Every finding on record at Legacy Rehabilitation and Living

Based on observation, interview and record review, the facility failed to ensure residents received care and treatment, consistent with professional standards of practice, to ensure residents assessed for pressure ulcers received treatment and care to prevent pressure ulcers from developing for 1 of 10 residents (Resident #1) reviewed for pressure ulcers. LVN A failed to change Resident #1 pressure ulcer dressings on both her ankles 3 times. Resident #1's dressing changes were ordered every Monday, Wednesday and Friday and PRN. The dressings on Resident #1's ankles were dated 7/12/26 (Sunday). The dressings were not changed on 7/13/26, 7/15/26 and 7/17/26. This failure could place residents at risk of skin breakdown resulting in developing pressure ulcers needing extensive care limiting resident's mobility and functionality, resulting in indue pain and discomfort, and deterioration on residents' general condition.Findings Included: Record review of Resident #1's clinical record revealed a [AGE] year-old female resident admitted to the facility on [DATE] with the following diagnoses: hypothyroidism, reflux, migraine, muscle weakness, unsteadiness on feet, cognitive communication deficit, dysphagia (difficulty or discomfort in swallowing), lack of coordination, trigeminal neuralgia (chronic pain condition), hyperlipidemia (high levels of fat in the blood), abnormalities of gait and mobility, iron deficiency anemia, rheumatoid arthritis (autoimmune disorder where the immune system attacks the lining of your joints causing painful swelling, cartilage damage and bone erosion), flexion deformity (joints become locked in a bent position and cannot be fully straightened), history of falling, osteoarthritis, need for assistance with personal care, pain in joints, pressure ulcer of left heel, stage 2, pressure ulcers of other site, Stage 2, pressure ulcer to lest ankle, Stage 4, pressure ulcer of right ankle, Stage 3, acute and chronic respiratory failure with hypoxia (body does not receive adequate oxygen to function properly), anemia (lack of healthy red blood cells), elevated c-reactive protein (inflammation in the body), major depressive disorder, hypotension (low blood pressure), partial traumatic amputation of right foot, partial traumatic amputation of one right lesser toe, abnormal posture and COPD (persistent airflow limitation). Record review of Resident #1's last MDS was a significant change, completed 7/3/26, listing a BIMS of 7 indicating she was moderately cognitively impaired, and her functional status was extensive two-person assistance for all ADLs. Resident #1 had 2 Stage 2 pressure ulcers, 3 stage 3 pressure ulcers and 2 stage 5 pressure ulcers and one unstageable pressure ulcer that were present on admission to the facility. Resident #1's care plan, dated 7/3/26, documented Resident has arterial ulcer of the right lateral foot, left ankle, left heel, left dorsum 2nd digit, coccyx, left dorsum 1st digit, left knee, left lateral foot, left dorsum 1st interdigit space, left medial foot, right medial malleolus (side of ankle joint) and right knee - administer treatments as ordered and monitor for effectiveness. Record review of Resident #1's progress notes, dated 7/6/26, signed by Resident #1's NP revealed the following: admission information relating to this stay: Resident #1 carries a high-burden chronic disease profile dominated by severe rheumatoid arthritis with profound joint deformities, Sjogren's disease (chronic autoimmune disorder where the immune system mistakenly attacks moisture producing glands), chronic pain, progressive cognitive impairment. Her baseline condition is complicated by ongoing multifocal chronic pressure injuries with recurrent infection risk and history of osteomyelitis (infection and inflammation of the bone, primarily caused by bacteria or fungi). She requires ongoing long-term care level management for safety, medication oversight, close monitoring for deterioration/infection, complex wound coordination and prevention of rehospitalization. Physical Exam: decreased mobility, painful movement, poor strength, significant deformity of bilateral hands, fingers, feet and toes with profound ulnar (long bone of the arms) deviation pain and crepitus (crunching, grating or popping sound) with movement of ankles, knees or shoulders. Goals of Care: Overall, she continues to decline with poor PO intake and lack of improvement in wounds, despite our best efforts. Overall, her goals of care are palliative and more focused on comfort and quality of life - does not want aggressive workups and diagnostics that will not offer pain control. DNR in place. Record review of Resident #1's Wound Administration Record, dated 7/1/26 through 7/31/26, documented the following wound care orders:Left knee - Cleanse with wound cleanser, pat dry with gauze, apply collagen and cover with super absorbent dressing every Monday, Wednesday and Friday and PRN.Left Medial Calf - Cleanse with wound cleanser, apply honey fiber to wound bed and cover with super absorbent dressing every Monday, Wednesday and Friday and PRN.Left second toe - Cleanse with wound cleanser, pat dry with gauze, apply thin layer of medi honey and cover with non-adherent dressing, wrap with kerlix, secure with tape and apply elastic tube stocking, every Monday, Wednesday, Friday and PRN.Left 5th toe - cleanse with wound cleanser, pat dry with gauze, paint with betadine, every Monday Wednesday and Friday for wound management.Left great toe - cleanse with wound cleanser, pat dry with gauze, apply thin layer of medi [NAME] and cover with non-adherent dressing, wrap with kerlix, secure with tape and apply elastic tube stocking, every Monday, Wednesday and Friday and PRN.Left lower extremity - medial shin - cleanse with wound cleanser, apply collagen calcium alginate with silver and super absorbent dressing every Monday, Wednesday and FridayPressure Injury: left ankle malleolus - cleanse with wound cleanser, pat dry with gauze, apply calcium alginate with silver and super absorbent dressing every Monday, Wednesday and Friday.Pressure Injury; right ankle malleolus - cleanse with wound cleanser, pat day with gauze, apply calcium alginate with silver and super absorbent dressing, every Monday, Wednesday and Friday and PRNPressure Ulcer left buttock: cleanse with wound cleanser, apply collagen sheet and cover with super absorbent dressing every Monday, Wednesday and Friday and PRNRight knee - cleanse with wound cleanser, pat dry with gauze, apply collagen and cover with super absorbent dressing every Monday, Wednesday and Friday and PRN An observation on 7/18/26 at 8:15 a.m. of Resident #1's dressings on both of her feet were dated 7/12/26, 6 days ago. Dressings on both of her knees were dated 7/17/26. During an interview on 7/18/26 at 10:45 a.m., LVN A stated Resident #1's dressing changes were Monday, Wednesday and Friday and PRN and were just for comfort only because her skin was deteriorating. LVN A was made aware that the dressings on Resident #1's feet were dated 7/12/26 which was 6 days prior, LVN A stated Resident #1 complained of pian, and she gets completed what she gets completed (referring to the dressing changes). LVN A stated she did not think she documented anywhere that Resident #1 refused dressing changes. LVN A stated she gives Resident #1 pain medications and does the dressing changes until she says to stop. During an interview on 7/18/26 at 11:30 a.m., the DON stated she had already spoken to LVN A about the dressing changes not being provided and LVN A will be suspended until the investigation is completed. The DON stated she had two staff members check all residents with dressing changes to ensure that all their dressings were changed, and there were no other residents that had not had their dressing changed in a timely manner. The DON stated Resident #1's wounds had not changed in appearance and there were no signs of infection. Record review of the Policy and Procedure titled: Skin and Wound Monitoring and Management, Section, revised 4/2025, 483.25 Quality of Care documented the following;It is the policy of this facility that: 2. A resident having pressure injury(s) receives necessary treatment and services to promote healing, prevent infection and prevent new, avoidable pressure injuries from developing.Once an area of alteration in skin integrity has been identified, assessed and documented, nursing shall administer treatment to each affected area as per the Physician's Order.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 1 of 10 residents (Resident #1) observed for infection control. The facility failed on 7/18/26 when LVN A failed to wash hands or change gloves while providing wound care to Resident #1. This failure could place residents at risk for the spread of infections, tissue breakdown and or worsening of wounds or pressure ulcers.Findings included: Record review of Resident #1's clinical record revealed a [AGE] year-old female resident admitted to the facility on [DATE] with the following diagnoses: hypothyroidism, reflux, migraine, muscle weakness, unsteadiness on feet, cognitive communication deficit, dysphagia (difficulty or discomfort in swallowing), lack of coordination, trigeminal neuralgia (chronic pain condition), hyperlipidemia (high levels of fat in the blood), abnormalities of gait and mobility, iron deficiency anemia, rheumatoid arthritis (autoimmune disorder where the immune system attacks the lining of your joints causing painful swelling, cartilage damage and bone erosion), flexion deformity (joints become locked in a bent position and cannot be fully straightened), history of falling, osteoarthritis, need for assistance with personal care, pain in joints, pressure ulcer of left heel, stage 2, pressure ulcers of other site, Stage 2, pressure ulcer to lest ankle, Stage 4, pressure ulcer of right ankle, Stage 3, acute and chronic respiratory failure with hypoxia (body does not receive adequate oxygen to function properly), anemia (lack of healthy red blood cells), elevated c-reactive protein (inflammation in the body), major depressive disorder, hypotension (low blood pressure), partial traumatic amputation of right foot, partial traumatic amputation of one right lesser toe, abnormal posture and COPD (persistent airflow limitation). Record review of Resident #1's last MDS was a significant change, completed 7/3/26 listing a BIMS of 7 indicating she was moderately cognitively impaired, and her functional status was extensive two-person assistance for all ADLs. Resident #1 has 2 Stage 2 pressure ulcers, 3 stage 3 pressure ulcers and 2 stage 5 pressure ulcers and one unstageable pressure ulcer that were present on admission to the facility. A skin Issue Assessment, dated 6/29/26, documented the following: almost all of Resident #1's wounds were described as deteriorating or plateaued and none of the wounds had an odor at that time. The left foot was documented as a deteriorating wound, characteristics deteriorated, Stage 4 full thickness wound and tissue loss. Wound was present on admission [DATE]), length 3 cm, width 2.6 cm, depth o.1 cm, no undermining or tunneling, slough 60%, exudated amount - moderate seropurulent: mixture of purulent and serous usually watery, yellow, green, tan, or brown. Odor after cleansing: none. A Progress Note dated 7/6/26 and signed by the NP, who documented the following: significant deformity of bilateral hands, gingers, feet and toes with terrible pain with movement of ankles, knees, or shoulders. Overall, she continues to decline with poor PO intake and lack of improvement in wounds, despite our best efforts. Resident does not want aggressive workups and diagnostics that will not offer pain control. During an observation on 7/18/26 at 10:20 a.m. Resident 1 being provided with wound care by LVN A revealed the following: LVN A removed the soiled dressing from Resident #1's right foot, cleaned the wound with wound cleanser and covered the wound was a large band aid and secured. LVN A never changed her gloves after removing the soiled dressing and before cleaning the wound or after cleaning the wound, or before placing a clean dressing on the wound. Stopped the dressing changes at 10:26 a.m. because the resident was complaining of pain. During an interview on 7/18/26 at 10:45 a.m., LVN A stated Resident #1's dressing changes were Monday, Wednesday and Friday and PRN and were just for comfort only because her skin was deteriorating. LVN A was made aware that the dressings on Resident #1's feet were dated 7/12/26 which was 6 days prior, LVN A stated Resident #1 complained of pian, and she gets completed what she gets completed (referring to the dressing changes). LVN A stated she did not think she documented anywhere that Resident #1 refused dressing changes. LVN A stated she gives Resident #1 pain medications and does the dressing changes until she says to stop. During an observation on 7/18/26 at 10:50 a.m., Resident #1 being provided wound care by LVN after giving Resident #1 time for the pain medications to work. LVN A removed the soiled dressing from Resident #1's right knee and discarded the soiled dressing. At this time, LVN A's gloves were contaminated and were never changed throughout this whole procedure. LVN A cleaned the right knee with wound cleaner and gauze, covered with a large band aid and secured. LVN A never washed her hands before the procedure and never changed her gloves after removing the soiled dressing and before cleaning the wound or after cleaning the wound. LVN A removed the soiled dressing from Resident #1's left knee and discarded the soiled dressing. LVN A cleaned the left knee with wound cleaner, placed bandages over the wound and secured, again without ever changing her gloves or washing her hands or using hand sanitizer between glove changes. LVN A cut most of the saturated and soiled dressing off Resident #1's left foot and discarded the soiled dressing. Resident #1's left foot had an odor but after cleaning there was no odor. LVN A sprayed the wound with wound cleanser, then cut the remainder of the dressing off the back of Resident #1's foot. LVN A never cleaned the wound but placed a clean large band aid over the wound and secured. LVN A never washed her hand or used hand sanitizer, never changed her gloves after discarding the saturated and soiled dressing, never changed her gloves before placing clean bandages on the wound. LVN A removed her contaminated gloves at this time. During an interview on 7/18/26 at 11:00 a.m., LVNA was asked what she did wrong while providing wound care, and LVN A said she was not sure she did anything wrong. When informed LVN A never changed her gloves after removing the soiled dressing, or after cleaning the wound or using any hand sanitizer, and did not wash her hands prior to the procedure, LVN A said, Ok, I thought that I did. During an interview on 7/18/26 at 11:30 a.m. the DON stated she was going to in-service all nurses about providing proper wound care and using infection control techniques. The DON stated Resident #1's wounds had not changed in appearance and there were no signs of infection. Record review of the facility's Policy and Procedure titled: Skin and Wound Monitoring and Management, revised 4/2025, Section 483.25 Quality of Care documented the following;It is the policy of this facility that: 2. A resident having pressure injury(s) receives necessary treatment and services to promote healing, prevent infection and prevent new, avoidable pressure injuries from developing.g. Ongoing Skin and Wound assessments:Once an area of alteration in skin integrity has been identified, assessed and documented, nursing shall administer treatment to each affected area as per the Physician's Order.5. Treatment c. wash hands. d. [NAME] appropriate PPE e. Provide Privacy and Introductions f. Provide treatment, remove dressing if needed g. Change gloves h. Disinfect hands after change of dirty/soiled dressing i. [NAME] appropriate PPE j. Provide treatment with dates k. Doff PPE l. disinfect hands m. document treatment Record review of the CDC's Infection Control Policy titled, CDC's Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 4/12/24, documented the following:Hand Hygiene:Require healthcare personnel to perform hand hygiene in accordance with Centers for Disease Control and Prevention (CDC) recommendations.Use an alcohol-based hand rub or wash with soap and water for the following clinical indications.Immediately before touching a patientBefore performing an aseptic task or handling invasive medical devices.Before moving from work on a soiled body site to a clean body site on the same patient.After touching a patient or the patient's immediate environment.After contact with blood, body fluids or contaminated surfaces.Immediately after glove removal. (cited from: https://www.cdc.gov/infection-control/hcp/core-practices)

Based on observation, interview and record review, the facility failed to ensure that the resident's environment remained as free from accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 2 residents reviewed for accident hazards. The facility failed to ensure Resident #1 was properly secured/fastened in the facility van resulting in bodily injury to the head, arm, stomach, and leg of Resident #1. An Immediate Jeopardy (IJ) was identified on 05/04/2026 at 4:47 PM. The IJ template was provided to the OM on 05/04/2026 at 5:21 PM. While the immediate jeopardy was lifted on 05/05/2026 at 3:23 PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated because all transportation staff had not been trained on 05/05/2026. The Plan of Removal (POR) of IJ will be included in the findings. This failure could place residents at risk for serious physical injury, including fractures, head trauma, or death from falls.Findings included: Resident #1Record review of Resident #1's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #1 had a medical history of encounter for orthopedic aftercare following surgical amputation (multi-phase process aimed at protecting the surgical site, promoting healing, and preparing for rehabilitation and prosthetic use), end stage renal disease (chronic kidney disease, where the kidneys can no longer function), Type 2 Diabetes (chronic condition with insulin resistance and high sugar levels), congestive heart failure (heart muscle is unable to pump enough blood to meet the body's need for oxygen and blood), and dependence on renal dialysis (therapy due to kidneys can no longer adequately filter waste and excess fluid from the body). Record review of Resident #1's admission MDS assessment, dated 04/28/2026, revealed a BIMS score of 15, which indicated normal cognitive function. Section GG, Functional Abilities, indicated that resident needed some help with self-care and functional cognition. Resident utilized a motorized wheelchair and/or scooter. Resident #1 was dependent on all activities of daily living with substantial/maximal assistance for shower/bath self. Record review of Resident #1's baseline care plan, dated 04/23/2026, revealed Resident #1 had a focus of risk for falls related to impaired mobility, visual impairment. Record review of Resident #1's progress note, dated 04/29/2026 at 5:58 PM, authored by RN A, revealed Resident #1 had fallen in the van. RN A had written that resident reported pain to touch on right side of face and to right upper extremity. Record review of Resident #1's incident report, dated 4/29/2026 at 3:00 PM, revealed under heading Injuries Report Post Incident-Injury Type- Abrasion, Injury Location 1) Top of Scalp. During an interview on 05/01/2026 at 9:10 AM, the ED K stated Resident #1 slid out of his wheelchair on in the van and there was a new driver. The ED K stated that the new van driver forgot to check if all residents were secure before she put the van in motion. ED K stated Resident #1 slid out of his chair and the incident report was still in the process of being completed. During an interview on 05/01/2026 at 9:41 AM, TA H confirmed there was an incident in the van. TA H indicated that she forgot to finish buckling Resident #1 and didn't double check. TA H stated she closed the van doors, went to drive, hit a pothole, and it made the van shake. TA H stated Resident #1 slid out of chair. TA H stated, it was not a hard fall. TA H stated she received one and half days of training and learned how to secure residents on the second day of training. During an interview on 05/01/2026 at 10:00 AM, RT G stated she did not know if Resident #1 hit his head. RT G stated Resident #1 fell on his right side and had pain over his right ribs. RT G stated they asked to assist with sitting the resident up to get his head off the ground. RT G stated Resident #1 refused a lift assist with the gait belt because of the pain in his ribs. During an observation/interview on 05/01/2026 at 12:39 PM, Resident #1 indicated he had pain on his right side the day after the fall. Resident #1 stated he was the last resident on the van. Resident #1 stated TA H only used the strap that connected the wheel to his wheelchair on the back, got in the driver's seat, began to drive, and turned the corner. Resident #1 stated he went flying from his chair. Resident #1 indicated he hit his head and the right side of his body. Assistance from DRN I with observing Resident #1's right side. Resident #1 had bruising identified on right flank, lower right abdomen, right rib area, and on the right calf on the backside. A discolored portion of skin was identified on the right side of Resident #1's forehead. In an interview on 05/01/2026 at 1:03 PM, Resident #2 stated she was on the van the day Resident #1 fell. Resident #2 stated that the bus took off and Resident #1's belts were not secure. Resident #2 stated Resident #1 flipped sideways to the right. Resident #2 stated it was because he was not secured properly. In an interview on 05/01/2026 at 2:14 PM, Resident #3 stated he was on the van the day Resident #1 fell. Resident #3 stated Resident #1 fell in the van, and the chair went over with him. During an interview on 05/04/2026 at 11:15 AM, RT G stated that she went to assist Resident #1 in the van. RT G stated Resident #1 was on the floor of the van in the back. During an interview on 05/04/2026 at 11:24 AM, RN A stated that Resident #1 returned to the facility after completing dialysis treatment. RN A stated that after performing a skin assessment, RN A identified there was a small skin tear to the forehead (less than a millimeter) and Resident #1 complained of back pain. During an interview on 05/04/2026 at 11:44 AM, MA J stated that Resident #1 was lying along the edge of the van between the double doors that were open. MA J stated that Resident #1 reported he thought he was okay, but he felt bruised up. MA J stated that Resident #1 also stated that he may have hit his head. MA J stated Resident #1 may have hit his head as it looked like he had road rash. MA J stated that when attempting to assist to lift Resident #1 with gait belt around the ribs, Resident #1 started groaning and stated it kind-of hurt. During a record review and interview on 05/04/2026 at 11:55 AM, TA H provided a written statement about the incident that occurred with Resident #1. TA H confirmed Resident #1 did not have his seat belt on, per the written statement, and he started sliding out of the wheelchair. During an observation/interview on 05/4/2026 at 12:58 PM, Resident #1 restated the incident that happened on 04/29/2026. Resident #1 stated that TA H locked the strap on the back of van and then went to the front of the van where she sat in the driver's seat. Resident #1 stated TA H took off and went south. Resident #1 stated the van was still in the parking lot of the dialysis center when the fall occurred. Resident #1 stated he was in pain on 05/01/2026. Resident #1 reported pain in his back, above his right eye and bruising on his right side. Resident #1 stated he fell to the right and hit the right side of his stomach. Resident #1 reported he fell completely out of the wheelchair, and the wheelchair was tilted on top of him. Resident #1 stated that there was only one strap on the back wheel. Resident #1 was observed for bruising with photographs obtained. Bruising along the right abdomen, appearing purple and blue in color, was consistent with the arm of a wheelchair. Video taken of Resident #1's power wheelchair showing wheelchair arms were loose. Resident #1 stated this was due to the fall in the van. Resident #1 was observed to have light colored bruises under right arm and right calf area. During an interview on 05/04/2026 at 01:05 PM, Resident #2 stated the wheelchair fell on top of Resident #1 because he was not strapped in. Resident #2 stated that Resident #1 fell on his right side and fell out of the chair. Resident #2 stated Resident #1 was the only one not strapped in that day. During an interview on 05/04/2026 at 2:03 PM, Resident #3 stated Resident #1's wheelchair was not on top of him but leaning on him. Resident #3 stated Resident #1 laid there for a while. During an interview on 05/04/2026 at 4:20 PM, TA H was asked to physically show how Resident #1 was strapped in the van on the day of the fall in the van. TA H stated that the wheelchair provided doesn't strap in the same but with Resident #1, TA H forgot to buckle the lap strap. Record review of undated document, titled Statement for the incident with the van on April 29th, MA J had written Resident #1 stated that maybe his ribs were slightly sore and asked us to look at his forehead as he felt a rug burn sensation on his forehead. Record review of untitled document dated 04/29/2026 revealed TA H's statement recorded as put the patients in the van, was pre-occupied with the seatbelt of another patient after locking and securing Resident #1's wheelchair, that I hadn't noticed that Resident #1 didn't have his seatbelt on. Record review of policy titled Fleet Safety Program, revised 04/14/2021, page 8 under heading 4. Preventable/Non-Preventable Accidents, Line B, stated, A preventable accident is defined as any accident/incident involving the vehicle, unless properly parked, which results in property damage or personal injury and in which the driver failed to do everything he/she reasonably could have done to prevent or avoid the accident. Page 14, under section X. Driver Safety Regulation, bullet point 1- The driver and all occupants are required to wear safety belts at all times when the vehicle is in operation or while riding in the vehicle. The driver is responsible for ensuring all passengers, including residents, wear their safety belts and are properly secured in the vehicle at all times using the existing harnesses and restraints. Page 16 under Associate Acknowledgement Statement revealed TA H's printed and signed name providing understanding that she had been trained on these procedures on unknown date. Page 19, under section XI. Wheelchair Securement, it stated, Residents must be secured in their wheelchair and secured in the vehicle before any movement of the vehicle or transportation of any kind is to occur. Record review of Policy/Procedure-Nursing that had a subject of: Fall Management System. The policy section read: It is the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complication if a fall occurs. The OM was notified that an IJ situation was identified due to the above failures on 05/04/2026 at 4:47 PM. The IJ template was provided on 05/04/2026 at 5:21 PM and plan of removal was requested. The Facility's Plan of Removal (as follows) was accepted on 05/04/2026 at 7:55 PM. It is alleged that the that the facility failed to ensure residents remained as free from accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents.Plan of RemovalProblem: Need for Immediate Action:The IJ documentation provided to the facility on [DATE] states: The facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents when a resident's wheelchair was not secured properly in the van. When the van driver placed the van in motion, the resident fell out of his wheelchair and his wheelchair tipped over on him, resulting in the resident suffering bruising on the right side of his body.Facility plan of Removal states:PLAN OF REMOVALImmediate Jeopardy Tag: F689 - Accidents/SupervisionIJ Identified: 05/04/2026 at 5:21 PMIJ Situation: Failure to ensure residents were properly secured in the facility van, resulting in a resident falling from his wheelchair and sustaining bruising and pain.1. Immediate Corrective Actions Taken to Remove the Jeopardy- Suspension of all resident transportation as of 05/01/2026 at 12:30 PM.- Assessment of injured resident and notification of physician and responsible party.- Removal of involved driver from transport duties.- Restriction of all transport staff pending retraining.2. Systemic Actions to Prevent Recurrence- Mandatory retraining for all transport staff on wheelchair securement, tie-down use, pre-trip checks, emergency procedures, and documentation.- Competency validation for all staff before resuming transport duties.- Inspection and replacement of securement equipment.- Review of Transportation Safety Policy.- Resident risk review and care plan updates.3. Monitoring and Quality Assurance- Daily monitoring of 100% of transports for 14 days.- Weekly administrative review of audits.- QA Committee oversight for six months.4. Date IJ Will Be RemovedAnticipated IJ Removal Date: 05/04/2026.5. Responsible PersonnelAdministrator, Director of Nursing, Maintenance Director,STAFF TRAINING OUTLINE - TRANSPORTATION SAFETY1. Overview of Transportation Risks and Resident Rights2. Wheelchair Securement Procedures (Hands-on)3. Use of Tie-Downs and Occupant Restraint Systems4. Pre-Trip Safety Checklist5. Emergency Procedures During Transport6. Documentation Requirements7. Return Demonstration and Competency Validation TRANSPORTATION SAFETY AUDIT TOOLDate: ________ Time: ________ Auditor: ________Resident Name: __________________________Wheelchair Secured Correctly (Yes/No)Occupant Restraint Applied (Yes/No)Tie-Downs Checked and Locked (Yes/No)Pre-Trip Checklist Completed (Yes/No)Driver Competency Verified (Yes/No)Comments: ___________________________________________Corrective Action Needed: _____________________________In-services began 05/05/2026 and all transportation staff to be in-serviced prior to transporting per POR.On 05/05/2026 at 3:23 PM, the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by:Monitoring of the Plan of Removal Included:In an observation and interview on 05/04/2026 at 6:45 PM, DON and DON L were in Resident #1's room. Resident #1 reported he had a goose egg on his forehead the day of the fall in the van. The DON and DON L viewed the bruising on Resident #1's right side. No additional questions were asked by the DON and DON L to Resident #1.In an observation and interview on 05/05/2026 at 2:56 PM, MA J was observed for competency of training. MA locked wheels after wheelchair was on the van. MA fastened right front strap to wheel, then fastened straps in the following order: left front strap to left front wheel, right back strap to right back wheel, and left back strap to left back wheel. MA fastened the should/lap belt and tightened it. During the demonstration, MA stated he did receive the retraining for transportation as he provides transportation for the facility. In an observation and interview on 05/05/2026 at 3:00 PM, REC O was observed for competency of training. REC O placed chair in the van, locked wheels, and fastened straps in the following order: attached right front strap to right front wheel, right back strap to right back wheel, left back strap to left back wheel, right front strap to right front wheel, and fastened the should/lap strap. REC O stated she did receive the retraining for transportation.In an observation and interview on 05/05/2026 at 3:16 PM, TA H was observed for competency of training. TA H placed wheelchair in the van, locked wheels, and fastened straps in the following order: attached right front strap to right front wheel, right back strap to right back wheel, left front strap to left front wheel, right front strap to right front wheel, and fastened should/lap strap. TA H stated she did receive the retraining for transportation. Record review of a document titled Counseling/Disciplinary Notice dated 5/1/2026, listed TA H as the employee with a check mark by text reading suspension, pending investigation, subject to change. The document was signed by the ADON and TA H, dated 05/01/2026 by both signatures. Attached to the disciplinary action was an in-service training report titled Transportation Driver and Resident Safety, dated 04/30/2026, conducted by ADON. TA signed in-service with training on ensuring safe transport to and from appointments, protect residents from harm during transit, communicate effectively with nursing staff, ensure wheelchair lift/ramp is working, confirm seat belts and restraints are functional, verify emergency equipment is functional and present, lock wheelchair breaks before loading, ensure lap and shoulder belts are properly fastened, recheck restraints before driving, and physically demonstrated proper securement.Record review of in-service In-service and Retraining for Fleet Supervisor after IJ had been started, dated 05/04/2026, revealed MA J completed the training which assisted with creations of binders, check lists, understanding expectations for reporting, and further training for additional staff.Record review of Transportation Audit Tool, dated 05/04/2026 at 10:00 AM, revealed a completed list of wheelchair secured correctly (N/A- no wheelchair), Occupant Restraint applied (Yes), Tie-Downs checked and locked (Yes), Pre-trip checklist completed (Yes), Driver competency verified (Yes), Comments (everything done correctly), Corrective Action Needed (None).Record review of Transportation Audit Tool, dated 05/05/2026 at 09:15 AM, revealed a completed list of wheelchairs secured correctly (Yes), Occupant Restraint applied (Yes), Tie-Downs checked and locked (Yes), Pre-trip checklist completed (Yes), Driver competency verified (Yes), Comments (Everything done correctly), Corrective Action Needed (None). Record review of in-service Transportation, dated 05/05/2026, RT G, TA H, MA J, ED K, and OM completed training covering overview of transportation Risks and Resident's Rights, wheelchair securement procedures, use of tie-downs and occupant restraint systems, pre-trip safety checklist, emergency procedures during transport, documentation requirements, and return demonstration and competency validation. Record review of Resident #1's care plan, dated 05/01/2026, revealed a new focus, goal, and interventions related to fall on 04/29/2026. Record review of Resident #1 progress note, dated 5/2/2026, revealed change of condition for fall with the provider and the resident's responsible party notified. On 05/05/2026 at 3:23 PM, the OM was notified that the IJ was removed. However, the facility remained out of compliance at a scope of isolation and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to report to the State Survey Agency an allegation of neglect involving a fall with injury within 2 hours of the allegation for 1 (Resident #1) of 1 resident.The facility failed to report a fall with an injury on [DATE] for Resident #1.This failure could place residents at risk of not having incidents of abuse, neglect, exploitation, and misappropriation of resident property being reviewed and investigated in a timely manner by the facility and state survey agency. This could place residents at risk of continued and/or unrecognized abuse, neglect, or exploitation.Findings Included:Resident #1Record review of Resident #1's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #1 had a medical history of encounter for orthopedic aftercare following surgical amputation (multi-phase process aimed at protecting the surgical site, promoting healing, and preparing for rehabilitation and prosthetic use), end stage renal disease (chronic kidney disease, where the kidneys can no longer function), Type 2 Diabetes (chronic condition with insulin resistance and high sugar levels), congestive heart failure (heart muscle is unable to pump enough blood to meet the body's need for oxygen and blood), and dependence on renal dialysis (therapy due to kidneys can no longer adequately filter waste and excess fluid from the body). Record review of Resident #1's admission MDS assessment, dated [DATE], revealed a BIMS score of 15, which indicated normal cognitive function. Section GG, Functional Abilities, indicated that Resident #1 needed some help with self-care and functional cognition. Resident utilized a motorized wheelchair and/or scooter. Resident #1 was dependent on all activities of daily living with substantial/maximal assistance for shower/bath self. Record review of Resident #1's baseline care plan, dated [DATE], revealed Resident #1 had a focus of risk for falls related to impaired mobility, visual impairment. Record review of SBAR, dated [DATE], revealed under heading of Situation, the change in condition, symptoms, or signs observed and evaluated is/are: Falls. Record review of Resident #1's progress note, date [DATE] at 5:58 PM, authored by RN A, revealed Resident #1 had fallen in the van. During an interview on [DATE] at 9:10 AM, ED K stated Resident #1 slid out of his wheelchair on the van and that new van driver forgot to check all the residents as she started to drive. During an interview on [DATE] at 9:26 AM, CNA C stated last in-service for abuse, neglect, and exploitation was approximately 3 months ago. CNA C stated that allegations of abuse, neglect, and exploitations are to be reported as soon as they are seen. CNA C stated that a negative outcome of not reporting ANE would be making the resident feel less important and the problem will keep happening without it being reported. During an interview on [DATE] at 9:31 AM, CNA D stated she completed abuse and neglect training upon hire. CNA D stated that a fall with an injury would be reportable and should be reported immediately. CNA D stated that a negative outcome would be an injury of unknown cause and it wouldn't be addressed, which could cause more problems. During an interview on [DATE] at 9:31 AM, CNA E stated it was reportable for a fall with injury and should have been reported immediately. CNA E stated a negative outcome was it could happen again. During an interview on [DATE] at 9:36 AM, CNA F stated an in-service of abuse, neglect, and exploitation was completed last month. CNA F stated she would have reported the fall. CNA F stated a negative outcome could be the resident could have died. During an interview on [DATE] at 9:41 AM, TA H stated she drove the van on [DATE]. TA stated she wrote a statement of Resident #1's fall on the incident report. TA H stated she forgot to finish buckling Resident #1's wheelchair and when she drove over a pothole, the van began to shake and Resident #1 started to slide out of the wheelchair. TA H stated that every fall was reportable and Resident #1 had no injuries. TA stated she received abuse and neglect training and thought the fall was reported. TA H stated she made OM aware of the fall. TA H stated a negative outcome would be that it could have been bad for the resident. During an interview on [DATE] at 10:00 AM, RT G stated she had seen Resident #1 on the van floor. RT G stated Resident #1 told her he fell on his right side and had pain over his right ribs. RT G stated that MA J assisted with attempt to put Resident #1 in his wheelchair. RT G stated they were not successful as Resident #1 stated he did not want to continue with lifting him to his wheelchair due to pain in ribs. RT G stated she completed abuse and neglect training about 3 months ago. RT G stated that Resident #1's fall was reportable. RT G stated a negative outcome could be permanent damage either physically or psychologically. During an interview on [DATE] at 11:01 AM, LVN I stated that any fall was reportable with a change of plane. LVN I stated a negative outcome was harm to the patient. During an observation and interview on [DATE] at 12:39 PM, Resident #1 a discolored area to the right side of Resident #1's forehead, above the eye was identified. Resident #1 stated that he went flying from his wheelchair on to the van floor. Resident #1 stated his right side was hurting. Resident #1's right side from arm to calf was observed with assistance from DRN D. Bruising identified to Resident #1's right upper arm, right calf area, right flank area (region on the sides of the torso between the lower ribs and the top of the hip bones), right ribs, and right abdomen area. During an interview on [DATE] at 1:03 PM, Resident #2 stated Resident #1 flipped sideways in the van and witnessed Resident #1 hit his head and arms. During an interview on [DATE] at 3:20 PM, SW stated that reporting a fall is contingent on some type of injury. SW stated that a fall should be reported immediately for the injury. SW stated a negative outcome could be significant damage physically or emotionally. During an interview on [DATE] at 3:36 PM, the OM, DON, and ADON were interviewed together. The OM stated for falls was to follow the policy and procedure. Best practice was to complete assessments, notify the nurse practitioner, continue monitoring. The OM stated a fall with injury should be reported as soon as possible. The ADON stated best practice to reach out to the DON and the fall would probably be reportable. The ADON stated the fall should be reported right away. The OM and DON stated a negative outcome of not reporting a fall with injury could be harm to the resident. The ADON stated the worst could be death. During an interview on [DATE] at 11:44 AM, MA J stated Resident #1 was lying along the edge of the van floor between the double doors. MA J asked Resident #1 about assistance with gait belt and Resident #1 declined due to pain in ribs. Record review of policy titled Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment, revised 04/2025, stated under subheading Alleged Violation- is a situation or occurrence that is observed or reported by staff, resident, relative, visitor, another health care provider, or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse including injury of unknown source, and misappropriate of resident property. Under subheading Procedure it stated: 1. In response to allegations of abuse, neglect, exploitation, or mistreatment, the Facility will: A. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment , including injuries of unknown source and misappropriation of resident property, are reported immediately but: -Not later than two hours after the allegation is made if the events that caused the allegation involves abuse or results in serious bodily injury. - Not later than twenty-four hours if the events that cause the allegation does not involve abuse and does not result in serious bodily injury.

Based on interview and record review, the facility failed to ensure the governing body of the facility had appointed an Administrator, who is licensed by the state, to be responsible for the management of the facility and report to the governing body. The facility had not had an Administrator since March 2026. This deficient practice could place residents at risk of decreased quality of life and quality of care due to lack of staff oversight and monitoring of care for all 128 residents at the facility. The findings included: Record review of the facility employee list printed on 5/1/26 by the facility revealed there was no ADM listed. In an interview on 5/1/26 at 8:40 am the former ADM stated he was not the ADM over the building anymore and had his license pulled from the building in March. He stated it had been over 30 days since the facility had had an ADM at the facility. He stated he did not know who the possible new ADM would be. He stated a new ADM had not been officially onboarded, which meant hired. During an interview on 5/1/26 at 10:25 am, the HRD confirmed the former ADM had pulled his license from the facility, but she did not remember when he had done so. She stated March sounded right. She stated she could not give a specific date because the ADM personnel information was located at the corporate office. She stated she did not have any info on the next ADM as he had not been hired yet. In an interview on 5/1/26 at 3:17 pm, the SW stated there was no current ADM and she did not know how long it had been since the facility had had an ADM. She stated she did not know when the facility was getting an ADM. The SW stated she heard there was an ADM coming but she did not know when he would start. In an interview on 5/1/26 at 3:40 pm, the AD stated the facility had not had an ADM since March. She stated she did not know when an ADM would start and she did not know who the new ADM would be. In an interview on 5/1/26 at 4:15 pm, the OM stated he was still in training and would hopefully be finished with his ADM training in the fall or spring. He stated there was not an ADM currently and he stated he did not remember when previous ADM had pulled his license from the building. He stated it was sometime in March. He stated he did not have that information as the corporate office kept information on the ADM. When asked about the consequences for not having an ADM he stated, Good Question. I do not know. Every building needs to have one. He stated there were no policies for having an ADM.

Based on interview, and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 (Resident #1) of 8 residents reviewed for respiratory care.The facility failed to ensure Resident #1 received O2 via NC continuously as ordered by her physician.This failure could place residents who receive oxygen at an increased risk of hypoxemia (low levels of oxygen in the blood, decreasing the oxygen supply to vital organs), and shortness of breath.Findings Included:Record review of Resident #1's admission record dated 01/21/26 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, single subsegmental thrombotic pulmonary embolism without acute cor pulmonale (blockage in the small branch of the pulmonary artery caused by a blood clot without right heart strain), chronic obstructive pulmonary disease (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath, and fatigue), malignant neoplasm of unspecified part of right bronchus or lung (cancer in the right lung or a passage in the lower respiratory tract which delivers air to the right lung), pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and in the heart leading to symptoms like shortness of breath and fatigue), acute on chronic diastolic (congestive) heart failure (a progressive heart disease that affects the pumping action of the heart muscles resulting in shortness of breath and fatigue), and acute and chronic respiratory failure with hypoxia (sudden and over time failure of lungs to deliver oxygen to the body leading to low levels of oxygen in the body tissues which can result in confusion, bluish skin, and changes in breathing and heart rate). Resident #1's discharge date was listed as 11/19/25.Record review of Resident #1's quarterly MDS completed on 11/10/25 revealed a BIMS of 6 which indicated severely impaired cognition. Section O Special Treatments, Procedures, and Programs revealed Resident #1 was receiving oxygen therapy While a Resident.Record review of Resident #1's care plan completed on 11/18/25 revealed the following:-a focus area of [Resident #1] has Oxygen Therapy r/t COPD, CHRONIC RESPIRATORY FAILURE WITH HYPOXIA which included the intervention Oxygen per MD orders.-an intervention under a focus area of chronic pain which read Observe and report changes in usual routines, . or resistance to care.-an intervention under a focus area of COPD which read, Give oxygen therapy as ordered by the physician.-an intervention under a focus area of congestive heart failure which read, Oxygen therapy per orders.Record review of Resident #1's orders revealed the following order with a start date of 11/04/25: O2 at 2-3 L/MIN CONTINUOUS PER NCRecord review of Resident #1's oxygen saturations revealed she was not receiving oxygen therapy on 11/18/25 at 05:00 PM and 08:15 PM when her oxygen saturation was checked. Her oxygen saturation both times was 90% on Room Air. The oxygen saturation documentation was completed by LVN B.Record review of Resident #1's progress notes for 11/18/25 revealed no mention of Resident #1 being resistant to oxygen use or removing her NC. The following notes were revealed:A note by LVN B on 11/18/25 at 05:00 PM which read, Patient found by CNA on the floor in her room. Patient lying on right side next to the bed. Patient reports she was trying to get help and was going to crawl out of here. Head to toe assessment completed. All neuro's intact to baseline. Patient denies hitting her head. O2 90% on room air.During an interview on 01/21/26 at 11:32 AM LVN B stated Resident #1 often had confusion and low oxygen levels when she was living in the facility.During an interview on 01/21/26 at 03:07 PM Resident #1's family member A stated he visited Resident #1 at the facility on 11/18/25 and fed her a dinner of barbeque. He stated he was with her for approximately an hour and a half and she did not have her oxygen on at any time during his visit. He stated she was seated in her wheelchair near the nurses' station on hall 100 and he was standing next to her for the visit. He stated he called Resident #1's family member B on a facetime call during a portion of his visit.During an interview on 01/21/26 at 03:10 PM Resident #1's family member B stated she was on a facetime call with Resident #1's family member A and Resident #1 on 11/18/25. She stated she took several screenshots of Resident #1 during the call.Record review of time stamps of 15 photographs sent by Resident #1's family member B revealed they were taken on 11/18/25 with times ranging from 05:31 PM to 06:14 PM.During an interview on 01/21/26 at 03:41 PM ADON stated if a resident had orders for continuous oxygen, they should not take it off to eat. She stated taking off oxygen that was ordered for continuous use could cause a resident to become hypoxic (low levels of oxygen in the body tissues which can result in confusion, bluish skin, and changes in breathing and heart rate), not have enough air, not be able to talk, pass out.During an interview on 01/21/26 at 04:11 PM RN C stated a resident with orders for continuous oxygen should not take the oxygen off at any time. She stated, Sometimes they (residents) will (take it off) and we (nursing staff) will encourage them to put it back on. RN C stated a possible negative outcome of a resident not receiving oxygen continuously as ordered was their oxygen saturation could drop and cause lightheadedness, dizziness . a lack of oxygen to the brain.During an interview on 01/21/26 at 04:34 PM OM stated a resident who had orders for continuous oxygen might be negatively affected if they did not receive oxygen for an hour or two. He stated, It kinda depends on the patient. If they're ordered continuous (oxygen) and take it off themselves, we can't force it. We should chart about it and put interventions in place if that is an issue with that resident.During an interview on 01/21/26 at 05:37 PM LVN A stated a resident with orders for continuous oxygen should not take the oxygen off at any time. She stated, If they take if off themselves, we chart it and monitor their sats (oxygen saturation levels) to be sure their oxygen stays within normal limits. LVN A stated a resident could become cyanotic (blue or purple discoloration of skin due to poor blood circulation or low oxygen levels) and they can get dizzy if they were not receiving oxygen as ordered. During an interview on 01/21/26 at 05:40 PM DON stated a resident could do whatever they want with their oxygen. She stated, It is their right. We encourage them not to (take oxygen off if it is ordered continuously), but that is all we can do. She stated a resident with orders for continuous oxygen going a few hours without oxygen might or might not be negatively affected. She stated, It is a case-by-case basis.Record review of an undated facility policy titled Oxygen therapy policy revealed the following: . Oxygen is considered a drug and must be prescribed by an authorized clinician.Record review of facility policy titled Administration of Medications and dated 7/2017 revealed the following: . It is the policy of this Facility, medication shall be administered as prescribed by the resident's physician, nurse practitioner, or physician's assistant. 2. Medications must be given in accordance with the resident's service plan. 3. Medications must be administered in accordance with the written orders of the attending physician. 10. Should a drug be . refused . the staff administering must indicate the reason on the MAR. For those utilizing eMARs, the appropriate code must be entered with any follow up documentation as appropriate for the situation.

Based on observation, interview, and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 (Resident #1) of 8 residents reviewed for unnecessary drugs.The facility failed to discontinue 4 medications (mirtazapine, escitalopram, tizanidine, and tramadol) as documented in the physician orders in Resident #1's hospital discharge records dated 08/01/25.This failure could place residents at risk of harm due to medication side effects and/or medication interactions.Findings Included:Record review of Resident #1's admission record dated 09/09/25 revealed a [AGE] year-old female admitted to the facility on [DATE] from an acute care hospital. She had diagnoses that included, but were not limited to, metabolic encephalopathy (problems in the brain from chemicals in the blood), acute pancreatitis (sudden inflammation of the pancreas resulting in severe abdominal pain), acute kidney failure (sudden episode of kidney failure that happens in hours or days), and unspecified depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).Record review of Resident #1's admission MDS completed on 08/14/25 revealed a BIMS score of 00 which indicated severely impaired cognition. Section N Medications of the MDS revealed Resident #1 was receiving antidepressant and opioid medication.Record review of Resident #1's care plan initiated on 08/02/25 revealed she had impaired cognitive function due to her diagnosis of metabolic encephalopathy and was at risk for depression. She was noted to be receiving escitalopram and mirtazapine to address this risk. One of the interventions was to Administer medications as ordered. Resident #1 was noted to have chronic pain. Tramadol and tizanidine were listed as the medications to address her pain.Record review of Resident #1's discontinued, struck out, and completed orders revealed mirtazapine, escitalopram, tizanidine, and tramadol were all discontinued on 08/25/25.Record review of Resident #1's active order summary revealed the following orders with corresponding start dates:08/25/25 Acetaminophen Oral Tablet 500 MG (Acetaminophen) Give 2 tablet by mouth every 8 hours as needed for Severe Pain .08/25/25 Sertraline HCI Oral Tablet 25 MG (Sertraline HCI) Give 1 tablet by mouth one time a day related to DEPRESSION, UNSPECIFIED .Record review of Resident #1's MAR for August 2025 revealed she had the following orders: . tiZANidine HCl Oral Tablet 2 MG (Tizanidine HCl) Give 2 mg by mouth every 8 hours as needed for pain related to OTHER CHRONIC PAIN (G89.29) -Order Date- 08/01/2025 1410 -D/C Date- 08/25/2025 0508 .Mirtazapine Tablet 45 MG Give 1 tablet by mouth at bedtime related to DEPRESSION, UNSPECIFIED (F32.A) -Order Date- 08/01/2025 1410 (02:10 PM) -D/C Date- 08/25/2025 0506 .Escitalopram Oxalate Tablet 10 MG Give 1 tablet by mouth one time a day for Depression related to DEPRESSION, UNSPECIFIED (F32.A) -Order Date- 08/01/2025 1410 -D/C Date-08/25/2025 0510 .traMADol HCl Oral Tablet 50 MG (Tramadol HCl) Give 50 mg by mouth every 8 hours as needed for pain related to OTHER CHRONIC PAIN (G89.29) -Order Date- 08/01/2025 1410 -D/C Date- 08/25/2025 0509 .The MAR for August 2025 further revealed Resident #1 did not receive tizanidine during the month of August 2025. She received mirtazapine 45 mg tablet every day from 08/01/25 to 08/24/25. Resident #1 received escitalopram 10 mg tablet every day from 08/03/25 to 08/24/25. She received tramadol 50 mg tablet 16 total times from 08/01/25 to 08/24/25. Resident #1 received tramadol on the following dates: 08/01/25, 08/02/25, 08/05/25, 08/07/25, 08/11/25 (Resident #1 received tramadol twice on this date), 08/13/25, 08/14/25, 08/15/25, 08/16/25, 08/18/25, 08/19/25, 08/21/25, 08/22/25, 08/23/25, and 08/24/25.Record review of Resident #1's hospital records in her EHR revealed an AFTER VISIT SUMMARY dated 08/01/25 with the following instructions: . Your medications have changed START taking: . sertraline ([brand name of sertraline]) Start taking on: August 2, 2025. STOP taking: escitalopram 10 mg tablet ([brand name of escitalopram]) mirtazapine 45 mg tablet ([brand name of mirtazapine]) tiZANidine 2 mg tablet ([brand name of tizanidine]) tramadol 50 mg tablet ([brand name of tramadol]) .Record review of a progress note with date of service of 08/21/25 and signed by NP A on 08/24/25 revealed under the Admit History section Resident #1 was on mirtazapine and escitalopram, but they were discontinued and replaced with sertraline per psych. The note further indicated due to her (Resident #1's) AMS tizanidine and tramadol were discontinued.Record review of a progress note with date of service of 08/25/25 and signed by NP A on 08/26/25 revealed under the Admit History section Resident #1 was on mirtazapine and escitalopram, but they were discontinued and replaced with sertraline per psych. The note further indicated due to her (Resident #1's) AMS tizanidine and tramadol were discontinued. NP A noted she spoke with Resident #1's family member and explained to [Resident #1's family member] the Tramadol, Tizanidine, Mirtazapine, and escitalopram. NP A explained to Resident #1's family member sertraline was started and was for Resident #1's mood.During an interview on 09/09/25 at 09:58 AM DON stated charge nurses, and MDS nurses were responsible to enter orders into the EHR when a new resident was admitted to the facility. She stated the two ADONs used to help with admissions, but both of them quit last week. DON stated the MDS nurses checked back over the admissions to ensure accuracy.During an observation and interview on 09/09/25 at 11:18 AM Resident #1 stated she had no concerns with the medications she had been receiving since her admission to the facility.During an interview on 09/09/25 at 01:56 AM MDS RN stated MDS LVN entered diagnoses codes for new admissions, and she (MDS RN) entered orders, medications, diets, code status, allergies, and completed the baseline care plan. She looked at Resident #1's admission and stated ADON was the one who entered orders for Resident #1. MDS RN stated a resident could be negatively affected if given medications that were supposed to be discontinued. She stated it would depend on the type of medication. MDS RN stated it can have serious negative outcomes. She gave an example of a resident continuing to receive a blood thinner when it was supposed to be discontinued. She stated in that case the resident would be at risk of bleeding out. When asked about antidepressant and pain medications she stated psychotropic medications sometimes had the opposite effect than expected. MDS RN stated Resident #1's diagnosis of kidney disease could lead to AMS.During an interview on 09/09/25 at 01:58 PM MDS LVN stated Resident #1's diagnosis of metabolic encephalopathy could lead to AMS.During an interview on 09/09/25 at 03:01 PM NP B stated she started working for the facility last week. She stated she did not know about Resident #1 receiving medications that were supposed to be discontinued. Regarding a possible negative outcome to Resident #1, NP B stated, I feel like it is hard for me to say because I don't know what her baseline was before.During an interview on 09/09/25 at 03:07 PM NP A stated she was on vacation at the beginning of August 2025 and her first day back in the facility was 08/11/25. She stated she saw Resident #1 on 08/11/25 and that evening she noticed the medications were not discontinued. NP A stated, I reviewed all the records and found she (Resident #1) was supposed to be off those 4 meds tramadol, tizanidine, mirtazapine and escitalopram. NP A stated she called to let staff know the medications should be discontinued. She stated she made the call on 08/24/25. She stated she did not know which staff member she talked to. She explained the delay from the time she found the medications had not been discontinued to the time she notified facility staff by saying she was behind in her charting and was playing catch up from her vacation. NP A stated she did not think Resident #1 would have been negatively impacted by taking the discontinued medications for 24 days because it was just a transcription error. NP A said, I dug and dug to try to find out why they (hospital) discontinued them (the four medications in question). NP A stated she could not find the reason the medications were discontinued.During an interview on 09/09/25 at 03:30 PM LVN C stated a resident could be negatively impacted by taking medications that were supposed to be discontinued. She stated, I mean surely a doctor said discontinue this for a reason.During an interview on 09/09/25 at 03:46 PM Resident #1's family member stated when NP A called to speak to her about Resident #1's care she (NP A) mentioned four medications were not discontinued as they were supposed to have been. She stated, It was a short conversation, she (NP A) didn't go into it. Resident #1's family member stated Resident #1 was taking mirtazapine and escitalopram prior to entering the hospital on [DATE].During an interview on 09/09/25 at 04:08 PM DON stated a resident could be negatively impacted by receiving medications that were supposed to be discontinued. She stated the negative impact would depend on the medication. DON stated she asked for a different NP than NP A due to concerns about NP A not getting her charting into the EHR timely. When asked why she though ADON did not catch the fact the four medications were to be discontinued, she stated she demoted ADON to a floor nurse when it became evident she did not have the necessary skills to be an ADON. DON did not answer what a specific negative outcome could be for taking discontinued antidepressant and/or pain medications. DON was asked for an unnecessary medication policy during this interview.During an interview on 09/09/25 at 04:16 PM RN D stated a resident could be negatively impacted if they received a medication that was supposed to be discontinued. She stated, If they no longer need it and it was discontinued at the hospital it can put the patient at risk.During an interview on 09/10/25 at 01:20 PM ADON stated she did not remember entering orders for Resident #1. She stated she did not remember Resident #1. ADON stated she only worked for the facility for a short time, and she entered admission orders for one, maybe two residents the whole time I was there. She stated she had an admission checklist and when she was finished the other ADON, DON, or MDS RN would look over her work and sign off on it to indicate it was correct.Record review of facility policy titled Care and Treatment Psychotropic Drug Use revealed the following: . 2. On admission, the admitting nurses will review the transfer orders for any psychotropic medications. Any information obtained will be documented in the resident's clinical record.Record review of facility policy titled Pharmacy Services Physician Orders revealed the following: . it is the policy of this facility that drugs shall be administered only upon the written order of a person duly licensed and authorized to prescribe such drugs.Record review of the facility policy titled Continuum of Care Admission, General revealed no mention of transcribing orders from the hospital into the facilities EHR.An unnecessary medication policy was not provided.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 (LVN A, CNA B, and CNA C) of 6 staff observed for resident care LVN A did not wear a gown when administering medications through Resident #11. CNA A and CNA B did not wear a gown when providing catheter care for Resident #86. This deficient practice could place residents at risk of cross-contamination and infections. Findings include: Resident #11:Record review of Resident #11's clinical record revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include metabolic encephalopathy (a chemical imbalance in the blood that causes problems in the brain), herpes viral encephalitis (a rare but serious inflammation of the brain caused by the herpes simplex virus (HSV)), cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), malnutrition (lack of proper nutrition), and dysphagia (difficulty or discomfort in swallowing).Record review of Resident #11's clinical record revealed her last MDS was a Medicare 5-Day completed 06/10/25 listing her with a BIMS of 14 indicating she was cognitively intact, she had a functionality of being dependent on staff for most of her activities of daily living, and she required a feeding tube. Record review of Resident #11's care plan with admission date of 06/04/25 revealed the following: Focus: Resident requires tube feedings r/t swallowing problems and weight loss. Intervention: Use Enhanced Barrier Precautions. Record Review of Resident #11's Active Orders As Of: 07/30/25 revealed the following order: ENHANCED BARRIER PRECAUTIONS: PPE required for high resident contact care activities. Indication: Central line, PEG tube every shift related to HERPESVIRAL ENCEPHALITIS (B00.4) Phone Active 06/04/2025 During an observation on 07/30/2025 at 11:00 AM LVN A administered 4 medications to Resident #11 through her feeding tube. LVN A used handwashing, ABHR, and gloves for the procedure, but LVN A never put a barrier gown on. There was a note posted above Resident #11's bed for Enhanced Barrier Precautions (EBP) to include instructions to wear a gown for Device care or use: central line, urinary catheter, feeding tube, tracheostomy. During an interview on 07/30/2025 at 10:51 AM LVN A reported that Resident #11 was on Enhanced Barrier Precautions (EBP) related to her feeding tube and should have worn a barrier gown during Resident #11's care. LVN A stated, I looked up halfway through the procedure and realized I should have put a barrier gown on, but it was too late. LVN A reported not wearing the proper PPE when Enhanced Barrier Precautions (EBP) were in infect could result in a staff member introducing other to outside bacteria. LVN A reported that the DON provided training on infection control processes. Resident #86:Record review of Resident #86's clinical record revealed a [AGE] year-old female resident admitted to the facility originally on 02/29/24 and readmitted on [DATE] with diagnoses to include urinary tract infection (an infection in any part of the urinary system, the kidneys, bladder, or urethra), flaccid neuropathic bladder (a type of neurogenic bladder dysfunction characterized by the bladders inability to contract effectively, leading to urinary retention and overflow incontinence), neuromuscular dysfunction of the bladder (the nerves and muscles of the bladder do not work well resulting in the bladder not filling or emptying well), and muscle weakness. Record review of Resident #86's clinical record revealed her last MDS was a quarterly completed 06/14/25 listing her with a BIMS that could not be evaluated because she was rarely/never understood, she had a functionality of being dependent on staff for her toileting hygiene, and she required an indwelling catheter for her bladder. Record review of Resident #86's care plan with admission date of 07/28/25 revealed the following: Focus: Resident has an indwelling urinary catheter for neurogenic bladder. Date initiated 03/08/24.Intervention: Use Enhance Barrier Precautions. Date initiated 04/26/24 Record Review of Resident #86's Active Orders As Of: 07/30/25 revealed the following order: ENHANCED BARRIER PRECAUTIONS: PPE required for high resident contact care activities. Indication: Foley Cath every shift. Phone Active 07/29/2025. Record Review of Resident #86's Active Orders As Of: 07/01/25 revealed the following order: ENHANCED BARRIER PRECAUTIONS: PPE required for high resident contact care activities. Indication: Foley catheter and wounds. Verbal Active 07/15/2024. During an observation on 07/30/2025 at 2:36 PM CNA B and CNA C provided catheter care for Resident #86. Both CNAs were observed using proper hand hygiene and glove changes but both CNAs did not wear a gown for Enhanced Barrier Precautions (EBP). A sign posted above Resident #86's bed included instructions to wear a gown for Device care or use: central line, urinary catheter, feeding tube, tracheostomy. During an interview with CNA B and CNA C on 07/30/2025 at 2:51 PM revealed CNA B reported not wearing a barrier gown and complying with EBP was the only thing she forgot. That Resident #86 was on EBP and that they both should have place a barrier gown since Resident #86 had a catheter. CNA B reported not complying with EBP could result in the spread of infection. CNA C stated she agreed with everything CNA B stated, and she did not have any other information other she just forgot to put on a barrier gown. Both CNA B and C reported that the DON provided most trainings on infection control processes. During an interview on 07/31/2025 at 7:39 AM the DON reported that training on infection control to include EBP was provided by the DON and ADON and she has only been the DON for the facility for two weeks. The DON reported this was her second week and she had not had time to correct any of the issues such as training on infection control processes. The DON reported staff not following recommended EBP would increase the risk of infection because they could have something on their cloths which will violate infection control. During an interview on 07/31/2025 at 10:21 AM ADON D reported CNA C was a new hire, and CNA C was trained verbally by herself (ADON D) on EBP when CNA C was hired but no written training was provided. ADON D reported she expects all staff to wear a gown and gloves when EBP was required and if a staff member does not comply with these requirements, then they can place the residents at risk for infection by bringing something in on their cloths or they could carry something out to another resident. Upon review of the last 12 months of training ADON D reported CNA C was hired on 1/14/25 and she (CNA C) was missed on the 3/21/25 training that was provided on Enhanced Barrier Precautions (EBP). Record review of the facility provided Enhance Barrier Precautions (EBP) educational posting placed in each resident's room that required Enhance Barrier Precautions (EBP) revealed the following information provided for visitors and staff: Enhanced Barrier Precautions.Providers and staff must also:Wear gloves and gowns for the following High Contact Resident Care Activities--Device care or use: Central line, urinary catheter, feeding tube, tracheostomy. Record review of the facility provide training to include the current Enhance Barrier Precautions (EBP) policy (undated) completed on 03/21/25 by ADON D revealed the following information: Enhanced Barrier Precautions (Gloves, Gowns, Face Shields/Goggles, Masks).Can be applied (when Contact Precautions do not otherwise apply) to resident with any of the following:Wounds or indwelling medical devices, regardless of MDRO colonization status.Noted that the in-service was signed by LVN A and CNA B.

Based on interviews and record reviews the facility failed to ensure residents had the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility through a means other than the postal service for 13 of 13 anonymous residents reviewed for Resident Rights The facility failed to ensure mail and packages from the U.S Postal Service were delivered to residents on Saturdays.The facility failed to ensure mail and packages delivered by means other than the postal service were delivered to residents on Saturdays and Sundays.These failures could cause residents to experience loneliness, depression, missing property and a decreased quality of life. Findings included: In a Resident Council meeting on 07/30/2025 at 2:00PM, 13 anonymous residents stated they had not received mail on Saturdays. One anonymous resident stated Act E delivered the mail to them Monday through Friday. Another anonymous resident stated packages delivered at a time other than 8AM-5PM, Monday through Friday, sat in the foyer of the facility until Act E returned to work on Monday. One anonymous resident stated she did not like her mail left on her bed or nightstand when she was not in her room. She stated anyone from the hallway could come and take a piece of mail and she would never have known; especially if she received a card for her birthday or other occasion that had money inside. An interview with Act E on 07/30/2025 at 2:32PM reflected she delivered the mail to the residents Monday through Friday, while she was working. She stated she was unsure who delivered the mail on Saturdays. She stated she delivered any packages that arrived over the weekend to the residents on Mondays when she returned to work. She stated it was not a good idea to leave the packages sitting in the foyer all weekend. She stated the negative outcome of leaving resident's mail on their bed or nightstand would be someone could take a bank statement or birthday card and the resident would not know it had been taken. She stated the negative outcome of leaving packages in the foyer over the weekend, would be visitors, staff members and other residents could easily take them. An interview with the Administrator on 07/30/2025 at 4:00PM reflected Recp F worked on the weekend and should deliver mail and packages to the residents. He stated he did not understand why Recp F was not delivering the mail; it was in her job description. He stated he was unsure if she knew it was in her job description due to him only being in his position for one month. He stated he would provide a copy of the job description showing Recp F should have been delivering mail. A telephone interview with Recp F on 07/31/2025 at 11:14AM reflected she was not aware it was part of her job description to deliver the mail and/or packages to the residents on the weekends. She stated she signed the job description before she started her duties as the weekend receptionist. She stated she was told by the Administrator to put any mail that arrived on Saturdays on the top of the shredded document storage container so it could be passed out by Act E on Monday. She stated it was not the current Administrator who told her to put the mail there, but the prior Administrator. She stated any packages that came over the weekend were placed in the foyer for Act E to pick up and distribute on Mondays. She stated Act E sometimes came to the facility on Sundays to play religious music for the residents, so she assumed Act E knew the mail and packages were there and she would hand them out if it was important. She was unable to state a negative outcome for residents not receiving mail and packages over the weekend. An interview with Act E on 07/31/2025 at 11:47AM revealed she came to the facility on Sundays occasionally to play religious music for the residents as a volunteer, not as a paid worker. An interview with the Administrator on 07/31/2025 at 2:02PM revealed he was conducting in-services with all weekend staff on Saturday and Sunday to cover job descriptions, resident rights and resident privacy. Review of the receptionist's job description dated 11/2021 revealed the following: Essential Duties and Responsibilities: Every effort has been made to identify the essential functions of this position. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is an essential function of the position. All duties and responsibilities shall be performed as set forth in our established policies and procedures. Receive, sort and distribute mail as directed. Make sure all mail is distributed before you go home. Monday through Friday, the Activity Supervisor will hand out mail. If the Activity Supervisor is out, you will be the backup person to hand out mail. On Saturdays, the mail will be handed out by the weekend receptionist.

Based on interview, record review, the facility failed to report an alleged violation of abuse/neglect immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation resulted in serious bodily injury, to officials in accordance with State law, including to the State Survey Agency for one (Resident #1) of 9 residents reviewed for abuse/neglect. The facility failed to report that Resident #1 alleged that she had been raped on 1-22-2025. The noncompliance was found to be Past Non-Compliance (PNC). The noncompliance began on 1-22-2024 and ended on 2-2-2024. The facility corrected the noncompliance before the investigation began. This failure could result in delayed identification of abuse or neglect and lack of timely follow-up on recommended interventions to prevent serious bodily harm, or lasting physical impairment. Findings include: Record review of Resident #1's face sheet dated 2-4-2025 revealed a [AGE] year-old female resident admitted to the facility originally on 10-21-2022 and readmitted on [DATE] with diagnoses to include drug induced subacute dyskinesia (a movement disorder that can develop over days or weeks after exposure to certain medications), muscle weakness (a lack of muscle strength), difficulty walking, diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), paranoid schizophrenia (a disease that affects a person's ability to think, feel, and behave clearly), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), anxiety disorder (a mental health disorder characterized by feeling of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), mild intellectual disabilities (a condition that affects a person's intellectual functioning and adaptive skills), and alcohol dependence. Record review of Resident #1's last MDS was a quarterly completed 11-26-2024 with a BIMS of 11 indicating she was moderately cognitively impaired, and she had a functionality of requiring set-up/clean up to supervision/touching assistance with most activities. Record review of Resident #1's care plan with admitted [DATE] revealed the following: Focus: Resident is at risk for delusions or an acute confusional episode r/t paranoid schizophrenia. - Date Initiated: 02-09-2024. Focus: Resident is at risk for impaired cognitive function/dementia or impaired thought processes r/t DX: Cancer, PARANOID SCHIZOPHRENIA. - Date Initiated: 10-21-2022. Focus: Resident has potential for a psychosocial well-being problem r/t hallucination, delusions, paranoia all that occur intermittently due to DX: Paranoid Schizophrenia. - Date Initiated: 01-22-2025. Record review of Resident #1's Progress Notes revealed the following note completed by LVN A on 1-22-2025: Note Text: Late Entry. Resident stated to this nurse during medication pass, A man comes in my room and rapes me while I'm sleeping. He makes my roommate get out and he rapes me. This nurse told resident that I have been here all night and the aids have been here as well and there has not been a man in her room. This nurse asked resident if she was having hallucinations or delusions and if she could have dreamt this happening. Resident denied hallucinations, delusions or dreaming that she had been raped. Resident stated, It happens while I'm asleep. This nurse told resident that the only resident in the room was the roommate, and she had been in there the whole night. Also let resident know that this nurse has been at the nurses' station all night and that no one has been in her room other than the roommate and aide to help. Resident stated, That makes me feel better. Maybe I did dream it. Left resident in room with equal rise and fall in chest and call light in reach. No further needs. Plan of care continues. Record review of the Provider Investigation Report dated 1-31-2025 revealed the following: Incident Date: 1-22-2025 Date Reported to HHSC: 1-26-2025. Description of Allegation: Resident stated to the nurse a man came into her room and raped her while she was asleep. During an interview on 2-4-2025 at 08:18 AM the ADM reported that the nurse who took the original report from Resident #1 when Resident #1 made her alleged rape on 1-22-2025 did not report this to management until 4 days later and then back dated her note. The ADM reported that LVN A had already been written up for the incident and reeducated. During an interview on 2-4-2025 at 10:23 AM PO B reported that he was early into the investigation with Resident #1 and was reluctant to give any opinion. PO B reported that he did not feel the allegation did occur, but he still needed to get records and interview staff before he would make an official finding. PO B was also waiting on records from another facility were apparently Resident #1 made similar allegations. PO B gave a case #25501238 for this incident. During an interview on 2-4-2025 at 10:32 AM LVN A reported that Resident #1 had reported to her on 1-22-2025 that a man was coming into her room every night while she was sleeping and raping her. LVN A reported that she waited 4 days to report the incident due to Resident #1's history of false allegation, that Resident #1 reported that night that the man involved made her roommate leave the room, and that he was the man from the couple that was always arguing across the hall. LVN A reported that only ladies lived across the hall, there were no males capable of assaulting Resident #1, that she (LVN A) was always up on the unit, and that at least one CNA was always working at the kiosk across from Resident #1's room. LVN A reported that they would have noticed a strange male on the unit, anyone entering or leaving the Resident #1's room to include Resident #1's roommate, so she (LVN A) did not feel the allegation was legitimate. LVN A stated, I didn't think it happened at all with all the false allegations Resident #1 makes. Resident #1's is always accusing someone of stealing or something of that nature. LVN A verified that she had been trained several times on ANE when the facility provides handouts and that she just finished her yearly computer training on 1-29-2025. During an interview on 2-4-2025 at 1:07 PM OM C reported that if an allegation of abuse or neglect was not reported immediately a resident could suffer and something could happen to that resident that we do not want them to have happen. During an interview on 2-4-2025 at 1:47 PM Per the ADM reported that he was aware that the facility was out of compliance with the reporting requirements and that he was aware that they would be cited for the noncompliance. He reported that was why he implemented their policy of a written reprimand for the employee involved and reeducation to include reeducation for all staff so that the noncompliance would not occur again, and resident safety would be maintained. Record review of the facility provided policy titled Nursing Administration revised 10-2013, revealed the following: Subject: Abuse Prevention Policy: It is the policy of this facility that each resident has the right to be free from abuse . D, Identification of Abuse All alleged violations, including injuries of unknow source and misappropriation of resident property are reported immediately to the administrator of the facility and to the officials in accordance with State law through established procedures. Record review of facility provided documents revealed a written warning given to LVN A Date of Notice - 1-27-2025 for failure to report abuse in a timely manner. Record review noted LVN A completed her required assigned retraining for Abuse: Preventing, Recognizing, and Reporting on 2-2-2025. Record review noted all staff completed a facility provided training for Abuse/Neglect and when to report Abuse/Neglect started 1-26-2025 with last date of staff signature 1-28-2025.

Based on observation, interview, and record review; the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 2 of 3 medication carts (2C-1 and 100 Skilled medication carts) observed. -1 loose pill (Meloxicam)discovered in 2C-1 medication cart. -2 loose pills (Flexeril and unidentified pill) and a packet of 50 (Methadone) pills not double locked. These failures could result in residents' medications not being properly stored and maintained at their best therapeutic level. Findings include: Observation on 06/05/24 at 08:41 AM of Medication cart 2C-1, 1 loose pill was discovered, and MA D was able to identify medication as Meloxicam (an anti-inflammatory medication to help with arthritic pain). Interview on 06/05/24 at 08:49 MA D stated that a negative outcome for having loose pills in the medication cart. MA D stated that it could lead to a missed medication dose for the resident. Observation on 06/04/24 at 11:59 AM of medication cart for 100 skilled Hall revealed 2 pills and a small packet of 50 pills identified as methadone for Resident # 252. 1 lose pill was identified as Flexeril and the 2nd pill was unidentifiable by LVN B. During an interview on 06/05/24 at 12:03 PM LVN B revealed that the negative outcome for having lose pills in medication drawers could lead to the resident not getting the medication, because the medication didn't get into the cup. LVN B stated that the negative outcome for not double locking-controlled substances could lead to drug diversion, that is my fault so sorry. During an interview on 06/05/24 at 04:09 PM LVN B revealed that the previous ADON would package excess medications in small packages in counts of 50 to make narcotic counts easier on staff. During an interview on 06/06/24 at 08:26 AM ADON stated that the previous ADON would take medications from residents' stock and place in a pill crusher pouch and then either staple or tape shut to send medication home with residents. Record review on 06/06/24 at 09:02 AM revealed statements were received from ADON and LVN E along with in-service to reeducate the staff and facility policy regarding medication storage. Record review of facility policy titled, Medication Access and Storage, undated, revealed the following: Policy: It is the policy of this facility to sore all drugs and biological in locked compartments. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications: Procedures: 1. The provider pharmacy dispenses medications in containers that meet legal requirements. Medications are kept and stored in these containers. .4. Schedule II, III, IV, V controlled medications are stored in a separate area under double locked from other medications in a locked drawer or compartment designated for that purpose.

Based on observation, interview, and record review, the facility failed to ensure that the menu was followed, for 2 out of 5 residents that received pureed food (Resident # 19 and 21), and one resident (#16) who had a mechanical soft diet in the Alzheimer's unit in that: 1. The facility failed to ensure Resident # 19 received a pureed pancake for breakfast on 6/5/24. 2. The facility failed to ensure Resident #16 received toast with her breakfast on 6/5/24. 3. Residents #16, 19 and # 21 received pudding for the lunch dessert instead of cream pie and pudding for the supper meal instead of the chocolate chip cookie the other residents received for 6/5/24. Residents #16,19 and 21 did not receive sweet potato casserole for lunch. 4. Residents #16, 19 and #21 received pudding for the lunch meal on 6/6/24 instead of the dessert empanada. 5. Residents #16, 19 and #21 received jello for the lunch meal on 6/6/24 instead of the mixed berry cake. These failures could place residents at risk for unwanted weight loss, hunger, unwanted weight gain, and metabolic imbalances. The findings include: Resident # 16 Record review of Resident # 16's face sheet revealed an [AGE] year-old-female admitted to the facility on [DATE] with diagnoses to include dementia (defective memory), dysphagia (difficulty swallowing), diabetes (a disease that results in too much sugar in the blood) and anxiety. Record review of comprehensive MDS assessment dated [DATE] revealed Resident # 16 was rarely understood. The MDS revealed Resident # 16 had a BIMS of 3 out of 15 which indicated the resident's cognition was severely impaired. Section K indicated Mechanically altered diet: Require change in texture of food or liquids. Record review of a care plan, dated 5/12/24 for Resident # 16 revealed the following: Category: Nutritional Status Resident has a potential for nutritional problem. Record review of Resident #16's order summary report dated 6/7/24 revealed the following orders: Diet ordered 01/26/24: LCS diet, Mechanical Soft Pureed bread and cakes, thin liquids consistency. Record review of Resident #16's diet card dated Wednesday 6/5/24 revealed under Special Notes: House Shake Sugar Free, Diabetic Snack, 2 bowls of cereal and toast for breakfast every day, Bread and cakes puree. An observation was made on 16/5/24 at 8:25 am of Resident #16's breakfast tray revealed there was no toast. Record review of Resident # 16's diet card dated Wednesday 6/5/24 revealed she should have received toast with her cereal. Record Review of the tray ticket for 6/5/24 for the lunch meal revealed Resident # 16 should have received cream pie and sweet potato casserole with her meal. An observation was made on 6/5/24 at 12:00 pm of Resident #16's lunch tray revealed she got pudding instead of a cream pie and there was no pureed bread or sweet potato casserole on the plate. Record Review of the tray ticket for 6/6/24 for the lunch meal revealed Resident # 16 should have received a dessert empanada with her meal. An observation was made on 6/6/24 at 12:00 pm of Resident #16's lunch tray revealed she got pudding instead of a dessert empanada on the plate. Record Review of the tray ticket for 6/7/24 for the lunch meal revealed Resident # 16 should have received mixed berry cake with her meal. An observation was made on 6/7/24 at 12:00 pm of Resident #16's lunch tray revealed she got jello instead of a mixed berry cake. Resident # 19 Record review of Resident #19's face sheet revealed a [AGE] year-old-female admitted to the facility on [DATE] with diagnoses to include Huntington's disease (a breakdown in the nerve cells in the brain), dysphagia (difficulty swallowing), and anxiety. Record review of comprehensive MDS assessment dated [DATE] revealed Resident #19 was rarely or never understood. The MDS revealed Resident # 19 had a BIMS of 0 out of 15 which indicated the resident's cognition was severely impaired. Section K indicated Mechanically altered diet: Require change in texture of food or liquids. Record review of a care plan, dated 05/31/24 for Resident # 19 revealed the following: Category: Nutritional Status Resident has a potential for nutritional problem. Record review of Resident # 19's order summary report dated 6/7/24 revealed the following orders: Diet ordered 02/07/24: Regular diet, Pureed texture, thin liquids consistency. Record review of Resident #19's diet card dated Wednesday 6/5/24 revealed Resident #19 should have received a pancake, sausage and oatmeal for breakfast. An observation was made on 6/5/24 at 8:26 am of Resident #19's breakfast tray revealed there was no pancake. Record Review of the tray ticket for 6/5/24 for the lunch meal revealed Resident # 19 should have received cream pie and sweet potato casserole with her meal. An observation was made on 6/5/24 at 12:03 pm of Resident #19's lunch tray revealed she got pudding instead of a cream pie and there was no sweet potato casserole on the plate. Record Review of the tray ticket for 6/6/24 for the lunch meal revealed Resident # 19 should have received a dessert empanada with her meal. An observation was made on 6/6/24 at 12:00pm of Resident #19's lunch tray revealed she got pudding instead of a dessert empanada on the plate. Record Review of the tray ticket for 6/7/24 for the lunch meal revealed Resident # 19 should have received mixed berry cake with her meal. An observation was made on 6/7/24 at 12:00pm of Resident #19's lunch tray revealed she got Jell-O, instead of a mixed berry cake. Resident #21 Record review of Resident #21's face sheet revealed a [AGE] year-old-male admitted to the facility on [DATE] with diagnoses to include dementia (defective memory), dysphagia (difficulty swallowing), diabetes (a disease that results in too much sugar in the blood) and pain. Record review of comprehensive MDS assessment dated [DATE] revealed Resident #21 was usually understood. The MDS revealed Resident # 21 had a BIMS of 3 out of 15 which indicated the resident's cognition was severely impaired. Section K indicated Mechanically altered diet: Require change in texture of food or liquids. Record review of a care plan, dated 05/9/24 for Resident # 21 revealed the following: Category: Nutritional Status Resident has a potential for nutritional problem. Record review of Resident # 21's order summary report dated 6/7/24 revealed the following orders: Diet ordered 10/16/23: LCS, Pureed texture, nectar thick liquids consistency. Record review of Resident #21's diet card dated Wednesday 6/5/24 for the lunch meal revealed Resident # 21 should have received cream pie and sweet potato casserole with his meal. An observation was made on 6/5/24 at 12:03 pm of Resident #21's lunch tray revealed he got pudding instead of a cream pie and no sweet potato casserole. Record Review of the tray ticket for 6/6/24 for the lunch meal revealed Resident # 21 should have received a dessert empanada with his meal. An observation was made on 6/6/24 at 12:00pm of Resident #21's lunch tray revealed he got pudding instead of a dessert empanada on the plate. Record Review of the tray ticket for 6/7/24 for the lunch meal revealed Resident # 21 should have received mixed berry cake with his meal. An observation was made on 6/7/24 at 12:00 pm of Resident #21's lunch tray revealed he got Jell-O, instead of a mixed berry cake. During a confidential interview on 6/6/24 at 12:20 pm an employee stated Resident's #16 #19 and #21 got pudding for the lunch meal on 6/5/24 instead of pie and pudding again for the supper dessert on 6/5/24 which listed a chocolate chip cookie. She stated most residents in the unit got a chocolate chip cookie on 6/5/24. The employee stated the residents with a pureed meal always got pudding instead of the listed dessert. The employee stated some of the other residents in the unit with a regular meal often get pudding instead of the scheduled dessert. The employee stated Resident # 21 was able to express his wants and he always asks for a dessert instead of pudding. The employee stated Resident #21 always looked sad when he did not get the same foods as other residents. The employee stated Residents #16 , 19 and 21 will eat everything they are given and enjoy eating different foods. During an interview on 6//7/24 at 11:00 am the RD stated she was not aware the menu for residents with purees were not being followed. She stated she expects residents to get what is listed on the menu in the correct form. She stated she trains the staff in policies and how to complete tasks in the kitchen. The Rd stated the consequences of not getting all menu items at meals could be a difference in the caloric intake and lost nutrients. During an interview on 6/7/24 at 12: 55 pm, Resident #21 stated loved the desserts and got tired of puddings all the time. He stated he was sad when he did not get the same foods as he saw on everyone else's plate. During an interview on 6/7/24 at 1:45 pm, the DM stated she was not aware residents on a pureed diet were not receiving pureed items as the menu listed. She stated the banana cream pie, the empanada and the chocolate chip cookie should have been pureed. The DM stated she was not aware residents with pureed diets were receiving pudding at multiple meals. She stated she could not say why residents received so much pudding for meals. She stated she had been short staffed in the kitchen, and she only had one cook. She stated the sweet potatoes for the meal on Wednesday lunch were not pureed. The DM stated she did not have any polices for the kitchen. She stated she trains staff by telling employees how to do a task. She stated the consequences of not providing all the menu items for meals would be not getting enough nutrition. Record review of the facility's undated policy titled, Quality of Care with the subject Therapeutic Diets revealed: It is the policy of this facility that therapeutic diets shall be prescribed by the attending physician. A tray identification system is established to ensure each resident receives his diet as ordered.

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 21 residents (Resident #94) reviewed for resident's rights. -CNA A was standing next to Resident #94's Geri-chair while feeding resident his lunch time meal. This failure could cause residents to feel humiliated and disrespected. Findings include: Record Review of Resident #94's clinical records revealed a [AGE] year-old male resident who was admitted to the facility on [DATE]. Resident #94 had the following diagnosis of personal history of transient ischemic attack (TIA), and cerebral infarction (stroke) without residual deficits, Hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs and facial muscles) and Hemiparesis (a nervous system disorder that causes a person to have a relatively mild loss of strength on one side of their body) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting right dominant side, Type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar (glucose) without complications, unspecified convulsions (seizures), post-traumatic stress disorder (disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), chronic, anxiety disorder (a mental health disorder characterized by feeling of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), unspecified, depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), unspecified, hemiplegia unspecified affecting right dominant side, generalized anxiety disorder, essential (primary) hypertension (a condition in which the force of the blood against the artery walls is too high), hypomagnesemia (low magnesium, acute kidney failure (sudden onset disease of the kidneys leading to kidney failure),, unspecified, hyperlipidemia (a condition in which there are high levels of fat particles in the blood), unspecified, other specified disorders of brain. Record review of Resident #94's MDS, dated [DATE] revealed a BIMS score that was blank and had functionality of complete dependency upon staff with every ADL. Record review of Resident #94's care plan dated 05/03/2024, revealed the following: Focus: [Resident #94] has ADL Self Care Performance Deficit r/t DX: CVA & encephalomalacia (the softening or loss of brain tissue after cerebral infarction, cerebral ischemia infection, craniocerebral trauma or other injury) of bilateral cerebrum (the principal and most anterior part or the brain) & cerebellum (the part of the brain at the back of the skull). Date Initiated: 05/03/2024 . .Interventions: o EATING: requires 1 person assistance to eat. Date Initiated: 05/03/2024 Observation on 06/07/24 at 1:10 PM revealed CNA A standing next to Resident #94's Geri-chair feeding Resident #94 in the dining room of facility. Once CNA A spotted surveyor she promptly got a chair and sat down next to Resident #94 and continued to feed him his lunch. During an interview on 06/07/24 at 1:16 PM, CNA A stated that she did not sit down next to resident due to so many residents being in the dining room. CNA A stated that once the smokers went out to smoke she would be able to find a chair more easily. CNA A stated that a negative outcome for not sitting next to the resident to feed him was there just weren't any chairs available. Record review of facility provided admission pack revealed the following policy Federal Resident Rights undated, revealed the following: As a resident of this nursing facility, you have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.

Based on observation, interview and record review the facility failed to ensure residents had the right to and the facility promoted and facilitated resident self-determination through support of resident choice, which included but not limited to the right to make choices about aspects of his or her life in the facility that were significant to the resident for 1 of 25 residents (Resident #21) reviewed for self-determination. The facility failed to ensure Resident #21 was allowed to choose the type of foods he preferred when he expressed he would like all the foods the other residents were served. This failure could place residents at risk for being denied the opportunity to exercise his or her autonomy regarding things that were important in their life and a decrease in their quality of life. Findings include: Record review of Resident #21's face sheet revealed a [AGE] year-old-male admitted to the facility on [DATE] with diagnoses to include dementia (defective memory), dysphagia (difficulty swallowing), diabetes (a disease that results in too much sugar in the blood) and pain. Record review of comprehensive MDS assessment dated [DATE] revealed Resident #21 was usually understood. The MDS revealed Resident # 21 had a BIMS of 3 out of 15 which indicated the resident's cognition was severely impaired. Section K indicated Mechanically altered diet: Require change in texture of food or liquids. Record review of a care plan, dated 05/9/24 for Resident # 21 revealed the following: Category: Nutritional Status Resident has a potential for nutritional problem. Record review of Resident # 21's order summary report dated 6/7/24 revealed the following orders: Diet ordered 10/16/23: LCS, Pureed texture, nectar thick liquids consistency. Record review of Resident #21's diet card dated Wednesday 6/5/24 for the lunch meal revealed Resident # 21 should have received cream pie and sweet potato casserole with his meal. An observation was made on 6/5/24 at 12:03 pm of Resident #21's lunch tray revealed he got pudding instead of a cream pie. There was no sweet potato casserole on his plate. Record Review of the tray ticket for 6/6/24 for the lunch meal revealed Resident # 21 should have received a dessert empanada with his meal. An observation was made on 6/6/24 at 12:00pm of Resident #21's lunch tray revealed he got pudding instead of a dessert empanada on the plate. Record Review of the tray ticket for 6/7/24 for the lunch meal revealed Resident # 21 should have received mixed berry cake with his meal. An observation was made on 6/7/24 at 12:00 pm of Resident #21's lunch tray revealed he got Jell-O, instead of a mixed berry cake. Record view of Resident # 21's weight log, March-May 2024, indicated there was no significant weight loss at the time of survey. During a confidential interview on 6/6/24 at 12:20 pm an employee stated Resident's #21 got pudding for the lunch meal on 6/5/24 instead of pie and pudding again for the supper dessert on 6/5/24 which listed a chocolate chip cookie. She stated most residents in the unit got a chocolate chip cookie on 6/5/24. The employee stated the residents with a pureed meal always got pudding instead of the listed dessert. The employee stated some of the other residents in the unit with a regular meal often get pudding instead of the scheduled dessert. The employee stated Resident # 21 was able to express his wants and he always asks for a dessert instead of pudding. The employee stated Resident #21 always looked sad when he did not get the same foods as other residents. The employee stated Residents # 21 will eat everything he was given and enjoyed eating different foods. During an interview on 6//7/24 at 11:00 am the RD stated she was not aware the menu for residents with purees were not being followed. She stated she expects residents to get what is listed on the menu in the correct form. She stated she trains the staff in policies and how to complete tasks in the kitchen. The Rd stated the consequences of not getting all menu items at meals could be a difference in the caloric intake and lost nutrients. During an interview on 6/7/24 at 12: 55 pm, Resident #21 stated loved the desserts and got tired of puddings all the time. He stated he was sad when he did not get the same foods as he saw on everyone else's plate. During an interview on 6/7/24 at 1:45 pm, the DM stated she was not aware residents on a pureed diet were not receiving pureed items as the menu listed. She stated the banana cream pie, the empananda and the chocolate chip cookie should have been pureed. The DM stated she was not aware residents with pureed diets were receiving pudding at multiple meals. She stated she could not say why residents received so much pudding for meals. She stated she had been short in the kitchen, and she only had one cook. She stated the sweet potatoes for the meal on Wednesday lunch was not pureed. The DM stated she did not have any polices for the kitchen. She stated she trains staff by telling employees how to do a task. She stated the consequences of not providing all the menu items for meals would be not getting enough nutrition. Record review of the facility's undated policy titled, Quality of Care with the subject Therapeutic Diets revealed: It is the policy of this facility that therapeutic diets shall be prescribed by the attending physician. A tray identification system is established to ensure each resident receives his diet as ordered.

Based on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 (Resident #5) of 21 residents reviewed for respiratory care. The facility failed to change Resident #5's nebulizer tubing and mask as per his physician orders. This failure could affect residents on respiratory therapy by placing them at risk for respiratory compromise and associated complications such as shortness of breath, confusion, respiratory failure, and exacerbation of their condition. Findings include: Record review of Resident #5's face sheet revealed a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include unspecified intracranial injury (brain dysfunction usually caused by an outside force, usually a violent blow to the head), chronic obstructive pulmonary disease (COPD refers to a group of diseases that cause airflow blockage and breathing-related problems), chronic pain (persistent pain that can last years), osteoarthritis (break down of joints causing pain related to age/wear and tear) or (degeneration of joint cartilage) malnutrition (lack of proper nutrition), coronary artery disease (damage or disease in the hearts major blood vessels), anxiety (a mental health disorder characterized by feeling of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), Type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), and cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it. Record review of Resident #5's clinical record revealed his last MDS was a quarterly completed 3-20-2024 listing him with a BIMS score of 12 indicating he was moderately cognitively impaired, and he had a functionality of requiring partial to moderate assistance with most of his activities of daily living. Record review of Resident #5's Order Summary Report with Active Orders as of: 6-5-2024 revealed the following order: - CHANGE NEBULIZER TUBING/MASK/MOUTHPIECE every night shift every Sun - Verbal Active 12/18/2023 - Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 3 ml inhale orally four times a day . Verbal Active 07/18/2023 Record review of Resident #5's clinical record revealed a care plan with the admitted [DATE], with the following: Focus-Resident has COPD (Chronic Obstructive Pulmonary Disease): med Ipratropium-Albuterol Inhalation Solution . Intervention-Give aerosol or bronchodilators as orders. (There was no intervention documented to address the nebulizer equipment care.) Focus-Resident has oxygen therapy r/t Dx of COPD: (date initiated 7-19-2023) Intervention-Change O2 tubing and humidifier bottle q week per physician orders. (Date initiated 7-19-2023) (There were no intervention documented to address the nebulizer equipment care.) During an interview on 06-05-2024 at 08:09 AM the Administrator reported that the previous DON resigned without notice and the new DON started last week and was currently at training and would be unavailable during the survey. During an observation and interview on 06-05-2024 at 09:27 AM Resident #5 was in his room sitting at the side of his bed eating his breakfast wearing his O2. Noted on Resident #5's bedside dresser was a nebulize with his mask that was noted to have particles in the mask and the mask was noted to have been used frequently. Noted at the base of the mask was tubing that was dated 4-21-2024 with no date noted on the mask. Resident #5 reported that he receives his nebulizer treatments 3 times a day. During an observation on 06-06-2024 at 08:42 AM of Resident #5's nebulizer equipment revealed the mask continued to have particulates in it from continued use (the mask looked dirty). Noted was a second date of 6-2-2024 written over the original date of 4-21-2-24. During an interview on 06-06-2024 at 09:21 AM LVN A (the nurse responsible for Resident #5 this shift) reviewed a photo of Resident #5's nebulizer tubing (taken 6-5-2024) and verified that it was dated 4-21-2024 and that Resident #5's nebulizer mask looked a little dirty. LVN A reported that the nebulizer equipment is usually changed once a month. LVN A was asked to verify Resident #5's orders and LVN A noted that the nebulizer equipment to include tubing was to be changed weekly on Sunday per physician orders. LVN A reported that he would get the mask and tubing changed immediately. LVN A was asked to verify physically that the mask was marked 4-21-2024 and that the mask was dirty. LVN A noted that the nebulizer tubing was marked 6-2-2024 and stated, its marked 6-2-2024 but it looks liked its marked over the 4-21-2024 and that is just lazy. LVN A reported that if the equipment is not changed as it should then the resident could get an infection. During an interview on 06-06-2024 at 09:25 AM the CRN verified that Resident #5's nebulizer tubing was dated 4-21-2024 and that the mask did look dirty. The CRN was asked to physically observe the mask and tubing and upon inspection the CRN again verified that the mask did look dirty and that the tubing was marked 4-21-2024 and someone wrote over the date with 6-2-2024. The CRN reported that if the nebulizer equipment is not changed and maintained then a resident can get an infection. Record review of the facility provided policy titled Oxygen Equipment undated revealed the following: Policy: It is the policy of this facility to maintain all oxygen therapy equipment in a clean and sanitary manner for resident receiving oxygen. Procedures: A. Pre-filled humidifier, when used, are to be dated and replaced every seven to ten days . 1. Tubing should be replaced every week. 2. Masks should be replaced ever week. C. Nebulizer Equipment Procedures 2. Store, clean, and dry until next use.

Based on observation, interview and record review the facility failed to ensure that residents had the right to reasonable access to the use of a telephone, and a place in the facility where calls can be made without being overheard for 9 of 99 (Residents #1, #2, #3, #4, #5, #6, #7, #8, and #9) residents reviewed for Resident Rights. Residents #1, #2, #3, #4, #5, #6, #7, #8 and #9 stated they did not have access to a telephone to make private calls. This failure could place residents at risk of increased social isolation and decreased psychosocial well-being. Findings Included: Resident #1 In an interview on 5/17/24 at 8:49AM Resident #1 stated he had been at the facility about a year and when he arrived, he had a personal cell phone to use to communicate with friends and family outside of the facility. The cell phone would not hold a charge and he was without cellular communication, beginning in August of 2023. Resident #1 had spoken to the SW regarding his cell phone and was told that documents indicating his financial need to purchase a new cell phone had been submitted to an outside entity who provides provided cell phones for those in need, but the request had been denied. Since August of 2023, Resident #1 has been without a communication device to make a private call. He stated if he wanted to make a personal call, he had to go to the Nurse's Station or to one of the offices of facility staff. He stated there are always nurses at the Nurse's Station, so no call made from there was completely private. He stated that he could use the phone in a staff member's office between the hours of 8AM and 5PM, but after those hours, there was no way for him to place a private call outside of the facility. Record review of Resident #1's Admission Record on 5/17/24 at 8:54AM revealed a [AGE] year-old male with a BIMS of 12, indicating moderate cognitive impairment, who was admitted to the facility on [DATE] with a diagnosis of, but not limited to Unspecified Symbolic Dysfunctions (social impairment); Cognitive Communication Deficit (trouble participating in conversations); Limitation of Activities Due to Disability; Depression, Unspecified; Other Specified Anxiety Disorders and Unspecified Sequelae of Cerebral Infarction (psychological distress and neuropsychiatric disturbance after a Stroke). An interview on 5/17/24 at 9:19AM with the Ombudsman revealed residents had complained to her about the lack of a portable phone in the facility, which they could use for personal communication. She stated she had tried to call Resident #1 on 5/16/24 and had spoken with the receptionist, who transferred her to the phone at the Nurse's Station on Resident #1's hall. The phone at the Nurse's Station had rung for about 10 minutes and had not been answered. She instead drove to the facility to speak with Resident #1 face-to-face. Resident #2 In an interview on 5/17/24 at 9:57AM Resident #2 stated he did not have a cell phone of his own and would have to go to the Nurse's Station or to a staff member's office to make a personal call. He stated the Nurse's Station was not private and staff members leave at 5PM, so there was no place to have a personal conversation by phone. He would like to have a cell phone of his own but cannot afford one. Record Review of Resident #2's Admission Record on 5/17/24 at 10:00AM revealed a [AGE] year-old male with a BIMS of 15, indicating he was cognitively intact, who was admitted to the facility on [DATE] with a diagnosis of, but not limited to, Dysphagia (difficulty swallowing); Cognitive Communication Deficit (trouble participating in conversations); Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety (a mental disorder in which a person loses the ability of think, remember, learn, make decisions, and solve problems); Personal History of Transient Ischemic Attack, and Cerebral Infarction without Residual Deficits (a short period of symptoms similar to those of a stroke). Resident #7 In an interview on 5/17/24 at 10:02AM Resident #7 stated she did not have a cell phone of her own and would have to go to the Nurse's Station or to a staff member's office to make a personal call, which was difficult due to her declining eyesight. She stated the Nurse's Station was not private and staff members leave at 5PM, so there was no place to have a personal conversation by phone. She would like to have a cell phone of her own but cannot afford one. Record Review of Resident #7's Admission Record on 5/17/24 at 10:07AM revealed a [AGE] year-old female who was admitted to the facility on [DATE] with a BIMS of 11, indicating moderate impairment and a diagnosis of, but not limited to Chronic Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure (a combination of the ventricles of the heart not producing enough pressure to push blood circulation and no relaxing enough to fill with blood), Presence of a Cardiac Pacemaker, and Legal Blindness as Defined in the United States of America. Resident #3 In an interview on 5/17/24 at 10:27AM Resident #3 stated he did not have a cell phone of his own and would have to go to the Nurse's Station or to a staff member's office to make a personal call. He stated the Nurse's Station was not private and staff members leave at 5PM, so there was no place to have a personal conversation by phone. He stated he would like to have a cell phone of his own but cannot afford one. Record Review of Resident #3's Admission Record on 5/17/24 at 10:30AM revealed a [AGE] year-old male who was admitted to the facility on [DATE] with a BIMS of 12, indicating moderate impairment and a diagnosis of, but not limited to Otitis Externa (inflammation, either infectious or non-infectious, of the external auditory canal); Limitation of Activities due to Disability; Other Specified Anxiety Disorders; Cognitive Communication Deficit (trouble participating in conversations); Unspecified Sequelae of Cerebral Infarction (psychological distress and neuropsychiatric disturbance after a Stroke) and Unspecified Symbolic Dysfunctions (social impairment). Resident #5 In an interview on 5/17/24 at 1:08PM Resident #5 stated he did not have a cell phone of his own and would have to go to the Nurse's Station or to a staff member's office to make a personal call. He stated the Nurse's Station was not private and staff members leave at 5PM, so there was no place to have a personal conversation by phone. He would like to have a cell phone of his own but cannot afford one. Record review of Resident #5's Admission Record 0n 5/17/24 at 1:12PM revealed a [AGE] year-old male who was admitted to the facility on [DATE] with a BIMS of 15, indicating he was cognitively intact and a diagnosis of, but not limited to Other Voice and Resonance Disorders (hoarseness, strained, breathy or raspy voice quality); Hypovolemia (a state of low extracellular fluid volume, combined with sodium and water loss); Schizoaffective Disorder, Bipolar Type (episodes of mania and sometimes depression), and Cognitive Communication Deficit (trouble participating in conversations). Resident #6 In an interview on 5/17/24 at 1:13PM Resident #6 stated she did not have a cell phone of her own and would have to go to the Nurse's Station or to a staff member's office to make a personal call. She stated the Nurse's Station was not private and staff members leave at 5PM, so there was no place to have a personal conversation by phone. She would like to have a cell phone of her own but cannot afford one. Record review of Resident #6's Admission Record on 5/17/24 at 1:17PM revealed an [AGE] year-old female with a BIMS of 04, indicating severe impairment who was admitted to the facility on [DATE] with a diagnosis of, but not limited to, Major Depressive Disorder, Recurrent, Severe Without Psychotic Features (Persistently low or depressed mood); Cognitive Communication Deficit (trouble participating in conversations); Other Reduced Mobility (limitation of independent, personal movement); Other Abnormalities of Gait and Mobility (difficulty walking), and Anxiety Disorder, Unspecified (significant anxiety or phobias without the exact criteria for any other anxiety disorders). Resident #8 In an interview on 5/17/24 at 1:34PM Resident #8 stated she did not have a cell phone of her own and would have to go to the Nurse's Station or to a staff member's office to make a personal call. She stated the Nurse's Station was not private and staff members leave at 5PM, so there was no place to have a personal conversation by phone. She would like to have a cell phone of her own but cannot afford one. Record review of Resident #8's Admission Record on 5/17/24 at 1:39PM revealed an [AGE] year-old female with a BIMS of 15, indicating she was cognitively intact and a diagnosis of, but not limited to, Dysphagia (difficulty swallowing); Cognitive Communication Deficit (trouble participating in conversations); Anxiety Disorder, Unspecified (significant anxiety or phobias without the exact criteria for any other anxiety disorders); Other Reduced Mobility (may require the use of a cane, walker, or wheelchair to ambulate), and Major Depressive Disorder, recurrent, severe with Psychotic Symptoms (persistently low or depressed mood with delusions, hallucinations, or both). Resident #9 In an interview on 5/17/24 at 2:47PM Resident #9 stated she did not have a cell phone of her own and would have to go to the Nurse's Station or to a staff member's office to make a personal call. She stated the Nurse's Station was not private and staff members leave at 5PM, so there was no place to have a personal conversation by phone. She would like to have a cell phone of her own but cannot afford one. Record review of Resident #9's Admission Record on 5/17/24 at 2:51PM revealed a [AGE] year-old female with a BIMS of 12, indicating moderate impairment who was admitted to the facility on [DATE] with a diagnosis of, but not limited to, Drug-Induced, Subacute Dyskinesia (sudden, uncontrollable movements of the face and body, caused by long-term use of anti-psychosis drugs); Acquired Stenosis of the External Ear Canal (stenosis caused by infections, inflammation, trauma and radiation therapy); Major Depressive Disorder (persistently low or depressed mood); Anxiety Disorder (response of fear and dread in certain situations), Localized Swelling, Mass and Lump (signs, symptoms and abnormal laboratory findings) and Acquired Absence of Right Breast and Nipple (the absence of one or more breasts, the cause of which is not present at birth). Resident #4 In an interview on 5/17/24 at 3:31PM Resident #4 stated he did not have a cell phone of his own and would have to go to the Nurse's Station or to a staff member's office to make a personal call. He stated the Nurse's Station was not private and staff members leave at 5PM, so there was no place to have a personal conversation by phone. He would like to have a cell phone of his own but cannot afford one. Record review of Resident #4's Admission Record on 5/17/24 at 3:36PM revealed a [AGE] year-old male with a BIMS of 15 (indicating cognitively intact) who was admitted to the facility on [DATE] with a diagnosis of, but not limited to, Acquired Absence of Left Leg (the absence of the left leg, the cause of which is not present at birth); Acquired Absence of Left Upper Limb Above Elbow (the absence of the left arm, above the elbow, which was not present at birth); Cognitive Communication Deficit (trouble participating in conversations), and Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy Without Gangrene (narrowing of the arteries which results in the undersupply of blood and oxygen to different organs). An interview on 5/17/24 at 9:08AM with the Social Worker revealed residents could use her office phone between the hours of 8AM and 5PM, to call outside of the facility, if they do not have a cell phone of their own. She stated if her office was closed, residents had to use the phone at the Nurse's Station. She stated she knew that the Nurse's Station was usually always occupied, so a phone call would not be completely private. An interview with LVN D on 5/17/24 at 1:19PM revealed residents came to the nurse's station to use the phone, but it was not a private place to have a conversation. An observation of Maintenance Supervisor E on 5/17/24 at 1:24PM revealed he received a cell phone call from Administrator C, asking him to purchase cordless phones for the facility, for resident use. When asked if a cordless phone was being bought for resident use, he stated he will be installing 2 cordless phones in the facility, for resident use. Residents will be able to take the phone to their room or to the parlor for more privacy when making a personal phone call. An interview with Medication Aide F on 5/17/24 at 1:29PM revealed residents came to the nurse's station to use the phone, but it was not a private place to have a conversation. An interview with the Administrator on 5/17/24 at 10:07AM revealed residents could use the receptionist's phone or the phone in a staff member's office if they wanted to make a personal call outside of the facility. He stated that after 5PM, residents would have to use the phone at the Nurse's Station, since there was no portable phone, which could be taken to a resident's room. He stated he was not aware of any problems with residents without personal cell phones, wanting to make a personal call. Record Review of the undated facility policy, Federal Residents Rights stated: Privacy and Confidentiality: You have the right to personal privacy and confidentiality, including accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. Information and Communication: You have the right to: have reasonable access to the use of a telephone, including TTY (Tele-typewriters) and TDD (Tele-communication devices for the deaf) services, and a place in the facility where calls can be made without being overheard.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 or 10 residents (Resident #1) reviewed for care plans . The facility failed to ensure that Resident #1's care plan was implemented correctly according to her needs. This failure could place residents at risk for not receiving the necessary care or receiving inappropriate care for their condition and diagnosis. Findings include: Record review of Resident #1's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included urinary tract infection, bipolar disorder, unspecified psychosis not due to a substance or known, physiological condition, mild protein-calorie malnutrition, mixed hyperlipidemia, history of falling, other dysphagia, oropharyngeal phase other dysphagia, unspecified other difficulty in walking, not elsewhere classified, depression, other dementia in other diseases classified elsewhere, mild, without other behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, other lack of coordination, other specified symptoms and signs involving the circulatory and other respiratory systems, cognitive communication deficit, vitamin deficiency, unspecified delusional disorders, other chronic pain, other conductive hearing loss, unspecified muscle weakness (generalized), other unsteadiness on feet, other abnormalities of gait and mobility, other reduced mobility, other need for assistance with personal care and Alzheimer's disease, unspecified Record review of Resident #1's Care Plan, dated 8/21/23, documented the resident was incontinent, was at risk for falls, required 2-person assistance for ADLs . The Care Plan reflected that Resident #1 requires to be in the locked unit. Record review of Resident #1's Quarterly MDS, dated [DATE], documented a BIMS score of 0 out of 15, indicating severe cognitive function. Record review of Resident #1's care plan reflected Resident #1 required the locked dementia unit, dated 11/14/2022. Record review of Resident #1's Progress Notes reflected no meetings or progress notes were documented for Resident #1 which stated the resident was being moved from the locked unit. During an interview on 9/6/2023 at 9:08 AM with Charge LVN , Charge LVN stated Resident #1 did not have a room on the locked unit. During an interview on 9/6/2023 at 9:19 AM with Charge LVN, Charge LVN stated the nurses assessed residents every day for changes in condition and if there was a change, they notified the physician as well as the DON so changes could be made to the care plan. Charge LVN stated they were told Resident #1 didn't meet the criteria to be in the locked unit anymore as she didn't wander, have behaviors or any issues . During an interview on 9/6/2023 at 9:46 AM with the Admin , the Admin stated Resident #1 was going to be moved back to the locked unit today since a new room opened up for them. The Admin stated Resident #1 did better in the group setting. During an interview on 9/6/2023 at 9:58AM with the DON, the DON stated staff on the LTC side got Resident #1 up in the morning and gave the resident their medications, then took them to the locked unit where Resident #1 spent the whole day until after dinner. The DON stated after dinner, staff brought Resident #1 back to the LTC side and they went to sleep in their room. The DON stated Resident #1 didn't meet the criteria to be in the locked unit anymore because they were not exit seeking . The DON stated Resident #1 did not try to elope. The DON stated changes like this needed to be evaluated and care planned. During an interview on 9/6/2023 at 1:50 PM with Family #1, Family #1 stated Resident #1 was moved out of the locked unit on 7/17/2023. Family #1 stated they had a meeting with the ADON, and their questions about why Resident #1 was moved were answered. Family #1 stated it wasn't a care plan meeting. During an interview on 9/6/2023 at 2:26 PM with FNP , the FNP stated they talked with the facility, and everyone agreed Resident #1 was a low elopement risk and not exit seeking so they thought they would do ok on the LTC unit. The FNP stated they talked about it, but an order was not written for the change. During an interview on 9/6/2023 at 2:34 PM with the SW , the SW stated Resident #1 was moved out of the locked unit without a meeting with the family. The SW asked if Resident #1 could be moved back to the locked unit as they were not doing as well in the LTC side. The SW stated the team said there were no rooms available for Resident #1 and they didn't meet the criteria to be on the locked unit. During an interview on 9/6/2023 at 2:50 PM with the DON , the DON stated the meeting with the family was not a care plan meeting and the ADON met with the family to answer any questions they had. The DON stated they couldn't tell why the care plan didn't reflect the change as the care plan still stated Resident #1 required a locked unit and that it was a system breakdown. The DON stated the DON and the MDS Coordinator were responsible for completing the care plans. During an interview on 9/6/2023 at 2:59 PM with the Admin, the Admin stated they looked at the care plan for Resident #1 earlier today and Resident #1's care plan shouldn't have said they required the locked facility and that it was a mistake. The Admin stated that the facility fixed the care plan a little bit ago. Record review of the facility policy for Comprehensive Person-Centered Care Planning, dated 2022, reflected the IDT shall develop a comprehensive person-center care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in a comprehensive assessment, and that the baseline care plan includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in the facility kitchen reviewed for dietary services in that: There was unlabeled, undated, and unsealed food in the refrigerators, freezers, and dry storage area; there was expired food in the refrigerators, freezer, and dry storage area; staff's personal food was in one of the service refrigerators; and refrigerator and freezer temperature logs were not updated. These failures placed residents who ate food served by the kitchen at risk for food-borne illness. Findings include: In an observation of the kitchen and refrigerator on [DATE] at 8:10 AM the following was observed: 1. The main trash can in the kitchen, had no cover and contained discarded food items. 2. The foods in the main refrigerator(s) were not labeled or dated with the contents of the containers, nor the received on, opened on or expiration dates; signs posted on all refrigerators, freezers, and pantry doors, clearly stated, All foods in walk-in and reach-in need a date in and a date out. 3. 24 individual cartons of Ensure, nutritional supplement drink, with an expiration date of [DATE]. 4. 2 food service containers of orange juice, with no date. 5. 4 food service containers of apple juice, with no date. 6. 24 individual glasses of fruit punch, covered, with no date. 7. 1 12-pound container of Three Bean Salad, with no date. 8. 1 dozen eggs, with no date. 9. 1 quart of gravy, with no date. 10. 1 food service container of melted butter, with no date. 11. 3 banana cream pies, with no date. 12. Temperature logs on the holding refrigerator, walk-in cooler and the freezer had not been updated since [DATE]. 13. 1 large zip top bag of tortilla quarters, open to air, with no date. 14. 2 food service packages of tortillas, open to air/, with no date. 15. 8 slices of cooked bacon in a zip top bag, with no date. In an observation of the walk-in freezer on [DATE] at 8:29 AM, the following was observed: 1. 24 1-pound rolls of sausage, with an expiration date of [DATE]. 2. 1 large food service bag of shredded cheddar cheese, open to the air, with no date. In an observation of the walk-in pantry on [DATE] at 8:42 AM, the following was observed: 1. 1 28-ounce box of Cream of Wheat, open to air, with no date. 2. 1 large food service container of peanut butter with an expiration date of [DATE]. 3. 1 large zip top bag of penne pasta, open to air, with no date. 4. 1 10-pound bag of dry spaghetti, open to air, with no date. In an interview on [DATE] at 1:30 PM, the Dietary Manager stated all foods were to be labeled and dated and were to be used in a first in, first out manner. She also stated that all foods were to be clearly marked with the contents and date opened. When asked why foods were not sealed properly and were left open to air, she stated that all food items, regardless of whether they are in the pantry, refrigerator or freezer should be sealed tightly to avoid spoilage, contamination and/or freezer burn. When asked how long foods that were opened should be kept in the refrigerator, she stated that their policy was to throw leftovers out after 7 days. In an interview on [DATE] at 4:09PM, dietary worker M and dietary worker N were asked what the consequences of serving expired food to the residents would be, Dietary Worker M stated, We could get written up! Dietary Worker N immediately stated that the residents could become sick, and all other workers agreed. A review of the facility's Dietary Services Policy and Procedures book revealed the following: 1. The facility will store, prepare, distribute, and serve food under sanitary conditions. 2. Foods placed in the freezer are to be left in the original wrapping with an identifying label. If an item must be rewrapped, a moisture proof wrapping or closed container should be used to prevent freezer burn. 3. Leftovers will be stored in a container or wrapped carefully and securely. Each item will be clearly marked, labeled, and dated before being refrigerated. Leftover food is to be used within 7 days or discarded. A review of the FDA Food Code 2017 revealed the following: 3_201.11 (C) PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under SS ,d+[DATE].17 and ,d+[DATE].18. Pf A review of the Food Storage Policy and Procedure revealed the following: Refrigerated food storage: 1. TCS food must be maintained at or below 41 degrees F unless otherwise specified by law. Periodically take temperatures of refrigerated foods to assure temperatures are maintained at or below 41 degrees F. Temperatures for refrigerators should be between ,d+[DATE] degrees F. Thermometers should be checked at least two times each day. Check for proper functioning of the unit at the same time. 2. All foods should be covered, labeled, and dated. All foods will be checked at assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable) or discarded. 3. Refrigerated food should be stored upon delivery and careful rotation procedures should be followed. Frozen Foods: 1. Frozen foods must be maintained at a temperature to keep the food frozen solid. Freezer temperatures should be checked at least two times each day. Check for proper functioning of the unit at the same time. Periodically, check the firmness of foods in the freezer to assure temperatures are maintained to keep food frozen solid. 2. All foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. 3. All food items should be stored upon delivery and careful rotation procedures should be followed.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 staff (CNA I, CNA J, and MA F) reviewed for infection control. The facility failed to ensure that CNA I, CNA J, and MA F performed hand hygiene appropriately during overall care of residents, this including medication pass. This failure could place the residents at an increased risk for potentially exposing them to viral infections, secondary infections, tissue breakdown, communicable diseases and feelings of isolation related to poor hygiene. The findings include: 04/12/23 10:03 AM-observed incontinent performed by CNA I and CNA J proceeded to performed incontinent care on resident #61. CNA J performed hand hygiene and donned clean gloves. CNA I did not perform hand hygiene before donning gloves. Resident #61 was seating in a chair in the shower room removing clothing. Resident #61 could do this alone and needed not assistance. Resident #61 was asked if she would like to take a shower and she refused. CNA I asked if resident would sign a refusal sheet. Resident #61 stated that she would sign the document. Resident #61 was then asked if she could stand so that peri-care could be performed. CNA J performed peri-care while standing behind the resident. CNA J wiped from front to back of resident. Wipe was discarded, another wipe was obtained and applied from front to back on resident. No peri-care was performed to the front of the resident's genital area. Resident sat on a towel that had been laid in the chair, a clean brief, and clean pants by CNA J without hand hygiene performed or removing of dirty gloves were provided to resident to put on. Hand hygiene was encouraged to resident by CNA I, who assisted resident with hand hygiene. 04/12/23 10:11 AM-observed incontinent care performed by CNA I with Resident #45. No hand hygiene was performed before starting peri-care. Soiled clothing and brief were removed by CNA I. There was no hand hygiene or glove change before peri-care was performed. CNA I performed peri-care starting at the back of the resident and performing peri-care to genitals last. No hand hygiene or glove change was performed before clean brief or clothing was placed on Resident #45. 04/12/23 10:19 AM- observed incontinent care performed by CNA I and CAN J. Resident #19. Resident #19 was wheeled into the shower room; CNA I did not perform hand hygiene before donning gloves to place a gait belt around resident. Resident #19 was assisted to a standing position form her chair. CNA J did not perform hand hygiene before donning gloves. CNA J proceeded to remove residents' pants and brief, while CNA I helped resident to stand. Peri-care was performed with peri wipes, buttocks and rectal area cleaned with wipes. No observation of female genital area being cleansed. No hand hygiene or glove change was performed before clean brief or clothing was placed on resident, by either CNA I or CNA J. 04/12/23 11:22 AM -Interview with CNA J was asked what the protocol for incontinent care for resident is, CNA J stated that she would wash hands before and after incontinent care. However, there was no mention of hand hygiene or change of gloves in between performing removal of soiled clothes or brief and placing clean brief and clean clothes. CNA J stated that any new skin issues or bruises are placed on a shower sheet and reported to LVN. 04/12/23 11:32 AM -Interview with CNA I stated all new bruises or skin issues are documented on shower sheets and reported to LVN on duty. CNA I was asked what the protocol was for incontinent care. CNA I stated that dirty soiled clothing and briefs will be discarded in dirty laundry. Doffing of dirty gloves, and hand hygiene performed before new gloves will be put on before perineal care is performed. When surveyor asked CNA I why she did not perform hand hygiene, CNA I stated that she did not have an answer. When asked what the negative outcome from lack of clean gloves and proper hand hygiene could be, CNA I stated, it is a break in infections control. 04/13/23 08:02 AM -observed MA F taking medication from a pill blister pack and dropping medication into her hand and then placing into medication cup. Let MA F know that medication pass observation was going to be performed. No hand hygiene was performed before, during, or after medication administration to Resident #3. Record review of infection control/hand hygiene-policy states that hand hygiene will be performed hand hygiene before preparing or handling medications. Hand hygiene will also be performed before and after the donning and doffing of gloves before moving from a contaminated body site to a clean body site during resident care. After reviewing handwashing check-offs CNA I, CNA J, MA F checkoffs were not found. Record review of a facility provided policy titled, Hand Hygiene, dated 05/2007, revealed, in part, B. Before and after direct contact with resident, C. Before preparing or handling medications .H. Before moving from a contaminated body site to a clean body site during resident care; I. After contact with a resident's intact skin; J. After contact with blood or bodily fluids. Record review of a facility provided policy titled, Infection Prevention and control Program, dated 06/2021, revealed, in part, .3. The facility personnel will conduct themselves and provide care in a way that minimizes the spread of infection . b. Facility personnel will wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice .

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life by failing to assure dignity and respect were provided for 2 of 2 residents (Resident #11 and Resident #67) reviewed for privacy and dignity issues. Resident #11 and Resident #67's abdomens were exposed in the multi-purpose room of the locked unit during their subcutaneous injection of insulin, that was administered by LVN D. This failure could cause residents to feel uncomfortable and disrespected. Findings include: Record Review of Resident #67's clinical records reveal an [AGE] year-old female resident admitted to facility 03/07/2021 with diagnosis, but not limited to include: UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL 01/20/2021 Primary DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS 01/20/2021 Other MILD COGNITIVE IMPAIRMENT OF UNCERTAIN OR UNKNOWN ETIOLOGY LONG TERM (CURRENT) USE OF INSULIN Record review of Resident #67's physician order revealed the following: Novolog Pen (Insulin Aspart Flexpen) per sliding scale for hyperglycemia (elevated blood glucose), and MDS shows a BIMS score of 5. 04/12/23 11:08 AM-During observation, Resident #67 received insulin in the multi-purpose room of the locked unit in front of family member and multiple other residents. Insulin was given in the LLQ of abdomen. LVN D lifted shirt for this medication to be administered. 04/13/2023-During an interview, Resident #67 was unable to answer any questions regarding how it made her feel to have medication administered in the multi-purpose room of the locked unit. Record review of Resident #11's clinical records reveal a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses, but not limited to include: UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL 01/20/2021 Primary DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY ALTERED MENTAL STATUS, UNSPECIFIED 04/12/2022 4 TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS 01/20/2021 Other MILD COGNITIVE IMPAIRMENT OF UNCERTAIN OR UNKNOWN ETIOLOGY 01/20/2021 Other LONG TERM (CURRENT) USE OF INSULIN Record review of Resident #11's physician order dated 1-13-2020 revealed the following: HumaLOG Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 200 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units; 401 - 450 = 10 units; 451+ notify provider, subcutaneously before meals for Diabetes /hyperglycemia MDS shows a BIMS score of 3 for resident #11. During observation: 04/12/23 11:19 AM -observed resident #11 receiving insulin in the LLQ in the multi-purpose room of the locked unit in front of multiple other residents in the room. Resident's shirt had to be lifted for this medication to be administered. This medication was administered by LVN D. 04/13/23 09:13 AM -Interviewed resident #11 and she was unable to answer questions regarding receiving insulin in front of other residents. Record review of facility provided admission pack revealed the following policy Federal Resident Rights undated, revealed the following: You have the right to personal privacy and confidentiality of your personal medical records. You have the right to: personal privacy, including accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

Based on observations, interviews and record review, it was determined the facility failed to ensure that residents received treatment and care in accordance with the professional standards of practice and comprehensive person-centered care plan for 1 of 7 residents (Resident #1) reviewed for care provided. The facility failed to ensure Resident #1's wound orders for 8/4/21 for dressing changes for a surgical incision to her left ankle were implemented and/or provided for 14 days. Van Driver failed to give the dressing change orders from Resident #1's follow-up appointment with the surgeon to LVN A who was taking care of Resident #1. In addition, LVN A failed to follow-up with the physician to see if there were any orders for Resident #1's surgical incision. Resident #1's surgical incision became infected, required a wound vac, and additional wound care from a wound care doctor. Surgeon and staff indicated Resident #1 may required amputation of her leg. This failure resulted in an identification of an Immediate Jeopardy on 8/23/21 at 1:15 p.m. While the IJ was removed on 8/25/21 at 10:00 a.m., the facility remained out of compliance at a level of actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for a delay in treatment or diagnosis, a decline in the resident's condition and/or the need for hospitalization and prolonged treatment. Findings included: Record Review of Resident #1's clinical record revealed she was [AGE] year-old female with an admitted [DATE]. She had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's nurses notes revealed there was no documentation of any new orders for dressing changes or physician visits with outcomes. In addition, there was no documentation that any dressing changes were done or if the surgical site was looked at and evaluated. Record review of the missed Surgeon wound care order dated 8/4/21 for Resident #1 that the facility never received documented the following: Daily moist to dry dressing changes to the left ankle. Will transition to a walking boot. Continue NWB to LLE. We will follow up next week. Finish [MEDICATION(S)] as prescribed. During an interview on 8/20/21 at 9:30 a.m., DON stated Resident #1 was non-weight bearing to her left lower extremity because she had a fracture in July of this year (2021). DON stated on 7/13/21, Resident #1 had surgery on left her ankle, and she had a splint on it that was not supposed to be removed until 7/27/21 at her follow-up appointment. DON stated on 8/4/21, Resident #1 got an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . DON stated on August 4th, Resident #1 went to her appointment with the surgeon for a follow-up and no new orders arrived back at the facility with the resident. DON stated when Resident #1 went back to the doctor on 8/18/21, the facility found out that Resident #1 was supposed to have been having daily wet to dry dressing changes. During an interview on 8/20/21 at 9:55 a.m., NP stated she was on vacation on 8/4/21 when Resident #1 went to her follow-up appointment. NP stated LVN A had informed her on 8/4/21 that Resident #1 had one order for an antibiotic and that was the only order LVN A received. NP stated she talked to Nurse B at the surgeon's office on 8/18/21 and was informed that there were three orders - the prescription for the antibiotic, a boot to place on her left foot and orders for a daily wet to dry dressing - that Nurse B gave to the van driver. NP stated Nurse B said the dressing she applied to Resident #1's ankle on 8/4/21 was the same dressing she had on her left ankle when she came back for another follow-up on 8/18/21 and the dressing had never been changed. NP stated she did not know if the orders for Resident #1's dressing change made it to the facility or not, but the paperwork (orders) should have been handed to the nurse taking care of Resident #1. NP stated if Resident #1 came back from a physician visit without orders, the nurse should have called the physician to ensure no new orders were given. During an interview on 8/20/21 at 10:40 a.m., Admin stated she was still trying to figure out what happened with the missing orders from the 8/4/21 appointment for Resident #1. Admin stated when Resident #1 came back from a follow-up appointment on 8/4/21, she had two orders, one for an antibiotic and a splint (boot) for her left foot but those were old orders from a visit in July (2021). Admin stated she was getting conflicting stories from the Van Driver and LVN A. Admin stated the Van Driver said she left the new orders for Resident #1 at the nurses station and LVN A said he did not receive any orders, so she was not sure what happened. During an interview on 8/20/21 at 11:20 p.m., Surgeon's Nurse B stated she was 100% positive that she gave the orders to Resident #1's van driver. Nurse B stated the three orders were folded together and she gave them to the van driver. Nurse B stated when Resident #1 came in on 8/4/21, she was a couple of weeks post-op and the doctor wanted a wet to dry dressing to help get the scab off the incision. Nurse B stated when Resident #1 came back on 8/18/21, the wound had not been touched since she changed the dressing on 8/4/21 and was infected. Nurse B stated it was very odd that the order for wet to dry dressing was missed and she could not figure out how the order got missed. Nurse B stated the surgeon was worried about Resident #1 possibly having her foot amputated. Record review of Resident #1's Surgeon wound care orders, dated 8/18/21, and received by the facility documented the following: Resident #1 followed up in our clinic today for a wound check. At the last visit (8/4/21) she was sent back with a note stating to change wet to dry dressings DAILY. Her dressing was not changed one time, which has caused her wound to become infected. We placed a wound VAC on her left ankle today and are trying to get her wound care. It is VERY important she attends either a wound care appointment OR let wound care in the facility to change dressings. She was given a script for [MEDICATION(S)] DS again today, please make sure she is taking this as prescribed. Thank you During an interview on 8/20/21 at 11:40 a.m., ADON B stated he had started an investigation and did a root cause analysis, and the van driver was the one who dropped the ball, but LVN A did not follow-up with the surgeon either. ADON B stated that was the only thing they could conclude. ADON B stated when a resident came back from a doctor's visit, the van driver was to give the orders to the nurse on duty and place a copy of the orders in the DON/ADONs box. During an interview on 8/20/21 at 12:10 p.m., Van Driver stated she picked Resident #1 up from her doctor's appointment on 8/4/21 and when she arrived at the doctor's office, Resident #1 was already outside waiting for her. Van Driver stated Resident #1 did not have any paperwork (orders) with her and no one gave her any orders. Van Driver stated she did leave some orders on the nurses station, but they were for a different resident. During an interview on 8/20/21 at 12:40 p.m., LVN A stated he never received any order for Resident #1 on 8/4/21. LVN A stated the Van Driver had a bad habit of leaving new orders on the key board of his computer. LVN A stated if the Van Driver left new orders for Resident #1 on his key board, the new orders could have ended up in the shred bin or anywhere. LVN A stated he never removed Resident #1's dressing or boot on her leg because there was not any orders to do that. LVN A could not recall why he did not give Resident #1's doctor a call to see about any wound care orders when she came back from the doctor on 8/4/21. During an interview on 8/20/21 at 12:55 p.m., Resident #1 stated yesterday (8/19/21) the doctor (surgeon) said he wanted to put her in the hospital and cut off her foot, but the doctor today (wound clinic) said he thought he could save her foot. An observation on 8/20/21 at 2:00 p.m. of Resident #1 being provided wound care and wound vac placement by ADON B revealed an open area to the outside of her left ankle which measured 6.0 cm by 1.5 cm open area with red granulation at the lower part of the wound, with the upper part of the wound open with some sloth. Resident #1 was grimacing in pain when the wound was cleaned. The Administrator was notified on 8/23/21 at 1:15 p.m. that an Immediate Jeopardy (IJ) had been identified due to the above failure. A copy of the IJ template was provided to the Administrator. The Plan of Removal, accepted on 8/23/21 at 4:55 p.m. documented the following: Plan of Removal: Per IJ Template, facility failed to ensure that physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Immediate Actions 1. Medical Director/Resident's physician notified of IJ; Responsible party notified of Resident's status. 2. Review of all doctor appointments over the last 30 days to reconcile orders. 3. Skin sweep completed to identify any other skin issues. 4. Review ANE policy 5. Nurse (LVN A) and Van Driver suspended, and subsequent termination. 6. Resident was seen by wound consultant/clinic with new orders for wound vac and antibiotic for infection. 7. QAPI committee did Root Cause Analysis to determine van driver failed to pass on orders given at appointment to nurse. 8. DON asked to step down, interim DON in place. Identification of others: There were no other residents identified with a failure to follow orders after appointment. Systemic change to prevent re-occurrence: 1. In-Service with Leadership Team and licensed nurses completed by interim DON or designee/RN Clinical Resource on ANE policy and reporting. In-service included verifying orders after appointment outside of facility upon resident return to facility. New Procedure is as follows: A. Resident appointments, doctor's orders and van procedure to include van schedule printed off daily by the social worker. (Revised procedure on 8/23/21 with on-service started on this process) B. Van schedule for resident appointment will be printed off daily by Social Worker or Nurse Management. A copy will be given to all nurses on duty, van driver and nurse managers (DON, ADONs, and/or supervisor). (Revised procedure on 8/23/21) C. Van Driver will write on actual schedule for each resident appointment 1) new orders received, 2) follow up appointments, 30 which staff member they handed information to (orders/appointments). (Revised procedure 8/23/21) D. Nurse on duty will write on actual schedule for use resident appointments on their hall 10 new orders received, 20 follow up appointments, 3) input new information into PCC. (Revised procedure 8/23/21) E. Nurse Managers or designee will write on actual schedule for use resident appointments 1) new orders received, 2) follow up appointments, 3) verify that new information is in PCC. (Revised procedure 8/23/21) F. If resident returns from appointment and no new information is received, nurse will call office and verify. (Revised procedure 8/23/21) G. Resident appointment return checklist will be verified the next day during clinical meeting. (Revised procedure 8/23/21). H. Skin Assessment (8/21/21) *Document any new skin issues/concerns (redness, swelling, skin tears, bruising, open areas, painful area) ONLY describe what you see. I. Changes of Condition (8/20/21) New orders/change in condition: *Make sure to write progress note including reason for order. Every new order has a {problem/assessment/vital signs, solution and follow-up/results}, also include notification of family RP for all new orders J. Daily Skilled Notes: (8/20/21) Must be completed daily Do Not copy and paste. Do your own assessment every time Add new vitals K. Wound Vac (8/19/21) Trouble-shooting the wound vac Monitoring: Interim DON or designee will review appointment procedure daily, orders to be verified in PCC, and Summary of findings to be present to QAPI daily until compliance is achieved. Monitoring of the facility's plan of removal: During an interview on 8/25/21 at 8:30 a.m., ADON C stated they had a new procedure put into place. ADON C stated when a resident came back from a doctor's appointment with orders, they have a form they have to fill out and a copy needed to be given to the nurse on duty, the ADONs and Medical Records. ADON C stated all three people - nurse, ADON and Medical Records, needed to sign the form. ADON C stated there was an appointment log that had to be filled out if there were new orders and if the resident came back with no orders, the physician at the appointment, had to be called to verify that there were no new orders. ADON C stated then the nurse needed to make a nurse's notes about the visit. During an interview on 8/25/21 at 8:40 a.m., LVN D stated if a resident came back from a doctor's visit with orders, a form was to be filled out and the van driver, ADONs and medical records needed to sign the form. LVN D stated if a resident came back from a doctor's appointment with no orders, the doctor 's office needed to be called to verify that there were no new orders. LVN D stated after that, a progress note needed to be put into PCC (electronic charting system) about the visit. During an interview on 8/25/21 at 8:52 a.m., CNA E stated she did not touch the orders when a resident came back from a doctor's appointment with them, but they did let the nurses know. CNA E stated she had been in-serviced over several things including equipment, - Hoyer lifts, infection control, skin assessments in the shower that if there is an issue about a resident's skin, the nurse was to be notified immediately. During an interview on 8/25/21 at 9:03 a.m., NA F stated she had been in-serviced on wound care and when to take bandages off in the shower and to notify the nurse if a resident came back from a doctor's appointment with orders. During an interview on 8/25/21 at 9:15 a.m., RN G stated every time a resident went to an appointment there was a form they had to sign and would give a copy to the ADONs and the medical records office. RN G stated if a resident came back from a doctor's visit and did not have any new orders, the nurse was to call the doctor's office and verify that there were no new orders, and a progress note needs to be documented in PCC. During an interview on 8/25/21 at 9:25 a.m., LVN H stated they were now getting a schedule on a daily basis of all residents who had doctor's visits. LVN H stated if a resident went to a doctor's visit and received new orders, the van driver gave the nurse a paper that the nurse, ADONs and medical records signed verifying the new orders. LVN H stated if a resident came back from a doctor's visit without any new orders, the nurse was to call the doctor's office to verify no orders were given, and a progress note needed to be documented in PCC. During an interview on 8/25/21 at 9:35 a.m., LVN I stated she was called yesterday (8/24/21) to come in and be in-serviced over the new procedure for new orders. LVN I stated when a resident came back from a doctor's appointment and had new orders, the van driver gave the orders to the nurse on duty, ADONs and Medical records and all had to sign the new communication sheet. LVN I stated there was a triple check on the orders. LVN I stated if a resident came back from a doctor's visit with no new orders, the nurse was required to call the doctor to verify that no new orders were sent and also make a progress note in PCC. During an interview on 8/25/21 at 9:45 a.m., Maintenance Supervisor stated he was also driving residents to their doctor's visits. Maintenance Supervisor stated he made up a folder for each resident which has the appointment date, time and the doctor's name on the first sheet titled Transportation Communication Form. Maintenance Supervisor stated he had the doctor's office sign the paper if the resident had orders or not and to write the orders on the sheet and sign it. Maintenance Supervisor stated when he got back to the facility, he made copies of the orders he received and handed a copy to the nurse on duty, ADON/DON and medical records and each had to sign the sheet. Maintenance Supervisor stated he then signed the sheet and kept it for his records. Record review on 8/25/21 at 9:55 a.m. of the booklet titled , Appointment Book revealed it had a few sheets in it from 8/24/21. Three residents had appointments but only one had orders. The orders were printed on the Transportation Communication Form and one resident went to the dentist and the dentist had written a question on the communication form about any medical records that would prohibit patient form extractions, scaling and root planning. The note also had the person's name to contact along with a phone number and was signed by the Charge Nurse, ADON/DON and Medical Records. The Administrator, DON and ADON were notified that the Immediate Jeopardy was removed on 8/25/21 at 10:00 a.m. The facility remained out of compliance at actual harm that is not immediate jeopardy identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure necessary treatment and services were provided based on the comprehensive assessment to prevent new pressure injuries from developing for 1 of 5 residents (Resident #1) reviewed for pressure injuries. Resident #1 was admitted without pressure injuries, but was at high risk for the development of pressure injuries. The facility did not ensure Resident #1 received skin assessments per the comprehensive assessment. The resident developed facility acquired stage 2 pressure injuries that facility staff were unaware of until after the Investigator informed them. This failure could place 53 residents who had range of motion/contractures/positioning issues and 6 residents with pressure injuries at risk for developing new or worse pressure injuries. The evidence is as follows: Review of Resident #1's clinical record revealed the following: -The face sheet documented an admitted [DATE] and readmitted on [DATE] after placing kidney drainage bags, was [AGE] years of age with the following Diagnoses: [REDACTED]. -A quarterly MDS resident assessment, dated 10/10/17, documented the resident usually understood and understands others, scored 11 of 15 on a mini-mental exam for mental status, totally dependent on two staff for transfers, totally dependent on one staff for bathing, required extensive assistance by two staff for bed mobility, dressing and toileting, required extensive assistance by one staff for eating and personal hygiene, used a wheelchair, had an indwelling catheter, incontinent of bowel, 72 inches tall and 198 pounds, high risk for pressure ulcer, no pressure ulcers at this time, no skin issues. -A Care Plan, initiated on 10/6/17, documented the following care would be provided to prevent skin breakdown: * has [MEDICAL CONDITION]/[MEDICAL CONDITION] - reposition/ambulate as tolerated and at least every two hours, skin inspections daily and report any findings to the nurse. * has bowel incontinence - check resident every two hours and assist with toileting as needed, may use Zinc Oxide cream to perineal and coccyx area if reddened or irritated, uses disposable briefs, change brief every two hours and prn * At risk for redness, dry and flaky skin related to seborrheic rash to the face * has [MEDICAL CONDITION] - encourage resident to change position frequently, not sitting in one position for long periods of time. * at risk for activity of daily living self-care deficit - totally dependent on staff for toilet use, requires two staff participation to reposition and turn in bed, requires total assistance with personal hygiene care, totally dependent on staff for dressing * has potential for pressure ulcer development related to immobility - have call light within reach, encourage fluid intake and assist to keep skin hydrated and educate resident, family/caregivers as to causes of skin breakdown, including transfer/positioning requirements, importance of taking care during ambulating mobility, good nutrition and frequent repositioning. One Skin Observation - Shower sheet was found for Resident #1. The Skin Observation sheet, dated 10/16/17, documented the resident had bruises to his left upper thigh area and redness to the buttocks. There was no documentation found or presented by the facility of Resident #1 receiving daily skin inspections, as required by the care plan. Review of an initial Admission Record, dated 10/5/17, documented the following contradictory information for skin integrity: Skin problem on admission - sacrum - closed sore to coccyx and chronic psoriasis to the body - additional documentation: skin intact, noted areas of psoriasis to upper and lower body. (This contradicted the previous description of a closed sore to coccyx.) Review of a PRN/Weekly Skin Evaluation, dated 10/12/17, documented the resident has dry and flaky skin on face and arms and excoriated buttocks. There was no documentation found that the nurse called the doctor to get orders for treatment of [REDACTED].#1's buttocks. Review of a PRN/Weekly Skin Evaluation, dated 10/19/17, documented the resident has dry and flaky skin on face and arms and excoriated buttocks. There was no documentation found that the nurse called the doctor to get orders for treatment of [REDACTED].#1's buttocks. Review of the Treatment Administration Record for October 2017 documented the following: Foley catheter care every shift - discontinued 10/5/17, the day Resident #1 readmitted to the facility. Moisture barrier to peri area and buttocks with each brief change on every shift - discontinued 10/5/17, the day Resident #1 readmitted to the facility. [MEDICATION NAME] Powder to peri area and buttocks PRN as needed for redness or yeast - discontinued on 10/5/17, the day Resident #1 readmitted to the facility. Review of Activities of Daily Living for Resident #1 revealed the following: On 10/21/17, the day Resident #1 was taken to the hospital by ambulance, the only documentation found was of assistance and amount eaten of the three meals. The three meals and fluid output to the right and left nephrostomy drain bags were documented. There was no documentation found for bathing, bed mobility, bladder continence, bowel continence, bowel movements, dressing, locomotion off unit, locomotion on unit, personal hygiene, toilet use, transferring and turned and repositioned. All those areas were documented at 7:50 p.m. that the resident was not available. A nurse's note, dated 10/21/17, documented the resident was complaining of hip pain and saying he wants to go to the hospital, on call doctor notified and would like to go ahead and send him out to hospital to be evaluated. Ambulance call at 5:40 p.m., arrived at 5:47 p.m. and left facility 5:55 p.m. At the hospital: Review of the Hospital Emergency Department Nursing Record, dated 10/21/17, documented Resident #1 had several areas of breakdown to the coccyx with excoriation to the buttocks, genitals and inner groin on both sides. Extensive skin breakdown on buttocks/groin area. Food crumbs matted into pubic hair. Review of an Emergency Physician Record, dated 10/21/17, documented EMS reports patient fell on e week ago in nursing home. Patient denies fall, states he is having low back pain and left hip pain. Pressure ulcer, sacral stage three. Progress/Medical Decision Making documented patient with chronic back pain complains of left hip pain, has stage 2 - 3 sacral pressure ulcers. During an interview on 10/24/17 at 11:50 a.m., Resident #1 stated he was at the hospital because his bottom was really, really red and sore. Resident #1 stated the nursing home staff don't care. Resident #1 stated staff were too busy trying to take care of everybody else. Resident #1 stated when he would call them about needing to be changed, it sometimes took staff two hours to get back to him to change him. Resident #1 stated staff need to come right away but they are so busy that they can't. During an interview on 10/24/17 at 4:26 p.m., Hospital RN stated she took care of Resident #1 when he arrived at the emergency room . Hospital RN stated Resident #1's bottom was just awful and was excoriated and very red and his scrotum was very tender and inflamed. Hospital RN stated Resident #1 had too many open areas to count and repeated that his bottom was just awful. Hospital RN stated Resident #1 had food crumbs in his sheets, his clothes and matted in his pubic hair. Hospital RN stated Resident #1 said his bottom was really hurting. Hospital RN stated, That should not happen. The way his bottom looked was just uncalled for. Hospital RN stated the doctor said Resident #1's legs were cramping because he was never repositioned and the muscle spasms would cause him alot of pain. An observation on 10/25/17 at 8:15 a.m. of Resident #1's bottom revealed the excoriation was from the top of his coccyx to his thighs and one upper thigh area was inflamed. There were small open areas on each buttock and his scrotum was very red and inflamed. There was a thin layer of white ointment covering all areas of his buttock, scrotum and thigh area. The nurse who was assisting the Investigator stated he was told in morning report that Resident #1's buttocks was much improved from when he arrived in the emergency room . Back at the facility: During an interview on 10/24/17 at 10:35 a.m., LVN A stated she had taken care of Resident #1 alot. LVN A stated Resident #1 was at the hospital because he had a low potassium level. LVN A stated Resident #1 had a red area on his peri area and red areas in some of his abdominal folds and he had psoriasis. During an interview on 10/24/17 at 10:58 a.m., CNA B stated Resident #1 did not have any open areas on his bottom but he was a little red. CNA B stated Resident #1 was turned every two hours when he was in bed. During an interview on 10/24/17 at 2:53 p.m., the OTA stated Resident #1could not reposition himself at all. During an interview on 10/24/17 at 3:02 p.m., the DON stated Resident #1's bottom had a small red area but it was not open. DON stated to her knowledge Resident #1 did not have any wounds to his bottom. At this time the DON was shown a picture of Resident #1's buttocks which was taken when he admitted to the hospital. The DON stated, That should have never happened. The DON stated she did not know what happened but that Resident #1's buttocks should never look like that. During an interview on 10/25/17 at 9:10 a.m., CNA B stated Resident #1 was already up in his electric wheelchair when she got to work on 10/21/17 around 6:45 a.m. During an interview on 10/25/17 at 9:38 a.m., CNA C stated Resident #1 was already up in his electric wheelchair when she got to work on 10/21/17 around 6:30 a.m. CNA C stated Resident #1 was up in his electric wheelchair all day the day he went to the hospital. When asked if she ever changed his brief that day, she stated no but she emptied his catheter bag. During an interview on 10/25/17 at 10:10 a.m., LVN D stated when Resident #1 came back from the hospital on [DATE], his face and arms had psoriasis and he did have a spot on his hip from psoriasis. LVN D stated Resident #1 did not have any redness to his bottom at that time. During an interview on 10/25/17 at 11:10 a.m., LVN D stated she took care of Resident #1 on 10/21/17. LVN D stated Resident #1 had been up all day in his wheelchair. LVN D stated she had changed his kidney drainage bags that day. LVN D stated she looked at Resident #1's bottom the day before he went to the hospital and he did not have any breakdown at all. During an interview on 10/25/17 at 4:06 p.m., CNA F stated she put Resident #1 to bed on the day he went to the hospital so the ambulance personnel could transfer him easier. CNA F stated she did not clean Resident #1 up or change his brief because he was not her resident. CNA F stated she just laid Resident #1 down. CNA F stated she was working on that hallway but Resident #1 was not her responsibility. Review of the Resident Roster, received from the facility on 10/24/17, documented 113 residents with 53 residents who had range of motion/contractures/positioning issues and 6 residents with pressure injuries.

Based on observation, interview and record review, the facility failed to ensure that 1 of 3 sampled residents (Resident # 11) who entered the facility without a pressure sore, did not develop a pressure sore or have a worsening of a pressure sore. While observing catheter care for Resident #11, the foreskin was retracted to cleanse the area and it was noted that Resident #11 had a Stage 2 pressure ulcer on his penis, which was not present on admission to the facility. This facility failed to provide appropriate catheter care, failed to recognize a developing pressure ulcer and did not have a system in place for reporting skin changes. This failure placed Resident #11 and the two remaining residents, at risk of developing additional pressure ulcers, infection and pain. Findings include: Record review of Resident #11's chart on 1-6-14 revealed a [AGE] year old admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE] documented that Resident #11 did not have pressure ulcers on admission. Resident #11 had a BIMS score of thirteen, (cognition intact). Resident #11 transferred with extensive assistance, (two person assist), extensive assistance with dressing, (two person assist), total dependence with bathing had a urinary catheter and was occasionally incontinent with bowel. During observation of catheter care for Resident #11 on 1-7-14 at 10:45, CNA C was retracting the foreskin on the penis to cleanse the area and surveyor noticed blood on the wipe. Surveyor asked CNA C to pull foreskin down further for a closer look. A wound was noted on Resident #11's penis, at the top of the shaft. CNA C stated she would go get the charge nurse. LVN 2 came in to look at the wound. LVN 2, stated she would get the ADON and have her come to look at this. ADON came to look at the wound and stated she would call physician and get orders for wound care. Wound measurements were taken by LVN 2. Wound measurements are 1.2 cm in length and 2.5 in width. Interview with CNA C on 1-7-14 at 10:00 a.m., surveyor asked how often they do catheter care on Resident #11. CNA C stated "once a week." When asked further about how often, stating specifically when they wash the tubing, etc., CNA C stated, "after each episode." Interview with CNA C on 1-7-14 after providing catheter care, CNA C stated she did not know the wound was present. CNA C stated "Aren't you glad we found this wound?" Interview with Resident #11 on 1-7-14 at 11:10, when asked if they always retract the foreskin when providing catheter care, Resident #11 stated " I don't know because I can't feel if they do." (Resident #11 is a paraplegic). Resident #11 acted upset about finding the wound and embarrassed about having multiple people look at this wound. Interview with DON on 1-7-14 at 11:45, revealed the DON was not aware of the wound. The DON was asked about catheter care and changing of the catheter for Resident #11 and when it is to be done. The DON stated she was not sure of when Resident #11's catheter was changed. The DON stated catheter care was to be done Q-shift. The DON stated CNA's are trained for providing incontinent/catheter care and nurses are supposed to watch CNA's perform incontinent/catheter care to demonstrate competency. The DON stated they will make sure FNP will see Resident #11's wound. DON stated she will also look at the wound. Interview with DON on 1-7-14 at 12:45 p.m., DON stated the last record in the chart for a catheter change was 11-12-13. DON stated Resident #11 refused to have his catheter changed, but it was not recorded in the chart. Interview with ADON on 1-7-14 at 12:05, ADON stated that the ADON does wound care monitoring weekly. The nurses monitor the CNA's for catheter care and incontinent care. ADON stated she was reminding them to retract the foreskin today after finding this wound on Resident #11. When ADON was asked what type of wound this was on Resident #11, the ADON stated maybe a pressure sore. ADON stated that LVN'S on each hall were responsible for their residents who require wound care. ADON stated they are going to get a camera to better assess wounds. ADON states she checks measurements weekly to see if improvements need to be made in regards to changing orders, etc. ADON stated an in service will be held today on males with foreskin and how to provide care. Interview with LVN 2 on 1-7-14, at 12:00 p.m., LVN 2 stated they watch incontinent/catheter care about every third day. LVN 2 stated she had not watched anyone provide incontinent/catheter care for Resident #11. Interview with FNP on 1-8- 14 at 9:00 a.m. revealed she had looked at Resident #11's wound. FNP stated it was a pressure sore. When asked if the CNA's should have noticed this if CNA's were providing proper catheter/incontinent care, FNP stated they should have noticed this. FNP was asked about the foley catheter not being changed since 11-22-13, FNP stated the guidelines are to change every month and she was not aware this had not been done. Interview with CNA D on 1-8-14 at 9:10 a.m., CNA D was asked how to perform catheter care for uncircumcised males, CNA D stated CNA's are supposed to pull the foreskin down and clean the penis. CNA D stated she was always on the 200 hall were Resident #11 resides. CNA D stated "I saw this wound on Resident #11 approximately two weeks ago and reported it." When the surveyor asked who it was reported to, CNA D stated "I can't really say who it was, I'm sorry, I know this doesn't help." Interview with CNA A on 1-8-14 at 9:15 a.m., revealed CNA A always works the 200 hall where Resident #11 resides. CNA A was asked how care was provided for an uncircumcised male, CNA A stated that, "I grab resident's privates and pull down the foreskin". CNA A stated she noticed this wound on Resident #11 at least two weeks ago. CNA A stated she reported it to a nurse but could not remember which nurse it was. Interview with CNA B on 1-8-14 at 10:00 a.m. revealed that they had an in service on peri-care upon hire. CNA B stated she was told in training to pull down the foreskin and cleanse. Record review of Resident #11's chart on 1-6-14 revealed a [AGE] year old admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Record review on 1-7-14 of Resident #11's physician orders, dated 12-1-13 through 12-31-13, documented foley care to is to be done every shift, every day and night shift related to [MEDICAL CONDITION] bladder, change catheter every month. Record review on 1-7-14 of Resident #11's nurse's notes from 10-11-13 through 1-6-14 documented the last catheter change for Resident #11 was 11-22-14. There was no notation of refusal by Resident #11 to have his catheter changed. Record review on 1-7-14 of the facilities in service records, show the last training for incontinent care was done on 9-19-13. Record Review on 1-7-14 of the facility's policy and procedure for Catheter, Indwelling Care of, dated 5-2007 state: Policy: It is the policy of this facility to improve hygiene/reduce infection by insuring that catheter care is done at least daily by CNA's. Procedures: 6. Wash and dry around urinary opening. Be sure to wash catheter tubing extending from the urinary opening with soap and water using wash cloth/cotton balls and soap. 7. Wash the shaft of penis, gently pull foreskin back, wash and rinse shaft of penis (for uncircumcised males). Wash surrounding area and two to three inches of catheter tubing. 12. Report any unusual finding to nurse in charge, such as suspicious drainage, blood. 13. Document on flow sheet, as needed. Record Review on 1-7-14 of the facility's policy and procedure on Skin assessment dated ,[DATE] state: Policy: It is the policy of this facility to assess all residents upon admission, when a comprehensive assessment is required and quarterly thereafter to identify risk of skin breakdown. Record review on 1-7-14 of the facility's policy and procedure for Pressure Ulcers dated 5-2007 state: Policy: It is the policy of this facility that 1. A resident having pressure ulcers receives necessary treatment and service to promote healing, prevent infection and prevent new sores from developing. Purpose: The purpose of this policy is that the resident does not develop pressure ulcers unless clinically unavoidable and that the facility provides care and services to: Promote the prevention of pressure ulcer development: Promote healing of pressure ulcers that are present (including prevention of infection to the extent possible; and prevent development of additional pressure ulcers.) Procedures: 1. Resident Assessment B. Identify risk factors such as Impaired /decrease mobility and decreased functional ability Resident Refusal of some aspects of care and treatment Skin assessment on admission, quarterly and change in condition. Change in condition recognized, evaluated, reported and addressed. C. Assessment of the ulcer Type Stage Characteristics Progress toward healing or potential complications 2. Treatment a. Continue preventative measure Pressure reductions Continence Care Mobility The CMS Resident Census and Condition of Residents obtained on 1-6-14 documented a census of 90.

Based on observation, interview and record review, it was determined that for 1 of 7 sampled residents (discharged Resident #1), who exhibited physically aggressive behaviors, the facility failed to follow written policy for prohibiting incidents of physical harm when they failed to provide adequate supervision to prevent Resident #1 from physical aggression towards other residents and failed to develop a policy addressing resident behaviors to prevent resident to resident abuse.On 6/1/11, at approximately 12:20 a.m., Resident #1, with a known history of physical aggression, was observed to be out of his room and had swelling and a laceration to his right hand. He was returned to his room, which was observed to be disheveled. His roommate, Resident #2, who had no history of behaviors or aggression, was found lying in his bed, with bruising, both eyes swollen shut and bleeding from his mouth. Vertical blinds had been torn off the window by his bed, and a book had fallen off his bed onto the floor. Three staff were on the secured unit at the time of the incident (LVN "A", and CNAs "B", "C"), all of whom heard nothing and were unaware the incident had occurred. Resident #1 was discharged from the facility. Resident #2 was relocated off the secured unit for closer observation. Four days earlier, on 5/28/11, at 2:30 a. m., Resident (#8), reported having had a physical altercation with Resident #1. A scratch was observed on Resident #8's right hand. The incident was not witnessed by staff. As of 7/1/11 at 3:00 p.m. (30 days after the incident), with 2 residents remaining on the secured unit who were identified by the facility as having physically aggressive behaviors, the facility failed to implement a monitoring system to ensure adequate and appropriate staff supervision of residents on the secured unit. The facility's failure to ensure necessary care and services to prevent physical harm to residents, placed the 27 residents who resided on the secured unit, at risk for neglect, physical harm, and mental anguish. The evidence is as follows: Review of the facility document titled Abuse Prohibition Protocol, dated September, 2009, documented: - It is the policy of Texan Nursing and Rehab of Amarillo, a Texan Healthcare, L.L.C. facility to prohibit mistreatment, neglect, and/or abuse of residents and misappropriation of residents' property. - Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Observation of the secured unit on 6/29/11 at 12:15 a.m., revealed the unit to be quiet, with three residents awake and sitting in the dining area near the nurse's station. It was revealed Residents' #1 and #2 room had been located approximately halfway down the hall from the nurse's station. While standing at the nurse's station, this surveyor was able to hear soft sounds coming from the last room at the farthest end of the hall. Sounds of a female resident during her sleep. The unit was very quiet, and a cough or sneeze could easily be heard. Three staff were observed on the unit. Review of Resident #1's closed medical record documented the following: - The Face Sheet documented he was admitted to the facility on [DATE], from a psychiatric hospital. His date of birth was 2/2/30. [DIAGNOSES REDACTED]. - The Minimum Data Set (MDS) admission assessment dated 5/24/11, documented admission from a psychiatric hospital, with moderately impaired cognitive skills for daily decision-making and fluctuating periods of inattention and disorganized thinking. The resident was delusional, and physical and verbal aggression had been present 1-3 times during the 7 day look-back period for the assessment. Additionally, Resident #1 wandered and rejected personal care during 4-6 days of the look-back period. Wandering behaviors were documented as placing the resident at significant risk of getting into a potentially dangerous situation, and significantly intruding on the privacy and activities of others. Resident #1 was independently ambulatory, and required limited assistance with most activities of daily living. - A psychiatric evaluation dated 4/26/11, documented he was admitted to the psychiatric hospital with physical aggression and wandering behavior. His daughter was concerned because he started being more aggressive a month earlier while living in her home. Psychiatric problems included [MEDICAL CONDITION], depressed mood, aggression, impulse control/intrusiveness, and agitation. Thought content included visual hallucinations and persecutory [MEDICAL CONDITION]. - The care plan dated 6/1/11 documented he was physically abusive towards others. Approaches to dealing with the behavior included trying to determine the cause of the physical abuse, and resolve the issue. There was no documentation regarding the level/amount of supervision required. - A daily skilled nurse's note dated 5/25/11 (no time), documented Resident #1 required very frequent redirection, due to spending a lot of his time exit-seeking and taking other residents' belongings. On the same date at 10:00 p.m., he was documented as having attempted to hit and kick another resident. - Nurse progress notes dated 5/28/11 at 10:30 a.m., documented he required constant redirection. The notes continued (no time), he was threatening to hit others and drew a fist at a nurse. He also turned over chairs and a table. At 2:30 a.m., he was redirected out of a female resident's room who reported she had "gotten in to it" with him. It was further documented no staff had seen any physical contact take place between the two residents. At 5:00 a.m., it was noted he had been up all night, going in to other residents' rooms. - A nurse's note dated 6/1/11 at 12:29 a.m., documented LVN "A" after being called to Residents' #1 and #2 room, observed both of Resident #2's eyes were totally swollen with bluish discoloration. There was bleeding to his mouth. A book had fallen from his bed to the floor. Review of Incident/Accident reports revealed the following: - An Incident/Accident report dated 5/25/11 at 10:00 p.m., documented Resident #1 was observed attempting to climb into bed with his roommate, moving his fists towards his roommate. The approaches documented on 5/26/11, as having been taken to prevent a reoccurrence, were for staff to monitor for safety. - An Incident/Accident report dated 5/28/11 at 2:30 a.m., documented a female resident (unsampled Resident #8), was observed to have a small scratch on her right hand of unknown origin, immediately following an incident where Resident #1 entered Resident #8's room. Resident #8 was documented as having said to staff "Me and that Mexican guy got in to it." Steps taken to prevent a reoccurrence were to monitor Resident #1. - An Incident/Accident report dated 6/1/11 at 12:29 a.m., documented staff entered Resident #1's room and observed his roommate (Resident #2) to have facial swelling around both eyes and bleeding from his mouth. Window blinds were observed on the bed and floor, as well as a book and a small rock (pebble), on the floor. Resident #1's right hand had a skin tear. Both residents were transported to a local hospital for evaluation. Witness statements attached to the 6/1/11 Incident/Accident report documented the following: - A witness statement by charge nurse, LVN "A", dated 6/1/11, documented Resident #1 had last been seen 45 minutes prior to Resident #2 being found beaten. - A witness statement by CNA "B", dated 6/1/11, documented during midnight rounds, Resident #1 had been found asleep in another resident's room. He was escorted back to his room, at which time his roommate, Resident #2, was observed with both eyes swollen shut. Resident #2 yelled "Help. Emergency." Resident #1 was then observed to have blood on his bed, with a swollen right hand that had teeth marks on it. - A witness statement by CNA "C", dated 6/1/11, documented during rounds, CNA "B" called for her assistance. She entered the room and observed Residents #1 and #2 "critically" harmed. The statement documented the incident was unwitnessed and no cries for help or noises had been heard from either resident prior to the incident. Review of the Provider Investigation Report dated 6/2/11, documented the following: - Resident #1 was housed on the secured unit, required minimal assistance, was independently ambulatory, combative and physically aggressive. - Resident #2 was housed on the secured unit, required total assistance, and had no history of aggressive behaviors. - There were no witnesses to the incident. on 6/1/11 at 12:29 a.m., CNA "B" discovered Resident #2 had been assaulted, as his face and both eyes were swollen shut. LVN "A" was immediately notified and assessed Resident #2 to have facial swelling and discoloration, as well as slight bleeding from his mouth. LVN "A" noted Resident #1 had a small amount of blood on his right hand as well as swelling, and it was tender to the touch. Both residents were transported to a local hospital for evaluation. Resident #1 sustained injuries to his hand with no fractures. Resident #2 sustained facial trauma with soft tissue swelling and bruising to his chest and forearms. The police department was notified (Incident #11- 0). Resident #1 returned to the facility the same day at 7:30 a.m. He was monitored one-on-one until his discharge to a psychiatric facility at 3:30 p.m. Resident #2 was transferred off the secured unit to another hallway at the facility, "for closer observation." The investigation summary concluded Resident #1 assaulted Resident #2, most likely between the hours of 10:30 p.m. and 11:30 p.m. on the evening prior to the incident having been discovered on 6/1/11 (12:29 a.m.). Note: This was approximately 1 to 2 hours during which Resident #1's who was known to be active and aggressive, with a history of aggression towards his roommate, whereabouts were unknown by the 3 staff who worked on the secured unit during night of 5/31/11-6/1/11, from 6:00 p.m. to 6:00 a.m. Furthermore, as a result of the incident, it was the facility's determination that Resident #2 could be more closely observed on a standard hallway, rather than on the secured unit. During an interview on 7/1/11 at 10:05 a.m., CNA "D" said she had formerly worked on the secured unit for approximately 2 years, adding she took one-on-one care of Resident #1 following the 6/1/11 incident, until he was discharged out of the facility. CNA "D" said Resident #1 was a very difficult resident who acted "horribly". Regarding staff supervision of residents on the secured unit, she said residents needed to be observed by staff at least every 15 minutes, but Resident #1 required constant supervision. CNA "D" Said "If he (Resident #1), moved, I moved. You couldn't leave him alone for 2 seconds." She said staff's failure to check on Resident #1 every 15 minutes would not have been good, that a 30 minute period of time would really not have been good, and 45 minutes would have been unacceptable by standards on the secured unit. CNA "D" said all residents housed on the secured unit needed constant supervision, particularly residents who exhibited aggressive behaviors. During an interview, Confidential Informant (CI), "E" said the 5/25/11 incident between Residents #1 and #2 had not been passed on during the shift change report, or staff "probably would have watched Resident #1 more closely in order to avoid the 5/28/11 and 6/1/11 incidents." The CI then reviewed the shift change logs and verified nothing had been documented to address the 5/25/11 incident. Regarding Resident #1, the CI said "If they ( LVN "A" and CNAs "B" and "C"), hadn't laid eyes on him for 45 minutes, somebody should have been hunting him down, especially a resident who wanders all night long like that. They should have known where he was and what he was doing at all times." The CI said "I can't believe something like that could happen with three staff on the unit and nobody heard a thing. The blinds were torn down and a book had fallen on the floor. Resident #2 hollered out anytime he needed anything and the unit is so quiet during the night." The CI said staff on the secured unit needed to know where all secured residents where and what they were doing at all times. The CI continued, stating staff from the 6:00 a.m. to 6:00 p.m. shift had on several occasions reported evidence that night staff (6:00 p.m. to 6:00 a.m.), had slept during the night; that empty beds not occupied by residents would have pillows and blankets on them, as if they had been slept on by staff. During a telephone interview on 7/1/11 at 11:15 a.m., the DON said she was unsure where the three staff (LVN "A" and CNAs "B" and "C"), had been during the time the 6/1/11 incident had occurred. She said Resident #1 had been misrepresented to the facility at the time of his admission and the facility's focus was to discharge Resident #1, rather than to ensure staff had been properly supervising the residents. During an interview on 7/1/11 at 11:30 a.m., CNA "F" said she had worked day shifts on the secured unit for three years, adding staff were always too busy to have been outside, unless taking a break, which then would have been coordinated for one staff at a time to leave the unit, rather than all three at the same time. During a telephone interview on 7/1/11 at 12:00 p.m., LVN "A" said she wore hearing aides on both ears, adding she did not hear any commotion coming from Residents #1 and #2's room during the 6/1/11 incident. She said she last observed Resident #1 at approximately 10:05 p.m. (Resident #2 was observed beaten at 12:29 a.m., approximately 2.5 hours later). She said when she entered the room at 12:29 a.m., the room was disheveled, with window blinds on the Resident #2's bed and on the floor. She said it looked as if a book had fallen off his bed onto the floor as well. She said she did not remember when CNA "B" took a smoking break after 7:00 p.m., and she did not remember when CNA "C" went off the unit for her breaks. LVN "A" said it was typical for Resident #1 to wander throughout the night, adding he would frequently attempt to leave the secured unit. LVN "A" then recalled one incident when Resident #1 had exited out the dining room window in a matter of about 25 seconds. She said that incident occurred during the night shift between 2:00 a.m. and 3:00 a.m., although she could not recall the exact date. Regarding Resident #1 she said "He was definitely one of those who had to be watched at all times because he was very active during the night and was in other residents' rooms all the time." She said there were still residents on the unit who were active throughout the night, and residents who exhibited aggressive behaviors. She said it was required that staff were aware of residents' whereabouts and activities at all times on the secured unit. LVN "A" said staff had not been re-in-serviced regarding supervision of residents following 6/1/11 incident, or as a result of the facility's investigation of the incident. During an interview on 7/1/11 at 2:15 p.m., the Administrator said no in-services had been conducted as a result of the incident. She acknowledged the facility had focused on getting Resident #1 removed from the facility, rather than on whether or not staff had sufficiently supervised during the night, so as to have heard the commotion of the assault. Attempts to interview CNAs "B" and "C" were unsuccessful. Review of the facility provided document titled Room Roster, dated 6/30/11, documented 27 residents were housed on the secured unit. Of these, 2 residents were documented as exhibiting physicaly aggressive behaviors.

Based on observation, interview and record review, it was determined that for 1 of 7 sampled residents (discharged Resident #1), who exhibited physically aggressive behaviors, the facility failed to implement their neglect prevention policy for prohibiting incidents of physical harm when they failed to provide adequate supervision to prevent Resident #1 from physical aggression towards other residents. On 6/1/11, at approximately 12:20 a.m., Resident #1, with a known history of physical aggression, was observed to be out of his room and had swelling and a laceration to his right hand. He was returned to his room, which was observed to be disheveled. His roommate, Resident #2, who had no history of behaviors or aggression, was found lying in his bed, with bruising, both eyes swollen shut and bleeding from his mouth. Vertical blinds had been torn off the window by his bed, and a book had fallen off his bed onto the floor. Three staff were on the secured unit at the time of the incident (LVN "A", and CNAs "B", "C"), all of whom heard nothing and were unaware the incident had occurred. Resident #1 was discharged from the facility. Resident #2 was relocated off the secured unit for closer observation. Four days earlier, on 5/28/11, at 2:30 a. m., Resident (#8), reported having had a physical altercation with Resident #1. A scratch was observed on Resident #8's right hand. The incident was not witnessed by staff. As of 7/1/11 at 3:00 p.m. (30 days after the incident), with 2 residents remaining on the secured unit who were identified by the facility as having physically aggressive behaviors, the facility failed to implement a monitoring system to ensure adequate and appropriate staff supervision of residents on the secured unit. The facility's failure to ensure necessary care and services to prevent physical harm to residents, placed the 27 residents who resided on the secured unit, at risk for neglect, physical harm, and mental anguish. The evidence is as follows: Observation of the secured unit on 6/29/11 at 12:15 a.m., revealed the unit to be quiet, with three residents awake and sitting in the dining area near the nurse's station. It was revealed Residents' #1 and #2 room had been located approximately halfway down the hall from the nurse's station. While standing at the nurse's station, this surveyor was able to hear soft sounds coming from the last room at the farthest end of the hall. Sounds of a female resident during her sleep. The unit was very quiet, and a cough or sneeze could easily be heard. Three staff were observed on the unit. Review of Resident #1's closed medical record documented the following: - The Face Sheet documented he was admitted to the facility on [DATE], from a psychiatric hospital. His date of birth was 2/2/30. [DIAGNOSES REDACTED]. - The Minimum Data Set (MDS) admission assessment, dated 5/24/11, documented admission from a psychiatric hospital, with moderately impaired cognitive skills for daily decision-making and fluctuating periods of inattention and disorganized thinking. The resident was delusional, and physical and verbal aggression had been present 1-3 times during the 7 day look-back period for the assessment. Additionally, Resident #1 wandered and rejected personal care during 4-6 days of the look-back period. Wandering behaviors were documented as placing the resident at significant risk of getting into a potentially dangerous situation, and significantly intruding on the privacy and activities of others. Resident #1 was independently ambulatory, and required limited assistance with most activities of daily living. - A psychiatric evaluation dated 4/26/11, documented he was admitted to the psychiatric hospital with physical aggression and wandering behavior. His daughter was concerned because he started being more aggressive a month earlier while living in her home. Psychiatric problems included [MEDICAL CONDITION], depressed mood, aggression, impulse control/intrusiveness, and agitation. Thought content included visual hallucinations and persecutory [MEDICAL CONDITION]. - The care plan dated 6/1/11, documented he was physically abusive towards others. Approaches to dealing with the behavior included trying to determine the cause of the physical abuse, and resolve the issue. There was no documentation regarding the level/amount of supervision required. - A daily skilled nurse's note dated 5/25/11 (no time), documented Resident #1 required very frequent redirection, due to spending a lot of his time exit-seeking and taking other residents' belongings. On the same date at 10:00 p.m., he was documented as having attempted to hit and kick another resident. - Nurse progress notes dated 5/28/11 at 10:30 a.m., documented he required constant redirection. The notes continued (no time), he was threatening to hit others and drew a fist at a nurse. He also turned over chairs and a table. At 2:30 a.m., he was redirected out of a female resident's room who reported she had "gotten in to it" with him. It was further documented no staff had seen any physical contact take place between the two residents. At 5:00 a.m., it was noted he had been up all night, going in to other residents' rooms. - A nurse's note dated 6/1/11 at 12:29 a.m., documented LVN "A" after being called to Residents' #1 and #2 room, observed both of Resident #2's eyes were totally swollen with bluish discoloration. There was bleeding to his mouth. A book had fallen from his bed to the floor. Review of Incident/Accident reports revealed the following: - An Incident/Accident report dated 5/25/11 at 10:00 p.m., documented Resident #1 was observed attempting to climb into bed with his roommate, moving his fists towards his roommate. The approaches documented on 5/26/11, as having been taken to prevent a reoccurrence, were for staff to monitor for safety. - An Incident/Accident report dated 5/28/11 at 2:30 a.m., documented a female resident (unsampled Resident #8), was observed to have a small scratch on her right hand of unknown origin, immediately following an incident where Resident #1 entered Resident #8's room. Resident #8 was documented as having said to staff "Me and that Mexican guy got in to it." Steps taken to prevent a reoccurrence were to monitor Resident #1. - An Incident/Accident report dated 6/1/11 at 12:29 a.m., documented staff entered Resident #1's room and observed his roommate (Resident #2) to have facial swelling around both eyes and bleeding from his mouth. Window blinds were observed on the bed and floor, as well as a book and a small rock (pebble), on the floor. Resident #1's right hand had a skin tear. Both residents were transported to a local hospital for evaluation. Witness statements attached to the 6/1/11 Incident/Accident report documented the following: - A witness statement by charge nurse, LVN "A", dated 6/1/11, documented Resident #1 had last been seen 45 minutes prior to Resident #2 being found beaten. - A witness statement by CNA "B", dated 6/1/11, documented during midnight rounds, Resident #1 had been found asleep in another resident's room. He was escorted back to his room, at which time his roommate, Resident #2, was observed with both eyes swollen shut. Resident #2 yelled "Help. Emergency." Resident #1 was then observed to have blood on his bed, with a swollen right hand that had teeth marks on it. - A witness statement by CNA "C", dated 6/1/11, documented during rounds, CNA "B" called for her assistance. She entered the room and observed Residents #1 and #2 "critically" harmed. The statement documented the incident was unwitnessed and no cries for help or noises had been heard from either resident prior to the incident. Review of the Provider Investigation Report dated 6/2/11, documented the following: - Resident #1 was housed on the secured unit, required minimal assistance, was independently ambulatory, combative and physically aggressive. - Resident #2 was housed on the secured unit, required total assistance, and had no history of aggressive behaviors. - There were no witnesses to the incident. on 6/1/11 at 12:29 a.m., CNA "B" discovered Resident #2 had been assaulted, as his face and both eyes were swollen shut. LVN "A" was immediately notified and assessed Resident #2 to have facial swelling and discoloration, as well as slight bleeding from his mouth. LVN "A" noted Resident #1 had a small amount of blood on his right hand as well as swelling, and it was tender to the touch. Both residents were transported to a local hospital for evaluation. Resident #1 sustained injuries to his hand with no fractures. Resident #2 sustained facial trauma with soft tissue swelling and bruising to his chest and forearms. The police department was notified (Incident #11- 0). Resident #1 returned to the facility the same day at 7:30 a.m. He was monitored one-on-one until his discharge to a psychiatric facility at 3:30 p.m. Resident #2 was transferred off the secured unit to another hallway at the facility, "for closer observation." - The investigation summary concluded Resident #1 assaulted Resident #2, most likely between the hours of 10:30 p.m. and 11:30 p.m. on the evening prior to the incident having been discovered on 6/1/11 (12:29 a.m.). Note: This was approximately 1 to 2 hours during which Resident #1's who was known to be active and aggressive, with a history of aggression towards his roommate, whereabouts were unknown by the 3 staff who worked on the secured unit during night of 5/31/11-6/1/11, from 6:00 p.m. to 6:00 a.m. Furthermore, as a result of the incident, it was the facility's determination that Resident #2 could be more closely observed on a standard hallway, rather than on the secured unit. During an interview on 7/1/11 at 10:05 a.m., CNA "D" said she had formerly worked on the secured unit for approximately 2 years, adding she took one-on-one care of Resident #1 following the 6/1/11 incident, until he was discharged out of the facility. CNA "D" said Resident #1 was a very difficult resident who acted "horribly". Regarding staff supervision of residents on the secured unit, she said residents needed to be observed by staff at least every 15 minutes, but Resident #1 required constant supervision. CNA "D" Said "If he (Resident #1), moved, I moved. You couldn't leave him alone for 2 seconds." She said staff's failure to check on Resident #1 every 15 minutes would not have been good, that a 30 minute period of time would really not have been good, and 45 minutes would have been unacceptable by standards on the secured unit. CNA "D" said all residents housed on the secured unit needed constant supervision, particularly residents who exhibited aggressive behaviors. During an interview, Confidential Informant (CI), "E" said the 5/25/11 incident between Residents #1 and #2 had not been passed on during the shift change report, or staff "probably would have watched Resident #1 more closely in order to avoid the 5/28/11 and 6/1/11 incidents." The CI then reviewed the shift change logs and verified nothing had been documented to address the 5/25/11 incident. Regarding Resident #1, the CI said "If they ( LVN "A" and CNAs "B" and "C"), hadn't laid eyes on him for 45 minutes, somebody should have been hunting him down, especially a resident who wanders all night long like that. They should have known where he was and what he was doing at all times." The CI said "I can't believe something like that could happen with three staff on the unit and nobody heard a thing. The blinds were torn down and a book had fallen on the floor. Resident #2 hollered out anytime he needed anything and the unit is so quiet during the night." The CI said staff on the secured unit needed to know where all secured residents where and what they were doing at all times. The CI continued, stating staff from the 6:00 a.m. to 6:00 p.m. shift had on several occasions reported evidence that night staff (6:00 p.m. to 6:00 a.m.), had slept during the night; that empty beds not occupied by residents would have pillows and blankets on them, as if they had been slept on by staff. During a telephone interview on 7/1/11 at 11:15 a.m., the DON said she was unsure where the three staff (LVN "A" and CNAs "B" and "C"), had been during the time the 6/1/11 incident had occurred. She said Resident #1 had been misrepresented to the facility at the time of his admission and the facility's focus was to discharge Resident #1, rather than to ensure staff had been properly supervising the residents. During an interview on 7/1/11 at 11:30 a.m., CNA "F" said she had worked day shifts on the secured unit for three years, adding staff were always too busy to have been outside, unless taking a break, which then would have been coordinated for one staff at a time to leave the unit, rather than all three at the same time. During a telephone interview on 7/1/11 at 12:00 p.m., LVN "A" said she wore hearing aides on both ears, adding she did not hear any commotion coming from Residents #1 and #2's room during the 6/1/11 incident. She said she last observed Resident #1 at approximately 10:05 p.m. (Resident #2 was observed beaten at 12:29 a.m., approximately 2.5 hours later). She said when she entered the room at 12:29 a.m., the room was disheveled, with window blinds on the Resident #2's bed and on the floor. She said it looked as if a book had fallen off his bed onto the floor as well. She said she did not remember when CNA "B" took a smoking break after 7:00 p.m., and she did not remember when CNA "C" went off the unit for her breaks. LVN "A" said it was typical for Resident #1 to wander throughout the night, adding he would frequently attempt to leave the secured unit. LVN "A" then recalled one incident when Resident #1 had exited out the dining room window in a matter of about 25 seconds. She said that incident occurred during the night shift between 2:00 a.m. and 3:00 a.m., although she could not recall the exact date. Regarding Resident #1 she said "He was definitely one of those who had to be watched at all times because he was very active during the night and was in other residents' rooms all the time." She said there were still residents on the unit who were active throughout the night, and residents who exhibited aggressive behaviors. She said it was required that staff were aware of residents' whereabouts and activities at all times on the secured unit. LVN "A" said staff had not been re-in-serviced regarding supervision of residents following 6/1/11 incident, or as a result of the facility's investigation of the incident. During an interview on 7/1/11 at 2:15 p.m., the Administrator said no in-services had been conducted as a result of the incident. She acknowledged the facility had focused on getting Resident #1 removed from the facility, rather than on whether or not staff had sufficiently supervised during the night, so as to have heard the commotion of the assault. Attempts to interview CNAs "B" and "C" were unsuccessful. Review of the facility document titled Abuse Prohibition Protocol, dated September, 2009, documented: - It is the policy of Texan Nursing and Rehab of Amarillo, a Texan Healthcare, L.L.C. facility to prohibit mistreatment, neglect, and/or abuse of residents and misappropriation of residents' property. - Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Review of the facility provided document titled Room Roster, dated 6/30/11, documented 27 residents were housed on the secured unit. Of these, 2 residents were documented as exhibiting physicaly aggressive behaviors.