or die from food poisoning. In an interview on 09/09/25 at 1:17 PM, [NAME] B stated it was everyone's responsibility to label and date food, that it was a group effort. She stated if food was not labeled or dated, they would not know when the food was brought into the kitchen or when it expired. In an interview on 09/09/25 at 2:59 PM, the ADM stated the facility does not have a policy for labeling and storage of food. In a phone interview on 09/09/25 at 3:16 PM, the RD stated she does in services and trainings on labeling and dating at the facility with employees of the kitchen and a handout should be available in the DM's office, and she also provided it to the ADM.In an interview on 09/09/25 at 3:46 PM, the ADM provided the in-service handout along with signatures of employees who attended the training done by the RD and stated that it was the policy that the kitchen followed. Record review of Dietary In-service, dated 01/30/25, revealed the following information in part:12 employee signatures. 1). Dietary staff will understand the importance of preventing cross contamination by storing food properly.2). Food must be properly stored to prevent contamination and freezer burn by closing all food products in the freezer and properly sealing all opened boxes and containers. a). All items in the freezer must also be dated when received. b). All items when removed from boxers are placed in sealed containers and labeled/dated. c). All items placed in the refrigerator to thaw must be redated with the date into thaw and date out (use by 72 hours). d). All food items prepared in the facility are dated and labeled so that the date of expiration is 72 hours due to serving as high-risk population.

Based on observation, interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices for 1 (Resident #1) of 6 residents reviewed for medical records. The facility failed to document wound care had been completed on 6 days of the previous 90 days that were reviewed. This failure could place all residents at risk of not receiving appropriate care through inadequate documentation possibly resulting in deterioration in condition, exacerbation of disease process, and increased risk of harm or injury.Findings include: Record review of Resident #1's clinical record revealed a [AGE] year-old-female admitted to the facility originally on 07/23/24 and readmitted on [DATE]. Resident #1's current diagnoses include peripheral vascular disease (a circulatory condition in which narrowed blood vessels recue blood flow to the limbs), atherosclerosis of native arteries of extremities (bilateral legs) (a medical condition where plaque builds up in the arteries that supply blood to the limbs), other injury of unspecified body region (graft site from left thigh). Record review of Resident #1's last MDS revealed an annual assessment completed on 07/11/25 with a BIMS of 12 indicating she was moderately cognitively impaired, she had a functional status of being dependent on staff for most of her activities of daily living, and she had 2 venous and arterial ulcers present. Record review of the care plan with admission date of 09/16/24 for Resident #1 revealed the following: Focus:I have Peripheral Vascular DiseaseFocus: Venous/Stasis Ulcer r/t PVD to LLEFocus: Venous/Stasis Ulcer r/t PVD to RLE-Further review revealed there were no interventions related to completion of wound care noted. Record review of Resident #1's physician orders printed 07/15/25 revealed the following orders:- Lt Calf- Cleanse with wound cleanser. Dry. Apply Mupirocin2%, Adaptec, ABD, and cover with ABD. wrap with Kerlix. wrap with Ace bandage. secure with Tetra-Net size 6 very day shift for wound .-Revision Date: 04/23/2025 - Lt Upper Thigh-Cleanse with wound cleanser. Dry. Apply Mupirocin 2%, Adaptec, ABD, and cover with ABD. wrap with Kerlix. secure with tape. every day shift for wound . -Revision Date: 04/23/2025 - Rt Calf- Cleanse with wound cleanser. Dry. Apply Mupirocin2%, Adaptec, ABD, and cover with ABD. wrap with Kerlix. wrap with Ace bandage. secure with Tetra-Net size 6 every day shift for wound . -Revision Date: 04/23/2025 Record review of Resident #1's WAR's from 04/17/2025 through 07/15/2025 (last 90 days) revealed the following: Left calf wound with a revised order for daily wound care started on 04/23/25. Noted no documentation of wound care completed for 04/27.25, 05/02/25, 05/07/25, 05/31/25, 07/04/25, and 07/13/25. Left upper thigh wound with a revised order for daily wound care started on 04/23/25. Noted no documentation of wound care completed for 04/27.25, 05/02/25, 05/07/25, 05/31/25, 07/04/25, and 07/13/25. Right calf wound with a revised order for daily wound care started on 04/23/25. Noted no documentation of wound care completed for 04/27.25, 05/02/25, 05/07/25, 05/31/25, 07/04/25, and 07/13/25. During an observation and interview on 07/15/2025 at 09:03 AM Resident #1 was in her room in her bed. Resident #1 was dressed well and appeared in good condition. Resident #1 reported that she had an issue with LVN C but that she had not received any care from LVN C in quite a while. All other staff have been very good at what they have done. Resident #1 reported that all wounds were doing better to include the graft site on her left upper thigh and both lower leg PVI/venous status ulcer wounds. During an interview on 07/15/2025 at 03:05 PM the DON reviewed Resident #1's WAR record and reported that the dates of 4/27/25, 5/2/25, 5/7/25, 5/31/25, 7/4/25, and 7/13/25 were not documented on the WAR that the wound care had been completed for Resident #1's right calf, left calf, and left upper thigh. The DON reported that she knew the wound care had been done because Resident #1 would always tell her if any of her wound care was missed, and Resident #1 did not report any of those dates. During an interview on 07/15/2025 at 03:56 PM the DON reported that she had talked with LVN B, and he reported that he had completed the wound care for Resident #1 on 04/27/25 and reported that he just did not document it. ADON A completed the wound care on 05/02/25 and ADON A reported that Resident #1's wound care was done but she forgot to document it in the resident records. On 05/07/25 Dr [NAME] was in the facility, performed the wound care, and whoever the staff that was with Dr. E did not document the wound care in Resident #1's records and she (the DON) was not able to determine who that was that day. On 05/31/25 Resident #1 refused wound care for LVN C, but LVN C did not document the refusal and LVN C was currently out of town on vacation and unavailable for contact. On 7/04/25 LVN D completed Resident #1's wound care and reported that she (LVN D) forgot to document that she completed the wound care in Resident #1's chart. On 07/13/25 she (the DON) covered the hall Resident #1 was on, and she could not remember what was done that day but she did know she (the DON) did not document that the wound care was completed since she did not mark the WAR. The DON again stated if the wound care had not been completed Resident #1 would have told her about it. During an interview on 07/15/2025 at 04:08 PM ADON A reported that she missed documenting the wound care that she had performed on Resident #1 on 05/02/25 and stated, I just missed it. I had to many things going on that day. ADON A reported that she did not feel this was an issue and would not affect the residents care since Resident #1 had received her wound care. During an interview on 07/15/2025 at 04:11 PM LVN B reported that he did Resident #1's wound care on 04/27/25 but that he did not document that he had completed the wound care in Resident #1's chart. LVN B stated that if you do not document the care was provided then that don't count. He reported that a resident can be affected if their care was not documented. During an interview on 07/15/2025 at 05:00 PM LVN D stated, I thought I did it, I might have missed the documentation, but the care was done. On 07/04/25 for Resident #1. LVN D reported that if the documentation was not completed then nobody knows that it was completed and the wound could get worse if it really wasn't done, but I did mine that day. During an interview on 07/15/2025 at 04:57 PM the DON reported that she could not find a facility policy on the accuracy of documentation. The DON stated, so I guess we do not have one.

Based on observation, interview, and record review the facility failed to ensure residents were free from misappropriation of property from 1 of 1 (LVN A) nurses reviewed. The facility did not prevent LVN A from taking narcotics from multiple unidentified residents. This failure could place residents at risk of continued misappropriation of property, increased pain, and lost trust in facility staff. Findings include: Resident #1 Record review of Resident #1's face sheet, dated 06/03/2025, revealed a [AGE] year-old male who was admitted to facility on 07/07/2023 with, but not limited to the following diagnosis: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (signs and symptoms of dementia and has a dementia diagnosis, but they lack any symptoms of behavioral disturbances), end stage renal disease (the final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own), infarction without residual deficits (a condition where a patient experiences a stroke due to a lack of blood flow to the brain (ischaemia) but does not exhibit any lasting neurological deficits after the event), depression, unspecified, essential (primary) hypertension (elevated blood pressure), dependence on renal dialysis. Record review of Resident #1's MDS, dated [DATE], revealed that Resident #1 had a BIMS of 14 and a functional capacity of total dependency upon staff in all care areas. Record review of MAR dated May 1-31, 2025, revealed no discrepancies noted. During an interview on 06/03/2025 at 1:02 PM with Resident #1 stated I am supposed to get hydrocodone at midnight and 6am and when that one nurse was still here she (LVN A) would say that she gave them to me, but I know that she did not. Because I know what I take. Resident #1 was able to name off all of his medications and what time he takes them. Resident #1 stated I take medication for my neuropathy in my hands and feet. Resident #1 stated since that one-night nurse (LVN A) had been let go she he had been receiving his medications and doing much better. Resident #2 Record review of Resident #2's face sheet revealed a [AGE] year-old male who was admitted to facility on 01/23/2025 with, but not limited to the following diagnosis: Type 2 diabetes mellitus with ketoacidosis without coma (where a lack of insulin causes harmful substances called ketones to build up in the blood), depression, essential (primary) hypertension (elevated blood pressure), chronic obstructive pulmonary disease (a common lung disease causing restricted airflow and breathing problems), acute kidney failure with tubular necrosis (a common lung disease causing restricted airflow and breathing problems). Record review of Resident #2's MDS, dated [DATE], revealed that Resident #3 had a BIMS of 14 and a functionality of maximal and moderate assistance is required in all care areas. Record review of Resident #2's MARs dated May1-31, 2025 revealed no discrepancies noted. During an interview on 06/03/2025 at 2:30PM Resident #2 stated that he has never gone without pain medication. When he requests it, he receives it. Resident #2 did not have any concerns at time of interview and stated that the staff was very good to him. Resident #3 Record review of Resident #3's face sheet revealed a [AGE] year-old female who was admitted to facility on 07/12/2024 with, but not limited to the following diagnosis: Type 2 diabetes mellitus without complications (where a lack of insulin causes harmful substances called ketones to build up in the blood), mild cognitive impairment of uncertain or unknown etiology (when a person starts to have problems with their memory or thinking), right heart failure due to left heart failure. (LVN A) Record review of Resident #3's MDS, dated [DATE], revealed that Resident #3 had a BIMS of 13 and a functionality of maximal assistance needed in most care areas. Record review of Resident #3's MARs dated May1-31, 2025 revealed no discrepancies noted. During an interview on 06/03/2025 at 2:39PM Resident #3 stated I only get my pain medication when I really, really need it. It is not a scheduled medication, and I don't need it all of the time. Resident #3 stated I can request the medication when I need it. There was one nurse that came into my room and told me that I had asked for it, but I never did, I wasn't sure what she was talking about. During an observation on 06/03/2025 at 12:13pm revealed video evidence dated 05/23/2025, of LVN A opening the medication cart for Hall 400. LVN A opened the narcotic drawer and started to pop out medications out of random residents bubble packs. LVN A popped out what appeared to be approximately 14 pills. In the video it was unclear who the medications belonged to. LVN A then proceeded to take the medications in her hand and then place them in her mouth and consumed them. In the 2nd video dated 05/17/2025 LVN A went to the medication cart for 400 Hall and opened the medication cart and was seen getting in to the Narcotic drawer, LVN A took a medication cup and started to pop out medications from multiple different residents bubble packs. LVN A then placed the medications in her hand and went to speak to an unidentified CNA. LVN A and CNA spoke for an extended amount of time and during that time LVN A placed the medication in her right pocket. When a 2nd unidentified CNA came into view, LVN A proceeded to walk back towards the medication cart, pulled out her cell phone, placed it on the medication cart, and then walked behind a wall that concealed her from the CNA's but not the camera and she proceeded to take the handful of medications and walked to the back side of the nurses station desk while taking a drink from her personal drink. During an interview on 06/03/2025 at 12:13pm ADM stated she did not have any suspicion until it was brought to her attention that Resident #1 was having pain and was not receiving medication for it. ADM stated that is when she started to review video footage and discovered LVN A was taking medications from the residents at the beginning of every shift that she worked. ADM stated that the narcotic counts were never wrong, and she (LVN A) never acted off. ADM stated that the police were called on the day LVN A was interviewed, and a police report was made and provided the incident #25-507802. ADM stated a Narcotic Detective came to the facility on the day of interview and while LVN A was being interviewed a UA drug panel was ran. LVN A came back positive for 12 out of the 15 drugs tested. LVN A was positive for amphetamine, barbiturates, benzodiazepines, buprenorphine, cocaine, marijuana, methadone, methamphetamine, ecstasy, oxycodone, phencyclidine, propoxyphene. During an interview on 06/03/2025 at 12:34pm LVN B stated she had suspicion on missing medications, due to when change of shift narcotic count was performed there were a lot of dropped or wasted medications with no second signature present of a witness nurse or MA. LVN B stated she noticed that residents were running out of medications more often and reported this to the DON. LVN B stated she had received re-education on ANE just in the past couple of days. LVN B stated the negative outcome for the residents not receiving their medication was an increase in pain for the resident and then not being able to provide medications due to it being documented that it had already been given when it had not been. During an observation on 06/03/2025 at 12:48pm of Hall 400 Narcotic log book revealed multiple choked, refused, and dropped narcotics with no 2nd signature for these wastes of medications. LVN A signature was the only signature present at time of incidents. During an interview on 06/03/2025 at 3:53pm ADON stated that LVN A never exhibited any behavior that would spike suspicion. ADON stated she and LVN A had worked the floor together and there was nothing that would have made the ADON suspicious. ADON stated she (ADON) is a part of the hiring process, and nothing came back on any background checks that were performed. On 06/03/2025 at 5:34pm attempted phone interview with Narcotic Detective, had to leave a voicemail with the State investigators phone number for officer to call back. No return call received. On 06/03/2025 at 5:46pm attempted phone interview with alleged perpetrator (LVN A), had to leave a voicemail with the State investigators contact information to call back. No return call received. During an interview on 06/03/2025 at 6:34pm LVN C stated she started noticing that she was having to order narcotics more frequently and thought that it was weird that these residents were going through meds so quickly. LVN C stated the negative outcome for residents was that the residents were complaining of pain and LVN C could not provide any pain medication due to it appearing to have been given already. During an interview on 06/04/2025 at 10:30am DON stated the negative outcome for residents would be that they would have an increase in pain, and lack of trust for the nursing staff. DON did state she was still performing re-education with nursing staff as they come in for their shifts. Inservices were stated on 05/29/2025, inservices included ANE, Quality of Care, signing out narcotics, medication administration, HIPPA, medicaid/medicare fraud, pharmacy. Record review of facility provided policy, titled, Abuse/Neglect, revised 11/15/2016, revealed the following: .9. Misappropriation of resident property: means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen observed for food storage, preparation, and distribution. Cooks C, D, and E failed to perform hand hygiene appropriately when preparing foods. This failure could place residents who ate food served by the kitchen at risk of food-borne illness from cross-contamination. Findings included: In an observation and interview on 9/30/24 at 11:30 am, [NAME] C was observed washing hands and putting gloves on. [NAME] C touched various kitchen surfaces in the kitchen. [NAME] C touched the prep counter, picked up a bag of ham chunks, attempted to open the bag, put the bag on the counter, and went to another area of the kitchen. [NAME] C opened the drawers in the kitchen and closed them then went to a different area of the kitchen, picked up the scissors and walked back to the preparation table. [NAME] C cut the bag of ham chunks open, then took disposable individual plastic serving cups and lids out of the packages. [NAME] C arranged the disposable individual serving cups in a line and picked up the bag of ham. [NAME] C attempted to pour the ham into the serving cups. [NAME] C then put her gloved hand inside the bag of ham chunks and took a handful of ham out and placed the ham into the individual serving cups. [NAME] C reached into the bag again with her gloved hand and filled more containers with ham. [NAME] C was asked if she realized she had changed tasks and had touched various kitchen surfaces then touched the food with contaminated hands. [NAME] C said, I forgot to change my gloves? [NAME] C continued to pick up ham with her gloved hand and place ham into the container cups. [NAME] C then picked up a pen and began making labels for the ham. [NAME] C snapped lids on the cups and carried the cups of ham to the salad bar in the dining room. In an observation and interview on 9/30 /24 at 11:55 am, [NAME] E was observed in the kitchen preparing dessert cups for the noon meal. [NAME] E was observed washing hands and putting on fresh gloves. [NAME] E touched various kitchen surfaces. [NAME] E touched the pans of desserts on the edges of the pan. [NAME] E picked up a knife and cut the dessert into slices touching the edges of the pan to turn it around. [NAME] E placed dessert cups onto the preparation table and unstacked the dessert cups. [NAME] E began plating the dessert and while attempting to put the dessert into the dessert cups with her spatula, [NAME] E used her gloved hand to swipe the dessert off the spatula into the dessert cup. [NAME] E was also observed using her gloved hand to push the dessert down into the dessert cups. [NAME] E said, So do I need to wash and change my gloves? [NAME] E stated she was not aware she had touched the food with her gloved hands. She stated she should have used a serving spoon to plate the dessert and should not have touched the desserts. She stated residents could get sick from contaminated food. In an observation and interview on 9/30/24 at 12:30 pm, [NAME] D washed his hands and changed his gloves. [NAME] D touched various kitchen surfaces then picked up a plate and a serving utensil. [NAME] D plated two enchiladas and used his fingers to push the enchiladas onto the plate off the serving spatula. [NAME] D picked up a plate cover, placed the plate cover on the plate then picked up a clean plate. [NAME] D picked up the serving spatula and placed 2 enchiladas on the plate. [NAME] D used his fingers to push the enchiladas off the serving spatula onto the plate. [NAME] D stated he should not have touched the food with his hand and should have washed his hands and changed his gloves. He stated not changing gloves and touching food could cause food borne illness to the residents. During an observation and interview on 9/30/24 at 12:25 am, [NAME] C was observed touching the prep table and various kitchen surfaces while cutting the lunch dessert into squares. [NAME] C touched the edges of the dessert pans, the serving utensils and various surfaces in the kitchen. [NAME] C was observed getting dessert cups from the shelf and went back to the prep table. [NAME] C picked up dessert cups and placed them on a serving tray in single order filling up the tray. [NAME] C picked up the serving cups and one by one began filling the cups with the dessert. [NAME] C began using her hands to push the dessert into the cups and used her hands to scoop up the dessert out of the pan into the dessert cups. [NAME] C did not change her gloves or wash her hands during this task. During an interview on 9/30/24 at 2:50 pm, the DM stated she was responsible for training staff in all kitchen areas. She stated she does frequent reminders about washing hands and changing gloves. The DM stated she was aware Cooks C, D, and E did not wash their hands or change gloves between tasks. The DM stated they should have washed their hands and changed their gloves when switching tasks. She stated all kitchen staff should have used utensils to serve and prepare the food and should not have touched the food with their hands. The DM stated not changing gloves and washing hands could cause food borne illness. The DM stated she trained the staff in hand washing techniques and glove use. Record review of an undated facility policy titled, Dietary Department Glove Standard Protocol, revealed, in part: there will be no bare hand to food contact in the kitchen. Use of tongs, spatulas, or deli tissue paper will be used whenever possible to avoid touching a ready to eat food item with a bare hand. If a glove must be used, hands will be washed prior to putting on the glove and immediately after removing it. Gloved hands are considered a food contact surface that can get contaminated. Failure to change gloves can contribute to cross contamination. 46534

Based on observations, interviews, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical well-being for 1 of 7 staff (RN J) reviewed for nursing services. The facility failed to ensure the following: -RN J used proper hand hygiene when administering medications -RN J observed resident consume their medications at time of administration. -RN J used proper hand hygiene while assisting an unidentified resident with eating their midday meal. -RN J locked and secured medication cart during medication administration. -RN J used proper hand hygiene or donning of gloves before breaking a pill with her hands for Resident #57. This facility's failure placed residents receiving medications at risk for drug diversion, drug overdose, and decrease efficacy of medications. These failures could expose residents to a risk of contracting viral infections, secondary infections and other communicable diseases. Findings included: Observation on 09/30/24 at 08:35 AM revealed the medication cart on Hall 100 unlocked and unattended. Observation on 09/30/24 at 08:37 AM RN J came out of Resident #57's room and took the medication cart further down the hall. Observation on 09/30/24 at 08:39 AM revealed Resident #57 was lying on her back with her eyes closed, and a medication cup was observed on Resident #57's bedside table with several medications in it. Resident #57 opened her eyes and was asked if this was a regular occurrence with the medications just being left on her bedside table, Resident #57 stated that it was not, and she was really not sure why it happened today. Observation on 09/30/24 at 08:45 AM revealed Resident #10 with a medication cup on her breakfast tray with medications in it. When Resident #10 was asked why medications weren't taken with the nurse, Resident #10 stated because she can't take it with water and will put the pills in her oatmeal. Interview on 09/30/24 at 08:53 AM with CNA L who was working Hall 100 stated that the leaving of medications has been observed by her a few times. CNA L stated, It isn't supposed to, but yes it does happen regularly with this nurse and another nurse. CNA L stated that the negative outcome could be that another resident could get a hold of the medications. Observation on 09/30/24 at 12:12 PM of RN J assisting unidentified resident with her mid-day meal. RN J took her left thumb and scooped some of the unidentified resident's food back on to the plate of resident. RN J then proceeded to lick her thumb and continued to feed the unidentified resident. No hand hygiene was performed before, during, or after the assistance with the meal. Observation on 10/01/24 at 09:18 AM RN J came to room and provided Resident #57 with her medications. Resident #57 asked RN J to break a pill for her. RN J grabbed pill from resident and broke pill with bare hands. No gloves and hand washing took place before breaking pill for resident. Interview on 10/01/24 at 09:22 AM with Resident #57 was asked if the staff normally stayed in the room with her when she was taking her medication and she stated, Most of the time. Interview on 10/01/24 at 01:50 PM with RN J stated that a negative outcome for leaving the medication cart unlocked and unattended could be that someone could get into it. Interview on 10/01/24 at 01:51 PM with RN J stated that a negative outcome for leaving pills on the bedside table would be that someone else could get a hold of those pills. Interview on 10/01/24 at 2:11 PM with ADM stated that there was not a policy regarding the security of Medication carts. Interview on 10/02/24 at 10:44 AM with ADON stated that the negative outcome of having an incompetent nurse was it could lead to medication errors, inaccurate assessments and the overall care for residents could be lacking. Interview on 10/02/24 at 02:09 PM with DON stated that a negative outcome for having an incompetent nurse could lead to injury to resident, medication errors, and documentation errors. Record review of the facility in-service dated 03/13/2024 regarding medication carts, HIPPA, abuse and neglect, infection control, and meds at bedside. RN J did attend this in-service, signature was present on sign-in sheet. Record review of facility in-service dated 06/20/2024 regarding medication administration, med carts, med rooms, meds aat bedside, shower cabinets, disposal of razors, closets, narcotic waste documentation. RN J did attend this in-service, signature was present on sign-in sheet. Record review of RN J's coaching form, undated, revealed that coaching and re-education was provided on the following areas of concerns: 1. Medication cart will always be locked when out of sight of nurse. 2. No further medications will be left sitting on bedside tables, nurses will hand resident medication and stad by to ensure resident takes medication. 3. No further setting up medications prior to giving. 4. Review in 30 days. Dates of occurrences that these concerns were noted were June 18th, 25th, and July 8th, 2024. Record review of personal file for RN J, revealed an Employee Disciplinary Review for RN J, dated 07/26/2024 revealed that on Various dates the medication cart was left unlocked. Record review of personal file for RN J, revealed an Employee Disciplinary Review for RN J, dated 10/01/2024 revealed that RN J was terminated from the facility due to multiple disciplinary reports. Record review of the facility provided policy titled, Competency of Nursing Staff, revised October 2017, revealed the following: Policy Statement 1. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by State law. 2. In addition, licensed nurses and nursing assistants employed (or contracted) by the facility will: a. participate in a facility-specific, competency-based staff development and training program; and b. demonstrate specific competencies and skill sets deemed necessary to care for the needs of resident, as identified through resident assessments and described in the plans of care. .4. Competency in skills and techniques necessary to care for residents' need includes but is not limited to competencies in areas such as: . .f. basic nursing skills; . .i. medication management; . .k. Infection control; . Record review of the facility provided policy titled, Hand Washing, undated, revealed no mention of when the appropriate times to perform hand hygiene would be. Record review of the facility provided policy titled, Crushing Medications, revised April 2007, revealed the following: .4. If a partial tablet is ordered, the nurse should break the tablet on the scored line. Hands must be cleaned before breaking the tablet. The other half tablet is to be discarded. (Note: The Vendor Pharmacist may be contacted to provide the half-tablet doses, thus eliminating the need for the nurse to split the tablets in half.) Record review of the facility provided policy titled, Storage of Medications, revised April 2007, revealed the following: .7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerator, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. .22. Staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable.

Based on observations, interviews, and record review, it was determined the facility failed to ensure drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 (Hall 100 medication cart and Hall 400 medication cart) of 3 medication carts reviewed for medication storage. -Hall 100 medication cart left unlocked and unattended. -Hall 100 medication cart revealed 4.5 lose pills in the bottom of medication drawers. -Hall 100 medication cart had insulin for Resident #41 with no open date on her Humulin N insulin. -Medication was left on beside table for Resident #57 by RN J -Medication was left on beside table for Resident #10 by RN J -Medication was left on bedside table for Resident #7 by LVN F -Hall 400 medication cart revealed expired control solutions for calibration of the glucometer machine. The facility's failure placed residents receiving medication at risk for drug diversion, drug overdose, and accidental or intentional administration to the wrong resident. Findings included: Observation on 09/30/24 at 08:35 AM revealed the medication cart on Hall 100 unlocked and unattended. Observation on 09/30/24 at 08:39 AM revealed Resident #57 was lying on her back with her eyes closed, and a medication cup was observed on Resident #57's bedside table with several medications in it. Resident #57 opened her eyes and was asked if this was a regular occurrence with the medications just being left on her bedside table, Resident #57 stated that it was not, and she was really not sure why it happened today. Observation on 09/30/24 at 08:45 AM revealed Resident #10 with a medication cup on her breakfast tray with medications in it. When Resident #10 was asked why medications weren't taken with the nurse, Resident #10 stated because she can't take it with water and will put the pills in her oatmeal. In an interview on 09/30/24 at 08:53 AM with CNA L who was working Hall 100 stated that the leaving of medications has been observed by her a few times. CNA L stated, It isn't supposed to, but yes it does happen regularly with this nurse and another nurse. CNA L stated that the negative outcome could be that another resident could get a hold of the medications. Observation on 09/30/24 at 09:31 AM revealed Resident #7 with a medication cup on her bed side table and several medication cups stacked on the nightstand. Resident #7 stated staff leave meds with her 60-75% of the time to take on her own. Resident #7 stated staff did not do that when she first got here. Observation on 09/30/24 at 09:37 AM revealed 4.5 lose pills found in the drawers of Hall 100 medication cart. 1 pill identified as Lorazepam 0.5mg was discovered in the Narcotic lock box. All other pills were unidentified by RN J. Insulin for Resident #41's Humulin N did not have an open date on it. According to manufacturer insert it should be discarded after 31 days of opening. In an interview on 09/30/24 at 09:40 AM with RN J, she was asked what the process was when medications are found in the medication cart. RN J stated that she takes them to her DON. RN J then took pills to the DON's office. In an interview on 09/30/24 at 09:51 AM with DON stated that the medications would be reconciled with the Narc count. DON asked RN J if the count was correct this morning. RN stated that it was. The count was confirmed and accurate. The Resident that the medication belonged to passed away last week. DON stated that nurses were responsible for the order and cleanliness of the carts that were use. In an interview on 09/30/24 at 09:55 AM RN J stated that a negative outcome for lose medications in the medication carts would be that someone was missing a medication and with the Lorazepam it could lead to increased anxiety for the resident. Observation on 09/30/24 at 10:05 AM revealed a blood glucose control solution that was dated 07/27/2023 in Hall 400 medication cart. LVN F was asked if this was used today. LVN F stated that it was used this morning to calibrate the glucometer for the day. In an interview on 09/30/24 at 10:16 AM LVN F was asked what a negative outcome was for using controls that were expired. LVN F stated that the reading could be too high or too low for the calibration. In an interview on 09/30/24 at 12:10 PM Resident #7 stated when staff left her pills with her she originally thought they were trusting her but now she thinks they were being lazy because it would not take long to stand and watch me swallow them. And there are people in here who have poor memory and I don't think it is safe for them. In an interview on 10/02/24 at 10:44 AM with ADON stated that the negative outcome for leaving the medication cart unlocked was We do have residents that wander both with and without dementia and they could get a hold of the medications in the carts. ADON stated that the negative outcome for leaving medications at the bedside was the resident could choke, hoard them for later and the medications would not be effective or therapeutic. ADON stated that the negative outcome for having lose medications and expired medications was that residents could go without a dose of medications which could lead to medication errors. The expired medications would not be effective. In an interview on 10/02/24 at 02:09 PM with DON stated that a negative outcome for leaving the medication cart unlocked was other residents or individuals could walk by and get into the cart. DON proceeded to give the negative outcome for having medications left at bedside could lead to the wrong person taking the medications and the resident choking on the medication. DON stated that the undated medications could not be effective because it could be out of date. In regard to the lose pills it could lead to a medication error and a missed dose for the resident. Record review of the facility provided policy titled, Storage of Medications, revised April 2007, revealed the following: .4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. .7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerator, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. Record review of the facility provided policy titled, Administering Medications, revised December 2012, revealed the following: .9. The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container. .16. During administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of communication diseases and infections for 3 (Resident #15, Resident #22, and Resident #57) of 17 Residents. The facility failed to ensure the following: -RN J used proper hand hygiene while assisting an unidentified resident with eating their midday meal. -RN J used hand hygiene and donning of gloves before breaking a pill with her hands for Resident #57. -CNA H perform hand hygiene during incontinent care of Resident #15. -CNA I perform hand hygiene during incontinent care of Resident #22. These failures had the potential to affect residents in the facility by placing them at risk of contracting, spreading, and/or exposing them to bacterial or viral infections that could lead to the spread of communicable diseases. Findings included: Observation on 09/30/24 at 12:12 PM of RN J assisting unidentified resident with her mid-day meal. RN J took her left thumb and scooped some of the unidentified resident's food back on to the plate of resident. RN J then proceeded to lick her thumb and continued to feed the unidentified resident. No hand hygiene was performed before, during, or after the assistance with the meal. Observation on 10/01/24 at 09:18 AM RN J came to room and provided Resident #57 with her medications. Resident #57 asked RN J to break a pill for her. RN J grabbed pill from resident and broke the pill with bare hands. No gloves or hand washing took place before breaking the pill for the resident. Observation on 10/01/24 at 01:45 PM of incontinent care for Resident #22 performed by CNA H and CNA I. Both CNA's performed hand hygiene before starting incontinent care with foley catheter care for Resident #22. CNA I was the primary and cleaned Resident #22 in an appropriate manner, clean to dirty. When CNA I went to change her gloves, she did not perform hand hygiene and donned new gloves and concluded catheter care and incontinent care for Resident #22. Hand hygiene was performed after the resident was placed into a comfortable position. Observation on 10/01/24 at 02:29 PM of incontinent care for Resident #15 performed by CNA H and CNA G. Both CNA's performed hand hygiene before starting foley catheter and incontinent care for Resident #15. CNA H was the primary and cleaned Resident #15 in an appropriate manner, clean to dirty. However, when Resident #15 was turned to the right side so that her buttocks could be cleaned CNA H still had soiled gloves on and proceeded to touch Resident #15's skin to assist CNA G in the turning process. CNA H proceeded to clean the backside of Resident #15, CNA H changed her gloves, but did not perform hand hygiene, and then proceeded to place the resident in a comfortable position. Hand hygiene was performed after the resident was covered and the room was being cleaned by CNA H and CNA G. Interview on 10/01/24 at 02:42 PM with CNA I stated that a negative outcome for not performing hand hygiene when glove changes took place could lead to cross contamination and infection for the resident. Interview on 10/01/24 02:46 PM with CNA H stated that a negative outcome for not performing hand hygiene when glove changes take place could lead to cross contamination. Interview on 10/02/24 at 10:44 AM with ADON stated that the negative outcome of not washing hands during incontinent care could lead to cross contamination between one resident and another. Interview on 10/02/24 at 02:09 PM with DON stated that the negative outcome for not washing hands during incontinent care could lead to cross contamination and a risk for increased infection. Record review of the facility provided policy titled, Incontinent Care/Perineal Care with or without a Catheter, dated 12/2017 revealed the following: Policy It is the policy of this home to provide incontinent care to residents in a manner which provides privacy, promotes dignity, and ensures not cross contamination. .3. If resident is heavily soiled with feces, turn resident on side and clean away feces with tissue, wipes, or incontinent brief. Discard soiled gloves along with the soiled brief and/or wipes. Cover resident, provide safety measures and wash hands with soap and water. 4. Cover resident with sheet or bath blanket. Raise cover to expose perineum. 5. Sanitize hands and put on gloves 6. Proceed with perineal care.

Based on observations, interviews, and record reviews, it was determined the facility failed to ensure each resident was provided the right to a dignified existence, self-determination, for 1 of 20 residents reviewed for Resident rights (Resident #15). -The facility failed to provide dignity and respect for Resident #15 by providing a privacy bag for her foley catheter. The facility's failure to ensure that each resident was treated with respect, dignity, and care in a manner that protects and promotes the rights of the residents. Findings included: Resident #15: Record review of Resident #15's clinical record, dated 10/02/2024, revealed that Resident #15 is a [AGE] year-old woman who was admitted to the facility on [DATE], with diagnosis to include type 2 diabetes mellitus without complications, mild cognitive impairment of uncertain or unknown etiology, pancreatic tumors, low potassium, depression, high blood pressure, asthma, perforation of intestine, retention of urine, history of blood clots, and stroke. Record review of Resident #15's most recent MDS assessment, dated 09/05/2024, revealed Resident #15's BIMS score was 14 out of 15, indicating no cognitive impairment and had a functionality of supervision and touch assistance. An observation on 10/01/24 at 02:29 PM of Resident #15 receiving incontinent care from CNA H and CNA G. Resident #15's foley catheter bag did not have a privacy bag. An interview on 10/02/24 at 10:44 AM with ADON, stated that a negative outcome for not having a cover on a foley catheter bag was, well 1st thing is the dignity thing, then the bag could touch the ground and now we have an infection issue. An interview on 10/02/24 at 02:09 PM with DON, stated that a negative outcome for not having a cover over Resident #15's foley catheter bag could be if the patient is alert they could have some humiliation from it. The bag could get pulled or fall to the floor. Record review of the facility provided policy titled, Resident Rights, revised December 2016, revealed the following: Policy Statement Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Record review of policy for Dignity, dated revised February 2021, states: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation 1. Residents are treated with dignity and respect at all times. 2. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay . 11. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; Record review of the facility provided policy titled, Texas State [NAME] of Rights of the Elderly, undated, revealed the following: In addition to other rights an elderly individual has, as a citizen, rights provided by this section. .3. An elderly individual should be treated with respect, consideration, and in recognition of the individual's dignity and individuality. An elderly individual should receive personal care and private treatment. Record review of the facility provided policy titled, Incontinent Care/Perineal Care with or without a Catheter, dated 12/2017 reveals no mention of a foley catheter bag privacy cover for residents indwelling foley catheters.

Based on interviews, and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 1 (Resident #10) of 20 residents reviewed for advanced directives. Resident #10 had a DNR in her record with no date for the physician signature. The facility's failure to ensure accuracy of resident medical records for advanced directives such as a DNR (Do Not Resuscitate), recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care could place residents a risk for not receiving healthcare as per their or their legal representatives wishes. Findings included: Resident #10 Record review of the clinical record dated 10/01/2024, for Resident #10 revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease with (acute) exacerbation, sleep apnea, lack of coordination, weakness, anemia, type 2 diabetes mellitus with elevated blood sugar, elevated calcium levels in the blood, and heart failure. Record review of the clinical record for Resident #10 revealed the last MDS dated [DATE] with a BIMS score of 12 indicting she was moderately cognitively impaired and a functional status indicating she required maximal assistance with the majority of activities. Record review revealed a DNR in Resident #10's clinical record dated 01/02/2024 with no date of signature by the physician in the Physician Statement section. An interview on 10/02/24 at 10:44 AM with ADON revealed that a negative outcome for not having the DNR dated makes the DNR not applicable and the resident would receive a full code and then we are in trouble. An interview on 10/02/24 at 02:09 PM with DON revealed that a negative outcome of not having the DNR dated essentially makes the form void, and we would not follow the final wishes of that resident. Record review of the facility provided policy titled ADVANCED DIRECTIVE GLOSSARY OF TERMS undated, revealed no information on the necessary signatures or/and dates on which the document would need to be valid. Record review of facility provided policy titled, Texas State [NAME] of Rights of the Elderly, undated, revealed the following: In addition to other rights an elderly individual has, as a citizen, rights provided by this section. .3. An elderly individual should be treated with respect, consideration, and in recognition of the individual's dignity and individuality. An elderly individual should receive personal care and private treatment. .13. An elderly individual may participate in planning the individual's total care and medical treatment.

Based on observation, interview, and record review the facility failed 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 and nursing needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #50) of 19 residents reviewed for care plans. The facility failed to update the wound care orders in Resident #50's care plan. This failure could put residents at risk of not receiving necessary care and treatment. Findings included: Record review of Resident #50's admission record dated 10/01/24 revealed a [AGE] year-old male originally admitted to the facility on [DATE] with diagnoses that included, but were not limited to, peripheral vascular disease (blood circulation disorder), type 2 diabetes (insufficient production of insulin, causing high blood sugar), acquired absence of left leg below the knee, and acquired absence of right leg below knee. Record review of Resident #50's quarterly MDS completed on 09/13/24 revealed he had a BIMS of 15 which indicated intact cognition. Record review of Resident #50's active orders revealed the following wound treatment order for his left leg amputation site with a start date of 08/21/24: Left BKA. Please soak with [brand name of wound cleanser] for 30 minutes prior to dressing change. Place [brand name of gauze used to promote wound healing] into wound bed then apply a thin layer of [brand name of antibiotic cream] to [brand name of absorbent dressing that helps with wound healing] cut to fit wound and apply. Cover with [absorbent pad] and secure with tape. Wrap localluwith (type-o for locally with) [brand name for sponge gauze bandage] and [brand name for stretchy self-adhering wrap] secure with [brand name for elastic spiderweb-like bandage]. Every day shift every Mon, Wed, Fri for Left BKA. Record review of Resident #50's discontinued orders revealed the following wound treatment order for his left leg amputation site with a start date of 07/18/24 and an end date of 08/21/24: Left BKA. Clean wounds with normal saline or wound cleanser and gauze. Skin prep to peri-wound and with [brand name of adhesive layer spread across foam dressing, used with wound vac]. Place [brand name of gauze that promotes wound healing] into wound bed then pack with black [brand name of very open pore foam used in wound healing especially with a wound vac] and cover with [brand name of adhesive layer spread across foam dressing, used with wound vac]. Bumper pad under suction port and cover with [brand name of adhesive layer spread across foam dressing, used with wound vac]. Wound Vac continuous suction at 125 mmHG. Then wrap locally with [brand name for sponge gauze bandage] and [brand name for stretchy self-adhering wrap] with very light compression. Secure with [brand name for elastic spiderweb-like bandage]. every day shift every Mon, Wed, Fri for Left BKA Record review of Resident #50's care plan dated 09/03/24 revealed the following: . I have actual impairment to skin integrity r/t BKA I will have no complications r/t surgical wound through the review date. Left BKA. Clean wounds with normal saline or wound cleanser and gauze. Skin prep to periwound and with [brand name of adhesive layer spread across foam dressing, used with wound vac]. Place [brand name of gauze used to promote wound healing] into wound bed then pack with black [brand name of very open pore foam used in wound healing especially with a wound vac] and cover with with [brand name of adhesive layer spread across foam dressing, used with wound vac]. Bumper pad under suction port and cover with [brand name of adhesive layer spread over foam dressing used with wound vac]. Wound Vac continuous suction at 125 mmHG. Then wrap locally with [brand name for sponge gauze bandage] and [brand name for stretchy self-adhering wrap] with very light compression. Secure with [brand name for elastic spiderweb-like bandage]. No mention was made of the new wound treatment order with start date of 08/21/24. During an observation and interview on 09/30/24 at 10:01 AM Resident #50 was seated in his w/c in his room. He stated staff do not change the bandage on his left leg amputation as often as ordered. During an observation and interview on 10/02/24 at 08:54 AM MDS LVN stated she was responsible for resident care plans. She stated when a resident received new orders she put them in (the care plan) the very next day. She stated there was a report she could run from PCC that would tell her each day what orders were new for which residents. MDS LVN stated, I run the report and see what orders were changed and I put them all into the care plans. When asked why the orders for Resident #50's wound care were not updated in his care plan she looked in PCC and said, I do see where it changed and I might have just overlooked this one. She stated a possible negative outcome of not having the orders in the care plan updated was, We don't have treatment properly documented. During an interview on 10/202/24 at 01:01 PM DON stated not documenting changed orders for Resident #50's wound care in his care plan could prolong his healing process and provide potential for more injury to the wound and of course infection. During an interview on 10/02/24 at 01:27 PM ADON B stated a possible negative outcome of not having a resident's orders updated in the care plan was, Treatment won't match. During an interview on 10/02/24 at 01:44 PM ADON A stated I need the care plan to match the orders. She said a possible negative outcome of not updating a resident's care plan with new orders was staff could not look at the care plan and know what is going on. Record review of facility policy titled Care Plans, Comprehensive Person-Centered and dated December 2016 revealed the following: . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: . g. Receive the services and/or items included in the plan of care; . 8. The comprehensive, person-centered care plan will: . b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; . 13. Assessments of residents are ongoing and care plans are revised as information about the resident and the residents' conditions change.

Based observation, interview, and record review the facility failed to, based on the comprehensive assessment of a resident, ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive, person-centered care plan, and the resident's choices for 1 (Resident # 50) of 20 residents reviewed for quality of care. The facility failed to provide wound care for Resident #50 as ordered. This failure could place residents at risk of poor healing, worsening infection, and increased pain. Findings Included: Record review of Resident #50's admission record dated 10/01/24 revealed a [AGE] year-old male originally admitted to the facility on [DATE] with diagnoses that included, but were not limited to, peripheral vascular disease (blood circulation disorder), type 2 diabetes (insufficient production of insulin, causing high blood sugar), acquired absence of left leg below the knee, and acquired absence of right leg below knee. Record review of Resident #50's quarterly MDS completed on 09/13/24 revealed he had a BIMS of 15 which indicated intact cognition. Record review of Resident #50's care plan dated 09/03/24 revealed the following: . I have actual impairment to skin integrity r/t BKA I will have no complications r/t surgical wound through the review date. Left BKA. Clean wounds with normal saline or wound cleanser and gauze. Skin prep to periwound and with [brand name of adhesive layer spread across foam dressing, used with wound vac]. Place [brand name of gauze used to promote wound healing] into wound bed then pack with black [brand name of very open pore foam used in wound healing especially with a wound vac] and cover with with [brand name of adhesive layer spread across foam dressing, used with wound vac]. Bumper pad under suction port and cover with [brand name of adhesive layer spread over foam dressing used with wound vac]. Wound Vac continuous suction at 125 mmHG. Then wrap locally with [brand name for sponge gauze bandage] and [brand name for stretchy self-adhering wrap] with very light compression. Secure with [brand name for elastic spiderweb-like bandage]. No mention was made of the new wound treatment order with start date of 08/21/24. Record review of Resident #50's quarterly MDS completed on 09/13/24 revealed he had a BIMS of 15 which indicated intact cognition. Record review of Resident #50's active orders revealed the following wound treatment order for his left leg amputation site with a start date of 08/21/24: Left BKA. Please soak with [brand name of wound cleanser] for 30 minutes prior to dressing change. Place [brand name of gauze used to promote wound healing] into wound bed then apply a thin layer of [brand name of antibiotic cream] to [brand name of absorbent dressing that helps with wound healing] cut to fit wound and apply. Cover with [absorbent pad] and secure with tape. Wrap localluwith (type-o for locally with) [brand name for sponge gauze bandage] and [brand name for stretchy self-adhering wrap] secure with [brand name for elastic spiderweb-like bandage]. Every day shift every Mon, Wed, Fri for Left BKA. Record review of Resident #50's TAR for the month of September 2024 revealed he did not receive wound care on Friday 09/13/24 or Wednesday 09/18/24. Record review of Resident #50's progress notes from 09/01/24 to 10/01/24 revealed no mention of Resident #50 having an appointment outside the facility on 09/13/24 or 09/18/24. There was one progress note on 09/13/24 and it did not pertain to wound care. There were no progress notes on 09/18/24. Record review of the dashboard (first page that opens for facility, where resident appointments were often documented, according to staff interviews below) in PCC from 03/01/24-10/02/24 revealed no appointment scheduled for Resident #50 on 09/13/24 or 09/18/24. During an observation and interview on 09/30/24 at 10:01 AM Resident #50 was seated in his w/c in his room. He stated staff do not change the bandage on his left leg amputation as often as ordered. During an interview on 10/02/24 at 08:27 AM DON stated the day nurse on duty on 09/13/24 was LVN F and the day nurse on duty on 09/18/24 was LVN M. During an interview on 10/02/24 at 08:50 AM LVN F stated ADON A was responsible for Resident #50's wound care on 09/13/24 because he was unhappy with her (LVN F). LVN F stated she found Resident #50 vaping in his room and his vape paraphernalia was taken from him; therefore, he was angry with her and ADON A took over wound care for a period. She stated a possible negative outcome of not providing wound care as ordered was the wound could get infected or get worse. During an observation and interview on 10/02/24 at 08:57 AM LVN F stated she remembered Resident #50 had appointments on 09/13/24 and did not return to the facility until 04:30 PM. She stated she remembered ADON A coming down the hall multiple times looking for Resident #50 to provide his wound care. When asked if she was certain the date she was remembering was 09/13/24, LVN F said she was certain. When asked if Resident #50's appointments and ADON A looking for Resident #50 on 09/13/24 were documented anywhere in his medical record LVN F stated she knew she documented that day. She sat down at a computer and began searching through progress notes for Resident #50 as well as through the dashboard of PCC where she stated sometimes resident's appointments were documented. She searched for approximately 4 minutes and concluded, I know I remember writing it down, maybe that was another day. She stated she was unable to find an appointment for Resident #50 noted on the dashboard in PCC. She stated nurses documented appointments in PCC most of the time. She continued, I know there was one day, it has to be that day (09/13/24) what she (ADON A) kept looking for him (Resident #50) so she could do it (wound care) and he was gone to an appointment, but I can't find anything in here (EHR). During an interview on 10/02/24 at 01:01 PM DON stated charge nurses were responsible for wound care. She stated Resident #50 was so unkind to our charge nurses that she had ADON A start doing his wound care, but the floor nurses were responsible to ensure it was performed. DON stated a possible negative outcome of not doing wound care as ordered was infection and a prolonged healing process. She stated if wound care was not performed as ordered the resident would not receive the care needed. DON stated if a resident had an appointment it should be in the progress notes. During an interview on 10/02/24 at 01:27 PM ADON B stated if wound care was not performed as ordered the wound could get worse and affect the healing process and/or possible infection. During an interview on 10/02/24 at 01:44 PM ADON A stated she was responsible for Resident #50's wound care for a period of time while he was needing a wound vac. She stated she was not responsible for his care on 09/13/24. She stated on that date the charge nurse was responsible for his wound care. ADON A stated staff were to document resident appointments on the dashboard of PCC. She stated Resident #50 did not experience a negative outcome due to not having his wound care performed as ordered. An attempted telephone interview on 10/02/24 at 02:17 PM with LVN M was unsuccessful. The phone was answered but no one spoke. Record review of facility policy titled Charting and Documentation and dated July 2017 revealed the following: . All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. 2. The following information is to be documented in the resident medical record: . c. Treatments or services performed; . 7. Documentation of procedures and treatments will

Based on observation, interview, and record review the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days for 1 (Resident #6) of 5 residents reviewed for unnecessary medication. Facility failed to ensure Resident #6's PRN order for psychotropic medication was limited to 14 days. This failure could place residents at risk of oversedation which could lead to falls and/or injuries as well as affect their quality of life. Findings Included: Record review of Resident #6's admission record dated 10/01/24 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, type 2 diabetes (insufficient production of insulin, causing high blood sugar), depression, and anxiety disorder. Record review of Resident #6's care plan completed 09/09/24 revealed she used antianxiety medications for anxiety disorder. The facility was to give the medications as ordered by the physician and monitor Resident #6 for side effects. Record review of Resident #6's annual MDS completed on 09/16/24 revealed the following: Section C: Resident #6 had a BIMS of 12 which indicated moderately impaired cognition. Section D: Resident #6 had felt down, depressed, or hopeless 2-6 of the 7 days in the look back period. Resident #6 felt lonely or isolated from those around her often. Section I: Resident #6 had a diagnosis of Anxiety Disorder. Section N: Resident #6 received anti-anxiety medication during the 7 days of the look back period. Record review of Resident #6's active order revealed an order for Alprazolam, an antianxiety medication, with the following directions: Give 1 tablet by mouth every 6 hours as needed for Anxiety. The order had a start date of 11/08/23. Record review of Resident #6's progress notes from 05/31/24-10/01/24 revealed no progress note from physician indicating need for continued PRN order for antianxiety med. Record review of Resident #6's EHR under the MISC tab revealed 4 physician's notes from the last 4 months with dates of 06/06/24, 07/10/24, 09/05/24, and 09/20/24. Record review of Resident #6's physician's note dated 06/06/24 indicated her anxiety disorder was Stable on current treatment. Has low dose [Brand name of antianxiety medication] PRN. There was no mention of duration of the PRN order. Record review of Resident #6's physician's note dated 07/10/24 indicated her anxiety disorder was Stable on current treatment. Has low dose [Brand name of antianxiety medication] PRN. There was no mention of duration of the PRN order. Record review of Resident #6's physician's note dated 09/05/24 indicated her anxiety disorder was Stable on current treatment. There was no mention of the PRN order or its duration. Record review of Resident #6's physician's note dated 09/20/24 indicated her anxiety disorder was Stable on current treatment. There was no mention of the PRN order or its duration. Record review of Resident #6's MAR for June 2024 revealed she was given her PRN antianxiety medication 5 times that month on the following dates 06/09, 06/13, 06/14, 06/18, and 06/19. Record review of Resident #6's MAR for July 2024 revealed she was given her PRN antianxiety medication 5 times that month on the following dates 07/09, 07/21, 07/25, 07/26, and 07/31. Record review of Resident #6's MAR for August 2024 revealed she was given her PRN antianxiety medication 12 times that month on the following dates 08/06, 08/08, 08/09, 08/13, 08/15, 08/19, 08/20 (she was given the medication two times on this date), 08/22, 08/24, 08/27, and 08/28. Record review of Resident #6's MAR for September 2024 revealed she was given her PRN antianxiety medication 11 times that month on the following dates 09/03, 09/04 (she was given the medication two times on this date), 09/05, 09/06, 09/10, 09/12, 09/17, 09/18, 09/20, and 09/25. During an interview on 10/02/24 at 01:06 PM DON stated PRN orders for psychotropic drugs were good for 14 days. She stated for a PRN order for psychotropic drug to be extended past 14 days the physician would have to write that a change in the medication might cause adverse reaction in the resident. She stated a possible negative outcome of a PRN order for a psychotropic drug extending past 14 days was over sedation, dependance. DON stated she did not know why Resident #6 had a PRN antianxiety medication order that had not been discontinued after 14 days. During an interview on 10/02/24 at 01:32 PM ADON B stated PRN orders for psychotropic medications were limited to 14 days. She stated nurses who input PRN orders for psychotropic medications were to put them in for 14 days. She said a possible negative outcome of PRN orders for an antianxiety medications being continued past 14 days was dependent on the case, the resident's response to the medication, as well as on how long the resident had been on the medication as PRN at home prior to admission. During an interview on 10/02/24 at 01:48 PM ADON A stated PRN orders for psychotropic medications should have a stop date when put in to the EHR by nurses. She said a possible negative outcome of a PRN order for antianxiety medication extending past 14 days was sedating them (residents) too much. Record review of facility policy titled Psychotropic Drugs and dated 10/25/17 revealed the following: . The intent of this policy is that each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing, . and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: . (iii) Anti-anxiety . The facility must ensure that- . 4. PRN orders for psychotropic drugs are limited to 14 days. Except as provided in 483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. PRN Orders for Psychotropic . Medications In certain situations, psychotropic medications may be prescribed on a PRN basis, such as while the dose is adjusted, to address acute or intermittent symptoms or in an emergency. However, residents must not have PRN orders for psychotropic medications unless the medication is necessary to treat a diagnosed specific condition. The attending physician or prescribing practitioner must document the diagnosed specific condition and indication for the PRN medication in the medical record.

Based on observation, interview, and record review the facility failed to implement written policies and procedures that prohibit mistreatment and neglect for 1 of 5 Residents (Resident #1) who was reviewed for neglect when; 1. Resident #1 was brought to her room by an aid (CNA C) not familiar with her routine, left sitting in a wheelchair in front of her recliner with a call light not accessible, and a wheelchair that did not lock properly on the left side. 2. Resident #1 attempted to get up from her wheel chair and into the recliner, and fell . Resident # 1 suffered severe lacerations and contusions to her left lower leg and her right elbow that required a trip to the emergency room for sutures. The facility's failure to ensure that Resident #1 was free from neglect, resulted in a fall with severe lacerations and contusions. This failure could possibly affect the other 92 residents in the facility, putting them at risk for falls with major injury. Findings include: Resident #1 Record review of Resident #1's medical chart revealed a [AGE] year old admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of the quarterly MDS dated [DATE] showed Resident #1 had a BIMS score of 11 (moderate impairment). Resident #1 needed extensive assistance with one person for transfer, bed mobility, and locomotion off the unit. Record review of the nurse's notes on 8-6-15 at 8:45 a.m. stated that Resident #1 was found on the floor next to the recliner and stated I tried to get to the recliner. An injury was noted to the left leg and right elbow, bleeding noted at the time. The nurse's notes stated that Resident #1 was alert and oriented x2, new order to transport Resident #1 to the emergency room for stitches. Record review of the care plan dated 12-21-14 for Resident #1 on 8-11-15 showed there was no care plan in place for falls or being at risk for falls. There was no updating of the care plan or interventions that were put in place when Resident #1 returned from the hospital after suffering a significant injury from falling. Record review of the incident and accident logs, for all Residents in the facility for the months of June, July and August showed a total of 25 falls in June, one resulting in a broken hip, 8 falls in July, and 4 falls so far in August. There was no incident or accident report for Resident #1 in regard to the fall on 8-6-15. The DON was asked for this report and it was not produced. Record review of the investigation report provided by the facility for the fall of Resident #1 on 8-6-15 revealed that it is stated in the report that Resident #1 needs minimal assistance with Activities of Daily Living, no special supervision. The MDS dated [DATE] states that Resident #1 needs extensive assistance with one person for transfer. There are no interviews of residents or staff other than a written statement by LVN A. During observation of Resident #1 on 8-6-15 at 8:05 a.m. she was asleep in her bed, breakfast tray in front of her. The call light was not visible, CNA E was asked where Resident #1's call light was and CNA E looked and stated It is under the pillow, it must have slipped under the pillow. During observation on 8-11-15 at 9:40 a.m. of Resident #1's wheelchair surveyor tested both brakes. The brake fully engaged on the right side of the wheelchair and did not fully engage on the left side of the wheelchair. The right wheel on the wheelchair did not move at all. The wheel on the left side of the wheelchair still turned and the wheelchair itself could be moved. During observation of Resident #1 on 8-11-15 at 11:00 a.m. she was sitting in her recliner and LVN A was in attendance. Observations were made of wounds to the left leg and the right arm. Observation of the wound to the left leg showed the wound extended from above the left ankle up to the knee with a large area of bruising concentrated on the calf area of the left leg. Surveyor observed a quick count of at least 22 stiches securing the edges of a curved laceration together. Observation of the wound on the right arm showed a large area of bruising from the mid forearm extending up the right arm to the shoulder. An area of concentrated bruising was noted around the elbow region where surveyor observed a quick count of at least 15 sutures. During an interview with Resident #1's FM on 8-11-15 at 9:35 a.m. FM stated Resident #1's wheelchair did not lock on the left side. FM took surveyor into room and showed her that the wheelchair did not lock on the left side (this was confirmed by surveyor). FM stated, This is what made her fall. She was left unattended in her wheelchair in her room after breakfast and Resident #1 was trying to get into the recliner, the wheelchair wasn't locked and Resident #1 fell . She had sutures in her arm and leg. The physician in the emergency room stated he wanted to take the sutures out himself; it took over an hour to suture her leg. I do not think Resident #1 should have been left alone by the recliner in a wheelchair, because the wheelchair does not lock. Resident #1 usually has help, she needs help. They need to check their equipment and make sure it is working. During an interview with CNA D on 8-11-15 at 11:45 a.m. she stated I was down the hall, I heard help, help! I ran down the hall to Resident #1's room and found her lying on the floor. I went to get LVN A and we went into her room. Resident #1 was by the recliner with her head towards the window. We cleaned her up and took her vitals and called the ambulance. I don't know anything about the wheelchair not locking; this is the first time I have heard about that. I do not know anything about what CNA C was doing or did not do. During an interview with LVN A on 8-11-15 at 11:55 a.m. she stated I was helping feed residents in the assisted dining room and CNA D came to get me and told me that Resident #1 was on the floor. I ran down, she was bleeding. I got a towel and put pressure on the arm and leg. Resident #1 was lying on the floor. I called for help and we called 911. Resident #1 was alert; she was trying to get out of her wheel chair and into the recliner. LVN A was asked to check the wheelchair with surveyor, and she was shown the left side lock on the wheel chair did not engage fully. LVN A stated she would tell Maintenance about the wheelchair. LVN A stated We always have standby assistance for Resident #1; it is not common practice to put her by her recliner and leave her. During an interview with Resident #1 on 8-11-15 at 12:05 p.m. Resident #1 stated I cannot talk, I'm just too sick. During an interview with the DON on 8-11-15 at 12:15 p.m. she asked about the fall Resident #1 experienced. The DON stated she had been on vacation when Resident #1 fell and had just returned today. The DON was asked about checking wheelchairs to ensure they are operating correctly. The DON stated We always check if there is a complaint. Usually the CNA's will tell us if something is not working, we pull them out of there. We have plenty of wheelchairs to substitute. The DON stated the FM is very vocal and they would tell us I feel if the wheelchair was not working. Surveyor took the DON to Resident #1's room and Maintenance had already come to get the wheelchair for repair. During an interview with the ADM on 8-11-15 at 12:25 p.m. he stated CNA D said CNA C brought Resident #1 to her room after breakfast and left the room. Resident #1 yelled, she was trying to get in her recliner. CNA C left Resident #1 by the recliner without her call light. CNA C was terminated that day. When asked about how equipment in the facility was monitored for safety (specifically wheelchairs) the ADM stated The CNA's are supposed to clean equipment and check to see if there are any problems. The ADM stated So, this is the first I have heard of any problems with wheelchairs. During a telephone interview with CNA D on 8-11-15 at 12:30 p.m. she stated I would never hurt anyone. I brought Resident #1 to her room after breakfast. I did not know if she could get up by herself, I should have checked. I put her in her room by the recliner. I did not put the call light within reach. I left her in the wheelchair. If I had known, she wanted to be put in the recliner; I would have put her there. They told me this wasn't the first time she had fallen. My question is why she didn't have a chair alarm if she had fallen before? I did not notice any problems with the wheelchair. I usually don't work that hall. I just took her after breakfast and put her in her room. I usually work the B hall. Resident #1 eats in the main dining room when she fell ; they called me into the room. She wasn't someone I took care of normally; I was not familiar with her routine. I was fired. During an interview with Maintenance on 8-11-15 at 2:10 p.m. when asked about Resident #1's wheelchair, he stated We fixed the wheelchair. During an interview with the DON on 8-11-15 at 3:00 p.m. about interviews not being done for neglect with residents or CNA's she stated I know it wasn't her regular hall (CNA C). We normally would interview everyone, Residents and CNA's on Hall A and the Hall CNA C worked on (Hall B). I don't know why the interviews weren't done, I was on vacation. During an interview with CNA F on 8-11-16 at 3:30 p.m. she was asked how problems with equipment are handled (specifically wheelchairs) she stated If we have difficulty, we let maintenance know. The night shift cleans the wheelchairs. During an interview with LVN B on 8-11-15 at 3:55 p.m. she was asked about maintenance of equipment and she stated If it puts them in immediate danger, we call the DON. If not, we fill out a work order. When asked about a wheelchair not locking she stated The resident or CNA's would tell me. During an interview with the ADM on 8-11-15 at 4:10 p.m. he was asked about the investigation into Resident #1's fall and that no interviews with residents or CNA's were conducted. The ADM stated I did not write it down, I didn't ask any residents. We have been doing rounds making sure call lights are within reach, we thought the issue was about call lights. During an interview with Maintenance on 8-11-15 at 4:20 p.m. he was asked what procedure they use to report faulty equipment and he stated They write it on the work order on my door of my shop, safety hazards first. When asked if a wheelchair that did not lock would be considered a safety hazard he stated Yes. The facility provided policy for abuse and neglect provided by the ADM dated 2-2010 stated: Our facility has a policy strictly prohibiting the abuse, neglect, mistreatment of [REDACTED]. We will not employ individuals who have been found to have engaged in abuse, neglect or mistreatment of [REDACTED]. Neglect means the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The policy did not address the 7 specific steps that need to be taken when an allegation of neglect has occurred. Review of the policy provided by the DON dated 7-2012 and titled Fall and Injuries stated: The facility strives to reduce the risk for falls and injuries by promoting the implementation of the Risk Reduction Falls and Injuries Program. Residents/patients are assessed for fall risk factors. The interdisciplinary team works with the resident/patient and family to identify and implement appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. Procedure: 1. Assess and review risk factors for falls and injuries. b. Complete the fall risk assessment. 2. Review/evaluate other interdisciplinary assessment. 3. Explore underlying medical and environmental conditions. 4. Discuss goals and interventions with resident/patient/family for inclusion in the Interdisciplinary Plan of Care (IPOC). 5. Schedule an IPOC meeting. 6. Initiate/revise the resident/patients Plan of Care based on individual resident/patient needs/risk score. 7. Complete the Individual Resident Care Plan. 8. Communicate interventions during Shift Report and Daily Clinical rounds to the care giving team. 9. Provide training to staff as needed. 10. Review and revise Interdisciplinary Plan of Care at subsequent IPOC meetings. 11. Educate resident/patient and family as indicated. The facility census provided by the facility at the time of the investigation showed a census of 92 residents.

Based on observation, interview, and record review, the facility failed to develop its policies and procedures for the prevention, identification, investigation and reporting of neglect, when the facility failed to conduct a thorough investigation of 1 of 5 Residents (Resident #1) reviewed for neglect. 1. Resident #1 was brought to her room by an aide (CNA C) not familiar with her routine, left sitting in a wheelchair in front of her recliner with a call light not accessible, and a wheelchair that did not lock properly on the left side. 2. Resident #1 attempted to get up from her wheel chair and into the recliner, and fell . Resident #1 suffered severe lacerations and contusions to her left lower leg and her right elbow that required a trip to the emergency room for sutures. 3. Interviews were not conducted with CNA's or Resident's to determine if there were any issues with other residents experiencing some of the same problems or other problems that might be related to issues of being left unattended. This facility failure to thoroughly investigate the fall of Resident #1 could result in all 92 residents of the facility being at risk of neglect. Findings include: The facility provided policy for abuse and neglect provided by the ADM dated 2-2010 stated: Our facility has a policy strictly prohibiting the abuse, neglect, mistreatment of [REDACTED]. We will not employ individuals who have been found to have engaged in abuse, neglect or mistreatment of [REDACTED]. Neglect means the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The policy did not address the 7 specific steps that need to be taken when an allegation of neglect has occurred. Review of the policy provided by the DON dated 7-2012 and titled Falls and Injuries stated: The facility strives to reduce the risk for falls and injuries by promoting the implementation of the Risk Reduction Falls and Injuries Program. Residents/patients are assessed for fall risk factors. The interdisciplinary team works with the resident/patient and family to identify and implement appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. Procedure: 1. Assess and review risk factors for falls and injuries. b. Complete the fall risk assessment. 2. Review/evaluate other interdisciplinary assessment. 3. Explore underlying medical and environmental conditions. 4. Discuss goals and interventions with resident/patient/family for inclusion in the Interdisciplinary Plan of Care (IPOC). 5. Schedule an IPOC meeting. 6. Initiate/revise the resident/patients Plan of Care based on individual resident/patient needs/risk score. 7. Complete the Individual Resident Care Plan. 8. Communicate interventions during Shift Report and Daily Clinical rounds to the care giving team. 9. Provide training to staff as needed. 10. Review and revise Interdisciplinary Plan of Care at subsequent IPOC meetings. 11. Educate resident/patient and family as indicated. Resident #1 Record review of Resident #1's medical chart revealed a [AGE] year old admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of the quarterly MDS dated [DATE] showed Resident #1 had a BIMS score of 11 (moderate impairment). Resident #1 needed extensive assistance with one person for transfer, bed mobility, and locomotion off the unit. Record review of the nurse's notes on 8-6-15 at 8:45 a.m. stated that Resident #1 was found on the floor next to the recliner and stated I tried to get to the recliner. An injury was noted to the left leg and right elbow, bleeding noted at the time. The nurse's notes stated that Resident #1 was alert and oriented x2, new order to transport Resident #1 to the emergency room for stitches. Record review of the care plan dated 12-21-14 for Resident #1 on 8-11-15 showed there was no care plan in place for falls or being at risk for falls. There was no updating of the care plan or interventions that were put in place when Resident #1 returned from the hospital after suffering a significant injury from falling. Record review of the incident and accident logs, for all Residents in the facility for the months of June, July and August showed a total of 25 falls in June, one resulting in a broken hip, 8 falls in July, and 4 falls so far in August. There was no incident or accident report for Resident #1 in regard to the fall on 8-6-15. The DON was asked for this report and it was not produced. Record review of the investigation report provided by the facility for the fall of Resident #1 on 8-6-15 revealed that it is stated in the report that Resident #1 needs minimal assistance with Activities of Daily Living, no special supervision. The MDS dated [DATE] states that Resident #1 need extensive assistance with one person for transfer. There are no interviews of residents or staff other than a written statement by LVN A. During observation of Resident #1 on 8-6-15 at 8:05 a.m. she was asleep in her bed, breakfast tray in front of her. The call light was not visible, CNA E was asked where Resident #1's call light was and CNA E looked and stated It is under the pillow, it must have slipped under the pillow. During observation on 8-11-15 at 9:40 a.m. of Resident #1's wheelchair surveyor tested Resident #1's wheelchair, the brake fully engaged on the right side of the wheelchair and did not fully engage on the left side of the wheelchair. The right wheel on the wheelchair did not move at all. The wheel on the left side of the wheelchair still turned and the wheelchair itself could be moved. During observation of Resident #1 on 8-11-15 at 11:00 a.m. she was sitting in her recliner and LVN A was in attendance. Observations were made of wounds to the left leg and the right arm. Observation of the wound to the left leg showed the wound extended from above the left ankle up to the knee with a large area of bruising concentrated on the calf area of the left leg. Surveyor observed a quick count of at least 22 stiches securing the edges of a curved laceration together. Observation of the wound on the right arm showed a large area of bruising from the mid forearm extending up the right arm to the shoulder. An area of concentrated bruising was noted around the elbow region where surveyor observed a quick count of at least 15 sutures. During an interview with Resident #1's FM on 8-11-15 at 9:35 a.m. FM stated Resident #1's wheelchair did not lock on the left side. FM took surveyor into room and showed her that the wheelchair did not lock on the left side (this was confirmed by surveyor). FM stated, This is what made her fall. FM stated Resident #1 told staff the wheelchair needed fixed. She was left unattended in her wheelchair in her room after breakfast and Resident #1 was trying to get into the recliner, the wheel chair wasn't locked and Resident #1 fell . She had sutures in her arm and leg. The physician in the emergency room stated he wanted to take the sutures out himself; it took over an hour to suture her leg. I do not think Resident #1 should have been left alone by the recliner in a wheelchair, because the wheelchair does not lock. Resident #1 usually has help, she needs help. They need to check their equipment and make sure it is working. During an interview with CNA D on 8-11-15 at 11:45 a.m. she stated I was down the hall, I heard help, help! I ran down the hall to Resident #1's room and found her lying on the floor. I went to get LVN A and we went into her room. Resident #1 was by the recliner with her head towards the window. We cleaned her up and took her vitals and called the ambulance. I don't know anything about the wheelchair not locking; this is the first time I have heard about that. I do not know anything about what CNA C was doing or did not do. During an interview with LVN A on 8-11-15 at 11:55 a.m. she stated I was helping feed residents in the assisted dining room and CNA D came to get me and told me that Resident #1 was on the floor. I ran down, she was bleeding. I got a towel and put pressure on the arm and leg. Resident #1 was lying on the floor. I called for help and we called 911. Resident #1 was alert; she was trying to get out of her wheel chair and into the recliner. LVN A was asked to check the wheelchair with surveyor, and she was shown the left side lock on the wheel chair did not engage fully. LVN A stated she would tell Maintenance about the wheelchair. LVN A stated We always have standby assistance for Resident #1; it is not common practice to put her by her recliner and leave her. During an interview with Resident #1 on 8-11-15 at 12:05 p.m. Resident #1 stated I cannot talk, I'm just too sick. During an interview with the DON on 8-11-15 at 12:15 p.m. she asked about the fall Resident #1 experienced. The DON stated she had been on vacation when Resident #1 fell and had just returned today. The DON was asked about checking wheelchairs to ensure they are operating correctly. The DON stated We always check if there is a complaint. Usually the CNA's will tell us if something is not working, we pull them out of there. We have plenty of wheelchairs to substitute. The DON stated the FM is very vocal and They would tell us I feel if the wheelchair was not working. Surveyor took the DON to Resident #1's room and Maintenance had already come to get the wheelchair for repair. During an interview with the ADM on 8-11-15 at 12:25 p.m. he stated CNA D said CNA C brought Resident #1 to her room after breakfast and left the room. Resident #1 yelled, she was trying to get in her recliner. CNA C left Resident #1 by the recliner without her call light. CNA C was terminated that day. When asked about how equipment in the facility was monitored for safety (specifically wheelchairs) the ADM stated The CNA's are supposed to clean equipment and check to see if there are any problems. The ADM stated So, this is the first I have heard of any problems with wheelchairs. During a telephone interview with CNA C on 8-11-15 at 12:30 p.m. she stated I would never hurt anyone. I brought Resident #1 to her room after breakfast. I did not know if she could get up by herself I should have checked. I put her in her room by the recliner. I did not put the call light within reach. I left her in the wheelchair. If I had known, she wanted to be put in the recliner; I would have put her there. They told me this wasn't the first time she had fallen. My question is why she didn't have a chair alarm if she had fallen before? I did not notice any problems with the wheelchair. I usually don't work that hall. I just took her after breakfast and put her in her room. I usually work the B hall. Resident #1 eats in the main dining room, when she fell ; they called me into the room. She wasn't someone I took care of normally; I was not familiar with her routine. I was fired. During an interview with Maintenance on 8-11-15 at 2:10 p.m. when asked about Resident #1's wheelchair, he stated We fixed the wheelchair. During an interview with the DON on 8-11-15 at 3:00 p.m. about interviews not being done for neglect with residents or CNA's she stated I know it wasn't her regular hall (CNA D). We normally would interview everyone, Residents and CNA's on Hall A and the Hall CNA D worked on (Hall B). I don't know why the interviews weren't done, I was on vacation. During an interview with CNA F on 8-11-16 at 3:30 p.m. she was asked how problems with equipment are handled (specifically wheelchairs) she stated If we have difficulty, we let maintenance know. The night shift cleans the wheelchairs. During an interview with LVN B on 8-11-15 at 3:55 p.m. she was asked about maintenance of equipment and she stated If it puts them in immediate danger, we call the DON. If not, we fill out a work order. When asked about a wheelchair not locking she stated the resident or CNA's would tell me. During an interview with the ADM on 8-11-15 at 4:10 p.m. he was asked about the investigation into Resident #1's fall and no interviews with residents or CNA's were completed. The ADM stated I did not write it down, I didn't ask any residents, or interviews. We have been doing rounds making sure call lights are within reach, we thought the issue was about call lights. During an interview with Maintenance on 8-11-15 at 4:20 p.m. he was asked what procedure they use to report faulty equipment and he stated They write it on the work order on my door of my shop, safety hazard first. When asked if a wheelchair that did not lock would be considered a safety hazard he stated Yes. The facility census provided by the facility at the time of the investigation showed a census of 92 residents.

Based on observation, interview, and record review the facility failed to ensure the environment remained free from accident hazards and each Resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 Residents (Resident #1) who was reviewed for accidents and supervision when; 1. Resident #1 was brought to her room by an aid (CNA C) not familiar with her routine, left sitting in a wheelchair in front of her recliner with a call light not accessible, and a wheelchair that did not lock properly on the left side. 2. Resident #1 attempted to get up from her wheel chair and into the recliner, and fell . Resident # 1 suffered severe lacerations and contusions to her left lower leg and her right elbow that required a trip to the emergency room for sutures. The facility's failure to ensure the environment remained free from accident hazards and each Resident received adequate supervision and assistance devices to prevent accidents resulted in Resident #1 sustaining a fall with severe lacerations and contusions. This failure could possibly affect the other 92 residents in the facility, putting them at risk for falls with major injury. Findings include: Resident #1 Record review of Resident #1's medical chart revealed a [AGE] year old admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of the quarterly MDS dated [DATE] showed Resident #1 had a BIMS score of 11 (moderate impairment). Resident #1 needed extensive assistance with one person for transfer, bed mobility, and locomotion off the unit. Record review of the nurse's notes on 8-6-15 at 8:45 a.m. stated that Resident #1 was found on the floor next to the recliner and stated I tried to get to the recliner. An injury was noted to the left leg and right elbow, bleeding noted at the time. The nurse's notes stated that Resident #1 was alert and oriented x2, new order to transport Resident #1 to the emergency room for stitches. Record review of the care plan dated 12-21-14 for Resident #1 on 8-11-15 showed there was no care plan in place for falls or being at risk for falls. There was no updating of the care plan or interventions that were put in place when Resident #1 returned from the hospital after suffering a significant injury from falling. Record review of the incident and accident logs, for all of the Residents in the facility for the months of June, July and August showed a total of 25 falls in June, one resulting in a broken hip, 8 falls in July, and 4 falls so far in August. There was no incident or accident report for Resident #1 in regard to the fall on 8-6-15. The DON was asked for this report and it was not produced. Record review of the investigation report provided by the facility for the fall of Resident #1 on 8-6-15 revealed that it is stated in the report that Resident #1 needs minimal assistance with Activities of Daily Living, no special supervision. The MDS dated [DATE] states that Resident #1 needs extensive assistance with one person for transfer. There are no interviews of residents or staff other than a written statement by LVN A. During observation of Resident #1 on 8-6-15 at 8:05 a.m. she was asleep in her bed, breakfast tray in front of her. The call light was not visible, CNA E was asked where Resident #1's call light was and CNA E looked and stated It is under the pillow, it must have slipped under the pillow. During observation on 8-11-15 at 9:40 a.m. of Resident #1's wheelchair surveyor tested both brakes. The brake fully engaged on the right side of the wheelchair and did not fully engage on the left side of the wheelchair. The right wheel on the wheelchair did not move at all. The wheel on the left side of the wheelchair still turned and the wheelchair itself could be moved. During observation of Resident #1 on 8-11-15 at 11:00 a.m. she was sitting in her recliner and LVN A was in attendance. Observations were made of wounds to the left leg and the right arm. Observation of the wound to the left leg showed the wound extended from above the left ankle up to the knee with a large area of bruising concentrated on the calf area of the left leg. Surveyor observed a quick count of at least 22 stiches securing the edges of a curved laceration together. Observation of the wound on the right arm showed a large area of bruising from the mid forearm extending up the right arm to the shoulder. An area of concentrated bruising was noted around the elbow region where surveyor observed a quick count of at least 15 sutures. During an interview with Resident #1's FM on 8-11-15 at 9:35 a.m. FM stated Resident #1's wheelchair did not lock on the left side. FM took surveyor into room and showed her that the wheelchair did not lock on the left side (this was confirmed by surveyor). FM stated, This is what made her fall. She was left unattended in her wheelchair in her room after breakfast and Resident #1 was trying to get into the recliner, the wheelchair wasn't locked and Resident #1 fell . She had sutures in her arm and leg. The physician in the emergency room stated he wanted to take the sutures out himself; it took over an hour to suture her leg. I do not think Resident #1 should have been left alone by the recliner in a wheelchair, because the wheelchair does not lock. Resident #1 usually has help, she needs help. They need to check their equipment and make sure it is working. During an interview with CNA D on 8-11-15 at 11:45 a.m. she stated I was down the hall, I heard help, help! I ran down the hall to Resident #1's room and found her lying on the floor. I went to get LVN A and we went into her room. Resident #1 was by the recliner with her head towards the window. We cleaned her up and took her vitals and called the ambulance. I don't know anything about the wheelchair not locking; this is the first time I have heard about that. I do not know anything about what CNA C was doing or did not do. During an interview with LVN A on 8-11-15 at 11:55 a.m. she stated I was helping feed residents in the assisted dining room and CNA D came to get me and told me that Resident #1 was on the floor. I ran down, she was bleeding. I got a towel and put pressure on the arm and leg. Resident #1 was lying on the floor. I called for help and we called 911. Resident #1 was alert; she was trying to get out of her wheel chair and into the recliner. LVN A was asked to check the wheelchair with surveyor, and she was shown the left side lock on the wheel chair did not engage fully. LVN A stated she would tell Maintenance about the wheelchair. LVN A stated We always have standby assistance for Resident #1; it is not common practice to put her by her recliner and leave her. During an interview with Resident #1 on 8-11-15 at 12:05 p.m. Resident #1 stated I cannot talk, I'm just too sick. During an interview with the DON on 8-11-15 at 12:15 p.m. she asked about the fall Resident #1 experienced. The DON stated she had been on vacation when Resident #1 fell and had just returned today. The DON was asked about checking wheelchairs to ensure they are operating correctly. The DON stated We always check if there is a complaint. Usually the CNA's will tell us if something is not working, we pull them out of there. We have plenty of wheelchairs to substitute. The DON stated the FM is very vocal and they would tell us I feel if the wheelchair was not working. Surveyor took the DON to Resident #1's room and Maintenance had already come to get the wheelchair for repair. During an interview with the ADM on 8-11-15 at 12:25 p.m. he stated CNA D said CNA C brought Resident #1 to her room after breakfast and left the room. Resident #1 yelled, she was trying to get in her recliner. CNA C left Resident #1 by the recliner without her call light. CNA C was terminated that day. When asked about how equipment in the facility was monitored for safety (specifically wheelchairs) the ADM stated The CNA's are supposed to clean equipment and check to see if there are any problems. The ADM stated So, this is the first I have heard of any problems with wheelchairs. During a telephone interview with CNA D on 8-11-15 at 12:30 p.m. she stated I would never hurt anyone. I brought Resident #1 to her room after breakfast. I did not know if she could get up by herself, I should have checked. I put her in her room by the recliner. I did not put the call light within reach. I left her in the wheelchair. If I had known, she wanted to be put in the recliner; I would have put her there. They told me this wasn't the first time she had fallen. My question is why she didn't have a chair alarm if she had fallen before? I did not notice any problems with the wheelchair. I usually don't work that hall. I just took her after breakfast and put her in her room. I usually work the B hall. Resident #1 eats in the main dining room when she fell ; they called me into the room. She wasn't someone I took care of normally; I was not familiar with her routine. I was fired. During an interview with Maintenance on 8-11-15 at 2:10 p.m. when asked about Resident #1's wheelchair, he stated We fixed the wheelchair. During an interview with the DON on 8-11-15 at 3:00 p.m. about interviews not being done for neglect with residents or CNA's she stated I know it wasn't her regular hall (CNA C). We normally would interview everyone, Residents and CNA's on Hall A and the Hall CNA C worked on (Hall B). I don't know why the interviews weren't done, I was on vacation. During an interview with CNA F on 8-11-16 at 3:30 p.m. she was asked how problems with equipment are handled (specifically wheelchairs) she stated If we have difficulty, we let maintenance know. The night shift cleans the wheelchairs. During an interview with LVN B on 8-11-15 at 3:55 p.m. she was asked about maintenance of equipment and she stated If it puts them in immediate danger, we call the DON. If not, we fill out a work order. When asked about a wheelchair not locking she stated The resident or CNA's would tell me. During an interview with the ADM on 8-11-15 at 4:10 p.m. he was asked about the investigation into Resident #1's fall and that no interviews with residents or CNA's were conducted. The ADM stated I did not write it down, I didn't ask any residents. We have been doing rounds making sure call lights are within reach, we thought the issue was about call lights. During an interview with Maintenance on 8-11-15 at 4:20 p.m. he was asked what procedure they use to report faulty equipment and he stated They write it on the work order on my door of my shop, safety hazards first. When asked if a wheelchair that did not lock would be considered a safety hazard he stated Yes. Review of the policy provided by the DON dated 7-2012 and titled Fall and Injuries stated: The facility strives to reduce the risk for falls and injuries by promoting the implementation of the Risk Reduction Falls and Injuries Program. Residents/patients are assessed for fall risk factors. The interdisciplinary team works with the resident/patient and family to identify and implement appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. Procedure: 1. Assess and review risk factors for falls and injuries. b. Complete the fall risk assessment. 2. Review/evaluate other interdisciplinary assessment. 3. Explore underlying medical and environmental conditions. 4. Discuss goals and interventions with resident/patient/family for inclusion in the Interdisciplinary Plan of Care (IPOC). 5. Schedule an IPOC meeting. 6. Initiate/revise the resident/patients Plan of Care based on individual resident/patient needs/risk score. 7. Complete the Individual Resident Care Plan. 8. Communicate interventions during Shift Report and Daily Clinical rounds to the care giving team. 9. Provide training to staff as needed. 10. Review and revise Interdisciplinary Plan of Care at subsequent IPOC meetings. 11. Educate resident/patient and family as indicated. The facility census provided by the facility at the time of the investigation showed a census of 92 residents.