Every finding on record at Hidalgo Nursing and Rehabilitation Center

Based on interviews and record reviews the facility failed to ensure the residents right to be informed of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers, for 1 resident (Resident #1) of 5 residents reviewed for consent for antipsychotic medications in that: Resident #1 was prescribed and administered olanzapine (Zyprexa)(an antipsychotic) without prior consent based on information of the benefits, risks, and options available. This failure could affect the right to self-determination of all facility residents who receive medication by allowing them to receive medication without their prior knowledge or consent, or that of their responsible party or emergency contacts. The findings included: Record review of Resident #1's admission record dated 04/29/2026, revealed an [AGE] year-old female with an admission date of 09/13/2025. Resident #1's diagnoses included moderate dementia (a decline in mental ability - such as memory, thinking, and reasoning - severe enough to interfere with daily life) with anxiety and depression. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 02, indicating severe cognitive impairment. There were no psychiatric or mood disorders noted. There were no indicators of psychosis (hallucinations or delusions) noted. There were no behavioral symptoms noted. Resident #1 was dependent for showers and toileting requiring the assistance of two helpers. Resident #1 required substantial/maximal assistance for personal hygiene where the helpers provided 50% or more of the effort. Antidepressants, an antibiotic, hypoglycemics (including insulin), and anticonvulsants were received on a routine basis. Record review of Resident #1's care plan, dated 03/10/2026, revealed FOCUS: The resident uses antipsychotic medications Zyprexa r/t Psychosis Date Initiated: 04/16/2026 Revision on: 04/17/2026. Record review of Resident #1's Progress Note dated 03/18/2026 at 03:38 am, written by LVN C revealed RESIDENT WAS SEEN BY [MH NP] NEW ORDERS WAS TO STOP, KEPPRA, BUSPAR AND MELATONIN, AND START ZYPREXA 10MG Q HS AND TOPAMAX 100MG BID. CALL IF CONDITION WORSENS OR PERSISTS. ORDER CARRIED OUT. RP NOTIFIED ON NEW MD ORDERS. Record review of Resident #1's Physician's orders dated 03/18/2026, revealed ZyPREXA Oral Tablet 10 MG (Olanzapine). Give 1 tablet by mouth at bedtime for depression. Record review of Resident #1's Physician's orders dated 03/20/2026, revealed ZyPREXA Oral Tablet 10 MG (Olanzapine). Give 1 tablet by mouth at bedtime for unspecified psychosis. Record review of Resident #1's Progress Notes dated 03/18/2026 at 03:47 pm, written by RN E revealed, [RP] understands psych recommendations per [MH NP]. Record review of Resident #1's Progress Notes dated 03/29/2026 at 04:12 pm, written by LVN G, revealed A CALL was made to [RP], r/t pending signature for consent, [RP] said he will stop by tomorrow after work to sign consent form, around 5 pm. Record review of Resident #1's Progress Note dated 04/03/2026 at 11:50 am, written by RN D revealed OKAY TO DC ZYPREZA AS PER RP. PENDING SIGNATURE FOR CONSENT. Record review of Resident #1's April 2026 MAR revealed Resident #1 was administered Zyprexa 10 mg tablet by mouth at bedtime on 04/01/2026 and 04/02/2026 at 08:00 pm with no consent signed by RP. During an interview on 04/29/2026 at 08:52 am Resident #1 stated she needed a lot of attention, and they did not give her the attention she needed. She said the female CNA at night was a womanizer. She said she lived at the facility for free because she never worked and could not get Social Security. She said she had a free place to sleep, free food, and free medication. She said she was alone and had no one. Resident #1 stated she was confused. She said her family did not come to visit her. During an interview on 04/29/2026 at 04:33 pm, LVN A stated a consent (for antipsychotics) needed to be signed by the RP/resident and doctor/NP before the medication could be given. He said there is a special consent form for antipsychotics. LVN A stated if an antipsychotic were given without RP/resident consent, it could be that the resident or RP was not informed of the medications side effects or anything about the medication. He said at the morning meetings, the charge nurse, ADONs, DON, and Administrator go over the antipsychotics and all medications with new orders to make sure everything is right and the RP has been notified and signatures on consents had been signed. During an interview on 04/29/2026 at 05:00 pm, LVN B stated for antipsychotics, a consent was needed before the antipsychotic could be given and it could not be a verbal consent. She stated the RP had to sign the consent. LVN B stated the negative outcome of not having a consent signed before administration could be the RP/family were not informed of side effects or they may not want them to give the medication. During an interview on 04/29/2026 at 06:05 pm, the DON stated the nurses had already been in-serviced on appropriate forms for antipsychotics, appropriate indications for antipsychotics, and signed consents by the doctor/NP and the RP for any antipsychotic for a resident with Alzheimer's/dementia. The DON agreed that Resident #1 had received Zyprexa on 04/01/2026 and 04/02/2026 without a consent form signed by the RP. A record review of the facility's policy Use of Psychotropic Medication(s), dated 03/05/2025, revealed, Policy Explanation and Compliance Guidelines: 9.Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase. 10. The resident has the right to accept or decline the initiation or increase of a psychotropic medication. 11.The facility will document that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and the preferred option to accept or decline in a format the facility deems to use (e.g., written consent form, narrative note, etc.).

Based on interview and record review, the facility failed to ensure that the residents were free from chemical restraints not required to treat the resident's medical symptoms for 1 (Resident #1) of 5 residents reviewed for unnecessary medications. The facility failed to have an adequate indication for the use of the medication olanzapine (Zyprexa)(an antipsychotic) for Resident #1 before administering the medication with a black box warning. This failure could put residents at risk of harm from adverse reactions or harmful side effects. Based on interview and record review, the facility failed to ensure that the residents were free from chemical restraints not required to treat the resident's medical symptoms for 1 (Resident #1) of 5 residents reviewed for unnecessary medications. The facility failed to have an adequate indication for the use of the medication olanzapine (Zyprexa)(an antipsychotic) for Resident #1 before administering the medication with a black box warning. This failure could put residents at risk of harm from adverse reactions or harmful side effects. The findings included: Record review of Resident #1's admission record dated 04/29/2026, revealed an [AGE] year-old female with an admission date of 09/13/2025. Resident #1's diagnoses included moderate dementia (a decline in mental ability - such as memory, thinking, and reasoning - severe enough to interfere with daily life) with anxiety and depression. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 02, indicating severe cognitive impairment. There were no psychiatric or mood disorders noted. There were no indicators of psychosis (hallucinations or delusions) noted. There were no behavioral symptoms noted. Resident #1 was dependent for showers and toileting requiring the assistance of two helpers. Resident #1 required substantial/maximal assistance for personal hygiene where the helpers provided 50% or more of the effort. Antidepressants, an antibiotic, hypoglycemics (including insulin), and anticonvulsants were received on a routine basis. Record review of Resident #1's care plan, dated 03/10/2026, revealed FOCUS: The resident uses antipsychotic medications Zyprexa r/t Psychosis Date Initiated: 04/16/2026 Revision on: 04/17/2026. Record review of Resident #1's Progress Note dated 03/18/2026 at 03:38 am, written by LVN C revealed RESIDENT WAS SEEN BY [MH NP] NEW ORDERS WAS TO STOP, KEPPRA, BUSPAR AND MELATONIN, AND START ZYPREXA 10MG Q HS AND TOPAMAX 100MG BID. CALL IF CONDITION WORSENS OR PERSISTS. ORDER CARRIED OUT. RP NOTIFIED ON NEW MD ORDERS. Record review of Resident #1's Physician's orders dated 03/18/2026, revealed ZyPREXA Oral Tablet 10 MG (Olanzapine). Give 1 tablet by mouth at bedtime for depression. Record review of Resident #1's Physician's orders dated 03/18/2026, revealed ZyPREXA Oral Tablet 10 MG (Olanzapine). Give 1 tablet by mouth at bedtime for unspecified psychosis. Black Box Warning:Increased mortality in elderly patients with dementia-related psychosisElderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Olanzapine is not approved for the treatment of patients with dementia-related psychosis. Record review of Resident #1's Physician's orders dated 04/16/2026, revealed ZyPREXA Oral Tablet 10 MG (Olanzapine). Give 1 tablet by mouth at bedtime for anxiety. Record review of Resident #1's Physician's orders dated 04/20/2026, revealed ZyPREXA Oral Tablet 10 MG (Olanzapine). Give 1 tablet by mouth at bedtime for bipolar disorder, unspecified. Record review of Resident #1's April 2026 MAR revealed Zyprexa 10 mg tablet was administered at bedtime 04/16/2026 through 04/21/2026 and 04/24/2026/ through 04/27/2026. During an interview on 04/29/2026 at 08:52 am Resident #1 stated she needed a lot of attention, and they did not give her the attention she needed. She said the female CNA at night was a womanizer. She said she lived at the facility for free because she never worked and could not get Social Security. She said she had a free place to sleep, free food, and free medication. She said she was alone and had no one. Resident #1 stated she was confused. She said her family did not come to visit her. During an interview on 04/29/2026 at 04:33 pm LVN A stated it was the nurse who took the order was the one who put the order in the computer. LVN A stated if he needed clarification on an order, he would call either the NP or doctor. He said a specific, accurate indication for an antipsychotic was needed for a resident who had an Alzheimer's or dementia diagnosis. He said an indication could not be like altered mental status. LVN A stated if a resident who had a diagnosis of Alzheimer's or dementia was receiving an antipsychotic with an inappropriate indication, the negative effect would be called a chemical restraint. During an interview on 04/29/26 at 05:00 pm, LVN B stated if an NP or doctor gave a verbal order for an antipsychotic, it would be the nurse who took the order who put the order in the computer. LVN A stated if she had questions about the order, she would call the doctor or NP to clarify the order. She said antipsychotics ordered for a resident with the diagnosis of Alzheimer's/dementia with an inappropriate indication would need to be clarified with the doctor. She gave an example of an inappropriate indication as altered mental status. She said the negative effect of giving a resident with the diagnosis of Alzheimer's/dementia an antipsychotic with an inappropriate indication could worsen the symptoms of what they were experiencing and there was a black box warning with antipsychotics stating if the antipsychotic were being given to a resident with Alzheimer's/dementia psychosis, it increased the risk of death. During an interview on 04/29/26 at 06:05 pm, the DON stated MH NP F had written the order for Zyprexa for Resident #1 with the indication of psychosis and a day or two later, they received paperwork from a facility that Resident #1 had had a diagnosis of Bipolar. She said MH NP E had stated and wrote that Resident #1 had a history of schizophrenia, but she could not locate that diagnosis anywhere. She said the nurses had already been in-serviced on appropriate forms for antipsychotics, appropriate indications for antipsychotics. She said the new antipsychotics were reviewed at morning meetings. Record review of the facility's Psychotropic Drug Use policy dated 03/05/2025 reflected: Policy: It is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience which would deem it a chemical restraint. of this facility to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. Definitions Chemical restraint refers to any drug used for discipline or makes it more convenient (i.e., less effort) for staff to care for a resident, and not required to treat medical symptoms. This includes instances when a psychotropic medication may be approved to treat certain symptoms, however, nonpharmacological interventions should be used or attempted, unless clinically contraindicated because they are less dangerous to a resident's health and safety. Policy Explanation and Compliance Guidelines:1.A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. 2.Psychotropic medications are to be used only when a practitioner determines that the medication(s) is appropriate to treat a resident's specific, diagnosed, and documented condition and the medication(s) is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s).

Based on record reviews and interviews, the facility failed to send a copy of the residents' discharge notice, prior to discharge, to the representative of the Office of State Long-Term Care (LTC) Ombudsman for 77 of 81 of residents discharged from the facility for the first 3 months in 2026. The facility failed to send a copy of the residents' discharge notice, prior to discharge, to the representative of the Office of State Long-Term Care (LTC) Ombudsman These failures could place residents at risk of not knowing their rights and receiving the services of the state LTC Ombudsman. Findings Included: Record review of the monthly report of discharges dated 04/14/2026 provided by the Social Worker revealed out of a total of 81 residents discharged only 4 discharges of AMA were sent to the LTC Ombudsman for the months of January, February, and March of 2026. Interview with the SW on 04/13/2026 at 4:16 PM she stated she was instructed by the Administrator that only the AMA stated she only sent the discharges of Against Medical Advice to the LTC Ombudsman for the months of January 2026 to March 2026 as instructed by her Administrator. The SW stated she did not have knowledge that she was to be sending all Resident discharges to the LTC Ombudsman bi-monthly or monthly. The SW stated she had sent the report of the discharges as soon as possible once she gathered all of the information. The SW stated she would be sending a monthly report every month to the Ombudsman starting the month of April 2026 that includes all discharges, so the Ombudsman was able to help with referrals to other resources that can help the resident. In an interview on 04/14/2026 at 11:05 AM with the ADON stated she was not aware the ombudsman was to receive notice of all discharges from the facility every month. The ADON stated the discharge procedure began with nursing team giving the social worker notice of a resident's discharge and the social worker was responsible for sending the letter the RP. The ADON stated the procedure for resident discharges would now include the administrator and medical records as a backup to ensure the ombudsman would be receiving a notice of all discharge notices every month. In an interview on 04/14/2026 at 1:23:PM with the Administrator he Stated the facility failed to follow the facility's policy and procedure of giving notice to the LTC Ombudsman monthly of the months of January, February, and March. The SW only sent notice of the discharges for residents leaving AMA for first three months in 2026. The Administrator stated he failed to have knowledge of the policy of the monthly notice as stated in the facility's policy and procedure for Transfer and Discharge. The Administrator stated there was now a backup to the SW that includes the Administrator and medical records to ensure the monthly report to the LTC Ombudsman was sent and received by the Ombudsman. The Administrator stated the facility's admission person did call the discharged residents and made sure the help and resources they needed were contacted and received. The Administrator also stated the DON and ADON were conducting an in-service for all nurses to educate them on what need to be done and who needs to be told about the discharges. The Administrator stated he and the person doing medical records would be doing audits for all residents being discharged as a back up to the SW to ensure the ombudsman is receiving the letters monthly. The Administrator stated the SW never brought the matter of the facility's failure to send the discharge letters to the ombudsman. The Administrator stated the facility admission coordinator did follow up with the discharged residents to see if all the referrals were completed by the referral agencies. The Administrator stated the negative outcome of the Ombudsman did not have notice of the discharges could affect the resident of being discharged without proper help. In record review of the facility's policies and procedures for Transfer and discharge date d 03/05/2025 stated It was the policy of the facility to permit each resident to remain in the facility and transfer of discharge the resident from the facility, except in limited circumstances. This policy applies to all residents regardless of their payment source.5. The facility will maintain evidence that the notice was sent to the Ombudsman.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. 1. The facility failed to ensure male kitchen staff were wearing beard restraints and wear them properly while in the kitchen.2. The facility failed to discard scratched non-stick pans. 3. The facility failed to wear gloves while cooking raw ground beef for consumption.4. The facility failed to ensure can opener was clean.5. The facility failed to ensure dinner rolls were covered while waiting for baking.6. The facility failed to ensure the air conditioning vents to be free of a black substance surrounding the vents and condensation. 7. The facility failed to ensure the safe distribution of the resident #45's food as the CNA stuck her finger in the residents food while serving the food to the resident causing cross contamination. These failures could place residents at risk of foodborne illnesses. Findings included: Observation and Initial tour of the kitchen on 04/12/24 at 1:30 p.m. revealed two male employees DA E was not wearing a beard restraint, and DA F was not wearing his beard restraint properly over mustache. In observation of dishwash room a set of 11 pans were hanging with a the non-stick coating scratched or peeling. The cook was observed cooking raw ground beef without gloves. In inspection of the can opener a black substance was seen coating the working side of the can opener. In observation of dining on 04/13/2026 at 5:23 PM CNA C was observed serving the Resident #45 with improper infection control procedure. CNA C was seen touching the rim of the drinking glass and dessert cups after removing protective covering. CNA C was seen touching the peaches with her finger as she placed the cup on the table of the resident. In a second observation on 04/13/2026 at 11:11. In observation of the self-standing oven two cookie sheets of rolls were seen uncovered and on sitting on top of self-standing oven. The oven doors were observed open while removing the rolls from the oven and not closed immediately when done. In observation of the 7 out of 9 ceiling air conditioning vents had a black substance surrounding the edges of the vents and condensation that was dripping on to the floor. In record review on 04/13/2026 of Resident #45's face sheet dated 04/13/2026 indicated Resident #45 was a [AGE] year-old female with the diagnoses Alzheimer's Disease with late on set (a progressive disease that destroys memory and other important mental functions), Alzheimer's Disease with late on set (a progressive disease that destroys memory and other important mental functions), Contracture ( a permanent, often painful tightening or shortening of muscles, tendons, ligaments, or skin causing ridged deformity and limited joint motion), Dementia (A group of thinking an social symptoms that interferes with daily functioning), Cognitive communication deficit(a communication impairment resulting from underlying cognitive issues such as memory, attention executive function and information processing rather than primary language deficits. In an interview on 04/13/2026 at 9:31 AM with Resident #45 the interview was unsuccessful as the resident could not answer the state surveyors' questions. In an interview with on 04/12/2026 at 2:01PM with DA E he stated he forgot to put on the beard restraint but did normally have one on every day. DA E stated he knew it was important to have a beard restraint on to prevent the resident's food becoming cross contaminated. In an interview with on 04/12/2026 at 2:17 PM with DA F he stated that he forgot to put on the beard restraint correctly covering his mustache. DA E stated he did not realize the beard restraint was not placed on face correctly. DA E stated it was important to have the beard restraint on when preparing food and in the kitchen, so the residents' food did not become cross contained possibly making the residents ill. In an interview on 04/12/2026 at 1:47 PM with the cook she stated she was not aware that she was to be wearing gloves while cooking food as she was using utensils and not touching food with bare hands. The cook stated she did wear gloves if she handled food with bare hands like cutting vegetables. In an interview with the DM on 04/12/2026 at 1:56 PM she stated the male employee would be reeducated with an in service about the importance of wearing beard restraints. The pans that were scratched were thrown away and would do a reeducation on why scratched nonstick pans are not to be used and need to be thrown away so they are not accidentally used for cooking. The DM stated she had an in-service with the staff on the importance of cleaning the can opener daily to ensure the food in the can did not become contaminated. The DM stated she did not realize the rolls were not covered and would reeducate the staff on the importance of food being covered at all times if not in a container to prevent them from being exposed to air and becoming contaminated. The DM stated the can opener was cleaned every day and it was all the staff's responsibility to clean the can opener after being used and could not say when it was last cleaned. The DM stated she would do an in-service with the staff about the importance of wearing gloves while handling raw meat and vegetables with a gloved hand to prevent cross contamination while preparing food. The DM stated she would reeducate the staff on the importance of not leaving the oven doors to prevent food from becoming contaminated and add to the heat in the kitchen that cause the condensation on the air condition vents in the ceilings dripping on to the floor and possible falling in to already cooked food and could cause the residents to become ill. The DM stated she did not realize the vents were producing condensation and dirty, but she would let the maintenance man know of the condensation on the vents and the black substance surrounding the vents. In an Interview on 04/14/2026 at 1:16 PM with the Maintenance Man stated he would be contacting the ac vac company for maintenance on temperature and condensation. The Maintenance Man stated he did preventive maintenance service for the air conditioning unit every month and had not seen any condensation. The Maintenance Man stated the weather was getting hotter, so the air conditioning unit was being used more frequently to keep the kitchen cool and with the heat from cooking might be the reason for the condensation on the vents. The Maintenance Man stated the air conditioning company only got called out for a service call if the unit was not working properly. The Maintenance Man would be wiping down and cleaning the area around the vents and stated the vents were just replaced last month. The maintenance Man would be monitoring the condensation to prevent it from happening again. In record review of the policy for Food Preparation and Handling dated 06/01/2019 the policy stated To ensure that all food severed by the facility was of good quality ad safe for consumption, all food would be prepared and handled according to the state and US Food Codes HACCP Guidelines. c. Prepare food with the least manual contact possible. Do not allow bare hands to touch raw food directly. In record review of Employee Sanitation policy dated 10/01/2018 stated The Nutrition & Foodservice employees of the facility would practice good sanitation practices in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illnesses. b. Hairnets, headbands, caps beard coverings and other effective hair restraints must be worn to keep hair from food and food-contacts surfaces.d. No fingernail polish or artificial fingernails can be worn when working with exposed food or unwrapped utensils unless wearing intact gloves in good repair. In record review of the Food Storage policy dated 06/01/2019 to ensure that all food served by the facility was of good quality and safe for consumption, all food would be stored according to the state, federal and US Food Codes and HACCP guidelines. g. Use the first-in-first out (FIFO)rotation method. Date packages and place new items behind existing supplies, so that the older items are used first.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for 1 of 3 residents (Resident#19) reviewed for quality of care. The facility failed to prevent Resident#19's urinary catheter tubing (bag) from touching the floor on 4/12/26. This failure could place residents at risk for cross contamination and urinary tract infections.Findings included: Record review of Resident#19's face sheet revealed a [AGE] year-old female originally admitted on [DATE]. Resident#19 had admitting diagnosis of neuromuscular dysfunction of bladder (is a condition where nerve damage disrupts the signals between the brain, spinal cord, and bladder muscles). Record review of Resident #19's MDS assessment dated [DATE], revealed Resident #19 had a BIMS score of 1 which indicated Resident #19 had severe impaired cognition. Resident #19 had an indwelling catheter. Record review of Resident #19's care plan dated 11/27/2018 revealed Resident #19 had a foley catheter for neuromuscular dysfunction of the bladder date initiated 11/25/24 and revised on 12/9/25. Intervention/tasks listed Resident #19 had an 18 french 30 milliliters balloon indwelling position catheter bag and tubing below the level of the bladder and away from entrance room door. Record review of Resident #19's Order Summary revealed order Foley Catheter 18 # French with 30milliliters balloon every night shift starting on the 18th and ending on the 18th every month. During an observation conducted on 04/12/26 at 5:15 PM, Resident #19's indwelling catheter bag was noted laying on the floor on the left side of Resident #19's bed. During an interview with LVN D on 04/12/26 at 5:25 PM, LVN D was informed Resident #19's catheter bag was laying on the floor. She stated it should not be touching the floor. She replied that a negative outcome of foley catheter bag being on the floor was the catheter wouldn't drain well and pick up bacteria from floor. During an interview with the ADON on 04/14/26 at 8:45 AM, she stated, for catheters, they should be on the side of the bed, not the on part that went up and down, so it didn't fall, but on frame. ADON stated, no, it should not be touching the floor. If on the floor, residents could be at risk of infection. ADON stated that the DON was not available. Record Review of facility's Nursing Pocedure 8th edition Titled Indwelling Urinary Catheter Care and Removal, revealed: Make sure the catheter is properly secured.

Based on observation, interview and record review the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 7 (100/200-hall and 300/400-halls) medication carts reviewed for pharmacy services. 1. The facility failed to store 5 loose tablets in their appropriate blister packs in the medication cart for halls 100 and 200 at 2:37 PM on 04/13/26. 2. The facility failed to store 8 loose tablets/capsules in their appropriate blister packs in the medication cart for halls 300 and 400 at 2:54 PM on 04/13/26. This deficient practice could place residents at risk of losing medications leading to medication shortage.The findings included:During an observation of the 100/200 hall medication cart at 2:37 PM on 04/13/26 five assorted tablets were found loose in the 2nd drawer from the top. The drawer contained blister packs of medications for residents living on the 100 and 200 halls along with the loose medications. During an observation of the 300/400 hall medication cart at 2:54 PM on 04/13/26 eight assorted tablets were found loose in the 2nd drawer from the top. The drawer contained blister packs of medications for residents living on the 300 and 400 halls along with the loose medications. In an interview with MA A at 3:43 PM on 04/13/26, MA A stated she was in charge of the 100/200 hall medication cart when the loose pills were found. MA A stated she always cleaned out her cart at the end of her shift. MA A stated she looked for expired medications and loose tablets when she cleaned out her cart. MA A stated she found loose tablets in her cart before when she cleaned it. MA A stated it was important to keep the cart clean and organized to help prevent contamination and to protect residents' property. In an interview with the ADON at 3:56 PM on 04/13/26, the ADON stated it was nursing best practice for whoever was responsible for the medication cart to ensure it was cleaned appropriately. The ADON stated each cart should be cleaned once per shift. The ADON stated when cleaning a cart, the staff member should ensure there were no loose pills, liquids were sealed properly, nothing was expired, the wheels, drawers and brakes on the cart all functioned appropriately, and it was generally clean and organized. The ADON stated this was important to prevent any contamination and to avoid possible administration errors. Record review of the facility's policy titled Medication Carts and Supplies for Administering Meds last revised 10/01/19, revealed the following: .10. The licensed nurse or medication aide should maintain a clean top surface on the medication cart while passing medications and clean and replenish the medication cart after each use. Equipment and supplies relating to medication administration are clean and orderly.

Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 8 residents (Resident #20) reviewed for respiratory care. 1. The facility failed to ensure Resident #20's oxygen tubing was not touching the floor on 4/12/2026. 2. The facility failed to post an Oxygen sign indicating Resident #20 received oxygen on 4/12/2026. These deficient practices could place residents who receive respiratory care at an increased risk of developing respiratory complications, a decreased quality of care, and at risk of fire hazards by not posting oxygen signs outside the residents' rooms.The findings included: Record review of Resident #20's face sheet, dated 04/12/2026, revealed a [AGE] year-old male with an admission date of 4/8/2026. Pertinent diagnoses included Acute Respiratory Failure with Hypercapnia (a sudden, life-threatening inability of the respiratory system to eliminate carbon dioxide from the blood), and Heart Failure. Record review of Resident #20's Comprehensive MDS assessment, dated 4/2/2026, revealed he was on Oxygen Therapy while a resident. Record review of Resident #20's Care Plan, dated 01/22/2019, revealed Resident #20 has oxygen therapy PRN r/t SOB with an intervention of oxygen settings:O2 via nasal Cannula, as per MD order. Record review of Resident #20's physician orders, started 4/12/2026, revealed an order for Oxygen at 2 liters per minute every shift for hypoxia (a dangerous condition where tissues receive inadequate oxygen, leading to symptoms like confusion, shortness of breath, rapid heart rate, and bluish skin). An observation on 4/12/2026 at 2:10 p.m. revealed Resident #20 was in his room lying on his bed. He was wearing a nasal canula and was receiving oxygen at 2 liters per minute. The oxygen tubing was touching the floor without a protective sleeve. There was no oxygen sign posted outside of his room. During an interview on 04/12/2026 at 2:15 p.m., LVN D stated that she was the nurse for Resident #20. She stated all staff were responsible for posting the oxygen sign outside the residents' rooms. LVN D verified Resident #20 did not have an oxygen sign posted outside his room. She stated all residents who were on oxygen, regardless of needing it continuously or prn, all needed a sign. LVN D stated it was important for the oxygen tubing not to touch the floor because it could get contaminated and Resident #20 could get an infection. LVN D stated that it was important for posting an oxygen sign outside the resident's rooms, so no one should [NAME], and everyone who went into the facility would be aware that there was oxygen in use inside the room, for safety. During an interview on 04/14/2026 at 8:45 a.m., the ADON stated the floor nurses were responsible for verifying the oxygen tubing was not touching the floor every shift because it's a risk for infection for the resident. She stated that anybody could post the oxygen sign on the outside of the residents' room, but it was the responsibility of the admitting nurse. The ADON stated that it was important for the oxygen sign to be posted for everyone to know that there was oxygen in use in that room. She stated that she does random compliance rounds. Record review of the facility's General Procedures and Treatment Modalities 1. Post a NO SMOKING sign on the outside of door to the residents room before starting use of oxygen.

Based on observation, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #20) reviewed for infection control. CNA B and CNA C failed to follow Enhanced Barrier Precautions for an indwelling catheter for Resident #20 on 4/12/26. This failure could place residents at risk for cross contamination and the spread of infection. Finding included: Record review of Resident #20's face sheet, dated 04/12/2026, revealed a [AGE] year-old male with an admission date of 4/8/2026. Pertinent diagnoses included Neuromuscular dysfunction of bladder (nerve damage from conditions like spinal cord injury, or Parkinson's that disrupts signals between the brain and bladder) and Heart Failure. Record review of Resident #20's Comprehensive MDS assessment, dated 4/2/2026, revealed Section H-Bladder and Bowel indicated Resident had an indwelling catheter while a resident. Record review of Resident #20's Care Plan, dated 01/22/2019, revealed Resident #20 has the need for Enhanced Barrier Precautions due to Foley Catheter. During an incontinent care observation on 4/12/26 at 4:05 p.m., CNA B and CNA C commenced incontinent care and indwelling catheter care of Resident #20. CNA B and CNA C entered Resident #19's room after knocking. CNA B and CNA C began with washing their hands for 30 seconds, gloved up, and prepared the table of needed supplies. CNA B and CNA C continued by raising bed and then discarded gloves. After discarding the gloves, CNA B and CNA C continued with applying hand sanitizer, and she applied new gloves. CNA B proceeded with catheter care and proceeded to clean the back area, removed brief, and applied new brief. CNA B and CNA C did not use gowns during incontinent care. During an interview on 04/12/26 at 4:15 p.m., CNA B stated any resident with an indwelling catheter was required for enhanced barrier precautions. She stated she should have worn a gown, and just overlooked it when she entered the room. She stated the risk of not following Enhanced Barrier Precautions was the spread of infection. During an interview on 4/12/26 at 4:20 p.m., CNA C said she forgot to use the gown. CNA C said it was important to use the EBP to protect residents from whatever microorganisms that she could carry and to protect other residents. CNA C said residents could be at risk of infection. During an interview on 4/14/26 at 8:45 a.m., the ADON stated EBP was staff needing to wear a gown and gloves for individuals with a catheter, feeding tube, or wounds. ADON said it was important to use PPE to prevent introducing any kind of infection to residents. ADON said not using EBP could put residents at a higher risk for infection. Record review of the facility's Enhanced Barrier Precautions policy dated 11/24/25 reflected: Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definition: enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and gloves to use during high contact resident care activities. Policy Explanation and Compliance Guidelines:.2. Initiation of Enhance Barrier Precautions:.b. An order for an enhanced barrier precautions will be obtained for residents with any of the following: .i. wounds (e.g., chronic wounds such as urinary catheters.)

Based on interviews and record reviews, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of property for 1 of 2 residents (Resident #1) reviewed for misappropriation and exploitation, in that: The facility failed to ensure Resident #1's debit card was secured resulting in 26 unauthorized transactions totaling $1,340.60. This failure could affect residents and their responsible party by preventing them from having access to their funds. The findings included: Record review of Resident #1's admission sheet dated 01/28/25, reflected a 58-tear-old male with an admission date of 11/30/25, an initial admission date of 09/05/25, and an original admission date of 01/28/25. His relevant diagnoses included absence of right and left leg below knee, morbid (severe) obesity, need for assistance with personal care, and diabetes (a chronic condition characterized by high blood sugar resulting from the body's inability to produce or effectively use insulin). Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 13, which indicated his cognition was intact. Record review of Resident #1's quarterly care plan dated 12/18/25 reflected [Resident #1] has diabetes date initiated 09/04/25 and revised 09/25/25. His interventions in part included. snacks allowed in daily nutritional plan. In an interview on 01/29/26 at 10:23 a.m., Resident #1 said he kept his wallet which included his driver's license, insurance cards, social security card, and debit card in a safe in the BOM's office. He said whenever he needed to purchase something, he would request his wallet from the BOM. He said he had never allowed anyone to use his debit card. No facility staff had never requested any money or loans from him. Resident #1 said the last time he had requested his debit card from the BOM was sometime in November 2025. He said he remembered requesting his debit card because he wanted a cinnamon roll from the vending machine that was in the employee's lounge. He said when the BOM gave him his debit card, he handed it over to the ABOM, so she could go to the employee's lounge and buy his snack. Resident #1 said as soon as he got the cinnamon roll, he went back to his room and the ABOM stayed with his debit card. He said the ABOM told him she was going to return his debit card to the BOM. Resident #1 said early January 2026, the BOM approached him and told him that someone had drained his account. Resident #1 said the BOM told him he had a negative balance and did not have the funds to pay his applied income (the amount of Medicaid-eligible nursing home resident's monthly income that they must contribute toward their cost of care) for the month of January 2026. Resident #1 said his immediate response was who in the $$$$ could have done that, if only you and your assistant had access to my debit card. Resident #1 said he suspected the ABOM had used his debit card without his permission since she was the last person who had possession of it. Resident #1 said he and the BOM had called his bank that same day to find out what was going on with his bank account. He said when he called, he asked for the latest transactions and that's when he found out someone had used his card without his permission. Resident #1 said his main concern was how he was going to pay his applied income for the month of January 2026. Resident #1 said he and the BOM went to his bank to get a printout of the transactions and to complete the required paperwork to dispute all transactions. Resident #1 said he was told by the bank they would be initiating their own investigation and if eligible he would get reimbursed by the bank. Resident #1 said he was told by the BOM (sometime in January 2026) that he had been reimbursed already. Resident #1 said the facility's Administrator had spoken to him about the unauthorized transactions and he too told him the facility would reimburse him whatever transactions the bank didn't. Resident #1 said he was satisfied with the facility's investigation and felt safe in the facility. Resident #1 said he had enough funds to pay his applied income the month of January 2026 after his money was reimbursed. In an attempted telephone interview on 01/29/26 at 10:35 a.m. and 11:00 a.m., with ABOM but no answer and unable to leave a voice message. In an interview on 01/29/26 at 11:05 a.m., the BOM said Resident #1 received $1214.00 a month from Social Security a month and his applied income was $1139.00 a month. She said Resident #1's had requested to keep his wallet in the safe she kept in her office. She said he would regularly request his debit card to buy cinnamon rolls from the vending machine that was in the employee's lounge. The BOM said whenever Resident #1 requested his debit card, she would hand it over to him and he in turn would ask the ABOM to go buy the cinnamon rolls for him from the vending machine in the employee's lounge. The BOM said she remembered that the end of November 2025, Resident #1 had requested his debit card to go buy a cinnamon roll. She said she remembered him giving the debit card to the ABOM but did not remember if the ABOM had returned the debit card to her. The BOM said prior to December 2025, she did not have a system in place to ensure Resident #1's debit card was returned to the safe. She said she trusted her ABOM and because she was always busy, she did not keep track of Resident #1's debit card and had not checked if the debit card was returned. The BOM said only she had access to the safe's combination. The BOM said the first week of January 2026, she tried to collect Resident #1's applied income, but the transaction was declined. She said she immediately informed Resident #1. She said she and Resident #1 had called the bank to inquire about the negative balance and requested a history of the most recent transactions. She said Resident #1 questioned all but 3 transactions and so she decided to take Resident #1 to bank so he could dispute the charges and complete the required forms. She said when they got to the bank, Resident #1 completed the required forms to formally dispute all unauthorized transactions. She said Resident #1 was told by the bank that tentatively he was eligible for a refund, but they still had to initiate a formal investigation. The BOM said during their provider investigation, it was concluded that the ABOM had used Resident #1's debit card without his permission. The BOM said the facility was ready to reimburse Resident #1 for any transactions the bank refused to reimburse. The BOM said Resident #1 received two letters from the bank informing him all but four transactions had been reimbursed ( sometime this month). The BOM said it was suspected that Resident #1's debit card had been used by ABOM who was suspended and later terminated. She said she now had a log where her new ABOM would sign out Resident #1's debit card and sign it back in when it was returned to her. She said she also created an inventory list of Resident #1's belongings that were in his wallet to ensure all items were there. Record review of Resident #1's bank statement dated 12/31/25 reflected the following unauthorized transactions between 12/01/25 to 12/30/25:12/01/25-$103.2512/11/25-$21.2312/15/25-$744.8212/22/25-$302.5912/23/25-$73.9612/24/25-$94.31Total: $1,340.16 Record review of Resident #1's correspondence he received from his bank on 01/15/26 which reflected a total of $459.92 had been denied for reimbursement. A telephone call on 01/29/26 at 3:00 p.m., this Surveyor was informed by the local police that police case remained open but the investigator working the case only worked on weekends. In an interview on 01/29/26 at 4:07 p.m., the Administrator said that on 12/31/25 the facility's BOM had informed him that Resident #1's debit card had been compromised. The Administrator said he had immediately initiated an investigation, reported the incident to HHSC and local police. He said on 12/31/25, he interviewed Resident #1 who informed him that he had not loaned his debit card to any family member or facility staff. He said Resident #1 mentioned the facility's ABOM had used his debit card late November 2025 when he had asked her to buy snacks for him from the employee's vending machine. The Administrator said he interviewed the ABOM on 12/31/25 and she denied the allegation of misappropriation of property. He said he suspended ABOM on 12/31/25 due to pending investigation. The Administrator said he was very concerned about what had happened, he decided to contact (in person) one of the vendors shown on Resident #1's bank statement. He said it was a local oil change company. He said they were able to give him a copy of the receipt that was used. The receipt had ABOM' s name, the make and model of her vehicle, the amount of $103.25, and Resident #1's debit card number. The Administrator said with that receipt he was able to confirm that it was the ABOM who had used Resident #1's debit card. He said he called the ABOM several times after he reviewed the oil change receipt, but she did not answer. He said ABOM had been terminated on 01/05/26 for misappropriation of property. The Administrator said the balance of the transactions that were not refunded by the bank to Resident #1, the facility was going to apply it to February's applied income ($459.92). The Administrator said after his investigation, he has substantiated the allegation of misappropriation of property. Record review of the facility's Abuse, Neglect, and Exploitation policy dated 07/11/25 reflected:Policy, It is a policy of this facility to provide protections for the health, welfare, and the rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation then misappropriation of resident property.Definitions:Misappropriation of Property: Means of deliberate misplacement, exploitation, wrongful, temporary, or permanent, use of a residence belongings or money without resident's consent. Policy Explanation and Compliance Guidelines:1.The facility will develop and implement written policies and procedures that: Prohibit And prevent abuse, neglect, and exploitation of residence and musical condition of resident property.

Based on interviews and record review, the facility failed to ensure that a resident who needed respiratory care was provided with such care, consistent with professional standards of practice for 1 (Resident #1) of 4 residents reviewed for oxygen management. The facility failed to provide Resident #1 with a BIPAP machine as per doctor's orders. This deficient practice could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of life. Record review of the facility's PIR revealed Resident #1 did not have the BIPAP machine on during the night of 11/26/25. Record review of Resident #1's admission record dated 11/18/25 revealed a [AGE] year-old male with an admission date of 08/01/25 and an initial admission date of 05/28/25. Resident #1's diagnoses included, acute and chronic respiratory failure with hypercapnia (excessive carbon dioxide in the bloodstream, typically caused by inadequate respiration), chronic obstructive pulmonary disease (a condition involving constriction of the airways and difficulty or discomfort in breathing), dependance on supplemental oxygen, obstructive sleep apnea (a disorder in which a person's breathing repeatedly stops and starts during sleep due to a blockage of the upper airway) and pulmonary hypertension (a serious condition of high blood pressure in the arteries of the lungs).Record review of Resident #1's MDS assessment dated [DATE] revealed respiratory treatment of BIPAP. Resident #1's BIMS score of 15, indicated he was cognitively intact. Record review of Resident #1's physician order dated 05/25/25 revealed BIPAP at HS and PRN 15/8, 15, 2LPM O2. Record review of Resident #1's person-centered care plan dated 05/25/25 revealed Resident #1 had oxygen therapy related to COPD. Intervention included, BIPAP per MD order.Record review of Resident #1's progress note dated 08/26/25 at 4:32 pm, revealed PA G had made a note which indicated Subjective: Patient seen and examined at bedside. Was called a few days ago secondary to patient having gastritis in addition patient with low O2 sat and now when uses BIPAP machine. Plan: Increased O2, educated on importance of using BIPAP machine.Record review of in-services given during the facility's investigation revealed RT J attended and signed off on in-services titled, Following Dr. Orders, indication and initiation of BIPAP use, proper documentation, use of back up equipment, and equipment malfunction. RT J's signature was dated 08/29/25.Interview on 11/18/25 at 5:05 pm, RT J stated he was the RT on shift for the night of 08/26/25. RT J stated his shift was from 6:00 pm through 6:00 am. RT J stated that at 11:50 pm, Resident #1 had on the BIPAP machine, but he had to remove it due to Resident #1 having to take medication. When Resident #1 finished taking his medication, RT J said he attempted to reapply the BIPAP mask, but the machine indicated an error message. RT J stated he attempted to troubleshoot the machine but could not get it to work again. RT J stated he placed Resident #1 on oxygen. RT J stated he was not aware there was a back-up BIPAP machine. RT J stated he realized there was a back-up BIPAP machine at around 3:00 am but by that time Resident #1 was already asleep and didn't want to disturb him. RT J stated that he and the overnight nurse continued to check on Resident #1 throughout the night. RT J stated Resident #1's saturation levels were fine, and Resident #1 did not have any shortness of breath. RT J stated had there been an emergency, 911 would have been called. RT J stated a negative outcome could have been that Resident #1's respirations levels and saturation levels could have been low, and Resident #1 could have had shortness of breath.Interview on 11/19/25 at 9:20 am, RT C stated Resident #1 required respiratory treatments such as nebulizer treatments, continuous oxygen and the use of BIPAP machine. RT C stated Resident #1 had those treatments upon admission. RT C stated he received report in the morning from the night shift RT. RT C stated that RT J had stated to him that Resident #1 used the BIPAP machine up until 2-3:00 am but then the machine malfunctioned. RT C stated that RT J informed him that Resident #1 was then placed on oxygen and was fine throughout the rest of the morning. RT C stated there is a backup BIPAP machine in the respiratory storage room. RT C stated all RTs are aware of the backup BIPAP machine because the BIPAP machine needs to be checked for functionality at the beginning and end of every shift. RT C stated that once the BIPAP machine has been checked, there is a sign off sheet that is signed by the RT. RT C stated that a negative outcome for a resident not using the BIPAP could cause a resident to become short of breath. RT C stated that the BIPAP machine is used to get rid of carbon dioxide in the body and helps the resident breath better. RT C stated that high levels of carbon dioxide in the body could cause increased sleepiness, confusion and other health problems. Interview on 11/19/25 at 10:54 am, RN F stated he was given report at the beginning of his shift from RT C that Resident #1 had not slept with the BIPAP machine. RN F stated he was told that the BIPAP machine had malfunctioned. RN F stated there is a backup BIPAP machine in the storage room. RN F stated nurses and RTs are in-serviced (trainings) on the back-up BIPAP machine. RN F stated having a BIPAP machine is a doctor's order and all doctor's orders need to be followed. RN F stated the BIPAP machine helped Resident #1 expand his lungs and prevent desaturation (drop in oxygen levels).Interview on 11/19/25 at 2:37 pm, the DON stated there was a back-up BIPAP machine available for Resident #1 for the night of 08/26/25. The DON stated that all nurses and RTs were aware of where the back-up BIPAP machine was located. The DON stated that there was no negative outcome because Resident #1 did not have any issues. The DON stated that there would not have been a negative outcome because nothing happened to Resident #1. Interview on 11/19/25 at 3:03 pm, the Administrator stated he did not know why RT J would have said he was not aware there was a back-up BIPAP machine. The Administrator stated there is always a back-up BIPAP machine for the reasons of malfunction. The administrator stated the facility also had another machine available that worked as a BIPAP and a ventilator. The administrator stated there was no excuse for Resident #1 to not have had a BIPAP machine. Record review of facility's policy Notification of Changes dated 10/24/22 revealed, Circumstances requiring notification include: 3. Circumstances that require a need to alter treatment. This may include: b. Discontinuation of current treatment due to: i. Adverse consequences

Based on interview and record reviews, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 1 resident (Resident #11) reviewed for residents needs as identified through resident assessments. The facility failed to ensure LVN P documented resident #11's assessment on 01/29/25 after CNA O informed her she had noticed redness on Resident #11's leg. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk of not having assessments documented resulting in potential delayed treatment and decreased quality of life. Findings included: Record review of R#11's admission record dated 02/12/25 reflected an [AGE] year-old female with an admitted [DATE]. Her diagnoses included Unspecified Dementia (loss of brain function that affects memory, thinking, behavior, and language) Unspecified Severity with Mood Disturbance, Cognitive Communication Deficit (difficulty communicating), Other Lack of Coordination, Age-Related Osteoporosis (bone disease that weakens bones, more likely to break), Without Current Pathological Fracture, and Rheumatoid Arthritis (inflammation and pain in joints) Without Rheumatoid Factor, Multiple Sites. Record review of Resident #11's quarterly MDS assessment dated [DATE] reflected a BIM score of 99 indicating resident was unable to complete the interview. MDS also reflected Resident #11 used a wheelchair to ambulate and was a substantial/maximal assist with chair to bed, bed to chair transfers. Record review on 02/11/25 of Resident #11's electronic medical record revealed no documentation done by LVN P on 01/29/25 or 01/30/25 on assessment done for Resident #11 after CNA O informed LVN P. An interview on 02/09/25 at 2:33 p.m. Resident #11 was alert, however, did not respond to questions and was heard repeating numbers. An interview on 02/10/25 at 8:19 p.m. LVN P said CNA O told her to check Resident #11. LVN P said CNA O had not told her what to assess Resident #11 for. She said she assessed the Resident for flu symptoms since there was another resident she had just assessed with those symptoms so she said she thought it was the same thing Resident #11 had. She said she did not do a skin assessment and did not document anywhere on Resident #11's medical record that she had assessed the resident. LVN P also said she did not let the oncoming nurse of the concern brought up by CNA O. She said she should have documented the assessment and said she didn't because she had a lot of things going on with other residents that day. She said they are in serviced on documenting residents assessments. An interview on 02/11/25 at 1:44 p.m. CNA O said when she was changing Resident #11, she said she had noticed redness on Resident #11's leg, below her knee. She said she had told LVN P and had shown her exactly where on the resident's leg was where she had seen redness. CNA O said the nurse assessed it and said she would document it. An interview on 02/11/25 at 2:40 p.m. CNA T said when she worked with Resident #11 on 01/30/25 she had not seen any bruising on her. She also had not seen the resident show any pain when she was providing care. She said they often get in-services on reporting abuse or neglect and they are told to report anything they see that's different in a resident. An interview on 02/11/25 3:30 p.m. LVN N said she completed a weekly assessment on Resident #11 on 01/30/25 and had not seen redness or bruising on Resident #11's leg. She also said had not seen signs or symptoms of pain. She said if she had, she would have reported and documented it. An interview on 02/12/25 at 1:31 p.m. the DON said the staff has been given in-services on documenting when assessing residents. When asked if LVN P should have documented what she assessed, DON said she couldn't tell me why LVN P did not document anything. She said LVN P and the rest of the staff was given an in-service on documenting. Record review of facility's policy dated 10/24/22, titled Documentation in Medical Record Policy: Each resident's medical record shall contain an accurate representation of actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.

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 the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 4 residents (Resident #247) reviewed for care plans, in that: The facility failed to ensure Resident #247's care plan revised on 01/17/25 reflected he required a mechanical lift to be transferred to and from bed. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs. The Findings included: Record review of Resident #247's admission sheet, dated 02/12/25, reflected a [AGE] year-old-male admitted on [DATE]. His relevant diagnoses included intervertebral disc degeneration (a condition where one or more discs in the spine deteriorates due to age, which results in back or neck pain), muscle wasting and atrophy (loss of muscle mass and strength), abnormalities of gait and mobility (disruptions in a person's walking pattern, including issues with balance and coordination), and history of falling. Record review of Resident # 247's MDS quarterly assessment dated [DATE], reflected a BIMS score of 11, which indicated his cognition was moderately impaired. Further review indicated Resident #247 required a wheelchair as a mobility device and required substantial/maximal assistance (helper does more than half of the effort) for chair/bed-to-chair transfer and tub/shower transfer. Record review of Resident #247's care plan dated 01/17/25, reflected he had an ADL self-care performance deficit related to intervertebral disc degeneration of lumbar region with discogenic back pain( a type of back pain that originates from the degeneration of the intervertebral disc), history of falls, lack of coordination, and abnormal gait and mobility. Date initiated 11/20/24 and revised on 01/2025. Resident #247 required extensive assistance by 2 staff for transferring. An observation and interview on 02/09/25 at 3:22 p.m., Resident #247 was observed awake in bed. His bed was set to the lowest position and his call light was within reach. Resident #247 said he did not want to talk to anyone and to leave his room. An interview on 02/12/25 at 10:00 a.m., CNA A said Resident #247 was a two person assist for all his ADL's. She said whenever Resident #247 was given a shower, she and her partner would transfer him to and from bed to the shower chair. She said they would use a mechanical lift for his and their safety. She said Resident #247 was a big man. She said she was not sure if the charge nurses knew they used a mechanical lift to transfer him. CNA B was not able to verify if the Kardex system indicated Resident #247 required a mechanical lift for transfer. She said the morning CNAs knew he required a mechanical lift for transfers due to his size. An interview on 02/12/25 at 10:45 a.m., CNA B said Resident #247 was a two person assist for all his ADL's. She said whenever Resident #247 was given a shower, she and her partner would transfer him to and from bed to the shower chair. She said they would use a mechanical lift for his and their safety. She said she did not remember how long he had been transferred by a mechanical lift. She said was not sure if the LVNs knew the CNAs used a mechanical lift to transfer Resident #247 to shower chair. CNA B was not able to verify if the Kardex system indicated Resident #247 required a mechanical lift for transfer. She said the morning CNAs knew Resident #247 was a mechanical transfer. An interview on 02/12/25 at 11:00 a.m., LVN C said she was not aware CNAs were using a mechanical lift to transfer Resident #247 to and from his bed to shower chair. She was not able to say if his care plan included that he was a mechanical lift for transfers. She said she would have to check with the DON before she answered any other questions. LVN C was not able to mention if there were any negative outcome to Resident #247's care plan not including that he required a mechanical lift for transfer. An observation and interview on 02/12/25 at 1:56 p.m., the DON checked Resident #247's medical electronic record and said he was a two person assist for bathing/showering and transfers. She said his care plan did not indicate he required a mechanical lift for transfer. She said she was not aware the CNAs had been using a mechanical lift to transfer Resident #247 to and from bed to shower chair. The DON said Resident #247 had not sustained any negative outcome for not having his care plan include that he required a mechanical lift for transfer. An interview on 02/12/25 at 2:12 p.m., Rehab Director, said she had been approached by one of Resident #247's CNAs and had asked if it was ok if they continued using a mechanical lift to transfer him to and from the shower chair. She said her response was yes just for safety measures. She said Resident #247 was a big guy and had uncoordinated movements so mechanical lift would be safer. She said after her conversation with the CNA , she advised the facility's DON of her recommendation. She said Resident #247 was currently receiving occupational, speech, and physical therapy five times a week and had no end date. The Rehab Director said had nothing to do with care plans, therefore, could not say if Resident #247 sustained any negative outcome that his care plan did not include, he required a mechanical lift for transfer. Record review of the facility's Comprehensive Care Plans policy dated 10/24/22 reflected: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 3. The comprehensive care plan will describe, at a minimum, the following: a) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial wellbeing.

Based on observation, interview and record review, the facility failed to ensure residents were free from verbal abuse for 1 of 4 residents (R# 1) reviewed for abuse. The facility failed to prevent CNA A, from verbally abusing R#1 on 05/20/24 when she used obscene language. This failure could place residents at risk of emotional distress, fear, decreased quality of life and further abuse. Findings included: Record review of R#1's admission record dated 01/15/25 reflected a [AGE] year-old male admitted to the facility on [DATE]. His relevant diagnoses included hemiplegia ( muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) affecting right dominant side, lack of coordination, dementia (A loss of brain function that worsens over time and affects memory, thinking, behavior, and language), cognitive communication deficit (difficulty with communication caused by an impairment in cognitive processes). Record review of R#1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 12, indicating R#1's cognition was moderately impaired. Section E reflected R#1 did not exhibited any behaviors. Record review of R#1's quarterly care plan assessment dated [DATE] reflected [R#1] had the potential to be physically aggressive, hits staff when providing care r/t dementia and poor impulse control. Date initiated 05/20/24 and revised on 05/23/24. R#1's interventions included to assess his needs (food, thirst, toileting, comfort level, body positioning, and pain). Record review of R#1's progress notes dated 05/20/24 at 7:00 a.m., authored by LVN B reflected, I was standing outside rm 308 when I heard loud obscene yelling in Spanish coming from rm 310. I immediately went into room [ROOM NUMBER] and saw [R#1] sitting on the side of bed and CNA A standing in from of [R#1] trying to assist him to transfer to wheelchair, but [R#1] was trying to punch CNA A. CNA A was deflecting the punches with her hands and yelling to resident in Spanish que chingado tienes (what the hell is wrong with you) A mi no me vas a pegar (you are not going to hit me) ya parale con [NAME] chingada (damn it, stop it) [R#1] stated he did not want to go to dining room, but did not say why he was hitting CNA. Skilled nurse told [R#1] to stop hitting CNA and that's when resident allowed to be assisted to wheelchair. Once [R#1] was safely seated in wheelchair skilled nursed immediately told CNA A to walk out of room and clock out and go home due to her agitated behavior. Head to toe assessment done on [R#1] with no visible skin issues noted at this time and [R#1] denies pain at this time. Administrator, DON and ADON notified. An observation and interview on 01/15/25 at 5:45 p.m., R#1 was observed in the dining room. R#1 said hace tiempo (some time ago) a CNA (did not remember her name) had used obscene language while she tried to transfer him from his bed to his wheelchair. R#1 said the only details he remembered was that CNA A trying to transfer him to his wheelchair, him punching her and CNA A responded with obscene language. R#1 said he was told by a staff member CNA A no longer worked at the facility. R#1 said after the incident, he felt safe in the facility and had no fears of retaliation or was afraid of any staff or resident. R#1 said the incident did not affect him in any way, the only thing he did not appreciate was the way CNA A had spoken to him. R#1 said he felt content with the investigation, especially LVN B who had walked in when CNA A was talking to him. Record review of the Administrator's written statement with R#1 on 05/20/24 reflected, Administrator interviewed [R#1] after incident occurred on 05/20/24. [R#1] stated CNA that helped him this morning told him bad words and he tried to hit her. He sated while trying to hit her he hit his hands in the wheelchair, and she was redirecting his arms away from her. Resident stated he attempted to pushed away and hit her. Record review of LVN B's written statement he provided on 05/20/24 reflected, On Monday 05-20-24, I [LVN B] was the charge nurse on 300 hall. At approximately 0700 I was standing outside rm 308 when I heard loud obscene yelling in Spanish coming from rm 310. I immediately went into room [ROOM NUMBER] and saw [R#1] sitting on the side of bed and CNA A standing in from of [R#1] trying to assist him to transfer to wheelchair, but [R#1] was trying to punch CNA A. CNA A was deflecting the punches with her hands and yelling to resident in Spanish que chingado tienes (what the hell is wrong with you) A mi no me vas a pegar (you are not going to hit me) ya parale con [NAME] chingada (damn it, stop it) [R#1] stated he did not want to go to dining room, but did not say why he was hitting CNA. Skilled nurse told [R#1] to stop hitting CNA and that's when resident allowed to be assisted to wheelchair. Once [R#1] was safely seated in wheelchair skilled nursed immediately told CNA A to walk out of room and clock out and go home due to her agitated behavior. Head to toe assessment done on [R#1] with no visible skin issues noted at this time and [R#1] denies pain at this time. Administrator, DON and ADON notified. A phone interview on 01/15/25 at 11:11 a.m., LVN B said that on 05/20/34, he was the charge nurse for hall 300 and as he was exiting another resident's room, he overheard a women's voice yelling obscene language coming from R#1's room. LVN B said he overheard her saying no me estes pagando con [NAME] chingada. (damn it, don't be hitting me) LVN B said he became concerned and immediately went into R#1's room to see what was going on. He said he observed R#1 sitting on the side of his bed and CNA A standing in front of him trying to transfer him to his wheelchair. He said he observe R#1 attempting to hit CNA A. He said CNA A tried to shield herself with her hands and yelled to R#1 in Spanish, que chingados tienes (what the hell is wrong with you) a mi no me vas a pegar (you are not going to hit me) ya parale con [NAME] chingada (damn it, stop it). He said he told R#1 to stop hitting CNA A and instructed CNA A to leave R#1's room and to clock out due to her inappropriate behavior. He said he stayed with R#1's and assessed him. He said R#1 voiced that he was ok and had no visible signs of injuries. LVN B said R#1 showed no signs of distress, his vitals were within range and did not complain of pain. LVN B said after he assessed R#1 he contacted the facility's Administrator who was the abuse coordinator to tell him what he had witnessed. He said the Administrator told him to immediately send CNA A home in which he responded he had already done so. He said the incident happened before breakfast. He said CNA A told him before she exited R#1's room that [R#1] was trying to hit her, and she had lost her temper. He said CNA A obeyed his orders without hesitation and left the facility. LVN B said he had never observed that behavior from CNA A before or any other staff member. LVN B said as soon as the Administrator started his investigation, he continued with her daily tasks. LVN B said CNA 's and nursing staff were in-serviced on the topic of ANE that same day. LVN B said he was frequently in-serviced on the topic of ANE. Record review of CNA A's written statement she provided on 05/20/24 reflected, Today 05/20/24 about 6:45 am I was working on the 300 hall .I went to [R#1's] to change him and get him up for breakfast .I started to change his diaper and to get him dressed for breakfast. As I sat him on the edge of the bed to change his shirt he was falling (leaning) back on the bed so I pulled him forward so I can change him he started calling me names and said he was going to hit me. I told him not to be hitting me and when I went to put my arms around him, he leaned back made a fist and hit me right in the middle of my chest. I kept saying in Spanish, no me estes pagando (don't be hitting me) but also at the same time trying to make the transfer to the chair. He hit me again and my reaction was no me estes pagando que chingaos tienes (don't be hitting me, what the hell is wrong with you). When LVN B entered the room and heard me say that he asked me what was going on I told him I'm trying to transfer him, but he started hitting me. LVN B goes just leave him there and come back later. I said I can't the bed is high, and he can fall. He goes I need to report what you said, what I saw. Put [R#1] in the chair and go the hallway. LVN B says everyone heard you. I said who it's just me, you, and roommate in the room. I know I shouldn't said that maybe something but not that. But that was my reaction at the moment. LVN B said you need to leave go home and DON will call you. And I left about 7 am. I never hit him never intended to hit him I just reacted verbally. A telephone interview on 01/15/24 at 12:24 p.m., CNA A said she no longer worked at the facility and did not remember the 05/20/24 incident with R#1. She said she had nothing else to say. Record review of R#1's progress notes dated 05/21/24 at 7:02 p.m., authored by SW reflected, SW met with [R#1] at bedside to follow up regarding abuse allegation from CNA during adl care the previous day. Investigation was completed, CNA involved suspended resident will continue to receive adl care assistance from other cna staff in the 300 hall. [R#1] laying down in bed [R#1] in a calm and pleasant mood, well-groomed and oriented x2. [R#1] reports he used the following coping mechanisms: talking to his family member and is trying not to think about the event because it gets him upset. [R#1]expressed no further concerns. SW notified resident outside counseling services will be coming out speak with him tomorrow resident verbalized understanding. Record review of R#1's progress notes dated 05/22/24 at 7:33 p.m., SW met with [R#1] at bedside to follow up regarding abuse allegation. [R#1] laying down in bed [R#1] in a calm and pleasant mood, well-groomed and oriented x2. [R#1] reports he is doing better and is no longer upset. [R#1] expressed no further concerns. [R#1]met with counseling services and enjoyed his session with SW. Outside counseling services will continue to meet with [R#1]. Record review of R#1's counseling notes from an outside source dated 05/23/24 reflected, [R#1] states CNA told him some mean things and used bad words. Resident reports this was the first time this happened .[R#1]was advised that CNA is no longer working at facility and reports he feels comfortable at facility. [R#1] report staff have tried to be helpful with him. [R#1] denied any feelings of not being safe or fear of retaliation. An interview on 01/15/25 at 4:25 p.m., Administrator said on 05/20/24, he received a telephone call from LVN B right before breakfast and advised him that he had overheard CNA A cussing at R#1. He said LVN B quickly intervened and deescalated the situation. He said LVN B instructed CNA A to leave R#1's room and to clock out. He said LVN B assessed R#1 and was fine. The Administrator said as soon as he arrived at the facility, he immediately interviewed R#1. He said R#1 told him CNA A had told him bad words and he admitted to trying to hit her. The Administrator said R#1 did not show any signs or symptoms of distress during his interview. He said he then called CNA A on her cell phone to get statement. The Administrator said CNA A told him she had yelled at R#1 and had told him a mi no me vas a pegar (you are not going to hit me) and used the Spanish word chingado (what the hell). The Administrator said CNA A told him the Spanish word chingado (what the hell) was not a bad word for her and would say it regularly. He said during their conversation, CNA A used the word Spanish word chingado (what the hell) while talking to him. The Administrator said his number one priority was the safety and wellbeing of his residents. He said CNA A was terminated due to her lack of professionalism. He said CNA A admitted to reacting verbally and apologized for using the word chingado (what the hell). The Administrator said CNA A was not referred because he felt she was remorseful. He said all staff were immediately in-serviced on the topic of abuse and neglect on 05/20/24. The Administrator said the facility had taken the following steps to remedy the situation, CNA A was immediately removed from the facility to protect all residents, R#1 was assessed and was found to be physically unharmed, CNA A was suspended while the investigation was on-going, staff were in-serviced on the topic of ANE on 05/20/24, after the investigation, CNA was terminated, reported the allegation of abuse to state, and R#1 was referred and continued receiving counseling services. Record review of facility's complaint/grievance follow-up report completed by the Administrator on 05/20/24 reflected the nature of the complaint was R#1 voiced CNA A was abusive toward him. The final resolution indicated the investigation had been completed, and the allegation were unfounded. Record review of CNA A's employee record reflected she was hired on 03/01/24. Her background check was clear and her last in-service on abuse and neglect was on 05/09/24. Record review of the facility's Employee Counseling Report completed by the Administrator, dated 05/23/24 reflected: Incident description: abuse allegations towards resident. Self-report submitted. Performance Improvement Plan: Suspension on 05/20/24, Termination on 05/23/24. Record review of the facility's Abuse, Neglect and Exploitation policy dated 08/12/22 reflected: Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Definitions: Staff: includes employees, the medical director, consultants, contractors, volunteers, caregivers who provide care and services to resident on behalf of the facility, students in the facility's nurse aide training program, and student from affiliated academic institutions, including therapy, social and activity programs. Verbal Abuse: means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Alleged Violation: is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with Federal requirement related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. IV. Identification of Abuse, Neglect and Exploitation B. Possible indicators of abuse include, but are not limited to: 1. Resident, staff, or family report of abuse 5. Verbal abuse of a resident overheard

Based on interviews and record reviews, the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who was licensed or registered by the state for 1 of 1 Activity Director reviewed, in that: The facility failed to ensure the AD was qualified to serve as the director of the activities program. This failure could place residents at risk for reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interests/preferences of each resident. The findings included: Record review of the staff roster, provided by the facility, undated, revealed the staff member was listed as Activities Director. Further review revealed the AD was hired on [DATE]. Record review of a certificate provided by the facility for the AD revealed she had been certified as an Activity Director through [name of certification company] with an expiration date of [DATE]. During an interview with the AD on [DATE] at 2:00 p.m., the AD stated her certification had expired on [DATE] during the COVID pandemic. The AD stated she had been unable to attend classes to renew her certification and could not afford the online classes during the COVID crises. The AD stated she was originally certified in 2016 and had renewed every 2 years until 2020. The AD stated she was finally able to get the funds together to pay the $1400 fee to begin the class for recertification since the facility did not assist with this cost. The AD provided a letter from the [name of certification company] instructor showing she had enrolled in the class effective [DATE]. The AD further stated she had been unable to afford to attend any continuing education courses since 2020. During an interview with the HR Director on [DATE] at 2:04 p.m., the HR Manager stated the AD's certification had expired and she had just enrolled for the class upon the surveyor requesting information regarding her certification and training. Review of the [name of certification company], website, https://ctractexas.org/, on [DATE] revealed the Recertification Process as The recertification process will occur every two (2) years. Two (2) continuing education units (CEUs) or 20 contact hours from at least four areas of the Body of Knowledge are required. During an interview with the Administrator on [DATE] at 2:50 p.m., the Administrator stated she was not aware the AD's certification had expired however added that she had been at the facility less than 3 weeks and was still learning all the staff. Record review of the AD's job description provided by the facility revealed a section, Qualifications: the activity program must be directed by a qualified professional and completes continuing education each year, per the requirements of licensure/certification.

Based on observation, interview, and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 3 of 3 residents (Resident #15, #55 and #97) reviewed for hospice services, in that: 1. The facility failed to obtain Resident #15's most recent hospice Plan of Care and documentation by specific interdisciplinary hospice staff providing services to the resident. 2. The facility failed to obtain Resident #55's most recent hospice Plan of Care and documentation by specific interdisciplinary hospice staff providing services to the resident. 3. The facility failed to obtain Resident #97's most recent hospice Plan of Care, Hospice Election Form and Physician Certification of Terminal Illness. These failures could place the resident who received hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings included: 1. Record review of Resident #15's face sheet, dated 11/16/2023, revealed the resident was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included: fractured right femur, muscle wasting and atrophy, dysphagia (difficulty swallowing), and moderate protein-calorie malnutrition. Record review of Resident #15's Significant change MDS, dated [DATE], revealed the resident had a BIMS score of 02, which indicated severe cognitive impairment. Further review revealed the resident had a life expectancy of less than 6 months and had received hospice care while a resident at the facility. Record review of Resident #15's Care Plan last review completed 07/12/2023, revealed a problem area, The resident has a terminal prognosis r/t CVA. admitted under services of [Hospice A]. Further review revealed an intervention consult with physician and social services to have hospice care for resident in the facility. There was no hospice interdisciplinary team information, visit frequencies, or coordination of care to be provided found in the care plan. Record review of Resident #15's electronic medical record Order Summary Report of Active Orders as of 11/16/2023, revealed an order on 10/19/2023 for: Admit into [Hospice A] under care of MD [name]. Record review of Resident #15's electronic medical record, miscellaneous documents, revealed no Hospice documentation. 2. Record review of Resident #55's face sheet, dated 11/16/2023, revealed the resident had an original admitted [DATE] and a most recent re-admitted [DATE] with diagnoses that included: heart failure, acute respiratory failure with hypoxia (condition where region of the body is deprived of adequate oxygen supply), sleep apnea (sleep disorder in which pauses in breathing or periods of shallow breathing during sleep occur more often than normal), and type 2 diabetes mellitus. Record review of Resident #55's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 99, which indicated the resident to have severe cognitive impairment. Further review revealed the resident had a life expectancy of less than 6 months and had received hospice care while a resident at the facility. Record review of Resident #55's Care Plan, last review completed 09/19/2023, revealed a focus: The resident has a terminal prognosis r/t bradycardia, not candidate for pacemaker. admitted under [Hospice A] services. Intervention listed was work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. There was no further hospice interdisciplinary team information, visit frequencies, or coordination of care to be provided found in the care plan. Record review of Resident #55's electronic medical record Order Summary Report of Active Orders as of 11/16/2023, revealed an order on 03/16/2023 for: Admit into [Hospice A] under care of MD [name]. DX CHF. Record review of Resident #55's electronic medical record, miscellaneous documents, revealed only an election of hospice benefits and certification of terminal illness. In an observation and interview with LVN D on 11/16/2023 at 1:39 p.m., LVN D located a hospice binder at the nurse's station and a hospice folder in Resident #15's room. Both the binder and folder contained only general information regarding the hospice agency but not specific to Resident #15. LVN D was unable to locate a binder for Resident #55. LVN D stated she could call the hospice agency to ask why the documentation was not in the facility. In an interview with the SW on 11/16/2023 at 1:50 p.m., the SW revealed she discusses with families their options and makes the referrals to hospice and then the charge nurse coordinates with the hospice representative and family to complete admission documentation. The SW stated Resident #15's hospice election form and certificate of terminal illness were found in the business office. The SW added that sometimes the hospice agencies leave those documents with the business office for billing purposes. In a follow-up interview with the SW on 11/16/2023 at 2:33 p.m., the SW provided the POC (Plan of Care) and stated the hospice agency had faxed the POC over today after the SW called and requested. The facility had not received any other IDT documentation. Record review of the facility's hospice services agreement with [Hospice Company A], with effective date October 24, 2023, revealed, in Agreements: 2. Services to be provided by hospice; 2.2 (a) Initial Plan of Care. In accordance with applicable federal and state laws and regulations, Hospice shall coordinate with Facility to timely develop a Plan of Care for each new Hospice Patient. Hospice shall furnish Facility with a copy of the Plan of Care within twenty-four (24) hours of its completion. 4. Communication; Hospice and Facility will communicate with each other either verbally weekly or at each hospice patient visit to ensure that the needs of each hospice patient are addressed and met 24 hours per day. Documentation of such communication shall be included in the patient's medical record. 3. Record review of Resident #97's Admission Record documented a [AGE] year old male admitted to the facility 10/05/23 with diagnoses that included unspecified dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems), heart failure, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), dysphagia (trouble swallowing), and acquired absence of left upper limb below elbow. Resident #97 was also noted to be on hospice services upon his admission to facility. Record review of Resident #97's Baseline Care Plan with the effective date of 10/06/23 upon admission indicated a code status of DNR and the name of the hospice company was under the section titled, DIsciplines that contributed to the Post Admission Plan of Care. Record review of Resident #97's MDS dated [DATE] in Section O - Special Treatments, Procedures, and Programs had Hospice Care checked under b. While a resident. During an interview with the DON on 11/15/23 at 3:25 PM, the presence of hospice binders was discussed. When surveyor had asked for the binder for Resident #97 at the nurse's station, no binders could be found. The DON stated she would have someone look for the binder since often the hospice agencies kept a folder in the resident's room. Record review of the information faxed to facility on 11/16/23 by [Hospice Company B] only revealed the Hospice Medicare Election Statement, the Hospice Admission Consent forms, and the Hospice Level of Care information. Record review of the hospice binder for Resident #97 produced on 11/16/23 at 03:47 PM revealed the hospice binder had information faxed earlier but was still missing the Individual Hospice Election Form 3071 and the Physician's Certification of Terminal Illness form 3074. Hospice Plan of Care forms listed Advance Directives as DNR, but no DNR form was in the binder and could not be located. During an interview on 11/17/23 at 10:47 AM with the DON, the DON stated, We are responsible for ensuring all the forms from hospice are here - especially for DNRs. Medical Records is responsible for ensuring Hospice forms are completed and in the building. The DON stated she did not know why the Forms 3071 and 3074 were not in the binder or available for Resident #97. Record review of the facility's policy titled, Hospice Program, revised July 2017, revealed, 12. Our facility has designated the DON and the SW to coordinate care provided to the resident by our facility staff and the hospice staff .He or she is responsible for the following: d. Obtaining the following information from the hospice: (1) The most recent hospice plan of care specific to each resident; (2) Hospice election form; (3) Physician certification and recertification of the terminal illness specific to each resident; (4) Names and contact information for hospice personnel involved in hospice care of each resident; (5) Instructions on how to access the hospice's 24-hour-on-call system; (6) Hospice medication information specific to each resident; and (7) Hospice physician and attending physician (if any) orders specific to each resident. .13. Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by the facility (including the responsible provider and discipline assigned to specific tasks) in order to maintain the resident's highest practicable physical, mental and psychosocial well-being. 44903

Based on interviews and record reviews, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program for 15 of 26 employees (CNA C, CNA E, CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, LVN L, LVN M, LVN N, RN O, PT P, the FNSD and the AD) reviewed for training, in that: The facility failed to ensure that quality assurance and performance improvement training was provided to CNA C, CNA E, CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, LVN L, LVN M, LVN N, RN O, PT P, the FNSD and the AD. This failure could place residents at risk of staff not being aware of the facility's QAPI processes that focus on the outcomes of care and quality of life due to a lack of training. The findings included: Review of the Facility Staff Roster, undated, revealed: CNA C - date of hire - 08/07/2013 CNA E - date of hire - 04/26/2022 CNA F - date of hire - 03/25/2022 CNA G - date of hire - 02/17/2022 CNA H - date of hire - 10/29/2021 CNA I - date of hire - 08/25/2021 CNA J - date of hire - 05/01/2019 CNA K - date of hire - 03/13/2015 LVN L - date of hire - 11/24/2021 LVN M - date of hire - 10/01/2021 LVN N - date of hire - 12/17/2015 RN O - date of hire - 01/16/2014 PT P - date of hire - 10/30/2015 FNSD - date of hire - 10/01/2021 AD - date of hire - 08/10/2017 During a record review and interview with the HR Personnel on 11/17/2023 at 1:55 p.m., the HR Director revealed online training transcripts for each reviewed employee. The HR Director confirmed QAPI was not one of the trainings that trigger for staff to take each month and therefore CNA C, CNA E, CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, LVN L, LVN M, LVN N, RN O, PT P, the FNSD and the AD had not received training of the QAPI program. The HR Director further explained that corporate had established a set of required trainings and staff were prompted each month to take a particular training modular to stay current. During an interview with the Administrator on 11/17/2023 at 2:40 p.m., the Administrator stated she was not aware of the requirement for QAPI training for all staff however she would discuss it with corporate staff to ensure the training was added for all staff. Record review of the facility's policy titled, Facility Assessment, revised October 2018, and the attached facility assessment, revealed, 7. Personnel. Training includes all required topics outlined in 483.95 (a)-(i).

Based on interviews and record reviews, the facility failed to ensure residents' right to formulate an advance directive for 4 of 12 residents (Residents #2, #34, #55, and #97) reviewed for advanced directives, in that: 1. The facility failed to ensure Resident #2's Out-of-Hospital Do Not Resuscitate (OOH-DNR) was executed correctly as it was not signed by witnesses or a physician and there were no dates on the form. 2. The facility failed to ensure Resident #34's OOH-DNR was executed correctly as the physician's printed signature and license number were missing from the form. 3. The facility failed to ensure Resident #55's OOH-DNR was executed correctly as it was not signed by the responsible party and there was no date the form was signed. 4. The facility failed to ensure Resident #97's OOH-DNR was in the medical record. These failures could place residents at-risk of not having their end of life wishes honored. The findings included: 1. Record review of Resident #2's Admission Record dated 11/17/23 documented an [AGE] year-old female admitted to facility 11/27/20. Her diagnoses included unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), dysphagia (difficulty swallowing), chronic kidney disease (long standing disease of the kidneys leading to renal failure), anemia (blood doesn't have enough healthy red blood cells), peripheral vascular disease (a slow and progressive circulation disorder - narrowing, blockage, or spasms in a blood vessel) and atherosclerotic heart disease of native coronary artery without angina pectoris (when fats, cholesterols and other substances collect on the inner walls of the heart's arteries which hinders the supply of blood and oxygen to the heart). The Admission Record also indicated resident was her own responsible party. Record review of Resident #2's Quarterly MDS dated [DATE] revealed a BIMS score of 2 indicating severe cognitive impairment. Record review of Resident #2's OOH-DNR form was signed by a person listed as Emergency Contact #1 on the Admission Record but checked as Guardian on the DNR. The form was dated 02/26/23. There were no witnesses on the form and an illegible signature on the line for the physician that read Declaration by physician based on directive to physicians by a person now incompetent or nonwritten communication to the physician by a competent person. The same illegible signature was found on the lines for the Physician's Statement, the line for Directive by two physicians as well as the line at the bottom of the form indicating the document has been properly executed. There was no printed signature for the physician, a license number or a date. The person who signed the form at the top of the page as guardian did not sign the bottom of the form. During an interview on 11/16/23 at 10:58 AM with the SW, the DNR form for Resident #2 was discussed. SW stated the form was not valid since it was not completed correctly. The SW stated, I will get with the resident and let her know that she will need to be a full code until the DNR is redone. I will call her family member since he signed the original form. I don't know why it was filled out like this. During the interview on 11/16/23 at 10:58 AM, the SW stated, our Medical Records person told our corporate office that we needed to have a paper copy of each DNR so I've started completing a DNR binder. The SW did not have a copy of Resident #2's DNR in the binder. The SW stated the purpose of having a readily available copy of the DNR was to be able to send a copy of the DNR along with the Face Sheet and MAR if EMS came to take a resident to the hospital. Furthermore, the SW stated it was the policy of this company to recognize a DNR as valid if the family or resident had signed the form along with witnesses even though they were waiting for the physician's signature. 2. Record review of Resident #34 Admission Record dated 11/14/23 documented an [AGE] year-old female admitted to the facility 03/25/21. The diagnoses included cerebral infarction due to thrombosis of unspecified cerebral artery (stroke caused by blood clot), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (severe or complete loss of strength on one side of the body following a stroke) and major depressive disorder (a persistently low or depressed mood). The Advance Directive status on this form was listed as DNR. Record Review of the DNR form for Resident #34 did not include a printed physician's signture or license number on the form. During an interview with the SW on 11/16/23 at 10:58 AM, the SW was asked to review the DNR form for Resident #34 that showed the form did not contain the physician's printed signature or license number. Although the SW thought the form would still be considered valid, she stated she would have the form corrected. 3. Record review of Resident #55's face sheet, dated 11/16/2023, revealed the resident had an original admitted [DATE] and a most recent re-admitted [DATE] with diagnoses that included: heart failure, acute respiratory failure with hypoxia (condition where region of the body is deprived of adequate oxygen supply), sleep apnea (sleep disorder in which pauses in breathing or periods of shallow breathing during sleep occur more often than normal), and type 2 diabetes mellitus. Further review of Resident #55's face sheet revealed under the section ADVANCE DIRECTIVE: **Code Status: ***DNR***. Record review of Resident #55's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 99, which indicated the resident to have severe cognitive impairment. Record review of Resident #55's Care Plan, last review completed 11/14/2023, revealed a focus: Resident is a DNR. Resident wishes will be followed. Date initiated 03/15/2023 and revision on 09/14/2023. Record review of Resident #55's electronic medical record Order Summary Report, Active Orders as of 11/16/2023, revealed an order dated 03/14/2023 for **Code Status: ***DNR***. Record review of Resident #55's OOH-DNR, dated 03/14/2012, revealed a family member, two witnesses and the physician had signed the OOH-DNR. Further review revealed Resident #55's OOH-DNR was not signed by the resident's responsible party and was not dated by the RP. In an interview with the SW on 11/16/2023 at 1:50 p.m., the SW revealed Resident #55 did not have an MPOA in place however one of her family members had been identified upon admission as her RP. The SW stated a family member had signed the OOH-DNR but it was not the designated RP. The SW further added that the OOH-DNR should have been signed and dated by the designated RP as the qualified family member approved to give consent. The SW stated she had not worked at the facility during that time period and hospice assisted with the completion of the OOH-DNR document, however the hospice agency did not have an MPOA on file. The SW stated the OOH-DNR would be considered invalid, and she would obtain a new OOH-DNR. 4. Record review of Resident #97's Admission Record documented a [AGE] year old male admitted to the facility 10/05/23 with diagnoses that included unspecified dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems), heart failure, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), dysphagia (trouble swallowing), and acquired absence of left upper limb below elbow. Resident #97 was also on hospice services. Record review of Resident #97's electronic medical record did not reveal the presence of a DNR form although his electronic chart indicated he was a DNR. Record review of Resident #97's undated Care Plan revealed a Problem area with a Date Initiated of 10/07/23 that stated, I have completed documentation for DNR status. Record review of the Hospice binder with information for Resident #97 revealed an IDT Care Plan form that indicated a certification period of 10/05/23 to 12/03/23. Under the Heading Advance Directive was written Do Not Resuscitate. During an interview on 11/16/23 at 11:03 AM, the SW indicated Resident #97 was on hospice. The SW stated the facility was not given a copy of the DNR when he transferred here. The SW stated she would try to contact the hospice company again to get the DNR form. During an interview and record review on 11/16/23 at 03:43 PM, the SW stated they had been unable to reach anyone at the hospice agency who could provide the DNR so the resident had to be treated as a full code until they could get the required document. Following this conversation with the SW, a further record review of the electronic medical record and Admission Record revealed Resident #97 code status was changed to reflect Full Code. The SW stated she had called the family to inform them of this situation. During an interview on 11/17/23 at 10:37 AM with the DON, the DNR process was discussed. The DON stated the DNR process was different from the hospital since the patient or family just had to ask to be a DNR at the hospital. The DON stated that in the long-term care facility, the family or resident had to sign the OOH-DNR form along with 2 witnesses and the physician had to sign. The DON stated the form was not valid until the physician had signed and dated the form, added the physician's license number and all parties had signed and dated in both places of the form. The DON was asked if there were risks related to invalid OOH-DNRs and the DON responded that a resident could be coded when they had chosen not to be, and their rights not honored. The DON added the SW had contacted the families to make the changes needed. The DON stated they had a code in-service to verify DNRs. Record review of the facility's policy titled, Do Not Resuscitate Order, undated, revealed, 1. Do not resuscitate orders must be signed by the resident's attending physician on the physician's order sheet maintained in the resident's medical record. 2. A Do Not Resuscitate (DNR) order form must be completed and signed by the attending physician and resident (or resident's legal surrogate, as permitted by state law) and placed in the front of the resident's medical record. 4. Should the resident be transferred to the hospital, a photocopy of the DNR order form must be provided to the personnel transporting the resident to the hospital. 5. Do not resuscitate (DNR) orders will remain in effect until the resident (or legal surrogate) provides the facility with a signed and dated request to end the DNR order. 6. The interdisciplinary care planning team will review advance directives with the resident during quarterly care planning sessions to determine if the resident wishes to make changes in such directives. 44903

Based on interview and record review, the facility failed to ensure the resident's right to participate in the development and implementation of his or her person-centered plan of care, for 1 of 6 Residents (Resident #73) reviewed for care plans. The facility failed to conduct 11 quarterly care plan meetings to discuss Resident #73's care since his admission in 2021. This failure could cause residents not to be able to participate in the planning of their care, not receiving the care they want or need, and not being informed of all services offered by the facility. The findings were: Record review of the Admission Record for Resident #73 documented a [AGE] year old male admitted to facility 12/15/21 with diagnoses that included Guillain-Barre Syndrome (a rare neurological condition in which a person's immune system attacks their peripheral nervous system), obstructive and reflux uropathy (when urine can't flow {either partially or completely} through the ureter, bladder or urethra due to some type of obstruction), presence of urogenital implants (injections of material into the urethra to help control urine leakage caused by a weak urinary sphincter), dysphagia (difficulty swallowing) and muscle weakness. Record review of Resident #73's MDS Annual assessment dated [DATE] revealed a BIMS score of 14 indicating resident was cognitively intact. During an interview with Resident #73 on 11/15/23 at 2:38 PM, resident stated he had not had any care plan meetings since he was admitted in 2021. Resident #73 stated he would like to have a meeting and his family member, who visits daily, would also be available to participate in a meeting. Resident #73 stated that neither he nor his family member had ever been asked to participate in a care plan meeting. On 11/16/23 at 11:28 AM, the Social Worker was interviewed regarding care plan meetings. The Social Worker stated the purpose of care plan meetings was to discuss an overview of the residents' services. The SW stated, We talk about any discharge plans, code status and concerns. The SW stated she had only been in the facility for 3 weeks so was trying to get acquainted with all the residents. She checked the records and could not find any record of care plan meetings that had been held in the past for Resident #73. The SW stated she was aware Resident #73's family member was here daily so it would be easy to schedule a meeting with her as well as the resident. The SW stated Resident #73 will be added to their care plan list for this month. Record review of an undated policy for the Comprehensive Resident Care Plans revealed: Each resident's plan of care shall be developed within seven days after completion of the comprehensive assessment. Comprehensive care plans are prepared by an interdisciplinary team that integrates resident participation and preferences. The interdisciplinary team includes .6. The resident, the resident's family, or the resident's representative to the extent practical. An explanation will be in a resident's medical record if the participation of the resident or their resident representative is determined not practicable for the development of the resident's care plan .The resident can request a care plan meeting; participate in setting goals and outcome of care regarding type, amount, frequency and duration of care; receive the services in the plan of care; see the care plan; request revisions; and sign after significant changes.

Based on observation, interview and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 2 of 7 residents (R#20 and 80), reviewed for care plan revisions, in that: R#20 requested an activity preference while in isolation that did not result in the revision of CP involving activities and CP was not revised. R#80 requested an activity preference while in COVID-19 isolation that did not result in the revision of CP involving activities and CP was not revised. These failures could place residents at risk for lack of coordination of services and activity preferences. The finding included: Record review of Resident #20's face sheet, dated 11/15/2023, and EMR revealed, the resident was admitted on [DATE] with diagnoses that included: MRSA (infection resistant to antibiotics), depression, and HTN. Resident was a male; age 91. RP was listed as: the resident. Record review of Resident #20's Care Plan, dated 10/27/2023, revealed, the goals and interventions for activities included: share the activity calendar and to remind the resident to attend group activities. CP was not revised to list the resident's activity preferences while the resident was in isolation for MRSA. Record review of Resident #20's MDS, dated [DATE], revealed: o BIMS Score was 13 (cognitively intact) o ADLs: B/B was continent of bowel; and catheter for bladder. Transfer was supervision. Bed Mobility was supervision. ROM: no impairment. Record review of an Activity Director's progress note for Resident #20 dated 11/08/2023 revealed: she attended the IDT meeting. Activity intervention was to visit resident. Record review of Resident #80's face sheet, dated 11/15/2023, and EMR revealed, the resident was readmitted on [DATE] with diagnoses that included: Acute and chronic respiratory failure, COVID-19, and depression. Resident was a female; age 80. RP was listed as: the resident. Record review of Resident# 80's Care Plan, dated 11/01/2023 , revealed, the goal of activity and interventions included: invite to group activities, AD will visit me 2-3 times per week and provide 1:1 [activity] .AD will visit me 2-3 times a week to provide activity supplies if needed and to engage in conversation ., and the share the activity calendar. CP was not revised to reflect activities while the resident was in isolation for COVID-19 (isolation started on 11/06/23). Record review of Resident #80's MDS, dated [DATE], revealed: o BIMS Score was 15 (cognitively intact) o ADLs: B/B was frequently incontinent for both. Transfer was required assistance one staff. Bed Mobility was required assistance one staff. ROM: no impairments. During an observation and interview on11/15/2023 at 10:44 AM revealed the resident (R#20) was in bed; alert and oriented. The resident stated that he felt bored and wanted some activities. The resident stated he enjoyed listening to music and family visits. The activity the resident requested was to leave his room and be outside in the sunlight. The resident stated he had no visits from the activity director. During an interview on 11/15/2023 at 11:51 AM, the Activity Director stated: there were about 12 residents that were bedfast or did not leave their room. She added that there were three residents in isolation. I have not developed an individualized calendar for residents who are bedfast or in isolation .Administration has never told me about an individualized calendar .I have not seen resident [R#20] lately and asked about activity .no summary notes on either resident [ R#20 and R#80] this past month .I am still looking for a policy on activities for bedfast residents or residents in isolation . The AD stated that the CP for R#20 and R#80 were not revised during the time the residents were in isolation. During an interview on 11/15/2023 at 2:32 PM, the Administrator stated: the Activity Director reports to the Administrator. The Administrator stated per policy every resident was assessed for activities and preferences. Also, per policy, the Administrator stated the Activity Director, or a designee will visit a bedfast resident. The Administrator's expectation was that the visit be documented; and CP updated as appropriate. The Administrator will check on the existence of documentation The Administrator stated the residence's activity assessment and any updates were captured in the comprehensive care plan. During an interview on 11/15/2023 at 3:06 PM, the DON stated that all staff knew if a resident verbalized an activity desire; it needed to be documented. Residents on hospice, isolation, cognitively impaired, bedfast and COVID positive were required an activity assessment and updated if there was a major change of condition. The DON stated the CP was updated for activities when a change of condition occurred and the resident expressed an activity preference that was new and not captured in the initial CP. The DON stated the facility had 7 residents in isolation and to include one resident in isolation for COVID 19 positive. The DON was not certain whether the care plans for residents (R#20 and R#80) had been updated to reflect any new activity preferences the resident made during isolation. The DON revealed that R# 80 was COVID-19 positive on 11/06/2023. During an observation and interview on 11/15/2023 at 5:35 PM, R#80, (isolated for COVID-19), revealed: she was alert and oriented to person and place; receiving continuous oxygen. The resident was in bed watching TV. The resident stated she had a visit from the Activity Director late in the afternoon (11/15/23) to discuss activity preferences while in isolation. Resident stated this was the first time since she was in isolation for COVID-19 that staff inquired about her activity preferences. The resident stated that an activity she wanted daily was to have a non-clinical interaction with a staff member so as to feel human. The resident stated she did not want her family to visit because of fear they would be exposed to COVID-19. During an interview on 11/16/2023 at 9:44 AM, LVN A (MDS) stated: the CP was revised when there was a change in the resident or a new assessment requiring a CP revision. LVN A stated that she was not aware of any revisions to the CP involving activities when the resident (R#80) converted to COVID-19 positive on 11/06/23. Regarding resident (R#20), he was put in isolation upon admissions (10/27/23) because of the diagnoses of MSRA. LVN A stated that (R#20's) CP had not been revised for activities since admissions. Record review of the facility's Comprehensive Care Plans, undated, read: Each resident's plan of care shall be reviewed by an interdisciplinary team after each MDS assessment is conducted and revised as necessary to reflect the resident's care needs .

Based on 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 include measurable objectives and time frames to meet residents' mental, nursing, and psychosocial needs and to ensure that the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including the right to refuse treatment for 1 of 6 residents (Resident #15) reviewed for care plans, in that: The facility failed to implement Resident #15's comprehensive person-centered care plan to address oxygen use and therapy services. This failure could affect residents who have care areas not addressed by the care plan by not having their needs met and putting them at risk of not receiving appropriate care. The findings included: Record review of Resident #15's face sheet, dated 11/16/2023, revealed the resident was initially admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included: fractured right femur, muscle wasting and atrophy, dysphagia (difficulty swallowing), and moderate protein-calorie malnutrition. Record review of Resident #15's Significant change MDS, dated [DATE], revealed the resident had a BIMS score of 02, which indicated severe cognitive impairment. Further review revealed the resident had a used oxygen while a resident at the facility and within the last 14 days. Continued review of Resident #15's MDS revealed resident had received PT, OT, and ST services in the last 7 days, with a start date for therapy services of 10/20/2023. Record review of Resident #15's Comprehensive Care Plan last review completed 11/05/2023, revealed no focus area related to oxygen use. Further review revealed no focus area related to PT, OT, or ST services. Record review of Resident #15's electronic medical record Order Summary Report of Active Orders as of 11/16/2023, revealed an order on 10/19/2023 for: 02 @ 4L/Min via NC PRN to maintain 02 sats > 92% PRN. Record review of Resident #15's electronic medical record Medication Administration Record dated 11/1/2023-11/30/2023, revealed oxygen therapy had been administered daily from 11/01/2023 through 11/15/2023. In an interview with LVN A, (one of the MDS coordinators) on 11/15/2023 at 2:54 p.m., LVN A revealed she and another LVN share the responsibility of updating care plans. LVN A stated the oxygen therapy, PT, OT, and ST services should have been on the comprehensive care plan and must have been overlooked. LVN A identified potential risks related to care plans due to care plans show the staff what the resident's needs are. In an interview with the DON on 11/15/2023 at 3:08 p.m., the DON revealed care plans must be accurate for staff to have the information needed to provide specific care for residents. Record review of the facility's policy titled, Comprehensive Resident Care Plans, undated, revealed, .All items or services ordered to be provided or withheld shall be included in each resident's plan of care .Each resident's plan of care shall be developed within seven days after completion of the comprehensive assessment.

Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for one (1) of seven (6) residents (Resident #1) reviewed for accidents and hazards: The facility failed to develop and implement interventions to prevent Resident #1 's elopement from the facility. Resident #1 eloped from the facility on 03/31/23 and was returned to the facility by local police department. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 03/31/2023 and ended on 03/31/2023. The facility corrected the non-compliance before the investigation began. This deficient practice could place the residents at risk for harm, serious injury or death. The findings were: Record review of Resident #1's admission record dated 10/31/23 documented an [AGE] year-old male admitted to the facility on [DATE] and discharged on [DATE]. The form further documented Resident #1 with diagnoses including, unspecified atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular beating of the atrial chambers of the heart), muscle weakness generalized (reduction in the power exerted by muscles resulting in an inability to perform a given task on first attempt), muscle wasting and atrophy (a decrease of muscle mass and strength), abnormalities of gait and mobility (any unusual or unexpected patters of movement or changes in the way an individual walks or moves), lack of coordination (group of symptoms that cause impaired direction), fall, Alzheimer's disease onset (progressive disease that destroys memory and other important mental functions). Resident #11 was not identified as his own responsible party. Record review of Resident #1's MDS assessment dated [DATE] revealed cognitive pattern was not tested . The MDS documented a 0 when asked Has the resident wandered?, indicating the behavior had not been exhibited. Record review of Resident #1's comprehensive care plan revealed that Resident #1 was an elopement risk/wanderer related to disoriented to place, history of attempts to leave facility unattended, resident wanders aimlessly with an initiated date of 03/31/23 and a revision date of 04/01/23. Listed goals included the resident's safety will be maintained through the review date. Listed interventions included, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Other goals included identify pattern of wandering and initiate visual checks Q2hrs (every two hours) . All with initiation date of 04/01/23. Record review of Resident #1's physician order revealed an order for behavior monitoring for (wandering, agitation, exit seeking behavior) medication (name of med) document # of times resident has exhibited the above behavior during shirt. Intervention codes: 00 none; 1) 1 on 1; 2) Activity; 3) Adjust room temperature; 4) Backrub; 5) Change position; 6) Give fluids; 7) Give food; 8) Redirect; 9) Remove resident from environment; 10) Return to room; 11) Toilet .every shift document resident outcome following intervention using the following codes . with a start date 03/31/23 and that was discontinued with no end date noted. Record review of Resident #1's April 2023 licensed nurse administration record of dated 11/03/23 revealed order had been completed and documented for every shift on 04/01/23 as ordered. Record review of Resident #1's Wandering Evaluation completed upon admission on 03/29/23 at 01:08 a.m., documented a summary of finding score of eight (8) indicating resident was a moderate risk for wandering. Additional comments included Patient tries to get out of bed and voices that he wants to leave the facility. A&Ox1 (alert and oriented to self). Record review of Resident #1's progress notes signed and dated by LVN D on 03/29/23 at 01:14 p.m. revealed, Resident was constantly getting up from bed and trying to go into other resident's room, [Nurse practitioner] was notified by night SN (skilled nurse) and got new orders for melatonin 5 mg (milligrams) prn (as needed) at bedtime. SN got verbal consent from resident's sister to administer medication as ordered. Medication was administered. Orders carried out. Record review of Resident #1's progress notes signed and dated by LVN E on 03/30/23 at 01:20 p.m. revealed, Behavioral issues: plays with feces, goes into other resident's rooms, and undresses .melatonin for insomnia. Record review of Resident #1's progress notes signed and dated by LVN B on 03/31/23 at 03:29 revealed, [Police] came to facility to ask if we were missing a resident. Did a quick head count and resident was not in bed. It was confirmed that it was our resident. Resident was placed in wheelchair and brought into facility and back to his room. Assessed resident and no injuries noted. Case # left by PD. Reported to [administrator] and RP made aware. Record review of Resident #1's progress notes signed and dated by MSW on 03/31/23 at 10:07 a.m. revealed, LMSW (licensed master social worker) spoke to patient's daughter/POA (power of attorney) via telephone. SW (social worker) informed patient's daughter that patient needs a memory care unit due to elopement and wandering behaviors. Patient's daughter in agreement with referral and chose [nursing facility]. SW sent clinical information to liaison for [nursing facility for processing. SW to follow. Record review of Resident #1's progress notes signed and dated by LVN A on 03/31/23 at 11:26 a.m. revealed, resident agitated wandering in 100 and 400 halls, redirected resident several times. Spoke with [physician assistant] regarding resident's condition and elopement episode from previous shift. New order for Zyprexa 5 mg (milligram) po (by mouth) x 1 (times one) dose and continue with Zyprexa 5 mg po qhs (every night at bedtime) orders carried out. Placed call to RP and second contact x 3 attempts to obtain consent for Zyprexa. No answer left voicemail. [Nurse Practitioner] aware of new order for Psych consult, pending at this time. Record review of Resident #1's progress notes signed and dated 03/31/23 at 07:54 p.m. by LVN C revealed, visual check every 2 hours. Record review of TULIP (HHSC online incident reporting application on 10/31/23 at 09:00 a.m. revealed the facility made a self-reported incident on 04/01/23 p.m. at 05:18 p.m. regarding Resident #1's elopement). Record review of facility Incidents by Incident Type dated 10/24/23 for reporting period March 2023 listed elopement incidents: Resident #1 dated 03/31/23 at 03:00 a.m. Record review of the facility map and evacuation routes, a total of eight (8) exits were identified as exit doors. Initial rounds were conducted on 10/31/23 beginning at 08:30 a.m. throughout the facility. The facility was well lit, temperature was comfortable, and staff were seen appropriately interacting and assisting residents in their rooms and in the hallways. The facility census was ninety-eight (98). Resident rooms were clean, orderly, without any noted hazards or clutter. There were no sounds of yelling, screaming, or moaning. Residents in bed had their call lights within their reach. Call lights were observed activated and timely answered. Nurses were administering care and medications in a timely manner. Water and belongings were observed at the bedside of the residents and within their reach. No resident was observed to display any disrupting or aggressive behaviors. No injuries or bruising was noted on any resident that would raise suspicion of abuse or neglect. There were no active cases of COVID-19 positive residents in the building. Visitors were observed entering and exiting through the main entrance after being allowed entrance. Other exit doors locked and secured with codes and screech alarm. Observation on 10/31/23 at 09:00 a.m. of the surrounding streets revealed a highly trafficked four lane road with a center lane and a speed limit of 40 miles per hour. Interview on 11/01/2023 at 10:45 a.m., CNA P revealed she had been employed eight (8) years by the facility and her responsibilities included assisting the nurses and residents on hall 100. CNA P stated exit doors have a code that allows entry or exit through them. CNA P stated staff should not be sharing codes with residents or visitors. CNA P stated she did not recall a resident who may have eloped anytime within the past year. Interview on 11/01/2023 at 11:00 a.m., CNA Q revealed she had been employed three (3) weeks by facility and her responsibilities were assisting the nurses and residents on hall 100. CNA Q stated she received report and rounded on all residents assigned to her on the hall she worked. CNA Q stated she tried to maintain an open communication with other staff to account for all residents. CNA Q stated she was not aware of any residents who had been missing recently. CNA Q stated if a resident was missing she would ask a coworker or nurse to assist in helping find the resident. that exit doors had alarms that activated if pushed. CNA Q stated she did not have access codes to the exit doors. Interview on 11/01/23 at 11:35 a.m., CNA R revealed she had been employed for three (3) years by the facility and her responsibilities included assisting the nurses and residents of hall 200. CNA R stated exit doors do not have cameras, but they do have alarms that are activated if pushed. CNA R stated alarms on the doors could be deactivated when a code is entered on the keypad. CNA R stated that not all staff members had the codes and if they did they should not share them with residents and visitors. CNA R stated she was unaware of how often the exit door codes were changed. CNA R stated residents could only go outside if they were signed out with a family member. CNA R stated she had not been in a situation like that. CNA R stated staff are instructed to search for the resident in every hall and room. CNA R stated she would ask other nurses or CNAs for the whereabouts of the resident and that the nurse would decide what protocol to follow. CNA R stated the nurse will notify administration and family. Interview on 11/01/23 at 12:20 p.m., CNA S revealed she had been employed for eight (8) years by the facility and her responsibilities including assisting the nurses and residents of hall 300. CNA S stated residents were not allowed to go outside unless with family members after they had signed them out but not by themselves or unsupervised. CNA S stated the facility was a nonsmoking facility and there was no designated area for smoking or staff to assist residents outside of the building. CNA S stated if a resident was missing, she would ask a nurse and other staff on the whereabouts of the resident and inform the administrator or the DON. CNA S stated she would look for the resident in hallways, rooms and everywhere until found. CNA S stated the next step would be to involve the police. CNA S stated exit doors have an alarm that is deactivated with a code that secures the exit. CNA S stated exit doors will alarm if a resident attempts to exit. CNA S stated staff do not share codes with residents or visitors. Interview on 11/01/23 at 12:35 p.m., CNA T revealed she had been employed for three (3) months by the facility and her responsibilities included assisting the nurses and residents of hall 300. CNA T stated residents are not allowed to go outside unsupervised. CNA T stated residents may go outside if accompanied by family. CNA T stated there was no assigned area outside for residents to out to. CNA T stated exit doors are secured by an alarm that would deactivate with a code entered on a keypad. CNA T stated codes are not shared with residents or visitors. CNA T stated residents were accounted for on each round. CNA T stated rounds were done every two (2) hours or more often if needed. Interview on 11/01/23 at 12:55 p.m., CNA U revealed she had been employed for five (5) months by the facility and her responsibilities included assisting the nurses and residents of the facility as a float CNA. CNA U stated residents are not allowed to go outside unsupervised unless with family. CNA U stated exit doors are secured with an alarm that will activate if opened. CNA U stated alarms can be deactivated by codes that must be entered on a keypad. CNA U stated residents nor visitors have access to the codes. CNA U stated she made sure all residents were in the facility during rounds and rounds are done every two hours or more often if needed. CNA U stated she will report to the nurse if a resident is not found in the facility. CNA U stated staff will look for resident in his/her room, restroom, and all areas of the facility. Interview on 11/01/23 at 02:50 p.m., RN/MDS revealed she had been employed for two and a half (2.5) years by the facility and her responsibilities included infection control duties, assistant director of nursing duties and as part of the interdisciplinary team to create patient care plans. RN/MDS stated the facility had no designated areas for smoking and residents were only allowed to go outside if supervised as part of their therapy or with family. RN/MDS stated residents were accounted for when staff performed their rounds. RN/MDS stated exit doors had codes that were not shared with residents or visitors. RN/MDS stated she was not aware of any incidents involving elopement. Interview on 11/01/23 at 03:20 p.m., LVN A revealed she had been employed for 9 years by the facility and her responsibilities included floor nurse and was recently promoted to assistant director of nursing one (1) month prior to this date. LVN A stated she accounts for all residents in the facility by doing a walking round when getting report. LVN A stated if a resident is missing at any time she will look in each room and ask other staff to help locate the resident in other areas of the facility. LVN A stated she would then notify the family, the physician, the administrator, and the police. LVN A stated she would then search outside the facility in each direction. LVN A stated this process is not delayed stating, immediately, you do not wait minutes, if you cannot find the resident in the facility you activate the elopement protocol if a resident cannot be found. LVN A stated rounds by staff are done every two (2) hours and more often if needed and this is how often it is checked to see if residents are here. LVN A stated if residents are at risk of elopement the rounds are increased to every thirty (30) minutes. LVN A stated the facility does not have a locked memory care unit. LVN A stated the facility had an elopement incident months ago, we did have a resident during night shift. LVN A stated staff did not know resident was at risk for elopement and continued by stating, he was a new patient. LVN A stated, he never voiced an intent to leave. He was in room [ROOM NUMBER], I was not here and was not the nurse. LVN A stated LVN B was the nurse assigned. LVN A stated residents are not allowed to go outside unsupervised and can only go with family members. LVN A stated residents nor visitors have access to the exit door codes. LV A stated staff do not know the exit door codes and do not share the codes with residents or visitors. LVN A stated exit doors have an alarm that will be activated if pushed. LVN A stated the push bar must be held for fifteen (15) seconds for the door to release and the alarm will sound. LVN A stated abuse including physical, mental, sexual, verbal, and negligence is reported to the abuse coordinator, the administrator. Interview on 11/01/23 at 04:00 p.m., LVN F revealed she was a new nurse to the facility on ly having been employed there for three (3) days and her responsibilities included floor nurse and administering medications. LVN F stated she was present when incident happened and did not know any of the details; however, she stated she was aware she needed to perform walking rounds to ensure all residents were in the facility. LVN F stated rounds were performed every two (2) hours or more often if needed. LVN F stated that if a resident could not be located within the facility, the elopement protocol would be initiated and that involved looking at all areas within the facility and outside the facility. LVN F stated physician, family and the police would be notified. LVN F stated exit doors were secured by alarms that were deactivated with a code. LVN F stated the alarm will not stop until someone deactivates it. LVN F stated abuse including verbal, physical, misappropriation of property, and neglect are reported to the abuse coordinator, the administrator. Telephone interview on 11/01/23 at 04:35 p.m., LVN C revealed he had been employed for eight (8) months by the facility and his responsibilities included floor nurse of hall 300. LVN C stated Resident #1 was admitted around 10:00 p.m. during his shift on 03/28/23. LVN C stated he performed his assessment, which included an elopement risk assessment, and it indicated Resident #1 was a Moderate risk. LVN C stated Resident #1 was ambulatory, he was curious about going to the therapy room, the halls, and going to other rooms. LVN C stated Resident #1 used a walker. LVN C stated his family was present at the time of admission and did not mention Resident #1 having a history of leaving or eloping. LVN C stated Resident #1 was alert and oriented only to self and not oriented to situation. LVN C stated, Resident #1's judgment and critical skills were impaired. LVN C stated he did not remember all of the details of the incident being that time had elapsed; however, LVN C stated Resident #1 was only at the facility for a short period due to Resident #1 being sent to the hospital. LVN C stated Resident #1 was brought back to the facility after his hospital stay but did not give me any details only that he [Resident #1] was brought back and no new implementations were placed. LVN C further went on to state he ensures all residents are in the facility by doing a walking round. LVN C stated rounds are performed every two (2) hours or more often if needed. LVN C stated other staff can alert nurses if a resident is missing. LVN C stated verify if resident was not out on pass, stepped out with family, on an appointment, or in an activity. LVN C stated staff involve other staff when searching for a missing resident and they must all look at other areas of the building including restrooms. LVN C stated the facility has no designated smoking area and residents are not allowed to go outside unsupervised. LVN C stated if a resident is unable to be located, the local authorities, director/administrator must be notified. LVN C stated that once the resident is found and returned to the facility a full head-to-toe assessment, skin assessment, vital signs must be completed. LVN C stated that the resident must also be interviewed if possible and it must be determined if the resident needs to go to the emergency room for further evaluation and treatment. LVN C stated exit doors have an alarm on top called a screamer. LVN C stated the alarm can be turned off by a key located at the nurse's station. LVN C stated only staff have access to the key. LVN C stated alarms can be deactivated with codes. LVN C stated staff do not know the codes. LVN C stated codes should not be shared with other staff, visitors, or residents. Telephone interview on 11/02/23 at 02:20 p.m., LVN B revealed she had been a nurse employed by the facility for two (2) years and her responsibilities included floor nurse of halls 100, 200 and 300. LVN B stated she was assigned to work hall 100 on 03/31/23. LVN B stated she did not recall the exact details of the incident that happened on 03/31/23 that involved Resident #1. LVN B stated she had performed her initial rounds and ensured the residents were in the facility. LVN B stated she physically rounded to ensure residents were in the rooms and in the facility every two (2) hours and more often if needed. LVN B stated no resident was missing during her last round. LVN B stated no exit door alarm was heard. LVN B stated that the local police department brought the resident to the facility and asked if the resident was missing. LVN B stated that after performing a quick headcount of the residents, the staff realized the resident was from hall 100. LVN B stated she could not remember resident's name or when exactly it happened. LVN B stated her CNA was on break during that time and the resident could not have been gone more than 30 minutes. LVN B stated resident was found by police walking towards [NAME] Road on Sugar Avenue. LVN B stated she performed a head-to-toe assessment upon his return, notified the administrator, the director, and the resident's family of his elopement. LVN B stated staff and herself inspected exit doors and discovered that the exit door at the end of hall 100 had been left unlocked. LVN B stated staff will check exit door to make sure they are locked. LVN B stated a red light above the door indicates the door is locked. LVN B stated that a turn switch can unlock the door and the red light will turn green. LVN B stated after Resident #1's return, the exit door was inspected and a green light indicating the door was unlocked was observed. LVN B stated she did not know how or who left the door unlocked. LVN B stated she could not predict any negative outcome that could have happened to Resident #1 or any other resident with elopement. Interview on 11/02/23 at 04:00 p.m., DON/RN revealed she had been a nurse employed by the facility and assigned to her position for two (2) months. DON/RN stated her responsibilities included oversight of the nurses and staff and oversight for the care of the residents. DON/RN stated she was not employed by the facility on 03/31/23 when the incident happened. DON/RN stated there was no provider investigation report related to the incident and could not reference or give any information related to the incident. DON/RN noted the resident was discharged from the facility since 04/01/23 and was unable to further investigate the incident. DON/RN outlined the facility's current elopement emergency response (ER) plan being implemented. DON/RN stated a code green announced to staff indicated an elopement or missing resident. DON/RN stated all staff were assigned to look in assigned areas and they had routes (such as emergency exit routes) to look for the missing resident. DON/RN outlined two different phases as part of their elopement ER plan. DON/RN stated phase I was when staff searched inside the facility and in the parking area. DON/RN stated phase II was when staff searched anywhere outside the property line. DON/RN stated the resident representative, physician and police would be notified of the resident's missing status. DON/RN stated staff did not waste time. DON/RN stated that once the resident was found, staff should perform a head-to-toe assessment of the resident, notify the resident representative and the physician, document, and place a one to one (1:1) observation of the resident. DON/RN stated the facility had taken an initiative to prevent future elopements including frequent in-servicing of staff on topics of elopement, perform wander/elopement risk assessment to identify high risk elopement residents, and frequent testing of the facility exit doors to make sure doors are locked and secured. Furthermore, the DON/RN stated the facility made sure someone was always at the reception area and that staff rounded to make sure doors remained locked. DON/RN stated exit door codes do not frequently change because not everyone has access to the codes and not everyone has access to the main key located at the nurse's station. Interview on 11/03/23 at 01:40 p.m., Interim Adm A revealed he had been an interim administrator for the facility and that 11/03/23 would be his last day before he was assigned to a different location. Interim Adm A stated he was not familiar with the incident that happened on 03/31/23 involving Resident #1 because he was not there. Interim Adm A stated there was no provider investigation report and he could not reference the report to give any information. Interim Adm A also noted Resident #1 was no longer an active resident of the facility. Interim Adm A stated he was informed a resident was missing and was not sure what process was done or not done. Interim Adm A stated the facility did have a code system that was announced when a resident was missing. Interim Adm A stated the code was divided into two (2) phases: phase I was characterized by immediately informing facility staff and searching for the resident within the facility, informing the ADON, DON and family and performing a head count of all residents. Interim Adm A continued explaining that phase II was characterized by calling the police and helping the entire interdisciplinary team locate the resident outside the facility. Interim Adm A stated exit doors are equipped with a secondary alarm with a 15 second delayed egress and a stop alarm (screech annunciator). Interim Adm A stated exit doors also backup system that was put up in April or May and had a key system with a light system indicating when the door was unlocked and locked (red indicates the door is locked and green indicates the door is unlocked). Interim Adm A stated the facility has prevented future elopements by conducting elopement drills and in-services amongst the staff, evaluation of every exit door at regular intervals, ensuring no one is given the codes to the exit doors, and changing the codes once the codes have been breached. Interim Adm A stated no other elopements have occurred since the single incident that occurred in March. Interim Adm A stated staff have been in-serviced. The following record reviews were conducted by the survey team to ensure the Past Non-Compliance was corrected The following interviews were conducted by the Survey Team on 11/02/2023 and 11/03/2023: 6 CNA's, 2 LVN's, and 2 RN. -Staff acknowledged understanding of the topics they were in-serviced regarding wandering and elopement. -Inservices reflected 45 nursing staff were trainined. Record review of work history report documentation stating, Category: Doors: Task Completion .Marked done on-time . marked each exit tested for dates 11/05/2022 through 10/31/2023 Record review of facility in-service training report revealed facility had a training over Missing Resident In-service on 04/04/23. Record review of facility policy and practices titled Door Alarm/Exit Stopper with no implemented date noted, quoted in part, Exit doors have a Door Alarm/Exit Stopper to provide safety for residents that are confused and have a tendency to wander about the facility . Record review of facility policy and practices titled Wandering/Missing Residents with no implemented date noted, quoted in part, some of the SCC''s facilities do not have secured units and it becomes very important to identify residents who walk or wheel themselves unrestricted and become a threat to leave the facility unattended due to their confusion .The facility must ensure the resident's safety while utilizing the least restrictive means available . Record review of facility policy and practices titled Missing Resident/Patient (Code Green) with no implemented date noted, quoted in part, Process .to help ensure all resources available are coordinated to locate a missing resident/patient, an aggressive campaign may be organized to safely locate and return the resident/patient who has wandered or is deemed missing .