Every finding on record at Landmark of Plano Rehabilitation and Nursing Cente

Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 4 residents (Resident #1) reviewed for neglect reporting.The facility failed to report an allegation of neglect and abuse to the State Agency when an allegation was made on 11/28/2025 that Resident #1's brief had not been changed in 5 hours.This failure could place residents at risk for not having allegations of neglect reported which could lead to injuries or worsening of condition.Review of Resident #1's MDS assessment, dated 12/10/25, reflected he was an [AGE] year-old male admitted to the facility on [DATE]. The resident had a BIMS score of 15 which indicated an intact cognitive status. His diagnoses included congestive heart failure (a chronic condition where the heart is unable to pump blood effectively, leading to fluid buildup in the lungs and other body parts), Type II Diabetes (a condition where the body can't properly use sugar for energy, leading to high blood sugar and possible complications), hyperlipidemia (like cholesterol or triglycerides in the blood, which can raise the risk of heart disease and stroke), major depressive disorder (severe, persistent sadness and loss of interest that interferes with daily life), and hypertension (blood pressure is consistently too high, which can strain the heart and blood vessels). The resident mobilized with a manual wheelchair and required one person assist for transfers, turning, positioning, and dressing. The resident had frequent bowel incontinence and required staff assistance with toileting and incontinent care. Record review of a complaint report dated 11/28/2025 revealed law enforcement responded to the facility at 8:55 AM for elder abuse. The complaint stated that Resident #1 reported staff had not changed him in over 5 hours. An observation and interview on 1/20/26 at 10:18 AM with Resident #1 revealed he was sitting in his wheelchair, brushing his teeth and appeared well-groomed. He reported he had called the police because it took 5 hours before someone showed up to change his brief. He reported he was changed before breakfast and later used his call light for help changing his brief. He said someone came in his room to bring his meal, but they did not change him during that time. An interview on 1/20/26 at 1:45 PM with the DON revealed he was at the facility the day law enforcement responded to Resident #1's call and spoke to the officer directly regarding the allegations of abuse. The DON stated he then spoke to the administrator about the reported abuse and neglect. He stated the administrator was the abuse coordinator who would call and report any allegations to HHSC. The DON denied that Resident #1 was left for 5 hours without incontinent care. The DON reported the resident was changed before breakfast and again after breakfast was served. During an interview on 1/20/2026 at 12:15 PM with CNA A, she reported she worked both shifts on the day Resident #1 stated he went without assistance for 5 hours. She reported Resident #1 required care assistance for bowel movements and could not clean himself. She stated neither he nor any other resident she cared for ever had to wait 5 hours to be changed. During an interview on 1/20/2026 at 11:36 AM with LVN B, he stated that the resident was changed before his breakfast around 8am on the day the police were called. LVN B stated that residents are changed as needed throughout the day, but they are all checked before each meal. LVN B denied that resident was left unattended for 5 hours. An interview on 1/20/26 at 2:00 PM with the Administrator revealed she was not the administrator at the time of the incident. She reported she became the administrator of the facility on December 22, 2025. She reported that the incident would have been a reportable allegation, and she would have reported it to HHSC if she were the administrator at that time. She stated if allegations of such are not reported, it could put residents at risk of possible continued abuse and neglect which could affect their care and mental health. Review of the facility policy, Abuse, undated, reflected: E. Reporting1. 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 services. State law mandates that citizens report all suspected cases of abuse, neglect or financial exploitation of the elderly and incapacitated persons.2. When a suspected abused, neglected, exploited, mistreated or potential victim of misappropriation of property comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse Preventionist or designee. If the discovery occurs outside of normal business hours, the Abuse Preventionist and/or designee will be called. 3. Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 2024-14 dated 8/29/24.If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegationIf the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation.

Based on interview and record review, the facility failed to provide specialized rehabilitative services for one of five residents (Resident #1) reviewed for specialized rehabilitative services. The facility failed to ensure Resident #1 received Occupational Therapy (OT), in accordance with her plan of treatment. This failure could place the residents at risk of not meeting their highest practicable well-being.Findings included: Record review of Resident #1's Face Sheet, dated 10/14/25, reflected she was a [AGE] year-old female, who admitted to the facility on [DATE], with diagnoses including hypertensive heart disease with heart failure (a condition where the heart muscle is weakened or stiffened, making it unable to pump blood effectively), polyneuropathy (a condition where multiple peripheral nerves throughout the body are damaged or malfunctioning), and chronic pain syndrome (a condition characterized by persistent pain that lasts for at least 6 months and significantly impacts a person's life). Resident #1 was discharged to the hospital on [DATE]. Record review of Resident #1's MDS Assessment, dated 09/15/25, reflected she had a BIMS Summary Score of 12, indicating she had moderate cognitive impairment. Resident #1 was identified as using a wheelchair and was unable to walk 10 feet. Record review of Resident #1's Care Plan, dated 09/28/25, reflected she had an ADL self-care performance deficit due to her disease process and medical diagnoses. Identified goals included, .the resident will maintain or improve current level of function. Outlined interventions included encouraging Resident #1 to discuss her feelings about her self-care deficit, encouraging Resident #1 to participate to the fullest extent possible with each interaction, encouraging Resident #1 to use her call bell for assistance, etc. There were no interventions which specified the need for rehabilitation services. Record review of Resident #1's Occupational Therapy Evaluation and Plan of Treatment, dated 09/04/25, reflected her plan of treatment included occupational therapy services three times per week for 60 days, from 09/04/25 to 11/02/25. Record review of Resident #1's Occupational Therapy Discharge summary, dated [DATE] (the same day in which the Occupational Therapy Evaluation and Plan of Treatment was completed), reflected the Discharge Summary was initiated but not completed or submitted. Record review of the Provider Notice of Adverse Benefit Determination, dated 10/08/25 (provided to the surveyor following the completion of the investigation, on 10/16/25), reflected the facility requested for Resident #1 to receive Occupational Therapy Services from 09/25/25 to 11/02/25. The letter outlined, .The principal reason for the adverse determination is: The request for Therapy-OT does not meet medical necessity. and .We denied because notes should show why the skills of a therapist are needed. We are missing information about your care (a note including the onset date(s) of the condition being treated). Please send this information if care is needed. During an interview with the Director of Therapy on 10/14/25 at 1:00PM, he stated he had been the interim Director of Therapy since 10/03/25. He stated he did not provide services for Resident #1, but based on her medical records, it appeared as though she received an evaluation for Occupational Therapy the day after her admission to the facility. Resident #1 was recommended to receive Occupational Therapy, per the recommendations of the evaluation. The Director of Therapy stated Resident #1 did not receive Occupational Therapy. He stated an Occupational Therapy Discharge Summary was initiated (but not completed) on the same day as the evaluation was completed, but he did not know why this was done. He stated he did not know why Resident #1 did not receive Occupational Therapy services as recommended. The Director of Therapy stated the individual who completed the Occupational Therapy Evaluation and Plan of Treatment, as well as initiated the Occupational Therapy Discharge Summary, was currently unable to be reached due to being out of the country. The Director of Therapy stated the risk of a resident not receiving therapy services included no progression in their skills and abilities. A policy related to rehabilitation services was requested by the Administrator on 10/14/25 at 1:30PM but was not provided. Per the Administrator, the facility did not have a policy related to rehabilitation services.

Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 (Residents #1 and #2) of 5 residents reviewed for ADL care. The facility failed to provide Residents #1 and #2 with showers based on their weekly shower/bathing schedule. This failure could place residents at risk of not receiving the care they require to maintain their highest practical well-being, and could result in low self-esteem, anxiety, embarrassment, and a decline in their quality of life.Findings included: Record review of Resident #1's MDS assessment, dated 08/26/25, reflected he was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE]. His BIMs score was 15 indicating his cognitive status was not impaired. His diagnoses included hypertension, acute kidney failure, need assistance with personal care and muscle weakness. The resident was dependent on staff for showering/bathing and required maximal assistance. Record review of Resident #1's care plan revised 06/25/24 reflected: The resident had an ADL self-care performance deficit related to impaired gait, impaired coordination. Facility interventions included resident required assistance with showering every other day and as necessary. Observation and interview on 10/01/25 at 10:52 a.m., of Resident #1 revealed he was in the wheelchair near his room. He stated he was heading to dialysis. Resident #1 stated he had issues with showers. He stated the facility did not offer showers consistently per the schedule, and at times he had requested a shower, but he was not provided with the shower. At times he would request the staff to come at a later time, but they did not. Resident #1 stated not being provided with a shower had been an ongoing issue. He stated the last time he was offered a shower had been more than one week. Resident #1 stated he would have loved to receive a shower per the scheduled days. He was supposed to receive showers on the days he did not go to dialysis. Record review of Resident #2's quarterly MDS assessment, dated 09/09/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His BIMs score was 14 indicating his cognitive status was not impaired. His diagnoses included hypertension, muscle weakness and abnormalities of gait and mobility. The resident was dependent on staff for showering/bathing and required total assistance. Record review of Resident #2's care plan revised 06/17/25 reflected: The resident had an ADL self-care performance deficit. The facility goal was for the resident to maintain or improve the current level of function.Observation and interview on 10/01/25 at 11:15 a.m., Resident #2 was in bed. Resident #2 stated he had been in the facility for a few months, and he had not been provided with showers/bed baths consistently. He stated he preferred a bed bath because he had right side weakness. He stated the last time he received a bed bath was last week, and when he asked the staff told him that he refused. He stated at times he refused the shower but not all the time as the staff was indicating. He stated he would like to be cleaned and offered the bed baths. Review of the showers sheets for the month of September, 2025 revealed there was missing shower sheets for Resident #1 and #2. In an interview on 10/01/25 at 12:32 p.m., CNA A revealed she was taking care of Resident #2. The resident required total assistance with activities of daily living and with showers. CNA A stated she had not given either of the residents shower/bed bath because the facility had shower staff who came in the evenings to provide only showers. CNA A stated if she gave a resident a shower she would document in the shower sheet that was at every nurse station, and then the charge nurse will sign the shower sheet. CNA A stated the resident was to be offered showers to prevent skin breakdown and foul smell. In an interview on 10/01/25 at 1:50 p.m., LVN B revealed she was the one responsible for making sure the residents was being offered showers/bed baths and shower sheets were completed on the days the residents was scheduled to be showered. LVN B stated she failed to follow up if the residents received showers/bed baths for the missing shower sheets, and she stated she did not have the record for the missing shower sheet. LVN B stated the residents were to be offered showers on their scheduled days, and if not, the aides were to report to the charge nurses. LVN B stated the residents were to be offered showers/bed baths to prevent skin breakdown. In an interview on 10/01/25 at 2:13 p.m., with the DON revealed LVN B was responsible for making sure showers were completed, and she was supposed to follow up if there were no records of any resident missing a shower record. The DON stated they had been reviewing showers every morning during the morning meetings, and LVN B had been indicating showers were offered and she had records. The DON stated he was not aware that Residents #1 and #2 were not being provided with showers/bed baths. In an interview on 10/01/25 at 2:50 p.m., with CNA C she stated she normally reports to work late in the evenings and provided showers/bed baths to the residents. CNA C stated she checked in the records to see the residents who were scheduled for showers/bed baths and got reports for the ones who had not been showered and then she would provide the showers. CNA C stated she had not showered or given bed bath to Residents #1 or #2. Facility policy review undated and titled Bath, Tub/Shower reflected, Bathing by tub bath or shower is done to remove soil, dead epithelial cells, microorganisms from the skin, and body odor to promote comfort, cleanliness, circulation, and relaxation.Goals1. The resident will experience improved comfort and cleanliness by bathing.2. The resident will maintain intact skin integrity.3. The resident will be free from soil, odor, dryness, and pruritus following bathing.Procedure1. The resident will receive assistance with bathing according to their resident centered plan of care.

Based on interview, observation and record review, the facility failed to ensure residents had the right to formulate an advanced directive for 3 (Resident #1, Resident #2 and Resident #3) of 8 residents reviewed for Advanced Directives.The facility failed to ensure that Resident #1, Resident #2 and Resident #3's OOH-DNR (Out of Hospital-Do Not Resuscitate) were completed correctly with both signatures of the resident/family and that it was signed by a physician making the forms invalid.This failure could affect all residents who have implemented an Advanced Directive and established their choice not to be resuscitated at the risk of receiving CPR (Cardiopulmonary Resuscitation) against their wishes.Findings included:Record review of Resident #1's face sheet dated [DATE] revealed he was admitted to the facility on [DATE] and was [AGE] years old. His diagnosis included Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Side, (paralysis to one side of the body caused by a stroke), Type 2 Diabetes and Hypertension (high blood pressure). Resident #1's electronic face sheet reflected he was a Code Status: DNR.Record review of Resident #1's MDS (Minimum Data Set) dated [DATE] reflected he scored a 15 on his BIMS (Brief Interview of Mental Status) indicating no cognitive impairment. Resident #1's needed extensive assistance with bed mobility, transfers and limited assistance with eating and toileting. Record review of Resident #1's undated care plan revealed, Focus: he had an order for Do Not Resuscitate (DNR), Date initiated: [DATE], Revision on [DATE] Goal: Resident/Responsible party's decision for DNR will be honored through the next review date. Date Initiated: [DATE], Revised on: [DATE].Interventions: All aspects of DNR will be explained to resident or responsible party, Date Initiated: [DATE] In absence of b/p, pulse, respiration, CPR will not be initiated, Date Initiated: [DATE] Notify MD of change of condition, Date Initiated: [DATE] Resident will be maintained at a level of comfort as ordered by physician, Date Initiated: [DATE] Social Services to consult with resident and RP regarding their decision to continue DNR, Date Initiated: [DATE] Record review of Resident #1's DNR dated [DATE] revealed it had been signed by the resident at the top of the form but did not have his second signature at the bottom of the form where all who signed must sign twice to make the document valid. In an interview on [DATE] at 3:10 pm. Resident # 1 stated he did not want CPR if his heart stopped and that he had a DNR in place already.Record review of the Code Status list that was generated from PCC provided by the facility revealed that Resident #1 was not listed on the document. Record review of Resident #2's face sheet dated [DATE] revealed she was admitted to the facility on [DATE] and was [AGE] years old. Her diagnosis included Unspecified Dementia, Unspecified Atrial Fibrillation (a condition in which the heart beats irregularly and often too fast), Hypertension (high blood pressure) and Muscle Wasting. Resident #2's electronic face sheet revealed she was a Code Status: DNR.Record review of Resident #2's Quarterly MDS dated [DATE] reflected that she scored a 3 on her BIMS indicating severe cognitive impairment. Resident # 2 needed supervision with toileting and dressing, moderate assistance with bathing and set up only for eating. Record review of Resident #2's undated care plan revealed, Focus: she had an order for Do Not Resuscitate (DNR), Date initiated: [DATE], Revision on [DATE] Goal: Resident/Responsible party's decision for DNR will be honored through the next review date. Date Initiated: [DATE], Revised on: [DATE].Interventions: All aspects of DNR will be explained to resident or responsible party, Date Initiated: [DATE] In absence of b/p, pulse, respiration, CPR will not be initiated, Date Initiated: [DATE] Notify MD of change of condition, Date Initiated: [DATE] Resident will be maintained at a level of comfort as ordered by physician, Date Initiated: [DATE] Social Services to consult with resident and RP regarding their decision to continue DNR. Date Initiated: [DATE] Record review of Resident #2's DNR dated [DATE] revealed it had been signed only once by the resident's representative at the top of the form and is missing the second signature and the physician at the bottom of the form to make it a valid document. Record review of Resident #3's face sheet dated [DATE] revealed she was admitted to the facility on [DATE] and was [AGE] years old. Her diagnosis included Alzheimer's, Type 2 Diabetes and Hypertension (high blood pressure). Record review Resident #3's Quarterly MDS dated [DATE] reflected that she scored a 00 on her BIMS, indicating she was unable to participate. The staff interview was conducted and indicated she did not know the current season, location of her room, staff names/faces or that she was in a nursing home. Her cognitive skill for making daily decisions was severely impaired. Record review of Resident #3's undated care plan revealed, Focus: she had an order for Do Not Resuscitate (DNR), Date initiated: [DATE], Revision on [DATE] Goal: Resident/Responsible party's decision for DNR will be honored through the next review date. Date Initiated: [DATE], Revised on: [DATE].Interventions: All aspects of DNR will be explained to resident or responsible party, Date Initiated: [DATE] In absence of b/p, pulse, respiration, CPR will not be initiated, Date Initiated: [DATE] Notify MD of change of condition, Date Initiated: [DATE] Resident will be maintained at a level of comfort as ordered by physician, Date Initiated: [DATE] Social Services to consult with resident and RP regarding their decision to continue DNR. Date Initiated: [DATE] Record review of Resident #3's DNR dated [DATE] revealed it was missing the first witness signature and it was signed by a Family Nurse Practitioner, and not the attending physician which the form indicates, to make it a valid document. Record review of the Code Status list that was generated from PCC provided by the facility revealed that Resident #1 was not listed on the document. In an interview on [DATE] at 3:35 PM, LVN A stated he has been at the facility for 2 months. When he needs to know the code status of a resident, he checks the system (PCC) to see what the code status is. He stated the risk to the residents for not following their wishes about their code status is it would affect their health.In an interview on [DATE] at 4:02 PM, ADON B stated that the social worker normally looks at the DNR's but since they don't have one at present, she does it. She stated she was unaware that 3 of the DNR's had not been filled out correctly. She stated the risk to the residents would be negligent on the part of the facility.In an interview on [DATE] at 4:25 PM, the DON stated he was not aware the DNR's had not been completed correctly and that he and the ADON check the documents for accuracy. He did not know why Resident #1's name was missing from the Code Status list since there was an order in the chart. He stated the risk to the residents was the facility would not fulfill their wishes. Record Review of the facility's Advanced Directive undated policy, Do Not Resuscitate Order revealed in part, Procedure: Texas Out of Hospital DNR Form 1. Any resident may initiate an Out of Hospital DNR Order.2. If the resident is capable of providing informed consent for the order, he/she will sign and date the DNR order on the front of the official DNR form from the state of Texas.5. In all cases the form must be signed and dated by two witnesses. Record review of the OOH DNR Order instructions for issuing and OOH-DNR Order revealed the following: Purpose: The Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) Order on reverse side complies with Health and Safety Code (HSC), Chapter 166 for use by qualified persons or their authorized representatives to direct health care professionals to forgo resuscitation attempts and to permit the person to have a natural death with peace and dignity. Applicability: This OOH-DNR Order applies to health care professions in out-of-hospital settings, including physicians' offices, hospital clinics and emergency departments. Implementation: A competent adult person at least [AGE] years of age, or the person's authorized representative or qualified relative may execute or issue an OOH-DNR Order. The person's attending physician will document existence of the Order in the person's permanent medical record. The OOH-DNR Order may be executed as follows: . In addition: the OOH-DNR Order must be signed and dated by two competent adult witnesses, who have witnessed either the competent adult person making his/her signature in section A, or authorized declarant making his/her signature in either sections B, C, or E, and if applicable, have witnessed a competent adult person making and OOH-DNR Order by nonwritten communication to the attending physician, who must sign in Section D and also the physician's statement section.

Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 5 (Resident's #54, #43, #66, #75, and #72) of 6 residents reviewed for ADL care. 1. The facility failed to provide Resident #54 with timely incontinence care on 08/24/25. 2. The facility failed to provide Residents #43, #66, #75, and #72 with showers based on their weekly shower/bathing schedule. This failure could place residents at risk of not receiving the care they require to maintain their highest practical well-being, and could result in low self-esteem, anxiety, embarrassment, and a decline in their quality of life. 1. Record review of Resident #54's quarterly MDS assessment, dated 05/15/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His BIMs score was a 03 indicating his cognitive status was severely impaired. His diagnoses included hypertension, dementia, muscle weakness and need for assistance with personal care. The resident was dependent on staff for toileting. The resident was always incontinent of bowel and bladder. The resident was depended on staff for toileting, and he was always incontinent of bowel and bladder. Record review of Resident #54's care plan initiated 02/10/25 reflected: The resident had an ADL self-care performance deficit. Facility interventions included resident required assistance with toileting with 2 persons assistance with toilet use. 02/10/25 The resident had bowel/bladder incontinence, the facility goal was for the resident not have any complications related to incontinence. Facility interventions included apply barrier cream with every incontinence, check resident every two hours and assist with toileting and provide pericare with every incontinent episode. An observation on 08/24/25 at 03:10 pm, revealed Resident #54 was in bed. The resident seemed confused from his conversation. The resident had a foul smell. On wound assessment with RN B of the sacrum area (Posterior part of the pelvis, below the lumbar vertebrae and above the coccyx), revealed the resident's brief was wet and the linen he was sleeping on was also wet. The RN B stated she was not aware what time the resident was provided with incontinent care. RN B stated the resident was to be kept dry and provided incontinent care timely to avoid skin breakdown or infection. In an interview on 08/25/25 at 01:55 pm with CNA D, she stated she was assigned to Resident #54 on the 2pm-10pm shift on the day the resident was noted to be lying on soiled linens. CNA D stated she had not completed the rounds on the resident at the time he was found to be heavily soiled. CNA D stated she was expected to complete rounds every 2 hours and as needed to make sure the resident was clean and dry. She stated the expectations were for the resident to be dry to prevent skin breakdown, to maintain the resident's dignity and prevent foul smell. In an interview on 08/26/25 at 12:50 pm with ADON E revealed the staff were expected to make sure the residents were changed timely and kept dry. He stated leaving the resident in soiled linens and brief could lead to skin breakdown and infections. He stated he completed random checks to make sure the residents had been cleaned and not left in soiled linens. In an interview on 08/26/25 at 02:15 pm with the DON, he stated he expected the staff to complete activities of daily living care timely. The residents were to be kept dry and well-groomed and free from soiled linens and brief to prevent skin breakdown. Record review of a policy dated 04/25/22 and titled Nursing: Personal Care reflected, An incontinent resident of urine and/or bowl should be identified, assessed, and provided appropriate treatment and services to restore as much normal bladder/bowel function as possible. It is essential that residents using various devices, absorbent products, external collection devices, etc., be checked (and changed as needed) on a schedule based upon the resident's voiding pattern, professional standards of practice, and the manufacturer's recommendations. Skin problems associated with incontinence and moisture can range from irritation to increased risk of skin breakdown. Moisture may make the skin more susceptible to damage from friction and shear during repositioning. Purpose This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and observing the resident's skin condition. 2. Record review of Resident #43's annual MDS dated [DATE], reflected the [AGE] year-old female resident was admitted to the facility on [DATE] and had intact cognitive functioning, meaning they were alert, oriented, able to understand and process information, make decisions, and communicate their needs appropriately. Diagnoses included cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery (a medical condition where a blood vessel in the brain becomes blocked or narrowed, leading to a loss of blood flow to the brain), hypothyroidism (underactive thyroid gland that did not make enough hormone), lack of coordination, and hypertension (high blood pressure). For showering/bathing and toileting hygiene the resident required substantial/maximal assistance, with the staff completing more than half the effort and full assistance with walking. For tub/shower transfer, toilet transfer, sit to stand, and chair/bed-to-chair transfers, the resident was required substantial/maximal assistance, with the staff completing more than half the effort. Record review of Resident #43's Comprehensive Care Plan dated 07/14/2025, reflected an ADL self-care performance deficit: [Resident] has an ADL Self Care Performance Deficit. Goal: [Resident] will maintain or improve current level of function in (Specify: bed mobility, transfers, eating, dressing, toilet use and personal hygiene; ADL Score) through the review date. Interventions: Assist with personal hygiene as required: hair, shaving, oral care as needed. Bathing: requires staff x1 for assistance. Bed mobility: requires staff x1 for assistance. Discuss with resident/family/POA care any concerns related to loss of independence, decline in function. Dressing: staff x1 for assistance. Bathing: Check nail length and trim and clean on bath day and as necessary. Record review of facility shower documentation dated August 2025 reflected Resident #43's shower/bath days were Tuesdays, Thursdays, and Saturdays. The shower/bathing documents reflected she was bathed/showered on the following days: 08/02/2025 (Saturday), 08/05/2025 (Tuesday), 08/07/2025 (Thursday), 08/12/2025 (Tuesday), and 08/14/2025 (Thursday). Record review of Resident #43's progress notes dated 08/22/2025 (Friday) reflected that the resident initially refused a shower/bath but was eventually bathed. During an observation and interview on 08/24/2025 at 9:45 AM with Resident #43, she was observed in her room lying in bed. She appeared to be well-groomed. She reported she had not had a shower in over a week. She reported her last shower was the week before last on Thursday, August 14, 2025. She stated she was then given a shower on the 22nd of August which was a Friday. She reported she was not bathed on 08/21/2025 because there were not enough towels. Resident #43 stated she was not given reasons as to why those days were missed. She reported she would prefer to have her showers as scheduled. Record review of Resident #66's annual MDS dated [DATE], reflected the [AGE] year-old female resident was admitted to the facility on [DATE] and had moderate cognitive impairment, as indicated by a BIMS score of 9. The score suggested the resident experienced some difficulty with memory and orientation but was still able to engage in conversation and participate in decision-making with support. Diagnosis included chronic obstructive pulmonary disease (a long-term lung disease that makes it hard to breathe), hypothyroidism (underactive thyroid gland that did not make enough hormone), muscle wasting and atrophy (when a part of the body, like a muscle or tissue, shrinks or wastes away from lack of use or disease), major depressive disorder (severe, persistent sadness and loss of interest that interferes with daily life), generalized anxiety disorder (ongoing excessive worry and nervousness that interferes with daily life), Type 2 diabetes (a condition where the body can't properly use sugar for energy, leading to high blood sugar and possible complications). The resident required some assistance with toileting, showing/bathing, and dressing (both upper and lower body), and was completely dependent on staff for putting on and taking off footwear and overall personal hygiene. The resident required extensive assistance to roll left and right, transition from sitting to lying and from lying to sitting on the side of the bed, and to move from sitting to standing. She was completely dependent on staff for chair-to chair toilet, tub/shower transfers, and walking any distance. Record review of Resident #66's Comprehensive Care Plan dated 05/28/2025, reflected an ADL self-care performance deficit: [Resident] has an ADL self-care performance deficit. Goal: [Resident] will maintain or improve current level of function in (Specify: bed mobility, transfers, eating, dressing, toilet use and personal hygiene; ADL Score) through the review date. Interventions: Assist with personal hygiene as required: hair, shaving, oral care as needed. Bathing: requires staff x1 for assistance. Bed mobility: requires staff x1 for assistance. During an observation and interview with Resident #66 on 08/24/2025 at 9:55 AM, she was observed lying in bed. She appeared to be well-groomed. She reported she had not been getting bathed regularly. She stated her last bath was Monday, August 18, 2025. The resident reported when the staff did not help with bathing, they would tell her that they were out of towels every time. Resident #66 stated she was worried about smelling bad and would like to bathe on her scheduled days. Record review of facility shower documentation dated August 2025 reflected Resident #66's shower/bath days were Mondays, Wednesdays, and Fridays. The shower/bathing documents reflected she was bathed/showered on the following days: 08/4/2025 (Monday), 08/11/2025 (Monday), and 08/13/2025 (Wednesday). Record review of Resident #66's progress notes from August 1, 2025, to August 25, 2025, revealed no documented shower/bath refusals. Record review of Resident #75's annual MDS dated [DATE], reflected the [AGE] year-old male resident was admitted to the facility on [DATE] and had intact cognitive functioning, meaning they were alert, oriented, able to understand and process information, make decisions, and communicate their needs appropriately, as indicated by a BIMS score of 15. Diagnoses included: Atrial Fibrillation (when the heart beats in an irregular and often fast rhythm), difficulty in walking, muscle wasting and atrophy (when a part of the body, like a muscle or tissue, shrinks or wastes away from lack of use or disease), and need for assistance with personal care. The resident was independent with oral hygiene, shower/bathing, dressing upper and lower body, putting on/taking off footwear, and personal hygiene. Record review of Resident #75's Comprehensive Care Plan dated 08/17/2025, reflected a performance deficit: Performance deficit: impaired balance, limited mobility. Goal: Improve current level of function in bed mobility, transfers, eating, dressing, toilet use and personal hygiene. Interventions: Bathing: the resident requires assistance, limited assistance with bathing/showering 3x a week and as necessary. During an observation and interview with Resident #66 on 08/25/2025 at 11:00 AM, the resident was observed sitting in his wheelchair. He appeared to be well-groomed. Resident #66 reported he was not getting showers as scheduled. He reported he was being told on days that he did not get one that the facility was out of towels. The resident did not recall when his last shower was. Record review of facility shower documentation dated August 2025 reflected Resident #75's shower/bath days were Tuesdays, Thursdays, and Saturdays. The shower/bathing documents reflected he was bathed/showered on the following days: 08/2/2025 (Saturday), 08/07/2025 (Thursday), 08/12/2025 (Thursday), 08/21/2025 (Thursday.) Record review of Resident #72's annual MDS dated [DATE], reflected the [AGE] year-old male resident was admitted to the facility on [DATE] and had moderate cognitive impairment, as indicated by a BIMS score of 11. The score suggested the resident experienced some difficulty with memory and orientation but was still able to engage in conversation and participate in decision-making with support. Diagnoses included unspecified dementia (memory loss and thinking problems caused by another medical condition, like Parkinson's or Huntington's (a rare, inherited neurodegenerative disorder that affects the brain, causing progressive physical, cognitive, and psychiatric symptoms), rather than Alzheimer's itself), muscle weakness, atherosclerotic heart disease (buildup of fatty deposits (plaque) inside the coronary arteries), depression (persistent sadness and loss of interest that interferes with daily life), hypertension (high blood pressure), and generalized anxiety disorder (ongoing excessive worry and nervousness that interferes with daily life.) The resident required partial/moderate assistance with shower/bathing. The resident was independent in aspects of mobility but required supervision/touching assistance for tub/shower transfers. Record review of Resident #72's Comprehensive Care Plan dated 08/07/2025, did not reflect an ADL Focus. Record review on 08/24/2025 of facility shower documentation dated August 2025 reflected Resident #72's shower/bath days were Mondays, Wednesdays, Fridays. The shower/bathing documents reflected he was bathed/showered on the following days: 08/2/2025 (Saturday), 08/05/2025 (Tuesday), 08/12/2025 (Thursday), and 08/13/2025 (Wednesday). Record review of facility shower sheet documentation dated 08/13/2025 with an unspecified time, completed and signed by CNA I reflected a shower was not given to Resident #72 due to no towels. During an observation and interview with Resident #72 on 08/24/2025 at 11:15 AM, he was observed lying in his bed and appeared to be well-groomed. Due to cognitive functioning, he was unable to provide reliable information regarding his showering/bathing. In an interview on 08/25/2025 at 1:15 PM with CNA G, she reported she ensured that all of the residents she was assigned to received their showers during her shift. She reported the only thing that would keep her from not bathing residents was when they were understaffed. She stated she brought that issue up to human resources and it was addressed. She stated they had hired more people. She said there were times some residents did miss a shower due to that but it had improved. In an interview on 08/25/2025 at 1:25 PM with CNA J, he reported that if a resident refused a shower, it was documented in their electronic health record. He stated the only reason a resident would not get a shower or bath was if the facility was short staffed or if they were low on supplies. He stated there was a time recently he was not able to shower/bathe residents because there were no towels. He stated he reported that issue to the next shift. He stated it was not typically documented if a resident was not showered or bathed due to no supplies. He stated if the linen closet was not stocked with towels, he would go to housekeeping to let them know. He stated housekeeping sometimes did have extra towels and sometimes they did not. In an interview on 08/25/2025 at 1:45 PM with LVN A, she stated there had been issues with getting all residents bathed and showered. She stated the only thing that would get in the way of that task was that towel laundry needed to be done quicker. She stated that had been an ongoing issue. In an interview on 08/26/2025 at 3:30 PM, Regional Compliance Nurse stated during every morning meeting they go over the shower sheets to see who refused and who was showered. He stated the refusals are documented on the shower sheets and in the resident's electronic health record. He denied low staffing as a reason as to why residents would miss a shower. He stated he had not been made aware that laundry was an issue and preventing residents from getting their showers. He stated the facility recently bought about 500 towels. He reported the residents were supposed to be offered showers per the schedule so that the residents were well groomed and maintained clean. On 08/25/2025 the facility showering/bathing policy was requested and was not provided by the facility by the time of exit.

Based on observation, interview, and record review, the facility failed to ensure the resident call light system was maintained within reach for 4 of 6 residents (Resident #14, Resident #3, Resident #21, and Resident #69) reviewed for call light system access. The facility failed to ensure Resident #14 had access to their call light by allowing it to remain on the floor at the foot of the bed, out of the resident's reach. The facility failed to ensure Resident #3 had access to their call light by allowing it to remain draped over a light fixture about the resident's bed, out of the resident's reach. The facility failed to ensure Resident #21 had access to their call light by allowing the cord to become unattached from the clip, resulting in the call light to dangle from the wall, out of the resident's reach. The facility failed to ensure Resident #69 had access to their call light by allowing it to remain on the floor in a shoe, out of the resident's reach. This failure could place residents at risk for delayed assistance and an inability to request help when needed. Record review of Resident #14's annual MDS dated [DATE], reflected the [AGE] year-old female resident was admitted to the facility on [DATE] and had severely impaired cognitive function. Diagnoses included: Parkinson's Disease (a neurodegenerative disorder that affects the dopamine-producing neurons in the brain, it causes slowed movements, tremors, balance problems, and changes in mood and behavior), Dementia (severe decrease in memory and intellectual functioning), hypertension (high blood pressure), and muscle weakness (less strength or control in muscles). She required substantial/maximal assistance for daily care tasks like toileting hygiene, bathing, dressing, and grooming. She also required similar support for mobility tasks like toilet transfer, rolling from side to side, chair/bed-to chair transfer. She was dependent on staff to assist with walking, taking steps, picking up objects and utilized a wheelchair for mobility. Record review of Resident #14's Comprehensive Care plan dated 05/15/2025 reflected a fall focus: [Resident] is at risk for falls. Goal: [Resident] will not sustain serious injury through the review date. Interventions included: Be sure the resident's call light is within reach and encourage resident to use it for assistance as needed. Review of Resident #14's Comprehensive Care Plan also revealed a communication focus. [Resident] has a communication problem. Goal: Resident will be able to make basic needs known by (specify) [sic] on a daily basis through the review date. Interventions included: Ensure/provide a safe environment: Call light in reach. During an interview and observation on 08/24/2025 at 9:44 AM, Resident #14 was observed in bed. The call light was on the floor at the end of the bed, out of the reach of the resident. Due to cognitive impairment, she was unable to provide reliable information during the interview. During an observation on 08/24/2025 at 10:15 AM, Resident #14 was observed in bed. The call light remained in the same location, on the floor and not accessible. During an interview with LVN A on 08/24/2025 at 10:56 AM, in response to the Resident's call light placement, LVN A reported Resident #14 did not use her call light and they would check on her every 30 minutes to an hour. Record review of Resident #3's annual MDS dated [DATE], reflected the [AGE] year-old male resident was admitted to the facility on [DATE] and had intact cognitive functioning, meaning they were alert, oriented, able to understand and process information, make decisions, and communicate their needs appropriately. Diagnoses included heart failure, Type 2 Diabetes (a condition where the body does not use insulin properly, causing high blood sugar levels over time), nuclear cataract (a clouding of the center of the eye's lens that make vision blurry), hypertension (high blood pressure), visual loss to both eyes, difficulty in walking and unsteadiness on feet. Resident #3 was independent with eating and oral hygiene, completing these tasks safely without staff assistance. For toileting hygiene, putting on/taking off footwear, and personal hygiene, the resident required setup assistance, with staff placing necessary supplies within reach; however, the resident completed the activities independently once prepared. With showering/bathing, upper body dressing, and lower body dressing, the resident required supervision and occasional touching assistance, including staff presence for safety, verbal cueing, and light physical guidance as needed. The resident was fully independent with rolling left and right, moving from sitting to lying and lying to sitting at the side of the bed, standing from a seated position, transferring between a chair and bed, using the toilet, and walking 10 feet. He required supervision or minimal assistance for tub/shower transfers, walking 50 feet with two turns, and walking 150 feet. The resident experienced frequent bowel incontinence and occasional urinary incontinence. Record review of Resident #3's Comprehensive Care plan dated 5/23/2025 reflected a fall focus: {Resident] is at risk for falls. Goal: [Resident] will not sustain serious injury through the review date. Interventions included: Be sure the resident's call light is within reach and encourage resident to use it for assistance as needed. During an interview and observation on 08/24/2025 at 9:30 AM, Resident #3 was observed in bed, awake and alert. The Resident's call light was observed hanging over a light fixture above his bed. Resident #3 stated he had his call light yesterday but could not locate it in his bed. He stated his bed was usually where his call light would be placed. During an observation on 08/24/2025 at 10:35 AM, Resident #3 was observed in bed and the call light remained in the same location, hanging over the light fixture and out of reach of the resident. During an interview with LVN A on 08/24/2025 at 11:06 AM, she confirmed the location of the call light hanging over the light fixture and immediately arranged the call light to be clipped next to the resident. She stated she was not sure who put it there or how long it had been like that. She stated the resident was blind and confused and she would check on him every 30 minutes to an hour. She reported she did not notice it was out of his reach during her last check at 9:00 AM. Record review of Resident #21's annual MDS dated [DATE], reflected the [AGE] year-old female resident was admitted to the facility on [DATE] and had intact cognitive functioning, meaning they were alert, oriented, able to understand and process information, make decisions, and communicate their needs appropriately. Diagnoses included: Parkinson's Disease (a neurodegenerative disorder that affects the dopamine-producing neurons in the brain, it causes slowed movements, tremors, balance problems, and changes in mood and behavior), transient ischemic attack and cerebral infarction (a type of stroke caused by blood vessel in the brain), generalized anxiety disorder, hemiplegia (paralysis on one side of the body), hemiparesis (weakness on one side of the body), muscle wasting in upper right and left arms, and muscle weakness. The resident was independent with eating and oral hygiene. She was dependent on staff for toileting hygiene, showering/bathing, and putting on/taking off footwear. She required setup assistance for both upper and lower body dressing, as well as for personal hygiene tasks such as washing her face and hands, shaving, and combing hair. She demonstrated very little mobility and required significant staff assistance for nearly all movements. She needed substantial assist to roll in bed, transition from sitting to lying, and move from lying to sitting at the side of the bed. All other mobility activities including standing, transferring between chair and bed, toilet and tub/shower transfers, and walking short distances were fully dependent on staff. Record review of Resident #21's Comprehensive Care Plan dated 07/15/2025 reflected the following focus: [Resident] uses one quarter or two quarter rails to enhance functional independence & promote skin integrity. Goal: [Resident] will maintain or increase functional independence through each use of: one partial (half) rail or two partial rails through the next review. Interventions included: Place the call light cord within easy reach. Focus: [Resident] is at risk of falls related to CVA (Cerebrovascular Accident, commonly known as a stroke, caused by interruption of blood flow to the brain, resulting in neurological changes), hemiplegia, pain, obesity, weakness in radiculopathy (nerve pain). Goal: [Resident] will have no injuries through the next review. Interventions included: Keep call light in reach when in room. During an interview and observation on 08/24/2025 at 9:15 AM, Resident #21 was observed in bed, awake and alert. The resident's call light was hanging down the wall and not clipped near the resident within her reach. She reported her call light clip had broken, and the call light cord would keep detaching from the clip. She pointed to the clip that was attached to her pillowcase that would hold the call light cord. She reported it had been broken for around a week and she had reported it to several staff. The resident stated she was told by staff it would be fixed but nothing had been done. She reported she would use her reach extender (a tool for reaching and grasping objects from a distance) to bring the call light closer to her when it would come unattached from the clip. She reported feeling frustrated about her call light and felt worried if she needed immediate assistance, she would not be able to get to her call light. During an observation on 08/24/2025 at 10:20 AM, the resident was observed in bed and the call light remained in the same location, out of reach of the resident. During an interview with LVN A on 08/24/2025 at 10:15 AM, LVN A confirmed the location of the call light that was out of reach of Resident #21. LVN A stated she had not been made aware that the cord kept coming detached from the clip. She stated she also had not been made aware that Resident #21 had to utilize a reach extender to access her call light. LVN A reattached the resident's call light back to the original clip. Record review of Resident #69 annual MDS dated [DATE], reflected the [AGE] year-old female resident was admitted to the facility on [DATE] and had severely impaired cognitive function. Diagnoses included: Alzheimer's Disease (a brain disease that slowly destroys memory, thinking, and the ability to carry out daily tasks), hypertension (high blood pressure), depressive disorder (a condition that causes persistent sadness, loss of interest, and low energy that affects daily life), dysphagia (difficulty speaking or understanding language), and muscle weakness. Resident #69 was dependent on staff for self-care tasks such as eating, oral hygiene, toileting hygiene, shower/bathing, dressing, putting on/off footwear, and personal hygiene. The resident was independent with some mobility, namely walking. She was dependent on staff for tub/shower transfers, toilet transfers, and the ability to roll from lying on back to her left or ride side. The resident experienced frequent urinary and bowel incontinence. Record review of Resident #69's Comprehensive Care plan dated 08/07/2025 reflected a fall focus: {Resident] is at risk for falls related to Alzheimer's Disease and pain. Goal: [Resident] will have no injuries due to falls through the next quarterly review. Interventions included: Keep call light in reach when in room. During an interview and observation on 08/24/2025 at 9:12 AM, Resident #69 was observed lying in bed. The call light was in the resident's shoe on the floor near the bed. Due to cognitive impairment, she was unable to provide reliable information during the interview. During an observation on 08/24/2025 at 11:10 AM, LVN A confirmed the location of the call light and LVN A immediately clipped it near the resident. LVN A stated she was not sure how it got there. She stated every staff member is responsible for ensuring the call light is within reach of the resident. During a follow up interview with LVN A on 08/24/2025 at 1:45 PM, she reported that she was unaware of any risk to residents due to them not being able to reach the call light. She reported she would check on her residents every 30 minutes. When asked if she did that on 08/24/2025 she reported it was more like every hour. During an interview with CNA G on 08/26/2025 at 1:15 PM, she reported it was everyone's responsibility to answer call lights. She reported it was also everyone's responsibility to ensure the call light is within reach of each resident. She reported she checked on residents as needed and every 30 minutes to an hour. During an interview with Regional Compliance Nurse on 08/26/2025 at 3:00 PM, he reported every staff member at the facility was responsible to ensure call lights were within reach of each resident. He reported the risk of it not being within reach was not being able to call for assistance if they needed water.

Based on interview and record review, the facility failed to ensure that PRN orders for psychotropic drugs were limited to 14 days and could not be renewed, unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of the medication for one (Resident #66) of six residents on psychoactive medication in that: The facility failed to ensure that Resident #66 had orders for psychotropic medication Lorazepam (brand name Ativan, a medication in the benzodiazepine class used to reduce anxiety, help with sleep, or control seizures) that did not contain PRN orders beyond 14 days without an end date and reassessment. This failure could place residents at risk for receiving unnecessary medications and adverse drug reactions. Record review of Resident #66's annual MDS dated [DATE], reflected the [AGE] year-old female resident was admitted to the facility on [DATE] and had moderate cognitive impairment, as indicated by a BIMS score of 9. This score suggested the resident experienced some difficulty with memory and orientation but was still able to engage in conversation and participate in decision-making with support. Diagnoses included chronic obstructive pulmonary disease (a long-term lung disease that makes it hard to breathe), hypothyroidism (underactive thyroid gland that did not make enough hormone), muscle wasting and atrophy (when a part of the body, like a muscle or tissue, shrinks or wastes away from lack of use or disease), major depressive disorder (severe, persistent sadness and loss of interest that interferes with daily life), generalized anxiety disorder (ongoing excessive worry and nervousness that interferes with daily life), Type 2 diabetes (a condition where the body can't properly use sugar for energy, leading to high blood sugar and possible complications). Record review of Resident #66's Comprehensive Care Plan dated 05/28/2025, reflected a Medication Focus: [Resident] requires antidepressant medication Depression [sic]. Goal: [Resident] will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. Interventions: Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of (Specify: antidepressant drugs being given). Medication Focus: The resident requires anti-psychotic medications. Goal: [Resident] will be/remain free from drug related complications, including movement disorder, discomfort, constipation/impaction or cognitive/behavioral impairment through the review date. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Consult with pharmacy, MD to consider dosage reduction when clinically appropriate. Discuss with MD, family re [sic] ongoing need for use of medication. Medication Focus: [Resident] uses anti-anxiety medications. Goal: [Resident] will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Interventions: Give anti-anxiety medications ordered by physician. Monitor/document side effects and effectiveness. ANTIANXIETY SIDE EFFECTS: Drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. PARADOXICAL SIDE EFFECTS: mania, hostility and rage, aggressive or impulsive behavior, hallucinations. Record review of Resident #66's Pharmacy Order Summary Report dated 08/26/2025 reflected an order for Lorazepam 0.5 mg oral tablets, with a start date of 06/20/2025. The order instructed that one tablet be given by mouth every 12 hours as needed for anxiety. The report did not state an end date for the medication. Record review of Resident #66's Medication Regimen Review, re: Psychotropic Medication Review: PRN Psychotropic, dated 05/02/2025 reflected a pharmacist recommendation of discontinuing Lorazepam Oral Tablet 0.5 mg unless there was a clinical rationale to continue the medication. The signing physician did not include a rationale in continuing the medication and their response checked on the form showed they agreed with the recommendation and was signed on 06/05/2025. Record review of Resident #66's monthly MAR, dated June 2025 reflected Lorazepam was administered to Resident #66 on 06/01/2025, 06/02/2025, 06/03/2025, 06/04/2025, and 06/05/2025. Record review of Resident #66's monthly MAR, dated July 2025 reflected Lorazepam was administered to Resident #66 on 07/04/2025, 07/05/2025, 07/06/2025, 07/14/2025, 07/15/2025, 07/25/2025, 07/26/2025, 07/28/2025, 07/29/2025, and 07/30/2025. Record review of Resident #66's monthly MAR, dated August 2025 reflected Lorazepam was administered to Resident #66 on 08/02/2025, 08/04/2025, 08/05/2025, 08/06/2025, 08/07/2025, 08/08/2025, 08/11/2025, 08/12/2025, 08/14/2025, and 08/15/2025, 08/16/2025, 08/18/2025, 08/20/2025, 08/22/2025, 08/25/2025, and 08/26/2025. In an interview on 08/26/2025 at 11:46 AM, Regional Compliance Nurse stated the ADON was responsible for following up with gradual dose reductions (slowly lowering a medication's dose over time to see if it is still needed or to reduce side effects safely). RN F reported the ADON was responsible to make sure residents who were on PRN antipsychotic medications were assessed every 14 days for the resident to continue with the medication. RN F stated the ADON had only been working at the facility for a couple of weeks, and they would begin an audit on all pharmacy recommendations. RN F stated the risk for residents continuing PRN medications past 14 days was that they might no longer benefit from the medication. Review of the facility policy undated, titled Psychotropic Medication, reflected: The facility will ensure that the resident is free from chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. Residents should only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Also, residents will only remain on psychotropic medications when a gradual dose reduction and behavioral interventions have been attempted and/or deemed clinically contraindicated. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: Anti-psychotic; Anti-depressant; Anti-anxiety; and Hypnotic. Based on a comprehensive assessment of a resident, the facility will ensure that: Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, to discontinue these drugs; Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and PRN orders for antidepressant, hypnotic, and antianxiety drugs are limited to 14 days. Except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document the rationale in the resident's medical record and indicate the duration for the PRN order. PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Based on observation, interview, and record review the facility failed to provide a safe, clean, comfortable and homelike environment for 1 (Bathroom [ROOM NUMBER]A/B) of 6 bathrooms reviewed for environmental concerns. The facility failed to ensure the bathroom located in room [ROOM NUMBER]A/B was effectively cleaned, as there was a large pile of feces located on top of a board that had been placed over the bathtub, as well as dried feces that appeared to have been smeared on top of the board. This failure could affect all residents, staff, and the public by placing them at risk for diminished quality of life due to the lack of a well-kept environment.Findings included: Observation of the bathroom located in room [ROOM NUMBER]A/B (memory care unit) on 08/26/25 at 1:08PM revealed there was a large pile of feces located on top of a board that had been placed over the bathtub, as well as dried feces that appeared to have been smeared on top of the board. There was a strong odor of feces in the bathroom. During an interview with the Regional Compliance Nurse on 08/26/25 at 1:10PM, he confirmed the presence of feces in the bathroom located in room [ROOM NUMBER]A/B. The Regional Compliance Nurse obtained cleaning supplies and gloves in order to clean the bathroom. During a subsequent interview with the Regional Compliance Nurse on 08/26/25 at 2:38PM, he stated he confirmed housekeeping staff knew about the presence of the feces in the bathroom located in room [ROOM NUMBER]A/B. He stated these staff advised that they saw the feces in the restroom prior to the lunch meal service, and they planned on waiting until after the meal service was completed to clean the feces. The Regional Compliance Nurse stated the risk of this included residents not having a hygienic or homelike environment. Review of the facility's Resident Rights policy, undated, reflected, .Safe environment - The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide- 1. A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. 2. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.

Based on observation, interview, and record review the facility failed to ensure a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #80) of 4 residents reviewed for oxygen administration. The facility failed to follow Resident #80's physician order for continuous oxygen. This failure could place residents at risk of receiving incorrect or inadequate oxygen support and could result in a decline in health.Findings included: Record review of Resident #80's Face Sheet, dated 08/26/25, reflected she was an [AGE] year-old female, who originally admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease with (acute) exacerbation (a sudden worsening of chronic obstructive pulmonary disease symptoms including shortness of breath), respiratory arrest (a serious medical condition caused by apnea or respiratory dysfunction), and dependence on supplemental oxygen (a condition where an individual requires supplemental oxygen due to respiratory disorders or other medical conditions). Record review of Resident #80's MDS Assessment, dated 07/13/25, reflected she had a BIMS score of 11, which indicated she had moderate cognitive impairment. Resident #80 was identified as requiring oxygen therapy. Record review of Resident #80's Physician's Orders, dated 08/26/25, reflected she had an order for continuous oxygen (2-5 liters per minute) for ineffective air exchange. The start date for this order was 08/20/25. Record review of Resident #80's Care Plan, dated 05/19/25, reflected she utilized oxygen therapy. Identified goals included for Resident #80 to have no signs or symptoms of poor oxygen absorption. Interventions included for Resident #80 to have continuous oxygen via nasal cannula, with settings at 2 liters per minute. Observation of Resident #80 on 08/24/25 at 9:43AM revealed she was ambulating throughout the facility in her wheelchair. Resident #80 had a portable oxygen tank hanging from her wheelchair; the oxygen level indicator reflected the oxygen tank was empty. During an interview with Resident #80 on 08/24/25 at 9:43AM, she stated she was unable to feel any oxygen coming from her nasal cannula and needed the oxygen tank replaced. During an interview with RN B on 08/24/25 at 9:55AM, she stated Resident #80 had a physician's order for continuous oxygen therapy. She confirmed the portable oxygen tank that Resident #80 was using had run out of oxygen and was empty. RN B stated she last checked the portable oxygen tank earlier this morning (unknown what time), and oxygen was being delivered at that time. RN B stated the risk of a resident not receiving continuous oxygen as ordered included the potential for shortness of breath, increased heartrate, and confusion. During an interview with the DON on 08/26/25 at 2:57PM, he stated the expectation for residents with physician's orders for continuous oxygen was for these residents to always have access to oxygen. The DON stated the risk of a resident not receiving continuous oxygen as ordered included not getting enough oxygen and the potential for shortness of breath. Record review of the facility's Oxygen Administration policy, dated 02/13/07, reflected, .Oxygen therapy includes the administration of oxygen (O2) in liters/minute (l/min) by cannula or face mask to treat hypoxemic conditions (low levels of oxygen in the blood) caused by pulmonary or cardiac diseases. O2 therapy is also prescribed to ensure oxygenation of all body organs and systems. The amount of oxygen by percent of concentration or L/min, and the method of administration, is ordered by the physician. The administration, monitoring of responses, and safety precautions associated with it are performed by the nurse. The nasal cannula delivers 22-40% oxygen and is the most common, inexpensive, and easiest device to use. Common oxygen sources for long-term administration include cylinder (portable or stationary) or wall system near the resident's bed or concentrator. All sources require humidification to prevent drying of mucous membranes and thickening of respiratory secretions if used routinely.

Based on interviews and record review, the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review for one (Resident #8) of six residents reviewed for PASRR services. The facility failed to ensure Resident #8 was properly screened for PASRR services. This failure could place residents at risk of not receiving specialized PASRR services which would enhance their highest level of functioning and could contribute to residents decline in physical, mental, and psychosocial well-being. Record review of Resident #8's quarterly MDS Assessment, dated 07/11/25, revealed a [AGE] year-old-male admitted to the facility on [DATE] and had intact cognitive functioning, meaning they were alert, oriented, able to understand and process information, make decisions, and communicate their needs appropriately. Diagnoses included: dementia in other diseases classified elsewhere (memory loss and thinking problems caused by another medical condition, rather than Alzheimer's itself), other bipolar disorder (a mood disorder causing unusual swings between high (manic) and low (depressive) moods), and major depressive disorder (a mental health condition causing severe, persistent sadness and loss of interest that interferes with daily life. Resident #8 required setup assistance with eating and oral hygiene. For toileting hygiene, putting on/taking off footwear, and personal hygiene, showering/bathing, upper body dressing, and lower body dressing, the resident required substantial assistance with the helper doing more than half the effort to complete the activity. Record review of Resident #8's PASRR Level I screen, dated 06/14/24, reflected the resident did not have a history of mental illness. Record review of Resident #8's Comprehensive Care plan dated 07/14/2025 reflected a medication focus: [Resident] requires anti-psychotic medications Behavior management [sic]. Goal: [Resident] will reduce the use of psychoactive medication through the review date. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Consult with pharmacy, MD (medical doctor) to consider dosage reduction when clinically appropriate. Monitor/record occurrence of for target behavior symptoms (Specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc.) and document per facility protocol. Under [XXXX] management. Antidepressant Medication Focus: [Resident] requires antidepressant medication. Goal: [Resident] will be free from discomfort or adverse reactions related to antidepressant therapy through the next review date. Interventions: Educate the resident/family/caregivers about risks, benefits, and the side effects and/or toxic symptoms of (Specify: anti-depressant drugs being given.) Behavior Problem Focus: [Resident] has a behavior problem of attention-seeking and accusatory behaviors, distorting the truth in attention seeking efforts and/or making false allegations, making negative statements about staff, excessive calling out for nursing staff but when the nursing staff go to attend to him, he states he is not ready for them, that he is watching his favorite television show. Goal: Reductions or absence or false accusations/attention seeking. Interventions: Encourage resident to participate in his care Give the resident as many choices as possible about care and activities. Provide positive feedback for good behavior. Emphasize the positive aspects of compliance. An interview on 08/26/25 at 11:46 AM with the MDS Nurse revealed she was responsible for entering PASRR information. The MDS Nurse reported the PASRR Level 1 for Resident #8 was received from a hospital upon his admission to the facility and was documented as it was. The MDS Nurse reported the resident did not receive an updated evaluation upon or after his admission to the facility and he did not receive a PASRR Level 2 screening. The MDS Nurse stated the resident was at risk of not receiving PASRR services. During an interview on 08/26/25 at 12:16 PM with Regional Compliance Nurse, he stated that the MDS Nurse was responsible for PASRR screenings. He reported he was unaware of how the resident's screening was missed. He reported the resident was at risk to miss out on PASARR services if his PL 1 was incorrect. A request on 08/25/2025 at 2:25 PM was made to review the facility's PASRR process and policy and was not provided by the time of exit.

Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #33) of 5 residents reviewed for quality of care. The facility failed to ensure Resident #33 received ordered treatments for a skin abrasion she sustained on her arm. This failure placed residents at risk of having untreated skin conditions, which could lead to delays in treatment and worsening of conditions.Findings included: Record review of Resident #33's Face Sheet, dated 08/26/25, reflected she was a [AGE] year-old female, who was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), unspecified dementia (a group of symptoms affecting memory, thinking and social abilities), and abnormalities of gait and mobility (deviations from a normal walking pattern, impacting how a person moves and their ability to maintain balance and coordination). Record review of Resident #33's MDS Assessment, dated 07/21/25, reflected she had a BIMS score of 03, indicating she had severe cognitive impairment. Record review of Resident #33's Nurse's Note, dated 08/19/25, reflected she was noted to have a small abrasion to her left forearm. Resident #33 was unable to state how the abrasion occurred. Record review of Resident #33's Physician's Orders, dated 08/20/25, reflected an order to apply A&D Ointment to bilateral arms (both the left and right arms of a person) every day until resolved (healed). Observation of Resident #33 on 08/24/25 at 10:25AM revealed she had a bandage on her left arm, dated 08/20/25. An attempted interview with Resident #33 on 08/24/25 at 10:25AM revealed she was confused and unable to participate in a reliable interview due to cognitive impairment. Resident #33 stated she could not recall how she obtained the injury to her left arm. During an interview with LVN H on 08/24/25 at 10:30AM, she stated she was the assigned weekend nurse for Resident #33. She confirmed the bandage on Resident #33's left arm was dated 08/20/25 and stated it appeared as though the skin tear had not been treated since that time. She stated Resident #33's orders were for the skin tear to be treated daily. LVN H stated she most recently worked with Resident #33 on 08/23/25 and did not treat the skin tear per physician's orders, because she was occupied with a different resident who had sustained a change in condition. LVN H stated she planned on treating Resident #33's skin tear and changing the bandage this morning (08/24/25). LVN H stated the risk of not treating skin tears/wounds as ordered included the potential for infection. During an interview with the DON on 08/26/25 at 2:57PM, he stated the facility's expectation was for skin treatments to be completed per physician's orders. He stated the risk of not treating skin tears/wounds as ordered was the potential for delayed healing. Record review of the facility's Medication Orders policy, dated 03/2025, reflected, .Each medication order is documented in the resident's medical record with the date, time, and signature of the person receiving the order. The order is recorded on the current physician order sheet, the telephone order sheet, if it is a verbal order, and the Medication Administration Record (MAR). The facility did not provide a policy related to following physician's treatment orders.

Based on observation, record review and interview the facility failed to ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for two (Residents #54 and #79) of three residents reviewed for pressure ulcers. The facility failed to provide appropriate treatment to Residents #54 and #79 on 08/24/25. This failure placed residents at risk for decline in quality of life and the wounds being infected or deteriorating. Findings include: Review of Resident #79's face sheet dated 08/26/25 revealed she was a [AGE] year-old male, he was originally admitted on [DATE]. Admitting diagnoses included, Type 2 diabetes, muscle weakness, dementia, anemia, gangrene, non-pressure chronic ulcer, need assistance with personal care. Review of Resident #79's quarterly MDS assessment dated [DATE] reflected he had a BIMS score of 15, indicating no cognitive impairment. The resident had a pressure ulcer, and he was at risk for the development of pressure ulcer. Review of Resident #79's care plan initiated 04/11/25 reflected the resident had a pressure ulcer or potential for pressure ulcer development, facility goal was for the resident's pressure ulcer to show signs of healing and remain free from infection. Review of Resident #79's physician summary dated 08/26/25 reflected an order dated 07/17/25; coccyx (located at the lower end of the spine) clean with wound cleanser, apply dakins moistened fluffed gauze and cover with abdomen and border foam every day for stage 4 pressure ulcer (a severe form of skin breakdown that extends through all layers of the skin and into underlying tissues, such as muscle, tendon, or bone). Review of Resident #54's face sheet dated 08/26/25 revealed she was a [AGE] year-old male, he was originally admitted on [DATE]. His diagnoses included hypertension, dementia, muscle weakness, need for assistance with personal care and non-pressure chronic ulcer for right heel and midfoot. Record review of Resident #54's quarterly MDS assessment, dated 05/15/25 reflected a BIMs score of 03 indicating his cognitive status was severely impaired. The resident was dependent on staff for activities of daily living. Review of Resident #54's care plan initiated 02/10/25 revealed resident had a pressure ulcer or potential for pressure ulcer development, and the facility goal was for the resident's pressure ulcer to show signs of healing and remain free from infection. Review of Resident #54's physician summary dated 08/26/25 reflected an order dated 08/22/25; stage 3 pressure ulcer ( a deep skin injury that extends through the dermis (second layer of skin) and into the subcutaneous tissue (fat layer). lateral left ankle, clean with wound cleanser, pat dry and apply collagen and calcium alginate cover with bordered form dressing every day. Another orders reflected stage 3 pressure ulcer lateral left foot, clean with wound cleanser, pat dry and apply collagen and calcium alginate cover with bordered form dressing every day. Observation and interview on 08/24/25 at 11:05 am of Resident #79 reflected he was resting in bed watching television. The resident stated he had a wound to his left foot and to the sacrum area. He stated the wound care had not been completed, the last time wound care was completed was Friday (08/22/25). He stated most of the time the wound care was not completed on the weekends. In an observation of wound care on 08/24/25 at 02:20 pm on Resident #79 with RN B revealed the resident had wounds to his sacrum area and on the right toes. During wound care, the resident did not have a dressing on the wound to the sacrum prior to the wound care. In an observation on 08/24/25 at 03:10 pm of Resident #54 reflected the resident was in bed. During a wound assessment with RN B, revealed the resident had wounds to the left foot and the dressings were dated 8/22/25 and the wound to the left buttock did not have a dressing on it. In an interview on 08/24/25 at 03:22 pm with RN B revealed she did not complete wound care for the residents on 08/23/25. RN B stated she was busy, and she was unable to complete the wound cares. She stated she did not inform anyone that she was unable to complete the wound cares. RN B stated failure of the wound care not being completed per the physician orders could lead to wound infection and or sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection). RN B stated she was expected to complete wound care per the orders, and if she was not able to, she was supposed to inform the ADON/DON, but she did not. In an interview on 08/26/25 at 12:50 pm with ADON E revealed he was not aware RN B did not complete wound care on 8/23/25 until 8/24/25 when the surveyor questioned RN B. He stated he expected the staff to complete wound care per the orders and if she could not, she was supposed to inform him or the DON, but she did not. ADON E also stated RN B was also to inform the night nurse that wounds were not completed, so the night nurse could help but RN B did not. ADON E stated wound care was to be completed per physician orders to prevent them from getting worse or being infected. In an interview on 08/26/25 at 02:15 pm with the DON, he stated each hall had an ADON who made sure that the wound care, or resident care was completed per the orders. He expected the charge nurse to notify the on-call staff if she was not able to complete wounds care or inform the night nurse, but the charge nurse did not inform anyone. The DON stated failure to provide wound care to the residents could lead to the wounds being infected or getting worse. Record review revised 05/05/25 and titled Pressure Injury: Prevention, Assessment and Treatment, reflected, Nursing personnel will continually aim to maintain the skin integrity, tone, turgor and circulation to prevent breakdown, injury and infection.

Based on observation, interview, and record review the facility failed to, in accordance with State and Federal laws, ensure all drugs were stored in locked compartments under proper temperature controls, and permit only authorized personnel to have access to these drugs for 1 (Resident #73) of 5 residents reviewed for medication storage. The facility failed to ensure Resident #73 did not have unsecured multivitamins in his room. This failure could place residents at risk of not being monitored for their medications, adverse reactions, and drug diversion.Findings included: Record review of Resident #73's Face Sheet, dated 08/26/25, reflected he was an [AGE] year-old male, who was admitted to the facility on [DATE], with diagnoses including dementia (a group of symptoms affecting memory, thinking and social abilities), abnormalities of gait and mobility (deviations from a normal walking pattern, impacting how a person moves and their ability to maintain balance and coordination), and need for assistance with personal care (when a person requires help with daily activities like bathing, dressing, or toileting due to a chronic health issue, physical disability, or aging). Record review of Resident #73's MDS Assessment, dated 06/25/25, reflected he had a BIMS score of 15, which indicated he was cognitively intact. Record review of Resident #73's Physician's Orders, dated 08/26/25, reflected there were no orders for Resident #73 to self-administer medications. There was not an order for multivitamins. Observation of Resident #73 on 08/24/25 at 10:53AM revealed he was ambulating in his room. Observation revealed Resident #73 was noted to have a bottle of multivitamins on his bedside table. During an interview with Resident #73 on 08/24/25 at 10:55AM, he reported he did not self-administer his multivitamins; he stated his family member brought them to the facility at some point, and he was not sure why they were on his bedside table. During an interview with the DON on 08/24/25 at 11:00AM, he stated Resident #73 was unable to safely self-administer medications. The DON stated the bottle of multivitamins on Resident #73's bedside table should have been appropriately secured and stored in the facility's medication cart. The DON stated the risk of unsecured medications (including multivitamins) included the potential for drug interactions. Record review of the facility's Medication Storage in the Facility policy, dated 03/25, reflected, .Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents (Residents #79 and #2) reviewed for infection control. 1. RN B failed to complete hand hygiene while providing wound care and incontinent care to Resident #79. 2. CNA C failed to complete hand hygiene while providing incontinent care to Resident #2. This failure could place residents at risk for infections and cross contamination. Findings included: Review of Resident #79's face sheet dated 06/26/25 revealed he was a [AGE] year-old male, he was originally admitted on [DATE]. Admitting diagnoses included hypertensive heart disease with heart failure, Type 2 diabetes, muscle weakness, dementia, and abnormalities of gait and mobility. Review of Resident #79's care plan initiated on 04/11/25 reflected, the resident had bowel incontinence. Goal, will not have complications r/t, bowel incontinence. Intervention, check resident every two hours and assist with toileting as needed. The resident had bladder incontinence. Goal, will remain free from skin breakdown due to incontinence and brief use. Intervention, check resident at least every two hours and assist with toileting as needed. Review of Resident # 79's quarterly MDS assessment dated [DATE] reflected he had a BIMS score of 15, indicating no cognitive impairment, he was dependent on staff for toileting, and he was always incontinent of bowel and bladder. Review of Resident #2's face sheet dated 06/26/25 revealed he was a [AGE] year-old male, and he was admitted on [DATE]. Admitting diagnoses included hypertension, muscle weakness, dementia and need for assistance for personal care. Review of Resident #2's care plan initiated 07/14/25 reflected, the resident had a selfcare deficit with activities of daily living. Goal, the resident was to maintain or improve the level of function, and the interventions revealed the resident required total assistance with toileting. Review of Resident #2's significant of change MDS dated [DATE] reflected, the resident had a BIMS score of 00, indicating severe cognitive impairment. He required maximum assistance with toileting, and he was always incontinent of bowel and bladder. Observation on 08/24/25 at 02:20 pm with RN B revealed the resident was in bed and he was placed on enhanced barrier precaution due to the wounds. RN B explained and positioned Resident #79 for wound care, but the resident indicated he needed to be provided incontinent care. Then RN B gathered the supplies to provide incontinent care. RN B cleaned the resident, the resident was soiled with urine and feces. After cleaning the resident, the staff used the same gloves to apply the clean brief on the resident. After completing the incontinent care, the staff completed hand hygiene and provided the resident with wound care. The resident had a wound to the sacrum area (Posterior part of the pelvis, below the lumbar vertebrae and above the coccyx). The staff cleaned the wound, and after cleaning the wound the staff did not complete any form of hand hygiene or change gloves. She applied the clean dressing on the resident and labeled and dated it. In an interview on 08/24/25 at 02:43 pm with RN B regarding infection control, she stated she was supposed to change gloves and clean hands after cleaning the resident during incontinent care before applying the clean brief, and she was also supposed to clean hands and change gloves after cleaning the resident's wound before applying the clean dressing, but she forgot. RN B stated she was supposed to complete hand hygiene and change gloves to prevent cross contamination. Observation on 08/25/2025 at 01:25 pm revealed CNA C providing incontinent care to Resident #2. CNA C was observed entering the room and gloved. CNA D was in the process of providing care to the resident, when CNA C stated she wanted to provide care to the resident. CNA C proceeded to clean the resident; the resident was soiled with bowel and urine. After cleaning the resident CNA C applied the clean brief without any form of hand hygiene. In an interview on 08/25/25 at 01:48 pm with CNA C she stated she was aware she was supposed to complete hand hygiene after cleaning the resident, but she did not have hand sanitizer. She stated regardless of changing the gloves she was supposed to complete hand hygiene for infection control, to prevent cross contamination. In an interview on 08/26/25 at 12:30 pm with ADON E he stated he was the infection preventionist. He stated he expected the staff to maintain infection control during care. He stated the staff were to complete hand hygiene after providing care to the resident before applying the clean brief and clean dressing. He stated he had in-serviced staff on infection control last week, but did not give a specific date. Review of the facility policy revised 01/08/23 and titled Infection Control Plan: Overview, reflected, Infection Control The facility will 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 disease and infection. The facility will require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. INTENT The intent of this policy is to assure that the facility develops, implements, and maintains an Infection Prevention and Control Program in order to prevent, recognize, and control, to the extent possible, the onset and spread of infection within the facility. Implement hand hygiene (hand washing) practices consistent with accepted standards of practice, to reduce the spread of infections and prevent cross-contamination.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 (Resident #73) of 6 residents reviewed for accidents and hazards. The facility failed to ensure Resident #73 did not have access to disposable razors. This failure could place residents at risk of injury or harm, as well as contribute to avoidable accidents.Findings included: Record review of Resident #73's Face Sheet, dated 08/26/25, reflected he was an [AGE] year-old male, who was admitted to the facility on [DATE], with diagnoses including dementia (a group of symptoms affecting memory, thinking and social abilities), abnormalities of gait and mobility (deviations from a normal walking pattern, impacting how a person moves and their ability to maintain balance and coordination), and need for assistance with personal care (when a person requires help with daily activities like bathing, dressing, or toileting due to a chronic health issue, physical disability, or aging). Record review of Resident #73's MDS Assessment, dated 06/25/25, reflected he had a BIMS score of 15, indicating he was cognitively intact. Resident #73 was identified as requiring partial/moderate assistance for personal hygiene (such as shaving). Review of Resident #73's Care Plan, dated 07/14/25, reflected no identified focus areas, goals, or interventions related to shaving. Observation of Resident #73 on 08/24/25 at 10:53AM revealed he was ambulating in his room. He was clean, well-groomed, and appropriately dressed. He was free from any odors. There were no concerning marks or bruises noted on his person. He displayed no apparent signs or symptoms of distress. Observation revealed there were two disposable razors placed in an open drawer of Resident #33's bedside table. During an interview with Resident #73 on 08/24/25 at 10:55AM, he reported he used the disposable razors located in the drawer of his bedside table to shave his face as needed, but facility staff assisted him with all other ADL's. During an interview with the DON on 08/24/25 at 11:00AM, he stated Resident #73 should not have had access to razors. He stated facility staff should supervise and assist residents with ADL's, such as shaving. The DON stated the risk of residents having access to razors included the potential for injury. A request was made to the Administrator for the facility's policy related to accident hazards (including not allowing residents to have access to potentially dangerous items, such as razors) on 08/25/25 at 3:18PM but was not provided prior to exit.

Based on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported no later than 2 hours if the events that caused the allegation did involve abuse or serious bodily injury to HHS, for 1 of 1 resident (Resident #1) reviewed for abuse, neglect, exploitation, or mistreatment. The facility failed to report to HHS within two hours, when a staff member reported CNA A spoke rudely and pushed Resident #1 down the memory care hallway on 07/05/25. This failure could place residents at risk of abuse or mistreatment. Findings included: Record review of Resident #1's face sheet, dated 07/18/25, reflected a [AGE] year-old female, with an initial admit date of 03/28/25, and a readmit date of 05/16/25. Resident #1 had diagnoses of Frontotemporal Neurocognitive Disorder (brain disease that leads to significant changes in behavior, language abilities, and personality), Dementia (Decline in memory, thinking, and social abilities), Muscle Weakness, Bipolar Disorder (Extreme Mood Swings), Depression (disorder causing feelings of sadness, anger, or loss), Manic Disorder (causes periods of extreme changes in mood or emotions and energy level), Impulse Disorder (Inability to resist strong urges), and Cognitive Communication Deficit (Communication difficulty). Record review of Resident #1's Quarterly MDS Assessment, dated 05/01/25, reflected Resident #1 had a BIMS score of 03, which indicated Resident #1 was severely impaired. In an interview on 07/18/25 at 11:45 AM, the Administrator stated he was informed by a Charge Nurse who worked in memory care, that CNA A allegedly abused a resident on 07/05/25. He stated he was told that CNA A spoke rudely to the resident. He stated he suspended CNA A, who allegedly abused Resident #1, and he stated he started an investigation. The Administrator stated he did not find any evidence of abuse. He stated Resident #1 was assessed and did not have any bruises, marks, or injuries, and he stated Resident #1 did not have an outcry of abuse. The Administrator stated he did not report the allegation to HHS, because it was not an abuse issue but a customer service issue. The Administrator stated CNA A was in-serviced on customer service. The Administrator stated he felt there was no risk of not reporting the allegations, because it was a customer service issue. In a telephone interview on 07/18/25 at 1:23 PM, CNA A stated she worked the 2:00 PM to 10:00 PM shift on 07/05/25. She stated she could hear someone beat on the door while she sat at the nurse's station. CNA A stated she had worked for years at the facility and was very familiar with Resident #1, so when she saw it was Resident #1 who made the noise, she went to calm her. She stated the staff knew to take Resident #1 to the back of memory care, to the sunroom area, where she was not around other residents, and had the opportunity to calm down. CNA A stated Resident #1 stated she wanted a snack and to use the bathroom. CNA stated Resident #1 was calm after she received a snack and had a trip to the bathroom. CNA A stated she never yelled, grabbed, pushed, pulled, or harmed Resident #1. CNA A stated she walked arm in arm with Resident #1 like she did often. CNA A stated she was trained on how to redirect residents in memory care, as well as on abuse and neglect. She stated three types of abuse were verbal, physical, and sexual. She stated she had never abused a resident, never witnessed any abuse at the facility, and would tell the abuse coordinator if she witnessed any type of abuse. In a telephone interview on 07/18/25 at 1:35 PM, the CNA Trainee stated she and the Charge Nurse went to the vending machine, and when they returned CNA B told them she did not like how that girl treated Resident #1. The CNA Trainee stated CNA B told them CNA A was very stern with Resident #1. The CNA Trainee stated CNA B told them CNA A forced Resident #1 down the hallway toward the sunroom. The CNA Trainee stated Resident #1 would yell loudly at times and had psychiatric issues. The CNA Trainee stated Resident #1 had to be redirected often. The CNA Trainee stated she did not witness the incident. She stated it happened while she and the Charge Nurse left to go to the vending machine. In a telephone interview on 07/18/25 at 1:45 PM, the Charge Nurse stated she was not in memory care to witness the incident. She stated was gone to the vending machine with the CNA Trainee. The Charge Nurse stated when they returned to the memory care unit CNA B told them she did not like how CNA A talked to Resident #1. The Charge Nurse stated at the time of the complaint, CNA A was in the bathroom with Resident #1. The Charge Nurse stated once they were finished, she asked CNA A to leave for the day. She stated CNA A was suspended, but she was not sure how long it was before she returned to work. She stated CNA B called and told the Administrator about the incident. In an interview on 07/18/25 at 5:18 PM, Resident #1 stated she could not think of any staff who were rude to her, and she stated she felt safe in the facility. Resident #1 stated she could not remember any staff member by name. She stated she could not remember any incidents were someone pulled her by the arm. In an interview on 07/18/25 at 6:18 PM, the DON stated she became aware of the abuse allegations the same day it happened on 07/05/25. She stated the staff had already notified the Administrator of the allegations. She stated CNA A was suspended, and the Administrator did an investigation. She stated she was not aware he did not report the abuse allegations to HHS. The DON stated she felt there was not a risk of the Administrator not contacting HHS, because he did his own investigation and found it to be a customer service concern and not abuse. Record review of the facility's policy, dated 03/29/18, titled, Abuse/Neglect, reflected the following: A. Reporting1. 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 services. State law mandates that citizens report all suspected cases of abuse, neglect or financial exploitation of the elderly and incapacitated persons.2. When a suspected abused. neglected. exploited. mistreated or potential victim of misappropriation of property comes to the attention of any employee, that employee will make an immediate verbal report to the Abuse Preventionist or designee. If the discovery occurs outside of normal business hours., the Abuse Preventionist and/or designee will be called.3. Facility employees must report all allegations of abuse. neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC all incidents that meet the criteria of Provider Letter 19-17 dated 7/10/19.a. if the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegationb. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation.

Based on observation, interview, and record review the facility failed to ensure a safe, clean, comfortable, and homelike environment for one (Resident #1) of six residents reviewed for decent living environment. 1. The facility failed to ensure Resident #1 had access to her bathroom. This failure could place residents at risk for diminished quality of life due to a lake of a well-kept environment. Findings included: Record review of Resident #1's face sheet, dated 07/18/25, reflected a [AGE] year-old female, with an initial admit date of 03/28/25, and a readmit date of 05/16/25. Resident #1 had diagnoses of Frontotemporal Neurocognitive Disorder (brain disease that leads to significant changes in behavior, language abilities, and personality), Dementia (Decline in memory, thinking, and social abilities), Muscle Weakness, Bipolar Disorder (Extreme Mood Swings), Depression (disorder causing feelings of sadness, anger, or loss), Manic Disorder (causes periods of extreme changes in mood or emotions and energy level), Impulse Disorder (Inability to resist strong urges), and Cognitive Communication Deficit (Communication difficulty). Record review of Resident #1's Quarterly MDS Assessment, dated 05/01/25, reflected Resident #1 had a BIMS score of 03, which indicated Resident #1 was severely impaired. In an observation and interview on 07/18/25 at 5:18 PM, Resident #1's bathroom in her room was locked. The Maintenance Director stated the bathroom was locked, because Resident #1 put all items down the toilet like clothes and briefs. He stated her toilet caused other toilets in memory care to back up in the memory care unit. In an interview on 07/18/25 at 6:50 PM, the DON stated Resident #1's bathroom was locked, because she had a behavior of throwing things down the toilet. She stated the door was locked to prevent flooding in the memory care unit. The DON stated the staff took her to the community restroom in the memory care unit if Resident #1 needed to use the bathroom. The DON stated the memory care unit community bathroom was locked, but the staff were able to unlock the community bathroom door. The DON stated she felt there was no risk since it was for Resident #1's safety and it prevented plumbing issues. In an interview on 07/18/25 at 8:10 PM, the Corporate Nurse stated the Administrator was suspended and no longer in the building. He stated Resident #1's bathroom was unlocked and would be cleaned for use. He stated he did know about the risks, but stated Resident #1 should have had access to an unlocked bathroom. Record review of the facility's undated policy, titled, Resident Rights, reflected the following: Resident Rights A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. The resident representative has the right to exercise the resident's rights to the extent those rights are delegated to the resident representative. Safe environment - The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide-- A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.

Based on observation, interview and record review, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized for three (Residents #2 , #3 and #7) of seven residents reviewed for resident records. 1. The facility failed to document if wound care was provided for Resident #2 in June 2025 on four occasions: 06/10/25, 06/14/25, 06/16/25 and 06/17/25. 2. The facility failed to document if wound care was provided for Resident #3 in June 2025 on three occasions: 06/10/25, 06/15/25 and 06/16/25. 3. The facility failed to document if wound care was provided for Resident #7 in May 2025 on four occasions: 05/05/25, 05/07/25, 05/21/25 and 05/26/25. These failures could place residents at risk of not receiving wound care, wounds worsening and a lack of oversight of their clinical records by the nursing staff and nursing management. Findings included: 1. Record review of Resident #2's Face Sheet dated 06/18/25 reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #2's active diagnoses included dementia (a decline in mental ability severe enough to interfere with daily life and can impact memory, thinking, language, judgment, and behavior), gangrene (a serious condition where body tissue dies due to a lack of blood supply or severe bacterial infection), non-pressure chronic ulcer of right foot (a persistent or recurring open sore on the foot that fails to heal within a typical timeframe), type 2 diabetes (a chronic disease where the body doesn't produce enough insulin or can't properly use the insulin it produces, leading to high blood sugar levels), malnutrition (a condition that arises from an imbalance or deficiency of essential nutrients in the body, leading to health problems) and rheumatoid arthritis (a chronic autoimmune disease that primarily affects the joints, causing inflammation, pain, and stiffness). Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected a BIMS score of 15, which indicated no cognitive impairment. Resident #2 had no signs or symptoms of delirium, no negative mood issues, no verbal or physical behaviors and no rejection of care issues. He had no range of motion impairments, was ambulatory and did not use any mobility devices. Resident #2 required substantial/maximum assistance for bed mobility, was frequently incontinent of urine and always incontinent of bowel. Resident #2 weighed 162 pounds and was at risk of developing pressure ulcers/injuries. He had one stage four pressure ulcer that was present upon admission. Resident #2 required a pressure reducing device for his bed, pressure ulcer/injury care and application of non-surgical dressings. Resident #2 also received hospice care during the assessment period and had a condition or chronic disease that could result in a life expectancy of less than 6 months. Record review of Resident #2's care plan dated 04/11/25 reflected, Focus: [Resident #2] has a pressure ulcer or potential for pressure ulcer development; Intervention: Ensure heels are floated with the use of pillows, Incontinent care after each episode and apply moisture barrier, Use lifting device, draw sheet, etc. to reduce friction, Requires a cushion to their wheel or Geri chair and needs assistance to turn/reposition at least every 2 hours. The care plan did not indicate what type of pressure ulcer or treatment orders he had. Record review of Resident #2's last wound care NP's visit dated 06/13/25 reflected he had a Stage 4 coccyx (commonly known as the tailbone, is the small bone located at the very bottom of the spine) wound with a measurement of 13.10 cm x 1.2 cm with a surface area of 144.10 cm, was undermining (a wound where the skin edges separate from the surrounding tissue, creating a pocket or cavity beneath the surface ) from 6 o'clock to 5 o'clock- 2.4 cm and tunneling (a type of wound where a narrow channel or passageway extends from the surface of the wound into deeper layers of tissue) at 12 o'clock- 2.4 cm . There was 0% epithelial (forms the protective outer layer of the skin), 50% granulation (a normal part of the wound healing process, appearing as a bumpy, pink or red, moist tissue that fills in the wound bed), 50% slough (which is a layer of dead tissue that can accumulate on the wound surface), 0% eschar (a collection of dead tissue, often black, brown, or tan, that forms on the surface of a wound) with bone exposed, intact wound edges, and the wound was intact and fragile. There was moderate exudate (the fluid produced by a wound as part of the natural healing process) that was serosanguineous (a wound that is draining a fluid that contains both blood serum [a clear, yellowish fluid] and blood). The wound NP noted the pressure ulcer was not acquired in-house and was stable and had not worsened. The wound order included daily and PRN dressing change with a wound cleanser with moistened fluffed gauze and ABD, with bordered foam. Additionally, Resident #2 also had a wound on his right fifth toe, right fourth toe, right third toe and right second toe that were all noted by the wound care NP to be stable and required a wound care betadine cleanser and were to be left open to air. Record review of Resident #2's Physician's Order Summary reflected the following orders related to wound care: Sacrum: Cleanse with wound cleaner [name] moistened fluffed gauze, and cover with ABD and bordered foam every day and as needed for wound management (start date 06/07/25). Record review of Resident #2's June 2025 TAR/WAR (treatment/wound administration record) reflected no documented treatment to his sacral wound on four occasions: 06/10/25, 06/14/25, 06/16/25 and 06/17/25. Record review of Resident #2's nursing progress notes for June 2025 reflected no additional wound treatment documented outside of what was already documented on the TAR. There was no documentation to indicate why the wound care was not performed on the numerous dates. 2. Record review of Resident #3's MDS quarterly assessment dated [DATE] reflected he was a [AGE] year-old male who admitted to the facility on [DATE] and re-admitted [DATE] from an acute hospital stay. Resident #3's active diagnoses included diabetes, aphasia, stroke, anoxic brain damage and dysphagia. Resident #3 had long and short-term memory problems with severely impaired cognitive skills for decision making. Resident #3 had no verbal or physical behaviors or rejection of care issues. He had range of motion impairment on one side of his upper and lower extremities and used a wheelchair for mobility. Resident #3 required substantial/maximum assistance for all ADLs as well as locomotion and bed mobility and was always incontinent of bowel and bladder. Resident #3 weighed 143 pounds at the time of the assessment and was noted not to be at risk for pressure ulcers and had no pressure ulcers. For Skin and Ulcer/Injury Treatments section of the MDS, it reflected, Pressure reducing device for bed. Record review of Resident #2's care plan dated 02/14/24 and last updated for wounds on 06/03/24 reflected, [Resident #3] has potential for pressure ulcer development; Interventions: .Do not massage over bony prominences and use mild cleansers for pericare/washing, Ensure heels are floated with the use of pillows, Follow facility policies/protocols for the prevention/treatment of skin breakdown; The resident needs assistance to turn/reposition at least every 2 hours., The resident requires a cushion to their wheel or gerichair, The resident requires the bed as flat as possible to reduce shear, Use lifting device, draw sheet, etc. to reduce friction. The care plan did not reflect a low air loss mattress as an intervention. Record review of Resident #3's physician order summary reflected, Sacrum: Cleanse with wound cleanser, apply collagen and cover with hydrocolloid every day shift every Mon, Wed, Fri and as needed for wound management (start date 06/18/25). Record review of Resident #3's June 2025 TAR/WAR (treatment/wound administration record) reflected the following treatment was order from 06/01/25 through 06/16/25, Sacrum: Cleanse with wound cleanser and apply triad cream every day shift for wound management (discontinue date 06/16/25). The record did not indicate the nurse signed off for wound care treatment on 06/10/25, 06/15/25 and 06/16/25. An observation of Resident #3 on 06/18/25 at 10:08 AM revealed he was in bed with no low air loss mattress in place. Resident #3 was not interviewable and had a triangular wedge under his legs, a contracted right hand and multiple pillow (approximately 3-4) around his body. His wound dressing with observed to be in place on his sacrum, covered and initiated/dated by the WC LVN C on 06/16/25. 3. Record review of Resident #7's Face Sheet dated 06/18/25 reflected he was a [AGE] year-old male who admitted to the facility on [DATE] and re-admitted [DATE] after an acute hospital stay. Resident # 7's active diagnoses included cellulitis, local infection of the skin and subcutaneous tissue, non-pressure chronic ulcer of lower leg, secondary gout, pain, localized edema and lymphedema. Record review of Resident #7's quarterly MDS assessment dated [DATE] reflected a BIMS score of 15 which indicated no cognitive impairment. Resident #7 had no rejection of care issues, had range of motion impairment on both sides of his lower extremities and used a wheelchair for mobility. Resident #7 was at risk of developing pressure ulcers/injuries and had six venous and arterial ulcers present at the time of the assessment. He required a pressure reducing device for the bed, application of nonsurgical dressings and applications of ointments/medications. Record review of Resident #7's care plan initiated 12/15/23 and last revised 06/09/25 reflected, Focus: [Resident #7] has a pressure ulcer or potential for pressure ulcer development; Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. The care plan also indicated Resident #7 had a behavior problem of picking at his skin and refusing wound care. The care plan did not address the numerous venous/arterial ulcers Resident #3 had. Record review of Resident #7's Order Summary reflected: -Left Medial Leg: Wash with hibiclens rinse, and pat dry thoroughly. Apply collagen, xeroform, then apply A&D ointment to areas of dryness secure with rolled gauze and ace wrap every day shift every Mon, Wed, Fri for wound management (discontinued 05/19/25) -Left Posterior Leg: Wash with hibiclens rinse,and pat dry thoroughly. Apply collagen, xeroform, then apply A&D ointment to areas of dryness secure with rolled gauze and ace wrap every day shift every Mon, Wed, Fri for wound management (discontinued 06/06/25) -Left second toe: Cleanse with wound cleaner apply betadine secure with dry dressing every day shift every Mon, Wed, Fri for wound management (discontinued 06/06/25) -Left Superior Lateral leg:Wash with hibiclens rinse,and pat dry thoroughly. Apply collagen, xeroform, then apply A&D ointment to areas of dryness secure with rolled gauze and ace wrap. every day shift every Mon, Wed, Fri for wound management (discontinued 06/06/25) -Right Dorsal Leg: Wash with Hibiclens, rinse and pat dry thoroughly. Apply collagen, xeroform. And apply A&D ointment to areas of dryness, secure with rolled gauze and ace wrap. every day shift every Mon, Wed, Fri for wound management (discontinued 06/06/25) -Right Medial Leg: Wash with hibiclens rinse, and pat dry thoroughly. Apply collagen, xeroform, then apply A&D ointment to areas of dryness secure with rolled gauze and ace wrap every day shift every Mon, Wed, Fri for wound management (discontinued 06/06/25). Record review of Resident #7's WAR/TAR for May 2025 did not indicate the nurse signed off for wound care treatment on 05/05/25, 05/07/25, 05/21/25 and 05/26/25. Record review of Resident #7's nursing progress notes for May 2025 reflected no additional wound treatment documented outside of what was already documented on the TAR. There was no documentation to indicate why the wound care was not performed on the numerous dates. An interview was attempted and unsuccessful with Resident #7 while in the hospital on [DATE] at 1:08 PM and rang busy. 4. An interview with ADON B on 06/19/25 at 10:45 AM revealed after treatment was done for a wound, there was a WAR (wound administration record) to complete and the nurse should not forget to document the treatment was provided because the e-charting system for that treatment administration will stay red on the screen until resolved. ADON B stated nursing management could see who was missing medications and treatment administrations and if that happened, the nursing management would go and talk to the nurse in question. She stated, in order for the red administration notification to go away in the e-charting system, the nurse would have to document and put a progress note in the resident's chart to state why the treatment was not completed. An interview with WC LVN C on 06/19/25 at 11:15 AM revealed she was responsible for documenting on the WAR when she changed a resident's wound dressing. She stated when there were blanks on the WAR, it could be because she was not at the facility working and the charge nurses were responsible for completing the wound care and WARs. An interview with LVN F on 06/19/25 at 12:58 PM revealed she only did wound care if the wound care nurse was not present at the facility. She stated wound care treatment was documented on the WAR and if the wound care nurse or charge nurse did not click and enter that it was done, the treatment administration time would remain showing red on the e-chart and it meant you probably didn't do it or forgot to click it off. An interview with the C-RN on 06/19/25 at 1:49 PM revealed the facility management had completed a one-on-one in-service with WC LVN C and ensured that she did do the wound care but did not check it off as completed on the WAR. He stated they did a one-on-one training to ensure she understood the point of doing treatment was to ensure the treatment was documented and if not clicked off at the point of care, then you get to the end of the day, you may forget. 5. Review of the facility's policy titled, Skin Integrity Management revised 10/05/2016, reflected, General Guidelines: 1. If wound is noted, perform an assessment and initiate a treatment plan as soon as possible. Document in resident's chart, area of change, who you notified and treatment applied; .3. Wound care should be performed as ordered by the physician.

Based on interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for two (Resident #2 and Resident #5) of seven residents reviewed for medications and pharmacy services. 1. The facility failed to administer Resident #2's blood pressure medication Carvedilol in accordance with physician orders, by not obtaining his blood pressure prior to administering the medication on nine occasions from 06/03/25 through 06/18/25. 2. The facility failed to administer Resident #5's blood pressure medication Midodrine in accordance with physician orders, by not obtaining his blood pressure prior to administering the medication on four occasions from 06/07/25 through 06/10/25. These failures could place residents at risk for not receiving therapeutic dosages of their medications as ordered by the physician and a potential for decreased health status, including low blood pressure which could cause fainting or dizziness because the brain was not receiving enough blood. Findings included: 1. Record review of Resident #2's Face Sheet dated 06/18/25 reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #2's active diagnoses included dementia (a decline in mental ability severe enough to interfere with daily life and can impact memory, thinking, language, judgment, and behavior), hypertensive heart disease (heart conditions that develop as a result of long-term high blood pressure), diabetes (a chronic disease where the body doesn't produce enough insulin or can't properly use the insulin it produces, leading to high blood sugar levels), malnutrition (a condition that arises from an imbalance or deficiency of essential nutrients in the body, leading to health problems) and rheumatoid arthritis (a chronic autoimmune disease that primarily affects the joints, causing inflammation, pain, and stiffness) and atherosclerosis of native arteries of extremities of the right leg (the buildup of plaque in the arteries of the limbs, which can restrict blood flow to the legs and feet) and atrial fibrillation (a common heart condition where the heart's upper chambers (atria) beat irregularly and sometimes rapidly). Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected a BIMS score of 15, which indicated no cognitive impairment. Resident #2 had no signs or symptoms of delirium, no negative mood issues, no verbal or physical behaviors and no rejection of care issues. He had no range of motion impairments, was ambulatory and did not use any mobility devices. Resident #2 required substantial/maximum assistance for bed mobility, was frequently incontinent of urine and always incontinent of bowel. Resident #2 received hospice care during the assessment period and had a condition or chronic disease that could result in a life expectancy of less than 6 months. Record review of Resident #2's care plan dated 04/08/25 and last revised on 05/28/25 reflected no discussion of his blood pressure medication and related health condition. Record review of Resident #2's Order Summary Report reflected he was prescribed Carvedilol Oral Tablet 3.125 MG twice a day for high blood pressure related to hypertensive heart disease with heart failure, Hold for BP <110/60, P 60 (start date 04/08/25). Record review of Resident #2's June 2025 MAR did not reflect all blood pressure recordings twice a day prior to the administration of his Carvedilol on 06/03/25 (PM shift), 06/05/25 (AM and PM shift), 06/09/25 (AM and PM shift), 06/10/25 (PM shift), 06/13/25 (PM shift), 06/16/25 (AM shift) and 06/18/25 (AM shift). Record review of Resident #2's nursing progress notes and vitals recordings in the e-chart did not reflect all additional blood pressure readings for June 2025 when there was none documented on the MAR. 2. Record review of Resident #5's Face Sheet dated 06/18/25 reflected he was a [AGE] year-old male who admitted to the facility on [DATE] and re-admitted on [DATE] after an acute hospital stay. Resident #5 had active diagnoses which included Parkinson's disease, diabetes, long term use of anticoagulants, dysphagia (difficulty swallowing), hyperlipidemia (a condition where there are abnormally high levels of lipids (fats) in the blood, including cholesterol and triglycerides) and seizures. Record review of Resident #5's annual MDS assessment dated [DATE] reflected his BIMS score was 12, which indicated moderate cognitive impairment. Resident #5 had no signs or symptoms of delirium, no negative mood problems, no behaviors and no rejection of care issues. He had range of motion issues on one side in his upper and lower extremities and was independently ambulatory. Record review of Resident #5's care plan initiated 05/27/22 and last revised on 12/27/24 reflected no discussion of his blood pressure medication and related health condition. Record review of Resident #5's Order Summary Report reflected he was prescribed Midodrine Oral Tablet 10 MG three times a day via the peg-tube for low blood pressure, hold if systolic BP greater than 120 (discontinued 06/12/25). Record review of Resident #5's June 2025 MAR did not reflect all blood pressure recordings three times a day prior to the administration of his Midodrine on 06/07/25 (PM and HS shift), 06/08/25 (HS shift), 06/10/25 (AM shift). Record review of Resident #5's nursing progress notes and vitals recordings in the e-chart did not reflect any additional blood pressure readings for June 2025 when there was none documented on the MAR. 3. An interview with ADON A on 06/18/25 at 3:16 PM revealed when a resident was prescribed Midodrine or Carvedilol, the charge nurse or med aide should document what the blood pressure was prior to administration. If the resident's blood pressure fell outside of the parameters noted on the order, then the med aide should report it to the nurse. ADON A stated Midodrine was given to residents who had low blood pressure to help elevate it. ADON A stated, If a doctor says hold if the blood pressure is this, and the patient has a blood pressure of 130 or 140 and you give the medication, it will shoot it up, that is why we hold. We check the vital and recheck because sometimes a resident might be upset or angry or annoyed when we go in and their blood pressure it up, we give then an hour and recheck. An interview with ADON B on 06/19/25 at 10:45 AM revealed it was important to document a resident's blood pressure prior to administering blood pressure medications, Because their blood pressure could be too low or too high and you could exacerbate the issue. We got to make sure of the vitals with blood pressure medications. They need to be writing it down. ADON B thought that the e-charting system would not let the med aide or nurse proceed in their administration documentation unless a blood pressure was entered. An interview with LVN F on 06/19/25 at 12:58 PM revealed it was important to take a resident's vitals prior to administering a blood pressure medication because it the parameters were not met, the medication had to be held. LVN F stated, For me, the medication aides check their own blood pressures but we let them know if there is something off, like 90/50, we do it [charge nurse] and follow up. LVN F stated the charge nurses were responsible for checking blood pressures daily on every resident along with the medication aides, A beds were done in the mornings and B beds were done in the afternoon/evening. LVN F stated, What happens when we put the orders in, if you don't pay attention to what the doctor is saying, there is a place on the MAR and if you don't put 'Add', it won't ask for any parameters. She stated the error could be that the person entering the order was not clicking on the parameters section when entering the order. 4. Review of the facility's policy titled, Medication Administration Procedures, revised 10/25/2017, reflected, .13. When ordered or indicated, include specific item(s) to monitor (e.g., blood pressure, pulse, blood sugar, weight), frequency (e.g., weekly, daily), timing (e.g., before or after administering the medication), and parameters for notifying the prescriber.

Based on observations, interviews and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for three (Resident #1, Resident #2 and Resident #4) of seven residents reviewed for treatment/services for pressure ulcers. 1. The facility failed to ensure Resident #2, who had a pressure ulcer on his coccyx, had a low air loss mattress pump with the correct settings for appropriate pressure redistribution on 06/18/25. 2. The facility failed to ensure Resident #3 and Resident #4 had a functioning low air loss mattress available to use to promote healing of their sacral wounds on 06/18/25. 3. The facility failed to ensure Resident #3 wound dressing was changed daily as per orders. These failures placed residents at risk of developing new or worsening pressure ulcers. Findings included: 1. Record review of Resident #2's Face Sheet dated 06/18/25 reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #2's active diagnoses included dementia (a decline in mental ability severe enough to interfere with daily life and can impact memory, thinking, language, judgment, and behavior), gangrene (a serious condition where body tissue dies due to a lack of blood supply or severe bacterial infection), non-pressure chronic ulcer of right foot (a persistent or recurring open sore on the foot that fails to heal within a typical timeframe), type 2 diabetes (a chronic disease where the body doesn't produce enough insulin or can't properly use the insulin it produces, leading to high blood sugar levels), malnutrition (a condition that arises from an imbalance or deficiency of essential nutrients in the body, leading to health problems) and rheumatoid arthritis (a chronic autoimmune disease that primarily affects the joints, causing inflammation, pain, and stiffness). Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected a BIMS score of 15, which indicated no cognitive impairment. Resident #2 had no signs or symptoms of delirium, no negative mood issues, no verbal or physical behaviors and no rejection of care issues. He had no range of motion impairments, was ambulatory and did not use any mobility devices. Resident #2 required substantial/maximum assistance for bed mobility, was frequently incontinent of urine and always incontinent of bowel. Resident #2 weighed 162 pounds and was at risk of developing pressure ulcers/injuries. He had one stage four pressure ulcer that was present upon admission. Resident #2 required a pressure reducing device for his bed, pressure ulcer/injury care and application of non-surgical dressings. Resident #2 also received hospice care during the assessment period and had a condition or chronic disease that could result in a life expectancy of less than 6 months. Record review of Resident #2's care plan dated 04/11/25 reflected, Focus: [Resident #2] has a pressure ulcer or potential for pressure ulcer development; Intervention: Ensure heels are floated with the use of pillows, Incontinent care after each episode and apply moisture barrier, Use lifting device, draw sheet, etc. to reduce friction, Requires a cushion to their wheel or Geri chair and needs assistance to turn/reposition at least every 2 hours. The care plan did not indicate what type of pressure ulcer or treatment orders he had. Record review of Resident #2's last wound care NP's visit dated 06/13/25 reflected he had a Stage 4 coccyx (commonly known as the tailbone, is the small bone located at the very bottom of the spine) wound with a measurement of 13.10 cm x 1.2 cm with a surface area of 144.10 cm, was undermining (a wound where the skin edges separate from the surrounding tissue, creating a pocket or cavity beneath the surface) from 6 o'clock to 5 o'clock- 2.4 cm and tunneling (a type of wound where a narrow channel or passageway extends from the surface of the wound into deeper layers of tissue) at 12 o'clock- 2.4 cm . There was 0% epithelial (forms the protective outer layer of the skin), 50% granulation (a normal part of the wound healing process, appearing as a bumpy, pink or red, moist tissue that fills in the wound bed), 50% slough (which is a layer of dead tissue that can accumulate on the wound surface), 0% eschar (a collection of dead tissue, often black, brown, or tan, that forms on the surface of a wound) with bone exposed, intact wound edges, and the wound was intact and fragile. There was moderate exudate (the fluid produced by a wound as part of the natural healing process) that was serosanguineous (a wound that is draining a fluid that contains both blood serum [a clear, yellowish fluid] and blood). The wound NP noted the pressure ulcer was not acquired in-house and was stable and had not worsened. The wound order included daily and PRN dressing change with a wound cleanser with moistened fluffed gauze and ABD, with bordered foam. Additionally, Resident #2 also had a wound on his right fifth toe, right fourth toe, right third toe and right second toe that were all noted by the wound care NP to be stable and required a wound care betadine cleanser and were to be left open to air. The wound care NP's note also reflected a summary of previous visits: - 04.11.25: Pt admitted to facility 04.08.25 under hospice services. Pressure injury to coccyx and wounds of undetermined etiology to right toes 1-5. Pt on air mattress .Continue pressure offloading and incontinence management. -05.28.25: .Pt tolerated debridement of coccyx wound. No s/s of infection noted . Air mattress in place. -06.06.25: Wounds stable. Tolerated debridement of coccyx wound without complications. -06/13/2025: Coccyx pressure injury stage 4 stable. Wound debridement tolerated. Recommend continuing offloading and frequent repositioning while in bed. Record review of Resident #2's Physician's Order Summary reflected the following orders related to wound care: May have pressure relieving mattress every shift (start date 04/08/25); Sacrum: Cleanse with wound cleaner [name] moistened fluffed gauze, and cover with ABD and bordered foam every day and as needed for wound management (start date 06/07/25). Record review of Resident #2's June 2025 TAR/WAR (treatment/wound administration record) reflected an entry for checking his pressure relieving mattress every shift three times a day. Each shift was initialed by various charge nurses from 06/01/25-06/17/25. The nurse who initiated she checked his low air loss mattress on the morning (6AM) on 06/18/25 was charge nurse LVN D. Record review of Resident #2's weights recorded for the past three months reflected he weighed 162.2 pounds on 06/05/25, 160.4 pounds on 05/15/25 and 161.6 pounds on 04/08/25. Observation of Resident #2's low air loss mattress on 06/18/25 at 10:32 AM revealed the unit was set to a weight of 280 pounds and normal pressure. An interview with Resident #2 on 06/18/25 at 10:40 AM revealed he felt the mattress was uncomfortable and lumpy. He stated he weighed somewhere between 160 to 180 pounds, but nowhere near 280. An interview with LVN D on 06/18/25 at 10:41 AM revealed she observed Resident #2's low air loss mattress and said the charge nurses were usually responsible for setting the mattresses at the correct weight. She was not sure how much Resident #2 weighed but surmised he was not 280 pounds and would follow up on it. 2. Record review of Resident #3's MDS quarterly assessment dated [DATE] reflected he was a [AGE] year-old male who admitted to the facility on [DATE] and re-admitted [DATE] from an acute hospital stay. Resident #3's active diagnoses included diabetes (disease where the body either doesn't produce enough insulin or can't properly use the insulin it produces, causing high blood sugar levels), aphasia (a language disorder that affects the ability to communicate), stroke (occurs when blood flow to the brain is interrupted or reduced, depriving brain tissue of oxygen and nutrients), anoxic brain damage (occurs when the brain is deprived of oxygen, leading to cell death and potential neurological damage) and dysphagia (difficulty swallowing). Resident #3 had long and short-term memory problems with severely impaired cognitive skills for decision making. Resident #3 had no verbal or physical behaviors or rejection of care issues. He had range of motion impairment on one side of his upper and lower extremities and used a wheelchair for mobility. Resident #3 required substantial/maximum assistance for all ADLs as well as locomotion and bed mobility and was always incontinent of bowel and bladder. Resident #3 weighed 143 pounds at the time of the assessment and was noted not to be at risk for pressure ulcers and had no pressure ulcers. For Skin and Ulcer/Injury Treatments section of the MDS, it reflected, Pressure reducing device for bed. Record review of Resident #2's care plan dated 02/14/24 and last updated for wounds on 06/03/24 reflected, [Resident #3] has potential for pressure ulcer development; Interventions: .Do not massage over bony prominences and use mild cleansers for pericare/washing, Ensure heels are floated with the use of pillows, Follow facility policies/protocols for the prevention/treatment of skin breakdown; The resident needs assistance to turn/reposition at least every 2 hours., The resident requires a cushion to their wheel or gerichair, The resident requires the bed as flat as possible to reduce shear, Use lifting device, draw sheet, etc. to reduce friction. The care plan did not reflect a low air loss mattress as an intervention. Record review of a Weekly Skin assessment dated [DATE] by the wound care nurse WC LVN C reflected Resident #3 had redness to his sacrum (a triangular bone in the lower back formed from fused vertebrae and situated between the two hipbones of the pelvis) noted under other skin findings present. Record review of the Wound Care NP's visit dated 06/06/25 reflected in a Skin and Wound Care Note that Resident #3 was being seen for a new skin and wound consult. The NP stated, 06.06.25: Pt being seen for new consult of breakdown to sacrum. On exam, fragility noted to sacrum with small superficial openings. No s/s of infection noted. Recommendations as noted in wound plan. Recommend continuing incontinence management and repositioning interventions. The primary etiology (cause) of the wound was noted to be incontinence associated dermatitis (skin inflammation, characterized by symptoms like itchiness, redness, and dryness) that was 4.5 cm x 5 cm x 0.1 cm and a surface area of 22.5 sq cm. The wound base was 100% epithelial , 0% granulation , 0% slough , 0% eschar with exposed dermis (middle layer of skin) tissue, attached wound edges and an intact and fragile periwound (the area of skin immediately surrounding a wound, extending outward from the wound's edge). There was no exudate (a fluid that leaks out of blood vessels into surrounding tissues, often due to inflammation or injury) and no wound pain. Treatment orders reflected, Wound # 3 Sacrum Incontinence Associated Dermatitis (IAD) Treatment Recommendations: 1. Cleanse with wound cleanser; 2. apply [name] paste to base of the wound; 3. secure with Leave open to air; 4. change Daily, and PRN. Preventative measures included, Continue with turning and repositioning schedule per protocol for pressure prevention. Use pillows for positioning to prevent pressure to bony prominences. Patient is at high risk for skin breakdown related to decreased mobility, inability to reposition self, incontinence of urine and stool. Record review of Resident #3's physician order summary reflected, May have pressure relieving mattress every shift (start dated 10/17/24); Sacrum: Cleanse with wound cleanser, apply collagen and cover with hydrocolloid every day shift every Mon, Wed, Fri and as needed for wound management (start date 06/18/25). Record review of Resident #3's June 2025 TAR/WAR (treatment/wound administration record) reflected an entry for checking his pressure relieving mattress every shift three times a day. Each shift was initialed by various charge nurses from 06/01/25-06/17/25. An observation of Resident #3 on 06/18/25 at 10:08 AM revealed he was in bed with no low air loss mattress in place. Resident #3 was not interviewable and had a triangular wedge under his legs, a contracted right hand and multiple pillow (approximately 3-4) around his body. His wound dressing with observed to be in place on his sacrum, covered and initiated/dated by the WC LVN C on 06/16/25. An interview with LVN E on 06/18/25 at 10:08 AM occurred where she was asked about the low air loss mattress not being in place for Resident #3, to which she replied, We don't leave him in bed all day, we like to keep him in his wheelchair until after lunch. LVN E did affirm that Resident #3 had a wound on his sacrum. 3. Record review of Resident #4's Face Sheet dated 06/19/25 reflected she was a [AGE] year-old female who admitted to the facility on [DATE] and had active diagnosis of lupus erythematosus (a chronic autoimmune disease where the body's immune system mistakenly attacks healthy tissues and organs), adult failure to thrive (a decline in physical and cognitive function, accompanied by weight loss, decreased appetite, and reduced activity levels), vascular dementia (a condition where damage to blood vessels in the brain impairs blood flow, leading to cognitive decline), diabetes (a disease where the body either doesn't produce enough insulin or can't properly use the insulin it produces, causing high blood sugar levels), psoriasis (a chronic, immune-mediated skin disease that causes red, scaly patches on the skin) and dysphagia (difficulty swallowing). Record review of Resident #4's quarterly MDS assessment dated [DATE] reflected she had long and short-term memory problems and severely impaired cognitive skills for decision making. Resident #4 did not have any behavioral symptoms or rejection of care issues. Resident #4 was totally dependent on staff for all ADLs, movement and bed mobility. She had no range of motion issues and used a wheelchair for ambulation. Resident #4 was always incontinent of bowel and bladder, weighed 127 pounds and was at risk of developing pressure ulcers/injuries. She did not have any identified wounds, ulcers or skin issues during the look back period but under the Skin and Ulcer/Injury Treatments, the box was checked that she had a pressure reducing device for her bed and applications of ointments and medications to areas other than feet. Resident #4 was also receiving hospice services and had a life expectancy of less than six months. Record review of Resident #4's care plan initiated 12/08/22 and last updated related to wounds on 01/23/24 reflected, Goal: [Resident #4] has a potential for skin breakdown r/t lupus (a chronic autoimmune disease where the body's immune system mistakenly attacks healthy tissue, causing inflammation and damage to various organs) and psoriasis (a chronic, immune-mediated skin condition that causes red, scaly patches on the skin); Interventions: .Provide pressure reducing mattress on bed, Weekly skin assessment to be completed. The care plan did not reflect she had a new skin alteration on her bottom. Record review of Resident #4's physician order summary reflected, Left buttock: Cleanse with wound cleanser pat dry, apply honey and calcium alginate. Cover, secure with border foam dressing. every day shift every Mon, Wed, Fri for wound management Hospice nurse will assess once a week (start date 06/18/25) . Right buttock: Cleanse with wound cleanser pat dry, apply xeroform and cover with border foam dressing every day shift every Mon, Wed, Fri for wound management (written 06/19/25 with a start date of 06/20/25). Resident #4 did not have an order for a pressure reducing mattress. An observation of Resident #4 on 06/18/25 at 10:25 AM revealed she was in bed, was not able to be interviewed as she was no responsive to questions. Resident #4 was observed to not have a low air loss mattress in place. She had a pillow minimally offloading her right butt cheek and another pillow under her thighs. The wound dressing was observed to be intact and on her left butt cheek and was dated 06/18/25 by WC LVN C. An interview with LVN D on 06/18/25 at 10:25 AM revealed Resident #4 had a blister on her bottom that had popped and was currently receiving treatment for it. 4. An interview with ADON A on 06/18/25 at 3:16 PM revealed the purpose of an air loss mattress was for when a resident had compromised skin or to prevent skin breakdown from happening or getting worse, to promote healing and to make the resident feel comfortable. He stated the setting for the pump should go by the weight of the resident according to what the rental company staff for the mattress have told him, But I am not exactly sure, mostly when they [DME rental company] comes, they set it up for us. Then the nurses check it to make sure it is running with that parameter. ADON A stated the charge nurse was supposed to be checking the low air loss mattress and pump settings during a daily routine check. ADON A said in order to prevent pressure ulcers from getting worse, as a unit manager, he assesses residents with wounds and made sure there was a low air loss mattress in place for a new or reopened wound. ADON A stated using pillows versus a low air loss mattress would depend on the physician's order. He stated, Mostly from my experience, I don't know if a pillow is enough for a pressure ulcer, we need a low air loss mattress. I don't know if you can replace that with a pillow. But to prevent a wound, you can reposition, use pillows but once the wound starts forming, we need a low air loss mattress. An interview with ADON B on 06/19/25 at 10:45 AM revealed the purpose of a low air loss mattress was to prevent pressure ulcers or other wounds and the setting should go by the resident's weight. She said the setting should be monitored daily by the ADONs, treatment (wound care) nurse and the DON. An interview with WC LVN C on 06/19/25 at 11:15 AM revealed the purpose of a low air loss mattress was to prevent wounds and the setting should go by the weight of the resident. She did not know who was responsible for setting the pump to the correct setting. WC LVN C stated, I probably should check the setting on the mattress, I should know how it is being effective with the wound, but I don't do it with every wound. An interview with the ADM on 06/19/25 at 11:45 AM revealed after investigator intervention, Residents #3 and #4 were ordered and provided a low air loss mattress. He stated central supply was present during the stand-up meetings and when she was made aware of the need for a low air loss mattress, she ordered it and it would usually come within the same day or within 24-48 hours. He stated hospice delivered Resident #4's and Resident #3's came in on 06/19/25. The ADM stated he was not sure why there was a delay in getting them. An interview with LVN F on 06/19/25 at 12:58 PM revealed the purpose of a low air loss mattress was to help with pressure sores and positioning. LVN F stated she would know if the mattress was not set correctly because an alarm would go off and give an alert on the pump unit. She said when the dial was turned on, It goes to 250 and that is where it should be put, it is the amount of air going into the mattress. LVN F stated the low air loss mattresses were usually for residents who might be at risk for pressure ulcers as well as for those residents who could not reposition themselves in bed. She stated the setting for the pump to ensure accuracy was usually monitored by the charge nurses and CNAs. 5. Review of the facility's policy titled, Skin Integrity Management revised October 16, 2016, reflected, .14. Any individual assessed to be at high risk for developing pressure ulcers should be placed when lying in bed on a pressure-reducing device.

Based on interviews and record review, the facility failed to ensure residents were free from abuse, neglect, misappropriation of resident property, and exploitation for one (Resident #1) of three residents reviewed for abuse. The facility failed to ensure CNA A did not abuse Resident #1 on 03/14/25 by taking a private photo of her. This was determined to be past non-compliance. The noncompliance was identified as PNC. The noncompliance began on 03/14/25 and ended on 03/16/25. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk of being abused by having their photo taken. Findings included: Review of Resident #1's Quarterly MDS Assessment, dated 01/05/25, reflected the resident had a BIMS score of 15 and was cognitively intact. The Resident had diagnoses which included hip fracture and diarrhea. The resident was always incontinent of bowel and bladder. The resident required maximum assistance with toileting. Review of Resident #1's Comprehensive Care Plan, dated 05/16/24, reflected the resident had bowel incontinence. Facility interventions included to check the resident every two hours and assist with toileting as needed. An interview on 03/18/25 at 10:55 am with Resident #1 revealed on 03/14/25, evening shift CNA A entered her room and was cursing. The resident said she turned her light on at 1:30 PM to be changed because she had a blow-out. CNA A entered the room and the resident said CNA A was mad because she had to perform incontinence care for the resident. The resident said CNA A told her that the day shift CNA should have changed Resident #1. The resident said CNA A took a phone out of her pocket, told the resident to turn her face to the side, and took a picture of the resident's private area. The resident said CNA A told her that she was going to send the picture to the DON because day shift should have changed the resident. Resident #1 said it really bothered her that CNA A would take such a private and embarrassing photo of her. Resident #1 said she was crying and called her family member on 03/15/25 about the incident. The resident said the did not tell anyone at the facility about the incident. The police were called on 03/15/25. Resident #1 said the DON came and spoke to her and said the incident was being addressed and CNA A was suspended. Resident #1 said the Administrator spoke to her and made sure the photo was deleted. An interview on 03/18/25 at 1:00 PM with the DON revealed she had been employed at the facility for a month. The DON said on 03/15/25 she received a call that the police were at the facility because CNA A took a photo of Resident #1. The DON said she never received a picture from CNA A and she never saw the photo. The DON said she spoke to the resident and told her the facility was investigating the incident. The DON said CNA A deleted the photo and did not share it with anyone. The DON said she had been monitoring the resident to ensure the resident did not have any on-going issues. An interview on 03/18/25 at 3:00 PM with the Administrator revealed CNA A admitted to him that she took the photo of the resident and deleted it. The Administrator said the facility was still investigating and CNA A was suspended and being terminated pending the investigation findings. An interview was attempted with CNA A on 03/18/25 at 12:20 PM. CNA A did not return the call of the Surveyor. Record reviews of facility in-services for abuse, personal cell phone usage, and HIPPA were completed. Some of the in-services were not dated and some were dated 03/16/25. The facility also completed safe surveys with residents. Interviews with facility staff and residents on 03/18/25 from 9:15 AM to 3:00 PM revealed staff knew not to take pictures of residents and the residents said no one had taken their picture. Review of the facility policy, Abuse, revised 05/09/17, reflected: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation .

Based on interview, and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one (Resident #1) of six residents reviewed for quality of care. The facility failed to assess Resident #1's left knee for pain and swelling on 05/22/23 and 05/28/23. There were multiple opportunities for the staff to assess the resident and provide follow-up care when it was noted by the facility staff and responsible party that Resident #1's leg was swollen, and she was in pain. As a result, she experienced continued pain per facility staff, and suffered fracture(s) of her left knee (acute transverse impacted fracture at proximal and fibular metaphysis which affects the neck of the bone (metaphysis), where the tibia starts to narrow down. Due to Resident #1's injury, she was sent to the hospital. On 06/21/23 at 2:05 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 06/22/23, the facility remained out of compliance at scope of pattern and severity of actual harm. This failure could place residents at the risk of not receiving appropriate medical interventions timely and effectively, which could result in severe illness, hospitalization or even death. Findings included: Review of Resident #1's Annual MDS Assessment, dated 04/21/23, reflected she was a [AGE] year-old who admitted to the facility on [DATE]. Her diagnoses included: hypertension, Alzheimer's Disease, Non-Alzheimer's Dementia, anxiety disorder, depression, and insomnia. Her BIMS score was 6 and indicated severe cognitive impairment. Her functional status reflected she required extensive assistance and one-person physical assistance with bed mobility, locomotion on unit, locomotion off unit, and personal hygiene. She required extensive assistance and two-person physical assistance with transfers, dressing, and toilet use. Her pain management revealed she received scheduled pain medication regimen. Record review of Resident #1's Care Plan, undated, revealed she required assistance with ADLs and was at risk of falls due to dementia, Alzheimer's. Her goal was to attempt/complete ADL tasks with staff assistance and have no injuries due to falls thru the next review. Her interventions were required extensive assist with bed mobility, transfers, toileting, personal hygiene, and bathing. She required limited assist and one-person assist with locomotion, eating, and walking. Notify and update MD and family as needed. Evaluate possible causes of falls and address issues to the extent possible. She had a fracture of the left knee, problems were manifested by impaired mobility. Her goal was to heal the fracture without complications thru next review. Her interventions were to follow up with ortho as indicated. Monitor and medicate for pain as needed. Record review of Resident #1's physician order recap report, dated 05/01/23 - 06/08/23, reflected she was ordered the following medications: Acetaminophen suppository 650 mg (every 4 hours as needed for pain), Acetaminophen suppository 650 mg (every 4 hours as needed for pain not to exceed 3 grams/24 hours), Tylenol extra strength oral tablet 500 mg (1 tablet every 6 hours as needed for pain), and Tylenol oral tablet (500 mg two times a day for pain). Record review of Resident #1's physician orders, dated 06/01/23, reflected x-ray left knee 2 views for continued pain and left knee getting bigger. One time only for pain and swelling to left knee for past two days. Record review of Resident #1's MAR , dated May 2023, reflected Acetaminophen suppository 650 mg (every 4 hours as needed for pain, dated 02/12/23) and Acetaminophen suppository 650 mg (every 4 hours as needed for pain not to exceed 3 grams/24 hours, dated 02/12/23) were not administered from 05/01/23 to 05/31/23. Tylenol extra strength oral tablet 500 mg (1 tablet every 6 hours as needed for pain, dated 05/23/23) was not administered from 05/01/23 to 05/31/23. Tylenol oral tablet (500 mg two times a day for pain, dated 02/13/23) was administered twice a day from 05/01/23 to 05/31/23. Record review of Resident #1's MAR, dated June 2023, reflected Acetaminophen suppository 650 mg (every 4 hours as needed for pain, dated 02/12/23) and Acetaminophen suppository 650 mg (every 4 hours as needed for pain not to exceed 3 grams/24 hours, dated 02/12/23) were not administered from 06/01/23 to 06/02/23. Tylenol extra strength oral tablet 500 mg (1 tablet every 6 hours as needed for pain, dated 05/23/23) was not administered from 06/01/23 to 06/02/23. Tylenol oral tablet (500 mg two times a day for pain, dated 02/13/23) was administered twice a day on 06/01/23. Tylenol oral tablet (500 mg two times a day for pain, dated 02/13/23) was administered once a day on 06/02/23. Record review of Resident #1's pain levels, dated 05/18/23 - 05/23/23, reflected her pain level was 0/10. Her pain level on 05/24/23 - 05/28/23 was 2/10. Her pain level on 05/29/23 was 0/10. Her pain level on 05/30/23 was 2/10. Her pain level on 05/31/23 was 1/10. Her pain level on 06/01/23 was 2/10. Record review of Resident #1's progress notes, dated 05/18/23, revealed she was administered Tylenol oral tablet twice a day for pain and did not have any signs/symptoms of pain (written by LVN A). Record review of Resident #1's nursing notes, dated 05/22/23, reflected Resident #1 complained of left leg pain. Resident #1 refused PRN pain medication. Resident #1 received two-person incontinent care. Resident's RP assisted with turn and incontinent care at the beginning of shift. Resident #1 was assessed and stated ouch when left leg was touched. Will continue to monitor (written by LVN B). Record review of Resident #1's nursing notes revealed there were no nursing notes from 05/23/23 to 05/31/23. Record review of Resident #1's nursing notes, dated 06/01/23, reflected per family request, Resident #1 was to be a two-person assist with all transfers. The information was entered in Resident #1's plan of care for aides on 06/01/23. Resident #1 complained of continued pain to her left knee and family was concerned her left knee was getting bigger. The physician was notified and a new order for Resident #1 was received for left knee x-ray. Per aide Resident #1 did yell like she was in pain during transfer (written by LVN A). Record review of Resident #1's nursing notes, dated 06/01/23, reflected her left knee x-ray results with impression of acute, transverse, impacted fracture at proximal and fibular metaphysis (this fracture affects the neck of the bone (metaphysis), where the tibia starts to narrow down) was sent to the physician. The physician recommended Resident #1 be sent to the ER in the morning of 06/02/23 or night of 06/01/23 as per her RP's request. Resident #1's RP was informed of the x-ray results and physician order to send her to the hospital. Resident #1's RP requested she be sent to the hospital in the morning (written by LVN C). Record review of Resident #1's nursing notes, dated 06/02/23, reflected Resident #1 was transported the hospital the morning of 06/02/23. Resident had x-rays done and results showed an acute transverse impacted fracture at proximal and fibular metaphysis (this fracture affects the neck of the bone (metaphysis), where the tibia starts to narrow down) . Resident #1's RP was with her. Resident #1's morning medications were given. Resident #1's Eliquis (medication) was held, and the physician was notified. Resident #1 was to possibly receive surgery (Written by LVN A). Record review of the facility's provider investigation report, dated 06/02/23, revealed the facility conducted confidential witness statements with staff on 06/02/23. The confidential witness statements reflected the following statements: CNA D stated she noticed swelling on both of Resident #1's legs and was screaming out in pain when being turned to reposition. She stated swelling and screaming out in pain was reported to the nurse; LVN B stated on 05/22/23, a CNA reported Resident #1 complained of pain. LVN B stated she assessed and upon light palpation Resident #1 stated ouch. LVN B stated the resident refused PRN pain medication. LVN B stated she did not notify the physician or complete change of condition assessment. LVN B stated a CNA continued to report pain from time to time. LVN B stated she physically assessed Resident #1 each time and she refused PRN pain medication. LVN B stated she did not note any swelling; CNA E stated Resident #1 yelled out in pain and exhibited signs of grimacing (placed hand on left lower extremity and stated no) during incontinent care (turning/repositioning). During a two-person transfer Resident #1 did not yell out in pain. CNA E stated she noticed swelling to the left lower extremity. She stated she reported pain and swelling to the nurse; LVN C stated Resident #1's RP reported increased pain on 05/31/23. LVN C stated he physically assessed Resident #1 and administered scheduled Acetaminophen. LVN C stated determining Resident #1's level of pain was hard because she always yelled out in pain during any care/repositioning; and LVN A stated pain/swelling had not been reported to her in the past two weeks. LVN A stated Resident #1's RP called her on 06/01/23. The RP stated she had been reporting Resident #1's increased pain and swelling for the past two weeks. The RP also stated she requested two-person assistance with Resident #1. LVN A stated an x-ray was ordered. LVN A stated she initiated an order in Resident #1's electronic plan of care to transfer her by two-person assist. In an interview with the RP on 06/08/23 at 11:10 AM revealed Resident #1's knee was swollen on 06/01/23. She stated she informed the nurse and the physician was notified. She stated the physician ordered an x-ray on 06/01/23. She stated the x-ray results revealed Resident #1's leg was broken in two places; below the left knee and her main bone was fractured. She stated Resident #1 was sent to the hospital on 06/02/23. She stated Resident #1 was discharged from the hospital on 06/07/23 and transferred to another facility. She stated Resident #1 informed her facility staff provided one-person transfers. She stated Resident #1 was forgetful and did not recall when staff provided one-person transfers. She stated Resident #1 would yell out in pain and would not allow her to touch her leg during visits. She stated Resident #1 received pain medication routinely. She stated she frequently visited Resident #1 at the facility. She stated during visits she assisted staff with incontinent care because the facility only used one-person assistance. She stated she frequently informed the facility Resident #1 required two-person assistance and had leg pain. She stated she also informed the facility to leave Resident #1 in bed if two-person assistance could not be provided. She stated Resident #1 would not be returning to the facility due to systemic problems. She stated the facility staff improperly transferred Resident #1 which resulted in injury. She stated the facility staff needed more training and did not know how to complete adequate transfers with Resident #1. In an interview with LVN B on 06/08/23 at 12:21 PM revealed a CNA reported Resident #1 was complaining of left leg pain on 05/22/23. She stated she did not remember which CNA. She stated the RP had assisted the CNA with incontinent care. She stated she assessed Resident #1 and touched her left leg. She stated Resident #1 yelled ouch when her left leg was touched. She stated she offered Resident #1 PRN pain medication and she refused. She stated she did not notify the DON or physician because she did not know if Resident #1's left leg pain was new or ongoing. She stated she continuously monitored Resident #1 throughout her 8-hour shift. She stated at the time of the assessment her response to Resident #1's pain was appropriate. She stated there were no risks to Resident #1 because she closely monitored Resident #1 throughout the shift. She stated she completed a facility in-service on 05/31/23 regarding change in condition. She stated she now believed she should have completed a change of condition evaluation and notified the physician on 05/22/23 because on 06/01/23 an x-ray revealed Resident #1 had a fracture. In an interview with LVN A on 06/08/23 at 1:37 PM revealed Resident #1 did not complain of leg pain on 05/18/23 . She stated Resident #1 did not complain of pain until 06/01/23. She stated she assessed residents every time a complaint of pain was made. She stated she assessed residents, had residents point to where pain was located, observed any signs of grimacing, and provided PRN pain medication. She stated she would inform the ADON and DON about residents' pain during the morning meeting. She stated she would inform the oncoming nurse about residents' pain during report. She stated the physician would be notified if residents' pain reoccurred or PRN medication was not working. She stated during the first shift on 06/01/23 the RP contacted the facility and reported Resident # 1 needed two-person assistance instead of one-person assistance with transfers. She stated the RP stated Resident #1 was complaining of more pain and swelling in Resident #1's left knee. She stated she educated the CNA assigned to Resident #1 on 06/01/23 regarding two-person assistance and contacting the nurse immediately when a resident was in pain. She stated she assessed the ROM of Resident #1's leg on 06/01/23. She stated Resident #1 yelled out in pain. She stated she noticed Resident #1's left knee was swollen. She stated she notified the physician on 06/01/23 and the second shift nurse regarding Resident #1's left knee pain and swelling. She stated the physician ordered an x-ray of Resident #1's left knee. She stated Resident #1 was administered scheduled Tylenol. She stated the x-ray revealed Resident #1 had a left knee fracture. She stated the physician recommended she be sent to the hospital. She stated she notified the RP. LVN A stated she completed an in-service regarding change of condition on 05/31/23. In an interview with CNA D on 6/08/23 at 2:47 PM revealed she noticed swelling in both of Resident #1's legs on 05/18/23. She stated Resident #1 complained of left leg pain during care on 05/18/23. CNA D stated Resident #1 was favoring her left leg during incontinent care on 05/18/23. She stated Resident #1 was previously able to assist with incontinent care and was one-person assist. She stated Resident #1 required two-person assistance with transferring from bed to wheelchair. CNA D stated she informed LVN A Resident #1 was experiencing left leg pain and both legs were swollen. CNA D stated LVN A was observed entering Resident #1's room to assess her legs. CNA D stated she had not worked with Resident #1 since 05/18/23. In an interview with CNA E on 06/08/23 at 3:32 PM revealed Resident #1's left knee was swollen on 05/28/23. CNA E stated the RP requested Resident #1 to be transferred to a shower chair for a shower. CNA E stated Resident #1 was lying in bed underneath her linens. CNA E stated she uncovered Resident #1's legs and her left knee was swollen. CNA E stated Resident #1's left knee and leg resembled the shape of a baseball bat (swelling of the knee). CNA E stated the RP alleged facility staff had twisted Resident #1's knee during a transfer. CNA E stated she left Resident #1's room and informed the nurse. CNA E stated she did not remember what nurse was assigned to Resident #1 on 05/28/23. CNA E stated the nurse did not assess Resident #1 on 05/28/23. CNA E stated the nurse informed her Resident #1 could be transferred into a shower chair for a shower. CNA E stated a CNA assisted her with transferring Resident #1 into the shower chair. She stated Resident #1 was grimacing in pain and would cover her knee for protection on 05/28/23. CNA E stated the nurse should have assessed Resident #1's left knee on 05/28/23. CNA E stated Resident #1 was at risk of injury due to experiencing swelling and pain in her left knee. In an interview with RNC on 06/08/23 at 3:57 PM revealed she was the acting DON. RNC stated Resident #1's care plan revealed she required one-person assistance with ADLs. RNC stated the RP requested Resident #1 receive two-person assistance. RNC stated she was unaware Resident #1's MDS assessment revealed two-person assistance was needed. RNC stated she referred to Resident #1's care plan regarding ADL assistance and not her MDS assessment. RNC stated CNAs should report any signs of pain and/or swelling to the nurse. RNC stated the nurse should assess the resident and offer pain medication. RNC stated if resident refused pain medication, the nurse should notify the physician. RNC stated the nurse would follow physician recommendations. RNC stated if the nurse did not assess the resident, the nurse would receive education and/or disciplinary action. RNC stated change of condition was anything different from baseline. RNC stated Resident #1 complained of pain to her left leg since admission (02/12/23). RNC stated Resident #1 received scheduled pain medication. RNC stated CNAs were not able to accurately determine if Resident #1's knee was swollen because she had big legs. RNC stated LVN B should have notified the physician and completed a change of condition evaluation on 05/22/23 regarding Resident #1 experiencing left leg pain and stated ouch to touch. RNC stated the nurse on 05/28/23 should have assessed Resident #1's left knee swelling and pain. RNC stated the nurse on 05/28/23 should have also notified the physician. RNC stated there were no concerns regarding Resident #1's left knee pain and swelling because staff did not voice any concerns. RNC stated the CNAs stated the nurses were informed of Resident #1's left knee pain and swelling. RNC stated the nurses stated Resident #1 was assessed for left knee pain and swelling 06/01/23. RNC stated the nurses stated the physician was notified on 06/01/23. RNC stated nurses were in-serviced on 05/31/23 regarding change in condition. RNC stated on 06/01/23 the RP contacted the facility and informed an LVN that Resident #1 was experiencing more pain and swelling than usual. RNC stated the LVN assessed Resident #1, administered pain medication, and notified the physician on 06/01/23. RNC stated the physician recommended an x-ray of Resident #1's left knee. RNC stated the x-ray revealed Resident #1 had a fracture toward her left knee. RNC stated the physician recommended Resident #1 be sent to the hospital. RNC stated she did not know how Resident #1 acquired a fracture. In an interview with the Physician on 06/08/23 at 4:17 PM revealed he was not notified by the facility on 05/18/23, 05/22/23, or 05/28/23 regarding Resident #1's left knee pain and swelling. He stated his expectation of the facility was for Resident #1 to be assessed for pain and swelling on 05/18/23, 05/22/23, and 05/28/23. He stated his recommendation for treatment would have been based on the results of Resident #1's nursing assessments. He stated the facility should have notified him regarding Resident #1's pattern of pain and swelling. He stated he was notified on 06/01/23 regarding Resident #1's left knee pain and swelling. He stated he ordered an x-ray of Resident #1's left knee on 06/01/23. He stated the x-ray results revealed a left knee fracture. He stated he ordered the facility to send Resident #1 to the hospital on 06/01/23. In an interview with LVN F on 06/08/23 at 5:13 PM revealed Resident #1 did not complain or exhibit any signs of pain and/or swelling on 05/28/23. He stated on 05/28/23, CNA E did not report Resident #1's left knee pain and swelling. He stated he monitored Resident #1 throughout his shift by making rounds. He stated he would have assessed Resident #1 if she complained or exhibited signs of pain and/or swelling. He stated after the assessment he would have notified the physician regarding change of condition. In an interview with the Administrator on 06/08/23 at 5:54 PM revealed during the facility investigation of the incident, the RP, physician, and ombudsman were notified. She stated staff interviews and resident safe surveys were conducted. She stated staff were in-serviced regarding abuse/neglect and change of condition. She stated the facility reviewed Resident #1's chart. She stated the facility contacted the hospital regarding Resident #1's update. She stated the RNC discussed findings regarding staff interviews. The Administrator stated based on the provider investigation findings, LVN B should have completed a change of condition evaluation and notified the physician regarding Resident #1's leg pain on 05/22/23. She stated as of 06/08/23, LVN B was suspended and removed from the schedule pending further investigation. Record review of the facility's policy titled, Change in Resident's Condition or Status, undated reflected, It is the policy of the facility to ensure that the resident's attending physician and representative are notified of changes in the resident's condition or status. The nurse will notify the resident's attending physician when: .there is a significant change in the resident's physical, mental, or psychological status . This was determined to be an Immediate Jeopardy (IJ) on 06/21/23 at 2:05 PM. The Administrator was notified. The Administrator was provided with the IJ template on 06/21/23 at 2:05 PM. The Facility Plan of Removal was accepted on 06/22/23. The plan of removal reflected: The facility failed to notify the physician regarding Resident #1's change of condition. Resident #1 was assessed on 6/1/2023 by LVN A charge nurse and was noted with swelling to the left knee, physician was notified and order for a stat x-ray was obtained. Facility received X-ray results noted an acute, transverse, impacted fracture at proximal received on 6/1/2023. 1.) Resident#1's attending physician was notified on 6/1/2023 of Resident #1 x-ray result. Resident's attending physician gave an order to send resident to the E.R. for further evaluation. 2.) On 6/1/2023 resident #1's family member was notified at resident #1's bedside of the fracture and physician orders to send resident to the hospital for further evaluation, but Resident#1's requested that be sent to the hospital the following morning 6/2/2023. Physician ok with request. 3.) Resident #1 was transferred to the hospital 6/2/2023 and discharged to another facility from the hospital. 4.) LVN B was suspended on 6/7/2023 pending investigation and was terminated on 6/9/2023 due to investigation findings. 5.) On 6/22/2023 a facility-wide 30 day look back audit was conducted to ensure that any resident who met the criteria for a change of condition, did, in fact, have this change of condition addressed per policy and regulation, to include making all appropriate notifications to the physician as well as the resident and/or the resident's responsible party. Additionally, to ensure that any appropriate assessments were completed and that any orders were obtained. Further, to see that the resident's care plan was revised as indicated. Any concerns were addressed. Training: A. During a mandatory nurse's meeting on 5/31/2023 the ADON in-serviced licensed nurses regarding documentation, proper assessments, notifying physicians regarding change of conditions. All nurses at the facility were in-serviced at this time. B. On 6/21/2023 after the IJ was identified the ADON began in-servicing all nursing staff, regarding documentation, proper assessments, notifying physicians regarding change of conditions. The facility does not use any agency staff. In the event of agency staff use, the facility will provide the same in-servicing before agency staff could work at the facility. o Change of Condition policy o Discussion of examples of changes of condition (to include pain, swelling, and fractures) o What should you do, in your staff member role if you observe what you believe to be a change in condition in a resident? Whom do you tell? When? Why? o (Nurses) What do you do? Assess? When? Whom do you notify? What/When do you document? What if the change of condition meets reportable criteria? Whom do you notify? When? o Discussion --- Questions/Answers Learning will be measured by a pre/post-test that required 100% of the questions to be answered correctly. Any staff who fail to comply with the points of the in-servicing will be further educated and/or progressively disciplined as indicated. C. Newly hired nurses will be in-serviced by the ADON/designee regarding documentation, proper assessments, notifying physicians regarding change of conditions during facility orientation upon hire. Any staff members who are unable to physically attend the in-service training in person will be in-serviced via phone and provided with in-service handouts via telephone or email. Staff members in-serviced over the phone will be required to obtain in person training prior to working completing the pre/post-tests. During the in-service training there will be a discussion QA to ensure staff understanding and competency. Learning will be measured by a pre/post-test that required 100% of the questions to be answered correctly. Any staff who fail to comply with the points of the in-servicing will be further educated and/or progressively disciplined as indicated. Nurses will not be allowed to work until they are in-serviced on documentation, proper assessments, and notifying physicians regarding change of conditions. The Regional Nurse consultant will be responsible for monitoring and ensuring compliance. Any staff who fail to comply with the points of the in-servicing will be further educated and/or progressively disciplined as indicated. If there was changes or new policy and procedures to prevent the failure from recurring, effective date and completion dates, when and who will implement: A. Starting on 6/22/2023 as the daily practice of the Clinical Morning Meeting agenda, the ADON/designee will monitor the progress notes since the previous Clinical Morning Meeting to ensure that all appropriate steps were taken and protocols followed to address any situation that met Change of Condition criteria for any resident. This would include but not be limited to: performing any needed assessments, obtaining any needed orders, notifications to all appropriate and required parties, care planning and updating any CNA information guidance. Additionally, beginning on 6/22/2023 the Medical Director will make rounds on residents at the facility weekly to ensure that any changes in condition over the previous week were identified and addressed per policy. B. The ADON/designee will review 24-hour report to ensure nurses document timely notifications to the attending physician of resident changes of condition 2x week X 6 weeks. Additionally, beginning 6/22/2023, the DON/designee began monitoring 10 residents, (on rotating basis), weekly x 4 weeks to ensure that any change of condition over the previous week was identified and addressed per policy and regulation. After 4 weeks, 3 residents will be monitored weekly x 3 months to ensure ongoing compliance. After that, random monitoring will continue ongoing. Any concerns will be addressed if found. The weekly monitoring by the DON/designee will be presented to the QAPI committee for review at the weekly QAPI meetings. Any concerns will have been addressed. However, any patterns will be identified. If needed, an action plan will be written by the QAPI committee. Any written action plan will be monitored weekly by the administrator until resolved. Review will be documented on an audit report form. C. Administrator will review the audit reports on a weekly basis to ensure nurse managers are following the plan of correction for six weeks. Review will be documented on an audit report form. The regional nurse consultant will be responsible for the plan of removal and its monitoring. Quality Assurance: An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 6/21/2023 with the Medical Director at 4:30pm. The Medical Director has reviewed and agrees with this plan. Monitoring of the Plan of Removal included the following: Record review of facility in-service training reports dated 06/21/23 and 06/22/23 revealed staff were in-serviced regarding change of condition, completion of interact change of condition, antibiotics, fall-complete daily progress note, antibiotic report daily while on antibiotics, all changes must be reported to physician/family, and change of condition policy. Newly hired nurses will be in-serviced by the ADON/designee regarding documentation, proper assessments, and notifying physicians regarding change of condition. Report any incident to the Administrator, DON, and ADON. Complete risk management, chart, and complete change of condition. No nurse will be able to work until all in-services are signed; to include changes of condition, (pain) follow up, assess when CNA reports to nurse resident pain or any change in condition (immediately). CNAs creating e-interact stop and watch, change in condition alerts. Licensed nurses monitor dashboard for any e-interact stop and watches. Record review of facility competency test, undated, revealed staff completed quizzes regarding change of condition. Record review of employee disciplinary action report, dated 06/09/23, reflected LVN B was terminated regarding failure to properly assess Resident #1 after a change of condition and notify the physician. Interviews were conducted on 06/22/23 starting at 4:20 PM through 06/23/22 at 10:37 AM with LVN A, LVN F, LVN C, RN G, LVN H, RN I, and MDS coordinator across all three shifts, the weekend, and PRN staff to ensure they had been properly in-serviced. All interviews revealed the staff were trained and completed a competency test regarding change of condition, notification of change, notification of physician and RP, documentation, assessment, clinical dashboard, and policy on change of condition. In an interview with RNC on 06/23/22 at 8:50 AM revealed she was the acting DON. RNC stated she was only at the facility for two to three days a week. RNC stated she supervised her staff to ensure policies/procedures were followed by making rounds. RNC stated the day shift nurses discuss the 24-hour report with her. RNC stated she informed nurses tasks that need to be completed and followed up on throughout the day. RNC stated she supervised nursing staff by delegating several tasks to the ADON because the facility did not have a DON. RNC stated she follows up behind the ADON to ensure tasks were completed. RNC stated there was a nurse on the weekends that assisted with nurse management tasks. RNC stated the facility received an IJ because HHSC identified a concurrent problem. RNC stated the facility had identified follow up issues with documentation and change of condition prior to the incident being reported to HHSC on 06/02/23. RNC stated staff in-servicing regarding change of condition was initiated on 06/02/23. RNC stated to prevent the reoccurrence of the IJ, the facility had additional staff reviewing the 24-hour report. RNC stated a form called Daily Clinical CQI meeting was used to follow up on residents' nursing concerns. RNC stated her responsibilities regarding the POR were to oversee the clinical aspects of the plan, audit ten residents' charts to ensure change of condition was noted and followed up. RNC stated she completed a 30-day look back regarding residents' change of condition. RNC stated she ensured CNAs completed stop and watches and had two ways to notify nurses regarding change of condition in EMR. RNC stated she assisted with in-servicing and testing staff regarding change of condition. In an interview with the Medical Director on 06/23/23 at 11:06 AM revealed he was notified regarding the facility's IJ. He stated his expectation for nursing staff regarding change of condition was to improve communication between nurses and the physician. He stated the IJ occurred because there was a communication issue with [TRUNCATED]

Based on interview and record review, the facility failed to consult the resident's physician, when the resident had an injury and had the potential for requiring physical intervention and when there was a significant change in the resident's physical, mental or psychosocial status for one (Resident #1) of six residents reviewed for resident rights. The facility failed to notify the physician when Resident #1 complained of right leg pain on 05/22/23. There were multiple opportunities for the staff to notify the physician when it was noted by the facility staff and responsible party that Resident #1's leg was swollen and she was in pain. The physician indicated he should have been notified on 5/18/23, 5/22/23, and 5/28/23. As a result, she experienced continued pain per facility staff, and suffered fracture(s) of her left knee (acute transverse impacted fracture at proximal and fibular metaphysis which affects the neck of the bone (metaphysis), where the tibia starts to narrow down. Due to Resident #1's injury, she was sent to the hospital. On 06/21/23 at 2:05 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 06/22/23, the facility remained out of compliance at a severity level of actual harm and scope of pattern. This failure could place residents at the risk of not receiving appropriate medical interventions timely and effectively, which could result in severe illness, hospitalization or even death. Findings included: Review of Resident #1's Annual MDS Assessment, dated 04/21/23, reflected she was a [AGE] year-old who admitted to the facility on [DATE]. Her diagnoses included: hypertension, Alzheimer's Disease, Non-Alzheimer's Dementia, anxiety disorder, depression, and insomnia. Her BIMS score was 6 and indicated severe cognitive impairment. Her functional status reflected she required extensive assistance and one-person physical assistance with bed mobility, locomotion on unit, locomotion off unit, and personal hygiene. She required extensive assistance and two-person physical assistance with transfers, dressing, and toilet use. Her pain management revealed she received scheduled pain medication regimen. Record review of Resident #1's Care Plan, undated, revealed she required assistance with ADLs and was at risk of falls due to dementia, Alzheimer's. Her goal was to attempt/complete ADL tasks with staff assistance and have no injuries due to falls thru the next review. Her interventions were required extensive assist with bed mobility, transfers, toileting, personal hygiene, and bathing. She required limited assist and one-person assist with locomotion, eating, and walking. Notify and update MD and family as needed. Evaluate possible causes of falls and address issues to the extent possible. She had a fracture of the left knee, problems were manifested by impaired mobility. Her goal was to heal the fracture without complications thru next review. Her interventions were to follow up with ortho as indicated. Monitor and medicate for pain as needed. Record review of Resident #1's physician order recap report, dated 05/01/23 - 06/08/23, reflected she was ordered the following medications: Acetaminophen suppository 650 mg (every 4 hours as needed for pain), Acetaminophen suppository 650 mg (every 4 hours as needed for pain not to exceed 3 grams/24 hours), Tylenol extra strength oral tablet 500 mg (1 tablet every 6 hours as needed for pain), and Tylenol oral tablet (500 mg two times a day for pain). Record review of Resident #1's physician orders, dated 06/01/23, reflected x-ray left knee 2 views for continued pain and left knee getting bigger. One time only for pain and swelling to left knee for past two days. Record review of Resident #1's MAR , dated May 2023, reflected Acetaminophen suppository 650 mg (every 4 hours as needed for pain, dated 02/12/23) and Acetaminophen suppository 650 mg (every 4 hours as needed for pain not to exceed 3 grams/24 hours, dated 02/12/23) were not administered from 05/01/23 to 05/31/23. Tylenol extra strength oral tablet 500 mg (1 tablet every 6 hours as needed for pain, dated 05/23/23) was not administered from 05/01/23 to 05/31/23. Tylenol oral tablet (500 mg two times a day for pain, dated 02/13/23) was administered twice a day from 05/01/23 to 05/31/23. Record review of Resident #1's MAR, dated June 2023, reflected Acetaminophen suppository 650 mg (every 4 hours as needed for pain, dated 02/12/23) and Acetaminophen suppository 650 mg (every 4 hours as needed for pain not to exceed 3 grams/24 hours, dated 02/12/23) were not administered from 06/01/23 to 06/02/23. Tylenol extra strength oral tablet 500 mg (1 tablet every 6 hours as needed for pain, dated 05/23/23) was not administered from 06/01/23 to 06/02/23. Tylenol oral tablet (500 mg two times a day for pain, dated 02/13/23) was administered twice a day on 06/01/23. Tylenol oral tablet (500 mg two times a day for pain, dated 02/13/23) was administered once a day on 06/02/23. Record review of Resident #1's pain levels, dated 05/18/23 - 05/23/23, reflected her pain level was 0/10. Her pain level on 05/24/23 - 05/28/23 was 2/10. Her pain level on 05/29/23 was 0/10. Her pain level on 05/30/23 was 2/10. Her pain level on 05/31/23 was 1/10. Her pain level on 06/01/23 was 2/10. Record review of Resident #1's progress notes, dated 05/18/23, revealed she was administered Tylenol oral tablet twice a day for pain and did not have any signs/symptoms of pain (written by LVN A). Record review of Resident #1's nursing notes, dated 05/22/23, reflected Resident #1 complained of left leg pain. Resident #1 refused PRN pain medication. Resident #1 received two-person incontinent care. Resident's RP assisted with turn and incontinent care at the beginning of shift. Resident #1 was assessed and stated ouch when left leg was touched. Will continue to monitor (written by LVN B). Record review of Resident #1's nursing notes revealed there were no nursing notes from 05/23/23 to 05/31/23. Record review of Resident #1's nursing notes, dated 06/01/23, reflected per family request, Resident #1 was to be a two-person assist with all transfers. The information was entered in Resident #1's plan of care for aides on 06/01/23. Resident #1 complained of continued pain to her left knee and family was concerned her left knee was getting bigger. The physician was notified and a new order for Resident #1 was received for left knee x-ray. Per aide Resident #1 did yell like she was in pain during transfer (written by LVN A). Record review of Resident #1's nursing notes, dated 06/01/23, reflected her left knee x-ray results with impression of acute, transverse, impacted fracture at proximal and fibular metaphysis (this fracture affects the neck of the bone (metaphysis), where the tibia starts to narrow down) was sent to the physician. The physician recommended Resident #1 be sent to the ER in the morning of 06/02/23 or night of 06/01/23 as per her RP's request. Resident #1's RP was informed of the x-ray results and physician order to send her to the hospital. Resident #1's RP requested she be sent to the hospital in the morning (written by LVN C). Record review of Resident #1's nursing notes, dated 06/02/23, reflected Resident #1 was transported the hospital the morning of 06/02/23. Resident had x-rays done and results showed an acute transverse impacted fracture at proximal and fibular metaphysis (this fracture affects the neck of the bone (metaphysis), where the tibia starts to narrow down) . Resident #1's RP was with her. Resident #1's morning medications were given. Resident #1's Eliquis (medication) was held, and the physician was notified. Resident #1 was to possibly receive surgery (Written by LVN A). Record review of the facility's provider investigation report, dated 06/02/23, revealed the facility conducted confidential witness statements with staff on 06/02/23. The confidential witness statements reflected the following statements: CNA D stated she noticed swelling on both of Resident #1's legs and was screaming out in pain when being turned to reposition. She stated swelling and screaming out in pain was reported to the nurse; LVN B stated on 05/22/23, a CNA reported Resident #1 complained of pain. LVN B stated she assessed and upon light palpation Resident #1 stated ouch. LVN B stated the resident refused PRN pain medication. LVN B stated she did not notify the physician or complete change of condition assessment. LVN B stated a CNA continued to report pain from time to time. LVN B stated she physically assessed Resident #1 each time and she refused PRN pain medication. LVN B stated she did not note any swelling; CNA E stated Resident #1 yelled out in pain and exhibited signs of grimacing (placed hand on left lower extremity and stated no) during incontinent care (turning/repositioning). During a two-person transfer Resident #1 did not yell out in pain. CNA E stated she noticed swelling to the left lower extremity. She stated she reported pain and swelling to the nurse; LVN C stated Resident #1's RP reported increased pain on 05/31/23. LVN C stated he physically assessed Resident #1 and administered scheduled Acetaminophen. LVN C stated determining Resident #1's level of pain was hard because she always yelled out in pain during any care/repositioning; and LVN A stated pain/swelling had not been reported to her in the past two weeks. LVN A stated Resident #1's RP called her on 06/01/23. The RP stated she had been reporting Resident #1's increased pain and swelling for the past two weeks. The RP also stated she requested two-person assistance with Resident #1. LVN A stated an x-ray was ordered. LVN A stated she initiated an order in Resident #1's electronic plan of care to transfer her by two-person assist. In an interview with the RP on 06/08/23 at 11:10 AM revealed Resident #1's knee was swollen on 06/01/23. She stated she informed the nurse and the physician was notified. She stated the physician ordered an x-ray on 06/01/23. She stated the x-ray results revealed Resident #1's leg was broken in two places; below the left knee and her main bone was fractured. She stated Resident #1 was sent to the hospital on 06/02/23. She stated Resident #1 was discharged from the hospital on 06/07/23 and transferred to another facility. She stated Resident #1 informed her facility staff provided one-person transfers. She stated Resident #1 was forgetful and did not recall when staff provided one-person transfers. She stated Resident #1 would yell out in pain and would not allow her to touch her leg during visits. She stated Resident #1 received pain medication routinely. She stated she frequently visited Resident #1 at the facility. She stated during visits she assisted staff with incontinent care because the facility only used one-person assistance. She stated she frequently informed the facility Resident #1 required two-person assistance and had leg pain. She stated she also informed the facility to leave Resident #1 in bed if two-person assistance could not be provided. She stated Resident #1 would not be returning to the facility due to systemic problems. She stated the facility staff improperly transferred Resident #1 which resulted in injury. She stated the facility staff needed more training and did not know how to complete adequate transfers with Resident #1. In an interview with LVN B on 06/08/23 at 12:21 PM revealed a CNA reported Resident #1 was complaining of left leg pain on 05/22/23. She stated she did not remember which CNA. She stated the RP had assisted the CNA with incontinent care. She stated she assessed Resident #1 and touched her left leg. She stated Resident #1 yelled ouch when her left leg was touched. She stated she offered Resident #1 PRN pain medication and she refused. She stated she did not notify the DON or physician because she did not know if Resident #1's left leg pain was new or ongoing. She stated she continuously monitored Resident #1 throughout her 8-hour shift. She stated at the time of the assessment her response to Resident #1's pain was appropriate. She stated there were no risks to Resident #1 because she closely monitored Resident #1 throughout the shift. She stated she completed a facility in-service on 05/31/23 regarding change in condition. She stated she now believed she should have completed a change of condition evaluation and notified the physician on 05/22/23 because on 06/01/23 an x-ray revealed Resident #1 had a fracture. In an interview with LVN A on 06/08/23 at 1:37 PM revealed Resident #1 did not complain of leg pain on 05/18/23 . She stated Resident #1 did not complain of pain until 06/01/23. She stated she assessed residents every time a complaint of pain was made. She stated she assessed residents, had residents point to where pain was located, observed any signs of grimacing, and provided PRN pain medication. She stated she would inform the ADON and DON about residents' pain during the morning meeting. She stated she would inform the oncoming nurse about residents' pain during report. She stated the physician would be notified if residents' pain reoccurred or PRN medication was not working. She stated during the first shift on 06/01/23 the RP contacted the facility and reported Resident # 1 needed two-person assistance instead of one-person assistance with transfers. She stated the RP stated Resident #1 was complaining of more pain and swelling in Resident #1's left knee. She stated she educated the CNA assigned to Resident #1 on 06/01/23 regarding two-person assistance and contacting the nurse immediately when a resident was in pain. She stated she assessed the ROM of Resident #1's leg. She stated Resident #1 yelled out in pain. She stated she noticed Resident #1's left knee was swollen. She stated she notified the physician on 06/01/23 and the second shift nurse regarding Resident #1's left knee pain and swelling. She stated the physician ordered an x-ray of Resident #1's left knee. She stated Resident #1 was administered scheduled Tylenol. She stated the x-ray revealed Resident #1 had a left knee fracture. She stated the physician recommended she be sent to the hospital. She stated she notified the RP. LVN A stated she completed an in-service regarding change of condition on 05/31/23. In an interview with CNA D on 6/08/23 at 2:47 PM revealed she noticed swelling in both of Resident #1's legs on 05/18/23. She stated Resident #1 complained of left leg pain during care on 05/18/23. CNA D stated Resident #1 was favoring her left leg during incontinent care on 05/18/23. She stated Resident #1 was previously able to assist with incontinent care and was one-person assist. She stated Resident #1 required two-person assistance with transferring from bed to wheelchair. CNA D stated she informed LVN A Resident #1 was experiencing left leg pain and both legs were swollen. CNA D stated LVN A was observed entering Resident #1's room to assess her legs. CNA D stated she had not worked with Resident #1 since 05/18/23. In an interview with CNA E on 06/08/23 at 3:32 PM revealed Resident #1's left knee was swollen on 05/28/23. CNA E stated the RP requested Resident #1 to be transferred to a shower chair for a shower. CNA E stated Resident #1 was lying in bed underneath her linens. CNA E stated she uncovered Resident #1's legs and her left knee was swollen. CNA E stated Resident #1's left knee and leg resembled the shape of a baseball bat (swelling of the knee). CNA E stated the RP alleged facility staff had twisted Resident #1's knee during a transfer. CNA E stated she left Resident #1's room and informed the nurse. CNA E stated she did not remember what nurse was assigned to Resident #1 on 05/28/23. CNA E stated the nurse did not assess Resident #1. CNA E stated the nurse informed her Resident #1 could be transferred into a shower chair for a shower. CNA E stated a CNA assisted her with transferring Resident #1 into the shower chair. She stated Resident #1 was grimacing in pain and would cover her knee for protection on 05/28/23. CNA E stated the nurse should have assessed Resident #1's left knee. CNA E stated Resident #1 was at risk of injury due to experiencing swelling and pain in her left knee. In an interview with RNC on 06/08/23 at 3:57 PM revealed she was the acting DON. RNC stated Resident #1's care plan revealed she required one-person assistance with ADLs. RNC stated the RP requested Resident #1 receive two-person assistance. RNC stated she was unaware Resident #1's MDS assessment revealed two-person assistance was needed. RNC stated she referred to Resident #1's care plan regarding ADL assistance and not her MDS assessment. RNC stated CNAs should report any signs of pain and/or swelling to the nurse. RNC stated the nurse should assess the resident and offer pain medication. RNC stated if resident refused pain medication, the nurse should notify the physician. RNC stated the nurse would follow physician recommendations. RNC stated if the nurse did not assess the resident, the nurse would receive education and/or disciplinary action. RNC stated change of condition was anything different from baseline. RNC stated Resident #1 complained of pain to her left leg since admission (02/12/23). RNC stated Resident #1 received scheduled pain medication. RNC stated CNAs were not able to accurately determine if Resident #1's knee was swollen because she had big legs. RNC stated LVN B should have notified the physician on 05/22/23 regarding Resident #1 experiencing left leg pain and stated ouch to touch. RNC stated the nurse on 05/28/23 should have assessed Resident #1's left knee swelling and pain. RNC stated the nurse on 05/28/23 should have also notified the physician. RNC stated there were no concerns regarding Resident #1's left knee pain and swelling because staff did not voice any concerns. RNC stated the CNAs stated the nurses were informed of Resident #1's left knee pain and swelling. RNC stated the nurses stated Resident #1 was assessed for left knee pain and swelling. RNC stated the nurses stated the physician was notified on 06/01/23. RNC stated nurses were in-serviced on 05/31/23 regarding change in condition. RNC stated on 06/01/23 the RP contacted the facility and informed an LVN that Resident #1 was experiencing more pain and swelling than usual. RNC stated the LVN assessed Resident #1, administered pain medication, and notified the physician on 06/01/23. RNC stated the physician recommended an x-ray of Resident #1's left knee. RNC stated the x-ray revealed Resident #1 had a fracture toward her left knee. RNC stated the physician recommended Resident #1 be sent to the hospital. RNC stated she did not know how Resident #1 acquired a fracture. In an interview with the Physician on 06/08/23 at 4:17 PM revealed he was not notified by the facility on 05/18/23, 05/22/23, or 05/28/23 regarding Resident #1's left knee pain and swelling. He stated his expectation of the facility was for Resident #1 to be assessed for pain and swelling on 05/18/23, 05/22/23, and 05/28/23. He stated his recommendation for treatment would have been based on the results of Resident #1's nursing assessments. He stated the facility should have notified him regarding Resident #1's pattern of pain and swelling. He stated he was notified on 06/01/23 regarding Resident #1's left knee pain and swelling. He stated he ordered an x-ray of Resident #1's left knee on 06/01/23. He stated the x-ray results revealed a left knee fracture. He stated he ordered the facility to send Resident #1 to the hospital on 06/01/23. In an interview with LVN F on 06/08/23 at 5:13 PM revealed Resident #1 did not complain or exhibit any signs of pain and/or swelling on 05/28/23. He stated on 05/28/23, CNA E did not report Resident #1's left knee pain and swelling. He stated he monitored Resident #1 throughout his shift by making rounds. He stated he would have assessed Resident #1 if she complained or exhibited signs of pain and/or swelling. He stated after the assessment he would have notified the physician regarding change of condition. In an interview with the Administrator on 06/08/23 at 5:54 PM revealed during the facility investigation of the incident, the RP, physician, and ombudsman were notified. She stated staff interviews and resident safe surveys were conducted. She stated staff were in-serviced regarding abuse/neglect and change of condition. She stated the facility reviewed Resident #1's chart. She stated the facility contacted the hospital regarding Resident #1's update. She stated the RNC discussed findings regarding staff interviews. The Administrator stated based on the provider investigation findings, LVN B should have completed a change of condition evaluation and notified the physician regarding Resident #1's leg pain on 05/22/23. She stated as of 06/08/23, LVN B was suspended and removed from the schedule pending further investigation. Record review of the facility's policy titled, Change in Resident's Condition or Status, undated reflected, It is the policy of the facility to ensure that the resident's attending physician and representative are notified of changes in the resident's condition or status. The nurse will notify the resident's attending physician when: .there is a significant change in the resident's physical, mental, or psychological status . This was determined to be an Immediate Jeopardy (IJ) on 06/21/23 at 2:05 PM. The Administrator was notified. The Administrator was provided with the IJ template on 06/21/23 at 2:05 PM. The Facility Plan of Removal was accepted on 06/22/23. The plan of removal reflected: The facility failed to notify the physician regarding Resident #1's change of condition. Resident #1 was assessed on 6/1/2023 by LVN A charge nurse and was noted with swelling to the left knee, physician was notified and order for a stat x-ray was obtained. Facility received X-ray results noted an acute, transverse, impacted fracture at proximal received on 6/1/2023. 1.) Resident#1's attending physician was notified on 6/1/2023 of Resident #1 x-ray result. Resident's attending physician gave an order to send resident to the E.R. for further evaluation. 2.) On 6/1/2023 resident #1's family member was notified at resident #1's bedside of the fracture and physician orders to send resident to the hospital for further evaluation, but Resident#1's requested that be sent to the hospital the following morning 6/2/2023. Physician ok with s request. 3.) Resident #1 was transferred to the hospital 6/2/2023 and discharged to another facility from the hospital. 4.) LVN B was in-serviced, then suspended on 6/7/2023 pending investigation and was terminated on 6/9/2023 due to investigation findings. 5.) LVN F was in-serviced regarding documentation, proper assessments, and notifying physicians regarding change of conditions on 5/31/2023. 6.) On 6/22/2023 a facility-wide 30 day look back audit was conducted to ensure that any resident who met the criteria for a change of condition, did, in fact, have this change of condition addressed per policy and regulation, to include making all appropriate notifications to the physician as well as the resident and/or the resident's responsible party. Additionally, to ensure that any appropriate assessments were completed and that any orders were obtained. Further, to see that the resident's care plan was revised as indicated. Any concerns were addressed. Training: A. During a mandatory nurse's meeting on 5/31/2023 the ADON in-serviced licensed nurses regarding documentation, proper assessments, notifying physicians regarding change of conditions. All nurses at the facility were in-serviced at this time. B. On 6/21/2023 after the IJ was identified the ADON began in-servicing all nursing staff, regarding documentation, proper assessments, notifying physicians regarding change of conditions. The facility does not use any agency staff. In the event of agency staff use, the facility will provide the same in-servicing before agency staff could work at the facility. o Change of Condition policy o Discussion of examples of changes of condition (to include pain, swelling, and fractures) o What should you do, in your staff member role if you observe what you believe to be a change in condition in a resident? Whom do you tell? When? Why? o (Nurses) What do you do? Assess? When? Whom do you notify? What/When do you document? What if the change of condition meets reportable criteria? Whom do you notify? When? o Discussion --- Questions/Answers Learning will be measured by a pre/post-test that required 100% of the questions to be answered correctly. Any staff who fail to comply with the points of the in-servicing will be further educated and/or progressively disciplined as indicated. C. Newly hired nurses will be in-serviced by the ADON/designee regarding documentation, proper assessments, notifying physicians regarding change of conditions during facility orientation upon hire. Any staff members who are unable to physically attend the in-service training in person will be in-serviced via phone and provided with in-service handouts via telephone or email. Staff members in-serviced over the phone will be required to obtain in person training prior to working completing the pre/post-tests. During the in-service training there will be a discussion QA to ensure staff understanding and competency. Learning will be measured by a pre/post-test that required 100% of the questions to be answered correctly. Any staff who fail to comply with the points of the in-servicing will be further educated and/or progressively disciplined as indicated. Nurses will not be allowed to work until they are in-serviced on documentation, proper assessments, and notifying physicians regarding change of conditions. The Regional Nurse consultant will be responsible for monitoring and ensuring compliance. Any staff who fail to comply with the points of the in-servicing will be further educated and/or progressively disciplined as indicated. If there was changes or new policy and procedures to prevent the failure from recurring, effective date and completion dates, when and who will implement: A. Starting on 6/22/2023 as the daily practice of the Clinical Morning Meeting agenda, the ADON/designee will monitor the progress notes since the previous Clinical Morning Meeting to ensure that all appropriate steps were taken and protocols followed to address any situation that met Change of Condition criteria for any resident. This would include but not be limited to: performing any needed assessments, obtaining any needed orders, notifications to all appropriate and required parties, care planning and updating any CNA information guidance. Additionally, beginning on 6/22/2023 the Medical Director will make rounds on residents at the facility weekly to ensure that any changes in condition over the previous week were identified and addressed per policy. B. The ADON/designee will review 24-hour report to ensure nurses document timely notifications to the attending physician of resident changes of condition 2x week X 6 weeks. Additionally, beginning 6/22/2023, the DON/designee began monitoring 10 residents, (on rotating basis), weekly x 4 weeks to ensure that any change of condition over the previous week was identified and addressed per policy and regulation. After 4 weeks, 3 residents will be monitored weekly x 3 months to ensure ongoing compliance. After that, random monitoring will continue ongoing. Any concerns will be addressed if found. The weekly monitoring by the DON/designee will be presented to the QAPI committee for review at the weekly QAPI meetings. Any concerns will have been addressed. However, any patterns will be identified. If needed, an action plan will be written by the QAPI committee. Any written action plan will be monitored weekly by the administrator until resolved. Review will be documented on an audit report form. C. Administrator will review the audit reports on a weekly basis to ensure nurse managers are following the plan of correction for six weeks. Review will be documented on an audit report form. The regional nurse consultant will be responsible for the plan of removal and its monitoring. Quality Assurance: An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 6/21/2023 with the Medical Director at 4:30pm. The Medical Director has reviewed and agrees with this plan. Monitoring of the Plan of Removal included the following: Record review of facility in-service training reports dated 06/21/23 and 06/22/23 revealed staff were in-serviced regarding change of condition, completion of interact change of condition, antibiotics, fall-complete daily progress note, antibiotic report daily while on antibiotics, all changes must be reported to physician/family, and change of condition policy. Newly hired nurses will be in-serviced by the ADON/designee regarding documentation, proper assessments, and notifying physicians regarding change of condition. Report any incident to the Administrator, DON, and ADON. Complete risk management, chart, and complete change of condition. No nurse will be able to work until all in-services are signed; to include changes of condition, (pain) follow up, assess when CNA reports to nurse resident pain or any change in condition (immediately). CNAs creating e-interact stop and watch, change in condition alerts. Licensed nurses monitor dashboard for any e-interact stop and watches. Record review of facility competency test, undated, revealed staff completed quizzes regarding change of condition. Record review of employee disciplinary action report, dated 06/09/23, reflected LVN B was terminated regarding failure to properly assess Resident #1 after a change of condition and notify the physician. Interviews were conducted on 06/22/23 starting at 4:20 PM through 06/23/22 at 10:37 AM with LVN A, LVN F, LVN C, RN G, LVN H, RN I, and MDS coordinator across all three shifts, the weekend, and PRN staff to ensure they had been properly in-serviced. All interviews revealed the staff were trained and completed a competency test regarding change of condition, notification of change, notification of physician and RP, documentation, assessment, clinical dashboard, and policy on change of condition. In an interview with RNC on 06/23/22 at 8:50 AM revealed she was the acting DON. RNC stated she was only at the facility for two to three days a week. RNC stated she supervised her staff to ensure policies/procedures were followed by making rounds. RNC stated the day shift nurses discuss the 24-hour report with her. RNC stated she informed nurses tasks that need to be completed and followed up on throughout the day. RNC stated she supervised nursing staff by delegating several tasks to the ADON because the facility did not have a DON. RNC stated she follows up behind the ADON to ensure tasks were completed. RNC stated there was a nurse on the weekends that assisted with nurse management tasks. RNC stated the facility received an IJ because HHSC identified a concurrent problem. RNC stated the facility had identified follow up issues with documentation and change of condition prior to the incident being reported to HHSC on 06/02/23. RNC stated staff in-servicing regarding change of condition was initiated on 06/02/23. RNC stated to prevent the reoccurrence of the IJ, the facility had additional staff reviewing the 24-hour report. RNC stated a form called Daily Clinical CQI meeting was used to follow up on residents' nursing concerns. RNC stated her responsibilities regarding the POR were to oversee the clinical aspects of the plan, audit ten residents' charts to ensure change of condition was noted and followed up. RNC stated she completed a 30-day look back regarding residents' change of condition. RNC stated she ensured CNAs completed stop and watches and had two ways to notify nurses regarding change of condition in EMR. RNC stated she assisted with in-servicing and testing staff regarding change of condition. In an interview with the Medical Director on 06/23/23 at 11:06 AM revealed he was notified regarding the facility's IJ. He [TRUNCATED]

Based on interview and record review, it was determined the facility failed to provide the necessary care and services to attain the highest practicable mental and psychosocial well-being for one (Resident #1) of 14 residents reviewed for quality of care. Resident #1 was found un-responsive, with a half empty syringe in her hand, an empty syringe at her bedside, and an empty bottle of [MEDICATION NAME] in her bag. Resident #1 had a psychiatric history, and a documented recent suicide attempt via drug overdose. Facility nurses did not assess, care-plan and implement nursing interventions in regard to the resident's psychiatric history and/or her suicide attempt. There was no Psychiatric follow-up for Resident #1 for 33 days. When Emergency Medical Services arrived at the facility, Resident #1's skin was cold and blue, her pupils were fixed and dilated, and her heart rhythm was in Asystole. (Asystole-absence of heartbeat.) These failures likely contributed to the death of Resident #1 and could affect the facility's 35 residents identified with Depression, placing them at risk for the potential of self harm. Findings included: Review of a hospital History and Physical, dated [DATE], signed by Physician F, revealed Resident #1 was 36-years old with [DIAGNOSES REDACTED]. The History and Physical reflected on [DATE], Resident #1 took 40 tablets of Tylenol PM and was hospitalized for [REDACTED]. Review of a hospital Psychiatric Note dated [DATE], signed by Physician C, revealed Resident #1 was diagnosed with [REDACTED]. The note reflected Resident #1 had "been feeling increasingly unhappy and depressed over the past year and had been recently non-compliant with antidepressant medications." Resident #1 was treated on the adult inpatient unit and maintained on suicide precautions. Resident #1 needed to be transferred due to increased drainage from her wound and the inability of the Psychiatric unit to manage the wound. Resident #1 was moved to the surgical floor for wound care. The note further reflected: "patient denied any thoughts of harm to self or others. Denied hallucinations and was not delusional. Mood was much less depressed. Thought processes were organized. Insight and judgement improved." Review of Physician C's transfer orders, dated [DATE] revealed the following orders: "Re-admit Resident (#1) to room ___ for skilled care of wound infection...." Review of Resident #1's clinical record revealed there were no Psychiatric visits from [DATE] through [DATE]. Review of a Nursing Comprehensive Admission Data assessment for Resident #1, dated [DATE] and signed by LVN O, revealed there was no Psychosocial assessment and no Behavioral Data Collection and Assessment tool completed, per facility policy. Review of a Pain Assessment for Resident #1 dated [DATE] and signed by LVN O, revealed Resident #1 had "feelings of sadness or loss of control as a result of pain." LVN O had inaccurately identified the resident as not being diagnosed or treated for [REDACTED]. Review of an Individual Care Plan for Resident #1, dated [DATE], signature illegible, revealed the resident's mood and/or behavior was not an identified need even though the resident had a history of [REDACTED]. Review of a Social Services Assessment for Resident #1, dated [DATE], signed by the Social Worker, revealed a prompt to "note whether Resident has a diagnosed Psychiatric Problem/Mental Health issue and specify Diagnosis: [REDACTED]. The assessment further reflected Resident #1 was "cooperative" and Resident #1's mood/behavior were listed as both deteriorated and improved. Additional comments included: "(Resident #1) attempted suicide and was in psychiatric for awhile. (Resident #1) has recovered and is feeling better psychologically. (Resident #1) stated (she) is not suicidal at this time." Review of Physician A's progress note for Resident #1, dated [DATE], revealed no assessment of mood or affect. Review of an MDS Mood Assessment, dated [DATE], un-signed, revealed Resident #1 had a total mood severity score of zero, meaning Resident #1 did not verbalize feelings of being down or depressed; having suicidal thoughts; and did not verbalize feeling a lack of pleasure. The Behavior section of the same MDS assessment for Resident #1 reflected "no overall presence of behavioral symptoms." Review of Physician A's progress notes for Resident #1, dated [DATE] and [DATE], revealed no assessments of mood or affect. Review of Resident #1's MAR for [DATE] revealed Resident #1 was taking [MEDICATION NAME] (anti-depressant) 75 mg by mouth every day. There was no evidence to reflect staff had been monitoring for side effects or effectiveness of the anti-depressant. Review of the Nursing 2011 Drug Handbook (page 615) regarding [MEDICATION NAME] revealed the Caution: "Use cautiously in patients at risk for suicide and in those with ...major affective disorder...." A Black Box Warning reflected: "Advise families and caregivers to closely observe patient for increased suicidal thinking and behavior." Review of the current facility Behavior Management Policy, dated [DATE], revealed the facility "recognizes that behaviors exhibited by residents/patients require appropriate identification, assessment, intervention, management, and evaluation to assist the resident/patient in obtaining their highest practicable level of functioning." The policy further reflected "Criteria for Path Two includes behaviors that: are harmful or potentially harmful to self and/or others, are interfering with the ability to function, are interfering with the ability to receive needed care and require psychoactive medications." The policy reflected to "Identify and address possible causes of the behavioral symptoms including medical conditions, medication interactions and side effects, psychosocial and environmental factors, psychiatric illness, and cognitive impairment; Identify and address possible causes of the behavioral symptoms that are potentially harmful; monitor and manage a resident receiving psychoactive medications; develop resident specific interventions that promote optimal function, independence, and well-being and monitor and evaluate interventions for effectiveness and progress towards goals." Review of Resident #1's Social Services assessment dated [DATE], signed by the SW, revealed Resident #1 had a [DIAGNOSES REDACTED]. There was no further documentation to indicate the observations had been followed up on in any way. Review of the Nurses Notes for Resident #1 from [DATE] to [DATE] revealed 18 total entries with two entries, which addressed affect, mood, or behavior. Nurses Notes dated [DATE] at 6:36 p.m. by LVN D reflected, "Patient is not eating much, sleeping a lot and really wants to be left alone per CNA (Certified Nurses Aide)." There was no further documentation to indicate the observations were followed up on in any way. Review of the Fire Emergency Medical Services (EMS) report, dated [DATE], signed by Paramedic P, revealed at 11:26 p.m., Resident #1 was unresponsive, was not breathing, lung sounds were absent and there was no visible chest expansion. Resident #1 did not have a carotid pulse, and skin temperature was cool and blue in color. Resident #1's pupils were fixed, dilated, and not responding to light. Resident #1's Electrocardiogram revealed Asystole at 11:36 p.m., was intubated at 11:38 p.m.(breathing tube place in throat via mouth) and manual CPR (Cardio [MEDICAL CONDITION] Resuscitation) was resumed while enroute to emergency room . Medications were given to reverse her condition without effect. Review of the emergency room note dated [DATE], signed by Physician Q, revealed Resident #1 arrived via ambulance at 11:45 p.m. Resident #1 was still unresponsive, had no pulse, and was not breathing. Resident #1's pupils remained fixed and dilated. CPR was continued by emergency room Staff, medications for narcotic overdose, possible [DIAGNOSES REDACTED], and [MEDICAL CONDITION] were given with no results. At 11:49 p.m., Resident #1 remained in Asystole with no palpable pulse and CPR was resumed until 11:52 p.m.. Resident #1 remained in Asystole, had no palpable pulse and no signs of life. Resident #1 was pronounced dead at that time. Review of the Police Department report, dated [DATE] at 9:15 a.m., signed by Detective R, revealed: "It is believed (Resident #1) injected the [MEDICATION NAME] through the port in her arm. There was a white visible substance in the port thought to be [MEDICATION NAME]. (Resident #1) was receiving medication for a hip wound. (Resident #1) is a paraplegic from a DWI accident in 1997." The report further reflected: "(Resident #1's) family member told me he/she wasn't surprised, (Resident #1) has attempted 3 suicides in the past and once told (family member) she wanted to die and thought of drinking pool chemicals to kill herself. Family member told me (Resident #1) had issues with pain meds and wanted to get high. Nursing staff also told me (Resident #1) was complaining to them that (Resident #1) wanted more pain meds. Family member told me (Resident #1) got very nauseous on (the) meds and...it is possible that (Resident #1) had no intention of killing (herself) by injecting the [MEDICATION NAME] and death was accidental." Review of a Nurses Note for Resident #1, signed by LVN E, on [DATE] at 4:29 a.m. revealed: "11:10 p.m. CNA stated patient was not talking and responding. Found patient lying towards right with a saline syringe half empty in right hand, unresponsive and diaphoretic with bluish tone to skin." Review of the facility investigation for Resident #1, dated [DATE], signed by the DON, revealed an incident report dated [DATE] at 3:30 p.m. The Incident Report reflected "resident found unresponsive, (on [DATE] at 11:10 p.m.) CPR started, expired shortly thereafter, unknown cause." The report further indicated EMS was called and transferred Resident #1 to the hospital. The Police Department was notified and an investigation was initiated by them on [DATE]. Resident #1's family and Physician were notified. Statements were obtained and in-services were initiated on [DATE] regarding the recognition of signs and symptoms of Depression and procedures for reporting Behavior issues. In an interview with RN N, on [DATE] at 1:20 p.m., she stated she "found (Resident #1) unresponsive at 11:10 p.m. on [DATE]. (Resident #1) had one syringe in her hand that was half-full with a clear liquid and there was an empty syringe on the bedside table. (Resident #1's) PICC line had what looked like a white milky substance in the port. I assessed for a pulse and didn't find one. I flattened the bed, called out to another nurse to call 911 and started CPR. I was never able to get a pulse. After (Resident #1) had been taken by EMS to the hospital, we found an empty bottle of [MEDICATION NAME] in (Resident #1's) back pack. I have no idea where (Resident #1) got it." When asked if she had admitted (Resident #1), she stated, "Yes." When asked if the bag was with (Resident #1) the evening of admission, she stated, "No." When asked if there was an admission checklist of (Resident #1's) belongings, she stated, "No." In an interview with RN B, on [DATE] at 1:30 p.m., she stated she had cared for Resident #1 for the last several admissions to the facility. She stated she knew Resident #1 "pretty well" and she did not at any time feel Resident #1 was suicidal. Resident #1 "was young and like most young people, liked privacy." When asked if Resident #1's affect was different from previous admissions, she stated, "No." In an interview with RN K, on [DATE] at 9:52 a.m., she stated she had cared for Resident #1 who had "slept all day long." In an interview with the DON on [DATE] at 10:00 a.m., she stated she was aware of Resident #1's Psychiatric history, although she (the DON) had been out on medical leave for over a week. When asked if she was aware of Resident #1's previous suicide attempt, she responded, "Yes. I heard that. I was concerned (Resident #1) was coming to the facility." When asked if she was familiar with Resident #1, she responded "Yes - (Resident #1) had [MEDICAL CONDITION] of the legs due to an auto accident some years back. (Resident #1) had severe depression and some days would yell out and other days would cry ...and was self-isolated by choice." When the DON was asked if she expected a care plan to be initiated regarding Depression, Behavior and Suicidal Ideation for Resident #1, she responded, "Yes. I would expect it to be care planned." When the DON was asked if she believed nurses should assess affect, mood and behaviors, she responded "No. I would expect that to be a Social Worker function." When the DON was asked if the facility had a Behavioral Monitoring Policy, she responded, "Yes." When the DON was asked if she believed Resident #1 needed to be followed by Psychiatric services while in the facility, she responded, "Yes." When asked if Resident #1 had been followed by Psychiatric services, she responded, "I don't know." When asked how the DON thought Resident #1 obtained possession of the syringes, she stated, "I think the nurses left them there. Sometimes the nurses will bring all the needed syringes into the resident's room, especially when the resident is in Isolation. They will leave them on the table to reduce the number of times they have to run back to the med room." When asked if she thought leaving syringes at the resident bedside was safe, she responded, "That's the way it's always been done here." In an interview with the SW on [DATE] at 11:00 a.m., she stated, Resident #1 was well known to her. Resident #1 had "good family support, church support and friends." She stated, "(Resident #1) had been hospitalized several times for a sacral wound that just would not heal," and "had stopped taking prescribed anti-depressants and had been non-compliant with wound care and was facing another surgical flap surgery for [REDACTED].#1 had experienced a great deal of nausea this last admission, had stopped eating, and cried a lot, stating, "I attributed the crying to pain." When asked if she thought Resident #1's depression had worsened, she responded "No. I really feel like (Resident #1) learned a lesson and was resolved to be compliant with the anti-depressants and wound care." The SW went on to say Resident #1 had told her "I'm not going to do this again." When asked if she had visited Resident #1, the SW responded, "Yes. I visited at least once every day. I just didn't document it." When asked if she thought Resident #1, based on history and diagnoses, would be followed by Psychiatric services, the SW responded, "In hindsight, yes." When asked if she had referred Resident #1 to Psychiatric services, she responded, "No." When asked if she had consulted with Resident #1's Physician at any point during the most recent admission, she responded "No." When asked how long Resident #1 had been on the anti-depressant, the SW responded, "I think about three weeks." When asked if she had any knowledge of when suicidal patients were most at risk for self-harm, she responded, "When the medication actually starts to work." On [DATE] at 1:50 p.m., the Administrator was asked to review Resident #1's clinical chart. When asked if there was a care plan for Depression, behaviors and suicidal ideation, she responded, "No. There is not." When asked if there were any behavioral flow sheets, she responded, "No. There is not." When asked if there was an admission checklist of resident belongings, she responded, "No. There is not." In an interview with the Medical Director on [DATE] at 2:45 p.m., he stated he had been made aware Resident #1 was found un-responsive, with a syringe in her hand, eight days ago. The Medical Director stated he did not have personal knowledge of Resident #1, as he was not the attending Physician. When asked if he was aware the nurses did not initiate a care plan for Depression/Suicidal Ideation, he responded he was not. When asked if he was aware there was no checklist of Resident #1's personal belongings upon admission, he stated he was not. When asked if he was aware there were only two documented observations regarding mood, affect or behavior for the resident's 33-day stay in the facility, he did not respond. When he was asked if he was aware both observations were of abnormal behaviors, and no Physician was notified, he stated he was not. In an interview with Physician A on [DATE] at 9:45 a.m., he stated he saw Resident #1 in the facility with Resident #1's family member present. He stated Resident #1 did not seem depressed or at risk. When asked if he expected the facility staff to assess mood/affect/behaviors on a routine basis in a resident with a Psychiatric history and recent suicide attempt, he responded, "Definitely!" The facility's CMS-802 provided by the facility reflected 35 residents were diagnosed with [REDACTED].