Every finding on record at Knopp Healthcare and Rehab Center Inc

Based on interviews and record review the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 kitchen reviewed.The facility failed to employ a qualified dietician or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified nutrition professional last employed with the facility was in October 2025.The facility failed to employ a qualified dietician who designates a person to serve as a full-time director of food and nutrition services for the facility. The person designated to serve as a director of food and nutrition services was employed for less than 25 hours per week.These failures could place residents at risk of not having their nutritional needs met.Findings included:In an interview on 1/09/2026 at 12:58 PM, the Dietary Manager stated she has been employed with the facility for nearly 21 years. She stated there was no dietician employed with the facility. Dietary Manager stated the last dietician or other clinically qualified nutrition professional last employed with the facility was in October 2025. She stated the facility management has had challenges with finding a dietician on a consultant basis due to being in a rural area. She stated that currently she works 40 hours between two different facilities owned by the company. She stated she feels she possesses the competencies to carry out the food and nutrition services for the facility. She stated that she was tasked with completing resident assessments, collaborating with the physician, DON, speech therapist, resident and at times families to develop individual plans of care. She stated that currently all the tasks required of a dietician or other clinically qualified nutrition professional are being met by her. She stated there is no effect on residents' nutritional needs by not having a dietician on staff.In an interview on 1/09/2026 at 1:22 PM, the ADM stated at this time that the facility has been unable to employ a dietician or clinically qualified nutrition professional. She stated she could not recall the date the last dietician was employed, but less than six weeks. She stated there have been some challenges with finding a dietician to hire on a consultation basis as it is a small city with limited options. She stated yes, the Dietary Manager is not employed on a full-time basis, but she can be contacted by phone if the need arises. She stated residents do not complain about the food they receive and she does not believe there is an impact to patient care or nutrition as the Dietary Manager is constantly collaborating with the DON and physician for resident nutritional needs.Review of the dietary schedule for the kitchen, dated 1/6/2026, reflected no dietician on roster. Surveyor requested information for last dietician employed by the facility and information was not provided prior to exit of survey.Record review of document titled, POLICY AND PROCEDURAL GUIDE FOR THE FOOD SERVICES OF [NAME] NURSING AND REHAB CNTER FREDERICKSBURG, TEXAS undated reflected the following: ORGANIZATION OF THE DEPARTMENTA qualified Dietitian will serve as consultant to the Administrator and to the Food Service Supervisor.The Dietary Consultant works with the Administrator and Food Service Supervisor to:1. Evaluate procedures2. Identify problems3. Establish department goals4. Set up priorities5. Develop in-service training programs6. Assist with specific problems as requested by the Administrator, and Food Service Supervisor B. The consultant will make regular scheduled visits of (16) sixteen hours each month or (20) twenty hours depending on monthly census.C. Planning of general diets, preparation and serving of all diets. The consultant will plan only therapeutic dietsMENUB. the Consultant will review all menus for nutritional adequacy and will plan therapeutic menus.THERAPEUTIC DIETSTherapeutic diets shall be planned and based on current diet manual which has been approved by medical staff and dietary consultantEach patient, upon admission, will be visited by the Food Service SupervisorThe consultant, when requested by the charge nurse, will visit all patients on therapeutic dietsDietary data pertinent to a patient will be recorded on patients' diet card on file in kitchen or chart by charge nurse or consultantThe dietary consultant is on call to give assistance on diets at the discretion of the staff.Record review of document titled, Dietary Consultant dated March 1, 2012, reflected the following: Purpose: To maintain a dietary department in compliance with roles and regulations of Federal, State and local authorities. To provide therapeutic diets and meals, as prescribed by the physician, in a well-balanced, attractive and appetizing manner under safe, sanitary conditions for a reasonable cost.Qualifications: Must be a professional dietitian who is a member of the American Dietetic Association and meets the registration requirements, or is a graduate of a baccalaureate degree program with major studies in food service management, or foods and nutrition. The Chief Nutritionist, Bureau of Long Term Care and Texas Department of Health shall evaluate and determine suitability of this person. A minimum of 15 clock hours of appropriate continuing education per year shall be completed, reported and approved according to instructions issued by the Texas Department of Health, Long [NAME] Care Division. Performance Requirements:1. To provide continuing liaison with medical and nursing staff2. To advise and provide consultation to the administrator3. To counsel with residents and/or families on special diets4. To provide input and review residents' total health care plans5. To visit regularly with residents and to document these visits on a written report6. To guide the supervisor and staff of the dietetic services7. To participate in development or review of dietetic policies and procedures8. To conduct in-service education programs 11. To develop menus and make individual facility changes as necessary12. To write or check meal patterns for therapeutic diets13. To review all substitutions on menus14. To inspect all areas of the Dietetic Department-equipment, sanitation and procedural follow-through, etc. and to advise the administrator of the results15. Though an exit conference on each visit, to apprise the food service supervisor and administrator of any recommendation and to leave a written report16. To schedule time of consultation at the facility with. the food service supervisor

Based on observation, interviews and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedure. In response to allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source for 1 of 2 residents (Resident #1) reviewed for reporting allegations of abuse and neglect. The facility DON failed to identify bruising to left eyebrow and right arm as an alleged violation of injury of unknown source for Resident #1 on 12/29/2025 resulting in the resident having a busted blood vessel to her left side of her head and bruising to her right shoulder in green stages of healing. The DON failed to report an alleged violation of injury of unknown source for Resident #1 on 12/29/2025 to the Administrator of the facility and the Administrator failed to report the violations of injury of unknown source not later than 24 hours to other officials (including to the State Survey Agency) in accordance with State law through established procedure.This deficient practice of not following ANE reporting protocol could place residents at risk of harm by not having their injuries investigated.The findings included:Review of Resident #1's admission record dated 1/07/2026 reflected that she was admitted to the facility on [DATE]. Her diagnoses included: Alzheimer's disease (progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior) with late onset, major depressive disorder (serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems), anxiety disorder (mental health condition characterized by excessive, uncontrollable worry about everyday issues, affecting daily functioning and quality of life, and type 2 diabetes mellitus without complications (condition where a person has elevated blood sugar levels but has not yet developed any secondary issues related to diabetes) and she was placed on hospice on 1/04/2026.Review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of 02, indicating severely impaired cognition. Resident #1's active diagnoses, included: non-traumatic brain dysfunction. Further review of Resident #1's quarterly MDS reflected that her functional abilities was Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity for toileting hygiene, shower/bathe self, and oral hygiene and functional abilities with mobility was Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity for sit to lying, lying to sitting on side of bed, chair/bed-to-chair transfer and she did not attempt sit to stand or toilet transfer due to medical condition or safety concerns.Review of Resident #1's care plan dated 10/08/2022 reflected the following: Resident #1 has a self-care performance deficit r/t Confusion, Dementia. The goals for Resident #1 were that she will maintain current level of function through next review period. Interventions, bathing/showering: Resident #1 is totally dependent on x1 staff to provide shower twice weekly and as necessary; bed mobility, Resident #1 is able to reposition herself in bed. Further review of #1's care plan reflected she required extensive assistance with x1 for incontinent care for toilet use and for transfers Resident #1 was totally dependent on x2 staff for transferring. Resident uses a Hoyer lift. Further review of Resident #1's care plan reflected that she had a terminal prognosis r/t Alzheimer's and Interventions included Consult with physician and Social Services to have Hospice care for resident in the facility. Review of Resident #1's EMR Nursing Visit Note dated 12/29/2025 at 8:45 AM revealed the following: Patient tolerated shower well.Multiple areas of bruising observed including right elbow, right distal/anterior shin, right lower extremity lateral aspect above the knee, left shoulder, left eyebrow, and right forearm.Patient remains total assist for all ADLs and is unable to verbalize needs; staff must anticipate all care needs.Review of an incident report titled #875 Injury dated 12/29/2025 at 12:36 PM reflected the following: Nursing Description: Resident has a blue/purple bruise with raised area to left eyebrow. Bruise to right arm had previously faded per wound healing, it is now dark purple in color. Resident Description: Resident Unable to give DescriptionWas the incident witnessed: NoImmediate Action Taken: Assessment complete, incident report made, notification made to DON, physician, hospice agency, and RP. DON to contact hospice company. Bruise was not present prior to resident shower with hospice.Resident Taken to Hospital? NoReview of Resident #'s EMR New Skin & Wound - Total Body Skin assessment dated [DATE] at 1:57 PM revealed the following: skin assessment: bruise: location: right & left hand, left eyebrow, light purple and green bruiseReview of Resident #1's EMR Health Status Note dated 12/30/2025 at 12:34 AM reflected nursing staff documented Resident day 1 post incident report left eye bruise and right forearm bruise. Slight bruising noted to left eyeReview of Resident #1's EMR Health Status Note dated 12/30/2025 at 6:12 PM reflected nursing staff entered late entry on 12/29/2025 when nurse noted bluish/purplish raised area to left eyebrow. Resident's family member was present and was looking and asking resident if she knew what happened, resident did not answer. Notified doctor of area per hospice nurse. Did not observe distress or discomfort from resident.Review of Resident #1's EMR Health Status Note dated 12/31/2025 at 2:02 AM reflected nursing staff documented Resident day 2 post incident report for left eye bruise and right forearm bruise.Observation on 1/07/2026 at 12:55 PM revealed Resident #1's left side of her face near her eyebrow had a yellowish-brown bruise in stage of healing and the resident was non-verbal.In an interview on 1/07/2026 at 5:51 PM, DON stated the incident report on 12/29/2025 regarding Resident #1 was written shortly after the hospice staff, RN A, CNA C, and CNA D showered her and dressed her. She stated CNA A was caring for the resident this day and notified her of the knot on Resident #1's face. She stated she went to observe Resident #1's face, and she did not see a bruise on her face. She stated it wasn't until later in the day when it started turning colors. DON stated Resident #1's family member was present when the aid identified this bruising. DON stated she contacted the hospice company supervisor who was also the Hospice Nurse Practitioner that provides hospice care to Resident #1. DON stated the Hospice Nurse Practitioner stated she would contact RN A, CNA C, and CNA D and speak to them about what may have happened and how they transferred the resident. DON stated she suspected the bruising was a result of how the staff transferred Resident #1. DON stated when preparing the hoyer lift you must protect the hands and arms, use the slings. She stated if the hoyer bar was not placed correctly it could have hit/bumped Resident #1 in the face. She stated Resident #1 had several days of bruising, she stated it was a head injury of some sort, but she did not direct staff to complete neurological checks as Resident #1 was on hospice and the Hospice Nurse Practitioner did not order checks and would not send her to the hospital if vitals were reading low. She stated she has not called the Hospice Nurse Practitioner to follow up on the 12/29/2025 incident. She stated that she believed the Hospice Nurse Practitioner would handle the incident as she was monitoring Resident #1's care closely. She stated Hospice agency RN A, CNA C, and CNA D have returned to the facility and have provided Resident #1 showers with no further incidents. DON stated the little dots of bruising on Resident #1's right arm appeared to be from the hoyer sling being put on incorrectly. She stated that by notifying the hospice agency supervisor they would also make an incident report on their end. DON stated Resident #1 has been on hospice for 7/8 months, she was total care. DON stated this incident would be considered an unknown origin injury as nobody can say what occurred. DON stated she spoke with CNA A and she reported she did not see this injury when she woke her up prior to the hospice staff coming in to shower her. DON stated she did not report this incident to the ADM as it was being handled directly with the hospice agency.In an interview on 1/08/2026 at 1:21 PM, Hospice Nurse Practitioner stated she received a phone call from DON on 1/29/2025 regarding bruising to Resident #1's face. She stated Resident #1 was doing okay and she gave directions to the DON to keep an eye on her and if any concerns to reach out directly to her. She stated she spoke to her hospice agency staff and was informed by CNA C and CNA D that the bruises had been present and identified during Resident #1's. She added that RN B had taken photos of the bruises and documented the multiple skin concerns on the Nursing Visit Note provided to the facility charge nurse, RN A. She stated RN B discussed the nursing visit note in detail with RN A. Hospice Nurse Practitioner stated Resident #1 bruises easily and RN B informed her that she does not know how the bruises occurred but wanted to take photos of the bruises for her visit notes. She stated as the DON was aware of the bruises she did not have any red flags or concerns for Resident #1. She stated if she were to see consistent bruising occurring on Resident #1 then it would be concerning. She stated Resident #1 gets random bruises and she knows she was well cared for by the facility staff. Hospice Nurse Practitioner opened a file on her work cell phone that contained photos from the 12/29/2025 visit made by her hospice nursing staff. The photos were of Resident #1 and the skin concerns observed by her nursing staff during the visit. There were 8 photos of Resident #1's skin concerns dated 12/29/2025. Photos observed on 1/8/2026 at 1:30 PM were of Resident #1 and the bruises the hospice nursing staff identified. Photos were of a raised bump and bruising to Resident #1's left eyebrow, right and left thigh, right forearm, outside of right arm elbow and all in different stages of healing. She stated she would need to obtain directions from her agency if she can release these photos to surveyor. In an interview on 1/08/2026 at 2:50 PM, CNA B stated she has been in-serviced on hoyer lifts. She stated when using the hoyer lift it requires a 2 person transfer and if you do not follow this procedure, you could injure the resident or yourself. She stated you need help to ensure the resident is not swinging during a hoyer lift transfer. She stated Resident #1 requires total care, she cannot roll over, cannot communicate her needs to be changed. CNA B stated she was off for two days and when she returned, she observed Resident #1's face bruising her left eye. She stated she immediately went to her charge nurse to report it and the charge nurse informed her it was already reported and being monitored.In an interview on 1/09/2026 at 12:17 PM, RN A stated Resident #1 was total care, requires hoyer lift for transfer, sits at feeder table, and she was on hospice. She stated hospice usually provides Resident #1 with showers. She stated that she was informed by CNA A that Resident # had a bruise and bump on her left eyebrow. She stated she had multiple transfers this day and hospice had showered Resident #1. She stated she doesn't believe the Hospice RN or CNAs who showered Resident #1 the day of the reported incident had spoken to her about the bruises, stated it was possible, but she couldn't recall. RNA A stated she recalls reporting the bruises directly to the DON who was going to reach out to the hospice company. She stated she felt the DON reaching out to hospice was sufficient and she didn't feel the need to report the incident further.In an interview on 1/9/2026 at 1:22 PM, ADM stated she was the abuse coordinator and incidents of suspected abuse are reported to her directly for follow-up. She stated her nursing staff are in-serviced on abuse, neglect, and exploitation and expected to report immediately to the charge nurse who then makes an incident report and notifies the management team. ADM stated that if staff do not report incidents of abuse, neglect, or exploitation it could affect residents and make them fearful and reluctant to care. ADM stated she was only informed of Resident #1's facial bruising incident this week. She stated she is not sure if the bruises occurred with a transfer or lift. She stated Resident #1 was total care and could not obtain bruising on her own. She stated that the DON informed her of the incident this week and she spoke with the hospice agency to discuss how the bruises occurred. She stated she is not aware of any additional follow-up or investigation. She stated that if she had been notified immediately after the incident occurred, she would have investigated to confirm if perhaps bruising was caused by a transfer or hoyer lift.Record review of facility document titled, Incident Reports, Resident undated reflected the following: POLICY: When an accident or Incident Involving a resident occurs any witnessing staff will offer immediate assistance. An accident/Incident report and the appropriate documentation will be completed by the end of the shift. Questions about what constitutes an accident/Incident should be Immediately directed to the Director of Nursing or the shift supervisor.PURPOSE: To assure appropriate follow through on all accidents and Incidents. To study the cause of accidents and Incidents and to give the guidance for corrective/preventive action.PROCEDURE:9. Complete an Incident report.10. Note the location and the time of the Incident. the names of witnesses, and the exact circumstancesof the Incident. Document who the witnesses were on the Incident report.13. Notify DON/ADON of injuries of unknown cause immediately.14. When complete the Incident report will be sent to the office where the administrator & Director of Nursing verifies and investigates the contents of the incident report. The medical records personnel will keep copies of the Incident reports on file in the office. They will then be reviewed at the quarterly QA meetings which Include the medical director.DON, or designated nurse, will investigate all injuries of unknown cause following DADSguideline. DON will report injuries to DADS based on DADS guidelines. Record review of facility document titled, Resident Abuse, Neglect or Mistreatment undated reflected the following: Each resident shall be free from abuse, neglect, mistreatment, exploitation and misappropriation of property. Abuse shall include physical harm, pain, mental anguish, verbal abuse (derogatory terms), sexual abuse or involuntary seclusion.Suspected or substantiated cases of resident abuse, neglect, misappropriation of property or mistreatment shall be thoroughly investigated and documented by the administrator, and reported to the appropriate state agencies.Procedure:Any alleged violation involving mistreatment, misappropriation of property, abuse, exploitation or neglect of a resident shall be reported to the administrator immediately.The administrator shall thoroughly investigate all allegations.The administrator will make initial report to state within 24 hours of the incident.5. The administrator will take steps to ensure and prevent further potential abuse while investigation is in process.8. An incident report will be completed.10. The administrator shall take the following actions to assure that investigation is conducted effectively.10. Results of investigation shall be reported to officials (state agency) in accordance with state law and within five (5) working days.

Based on observation, interviews and record review, the facility failed to have evidence all allegations of abuse, neglect, or mistreatment were thoroughly investigated and documented for 1 of 2 residents (Resident #1) reviewed for an injury of unknown origin.The facility failed to have evidence that a thorough investigation was conducted following the allegation Resident #1 had bruising to her left side of her face and right arm and origin was unknown on 12/29/2025.This deficient practice could place residents at risk for abuse and neglect by not investigating injuries of unknown origin.The findings included:Review of Resident #1's admission record dated 1/07/2026 reflected that she was admitted to the facility on [DATE]. Her diagnoses included: Alzheimer's disease (progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior) with late onset, major depressive disorder (serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems), anxiety disorder (mental health condition characterized by excessive, uncontrollable worry about everyday issues, affecting daily functioning and quality of life, and type 2 diabetes mellitus without complications (condition where a person has elevated blood sugar levels but has not yet developed any secondary issues related to diabetes) and she was placed on hospice on 1/04/2026.Review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of 02, indicating severely impaired cognition. Resident #1's active diagnoses, included: non-traumatic brain dysfunction. Further review of Resident #1's quarterly MDS reflected that her functional abilities was Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity for toileting hygiene, shower/bathe self, and oral hygiene and functional abilities with mobility was Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity for sit to lying, lying to sitting on side of bed, chair/bed-to-chair transfer and she did not attempt sit to stand or toilet transfer due to medical condition or safety concerns.Review of Resident #1's care plan dated 10/08/2022 reflected the following: Resident #1 has a self-care performance deficit r/t Confusion, Dementia. The goals for Resident #1 were that she will maintain current level of function through next review period. Interventions, bathing/showering: Resident #1 is totally dependent on x1 staff to provide shower twice weekly and as necessary; bed mobility, Resident #1 is able to reposition herself in bed. Further review of #1's care plan reflected she required extensive assistance with x1 for incontinent care for toilet use and for transfers Resident #1 was totally dependent on x2 staff for transferring. Resident uses a Hoyer lift. Further review of Resident #1's care plan reflected that she had a terminal prognosis r/t Alzheimer's and Interventions included Consult with physician and Social Services to have Hospice care for resident in the facility. Review of Resident #1's EMR Nursing Visit Note dated 12/29/2025 at 8:45 AM revealed the following: Patient tolerated shower well.Multiple areas of bruising observed including right elbow, right distal/anterior shin, right lower extremity lateral aspect above the knee, left shoulder, left eyebrow, and right forearm.Patient remains total assist for all ADLs and is unable to verbalize needs; staff must anticipate all care needs.Review of an incident report titled #875 Injury dated 12/29/2025 at 12:36 PM reflected the following: Nursing Description: Resident has a blue/purple bruise with raised area to left eyebrow. Bruise to right arm had previously faded per wound healing, it is now dark purple in color. Resident Description: Resident Unable to give DescriptionWas the incident witnessed: NoImmediate Action Taken: Assessment complete, incident report made, notification made to DON, physician, hospice agency, and RP. DON to contact hospice company. Bruise was not present prior to resident shower with hospice.Resident Taken to Hospital? No Review of Resident #'s EMR New Skin & Wound - Total Body Skin assessment dated [DATE] at 1:57 PM revealed the following: skin assessment: bruise: location: right & left hand, left eyebrow, light purple and green bruiseReview of Resident #1's EMR Health Status Note dated 12/30/2025 at 12:34 AM reflected nursing staff documented Resident day 1 post incident report left eye bruise and right forearm bruise. Slight bruising noted to left eyeReview of Resident #1's EMR Health Status Note dated 12/30/2025 at 6:12 PM reflected nursing staff entered late entry on 12/29/2025 when nurse noted bluish/purplish raised area to left eyebrow. Resident's family member was present and was looking and asking resident if she knew what happened, resident did not answer. Notified doctor of area per hospice nurse. Did not observe distress or discomfort from resident.Review of Resident #1's EMR Health Status Note dated 12/31/2025 at 2:02 AM reflected nursing staff documented Resident day 2 post incident report for left eye bruise and right forearm bruise.Observation on 1/07/2026 at 12:55 PM revealed Resident #1's left side of her face near her eyebrow had a yellowish-brown bruise in stage of healing and the resident was non-verbal.In an interview on 1/07/2026 at 5:51 PM, DON stated the incident report on 12/29/2025 regarding Resident #1 was written shortly after the hospice staff, RN A, CNA C, and CNA D showered her and dressed her. She stated CNA A was caring for the resident this day and notified her of the knot on Resident #1's face. She stated she went to observe Resident #1's face, and she did not see a bruise on her face. She stated it wasn't until later in the day when it started turning colors. DON stated Resident #1's family member was present when the aid identified this bruising. DON stated she contacted the hospice company supervisor who was also the Hospice Nurse Practitioner that provides hospice care to Resident #1. DON stated the Hospice Nurse Practitioner stated she would contact RN A, CNA C, and CNA D and speak to them about what may have happened and how they transferred the resident. DON stated she suspected the bruising was a result of how the staff transferred Resident #1. DON stated when preparing the hoyer lift you must protect the hands and arms, use the slings. She stated if the hoyer bar was not placed correctly it could have hit/bumped Resident #1 in the face. She stated Resident #1 had several days of bruising, she stated it was a head injury of some sort, but she did not direct staff to complete neurological checks as Resident #1 was on hospice and the Hospice Nurse Practitioner did not order checks and would not send her to the hospital if vitals were reading low. She stated she has not called the Hospice Nurse Practitioner to follow up on the 12/29/2025 incident. She stated that she believed the Hospice Nurse Practitioner would handle the incident as she was monitoring Resident #1's care closely. She stated Hospice agency RN A, CNA C, and CNA D have returned to the facility and have provided Resident #1 showers with no further incidents. DON stated the little dots of bruising on Resident #1's right arm appeared to be from the hoyer sling being put on incorrectly. She stated that by notifying the hospice agency supervisor they would also make an incident report on their end. DON stated Resident #1 has been on hospice for 7/8 months, she was total care. DON stated this incident would be considered an unknown origin injury as nobody can say what occurred. DON stated she spoke with CNA A and she reported she did not see this injury when she woke her up prior to the hospice staff coming in to shower her. DON stated she did not report this incident to the ADM as it was being handled directly with the hospice agency.In an interview on 1/08/2026 at 1:21 PM, Hospice Nurse Practitioner stated she received a phone call from DON on 1/29/2025 regarding bruising to Resident #1's face. She stated Resident #1 was doing okay and she gave directions to the DON to keep an eye on her and if any concerns to reach out directly to her. She stated she spoke to her staff and was informed by CNA C and CNA D that the bruises had been present and identified during Resident #1's. She added that RN B had taken photos of the bruises and documented the multiple skin concerns on the Nursing Visit Note provided to the facility charge nurse, RN A. She stated RN B discussed the nursing visit note in detail with RN A. Hospice Nurse Practitioner stated Resident #1 bruises easily and RN B informed her that she does not know how the bruises occurred but wanted to take photos of the bruises for her visit notes. She stated as the DON was aware of the bruises she did not have any red flags or concerns for Resident #1. She stated if she were to see consistent bruising occurring on Resident #1 then it would be concerning. She stated Resident #1 gets random bruises and she knows she is well cared for by the facility staff. Hospice Nurse Practitioner opened a file on her work cell phone that contained photos from the 12/29/2025 visit made by her hospice nursing staff. The photos were of Resident #1 and the skin concerns observed by her nursing staff during the visit. There were 8 photos of Resident #1's skin concerns dated 12/29/2025. Photos observed on 1/8/2026 at 1:30 PM were of Resident #1 and the bruises the hospice nursing staff identified. Photos were of a raised bump and bruising to Resident #1's left eyebrow, right and left thigh, right forearm, outside of right arm elbow and all in different stages of healing. She stated she would need to obtain directions from her agency if she can release these photos to surveyor. In an interview on 1/08/2026 at 2:50 PM, CNA B stated she has been in-serviced on hoyer lifts. She stated when using the hoyer lift it requires a 2 person transfer and if you do not follow this procedure, you could injure the resident or yourself. She stated you need help to ensure the resident is not swinging during a hoyer lift transfer. She stated Resident #1 requires total care, she cannot roll over, cannot communicate her needs to be changed. CNA B stated she was off for two days and when she returned, she observed Resident #1's face bruising her left eye. She stated she immediately went to her charge nurse to report it and the charge nurse informed her it was already reported and being monitored.In an interview on 1/09/2026 at 12:17 PM, RN A stated Resident #1 was total care, requires hoyer lift for transfer, sits at feeder table, and she is on hospice. She stated hospice usually provides Resident #1 with showers. She stated that she was informed by CNA A that Resident # had a bruise and bump on her left eyebrow. She stated she had multiple transfers this day and hospice had showered Resident #1. She stated she doesn't believe the Hospice RN or CNAs who showered Resident #1 the day of the reported incident had spoken to her about the bruises, stated it is possible, but she couldn't recall. RNA A stated she recalls reporting the bruises directly to the DON who was going to reach out to the hospice company. She stated she felt the DON reaching out to hospice was sufficient and she didn't feel the need to report the incident further.In an interview on 1/9/2026 at 1:22 PM, ADM stated she is the abuse coordinator and incidents of suspected abuse are reported to her directly for follow-up. She stated her nursing staff are in-serviced on abuse, neglect, and exploitation and expected to report immediately to the charge nurse who then makes an incident report and notifies the management team. ADM stated that if staff do not report incidents of abuse, neglect, or exploitation it could affect residents and make them fearful and reluctant to care. ADM stated she was only informed of Resident #1's facial bruising incident this week. She stated she is not sure if the bruises occurred with a transfer or lift. She stated Resident #1 is total care and could not obtain bruising on her own. She stated that the DON informed her of the incident this week and she spoke with the hospice agency to discuss how the bruises occurred. She stated she is not aware of any additional follow-up or investigation. She stated that if she had been notified immediately after the incident occurred, she would have investigated to confirm if perhaps bruising was caused by a transfer or hoyer lift.Record review of facility document titled, Incident Reports, Resident undated reflected the following: POLICY: When an accident or Incident Involving a resident occurs any witnessing staff will offer immediate assistance. An accident/Incident report and the appropriate documentation will be completed by the end of the shift. Questions about what constitutes an accident/Incident should be Immediately directed to the Director of Nursing or the shift supervisor.PURPOSE: To assure appropriate follow through on all accidents and Incidents. To study the cause of accidents and Incidents and to give the guidance for corrective/preventive action.PROCEDURE:9. Complete an Incident report.10. Note the location and the time of the Incident. the names of witnesses, and the exact circumstancesof the Incident. Document who the witnesses were on the Incident report.13. Notify DON/ADON of injuries of unknown cause immediately.14. When complete the Incident report will be sent to the office where the administrator & Director of Nursing verifies and investigates the contents of the incident report. The medical records personnel will keep copies of the Incident reports on file in the office. They will then be reviewed at the quarterly QA meetings which Include the medical director.DON, or designated nurse, will investigate all injuries of unknown cause following DADSguideline. DON will report injuries to DADS based on DADS guidelines. Record review of facility document titled, Resident Abuse, Neglect or Mistreatment undated reflected the following: Each resident shall be free from abuse, neglect, mistreatment, exploitation and misappropriation of property. Abuse shall include physical harm, pain, mental anguish, verbal abuse (derogatory terms), sexual abuse or involuntary seclusion.Suspected or substantiated cases of resident abuse, neglect, misappropriation of property or mistreatment shall be thoroughly investigated and documented by the administrator, and reported to the appropriate state agencies.Procedure:Any alleged violation involving mistreatment, misappropriation of property, abuse, exploitation or neglect of a resident shall be reported to the administrator immediately.The administrator shall thoroughly investigate all allegations.The administrator will make initial report to state within 24 hours of the incident.5. The administrator will take steps to ensure and prevent further potential abuse while investigation is in process.8. An incident report will be completed.10. The administrator shall take the following actions to assure that investigation is conducted effectively.10. Results of investigation shall be reported to officials (state agency) in accordance with state law and within five (5) working days.

Based on interview and record review, the facility failed to ensure all individuals with mental health disorders were provided with accurate Preadmission Screening and Resident Review (PASRR) Screenings for 1 of 4 residents reviewed for PASRR. The facility failed to ensure that Resident #7 had an accurate PASRR Level 1 Screening which indicated a diagnosis of mental illness (Bipolar Disorder) and refer Resident #7 to the state designated authority. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs.The findings included: Record review of Resident #7 face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #7 had diagnosis which included Bipolar Disorder (serious mental illness causing extreme mood swings, from manic highs to depressive lows), Senile Degeneration of the Brain (age related cognitive decline), Seizures (temporary disruption of brain activity from uncontrolled electrical signals), Depression (serious mood disorder causing persistent sadness and loss of interest, affecting how you feel, think, and handle daily activities like sleeping, eating or working), Anxiety Disorder (mental health condition causing persistent excessive fear and worry that significantly interfere with daily life, going beyond normal occasional anxiety), and Cognitive Communication Deficit (difficulty with talking, listening, reading, or writing due to problems with thinking skills like memory, attention, problem-solving, and organization). Record review of Resident #7 quarterly MDS, dated [DATE], revealed diagnosis which included bipolar disorder and BIMS of 14. Record review of Resident #7 care plan revealed the resident suffered from depression related to the bipolar disorder, dated 12/10/2025. Care plan also stated that Resident #7 has little or no activity involvement related to anxiety, depression, disinterest, physical limitations, poor adjustment to facility/unit, resident wishes to not participate. Resident #7 care plan also states that resident has chronic pain related to depression. Record review of Resident #7 admission paperwork from referring facility, dated 04/23/2025, reflected a list of Resident #7 diagnosis which included bipolar disorder. Record review of Resident #7 Level 1 PASRR screening that was completed by the referring entity on 05/24/2025 indicated in section C0100 there was no evidence of this individual having mental illness. Record review of Resident #7 12/07/2025 indicated that there was not a THHS Form 1012 used for PASRR in resident paperwork. During an interview on 01/07/2026 at 12:05a.m. LPNM stated that she was responsible for entering the information from the PASRR into their system. She stated that she can only put what the screener marked and therefore could not make changes to PASRR. Surveyor asked how LPNM would she obtain a Level II screening for a resident with a newly diagnosed mental illness, and she stated that she would rescreen the resident since it was not accurate any longer. Surveyor then asked why LPNM could not do the same on admission when she noticed that the resident had a bipolar diagnosis. LPNM stated that the diagnosis of Senile Degeneration of the brain trumped the bipolar disorder diagnosis, which would in turn negate the need for a positive PASRR and a Level II PASRR screening. That would be why section C0100 of the PASRR was marked 'NO'. During an interview on 01/08/2026 at 10:33 DON stated that the facility does not have a policy for PASRR and that they just follow the guidelines. During a follow-up interview on 01/09/2026 at 1:35p.m. surveyor asked LPNM if they had completed a THHS Form 1012, the Mental Illness and Dementia Resident Review. LPNM was unsure what the form was. Surveyor explained that the form was completed only for nursing facility residents with a current Negative PASRR Level 1 (PL1) Screening for Mental Illness to determine whether to submit a new positive PL1 screening form on the Long-Term Care Portal because further evaluation was needed. LPNM claimed that they did not but that she would obtain it before the end of the day. LPNM was trained as a MDS Nurse per guidelines. LPNM will apply all guidelines moving forward. During a follow-up interview with LPNM on 01/09/2026 at 3:45p.m. LPNM presented surveyor with a Form 3071 that was filled out by hospice on 05/23/2025 that listed Senile degeneration of the brain as the primary diagnosis. PASRR guidelines for Health and Human Services dated June 2023 state that if a resident has a diagnosis for mental illness, a PASRR level II must be completed by appropriate entity. PASRR guidelines list bipolar disorder as a qualifying diagnosis to initiate this next step.

Based on observations, interviews, and record reviews the facility failed to ensure the residents' environment remains was free from accidents and hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents, for 1 of 8 residents (Resident #48) and 1 facility reviewed for a wander guard system (a wander management system used in healthcare facilities to prevent residents at risk of wandering, such as those with dementia, from leaving safe areas, offering them freedom while ensuring safety through wearable devices and automated alerts. The system uses radio frequency identification technology with wristbands and door sensors that trigger alarms and notifications to staff when a resident approaches an exit, often locking doors automatically.) The wander guard system for the facility had an exit door without a functioning wander guard system. The facility failed on 01-06-206 when the door that gave access through wing-4 hallway. The door gave a person access to the facility exterior courtyard. The courtyard was not fenced and had a cement sidewalk which had access to state a state highway. The wing-4 hallway door was used by residents to get to the dining room and activities areas and the wander guard box had loose wires exposed, not connected and the wander guard system was disabled. This failure could place residents at risk of harm by elopement. The findings included: A record review of Resident #48's admission record dated 1/8/2025 revealed an admission date of 12/30/2024 with diagnoses which included dementia (a range of neurological conditions affecting the brain that worsens over time. It is the loss of the ability to think, remember, and reason to levels that affect daily life and activities), repeated falls, osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes. This can lead to a decrease in bone strength that can increase the risk of fractures (broken bones). A record review of Resident #48's quarterly MDS assessment dated [DATE] revealed Resident #48 was an [AGE] year-old female admitted for long term care with safety and activities of daily life (ADLs). Resident #48 was assessed with adequate hearing and impaired vision. Resident #48 was assessed with a BIMS score of 7 out of 15 which indicated severe cognitive impairment. Resident #48 was assessed to use a walker to ambulate. Resident #48 was assessed with the ability to walk 150 feet independently. A review of Restraints and Alarms revealed Resident #48 was assessed with a need for a daily wander / elopement alarm. A record review of Resident #48's care plan dated 1/8/2025 revealed, Risk for Wandering / Elopement Identified, Date Initiated: 12/30/2024 . Goal: The Resident's safety will be maintained, Date Initiated: 01/29/2025, Target Date: 01/28/2026 . Risk for Falls, Date Initiated: 12/30/2024, Goal; Resident Will Be Free of Falls Date Initiated: 12/30/2024, Target Date: 01/28/2026. The resident is dependent on staff etc. for meeting emotional, intellectual, physical, and social needs r/t severe Cognitive deficits, Physical Limitations. Date Initiated: 01/08/2025 Revision on: 01/08/2025. Goal; . Resident will be participate in activities that are suitable for her, and not overly demanding due to sever cognitive impairment. Date Initiated: 01/08/2025, Target Date: 01/28/2026. Encourage out of room activities, and meals. Date Initiated: 01/08/2025. Redirect resident when resident is attempting to get out of her w/c, and wander. Date Initiated: 01/08/2025. A record review of Resident #48's physician's orders dated 1/8/2026 revealed on 12/30/2024 the physician prescribed a wander guard for Resident #48 and for it to be checked every shift. During an observation on 1/6/2025 at 5:10 PM, revealed an exit door which was accessed through wing-4 hallway. The door gave a person access to the facility exterior courtyard. The courtyard was not fenced and had a cement sidewalk which had access to state a state highway. wing-4 hallway was used by residents to get to the dining room and activities areas. Observation of the exit door revealed a wander guard system box affixed to the upper right door frame, however the wander guard box had loose wires exposed. During an observation and interview on 1/7/2025 at 8:35 AM revealed Resident #48 walked with her walker rollator (a four- or three-wheeled mobility aid designed for stability, featuring hand brakes, a seat, and a storage basket/pouch for increased independence) from the dining room, throughout the facility which included the wing-4 hallway, to her room, where CNA C assisted her to bed. CNA C stated Resident #48 was a wander risk and had a need for a wander guard bracelet and demonstrated the bracelet on Resident #48's right wrist. CNA C stated the doors were alarmed with the wander guard system. CNA C stated Resident #48 could walk through out the facility. During an observation and interview on 1/7/2026 at 10:29 AM revealed an exit door which was accessed through wing-4 hallway. The door gave a person access to the facility exterior courtyard. The courtyard was not fenced and had a cement sidewalk which had access to state a state highway. The wing-4 hallway was used by residents to get to the dining room and activities areas. Observation of the exit door revealed a wander guard system box affixed to the upper right door frame, however the wander guard box had loose wires exposed. LVN D Stated the door allowed access to the kitchen courtyard and had access to the street (state highway). LVN D stated the door had a wander guard system, and the box had loose wires which were not connected and may not be functioning. During an interview on 1/7/2025 at 2:00 PM the Activities Director (AD) stated he was responsible for ensuring the facility's wander guard system was working. The AD stated 9 residents were assessed as elopement risk and were supported with wander guard bracelets on the person's right wrist. The AD stated he checked the wander guard bracelets daily Monday through Friday and maintained a log of the checks. The AD stated he checked each residents wander guard bracelet with a wander guard hand held device which would indicate if the bracelet was functioning. The AD stated he did not check the facility exit doors for the wander guard system and had not recognized the exit door from the wing-4 hallway to the kitchen courtyard had the wander guard monitor disabled. A policy was requested from the Administrator on 1/7/2026 at 9:51 Am and as of 1/15/2026 the policy was not provided. A record review of The United States of Americas Agency for Healthcare Research website titled Elopement accessed 1/19/2026 revealed, https://psnet.ahrq.gov/web-mm/elopement#:~:text=An%20immediate%20organizational%20response%20should,and%20diversion%20activities. An immediate organizational response should be initiated when any patient with decreased mental capacity has left the unit or treatment area without authorization. Health care organizations should have policies and procedures in place indicating the steps that personnel are to follow in any elopement situation, and adequate training should be provided for all staff. These protocols should include assessment and prevention procedures to reduce the risk of harm for patients with diminished capacity. Such preventive measures may include placing the patient on an observation protocol (special precautions for patients requiring frequent or constant monitoring). Such a protocol may include locating the patient close to the desk, placing an electronic monitoring device on the patient when available, partnering the patient with a roommate, or requesting a family member or nursing assistant to sit with the patient. Additional precautions common in mental health and rehabilitation facilities include automatic door locks, alarms, and diversion activities.

Based on observations, interviews and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 facility's reviewed for safe and functioning equipment in the laundry department. The facility had 3 commercial clothes washers with one of the three inoperable. The facility had 4 commercial clothes dryers with one of the four in-operable. This failure could place residents at risk for neglect by not having laundry services. The findings included: A record review of the facility's Resident census report dated 1/6/2026 revealed a census of 56 residents. A record review of the facility's Facility Assessment dated 8/12/2025 revealed, The purpose of this assessment is to determine what resources are necessary to care for our residents competently during both day-to-day operations (including nights and weekends) and emergencies. Scope: this assessment addresses the following elements: the facility's Resident population, including but not limited to: the number of residents and the facility's Resident capacity. Licensed beds 119 . physical resources . laundry building . During an observation and interview on 1/7/2026 at 8:00 AM revealed the facility's laundry department had 3 commercial clothes washers and 4 commercial clothes dryers. One of the 3 commercial clothes washer was not in service and one of the four commercial clothes dryers was not in service. The Laundry Services Manager (LSM) stated she had been the LSM for the last year and during that time One of the 3 commercial clothes washer was not in service and one of the four commercial clothes dryers was not in service. The LSM stated laundry services were being provided for the 50-60 average census of residents, however the facility had a license for 119 and if the facility were to receive more residents the laundry services may not be accommodated without the in-operable equipment. A policy review was requested from the Administrator on 1/7/2026 at 9:51 AM and as of 1/15/2026 a policy was not provided prior to exit.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen reviewed for food service safety. The facility failed to recognize and dispose of food which had pests, including maggots on the food items. This failure could place residents who receive food and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation by a Life Safety Code inspector on 10/16/2024 at approximately 2:30 PM revealed an opened box of vanilla pudding cups in the dry storage area of the kitchen. Upon further inspection, the box was revealed to have a foul odor and bugs flew out of the box. Observation on 10/16/2024 at 3:55 PM revealed an opened box of vanilla pudding cups with an opened pudding container inside of the box. Inside the box and on the open pudding container were maggots and what appeared to be insect eggs on and around the pudding cups. Interview and observation on 10/16/2024 at 3:58 PM, [NAME] A stated she was not the person who put away the food delivery after it was completed yesterday, and that neither of the staff who did were at the facility or available that day. [NAME] A stated that no pudding from the box was served or put away onto the shelves. Observation of the dry storage shelves revealed one (1) vanilla pudding cup with an insect egg on the outside of the pudding container. [NAME] A stated that she believed it was appropriate to serve this vanilla pudding cup to residents and would likely move it from this container into a bowl so it would be easier for the residents to consume. [NAME] A stated the item on the outside of the pudding container appeared to be dirt. [NAME] A did not state why she believed it was appropriate to give to residents or what could happen if spoiled food was served. Interview on 10/16/2024 at 5:00 PM, the DM stated she would not serve the pudding to residents and would expect her staff to not serve it to residents as well. The DM stated that her expectation would be for staff to take photos of the damaged food and to immediately throw the damaged food away. The DM stated that what [NAME] A said was not acceptable and is not how kitchen staff are trained. The DM stated she is responsible for training staff and that food is inspected at delivery and before and during preparation of the food. Record review of facility policy titled, Purchasing and Storage, undated, reflected, Leaking cans and spoiled foods are to be thrown away immediately.

Based on observation, interview, and record review the facility failed to maintain an effective pest control program so that the facility is free of pests for 1 of 1 facility reviewed for physical environment. The facility was observed to have numerous crickets scattered throughout the floor of the facility both alive and dead. This failure could place residents at risk for not having a home free of pests, and a comfortable environment in which to live. The findings included: Observation on 10/16/2024 at 2:30 PM, more than 10 crickets were observed down a hallway in the facility as well as in a common sitting area of the facility. All crickets were in various stages of life, including some dead and some alive crickets. Interview on 10/16/2024 at 4:45 PM, the Administrator stated she believed the contracted pest control company would be at the facility the following day. The Administrator stated they have pest control for the crickets and that they come monthly to spray for general pests to include crickets. Record review of the facility pest control record, undated, reflected that the facilities contracted pest control company came to the facility to treat for pest control monthly and treated for general pests to include crickets. After requesting the pest control policy on 10/16/2024 at 5:00 pm from the administrator, the pest control policy was not provided upon exit.

Based on observation, interview, and record review the facility failed to ensure its medication error rates were not 5% or greater. The facility had a medication error rate of 24%, based on 6 errors out of 25 opportunities which involved 1 of 3 residents (Resident #7) reviewed for medication administration and medication errors. 1. RN B crushed pills and capsules, 3 medications; bisacodyl 5mg delayed release, duloxetine 60mg delayed release, and divalproex 125mg delayed release, which should not be crushed per professional standards, and administered the crushed medications to Resident #7. 2. RN B administered acetaminophen 650mg, whole pill, to Resident #7 who was ordered by her physician to have crushed medications due to her swallowing difficulties. 3. RN B administered medication Carvedilol 6.25mg on 10/03/2024 at 10:01 AM, 1 hour late. 4. RN B administered medication acetaminophen 650mg on 10/03/2024 at 10:01 AM, 1 hour late. These failures could place residents at risk for not having the intended therapeutic benefit or an adverse reactions from the medication. The findings included: A record review of Resident # 7's admission record dated 10/03/2024 revealed an admitted [DATE] with diagnoses which included dysphasia pharyngoesophageal phase (a medical term for difficulty swallowing. Dysphagia can be a painful condition. In some cases, swallowing is impossible), heart failure, dementia (a group of symptoms affecting memory, thinking and social abilities. In people who have dementia, the symptoms interfere with their daily lives), and constipation. A record review of Resident #7's quarterly MDS assessment dated [DATE] revealed Resident #7 was an [AGE] year-old female Resident admitted for long term care and assessed with a BIMS score of 06 out of a possible 15 which indicated severe cognitive impairment. Resident #7 was assessed as having medical problems which included, a swallowing disorder, heart and respiratory debility, and a seizure disorder. A record review of Resident #7's care plan dated 10/03/2024 revealed, The resident has Congestive Heart Failure . Give cardiac medications as ordered . The resident has hypertension (HTN) r/t CHF. She is taking Coreg (carvedilol) two times daily . Give anti-hypertensive medications as ordered . has impaired cognitive function/dementia or impaired thought processes r/t Difficulty making decisions, Impaired decision-making, long-term memory loss, Short term memory loss . Administer medications as ordered uses antidepressant medication Cymbalta (duloxetine) r/t Depression . Administer antidepressant medications as ordered by physician A record review of Resident #7's physicians orders, dated 10/04/2024, revealed on 06/14/2024, the physician ordered for Resident #7 to receive crushed medications. Further review revealed the physician ordered on 12/01/2021 for Resident to have medications, may alter medication by crushing, opening caps, or administering in foods or fluids. (Only open or crush if manufacture allows) A record review of Resident #7's physicians orders dated 10/04/2024 revealed Resident #7 was ordered to receive, bisacodyl 5mg delayed release (a stool softener), duloxetine 60mg delayed release (an anti-depressant), divalproex 125mg delayed release (anti-seizure medication) twice a day at 09:00 and at 06:00 PM, acetaminophen 650mg (a non-steroidal pain relief medication) three times a day at 08:00 AM, 01:00 PM, and at 08:00 PM, and carvedilol 6.25mg (a medication to treat high blood pressure) at 08:00 AM and at 05:00 PM. During an observation on 10/03/2024 at 10:01 AM, RN B prepared and administered bisacodyl 5mg delayed release pill, duloxetine 60mg delayed release pill, and divalproex 125mg delayed release pill by crushing the medications. Further observation revealed RN B administered acetaminophen 650mg enteric coated delayed release pills whole without crushing and 1 hour late. Further observation revealed RN B administered carvedilol 6.25mg 1 hour late. During an interview on 10/03/2024 at 10:10 AM, RN B stated she had administered the bisacodyl, duloxetine, and the divalproex by crushing the medications because she believed she could crush those medications and administered the acetaminophen whole because Resident # 7 could tolerate some pills whole. RN B stated she did administer the carvedilol and the acetaminophen 1 hour late, RN B stated she had not reported to her supervisor, the DON, any potential late medication administrations . During an interview on 10/03/2024 at 01:00 PM, the DON stated RN B had not reported any potential late medication administrations. The DON stated Resident #7's bisacodyl, duloxetine and divalproex medications were delayed release formulations and should not be crushed and were inappropriate formulations for Resident #7. The DON stated Resident #7 was prescribed crushed medications due to Resident #7's swallowing difficulties and should not be administered whole pills. The DON stated her expectations and facility policy was for residents to receive their medications as ordered and within 1 hour of their scheduled administration. The DON stated the nurse was counseled and received re-enforced training on safe medication administration, Resident #7 was assessed without injury, and the physician received a report of the medication errors and Resident #7 did not receive any new orders. The DON stated medication error could place residents a risk form harm by adverse effects of the medication administration errors. A record review of the Institute for Safe Medication Practices website; https://www.ismp.org/sites/default/files/attachments/2018-02/tasm.pdf Accessed 10/04/2024, titled ISMP Acute Care Guidelines for Timely Administration of Scheduled Medications revealed, Medications administered more frequently than daily but not more frequently than every 4 hours (e.g., BID, TID, q4h, q6h) Administer these medications within 1 hour before or after the scheduled time. A record review of the facility's undated Medication Error policy revealed, It is the policy of (facility), Inc. to be free of significant medication errors and error rates. A medication error report (see next page for example) will be filled out for each medication or treatment error. PURPOSE: To define error, investigate error, determine reason for error and consider preventative measures. MEDICATION ERROR: Federal regulations state a medication error is a discrepancy between what the physician ordered and what is actually administered. Significant medication error causes the resident discomfort or jeopardizes his or health and sample. Example are listed below: o Omissions o Unauthorized drugs (drugs administered without a doctors order) o Wrong Dose o Wrong route of administration o Wrong dosage form o Wrong time including AC's give PC or vice versa or drug administered 60 minutes earlier or later than scheduled time. Any medication error must immediately be reported to the resident's attending physician, a medication error form completed, and the immediate supervisor notified. A record review of the bisacodyl manufactures website; https://healthy.kaiserpermanente.org/health-wellness/drug-encyclopedia/drug.dulcolax-bisacodyl-5-mg-tablet-delayed-release.297753 Accessed 10/04/2024, titled Drug Encyclopedia Ducolax (bisacodyl) 5mg tablet, delayed release revealed, How to use: Take this medication by mouth as directed by your doctor. If you are self-treating, follow all directions on the product package. If you have any questions, ask your doctor or pharmacist. Swallow this medication whole. Do not crush, chew, or break the tablet or take it within 1 hour of antacids, milk, or milk products. Doing so can destroy the coating on the tablet and may increase the risk of stomach upset and nausea. A record review of the United States of America's Food and Drug Administrations website; https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/022516lbl.pdf accessed 10/04/2024, titled Cymbalta (duloxetine hydrochloride) Delayed-Release Capsules for Oral revealed, DOSAGE AND ADMINISTRATION Cymbalta should be swallowed whole and should not be chewed or crushed, nor should the capsule be opened and its contents sprinkled on food or mixed with liquids. All of these might affect the enteric coating. A record review of the United States of America's Food and Drug Administrations website; https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/018723s037lbl.pdf , accessed 10/04/2024 titled Depakote (divalproex sodium) Tablets for Oral use revealed, Swallow Depakote ER tablets or DEPAKOTE delayed-release tablets whole. Do not crush or chew them. Tell your healthcare provider if you cannot swallow Depakote ER tablets or DEPAKOTE delayed release tablets whole. You may need a different medicine. A record review of the acetaminophen manufactures website; https://healthy.kaiserpermanente.org/health-wellness/drug-encyclopedia/drug.tylenol-8-hour-650-mg-tablet-extended-release.450881 , accessed 10/04/2024, titled Tylenol (acetaminophen) 8 Hour 650 mg tablet, extended release revealed, How to use . Do not crush or chew extended-release tablets. Doing so can release all of the drug at once, increasing the risk of side effects. Swallow the tablets whole.

Based on observations, interviews, and record reviews the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 of the facility's laundry department reviewed for patient care equipment in safe operating condition. The facility presented 4 installed dryers of which 2 were inoperable and the facility presented with 3 washers of which 2 were inoperable. These failures could place residents at risk for harm by the facility's inability to provide clean sanitary linens. The findings included: A record review of the facility's census Resident List Report dated 10/01/2024 revealed a census of 50 residents. During an observation on 10/01/24 at 09:59 AM, the facility's laundry department revealed 3 commercial washers of which 1 of the 3 was operational. Further review revealed 4 commercial dryers of which 2 were operational. During an interview on 10/03/2024 at 10:10 AM, laundry Aide D stated she had been the laundry attendant for the past year and of the 3 washers only 1 worked and of the 4 dryers only 2 worked. Laundry Aide D stated the dryers and washers had been inoperable for months. Laundry Aide D stated she was able to provide clean linens for the facility's residents with the current operational equipment but could be challenged to provide clean laundry if the demand increased with an increased census . During an interview on 10/04/2024 at 01:30 pm, the Administrator stated she had been attempting to secure BIDS and funding for the repair and or replacement of the dryers and washers and had not yet secured the equipment repairs or replacement. The administrator stated the facility had just bought the 1 operational commercial washer . A policy for maintaining essential equipment for resident care was requested on 10/4/2024 at 12:46 PM and the administrator stated the facility had no policy and followed and adhered to the HHSC guidelines at maintaining essential equipment.

Based on interviews and record reviews the facility failed to electronically transmit encoded, accurate, and complete MDS data to the CMS System, within 14 days, upon a resident's transfer, reentry, discharge, and death, for 1 of 8 residents (Resident #25) reviewed for transmitted MDS data to the CMS System. The facility failed to transmit a discharge MDS assessment to the CMS system for Resident #25. This failure could place residents at risk for not having their assessments transmitted timely which could cause a delay in treatment. The findings included: A record review of Resident #25's admission record dated 10/03/2024, revealed an admitted [DATE] and a discharge date of [DATE] with diagnoses which included heart disease and hypertension (high blood pressure). A record review of Resident #25's medical record revealed an admission MDS assessment dated [DATE] which revealed Resident #25 was a [AGE] year-old male admitted for care and assessed with a BIMS score of 15 which indicated no impairment to his cognition. Further review of Resident #25's medical record revealed no other MDS assessment and or transmittal to the CMS system. During an interview on 10/03/2024 at 06:44 PM, LVN C stated she was the MDS coordinator and began her position on 06/01/2024. LVN C stated Resident #25 had discharged to an assisted living facility on 06/18/2024 and she had not recognized the discharge and did not initiate an MDS discharge assessment to transmit to the CMS system. LVN C stated the electronic record system would prompt her to initiate discharge assessments for residents MDS transmittals to the CMS system for discharges within 14 days post discharge. LVN C stated she did not see Resident #25's discharge alert and did not produce the discharge assessment. LVN C stated the DON was her supervisor and was responsible for oversight of residents' discharges. During an interview on 10/04/2024 at 03:00 PM, the DON stated Resident #25 was discharged to an assisted living facility due to his improved health status and she had failed to have oversight to ensure Resident #25's MDS discharge assessment was captured and transmitted to the CMS system. The DON stated the failure to transmit accurate and timely MDS assessments could place residents at risk for harm by inaccurate records reported to the CMS system. A policy for MDS transmittals to the CMS system was requested on 10/4/2024 at 12:46 PM and the administrator stated the facility had no policy and followed and adhered to the HHSC guidelines at Resident assessments related to MDS assessments and reporting.

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, for 1 of 3 the residents (Resident # 3) reviewed for oxygen in that: The Facility failed to ensure Residents #3's, nebulizer tubing was bagged. This deficient practice could place residents who received oxygen therapy at risk for an increase in respiratory complications. The findings were: Record review of Resident # 3's face sheet dated 10/1/24 revealed an 84-year female admitted to the facility on [DATE] with the diagnoses that included: Chronic Obstructive Pulmonary Disease [disease is characterized by breathlessness] ,Gastroesophageal reflux disease [condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach] and Major Depressive Disorder [mood disorder that causes a persistent feeling of sadness and loss of interest] . Record review of Resident # 3's Quarterly MDS dated [DATE] revealed a BIMS of 15, which indicated intact cognition. Record review of Resident #3's Physician monthly orders dated October 2024 revealed an order start date of 04/01/24: Albuterol Sulfate Inhalation Solution for nebulization 0.5 mg -3mg twice a day as needed for shortness of breath. Observation on 10/01/24 at 11:45 a.m. revealed that Resident # 3 's nebulizer tubing was unbagged on the bedside table. In an interview with Resident # 3 on 10/01/24, at 12:01 p.m., she stated they only bag the nebulizer tubing at this facility every once in a while, depending on the nurse. In an interview with RN A on 10/01/24, at 1:38 p.m., she stated she was the assigned RN to Resident # 3. It was revealed that it was every nurses responsibility to change nebulizer tubing weekly and bag them. However, she did not know why the nebulizer tubing was not being bagged. RN A stated that the Resident was at risk of possible respiratory infection due to the nebulizer tubing being undated and unbagged. During an interview with the (DON) on 10/01/24 at 3:55 p.m., it was revealed that Resident #3 should have had their nebulizer tubing changed and bagged by the night shift. The DON mentioned that she needed to determine why the nebulizer tubing was not bagged for Resident #3. She also stated that she oversaw this task and assured that she would monitor it for compliance. The DON stressed that Resident #3 was at risk of a possible respiratory infection due to the outdated and unbagged nebulizer tubing and unfortunately, she had no policy indicating that the nebulizer should be bagged.

Based on observation , interview and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record, and indicate the duration for the PRN order for 1 of 3 residents (Resident #150) reviewed for pharmacy services . The facility failed to ensure Resident # 150 had a stop date for PRN Lorazepam 0.5 mg (a medicine used to treat the symptoms of anxiety) This failure could affect residents who received antipsychotic/psychoactive medications and could place residents at risk of receiving unnecessary psychotropic medications. The findings included: Record review of Resident # 150's face sheet dated 10/02/24, reveled a 98- year old female admitted to the facility on [DATE] with diagnosis that included : [Anxiety] a feeling of fear, dread, and uneasiness , Type II Diabetes [ condition that happens because of a problem in the way the body regulates and uses sugar as a fuel and Depression [ a mood disorder that causes a persistent feeling of sadness and loss of interest. Record review of Resident #150 's most recent comprehensive MDS assessment, dated 9/19/2024 revealed the resident was moderately cognitively impaired for daily decision-making skills and was treated with anti-anxiety medications. Record review of Resident #150's comprehensive care plan dated 9/09/24 revealed the resident had a diagnosis of anxiety and used antianxiety medication as ordered by the physician with interventions monitor and document reactions to antianxiety medication such as confusion, and disorientation. Record review of Resident #150s Order Summary Report, dated 10/02/24 revealed the following: - Lorazepam Oral Tablet 0.50 MG, give 1 tablet by mouth every 4 hours as needed for anxiety disorder, with start date 9/20/24 and no stop date. Record review of Resident #150's Medication Administration Record for October 2024 revealed the following: - Lorazepam 0.50 mg was not administered PRN all month in September 2024. During an observation and interview on 10/02/24 at 1:30 p.m., Resident #150 was observed in wheelchair awake and alert. Resident # 150 stated she needed the anxiety medication at times but does not recall when she last had it . On 10/2/2024 at 1:25 p.m., during an interview, RN A disclosed that she had previously given lorazepam to Resident # 150 to help with anxiety. RN A explained that psychotropic medications like Lorazepam should be used for a limited time, not to exceed 14 days. After 14 days, the nurse is required to contact the physician to reassess the resident's need for the medication. RN A was unsure why the order for Lorazepam for Resident #150 was written for an indefinite period, and she expressed concern that the resident was at risk of confusion and disorientation by taking the medication for more than 14 days. During an interview and record review on 10/3/2024 at 2:30 p.m., the (DON) revealed that Resident #150 required the use of Lorazepam as recommended by the physician due to the resident's diagnosis. The DON stated that if the medication was taken all the time, it could result in Resident # 150 being overmedicated. After reviewing Resident # 150's order summary, the DON confirmed that there was no stop date on the order for prn Lorazepam. The DON revealed that the order for Lorazepam was possibly overlooked, The DON stated that she was currently responsible for overseeing that psychotropic drugs are limited to only 14 days, and she would start monitoring this monthly moving forward to prevent this from occurring again. Record review of the facility policy and procedure undated, Titled Medication Drug Review Regimen ,revealed in part, When possible irregularities or unnecessary drugs are identified , the pharmacist shall prepare a drug irregularity report and submit the report to the DON .

Based on observations, interviews, and record reviews the facility failed to ensure residents could call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 1 of 8 residents (Resident #16) reviewed for the ability to call for staff assistance. The facility failed to ensure Resident #16's call light was within reach while she was positioned in her wheelchair. This failure could place residents at risk for delay in care and services, and increased risk of falls and injuries. The findings included: A record review of Resident #16's admission record dated 10/03/2024 revealed an admitted [DATE] with diagnoses which included Parkinson's disease (a movement disorder of the nervous system that worsens over time. Parkinson's symptoms may include tremors, slowed movement, rigid muscles, and poor balance), spinal stenosis (a condition that narrows the spaces in your spine, squeezing your spinal cord and nerves.), and incontinence without sensory awareness. A record review of Resident #16's quarterly MDS assessment dated [DATE] revealed Resident #16 was an [AGE] year-old female admitted for long term care and assessed as medically complex with a BIMS score of 09 out of a possible 15 which indicated a mild cognitive impairment. Resident #16 was assessed as totally dependent on staff for activities of daily life (toileting, positioning, and hygiene) and required a wheelchair. A record review of Resident #16's care plan dated 10/03/2024 revealed, (Resident #16) is High risk for falls r/t Gait/balance problems, Hypotension r/t Parkinson's Disease. She had a fall 5/1/24 . Anticipate and meet The resident's needs . Be sure The resident's call light is within reach and encourage the resident to use it CNA for assistance as needed. The resident needs prompt response to all requests for LPN assistance. During an observation and interview on 10/03/2024 at 09:17 AM, revealed Resident #16 was seated in her wheelchair in her room, alone without staff, approximately 4- 6 feet away from her call light. The call light was dangled off of the bed, above the floor. Resident #16 requested help from the surveyor and stated she was uncomfortable due to her position in the wheelchair. Resident #16 stated her lower back was in pain with some clothing and or adult brief binding her. Resident #16 stated if she attempted to stand she would fall. The surveyor alerted staff and CNA E stated Resident #16's call light was out of Resident #16 reach. CNA E repositioned Resident #16 and repositioned her call light to be at Resident #16's side. During an interview on 10/04 2024 at 03:45 PM the DON stated her expectation, and the facility policy was for residents to have their call lights within their reach when in their rooms. The DON stated the inability for residents to call staff for assistance could lead to falls. A record review of the facility's Call Light use of policy dated 2005, revealed, BASIC RESPONSIBILITY; Licensed Nurse and Nursing Assistant, all Facility Staff. PURPOSE; To respond promptly to resident's call for assistance. To assure call system is in proper working order. EQUIPMENT; Bedside call light in functioning order . When providing care to residents be sure to position the call light conveniently for the resident to use. Tell the resident where the call light is and show him/her how to use the call light

Based on interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or serious bodily injury for 1 (Resident #4) of 4 residents reviewed for freedom from abuse, neglect, and exploitation. The nursing staff of the facility failed to report an allegation of resident abuse made by Resident #4, which occurred on 09/10/24, to the administrator immediately, per facility policy. This failure could place all residents at increased risk for potential neglect due to unreported allegations of neglect. The findings included: Record review of Resident #4's admission record, dated 09/20/24, reflected a [AGE] year-old male who was readmitted on [DATE] with no relevant diagnoses. Record review of Resident #4's quarterly MDS assessment, dated 07/20/24 reflected no BIMS score and had modified independence (some difficulty in new situations only) with cognitive skills for daily decision making. Record review of a late entry for a Health Status Note, dated 09/09/24 at 10:45 PM, authored by LVN B, reflected, This nurse went to check on [Resident #4], he had drank water and had no blood in mouth at present. [Resident #4] has trouble with canker sores and bad teeth. Asked him if he said the CNAs hit him and he said No I was joking, informed him that was not something to joke about and to not make False statements like that unless it really happened he said okay. Record review of Behavior Note, dated 09/09/24 at 10:55 PM, authored by LVN B, reflected, [10:30 PM]- [CNA D] went into room for last round and resident asked for a drink of water, [CNA D] handed him his water and noticed he had a little blood in mouth, so [CNA D] asked resident what happened, and he replied you hit me, [CNA D] said no I didn't, don't say that because I can get in trouble for you lying about something like that, resident Laughed then [CNA D] made sure he had his call light and said if you need something just call. Resident then said your going to leave when I have blood in my mouth, [CNA D] stated she was going to report it to this nurse. He then said oh my gosh and laughed. [CNA D] exited room. Record review of Behavior Note, dated 09/09/24 at 11:03 PM, authored by LVN B, reflected, [10:35 PM] - [CNA D] went and asked [CNA C] to go in room with her to check on resident status. [CNA C] said resident has canker sores a lot. They both went into resident's room, [CNA C] asked him what happened in Spanish, he then told [CNA C] you hit me and [CNA C] replied no I didn't, don't say stuff like that because we can get into trouble for stuff that's not true. He then replied well who hit me then, CNA's said no one, he stated well I'm going to tell them in the morning then. During an interview on 09/19/24 at 01:20 PM, Resident #4 revealed he was joking around when he said a CNA hit him. He revealed he feels safe at this facility and had never experienced any abuse at this facility. During an interview on 09/19/24 at 03:11 PM, LVN B revealed she worked shift 6PM to 6AM for a couple of years. She said she did not want to bother anyone about the abuse allegation involving Resident #4. She revealed it was important to report allegations according to protocol for resident safety. During an interview on 09/19/24 at 04:30 PM, the DON revealed CNA D reported to DON that Resident #4 accused CNA D and CNA C of hitting him . The DON was told Resident #4 said he was joking, and the nurse found the resident was bleeding due to a canker sore. The DON revealed she learned about this at about 06:00AM on 09/10/24 from CNA D. The DON further revealed this did not need to be reported to the administrator because it was not an abuse allegation because they found the source of why Resident #4 was bleeding. The DON further revealed after reading LVN B's progress note she thought this incident needed to be reported because of how it was documented. The DON revealed the documentation did not include the nursing staff found why the resident was bleeding and the progress note read as an abuse allegation. She revealed she reported this abuse allegation at around 03:00 PM on 09/10/24. During an interview on 09/19/24 at 04:43 PM, the administrator revealed the incident where Resident #4 accused 2 CNAs of hitting him should have been reported to the administrator immediately. She revealed she let staff know that she didn't care when they contact her or how many people contact her. She revealed this would allow her to decide if this would be something to report to state. She revealed because the resident accused someone of hitting him, even if he was joking, the CNAs, nurse, and DON should've reported this incident to her. During an interview on 09/19/24 at 05:18PM, CNA D revealed Resident #4 was bleeding in his mouth. CNA D asked Resident #4 why he was bleeding and he accused her of hitting him. CNA D requested CNA C to speak with Resident #4 to confirm or deny Resident #4's accusations. CNA D said CNA C was now accusing CNA C of hitting him. CNA D revealed she should have reported this incident to the administrator. CNA D revealed she told LVN B before she left the facility because her shift ended. CNA D further revealed she was going to call the DON because it was an abuse allegation, however, CNA D was told by LVN B not to bother the DON. CNA D revealed she listened to her coworkers as they worked at the facility longer than her. CNA D revealed it was important to report right away even though Resident #4 was joking about being hit, because it could be a possibility, he was remembering someone else at the facility was hitting him. She further revealed she made a mistake and realized it the next day. She further revealed she should've called the administrator because I know better. Record review of the facility's policy Resident Abuse, Neglect or Mistreatment, undated, reflected Any alleged violation involving mistreatment, misappropriation of property, abuse, exploitation or neglect of a resident shall be reported to the administrator immediately.

Based on observation, interview, and record review the facility failed to review and revise Resident Care Plans after each assessment for 2 of 4 Residents (Resident #1 and Resident #3) whose records were reviewed for care plan revision/timing, in that:. 1. Resident #1's Care Plan was not updated after her annual MDS assessment reflected she was dependent on staff for ADL care . 2. Resident #3's Care Plan was not updated after she had a significant change and required a mechanical lift for transfers. These deficient practices could affect any resident and contribute to Residents not receiving the care and services they needed. The findings were: 1. Record review of Resident #1's admission record, dated 09/18/24, reflected a [AGE] year-old female who was admitted on [DATE] with diagnoses to include Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and weakness. Record review of Resident #1's annual MDS assessment dated [DATE] reflected a BIMS score of 6 out of 15, indicating severely impaired cognition. It further reflected Resident #1 required dependent (helper does all the effort) for lying to sitting on side of bed, sit to lying, sit to stand, and chair/bed-to-chair transfer. Record review of Resident #1's care plan, undated, reflected [Resident #1] has an ADL self-care performance deficit r/t confusion, dementia with an intervention TRANSFER: [Resident #1] is totally dependent on x1 staff for transferring., revised 10/08/22. 2. Record review of Resident #3's admission record, dated 09/19/24, reflected a [AGE] year old female who was admitted on [DATE] with diagnoses to include dementia (a group of symptoms affecting memory, thinking and social abilities), weakness, cognitive communication deficit, unsteadiness on feet, and other lack of coordination. Record review of Resident #3's quarterly MDS assessment, dated 08/24/24 reflected no BIMS score with a short-term and long-term memory problem. It further reflected resident #1 required dependent (helper does all the effort) for lying to sitting on side of bed, sit to lying, sit to stand, and chair/bed-to-chair transfer. Record review of Resident #3's care plan, undated, reflected there was no section in her care plan that reflected ADLs or transfers. During an interview and observation on 09/19/24 at 05:49 PM, CNA H revealed Resident #1 required a mechanical lift for transfers. CNA H revealed she was not able to access resident care plans from her POC screen. When CNA H clicked on the care plan tab, which would show a resident's care plan, there was a blank window with no care plan shown. CNA H revealed she knew how to transfer residents from other CNAs' verbal report and POC documentation. She further revealed she adjusted her transfers based on how the resident responded to assistance or what was needed due to resident's possible physical limitations. CNA H revealed Resident #3 did not require a mechanical lift and she was able to transfer Resident #3 without a mechanical lift. She further revealed the morning shift liked to use a mechanical lift for Resident #3. CNA H further revealed there was no note that Resident #1 or Resident #3 required a mechanical lift for transfers on her POC screen or Kardex report. During an interview on 09/20/24 at 10:25 AM, Physical Therapist G revealed Resident #1 and Resident #3 needed the mechanical lift for transfers. She revealed the nursing staff were in charge of updated the residents' care plans for type of transfers. During an interview with CNA I on 09/20/24 at 10:35 AM revealed Resident #1 and Resident #3 were transferred by Mechanical lifts and required 2 people. She revealed she knew this information from the DON or other nursing staff that shared this information. She did not look at care plans for this information. She revealed it was important to lift resident appropriately for resident safety. During an observation and interview on 09/20/24 at 10:45 AM, the MDS nurse revealed when Resident #1 came back from 09/08/24 hospitalization , Resident #1's care plan should have been updated to reflect resident #1 needed to be transferred by a Mechanical lift. She further revealed any nurse had access to the care plan and could have updated how the resident got transferred. She further revealed there were no details on how Resident #3 was transferred. She further revealed there was not a section in Resident #3's care plan that explained the ADL care for Resident #3. The MDS nurse further revealed a lot of staff were involved in the care plans. The DON or the admitting nurse oversaw the initial care plan which would include details on how a resident was to be transferred. She revealed the DON or the MDS nurse oversaw ensuring care plans are updated as needed. She revealed CNAs had access to the Kardex report, where data came from the residents' care plan, to see if a resident required a Mechanical lift for transfers. She revealed the CNAs should have access to resident care plans to give appropriate resident care. She reviewed the Kardex report and care plans for Resident #1 and Resident #3 and confirmed Resident #1 did not have a Mechanical (2-person) transfer in her care plan but had a 1-person transfer and Resident #3 did not have an ADL section in her care plan that specified any transfers. She further revealed care plans needed to be updated with an ADL section, so the nursing staff knew how to take care of resident. She further revealed if the transfers in the care plans were not updated appropriately, this could lead to an injury or fall. During an interview on 09/20/24 at 01:46 PM, the DON revealed Resident #1 and Resident #3's care plans should be updated to include they needed to be transferred via Mechanical lifts with 2 people. She revealed they worked with physical therapy to update transfers because of safety issues for staff and residents. She further revealed this information was exchanged verbally in between all nursing staff. Record Review of facility's policy Care plan/comprehensive interdisciplinary, dated 2005, reflected, The comprehensive care plan will periodically be reviewed and revised by the interdisciplinary team after each resident assessment, assessment review, or significant change in condition. The care plan will be otherwise updated as warranted by changes in medication, treatment or other changes in condition.

Based on interview and record review, the facility failed to utilize the services of a registered nurse for at least eight consecutive hours per day, seven days per week and the facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis for 3 of the 13 months reviewed, in that: The facility did not employ a Director of Nursing and did not employ sufficient full-time registered nurses to utilize their services for at least eight consecutive hours per day, seven days per week from July 2022 to October 2022. This deficient practice could place all residents in danger of not receiving adequate care. The findings were: During an interview with the Administrator on 08/23/2023 at 3:36 p.m., the Administrator stated the DON began working in October 2022 and prior to that, the facility had not employed a Director of Nursing since before the time of the previous re-certification survey in July 2022. The Administrator further stated the facility had not employed sufficient full-time registered nurses to utilize their services for at least eight consecutive hours per day, seven days per week from July 2022 to October 2022. Record review of the facility document, Staff List, undated, revealed the DON was hired in October 2022. During an interview with the DON on 08/24/2023 at 3:18 p.m., the DON confirmed she began her tenure as Director of Nursing in October 2022 and worked full-time. During an interview with the DON on 08/24/2023 at 4:02 p.m., the DON stated there was no facility policy regarding the employment of a registered nurse for at least eight consecutive hours per day, seven days per week and the designation of a registered nurse to serve as the director of nursing on a full-time basis.

Based on interview and record review, the facility failed to include as part of its QAPI program, mandatory training that outlined and informed staff of the elements and goals of the facility's QAPI program, for 20 of the 25 staff members reviewed for mandatory training, in that: Twenty of the twenty-five staff members reviewed for mandatory training had not received training regarding the facility's QAPI program. This deficient practice could place residents at risk of receiving inadequate care from staff who are unfamiliar with the facility's QAPI program. The findings were: Record review of LVN E's employee file revealed LVN E was hired on 07/27/2023 and had not received training regarding the facility's QAPI program. Record review of RN H's employee file revealed RN H was hired on 08/10/2023 and had not received training regarding the facility's QAPI program. Record review of RN I's employee file revealed RN I was hired on 06/13/2023 and had not received training regarding the facility's QAPI program. Record review of LVN J's employee file revealed LVN J was hired on 05/22/2023 and had not received training regarding the facility's QAPI program. Record review of 's Dietary Aide K's employee file revealed Dietary Aide K was hired on 05/18/2023 and had not received training regarding the facility's QAPI program. Record review of Restorative Aide L's employee file revealed Restorative Aide L was hired on 02/09/1994 and had not received training regarding the facility's QAPI program. Record review of CNA M's employee file revealed CNA M was hired on 02/06/1996 and had not received training regarding the facility's QAPI program. Record review of CNA N's employee file revealed CNA N was hired on 11/20/2022 and had not received training regarding the facility's QAPI program. Record review of CNA B's employee file revealed CNA B was hired on 12/07/2009 and had not received training regarding the facility's QAPI program. Record review of CNA O's employee file revealed CNA O was hired on 09/20/2017 and had not received training regarding the facility's QAPI program. Record review of PTA P's employee file revealed PTA P was hired on 03/28/2019 and had not received training regarding the facility's QAPI program. Record review of RA A's employee file revealed RA A was hired on 07/06/2009 and had not received training regarding the facility's QAPI program. Record review of OTA Q's employee file revealed OTA Q was hired on 03/30/2020 and had not received training regarding the facility's QAPI program. Record review of LVN R's employee file revealed LVN R was hired on 04/26/2021 and had not received training regarding the facility's QAPI program. Record review of LVN G's employee file revealed LVN G was hired on 11/23/2022 and had not received training regarding the facility's QAPI program. Record review of MDS/LVN S's employee file revealed MDS/LVN S was hired on 02/13/2023 and had not received training regarding the facility's QAPI program. Record review of LVN D's employee file revealed LVN D was hired on 10/24/1994 and had not received training regarding the facility's QAPI program. Record review of PT T's employee file revealed PT T was hired on 02/22/2019 and had not received training regarding the facility's QAPI program. Record review of OT U 's employee file revealed OY U was hired on 02/22/2019 and had not received training regarding the facility's QAPI program. Record review of ST V's employee file revealed ST V was hired on 07/18/2023 and had not received training regarding the facility's QAPI program. During an interview with the Office Manager and the Administrator on 08/24/2023 at 3:42 p.m., the Office Manager and Administrator stated they were jointly responsible for ensuring staff members completed mandatory training. The Administrator stated she was unaware of the requirement that all staff receive training regarding the facility's QAPI program. The Administrator further stated there was no facility policy regarding staff training and the QAPI program.

Based on observation, interview, and record review, the facility failed to ensure the residents' right to right to a safe, clean, comfortable and homelike environment for 3 of 3 communal shower rooms (shower room A located near the small dining room, shower room B located near conference room, and shower room C on 200 Hall) reviewed, in that: Barrels containing soiled linens and barrels containing trash were stored in three communal shower rooms, and equipment in Shower Room C was in disrepair. This deficient practice could place residents who utilize communal shower rooms at risk of psychosocial harm due to feeling disrespected or uncomfortable, with decreased self-esteem and quality of life. The findings were: Observation on 08/21/2023 at 10:42 a.m. revealed barrels containing soiled linens and barrels containing trash were in communal shower room A on the resident hallway near the small dining room. During an interview with the Social Worker on 08/21/2023 at 10:48 a.m., the Social Worker confirmed barrels containing soiled linens and barrels containing trash were in the communal shower room on the resident hallway near the small dining room. Observation on 8/21/2023 at 11:41 a.m., on the 200-wing Shower Room C, on the right side of the hallway from the nurses' station, the wall next to the toilet was observed to have a missing toilet paper holder exposing the drywall behind the tiled wall. Additionally, the toilet seat had multiple gouges in the finish, mostly centered around the front of the toilet seat, which exposed the rough wood like material underneath. The toilet seat lid had deterioration in the finish, in the area where it attached to the toilet seat and toilet, which exposed the rough wood like material underneath. The screws embedded in the toilet seat appeared to have a reddish-brown material seeping on to the bracket. There were two large plastic bins on wheels with lids, that contained dirty and visibly soiled clothes which emanated a malodorous smell that permeated the entire shower room. Observation on 08/24/2023 at 3:12 p.m. revealed barrels containing soiled linens and barrels containing trash were in the communal shower room B on the resident hallway near the conference room. During an interview with the DON, at the same time as the observation, the DON confirmed barrels containing soiled linens and barrels containing trash were in the communal shower room on the resident hallway near the conference room and stated it was the usual practice for the barrels with soiled linen and trash to be stored in communal shower rooms. During an interview with the DON on 08/24/2023 at 4:02 p.m., the DON stated there was no facility policy regarding resident dignity.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 2 halls (disused hall near therapy gym and hall near conference room), and 1 shower room (Shower Room C) reviewed for environment, in that: Hazardous materials, sharp tools, and equipment in disrepair were found in areas accessible by facility residents. This deficient practice could place all residents at risk of injury due to exposure to hazardous materials, sharp tools, and equipment in disrepair. The findings were: Observation on 8/21/2023 at 11:41 a.m., on the 200-wing shower room (Shower Room C) on the right side of the hallway from the nurses' station, the wall next to the toilet was observed to have a missing toilet paper holder exposing the drywall behind the tiled wall. Additionally, the toilet seat had multiple gouges in the finish, mostly centered around the front of the toilet seat, which exposed the rough wood like material underneath. The toilet seat lid had deterioration in the finish, in the area where it attached to the toilet seat and toilet, which exposed the rough wood like material underneath. The screws embedded in the toilet seat appeared to have a reddish-brown material seeping on to the bracket. Observation on 08/21/2023 at 12:02 p.m. of the Maintenance Closet located on the hall near the conference room, revealed it was unlocked and contained: four containers of cleaning materials, each with a label which stated the material was harmful if it came into contact with eyes and/or harmful if swallowed. During an interview with RA A and CNA B on 08/21/2023 at 12:05 p.m., RA A and CNA B confirmed the Maintenance Closet was unlocked and contained bottles labeled as hazardous. Observation on 08/24/2023 at 2:14 p.m. revealed the shower room next to the therapy gym was used for therapy sessions and contained a sink which was loosely affixed to the wall and a toilet which was loosely affixed to the floor. During an interview with the Office Manager on 08/24/2023, at the same time as the observation, the Office Manager confirmed the presence of a sink which was loosely affixed to the wall and a toilet which was loosely affixed to the floor in the therapy shower room. Observation on 08/24/2023 at 2:17 p.m., in the disused hallway near the therapy gym, revealed the bathroom of room [ROOM NUMBER] had a toilet which was loosely affixed to the floor and contained a bottle of cleaning material with a label which stated the material was harmful if swallowed. Further observation revealed a room labeled Hopper Room, in which was a toilet with no seat which contained brown liquid with a foul odor. Further observation revealed a communal shower room which contained three gallon sized containers of cleaning material with labels which stated the material was harmful if swallowed. During an interview with the Office Manager on 08/24/2023, at the same time as the observation, the Office Manager confirmed the presence of hazardous materials and equipment in disrepair on the disused hallway near the therapy gym. The Office Manager further confirmed that residents could access the disused hallway from resident halls which were in use, and that residents could also access the disused hallway from the therapy gym. Observation of the Maintenance Room, located next to snack and drink dispensers in the disused resident hall, revealed it contained numerous tools with sharp edges. Further observation revealed the presence of containers of cleaning and maintenance materials each with a label which stated the material was harmful if it came into contact with eyes and/or harmful if swallowed. During an interview with the Office Manager on 08/24/2023, at the same time as the observation, the Office Manager confirmed the presence of sharp tools and hazardous materials in the Maintenance Room located next to snack and drink dispensers, and confirmed the room was accessible by residents. During an interview with the Administrator on 08/24/2023 at 4:00 p.m., the Administrator stated all staff were responsible for storing hazardous materials behind locked doors. The Maintenance Director was not available for interview. During an interview with the DON on 08/24/2023 at 4:02 p.m., the DON stated there was no facility policy regarding accident hazards.