Every finding on record at Legacy at Corsicana Rehabilitation and Healthcare

Based on interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of seven residents (Resident #1) reviewed for post fall neuro assessments. The facility failed to complete neuro checks on Resident #1 after a fall on 5/13/2026 at 7:30 am, 8:30 am, 10:30 am, and 12:30 pm. This failure could cause residents injuries, pain, hospitalization and decreased quality of life. Findings include:Review of Resident #2's face sheet dated 6/1/2026 reflected he was an [AGE] year-old male admitted on [DATE] with diagnoses that included: acute respiratory failure with hypoxia (inadequate oxygen distribution to the body tissues), muscle wasting, chronic obstructive pulmonary disease (progressive, irreversible lung disease that restricts airflow), hypertension (high blood pressure), hyperlipidemia (high cholesterol), malignant neoplasm of broncos or lung (lung cancer) and dementia. (decline in mental abilities) Review of Resident #2's admission MDS dated [DATE] reflected a BIMS of 1 suggesting severe cognitive impairment. Review of Resident #2's care plan dated 6/1/2026 reflected the following focus: The resident is risk for falls [related to] confusion, deconditioning, gait/balance problems, incontinence. 5/13/2026 observed on floor beside bed - no injury. Review of progress dated 5/13/2026 at 4:30 am reflected: Summoned to room by staff member. Notified that resident was half way off the bed. On entering the room this nurse noted residents torso on the floor. posterior torso against the floor while [bilateral extremities] still on the bed. Complete [head to toe] assessment done [no apparent] injuries noted.I dont know.states [resident] when asked what happened. Assist [x2] back to bed. MD. RP & DON notified. Encouraged to use c/I for assistance. verbalized understanding. [call light] functional & [within] reach. No Pain.Resident Statement: I dont know. states when asked what happened. Review of Fall event note dated 5/13/2026 at 4:30 am reflected 2. Fall1. Location Event Occurred1) Resident Room2. Unwitnessed or Hit Head? (select all that apply)[box checked] 1. UnwitnessedFall3. (Select all that apply)[box checked] 9. Discovered on floor Review of neuro assessments for Resident #2 in the EMR on 6/1/2026, reflected assessments were not completed for 5/13/2026 at 7:30 am, 8:30 am, 10:30 am, and 12:30 pm. Further review reflected an off-cycle neuro assessment was completed at 9:30 am. During an interview on 6/1/2026 at 1:54 pm DON stated any unwitnessed fall the staff are supposed to initiate neuro checks. If it was witnessed fall with head injury, neuro checks should also be done. She stated she was not aware that some neuro checks for Resident #2 had been missed. She stated potential injuries or changes in condition could be missed if neuro checks are not done. During an interview on 6/1/2026 at 2:55 pm MD stated he had seen Resident #1 a few times after his admission and he saw him on 5/13/2026 and he was admitted to hospice later than day. MD stated Resident #1 had lung cancer with hypoxia and significant dementia. He stated he had recommended hospice to FM about 2 weeks prior as Resident #2 was in a pretty poor state when he saw him, was not eating or drinking very much and was not going to get better. He stated any unwitnessed fall or a fall with a head injury should have neuro checks done. He stated he was not aware neuro checks were missed for Resident #2, but he was a very sick man and does not believe the resident had any injuries and this did not have any impact on his end-of-life care. During an interview on 6/1/2026 at 5:00 pm, Regional Compliance Nuse stated neuro assessments were to be completed in the EMR. She stated if an assessment stayed open in the EMR it will not trigger the next one and that is what they think happened with Resident #2 and why they had not been visible. She stated the neuro checks were completed on night shift, but several were missed on day shift by Nurse A. She stated her expectation was that neuro assessments would be completed timely or they could potentially miss a decline in cognition status for the resident. She stated it is DON's responsibility to make sure neuro checks are completed in the EMR. During an interview on 6/1/2026 at 5:10 pm, DON stated she was responsible for getting the neuro assessments done and she was able to get information on falls in the morning meeting so she would know who was supposed to be getting neuro checks. She stated Nurse A had missed several neuro checks on Resident #2 that day. During an interview on 6/1/2026 at 5:24 pm, Nuse A stated she had been working 6 am to 6pm on 5/13/2026 and she was aware that she had missed some neuro checks on Resident #2. She stated, that morning was busy - that is not an excuse - but I recall it being very busy. She stated the EMR should trigger neuro checks but even if it did not, she knew what needed to be done when she got a fall passed on in report. Nurse A stated it was the nurse's responsibility to complete the neuro checks, and she had been checking on him frequently because of the decline in his condition and going on hospice, but she had not documented any of this in the EMR so she could not prove it had been done. She stated not doing neuro checks could potentially cause them to miss a patient decline due to an injury from the fall - head injury from a fall - ultimately - depending on severity, they could get very sick even death. Review of an email from Senior VP of Clinical Services daated 6/1/2026 at 2:56 pm reflected the neuro assessment schedule as follows in EMR: Per [EMR] the first neuro is done on the fall event note then triggered:Every 15 minutes x4, thenEvery 30 minutes x2, thenEvery 1 hr x2, thenEvery 2 hr x2, thenEvery 8hr x 8. Review of undated Facility Policy Neurologic Checks reflected: Neurologic checks are a combination of objective observations and measurements done to evaluate neurologicstatus. The results of the checks assist to determine nervous system damage and/or deterioration.Goals1. The caregiver will identify changes indicating progressive improvement or deterioration in neurologicstatus.2. The resident will be free from injury.

Based on interviews 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, are reported immediately for one of seven (Resident #2) Residents reviewed for abuse and neglect. The ADM failed to report an allegation of abuse from Resident #2 on 5/14/2026 to the state agency. This failure placed residents at risk of not being protected from abuse, neglect, or exploitation.Findings include: Review of Resident #2's face sheet dated 6/1/2026 reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: heart disease, muscle wasting, high blood pressure, type 2 diabetes mellitus (blood sugar regulation disorder), hyperlipidemia (high cholesterol), hearing loss, and enlarged heart. Review of Resident #2's quarterly MDS dated [DATE] reflected a BIMS of 4 suggesting severe cognitive impairment. Review of Resident #2's census record in the EMR reflected she was discharged on 5/11/2026. Review of hospice progress note dated 6/1/2026 by HN reflected: 5/14/2026-WHILE AT [facility] VISITING WITH OTHER [agency] HOSPICE PATIENTS, THIS RN NOTIFIED [HR], HUMAN RESOURCES AND [ADM] IMMEDIATELY UPON ARRIVAL OF ABUSE ALLEGATIONS THAT [Resident #2] HAD STATED TO THIS RN. RN EXPLAINED EVENTS OF THE ALLEGATIONS:PT CLAIMS WHEN SHE WAS LIVING AT facility] THAT A BIG TALL AFRICAN AMERICAN MAN THAT WORKED AS EITHER AN AIDE OR A NURSE GRABBED HER LEFT WRIST AND PULLED HER ONTO THE FLOOR AND STATED THIS HAS HAPPENED PREVIOUSLY BUT PT UNAWARE OF DATES OF EITHER OCCURENCES. PT HAS BRUISING PRESENT TO LEFT WRIST. FAMILY AWARE AND PRESENT DURING THE ACCUSATIONS. RN INFORMED PT THAT SHE IS AT A DIFFERENT FACILITY AND THAT SHE IS SAFE.[facility] ADMINISTER AND [facility] HR WERE MADE AWARE THAT FAMILY WAS PRESENT DURING ALLEGATIONS AND THAT THEY ARE AWARE AS WELL. [ADM] STATED THAT SHE WAS NOT PLANNING TO REPORT ALLEGATIONS TO STATE. [Hospice Agency] REPORTED ALLEGATIONS OF ABUSE TO STATE. During an interview on 6/1/2026 at 11:50 am, HN stated she visited Resident #2 on 5/12/2026 at the facility she had been transferred to and the Resident told her, She was pulled by the left wrist out of her wheelchair to the floor by the big black man. HN stated Resident #2 could not provide a date or time frame in which this happened. HN stated she assessed Resident #2 in the wrist area and noticed some discoloration but was not sure if it was bruising or skin discoloration due to aging. HN stated on 5/14/2026 while at the facility, she spoke to the ADM and HR staff in person and informed them of the abuse allegations. HN stated the ADM stated she would not be reporting this to the state. During an interview on 6/1/2026 at 12:20 pm ADM stated HN spoke to her on 5/14/2026 and mentioned Resident #2's allegations that she had been grabbed. She stated she immediately called the FM and he stated he did not feel like they had mistreated her. She stated she did not report it because she didn't feel like she had been abused and she was not aware of any injuries or bruising. She stated she doesn't remember the conversation with the HN word for word. She stated the day before she transferred to the other facility, Resident #2 had been aggressive with staff, hitting the staff, hitting the doors, and trying to get out the door of the facility. She stated it was her responsibility to report any allegation of abuse or neglect and if potential allegations are not reported - if someone is in danger - they could get hurt. During an interview on 6/1/2026 at 12:28 pm, FM stated he was aware of the allegations from Resident #2. He stated he had no concerns with Resident #2's care while at the facility. He stated he had been aware of Resident #2 being very disruptive and exit seeking the day before they transferred her. He stated the ADM called him on 5/14/2026 and asked him about the allegations and he honestly did not see anything there as far as abuse. He stated he did not notice any bruising on her left wrist, but she did have some discoloration on her wrists and arms. He added that Resident #2 is older and had changes to her skin so he could not say it was bruising. He stated he had no suspicions of abuse or neglect and had been up to the facility at all hours of the day or night and does not think anyone would have done anything to harm her. During an interview on 6/1/2026 at 1:41 pm, ADO stated he was not aware of the allegation of abuse from Resident #2 until today and there was no bruising noted when she arrived at the other facility on 5/11/2026. He stated ADM normally calls him on everything and thinks this is an isolated case and not a pattern. She usually reports everything- it's a one-off situation. ADO stated it is the ADM's responsibility to report all allegations of abuse or neglect per the provider letter and that he would be doing an in-service with her that day. He stated unreported abuse or neglect could lead to us not knowing a situation in the facility. Review of skin assessment for Resident #2 dated 5/11/2026, from the facility she transferred to reflected: 3. Check if the resident has any of the following. If so describe in the space provideda. bruisea Nob. Skin Teara. Noc. Abrasiona. Nod. Lacerationa. [NAME]. Surgical Incisiona. No i. Other skin findingsseveral dark skin spots sporadic on arms, back and lower legs. Review of undated Facility Policy Abuse and Neglect reflected: C. Prevention3. All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated asper facility protocol. Investigations will be reviewed by the facility administrator and/or AbusePreventionist within 24 hours of complaint. Appropriate notification to state and home office will be theresponsibility of the administrator and per policy. E. Reporting3. 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. Thefacility administrator or designee will report to HHSC all incidents that meet the criteria of ProviderLetter 2024-14 dated 8/29/24.a. If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2hours of the allegationb. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24hours of the allegation.

Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 3 of 5 residents (Resident #1, Resident #23, Resident #60) reviewed for comprehensive care plans. 1. The facility failed to indicate what Resident #1's communication problem was related to, and why he required tube feeding.2. The facility failed to indicate what Resident #23 was allergic to, what her pain level goals were, what her pain was aggravated by and what alleviated her pain, and her discharge plans.3. The facility failed to indicate what Resident #60's swallowing problem was related to, why he required tube feedings, and how many cc's of gastric contents were needed in order to hold a tube feeding. These failures could place residents at risk for not receiving necessary care and services or having important care needs identified and met.Findings included:Review of Resident #1's comprehensive MDS assessment dated [DATE] reflected a[AGE] year-old male who admitted to the facility on [DATE]. He had the following diagnoses: Gastroesophageal Reflux Disease (chronic condition where stomach acid flows back into the esophagus), septicemia (blood poisoning), seizure disorder (neurological condition characterized by recurrent, unprovoked seizures), muscle wasting and atrophy, and dysphagia (difficulty swallowing). In section K - Swallowing/Nutritional Status Resident #1 was indicated as having a feeding tube On Admission, While not a resident, and While a resident. Resident #1 had clear speech, was able to make himself understood, and was able to understand others. Resident #1 had a BIMS score of 04, indicating severe cognitive impairment.Review of Resident #1's comprehensive care plan dated 01/22/2026 reflected a focus of The resident has a communication problem r/t and The resident requires tube feeding r/t initiated by the CCN.In an observation/interview on 02/18/2026 at 10:26AM with Resident #23 she stated that she had been in and out of the hospital related to her heart recently. She stated that it caused her pain frequently, and so did her arm that she received physical therapy for. She stated that her body was tired a lot due to dialysis and physical therapy. She stated that taking medication, doing physical therapy, and going to sleep were all ways in which her pain was alleviated. Review of Resident #23's comprehensive MDS assessment dated [DATE] reflected a [AGE] year-old female who admitted to the facility on [DATE]. She had the following diagnoses: coronary artery disease (when the coronary arteries become narrowed or blocked due to plaque buildup), heart failure (when the heart muscle is unable to pump enough blood to meet the body's needs), renal failure (when the kidneys can no longer effectively filter waste and toxins from the blood), diabetes (chronic condition where the body cannot properly use blood sugar), cirrhosis of liver (chronic condition in which healthy liver tissue is replaced by scar tissue), fibromyalgia (widespread pain and other symptoms such as fatigue, muscle stiffness, and insomnia), and chest pain. The MDS indicated she had not had any falls since admission. In Section J - Health Conditions, under the question Should Pain Assessment Interview be conducted? the answer was Yes. In the Pain Assessment Interview Resident #23 indicated she had not experienced pain in the last 5 days, therefore the assessment was concluded. Resident #23 had a BIMS score of 15, indicating intact cognition. Review of Resident #23's comprehensive care plan dated 02/17/2026 reflected a focus of Allergic to (specify) a goal of will not receive (specify) over the next 90 days. A goal of The resident's pain level goal is (__). The resident will maintain or have a lower pain level than this number. Interventions of The resident's pain is aggravated by: (specify) and The resident's pain is alleviated/relieved by: (Specify) A focus of Discharge from the facility is not feasible as evidenced by (reason discharge is not feasible).Review of Resident #23's physician orders active as of 02/17/2026 reflected allergies of iodine, lidocaine, sulfa antibiotics, and TAPE. Resident #23 had the following orders related to pain: Acetaminophen 500 MG every 6 hours as needed for pain. Diclofenac gel applied two times a day to knees for pain. Pregabalin 100 MG 1 time a day for pain in right shoulder. Tramadol 50 MG 3 times a day related to pain in right shoulder. In an observation/attempted interview on 02/17/2026 at 10:55AM with Resident #60, he was observed lying in bed with the head of bed elevated, when asked questions by the state surveyor he made noises but did not answer coherently. Review of Resident #60's comprehensive MDS assessment dated [DATE] reflected a [AGE] year-old male who admitted to the facility on [DATE]. He had the following diagnoses: stroke (sudden interruption of blood flow to the brain), anemia (deficiency of healthy red blood cells), high blood pressure, and pneumonia (infection that inflames the air sacs in the lungs). In section K - Swallowing/Nutritional Status, Resident #60 was coded as having a tube feeding upon admission and while a resident. He was indicated as receiving 51% or more of his total calories by tube feeding, and his average fluid intake per day by tube feeding was 501 cc a day or more. Resident #60 had a BIMS score of 02, indicating severe cognitive impairment. Review of Resident #60's comprehensive care plan dated 02/18/2026 reflected a focus of The resident has a swallowing problem r/t, initiated by the MDSC. The resident requires tube feeding r/t. An intervention of Check for tube placement and gastric contents/residual volume per facility protocol and record. Hold feed if greater than (X) cc aspirate initiated by LVN K.Review of Resident #60's physician orders active as of 02/17/2026 reflected an NPO diet, an enteral feed order and to keep HOB elevated 30-45 degrees at all times, aspiration precautions. Resident #60 had an enteral feed order for 1 carton of 250 ml five times a day. In an interview on 02/19/2026 at 1:44 PM with the SCNA, she stated that she had been working at the facility for about 3 months. She stated that she provided care to Resident #23 and was assigned to work with her today. She stated they (CNA's) would chart certain tasks in the computer such as, the amount of food eaten by the resident, if the resident showered. She stated the nurse or med aide charted pain levels. She stated that she was not aware of Resident #23 complaining of pain, and that the nurse or medication aide could administer pain medication if needed. She stated that nurses or family could notify CNA's of what was on the resident's care plan, but she did not have access to the care plan itself. In an interview on 02/19/2026 at 1:48 PM with MA C, she stated that she passed medications to Resident #23. She stated that she was not responsible for charting resident pain levels, unless the nurse told her to. She stated that Resident #23 received routine Hydrocodone, and that Resident #23 complained of pain approximately a couple times a week . She stated she had access to the POC (it would tell her resident ADL needs, showers, anything in the care plan), or the nurse could tell her what was on the resident's care plan. She stated if she had questions about a care plan, she could ask the nurse or the social worker. She stated she thought therapy aggravated Resident #23's pain and that medication or going to lay down in bed would usually alleviate the resident's pain. In an interview on 02/19/2026 at 1:59 PM with LVN K, she stated that she became the ADON about 2 weeks ago, before she worked on the floor as an LVN for about 8 months. She stated that regarding Resident #60's care plan she was not aware of the care plan being incomplete. She stated that he required tube feeding d/t stroke. She stated the cc's should have been 100. She stated that best practice as a nurse was to check for residual (malabsorption, stomach being too full) before administering a feeding. She stated that she would update the care plan. She stated that everyone (department heads) could modify the care plans.In an interview on 02/19/2026 at 2:38 PM with LVN D, she stated that she had been working at the facility for 2 years as an MDSC. She stated that everyone (department heads) could edit the care plans and not just one person was assigned to oversee them. She stated the DCS could see what was on the care plan from the Kardex. She stated that for Resident #60, the swallowing problem was r/t to his CVA. She stated that Resident #60's comprehensive care plan was due on 2/18/2026, so it was recently completed, and she thought she had been working too fast and missed the specifics on some areas. She stated she was also responsible for not accurately completing Resident #1's care plan and that she was just working too fast. In an interview on 02/19/2026 at 3:15 PM with the DON and ADM, they stated their expectations regarding care plans were that they were done completely and accurately. They stated that all department heads could access and edit the care plans, and at the time there was no one person that went back and checked for accuracy, they could correct things as they were made aware. They stated that the DCS would use the Kardex to understand the care plan, but the nurses would have access to the full care plans. The DON stated that it was standard practice as a nurse, that before going to administer a tube feeding, the nurse should check for residuals and not administer a feeding if there was 100 CC's. In regard to Resident #23's allergies, they stated that resident allergies were posted in red lettering under the resident name in the computer, and for dietary, allergies were printed on the meal tickets. In an interview on 02/19/2026 3:26 PM with the CCN, she stated that she assisted the facility staff with care plans. She stated that she activated the CAA's to go over with the families. She stated that once the CAA's were activated, they discussed it with the family. She stated that MDS would go in an update the care plan within 21 days of admission. She stated the issue with Resident #23's care plan did not cause any harm because allergies were listed in red in the PCC home screen, and dietary would have it printed on tickets. She stated that if anywhere on the UDA had pain indicated, it would transfer to the baseline care plan. She stated MDS was responsible for ensuring accuracy. Review of the facility's policy titled Comprehensive Care Planning undated, reflected: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.The comprehensive care plan will describe the following - The residents' goals for admission and desired outcomes.Each resident will have a person-centered comprehensive care plan developed and implemented to meet his otherpreferences and goals, and address the resident's medical, physical, mental and psychosocial needs. Residents' goals set the expectations for the care and services he or she wishes to receive. Measurable objectives describe the steps toward achieving the resident's goals, and can be measured, quantified, and/or verified.The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventionsare the specific care and services that will be implemented.

Based on observation, interviews, and record reviews, the facility failed to ensure the resident's right to secure and confidential personal and medical records for 1 (unknown resident) of 21 residents.The facility failed to ensure the privacy of the unknown resident by not locking the laptop screen on the medication cart, so the resident's information could not be seen by someone walking by.This failure puts residents at risk for confidential health information exposure, and decreased quality of life. Findings included:In an observation on 02/18/2026 at 9:17AM, a med cart was parked in front of room [ROOM NUMBER] unlocked. MA A was behind a privacy curtain administering medication. The computer screen was visible with unknown residents' medication medical information. The MA could not see medication cart from behind the curtain In an interview on 02/18/2026 at 10:00 AM, MA A stated she could not see the medication cart from where she was in the resident's room behind the privacy curtain. MA A stated every time she stepped away from the medication cart the screen should not be visible. She stated she had been trained on locking the computer screen when not in direct line of eyesight or in use. She stated she had been checked off on medication pass yearly by the pharmacist and as needed by the DON. MA A stated negative effects for leaving screen visible was that medical records could be seen, violating resident rights.In an interview on 02/18/2026 at 2:44 PM, the DON stated she had worked for facility for 8 weeks as interim DON. The expectation was that when the medication aide was passing pills the computer screen should be closed so no one could see resident information. She stated the medication aides were monitored by the pharmacy consultant who made medication pass observations with the medication aides. She said the Administration nurses also do random audits as needed. The DON stated leaving the computer screen visible would lead to violations of resident rights to privacy. In an interview on 02/18/2026 at 2:52 PM, the ADM stated she expected the cart to be locked and computer screen where no patient information was visible when the medication cart was not in use. The ADM said Supervisors monitored by spot checking the medication carts and educating the medication aides as needed on privacy. The risk included resident rights to privacy violation, others could potentially have access to other resident private medical information.Record review of facility policy titled RESIDENT RIGHTS undated reflected Privacy and confidentiality - The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals were in locked compartments and inaccessible to unauthorized staff, visitors, and residents for 1 of 2 medication carts (Med Cart #1) reviewed for medication storage in that:The facility failed to prevent Med Cart #1 from being unattended and unlocked in front of room [ROOM NUMBER] on 02/18/2026.This failure could allow residents, visitors, staff, and unauthorized individuals unsupervised access to prescription and over-counter medications.Findings included:In an observation on 02/18/2026 at 9:17 AM a med cart was parked in front of room [ROOM NUMBER] unlocked. MA A was behind a private curtain with a resident. The screen was visible with unknown resident information. A box of eye lubricating drops was on top of the medication cart. There were other unknown residents in wheelchairs with their family members in the hallway.In an interview on 02/18/2026 at 10:00 AM, MA A stated she could not see the medication cart from where she was. MA A stated that every time she stepped away from the medication cart all medications and the cart should be locked up and secured. She stated she had been trained on medication storage and locking the cart when not in direct line of eyesight or in use. She stated she had been checked off on medication pass yearly by the pharmacist and as needed by the DON. MA A stated negative effects for leaving medications out and an unlocked medication cart was that medications could be accessed by another person family or residents that walked by.In an interview on 02/19/2026 at 2:44 PM, the DON stated she had worked for facility for 8 weeks as interim DON. The expectation was that when the medication aide was passing pills all medications were put away and the medication cart locked. She stated the medication aides were monitored by the pharmacy consultant who made medication pass observations with the medication aides. She said the Administration nurses also do random audits as needed. She stated administration staff also monitor by making rounds frequently throughout the halls and monitored daily. She stated leaving the cart unlocked could result in medication being in the wrong hands.In an interview on 02/19/2026 at 2:52 PM, the ADM stated she expected the medication cart to be locked and all medications locked away. The ADM said Supervisors monitor by spot checking the medication carts and educating the medication aides as needed on locking the cart. The ADM said risks included other residents or visitors could potentially have access to other medication that was not assigned to them. Record review of facility policy titled Medication Storage in the Facility dated 2025 reflected, Medications and biologicals are stored safely, securely, and properly following manufacturers recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on observations, interviews and record reviews, the facility failed to ensure each resident was provided with food that accommodates resident allergies, intolerances, and preferences for 2 (Resident #34 and Resident #36) of 3 residents reviewed for food and nutritional services.1. The facility failed to provide Resident #34 with an alternative or substitute meal of similar nutritive value to the main meal served during lunch service on 2/17/2026. 2. The facility failed to provide Resident #36 with an alternative meal that took into consideration the resident's preferences and condition during lunch service on 2/17/2026 These failures placed the residents at risk of weight loss, malnutrition, pain and discomfort, and a diminished quality of life. Findings included:Review of Resident #34's face sheet on 2/19/2026 reflected a [AGE] year-old female admitted to the facility on [DATE], with diagnoses including malignant neoplasm of head of pancreas (pancreatic cancer), hypertension (high blood pressure), Type 2 Diabetes Mellitus (metabolic disorder related to the body's resistance to insulin or the pancreas' failure to produce enough insulin), Hypercholesterolemia (high cholesterol), and Major Depressive Disorder Recurrent (repeated episodes of major depression). Review of Resident #34's comprehensive MDS admission assessment dated [DATE], revealed the resident had a BIMS score of 13, which indicated mild cognitive impairment. Furthermore, the assessment revealed Resident #34 utilized a nutritional approach in the form of a therapeutic diet (e.g. low salt, diabetic, low cholesterol) while a resident at the facility and within the prior 7 days of the assessment. Resident #34's oral/dental status was assessed to have obvious or likely cavity or broken natural teeth, inflamed or bleeding gums or loose natural teeth, and mouth or facial pain, discomfort or difficulty with chewing. Review of Resident #34's progress notes revealed the following:2/17/2026 22:33 Resident on oral antibiotic therapy amoxicillin 875 mg po for treatment for dental infection no adverse reaction noted2/17/2026 16:47 Resident continues on oral antibiotic therapy amoxicillin 875 mg po for treatment for dental infection no adverse reaction noted at this time2/16/26 22:57 Resident on oral antibiotic therapy amoxicillin 875 mg po for treatment for dental infection no adverse reaction noted2/13/26 10:28 Returned from appointment [at local dental clinic] .[prescribed] Amoxicillin 875mg 1-tab po twice day x 7 days for dental infection; RP inquired about issues resident is experiencing [with] her pancreas 2/13/26 20:54 Initial dosage administered at 8:30p.m on 2-13-26. Amoxicillin Oral Tablet 875mg bid x 7 days related to dental infection.2/11/26 17:44 .poor appetite. Refused lunch and supper. Offered a health shake. Pending consummation. Staff to monitor. Review of Resident #36's face sheet on 2/19/2026 revealed a [AGE] year-old female resident admitted to the facility 1/14/2022 with diagnoses that included unspecified dementia (a decline in cognitive function and memory), protein calorie malnutrition (a condition caused by insufficient intake of protein and calories), and hyperlipidemia (lipids or fats in the blood). Review of Resident #36's annual comprehensive MDS assessment dated [DATE] revealed the resident had a BIMS score of 15, indicating intact cognitive functioning. The assessment revealed no nutritional approaches had been utilized by the resident. The resident's oral/dental status indicated the resident had no natural teeth or tooth fragments. Review of Resident #36's progress notes revealed the following:02/17/2026 14:03 Promethazine HCl Tablet 25 MG Give 1 tablet by mouth every 6 hours as needed for Nausea and Vomiting02/17/2026 13:37 Promethazine HCl Tablet 25 MGGive 1 tablet by mouth every 6 hours as needed for Nausea and Vomiting c/o nausea2/16/2026 13:35 Promethazine HCl Tablet 25 MGGive 1 tablet by mouth every 6 hours as needed for Nausea and Vomiting2/16/2026 1259 resident at nurses' station dry heaving NO vomit at this time. Resident states she is nauseas Observation and interview of Resident #36 on 2/17/2026 at 12:27 PM revealed the resident sitting alone near a dining table in her wheelchair. The resident was not eating from any served plate and appeared discontent. The resident shared that she had not been feeling well for the last few days. She stated that she had been throwing up and had an upset stomach. The resident stated that she requested a bowl of soup instead of the alternate meal provided, which was a meat and cheese sandwich and potato chips, but staff refused. Record review of Resident #36's printed meal ticket on 2/17/2026 at 12:27 PM reflected no indication that the resident was served an alternate or substitute meal. The ticket reflected the resident's dislikes: fish/tuna, tomato products, tomatoes (fresh or cooked) and juice. The special notes section of the ticket stated the resident was allergic to tomatoes and apple juice, and DON'T EAT BEEF OR PORK ALL THE TIME, JUST SOMETIMES. Observation on 02/17/2026 at 12:30 PM of the facility's only dining room, revealed no alternate menu posting. Observation and interview on 2/17/26 at 12:27 PM of Resident #34, revealed the resident sitting alone at a dining table in her wheelchair attempting to eat a plain meat and cheese sandwich cut in half and with a side of crumbled potato chips. When asked if the resident was satisfied with her meal she stated not really. She said that she had been unable to bite or chew due to dental problems and mouth, gum and tooth pain. The resident stated that she had been to a dentist recently and was being treated for an infection. The resident indicated that she was missing most of her teeth which also contributed to her inability to chew food. The resident stated that she requested the alternate menu today and was served the observed sandwich and chips. She thought the sandwich might have been soft enough for her to chew, but it was not. Record review of Resident #34's printed meal ticket on 2/17/2026 at 12:32 PM reflected the resident's dislikes to be rice, raw celery, raw apples, raw apricots, lettuce, salads, and raisins. The special notes section of the ticket stated, NO SPICY FOOD NO CHOCOLATE. Under the special notes section handwritten in pen it stated, Sandwich Chips. In an interview on 02/17/2026 at 12:30 PM DC A stated that the microwave in the kitchen was broken and they could not heat up the individual soups from the always available menu. When asked if they could use the stove to heat up the soup, she questioned the surveyor about using the stove for 1 little soup. The cook stated they did have always-available menu, but it was not posted. Some of the items she listed were a chef's salad, tomato soup, and sandwiches. In an interview on 2/17/2026 at 12:35 PM the DM stated that kitchen staff were in the process of heating up soup for Resident #34 and Resident #36. The DM stated that DC A should not have refused or denied Resident #36's request for soup. The DM stated that residents usually let them know in advance if they want an alternative menu item. She said often when alternative menu items were requested by residents it was usually for a sandwich and chips, so that was what was served to the residents. In an interview on 2/19/2026 at 3:00 PM the ADM stated that it was her expectation that facility policies be followed regarding honoring resident requests for alternative menu items and staff should never refuse a resident's request for an alternative menu item out of convenience for staff. The ADM stated that was not the typical practice of the staff at the facility. Record Review of the facility's Dietary Services Policy & Procedure Manual FP 00-10.0 regarding menu approval and honoring resident special requests, and food brought to the facility from unapproved sources, reflected the following: 4. Every attempt will be made to honor resident food preferences the facility has a five week cycle menu that can be modified by the dietary manager to meet the preferences of the majority of the residents in addition an appealing option of similar nutritive value is provided for each meal for those residents who do not like the main menu items being served there are other items that can also be prepared on demand when a resident does not like the main menu or alternate option these include sandwiches soup salads fruit and other foods that can be prepared quickly if the resident has notified the kitchen of an available food request that can be prepared prior to the meal this item will be provided when the meal tray is prepared and usual sequence if the resident receives his or her meal and then requests an alternate option or substitute that will require additional preparation prior service then it will be provided once the other residents have been served their meal.

Based on observations, interviews, and record reviews, the facility failed to update and follow posted menus in accordance with professional standards for all residents for 1of 2 meals observed. The facility failed to follow their posted lunch menu for Tuesday, 2/17/2026.The facility failed to update their posted lunch menu for Tuesday, 2/17/2026 when a substituted menu was provided. These failures could place residents at risk for dissatisfaction with their meals and decreased nutritional intake. Findings included: Observation of the kitchen on 2/17/2026 at 11:43 AM revealed kitchen staff preparing white rice, a variety of combined meats with vegetables, including chopped chicken and sausage, and individual servings of ribs with no apparent sauce. In an interview on 2/17/2026 at 11:43 AM, DC A stated the meal being prepared was jambalaya in honor and in celebration of Mardi Gras. In an interview on 2/17/2026 at 11:43 AM, the DM stated that the facility was celebrating Mardi Gras with themed activities and foods, which included serving jambalaya and other traditional type foods. Observation on 2/17/2026 at 12:10 PM of residents' plated and served meals in the facility's only dining room revealed residents were served a combination of white rice, vegetables and meat along with a cupcake for dessert, tea, and a roll. No concerns with the appearance of the meal or its nutritional value were noted. In an interview on 2/17/2026 at 12:20 PM, Resident #41 stated that he enjoyed the meal he was served. The resident stated that the meal tasted good and the portion sizes and variety met his needs and preferences. The resident indicated the meal served was not what was listed on his meal ticket or what was expected as he was not served baked macaroni and cheese or apple cobbler, but the resident expressed satisfaction with the meal and had no complaints. The resident stated that he was typically served what was listed on the menu or on his meal ticket. The resident denied suffering from unwanted weight loss, appetite loss, or problems related to the food served at the facility. Observation of residents in the facility's only dining room on 2/17/2026 at 12:21 PM revealed the residents consumed most, if not all, of the meal that was served without complaint or dissatisfaction expressed. Record review of residents' individually printed meal tickets on 2/17/2026 from 12:23 PM to approximately 12:30 PM revealed the meal tickets did not correctly reflect the meal the residents were served. The residents' meal tickets indicated the following items were served: Entree 3 oz GR Chicken QTR w/ BBQ Sauce Starch 1/2 C Baked Macaroni & Cheese Vegetable 1/2 C Homestyle Grean Beans Bread 1 Ea Margarine Dessert 1/2 C Apple Cobbler Beverage 8 fl oz Iced Tea Observation of the facility's only dining room on 02/17/2026 at 12:30 PM, revealed the posted menu for 02/17/2026 did not match what residents were being served. Record review of the posted printed Weekly Menu For Creative Solutions FW 25-26 - Week 1 Regular Diet on 2/17/2026 at 12:35 PM reflected the lunch menu for Tuesday, 17-FEB to be BBQ Chicken Quarter, Baked Macaroni and Cheese, Homestyle [NAME] Beans, Honey Kissed Roll, Apple Cobbler, Iced Tea. No modifications or changes were observed to have been made to the posted printed menu. In an interview on 2/17/2026 at12:35 PM, the DM stated that residents' meal tickets did not reflect the meal being served because the meal was a substitution initiated and implemented by their corporate office in recognition of Mardi Gras. The DM stated that she noted the substitution in her own records but did not electronically make the menu changes because she didn't know how. The DM stated that she did not make the changes to the posted printed menu because it was overlooked. In an interview on 2/19/2026 at 1:49 PM, the DM stated that she had been employed with the facility since 12/10/2025, but she had several years of prior experience working in and running kitchens in different types of establishments. The DM stated that she was comfortable in her role and could manage the facility's dietary service requirements and needs. The DM stated upon being hired she received proper orientation and training that assisted her when she assumed her supervisory role. She stated that in-service training was provided regularly and included a variety of topics including resident care and needs. The DM stated that the facility utilized an electronic menu and ticketing system. The DM stated she was not aware she could electronically override the scheduled menu and add a substituted menu in the system. The DM stated that the lunch meal served on 2/17/2026 was pre-planned and pre-approved by their corporate office. She stated that she consulted her corporate office supervisor after this issue was brought to her attention on 2/17/2026, and she was now fully aware of their system's functions, and the menu change process. The DM stated that the substitute meal and menu served on 2/17/2026 was generated by their electronic menu service, which took the residents' dietary needs into consideration when the menu was developed. The DM acknowledged that residents could have suffered negative outcomes because of the menu not being followed, such as displeasure or intolerance of ingredients, but she denied that had occurred. The DM stated that she felt supported by management and staff and the facility was a positive environment for the residents and staff. In an interview on 2/19/2026 at 2:01 PM, the DA stated she had been employed with the facility since October 2025. She stated that she received orientation and training related to her position and duties and resident care and needs. She stated that staff were regularly in-serviced on a variety of topics, not just those related to dietary services. The DA stated that she didn't manage, create or modify menus, but she was required to follow the menus unless instructed otherwise. The DA stated that the DM was responsible for managing their menus and did so well. The DA stated that the DM had made a positive difference in the kitchen since she took the position. She said the DM was supportive of the dietary staff, positive, and willing to help. The DA said the DM was knowledgeable about the management and oversite of the kitchen and has taught the dietary staff a lot. The DA said the DM was considerate of the residents' needs and preferences and made sure the residents' were happy and satisfied. In an interview on 2/19/2026 at 2:01 PM, DC B stated that she had been employed with the facility since March 2025. She stated that she received orientation and training related to her position and duties. She said she had also been trained in resident care and needs. DC B stated that she wasn't responsible for creating, managing or updating the facility's menus, but she was responsible for preparing scheduled meals according to instructions and recipes. DC B stated that the DM was knowledgeable in kitchen management and practices and had made a positive difference in the kitchen with willingness to help and teach. In an interview on 2/19/2026 at 3:00 PM, the ADM stated that the facility utilized an electronica menu management system for the development and management of their menus. The ADM stated that their corporate office was responsible for the approval of menus, including substituted menus, in accordance with and in consideration of resident's needs, preferences, and restrictions. She stated that their corporate office was also responsible for uploading their menus into their digital system. The ADM stated that the DS was responsible for updating their electronic and printed menus when menu modifications occurred, which was her expectation too. The ADM stated that the DS was new to her position, in that she began her employment in December 2025, but she had been trained on how to override and modify menus in their electronic meal ticketing system. The ADM stated that the special menu served on 2/17/2026 had been developed and served specifically to promote a positive experience and outcomes for the residents. The ADM stated that the substituted menu was well thought out, met the nutritional needs of each resident, and included items in accordance with residents' known preferences. The ADM stated that the dietary staff go above and beyond to accommodate the residents' dietary likes and dislikes, and residents have not expressed displeasure with their menus or dietary services. The ADM stated they have had no recent complaints or grievances filed about the food or menus. The ADM denied any resident suffering any negative outcome due to the modification of the menu. In an interview on 2/19/2026 at 3:20 PM, the DON stated that she had been the interim DON at the facility for 8 weeks. She stated that she has extensive experience and training in the provision of care in long-term care facilities and was aware of the possible negative impact inconsistent or unexpected menus or meals could have on residents. The DON stated that residents who were not served food or meals according to their preferences and specific needs run the risk of negative outcomes including poor appetite, malnutrition, and weight loss. The DON stated that the residents at the facility have not experienced negative outcomes because of their menus or meals. She stated that nurses conduct Ambassador Rounds daily and are required to conduct observations and monitoring during each meal service. She stated that the residents were treated well and their preferences were a priority. The DON stated that the staff at the facility were competent, caring, and invested in the overall well-being of the residents. The DON stated that the DS was knowledgeable, competent and invested in the resident's care and needs. Record Review of the facility's Dietary Services Policy & Procedure Manual FP 00-10.0 regarding menu approval and honoring resident special requests, and food brought to the facility from unapproved sources, reflected the following: 4. Every attempt will be made to honor resident food preferences. The facility has a five-week cycle menu that can be modified by the dietary manager to meet the preferences of the majority of the residents.8. The menu will reflect the religious, cultural, and ethnic needs of the resident population as well as input received from residents and resident groups, based on the facility's reasonable efforts.

Based on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 5 residents (Resident #19) reviewed for care plans. The facility failed to ensure Resident #19's care plan dated 05/31/2024 reflected the resident's recent left below knee amputation which had been updated/changed on 09/30/2024. This failure could place residents at risk of not receiving appropriate care to meet their current needs. Findings include: Record review of a facility face sheet for Resident #19 dated 11/21/24 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included peripheral vascular disease (also known as peripheral artery disease, is a condition that occurs when blood vessels narrow or become blocked, reducing blood flow to the body) (peripheral vascular disease can affect any blood vessel outside of the heart, but it most commonly affects the legs and feet), atrial fibrillation (irregular, often rapid heart that causes poor blood flow), osteoarthritis (a degenerative joint disease that causes the cartilage and bone in a joint to break down over time), cerebrovascular disease (a general term for conditions that affect the blood vessels in the brain and spinal cord, which can lead to serious complication), and white matter disease (a progressive disorder that occurs when the white matter in the brain is damaged.) Record review of Resident #19's Quarterly MDS assessment dated [DATE], reflected under Section C Cognitive Patterns, a BIMS score of 15 indicating Resident #15 was cognitively intact. Further review of the MDS assessment under Section K - Swallowing/Nutritional Status reflected resident required set-up or clean up assistance with eating, substantial/maximal assistance with toileting and showering, and partial/moderate assistance with personal hygiene. MDS reflected under Section I reflected Resident #19 had active diagnoses of peripheral vascular disease and acquired absence of left foot. Record review of Resident #19's Care Plan initiated 05/31/24 revealed a problem: Impaired physical Mobility r/t loss of balance and coordination Secondary to CVA; Muscle weakness Goal: Resident's needs will be met daily over the next 90 days. Interventions include: assist with mobility as needed daily, encourage ROM exercises as needed, may provide therapy as needed. Problem: Has an ADL self-care performance deficit r/t pain, S/P Fracture, weakness. Resident chooses to sleep in recliner at times. Goal: Will demonstrate the appropriate use of adaptive device to increase ability in ADLS. Interventions include: MOBILITY: Requires moderate assist to ambulate x 1 staff, TRANSFER: Resident requires maximal assistance for all transfers. Record review of physician orders dated 11/08/24 for Resident #19 revealed an order for Float right heel when in bed every shift. In an interview on 11/19/24 at 11:07 AM, Resident #19 stated she was doing fine. She stated she recently had her left leg amputated below her knee. She stated staff took care of everything and all treated her well. She stated she used a call light and staff got to her quickly when she called for them. She stated she participated in therapy and had learned a lot from them. She stated she had no concerns. In an interview on 11/21/24 at 11:30 AM, the MDS stated the purpose of a care plan was to explain what they treated a resident for and informed staff of the residents plan of care. She stated she was responsible for completing and revising care plans. She stated the DON, or a corporate nurse were responsible for ensuring the accuracy of the care plans. She stated she had been trained on completing and revision of care plans. She stated if a resident had an amputation, it should have been included on their care plan and it could have affected the residents ADL's. She stated she was not aware that Resident #19's care plan did not include that Resident #19 had an amputation to her left leg below her knee. She stated Resident #19's amputated left leg below the knee should have been care planned. She stated if an amputation was not care planned it could have affected how the staff knew what to do for the resident or could have affected the care or transfer of a resident. In an interview on 11/21/24 11:40 AM, the DON stated the purpose of a care plan was to have known the plan of care for the residents. She stated the MDS nurse was responsible for completing and revising care plans. She stated they had care plan meetings and revised the care plans as needed and they also had care plan meetings and went over the care plans during the meetings and made changes as needed. She stated the corporate nurse was responsible for ensuring the accuracy of the care plans. She stated the MDS nurse was trained on completing and revision of care plans. She stated if a resident had an amputation, it should be included in the care plan. She stated she was not aware that Resident #19's left below knee amputation was not included in her care plan, but that it should have been in the care plan. She stated if an amputation was not included in a care plan, staff may not know a residents correct status, and it could have affected the safety awareness or transfers. In an interview on 11/21/24 11:55 AM, the ADM stated the purpose of a care plan was to inform nursing staff of how to properly care for the resident. She stated the MDS nurse was responsible for completing and revising the care plans and she had been trained on how to complete and revise the care plans accurately. She stated the IDT reviewed the care plans quarterly and initially the MDS nurse should ensure the care plans were done correctly. She stated any amputation should be care planned. She stated she was not aware that Resident #19's left below knee amputation was not care planned. She stated Resident #19 was one of their long-term residents and she had recently gone out to have the amputation done and then to a rehabilitation hospital. She stated Resident #19's amputation should have been care planned upon her re-admission. She stated if an amputation was not care planned it may have caused confusion for the staff and if the care plan had been done, it could have provided more direction for resident positioning. Record review of the facility policy titled Comprehensive Care Plans dated 04/14/24 reflected the following documentation: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma informed. 2. The comprehensive care plan will be developed along with the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. d. The resident's goals for admission, desired outcomes, and preferences for future discharge. f. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. If the resident is non-English speaking, the facility will identify how communication will occur with the resident. The care plan will identify the language spoken and tools used to communicate. g. Individualized interventions for trauma survivors that recognizes the interrelation between trauma and symptoms of trauma, as indicated. Trigger-specific interventions will be used to identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident. 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. 7. The physician, other practitioner, or professional will inform the resident and/or resident representative of the risks and benefits of proposed care, of treatment, and treatment alternatives/options. The facility will attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record, including discussions with the resident and/or resident representative. 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

Based on interviews and record reviews the facility failed to immediately report allegations that involved abuse, neglect, exploitation or mistreatment, including injuries of unknown source or misappropriation of resident property to HHSC, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse, or result in serious bodily injury for one of five residents (Resident #1) reviewed for injury of unknown origin. The facility failed to report to HHSC, an unwitnessed fall that resulted in major injuries. Resident #1 sustained two fractures, one to her right hip (Pelvis CT shows proximal right femoral fracture with moderate displacement) and one to her right wrist (X-Ray shows right distal radius and ulnar fracture). Resident #1 was unable to provide details of how she fell . This failure placed residents at risk of not having abuse or neglect reported promptly to HHSC and being subjected to further abuse or neglect. Findings included: Review of the undated face sheet for Resident #1 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of dementia (loss of thinking, remembering, and reasoning skills), other frontotemporal neurocognitive disorder (damage to neurons in the frontal and temporal lobes of the brain), cognitive communication deficit (difficulty with thinking and how someone uses language), and muscle weakness. Review of the Annual MDS for Resident #1 dated 01/24/2024 reflected a BIMS score of 4, which indicated a severe cognitive impairment. In Section GG - Functional Abilities and Goals reflected Resident #1 ambulated independently and had no limitation in range of motion. In Section I - Active Diagnoses reflected Resident #1 was diagnosed with Non-Alzheimer's Dementia. Review of the undated care plan for Resident #1 reflected the following: The Resident is an elopement risk/wanderer related to impaired safety awareness, Resident wanders aimlessly, Resident sleeps in others rooms/beds due to cognitive impairment. The Resident's safety will be maintained through the review date. Redirect resident when found in others' rooms/beds. The resident is at risk for falls related to confusion, wandering - actual falls: 6/4/23, 6/13/23, 8/10/23, 11/28/23, 12/1/23, 1/12/24 and 2/4/24. The resident will be free of falls through the review date. The resident will be free of minor injury through the review date. The resident will not sustain serious injury through the review date. Educate the resident about safety reminders and what to do if a fall occurs. Review of a Fall Risk Evaluation dated 02/04/2024 for Resident #1 reflected the total number of falls within the last 3 months were 1 or 2 times. Under Memory and Recall Ability it reflected in the last 7 days, Resident #1 never recalled three out of four of the following: current season, he/she is in a nursing home, location of room, staff names/faces. Under Gait, it revealed, Resident #1 gait was normal. Under Mobility, it revealed Resident #1 had no limitations. Review of an un-witnessed fall incident report for Resident #1 dated 02/04/24 at 05:40 PM completed by LVN A reflected, This nurse entered Resident's room with meal tray and noted Resident laying on her right side in her roommate's bed. Attempted to assist Resident to upright position in bed, ineffective. Requested assistance from CNA staff. Upon standing, Resident immediately called out related to right hip and leg pain as well as right arm pain. Upon questioning Resident regarding pain Resident stated, I accidentally fell and hurt myself. Resident was unable to describe how fell happened. Her level of Pain was 9. Review of the progress notes for Resident #1 dated 02/04/2024 at 05:53 PM written by LVN A reflected, This nurse entered Resident's room with evening meal tray. Noted Resident laying on side in roommate's bed, shoes on floor beside bed. Attempted to help Resident sit up for mealtime. Resident unable to stand with assistance x1. Help requested from CNA staff with transfer. Upon attempted standing Resident, she called out right leg and hip pain. Resident also stated, my arm hurts too, regarding right arm. Upon questioning about what caused pain, Resident stated, I accidentally fell and hurt myself. Vitals were taken and within normal limits. Resident assisted to lying position in bed. Medical Director notified for emergency room transport due to pain and symptoms. EMS personnel arrived at the facility and Resident transported to NRH emergency room for evaluation and treatment. Review of the progress notes for Resident #1 dated 02/12/2024 at 06:36 PM written by LVN B reflected, Resident returned to facility via ambulance. Resident was diagnosed with right hip fracture and right wrist fracture. Resident had a wound vac to her right hip and a sling placed on her right wrist. Resident denies pain. Resident presented to facility with blisters and bruising to right thigh. Review of the hospital paperwork dated 02/04/2024 at 11:58 PM under Physical Summary for Resident #1 revealed, [AGE] year-old female, with advanced dementia, apparently had a fall at the nursing home on her right side. In the ER, she was noted to have both a femoral neck fracture as well as a wrist fracture on the right, currently splinted. Patient is unable to give any history secondary to dementia. The Imaging Results revealed, Pelvis CT shows proximal right femoral fracture and Wrist X-Ray shows right distal radius and ulnar fracture. During an attempted interview on 02/21/2024 at 12:45 PM with Resident #1, she was unable to explain how she sustained the multiple fractures. During an interview on 2/21/2024 at 3:20 PM with LVN A, she stated she went to assist with the trays and realized Resident #1 was not in the dining room. LVN A stated she took Resident #1's tray to her room and when she opened the door, Resident #1 was laying in her roommate's bed on her right side. LVN A stated she went to assist Resident #1 up because she was not getting up on her own. LVN A stated she realized Resident #1 was not sitting up as she normally does. LVN A stated she and CNA A attempted to sit Resident #1 up in bed and when they tried to stand her up, Resident #1 said her right leg and wrist hurt. LVN A stated there was swelling around Resident #1's wrist. LVN A stated Resident #1 was making vocal complaints of pain and they assisted her to lay back down. LVN A stated Resident #1 said she fell and hurt herself but could not tell her what happened or how she fell . LVN A stated she took Resident #1's vital signs and assessed her pain level. LVN A stated she notified everyone and called for transport to the emergency room . LVN A stated when the emergency personnel questioned Resident #1, she started talking about her grandmother which was not relevant to the questioning. LVN A stated the incident started around 5PM and she left work at 6PM and found out about the fracture when she returned to work the next morning. LVN A stated per policy, they must complete an Unwitnessed Fall Incident Report and complete notifications. LVN A stated they continue to treat any injuries or send the Resident out for further evaluation if necessary. LVN A stated by this incident not being reported to the State, there could possibly be things not being followed through or handled appropriately. LVN A stated she knows this is the purpose of reporting things to the State. LVN A stated she has never been in a situation where incidents were not reported to the State. During an interview on 02/16/2024 at 03:50 PM, CNA A stated she saw LVN A in Resident #1's room and asked if she needed help. CNA A stated LVN A said yes because she was having a hard time standing Resident #1 up. CNA A stated they both took an arm to assist Resident #1 up and Resident #1 yelled out it hurts. CNA A stated Resident #1 pointed to her right side. CNA A stated LVN A asked Resident #1 what happened, and Resident #1 said she fell . CNA A stated they repositioned Resident #1 into the bed she was already sitting. CNA A stated then LVN A sent Resident #1 out to the hospital for further evaluation. During an interview on 02/16/2024 at 04:20 PM, the DON stated she was informed by LVN A that Resident #1 told her she fell and when LVN A tried to help Resident #1 up, she could not stand, so she sent her out. The DON stated LVN A told her Resident #1 said, I did not tell anyone, but I fell and hurt myself earlier today. The DON stated she interviewed the CNAs, and no one saw or heard Resident #1 fall. The DON stated Resident #1 did not have any bruising or bleeding. The DON stated they follow the guidelines and depending on the severity and the scope, if the resident was not able to give an account, or it is an area of suspicion, it needs to be reported to the State. The DON stated everything is reported to the ADM, they complete an internal investigation, and all major injuries of a suspicious nature need to be reported to the State. During an interview on 02/16/2024 at 05:45 PM, the ADON stated in the group text she was informed Resident #1 informed LVN A she fell and due to her crying out in pain, LVN A sent Resident #1 out to the hospital for further evaluation. The ADON stated they later learned Resident #1 had sustained a fractured right hip and a fractured right wrist. The ADON stated the alleged fall was unwitnessed. The ADON stated when a Resident experiences an unwitnessed fall, you assess them and call EMS if necessary. The ADON stated a report should have been called into the Stated due to the fall being unwitnessed with major injuries and the resident not being able to say exactly what happened. During an interview on 02/16/2024 at 06:10 PM, the ADM stated at the time of the incident, Resident #1 was found laying on her right arm crooked in her roommate's bed. The ADM stated Resident #1 ambulates independently. The ADM stated LVN A reported she tried to get Resident #1 up for dinner and walk her over to her own bed. The ADM stated when LVN A and CNA A attempted to stand Resident #1 up, Resident #1 responded, Ow ow, I had an accident and fell . The ADM stated LVN A called the DON and herself to inform them Resident #1 was being sent out. The ADM stated the family member texted her on 02/4/2024 at 10:37 PM and informed her Resident #1's wrist and hip was broken. The ADM stated she did not report it as an unwitnessed fall with injury due to it not being suspicious. The ADM stated Resident #1 told LVN A she fell . The ADM stated there was no allegation of abuse or neglect. The ADM stated she conducted an internal investigation and discovered there was no foul play and the resident fell . The ADM stated she did not report the injury to the State because she did not deem it suspicious. Review of facility policy titled, Abuse Prohibition Guideline 2023 reflected the following: Injuries of Unknown Source: An injury should be classified as an injury of unknown source when both of the following conditions are met: 1. The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and 2. The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. Investigations The Health Care Center will thoroughly investigate all alleged violations/allegations and take appropriate actions. No later than 2 hours if the allegation involves abuse or results in serious bodily injury, and no later than 24 hours if the allegation does not involve abuse and does not result in serious bodily injury. Reporting 4. The Health Care Center will report allegations to the state agency in accordance with state law. (Note timeframe requirement)

Based on interviews and record review, the facility failed to ensure residents had the right to be free from exploitation and misappropriation of property for 1 of 8 residents (Resident #2) who were reviewed for misappropriation of resident property. The facility failed to protect RES #2 from CNA A stealing two items of personal jewelry on 11/20/2023 at 9:50 PM. This failure placed residents at risk for loss of possessions and the feeling of loss. Findings include: Record review of RES #2's AR indicated RES #2 was a [AGE] year-old-male who was admitted to the facility on [DATE]. RES #2 was diagnosed with Dementia, which was an impaired ability to remember, think, or make decisions that interfere with doing everyday activities. Record Review of RES #2's Quarterly MDS assessment, dated 10/24/2023, indicated RES #2 had a BIMS Score of 2. A BIMS Score of 2 indicated RES #2 had severe cognitive impairment. Record review of RES #2's CP indicated a Focus Area, initiated on 11/20/2023, which pertained to keeping valuable personal belongings in a lockbox or with family. The Goal, with a target date of 12/13/2023, was to keep valuable belongings in a lockbox, or with family members. Record review of RES #1' AR indicated RES #1 was an [AGE] year-old woman who was admitted to the facility on [DATE]. RES #1 was diagnosed with Unspecified Degeneration of Eyes. Record review of RES #1's Quarterly MDS assessment, dated 11/30/2023, indicated RES #1 had a BIMS Score of 15. A BIMS Score of 15 indicated RES #1 had intact cognition. Interview on 12/7/2023 at 10:30 AM with RES #1 revealed CNA A was in her, and RES #2's, room on the night of 11/20/2023 at 9:50 PM. CNA A was looking at RES #1's jewelry and took RES #1's rings and bracelet off her hand and wrist. CNA A was looking at the jewelry under a lamp when RES #1 demanded CNA A return her jewelry. CNA A returned RES #1's jewelry and asked RES #1 where RES #2's rings were. RES #1 told CNA A the rings were on RES #2's fingers. CNA A stopped talking to RES #1 and approached RES #2 in the hallway, just outside of RES #1 and RES #2's room. RES # 1 stated CNA A spoke to RES #2 and offered to take and clean RES #2's rings. CNA A took two rings off RES #2's fingers and proceeded to leave the facility. RES #1 stated she felt odd about the situation, reported the matter to staff, and called the police. The police responded, investigated, and recovered RES #2's rings at a pawn shop. RES #2's rings were returned on 11/27/2023. Interview on observation on 12/7/2023 at 10:35 AM with RES #2 revealed he stated he was disappointed in himself and wished he had been able to respond differently and tell CNA A she could not take his rings. RES #2 thought he could trust CNA A because she was an employee; furthermore, he did not think someone who worked at the facility would commit such an act. RES # 2 felt like he lost some ability to trust people. RES #2 was observed wearing his rings at the time of the interview. Record review of the Facility's PIR for Misappropriation of Property, dated 11/27/2023, indicated CNA A, an employee with a TA, exploited RES #2 on 11/20/2023 at 9:50 PM when she stole two gold rings. CNA A approached RES # 2 in the hallway, outside of his room, and told RES # 2 she would take 2 of his rings and have them cleaned. RES #2 handed over his jewelry, which he was wearing, and gave them to CNA A. CNA A left the facility with RES #2's property and did not return the jewelry. The PIR indicated CNA A did not respond to phone call attempts from the facility administration. Interview on 12/7/2023 at 9:05 AM with DET revealed she was the investigating officer to the report of misappropriation of property at the facility on 11/20/2023. DET stated the case was still open, but that the police department was able to track down CNA A to a local pawn shop. The DET stated CNA A was recorded on video having entered the pawn shop and sold RES #2's rings. The property was returned to RES #2 on 11/27/2023. A warrant for CNA A's arrest was initiated. Record review of CNA B written statement, undated, described she learned of the incident between CNA A and RES #2 right after it happened on 11/20/2023. CNA B walked to the parking lot and confronted CNA A about RES #2's rings and asked CNA A to come back inside to speak with the charge nurse. CNA A stated she would come back inside but did not return. It was reported that CNA A left the parking lot in her vehicle. Interview on 12/7/2023 at 2:10 PM with the [NAME] revealed the TA contracted with members of the medical field and provided them with a platform to pick up shifts from local agencies. The [NAME] stated each employee was considered a private contractor that each had to pass background checks and possess a current license in their field to be eligible for the platform. On the date of the interview, the [NAME] stated he had already removed CNA A from the TA platform, based on what he learned about CNA A having misappropriated property from RES #2 on 11/20/2023. Interview on 12/7/2023 at 2: 23 PM with the DON reflected the facility was responsible for the resident's welfare and it was the facility's responsibility to protect RES #1 and RES #2. The DON stated that the facility performed background checks before hiring an employee. Interview on 12/7/2023 at 12:45 PM with CNA B revealed she was an employee with the TA. CNA B stated the TA required drug tests, background checks, and a current license to pick up shifts on the platform. CNA B stated that TA employees do not always get to participate in regular employee trainings at the facility, but she knows to report misappropriation of property to the charge nurse and the ADM. Interview on 12/7/2023 at 3:05 PM with RN A revealed all staff must go through a background check before hired and must pass yearly employee misconduct checks. RN A stated that criminal background checks only worked if an employee had a documented criminal history, and the facility could not tell what an employee might do. RN A stated that the facility trained its employees to recognize suspicious employee behavior and report misappropriation of a resident's property to the charge nurse and the ADM immediately. Interview on 12/7/2023 at 3:10 PM with HK A revealed the facility trained housekeeping staff to respect resident's property and it was never ok to take something from a resident. HK A stated any incidents of misappropriation of property were reported to her supervisor immediately. Interview on 12/7/2023 at 3:30 PM with LVN B revealed she was trained on Misappropriation of Property as a part of facility training. Most recently, an in-service was given for Resident Rights. LVN B stated she would report suspicious behavior of an employee and misappropriation of property to the ADM. Interview on 12/7/2023 at 4:30 PM with the facility SW revealed she spoke with RES #1 and RES #2 on 11/21/2023, the morning after the incident on 11/20/2023. The SW stated that RES #1 and RES #2 were pleased with how the facility was overseeing the incident with CNA A and RES #2. The SW described RES #1 and RES #2's mood as a little sad and stated RES #1 and RES #2 were a resilient couple and did not let things get them down. Interview on 12/7/23 at 5:00 PM with the ADM revealed CNA A's first day as a TA employee at the facility was on 11/20/2023, which was the same day of the incident of Misappropriation of Property. CNA A's last date of eligibility for employment was on 11/20/2023 and CNA A has not been allowed to return to the facility. The ADM felt she did everything she could do to get RES #2's jewelry back. She stated she spoke to the police, provided pictures of the rings to the police, and kept RES #1 and RES #2 informed every step of the way. The ADM called the TA, with which CNA A contracted, and told the [NAME] what occurred. She stated the [NAME] decided to remove CNA A from the platform. The ADM stated she spent at least 30 minutes a day with RES # 1 and RES #2 since the incident on 11/20/2023 and did not notice any decline, changes in behaviors, or deviation from normal routine. The ADM stated the facility policy for valuable items was covered in Abuse Prohibition Guideline and RES #2 was counseled on wearing expensive jewelry and encouraged to keep expensive jewelry locked up or sent home with family. Record review of RES #2's PN from a clinical counseling service performed by PSY D, dated 11/27/2023, reflected a counseling session, where RES #1 and RES #2 shared grief regarding an incident, which resulted in the loss of the resident's jewelry. Support was provided and both residents stated they felt confident and appreciated how the administration oversaw the situation. Both residents reported they enjoyed living at the facility and felt safe. Record review of the facility Abuse Prohibition Guideline in-services, dated 2023, reflected Misappropriation of Property includes but is not limited to the deliberate misplacement, exploitation, or wrongful temporary or permanent use of your residents' belongings or money without the resident's consent. The Abuse Prohibition Guideline identified procedures for prevention of misappropriation of resident's property by (1) upon admission, the health care center will assist the resident and resident family to identify and mark personal possessions; and (8) the healthcare center will educate the family and residents on risks associated with keeping valuable items and options for safe keeping, such as taking them home or storing them in a lockbox.

Based on observations, interviews, and record reviews the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 3 of 23 residents (Resident #73, Resident #25, and Resident #51) reviewed for resident rights; in that: The facility failed to ensure Resident #73, Resident #25, and Resident #51 call lights were within reach. This failure could place residents at risk of needs not being met. Findings included: Resident #73 Record review of Resident #73's admission record, dated 09/27/23, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #73 had diagnoses which included: dementia (general decline in cognitive abilities), muscle wasting and atrophy (wasting [thinning] or loss of muscle), gross hematuria (visible blood in urine), need for assist with personal care, and acute myocardial infarction (heart attack). Record review of Resident #73's quarterly MDS assessment, dated 08/15/23, reflected Resident #73 had a BIMS score of 02, which indicated the resident was cognitively impaired. The resident required extensive assistance in various areas of activities of daily living such as bed mobility, transfer, toilet use. Resident #73 required limited assist for locomotion on unit, dressing, eating, and personal hygiene. Record review of Resident #73's care plan, initiated 05/24/23 and revised 07/07/23, reflected Resident #73 was care planned for has an ADL self-care performance deficit r/t Confusion, Dementia, Impaired balance with a goal of [Resident #73] will demonstrate the appropriate use of adaptive device(s) to increase ability through the review date. and had an intervention of be sure [Resident #73's] Encourage the resident to use bell to call for assistance. In an observation on 09/25/23 at 1:30 PM, observed Resident #73's call light out of reach. Resident #73's call light was sitting on a recliner behind where Resident #73 was sitting in a wheelchair. Resident #73 attempted to stand and get the call light but was unable to reach call light. In an interview on 09/25/23 at 1:32 PM, Resident #73 stated he used a call light to call for help when he needed it. Resident #73 stated he could get up and get the call light if he needed to. Resident #25 Record review of Resident #25's admission record, dated 07/27/23, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #25 had diagnoses which included: type 2 diabetes mellitus (a chronic condition that affects the way the body processes the blood sugar), muscle wasting and atrophy (wasting [thinning] or loss of muscle), history of falling, need for assistance with personal care, and dysphagia (difficulty swallowing). Record review of Resident #25's quarterly MDS assessment, dated 09/07/23, reflected the resident had a BIMS score of 02, which indicated the resident was cognitively impaired. The resident required extensive assistance for dressing and supervision in various areas of activities of daily living such as bed mobility, transfer, locomotion on and off unit, eating, toilet use, and personal hygiene. Record review of Resident #25's care plan, initiated 02/21/20 and revised 09/24/23, reflected Resident #25 was care planned for at risk for falls r/t confusion, gait/balance problems, poor communication/comprehension, psychoactive drug use, unaware of safety needs, vision/hearing problems with a goal of [Resident #25] will be free of falls through the review date and had an intervention of be sure [Resident #25's] call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. In an observation on 09/26/23 at 11:59 AM, observed Resident #25's call light not in reach and on the floor beside his bed. In an interview on 09/26/23 at 12:01 PM, Resident #25 stated the staff come quick when needed. Resident #51 Record review of Resident #51's admission record, dated 09/26/23, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #51 had diagnoses which included: type 2 diabetes mellitus (a chronic condition that affects the way the body processes the blood sugar), dementia (general decline in cognitive abilities), muscle wasting and atrophy (wasting [thinning] or loss of muscle), need for assistance with personal care, cognitive communication deficit (difficulty thinking and using language) Record review of Resident #51's Annual MDS assessment, dated 07/21/23, reflected Resident # 51 required extensive assistance for dressing and supervision in various areas of activities of daily living such as bed mobility, transfer, locomotion on and off unit, eating, toilet use, and personal hygiene. Record review of Resident #51's care plan, initiated 02/21/20 and revised 09/24/23, reflected Resident #51 was care planned for at risk for falls r/t confusion, gait and balance problems, unaware of safety needs, wandering, Dementia with a goal of [Resident #51] will be free of falls through the review date and had an intervention of be sure [Resident #51's] call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. In an observation 9/25/23 1:41PM Resident #51 was lying in bed sleeping with call light on floor rolled up next to head of the bed on the floor. In an observation 09/26/23 10:22 AM Resident #51 observed resident lying in bed, call light remains rolled up next to the head of the bed on the floor In an interview on 09/27/23 10:34 AM with Resident #51 she stated I do not know how to call for help if needed. Resident #51 appeared confused. In an Interview on 09/27/23 10:47 AM CNA B stated call lights needed to be within reach in case the resident's needed assistance. Everyone that works should have made sure the call light was within reach of the resident. Staff were educated to keep them within reach. Risk to the resident for not having call light in reach is the resident would not be able to get help if needed. In an interview on 09/27/23 10:38 AM LVN A stated call lights should be attached to beds and within reach for safety. Staff are educated on keeping the call lights within reach in the form of reminders and in-services from DON and ADON. The Certified Nurse's Aides were responsible for making sure the call lights are attached. The risk to the resident for not having access to their call light is the inability to obtain staff assistance when needed. In an interview on 09/27/23 11:41AM with DON stated all residents should have had access to a call light while in bed. All staff are responsible and should have placed call lights within reach of the residents . In an interview on 09/27/23 at 10:38 AM, the ADM stated the purpose of a residents call light was for residents to notify staff that they needed assistance. He stated if a residents call light was out of reach and the resident needed help, the time could be extended for staff to provide assistance to residents. He stated staff should have made sure residents call lights were in reach when they did their rounds because residents could knock it off the bed or something. He stated they did angel rounds every morning and they checked for the call lights being in reach. The ADM stated the staff has not been in-serviced since he had been there, and they had not had the need to in-service staff because there had been no issues with call lights. Record review of the facility's Answering the Call Light policy dated 10/2010 revealed General Guidelines bullet #5 When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on observation, interview, and record review, the facility failed to ensure residents received food that is palatable and attractive for the facility's only1 kitchen reviewed for palatable and attractive food. 1. The facility failed to provide an entree at lunch that was palatable as residents were unable to eat the pork chop served because it was tough to chew. 2. The facility failed to provide an entree at dinner that was attractive and palatable in that the meal color was brown and yellow and the potato salad had an odor. These failures could lead to a diminished quality of life and expose residents to food borne pathogens and illness. Findings included: In an interview on 08/09/22 at 9:57 AM, Resident #37 stated the food is lousy and they did get enough to eat. She said when the food was good, they only gave you a little food. She said she complained to the DM, but it didn't do any good. An observation on 08/09/2022 at 10:00 AM revealed the menu for lunch and dinner was not posted in the menu frames in the dining room. There was a menu posted titled Everyday Menu with instructions to please order 2 hours before. In an interview on 08/09/2022 at 11:23 AM, the DM stated they were serving pork chops with brown gravy, green beans, black-eyed peas and dinner roll. For dessert she served [NAME] mousse. She said the alternative meal if residents did not like the entree would be from the Everyday Menu posted outside. She said alternatives included chicken tenders, cheeseburger or a chef salad. When asked where those items were for serving, DM stated she would have to cook them to order they were not prepared until a resident did not like their meal. She was cooking today because they had a cook quit and had not replaced her yet. An observation on 08/09/2022 at 12:00 PM revealed no menu posted outside dining room except Everyday Menu. An observation and interview on 08/09/2022 at 12:20 PM revealed Resident #36's plate with a pork chop on it and black-eyed peas. He said the pork chop was tough because the cook boils them and he could not chew it. He said he doesn't have problems with his teeth or anything, the pork chop was just bad. He said if he asked for something else they would not bring him anything. He did not eat the black-eyed peas either because he did not like them. He ate green beans only for lunch because the [NAME] mousse dessert was an odd color and did not taste good. He said sometimes the food was good, but it depended on who was cooking. An observation and interview on 08/09/2022 at 12:30 PM revealed Resident #57 had a pork chop on her plate with chewed up pieces of meat in her napkin. She said the pork chop was too tough to eat and she spit it out. When asked if she asked for something else, she said she didn't know she could ask for other food. In an interview on 08/09/2022 at 12:39 PM, LVN F stated if a resident did not eat their food, they could pre-order food off the Everyday Menu or have a sandwich as an alternative. She said most of the time the food was good at the facility, but it depended on who was cooking. She said the residents preferred when COOK G prepared the food rather than DM. She said they rarely had complaints when COOK G was the cook but she was off this week. In a confidential group meeting on 08/10/2022 at 10:00 AM, the residents stated the food was not good and they have complained without much change. One resident stated they sent out my meal yesterday and the pork was hard, and I couldn't cut it . They take the plates out of plate warmer and put it under the food warmer and the food was cold by time it got to their room. One resident stated he didn't know they had anything else to eat if you don't like the meal. Another resident stated they will say they have hot dogs or corn dogs to eat and they did not have it to choose if you don't like the meal. The group stated when we asked for something else to eat, they did not have it and say they ran out of the food. They stated you can get a hamburger or cheeseburger, but you had to order it ahead of time. They did not post what the meals were in the facility and the residents did not know to order a hamburger or cheeseburger two hours ahead of time because they did not know what the meal would be. One resident stated they will post the menu ahead of time, but then the actual meal served was not the same as the one posted. They stated the variety they serve you is poor, and they will serve 2 starches at meals. For instance, yesterday they had black eye peas and green beans. An observation on 08/10/2022 at 5:30 PM reflected the dinner entree for 08/10/2022 which was bratwurst, cooked cabbage and potato salad with a slice of white bread. Banana pudding with vanilla wafers was for dessert. The color of the meal was brown and yellow and lacked appeal. The bratwurst was served alone on the plate with no condiments. It was tough to chew the outer membrane of the bratwurst. The cabbage was slimy and lacked flavor. The potato salad was unusually yellow and had an unappealing odor. In an interview on 08/10/2022 at 5:32 PM, DM stated she had not received complaints about the food recently. She said if residents did not like what was served, they could order food from the Everyday Menu as a substitute. She said the bratwurst, cabbage and potato salad were usually well-received. An observation on 08/10/2022 at 5:50 PM revealed 12 resident trays in the dining room and four had the cabbage left on the tray and other foods eaten. Six trays had the potato salad and cabbage left on the tray. Two trays had the whole entree remaining on the tray with only the dessert and bread eaten by the resident. In an interview on 08/11/2022 at 9:40 AM, RN C stated residents will sometimes complain about the food, but it depended on the cook. She said some cooks were better than others. In an interview on 08/12/2022 at 9:50 AM, MA H stated the food was gross depending on the cook. It's cold sometimes and there were not options offered to residents. When COOK G prepared the food, it was good, and residents can get something else if they did not like what was served. She stated when the DM prepared the food, they received a lot of complaints and residents refused to eat the food. She stated the residents would then eat snacks or they would offer them a health shake. In an interview on 08/12/2022 at 10:00 AM, LVN J stated food quality was dependent on who was cooking. COOK G gets it right and [DM] doesn't. Last night, they ran out of sausage and not all residents got a sausage. She said it was usually just sliced white bread with meals not rolls or other type of bread. She said COOK G customized food for residents and honored food preferences. They had to check trays closely when DM was cooking and doing trays because residents received the wrong diet orders. If residents did not like food, they might get a sandwich from the kitchen, but the Everyday Menu was not always available. In an interview on 08/12/2022 at 11:21 AM, the ADMIN stated she had not received complaints recently regarding food quality. She said the current complaints and food quality was more related to who was cooking, and they are down to one cook, so the DM was cooking. She stated residents preferred COOK G's cooking. In an interview on 08/12/2022 at 12:33 PM, the DON said, every once in a while, they received complaints regarding the food. She said most of the time food was well plated and appealing. She has heard the biscuits are too hard. She stated the facility's kitchen needed to improve upon serving quality food all the time and not be cook dependent. In an interview on 8/11/22 at 11:21 AM, the ADMIN stated the facility did not have a policy regarding food quality and/or monitoring of meal quality.

Based on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided appealing options of similar nutritive value to residents who chose not to eat food that was initially served or who requested a different meal choice for 15 of 20 residents (Residents#36, Resident #57 and 13 residents in a confidential group setting) reviewed for resident preferences and substitutes. The facility failed to ensure an alternative entree was available when residents did not eat the meal they were served. These failures put residents at risk for poor oral intake, weight loss, and poor quality of life. Findings included: An observation on 08/09/2022 at 11:30 AM revealed the steam table with the food for lunch with one entree which inlcuded pork chops, black-eyed peas, green beans with a roll. In an interview on 08/09/2022 at 11:32 AM, the ADMIN stated there was not an additional entree available on the steam table. In an interview on 08/09/2022 at 11:35 AM, the DM stated there was an alternate choice of entrees and resident's could order from the Everyday Menu if they did not like the food. In an interview on 08/09/22 at 9:57 AM Resident #36 said she was not offered an alternative entree choice if she did not like the main entree served. She said if you wanted something else besides what was served, you had to order it two hours before the meal. She said if the menu was not posted in advance to know what was being served, how would a resident know to order two hours before the meal. An observation and record review on 08/09/2022 at 10:00 AM revealed the menu for lunch and dinner dated 08/09/2022 was not posted in the menu frames in the dining room. There was a menu posted titled Everyday Menu with instructions to please order 2 hours before. The Everyday Menu included: Breakfast: Eggs made to order scrambled, fried, hard boiled Assorted Cereals Hot or Cold Pancakes Creamy Butter or Maple Syrup Toast Creamy Butter or Jelly Preserves Lunch and Dinner: Soup and Sandwich of the day Hamburger with Assorted Chips Chef Salad Cottage Cheese and Fruit Plate Dessert: Fruit Cup: Always available as a healthy alternative to the menu dessert In an interview on 08/09/2022 at 11:23 AM, the DM stated they were serving pork chops with brown gravy, green beans, black-eyed peas, and dinner roll. For dessert she served [NAME] mousse. She said the alternative meal, if residents did not like the entree, would be from the Everyday Menu posted outside. She said alternatives included chicken tenders, cheeseburger, or a chef salad. When asked where those items were for serving, DM stated she would have to cook them to order they were not prepared until a resident did not like their meal. She was cooking today, because they had a cook quit and had not replaced her yet. An observation and interview on 08/09/2022 at 12:20 PM revealed Resident #36's plate with a pork chop on it and black-eyed peas. He said the pork chop was tough because the cook boils them and he could not chew it. He said he did not have problems with his teeth or anything, the pork chop was just bad. He said if he asked for something else they would not bring him anything. He did not eat the black-eyed peas either because he did not like them. He ate green beans only for lunch because the [NAME] mousse dessert was an odd color and did not taste good. He said sometimes the food was good, but it depended on who was cooking. When asked if he wanted to ask for something else today, he said no. An observation and interview on 08/09/2022 at 12:30 PM revealed Resident #57 to have a pork chop on her plate with chewed up pieces of meat in her napkin. She said the pork chop was too tough to eat and she spit it out. When asked if she asked for something else, she said she didn't know she could ask for other food. In an interview on 08/09/2022 at 12:39 PM, LVN F stated if a resident did not eat their food they could pre-order food off the Everyday Menu or have a sandwich as an alternative. She said most of the time the food was good at the facility, but it depended on who was cooking. She said the residents preferred when COOK G prepared the food rather than the DM. She said they rarely had complaints when COOK G was the cook, but she was off this week. In a confidential group meeting, of 13 residents, on 08/10/2022 at 10:00 AM, the residents stated the food was not good and they have complained without much change. One resident stated they sent out my meal yesterday and the pork was hard and I couldn't cut itOne resident stated he did not know they had anything else to eat if you don't like the meal. Another resident stated they will say they had hot dogs or corn dogs to eat and they did not have it to choose, if you did not like the meal. The group stated when we asked for something else to eat the staff said they did not have it and say they ran out of the food. They stated you can get a hamburger or cheeseburger, but you have to order ahead of time. They did not post the menu in the facility and the residents did not know to order a hamburger or cheeseburger two hours ahead of time because they did not know what the meal would be. One resident stated they will post the daily menu ahead of time sometimes, but then the actual meal served was not the same as the one posted. They stated the variety they serve was poor and they often serve two starches at meals. For instance, yesterday they had black eye peas and green beans. In an interview on 08/10/2022 at 10:30 AM, the RD stated residents should be able to order from the Everday Menu if they want a different entree from what was on the menu. She said she was unaware of the rule that the resident had to order from the Everyday Menu two hours in advance of mealtime. In an interview on 08/10/2022 at 5:32 PM, DM stated she had not received complaints about the food recently. She said if residents did not like what was served, they could order food from the Everyday Menu as a substitute. She said the bratwurst, cabbage and potato salad were usually well-received. She usually posted the menu first thing in the morning but due to having to cook because of being short staffed she did not get the menu posted yesterday or today. In an interview on 08/11/2022 at 9:40 AM RN C stated residents will sometimes complain about the food, but it depended on the cook. She said some cooks were better than others. In an interview on 08/12/2022 at 9:50 AM, MA H stated the food was gross depending on the cook. It's cold sometimes and there were not options or alternatives offered to residents except a sandwich. When COOK G prepared the food, it was good and residents could get something else if they did not like what was served. She stated when the DM prepared the food they received a lot of complaints and residents refused to eat the food. She stated the resident would then eat snacks or they would offer them a health shake. She said residents had to order two hours before the meal if they wanted a sandwich or burger. She said the menu was posted sometimes outside dining room and no other place. She said she would not know how a resident would know to order alternative entree if the menu was not posted. In an interview on 08/12/2022 at 10:00 AM LVN J stated food quality was dependent on who was cooking. COOK G gets it right and DM doesn't. Last night they ran out of sausage and not all residents got a sausage. She said it was usually just sliced white bread with meals and not rolls or other types of bread. She said COOK G customized food for residents and honored food preferences. She said the menu was not posted in advance because the kitchen was constantly changing what was served. If resident did not like food, they might get a sandwich from the kitchen. The Everyday Menu was not always available. In an interview on 08/12/2022 at 11:21 AM ADMIN stated if residents did not like the entree served at a meal, they could request food from Everyday Menu. She stated the DM should post the menu daily outside the kitchen in the dining room. She said the kitchen was short-staffed in the kitchen right now and that was likely why it was not posted. She stated residents should be offered an alternative if they did not like the entree served or eat the entree well. She stated she was under the impression the Everyday Menu could be prepared at any time, if a resident requested it. She said the process of ordering in advance of the meal needed to be worked out by posting the menus. In an interview on 08/12/2022 at 12:33 PM, the DON said occasionally they received complaints regarding the food. She said most of the time food was well plated and appealing. She stated menus should be posted next to kitchen in the dining room. The DM should be posting it daily. She stated she was not sure why a second entree was not offered or served at meals. She said other facilities she worked at had a hot second entree but not here. She said they serve from the Everyday menu if residents want an alternative. She said she could see the problem of not posting the menu so residents would know whether to order from Everyday menu. She said staff should offer residents an alternate should be offered if a resident did not eat well. She stated the facility needed to fix the process of posting the menu and making alternatives available to residents. In an interview on 8/11/22 at 11:21 AM, the Administrator stated the facility did not have a policy regarding food choices for residents.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions for two (NTR REF #1 and NTR REF #2) out of two resident nourishment refrigerators. 1. The facility failed to ensure expired nutritional supplements were not available for distribution to residents in the NTR REF #2. 2. The facility failed to ensure labeling and dating of resident leftover food kept in NTR REF #1 and that the refrigerator was clean without dried liquid and debris in the bottom of the refrigerator. 3. The facility failed to ensure staff food and drinks were not stored with resident snacks, drinks and supplements in NTR REF #1 and NTR REF #2. These failures could place residents who received snacks and supplements from the nourishment storage area and refrigerator at risk of foodborne illness. Findings included: An observation on [DATE] at 2:00 PM revealed in NTR REF #1 in a night pantry at the nurse's station between the 400 and 500 hallway with unlabeled food in containers. There were cut-up tomatoes in a resealable bag, three plastic containers with food and an open Gatorade bottle with no label or date. There was mustard, ketchup, grape jelly and salad dressing opened with no label or date. Dried liquid and debris was observed at the bottom of refrigerator. An observation on [DATE] at 2:10 PM revealed in NTR REF #2 in a night pantry at the nurses' station between the 100, 200 and 300 hallway, a Ready shake that expired [DATE] and milk that was past best buy date of [DATE]. There was an open unlabeled coffee drink and a cup with liquid and no lid or label. In an interview on [DATE] at 2:25 PM, CNA E stated she did not know who maintained the nourishment refrigerators. She stated she did not know who the containers in the refrigerator on the 400 and 500 hallway night pantry belonged to or whether the containers were from staff or residents. She stated she thought the refrigerators in the night pantry were for residents who did not have a refrigerator in their room. She stated food should be labeled and dated in the refrigerator. In an interview on [DATE] at 4:00 PM, the DON stated there should not be expired or products in the nourishment refrigerators past their best by or expiration date. She stated staff on each hallway should maintain the nourishment refrigerators. She stated there should not be staff food or drinks in the refrigerators with resident food and drinks as it could expose the residents to cross contamination. In an interview on [DATE] at 1:28 PM, RN C stated she did not know who maintained the nourishment refrigerators for resident food and drinks. She stated the refrigerator in the night pantry was for residents who did not have a refrigerator in their room. She stated products in the refrigerator should be labeled with the resident's name with a date of when opened and when to throw away. In an interview on [DATE] at 1:40 PM, CNA D stated residents who did not have a refrigerator in their room, could store their food in the refrigerator. She said they labeled the food with the resident's name. She said she did not know who was supposed to ensure the refrigerator was cleaned out and dispose of expired foods. In an interview on [DATE] at 12:01 PM, the ADON stated the charge nurses should check the refrigerators in the night pantries for food to be labeled and dated and dispose of expired food and drinks. She stated staff should not keep their food or drinks as it could expose the residents to germs from cross contamination. She said products past their best buy should be thrown away and not given to residents. In a follow-up interview on [DATE] at 12:33 PM, the DON stated the charge nurses should check the nourishment refrigerators each shift to ensure no food was expired and no food or drinks from staff were kept in the refrigerator with resident food. She stated all food and drinks should be labeled with the resident's name and throw away date. She stated staff threw away the expired Ready shake and milk that was past its best buy date. Review of the facility's Foods Brought by Family/Visitors policy dated February 2014, revealed perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. Containers will be labeled with the resident's name, the item and the use by date. The nursing staff is responsible for discarding perishable foods on or before the use by date. Review of the facility's Refrigerators and Freezers policy dated [DATE] revealed this facility will ensure safe refrigerator and freezer maintenance, temperatures and sanitation, and will observe food expiration guidelines. The policy noted all food shall be appropriately dated to ensure proper rotation by expiration date.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one (Resident #26) of 8 residents reviewed for reasonable accommodations. The facility failed to ensure Residents #26 received a shower chair for his personal bathroom after the shower bench in his shower broke. This failure could place residents at risk of injuries, health complications and decreased quality of life. Findings included: Review of Resident #26's face sheet dated 08/10/2022 revealed Resident #26 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #26's annual MDS assessment dated [DATE] revealed Resident #26 had a BIMS score of 15 to indicate intact cognition. Resident #26 required supervision and one person assistance with ADL's including physical help, in part, with bathing. Review of Resident #26's care plan dated 05/10/2021 revealed Resident #26 required assistance by one staff member for bathing and showering. In an interview on 08/10/2022 at 8:30 AM, Resident #26 stated he had not showered in almost two weeks because the shower bench in his shower broke while he was sitting on it. He said the facility had not provided him with a shower chair since the bench broke and he was unable to safely take a shower without a shower chair. He said the bench broke because the hardware had corroded, and it snapped off the wall. He said when the bench broke, he fell and had a bruise and skin tear on his left arm. He said the maintenance man told him they would either replace the shower bench or he would have a shower chair for showers. Review of Resident #26's progress notes dated 08/01/2022 - 08/10/2022 did not reveal a progress note regarding the broken bench or skin tear. Review of Resident #26's electronic medical record dated 08/01/2022 - 08/10/2022 did not reveal an incident report for the broken bench or skin tear. Review of Resident #26's shower records dated 07/29/2022 - 08/09/2022 revealed Resident #26 did not shower during this time period An observation on 08/10/2022 at 8:40 AM revealed Resident #26 did not have a shower chair or shower bench in his shower. Resident #26 had a bandage on his left upper arm. In an interview on 08/10/2022 at 8:45 AM MAINT DIR said Resident #26's shower bench broke and they had not replaced it with anything because Resident #26 would not sit on shower chair that had a toilet seat that had been previously used by another resident. He said he removed the broken shower bench and the facility would not be replacing it because finding a replacement to fit the hardware in the shower wall would be costly and difficult. He said he thought a family member of Resident #26 was bringing a shower chair from his home but did not know when or if his family member had brought the shower chair to the facility. He said he was looking at ordering a different shower chair for Resident #26 but had not ordered one. In an interview on 08/10/2022 at 10:41 AM, the DON knew of Resident #26's shower bench breaking last week and thought a family member was bringing him a shower chair from home. She said she was not sure of the exact date of when it broke or how long the resident had been without a shower. She said she would have to check to see if the family member was able to bring the shower chair to the facility. In an interview on 08/10/2022 at 1:28 PM, RN C stated one of the nurse aides, CNA D, told her Resident #26's shower bench broke. She said she went to check on Resident #26 and he reported to her the bench broke. She said he did not report he fell when the bench broke. She treated a skin tear on his arm and thought he had it from hitting arm on wall or toilet when the bench broke. She said Resident #26 was not taking a shower when the bench broke. Resident #26 was sitting on the bench looking at an issue with his toilet. She said Resident #26 did not request a shower chair from her and thought maintenance was taking care of a new shower chair or bench. She said other residents who did not have a shower bench in their shower used a shower chair, and the facility provided the shower chair to them. In an interview on 08/10/2022 at 1:37 PM, CNA D stated Resident #26 called her into his bathroom because his shower bench broke, and he had skin tear to his arm. She said he made a mess in his bathroom when he was looking at something on the toilet and sat on the shower bench to look at it. She was not aware Resident #26 fell when the bench broke. She said she immediately reported the broken bench and skin tear to RN C. RN C reported the broken bench to the MAINT DIR . Resident #26 did not ask her for a shower chair, and one had not been brought to him. She said for other residents without a shower bench, they have a shower chair that wheels in and out of the shower in their bathroom. In a follow-up interview and observation on 08/10/2022 at 2:45 PM, Resident #26 said they brought a shower chair in today. Shower chair observed in his shower. He wanted the bench back but MAINT DIR said they would not be replacing it. He was not aware of a discussion in which his family member was going to bring a shower chair from home for him. In a follow-up interview on 08/11/2022 at 11:21 AM, the ADMIN stated Resident #26 should have had a shower within the next day after the bench broke on 08/01/2022. She said facility staff should have followed up with the family member regarding a shower chair from home and provided Resident #26 with a shower chair if the one from home was not brought. Review of the facility's policy Equipment - General Use for All Residents (undated) revealed our facility should provide routine equipment for the general use of the resident population.

Based on record review and interview, the facility failed to conduct an accurate comprehensive assessment of each resident's functional capacity for 2 of 16 residents reviewed for MDS accuracy (Resident #4 and Resident # 219). 1. The facility failed to ensure Resident # 4's annual assessment was completed. 2. The facility failed to ensure Resident #219's admission assessment was completed by the 14th day of admission. These failures placed residents not receiving the proper care required to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Findings included: Review of Resident's # 4's Face Sheet, dated 08/11/2022, reflected an [AGE] year-old female admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Muscles that lose their nerve supply can atrophy and simply waste away). Review of Resident #4's MDS assessments dates reflected the last MDS completed was a Quarterly MDS on 04/06/2022. Her Annual MDS was due in July 2022. Her last annual assessment was completed on 07/26/2021 Her Annual MDS was approximately 417 days late. Review of Resident #219's face sheet dated 08/11/2022 revealed Resident #219 was a [AGE] year-old male admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #219's electronic medical record as of 08/10/2022 revealed Resident #219 did not have a completed admission MDS Assessment. In an interview on 08/11/2022 at 10:23 AM the MDS NURSE stated she had been on leave beginning 07/20/2022 and would need to refer to her calendar of the exact date she returned to work. She stated the corporate MDS nurse was to assist with MDS' assessments when the MDS nurse was not working for a long period of time. She stated the admission MDS Assessment for Resident #219 would have been due to be completed and exported by 08/02/2022, 14 days after his admission. She stated it was not completed by the due date. In an interview on 08/11/2022 at 11:27 AM, the ADMIN stated the MDS assessments should have been completed within the required time frames, and due to the MDS NURSE being out on leave, they were not completed. She stated the facility had a back-up plan for the corporate MDS nurse to complete MDS assessments if the facility's MDS NURSE was out, but the corporate MDS nurse was out on vacation as well. The ADMIN did not answer the question of the potential consequences if the MDS assessments were not completed within the required time frames. Review of the RAI manua,l dated October 2019, reflected admission assessments are completed no later than the 14th calendar day of the resident's admission. Annual assessments were to be completed within 366 calendar days of previous annual assessment and within 92 days of previous quarterly assessment.

Based on interview and record review, the facility failed to assess each residents quarterly (every 3 months) using the Minimum Date Set form specified by the state and approved by CMS for 2 of 20 residents (Resident #3, Resident #34 ) reviewed for assessments. The facility failed to ensure Residents #3's and #34's MDS assessments were completed quarterly. This failure could place residents at risk of not receiving necessary care or receiving inappropriate care for their conditions. Findings included: Review of Resident #3's Face sheet dated 08/11/2022 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's last completed Quarterly assessment dated [DATE] reflected a BIMS score was not conducted indicating she had severe cognitive impairment. Resident #3 was further assessed to require extensive assistance with ADLs. Review of Resident #3's EMR on 08/11/2022 reflected Resident #3's quarterly assessment was due on 07/05/2022 and was 22 days overdue. Review of Resident #34's Face Sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #34's Quarterly MDS Assessment, dated 4/6/2022, reflected a BIMS of 12, indicating she is capable of being interviewed and providing input regarding her care. Review of Resident #34's MDS Assessment (ARD (Q4)) reflected it was started on 7/5/2022. It has not been completed and is now 21 days overdue. On the last day of the Survey, the MDS Assessment is still showing In Progress. In an interview on 08/11/2022 at 10:39 AM, the MDS Coordinator stated that Resident #3 and #34's MDS Assessments were overdue. The MDS Coordinator stated she was out sick starting on 07/20/2022 and had been in and out of the facility the month of August due to health issues. She stated the care plan is always there, and they have access to it, regardless if the MDS is late or not. The MDS Coordinator stated she knew the MDS's were late, and she is working on getting them completed. She further stated it is the IDT Team and her responsibility to ensure the Assessments are completed timely. She is not sure why the Corporate office did not assist in completing the Assessments, but they are working on the issue now. In an interview on 08/11/2022 at 11:22 AM with the Administrator regarding Care Plans and MDS Assessments, she stated the MDS Coordinator had a medical emergency that prevented her from coming to work. They had someone from the corporate office that assists, but they are still playing catch up. The Administrator stated she was able to provide the MDS Coordinator a laptop for a few days, unfortunately, they are still not caught up. In an interview on 8/11/22 at 11:45 AM, the DON stated she expected the resident's MDS assessments to be timely and further stated the consequences of care plans and MDS Assessments not being completed timely was that staff could miss something crucial that was going on with the residents' health. The DON stated the facility did not have a policy regarding MDS completion timelines. She stated the facility used the RAI manual. Review of the RAI manual dated October 2019 reflected quarterly assessments are completed by calculating from the ARD (assessment reference date) of the previous assessment plus 92 calendar days.

Based on observation, interview and record review, the facility failed to use the results of an assessment to develop, review and revise a comprehensive care plan of each resident that included measurable objectives and timetables to meet a resident's medical and nursing needs for two of eight residents reviewed for care plans (Resident's # 37 and # 45). 1. The facility failed to ensure Resident #37's care plan accurately reflected her diabetic status. 2. The facility failed to ensure Resident #45's care plan was updated and revised after completion of annual MDS assessment on 06/27/2022. The following was not reviewed/ revised and/ or added to the care plan: cognitive patterns, mood, behaviors, preferences for customary routine and activities, ADL status, active diagnosis, health conditions, skin conditions, special treatment, urinary incontinence, falls, dehydration/ fluid maintenance, pain and new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures could place residents at risk of not having their individualized needs met in a timely manner and communicated to providers and could result in injury, a decline in physical, mental, quality of life and/ or psychosocial well-being. Findings included: Review of Resident #37's Face Sheet, dated 08/10/2022, reflected an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #37's Quarterly MDS assessment, dated 06/16/2022, reflected resident had a BIMS score of 15 indicating her cognition was intact. Resident required assistance with ADL's. Review of Resident #37's Comprehensive Care Plan dated 07/19/2022 reflected Review of Resident #37's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #37's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #37's Blood Sugar Report dated 08/10/2022 reflected resident blood sugar was checked 2-4 times per day from 08/01/2022 thru 08/10/2022. During this period resident blood sugar was the following: - 08/01/2022 563.0 mg/dL - 08/02/2022 thru 08/03/2022 was between 302.0 - 485.0 mg/dL - 08/04/2022 thru 08/05/2022 was between 309.0- 460.0 mg/dL - 08/06/2022 thru 08/07/2022 was between 117.0- 340.0 mg/dL - 08/08/2022 thru 08/10/2022 was between 173.0- 258.0 mg/dL Observation on 08/09/2022 at 9:57 AM revealed Resident # 37 was in her room sitting in wheelchair. Her breakfast tray was on her bedside table. Resident # 37 did not eat her breakfast. In an interview on 08/09/2022 at 10:00 AM, Resident #37 stated she did not like any of the food on her tray. She stated she wanted cheerios and they brought her frosted flakes. She stated cheerios was going to be delivered to the facility on the food truck today. She also stated she was a diabetic and was not happy about it. She stated getting shots every day was the only information she knew about being a diabetic. She stated she was frustrated and a little sad about being a diabetic. She also stated she was seeing a counselor and she would talk to the counselor about her feelings. In an interview on 08/09/2022 at 12:35 PM, LVN A stated Resident #37 was a new diabetic. She stated Resident #37 was refusing her lunch and she attempted four times to persuade resident to eat her lunch. She also stated resident was upset with the new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She also stated resident told her she ate her breakfast today and when she went to resident's room, she did not eat her breakfast. She stated this could affect Resident #37's blood sugar if she begins to refuse to eat her meals and prefers to eat snacks for meal substitute. In an interview on 08/09/2022 at 12:45 PM CNA B stated she did not realize Resident #37 was a diabetic. She stated they do have a guide of what type of care residents require and it is on the electronic medical record. She also stated Resident #37 refused her lunch and breakfast today. She stated Resident #37 would eat snacks in her room. Review of Resident # 45's Face Sheet, dated 08/09/2022, reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Have difficulty in social situations and problems with social cues and judgement) and autonomic dysreflexia (an abnormal, overreaction of the involuntary nervous system to stimulation. This reaction may include change in heart rate and high blood pressure). Review of Resident #45's Annual MDS Assessment, dated 06/27/2022, reflected resident had a BIMS score of 4 indicating his cognition was severely impaired. Resident required assistance with all ADLs and required the use of a mechanical lift for transfers. Resident #45 was assessed as having an indwelling catheter and had malnutrition. Resident was also assessed for pain. The MDS further reflected resident's height was 66 inches. He weighed 168 pounds. Review of Resident #45's Comprehensive Care Plan dated 03/09/2022 reflected the care plan was not reviewed/ updated/ revised after the comprehensive assessment on 06/27/2022. The care plan team failed to add Resident #45's [CONDITION(S)] with start date 06/23/2022 to the care plan. Review of Resident #45's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . House Supplement 2.0 two times a day for weight loss start date 07/28/2022. Regular Diet, regular texture and consistency and add fortified food with meals revision date 7/28/2022. Review of Resident #45's Director of Nurses note in the electronic medical record dated 08/10/2022 reflected weight loss follow-up. On 06/23/2022 resident was started on IV antibiotic for a [CONDITION(S)]. He had a poor appetite. On 07/28/2022 resident started on [MEDICATION(S)] for [CONDITION(S)], house supplement two times per day and fortified foods with diet order. The Dietary consultant reviewed today see note for more details related to weight . Will continue to monitor weekly weights. Review of Resident #45's Nutrition Service Note dated 08/10/2022 reflected Resident had significant weight loss 8% x 90 days. No recent labs to access. Resident receives fortified foods with meals and house supplements 2.0 60 cc x 30 days for weight loss. Med review for possible appetite stimulants. Resident PO intake varies from 0-100% but usually 51 % - 75 %. No recent reports of chewing and swallowing problems. Review of Resident #45's Nutrition Service Note dated 07/22/2022 reflected Resident had a weight loss of 6.5 % x 30 days and 8.4 % x 90 days. PO intake varies 0-100 %. Resident does not have any chewing or swallowing problems. Will monitor weights. Recommend fortified foods with meals, Med pass 2.0 BID x 30 days to maximize weights, PO intakes and fluid intakes and will remain available PRN. Review of Resident #45's Electronic Medical Weight Record dated from 03/03/2022 thru 08/09/2022 reflected resident weight: 03/03/2022- 169.0 pounds 07/03/2022- 155.0 pounds 08/09/2022- 147.5 pounds In an interview on 08/11/2022 at 10:23 AM , MDS Nurse stated if there was something pertinent that could change the residents' care, it would need to be on the care plan. She stated a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated this could interfere with resident's care if a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated if a resident had a new [CONDITION(S)] and weight loss his care plan was expected to be updated. She stated if a resident's care plan was last completed on 03/09/2022, the resident's care plan was required to be reviewed/ revised/ updated in June of 2022. She stated Resident #45's care plan was considered late. In an interview on 08/11/2022 at 11:45 AM, the ADMIN stated resident care plans were expected to be updated after 90 days or before the 90 days if there were any changes in resident's condition. In an interview on 08/11/2022 at 12:08 PM, the DON stated she would need to refer to the care plan policy to determine when a care plan was required to be updated, reviewed and/or revised She stated if Resident #37 had concerns about her diabetes, it would be discussed with the resident. She also stated Resident # 45's weight loss was after being diagnosed with a [CONDITION(S)] in June. Review of the facility's policy Care Plans, Comprehensive Person-Centered dated 12/2016 reflected assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. Reflect the resident's expressed wishes regarding care and treatment goals .

Based on observation, interview and record review, the facility failed to ensure resident weights were completed consistently with the same method, and variances were verified with interventions documented in the resident's EMR to ensure residents were maintaining acceptable parameters of nutritional status for one residents (Resident #61) out of four residents reviewed for accurate weights. 1. The facility failed to establish a consistent method of weighing Resident #61 to ensure accuracy of resident weights and did not follow facility policy to re-weigh within one day to verify the significant weight variance. 2. The facility failed to document interventions in Resident #61 who experienced a severe weight loss. These failures put residents at risk for undetectable weight loss, malnutrition, and poor quality of life. Findings included: Review of Resident #61's face sheet revealed Resident #61 was a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #61's quarterly MDS assessment dated [DATE] revealed Resident #61had a BIMS score of five to indicate severely impaired cognitive status. Resident #61 required total assistance by two or staff members for ADL's. Resident #61 was not noted to have experience significant weight gain or loss. Review of Resident #61's care plan dated 08/10/2022 revealed Resident #61 had a nutritional problem or potential nutrition problem related to weight loss. Resident #61's interventions included the facility would provide and serve regular diet with fortified foods as ordered by the MD. The plan stated that the facility should notify the MD of further weight loss. Review of Resident #61's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #61 Weight Summary dated 08/11/2022 revealed Resident #61's weight as follows dated: 08/09/2022 248.0 lbs Sitting 08/04/2022 248.8 lbs No method recorded 07/27/2022 254.0 lbs Sitting 07/20/2022 271.0 lbs Sitting 07/13/2022 280.0 lbs Wheelchair 07/06/2022 282.0 lbs Wheelchair 12.05% weight loss in 30 days Review of Resident #61's Nursing Progress notes dated 07/06/2022 - 08/09/2022 did not reveal documentation regarding Resident #61's weight variances or MD notification for weight loss. Review of Resident #61's Medical Nutrition Therapy assessment dated [DATE] revealed Resident #61 was obese with poor oral intake. RD recommended Resident #61 to have fortified foods related to poor appetite and weekly weights. Review of Resident #61's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 07/06/2022 Regular diet, regular texture 07/14/2022 Regular diet, pureed texture with fortified foods 07/21/2022 Regular diet, mechanical soft texture 08/05/2022 Regular diet, regular texture In an interview on 08/09/2022 at 4:00 PM, the DON stated she monitored the resident weights for accuracy and consistency. She stated the transport aide at the facility weighed the residents and she entered the weights into the EMR. She stated they had three scales they use for weighing residents and she tried to ensure the method used was documented along with the weight. She said they had a standing scale that a resident in a wheelchair could be weighed on, a scale with a chair that residents could sit on and be weighed, and mechanical lift with a scale. She stated she had several weights from 08/04/2022 that required a re-weigh because there was a large variance including Resident #61. She said Resident #61 was one of the residents that needed to be re-weighed. An observation on 08/10/2022 at 3:30 PM revealed a standing scale that was large enough for a resident in a wheelchair to be weighed on and a scale with a chair that a resident could sit on and be weighed. There was a mechanical lift observed that had the ability to weigh a resident when being transferred via mechanical lift. In an interview on 08/10/2022 at 1:28 PM, RN H stated she did not weigh residents routinely and that a transport aide weighed all residents and the DON monitored resident weights. She stated if she noted a large variance in a weight, she would notify the DON. She stated a sitting weight could be either the resident sitting on the chair scale or a resident sitting in their wheelchair on the standing scale. She stated she was unsure of whether a sitting weight documented in the EMR meant sitting scale or wheelchair on the standing scale. In an interview on 08/10/2022 at 4:00 PM, RD stated she monitored resident weights and would request a re-weigh if there was a large variance or inconsistent weight. She stated there were three scales. She stated she did not know if sitting weight was for the chair scale or a wheelchair on the standing scale. She stated residents should be weighed using the same method consistently to ensure accuracy of the weight. She stated she will make recommendations based upon resident weights and if a resident was not weighed accurately, it could put the resident at risk for unaddressed weight loss or gain and malnutrition. She stated for Resident #61 she noted the large decrease in the month of July and had them re-weigh her. She stated the drop was largely due to Resident #61 started on a diuretic and had fluid loss with reduced [CONDITION(S)] therefore some part of the weight loss was unavoidable, She stated Resident #61 reported a decreased appetite in July and she recommended an appetite stimulant and dietary supplement if her oral intake was poor. She stated the facility implemented the interventions to prevent further dramatic weight loss. In an interview on 08/11/2022 at 9:40 AM, RN K stated they weigh residents at the scales in hallway near the dining room or the mechanical lift scale. She stated she would then add the weight in the EMR and if there was a big change, she would notify the resident's MD for orders. She stated they should chart a progress note for weight variance and MD notification. She said the sitting method documented in the weight record could mean sitting on chair scale or sitting in wheelchair on standing scale . She stated Resident #61 did not eat well when she was first admitted to the facility due to having trouble chewing her food and she was downgraded to pureed. She said Resident #61 continued to not eat well and did not like the pureed textured food. She said they upgraded her to mechanical soft and her intake improved slightly. She said she was recently changed to regular texture food at the resident's request and since she was stronger and more alert she was able to chew her food without issues. In a follow-up interview on 08/11/2022 at 12:33 PM, the DON stated she monitored all resident weights weekly/monthly depending on the resident's orders. She stated new admissions were weighed weekly for four weeks or until stable after four weeks. She stated a resident who experienced a significant weight loss or gain would be weighed weekly for four weeks until stable. She stated when she added the weights to the EMR, she should be adding the method of weighing the resident each time and it should be consistent to ensure accuracy of the weight. She stated she kept her records in a separate binder and made notes there about the method used and was not fully transferring the record into the EMR. She stated she also kept her notes, MD notifications and interventions for residents who experienced significant weight loss or gain in her separate binder. She stated the documentation should also be in the residents' EMR. She stated she would need to clarify sitting weights to ensure residents who are weighed in their wheelchair on the standing scale were identified differently than residents who were weighed using the chair scale. She stated interventions were completed for Resident #61 as she was losing weight including liberalizing her diet, adding fortified foods, adding an appetite stimulant and accounting for some of the weight loss related to diuretic use. She stated Resident #61 was admitted on a regular diet but then downgraded to a pureed diet due to trouble chewing. She stated her intake was poor so her diet was upgraded to mechanical soft. As Resident #61 became stronger and able to chew easier, the physician assistant upgraded her diet to a regular diet to improve her intake from 10%-25% of meal to greater than 70% of meals. She stated Resident #61 had expressed wanting to lose some weight, but they did not want her losing weight too fast which could complicate other health issues. She stated Resident #61 was admitted with C-Diff which could also account for some of the weight loss. She stated the variance of her weight should have been documented in her EMR and the facility's response also noted. Review of Weight Assessment and Intervention Policy dated September 2008 revealed the nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. Weights will be recorded in each unit's Weight Record chart or notebook and in the individual's medical record. Any weight changes of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing.

Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent or greater when the facility had a medication error rate of 7.14% based on 2 of 28 opportunities, for 1 of 4 residents (Resident #31) reviewed for medication administration. 1. The facility failed to ensure Resident #31's Potassium Chloride was not crushed before administration. 2. The facility failed to ensure Resident #31 was administered Pepcid instead of omeprazole ([MEDICATION(S)]). These deficient practices could place residents at risk of not receiving therapeutic dosage of medications. Findings Include: Review of Resident #31's Face Sheet dated 08/10/2022 reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #31's Quarterly MDS assessment dated [DATE], reflected Resident #31 was assessed to have a BIMS score of 14 indicating he was cognitively intact. Review of Resident #31's Comprehensive Care Plan dated 02/28/2022 reflected no plan of care for his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation and interview on 08/10/2022 at 8:38 AM revealed MA C preparing Resident #31's AM medication. MA C placed Resident #31's Potassium CL ER 20 mg into a medication bag used for crushing medications. MA C was asked if she should crush the medication she stated, I don't know why they want it like that since it dissolves in water, it is the only pill he has problems with. MA C then proceeded to crush the potassium and placed the crushed tablet into a small amount of pudding. MA C then removed a bottle of [MEDICATION(S)] (omeprazole) 20 mg from the cart and placed two tablets in the medication cup with Resident #31's other medications. MA C then prepared the rest of Resident #31's medication and entered his room and administered the medications to Resident #31. Review of Resident #31's Consolidated Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of his consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident #31's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation and interview on 08/10/2022 at 9:30 AM revealed MA C was asked to remove the medication [MEDICATION(S)] (omeprazole) 20 mg from the medication cart and was asked if it was the medication, she gave to Resident #31 during his morning medication pass, she stated Yes. MA C was asked why she gave [MEDICATION(S)] (omeprazole) 20 mg two tablets when Resident #31's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . MA C stated that was what they give for Pepcid. Surveyor then pointed to the Pepcid bottle in the cart which was located next to the [MEDICATION(S)] bottle and asked why she did not give the Pepcid instead. The MA C looked at both bottles and stated she did not notice that. When MA C was asked why she crushed the potassium tablet when Resident #31's order stated not to crush the medication, she stated she did not notice that and then pulled out a list of do not crush medications that was on her cart which reflected the potassium should not be crushed. MA C then stated she should not have crushed the medication since it was on the do not crush list and his order stated not to crush it. In an interview on 08/10/2022 at 9:50 AM, the DON stated she expected the medication aide to follow medication instructions for administration and to ensure they administered the right medications and follow the right procedures for crushing medications. In an interview on 08/10/2022 at 10:10 AM, Resident #31 was asked if the potassium he took this morning upset his stomach. Resident #31 stated he has had an upset stomach for a long time and been on medications for it and was not able to tell if the potassium had anything to do with. In an interview on 08/10/2022 at 4:30 PM, the Pharmacy Consultant stated that potassium, when crushed, can cause the stomach to become upset. She stated Resident #31 had GERD before starting the potassium, so she did not feel like the potassium caused the GERD. She stated it will cause discomfort but the pill does dissolve fast so she did not feel it would cause damage to his stomach lining. In an interview on 08/11/2022 at 11:44 AM, the Administrator stated, regarding MA C's errors during medication pass, that it must have been a training issue with MA C. She stated she had been a MA for a long time and should have known better. She stated when she talked with MA C, MA C was not able to tell her why she made the errors. The Administrator further stated she expected the medication aides to follow the policy and ensure residents receive their medications as ordered. Review of the facility's policy Administering Medications dated 12/2012 reflected Medications shall be administered in a safe and timely manner, and as prescribed .The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication . Review of the facility's policy Crushing Medications dated 04/2007 reflected Medications shall be crushed only when it is appropriate and safe to do so, consistent with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent accidents for one (Resident #4) of eight residents for falls. 1) Resident #4 experienced a fall on 12/02/14, resulting in a fracture through the distal metaphysis of the right femur. There were no safety interventions in place at that time, although the resident was a high fall risk. 2) Resident #4 re-admitted to the facility on [DATE], with a history of falls and fractures. Resident #4 had Fall Risk Assessments that indicated she was a high risk for falls. The facility's staff had interventions in place that were considered ineffective and were removed, but no new safety interventions were put in place. These failures placed the 21 residents identified with falls, including Resident #4, at risk for additional falls with injuries that could cause a decline in her highest particle level of physical, mental and psychosocial well-being. Findings included: Review of Resident #4's Face Sheet, dated 02/11/14, revealed she was an [AGE] year-old female who was readmitted to the facility on [DATE], with a fractured pelvis. Review of Quarterly Minimum Data Set (MDS) assessment, dated 08/26/14, revealed Resident #4's BIMS score was 12 out of 15, which indicated the resident was moderately impaired cognitively. Further review of the MDS assessment revealed Resident #4 was mildly depressed, exhibited no behaviors, and was occasionally incontinent of urine. Resident #4 required set-up help and supervision for transfers and mobility. Resident #4's [DIAGNOSES REDACTED]. Resident #4 required no pain management at that time with no falls since readmission. Resident #4 was observed on 01/12/15 at 7:10 p.m., during initial tour with LVN A, sitting in the hallway in a wheelchair, with her right leg in an immobilizer. Resident #4 was yelling at the staff to put her in the bed. CNA H offered to assist the resident to bed, which she refused. CNA H stated this was her usual behavior; we will have to call another staff member to assist the resident to bed. LVN A stated they would call another staff member that Resident #4 liked and maybe then she would go to bed. During initial tour the telephone was brought to Resident #4 and CNA H attempted to get Resident #4 to talk on the telephone; however, the resident continued to yell into the telephone, then finally calmed down and said, "Well okay, you come then, if they don't kill me before you get here." LVN A stated Resident #4 was an alert resident with impulsive behaviors and a history of falls with fractures. The facility had no interventions in place to prevent falls because she got around well; Resident #4 experienced a fall resulting in a fracture through the distal metaphysis of the right femur. The resident was referred for physical therapy, but no other interventions were provided. Observation on 01/13/14 at 11: 45 a.m., revealed Resident #4 in the hallway, in her wheelchair, with a knee immobilizer on her right leg. Review of significant change in condition MDS assessment, dated 12/10/14, revealed Resident #4 had exhibited verbal behaviors toward the staff, required extensive assistance of two people for transfer, supervision for mobility in her wheelchair, walking had not occurred, and was continent of bowel and bladder. Further review revealed [DIAGNOSES REDACTED]. Resident #4 now required pain management, and had one fall (12/04/14) with major injury. Review of the "Incident/Accident Report." dated 12/02/14, revealed Resident #4 was trying to get in the wheelchair to go to the bathroom, did not call for help, and fell was complaining of knee pain. Further review of the Incident/Accident Report revealed the "Incident/Accident Action Plan," dated 12/05/14, was for Resident #4 to call for assist, immobilizer, bed pan at that time, and referred to therapy. An interview on 01/13/15 at 11:50 a.m. with ADON D revealed Resident #4 got up in the night and fell , X-rays were ordered and when the results came back she was sent to the emergency room for further treatment. Review of X-ray reports, dated 12/03/14, revealed a suspect distal metaphysis of the femur. Following the evaluation at the hospital, on 12/03/14, the [DIAGNOSES REDACTED]. An interview on 01/13/15 at 12:25 p.m. with CNA B revealed Resident #4 had been to the facility before. Resident #4 had lived at home and had fallen and broken her hip and came for rehabilitation. CNA B said, "(Resident #4) returned home and fell again, braking something else; returning for rehabilitation and ended up not going home." CNA B said Resident #4 was "very paranoid" and she always thought someone was trying to kill her. CNA B also stated Resident #4 had good days and bad days. CNA B stated, "The facility staff call me all the time because for some reason, she will most of the time, do what I ask her to." CNA B said "(Resident #4) was very stubborn, and it was hard to get her to understand she needed to be here and to ask for help." CNA B further stated when Resident #4 got ready to do something she just did it, she would not wait for assistance. An interview on 01/13/15 at 4:07 p.m., with LVN A and ADON D revealed LVN A had taken care of Resident #4 for some time and her aggressive behaviors would come and go. LVN A said Resident #4 had seen the psychologist and the physician who had changed her medications multiple times. LVN A said, "(Resident #4) was very stubborn and if she makes her mind up to do something, she is going to do it, regardless." LVN A said she was there the night Resident #4 fell . She stated, she was coming down the hallway with another nurse and heard Resident #4 yelling for help. LVN A stated she went into the room and observed Resident #4 sitting on the floor between her recliner and her bed. LVN A said the resident told her she had gotten up from her recliner and had gotten her legs "tangled up" and had fallen, while trying to reach the bed. LVN A said she assessed her, and called the physician and gotten X-rays ordered. LVN A further stated they notified the ADON, the physician, and the family. When the surveyor queried LVN A whether she was involved in the follow-up interventions concerning safety for residents, she replied, "No, but I could think of some." LVN A said Resident #4 had done very well for a long time and had not had any falls, but she use to have a "tab alarm" in her recliner and her wheelchair that would alert them to when she was up. LVN A further stated the previous DON had the staff take the alarm away. An interview on 01/13/15 at 4:15 p.m. with ADON D revealed she was involved in follow-up investigation and interventions. ADON D said Resident #4 did have a "tab alarm," but the previous DON said there would be no alarms in the facility, so Resident #4's alarm was removed, there were no other interventions put into place. ADON D further stated the "alarm" was encouraging Resident #4 to have increase with incontinent episode. Resident #4's behaviors escalated. ADON D stated she thought Resident #4 would be okay when the alarm was removed since there had been no falls since her readmission. Review of "Fall Risk Assessments," dated 10/08/14 and 12/10/14, revealed a score of 15, indicating a "high risk for falls." Further review of a "Falls Risk Assessment," dated 12/10/14, revealed a "zero" had been documented in the "History of Falls for the past three month's box." When the surveyor queried who completed the "Fall Risk Assessments," ADON D and LVN A replied, "We all do them." The surveyor queried if LVN A or ADON D had an idea what Resident #4's fall risk score was, and they both replied, "No." When the surveyor queried if the staff, including ADON D and LVN A, considered assisting Resident #4 to the bathroom, they both replied, "No." ADON D said Resident #4 had really done well. The surveyor queried if Resident #4 had a history of [REDACTED]." An interview on 01/13/15 at 5:00 p.m. with CNA F revealed if one of the residents fell , she was to report to her charge nurse and do what needed to be done. The surveyor queried concerning Resident #4 and her fall, and CNA F replied Resident #4 was a very "stubborn person" who was going to do what she wanted to do regardless of what you told her. CNA F said the resident used to have an alarm in her chair that sounded when she got up, but they had taken it away, and she did not know why. When the surveyor queried CNA F regarding her involvement in choosing interventions for safety concerning residents who have falls, she replied there was a suggestion box in the break room and there were "pink sheets" you could fill out. However, CNA F did not know where the slips were located. An interview on 01/13/15 at 5:05 p.m. with MA G revealed if a resident fell , you were supposed to report it immediately to your charge nurse. When MA G was asked about interventions for safety with residents who fall, MA G replied, "We are just to keep them safe, no one ever asked me about what might be done to keep a resident from falling." When MA G was asked about Resident #4, MA G replied, "She is a very angry lady. I just hope she will take her medications, but I do know if she has her mind made up, she is going to do what she wants." An interview on 01/13/15 at 5:30 p.m. with the DON revealed she was aware of the surveyors' concerns about Resident #4 and she was working on interventions to prevent further falls. The DON said, "With a resident like her we need to think outside the box." The DON further stated since she had been at the facility, incident/accidents were discussed in their morning "stand up meeting." The DON said she realized they (department heads) needed to include the staff in those meetings when it was necessary to get suggestions, since they take care of the residents. An interview on 01/14/15 at 1:15 p.m. with LVN E revealed she was making walking rounds with the other nurse on 12/04/14, and heard Resident #4 yelling for help in her room. LVN E stated when they entered into the room, the resident was on the floor and was complaining with pain in her knees. The family, physician, and the ADON were called and the physician ordered X-rays of her knees. LVN E said she completed the reports and was not really clear if the resident fell when going from the bed to the wheelchair or the recliner, but she knew she had been in bed earlier. LVN E said Resident #4 walked from place to place in her room. LVN E said there were no other interventions for Resident #4. An interview on 01/14/15 at 2:45 p.m. with Resident #4 revealed she was going to go to the doctor soon and she was going to get "this thing off" (leg immobilizer). Resident #4 said she really did not need it anyway because there was nothing wrong with her leg. Resident #4 stated, "I cannot get up and go the bathroom. I have to pee in a pan. It makes everything hard when you are used to doing everything for yourself, and then for some reason suddenly you cannot." An interview on 01/15/15 at 11:30 a.m. with the Director of Rehabilitation (DOR) revealed they had treated Resident #4 previously for falls and fractures. The DOR stated Resident #4 had rehabilitated for safety and transfers then had discharged home. The DOR said Resident #4 was currently on therapy services due to the recent fall to strengthen her upper body, until the physician released the resident from a non-weight-bearing status. When the surveyor queried the DOR concerning safety and interventions for Resident #4, the DOR replied, "No one has ever asked us anything concerning (Resident #4) or any other resident." The DOR said Resident #4 was a high risk for falls, and always had been. Review of a Care Plan, dated 10/13/14 revealed: "1) Problem:...Resident has an increased risk for fracture r/t (right) bone thinning and brittle bones due to Osteoporosis...Approaches included: Monitor for unsteady gait or decreased mobility, assist with transfers and mobility.... 2) Problem:...Requires assist for transfer and locomotion.... 3) Problem:...Resident has a history of falls and is at risk for potential falls....Approaches: Assist with ambulation and transfers; remind to ask for assist for all ambulation, use tab alarm.... 4) Problem:...Resident has short term and long term memory deficits and requires assistance with decision making....Approaches:...assist resident with decision making, encourage resident to participate in the decision making process...." Review of the updates to the Care Plan, dated 12/03/14, revealed a mobilizer in place, and Resident #4 was now a two person sheet transfer, and to utilize a "bed pan." Further review of the Care Plan, dated 01/07/15, revealed a "Care Plan Conference" with topics discussed to include: Activities of Daily living (assist of one staff member), and Falls/safety (potential). The "Summary of Discussion" revealed no new problems...related to the current fall and only had falls/safety as a potential. The DON provided updated Comprehensive Plan of Care, dated 01/13/15, for Resident #4 revealed the following: "Problems: 1) Falls: as evidenced by cognitive impairment, non-weight bearing, and physical impairment.... Encourage resident to ask for assistance of staff, anticipate needs, and provide prompt assistance.... All previous interventions for fall precautions ineffective: alarm placement unsuccessful-caused increased anxiety/delusions, floor mat deemed unsafe due to resident self-transfers. 2) Altered thought process: Short term memory deficit, long term memory deficit, delusions, and behaviors: Impulsive refuses to call for assistance.... Psyche services as needed, medications as ordered, assign familiar staff as needed, and encourage and allow time for coping...." Review of a progress note of the Nurse Practitioner (NP), dated 12/19/14, revealed Resident #4 had a history of [REDACTED]. Resident #4 had a history of [REDACTED]. Review of the History and Physical, dated 12/20/14, revealed Resident #4 was alert, and confused in the early stages of recovery from a right femoral fracture, and suffering from depression. Review of the "ADL Report" for CNAs, dated 10/16/14 through 01/14/15, revealed Resident #4 required inconsistent support for transfer assist of one to two staff members. Following the fall on 12/02/14, Resident #4 required total assist for transfer, or the transfer did not occur. Review of the "Occupational Therapy Plan of Care," dated 12/01/14, revealed Resident #4's previous therapy treatment was 04/22/14, "with medical history related to history of falls...." Review of "Physical therapy Plan of Care," dated 12/01/14, revealed Resident #4's previous therapy had been May 2014, for falls with fracture. Long-term goals revealed stand-by assistance for transfers. Review of the "Physical Therapist Progress & Discharge Summary," dated 04/22/14, revealed "End of Goal Status" goals not met this patient is able to complete bed to chair transfers requiring supervision...."Patient has reached plateau...." The Accident/Incident Policy provided by the Administrator, dated January 2009 revealed: "...To provide a safe environment.... Investigation Action:...10) corrective action taken.... ...11) Other pertinent data as necessary or required...." Further review of the Policy/Procedure revealed no further information on interventions to assist further occurrences. Form CMS-802, Roster/Sample Matrix, completed by the facility and provided to the survey team on 01/12/15, identified 21 residents with falls at the time of the survey.

Based on observation, interview and record review, it was determined the facility failed to implement the facility's policies and procedures that prohibited neglect for one (Resident #1) of four residents reviewed for neglect. 1) CNA E attempted to transfer Resident #1 without assistance from the scooter to the toilet on 11/19/11. Resident #1, who required the total assistance of two staff to transfer, collapsed with both knees on the floor with her lower legs turned to the side. The resident sustained [REDACTED]. This failure to provide Resident #1 a transfer with the assistance of two staff resulted in the resident sustaining fractures to both her legs, have pain, having to be hospitalized , having to have surgical repair and place herself at risk, now being unable to bend her legs as they heal, unable to use her scooter, resulting in decreased socialization and increased need for bed rest, which could result in an overall decrease in her health and cause an exacerbation in her Depression. 2) CNA A stated she still transferred residents without help, who were assessed as requiring two staff to assist with transfers. This failure could affect the 108 residents, who require assistance with transfers or were totally dependent on staff for transfers and placed them at risk for skin tears, lacerations, bruises, pain and discomfort, injury, and fractures resulting in the potential need for hospitalization . Findings included: 1) Resident #1's November 2011 consolidated physician orders [REDACTED]. A review of Resident #1's MDS assessment dated [DATE] revealed the resident was totally dependent upon staff for transfers and required the physical assistance of two plus staff for transfers. The MDS assessment reflected Resident #1 had not attempted to move from a sitting to standing position, walking, turning, moving on and off toilet, or a surface to surface transfer. Resident #1's care plan initiated on 04/19/11 and continued on 10/05/11 reflected Resident #1 required staff assistance for all ADLs. Goals included Resident #1's needs would be anticipated and the resident would receive assistance with ADLs over the next 90 days. The resident's care plan also reflected she was noted to be at risk for falls related to the need for assistance with transfers and lower extremity muscle weakness. Goals included Resident #1 would have her needs anticipated by staff and would not have any injuries due to falls over the next 90 days. Under approaches, Resident #1 would be evaluated as to her risk for falls, assisted with transfers and mobility, the call light would be kept in reach and her room free of clutter, the resident would be monitored and changes would be reported in her endurance, transfers, and mobility. She would be assisted with toileting as needed and monitored for side effects of medication. In an interview on 12/14/11 at 3:10 PM with Resident #1's family member, he/she stated the resident had two broken legs and had to have surgery. He/She stated he/she had been concerned because Resident #1 had never been able to pick up her legs or lift herself. He/She stated the facility had told him/her Resident #1 had been lowered to the floor on 11/19/11. He/She stated the facility had gotten x-rays of the resident's hip then and there was another x-ray completed on 11/28/11. He/She told the surveyor Resident #1 never showed her emotions and the surgeon could not believe the resident had not been screaming out in pain. The family member further stated Resident #1 had always required two people to transfer her. He/She stated, "Why did she (CNA D) lift her by herself? She should have asked (for assistance)." In an interview with LVN F on 12/15/11 at 10:10 AM, she stated Resident #1 was not able to transfer herself. The staff would put the resident in her motorized scooter, and the resident would move around the facility independently in her scooter. She stated she had been notified about Resident #1 being lowered to the floor on a weekend. LVN F stated she had first noticed Resident #1's bruising on the Wednesday (11/23/11), the day the resident had complained of her legs hurting. Observation on 12/15/11 at 10:14 AM revealed Resident #1 was in a geri-chair. She was observed with dressings on both of her legs. When asked what happened, the resident stated, "I remember I fell against the wall in the bathroom." LVN F told the surveyor Resident #1 could not bend her legs at all. The resident told the surveyor she now had to have five people to transfer her. The resident added she was not able to use her motorized wheelchair now. A review of a non pressure skin condition report revealed, on 11/23/11, Resident #1 was noted to have one 5.5 cm x 5 cm bruise, one 7.5 cm x 3 cm bruise and a 2.5 cm x 3.5 cm bruise. All these bruises were on Resident #1's upper left posterior thigh. The bruises were purple and yellow. A review of the facility's Incident/Accident Report dated 11/23/11 at 10:00 AM revealed Resident #1 was alert and oriented x 2. The report reflected: The CNA reported the resident had bruising to her left leg with purple and greenish bruising to her left posterior thigh and left knee with slight swelling of her the back of her knee. A description of the situation reflected during ADL care, the CNA found the bruising, which she immediately reported to the charge nurse, LVN F. During the investigation, it was learned on 11/19/11 Resident #1 was in the bathroom and had to be lowered to the floor to prevent a fall. Her left knee was bent below the resident before she was assisted to a sitting position. Resident #1 denied any discomfort. Recommendations/New Interventions included: Inservices on Abuse/Neglect, Fall Prevention, DOT system for resident care/identification for all nursing staff; enhancement/reinforcement of same for new employee orientation; and disciplinary action if needed. Dated 11/29/11: updating of Resident #1's care plan upon her return from the hospital. The Incident/Accident Report was signed by the DON and Administrator and dated 11-23-11/11/28/11 by both of their signatures. Resident #1's Nurse's Notes dated 11/23/11 at 6:00 PM reflected an order was received from the resident's primary care physician for a portable x-ray of both hips. Review of the Physician's Telephone Orders dated 11/23/11 for Resident #1 revealed an order for [REDACTED]. The Radiology Report dated 11/23/11 for Resident #1 reflected no fracture or dislocation was seen of the resident's hips. [MEDICAL CONDITION] was present, there's was modest [MEDICAL CONDITION] of the right hip and an old healed left [MEDICAL CONDITION]. The facility's Incident/Accident Report dated 11/28/11 at 4:30 PM reflected Resident #1's family asked for repeat x-rays on 11/25/11 because of the resident's continued bruising. Resident #1 continued to deny pain/injury. The resident's physician replied on 11/28/11 to "x-ray (Resident #1) if still symptomatic (bruising)" and the nurse, as a precaution ordered x-rays of the left leg. During the process of the resident being x-rayed, the RN observed new [MEDICAL CONDITION] to the right knee and requested an x-ray of the right leg also. The results of the x-rays reflected fractures in both legs, which were immediately reported to the family and physician. Orders were received to transfer Resident #1 to the hospital for admission. Resident #1's Radiology Reports dated 11/28/11 reflected the resident sustained [REDACTED]. The Provider Investigation Report dated 11/29/11 reflected the following statement of CNA E regarding the incident on 11/19/11 when Resident #1 was lowered to the floor: "I saw bathroom call light on for resident, ____ (Resident #1). _____ (Resident #1) was in the bathroom, pulled up to the toilet. I asked her what she needed and she said, 'help to the bathroom.' I asked ____ (Resident #1) if she felt that I could assist her up and to the toilet. ____ (Resident #1) indicated, 'yes.' I assisted ____ (Resident #1)) to stand from her scooter and then she said her knees where (sic) buckling. I assisted ____ (Resident #1) back to the edge of her scooter seat and then assister her slowly to the floor. At no time did ____ (Resident #1) fall. She did not fall but was assisted to the floor. When I had her safe, I put on the bathroom call light and left ____ (Resident #1) for 5-10 seconds to call for additional help to assist ____ (Resident #1) back to her chair...." The Provider Investigation Report's Description of Assessment: 11/19/11 - No injury noted from resident being lowered to the floor. Resident #1 indicated she was okay and no complaints of pain were voiced. 11/20/11 - Resident #1 said she was okay but did not want to get up from bed. This was not unusual. Resident #1 would rather stay in bed and watch TV. She was given Tylenol due to minor aches and pains, which she often has. 11/21/11 - Assessed resident for any delayed problems related to resident being lowered to the floor in the bathroom. On 11/19, Resident #1 stated she had pain and the pain she had was no worse than she normally has. No bruising or swelling noted to either leg during the assessment. 11/23/11 - Resident noted to have greenish-purple bruising the left posterior leg and left posterior knee. A small area of slight swelling was noted to left posterior knee. Resident showed increased pain to bilateral legs when legs were raised. Doctor was notified by fax, reporting bruising and increased pain when lifting. 11/24/11 - X-ray to hips and pelvis were obtained with negative results. The Provider Investigation Report's Investigation Summary: The facility was unable to confirm the allegation of neglect. Staff were re-educated on safe resident handling, preventive falls, the DOT system, abuse and neglect. Resident needs will be reassessed upon return to the facility. A review of a written statement dated 12/06/11 by CNA E revealed, "On Nov. 9th 2011, I answered a red call light in Mrs. ___ (Resident #1's) bathroom. She was in or on scooter pulled up to toilet and stated she needed to use toilet. I assisted her to stand she had put her hands on grab rail She froze and was unable to turn so I told her to sit. She sat on the edge of the scooter. I turned light back on and attempted to get her repositioned but was unable to. She began to slide slowly, when her knees made contact with wall, they began to turn to left and she continued to slide to floor. Her hands remained on rail and she was sitting upright with her legs under her when I left the room to get help and was in the same position when I returned." A review of Resident #1's H&P from a local hospital, admitted d 11/28/11, revealed the plan was for the resident to have surgery to stabilize the fractures so the resident can be provided routine care. The resident's family member was made aware of the significant risks involved with the surgery, but also the information the resident may not survive for long if not provided the surgery as recommended. A review of Resident #1's "Transfer to Nursing home orders" from the hospital dated 12/08/11 revealed. "Distal Femur Fx's" Chair rest, not bending knees. dressing CDI on side of both legs." out of bed to "Geri Chair, twice a day, Don't flex bend both knees. Keep them in extended position." On 12/15/11 at 11:40 AM, CNA A was interviewed regarding Resident #1. She stated she had taken care of Resident #1 for quite a while. She stated the resident had been able to use her electric scooter independently and feed herself, but the resident required the assistance of two staff for transferring. CNA A stated the residents on her hall would do things for her they would not do for other staff and/or CNAs. She (CNA A) could transfer residents by herself, who otherwise required two staff to transfer the same resident. She acknowledged she had transferred Resident #1 by herself in the past. CNA A then explained there was a system with index cards in each resident's closet. The card contained information about each resident's transfer abilities. CNA A stated staff knew to look in the closet to find out about a resident's transfer status if they had any questions. CNA A further stated she had came in on the Sunday (11/20/11) and the resident's family members had been singing in the facility. CNA A stated she went to get Resident #1 up but the resident refused. The resident complained she did not feel good. Resident #1 had complained of leg pain. CNA A stated she went and asked LVN B, "What's going on with ___ (Resident #1)?" CNA A stated she was told Resident #1 had been lowered to the floor on Saturday (11/19/11) while being transferred to the bathroom. CNA A stated she had noticed the bruising on Resident #1 on Wednesday (11/23/11) on the left side of the resident. CNA A also stated the facility had placed the information cards in all of the residents' closets. The cards would reflect whether the residents were a one or two-person transfer. At that time, the surveyor looked into the closet of one of the residents. Inside the closet, hanging in a plastic cover was an index card with information regarding the resident's transfer status. In an interview with CNA C on 12/15/11 at 2:00 PM, she stated she had worked on Resident #1's hall for about four months. She stated Resident #1 had never been able to stand independently, and she always required two people to transfer her. The surveyor interviewed CNA D on 12/15/11 at 3:00 PM, who told the surveyor she had worked on 11/19/11. The surveyor asked CNA D about what had occurred on 11/19/11 with Resident #1. CNA D told the surveyor she had been in another resident's room and "Miss __ (CNA E), one of the aides, said 'I need your help.' I went with ___ (CNA E) and Ms. ___ (Resident #1) was holding onto the wall." CNA D explained there was a bar attached to the wall, and the resident was holding onto the bar. Resident #1's motorized scooter was behind the resident. CNA D further stated, "Her two knees were bent really bad, and her legs were not directly behind her because the scooter was in the way." The resident's legs were bent sideways facing the commode. The surveyor interjected and asked CNA D why she didn't get the nurse and someone else to help move the resident. CNA D told the surveyor, "When I saw the position the resident was in, her pain was bad. She was saying, 'Help me! Help me!' All the pressure was on her knees. She wasn't comfortable. We pulled the scooter back. She was in pain in that position." CNA D stated she and CNA E decided to move the resident. They went under the resident's shoulders. CNA D stated they could not lift the resident very well, because "she was real heavy." They lifted the resident and pulled her back to straighten her legs out. CNA D told the surveyor Resident #1 was a two-person transfer. She stated the nurse was notified after they had straightened out the resident's legs. The surveyor then interviewed CNA E on 12/15/11 at 3:40 PM regarding the incident with Resident #1 on 11/19/11. CNA E told the surveyor she had answered Resident #1's call light. The resident was in her scooter and wanted to go to the bathroom. She stated she had asked Resident #1 if "we could do this." She stated the resident attempted to get up, but the resident could not turn towards the commode. The resident started to slide, and the resident's knees came in contact with the wall. The resident ended up sitting on her left leg. CNA E stated, "I ran and got help from __ (CNA D)." She stated she and CNA D straightened out the resident. They notified the nurse after they had lifted the resident to straighten her legs. CNA E was further interviewed regarding the information provided on the resident's card regarding her transfer status in her closet. CNA E stated she did not check the closet (for the information on Resident #1). In a subsequent interview with LVN F on 12/16/11 at 11:40 AM, she stated, "____ (Resident #1) must have a really high pain tolerance, even to this day, you have to asked her if she is in pain. She doesn't grimace or anything." Observation at that time of Resident #1 revealed she was in a geri-chair in her room asleep. 2) A review of the facility's current Resident Abuse Policy, undated, revealed the following: The resident has the right to be free from verbal, sexual, physical or mental abuse, corporal punishment and/or voluntary seclusion and/or injury from unknown source. In any event or cause to believe that a resident has suffered any of the above abuses, employee, visitor, or family members are requested to report all allegations, suspicions, or incidents to the administrator of the facility or to the state officials posted in the facility. Upon report of any allegations or violations, the administrator or his or her designated representative will thoroughly investigate the situation in accordance with the Texas law. Any employee suspected of abuse or neglect will be removed from direct care of the resident/residents while the investigation is in progress. 3) Review of Reporting Requirements, undated, provided by the facility as current revealed the following reporting requirements. The following incidents must be reported to the Texas Department of Aging and Disability Services state office, in Austin, regardless of the time of day. 3: Neglect allegations. The facility must determine if the injury, harm, or death of a resident was due to facility failure to provide services, treatment, or care to a resident. The following examples of reportable neglect are not all inclusive. Examples B: A resident, according to his care plan, requires a two-person transfer from bed to chair. One staff assists the resident from transferring from his bed to chair and the resident falls resulting in massive bruising to thigh. 4) A review of a facility training record (undated) provided by the facility entitled Preventing Abuse and Neglect revealed the following: Neglect is defined as harming the person in your care either physically, mentally, or emotionally by failing to provide needed care. To put it simply: Neglect is something you do NOT DO. Different types of neglect include the following: active neglect, passive neglect and self-abuse or self-neglect. Active neglect means purposely harming a person physically, mentally, or emotionally by failing to provide needed care. Examples include deliberately leaving a bedridden person alone for lengthy periods, ignoring the person, or willfully denying the person food, medication, dentures, or eyeglasses. Passive neglect is unintentionally harming a resident physically, mentally, or emotionally by failing to provide needed care. The caregiver may not know how to properly care for that resident or may not understand the person's needs. Self-neglect is any of the activities mentioned above committed by the person himself. 5) The CMS Form-672, Resident Census and Conditions of Residents, dated 12/15/11 and signed by LVN G reflected 82 residents required the assistance of one or two staff for transfers, 26 residents were totally dependent on staff for transfers and the facility census was 118.

Based on observation, interview and record review, it was determined the facility failed to implement the facility's written policies and procedures that prohibited neglect for one (Resident #1) of four residents reviewed for neglect as evidenced by the following: 1) CNA E attempted to transfer Resident #1 without assistance from the scooter to the toilet on 11/19/11. Resident #1, who required the total assistance of two staff to transfer, collapsed with both knees on the floor with her lower legs turned to the side. The resident sustained [REDACTED]. This failure to provide Resident #1 a transfer with the assistance of two staff resulted in the resident sustaining fractures to both her legs, have pain, having to be hospitalized , having to have surgical repair and place herself at risk, now being unable to bend her legs as they heal, unable to use her scooter, resulting in decreased socialization and increased need for bed rest, which could result in an overall decrease in her health and cause an exacerbation in her Depression. 2) CNA A stated she still transferred residents without help, who were assessed as requiring two staff to assist with transfers. This failure could affect the 108 residents, who require assistance with transfers or were totally dependent on staff for transfers and placed them at risk for skin tears, lacerations, bruises, pain and discomfort, injury, and fractures resulting in the potential need for hospitalization . Findings included: 1) A review of the facility's current Resident Abuse Policy, undated, revealed the following: The resident has the right to be free from verbal, sexual, physical or mental abuse, corporal punishment and/or voluntary seclusion and/or injury from unknown source. In any event or cause to believe that a resident has suffered any of the above abuses, employee, visitor, or family members are requested to report all allegations, suspicions, or incidents to the administrator of the facility or to the state officials posted in the facility. Upon report of any allegations or violations, the administrator or his or her designated representative will thoroughly investigate the situation in accordance with the Texas law. Any employee suspected of abuse or neglect will be removed from direct care of the resident/residents while the investigation is in progress. 2) Review of Reporting Requirements, undated, provided by the facility as current revealed the following reporting requirements. The following incidents must be reported to the Texas Department of Aging and Disability Services state office, in Austin, regardless of the time of day. 3: Neglect allegations. The facility must determine if the injury, harm, or death of a resident was due to facility failure to provide services, treatment, or care to a resident. The following examples of reportable neglect are not all inclusive. Examples B: A resident, according to his care plan, requires a two-person transfer from bed to chair. One staff assists the resident from transferring from his bed to chair and the resident falls resulting in massive bruising to thigh. 3) A review of a facility training record (undated) provided by the facility entitled Preventing Abuse and Neglect revealed the following: Neglect is defined as harming the person in your care either physically, mentally, or emotionally by failing to provide needed care. To put it simply: Neglect is something you do NOT DO. Different types of neglect include the following: active neglect, passive neglect and self-abuse or self-neglect. Active neglect means purposely harming a person physically, mentally, or emotionally by failing to provide needed care. Examples include deliberately leaving a bedridden person alone for lengthy periods, ignoring the person, or willfully denying the person food, medication, dentures, or eyeglasses. Passive neglect is unintentionally harming a resident physically, mentally, or emotionally by failing to provide needed care. The caregiver may not know how to properly care for that resident or may not understand the person's needs. Self-neglect is any of the activities mentioned above committed by the person himself. 4) Resident #1's November 2011 consolidated physician orders [REDACTED]. A review of Resident #1's MDS assessment dated [DATE] revealed the resident was totally dependent upon staff for transfers and required the physical assistance of two plus staff for transfers. The MDS assessment reflected Resident #1 had not attempted to move from a sitting to standing position, walking, turning, moving on and off toilet, or a surface to surface transfer. Resident #1's care plan initiated on 04/19/11 and continued on 10/05/11 reflected Resident #1 required staff assistance for all ADLs. Goals included Resident #1's needs would be anticipated and the resident would receive assistance with ADLs over the next 90 days. The resident's care plan also reflected she was noted to be at risk for falls related to the need for assistance with transfers and lower extremity muscle weakness. Goals included Resident #1 would have her needs anticipated by staff and would not have any injuries due to falls over the next 90 days. Under approaches, Resident #1 would be evaluated as to her risk for falls, assisted with transfers and mobility, the call light would be kept in reach and her room free of clutter, the resident would be monitored and changes would be reported in her endurance, transfers, and mobility. She would be assisted with toileting as needed and monitored for side effects of medication. In an interview on 12/14/11 at 3:10 PM with Resident #1's family member, he/she stated the resident had two broken legs and had to have surgery. He/She stated he/she had been concerned because Resident #1 had never been able to pick up her legs or lift herself. He/She stated the facility had told him/her Resident #1 had been lowered to the floor on 11/19/11. He/She stated the facility had gotten x-rays of the resident's hip then and there was another x-ray completed on 11/28/11. He/She told the surveyor Resident #1 never showed her emotions and the surgeon could not believe the resident had not been screaming out in pain. The family member further stated Resident #1 had always required two people to transfer her. He/She stated, "Why did she (CNA D) lift her by herself? She should have asked (for assistance)." In an interview with LVN F on 12/15/11 at 10:10 AM, she stated Resident #1 was not able to transfer herself. The staff would put the resident in her motorized scooter, and the resident would move around the facility independently in her scooter. She stated she had been notified about Resident #1 being lowered to the floor on a weekend. LVN F stated she had first noticed Resident #1's bruising on the Wednesday (11/23/11), the day the resident had complained of her legs hurting. Observation on 12/15/11 at 10:14 AM revealed Resident #1 was in a geri-chair. She was observed with dressings on both of her legs. When asked what happened, the resident stated, "I remember I fell against the wall in the bathroom." LVN F told the surveyor Resident #1 could not bend her legs at all. The resident told the surveyor she now had to have five people to transfer her. The resident added she was not able to use her motorized wheelchair now. A review of a non pressure skin condition report revealed, on 11/23/11, Resident #1 was noted to have one 5.5 cm x 5 cm bruise, one 7.5 cm x 3 cm bruise and a 2.5 cm x 3.5 cm bruise. All these bruises were on Resident #1's upper left posterior thigh. The bruises were purple and yellow. A review of the facility's Incident/Accident Report dated 11/23/11 at 10:00 AM revealed Resident #1 was alert and oriented x 2. The report reflected: The CNA reported the resident had bruising to her left leg with purple and greenish bruising to her left posterior thigh and left knee with slight swelling of her the back of her knee. A description of the situation reflected during ADL care, the CNA found the bruising, which she immediately reported to the charge nurse, LVN F. During the investigation, it was learned on 11/19/11 Resident #1 was in the bathroom and had to be lowered to the floor to prevent a fall. Her left knee was bent below the resident before she was assisted to a sitting position. Resident #1 denied any discomfort. Recommendations/New Interventions included: Inservices on Abuse/Neglect, Fall Prevention, DOT system for resident care/identification for all nursing staff; enhancement/reinforcement of same for new employee orientation; and disciplinary action if needed. Dated 11/29/11: updating of Resident #1's care plan upon her return from the hospital. The Incident/Accident Report was signed by the DON and Administrator and dated 11-23-11/11/28/11 by both of their signatures. Resident #1's Nurse's Notes dated 11/23/11 at 6:00 PM reflected an order was received from the resident's primary care physician for a portable x-ray of both hips. Review of the Physician's Telephone Orders dated 11/23/11 for Resident #1 revealed an order for [REDACTED]. The Radiology Report dated 11/23/11 for Resident #1 reflected no fracture or dislocation was seen of the resident's hips. [MEDICAL CONDITION] was present, there's was modest [MEDICAL CONDITION] of the right hip and an old healed left [MEDICAL CONDITION]. The facility's Incident/Accident Report dated 11/28/11 at 4:30 PM reflected Resident #1's family asked for repeat x-rays on 11/25/11 because of the resident's continued bruising. Resident #1 continued to deny pain/injury. The resident's physician replied on 11/28/11 to "x-ray (Resident #1) if still symptomatic (bruising)" and the nurse, as a precaution ordered x-rays of the left leg. During the process of the resident being x-rayed, the RN observed new [MEDICAL CONDITION] to the right knee and requested an x-ray of the right leg also. The results of the x-rays reflected fractures in both legs, which were immediately reported to the family and physician. Orders were received to transfer Resident #1 to the hospital for admission. Resident #1's Radiology Reports dated 11/28/11 reflected the resident sustained [REDACTED]. The Provider Investigation Report dated 11/29/11 reflected the following statement of CNA E regarding the incident on 11/19/11 when Resident #1 was lowered to the floor: "I saw bathroom call light on for resident, ____ (Resident #1). _____ (Resident #1) was in the bathroom, pulled up to the toilet. I asked her what she needed and she said, 'help to the bathroom.' I asked ____ (Resident #1) if she felt that I could assist her up and to the toilet. ____ (Resident #1) indicated, 'yes.' I assisted ____ (Resident #1)) to stand from her scooter and then she said her knees where (sic) buckling. I assisted ____ (Resident #1) back to the edge of her scooter seat and then assister her slowly to the floor. At no time did ____ (Resident #1) fall. She did not fall but was assisted to the floor. When I had her safe, I put on the bathroom call light and left ____ (Resident #1) for 5-10 seconds to call for additional help to assist ____ (Resident #1) back to her chair...." The Provider Investigation Report's Description of Assessment: 11/19/11 - No injury noted from resident being lowered to the floor. Resident #1 indicated she was okay and no complaints of pain were voiced. 11/20/11 - Resident #1 said she was okay but did not want to get up from bed. This was not unusual. Resident #1 would rather stay in bed and watch TV. She was given Tylenol due to minor aches and pains, which she often has. 11/21/11 - Assessed resident for any delayed problems related to resident being lowered to the floor in the bathroom. On 11/19, Resident #1 stated she had pain and the pain she had was no worse than she normally has. No bruising or swelling noted to either leg during the assessment. 11/23/11 - Resident noted to have greenish-purple bruising the left posterior leg and left posterior knee. A small area of slight swelling was noted to left posterior knee. Resident showed increased pain to bilateral legs when legs were raised. Doctor was notified by fax, reporting bruising and increased pain when lifting. 11/24/11 - X-ray to hips and pelvis were obtained with negative results. The Provider Investigation Report's Investigation Summary: The facility was unable to confirm the allegation of neglect. Staff were re-educated on safe resident handling, preventive falls, the DOT system, abuse and neglect. Resident needs will be reassessed upon return to the facility. A review of a written statement dated 12/06/11 by CNA E revealed, "On Nov. 9th 2011, I answered a red call light in Mrs. ___ (Resident #1's) bathroom. She was in or on scooter pulled up to toilet and stated she needed to use toilet. I assisted her to stand she had put her hands on grab rail She froze and was unable to turn so I told her to sit. She sat on the edge of the scooter. I turned light back on and attempted to get her repositioned but was unable to. She began to slide slowly, when her knees made contact with wall, they began to turn to left and she continued to slide to floor. Her hands remained on rail and she was sitting upright with her legs under her when I left the room to get help and was in the same position when I returned." A review of Resident #1's H&P from a local hospital, admitted d 11/28/11, revealed the plan was for the resident to have surgery to stabilize the fractures so the resident can be provided routine care. The resident's family member was made aware of the significant risks involved with the surgery, but also the information the resident may not survive for long if not provided the surgery as recommended. A review of Resident #1's "Transfer to Nursing home orders" from the hospital dated 12/08/11 revealed. "Distal Femur Fx's" Chair rest, not bending knees. dressing CDI on side of both legs." out of bed to "Geri Chair, twice a day, Don't flex bend both knees. Keep them in extended position." On 12/15/11 at 11:40 AM, CNA A was interviewed regarding Resident #1. She stated she had taken care of Resident #1 for quite a while. She stated the resident had been able to use her electric scooter independently and feed herself, but the resident required the assistance of two staff for transferring. CNA A stated the residents on her hall would do things for her they would not do for other staff and/or CNAs. She (CNA A) could transfer residents by herself, who otherwise required two staff to transfer the same resident. She acknowledged she had transferred Resident #1 by herself in the past. CNA A then explained there was a system with index cards in each resident's closet. The card contained information about each resident's transfer abilities. CNA A stated staff knew to look in the closet to find out about a resident's transfer status if they had any questions. CNA A further stated she had came in on the Sunday (11/20/11) and the resident's family members had been singing in the facility. CNA A stated she went to get Resident #1 up but the resident refused. The resident complained she did not feel good. Resident #1 had complained of leg pain. CNA A stated she went and asked LVN B, "What's going on with ___ (Resident #1)?" CNA A stated she was told Resident #1 had been lowered to the floor on Saturday (11/19/11) while being transferred to the bathroom. CNA A stated she had noticed the bruising on Resident #1 on Wednesday (11/23/11) on the left side of the resident. CNA A also stated the facility had placed the information cards in all of the residents' closets. The cards would reflect whether the residents were a one or two-person transfer. At that time, the surveyor looked into the closet of one of the residents. Inside the closet, hanging in a plastic cover was an index card with information regarding the resident's transfer status. In an interview with CNA C on 12/15/11 at 2:00 PM, she stated she had worked on Resident #1's hall for about four months. She stated Resident #1 had never been able to stand independently, and she always required two people to transfer her. The surveyor interviewed CNA D on 12/15/11 at 3:00 PM, who told the surveyor she had worked on 11/19/11. The surveyor asked CNA D about what had occurred on 11/19/11 with Resident #1. CNA D told the surveyor she had been in another resident's room and "Miss __ (CNA E), one of the aides, said 'I need your help.' I went with ___ (CNA E) and Ms. ___ (Resident #1) was holding onto the wall." CNA D explained there was a bar attached to the wall, and the resident was holding onto the bar. Resident #1's motorized scooter was behind the resident. CNA D further stated, "Her two knees were bent really bad, and her legs were not directly behind her because the scooter was in the way." The resident's legs were bent sideways facing the commode. The surveyor interjected and asked CNA D why she didn't get the nurse and someone else to help move the resident. CNA D told the surveyor, "When I saw the position the resident was in, her pain was bad. She was saying, 'Help me! Help me!' All the pressure was on her knees. She wasn't comfortable. We pulled the scooter back. She was in pain in that position." CNA D stated she and CNA E decided to move the resident. They went under the resident's shoulders. CNA D stated they could not lift the resident very well, because "she was real heavy." They lifted the resident and pulled her back to straighten her legs out. CNA D told the surveyor Resident #1 was a two-person transfer. She stated the nurse was notified after they had straightened out the resident's legs. The surveyor then interviewed CNA E on 12/15/11 at 3:40 PM regarding the incident with Resident #1 on 11/19/11. CNA E told the surveyor she had answered Resident #1's call light. The resident was in her scooter and wanted to go to the bathroom. She stated she had asked Resident #1 if "we could do this." She stated the resident attempted to get up, but the resident could not turn towards the commode. The resident started to slide, and the resident's knees came in contact with the wall. The resident ended up sitting on her left leg. CNA E stated, "I ran and got help from __ (CNA D)." She stated she and CNA D straightened out the resident. They notified the nurse after they had lifted the resident to straighten her legs. CNA E was further interviewed regarding the information provided on the resident's card regarding her transfer status in her closet. CNA E stated she did not check the closet (for the information on Resident #1). In a subsequent interview with LVN F on 12/16/11 at 11:40 AM, she stated, "____ (Resident #1) must have a really high pain tolerance, even to this day, you have to asked her if she is in pain. She doesn't grimace or anything." Observation at that time of Resident #1 revealed she was in a geri-chair in her room asleep. 5) The CMS Form-672, Resident Census and Conditions of Residents, dated 12/15/11 and signed by LVN G reflected 82 residents required the assistance of one or two staff for transfers, 26 residents were totally dependent on staff for transfers and the facility census was 118.

Based on observation, interview, and record review it was determined the facility failed to ensure one (Resident #6) of ten residents with pressure ulcers received necessary treatment and services to promote healing of current pressure ulcers and to prevent new pressure ulcers from developing. Resident #6 was admitted on [DATE] with two pressure ulcers identified as Stage I. On 01/10/11 the facility identified three additional pressure ulcers documented as "SDTI" (suspected deep tissue injury). On 01/14/11 the facility identified an additional "SDTI." This failure placed all 10 residents including Resident #6 who resided in the facility with pressure ulcers at risk for undue pain and suffering. Findings included: Review of the face sheet dated 01/20/10 revealed Resident #6 was an [AGE] year-old male admitted on [DATE] from the hospital after a surgical repair of his Fractured Femur with [DIAGNOSES REDACTED]. On 01/24/11 at 10:14 a.m. during observation rounds, Resident #6 was observed to be lying on his left side on an air mattress. There was no abduction pillow between his legs. RN E stated Resident #6 was recently transferred from hall 300. RN E stated Resident #6 was incontinent of bowel and bladder; was alert and oriented to person, place and time; was confused and forgetful; had skin problems; was assisted/fed with meals and ate in his room; was admitted after a fall at home where he fractured his right hip and had right side weakness. RN E identified Resident #6's pressure ulcers as "Stage 3's to heels (1 DTI (Deep Tissue Injury)), and Stage 1's on his feet." Observation on 01/24/11 at 12:15 p.m. revealed for lunch Resident #6 received a regular portion size serving of ham, peas, brussel sprouts, a brownie, milk, ice tea and corn bread. Resident #6 ate approximately 60% of his meal. His milk was not opened. He asked the surveyor to open it. The surveyor requested staff to open it. (Resident #6 then drank all his milk, which was included in the 60% total consumption of lunch.) On 01/25/11 at 10:25 a.m. RN E, assisted by LVN F, was observed to provide wound treatments to Resident #6. When asked to measure the areas, RN E said she did not have any measuring devices with her on her cart. (Measuring was to be conducted on 01/26/11.) Resident #6 was observed to have eschar on the left heel and a "deep tissue injury" was noted below the left heel eschar. A third area was on the left medial ankle. A fourth area was on the right heel, and a fifth area was observed on the right lateral ankle. Kerlix dressings were applied to both feet leaving the "deep tissue injury" open to air. RN E checked pedal pulses to both feet. (In an interview, RN E said the pedal pulses were 1+.) Although RN E did not measure the pressure areas, the above areas were documented with sizes as follows on the skin sheets for Resident #6 dated 01/25/11 at 10:30 a.m. 1. "Right top of ankle 1 cm x 0.5 cm 2. Left inner ankle 2 cm x 2 cm 3. Left upper heel 3 cm x 2 cm 4. Right heel 2 cm x 2 cm" Review revealed additional documentation of Resident #6's ulcers on 01/25/11 by RN E: 1. "Left heel 0900 (9:00 a.m.) 2 cm x 2 cm" 2. "Right upper heel (- no time -) see wound sheet for letter (J) (right heel) due to the two wounds are now one wound." (Review of a previous measurement documented on 01/24/11 revealed this wound was 2 cm x 2 cm Stage 2.) On 01/26/11 at 11:39 a.m., RN E, assisted by LVN F, was observed to measure Resident #6's pressure ulcers. The following measurements and descriptions were obtained by RN E: 1. Left Heel - "SDTI 2 cm x 5 cm mottled purple dry and firm." (Indicated an increase in size) 2. Left Heel (above aforementioned) - "2.5 cm x 2.5 cm with 5% yellow slough, 95% eschar surrounded by pink tissue firm - Stage 3-4 unstageable." (Indicated a .5 cm reduction in the length and a .5 cm increase in the width.) (When a pressure ulcer is determined to be unstageable, it is not staged.) 3. Right Heel - "7 cm x 3 cm x .2 Stage 3-4 with Black eschar with surrounding pink tissue - no slough" (Indicated two wounds were now one wound and were larger than both wounds previously documented.) 4. Left Ankle Medial aspect (inside) "1.3 cm x .5 cm SDTI firm, dry, no slough with Black eschar" (Indicated a decrease in size of this wound.) 5. Right Ankle Lateral aspect (outside) "1.1 cm x .5 cm stage 2 no slough or eschar." (Indicated a slight increase in size of this wound) RN E was asked if she could feel Resident #6's pedal pulses when she checked them on 01/25/11. RN E said she "could palpate them at a "1" not a "2". (Reference obtained from <http://allnurses.com/nursing-student-assistance/pedal-pulse- 0.html> on 02/10/11stated, "The most popular grading scale that is used included from page 330 of Textbook of Physical Diagnosis: [REDACTED]. Swartz, M.D., are: 0 - absent, 1 - diminished, 2 - normal, 3 - increased, and 4 - bounding.") On 01/27/11 Review of the documentation of Resident #6's Pressure ulcers reflected the wounds were re-measured on 01/26/10 with the following documentation by an (unidentifiable) RN: 1. "Right top ankle 01/26 1900 (7:00 p.m.) SC (Identified under terms as skin condition - an abnormal finding on the surface of the skin - 8 other abrasion) 1 cm x 0.5 cm red (in color) no drainage odor or pain heels floated." (Indicated a change from Stage 2 identified on 01/26/11 observation at 11:39 a.m. with RN E and LVN F to only a skin condition classified as an abrasion.) 2. "Left inner ankle 01/26 1900 (7:00 p.m.) Stage 1 and unstageable 4.2 cm x 3.5 red, blanchable area (stage 1) surrounding 1 cm x ? cm area of soft black eschar (unstageable) - no site pain on palpation no [MEDICAL CONDITION], drainage, odor or sx of infx (signs of infection) (pain on movement of BLE (bilateral lower extremities) for assessment (rec [MEDICATION NAME])." (Indicated a change from SDTI with a decrease in size identified on 01/26/11 observation at 11:39 a.m. with RN E and LVN F to an unstageable area of soft black eschar.) (According to the terms on the facility's wound/skin assessment tool a stage 1 is NONBLANCHABLE.) 3. "Left heel 01/26 1900 (7:00 p.m.) unstageable 2 cm x 4.5 cm - UTD depth (unable to determine), no tunneling, black/red color, no drainage no odor, yes pain santyl to debride." (Indicated a change from SDTI with a decrease in size identified on 01/26/11 observation at 11:39 a.m. with RN E and LVN F.) 4. "Left upper heel 01/26/11 1900 (7:00 p.m.) unstageable 2.5 cm x 2.2 cm red/black color no drainage n odor no pain santyl to debride." (Indicated a change from SDTI with a decrease in size identified on 01/26/11 observation at 11:39 a.m. with RN E and LVN F.) 5. "Right heel 01/26 7:30 p.m. unstageable 3 cm x 2 cm red/black color no drainage no odor yes pain santyl to debride." (Indicated a change from stage 3/4 measuring 7 cm x 3 cm with a decrease in size identified on 01/26/11 observation at 11:39 a.m. with RN E and LVN F to two ulcers. RN E documented the two had become one ulcer on 01/26/11 at 1200 (12:00 noon.) 6. "Right Upper heel 01/26 1930 (7:30 p.m.) unstageable 0.5 cm x p.5 cm red/black color no drainage no odor yes pain santyl to debride." (Indicated a change from stage 3/4 measuring 7 cm x 3 cm with a decrease in size identified on 01/26/11 observation at 11:39 a.m. with RN E and LVN F to two ulcers. RN E documented the two had become one ulcer on 01/26/11 at 1200 (12:00 noon.) Observation on 01/25/11 at 12:14 p.m. revealed Resident #6 received for lunch a regular portion size serving of corn dog, green beans, pie, ice tea and bread. (This was the alternate meal - Resident #6 said he did not like meatloaf, which was on the menu. He further stated he did not like corn dogs either.) Resident #6 ate approximately 46% of his lunch. He was not observed to be offered a supplement. On 01/25/11 review of the clinical record revealed Resident #6's MDS assessment with the reference date of 01/14/11 and a print date of 01/21/11 had identified seven stage 1 pressure ulcers. On 01/25/11 review of Resident #6's care plan with the problem onset date of 01/21/11 revealed the staff had also identified seven stage 1 pressure ulcers. The MDS assessment and care plan were signed by all disciplines on 01/21/11. On 01/27/11 review of the MDS with the assessment reference date of 01/14/11 revealed a print date of 01/26/11, and the section on skin conditions had been changed to reflect Resident #6 had "3 Stage 1 pressure ulcers and 4 Unstageable - Deep tissue: suspected deep tissue injury in evolution." On 01/28/11, review of Resident #6's care plan for pressure ulcers revealed a new care plan dated 01/25/11, which identified three stage 1 pressure ulcers and 4 SDTI. Handwritten entries on the 01/25/11 pressure ulcer care plan, which were not on the care plan when reviewed on 01/25/11 earlier in the day reflected the following: 1) Pressure relief devices used: 1/10/11 air mattress ? (change) 1/27/11; 1/19 heel protectors, donut heel lifters, off load feet - propped up on pillows. 2) Surgeon referral to (named doctor) 3) Dietary consult - recommends large portions; liquid protein 30 cc TID, and [MEDICATION NAME] 1 pkt BID 4) Resident is non-compliant with heel protectors and off loading heels - continues to have direct contact with mattress at times. Continues at risk due to his [MEDICAL CONDITION] problems. 5) 1/26/11 Added LAL mattress, bed cradle, wounds unstageable, no pulses per vascular consult. Further care plan review revealed an added "Problem onset: 01/27/11 Resident has vascular ulcers to bilateral lower extremeties (sic) related to a [DIAGNOSES REDACTED]." Record review revealed Resident #6 saw his Orthopedic Surgeon on 1/17/11 and a General Surgeon on 01/24/11. There was no record of Resident #6 having a Vascular Consult. There was no record of a progress note from the Orthopedic Surgeon. The General Surgeon's progress note did not mention [MEDICAL CONDITION]. Review of the Surgeon Consult report dated 01/24/11 revealed, "...Physical Examination: Reveals his feet to be warm and there is mild [MEDICAL CONDITION]. No pulses, but I think it is just related to his [MEDICAL CONDITION]. His ulcers are clean...." On 01/27/11 at 10:50 a.m. LVN H was asked about the change to Resident #6's MDS assessment skin condition. LVN H stated, "They told me it wasn't right, and I corrected it. The DON brought it to my attention that the care plan wasn't right. I corrected the MDS on 01/25/11." (The day the surveyor brought it to the attention of the DON.) On 01/25/11, review of the admission documentation revealed there was no completion of the Braden Scale for predicting the development of pressures ulcers. The Braden Scale page was in the chart; however, it was blank. On 01/25/11 at 4:15 p.m. in an interview, the DON stated "I don't know why the Braden Scale was not done. It's supposed to be done on all new admissions and quarterly." On 01/25/11 review of the Admission Nursing assessment dated [DATE] revealed the box for "Skin Concern *(*See Skin/Wound Assessment Record)" was checked. On 01/25/11 review of the Wound/Skin Assessment Tool(s) dated 01/07/11 revealed the admission nurse, LVN D, who worked the 2-10 shift documented the following: 1) Stage 1 (nonblanchable [DIAGNOSES REDACTED] of intact skin, or discoloration, [MEDICAL CONDITION], induration, and warmth over a bony prominence....) on (L) top foot that measured 1 centimeter (cm) x .5 cm with no depth, tunneling, odor or pain." The color was "red." The comments reflected Monitor Reddness (sic). 2) Stage 1 (R) top ankle that measured 1 cm x 0.5 cm with no depth, tunneling, odor or pain. The color was "red." The comments reflected Monitor Reddness (sic). 3) Stage 1 (L) inner ankle that measured 2 cm x 2 cm with no depth, tunneling, odor or pain. The color was "red." The comments reflected Monitor Reddness (sic)." Review of the Wound/Skin Assessment Tool(s) dated 01/10/11 revealed at 8:00 p.m. LVN D documented the following: 1) Although "Stage 1" was circled on the form, the term "SDTI" (Suspected Deep Tissue Injury) was also documented at 8:00 p.m., for a wound to the left heel that measured 2 cm x 2 cm with no depth, tunneling, drainage, odor or pain. The color was identified as "red." The comments reflected "skin protector/OTA" (open to air). (Reference obtained on 02/03/11 from the National Pressure Ulcer Advisory Panel at <http://www.npuap.org/pr2.htm> reflected, Suspected Deep Tissue Injuries are "Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.") 2) Although Stage 3-Stage 4 - wound completely covered with necrotic tissue, cannot be staged until wound base is visible was circled on the form, the term SDTI was also documented at 8:00 p.m. for a wound to the (L) upper heel which measured 3 cm x 2 cm with no depth, tunneling, drainage, odor or pain. The color was identified as "red." The comments reflected "skin protector/OTA" (open to air). 3) Although "Stage 2 - partial thickness skin loss involving epidermis or dermis; ulcer is superficial; presents as an abrasion, blister, or shallow crater was circled on the form, the term "SDTI" was also documented at 8:00 p.m. for a wound to the (R) heel which measured 1 cm x 1 cm with no depth, tunneling, drainage, odor or pain." The color was identified as "red." The comments reflected "skin protector/OTA (open to air)." Review of the Wound/Skin Assessment Tool(s) dated 01/14/11 revealed LVN D documented the following: 2) The "(R) upper heel was identified as SDTI that measured 3 cm x 2 cm with no depth, tunneling, drainage, odor or pain" was documented at 4:00 p.m. The color was identified as "red." The comments reflected "skin protector/OTA" (open to air). On 01/25/11 review of the physician's orders [REDACTED]. 1) An order dated 01/10/11 to "Apply air mattress to bed to promote pressure reduction and comfort." 2) An order dated 01/17/11 for "Start Santyl & [MEDICATION NAME] with gauze dressing to (L) heel QD (daily)." (Reference obtained on 02/03/11 from <http://www.santyl.com/about> states "SANTYL? Ointment is an active enzymatic therapy that continuously removes necrotic (dead) tissue from wounds at the microscopic level." ) (Reference obtained on 02/03/11 from <http://www.[MEDICATION NAME].com> states, [MEDICATION NAME]? is a "First Aid Antibiotic Ointment." 3) An order dated 01/19/11 to "Refer to Dr ____ for eval of pressure ulcers to heels and N/O (new order heel protectors to heels while in bed." 4) An order dated 01/24/11 from the above named referral doctor which reflected, "Current management - RTC" (Return to Clinic 3 wks). On 01/27/10 review of the physician's orders [REDACTED]. 1) 1/26/11 (1) Add large portions to diet, large eggs in AM (2) Liquid Protein 30 cc TID, (3) [MEDICATION NAME] 1 pkt BID 2) 1/26/11 LATE ENTRY 1/7/11 until F/U (follow-up) with (Named Orthopedic Surgeon) (1/17/11) Clarification: Abduction Pillow 3) 1/26/11 LATE ENTRY 1/7/11 until F/U (follow-up) with (Named Orthopedic Surgeon) (1/17/11) Clarification: Abduction Pillow. (This was entered twice) 4) DC (discontinue) Heel protectors. On 01/25/11 review of the Physician's Progress notes revealed the referring doctor wrote "Bilateral stage II pressure ulcers of heels - Will need to debride but cont. to let them demarcate better - F/U 3 wks. Encourage to ambulate." Review of the daily nursing assessments dated 01/07/11 at 4:30 p.m. through 01/10/11 at 4:00 p.m. revealed no documentation of wounds on Resident #6's heels and no protective measures to prevent the development of pressure ulcers. These nursing assessments repeatedly document "Abduction pillow in place." The daily nursing assessments first mention of Resident #6 "is resting in his bed with his feet on pillows" occurred on 01/10/11 at 11:30 p.m. (Reference obtained on 02/03/11 from <http://www.freepatentsonline.com/ 28.html> states, "An abduction pillow used to immobilize a patient's legs after hip surgery....") Review of the Initial Care Plan dated 01/07/11 revealed a check mark for Pressure ulcer/Skin at Risk Goal Prevent/Heal pressure ulcers. The remaining boxes for TX: (treatment), Preventive: Position: Supplements: and RD (Registered Dietitian) Ref: were blank. Review of the History and Physical dated 01/15/11 and signed by Resident #6's attending physician revealed "....Strong PT pulse (R)" (Reference obtained on 02/03/11 from <http://medical-dictionary.thefreedictionary.com/Pt> states, "PT - . . .7 Posterior tibialis pulse. McGraw-Hill Concise Dictionary of Modern Medicine. ? 2002 by The McGraw-Hill Companies, Inc.") On 01/25/11 at 4:15 p.m., the DON was informed of the concern regarding Resident #6's pressure ulcers. The DON acknowledged Resident #6 "developed some of his pressure ulcers in the facility." On 01/26/11 at 10:00 a.m., Resident #6 was observed in the therapy room using hand exercise equipment. OTA G stated, "We stood him at the bars but he has ulcers on his feet and they hurt when he stands." On 01/26/11 between 11:53 a.m. and 12:20 p.m. an interview was conducted with Resident #6's family. When asked if he/she had been notified when Resident #6's pressure ulcers developed, he/she stated, "They let me know about the ulcers on his feet." When asked if he was turned from side to side or did he stay on his back, he/she stated, it was "four to five days after admission before they started turning him side to side." When asked how long Resident #6 had the heel protectors on his feet, he/she stated, "Heel protectors have been on for one to one and half weeks." On 01/28/11 at 9:46 a.m. a second interview with Resident #6's family revealed, "Some of my words got misrepresented. As far as I know he had that thing between his legs, and they didn't turn him. I did see his feet propped on pillows. He didn't have the problem with his feet when he first came in. He didn't come into (named the facility) with visible signs on his feet of the ulcers. I saw his feet. They didn't put him on his side because they didn't want his hip to come out. They did prop his feet on pillows when he came in. They were doing that in the hospital. I don't remember the doctor telling me ____ (Resident #6) had diminished circulation to his feet. They turned him to clean him up." (In this second interview, the family member did not deny his/her previous statements however, he/she did add that Resident #6's feet were propped on pillows and he did not have the ulcers on his feet when he was admitted , because he/she saw his feet.) On 01/26/11 at 3:30 p.m. the DON brought Resident #6's chart to the surveyor to provide information regarding a progress note written by Resident #6's physician on 01/25/11. The progress note reflected "IM (Internal Medicine) follow-up re: heel ulcers. When (named Resident #6) transferred to (named nursing facility) from (named hospital) where he had ORIF (Open Reduction Internal Fixation) (R) [MEDICAL CONDITION] he reports his heels were "burning" he believes from "rubber boots" while on ward there. He had ? tissue turgor at that time. Off loading of heels thru various documented means was instituted to contain the area of preexisting subcutaneous tissue injury. Since then Mr (initial of Resident #6) has become ambulatory via PT. His burning pain has persisted as the injury declared itself with dry escharification. He awaits surgical follow-up for removal of nonviable tissue. I agree with (named surgeon) we should wait because in spite of large vessel [MEDICAL CONDITION] he has pulses to knee on left: PT (Posterior tibialis pulse) & DP (Dorsalis Pedis) on R with continued aggressive off loading the tissue loss may well allow healing without a graft. No sign of infection. The primary and dominant injury was antecedent to admission here." (Resident #6's physician is also the Medical Director of this facility.) (This note was dated after the DON was notified by the surveyor of the concerns regarding Resident #6's pressure ulcers. The above information was not in the clinical record for 18 days after admission.) In an interview on 01/26/11 at 1:45 p.m., the Physical Therapist stated, "Cognition from his (Resident #6's) [MEDICAL CONDITION] a factor in rehab as well as the pressure ulcers. Resident has regressed to transfer board. His upper arm strength is not good and limits his ability to stand and support himself with his arms. His right leg externally rotates in bed and when he stands. Abductor pillow is not routinely used when residents are on their side - use pillows if on their side. Abductor pillow is used when on their back." Review of Resident #6's MDS assessment dated [DATE] revealed Resident #6 was 73 inches tall and weighed 214 pounds. Review of Resident #6's weekly weight record dated 01/24/11 reflected he continued to weigh 214 lbs. On 01/27/11 at 10:08 a.m., RA I, with the assistance of OTA G, and PTA J were observed to weigh Resident #6, who weighed 211.4 pounds. Resident #6 was weighed in a chair scale. RA I acknowledged she routinely weighs residents in the chair scale. Review of the form "Communication Between the Dietitian" and Resident #6's physician dated 01/20/11 revealed the Problem or Concern: "1) Res with multiple pressure ulcers, and 2) Res with increased caloric and protein needs d/t (due to) ht/wt and pressure ulcers." Recommendation was: "1) add large portions to diet, large eggs in AM, 2) liquid protein 30 cc tid and 3) [MEDICATION NAME] 1 pkt bid." This communication was signed by Resident #6's attending physician on 01/25/11. There was a handwritten note on this form which stated, "Noted and done 01/26/11." There was no legible signature. Review of Resident #6's January 2011 MAR indicated [REDACTED] Review of Resident #6's physician's telephone orders dated 01/25/11 revealed orders for "1) Large portions Large eggs A.M. 2) Liquid protein 30 cc tid, 3) [MEDICATION NAME] 1 pkt bid per RD consult rec. to promote wound healing." On 01/27/11 at 7:25 a.m., observation revealed for breakfast, Resident #6 received a regular portion size serving of toast, oatmeal, eggs (regular size) 2 pieces of bacon, coffee, 2% milk, and 3 ounces of cranberry juice. On 01/27/11 at 7:30 a.m. in interview, the Dietary Manager was asked to show the surveyor double portion amounts, which were bigger than what Resident #6 received. The Dietary Manager stated we "don't serve double portions, just large (portions). A large portion was 2 scoops. If the (resident was to receive) large portion and received the same size as everybody, it's an oversight." In an interview on 01/27/11 at 12:40 p.m. LVN D stated, on admission "right heel was clear (on Resident #6). The left heel was soft but not mushy. There was no discoloration... Since there was no discoloration of skin, I did not document it on the skin sheet. I did not work the weekend. When I came back Monday, there was discoloration on the left heel - deep red color. Both areas were present. The heel was deeper red than the upper part. I can't remember the right heel. I called the ADON to let her know. She came to the room. She was as shocked as I was." In an interveiw on 01/27/11 at 1:16 p.m., the ADON stated, "____ (LVN D) came and got me to look at him the day he came. They (Resident #6's heels) were ulcer and mushy when he came in. He said they were tender. She came rushing down the hall Monday and got me. I couldn't believe they were open. _____ (LVN D) made sure pillows were there." On 01/28/11 at 10:26 a.m., Resident #6 was observed lying on an AiroDyne Mattress (alternating pressure mattress). RA I stated, "He got it yesterday." Resident #6 was also observed to have a foot cradle on his bed to keep the bed covers off his feet. The form CMS-672 (Resident Census and Conditions of Residents) dated 01/24/11 and provided by LVN H, the MDS PPS Coordinator reflected ten residents had pressure ulcers with only one resident, who had a pressure ulcer on admission and a census of 126 residents.