Every finding on record at Legend Oaks Healthcare and Rehabilitation-Kyle

Based on observation, interview, and record review, the facility failed to ensure that the medical records were in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete, accurately documented, readily accessible; and systematically organized for 3 of 5 residents (Resident#1,Resident #2 and Resident#3) reviewed for respiratory care. The facility failed to ensure LPN A not documenting the of changing of water bottle and oxygen cannula connected to the oxygen concentrator of Resident#1, Resident #2 and Resident #3 as completed on 05/24/26, on MARs, when it was not completed on that day, as ordered by the physician.This failure placed residents at risk for respiratory infections through contamination.Findings included:Record review of Resident #1's face sheet dated 05/26/26 reflected Resident #1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. She was an [AGE] year-old female diagnosed withmultiple fractures of ribs, acute and chronic respiratory failure with hypoxia(low oxygen level), chronic obstructive pulmonary disease( breathing difficulty), type 2 diabetes, muscle weakness and unsteadiness on feet.Record review of Resident #1's initial MDS dated [DATE] reflected a BIMS score of 12 indicating her cognition was moderately impaired. Further review revealed she was on oxygen therapy for respiratory issues.Record review of Resident #1's care plan dated 03/09/25 reflected that she had Chronic ObstructivePulmonary Disease and was on oxygen therapy. The relevant intervention was administering oxygen as per physician's order.Record review of Resident #1's physician's order reflected : Change O2 tubing &humidifier bottle every night shift every Sunday. -Order Date-03/07/2026.During an observation on 05/26/26 at 10:45 am it was revealed that Resident#1 was resided in Hall100 and on continuous oxygen therapy. Observation of the humidifier bottle revealed the changed date written on it was 05/18/26 Record review of the MAR of Resident #1 revealed LPN A documented that the Oxygen tubing &humidifier bottle were changed on 05/24/26. Record review of Resident #2's face sheet dated 05/26/26 reflected Resident #2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. She was an [AGE] year-old female diagnosed withpneumonia, heart failure, chronic kidney disease, personal history of other diseases of the respiratory system, dementia, muscle weakness, hypertension and need for assistance with personal care. Record review of Resident #2's quarterly MDS dated [DATE] reflected a BIMS score of 07 indicating her cognition was severely impaired. Further review revealed she was on oxygen therapy for respiratory issues.Record review of Resident #2's care plan dated 03/09/25 reflected that she had oxygen therapy r/t ineffective gas exchange due to hypoxia. The relevant intervention was administering oxygen as per physician's order.Record review of Resident #2's physician's order reflected : Change O2 tubing &humidifier bottle every night shift every Sunday. -Order Date-05/07/2025.During an observation on 05/26/26 at 11:00 am it was revealed that Resident#2 was resided in Hall100 and on continuous oxygen therapy. Observation of the humidifying bottle revealed the changed date written on it was 05/18/26Record review of the MAR of Resident #2 revealed LPN A documented that the Oxygen tubing &humidifier bottle were changed on 05/24/26.Record review of Resident #3's face sheet, dated 05/26/26 , reflected Resident #3 was initially admitted to the facility on [DATE] and readmitted on [DATE]. She was an [AGE] year-old female diagnosed withacute respiratory failure with hypoxia, pneumonia, muscle weakness, unsteadiness on feet and other lack of coordination.Record review of Resident #3's quarterly MDS dated [DATE] reflected a BIMS score of 15 indicating her cognition was intact. Further review revealed it did not reflect her diagnoses of acute respiratory failure.Record review of Resident #3's care plan dated 05/18/26 reflected that she was on oxygen therapy r/t respiratory illness and relevant intervention was providing oxygen as ordered by the physician.Record review of Resident #3's physician's order reflected : Change O2 tubing &humidifier bottle every night shift every Sunday. -Order Date-05/16/2025.During an observation on 05/26/26 at 11:15 am it was revealed that Resident#3 was resided in Hall100 and on continuous oxygen therapy. Observation of the humidifying bottle revealed the changed date written on it was 05/17/26Record review of the MAR of Resident #3 revealed LPN A documented that the Oxygen tubing &humidifier bottle were changed on 05/24/26.During a telephone interview on 05/26/26 at 1:35pm, LPN A stated that he served as the night shift nurse for Hall 100 on 04/18/26. He indicated that it was his responsibility as the Sunday night shift nurse to change the humidifier bottles and oxygen tubes for residents in that hall. He identified Residents #1, Resident#2, and Resident#3 as being on continuous oxygen therapy provided by an oxygen concentrator. LPN A said that he had planned to change these items but, due to being occupied with other nursing tasks, he forgot to do so. He stated that he was aware that nurses are supposed to sign the MAR only after completing the task. He said that he marked the task as completed in advance in MAR, before actually performing it, and stated that this practice was not compliant with professional standards. He said he would not repeat this mistake in the future.During an interview on 05/26/26 at 1:45pm, LVN B stated that she was the charge nurse on Hall 100 on that day. She reported that approximately 30 minutes prior, the ADON had asked her to check whether the humidifiers of Residents #1,Resident #2, and Resident#3 had been changed on 05/24/26, and to change them if they had not. She confirmed that she had replaced the humidifier bottles and oxygen tubes for all three residents, as they had not been changed on the specified date. LVN B explained that the physician's order specifically required these components to be changed every Sunday during the night shift. She stated that she had not noticed that the task had been marked as completed on 05/24/26 , on the MAR. LVN B explained that part of her responsibilities included the administration of medication and treatments, and she would only document in the MAR after administering each medication or treatment, not beforehand.In an interview conducted on 05/26/26 at 3:00 pm, the DON stated that humidifier bottles, tubing, and oxygen nasal cannulas should be removed and replaced with new ones as ordered by the physician. She explained that this practice was intended to minimize the risk of respiratory infections caused by contaminated equipment. The DON further clarified that it was the responsibility of the nurse on the Sunday night shift to ensure that this task was completed routinely. She stated that nurses are supposed to document a task in the medical record only after it has been completed. She said that false documentation could negatively impact the residents' plan of care and that in turn negatively impact the quality of care.Record review of the facility policy Documentation and Charting revised in July 2022 indicated POLICY:It is the policy of this facility to provide.1. A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care.

Based on observation, interview, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 3 of 5 residents (Resident#1, Resident #2 and Resident#3) reviewed for respiratory care.The facility failed to ensure the humidifier water bottle and oxygen cannula connected to the oxygen concentrator of Resident#1, Resident #2 and Resident #3 were changed every Sunday as ordered by the physician.This failure could place residents at risk for respiratory infections through contamination.Findings included:Resident #1Record review of Resident #1's face sheet dated 05/26/26 reflected Resident #1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. She was an [AGE] year-old female diagnosed with multiple fractures of ribs, acute and chronic respiratory failure with hypoxia(low oxygen level), and chronic obstructive pulmonary disease( breathing difficulty.Record review of Resident #1's initial MDS dated [DATE] reflected a BIMS score of 12 indicating her cognition was moderately impaired. Further review revealed she was on oxygen therapy for respiratory issues.Record review of Resident #1's care plan dated 03/09/25 reflected that she had Chronic Obstructive Pulmonary Disease and was on oxygen therapy. The relevant intervention was administering oxygen as per physician's order.Record review of Resident #1's physician's order reflected : Change O2 tubing &humidifier bottle every night shift every Sunday. -Order Date-03/07/2026.During an observation on 05/26/26 at 10:45 am it was revealed that Resident#1 was resided in Hall 100 and on continuous oxygen therapy. Observation of the humidifier bottle revealed the date written on it was 05/18/26.Record review of the MAR of Resident #1 revealed LPN A documented that the Oxygen tubing &humidifier bottle were changed on 05/24/26. Resident #2Record review of Resident #2's face sheet dated 05/26/26 reflected Resident #2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. She was an [AGE] year-old female diagnosed with pneumonia and personal history of other diseases of the respiratory system,.Record review of Resident #2's quarterly MDS dated [DATE] reflected a BIMS score of 07 indicating her cognition was severely impaired. Further review revealed she was on oxygen therapy for respiratory issues.Record review of Resident #2's care plan dated 03/09/25 reflected that she had oxygen therapy r/t ineffective gas exchange due to hypoxia. The relevant intervention was administering oxygen as per physician's order.Record review of Resident #2's physician's order reflected : Change O2 tubing &humidifier bottle every night shift every Sunday. -Order Date-05/07/2025.During an observation on 05/26/26 at 11:00 am it was revealed that Resident#2 was resided in Hall 100 and on continuous oxygen therapy. Observation of the humidifying bottle revealed the date written on it was 05/18/26.Record review of the MAR of Resident #2 revealed LPN A documented that the Oxygen tubing &humidifier bottle were changed on 05/24/26. Resident #3Record review of Resident #3's face sheet, dated 05/26/26 , reflected Resident #3 was initially admitted to the facility on [DATE] and readmitted on [DATE]. She was an [AGE] year-old female diagnosed with acute respiratory failure with hypoxia and pneumonia.Record review of Resident #3's quarterly MDS dated [DATE] reflected a BIMS score of 15 indicating her cognition was intact. Further review revealed it did not reflect her diagnoses of acute respiratory failure. There was no respiratory therapy reflected on the MDS.Record review of Resident #3's care plan dated 05/18/26 reflected that she was on oxygen therapy r/t respiratory illness and relevant intervention was providing oxygen as ordered by the physician.Record review of Resident #3's physician's order reflected : Change O2 tubing &humidifier bottle every night shift every Sunday. -Order Date-05/16/2025.During an observation on 05/26/26 at 11:15 am it was revealed that Resident #3 resided in Hall 100 and was on continuous oxygen therapy. Observation of the humidifier bottle revealed the date written on it was 05/17/26.Record review of the MAR of Resident #3 revealed LPN A documented that the Oxygen tubing &humidifier bottle were changed on 05/24/26.During a telephone interview on 05/26/26 at 1:35 pm, LPN A stated that he served as the night shift nurse for Hall 100 on 05/18/26. He indicated that it was his responsibility as the Sunday night shift nurse to change the humidifier bottles and oxygen tubes for residents in that hall. He identified Residents #1, Resident#2, and Resident#3 as being on continuous oxygen therapy provided by an oxygen concentrator. LPN A said that he had planned to change these items but, due to being occupied with other nursing tasks, he forgot to do so. He said that regular changing of these components was necessary to minimize the risk of respiratory infections and stated that failing to do so compromised infection control protocols. He said that it was the duty of every nurse to adhere to physician's orders by administering medications, therapies, and treatments as prescribed. He stated that he was aware that nurses are supposed to sign the MAR only after completing the task. He said that he marked the task as completed in advance in MAR, before actually performing it, and stated that this practice was not compliant with professional standards. He said he would not repeat this mistake in the future.During an interview on 05/26/26 at 1:45pm, LVN B stated that she was the charge nurse on Hall 100 on 05/24/26. She reported that approximately 30 minutes prior, the ADON had asked her to check whether the humidifiers of Residents #1,Resident #2, and Resident#3 had been changed on 05/24/26, and to change them if they had not. She stated that she had replaced the humidifier bottles and oxygen tubes for all three residents, as they had not been changed on the specified date. LVN B explained that the physician's order specifically required these components to be changed every Sunday during the night shift. She noted that although she routinely checked the equipment daily, she did not notice in the last two days that the changes had not been completed. She stated that routine replacement was important to reduce the risk of infection. She stated that she had not noticed that the task had been marked as completed on 05/24/26 , on the MAR. LVN B explained that part of her responsibilities included the administration of medication and treatments, and she would only document in the MAR after administering each medication or treatment, not beforehand.In an interview conducted on 05/26/26 at 3:00 pm, the DON stated that humidifier bottles, tubing, and oxygen nasal cannulas should be removed and replaced with new ones as ordered by the physician. She explained that this practice was intended to minimize the risk of respiratory infections caused by contaminated equipment. The DON further clarified that it was the responsibility of the nurse on the Sunday night shift to ensure that this task was completed routinely. She also stated that all nurses on other shifts had a duty to verify that the Sunday night nurse had completed this task and to make replacements as soon as they were noticed if not. She stated that nurses are supposed to document a task in the medical record only after it has been completed. She said that false documentation could negatively impact the residents' plan of care and that in turn negatively impact the quality of care.Record review of the in-service since Marh 2026 revealed there were no in services on safe handling of respiratory equipment.Review of the facility policy Oxygen Administration(Mask, Cannula, Catheter)revised in May,2007 reflected : It is the policy of this facility that oxygen therapy is administered, as ordered by the physician or as an emergency measure until the order can be obtained.2. Oxygen tubbing is to be replaced every seven (7) days. Oxygen masks or nasal prongs are to be replaced every seven (7) days.3. Replace disposable humidifiers every seven (7) days or as needed when empty.

Based on observation, interviews, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 3 of 4 residents (Resident #1, Resident #2, and Resident #3) reviewed for homelike environment. The facility failed to ensure Resident #1's, Resident #2's and Resident #3's privacy curtains were free of stains. This failure could place residents at risk of living in an unclean or unsanitary environment, decreased quality of life, or shame. Findings included: Review of Resident #1's face sheet dated 01/29/2026 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of other cerebral infarction due to occlusion or stenosis of small artery (type of stroke caused by blockage or narrowing in deep-brain arteries), and hemiplegia and hemiparesis following cerebral infarction (motor impairments affecting one side of body following a stroke). Review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of 12 which indicated moderate cognitive impairment. Observation on 01/29/2026 at 9:40 AM, revealed HSK on a ladder in Resident #1's room. Observation revealed privacy curtain in the middle of Resident #1's room was removed and replaced with a different curtain. During an interview on 01/29/2026 at 9:40 AM, Resident #1 stated that they were just now putting a new curtain up and that it had been dirty for at least three weeks. During a subsequent interview on 01/29/2026 at 11:05 AM, Resident #1 stated that his curtain was dirty for about 2 1/2 weeks. Resident #1 sated that CNA C changed his roommate and splattered bowel movement on the privacy curtain. Resident #1 stated CNA C tried to wipe it, but it stayed there. Resident #1 stated no one made an effort to clean it after that. Resident #1 stated that something similar happened once before. Resident #1 stated that FM B reported it to someone, but it was not changed until this morning (01/29/2026). Resident #1 stated that when his family visited they did not want to sit near the curtain. Resident #1 stated he does not want his room to be dirty. Review of Resident #2's face sheet revealed dated 01/29/2026 an [AGE] year-old female admitted on [DATE] with diagnoses of paroxysmal atrial fibrillation (type of irregular heart beat where heart rhythms start and stop on their own), muscle weakness and cognitive communication deficit (communication impairment caused by disruption in cognitive process like memory, attention and problem-solving). Review of Resident #2's annual MDS reflected a BIMS score of 14 no cognitive impairment. During an observation and interview on 01/29/2026 at 9:16 AM, it was revealed that Resident #2's privacy curtain between her and her roommate had several brown splattered dots. Resident #2 stated she did not know what was on her curtain and she wished it could be washed. Resident #2 stated that since she had been in her room she was not sure that the curtain was ever washed. Review of Resident #3's face sheet dated 01/29/2026 revealed a [AGE] year-old male admitted on [DATE] with diagnoses of post polio syndrome (neurological condition affecting polio survivors causing muscle weakness, fatigue, pain years after initial infection), major depressive disorder (mood disorder characterized by persistent sadness), and need for assistance with personal care. Review of Resident #3's quarterly MDS dated [DATE] reflected a BIMS of 15 which indicated no cognitive impairment. During an observation and interview on 01/29/2026 at 9:23 AM, it was revealed that Resident #3's privacy curtain in the middle of the room had brown streaks and spots. Resident #3 stated that he did not think the curtain got laundered very often, and he thought it was food. During an interview on 01/29/2026 at 12:44 PM, CNA D stated that when privacy curtains were soiled, they request to have the curtain taken down and laundered. This request was put into TELS (work order system). CNA D stated that TELS allowed for documentation as to why the curtain needed to be laundered and stated it was usually taken down the same day. CNA D stated she had no observed curtains with stains or that were soiled. During an interview on 01/29/2026 at 12:58 PM, CNA C stated that she worked PRN at the facility. CNA C stated that she has put in a resident on TELS for the maintenance team and that she was informed with a curtain like that it needs to be quickly replaced. CNA C stated that she reported to maintenance this morning that Resident #1's curtain needed to be replaced and had not seen it that dirty before. CNA C stated that it had a black stain and was soiled. During an interview on 01/29/2026 at 1:07 PM, LVN A stated that if privacy curtains were stained or soiled that nursing staff could not take the curtain down and that it was put into TELS and they were to notify maintenance. LVN A stated if housekeeping was available they could also be notified as well, but it was usually put into TELS. LVN A stated there was one time Resident #1 brought to her attention the curtain was soiled in his room and she notified him she could not take the curtain down but could put it in TELs to get changed. LVN A stated she did not recall when this happened. LVN A stated the stain was a dark color and had smearing as if someone had attempted to wipe it, but she was unsure exactly what it was. LVN A stated she was not sure if there was a routine for laundering curtains. During an interview on 01/29/2026 at 1:26 PM, RN B stated she was unsure what the process was for laundering privacy curtains and unsure if there was a frequency at which they were laundered. During an interview on 01/29/2026 at 1:35 PM, the HSK stated that he was the laundry and house keeping supervisor and also helped with maintenance work orders if the MS was not there or if he had time to help. The HSK stated that this morning (01/29/2026) he removed the privacy curtain in Resident #1's room because it was a work order. The HSK stated that the urgency of getting the curtain laundered depended on the type of stain. The HSK stated if the note said there was bowel movement on the curtain it would be more urgent and it was to be changed right away. The HSK stated that privacy curtains were laundered on a deep cleaning schedule which occurred once a month for each room. The HSK stated that when the resident room was scheduled for deep cleaning the curtain was removed and laundered. The HSK stated that the curtain in Resident #1's room looked like it had something dried on it that was a dark black color, but he was unable to say what it was. During an interview on 01/29/2026 at 1:54 PM, the MS stated that soiled curtains were put into the TELS system as a work order. The MS stated that when a curtain was soiled, he tried to get it changed with in 24 hours. The MS stated that there was a rotation to have the curtains cleaned once a month when the resident rooms were deep cleaned and during that time the privacy curtains were taken down and laundered. The MS stated that if there was bodily fluids or bowel movement noted on the work order there was increased urgency to have it changed because bodily fluids would be an infection control issue. During a subsequent interview on 01/29/2026 at 2:00 PM, RN B stated that privacy curtains were laundered once a month and as needed and that the request could be put in through TELS. During an interview on 01/29/2026 at 2:42 PM, the ADM stated that privacy curtains were laundered as needed that that deep cleanings were done upon resident discharge. The ADM stated that staff were expected to report soiled privacy curtains through TELS. The ADM stated that MS and the ADM were responsible to monitor TELS and that a notification were received as soon as a request was put in. The ADM stated that he expected the soiled curtain to be changed as soon as possible. The ADM stated that if it was notated that bowel movement or bodily fluids were on the curtain the urgency was increased and the curtain should have been changed as soon as possible. The ADM stated that residents have the right to a clean environment. Review of work order logs reflected request for room [ROOM NUMBER] curtain to be changed due to large black stain, with request to be changed as soon as possible with an open date of 12/21/2025 and close date of 1/2/2026. Review reflected a second request for room [ROOM NUMBER] curtain to be changed with note It has had large stain on B side that looks like feces for well over 2 weeks. We have tried to report it multiple times with an open date of 12/31/2026 and close date of 01/2/2026. Review of work order log reflected request for Resident #1's curtain to be changed with note privacy curtain has BM on it with an open date of 01/08/2026 and close date of 01/15/2026. Review of work order log reflected request for Resident #1's curtain needed to be cleaned with an open date of 01/10/2026 and close date of 01/12/2026 with a note of repeat. Review of work order log reflected request for Resident #1's room with note privacy curtain needs to be washed with an open date of 1/14/2026 and close date of 1/15/2026. Review of work order log reflected request for Resident #1's curtain to be changed with note curtain has poop on it please change it with an open date of 01/27/2026 and close date of 01/29/2026. Review of facility policy titled Physical Environment with revision date of 05/2023 reflected the facility utilized TELS to track and document maintenance and regular tasks. Review reflected that it was the policy of the facility to establish procedures to ensure the facility remains in good working order for resident and staff safety.

Based on interview and record review the facility failed to ensure residents had the right to be informed of, and participate in, his or her treatment which included, the right to be informed in advance, by the physician or other practitioner or other professional, of the risks and benefits of proposed care, treatment and treatment alternatives or treatment options to choose the alternative or option he or she preferred for one of (Resident #1) of four residents review for medication changes. The facility failed to ensure Resident #1 was made aware that he was prescribed oseltamivir phosphate (for influenza A prophylaxis) on 01/20/2026. This failure could place residents at risk of receiving medications without their prior knowledge or consent, being unaware of the benefits and risks of the medications prescribed and place residents at risk of diminishing their right to autonomy.Findings included: Review of Resident #1's face sheet dated 01/29/2026 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of other cerebral infarction due to occlusion or stenosis of small artery (type of stroke caused by blockage or narrowing in deep-brain arteries), and hemiplegia and hemiparesis following cerebral infarction (motor impairments affecting one side of body following a stroke). Review reflected FM B and FM C were listed as POA - financial. There was no indication that FM B or FM C were Resident #1's MPOA or RP for medication decisions. Review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of 12 which indicated moderate cognitive impairment. Review of Resident #1's January 2026 MAR reflected an order for Tamiflu Oral Capsule (oseltamivir phosphate) 75 MG with instructions to take 1 capsule by mouth for influenza A prophylaxis for 14 days with a start date of 01/21/2026. Review of Resident #1's care plan dated 08/13/2026 reflected Resident #1 was at risk for impaired cognitive function with intervention to engage in simple structured activities. Review of Resident #1's POA dated 04/29/2021 reflected FM B and FM C could act as agents in matters regarding banking, insurance and funeral arrangements. There was no medical authority noted. Review of Resident #1's immunization record reflected he receive the influenza vaccine on 10/01/2025. Review of Resident #1's nursing progress note by LVN A reflected date of 01/20/2026 at 2:01 PM for Tamiflu oral capsule 75 MG, Give 1 capsule by mouth in the evening for influenza A. Review of Resident #1's nursing progress note dated 01/21/2026 by ADON reflected Resident recently exposed to influenza a in the facility. Currently no symptoms reported. Resident was not tested for influenza at this time [per] protocol. New order received from in-house provider to start Influenza A Prophylaxis.Notified RP and approves of medications Review of Resident #1's chart reflected there were no notes from 01/21/2026 to 01/29/2026 that reflected NP, ADON , LVN A or any other facility staff notified Resident #1 a medication was being added to his regimen. During an interview on 01/29/2026 at 11:05 AM, Resident #1 stated that he was started on flu medication and did not find out what it was for until three days after. Resident #1 stated that FM B asked Resident #1 if he knew he was started on Tamiflu and that the facility had reached out to FM C to ask for permission for Resident #1 to start Tamiflu. Resident #1 stated that he was not a vejito (little old man) who was crazy and that he could still make his own decisions. Resident #1 stated that he would have preferred to discuss what the medication was for. Resident #1 stated he was still in his right mind and only wanted the facility to reach out to FM B or FM if he was completely out of it and unable to make decisions. Resident #1 stated no one came in to ask him about getting the medication or if he wanted to take it. During an interview on 01/29/2026 at 1:07 PM, LVN A stated that she usually worked 6:00 AM to 6:00 PM shift. LVN A stated that there were a few residents with the flu and Tamiflu was given to other residents prophylactically as prescribed by the nurse practitioner. LVN A stated when there was a new medication order that the resident and their family were notified. LVN A stated that the nurse administered the first dose of the new medication. LVN A stated that it was important to notify the resident of medication changes because they were taking the medication and to be aware if they wanted to take the medication or not and to have an opportunity to ask questions or not. LVN A stated typically both the resident and family are notified depending on their BIMS score and if they can understand. LVN A stated Resident #1 was able to consent to his own treatment. LVN A stated Resident #1 was oriented to person, time, place and situation. LVN A stated that she does not recall if Resident #1 was notified of his new order for Tamiflu. LVN A stated she knew she told some residents, but could not recall who. LVN A stated someone helped with notification to families, but could not recall who. LVN A stated that resident rights included the right to take medication or not and the right to be notified of any changes in their treatment. During an interview on 01/29/2026 at 1:26 PM, RN B stated that the facility did prophylactic treatment to treat the flu. RN B stated that when there was a new order for medication she talked to the resident and also communicated with the provider and contact the family member listed on the resident's profile. RN B stated usually she would put in a progress note and specify that the family was contacted, ADON/DON, provider and that it was discussed with family. RN B stated that it was important to discuss changes in medication for the resident's autonomy, so they were aware of their care and to keep them involved of their care. RN B stated cognition level does not affect whether or not they are involved, and the resident should be notified regardless. During a telephone interview on 01/29/2026 at 2:02 PM, the ADON stated she was at training. The ADON stated that residents were started on Tamiflu prophylactically. The ADON stated she helped with notifying the families of the change. The ADON stated that the nurse or nurse practitioner was responsible to speak with the resident and tell the resident they were going to start Tamiflu. The ADON stated that sometimes Resident #1 was forgetful, but he recognized faces and sometimes had to be reminded of things that were done. The ADON stated it was important to notify residents of new medications so they were aware of what they were taking and what to expect. During an interview on 01/29/2026 at 2:08 PM, DON A stated that DON B was at a training and she was helping at the facility. DON A stated that the protocol for new medications would be for the nurse to notify the family member and if the resident was alert and oriented then the resident would be notified as well. DON A stated that it should be documented in a progress note and that included if the resident was notified as well. DON A stated notification to the resident depended on if they were aware of the medications they took, they can recall their daily routine, voice their needs and their BIMS score. DON A stated it was important to notify of any changes in medication so that the resident was aware of their plan of care. During an interview on 01/29/2026 at 2:42 PM, the ADM stated that he would defer notification of medications changes to the DON and it was not within his scope to answer. The ADM stated that documentation of notifications were also deferred to the DON. The ADM stated that it was important for the resident to be made aware of medications because it was apart of their place of care. The DON stated if the resident was alert and oriented, they would be notified as well and their RP. During an exit conference interview on 01/29/2026 at 3:45 PM, DON B stated that Resident #1 was notified by the nurse practitioner that Tamiflu was being started. The DON stated that the nurse practitioner did not notify all residents, only some. The DON stated that Resident #1 had a BIMs of 12 and that his RP/FM was notified to start the medication. The DON stated that residents did not have to have a MPOA in place to notify the FM. Review of the facility policy titled 'Resident Rights and Responsibilities, Notice of with revision date of 04/2025 reflected should a resident be found incompetent by a court of law, the resident's representative shall act on behalf of the resident.

Based on interview, observation, and record review, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing for one (Resident #90) of five residents reviewed for pressure injuries. The facility failed to ensure Resident #90 received wound care treatments for eight days after admission, from 11/26/2025 to 12/04/2025. This failure could place residents at risk of improper wound management, the development of new pressure injuries, deterioration in existing pressure injuries, infection, and pain.Findings included: Record review of Resident #90's undated face sheet reflected a [AGE] year-old female admitted on [DATE]. Her diagnoses included end stage renal disease (a life-threatening disease in which the kidneys no longer filter the blood), diabetes mellitus II (a problem producing the hormone insulin to metabolize carbohydrates), and congestive heart failure (a condition in which the heart cannot pump blood effectively, leading to fluid accumulation in the lungs and legs). Record review of Resident #90's admission MDS assessment, dated 11/29/2025, reflected a BIMS score of 15, indicating no cognitive impairment. Section M (Skin Conditions) reflected Resident #90 was at risk of developing pressure ulcers, but had no unhealed pressure ulcers at the time of this assessment. Record review of Resident #90's care plan, dated 12/08/2025, reflected the following: I have pressure ulcer or potential for pressure ulcer development r/t stage 3 to coccyx. Pressure ulcer would show signs of healing and remain free from infection by/through review date. -Administer medications as ordered. Monitor/document for side effects and effectiveness. -Administer treatments as ordered and monitor for effectiveness. Assess/record/monitor wound healing. Measure length, width and depth where possible. -Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. -Call light within reach. If refuses treatment, meet with resident, IDT and family to determine why and try alternative methods to gain compliance. Document alternative methods. -Monitor dressing to ensure it is intact and adhering. Report lose dressing to treatment nurse. -Monitor nutritional status. Serve diet as ordered, monitor intake and record. -Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. -Treat pain as per orders prior to treatment/turning etc. to ensure comfort. Turn and reposition as tolerated.-Use Enhanced Barrier Precautions. -Weekly head to toe skin at risk assessment. Record review of Resident #90's clinical admission assessment, dated 11/26/2025, not completed by LVN I, reflected, Pt has pressure ulcer at sacrum. typed in under the skin assessment area. Record review of Resident #90's clinical admission assessment, dated 11/28/2025, and completed by LVN I, reflected, No skin issues under the skin assessment area. Record review of Resident #90's Skin Issues assessment, dated 12/01/2025, reflected resolved for redness documented to Buttocks-generalized. Record review of Resident #90's Skin Issues assessment, dated 12/03/2025, reflected, New Issue for Coccyx [tailbone] with pressure ulcer/injury indicated for skin issue. Progress reflected Stable: previously deteriorating wound characteristics plateaued. Pressure ulcer staging reflected Stage 3 Pressure Ulcer/Injury: Full-thickness skin loss. Acquired reflected Present on admission. Onset reflected Chronic >3 months. Presences of wound pain reflected no. Staged by: reflected In-house nursing. Length reflected 4.5. Width reflected 2.5. Depth reflected 2. Granulation [healthy tissue that has formed] reflected 80%. Slough [dead tissue that sits on top of a wound] reflected 20%. Exudate [drainage] amount reflected Moderate. Exudate type reflected Serosanguineous: mixtures of serous [clear fluid] and sanguineous [resembles blood] fluid, typically pale, red, and watery. Record review of Resident #90's Skin Issues assessment, dated 12/10/2025, reflected Evaluated for Coccyx [the tailbone] with Pressure ulcer/injury indicated for skin issue. Progress reflected Deteriorating: wound characteristics deteriorated. Pressure ulcer staging reflected Stage 3 Pressure Ulcer / Injury: Full-thickness skin loss. Acquired reflected Present on admission. Onset reflected Chronic >3 months. Signs and symptoms of infection reflected Increased exudate [drainage] and Smell increased. Staged by: reflected In-house nursing. Measurements not documented as part of this assessment was documented on the form with reasoning previous measurement. Granulation [healthy tissue that has formed] reflected 30%. Slough [dead tissue that sits on top of a wound] reflected 70%. Exudate[drainage] amount reflected Heavy. Exudate type reflected Seropurulent [mix of clear fluid with pus]: mixture of purulent[pus] and serous [clear fluid], usually watery, yellow, green, tan or brown. Record review of Resident #90's Skin Committee IDT (documented by the WCN) note, dated 12/04/2025, reflected has stg 3 to coccyx that she reports having for long time. Treatment in place. Repositions self. On dialysis, hx of left leg amputation. Record review of Resident #1's progress notes reflected the following:11/28/2025 at 3:00 a.m. (documented by LVN I) Pressure ulcer to sacrum, discoloration to left arm that had fistula (surgical port of entry in the skin for hemodialysis) , surgical wounds covered by dressing to right femur (thigh bone including hip ball);12/01/2025 at 02:06 AM (documented by LVN L) skin note: skin warm and dry. X8 surgical wounds (meaning there were eight surgical wounds) on right leg. Bottom wounds.12/11/2025 17:26 [05:26 PM] (documented by the WCN) upon wound care to coccyx, foul odor noted with slough [dead tissue that sit on top of the wound] present to wound bed. Continues with calcium alginate for large amt of drainage. NP notified, will evaluate in the morning. Resident currently on air mattress. w/c cushion in place. Resident educated on increased pressure d/t staying up in w/c for prolonged periods at a time. States understanding but reports not wanting to be transferred with [mechanical lift] multiple times a day and would prefer to stay up in chair. Record review of Resident #90's order summary, dated 12/10/2025, reflected the following:Stg 3 coccyx: cleanse with wound cleanser, pat dry, apply calcium alginate, cover with dry dressing as needed for dislodgement and/or soilage. Order date and implementation 12/04/2025.Stg 3 coccyx: cleanse with wound cleanser, pat dry, apply calcium alginate, cover with dry dressing ever day shift. Order date and implementation 12/04/2025. Record review of Resident #90's shower sheets from 11/26/2025 to 12/04/2025 reflected she received a shower on 11/27/2025, 11/29/2025, 12/01/2025, and 12/02/2025. There were no skin issues documented on any of these shower sheets. During an interview on 12/09/2025 at 01:37 p.m., Resident #90 stated she had a wound to her sacrum before admission and did not feel it was cared for appropriately. She stated they did wound care treatments to the site, but she was unsure what was done or if the wound looked better or worse than when she was admitted to the facility. During an interview on 12/10/2025 at 03:56 PM with the WCN she stated she had worked at the facility four years and took over as the treatment nurse within the past year. She stated Resident #90 was admitted with a pressure wound to her coccyx. She stated the wound had not increased in size since admission. The WCN stated the wound had a lot of serosanguineous (mixture of clear serum and blood) drainage upon admission so they started putting calcium alginate to dry the wound up some. She stated wound treatment for the wound to Resident #90's coccyx started on 12/04/2025. She stated the normal protocol for new residents who are admitted with wounds was for the admitting nurse to contact the MD and initiate an order for wound care treatments. The WCN stated she was not notified about the wound until 12/03/2025 and she assessed the wound that day. She stated the wound currently had more slough than when she first assessed it on 12/03/2025. She stated she felt the wound had deteriorated because Resident #90 sat up in her wheelchair for extended periods of time despite education. She stated they had a wheelchair cushion in place and she had an air mattress on her bed. The WCN stated the wound care specialist would see Resident #90 on the upcoming Monday after she returned from dialysis. She stated the wound appeared to be infected to her and she was planning on contacting the NP after the interview. The WCN stated if a pressure ulcer went 8 days without being treated then the wound could deteriorate quicker than if it were being treated, increased pain to the resident, and/or infection. Attempted phone interview on 12/11/2025 at 10:01 AM with LVN I without return call prior to exit. During a phone interview on 12/11/2025 at 10:03 AM with the MD, she stated she was the provider for Resident #90. She stated she assessed Resident #90 the previous Thursday and they discussed the wound to Resident #90's coccyx. She stated it was an existing wound prior to admission because Resident #90 was getting wound care through home health prior to admission. She stated she expected the nurses to communicate wounds on new residents through their nursing notes. She stated she observed the area with the wound the week prior during her visit with Resident #90. The MD stated Resident #90's coccyx had some superficial maceration [the softening and breakdown of the skin due to prolonged exposure to moisture]. She stated she expected nursing to do what nursing does when asked about her expectations for assessment of the wound and if she expected measurements for open wounds. During a phone interview on 12/11/2025 at 10:30 AM with the NP, she stated she was one of the responsible providers for Resident #90. The NP stated she first assessed Resident #90 on 12/02/2025 and she did not document any knowledge of a wound. She stated she had not observed any wounds to Resident #90's coccyx, but she was aware Resident #90 had a wound and was scheduled to observe the wound on her rounds that day. She stated the WCN had contacted her yesterday related to the wound, but she told the WCN that she would see the resident during her next rounds and make any decisions then. She stated if a resident was admitted with a wound, she expected the nurse to do an initial assessment of the wound and initiate wound care orders. She stated the pressure ulcer staging was based off the initial assessment of the wound. The NP stated calcium alginate was an appropriate treatment for a stage 3 pressure ulcer. The NP stated she did weekly wound care rounds with the WCN to monitor the progress of the wounds in the facility. She stated she could not say how it might affect a resident if a pressure ulcer went without treatment for eight days because that was not typical of the facility. During an interview on 12/11/2025 at 10:42 AM, C.N.A. D stated she remembered Resident #90 but did not remember anything about the condition of her skin during incontinent care or showering. She stated she could not remember whether there was a wound on or near her coccyx or sacrum. During an interview on 12/11/2025 at 10:50 AM, C.N.A. C stated she provided incontinent care and showers to Resident #90 but did not remember if Resident #90 had any skin issues. She stated she had cared for so many residents and had so much work to do that she could not recall experiences she had in previous weeks with residents no longer in her care. During an interview on 12/11/2025 at 11:08 AM with the DON, she stated she had worked at the facility for about 15 years as the DON. She stated she was a little familiar with Resident #90. She stated she had answered Resident #90's call light on occasion and had a few small conversations with her. She stated Resident #90 had denied any concerns to her during their conversations. The DON stated she was notified of Resident #90's pressure ulcer to the coccyx the week prior. She stated she was notified by an unknown nurse, and she had the WCN assess Resident #90 and initiate orders. The DON stated she was not sure if the wound was present upon admission. The DON stated she had not personally assessed the pressure ulcer to Resident #90's coccyx. She stated she had discussed the wound with the WCN about a week ago and was told that the wound was not getting any worse. After reviewing Resident #90's electronic health record she stated the nurses' notes were conflicting on if a wound was present on admission. She stated if a wound was present upon admission, then she expected the admitting nurse to perform a full skin assessment, notify the provider to obtain wound care orders, initiate the orders and notify the WCN. She stated she then expected the WCN to assess the wound including obtain measurements of the wound, stage the wound, and adjust the orders for wound care as needed. The DON stated she expected the admitting nurse to describe the wound including measurements and location if the WCN was unavailable or they are unsure how to obtain the measurements. The DON stated she expected all skin issues to be documented in the skin assessment upon admission. She stated she expected to be notified if a wound had deteriorated. The DON stated she expected to be notified of all new residents with wounds. She stated she expected staff to notify her by any means, email, phone call, or teams. The DON stated after reviewing all the nursing notes in the electronic health record, she believed the new electronic health record was compiling records and the nurses did not fill out all portions of the assessments. She stated the new electronic health record was still a little confusing to her. She stated if a wound went without treatment for eight days, then it could get bigger, worse or infected. During an observation on 12/11/2025 at 01:14 PM of Resident #90's wound care, a malodorous wound to Resident #90's coccyx was observed with measurements provided by the WCN of 4.2cm x 6.5cm x 3cm with 70% light green colored slough. The old dressing that was removed was saturated in a brown colored drainage. During an interview on 12/11/2025 at 01:24 PM, the NP stated Resident #90 was scheduled to be seen by the wound care specialist on the following Monday. She stated she was unsure if the wound was infected and she was going to consult with the MD and if an antibiotic were started it would be for empirical [the practice of administering antibiotics based on the most likely pathogen causing the infection] treatment only. During an interview on 12/11/2025 at 01:27 PM, the DON stated, there is no way that wound was there, and no one did anything about it. She stated she knew Resident #90 had a history of a pressure ulcer to the area of the coccyx and through her investigation she gathered that Resident #90 had incurred some moisture associated skin damage to the scar tissue to her coccyx and it opened back up. She stated she observed some granulation to the wound base with a lot of slough. She stated she did not get to observe the old dressing due to her stepping out of the room briefly during the wound care. The DON stated the wound was very malodorous. She stated she expected the WCN to perform measurements weekly on all wounds. During an interview on 12/12/2025 at 11:18 AM with the MDS Coordinator, she stated she fills out the MDS by collecting data from the electronic health record. She stated she looked at the clinical assessment and a wound was not identified, so she did not include it in the admission MDS. She stated the admitting nurse should have put surgical incisions on the skin assessment, but they were not included either. She stated she used the orders for monitoring and treatment of the surgical incisions to know Resident #90 had surgical wounds as indicated on the admission MDS. The MDS Coordinator stated she did not have any role in monitoring or training floor staff. She stated if a wound went eight days without treatment, then it could get worse or get infected. During an interview on 12/12/2025 at 11:50 AM with MD K, he stated he looked over Resident #90's hospital records prior to admission and he stated based off records it was hard to say if a pressure wound existed prior to admission to the facility. He stated the hospital records indicated Resident #90 had dry skin, but the records only referenced a healing/healed bedsore. He stated if there was a stage 3 pressure wound, then the hospital would have orders for treatment of the wound. MD K stated a healed pressure wound could open up to a really large wound for someone with Resident #90's health conditions. MD K stated based off the information he had, he could not determine if the wound was unavoidable for Resident #90. During an interview on 12/12/2025 at 01:08 PM with ADON A, she stated she was unsure if Resident #90 was admitted to the facility with any pressure ulcers. She stated it was policy for the nurses to perform a skin assessment within 24 hours of a new admission, initiate orders and notify management and the WCN if there was a wound present upon admission. ADON A stated wounds should be assessed with every dressing change. She stated all residents were scheduled to have a skin assessment weekly. She stated the CNAs were trained see something, say something, meaning if they saw something new then they were to inform their nurse, verbally was appropriate. ADON A stated a wound could get worse and even cause death if it went untreated for eight days. During an interview on 12/12/2025 at 1:43 PM with the DON, she stated that she felt there was an original discrepancy on the admission documentation because the shower sheets did not reflect a wound. She stated the treatments were initiated for the surgical sites and she felt if there was a wound then there would have been orders initiated too. She stated she was able to talk to LVN I and LVN I stated she did not see any wounds on admission. The DON stated she questioned LVN I about why she indicated pressure on the clinical assessment but did not give an answer to why pressure was indicated. The DON stated she in-serviced LVN I about accurate documentation according to policy. The DON stated the nurses were expected to do a complete skin assessment and describe any abnormalities upon any resident admission to the facility. She stated if there were any wounds upon assessment then she expected the nurse to contact the provider and obtain and initiate orders for treatment of the wound. The DON stated they also relied on the shower sheets to identify new skin issues. She stated the shower sheets should continue to reflect the skin issue until it resolved. During an interview on 12/12/2025 at 02:08 PM with the ADM, he stated he was not familiar with Resident #90 until that morning when he had a conversation with her. He stated he was not a clinician but expected the nurses to contact the DON and provider if a resident was admitted to the facility with wounds. He stated he would expect the nurse to document the wounds upon admission including a detailed description and measurements of the wound. He stated the DON and ADONs were responsible for reviewing all new admissions the day after the admission to ensure accuracy and completion of the admission. He stated staff were available on holidays and weekends to review admissions. The ADM stated if a pressure wound went eight days without treatment, then there could be a negative outcome including potential damage to the site of the wound. Record review of in-services for 2025 reflected one conducted on 04/15/2025 titled Skin Integrity and Prevention. The in-service material did not include information related to admission skin assessments Notify charge nurse on any new skin issues. Continue with skin shower sheets for wound care and charge nurse to review. Review of facility policy titled Skin and Wound Monitoring and Management, dated 03/2015 and last revised 04/2025, reflected the following: It is the policy of this facility that:1. A resident who enters the facility without pressure injury does not develop pressure injury unless the individual's clinical condition or other factors demonstrate that a developed pressure injury was unavoidable; and2. A resident having pressure injury(s) receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing.The purpose of this policy is that the facility provides care and services to:1. Promote interventions that prevent pressure injury development;2. Promote the healing of pressure injuries that are present (including prevention of infection to the extent possible); and3. Prevent the development of additional, avoidable pressure injury.Current evidence documents that, in certain circumstances, the development of pressure injury is an unavoidable occurrence. In accordance with the guidance issued by the National Pressure Ulcer Advisory Panel (March 2010), the facility recognizes that an unavoidable pressure injury is one that developed even though the provider evaluated the individual's clinical condition and pressure injury risk factors; defined and implemented interventions that are consistent with individual needs goals and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate.Facility nursing staff will identify and document in the resident's clinical records, the condition and pressure injury risk factors related to the development of unavoidable pressure injury. This identification and implementation of a plan of care will begin at admission with the initial care plan and be completed throughout assessment process for developing a comprehensive plan of care.Procedurea. Resident Assessment: the nurse responsible for assessing and evaluating the resident's condition on admission and readmission is expected to take the following actions:a. Complete Initial admission Record and Braden Scale to identify risk and to identify any alterations in skin integrity noted at that time.c. Identify risk factors which relate to the possibility of skin breakdown and/or the development of pressure injury which include, but are not limited to: Impaired/decreased mobility and decreased functional ability Co-morbid conditions, such as end stage renal disease, thyroid disease or diabetes mellitus Drugs, such as steroids, that may affect wound healing Impaired diffuse or localized blood flow, generalized atherosclerosis or lower extremity arterial insufficiency Resident refusal of some aspects of care and treatment Cognitive impairment Exposure of skin to urinary and fecal incontinence Nutrition, malnutrition, and hydration deficits History of a healed pressure injury and its stage (if known)d. Risk factors identified on assessment should be documented in the resident's clinical record and, when appropriate, be addressed through a care plan.e. Develop an individualized person-centered care plan based on the assessment and designed to minimize the possibility of skin breakdown.f. Skin and wound assessment on admission and readmission: A licensed nurse must assess/evaluate a resident's skin on admission. All areas of breakdown, excoriation, or discoloration, or other unusual findings, will be documented on the Initial admission Record. A licensed nurse will assess/evaluate each pressure injury and/or non-pressure injury that exists on the resident. This assessment/evaluation should align with the scope of practice and include but not limited to:1) Measuring the skin injury2) Staging the skin injury (when the cause is pressure)3) Describing the nature of the injury (e.g., pressure, stasis, surgical incision)4) Describing the location of the skin alteration5) Describing the characteristics of the skin alterationg. Ongoing Skin and Wound Assessments: A licensed nurse will assess/evaluate a resident's skin at least weekly. Areas of breakdown, excoriation, or discoloration, or other unusual findings (either initially identified at the time of admission or as new findings) must be documented in the nursing notes or on the appropriate weekly assessment form. A licensed nurse will assess/evaluate at least weekly each area of alteration/injury, whether present on admission or developed after admission, which exists on the resident. This assessment/evaluation should include but not be limited to:1) Measure the skin injury2) Staging the skin injury (when the cause is pressure)3) Describing the nature of the injury (e.g., pressure, stasis, surgical incision)4) Describing the location of the skin alteration5) Describing the characteristics of the skin alteration6) Describing the progress with healing, and any barriers to healing which may exist7) Identifying any possible complications or signs/symptoms consistent with the possibility of infectionh. It is understood that a resident may experience pain associated with the presence of a skin injury and/or any form of skin compromise. Therefore, the nursing staff shall be responsible to assess the resident for complaints of pain on assessment, prior to treatment, and as appropriate.i. Once an area of alteration in skin integrity has been identified, assessed, an documented, nursing shall administer treatment to each affected area as per the Physician's Order.j. Treatments per physician order, should be documented in the resident's clinical record at the time they are administered.4. Documentationa. Pressure Ulcer, Non-pressure Ulcer, and PRN/Weekly skin assessment/evaluation forms: If the clinical assessment/evaluation indicates a change in condition or decline in the wound, the assessing/evaluating nurse will notify the physician and create a narrative note documenting that notificationb. Weekly Skin Check Licensed nurse should document skin evaluations in accordance with this policy and document on the appropriate skin assessment/evaluation weekly/PRN form.

Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food safety. 1. The deep fryer was dirty on 12/09/2025.2. The commercial dishwasher did not meet the minimum required threshold for chemical sanitizing on 12/09/2025. This failure could place residents at risk of food-borne illnesses.Findings included: 1. Observation on 12/09/2025 at 9:03 a.m. revealed the deep fryer in the facility kitchen was covered in cornmeal breading crumbs. There were crumbs on the rim of the fryer as well as floating in the oil inside the fryer. There were streaks of dark brown substances on the inside walls of the fryer, and the fry baskets contained crumbs and other solid matter inside the basket and embedded in the basket wires. During an interview on 12/09/2025 at 9:05 AM, the DS stated the deep fryer was deep cleaned weekly and food particles from use were cleaned daily after each meal. He stated the last time the deep fryer was used was the day prior, 12/08/2025, and the crumbs seen on it were from the fish cakes they made for lunch the day before. Observation on 12/09/2025 at 11:37 AM revealed DM, the dietary manager for a sister facility, cleaning and scrubbing the deep fryer. When he finished, there were no more crumbs, and the brown streaks were gone. 3. Observation and interview on 12/09/2025 at 9:10 AM revealed the DA ran the mechanical dishwasher and tested the water on dishes as well as in the bottom of the dishwasher after the rinse cycle. The test strip that measured chlorine PPM became the color that indicated 25 PPM. The DA stated he thought the PPM had to be at 50. The DA stated he had just done something to ensure the chemicals were flowing freely into the dishwasher but did not explain what he had done when asked. He stated he was frustrated that the effort he had made was not effective. He stated he tested the dishwasher sanitizer every day. He stated when he tested it this morning, it was after running the machine two or three times and he noticed the test strip was not dark enough. He stated he would have to call the company that furnished their dishwashing chemicals, the name of which was embossed in the metal outside of the dishwasher. He stated he did not know where to find the model number for the unit. The DS entered the dishwashing area at this time, and he tested the dishwasher again. The color of the test strip was the same as before, the DS stated he would call the company that provides their supplies and ask them to come service the machine right away. He stated they would sanitize dishes in the three-compartment sink in the meantime. A test of the quaternary ammonium solution (ammonia-based cleaner) in the rinse compartment of the three-compartment sink revealed the PPM was high enough for sanitizing thoroughly. Neither the DS, the DA, nor the surveyor could locate a model number for the unit. Observation on 12/09/2025 at 11:35 AM revealed the chlorine test strip measured consistent with 50 PPM when run through the commercial dishwasher rinse water. During an interview on 12/10/2025 at 2:44 PM, the DS stated he was the person responsible for ensuring the kitchen dishwasher was sanitizing effectively and the deep fryer was cleaned according to their policy. He stated he monitored for compliance by conducting daily walkthroughs of the kitchen when he first arrived each morning, and part of that was de-liming (removing the limestone deposits left on the machine by the area's hard water) and checking sanitization levels. He stated the dishwasher technician came to the facility on [DATE] and determine that one of the hoses delivering chlorine sanitizer had disconnected. The DS stated the technician fixed the problem. He stated the potential negative outcome was it could be an outbreak of food-borne illness. He stated the policy for cleaning the deep fryer was a deep clean once per week, and the staff were also supposed to clean the deep fryer after every use. He stated he monitored for compliance by conducting his walkthroughs. He stated the deep clean of the deep fryer was assigned as his responsibility on the checklist, and he did not think he had done the deep clean on (12/05/2025). He stated the potential negative outcome of a dirty deep fryer was food-borne illness. During an interview on 12/12/2025 at 2:07 PM, the ADM stated the DS was responsible for ensuring the dishwasher sanitized the dishes adequately and the deep fryer was cleaned. He stated he oversaw the process by monitoring logs and resources and giving the DS feedback (did not elaborate). He stated there was also a regional resource staff who visited and gave feedback on the conditions of the kitchen. He stated the potential negative outcome of the dishwasher not sanitizing was the residents could get some kind of illness, and he did not know what the potential negative outcome of a dirty deep fryer would be. Review of an undated document posted in the kitchen and titled Friday Weekly Deep Cleaning Day reflected the DS was responsible for cleaning the fryer machine. Review of a document dated December 2025 and titled Dishwasher Log reflected the sanitizer PPM was marked at 50 for every meal (breakfast, lunch, and dinner) for every day in December. The wash and rinse temperatures for every entry were at 120 degrees Fahrenheit. The facility policy provided by the ADM on 12/11/2025 in response to a request for policy related to food storage and preparation reflected no specific guidance about food preparation, clean equipment, or dishwasher sanitation. Review of the Texas Food Establishment Rules dated August 2021 reflected the following: (2) Mechanical. Cleaning and sanitizing may be done by spray-type or immersion dishwashing machines or by any other type of machine or device if it is demonstrated that it thoroughly cleans and sanitizes equipment and utensils either by chemical or mechanical sanitization.

Based on observations, interviews and record review, the facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 2 (Resident #2, Resident #5) of 10 residents reviewed for infection control. The facility failed to properly use EBP personal protective equipment during perineal care for Resident #2 and Resident #5. This failure could place residents at risk for infection transmission, sepsis, and hospitalization. Findings included:Record review of Resident 5's face sheet, dated 12/10/2025, revealed a [AGE] year-old male admitted on [DATE]. His diagnoses included AC, BPH, anemia, glaucoma, recurrent falls, and persistent pain in both hips.Review of Resident 5's physician orders dated 12/01/2025, revealed that this resident was on contact precautions for wounds, indwelling medical devices, infection, and/or MDRO status (indwelling). Review of Resident 5's physician orders dated 12/06/2025, revealed that PPE was required for high resident contact care activities, indicated for wounds, indwelling medical devices, infection, and/or MDRO status (wound) every shift. Record review of Resident 2's face sheet, dated 12/12/2025, revealed a [AGE] year-old female admitted on [DATE]. Her diagnoses included cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, vascular dementia of unspecified severity. Review of Resident 2's physician orders dated 4/18/2024, revealed that PPE was required for high resident contact care activities, indicated for wounds, indwelling medical devices, infection, and/or MDRO status (wound) every shift. Observation on 12/10/2025, at 8:39 a.m. revealed that LVN J and C.N.A. D did not put on the PPE personal protective equipment (gown) provided outside of Resident 5's room before starting perineal care. It was also observed that when LVN J exited Resident 5's room with the waste, a blue gown could not be seen in the clear waste bag carried to the trash can in an undisclosed area. Observation on 12/10/2025 at 10:22 a.m. revealed that LVN J and C.N.A. D did not put on the personal protective equipment (gown) provided outside of Resident 2's room. In an interview on 12/03/2025, at 8:48 a.m., Resident 5's daughter stated that LVN J and C.N.A. D performed perineal care for Resident #5 without the blue gowns on kept at the residents' door for enhanced barrier precautions EBP. Resident #5's family member stated staff sanitized their hands but only wore gloves to perform the care. In an interview on 12/11/2025, at 10:58 a.m., LVN J stated she was in-serviced on enhanced barrier precautions and contact precautions protocol with infection control policies and wound care summer 2025 She said that enhanced barrier precautions included wearing a gown and gloves when conducting perineal care on residents with an order for enhanced barrier precautions. She stated that this will be listed outside the residents' rooms and an orange dot on the resident nameplate. She understood the negative effects of not following proper enhanced barrier precautions and noted that if these precautions were not followed, residents and staff were at risk for contamination. In an interview on 12/11/2025, at 10:58 a.m., C.N.A. D, stated that she provides resident care, such as helping them shower and handling their daily care. She mentioned that the enhanced barrier precautions for the facility entail sanitizing hands and wearing a gown while providing care. She also stated that if the enhanced barrier precautions are not followed, both the residents and staff could be at risk of disease. In an interview on 12/11/2025, at 11:16 a.m., C.N.A. F, stated she has worked at the facility for over a year and assisted residents with their daily care. She stated that the enhanced barrier precautions protocol requires all staff to wear the blue gowns that are attached to all resident doors with enhanced barrier precautions. She stated that staff must knock on the resident's door before entering, wash their hands, and wear gloves while performing care. If this is not done correctly, residents may be placed at risk. In an interview on 12/11/2025, at 11:25 a.m., C.N.A. C, stated she has worked at the facility for six months and helped residents with daily activities such as feeding, showering, cleaning nails, and reporting any changes in condition. She stated she received in-service training that day 12/11/2025 on enhanced barrier precautions. This training covered that all enhanced barrier precautions rooms will have an orange dot for wounds. She stated that if she has a resident with enhanced barrier precautions, she knocked on the door, put on a gown, a mask, and face shield before entering the room to minimize risk to both the residents and the aides. In an interview on 12/11/2025, at 11:35 a.m., LVN H, stated she is a supervisor and monitors the medication aides. She stated she received in-service training that morning 12/11/2025 on abuse and neglect and was able to provide the name of the abuse and neglect coordinator. She named two types of abuse and noted that enhanced barrier precautions are for residents with wounds and pic lines, requiring staff to wear gown and gloves. She reiterated that she received in-service training that morning on enhanced barrier precautions and emphasized that failure to follow these procedures could place residents and staff at risk for disease. In an interview on 12/11/2025, at 11:35 a.m., ADON B, stated she is responsible for all training related to enhanced barrier precautions. She mentioned that she also serves as the facility's Infection Control Prevention Nurse. She stated that enhanced barrier precautions training is provided monthly to staff and that these precautions are necessary for residents with indwelling devices. An orange dot is placed on their room door to protect others and inform them of their condition. Hand hygiene must be performed before and after care, and all staff must wear gowns. She noted there is a section in the PCC titled Special Requirement where enhanced barrier precautions can be found; it is also listed in the orders. If enhanced barrier precautions were not executed correctly, according to ADON B, this placed residents and staff at risk and compromised infection control measures. In an interview on 12/12/2025, at 2:26 p.m., ADM stated that the ICP nurse is responsible for all the enhanced barrier precautions training in his facility. He mentioned they have been trying to train staff monthly on enhanced barrier precautions.Review of facility's IPCP Standard and Transmission-Based Precautions, dated 10/2022, reflected: 3. Enhanced Barrier Protection (EBJ): expand the use of PPE refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of [NAME] to staff hands and clothing then indirectly transferred to residents or from resident-to-resident.(e.g., residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. PPE: The use of gown and gloves for high-contact resident care activities is indicated, whenContact Precautions do not otherwise apply, for nursing home residents with:i. Wounds and/or indwelling medical devices regardless of [NAME] colonization as well as forresidents ii. [NAME] infection or colonization.Multi-drug-Resistant Organisms ([NAME])- the MDROs for which the use of EBP applies are based onlocal epidemiology. At a minimum, they should include resistant organisms targeted by CDC but canalso include other epidemiologically important MDROs i. Examples of MDROs Targeted by CDC include: Pan-resistant organisms, Carbapenemase-producing carbapenem-resistant Enterobacterales, Carbapenemase-producing carbapenem-resistant Pseudomonas spp., Carbapenemase-producing carbapenem-resistant Acinetobacter baumannii, and Candida auris ii. Additional epidemiologically important MDROs may include, but are not limited to: Methicillin-resistant Staphylococcus aureus (MRSA), ESBL-producing Enterobacterales, Vancomycin-resistant Enterococci (VRE), Multidrug-resistant Pseudomonas aeruginosa, Drug-resistant Streptococcus pneumoniae Examples of high-contact resident care activities requiring gown and glove use for EnhancedBarrier Precautions include:i. Dressingii. Bathing/showeringiii. Transferringiv. Providing hygienev. Changing linensvi. Changing briefs or assisting with toiletingvii. Device care or use: central vascular line (including hemodialysis catheters}, indwellingurinary catheter, feeding tube, tracheostomy/ventilator Devices that are fully embedded in the body, without components thatcommunicate with the outside, such as pacemakers, would not be considered an indication forEnhanced Barrier Precautions.viii. Wound care: any skin opening requiring a dressingix. In general, gown and gloves would not be required for resident care activities other than thoselisted above, unless otherwise necessary for adherence to Standard Precautions.d. Room restriction: Residents are not restricted to their rooms or limited from participation ingroup activities while on EBP. Although a private room is not required for residents on EBP, thefollowing may be implemented: i. At least 3 feet of separation between beds

Based on observation, interview, and record review, the facility failed to conduct an accurate assessment of each resident's functional capacity for 1 of 24 residents (Resident #90) reviewed for comprehensive assessments. The facility failed to ensure Resident #90's pressure wound, present on admission, was included in the admission MDS assessment. This failure placed residents at risk of wound deterioration.Findings included: Review of Resident #90's undated face sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included end stage renal disease (a life-threatening disease in which the kidneys no longer filter the blood), diabetes mellitus II (a problem producing the hormone insulin to metabolize carbohydrates), and congestive heart failure (a condition in which the heart cannot pump blood effectively, leading to fluid accumulation in the lungs and legs). Review of Resident #90's admission MDS assessment, dated 11/29/2025, reflected a BIMS score of 15, indicating no cognitive impairment. Section M (Skin Conditions) reflected Resident #90 was at risk of developing pressure ulcers, but had no unhealed pressure ulcers at the time of this assessment. Record review of Resident #90's care plan, dated 12/08/2025, reflected the following: I have pressure ulcer or potential for pressure ulcer development r/t stage 3 to coccyx. Pressure ulcer would show signs of healing and remain free from infection by/through review date.-Administer medications as ordered. Monitor/document for side effects and effectiveness.-Administer treatments as ordered and monitor for effectiveness. Assess/record/monitor wound healing. Measure length, width and depth where possible.-Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD.-Call light within reach. If refuses treatment, meet with resident, IDT and family to determine why and try alternative methods to gain compliance. Document alternative methods.-Monitor dressing to ensure it is intact and adhering. Report lose dressing to Treatment nurse.-Monitor nutritional status. Serve diet as ordered, monitor intake and record.-Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated.-Treat pain as per orders prior to treatment/turning etc. to ensure comfort. Turn and reposition as tolerated.-Use Enhanced Barrier Precautions.-Weekly head to toe skin at risk assessment. Review of Resident #90's clinical admission assessment, dated 11/26/2025, not completed by LVN I, reflected, Pt has pressure ulcer at sacrum. typed in under the skin assessment area. Review of Resident #90's clinical admission assessment, dated 11/28/2025, and completed by LVN I, reflected, No skin issues under the skin assessment area. Review of Resident #1's progress notes reflected the following:11/28/2025 at 3:00 a.m. (documented by LVN I) Pressure ulcer to sacrum, discoloration to left arm that had fistula (surgical port of entry in the skin for hemodialysis) , surgical wounds covered by dressing to right femur (thigh bone including hip ball);12/01/2025 at 02:06 AM (documented by LVN L) skin note: skin warm and dry. X8 surgical wounds (meaning there were eight surgical wounds) on right leg. Bottom wounds. Review of Resident #90's Skin Issues assessment, dated 12/03/2025, reflected, New Issue for Coccyx [tailbone] with Pressure ulcer/injury indicated for skin issue. Progress reflected Stable: previously deteriorating wound characteristics plateaued. Pressure ulcer staging reflected Stage 3 Pressure Ulcer/Injury: Full-thickness skin loss. Acquired reflected Present on admission. Onset reflected Chronic >3 months. Presences of wound pain reflected no. Staged by: reflected In-house nursing. Length reflected 4.5. Width reflected 2.5. Depth reflected 2. Granulation [healthy tissue that has formed] reflected 80%. Slough [dead tissue that sits on top of a wound] reflected 20%. Exudate [drainage] amount reflected Moderate. Exudate type reflected Serosanguineous: mixtures of serous [clear fluid] and sanguineous [resembles blood] fluid, typically pale, red, and watery. Review of Resident #90's Skin Issues assessment, dated 12/10/2025, reflected Evaluated for Coccyx [the tailbone] with Pressure ulcer/injury indicated for skin issue. Progress reflected Deteriorating: wound characteristics deteriorated. Pressure ulcer staging reflected Stage 3 Pressure Ulcer / Injury: Full-thickness skin loss. Acquired reflected Present on admission. Onset reflected Chronic >3 months. Signs and symptoms of infection reflected Increased exudate [drainage] and Smell increased. Staged by: reflected In-house nursing. Measurements not documented as part of this assessment was documented on the form with reasoning previous measurement. Granulation [healthy tissue that has formed] reflected 30%. Slough [dead tissue that sits on top of a wound] reflected 70%. Exudate[drainage] amount reflected Heavy. Exudate type reflected Seropurulent [mix of clear fluid with pus]: mixture of purulent[pus] and serous [clear fluid], usually watery, yellow, green, tan or brown. Observation and interview on 12/11/2025 at 11:00 AM, revealed Resident #90 seated in her wheelchair in her room. She had an above knee amputation of her left leg and surgical scars were visible on her right leg. She stated the pressure ulcer to her coccyx had been there for over a year, but it was healed at some point. She stated she started feeling a burning sensation to the area and thought the wound to her coccyx reopened a week prior to admission to the hospital and the facility. During an interview and record review on 12/12/2025 AM 1:18 p.m., the MDS Coordinator stated she learned what needed to go on the skin section of the MDS assessment by looking at the admission skin assessment. She said the skin assessment was found in the Clinical admission Assessment. She reviewed the two assessments for Resident #90 and said she saw the pressure ulcer to the sacrum on the assessment dated [DATE], but that assessment had not been completed and submitted, so she reviewed the assessment completed and submitted 11/28/2025. She stated the surgical incisions Resident #90 had from the hospital were also not in the Clinical admission assessment dated [DATE], so it seemed LVN I did not do a skin assessment at all for that version. She stated she included the surgical sites to the admission MDS because she reviewed the orders. The MDS Coordinator stated she had no role in training the floor staff to do assessments or anything else. She stated the potential negative impact of a wound present on admission not reflected in the MDS was the wound could worsen and/or become infected. During an interview on 12/12/2025 at 1:07 PM, ADON A stated she assisted in training the floor nurses on the clinical admission process. She stated LVN I worked as a night nurse and was at their skills fair, which included training on the clinical admission process. She stated she conducted in-services regularly. She stated the nurses needed to complete the clinical admission assessment thoroughly and correctly because otherwise the resident may not receive important interventions for clinical problems. She stated she had not investigated the situation regarding Resident #90's pressure wound not being on the MDS or clinical admission assessment, but she assumed LVN I did not fill out the admission assessment correctly. She stated the person responsible for making sure a wound present on admission was documented on the admission MDS assessment was the MDS Coordinator, but she (ADON A) also had a role because she was part of the IDT and involved in scrubbing the chart, which was a process their team used to review all the medical records and ensured nothing fell through the cracks. She stated they had not scrubbed Resident #90's chart yet. She stated the potential negative outcome of a pressure wound present on admission not listed on the admission MDS was worsening of the wound. She stated it was also possible there could be less financial reimbursement for the residents while in the facility. During an interview on 12/12/2025 at 1:31 p.m., ADON B stated she assisted in training nurses to complete the clinical admission tool when they were hired, and they asked her questions afterward if they needed help. She stated she trained them to perform a full skin assessment and to identify anyone at risk of skin breakdown. She stated she did not have a role in assuring information was on the admission MDS assessment. She stated she did not know what the potential negative outcome was to the resident for a wound present on admission not added to the admission MDS. During an interview on 12/12/2025 at 1:43 p.m., the DON stated she felt there was a discrepancy on the initial clinical admission assessment for Resident #90 when LVN I added pressure ulcer to sacrum it was a mistake. She stated she reviewed the shower sheets and there were no skin issues documented, which was inconsistent with the surgical incision present on admission. The DON stated she had spoken to LVN I about the discrepancy and LVN I stated she did not see a wound on Resident #90 upon admission. The DON stated LVN I did not answer when asked why she documented pressure ulcer on the initial version of the admission assessment. The DON stated the person responsible for ensuring conditions present on admission were included in the admission MDS assessment was the MDS Coordinator, but she relied on the charge nurses to include the essential information in the clinical admission assessment. The DON stated a potential negative outcome to a wound present at admission not included in the admission MDS assessment was not as many people would know about the wound. During an interview on 12/12/2025 at 2:16 p.m., the ADM stated the person responsible for ensuring clinical conditions present on admission were included in the MDS assessment was the MDS nurse. He stated he did not have a role in ensuring compliance with that process as it was the responsibility of the clinical team. He stated a potential negative impact of Resident #1's pressure wound not b coded on the MDS was the nursing staff would not have an accurate picture of what care the resident needed. Record review of facility policy, dated 07/2023, titled Admission reflected the following: PolicyIt is the policy of this facility to have well defined guidelines for processing the resident's entry into the nursing facility and the resident's right guaranteed under federal and state law are protected.PURPOSE4. Obtain information about the resident to establish baseline data for the MDS and provide the basis for interdisciplinary assessment, care, planning, and rehabilitation of each resident.PROCEDURE4. The resident shall be admitted , according to procedure by the licensed nurse.Licensed Nurse Procedure2. Initiate any treatments as ordered4. Initiate admission assessments. Record review of facility policy, dated 04/2025, titled Skin and Wound Monitoring and Management reflected the following: Procedurea. Resident Assessment: The nurse responsible for assessing and evaluating the resident's condition on admission and admission is expected to take the following actions:f. Skin and wound assessment on admission and readmissionA licensed nurse must assess/evaluate a resident's skin on admission. All areas of breakdown, excoriation, or discoloration, or other unusual findings will be documented on the initial admission record.A licensed nurse will assess/evaluate each pressure injury and/or non-pressure injury that exists on the resident. This assessment/evaluation should align with the scope of practice and include, but not be limited to:1. Measuring the skin injury2. Staging the skin injury (when the cause is pressure)3. Describing the nature of the injury (e.g. pressure, stasis, surgical incision)4. Describing the location of the skin alteration5. Describing the characteristics of the skin alteration i. 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 and prevention control program that included, at a minimum, a system for preventing and controlling infections for 2 of 4 residents (Residents #3 and Resident #4) reviewed for infection control, as indicated by: MA A did not clean and disinfect the blood pressure monitor while using it on Resident #3 and Resident #4 and failed to keep away opened personal drinks from the med cart , on 11/20/24 at 10:25am . This failure could place the residents at risk of transmission of disease and infection. Findings included: Record review of Resident #3's face sheet on 11/20/24 revealed an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses were, Orthostatic hypotension, Type 2 diabetes, Hypertension, Lack of coordination, Muscle weakness, Dementia and Cognitive communication deficit. Record review on 11/20/24 of Resident #3's quarterly MDS assessment, dated 09/19/24 revealed a BIMS of 06 indicating his cognition was severely impaired. Record review on 11/20/24 of Resident #3's care plan dated 11/20/24 indicated resident has orthostatic hypotension and hypertension and relevant intervention was monitoring blood pressure daily. Record review of Resident #4's face sheet on 11/20/24 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses were, ,Type 2 diabetes, Chronic pain, Presence of cardiac pacemaker, Lack of coordination, Hypertension, Muscle weakness, Dementia and Cognitive communication deficit. Record review on 11/20/24 of Resident #4's quarterly MDS assessment, dated 10/31/24 revealed a BIMS of 08 indicating his cognition was severely impaired. Record review on 11/20/24 of Resident #3's care plan dated 11/20/24 indicated Resident #3 had blood pressure and it had to be monitored daily. An observation on 11/20/24 at 10:25am , revealed MA A failed to sanitize the blood pressure monitor before using it on Resident #3, in between Resident #3 and Resident #4 and after Resident #4. MA A took the blood pressure monitor from the top of the med cart and without sanitizing it she took the blood pressure of Resident #3. MA A then moved on to Resident #4 and took his blood pressure with the same blood pressure monitor without sanitizing it. After completing the measurement on Resident #4, without cleaning the blood pressure monitor, she kept it on the top of the med cart. Observation of the med cart revealed there was an opened energy drink and a water bottle at the top of the cart. It was observed MA A taking sip from the bottles while she was administering medications to residents. During an interview on 11/20/24 at 10:50am , MA A stated she was working at the facility more than a year and started working as MA recently. She said it was essential to minimize the risk of spreading contagious diseases by sanitizing the blood pressure cuff in between the residents . MA A stated she was aware of the facility policy of should not have personal food items and drinks on the med cart. She said she did not know why staff should not keep food and drinks on the med cart and use it while administering medications. MA A stated she received in services on infection control however did not remember the exact date. Review of facility policy 'Infection Prevention and Control program revised in December ,2023 reflected : The infection prevention and control program is comprehensive in that it addresses detection, prevention and control of infections among residents and personnel. (Personnel covers staff, volunteers, visitors, and other individuals providing services under a contractual agreement). 2. Process Surveillance is the review of practices by staff directly related to resident care. Some considerations for this process may Include, but are not limited to: a. Hand hygiene b. Appropriate use of personal protective equipment (PPE) . e. Infection control practices during the provision of resident care and treatments f. Managing bloodborne pathogen exposure g. Cleaning and disinfection production and procedures for environmental surfaces and equipment h. Appropriate use of transmission-based precautions.

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for one (Resident #1) of four residents reviewed for abuse. The facility failed on 11/07/24 to protect Resident #1 from physical and emotional abuse by Resident #2. Resident #2 screamed at Resident #1 and grabbed her right arm with the history of nondisplaced fracture of triquetrum [cuneiform] bone of the wrist, caused erythema (redness of skin) that lasted for 4 days. This failure could place residents at risk of serious physical and emotional injury and harm. The findings included: Record review of Resident #1's face sheet on 11/20/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses were, Wedge compression fracture of second lumbar vertebra (back bone at lumbar area), Maxillary (upper jaw) fracture, Fracture of tooth, Repeated falls, Alzheimer's disease, Nondisplaced fracture of triquetrum bone (bone on the wrist), right wrist, Insomnia, Hypertension, Muscle weakness, Unsteadiness on feet, Lack of coordination and Cognitive communication deficit. Record review on 11/20/24 of Resident #1's initial MDS assessment, dated 08/30/24 revealed a BIMS of 03 indicating her cognition was severely impaired. Record review on 11/20/24 of Resident #1's care plan dated 08/28/24 indicated : 1.She was at the risk for impaired cognitive function or impaired thought processes r/t cognitive deficits and relevant intervention was, facilitate her wish as she liked to ambulate via wheelchair throughout the facility and liked to look out the Hall 100 door /windows. 2.Potential for a psychosocial well-being problem r/t 11/7/24 altercation with another resident [Resident #2] and had red discoloration to right arm from that and the relevant intervention was, when conflict arises, remove residents to a calm safe environment and allow to vent/share feelings. Record review of Resident #2's face sheet on 11/20/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses were, Dementia, Chronic kidney disease, Hypertension, Chronic pain, Parkinson's disease, Lack of coordination, Anxiety disorder and Cognitive communication deficit. Record review on 11/20/24 of Resident #2's quarterly MDS assessment, dated 08/02/24 revealed a BIMS of 12 indicating her cognition was moderately impaired. Record review on 11/20/24 of Resident #2's care plan dated 08/28/24 indicated she was on an antidepressant medication and the relevant intervention was monitoring for adverse side effects of agitation. Record review of facility investigation report dated 11/08/24 stated it was confirmed that during an incident on 11/07/24 at 3:00pm Resident #2 screamed at Resident #1's face , raised her arm up and grabbed her right arm. During an observation and interview on 11/20/24 at 11.30am Resident #2 was sitting on her bed and playing cards by self. Her room was adjacent to the exit door from hall 100. When asked about the incident that happened on 11/07/24 between her and Resident #1, her mood elevated and became animated . She conversed in a raised voice and stated that Bitch [Resident #1] lived in Hall 400 however wanted to come to hall 100 all the time. Resident #2 stated she was a nuisance and made numerous attempts to get into her room and on few occasions succeeded too. She stated she did not like anyone invading into her privacy. Resident #2 stated, on 11/07/24 in the evening Resident #1 entered her room , stood up on her feet and tried to assault her . Resident #2 stated at that time she pushed her wheelchair away and out of her room. Resident #2 stated she did not touch her body, only the wheelchair. Resident #2 said Resident #1 was in Hall 100 even after the incident and made attempt to enter her room. Resident #2 stated she was on watch for 10 days for a mistake that Resident #1 had done. Resident #2 said she would not hesitate to physically handle anyone as a last resort if anyone intrude into her room. Resident #2 stated she was a rape victim in the past and still had paranoia about intruders as she was not sure about their motives were. During an observation and interview on 11/20/24 at 2:00pm Resident #1 was sitting on her wheelchair, in her room. She was wearing a helmet for fall protection. She appeared as fragile and delicate. She was pleasant and happy in her presentation and interacted in a passionate manner. Resident #1 stated all the staff and residents at the facility were compassionate, friendly, and helpful. When the investigator asked about the incident that occurred between her and Resident #2 on 11/07/24, she stated she did not remember who Resident #2 was or what the incident was. She stated she did not have any complaint about any staff or residents as all of them were lovely people. When asked if she had visited any residents in their room, she stated she did not . She said she liked to look through one of the glass doors at the facility . She said the view from there was very nice and she liked to watch the activities in the nature on that side. She thanked for talking to her and suggested to stay happy and blessed. During an interview on 11/20/24 at 1:00 pm the FM of Resident #1 stated he was aware of the incident . He said the incident occurred when Resident #1 tried to enter Resident #2's room. He said the facility provided best services to Resident #1 however unsure if the facility made sure that Resident #1 would not wander into other residents' rooms or any other unsafe places due to her dementia. He stated he hope another incident would not occur from the same resident as Resident #1 still liked to go to the door next Resident #2's room. He stated he was afraid of her safety if she gets into Resident #2's room due to the lack of observation by the staff. During a telephone interview on 11/20/24 at 2:50pm LVN B stated while she was doing her round about at about 3:00pm in the Hall 100, she heard a scream . She stated she saw Resident #2 raised her arm up, grabbing Resident #1's right arm, and yelling at Resident #1. LVN B stated she did not notice at that time what Resident #1's expression or response was. She said when she arrived at the incident site CNA C was already there trying to deescalate the situation. She stated MD also rushed to the incident site at that time. On 11/20/24 at 3:00pm made a phone call to CNA C and kept a voice message to call back. There was no response as on 11/20/24 at 6:00pm. During a telephone interview on 11/20/24 at 2:40pm MD stated she was in the Hall 100 while the incident occurred. She stated she was rushing to the incident site and saw Resident #1 was pushed out of Resident #2's room by Resident #2 . MD stated Resident #2 was furious and grabbed Resident #1's arm as if she wanted to hurt her . MD stated she observed Resident #1 was upset and was visibly shaking from the commotion. MD stated the situation was deescalated by staff by removing Resident #1 from the incident site. MD stated she visited Resident #1 in her room after about 20 minutes. MD said Resident #1 was resting in her room quietly and appeared peaceful. MD said she examined Resident #1's right arm, the area Resident #2 had grabbed, and it was reddish in color without any open skin. During an interview on 11/20/24 at 1:30pm ADON stated she was the one completed the facility investigation . She stated she and ADM watched the video footage of the incident during the investigation. She stated contrary to what they thought, Resident #1 had not entered Resident #2's room. She said ,on the video it was showed Resident #2 came out of her room yelling and screaming while Resident #1 was attempting to enter her room by opening the door. She stated she also had observed in the video that Resident #2 was grabbing Resident #1's right arm . ADON stated Resident #2 had behavioral concerns and the facility tried to refer her to behavioral health service however Resident #2 and her family declined the referral. ADON stated Resident #1 was a sweet person with no behavioral concerns. She said Resident #1 liked to sit at the exit door at Hall100 and observe the nature outside. ADON stated there was something fascinating for Resident #1 on that side so much so that she wanted to spend good amount of time there. During an interview on 11/20/24 at 4:10pm the ADM stated he watched the video of the incident, and it was showing that Resident #2 grabbing Resident #1's hand during the incident. ADM stated, until watched the video footage, the impression was Resident #1 intruded into Resident #2's room .He said it was clearly shown that Resident #1 did not enter the room however tried to enter the room by pulling the door handle. ADM stated he believed the facility taken all the measures to deescalate the situation and ensuring safety of Resident #1. ADM stated he did not think Resident #1 was physically and emotionally hurt from the incident as the staff intervened at the right time. ADM stated the video was not available as on 11/20/24 as it was overridden by new recordings. Record review of the skin assessment dated [DATE] at 4:17pm reflected : re: altercation- skin intact, red discoloration noted to right arm. Record review of the skin assessment dated [DATE] at 5:36pm reflected : . noted slight discoloration to right arm, no other injuries noted. Record review of the skin assessment dated [DATE] at 6:11pm reflected : Continues with slight discoloration to right arm, denies pain or discomfort. Record review of the skin assessment dated [DATE] at 1:02pm reflected : . noted slight discoloration to right arm, no other injuries noted from recent incident. Record review on 11/20/24 of in-services records since August 2024 revealed there were in-services on 'abuse and neglect' on 08/01/24 and 11/08/24. On 11/08/24 there were in- services conducted on How to responds to resident altercations and identify triggers and what to do when you see residents wanders. Record review of facility's undated policy Investigations of Abuse and Neglect Allegations reflected: .The facility staff will ensure the resident is protected from potential future abuse and neglect while the investigation is being conducted.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen observed for food storage, preparation, and distribution. Cook C did not perform hand hygiene appropriately when preparing pureed foods. This failure could place residents who ate food served by the kitchen at risk of food-borne illness from cross-contamination. Findings included: An observation of CK C on 09/03/24 at 11:30 a.m., CK C staff washed her hands, did not put on gloves, pushed the blade down into the machine with her hand and started putting the meat into the puree machine. She put the pureed meat in a pan on the steam table. She then got a pan of green peas off the stove and put by puree machine went. She then went and washed hands. She then moved the pan regular meat back to the stove. She looked at the recipe, put her hands in her pockets and came back to pan of peas. She then got a ladle and stirred the peas. She did not wash her hands between the tasks. CK C then pushed the blade down with her hand and proceeded to put green peas in the puree machine. She checked the peas pushed the middle blade down again with her hand started the machine again. When finished she put the pureed peas on the steam table. She went and washed her hands. She went and opened the warmer and the oven. She touched her pants and put her hands on her hips while waiting for the puree machine. She then proceeded to push the blade down with her hand in the puree machine. She did not wash her hands in between tasks. An interview with the DM on 09/05/2024 at 9:40 a.m., revealed that kitchen staff have been trained on hand hygiene. She stated that staff are only required to wear gloves when handling ready to make foods. She said that if staff were pureeing food and then touched a drawer, they need to wash their hands. She said all staff are required to practice hand hygiene. She said that hand hygiene prevents cross contamination. She said that if staff fail to wash their hands between tasks it would put the residents at risk for food borne illness. She said that CK C might have gotten nervous with the surveyors watching. She said she would have to ask CK C since she had been out. An interview with CK D on 09/05/2024 at 9:42 a.m., revealed she had been trained on hand hygiene. She stated that staff were supposed to wash their hands in between tasks. She said everyone was to practice hand hygiene in the kitchen. She also said that it was important to wash your hands to prevent the spread of germs and diseases. She said that if staff did not wash their hands, it would put the residents at risk of getting sick. She stated she did not know why the cook did not wash her hands between tasks. An interview with the ADM on 09/05/2024 at 2:41 p.m., revealed that all staff hand been trained on hand hygiene. He also said that all staff are to wash their hands in between tasks to prevent the spread of infections. He also said that if staff do not wash their hands in between tasks, it could put the residents at risk of getting sick. He stated he did not know why the cook was not washing her hands between tasks. Record review of Hand Hygiene Policy dated 10/2022 revealed all personnel shall follow the handwashing/hand hygiene procedure to help prevent the spread of infections to other personnel, residents, and visitors. Staff are to wash their hands before and after eating or handling food.

Based on observations, interviews, and record review the facility failed to ensure resident rights for personal privacy for 4 of 10 residents (Resident #5, Resident #14, Resident #92 and Resident #459) reviewed for personal privacy. The facility failed to knock on Residents #5, #14, #92 and #459's room when going into the residents' rooms. The deficient practice could affect all residents right to privacy in the facility and cause the resident to feel like their privacy was being invaded or the facility was not their home. Findings included: Review of Resident #5's Face Sheet dated 09/05/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5's diagnoses included closed fracture with routine healing, fall, type 2 diabetes mellitus with hyperglycemia (high blood sugar), heart failure, hypertension (high blood pressure), counseling, muscle weakness, dysphagia (difficulty swallowing), cognitive communication deficit (problems with communication), Asthma, unsteadiness on feet, abnormalities of gait and mobility, need for assistance with personal care, and personal history of respiratory disease. Record review of Resident #5's Quarterly MDS dated [DATE] revealed Resident #5 had a BIMS score of 15 indicating resident understood and could make self-understood some all the time. Review of Resident #14's Face Sheet dated 09/05/2024 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #14's diagnoses included dementia (memory, thinking, difficulty), bipolar (extreme mood swings), major depressive disorder, osteoporosis (disease that weakens the bones and make them more likely to break), stiffness of ankles, abnormal posture, need for assistance with personal care, reduced mobility, lack of coordination, cognitive communication deficit (problems with communication), muscle weakness, dysphagia (difficulty swallowing), stiffness of hip and knee and dementia (memory, thinking, difficulty). Record review of Resident #14's Quarterly MDS dated [DATE] revealed that Resident #14 had a BIMS score of 09 indicating the resident could understand and make self-understood most of the time. Review of Resident #92's Face Sheet dated 09/05/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #92's diagnoses included intraspinal abscess and granuloma (rare but serious infection in the spine), pulmonary embolism without acute cor pulmonale (blood clot in the lungs without difficulty breathing), type 2 diabetes mellitus with other specified complications (high blood sugar), morbid obesity, paroxysmal atrial fibrillation (irregular heart beat that comes and goes), hyperlipidemia (high cholesterol), thrombophilia (blood disorder that causes clotting), hypertension (high blood pressure), constipation, muscle weakness, dysphagia (difficulty swallowing), cognitive communication deficit (problems with communication), reduced mobility, need for assistance with personal care, and cardiac defibrillator (detects and stops irregular heartbeats). Record review of Resident #92's Quarterly MDS dated [DATE] revealed that Resident #92 had a BIMS score of 15 indicating the resident could understand and make self-understood all the time. Review of Resident #459's Face Sheet dated 09/05/2024 revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #459's diagnoses included fracture of the right hip, anemia (not enough healthy red blood cells), and kidney failure. Record review of Resident #459's Quarterly MDS dated [DATE] revealed that Resident #459 had a BIMS score of 15 indicating the resident could understand and make self-understood all the time. Observation of meal tray pass on 09/03/2024 at 1:08 p.m., revealed that LVN A opened Resident #14's door and just walked in without knocking. Observation of meal tray pass on 09/04/2024 at 12:55 p.m., revealed that cna B did not knock on Resident #5, Resident #92, and Resident #459's door before entering the room. An interview with CNA B on 09/05/2024 at 9:15 a.m., revealed that she had been trained on resident rights. She stated that the policy for knocking was staff were to knock and always ask permission to enter. She said that staff were expected to knock on the residents door all the time. She also said if staff did not knock on the resident's door the resident may feel annoyed or upset. She said she did not knock on the residents doors because she is used to them, and they are used to her, and it was just a habit. She also said that even if the resident is used to her, she should have knocked. An interview with LVN A on 09/05/2024 at 9:22 a.m., revealed she had been trained on resident rights. She stated the policy was that all staff were to knock and wait to get an answer then announce yourself before entering. She said all staff were supposed to knock before going into the resident's room. She said that if staff do not knock the resident may get upset or it may surprise the resident. She also stated that she did not know why she did not knock on the resident's door. She stated that she may have been rushing to get their blood sugar before the resident had their lunch. An interview with the DON on 09/05/2024 at 10:46 a.m., revealed she had been trained on resident rights. She stated that the policy was that all staff were required to knock on the residents door before going into the resident's room. She said that if staff do not knock on the resident's door they may get upset. She said that staff may have gotten distracted or got task oriented and forgot. An interview with the ADM on 09/05/2024 at 2:41 p.m., revealed he had been trained on resident rights. He stated he did not have a policy for knocking on the residents' doors, but his expectation was that all staff knock before entering. He said that if staff did not knock on the resident's door staff could surprise the resident. He also said that depending on the resident they may get upset about staff not knocking. He said he did not know why the staff were not knocking on the residents doors. An interview with Resident #5 on 09/05/2024 at 12:31 p.m., revealed that staff do knock sometimes before entering her room. She said that it did not bother her if staff did not knock. An interview with Resident #14's roommate on 09/05/2024 at 12:20 p.m., revealed Resident #14 went to the dining room for lunch. She stated that staff usually knock on her door before entering. She said there are times that staff do not knock and that she would like for them to knock. An interview with Resident #92 on 09/05/2024 at 12:42 p.m., revealed that staff knock on the resident's door most of the time before entering. She said that she would like for staff to knock all the time. An interview with Resident #459 on 09/05/2024 at 12:36 p.m., revealed that staff knock on the door most of the time. She stated there are times when staff do not knock. She stated she would like staff to knock all the time. Record review of Resident Rights dated October 4, 2016, revealed residents have the right to be treated with dignity and respect. The resident also has the right to personal privacy.

Based on observation, interview, and record review, the facility failed to ensure the resident's right to a dignified existence for 2 of 8 residents (Residents #34 and #67) reviewed for dignity. The facility failed to ensure Resident #34 was wearing clean clothing throughout the day on 09/04/24 and that Resident #67 was wearing clean clothing throughout the day on 09/03/24 and 09/04/24. This failure placed residents at risk of embarrassment and a loss of dignity. Findings included: 1. Review of the undated face sheet for Resident #34 reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included dementia, lack of coordination, abnormal posture, traumatic subdural hemorrhage with loss of consciousness, muscle weakness, malaise, cognitive communication deficit, need for assistance with personal care. Review of the quarterly MDS for Resident #34 dated 05/29/24 reflected a BIMS score of 99, indicating she was unable to complete the interview. Review of the section on functional abilities and goals reflected she was completely dependent on staff for upper and lower body dressing and moderate/partial assistance in activities of personal hygiene. Review of the care plan for Resident #34 dated 08/19/24 reflected the following: [Resident #34] is at risk for ADL Self Care Performance Deficit. Will maintain current level of function in: Bed Mobility, Transfers, Eating, Dressing, Grooming, Toilet Use and Personal Hygiene; ADL Score through the review date. PERSONAL HYGIENE ROUTINE: requires extensive staff participation for personal hygiene. DRESSING: Requires extensive assistance to dress. Review of the CNA documentation system reflected Resident #34 received assistance with dressing and personal hygiene at 11:18 AM on 09/04/24 by CNA E. Observation on 09/04/24 at 08:39 AM revealed Resident #34 in a tilted-back wheelchair wearing a t-shirt with a popular cartoon character on it. The front of the shirt was wet with thick yellow stains running down. Resident #34 did not respond to efforts to interview her. Observation on 09/04/24 at 12:59 PM, revealed Resident #34 was sitting in her wheelchair at a table in the dining room. She was wearing the same dirty t-shirt, though it was no longer visibly wet. She did not respond to efforts to interview her. Observation on 09/04/24 at 03:04 PM, revealed Resident #34 lying in bed asleep and wearing the same dirty t-shirt. 2. Review of the undated face sheet for Resident #67 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Parkinson's disease with dyskinesia (abnormality or impairment of voluntary movement), dementia, malaise (a general feeling of discomfort, illness, or uneasiness whose exact cause is difficult to identify), lack of coordination, muscle, weakness, abnormal posture, cognitive communication deficit, aphasia, and need for assistance with personal care. Review of the quarterly MDS for Resident #67 dated 07/01/24 reflected a BIMS score of 10, indicative moderately impaired cognition. The section on functional abilities and goals reflected he required substantial/maximal assistance with upper body dressing and was totally dependent on staff for lower body dressing. Review of the care plan for Resident #67 dated 08/27/24 reflected the following: I have ADL Self Care Performance Deficit r/t impaired mobility, weakness. Will maintain current level of function in (SPECIFY) Bed Mobility, Transfers, Eating, Dressing, Grooming, Toilet Use and Personal Hygiene; ADL Score) through the review date. DRESSING: Requires extensive staff participation to dress. Review of the CNA documentation system reflected Resident #67 received assistance with dressing and personal hygiene at 11:24 AM on 09/04/24 by CNA F. Observation on 09/03/24 at 10:02 AM, revealed Resident #67 sitting in his wheelchair in his room with a plastic clothing protector around his neck that had lots of food on it. There was also food and moisture on his shirt behind the clothing protector. He did not respond verbally but made eye contact. Observation on 09/03/24 at 11:30 AM, revealed Resident #67 in his room, still wearing the dirty clothing protector and dirty shirt. Observation on 09/03/24 at 02:48 PM, revealed Resident #67 in his bed, still wearing the dirty shirt but no longer wearing the clothing protector. During an interview on 09/03/24 at 03:09 PM, a FM for Resident #67 stated the only problem she had with the facility was they did not clean his bib or change his pants and clothing when they were dirty from his meals. She stated he wanted to eat independently, and that was great, but he generally made a mess, and the staff often left him that way. The FM stated the issue had been reported to the charge nurse and management, but it continued to occur. Observation on 09/04/24 at 12:51 PM, revealed Resident #67 was wearing a long-sleeved cotton t-shirt and shorts, and there was food and moisture that had spilled down the entire right front half of shirt and shorts. Observation on 09/04/24 at 03:04 PM revealed Resident #67 still wearing the shirt and shorts with food and liquid on his shorts and shirt. Still in his clothing protector. During an interview on 09/05/24 at 11:35 AM, CNA E stated Resident #34 could be combative, but not frequently. CNA E stated they changed her clothes if they became dirty. She stated she had not noticed Resident #34's clothes were dirty on 09/04/24. CNA E stated she was supposed to change resident's clothing if they became dirty. CNA E stated Resident #67's family always wanted the clothing protector on him. She stated he got dirty from eating and they should have changed his clothes if he was dirty or wet as well as cleaned the clothing protector if it got dirty. She stated she had not helped him eat the last couple of days and his primary aide was CNA F. During an interview on 09/05/24 at 12:55 PM, CNA F stated she had not noticed anyone with dirty clothing on. She stated she saw Residents #34 and #67 get dirty sometimes. She stated she had not seen that either of them was dirty on 09/04/24, and she did not work on 09/03/24. She stated she was supposed to change residents if their clothing became dirty. During an interview on 09/05/24 at 01:07 PM, LVN G stated if residents spilled food during meals, the staff should have changed them as soon as the meal was over. She stated Resident #67 often had food or saliva on his clothes, and his family wanted his clothing protector on all the time when he was in his chair. She stated Resident #34 also sometimes got food on herself, because grabbed at everything she could. She stated she had not noticed long stretches of Residents #34 and #67 on 09/04/24, and she had not worked on 09/03/24. She stated they should have been changed into clean clothing right after their meals unless they refused, and if they refused, it should have been documented and reported to her. She stated the potential impact of sitting in a food-stained shirt was that the resident's dignity could have been compromised. During an interview on 09/05/24 at 01:53 PM, the ADON stated her expectation of when residents were helped to change clothing when they became dirty, was that they be changed when they went back to their rooms after their meals before they did anything else. She stated the charge nurse was responsible for monitoring to ensure dirty clothes were changed. The ADON stated a potential negative impact of the clothing not being changed was the resident would not feel clean. During an interview on 09/05/24 at 02:14 PM, the DON stated she monitored to ensure residents were changed after their clothing became dirty with food by doing rounds and checking residents. She stated the charge nurse, the ADON, and she were all responsible for ensuring residents were in clean clothing. She stated the potential negative impact of residents sitting in dirty clothes was they could be embarrassed. During an interview on 09/05/24 at 02:42 PM, the ADM stated residents who became dirty during meals needed to be changed right after the meal. He stated the CNAs had hands on responsibility and the nurses needed to be checking to make sure it was done. He stated the rest of the management team also had some responsibility to look out for people and make sure their clothes were clean. He stated a potential negative impact of the failure was that the residents could feel they were being looked at as dirty people. He stated he would not want to be looked at that way. Review of facility policy dated 2023 and titled Resident Rights reflected 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 of the facility. You have the right to exercise your rights without interference, coercion, discrimination, or reprisal from the facility as a resident of the facility and as a citizen or resident of the United States. You have the right to be treated with respect and dignity, including the right to reside and receive services in the facility with reasonable accommodation of your needs and preferences except when to do so would endanger your or other residents' health or safety. 49097

Based on observations, interviews, and record review, the facility failed to be equipped to allow residents to call for staff through a communication system which relayed the call directly to a centralized staff work area for 1 of 15 residents (Resident #459) reviewed for call lights. The facility failed to ensure Resident #459's emergency call button in the bedroom was operating properly. This failure could place residents at risk of injury, pain, and hospitalization . The findings included: Record review of a face sheet dated 8/25/2024 for Resident #459 indicated she was a [AGE] year old female admitted [DATE] with diagnoses of fracture of the right femur (broken leg), anemia (low red blood cells in the blood), and acute kidney failure. Record review of a MDS dated [DATE] for Resident #459 indicated she had a BIMS score of 15 indicating she had no cognitive impairment. Record review of a care plan dated 8/26/2024 for Resident #459 indicated she was at risk for falls and was dependent on staff for assistance. During an interview and observation on 9/03/2024 at 10:35 a.m. at Resident #459's room, Observation reflected the bedroom call button in Resident #459's room was not functioning after being pressed twice by resident. The light outside of the room was not illuminated to alert staff that the resident may need assistance . During an interview with Resident #459 stated I feel staff is too young and doesn't follow through timely. When call light pressed takes a long time. During an interview on 9/3/24 at 12:34 p.m., CNA H stated she observed and verified the call light was not working. She stated the call light had worked earlier that morning but was not working at the time of observation. She verified that the potential for harm towards the resident could be an injury, pain or hospitalization . During an interview on 9/3/24 at 12:59 p.m., the maintenance director stated the call light wires were not functioning properly and were replaced upon discovery. He stated the issue was fixed and that the call light was functioning properly. During an interview on 9/4/24 at 9:26 a.m., the DON stated her expectation is to have call lights answered timely and functioning. She stated that malfunctioning call light system could place the resident at risk of not having their needs met. During an interview on 9/5/24 at 2:39 p.m., the Administrator stated It is my expectation that resident call lights be functioning at all times. There could be an urgent resident need that needs to be addressed. He also stated the entire staff is responsible for ensuring call lights are functioning properly. Record review of maintenance logs dated 7/3/24 and 8/22/24 show functioning bedroom call light tests in Resident #459's room. Record review for undated policy titled, Call Light/Bell, indicated, Answer the light/bell within a reasonable time. If the call light/bell is defective, immediately report this information to the unit supervisor.

Based on interview and record review, the facility failed to ensure the residents rights to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 1 of 5 residents (Resident #49) reviewed for advanced directives: The facility failed to ensure Resident #49's out of hospital do-not-resuscitate (OOH-DNR) form included all required signatures including a second signature from the resident, witnesses, and physician. This failure could place residents at-risk of having their wishes dishonored or delay necessary medical treatment or intervention. Findings included: Review of Resident #49's face sheet dated 09/05/2024 revealed Resident #49 was admitted on [DATE] with diagnoses of unspecified fracture of right femur (injury between to the bone between the hip and knee), unspecified sequelae of cerebral infarction (conditions as result of stroke), unspecified atrial fibrillation (irregular heartbeat), and dysphagia (difficulty swallowing). Review of Resident #49's care plan dated 07/21/2024 revealed the focus I have elected to be DNR code status. Interventions included to review code status quarterly and as needed with resident. Review of physician's orders for Resident #49 revealed DNR/Do Not Attempt Resuscitation order dated of 09/04/2024. Review of Resident #49's clinical record revealed she had an OOH-DNR form dated 06/06/2019. Further review revealed that under the section all persons who have signed above must sign below, acknowledging that this document has been properly completed there were no signatures from the resident/proxy, witnesses/notary or physician. Review of Resident #49's IDT care plan review dated 08/07/2024 revealed that it was reviewed Resident #49 had a DNR in place and wished to remain DNR at time of the review. During an interview on 09/04/2024 at 3:09 PM with LVN G, she stated that residents are asked when they arrive if they have a DNR in place or if they would like to put one in place if they are cognitive enough to sign. She stated that if they have a DNR form and it is filled out, the nurse reviews it to ensure it has witness signatures and is signed by the doctor. LVN G stated that she looked at the form to see if all the necessary spaces are filled out. LVN G was observed viewing Resident #49's DNR form and stated that it was not valid due to missing second signature. LVN G stated that the nurse is supposed to ensure the form is filled out prior to putting the order in. She stated that the DON, ADON and SW usually view the form before it is put in the resident's record. During an interview on 09/04/2023 at 3:18 PM, LVN I stated that the nurse and DON verify that a DNR is complete. She stated that when a resident comes in with a form that is completed copies are provided to the physician and medical records for review. LVN I was observed viewing Resident #49's DNR and stated that it was not valid, and it was missing signatures. LVN I stated that there is a potential of the resident's wishes not being met due to the form being incomplete. During an interview on 09/05/2024 at 11:14 AM, she stated that social services and nursing are responsible for ensuring advanced directives are valid. She stated that a nurse should have reviewed them, and social services is trained to review any advanced directives prior to the document going into the resident's chart. She stated that any advanced directive should have been completed filled out before it was put in the resident's chart. She stated that nurses were trained to recognize that a DNR should be filled out completely before it is excused. She stated that Resident #49's DNR was missing signatures and not considered valid. During an interview on 09/05/2024 11:31 AM with SW, she stated that she has witnessed advanced directives and does also assist with sending them to the doctor to be signed. She stated that she has reviewed DNRs to ensure it complete and will review the document if medical records sent it to her as well. She stated that advanced directives, including DNRs, are audited about every 6 to 8 weeks. She stated that for a DNR it required the name of the resident and signature, two witness signatures and printed names and the doctor signature. She stated that witnesses, resident, and doctor are required to sign twice. She stated that a DNR would not be considered valid if it was missing second signatures. During an interview on 09/05/2024 at 2:19 PM, the ADM stated that he expected that advanced directives are accurately completed prior to the document being entered in the resident charge. He stated that a complete chart review was completed after a resident was admitted ensuring that advanced directives that were provided were accurate. He stated that if a DNR is not filled out correctly then a patient should have been treated as a full code until it is corrected and stated that there were a lot of things that could potentially have happened or nothing at all. Review of facility policy titled Advanced Directives and Associated Documentation with revision date of 12/2023 reflected it is the policy of this facility to implement the resident decisions and directives that are in compliant with State and/or Federal Law and the policies of this facility. Further review revealed that it is the facility's policy to review the Advanced Directive to validate the document reflects the resident choices and that the document is signed and dated by the resident or responsible agent. Review of Health and Safety Code 166.083(7)(13) revealed that a OOH-DNR must contain a statement at the bottom of the document, with places for the signature of each person executing the document, that the document has been properly completed.

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 1 of 8 residents (Resident #34) reviewed for ADL care. The facility failed to ensure Resident #34's fingernails were clean and smooth from 09/03/24 to 09/05/24. This failure placed residents at risk of skin tears and infection. Findings included: Review of the undated face sheet for Resident #34 reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis included dementia, lack of coordination, abnormal posture, traumatic subdural hemorrhage with loss of consciousness, muscle weakness, malaise (a general feeling of discomfort, illness, or uneasiness whose exact cause is difficult to identify), cognitive communication deficit, need for assistance with personal care. Review of the quarterly MDS for Resident #34 dated 05/29/24 reflected a BIMS score of 99, indicating she was unable to complete the interview. Review of the section on functional abilities and goals reflected she required moderate/partial assistance in activities of personal hygiene. Review of the care plan for Resident #34 dated 08/19/24 reflected the following: [Resident #34] is at risk for ADL Self Care Performance Deficit. Will maintain current level of function in: Bed Mobility, Transfers, Eating, Dressing, Grooming, Toilet Use and Personal Hygiene; ADL Score through the review date. PERSONAL HYGIENE ROUTINE: requires extensive staff participation for personal hygiene. Review of the CNA documentation system reflected Resident #34 received assistance with personal hygiene at 11:18 AM on 09/04/24 by CNA E. Review of the CNA documentation system reflected no nail care was documented for Resident #34 from 08/07/24-09/05/24. During an interview on 09/05/24 at 11:35 AM, CNA E stated Resident #34 was very clingy and liked to grab and snatch everything, so her fingernails often got dirty. CNA E stated Resident #34 could be combative, but not frequently. She stated they tried to get to the fingernails, but there was sometimes not enough time. She stated she did not think nail care was assigned to a particular nursing person. She stated she had not noticed that resident #34's fingernails were long, jagged, or dirty. During an interview on 09/05/24 at 01:07 PM, LVN G stated there were no showers scheduled Sundays, and that was when nail care should have been done. She stated nails should have also been cleaned as needed and in resident showers. LVN G stated some residents were combative, and the CNAs sometimes got scared and came to her for help. She stated she addressed combativeness or refusals by offering residents something different, someone different to care for them, or distracting them with snacks, treats, or music. She stated she monitored to ensure nail care was done by doing rounds, but she mostly relied on the aides to tell her if something needed her attention. LVN G stated no combativeness or refusals by Resident #34 had been reported to her. She stated the potential negative outcome of having long, dirty, jagged fingernails, was Resident #34 could scratch herself or someone else. During an interview on 09/05/24 at 01:53 PM, the ADON stated nail care was delegated to the CNAs as long as the resident did not have diabetes. She stated the expectation was if staff saw long, jagged, or dirty nails, they should be addressed right away. She stated the person responsible for monitoring to ensure nail care was done was the charge nurse. She stated the potential negative outcome to residents for not providing their nail care was bacterial infection and skin alteration. During an interview on 09/05/24 at 02:14 PM, the DON stated she monitored nail care by going around and checking nails, tells CNAs to check nails, and telling nurses to check nails. She stated if residents refused, they tried to send someone back to try again. The DON stated the charge nurses and CNAs were responsible for ensuring nails were done. The DON stated a potential negative impact of not keeping up with nail care was residents could have a skin alteration or infection. During an interview on 09/05/24 at 02:42 PM, the ADM stated they did rounds to ensure nail care had been performed. He stated nursing was responsible for ensuring nail care was done. He stated a potential negative outcome of nail care not being done was the residents could hurt themselves. Review of facility policy dated 05/2007 and titled ADLs reflected the following: Nursing service staff cares for its residents in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life and promotes care for residents in a manner and in an environment that maintains or enhances each resident's dignity, and respect in recognition of his or her individuality. Each resident receives assistance as needed to manage their physical needs, which includes personal hygiene, grooming, dressing, toileting, transferring, and ambulating.

Based on observation, interview and record review, the facility failed to assist residents in obtaining dental services for 2 of 5 (Resident #46, Resident #74) residents reviewed for routine dental services in that: The facility failed to assist Resident #46 in obtaining dental services after learning that her dentures were uncomfortable. The facility failed to assist Resident #74 in obtaining dental services after learning her dentures were uncomfortable. These failures could place residents with dental care concerns at risk for pain, declined oral health, weight loss and decreased quality of life. Findings included: 1. Review of Resident #46 face sheet dated 09/05/2024 revealed Resident #46 was admitted on [DATE] with diagnoses of other sequelae of cerebral infarction (conditions as result of stroke), dysphagia (difficulty swallowing, hemiplegia and hemiparesis following unspecified cerebrovascular disease (paralysis and weakness in part of body following stroke). Review of Resident #46's annual MDS dated [DATE] revealed a BIMS score of 13 which indicated she was cognitively intact. Review of Resident #46's last IDT care plan review dated 07/10/2024 revealed under Dietary Plan of Care (Dental, Oral, and Hydration and Nutritional Status) we will try to incorporate more soft foods as her (Resident #46) dentures have been bothering her Observation on 09/04/2024 at 8:50 AM, revealed Resident #46 had white and grey build up on her bottom teeth near her gums. 2. Review of Resident #74's face sheet dated 09/05/2024 reflected Resident #74 was admitted on [DATE] with diagnoses of End Stage Renal Disease (terminal illness when kidneys can no longer function properly), Type 2 Diabetes Mellitus (a chronic condition that causes high blood sugar levels due to a lack of insulin or insulin resistance), and Peripheral Vascular Disease (a chronic in which blood flow is reduced to organs and limbs outside of the heart and brain). Review of Resident #74's quarterly MDS dated [DATE] reflected a BIMS score of 15 which indicated that she was cognitively intact. Observation on 09/03/2024 at 2:14 PM, revealed resident had no teeth (natural or dentures) in her mouth. During an interview on 09/03/2024 at 2:15 PM, Resident #76 stated that she needed to get her bottom dentures fixed. Resident #76 stated that a CNA dropped her dentures in the skin and broke them. She stated that it had been a few months ago. During an interview on 09/04/2024 at 8:50 AM, Resident #46 she stated that she has upper dentures and stated that she needed to see a dentist, really bad. She stated that she only has upper dentures and that her bottom teeth were her own. She stated that sometimes her teeth hurt and stated that her dentures have been bothering her. She stated that she has asked to see a dentist two or three times. During an interview on 09/04/2024 at 1:57 PM, the ADM stated that he does not have record of Resident #46 seeing a dentist in the last year. During an interview on 09/04/2024 at 2:56 PM, SW stated that she does not believe Resident #46 has seen a dentist tin the last year. She stated that the dentist come at least once a month. She stated that the dentist usually lets her know a week in advance of who would be seen. She stated that she knew Resident #46 wanted to get new dentures and she believed the dentist told her that it may not be possible. She stated that that may have been two or three months ago. SW stated she was not present during the last care plan meeting and was unsure why Resident #46 was not referred to the dentist if she had concerns about her dentures then. She stated that the social worker is responsible for sending referrals to the dentist. She stated she also sent referrals to the dentist and would send it within a day. During an interview on 09/04/2024 at 3:01 PM, SW stated that she did not see any documentation that Resident #74 had been seen by the dentist in the last year. During an interview on 09/04/2024 at 3:05 PM, CNA J stated that the oral care that is provided to residents depends on their needs. She stated that if a resident can brush their teeth on their own, they may just help them set up. She stated that if she noticed a resident's teeth or denture was broken, she would report it to the nurse. She stated that she did not believe Resident #74 had dentures, but she stated that usually Resident #74 does her own oral care. During an interview on 09/04/2024 at 3:07 PM, CNA J stated that Resident #46 has top dentures and that her dentures get taken out at night and sanitized. She stated that she Resident #46 were to complain about her dentures she would let a nurse know. CNA J stated that she had not noticed any build up on Resident #46's teeth. During an interview on 09/05/2024 at 9:58 AM, CNA E she stated that some residents can do their own oral care in the mornings. She stated that some require set up such as getting the toothbrush ready with toothpaste. She stated that if residents cannot do their own oral care, they are offered more assistance. She stated that Resident #74 can do so and believes she has her own teeth. During an interview on 09/05/2024 at 9:59 AM, CNA E stated that Resident #46 has dentures but had a hard time with the dentures fitting. She stated that half of the time she has difficult time with the dentures because they do not fit. She stated that she feels her gums are shaped differently that the dentures. She stated that Resident #46 had top dentures. She stated that Resident #46 has told her she wanted to see a dentist and she has overheard her talking with her family about wanting to see a dentist. CNA E stated that she did not let anyone know that Resident #46 wanted to see the dentist because she was unsure if the facility provides dental services or if the resident's family would provide it. She stated that if she noticed dentures were broken or if the resident was having pain, she would let the nurse know. During an interview on 09/05/2024 at 10:09 AM, CNA F she stated that almost all residents need assistance with oral care. She stated that Resident #46 has dentures and can brush her own teeth. She is not aware if Resident #46 has complained about her teeth but if she noticed broken dentures she would report to the nurse. During an interview on 09/05/2024 at 10:16 AM, LVN G stated that Resident #74 performs her own oral care and can put her dentures on and take them off but sometimes prefers to have her dentures off. She stated that when she asked Resident#74 if she wanted to wear her dentures Resident#74 would reply are you crazy. She stated that Resident #74 sometimes asked for soft feeds. She stated that she has not asked Resident #74 if she needed to see a dentist. During an interview on 09/05/2024 at 10:17 AM, LVN G stated that Resident #46 is able to do her own oral hygiene and has top dentures and her own teeth on the bottom. She stated that if a resident were to complain about broken teeth or dentures, they could offer softer food. LVN G stated that normally the social worker is in charge or dental appointments, but ADON can help too. During an interview on 09/05/2024 at 11:17 AM, the DON stated that if there is an emergency the resident can be sent out for emergency dental. She stated that there are some residents that had insurance that dental services were not covered, or families elect to have the insurance that do not cover dental services. She stated that if a CNA overheard a resident say that they needed to see a dentist they should tell a nurse and the nurse should have notified the DON or NP. She stated that a dental would be made depending on if the complaint was a one-time complaint or if it was consistent. She stated that she would have expected a CNA to tell a nurse if they dropped dentures and were broken. She stated that Resident #74 is very vocal, and she had not heard of issues with her dentures. She stated that she believes Resident #46 family was going to take her to the dentist. During an interview on 09/05/2024 at 2:15 PM, the ADM stated that referring a resident to the dentist would depend on their insurance coverage. He stated that the facility would need to investigate what caused the dentures to break and if the facility caused the issue, then the facility would pay to get them fixed. He stated that the social worker is the person who sets up dental services. He is unsure why Resident #46 had not seen a dentist and stated that she may have potentially had no coverage and he believed the family was going to take Resident #46 to the dentist. Review of facility dental record for last year revealed Resident #46 and Resident #74 had not been seen by the dentist. Review of Resident #46 progress notes revealed no indication that family had planned to take her to see a dentist or that the facility offered to refer her to the dentist. Review of Resident #74 progress notes revealed no indication that she was offered to see a dentist by the facility despite her asking for softer foods and preferring not to wear her dentures. Review of facility policy titled Dental Services with revision date of 01/2022 revealed it is the policy of this facility to ensure that its residents who require dental services on a routine or emergency basis have access to such services without barrier. It is likewise the policy of the Facility to repair or replace the dentures of a resident except in those situations where the loss or damage directly results from the action of an alert or oriented resident who is responsible for his/her own medical decisions. Further review revealed that the facility will investigate in the event a resident experiences damage to his/her dentures to determine financial responsibility for replacement or repair. For Medicare and Medicare residents, the facility will ensure that needed/emergency dental services are available and may bill or inform resident a deduction for incurred expense may occur. Further review revealed if a resident is unable to pay for dental services the facility will attempt to find alternative funding so that the resident may receive the services to meet their dental needs and maintain their highest practicable level of well-being. Facility policy reflected the facility will promptly (within three business days) refer the resident for dental services and if services does not occur within three business days the facility will documentation actions taken to ensure resident can eat, drink and communication and document the nature of the extenuating circumstances which led to the delay.

Based on interview and record review the facility failed to report alleged violations related to abuse and report the results of all investigations to the proper authorities within prescribed timeframes for one (Resident #1) of five residents reviewed for abuse and neglect, in that: The facility failed to report an allegation of neglect to the State Agency when Resident #1 was found in her room with a steak knife and voicing suicidal intent. This failure placed residents at risk of further abuse or neglect. Findings Included: Review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including major depressive disorder, general anxiety disorder, unspecified dementia, and frontal lobe and executive function deficit following other cerebrovascular disease (includes a variety of medical conditions that affect the blood vessels of the brain and the cerebral circulation). Review of Resident #1's quarterly MDS assessment, dated 09/21/23, reflected a BIMS of 12, indicating a moderate cognitive impairment. Section D (Mood) reflected she had little interest or pleasure in doing things, felt down, depressed, or hopeless, and felt bad about herself nearly every day. Review of Resident #1's quarterly care plan, revised 10/07/23, reflected she was at risk for potential for a psychosocial well-being problem with an intervention of evaluating her emotional status. She had potential for mood problem with an intervention of monitoring/recording/reporting to MD mood patterns or s/sx of depression, anxiety, or sad mood. Review of Resident #1's progress notes in her EMR, dated 09/05/23 and documented by LVN A, reflected the following: Around 4:15 PM, [LVN A] went into [Resident #1]'s room to admin topical analgesic medications and topical lotions to BLE. [Resident #1] was not tearful nor in any distress. At 5:58 PM, [LVN A] received a call from [Resident #1]'s [FM B], asking [LVN A] to check on [Resident #1]. [FM B] stated [Resident #1] called him tearful, stated she loved [FM B] and hung up. [FM B] said he tried calling her back, but she did not answer. [FM B] yelled at [LVN A] to check on her, then hung up. Immediately after that phone call, [LVN A] asked CNA to check on [Resident #1]. At 6:05 PM, CNA called [LVN A] and said I (LVN A) was needed ASAP. [LVN A] immediately went to [Resident #1]'s room. [LVN A] noted CNA and [Resident #1] in bathroom. [Resident #1] was tearful. CNA notified [LVN A] that [Resident #1] has a knife in her sleeve. Review of Resident #1's progress notes in her EMR, dated 09/05/23 and documented by the DON, reflected the following: .[DON] told [Resident #1] that [DON] was informed she had a knife. [Resident #1] said yes I do have a knife. [DON] told [Resident #1] to give me knife and she said, No I am not going to give you the knife, and matter of fact, I am going to use it now. [Resident #1] pulled knife from her sleeve and was about to cut her wrist. [DON] grabbed knife from her with the help of [LVN A] Review of Resident #1's [NAME] in Condition Evaluation , dated 09/05/23, reflected the following: Change in condition: Behavioral symptoms Behavioral Evaluation: depression, danger to self or others, suicidal potential Describe behavioral changes: crying, complaints, and tried to cut wrist with kitchen knife Recommendation of Primary Clinician: Send to ER for evaluation Review of Resident #1's Psychiatric Physician's note, dated 09/06/23, reflected the following: [Resident #1] hospitalized after taking a knife and stating suicidal intent. Tearful. During an interview on 11/21/23 at 12:50 PM, the DON stated the Abuse and Neglect Coordinator was the ADM. She stated on 09/05/23 a CNA called to let her know that LVN A needed her. She stated she went to Resident #1's room and LVN A was talking to her. She stated before Resident #1 was able to slit her wrist she was able to grab her hand and stop her. She stated it was a steak knife and they were unsure where she had gotten it from. She stated no one reported seeing her with the knife until that day. She stated she was sent to the ER and then to a psychiatric hospital for two weeks before returning to the facility. She stated she did not believe that a self-report was initiated to the State because there had been no actual harm . During an interview on 11/21/23 at 1:31 PM, the ADM stated he was the Abuse and Neglect Coordinator and it was his expectation that the facility was abuse-free. He stated he was notified by the DON right away after Resident #1 was found with the knife. He stated Resident #1 was admitted to a psychiatric hospital for two weeks and when she was readmitted , she told him she had obtained the knife from a restaurant. He stated the incident was a reportable incident to the State and he was sure had reported it. During an interview on 11/21/23 at 1:58 PM, the ADM stated he did not have a file on the incident, which meant it was not reported to the State. He stated it was not a reportable incident because all parties were notified and there was no actual harm. He stated their policy regarding self-reports they followed was HHSC's PL 19-17. Review of HHSC's PL 19-17, dated 07/10/19, reflected the following: A NF must report to HHSC the following types of incidents, in accordance with applicable state and federal requirements: - Abuse - Neglect . - Emergency situations that pose a threat to resident health and safety An incident that does not result in serious bodily injury and involves an emergency situation that poses a threat to resident health and safety should be reported immediately, but no later than 24 hours after the incident occurs or is suspected.

Based on interviews and record reviews, the facility failed to ensure the resident's had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 1 of 5 residents (Resident #1) reviewed for resident rights . The facility failed to provide information to Resident #1 in advance about his newly diagnosed mental illness and the benefits and risks of Chlorpromazine (an anti-psychotic medication) therapy and alternative options available to him. This failure could place residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party. The findings include: Record review of Resident #1's face sheet, dated 08/10//2023, revealed a [AGE] year-old male whose admission to the facility was 08/02/2023. The resident had diagnoses of Cellulitis(Bacterial infection) of right toe, Osteomyelitis (inflammation or swelling of bone tissue ), right ankle and foot, Hypertension, Chronic Kidney Disease, Atherosclerotic heart disease( thickening or hardening of the arteries) of native coronary artery9 Artery of the heart) without angina pectoris(Chest pain), Type 2 diabetes mellitus with diabetic nephropathy(the deterioration of kidney function.), Diastolic (congestive) Heart Failure, Gastro-Esophageal Reflux disease (Acid reflex) without esophagitis(inflammation of the upper digestive tract), Asthma, Allergy, Dry eye syndrome of bilateral lacrimal glands (Tear glands), Posttraumatic Stress Disorder, Gout, Cough, Functional Dyspepsia(Indigestion), Acquired absence of right toe. Record review of Resident #1's [NAME] hospital discharge summary dated 08/01//2023 revealed, a [AGE] year-old male who was admitted to a hospital in [NAME] on 07/23/23 and his diagnoses did not include Post Traumatic Stress Disorder (PTSD). Record review of Resident #1's Care Plan, dated 08/03/23, revealed: I'm on psychotropic medications use related to (agitation /PTSD): Chlorpromazine and the relevant interventions were Administer medications as ordered. Monitor/document for side effects and Effectiveness, consult with pharmacy, MD to consider dosage reduction when clinically appropriate, Discuss with MD, family re ongoing need for use of medication and Educate resident, family/caregivers about risks, benefits and the side effects of medication drugs being given. Record review of Resident #1's MDS, dated [DATE] revealed, Section C (BIMS) and Section N (Medications) were not completed. Record review of Resident #1's Physician Order dated 08/02/23 stated: Chlorpromazine HCl Oral Tablet 10 MG (Chlorpromazine HCl): Give 1 tablet by mouth one time a day for Agitation/PTSD. Order Date and D/C date were 08/02/2023 and 08/07/2023 respectively. Record review of Resident #1's MAR of August 2023 revealed that Chlorpromazine HCl Oral Tablet 10 MG was administered on 08/03/23,08/04/23, 08/05/23, 08/06/23 and 08/07/23. Record review of Resident #1's consent form revealed, Resident #1 had PTSD and was based on review of available medical records. The consent form was created on 08/02/23 and signed by the resident on 08/08/23 (after the discontinuation of Chlorpromazine HCl on 08/07/23). In a telephone interview on 08/10/23 at 12:00 PM the FM stated she was an RN by profession and on 08/07/23 when she was going through Resident #1's MAR, she had noticed Resident#1 was administered with Chlorpromazine HCl Oral Tablet 10 MG once a day. The start date for this medication was 08/02/23 and was for Agitation/PTSD. FM stated Resident # 1 never diagnosed with PTSD or any other mental illness at any point of time in his life. She said she requested the NP to stop giving this unnecessary medication to him and NP discontinued the medication on 08/07/23 with immediate effect. FM said, at the hospital, Resident #1 was prescribed for Chlorpromazine for hiccough (A characteristic sound like that of a cough due to the spasm of the diaphragm) that he had developed after the surgery, and it was resolved before admitting to the facility. FM said no one from the facility explained to the resident or family about the rationale for administering this medication at the facility for agitation/PTSD. She stated, had they discussed this with family and/or resident, this mistake could have been avoided. In a telephone interview on 08/10/23 at 3:00PM Resident #1 stated he never had any kind of mental illness. Resident #1 said, on the admission day LVN A asked him if he had any mental illness since he had an antipsychotic medication in the list. Resident #1 reported, when he stated he was not diagnosed with any mental illness, LVN A stated he had to take a medication for some kind of mental illness since it was ordered by the NP (Resident was unable to name the medication as Chlorpromazine). When investigator asked him, if LVN A explained about the effect and side effect of the medication and what mental illness the medication was for, Resident #1 stated she did not. Resident #1 stated he would not have agreed to take that medication if he knew that it was for managing agitation since he was not an angry man. He stated, 3 days before the FM identified this mistake and made aware to the people at the facility. In a telephone interview on 08/10/23 at 2:00 PM. the NP stated she discontinued Chlorpromazine on 08/07/23 on FM's request. When the investigator asked NP why Chlorpromazine was prescribed, NP stated since it was given at the hospital and was listed in the discharge summary as home medication, she guessed Resident #1 might have some kind of mental illness. When the investigator asked, since there was no information regarding Resident #1 having any mental illness, had she discussed about the diagnosis and effect and side effect of Chlorpromazine to the resident or his family and received a consent before commencing the medication, she stated she did not as the consent forms were completed by the nurses. When the investigator asked, what would have been the appropriate action, NP stated, before placing the order for Chlorpromazine she should have discussed and confirmed about it, with the hospital clinical staff, Resident #1, or FM, why it was administered at the hospital and the rationale for listing it among the home medicines. During an interview and record review on 08/10/23 at 3:30PM LVN A stated that she was the nurse who went to get the consent for Chlorpromazine. LVN A stated, when she stated he had mental illness and there was a medication prescribed for that, Resident #1 reported to her that he never had a diagnosis of any mental illness. LVN A said, when she stated Chlorpromazine, an antipsychotic medication was there in the discharge medication list from the hospital, Resident #1 agreed to sign a consent form, stating there must be some reason then. LVN A showed a consent form that was dated 08/02/23 and signed by resident on the same day. Review of this form revealed, the consent form did not have the information about the diagnosis, diagnostic criteria, name of the medication, probable clinically significant side effect of the medication and need and benefit of the medication. When investigator asked LVN A, if she explained to Resident #1 about the basis of the diagnostic criteria, the medication and clinically significant side effects of the medication, LVN A stated she did not as it had to be done later by the NP who prescribed the medication. In a telephone interview on 08/10/23 at 2:00 PM, the MD stated administration of Chlorpromazine at a lower dose was not harmful to Resident #1 since he was taking it at the hospital and at the facility, it was the continuation of it. When investigator asked, if diagnosing mental illness based on guess work was appropriate, he stated continuing the psychotropic medication irrespective of diagnosis was the right decision since stopping psychotropic medication suddenly have consequences to the safety of residents. When the investigator asked about the appropriateness of administering psychotropic medications without proper explanation and consent, MD stated since it was the continuation of the medication that he was receiving at the hospital, Resident #1 might be aware of it. He added, it was not reasonable to delay the order of psychotropic medications that residents were already receiving in the community, for a reason of obtaining informed consent. In an interview on 07/10/2023 at 4:30 PM, the DON stated, there was a consent form created by the NP and signed by Resident #1. She said the consent had all the component like diagnosis, explanation of possible side effect. When investigator pointed out that the resident had no diagnosis of PTSD in any records, DON stated since Chlorpromazine was ordered for a wrong diagnosis, the medication was unnecessary, and the expectation was no unnecessary medication would be administered to any residents. She stated, the confusion occurred because the medication listed as home medication in the discharge summary from ASW hospital however diagnosis without accurate information was not the best practice. When investigator stated that Resident #1 signed the consent on 08/08/23, DON said though it was signed after the discontinuation of the medication, there was a possibility that the nurses or NP explained about the effect and side effect of the medication while he was taking the medication. Record review of the facility's policy revised on 01/2022, titled Resident Rights reflected: It is the policy of this facility to inform the resident both orally and in writing of his/her rights as a resident, as well as the rules and regulations governing the resident's conduct and responsibilities during his/her stay in the facility . .4. The facility will inform the resident of his/her rights and responsibilities in a language that is both clear and understandable to the resident. Should the resident's knowledge of English be inadequate for understanding such rights and responsibilities, his/her rights and responsibilities will be explained in the language that is familiar to the resident

Based on observation, interview, and record review, the facility failed to ensure the services provided by the facility meet professional standards of quality for 1 of 5 residents (Resident # 1) reviewed for professional standards in that: -The facility failed to ensure Resident #1 was not diagnosed without subjective or objectives evidences and based on assumptions and judgements, that leads to administering unnecessary psychotropic medication. This failure placed residents at risk of receiving unnecessary psychotropic medications which could result in decline in health status. The findings include: Record review of Resident #1's face sheet, dated 08/10//2023, revealed a [AGE] year-old male whose admission to the facility was 08/02/2023. The resident had diagnoses of Cellulitis(Bacterial infection) of right toe, Osteomyelitis (inflammation or swelling of bone tissue ), right ankle and foot, Hypertension, Chronic Kidney Disease, Atherosclerotic heart disease( thickening or hardening of the arteries) of native coronary artery9 Artery of the heart) without angina pectoris(Chest pain), Type 2 diabetes mellitus with diabetic nephropathy(the deterioration of kidney function.), Diastolic (congestive) Heart Failure, Gastro-Esophageal Reflux disease (Acid reflex) without esophagitis(inflammation of the upper digestive tract), Asthma, Allergy, Dry eye syndrome of bilateral lacrimal glands (Tear glands), Posttraumatic Stress Disorder, Gout, Cough, Functional Dyspepsia(Indigestion), Acquired absence of right toe. Record review of Resident #1's [NAME] hospital discharge summary dated 08/01//2023 revealed, a [AGE] year-old male who was admitted to a hosptal in [NAME] on 07/23/23 and his diagnoses did not include Post Traumatic Stress Disorder (PTSD). Record review of Resident #1's Care Plan, dated 08/03/23, revealed: I'm on psychotropic medications use related to (agitation PTSD): Chlorpromazine and the relevant interventions were Administer medications as ordered. Monitor/document for side effects and Effectiveness, consult with pharmacy, MD to consider dosage reduction when clinically appropriate, Discuss with MD, family re ongoing need for use of medication and Educate resident, family/caregivers about risks, benefits and the side effects of medication drugs being given. Record review of Resident #1's MDS, dated [DATE] revealed, Section C (BIMS) and Section N (Medications) were not completed. Record review of Resident #1's Physician Order dated 08/02/23 stated: Chlorpromazine HCl Oral Tablet 10 MG: Give 1 tablet by mouth one time a day for Agitation/PTSD. Order Date and D/C date were 08/02/2023 and 08/07/2023 respectively. Record review of Resident #1's MAR of August 2023 revealed that Chlorpromazine HCl Oral Tablet 10 MG was administered for PTSD/Agitation on 08/03/23,08/04/23, 08/05/23, 08/06/23 and 08/07/23. In a telephone interview on 08/10/23 at 12:00 PM the FM stated she was an RN by profession and on 08/07/23 when she was going through Resident #1's MAR, she had noticed Resident#1 was administered with Chlorpromazine HCl Oral Tablet 10 MG once a day. The start date for this medication was 08/02/23 and was for Agitation/PTSD. FM stated Resident # 1 never diagnosed with PTSD or any other mental illness at any point of time in his life. She said she requested the NP to stop giving this unnecessary medication to him and NP discontinued the medication on 08/07/23 with immediate effect. FM said at the hospital, Resident #1 was prescribed for Chlorpromazine for hiccough (A characteristic sound like that of a cough due to the spasm of the diaphragm ) that he had developed after the surgery, and it was resolved before admitting to the facility. FM said no one from the facility explained to the resident or family about the rationale for administering this medication at the facility. She stated, had they discussed this with family and/or resident, this mistake could have been avoided. In a telephone interview on 08/10/23 at 3:00PM Resident #1 stated he never had any kind of mental illness. Resident #1 said, on the admission day LVN A asked him if he had any mental illness since he had an antipsychotic medication in the list. Resident #1 reported, when he stated he was not diagnosed with any mental illness, LVN A stated he had to take a medication for some kind of mental illness since it was ordered by the NP (Resident was unable to name the medication as Chlorpromazine). When investigator asked him, if LVN A explained about the effect and side effect of the medication and what mental illness the medication was for, Resident #1 stated she did not. Resident #1 stated he would not have agreed to take that medication if he knew that it was for managing agitation since he was not an angry man. He stated, 3 days before the FM identified this mistake and made aware to the people at the facility In a telephone interview on 08/10/23 at 2:00 PM. the NP stated she discontinued Chlorpromazine on 08/07/23 on FM's request. When the investigator asked NP why Chlorpromazine was prescribed, NP stated since it was prescribed at the hospital and was listed in the discharge summary as home medication, she guessed Resident #1 might have some kind of mental illness. When investigator asked about the appropriateness of diagnosing mental illnesses based on guess work, NP said it was a mistake and never should have done that. She said she had requested medical record from VA since Resident #1 was a veteran, to confirm whether he had any mental illness. She added, since it takes time to get those records and the medication was already in the list of home medication, she thought Resident #1 had PTSD. When Investigator asked what would have been the appropriate action, she stated, before placing the order for Chlorpromazine she should have discuss with the hospital clinical staff, Resident #1 or FM for clarification. In a telephone interview on 08/10/23 at 2:00 PM, the MD stated administration of Chlorpromazine at a lower dose was not harmful to Resident #1 since he was taking it at the hospital and at the facility it was the continuation of it. When investigator asked, if diagnosing mental illness based on guess work was appropriate, he stated continuing the psychotropic medication irrespective of diagnosis was the right decision since stopping psychotropic medication suddenly have consequences to the safety of residents. He stated, generally the psychotropic medications were tapering down before discontinuation for avoiding the consequences from suddenly stopping the medication. When investigator pointed out that resident#1's Chlorpromazine stopped abruptly on 08/07/23 without tapering down, MD stated it was fine since the medication was already at a lower dose. In a telephone interview on 08/10/23 at 2:00 PM with the Pharmacist, she stated if resident had no justifiable diagnosis the prescribed Chlorpromazine was unnecessary. When the investigator asked her, if she would have identified Chlorpromazine as an unwanted medication during her next MRR at the facility, RP stated it was most unlikely since the medication was in its lower dose with a diagnosis of PTSD. In an interview on 07/06/2023 at 2:21 PM, the DON stated, Since Chlorpromazine was ordered for a wrong diagnosis, the medication was unnecessary. She stated, the confusion occurred because the medication listed as home medication in the discharge summary from ASW hospital however the practice of diagnosing without any subjective or objective evidence did not meet professional standards. DON stated, since the medication was at its lower dose and taken at the facility only for 6 days, the possibility of any negative outcome was minimal. Before leaving the room after the interview DON took off the consent form created by LVN A. DON stated she was taking it away for shredding as it was not a valid document due to the lack of information like diagnosis, name of the medication, and other relevant information on it. DON stated the consent form created by NP was the valid one. Records review of facility policy Psychotropic drug use revised on 08/2017 reflected: It is the policy of this facility to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record . . 2.On admission, the admitting nurses will review the transfer orders for any psychotropic medications. All effort will be made by the Licensed Nurses to obtain as much history regarding these medications, including prior informed consents. from the previous facility or through resident or resident representative interview. Any information obtained will be documented in the resident's clinical record. 3.The Licensed Nurses shall review the classification of the drug, the appropriateness or the diagnosis, its indication/ behavior monitors and related adverse side effects prior to verification of admission orders with the Attending Physician.