Every finding on record at La Hacienda De Paz Rehabilitation and Care Center

Based on interview and record review, the facility failed to ensure residents were seen by a physician at least once every 30 days for the first 90 days after admission for 4 of 4 residents (Resident #10, #11, #12, #91) and at least once every 60 days thereafter for 10 of 22 residents (Resident #1, #2, #3, #7,#9, #13, #20, #29, #67, #94) reviewed for physician services. 1. The facility failed to ensure Resident #10 was seen by the physician every month for the first three months since admission on [DATE].2. The facility failed to ensure Resident #11 was seen by the physician every month for the first three months since admission on [DATE].3. The facility failed to ensure Resident #12 was seen by the physician every month for the first three months since admission on [DATE].4. The facility failed to ensure Resident #91 was seen by the physician every month for the first three months since admission on [DATE].5. The facility failed to ensure Residents #1, #2, #3, #7, #9, #13, #20, #29, #67, and #94 were seen by the physician every 60 days. These failures could place residents at risk for medical conditions not being identified, care needs not being met, and a decline in health status. Findings include: Findings include: 1. Record review of Resident #10's face sheet dated 09/24/2025 revealed a [AGE] year-old female admitted to the facility with an original date of 08/20/2024 and a readmission date of 06/17/2025 with a diagnosis of pneumonia. Record review of Resident #10's MDS dated [DATE] documented a BIMS of 3 out of 15 indicating severely impaired cognition and recorded the use of antipsychotic, antidepressant, anticonvulsant, and hypoglycemic medications. Record review of Resident #10's Nursing Home Visit note dated 07/19/2025 revealed the resident was last seen by the primary care physician on 07/19/2025. 2. Record review of Resident #11's face sheet dated 9/26/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included diabetes, urinary tract infection, and hypothyroidism. Record review of Resident #11's most recent quarterly MDS assessment dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making skills and received insulin injections. Record review of Resident #11's progress note reflected the resident was seen by the primary care physician to establish care on 4/1/25 and again on 6/27/25 since the time of admission on [DATE]. 3. Record review of Resident #12's face sheet dated 9/26/25 revealed a [AGE] year old male admitted to the facility on [DATE] with diagnoses that included acute metabolic acidosis (sudden, serious disturbance in the body's acid-base balance where there is an excess of acid or a loss of bicarbonate in the blood), diabetes (a chronic medical condition in which the body either does not produce enough insulin or cannot use insulin effectively), dependence on renal dialysis (medical treatment that performs the job of the kidneys when they are not working properly), and heart disease. Record review of Resident #12's most recent quarterly MDS assessment dated [DATE] revealed the resident was moderately cognitively impaired for daily decision-making skills and required dialysis treatments. Record review of Resident #12's History and Physical document reflected the resident was seen by the primary care physician once on 6/13/25 since admission on [DATE]. 4. Record review of Resident #91's face sheet dated 09/24/2025 revealed a [AGE] year-old female admitted to the facility with an original date of 01/12/2021 and a readmission date of 06/24/2025 with diagnoses that included a fracture of superior rim of right pubis (right hip bone), osteoporosis, fracture of sacrum , diabetes, major depressive disorder, hyperlipidemia, hypertension, and heart disease. Record review of Resident #91's MDS dated [DATE] documented a BIMS of 3 out of 15 indicating severely impaired cognition. Record review of Resident #91's Nursing Home Visit note dated 06/24/2025 revealed the resident was last seen by the primary care physician on 06/24/2025. 5. Record review of the admission Record, dated 9/26/25, reflected Resident #1 was a [AGE] year-old male originally admitted on [DATE] and readmitted on [DATE] with diagnosis that included unspecified protein-calorie malnutrition (deficient protein and calorie intake that can lead to muscle loss and fat loss) and atherosclerotic (A buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow) heart disease of native coronary artery without angina pectoris. Record review of Resident #1's significant MDS assessment, dated 9/15/25, showed his memory was severely impaired for daily decision making. Record review of Resident #1's hospital documentation, dated 9/4/25, revealed he was admitted on [DATE] and discharged on 9/10/25. Resident #1's most recent primary care physician notes were requested and this hospital documentation was instead provided. Record review of Resident #2's admission record, dated 9/26/25, revealed a [AGE] year-old male resident, admitted on [DATE], and readmitted on [DATE], with diagnosis of diffuse traumatic brain injury with loss of consciousness of unspecified duration. Record review of Resident #2's Quarterly MDS dated [DATE] revealed Resident #3's cognition was severely impaired for daily decision making. Record review of Resident #2's Nursing Home Visit note dated 6/13/25 revealed the resident was last seen by the primary care physician on 6/13/25. Record review of Resident #3's admission sheet dated 6/26/25, documented a [AGE] year-old female resident, admitted on [DATE] and readmitted on [DATE], with diagnoses including cerebral infarction (occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it) and chronic kidney disease (your kidneys have mild to moderate damage, and they are less able to filter waste and fluid out of your blood). Record review of Resident #3's Quarterly MDS dated [DATE] revealed Resident #3's cognition was severely impaired for daily decision making. Record review of Resident #3's Nursing Home Visit note dated 9/26/24 revealed the resident was last seen by the primary care physician on 9/26/24. Record review of the admission Record, dated 9/26/25, reflected Resident #7 was a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnosis that included sepsis (the body's extreme response to an infection), atherosclerotic (A buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow) heart disease of native coronary artery without angina pectoris, and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with mood disturbance. Record review of Resident #7's quarterly MDS assessment, dated 9/2/25, showed her memory was severely impaired for daily decision making. Record review of Resident #7's Nursing Home Visit note dated 6/13/2025 revealed the resident was last seen by the primary care physician on 6/13/25. Record review of Resident #9's admission sheet dated 3/23/2025 documented a [AGE] year-old female resident with diagnoses including diabetes mellitus, hyperlipidemia (high cholesterol), dementia, and schizophrenia. Record review of Resident #9's MDS dated [DATE] documented a BIMS of 15 indicating intact cognition and recorded the use of antipsychotic, antibiotic, diuretic, and hypoglycemic medications. Record review of Resident #9's Nursing Home Visit note dated 6/13/2025 revealed the resident was last seen by the primary care physician on 6/13/25. Record review of Resident #13's admission sheet dated 7/03/2025 with an original date of 12/21/2023 documented a [AGE] year-old female resident with diagnoses including depression, dementia, hyperlipidemia, hypertension (high blood pressure) and diabetes mellitus. Record review of Resident #13's MDS dated [DATE] documented a BIMS of 12 indicating moderate cognitive impairment and recorded the use of antidepressant and hypoglycemic medications. Record review of Resident #13's Nursing Home Visit note dated 7/19/2025 revealed the resident was last seen by the primary care physician on 7/19/2025. Record review of Resident #20's admission sheet dated 9/01/2020 with an original date of 5/15/2020 documented an [AGE] year-old female resident with diagnoses including dementia, chronic kidney disease, anxiety, depression, hyperlipidemia, heart disease, and diabetes mellitus. Record review of Resident #20's MDS dated [DATE] documented a BIMS of 3 indicating severe cognitive impairment and recorded the use of anticonvulsant and hypoglycemic medications. Record review of Resident #20's Nursing Home Visit note dated 6/13/2025 revealed the resident was last seen by the primary care physician on 6/13/25. Record review of Resident #29's face sheet dated 09/24/2025 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (movement disorder), psychotic disorder with delusions to known psychological condition, generalized anxiety disorder, diabetes, edema, epilepsy and major depressive disorder. Record review of Resident #29's MDS dated [DATE] documented a BIMS of 5 out of 15 indicating severely impaired cognition and recorded the use of antipsychotic, antianxiety, antidepressant, anticonvulsant, and hypoglycemic medications. Record review of Resident #29's Nursing Home Visit note dated 07/21/2025 revealed the resident was last seen by the primary care physician by telehealth visit on 07/21/2025. Record review of Resident #67's admission sheet dated 02/04/2022 with an original date of 02/23/2018 documented an [AGE] year-old female resident with diagnoses including schizophrenia, anxiety, epilepsy (seizure disorder), dementia, hyperlipidemia, heart disease, hypertension, anxiety, and diabetes mellitus. Record review of Resident #67's MDS dated [DATE] documented a BIMS of 99 indicating the resident was unable to complete the interview and recorded the use of antidepressant, antibiotic, and anticonvulsant medications. Record review of Resident #67's Patient Progress Notes dated 9/5/2025 revealed the resident received a telephone visit by the primary care physician on 9/5/25. An in-person physician visit could not be found in the medical record in the last sixty days at the time of the survey. Record review of Resident #94's face sheet dated 09/26/2025 revealed a [AGE] year-old female admitted to the facility with an original date of 10/30/2018 and a readmission date of 01/02/2024 with diagnoses that included sepsis , acute pyelonephritis (kidney infection), diabetes, hyperlipidemia, glaucoma, hypertension, pulmonary disease, gastro-esophageal reflux disease, and osteoporosis. Record review of Resident #94's MDS dated [DATE] documented a BIMS of 7 out of 15 indicating moderate cognitive impairment and recorded the use of antidepressant, antibiotic, opioid, anticonvulsant and hypoglycemic medications. Record review of Resident #94's Nursing Home Visit note dated 07/19/2025 revealed the resident was last seen by the primary care physician on 07/19/2025. During an interview on 9/26/25 at 10:15 a.m. the DON stated the facility did not utilize nurse practitioners. She stated there were Physician assistants that assisted once a week. The survey team requested the most recent physician visit notes from the DON. The resident primary care physician notes provided by the DON are included above. During an interview on 9/26/25 at 11:49 a.m. The Administrator stated they had physician services every 30 days for new admissions and visit every 90 days after the first 90 days after admission. The Administrator stated she was unsure if they had a policy for physician services but followed the regulation. During an interview on 9/26/25 at 12:31 p.m. with the Medical Director stated he is in the facility every week and had an office close by that residents can see him at. He stated he saw new admission residents every month for three months and then every three months or 90 days after admission. He stated he was not aware the regulation was to see them every 60 days. He stated although the residents needed to be seen by a doctor, he relied on nursing staff to communicate any problems patients might have. He stated the DON and Administrator had not had any conversations with him about the frequency of visits. Record review of Texas Administrative Code, Rule S554.1203, Frequency of Physician Visits, effective January 15, 2021, reflected, (2) Medicaid-certified facilities and Medicare skilled nursing facilities.(A) The resident must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter.(B) A physician visit is considered timely if it occurs no later than ten days after the date the visit was required.(C) Except as provided in paragraph (3) of this section 19.1205(c) of this subchapter (relating to Physician Delegation of Tasks), all required visits must be made by the physician personally.(3) Medicare skilled nursing facilities. At the option of the physician, required visits in Medicare skilled nursing facilities after the initial visit may alternate between personal visits by the physician and visits by a physician assistant or an advanced practice registered nurse in accordance with S19.1205 of this subchapter.

Based on observation, interview, and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for 5of 7 residents (Resident #1, Resident #20, Resident #32, Resident #100, and Resident #10) who were reviewed for resident assessments. 1. The facility failed to accurately documents Resident #1's skin conditions on his significant change MDS. 2.The facility failed to document Resident #20's use of pain medication and antiplatelet medication on the quarterly MDS assessment. 3. The facility failed to document Resident #32's use of antidepressant medication and antiplatelet medication on the quarterly MDS assessment. 4. The facility failed to document Resident #100's use of antidepressant medication on the quarterly MDS assessment. 5. The MDS Case Manager incorrectly coded Resident #10 with a primary diagnosis of dementia and with no mental illness. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. The findings included: 1. Record review of the admission Record, dated 9/26/25, reflected Resident #1 was a [AGE] year-old male originally admitted on [DATE] and readmitted on [DATE] with diagnosis that included unspecified protein-calorie malnutrition (deficient protein and calorie intake that can lead to muscle loss and fat loss) and atherosclerotic (A buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow) heart disease of native coronary artery without angina pectoris. Record review of Resident #1's significant MDS assessment, dated 9/15/25, showed his memory was severely impaired for daily decision making. Section M showed he had unhealed pressure ulcers and then showed 0 number of current unhealed pressure ulcers. Record review of Resident #1's care plan, dated 5/26/25, revised 9/25/25, stated the resident had potential for pressure ulcers development with interventions to Administer treatments as ordered and monitor for effectiveness. Replace loose or missing dressings as needed, notify nurse immediately of any new areas of skin breakdown: open area, redness, Blisters, Bruises, discoloration noted during bath or daily care, the resident needs assistance to turn/reposition at least every 2 hours. Record review of Resident #1's physician orders, dated 9/26/25, revealed an order to apply hydrocolloid dressing to buttocks for preventative as needed for preventative previous injury site, with a start date of 9/11/25, and no end date. During an interview on 9/25/25 at 2:50 p.m. with the MDS Case Manager and MDS I stated Resident #1 used to have a pressure ulcer, but it was resolved. The MDS case Manager stated that MDS I should have entered no pressure ulcers on the significant changed MDS from 9/15/25. The MDS Case Manager stated when MDS I entered 0 pressure ulcers she should have been given an error. The MDS Case Manager stated the residents' MDS helps to determine their level of care and should be accurate to the residents. 2. Record review of Resident #20's admission sheet dated 9/01/2020 with an original date of 5/15/2020 documented an [AGE] year-old female resident with diagnoses including dementia, chronic kidney disease, anxiety, depression, hyperlipidemia (high cholesterol), heart disease, and diabetes mellitus. Record review of Resident #20's MDS dated [DATE] documented a BIMS of 3 indicating severe cognitive impairment and recorded the use of anticonvulsant and hypoglycemic medications. Further review of Resident #20's MDS revealed the assessment did not include the use of pain medication or antiplatelet medication, despite the resident receiving Acetaminophen (a non-opioid analgesic medication) and Aspirin (an antiplatelet medication). Record review of Resident #20's order summary documented active orders for the analgesic medication Acetaminophen with an order date of 8/25/25 and the antiplatelet medication Aspirin with an order date of 6/27/23. Record review of Resident #20's August 2025 and September 2025 MARs documented the resident had been receiving Acetaminophen and Aspirin as prescribed. Further review of the August and September MARs recorded Acetaminophen was ordered as Acetaminophen 325mg, give 2 tablets by mouth two times a day for pain. Aspirin was ordered as Aspirin 81mg, give 1 tablet by mouth one time a day. Record review of Resident # 20's care plan with an initiation date of 6/9/2020 documented resident has primary osteoarthritis of right knee with interventions including Give analgesics as ordered by the physician. The care plan further documented The resident receives an aspirin medication, with the goal of The resident will be free from discomfort or adverse reactions related to antiplatelet use. 3. Record review of Resident #32's admission sheet dated 7/26/2025 with an original date of 6/5/2025 documented a [AGE] year-old female resident with diagnoses including insomnia, dementia, diabetes mellitus, hyperlipidemia, hypertension (high blood pressure), depression, and heart disease. Record review of Resident #32's MDS assessment dated [DATE] documented a BIMS of 13 indicating intact cognition and recorded the use anticonvulsant and hypoglycemic medications. Further review of Resident #32's MDS revealed the assessment did not include the use of antiplatelet or antidepressant medication, despite the resident receiving Aspirin (an antiplatelet medication) and Duloxetine (an antidepressant medication). Record review of Resident #32's order summary documented orders for the antiplatelet medication Aspirin with an order date of 7/26/25 and the antidepressant medication Duloxetine with an order date of 7/26/25. Record review of Resident #32's August 2025 MAR documented the resident had been receiving Aspirin and Duloxetine as prescribed. Further review of the August MAR recorded Aspirin was ordered as Aspirin 81mg, give 1 tablet by mouth one time a day. Duloxetine was ordered as Duloxetine 20mg, give 1 capsule by mouth one time a day. Record review of Resident #32's care plan with an initiation date of 8/18/25 documented The resident receives an antiplatelet medication, with the goal of The resident will be free from discomfort or adverse reactions related to antiplatelet use. The care plan further documented a diagnosis of depression with interventions including Administer medications as ordered, and Arrange for psych consult. 4. Record review of Resident #100's admission sheet dated 2/26/2025 with an original date of 3/02/2020 documented an [AGE] year-old male resident with diagnoses including depression, cerebral infarction (stroke), hyperlipidemia, diabetes mellitus, and hypertension. Record review of Resident #100's MDS dated [DATE] documented a BIMS of 11 indicating moderate cognitive impairment and recorded the use of anticoagulant, diuretic, and hypoglycemic medications. Further review of Resident #100's MDS revealed the assessment did not include the use of antidepressant medications despite the resident receiving Sertraline (a selective serotonin reuptake inhibitor) and Trazodone (a serotonin-antagonist-and-reuptake-inhibitor). Record review of Resident #100's order summary documented orders for the antidepressant medication Sertraline with an order date of 8/05/2025 and the antidepressant medication Trazodone with an order date of 4/01/2025. Record review of Resident #100's August 2025 MAR documented the resident had been receiving Sertraline and Trazodone as prescribed. Further review of the August MAR recorded Sertraline was ordered as Sertraline 50mg, give 1 tablet by mouth one time a day. Trazodone was ordered as Trazodone 50mg, give 0.5 tablet by mouth one time a day. Record review of Resident #100's care plan with an initiation date of 5/01/2023 documented The resident requires antidepressant medication related to Depression with interventions including Give antidepressant medications ordered by physician. In an interview with the MDS Case Manager on 9/25/25 at 2:47 PM, the MDS Case Manager stated it was her responsibility to sign the MDS for completeness and accuracy before submission. The MDS Case Manager further stated it was important to include all necessary information on the MDS, so it is an accurate and true reflection of the care provided to residents. In an interview with the DON on 9/25/25 at 4:40 PM, the DON stated it is important for the MDS to be accurate because it represents the current level of care needed by a resident. The DON further stated her expectation is for the MDS to be accurate and for staff to use the documentation present in the medical record for compiling the MDS. 5. Record review of Resident #10's face sheet, dated 09/24/2025, revealed the resident was a [AGE] year-old female and admitted to the facility on [DATE], with a readmission date of 6/17/2025, with the diagnoses of Pneumonia (an infection in the lugs that causes difficulty in breathing), and other diagnoses such as Bipolar disorder (mental health condition characterized by extreme mood swings) and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (decline in functioning, affecting memory, thinking, and social abilities). Record review of Resident #10's MDS, dated [DATE], revealed the resident's BIMS score a 3 out of 15 which suggested the resident's cognition was severely impaired for daily decision-making skills. Record review of Resident #10's PASARR Level 1 Screening dated 08/16/2024 revealed and completed at a local hospital:-The question, Is there evidence that dementia is the primary diagnosis for this individual? marked as yes. -The questions, Is there evidence or an indicator this is an individual that has a mental illness? marked as no. Record review of Resident #10's medical record revealed no PASARR Level 1 Screening completed by the facility. Record Review of Resident #10's diagnosis information on the face sheet dated 09/24/2025 revealed a secondary diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Record Review of Resident #10's diagnosis information on the face sheet dated 09/24/2025 revealed a diagnosis of bipolar disorder. Record review of Resident #10's hospital records dated 8/20/204 revealed the resident was discharged from the hospital with an ongoing treatment for dementia. During an interview on 09/25/2024 at 3:10 p.m., the MDS Case Manager stated they were responsible for the assessment of the residents and PASARR. When asked what the process was regarding PASARR when a resident was admitted to the facility the MDS Case Manager stated they received the PL1 (PASARR level 1 screening) from the referring entity, the Business Manager entered the patient's demographics in the system, then they entered the PL1. When asked who was responsible for ensuring accuracy of the PL1 assessment the MDS Case Manager stated we usually look over them. When asked what could happen when PL1 assessments were inaccurate the MDS Case Manager stated if they were a true PASSAR positive they would lose out on benefits of the services. When asked if bipolar disorder was considered a mental illness the MDS Case Manager stated they would say it was. The MDS Case Manager stated they could submit to the state to change the PASARR level 1 screening form for accuracy. The MDS Case Manager stated dementia would have been marked as a primary diagnosis if the hospital answered it like that and it was double checked if it's correct based off of hospital records. During an interview on 09/25/2025 at 4:42 p.m., the DON stated MDS was responsible for looking over PASARR level 1 screening assessments making sure everything was correct as well as if they were positive. When asked what can happen when PL1 assessments were inaccurate the DON stated possibly the resident isn't going to get all the care they need and the benefits and added assistance they get with PASARR. The DON stated if PASARR was incorrect they could call the people that did it, the hospital, and that they need to review it and see if was accurate; and if not, they need to go back and fix it or redo it. When asked where to find if a diagnosis is primary or secondary the DON stated under the list of diagnoses it would say whether it was a primary or secondary diagnosis. The DON stated they weren't sure whether MDS would confirm if dementia was a primary diagnosis outside of looking under list of diagnoses. Record review of facility document labeled PASRR Level 1 Screen Policy and Procedure, revised on 03/16/2019, reveals: 7. The facility will maintain PL1 best practices as followed: Review the PL1 form for completion and correctness before admission Review of the facility policy titled Resident assessment dated 2003 noted The facility will utilize the Resident Assessment Instrument (RAI). The assessment will include at least the following: m. Drug therapy.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles for 2 of 6 medication carts (the 300/400 hall PO cart and the 500/600 hall PO cart) assessed for medication storage and labeling. 1. The facility failed to ensure all medications located inside the 300/400 hall PO cart were stored in labeled containers.2. The facility failed to ensure the 500/600 hall PO cart was locked and secured. These failures could place residents at risk of receiving inadequate treatments or ingesting medications for which they were not prescribed. The findings included: 1. During an observation of the 300/400 hall PO cart on 9/25/2025 at 10:00 AM, one loose pill was discovered lying in the bottom of the drawer of the of the medication cart. During an interview with LVN C on 9/25/2025 at 10:00 AM, LVN C stated if a pill is in the cart unlabeled, they would not know what medication it was or for which resident it was prescribed. During an interview with the DON on 9/25/25 at 3:25 PM, the DON stated her expectation regarding medication storage was for everything to be accurate and to be contained where it should be. The DON further stated her expectation for carts were for items to be dated, nothing to be missing, medications to be reordered timely, carts to be clean, and there should be no loose pills. During an interview with the Administrator on 9/25/25 at 3:25 PM, the Administrator stated her expectations were for there to be no medication errors, drug diversion, or any resident or staff having access to any loose pills which could lead to an incident. 2. Observation on 9/25/25 at 10:04 a.m. revealed the 500-hall medication cart was left unlocked and unattended. During an observation and interview on 9/25/25 at 10:08 a.m., LVN E confirmed the 500-hall medication cart was unlocked and unattended and stated the medication cart was assigned to two nurses, LVN C and RN F. LVN E stated, a medication cart was never supposed to be left unlocked and unattended because people who were not supposed to have access to the cart could get a medication that did not belong to them. LVN E stated the facility had residents who wandered and if unauthorized persons got into the medication cart, they could take medication that could make them sick, and they could have a serious reaction. During an interview on 9/25/25 at 10:19 a.m., LVN C stated she had used the 500-hall medication cart earlier in the morning, before breakfast, maybe between 6:30 a.m. and 7:00 a.m. LVN C stated RN F had also used the 500-hall cart the same day. LVN C stated, a medication cart was never supposed to be left unlocked and unattended because somebody could get into it when they were not supposed to. LVN C stated, the 500-hall medication cart had blood pressure medications stored in it and if a person took those medications not prescribed to them it could cause a serious reaction, such as their blood pressure dropping. LVN C stated the facility also had residents who wandered, and those residents could potentially get into the cart. During an interview on 9/25/25 at 5:51 p.m., the DON stated, medications carts should always remain unlocked when unattended for safety reasons. The DON stated, residents and other unauthorized people could get into an unlocked medication cart and consume medications that were not prescribed to them and could cause an adverse reaction. Record review of the facility policy titled Medication Storage in the Facility dated 2025 noted Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier, and the pharmacy dispenses medications in containers that meet legal requirements, including requirements of good manufacturing practices where applicable. Medications are kept and stored in these containers. The policy further noted Medication rooms, carts, and medication supplies are locked or attended to by persons with authorized access.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 7 residents (Resident #90) reviewed for infection control: The facility failed to ensure staff maintained proper hand hygiene during wound care on Resident #90. These failures could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #90's admission record, dated 9/26/25, revealed an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included pressure ulcer of sacral region stage 4 (A stage 4 pressure ulcer is characterized by significant tissue loss and damage. These ulcers penetrate deep into the skin and underlying tissues, affecting muscles, tendons, and even bones.). Record review of Resident #90's quarterly MDS assessment, dated 8/12/25, revealed the resident cognition was severely impaired for daily decision-making skills, and section M revealed he had 2 stage 4 pressure injuries. Record review of Resident #90's care plan, initiated 5/30/22, revised 7/10/23, revealed the resident had pressure injuries: stage IV to right buttocks and stage IV to sacrum with interventions to follow facility policies/protocols for the prevention/treatment of skin breakdown. Record review of Resident #90's Physician Order, dated 9/26/25, revealed the following:- Stage 4 to right buttock: cleanse site with wound cleanser, pat dry, apply silver alginate, cover with dry dressing, secure with tape one time a day, with a start date of 9/24/25. During an observation on 9/25/25 at 9:57 a.m. LVN G provided wound care to Resident #90's pressure wounds. LVN G left the bedside to wash her hands in the resident's bathroom. LVN G returned and touched the privacy curtain with her barehand, put on gloves, and returned to cleaning the resident's 1st wound bed. LVN G removed the old dressing from the 2nd wound and again went to wash her hands. LVN G left the bathroom and touched the door handle with her bare hand, opened and touched the privacy curtain with her bare hand, put on gloves, and began to clean the 2nd wound bed. During an interview on 9/25/25 at 10:18 a.m. LVN G stated she did not touch the door with her bare hand or the privacy curtain. LVN G stated if she had touched the door handle or curtain with her bare hand, then directly put on gloves, germs from the door handle would be transferred to the resident. During an interview on 9/25/25 at 4:59 p.m., the DON stated LVN G should have used hand sanitizer if she touched something on the way back from washing her hands. The DON stated if not possible cross contamination of the wound could happen. Record review of the facility policy titled Fundamentals of Infection Control Precautions, dated 3/2024, stated A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control precautions.1. Hand Hygiene, Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene. Before and after assisting a resident with personal care.After contact with a resident's mucous membranes and body fluids or excretions; After handling soiled or used linens, dressings, bedpans, catheters and urinals; After handling soiled equipment or utensils.After removing gloves or aprons.

Based on observation, interviews and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (Resident #7) of 7 residents reviewed for resident rights. The facility failed to notify Resident #7's physician of her change of condition when LVN G documented on 9/1/25, 9/15/25, and 9/22/25 the resident had bruising to multiple areas and did not notify the physician. This failure could affect residents by placing them at risk for a delay in medical treatment, decline in health, and death. The findings included: Record review of the admission Record, dated 9/26/25, reflected Resident #7 was a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnosis that included sepsis (the body's extreme response to an infection), age related cognitive decline, atherosclerotic (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow) heart disease of native coronary artery without angina pectoris, and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with mood disturbance. Record review of Resident #7's quarterly MDS assessment, dated 9/2/25, revealed her memory was severely impaired for daily decision making. Section N revealed she was taking an anticoagulant (medication that stops your blood from clotting too easily). Record review of the Resident #7's Care Plan, dated 4/7/25, revealed she was on aspirin therapy and anticoagulant therapy with interventions to report immediately to the charge nurse if bruising, nosebleeds, bleeding gums, prolonged bleeding from wound, IV, or surgical sites, blood in urine/feces/vomit, coughing up blood and monitor/document/report to MD PRN s/sx of aspirin complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy (lack of energy), bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Another care area reflected the resident received antiplatelet medication related to PVD (peripheral vascular disease is a progressive disorder that affects blood flow to arms, legs, or other body parts due to narrowed or blocked blood vessels). Record review of Resident #7's physician's orders, dated 9/26/25, revealed orders for:-apixban (blood thinner that prevents blood clots and to prevent strokes) oral 2.5 mg tablet, give 1 tablet by mouth two times a day related to atherosclerotic heart disease of native coronary artery without angina pectoris. Monitor for signs and symptoms of anticoagulant use: bruising, bleeding, sore gums, sore joints, nose bleeds, petechiae (tiny red, purple, or brown spots on the skin caused by bleeding from small blood vessels that have broken), rectal bleeding, hematemesis (vomiting of blood) or hematuria (blood in urine). If noted notify MD. The order had a start date of 11/22/24, and no end date.-Aspirin (a nonsteroidal anti-inflammatory drug (NSAID) and a salicylate, commonly used for pain relief, inflammation reduction, and cardiovascular protection) 81 mg tablet, give 1 tablet by mouth one time a day related to atherosclerotic heart disease of native coronary artery without angina pectoris. Monitor for signs and symptoms of anticoagulant use: bruising, bleeding, sore gums, sore joints, nose bleeds, petechiae (tiny red, purple, or brown spots on the skin caused by bleeding from small blood vessels that have broken), rectal bleeding, hematemesis (vomiting of blood) or hematuria (blood in urine). If noted notify MD. The order had a start date of 11/22/24, and no end date.-Cilostazol (vasodilator that improves blood flow by relaxing blood vessels) tablet 50 mg give 1 by mouth one time a day related to peripheral vascular disease. Monitor for signs or symptoms of antiplatelet use: bruising, bleeding, sore gums, sore joints, nose bleeds, petechiae (tiny red, purple, or brown spots on the skin caused by bleeding from small blood vessels that have broken), rectal bleeding, hematemesis (vomiting of blood) or hematuria (blood in urine). If noted notify MD. The order had a start date of 6/28/25, and no end date.-May use geri sleeves (protective garments designed to shield the arms from damage caused by friction and shearing) on both arms, one time a day for fragile skin, with a start date of 7/12/25, and no end date. Record review of Resident #7's progress notes, dated 9/26/25, revealed notes written by LVN G-9/1/25 Weekly skin assessment.bruise present: Yes. Location, measurement of bruising: multiple arms.-9/15/25 weekly skin assessment. Bruise present: Yes. Location, measurements of bruising: BIL (bilateral-both) UPPER AND LOWER EXT (extremity) . -9/22/25 weekly skin assessment. Bruise present: Yes. Location, measurements of bruising: multiple bruising to upper and lower extremities. During an observation and interview on 9/24/25 at 8:44 a.m. revealed Resident #7 was lying in bed. She had dark purplish discoloration on both arms from about her knuckles to midway up to her upper arms. The resident stated she had the bruises for about 15 days and was unsure why or where they came from. She stated they were not painful, and she had no issues with staff. She stated she had just come from showering and needed her arm covers because she was cold. During an interview on 9/24/2 at 8:45 a.m. NA H stated Resident #7 had confusion at times. NA H stated Resident #7 bruised easily and they had to be careful when they transferred the resident. NA H stated they had recently showered the resident and needed to place her arm sleeves on. During an interview on 9/26/25 at 8:55 a.m. LVN G stated the resident was known to bruise and that was why they used the geri sleeves. LVN G stated Resident #7's bruises would come and go. LVN G stated she had not had a recent conversation with Resident #7's doctor about the bruising she documented but the doctor was aware of her bruising. During an interview on 9/26/25 at 9:35 a.m. the DON stated LVN G should have completed an incident report for the bruises the resident had, notified her, and notified her doctor. The DON stated she spoke with the resident's doctor on 9/26/25 and he gave directions to discontinue her apixaban and cilostazol. The DON stated the resident had no recent known incidents in the past month that could have caused the bruising, and they were most likely from her anticoagulant medications, transferring her, and self-inflicted because she was known to scratch herself. The DON stated if staff did not report bruises to the doctor the resident could continue to bruise easily or have internal bleeding. During an interview on 9/26/25 at 12:31 p.m. Resident #7's primary Doctor stated nursing staff would let him know if the resident had bruising, but he was not aware of her recent bruising until the morning of 9/26/25 when the DON notified him. He informed them they could discontinue her apixaban and cilostazol. The Doctor stated if he was not informed of her bruising she would continue to bruise and worst-case scenario if she had a fall and she could have bleeding from nose or head. Record review of the facility's policy titled Notifying the Physician of Change in status, no date, stated The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention. 1. The nurse will notify the physician or their delegated nurse practitioner or physician assistant with change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record.3. The nurse may collect several non-emergent items and place one telephone call during the shift in order to avoid multiple calls to a physician with non-emergent questions. The nurse is responsible, however, for responding to a change of condition in a timely and effective manner. The nurse will document the time of the call to the physician in the clinical record. 4. If the physician does not return the call within a reasonable amount of time, the nurse will attempt to contact the physician a second time. If the situation is an emergency, and the physician does not call back within a reasonable amount of time, the nurse will contact the Medical Director or the nearest ambulance service for assistance. The nurse will document all attempts to contact the physician in the resident's clinical record. 5. The resident's family member or legal guardian should be notified of significant change in resident's status unless the resident has specified otherwise. 6. The nurse will monitor and reassess the resident' s status and response to interventions. Physicians should develop a working diagnosis and guide nursing staff in what to monitor, and when to notify the physician if the resident' s condition does not improve. 7. The nurse will document all attempts to contact the physician, all attempts to notify the family and/or legal representative, the physician's response, the physician's orders and the resident's status and response to interventions.

Based on interview and record review, the facility failed to ensure the residents' right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 1 of 12 residents (Resident #75) reviewed for advanced directives. Resident #75's OOH-DNR was missing a physician's signature and was therefore invalid. This deficient practice could place residents at-risk of having their end of life wishes dishonored and of having CPR performed against their will. The findings included: Record review of Resident #75's face sheet dated [DATE] revealed an [AGE] year old male admitted to the facility on [DATE] and re-admitted on [DATE] and [DATE] with diagnoses that included acute kidney failure (sudden loss of the kidneys' ability to filter waste products), dependence on renal dialysis (medical treatment that performs the job of the kidneys when they are not working properly), hypertension (medical condition where the force of blood against the walls of the arteries is consistently too high), hyperlipidemia (medical condition in which there are abnormally high levels of fats in the flood), and heart failure. Record review of Resident #75's most recent significant change MDS assessment dated [DATE] revealed the resident was severely cognitively impaired for daily decision-making skills and required renal dialysis treatments. Record review of Resident #75's Order Summary Report dated [DATE] revealed the following:- DNR, with order date [DATE] and no end date. Record review of Resident #75's comprehensive care plan with date of initiation [DATE] reflected the resident had an order for DNR with the goal to honor the resident/responsible party's decision for DNR and interventions that included for the SW to consult with the resident and RP regarding their decision to continue DNR. Record review of Resident #75's Request for Do Not Resuscitate (DNR) document dated [DATE] reflected the request for DNR was requested by the resident representative on [DATE] and the attending physician was informed of the request for DNR on [DATE]. Record review of Resident #75's OOH DNR revealed the resident's representative signed the form but did not include the date the document was signed. Resident #75's OOH DNR revealed two witness signatures signed the form on [DATE]. Resident #75's OOH DNR revealed the physician failed to sign the upper portion and lower portion of the form. During an interview on [DATE] at 11:28 a.m., LVN B stated she was uncertain if Resident #75 had a DNR code status, but if she needed to find out it was in the profile section of the electronic record. LVN B confirmed Resident #75 was identified in the profile section of the electronic record as having a DNR code status. LVN B stated, code status was determined at the time of admission, and the admitting charge nurse was responsible for inputting the DNR/Full Code information in the computer with the help of the ADON's, after an order from the physician was obtained. LVN B stated there was somebody in the front office that obtained the paperwork to initiate the DNR. During an interview on [DATE] at 11:34 a.m., ADON D stated the nursing staff could obtain a resident's code status from the profile section in the electronic record and code status information could also be obtained from a binder on the crash cart that listed the resident's code status. ADON D stated the code status resident list on the crash cart was updated every night at midnight in case there were any new admissions. ADON D stated, Resident #75 had a DNR code status and reviewed Resident #75's OOH DNR and stated the form was missing the physician's signature and therefore was considered invalid. ADON D stated, since the OOH DNR form for Resident #75 was missing the physician's signature, the resident would have to be considered full code status. ADON D stated, if Resident #75 had suffered cardiac arrest (heart attack) and the OOH DNR form was not valid, then the resident would receive CPR, and that would not be following their wishes because they wanted the DNR status. During an interview on [DATE] at 11:54 a.m., the SW stated code status was discussed at the time of admission and if the resident or representative chose OOH DNR status, the admission office would initiate the OHH DNR form and would only refer to the SW if the resident or representative had any questions. The SW stated she was responsible for auditing OOH DNR forms every two weeks. The SW confirmed Resident #75's OOH DNR filed in the electronic record was not signed by the attending physician and they were still waiting for the doctor to sign it. The SW stated, If the resident should have a cardiac arrest, the staff would not initiate CPR because the family signed the Request for Do Not Resuscitate (DNR) document. The SW stated sometimes the doctors were really fast and sometimes they take a while to get documents signed. The SW reiterated, The staff would not initiate CPR because that would be going against the family's wishes, and we have proof that was their wish because they signed the Request for DNR status. During an interview on [DATE] at 2:31 p.m., the DON stated, Resident #75's code status changed from full code status to DNR status in early September. The DON stated, after Resident #75's last hospitalization he started to receive dialysis treatments, and his code status changed from full code to DNR. The DON stated, the OOH DNR forms were initiated on admission, the admissions office obtained the required signatures from the RP or resident, then the form was given to the nursing department, and nursing initiated the Request for DNR document. The DON stated, then the nursing department notified the physician of the OOH DNR request and obtained orders from the physician. The DON confirmed Resident #75's OOH DNR document uploaded into the electronic record on [DATE] did not have the physician's signature. The DON stated, the turnaround to get the doctor's signature is typically a week, it's not usually this long. The DON stated, even though Resident #75's OOH DNR was not signed by the doctor, the facility followed through as an OOH DNR code status for Resident #75 per the resident/family wishes based on the Request for DNR document. During an interview on [DATE] at 2:40 p.m., the Admissions Staff stated she was responsible for initiating OOH DNR form per the resident/representative request. The Admissions Staff stated, once signatures were obtained by the resident/representative, the OOH DNR form was provided to the nursing department for completion. The admission Staff stated she was aware the SW audited the OOH DNR forms. The Admissions Staff stated it was not her department who determined how long the OOH DNR form needed to be signed by the doctor. The Admissions Staff stated, I don't know what the doctor's turnaround time is. The Admissions Staff stated, the Medical Records department followed up with the doctor. During an interview on [DATE] at 2:48 p.m., the Medical Records staff stated the OOH DNR form was initiated by the admissions office, it was then provided to the nurses, who then contacted the doctor to obtain orders. The Medical Records staff stated, after the nursing staff notified the doctor, the OOH DNR form was given to her, and she then prepared a folder with the OOH DNR document and took it to the doctor's office and dropped off the folder so the physician could sign it. The Medical Records staff stated, once she received the OOH DNR document for the physician to sign she dropped off the form to the physician on the same day or the following day. The Medical Records staff stated, Sometimes the doctor takes a while, a lot of times and Usually, I drop off the packet, and I stand there waiting for it, but sometimes I am told the doctor is not there, he's out of town, he's on vacation. And I tell them we really need it because the resident is already in the facility. It's important to have the signature on the DNR, but I'm not a nurse, I'm a medical records and central supply staff. The Medical Records staff stated, once the OOH DNR document was uploaded into the electronic record, the SW checks the form to make sure the OOH DNR was completed correctly, I just make sure it gets to the doctor. During an interview on [DATE] at 5:39 p.m., the Administrator stated sometimes the Medical Records staff went to the doctor's office three times a week and could not put a time frame on an appropriate time for the doctor to sign the OOH DNR form. The Administrator stated, the OOH DNR form was important because it was a life or death decision. During an interview on [DATE] at 12:31 p.m., the Medical Director stated, once an OOH DNR form was initiated, completion of the OOH DNR should be done as soon as the order was put in the electronic record. The Medical Director stated, the OOH DNR should be signed, the same day, within 24 hours. The Medical Director stated, for a resident who requested an OOH DNR, and was not signed by a doctor, the OOH DNR was not valid, and would make the resident a full code, and if something happens, they will have to do CPR, against the resident's/RP's wishes. Record review of the Texas Health and Human Services webpage titled, Out of Hospital Do Not Resuscitate Program, updated [DATE], revealed, Frequently Asked Questions for DNR: What happens if the form is not filled out correctly or EMS has doubts about any of the information? Health professionals can refuse to honor a DNR if they think: The form is not signed twice by all who need to sign it or is filled out incorrectly. Record review of the facility document titled Do Not Resuscitate Order, undated, revealed in part, The facility will honor two types of Do Not Resuscitate orders: a physician's order for Do Not Resuscitate and the Texas Out-of-Hospital DNR Order.All validly executed physician orders for DNR orders will be honored by the facility.Emergency workers will not honor the physician's order for DNR.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 nourishment room fridges. The nourishment room had undated opened items in the fridge. This deficient practice could place residents who ate food from the nourishment room fridge at risk for foodborne illness. The findings include: During observation on 09/23/2025 at 11:13 a.m., the following containers of food looked to have previously been opened with no date to include, a bottle of chocolate milk, a clear container with soup-like substance, a to go box, an item in foil, a soup-like substance in a clear container with a blue lid, a plastic wrapping with cheese slices in it, and a container of meat. During an interview on 09/23/2025 at 11:15 a.m., the Dietary Manager stated they are only responsible for the snacks they put in the fridge for the residents. When asked about the other items in the fridge the dietary manager stated she did not know what they were or where they came from. The Dietary Manager stated they change out their snacks every day and that they are labeled and dated with the residents' names and what the snack is. The Dietary Manager stated they label items with dates to know when they need to be out by so residents aren't eating bad food. During an interview on 09/24/2025 at 7:18 a.m., the Administrator stated anything pertaining to the residents goes in the nourishment room and that everyone has access to it which includes staff and families. The Administrator stated the nourishment room has no code, and the fridge is for residents only. The Administrator stated the nourishment room falls under the kitchen and follows the same polices as the kitchen. The Administrator stated items in the fridge should follow the kitchen policies in order to be safe for residents to consume. Record review of facility document titled Food Storage and Supplies reveals:4. Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened.

Based on interview and record review, the facility failed to ensure the services provided or arranged by the facility, as outlined by the comprehensive care plan, meet professional standards of quality for 1 of 7 residents (Residents #7) reviewed for following physician orders. The facility failed to obtain all 3-guaiac test (also known as the fecal occult blood test (FOBT), is used to detect hidden (occult) blood in stool samples) ordered for Resident #7 on 5/13/25 and report new onset bruising to the physician as directed in the physician orders and care plan. These failures could place the residents at risk of not having their individual needs met and of not receiving adequate care and medical interventions to maintain their health and prevent worsening health conditions. Findings included: Record review of the admission Record, dated 9/26/25, reflected Resident #7 was a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnosis that included sepsis (the body's extreme response to an infection), age related cognitive decline, atherosclerotic (A buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow) heart disease of native coronary artery without angina pectoris, and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with mood disturbance. Record review of Resident #7's quarterly MDS assessment, dated 9/2/25, revealed her memory was severely impaired for daily decision making. Section N showed she was taking an anticoagulant. Record review of the Resident #7's Care Plan, dated 4/7/25, revealed she was on aspirin therapy and anticoagulant therapy with interventions to report immediately to the charge nurse if bruising, nosebleeds, bleeding gums, prolonged bleeding from wound, IV, or surgical sites, blood in urine/feces/vomit, coughing up blood and monitor/document/report to MD PRN s/sx of aspirin complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy (lack of energy), bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Another care area stated the resident received antiplatelet medication related [NAME] PVD (peripheral vascular disease is a progressive disorder that affects blood flow to arms, legs, or other body parts due to narrowed or blocked blood vessels). Record review of Resident #7's laboratory report, dated 4/10/25, revealed Resident #7 had low hemoglobin at 7.9 g/dL (a protein in red blood cells that carries oxygen throughout the body; normal levels are between 11.2 and 15.7 g/dL), low hematocrit at 24.5% (volume percentage of red blood cells in the blood; normal ranges are between 34.1% and 44.9%), and low red blood cell count 2.68 x10^6/uL (is a blood test that measures the number of red blood cells in your body which are essential for transporting oxygen; normal levels are between 3.93 and 5.22 x10^6/uL) levels. The doctor wrote on the lab report an order for x3 days of guaiac test and signed it on 5/13/25. Record review of Resident #7's lab test results revealed 2 stool tests were completed on 5/24/25 and 5/26/25 with negative occult blood results for both tests. No results for the 3rd test were located in the resident's medical records. During an interview on 9/26/25 at 2:41 p.m. the DON stated they only had results for 2 tests and was unsure why they did not have 3 results for the order for x3 days of guaiac testing. Record review of the facility's policy titled Notifying the Physician of Change in status, no date, stated The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention. 1. The nurse will notify the physician or their delegated nurse practitioner or physician assistant with change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record.3. The nurse may collect several non-emergent items and place one telephone call during the shift in order to avoid multiple calls to a physician with non-emergent questions. The nurse is responsible, however, for responding to a change of condition in a timely and effective manner. The nurse will document the time of the call to the physician in the clinical record. 4. If the physician does not return the call within a reasonable amount of time, the nurse will attempt to contact the physician a second time. If the situation is an emergency, and the physician does not call back within a reasonable amount of time, the nurse will contact the Medical Director or the nearest ambulance service for assistance. The nurse will document all attempts to contact the physician in the resident's clinical record. 5. The resident's family member or legal guardian should be notified of significant change in resident's status unless the resident has specified otherwise. 6. The nurse will monitor and reassess the resident' s status and response to interventions. Physicians should develop a working diagnosis and guide nursing staff in what to monitor, and when to notify the physician if the resident' s condition does not improve. 7. The nurse will document all attempts to contact the physician, all attempts to notify the family and/or legal representative, the physician's response, the physician's orders and the resident's status and response to interventions.

Based on observation, interview and record review the facility failed to, in response to allegations of abuse, neglect, exploitation, or mistreatment, have evidence that all alleged violations are thoroughly investigated and report the results of all investigations to the state survey agency within five working days of the incident for 1 of 7 residents (Resident #7) reviewed for abuse and neglect. The facility failed to investigate when Resident #7 had bruising to both her arms and could not state how they happened. This deficient practice placed all residents at risk of harm from neglect due to not having a thorough investigation. The findings Include: Record review of the admission Record, dated 9/26/25, reflected Resident #7 was a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnosis that included sepsis (the body's extreme response to an infection), age related cognitive decline, atherosclerotic (a buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow) heart disease of native coronary artery without angina pectoris, and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with mood disturbance. Record review of Resident #7's quarterly MDS assessment, dated 9/2/25, revealed her memory was severely impaired for daily decision making. Section N revealed she was taking an anticoagulant (medication that stops your blood from clotting easily). Record review of the Resident #7's Care Plan, dated 4/7/25, revealed she was on aspirin therapy and anticoagulant therapy with interventions to report immediately to the charge nurse if bruising, nosebleeds, bleeding gums, prolonged bleeding from wound, IV, or surgical sites, blood in urine/feces/vomit, coughing up blood and monitor/document/report to MD PRN s/sx of aspirin complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy (lack of energy), bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Another care area reflected the resident received antiplatelet medication related to PVD (peripheral vascular disease is a progressive disorder that affects blood flow to arms, legs, or other body parts due to narrowed or blocked blood vessels). Record review of Resident #7's physician orders, dated 9/26/25, revealed orders for:-May use geri sleeves (protective garments designed to shield the arms from damage caused by friction and shearing) on both arms, one time a day for fragile skin, with a start date of 7/12/25, and no end date. Record review of Resident #7's progress notes, dated 9/26/25, revealed notes written by LVN G-9/1/25 Weekly skin assessment.bruise present: Yes. Location, measurement of bruising: multiple arms.-9/15/25 weekly skin assessment. Bruise present: Yes. Location, measurements of bruising: BIL (bilateral) UPPER AND LOWER EXT (extremity) .-9/22/25 weekly skin assessment. Bruise present: Yes. Location, measurements of bruising: multiple bruising to upper and lower extremities. During an observation and interview on 9/24/25 at 8:44 a.m. revealed Resident #7 was lying in bed. She had dark purplish discoloration on both arms from about her knuckles to midway up to her upper arms. The resident stated she had the bruises for about 15 days and was unsure why or where they came from. She stated they were not painful, and she had no issues with staff. She stated she had just come from showering and needed her arm covers because she was cold. During an interview on 9/24/25 at 9:45 a.m. NA H stated Resident #7 had confusion at times. NA H stated Resident #7 bruised easily and they had to be careful when they transferred the resident. NA H stated they had recently showered the resident and needed to place her arm sleeves on. During an interview on 9/26/25 at 8:55 a.m. LVN G stated the resident was known to bruise and that was why they used the geri sleeves. LVN G stated Resident #7's bruises would come and go. LVN G stated she had not had a recent conversation with Resident #7's doctor about the bruising she documented but the doctor was aware of her bruising. During an interview on 9/26/25 at 8:55 a.m. LVN G stated the resident was known to bruise and that is why they used the geri sleeves. LVN G stated Resident #7's bruises would come and go. LVN G stated she had not had a recent conversation with Resident #7's doctor about bruising she documented but the doctor was aware of her bruising. During an interview on 9/26/25 at 9:35 a.m. the DON stated LVN G should have completed an incident report for the bruises the resident had, notified her, and notified her doctor. The DON stated she spoke with the resident's doctor on 9/26/25 and he gave directions to discontinue her apixaban and cilostazol. The DON stated the resident had no recent known incidents in the past month that could have caused the bruising, and they were most likely from her anticoagulant medications, transferring her, and self-inflicted because she was known to scratch herself. The DON stated if staff did not report bruises to the doctor the resident could continue to bruise easily or have internal bleeding. Record review of the facility's policy titled Abuse/Neglect, no date, stated The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart.12. Injury of Unknown Source any injury to a t resident observed where: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time.D. Identification The facility will identify and investigate events that may constitute abuse/neglect. The facility will determine the direction of the investigation based on a thorough examination of events. Opportunities to prevent abuse/neglect will be managed accordingly. E. Reporting Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse neglect or exploitation must report this to the DON, administrator, state and/or adult protective service. State law mandates that citizens report all suspected cases of abuse, neglect or financial exploitation of the elderly and incapacitated persons.

Based on observation, interview, and record review, the facility failed to ensure drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for 2 of 6 carts (the 500/600 hall PO cart and the 100/200/600 hall PO cart) reviewed for pharmacy services. The facility failed to ensure the controlled substance reconciliation logs were signed for accuracy of medication quantities during shift change. This failure could place residents at risk of not receiving their prescribed medications, experiencing untreated pain and anxiety, and a decreased quality of life. The findings included: During an observation of the 500/600 hall po cart on 9/25/2025 at 9:45 AM, a sample of controlled medications was inventoried for accuracy with RN A. The sample inventory showed no discrepancies between medication quantities documented on the individual controlled substance logs and the number of pills remaining in the blister packs, however record review of the comprehensive controlled medication reconciliation log used for cart audit during shift change revealed the log was missing two signatures. During an interview with RN A on 9/25/2025 at 9:45 AM, RN A stated it was important for the control log to be signed during shift change by the staff member taking control of the cart and the staff member relinquishing control of the cart, because the count of controlled medications could be inaccurate, and residents might not get their medication. During an observation of the 100/200/600 hall PO cart on 9/25/2025 at 10:10 AM a sample of controlled medications was inventoried for accuracy with RN A. The sample inventory showed no discrepancies between medication quantities documented on the individual controlled substance logs and the number of pills remaining in the blister packs, however record review of the comprehensive controlled medication reconciliation log used for cart audit during shift change revealed the log was missing one signature. During an interview with RNA on 9/25/2025 at 10:10 AM, RN A stated it is important for the reconciliation log to be signed at every shift change to make sure the count of controlled substances is accurate. During an interview with the DON on 9/25/2025 at 3:20 PM, the DON stated her expectation for the controlled substance reconciliation log was for staff to reconcile the controlled medications daily. The DON further stated everything contained in the medication carts has to be accounted for and double checked every shift to make sure it is accurate to avoid drug diversion or missing items. During an interview with the Administrator on 9/25/2025 at 3:20 PM, the Administrator stated her expectation regarding the controlled medication log was for the log to be accurate to avoid drug diversion, medication errors, and to ensure they provide proper care for residents. Record review of the facility policy titled Controlled Medications - Administration dated 2025 noted At each shift change, a physical inventory of all controlled medications is conducted by two licensed nurses and/or one nurse and a CMA, QMAP, Med Tech or equivalent as allowed by your State regulatory agency and is documented on an audit record.

Based on interview and record review revealed the facility failed to promptly notify the ordering physician, physician assistant, nurse practitioner or clinical nurse specialist of results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders for 1 of 7 Residents (Resident #7) whose records were reviewed for lab services. 1. The facility failed to report to Resident #7's physician and document abnormal laboratory results on 4/11/25. This deficient practice could affect any resident and contribute to residents' decline of health condition by not providing the physician information necessary to be informed decisions. The findings were: Record review of the admission Record, dated 9/26/25, reflected Resident #7 was a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnosis that included sepsis (the body's extreme response to an infection), age related cognitive decline, atherosclerotic (A buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow) heart disease of native coronary artery without angina pectoris, and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with mood disturbance. Record review of Resident #7's quarterly MDS assessment, dated 9/2/25, showed her memory was severely impaired for daily decision making. Section N showed she was taking an anticoagulant. Record review of the Resident #7's Care Plan, dated 4/7/25, showed she was on aspirin therapy and anticoagulant therapy with interventions to report immediately to the charge nurse if bruising, nosebleeds, bleeding gums, prolonged bleeding from wound, IV, or surgical sites, blood in urine/feces/vomit, coughing up blood and monitor/document/report to MD PRN s/sx of aspirin complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy (lack of energy), bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Another care area stated the resident received antiplatelet medication related [NAME] PVD (peripheral vascular disease is a progressive disorder that affects blood flow to arms, legs, or other body parts due to narrowed or blocked blood vessels). Record review of Resident #7's laboratory report, dated 4/10/25, revealed Resident #7 had low hemoglobin at 7.9 g/dL (a protein in red blood cells that carries oxygen throughout the body; normal levels are between 11.2 and 15.7 g/dL), low hematocrit at 24.5% (volume percentage of red blood cells in the blood; normal ranges are between 34.1% and 44.9%), and low red blood cell count 2.68 x10^6/uL (is a blood test that measures the number of red blood cells in your body which are essential for transporting oxygen; normal levels are between 3.93 and 5.22 x10^6/uL) levels. The doctor wrote on the lab report an order for x3 days of guaiac test (also known as the fecal occult blood test (FOBT), is used to detect hidden (occult) blood in stool samples) and signed and dated it on 5/13/25. Record review of Resident #7's nursing progress notes, dated 9/26/25, revealed between 4/10/25 and 4/25/25 there were no progress notes referencing Resident #7's abnormal lab results from 4/10/25. Record review of Resident #7'd lab test results revealed 2 stool tests were completed on 5/24/25 and 5/26/25 with negative occult blood results for both tests. The facility collected 2 of the 3 samples ordered for testing over 3 days. During an interview on 9/26/25 at 2:41 p.m. the DON stated staff should notify the doctor immediately of any abnormal labs or critical labs and it should be documented in a progress note. The DON stated she was unsure why the labs were not reviewed by the physician until 5/13/25 and the additional labs ordered were not collected until 5/24/25. Record review of the facility's policy titled Notifying the Physician of Change in status, no date, stated The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention. 1. The nurse will notify the physician or their delegated nurse practitioner or physician assistant with change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. 11. Abnormal lab, x-ray and other diagnostic reports require physician notification.

Record review of the admission Record, dated 9/26/25, reflected Resident #7 was a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnosis that included sepsis (the body's extreme response to an infection), age related cognitive decline, atherosclerotic (A buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow) heart disease of native coronary artery without angina pectoris, and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with mood disturbance. Record review of Resident #7's quarterly MDS assessment, dated 9/2/25, revealed her memory was severely impaired for daily decision making. Section N revealed she was taking an anticoagulant (medication that stops your blood from clotting easily). Record review of the Resident #7's Care Plan, dated 4/7/25, revealed she was on aspirin therapy and anticoagulant therapy with interventions to report immediately to the charge nurse if bruising, nosebleeds, bleeding gums, prolonged bleeding from wound, IV, or surgical sites, blood in urine/feces/vomit, coughing up blood and monitor/document/report to MD PRN s/sx of aspirin complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy (lack of energy), bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Another care area reflected the resident received antiplatelet medication related [NAME] PVD (peripheral vascular disease is a progressive disorder that affects blood flow to arms, legs, or other body parts due to narrowed or blocked blood vessels). Record review of Resident #7's physician orders, dated 9/26/25, revealed orders for:-May use geri sleeves (protective garments designed to shield the arms from damage caused by friction and shearing) on both arms, one time a day for fragile skin, with a start date of 7/12/25, and no end date. Record review of Resident #7's progress notes, dated 9/26/25, revealed notes written by LVN G-9/1/25 Weekly skin assessment.bruise present: Yes. Location, measurement of bruising: multiple arms.-9/15/25 weekly skin assessment. Bruise present: Yes. Location, measurements of bruising: BIL (bilateral) UPPER AND LOWER EXT (extremity) .-9/22/25 weekly skin assessment. Bruise present: Yes. Location, measurements of bruising: multiple bruising to upper and lower extremities. During an observation and interview on 9/24/25 at 8:44 a.m. revealed Resident #7 was lying in bed. She had dark purplish discoloration on both arms from about her knuckles to midway up to her upper arms. The resident stated she had the bruises for about 15 days and was unsure why or where they came from. She stated they were not painful, and she had no issues with staff. She stated she had just come from showering and needed her arm covers because she was cold. During an interview on 9/24/25 at 8:45 a.m. NA H stated Resident #7 had confusion at times. NA H stated Resident #7 bruised easily and they had to be careful when they transferred the resident. NA H stated they had recently showered the resident and needed to place her arm sleeves on. During an interview on 9/26/25 at 8:55 a.m. LVN G stated the resident was known to bruise and that was why they used the geri sleeves. LVN G stated Resident #7's bruises would come and go. When asked by this surveyor if she reported the bruises to anyone LVN G stated the provider was aware, but she had not recently reported them to anyone. During an interview on 9/26/25 at 9:35 a.m. the DON stated LVN G should have completed an incident report for the bruises the resident had, notified her, and notified her doctor. The DON stated she spoke with the resident's doctor on 9/26/25 and he gave directions to discontinue her apixaban and cilostazol. The DON stated the resident had no recent known incidents in the past month that could have caused the bruising, and they were most likely from her anticoagulant medications, transferring her, and self-inflicted because she was known to scratch herself. The DON stated if staff did not report bruises to the doctor the resident could continue to bruise easily or have internal bleeding. Record review of the facility's policy titled Abuse/Neglect, no date, stated The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart.12. Injury of Unknown Source any injury to a t resident observed where: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time.D. Identification The facility will identify and investigate events that may constitute abuse/neglect. The facility will determine the direction of the investigation based on a thorough examination of events. Opportunities to prevent abuse/neglect will be managed accordingly. E. Reporting Any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse neglect or exploitation must report this to the DON, administrator, state and/or adult protective service. State law mandates that citizens report all suspected cases of abuse, neglect or financial exploitation of the elderly and incapacitated persons.

Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 3 residents (Resident #2) reviewed for abuse, in that: The facility failed to supervise and protect Resident #2, who did not have the ability to consent, from harm when Resident #1, on 3/27/25, was observed leaning over Resident #2's bed with his hand under her brief touching her genital area. An Immediate Jeopardy (IJ) was identified as past noncompliance. The noncompliance began on 03/27/25 and ended on 03/29/25. The facility had corrected the noncompliance before the survey began. A PNC IJ template was presented to the Director of Nursing at 5:45 pm on 05/15/25. These deficient practices placed residents at risk of psychosocial harm and continued abuse. The findings were: Record review of admission Record dated 05/14/25 for Resident #1 revealed an [AGE] year-old male admitted to the facility 02/14/25. Resident #1's diagnoses included encounter for orthopedic aftercare following surgical amputation, generalized anxiety disorder (a disorder characterized by excessive, uncontrollable and often irrational worry about events or activities); unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (a person has been diagnosed with dementia and exhibits cognitive decline (memory loss, difficulty thinking, etc) but does not show accompanying behavioral symptoms; mood disorder due to known physiological condition (diagnosis where a person experiences depressed mood or diminished interest/pleasure that is directly related to the physiological effects of another medical condition); and end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids). Record review of Resident #1's admission MDS dated [DATE] revealed a BIMS score of 5, indicating severe cognitive impairment. Record review of Resident #1's Care Plan with revision date of 03/27/25 had a focus of The resident has potential to demonstrate physical behaviors related to dementia. The Interventions included May be evaluated and treated by [NAME] psych services; May be evaluated and treated by [ NAME] behavioral health associates; Give resident as many choices as possible about care and activities; Monitor/document/report to MD of danger to self or others; Notify the charge nurse of any physically abusive behaviors. Record review of admission Record dated 05/15/25 for Resident #2 revealed a [AGE] year-old female admitted to the facility 02/29/20 with the most recent admission date of 07/05/23. Resident 2's diagnoses included cerebral infarction (known as a stroke, a medical condition where brain tissue dies due to a lack of blood flow), aphasia following cerebral infarction (language disorder caused by damage to the brain's language centers, that impairs communication, comprehension and expression), dysphasia (impaired ability to understand or use the spoken word) and hemiplegia and hemiparesis following cerebral infarction affecting left dominant side (muscle weakness or partial paralysis on one side of the body). Record review of Resident #2's Quarterly MDS dated [DATE] documented that resident was unable to complete a BIMS and a staff interview revealed she is severely cognitively impaired. Record review of Resident #2's Care Plan revised 5/22/23 indicated a Focus of The resident has a psychosocial well-being problem related to abuse allegation. The Interventions included Allow the resident time to answer questions and to verbalize feelings perceptions and fears; Initiate referrals as needed Social Services consult and referral to psych services. According to the Facility Provider Investigation Report 3613-A, on 3/27/25 CNA R reported to charge nurse that she heard screaming coming from Resident #2's room. CNA R found Resident #1 on the floor next to the low bed for Resident #2 with his hand under her diaper in her genital area. CNA R immediately told him to remove his hand and she called for the charge nurse, LVN S, to come and assist her to get Resident #1 out of the room. Attempts were made to call CNA R and LVN S for further comment on 05/14/25 at 4:32 pm but neither one returned the call after voicemails were left. Record review showed Head to toe assessments were completed for both residents following this event. Resident #2 was sent to the hospital for further exam to ensure there were no physical changes noted and physician confirmed there were no abnormal findings. Resident #1 was referred for psych services. Following the event, both residents were interviewed and neither could tell anything that happened and were not aware of what had occurred. Record review shows Safe surveys were conducted with 11 female residents and all expressed they could tell a staff members if they felt threatened but all said they felt safe at the time of interview. Five of the females were referred to psychiatric services for a Trauma Informed PRN Assessment. 3 of these 5 were seen on 04/22/25 and 2 were seen on 4/23/25. Record review of psychiatric consultant visits for Resident #1 revealed he was seen on 4/11/24, 4/18/24, 5/1/24, 5/7/24 and 5/14/24. Record review of email dated 04/23/25 sent from Director of Operations for the facility to local Ombudsman revealed the list of names of females that had trauma informed assessments and the Ombudsman was asked to visit with them. Review of Progress Notes from the time of his admission, revealed Resident #1 was frequently found wandering into other residents' rooms, especially female rooms, expressing that he was looking for his mother or his wife. Due to the wandering, review of observations logs revealed Resident #1 was placed on intermittent periods of increased observation beginning 03/04/25 through 03/06/25 (every hour from 10:00 pm to 5:00 am), and on 3/23/25 every 30 minutes (from 10:00 pm to 5:00 am). After the incident with Resident #2, he was placed on 1 to 1 monitoring 24 hours per day beginning 03/27/25. During the surveyor's investigation, confidential interviews revealed several women who had previous encounters with Resident #1. They all expressed anxiety and unease about Resident #1 coming in their rooms but stated they felt the facility staff were doing their best to keep them safe. Record review of the 30-Day Discharge Notice in the Medical Record documented that on 04/11/25, the facility gave Resident #1's representative a 30-day discharge notice due to facility not being able to meet resident's needs. The notice stated Resident requires an all-male facility. Resident continuously exhibits behavior to enter women's rooms. On 03/27/25 a nonconsensual sexual incident involving Resident #1 with a female resident was witnessed. Since incident Resident #1 continues on 1:1 supervision. Resident #1 was observed in his room on 05/15/25 at 7:00 am eating his breakfast. He was confused and not able to be interviewed. According to the sitter, he was leaving to go to hyperbaric treatment at 7:30 am which was scheduled twice a week due to his non-healing wounds. Resident #2 was observed in her room in bed on 05/15/25 at 7:15 am. Observation made with DON present. Resident #2 appeared to be asleep. DON stated resident no longer talks but appears to understand some simple things that are said to her. According to the DON on 05/15/25 at 9:50 am, during the last care plan meeting with the responsible party, facilities who could provide the needed care due to Resident #1's wandering and behavior with female residents were discussed and permission was given to send clinical documentation for the facilities' review. The representative then decided to appeal the discharge and the appeals hearing will be held 05/27/25. Review of the facility policy titled Abuse/Neglect dated 09/09/24 stated: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in the subpart. 1. Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. (sic) .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. 4. Sexual Abuse: non-consensual sexual contact of any type with a resident. 9. Misappropriation of resident property: means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Inservice training was reviewed for training in misappropriation of property and abuse and neglect. The following inservices were noted: 10/11/24 - Topic: Abuse and Neglect - Signed by 101 of 105 staff members 12/12/24 - Topic: Signed by 133 of 133 staff members 3/28/25 - Topic: Abuse, Neglect and Exploitation - Signed by 79 staff members Following this incident, the facility conducted safe surveys of residents. One unidentified resident stated she felt anxious in Resident #1's presence but denied feeling unsafe. Surveyors interviewed staff members on 05/14/25 and 05/15/25 by asking Have you had training about abuse/neglect/misappropriation? When was the most recent time? How would you respond to allegations of abuse/neglect/misappropriation? The purpose of these interviews was to cover staff members understanding of how to prevent misappropriation of resident's property as well as prevention of abuse. 5/14/25 8:30 am - CNA C - Have had training on ANE - would report any incidents to Administrator 5/14/25 10:20 am - LVN D - Have had training on ANE - would report any incidents to Administrator 5/14/25 1:00 pm - Interviews with COTA E, PTA F and OT G in therapy department. All said they had training about 2 weeks ago and received information on protocols for ANE and how to keep resident safe. 5/15/25 9:26 am - LVN A - Stated we get inservices on ANE regularly. I would let the DON and ADM know if I was aware of any incident. 5/15/25 9:27 am - LVN H - Yes we had one recently like last month. I would tell the DON or ADM. 5/15/25 9:30 am - LVN I - I believe last month was the last time we had an inservice. For misappropriation I would report to the finance person and the supervisor. 5/15/25 9:31 am - CNA J - We had an inservice a few weeks ago. We report to the DON and ADM. 5/15/25 9:35 am - HSK K - We have had a lot of inservices on ANE. I have been here 5 years. For misappropriation, we would try to find out who took the money. We would report to the DON or ADM. 5/15/25 9:35 am - HSK L - I had an inservice a month ago. For misappropriation, I would first help them look for their money and then tell ADM and my supervisor. 5/15/25 12:00 - CNA M - Yes we had training about a month ago. I would report ANE immediately to the ADM. 5/15/25 12:00 - CNA N - We had an inservice about a month ago. I would report to the ADM and charge nurse. 5/15/25 3:21 pm - CNA O (Night shift via phone) We have had a lot of inservices on ANE. I would report it immediately to ADM. 5/15/25 3:24 pm - CNA P - (Night shift via phone) Anytime something happens they do an inservice. I would report to ADM. 5/15/25 3:30 pm - CNA Q - (Night shift via phone) We have had a lot of inservices on ANE. I would report immediately to ADM.

Based on observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes enhancement of his or her quality of life, recognizing each resident's individuality for 2 of 3 Residents (Resident #4 and Resident #5) who were interviewed regarding the method of transportation used to take them to doctor's appointments. 1. Resident #4 stated that the van driver had taken her in her wheelchair instead of the van across the street from the facility for a doctor's appointment which created pain in her knees. 2. Resident #5 was also wheeled across the street in her wheelchair for a doctor's appointment which embarrassed her. These deficient practices could affect dependent residents and contribute to feelings of shame or feeling uncomfortable and could place residents at risk of embarrassment, lack of privacy, and loss of dignity. Findings include: 1. Record review of admission Record for Resident #4 revealed an [AGE] year old female originally admitted to the facility 10/30/2018 with the most recent admission date of 01/02/24. The diagnoses for Resident #4 included sepsis (a very serious condition that occurs as a result of a complication with an infection), pyogenic arthritis (a serious and painful infection of a joint), chronic obstructive pulmonary disease (a progressive lung disease characterized by chronic respiratory symptoms and airflow limitation), and acute pyelonephritis (a serious kidney infection affecting both kidneys). Record review of Resident #4's Quarterly MDS dated [DATE] revealed a BIMS score of 13 indicating resident was cognitively intact. During an interview with Resident #4 on 05/14/25 at 11:45 am, resident stated that the van driver had decided to take her to her doctor's appointment across the street by pushing her wheelchair to the office. Resident #4 stated this was very painful since she had a great deal of pain in her knee and was supposed to get an injection in the knee at the doctor's office. Being pushed in a wheelchair along a bumpy street created a great deal of pain in her leg. Resident #4 did not know why she was not taken in the van. During an interview with the Van Driver on 05/14/25 at 12:49 pm, she was asked if she took residents to the doctor's office in their wheelchairs rather than in the van. The Van Driver stated that since residents don't get to go out of the facility very often and they like to get fresh air, she takes them in their wheelchairs since the offices are just across the street. She stated that sometimes families take residents out as well. She then claimed that she knew that Resident #4 was upset about going in the wheelchair but that she did not take her and someone else must have taken her. She was asked for the names of other residents who she has taken to the doctor in their wheelchair. There was no documentation in the medical record as to why the van was not used. 2. Record review of admission Record dated 05/14/25 for Resident #5 revealed a [AGE] year-old female admitted to the facility 09/20/24. Resident #5's diagnoses included aftercare following joint replacement surgery, overactive bladder, difficulty in walking, anxiety disorder (a mental health condition that causes fear, dread and other symptoms that are out of proportion to the situation), and Type 2 Diabetes Mellitus (a group of diseases that result in too much sugar in the blood). Record review of Resident #5's Quarterly MDS dated [DATE] revealed a BIMS score of 13 indicating she was cognitively intact. An interview with Resident #5 on 05/14/25 at 1:35 pm revealed she had been taken to the doctor via wheelchair. Resident #5 stated the van driver told her it would be too much trouble to load her into the van, go across the street and then have to unload her. She also stated she felt embarrassed when she was pushed in the wheelchair down the street. Resident #5 stated she was not given a choice as to how she wanted to be transported to the doctor's office. During an interview with Resident #6 on 05/14/25 at 1:12 pm, he acknowledged he had been taken to the doctor via wheelchair. Resident #6 stated he would go either way and didn't mind going in the wheelchair. Resident #6 was asked if the Van Driver ever asked for his preference and he said its whatever is available. An interview with the DON on 05/14/25 at 2:46 pm revealed that Resident #4 had mentioned to the charge nurse that she didn't want to go to the doctor's appointment if she was going to be taken in the wheelchair. The DON stated that resident should have expressed her concerns about this to her so it could be addressed. After discussing the issues that were expressed by the residents with surveyor, the DON stated that residents would no longer be taken via wheelchair and only be transported via facility van. An undated policy titled Transportation of a Resident (non-emergency) states: Residents requiring transportation in non-emergency situations to and from the nearest medical service provider will be transferred by a facility employee in a safe manner. 1. The driver must be a licensed driver in the state and an employee of the nursing facility. 2. All residents must be secured in the vehicle by seat belt. 3. Residents must be physically assisted in and out of the vehicle by a trained employee using appropriate transfer techniques.Based on observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes enhancement of his or her quality of life, recognizing each resident's individuality for 2 of 3 Residents (Resident #4 and Resident #5) who were interviewed regarding the method of transportation used to take them to doctor's appointments. 1. Resident #4 stated that the van driver had taken her in her wheelchair instead of the van across the street from the facility for a doctor's appointment which created pain in her knees. 2. Resident #5 was also wheeled across the street in her wheelchair for a doctor's appointment which embarrassed her. These deficient practices could affect dependent residents and contribute to feelings of shame or feeling uncomfortable and could place residents at risk of embarrassment, lack of privacy, and loss of dignity. Findings include: 1. Record review of admission Record for Resident #4 revealed an [AGE] year old female originally admitted to the facility 10/30/2018 with the most recent admission date of 01/02/24. The diagnoses for Resident #4 included sepsis (a very serious condition that occurs as a result of a complication with an infection), pyogenic arthritis (a serious and painful infection of a joint), chronic obstructive pulmonary disease (a progressive lung disease characterized by chronic respiratory symptoms and airflow limitation), and acute pyelonephritis (a serious kidney infection affecting both kidneys). Record review of Resident #4's Quarterly MDS dated [DATE] revealed a BIMS score of 13 indicating resident was cognitively intact. During an interview with Resident #4 on 05/14/25 at 11:45 am, resident stated that the van driver had decided to take her to her doctor's appointment across the street by pushing her wheelchair to the office. Resident #4 stated this was very painful since she had a great deal of pain in her knee and was supposed to get an injection in the knee at the doctor's office. Being pushed in a wheelchair along a bumpy street created a great deal of pain in her leg. Resident #4 did not know why she was not taken in the van. During an interview with the Van Driver on 05/14/25 at 12:49 pm, she was asked if she took residents to the doctor's office in their wheelchairs rather than in the van. The Van Driver stated that since residents don't get to go out of the facility very often and they like to get fresh air, she takes them in their wheelchairs since the offices are just across the street. She stated that sometimes families take residents out as well. She then claimed that she knew that Resident #4 was upset about going in the wheelchair but that she did not take her and someone else must have taken her. She was asked for the names of other residents who she has taken to the doctor in their wheelchair. There was no documentation in the medical record as to why the van was not used. 2. Record review of admission Record dated 05/14/25 for Resident #5 revealed a [AGE] year-old female admitted to the facility 09/20/24. Resident #5's diagnoses included aftercare following joint replacement surgery, overactive bladder, difficulty in walking, anxiety disorder (a mental health condition that causes fear, dread and other symptoms that are out of proportion to the situation), and Type 2 Diabetes Mellitus (a group of diseases that result in too much sugar in the blood). Record review of Resident #5's Quarterly MDS dated [DATE] revealed a BIMS score of 13 indicating she was cognitively intact. An interview with Resident #5 on 05/14/25 at 1:35 pm revealed she had been taken to the doctor via wheelchair. Resident #5 stated the van driver told her it would be too much trouble to load her into the van, go across the street and then have to unload her. She also stated she felt embarrassed when she was pushed in the wheelchair down the street. Resident #5 stated she was not given a choice as to how she wanted to be transported to the doctor's office. During an interview with Resident #6 on 05/14/25 at 1:12 pm, he acknowledged he had been taken to the doctor via wheelchair. Resident #6 stated he would go either way and didn't mind going in the wheelchair. Resident #6 was asked if the Van Driver ever asked for his preference and he said its whatever is available. An interview with the DON on 05/14/25 at 2:46 pm revealed that Resident #4 had mentioned to the charge nurse that she didn't want to go to the doctor's appointment if she was going to be taken in the wheelchair. The DON stated that resident should have expressed her concerns about this to her so it could be addressed. After discussing the issues that were expressed by the residents with surveyor, the DON stated that residents would no longer be taken via wheelchair and only be transported via facility van. An undated policy titled Transportation of a Resident (non-emergency) states: Residents requiring transportation in non-emergency situations to and from the nearest medical service provider will be transferred by a facility employee in a safe manner. 1. The driver must be a licensed driver in the state and an employee of the nursing facility. 2. All residents must be secured in the vehicle by seat belt. 3. Residents must be physically assisted in and out of the vehicle by a trained employee using appropriate transfer techniques.

Based on interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 resident (Resident #3) reviewed for misappropriation. The facility failed to prevent misappropriation of property when HSK B took money via cash app directly from a bank card from Resident #3 in the amount of $891. The noncompliance was identified as past noncompliance. The noncompliance began on 09/30/24 and ended on 10/01/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of misappropriation which could lead to further exploitation of other residents. Findings included: Record review of Resident #3's admission Record dated 05/13/25 documented a [AGE] year-old female admitted to the facility 07/17/24. Resident #3's diagnoses included sepsis (a very serious condition that occurs as a result of a complication with an infection), mild cognitive impairment, Type 2 Diabetes Mellitus without complications (a group of diseases that result in too much sugar in the blood), and extended spectrum beta lactamase (ESBL) resistance (the development of resistance by bacteria to a broad range of antibiotics including penicillins, cephalosporins and aztreonam. A review of the Care Plan for Resident #3 revealed a BIMS score of 8 indicating impaired cognitive function. The BIMS was initiated on 07/26/24. Although she had diabetes, she was on a regular diet and enjoyed ordering food through a food delivery service from area restaurants. An intervention for this was to monitor her blood sugar and weight per policy. Review of Facility Investigation Report dated 10/01/24 revealed that while trying to pay Resident #3's applied income on 09/30/24 using her bank card, the Business Office Manager discovered Resident #3 did not have sufficient funds in her bank account due to a number of Cash App withdrawals made to HSK B. The facility immediately suspended HSK B on 9/30/24 and made a police report. When confronted by facility, HSK B denied taking any money from the resident but one of the withdrawals was to the name of HSK B's boyfriend who did not work at the facility. The employee did not return to work after being suspended and was terminated following the investigation. Record review of Inservice training revealedtraining for misappropriation of property and abuse and neglect. The following inservices were noted: 10/11/24 - Topic: Abuse and Neglect - Signed by 101 of 105 staff members Record review noted that on 10/01/24, the facility conducted an inservice on exploitation and had staff members complete a questionnaire. On 10/02/24, a Safe Survey was conducted with residents. No other residents reported any issues with staff members requesting money from them or having money taken without their consent. Record review of Discharge Summary revealed Resident #3 was discharged home from the facility on 10/31/24. Review indicated 8 residents were interviewed for Safe Surveys on 10/03/25. Resident Grievance log was also reviewed but there were no further allegations of misappropriation. Record review of facility investigation file revealed Resident #3 received a reimbursement check in the amount of #$891 dated 11/22/24 from the facility. Resident #3 signed a statement that she had received the check. Review of the Police Report dated 10/01/24 revealed a report was taken and given Incident #202400022660.The report stated the case was referred to the Criminal Investigation Division. A phone interview on 05/13/25 at 2:31 pm with police officer who took the report revealed that the case was investigated by one of the detectives. The officer stated they still needed documents from the victim and have been unable to get them. He stated we cannot file charges until we get those documents. Apparently, Resident #3 told the investigator she was moving to Mexico. The officer could not tell surveyor what documents they were still needing without clearance from the resident. On 05/13/25 at 3:20 pm, the DON stated she had obtained Resident #3's phone number from one of her family members and talked with her. Resident #3 is still in the city and stated she would call the police department to provide the needed information. Record review of HSK B's personnel file did not reveal any previous disciplinary activity. A phone call was attempted to HSK B on 05/15/25 but she did not return the call. Review of the facility policy titled Abuse/Neglect dated 09/09/24 stated: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in the subpart. 9. Misappropriation of resident property: means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Surveyors interviewed staff members on 05/14/25 and 05/15/25 by asking Have you had training about abuse/neglect/misappropriation? When was the most recent time? How would you respond to allegations of abuse/neglect/misappropriation? The purpose of these interviews was to cover staff members understanding of how to prevent misappropriation of resident's property as well as prevention of abuse. 5/14/25 8:30 am - CNA C - Have had training on ANE - would report any incidents to Administrator 5/14/25 10:20 am - LVN D - Have had training on ANE - would report any incidents to Administrator 5/14/25 1:00 pm - Interviews with COTA E, PTA F and OT G in therapy department. All said they had training about 2 weeks ago and received information on protocols for ANE and how to keep resident safe. 5/15/25 9:26 am - LVN A - Stated we get inservices on ANE regularly. I would let the DON and ADM know if I was aware of any incident. 5/15/25 9:27 am - LVN H - Yes we had one recently like last month. I would tell the DON or ADM. 5/15/25 9:30 am - LVN I - I believe last month was the last time we had an inservice. For misappropriation I would report to the finance person and the supervisor. 5/15/25 9:31 am - CNA J - We had an inservice a few weeks ago. We report to the DON and ADM. 5/15/25 9:35 am - HSK K - We have had a lot of inservices on ANE. I have been here 5 years. For misappropriation, we would try to find out who took the money. We would report to the DON or ADM. 5/15/25 9:35 am - HSK L - I had an inservice a month ago. For misappropriation, I would first help them look for their money and then tell ADM and my supervisor. 5/15/25 12:00 - CNA M - Yes we had training about a month ago. I would report ANE immediately to the ADM. 5/15/25 12:00 - CNA N - We had an inservice about a month ago. I would report to the ADM and charge nurse. 5/15/25 3:21 pm - CNA O (Night shift via phone) We have had a lot of inservices on ANE. I would report it immediately to ADM. 5/15/25 3:24 pm - CNA P - (Night shift via phone) Anytime something happens they do an inservice. I would report to ADM. 5/15/25 3:30 pm - CNA Q - (Night shift via phone) We have had a lot of inservices on ANE. I would report immediately to ADM.

Based on observations, interviews and record reviews, the facility assessments failed to ensure that the assessment accurately reflected the resident's status for two residents (Resident #42 and #84) of 24 residents reviewed for assessments. 1. Resident #42's cardiac pacemaker was not identified as an active diagnosis on his quarterly MDS assessment with an ARD of 07/09/2024. 2. Resident #84's falls since admission were not reflected on her quarterly MDS assessment with an ARD of 08/09/2024. These failures placed residents at risk for missed or inaccurate care. The findings were: 1.Record review of Resident #42's electronic face sheet dated 08/22/2024 reflected he was admitted to the facility on [DATE]. The resident's diagnoses included: diabetes mellitus (a disease of inadequate control of blood levels of glucose), unspecified atrial fibrillation (a common type of arrhythmia, or irregular heart rhythm, that causes the upper chambers of the heart to beat rapidly and irregularly), anemia (a blood disorder that occurs when the body does not produce enough healthy red blood cells, or the red blood cells do not function properly), atherosclerotic heart disease (a condition that causes arteries to narrow and harden due to plaque buildup) and presence of cardiac pacemaker (a device used to control an irregular heart rhythm). Record review of Resident #42's quarterly MDS assessment with an ARD of 07/09/2024 reflected he was understood and usually able to understand. He scored a 14 out of 15 on his BIMS which signified he was cognitively intact. Review of Section I-Active Diagnoses did not reflect his presence of cardiac pacemaker. Record review of Resident #42's comprehensive care plan revised on 01/31/2024 reflected Focus, has a defibrillator pacemaker, Interventions/Tasks, Apical pulse daily to monitor proper function of the pacemaker, notify MD if pulse is less than 60 or greater than 100. Record review of Resident #42's Active Orders as of: 08/22/2024 reflected APICAL PULSE DAILY TO MONITOR PROPER FUNCTION OF PACEMAKER one time a day related to PRESENCE OF CARDIAC PACEMAKER (Z95.0) NOTIFY MD IF PULSE < 60 BPM > 100 Phone Active 01/27/2022 01/28/2022. Record review of Resident #42's TAR dated 08/01/2024-08/31/2024 reflected APICAL PULSE DAILY TO MONITOR PROPER FUNCTION OF PACEMAKER one time a day related to PRESENCE OF CARDIAC PACEMAKER (Z95.0) NOTIFY MD IF PULSE < 60 BPM > 100 Phone Active 01/27/2022 01/28/2022. And nurses initialed off daily that Resident #42's apical pulse was checked and noted the corresponding pulse rate. Observation on 08/22/2024 at 11:32 a.m. of Resident #42 revealed he showed the surveyor a scar on his upper left chest where he had a pacemaker. Interview on 08/22/2024 at 11:34 a.m. with Resident #42, he stated he had the pacemaker since 2007. 2.Record review of Resident #84's electronic face sheet dated 08/21/2024 reflected she was admitted to the facility on [DATE]. Her diagnoses included: unspecified dementia (a general term for a range of neurological conditions that cause a loss of brain function and impair a person's ability to think, remember, and make decisions), muscle weakness (commonly due to lack of exercise, ageing or muscle injury) and psychotic disorder (a condition that causes people to lose touch with reality) Record review of Resident #84's quarterly MDS assessment with an ARD of 08/09/2024 reflected she scored a 04 out of 15 on her BIMS which signified she was severely cognitively impaired. She required substantial assistance with her ADL's. Review of Section J-Health Conditions reflected Number of Falls Since Admission/Entry or Reentry or Prior Assessment, whichever is more recent, No boxes were coded to indicate, None, One or Two or more. Record review of Resident #84's comprehensive care plan revised date of 07/22/2024 reflected Focus, resident has a hx of falls due to limited mobility, impaired vision, weakness and use of antipsychotic medications and poor safety awareness. Record review of Resident #84's Fall Nurses Note dated 06/04/2024 reflected Resident #84 had a fall with no injury. Record review of Resident #84's Fall-Risk Assessments dated 07/10/2024 reflected she scored a 10 which signified she was High Risk for falls and had 1-2 Falls in the past 3 months. Observation on 08/23/2024 at 10:00 a.m. of Resident #84's room revealed she had a low bed with a fall mat. Interview on 08/23/2024 at 10:00 am with the ADM revealed she was accountable for the MDS's and stated it was important to show residents care as accurate and to be transparent as a provider. She stated care could be missed if the MDS was not accurate and result in demise. Interview on 08/23/2024 at 10:15 a.m. with MDS A revealed a new MDS nurse completed the quarterly MDS for Resident #42, and she started in 04/2024 and was still learning. She stated it was important to have accurate MDS's because care could be missed and she would double check MDS B's work, because she was the RN who signed the MDS's for accuracy. Interview on 08/23/2024 at 10:23 a.m. with MDS B revealed she missed the cardiac pacemaker diagnosis for Resident #42, and she was trained, but still learning. She stated she needed to review the falls for residents. She stated the MDS's for Residents #42 and #84 had since been modified to correct the errors. She stated it could have resulted in missed care. Interview on 08/23/2024 at 10:36 a.m. with the DON revealed MDS's trigger components and are the base of the care plan, so they must be accurate. She stated important care could be misinterpreted or missed and result in harm. Record review of the facility policy and procedure titled Minimum Data Set (MDS) policy for MDS assessment Data Accuracy 2.2021 (undated) reflected The purpose of the MDS policy is to ensure each resident receives an accurate assessment by qualified staff to address the needs of the resident who are familiar with his/her physical, mental, and psychosocial well-being. Record review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, October 2019 reflected The RAI process has multiple regulatory requirements . (1) the assessment accurately reflects the resident's status.

Based on observation, interviews and record reviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one resident (Resident #42) out of 24 residents reviewed for quality of care. RN C did not perform an apical pulse for Resident #42 in August 2024 as ordered to check the function of his cardiac pacemaker. This deficient practice could affect residents with cardiac pacemakers and could result in dysrhythmias (irregular heartbeats). The findings included: Record review of Resident #42's electronic face sheet dated 08/22/2024 reflected he was admitted to the facility on [DATE]. The resident's diagnoses included: diabetes mellitus (a disease of inadequate control of blood levels of glucose), unspecified atrial fibrillation (a common type of arrhythmia, or irregular heart rhythm, that causes the upper chambers of the heart to beat rapidly and irregularly), anemia (a blood disorder that occurs when the body does not produce enough healthy red blood cells, or the red blood cells do not function properly), atherosclerotic heart disease (a condition that causes arteries to narrow and harden due to plaque buildup) and presence of cardiac pacemaker (a device used to control an irregular heart rhythm). Record review of Resident #42's quarterly MDS assessment with an ARD of 07/09/2024 reflected he was understood and usually able to understand. He scored a 14 out of 15 on his BIMS which signified he was cognitively intact. Review of Section I-Active Diagnoses did not reflect his presence of cardiac pacemaker. Record review of Resident #42's comprehensive care plan revised on 01/31/2024 reflected Focus, has a defibrillator pacemaker, Interventions/Tasks, Apical pulse daily to monitor proper function of the pacemaker, notify MD if pulse is less than 60 or greater than 100. Record review of Resident #42's Active Orders as of: 08/22/2024 reflected APICAL PULSE DAILY TO MONITOR PROPER FUNCTION OF PACEMAKER one time a day related to PRESENCE OF CARDIAC PACEMAKER (Z95.0) NOTIFY MD IF PULSE < 60 BPM > 100 Phone Active 01/27/2022 01/28/2022. Record review of Resident #42's TAR dated 08/01/2024-08/31/2024 reflected APICAL PULSE DAILY TO MONITOR PROPER FUNCTION OF PACEMAKER one time a day related to PRESENCE OF CARDIAC PACEMAKER (Z95.0) NOTIFY MD IF PULSE < 60 BPM > 100 Phone Active 01/27/2022 01/28/2022. And nurses initialed off daily that Resident #42's apical pulse was checked and noted the corresponding pulse rate. Observation on 08/22/2024 at 11:32 a.m. of Resident #42 revealed he showed the surveyor a scar on his upper left chest where he had a pacemaker. Interview on 08/22/2024 at 11:34 a.m. with Resident #42, he stated he had the pacemaker since 2007. When asked by the surveyor if nurses listen to his heart, he stated the only one that listened to his heart was the doctor. He stated the nurses used a cuff to take his vital signs. Interview on 08/22/2024 at 11:45 a.m. with RN C who was assigned to Resident #42, she stated she took his vital signs with a machine and a cuff, and it was important because he was on cardiac medications. When shown the by the surveyor she initialed off on the apical pulse check, she stated she did not read it and marked it off. She stated she did not know he had a cardiac pacemaker. She stated she had a stethoscope and knew how to take an apical pulse, but she did not do it. She stated she did not get assigned to that hall much. Interview on 08/23/2024 at 10:36 a.m. with the DON, she stated she in-serviced her nurses on the apical pulse, and she was not aware normal vital signs were taken. She stated nurses were trained and knew how to take an apical pulse. She stated it was an older but thorough way of listening to any irregularity in the heartbeat which was important with a resident who had a pacemaker. She stated she was responsible for overseeing resident care, and checked that physician orders were followed. Record review of RN C's Nurse Proficiency Audit dated 11/5/2023 reflected she was signed off as s or satisfactory for Cardiovascular Assessment Skills. Record review of the facility policy and procedure titled Permanent Pacemaker revised February 13, 2007, reflected The resident will experience correct functioning of the pacemaker. Record review of Resident #42's cardiac follow-up dated 05/4/2024 reflected Normal Pacemaker Examination. Record review of the facility policy and procedure titled Pulse, Apical dated 2003, reflected Auscultate for the sound (lub-dub) of the heartbeat and count beats for 60 seconds with each lub-dub signifying a single beat and note rhythm and quality and any deviations from baseline values.

Based on observation, interviews and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 resident (Resident #8) of 4 observed for peri care and wound care in that: CNA D and RN C failed to sanitize their hands between glove changes while performing peri care and wound care for Resident #8. These failures could result in cross contamination of germs and could result in an infection or hospitalization . The findings were: Record Review of Resident #8's face sheet dated 08/20/2024 revealed she had an original admission on 04/19/2023 and a re-admission on 12/04/2023, with diagnoses of: cerebral infarction (a stroke), chronic atrial fibrillation (irregular heart rhythm), heart failure (heart does not pump enough blood), and dysphasia (difficulty swallowing). Record Review of Resident #8's quarterly MDS assessment with an ARD of 08/13/2024 revealed Resident #8 had frequent incontinent bowel and bladder. Further review of the MDS revealed Resident #8's SAMS score was a 3, indicating rarely/never understood. Observation on 08/21/2024 at 9:21 a.m. of CNA D performed peri care for Resident #8, during peri care, CNA D did not sanitize her hands in-between glove changes. Interview on 08/21/2024 at 9:37 a.m. with CNA D stated not sanitizing her hands between glove changes could cause cross contamination and could result in the resident getting an infection or being hospitalized . Observation on 8/21/2024 at 9:45 am of RN C performed wound care for Resident #8, during wound care, RN C did not sanitize her hands in-between glove changes. Interview on 8/21/2024 at 10:00 am with RN C stated she should have sanitized her hands in-between gloves changes to prevent cross-contamination. Interview on 8/21/2024 at 10:15 am with the DON stated the nurse and CNA should have sanitized their hands in-between glove changes to prevent any infections from cross-contamination. Record Review of CNA D's Nurse Aide Incontinence Care Proficiency Assessment (not dated) revealed they were checked off for completing incontinent care which included washes hands/changes gloves. Review of the facility policy and procedure guide titled Perineal Care dated 4/27/2022, revealed Always perform hand hygiene before and after glove use.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: 1. The facility failed to maintain the cleanliness of the ice maker found within the kitchen 2. The facility failed to label and date food containers found within the kitchen. 3. The facility failed to complete daily temperature logs of reach-in refrigerators and freezers found within the kitchen and nourishment room. 4. The facility failed to ensure the walk-in freezer and nourishment room freezer maintained a temperature below 0 degrees Fahrenheit. These failures could place residents at risk for cross-contamination and foodborne illnesses. The findings included: Observation on 7/9/23 at 11:10 AM revealed a black substance build-up within the ice maker in the kitchen. Upon further inspection revealed a reach-in fridge with the corresponding temperature log completed through 7/6/23 containing three plastic containers of food without labels or dates. Inspection of the walk-in freezer revealed the temperature log completed through 7/6/23 and an internal freezer temperature of 20 degrees Fahrenheit. Displayed on the digital thermometer to the freezer read an error code of APn6. Interview on 7/9/2022 at 11:11 AM, the DM stated the kitchen staff was responsible for emptying and cleaning out the ice maker every 3 months by draining and emptying the ice maker and cleaning it from the inside. She stated the MS had just cleaned the ice maker within the last few weeks. The DM stated she did not notice the black substance build-up and could not identify what it was. The DM stated the ice maker should be cleaned and would contact his MS to have it partially disassembled to remove the black substance build up as the substance could cause foodborne illness in residents who consume ice from the ice maker. The DM stated the staff who enter the kitchen in the morning are responsible for completing the temperature logs for all fridges and freezers, in addition to reporting to herself and the MS if the fridges or freezers are reaching high temperatures. The DM stated the cook who assembled the food was responsible for storing the food and placing the content/date sticker on the food for recording. The DM stated the risks associated with these failures was a potential for foodborne illness in residents. Observation on 7/11/23 at 4:42 PM, of the nourishment room refrigerator/freezer combination unit revealed to contain a temperature log for the refrigerator but not the freezer portion of the unit. Additionally, the internal temperature was revealed to be 8 degrees Fahrenheit. Interview on 7/12/23 at 9:14 AM, the DON stated it was her expectation that food prepared in the kitchen be dated and labeled, that the ice provided to residents be from a clean ice maker, that the freezer be at a freezing temperature, and all fridges and freezers intended for resident use be continuously documented in their respective temperatures. The DON stated these aforementioned concerns have a direct correlation to resident health and safety in that they could cause foodborne illness. Record review of the facility nutritional policy titled Refrigerator/Freezer Temperature log, undated, reflected Person assigned or DSM must record temperature for each refrigerator and freezer and sign in column provided . take temperatures at same time every morning (AM) and evening (PM). The morning reaching should preferably be taken upon opening the department. Record review of the facility nutritional policy titled Cleaning of the Ice Machine, undated, reflected The ice machine shall be cleaned and sanitized according to manufacturer's instructions to maintain sanitary conditions in order to prevent food contamination and the growth of disease producing organisms and toxins. Record review of the facility nutritional policy titled Food Storage and Supplies, undated, reflected All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry, and protected from vermin and insects . Record review of US FDA Food Code, dated 2022, revealed Surfaces of utensils and equipment contacting food that is not time/temperature control for safety food such as . ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. Some equipment manufacturers and industry associations, e.g., within the tea industry, develop guidelines for regular cleaning and sanitizing of equipment . and 3-304.11 Food Contact with Equipment and Utensils. FOOD shall only contact surfaces of: (A) EQUIPMENT and UTENSILS that are cleaned as specified under Part 4-6 of this Code and SANITIZED as specified under Part 4-7 of this Code; P (B) Single-service and single-use articles.

Based on observation, interview, and record review the facility failed to ensure residents who were unable to carry out activities of daily living were provided with the necessary services to maintain good personal hygiene for one (Resident #53) of six residents reviewed for ADL care, in that: The facility failed to ensure Resident #52 was provided bathing as scheduled. This failure could place residents who require assistance from staff for personal hygiene at risk of not receiving care and services to meet their needs and not reaching their highest practicable physical and psychosocial well-being. The findings were: Record review of the admission record dated 7/12/2023, reflected Resident #52 was a [AGE] year-old male with an initial admitted [DATE] and a primary diagnosis of Parkinson's Disease. Record review of the comprehensive MDS assessment dated [DATE], reflected Resident #52 was admitted under the primary medical condition category of Progressive Neurological Conditions. Other active diagnoses included unspecified intellectual disabilities. Resident #52's summary BIMS score was a 6, which was indicative of severely impacted cognition. The field of showering in the admission performance was rated as 2, which was indicative of requiring substantial to maximal assist with at least half of the effort being supplied by staff assistance. Record review of the comprehensive care plan, dated 7/12/2023, revealed Resident #52 had a focus area of ADL Self Care Performance Deficit due to cognitive impairment and weakness with the following associated interventions: bathing - assistance by one staff initiated on 6/1/2018. Record review of the ADLs task sheet revealed Resident #52 was scheduled for bathing on Monday's, Wednesday's and Friday's on the 6:00 AM to 2:00 PM shift. Further review reflected no documented evidence Resident #52 received a scheduled shower on 6/16/2023, 6/21/2023, 6/23/2023, 7/7/2023, 7/10/2023. Observation on 7/09/2023 at 12:07 PM, revealed Resident #52 was laying in his bed requesting assistance from staff. Resident #52 presented with a bare brief and t-shirt on. Interview on 7/12/2023 at 8:29 AM, CNA G stated she operated as a shower aide primarily and would shower residents with the CNA of that shift. CNA G stated the showers for that shift would be documented solely by the CNA of that shift even if CNA G completed them. CNA G stated she would not document the showers she completed as that was the responsibility of the CNA of that shift. Interview on 7/12/2023 at 8:44 AM, CNA H stated he operated as a CNA primarily and would assist with showering residents with shower aides on that shift. CNA H stated he would document the showers completed by the shower aids of that shift but if he did not do them himself he would not complete the questions within the ADL task sheet and would instead mark Not Applicable. CNA H stated he understood the showers to have been completed by the shower aides, but it was their nursing protocol to document only from the shift CNA. Interview on 7/12/2023 at 9:14 AM, the DON stated showers should be documented in the electronic health record. The DON stated the individual shower aides and CNAs all had access to the ADL task sheet and could complete the questions themselves to affirm the ADL care was provided and should be completing them for the showers that they completed. The DON stated the shower documentation did not reflect that the showers were completed for Resident #52 due to the discrepancy in the Not Applicable answer choices selected on the ADL shower sheet. The DON stated the risk associated with the CNAs completing the ADL task in the EHR would be that documentation could potentially be recorded incorrectly and result in insufficient care provided to residents. Record review of the policy entitled Resident Showers, copyrighted 2022, revealed the facility's policy was to . Assist residents with bathing to maintain proper hygiene, stimulate circulation, and help prevent skin issues . Under the section entitled Policy Explanation and Compliance Guidelines: 1.) . provided showers as per request, or as per facility schedule protocols, and based upon resident safety. 11.) Assist the resident was showering as needed.