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

Based on observation, interview and record review, the facility failed to care for residents in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for three (Resident #3, Resident #31, and Resident #106) out of 10 residents reviewed for resident rights. The facility failed to knock on Resident #3's, Resident #31's and Resident # 106's doors prior to entry when going into the residents' rooms. The deficient practice could place residents at risk of feeling like their privacy is being invaded or the facility is not their home. Findings included: Review of Resident #3's Face Sheet dated 04/23/26 revealed he was a [AGE] year-old male who was readmitted to the facility on [DATE]. Resident #3's diagnoses included OTHER ACUTE OSTEOMYELITIS of LEFT ANKLE AND FOOT, (a rapid-onset bone infection), TYPE 2 DIABETES MELLITUS, (A condition results from insufficient production of insulin, causing high blood sugar.) and SCHIZOAFFECTIVE DISORDER, (includes bouts of hypomania or mania and sometimes major depression.) Record review of Resident #3's Quarterly MDS assessment dated [DATE] revealed that Resident #3's BIMS score was 15 indicating Resident #3 had intact cognitive response. Record review of Resident #3's Care Plan dated 04/01/26 reflected that he is at risk for falls r/t gait/balance, decreased safety awareness, and increased confusion. The goal is he will be free of falls through the review date of 04/26/26. Interventions: Be sure the call light is within reach and encourage him to use it to call for assistance as needed. Review of Resident #31's Face Sheet dated 04/22/26 revealed she was a [AGE] year-old female who was readmitted to the facility on [DATE]. Resident #31's diagnoses included HEMIPLEGIA AND HEMIPARESIS, (Hemiplegia is a symptom that involves one-sided paralysis. Hemiplegia affects either the right or left side of your body.) FOLLOWING CEREBRAL INFARCTION, (the pathologic process that results in an area of necrotic tissue in the brain. It is caused by disrupted blood supply (ischemia) and restricted oxygen supply (hypoxia) and EPILEPSY, (A neurological disorder that causes seizures or unusual sensations and behaviors). Record review of Resident #31's Quarterly MDS dated [DATE] revealed that Resident #31's BIMS score could not be obtained. Resident # 31 was Dependent (helper does all the effort) regarding ADLs. Record review of Resident #31's Care Plan dated 02/09/26 reflected that she is at risk for impaired cognitive function or impaired thought process r/t stroke and brain injury. The goal is she will maintain current level of cognitive function through the review dated 4/20/26. Interventions: Identify yourself at each interaction. Face when speaking and making eye contact. Review of Resident #106's Face Sheet dated 04/22/26 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #106's diagnoses include: Unspecified Dementia, (A group of symptoms that affects memory, thinking and interferes with daily life.), Anxiety, (feeling of uneasiness or worry), Major Depressive Disorder, (A mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts.) Review of Resident # 106's Quarterly MDS dated [DATE] revealed that Resident #106's BIMS score could not be obtained. Resident # 106 was Dependent (helper does all the effort) regarding ADLs. Record review of Resident #106's Care Plan dated 04/07/26 reflected that she is at risk for impaired cognitive function/dementia or impaired thought processes r/t dementia. The goal is she will maintain current level of cognitive function through the review dated 5/10/26. Interventions: Identify yourself at each interaction. Face when speaking and making eye contact. Observation on 200-hall on 04/21/26 at 06:29 am revealed that HK G did not knock on Resident #31's and Resident # 106's doors before entering. Observation of lunch trays being passed on 300-hall on 04/21/26 at 12:17 p.m., revealed that CNA H did not knock on Resident #3's door before entering. An interview on 04/21/26 at 12: 15 p.m., revealed Resident # 3 was dining and refused to be interviewed. An interview with Resident # 106 on 04/21/26 at 1:02 p.m., revealed that Resident # 106 was not aware that Housekeeping and other staff are required to knock on her door before coming into the room. Resident # 106 stated, she would like for staff to knock first so she is not surprised when she sees staff enter. An interview with Resident #31 on 04/23/26 at 2:49 p.m., revealed that staff did not always knock on the door when going into her room. She stated that the staff should knock before they enter the room. She said, sometimes I am surprised by an unannounced visit. An interview with HK G on 04/21/2026 at 6:29 a.m., revealed that HK G did not know why she forgot to knock on doors while she was working the 200 hallways. She said, residents could feel like they are not given privacy if we don't knock on doors. An interview with CNA H on 04/23/2026 at 1:29 p.m., revealed that she had been trained on resident rights. She stated the policy for knocking was that all staff were to knock before entering the resident's room. She said that a resident may feel like his or her privacy was being invaded or may feel as if the facility was not their home. She said nurses were responsible for monitoring to ensure staff were knocking. She said it was monitored by observations and when the facility did skill checks. She said she did not realize she did not knock because she was probably in a rush to do something. An interview with DON on 04/23/2026 at 2:02 p.m., revealed that knocking on the resident's door is part of the Residents Rights Policy. She stated, we always tell them, knock on the door and introduce yourself before entering. DON stated, This is the Residents home, and they have a right to privacy and respect She said, staff knocking on doors is monitored by the Management staff and if I see staff not knocking, I will stop and educate them. An interview with ADM on 04/23/2026 at 3:00 p.m., revealed, ADM understands that knocking on the resident's door is considered a resident right. He said, the purpose for staff being required to knock on doors before entering a resident's room is so the facility staff will comply with the residents' right to privacy. He said, we are training staff each and every day to ensure the staff remember to knock on doors before entering a resident's room. He stated, residents may not feel respected if we do not knock on the resident's door. ADM said he did not know why housekeeping staff failed to knock on Resident # 31's and Resident # 106's doors. Record Review of Resident Rights and Responsibilities Policy amended 07/13/17 revealed: Privacy and Confidentiality: You have the right to personal privacy and confidentiality of your personal and medical records. You have the right to:Personal privacy, including accommodation, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. Secure and confidential personal and medical records.Personal privacy, including the right to privacy in your oral, written, and electronic communications. Safe Environment.Grievances. Resident Rights:. You have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.

Based on observation, interview, and record review, the facility failed to ensure residents could call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 4 of 17 residents (Resident #31, #41, # 42 and # 76) reviewed for the ability to call for staff assistance. The facility failed to provide a working communication system that was easily at reach, which would allow Resident #31, # 41, #42 and # 76 the ability to safely call for staff for assistance. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they needed support for daily living.Findings include: Review of the face sheet for Resident #41 reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included PRIMARY OSTEOARTHRITIS (the protective cartilage that cushions the ends of the bones wears down over time.), CARPAL TUNNEL SYNDROME related to Right wrist, (an Irritation or damage inside the carpal tunnel in your wrist causes it when swelling presses on your median nerve), AGE-RELATED COGNITIVE DECLINE (memory loss, difficulty with decision -making). Review of Resident #41's Quarterly MDS dated [DATE] reflected a BIMS Score of 15, which indicated she was intact. The MDS also reflected Resident #41 needs Supervision or touching assistance for lying to sitting on bed and positioning of sitting to standing. Record review of Resident #41's Care Plan dated 03/25/26 reflected she has ADL Self Care Performance Deficit related to weakness. The goal indicated Resident #41 will maintain current level of function in Bed Mobility, Transfers, Eating, Dressing, Grooming, Toilet Use and Personal Hygiene; Intervention reflected Be sure the call light is within reach and encourage to use it to call for assistance as needed. An observation and interview on 04/21/26 at 6:41 a.m., reflected Resident #41 was lying in her bed and call light was observed wrapped around the right bed frame out of reach of Resident #41. Resident #41 stated, she could not reach the call light. Review of the face sheet for Resident #31 reflected a [AGE] year-old female readmitted to the facility on [DATE]. Her diagnoses included HEMIPLEGIA AND HEMIPARESIS (Hemiplegia is a symptom that involves one-sided paralysis. Hemiplegia affects either the right or left side of your body.) FOLLOWING CEREBRAL INFARCTION, ( refers to the long-term, late effects or conditions that can occur after a cerebral infarction (ischemic stroke) , Primary AFFECTING LEFT NON-DOMINANT SIDE, EPILEPSY, (A neurological disorder that causes seizures or unusual sensations and behaviors.) and COGNITIVE COMMUNICATION DEFICIT (difficulties in communication that arise from impairments in cognitive processes such as attention, memory, perception, and executive function). Review of Resident #31's Quarterly MDS dated [DATE] reflected Resident #31's functional ability was 'dependent', and helper does all the effort for ADLs. Record review of Resident #31's Care Plan dated 03/25/26 reflected she has ADL Self Care Performance Deficit related to weakness. The goal indicated Resident #31 will safely perform Bed Mobility, Transfers, Eating, Dressing, Grooming, Toilet Use and Personal Hygiene) with 1 person assist or supervision, through the review date. Interventions reflected Occupational, Physical, Speech-Language Therapy evaluation and treatment per physician orders. An observation and interview on 04/21/26 at 6:37 a.m., reflected Resident #31 was lying in her bed and call light was observed on the floor, out of resident's reach. Resident # 31 stated she could not reach the call light. Review of the face sheet for Resident #42 reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included PRIMARY UNSPECIFIED DEMENTIA (memory, thinking, difficulty), UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PERSONAL HISTORY OF TRANSIENT ISCHEMIC ATTACK (temporary blockage of blood flow to the brain), AND CEREBRAL, DEPRESSION (brain experiences insufficient oxygen during or immediately after birth, leading to impaired neurological function). And Cognitive communication Deficit (ability to communicate effectively is impaired due to underlying cognitive dysfunction rather than a primary language or speech problem.). Review of Resident #42's Quarterly MDS dated [DATE] reflected Resident #42 is dependent; helper does all the efforts needed for ADLs. Record review of Resident #42's Care Plan dated 02/12/26 reflected that she is at risk for impaired cognitive function/dementia or impaired thought processes r/t Dementia. Goal indicated Resident #42 will maintain current level of cognitive function through the review date. Intervention reflected communication: Identify yourself at each interaction. Face when speaking and making eye contact. Reduce any distractions- turn off TV, radio, closed door etc. Use simple, directive sentences. Provide with necessary cues- stop and return if agitated. An observation and Interview on 04/21/26 at 6:43 a.m., revealed Resident #42 was lying in her bed and her call light was observed wrapped around the left bedframe, out of resident's reach. Resident #42 stated she could not reach the call light button. Review of the face sheet for Resident #76 reflected an [AGE] year-old female readmitted to the facility on [DATE]. Her primary diagnoses included HEMIPLEGIA AND HEMIPARESIS (Hemiplegia is a symptom that involves one-sided paralysis. Hemiplegia affects either the right or left side of your body.) FOLLOWING CEREBRAL INFARCTION or stroke, (a sudden interruption of blood flow to the brain.) AFFECTING RIGHT DOMINANT SIDE and PARKINSON'S DISEASE (A movement disorder of the nervous system). Review of Resident #76's Quarterly MDS dated [DATE] reflected Resident #76 is dependent; helper does all the efforts made for ADLs. Record review of Resident #76's Care Plan dated 03/24/26 reflected that she is at risk for impaired cognitive function/dementia or impaired thought processes r/t Dementia. Goal indicated Resident #76 will maintain current level of cognitive function through the review date. Intervention reflected Engage in simple, structured activities that avoid overly demanding tasks. An observation on 04/21/26 at 6:18 a.m., revealed Resident #76 was lying in her bed and she could not be interviewed. Resident # 76's call light was observed hanging off the left side of the bed out of her reach while she was in bed. During an interview on 04/23/2026 at 1:29 PM CNA H revealed CNAs are responsible for placement of call lights so that residents have access to their call lights. CNA H stated that the location and placement of a call light may be different for each resident. She stated, 'it depends on the condition of that resident as to where it is placed for them.' She stated, 'it is never ok for a call light to be on the floor because the residents will not be able to use it to get the care they need. During an interview on 04/23/2026 at 1:25 p.m., MA E revealed that she has been trained in call light placement. MA E stated, 'all staff are responsible for ensuring that call lights are placed within the residents' reach. She stated if a call light button is not located properly for that resident, the staff may not be able to meet the needs of that resident. MA E explained that ADM and Managers do rounds in the morning and they check on call light placement. During an interview on 04/23/2026 at 2:02 p.m., DON revealed that the facility policy and procedure subject: Call Light/ Bell states, the call device should be within residents' reach before staff leave the room. She stated the nursing staff are responsible for determining what type of call light will be used for each resident. She said, some residents cannot maneuver the button, so they provide a flat call one to them. She stated, the call lights should be within reach of the residents, or their needs may not be met. During an interview on 04/23/2026 at 3:00 p.m., ADM revealed the call lights should be within reach of the residents. He said, 'every morning we do Angel rounds we check on the resident's wellbeing including the availability of the call light for each resident. ADM said every resident is different so the location and type of call device may be different. He said it must be within reach of the resident. Review of the facility Policy & Procedure for Call Light/Bell dated May 2007 reflected, It is the policy of this facility to provide a means of communication with nursing staff. 1. Answer the light/bell within a reasonable time.2. Turn off the call light/bell.3. Listen to the president's request/need.4. Respond to the request. If the item is not available or you are not able to attend, explain to the residents and notify the charge nurse for further instruction.5. Leave the resident comfortable. Place the call device within the resident's reach before leaving room. If the call light/ bell is defective, immediately report this information to the unit supervisor.

Based on observation, interview, and record review, the facility failed to follow menus for 3 (Resident #2, Resident #23, and Resident #88) of 3 residents reviewed for a pureed diet. The facility failed to use a large enough scoop when serving residents on a pureed diet on 4/21/26, 4/22/26, and 4/23/26. This failure placed residents at risk for decreased intake and weight loss.Findings included: A record review of Resident #2's face sheet dated 4/23/2026 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of cerebral infarction (stroke), atrial fibrillation (irregular heartbeat), dysphagia (difficulty swallowing), pneumonitis (inflammation of the lung) due to inhalation of food and vomit, muscle wasting and atrophy (muscle loss), cognitive communication deficit (difficulty communicating), gastrostomy status, (presence of feeding tube) and need for assistance with personal care. A record review of Resident #2's MDS assessment dated [DATE] reflected that she could not be assessed for BIMS because she was rarely/never understood. A record review of Resident #2's care plan last revised on 3/30/2026 reflected that she had nutritional problems related to dysphagia and protein calorie malnutrition. Interventions included a pureed diet as ordered by the physician. A record review of Resident #2's physician order dated 3/30/2026 reflected she was on a pureed diet. A record review of Resident #2's weight history reflected that she weighed 145.9 pounds on 3/22/2026 and 135.4 pounds on 4/22/2026. A record review of Resident #23's face sheet dated 4/23/2026 reflected a [AGE] year-old male readmitted on [DATE] with diagnoses of Parkinson's disease (progressive neurological disorder), unspecified dementia, muscle wasting and atrophy (muscle loss), dysphagia (difficulty swallowing), cognitive communication deficit (difficulty communicating), and need for assistance with personal care. A record review of Resident #23's MDS assessment dated [DATE] reflected that he had not yet been assessed for a BIMS score. A record review of Resident #23's care plan revised on 4/22/2026 reflected that he had a potential nutritional problem related to dysphagia and newly diagnosed aspiration pneumonia. Interventions included a pureed diet as ordered by the physician. A record review of Resident #23's diet order dated 4/22/2026 reflected that he required a pureed diet. A record review of Resident #23's weight record reflected that he weighed 133.9 pounds on 4/22/2026 and 134.8 pounds on 2/25/2026. A record review of Resident #88's face sheet dated 4/23/2026 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of psychotic disturbance, diverticulitis of intestine (pouches in colon), dementia, muscle wasting and atrophy (muscle loss), dysphagia (difficulty swallowing), cognitive communication deficit (difficulty communicating), anorexia, and need for assistance with personal care. A record review of Resident #88's MDS assessment reflected a BIMS score of 15, which indicated intact cognition. A record review of Resident #88's care plan revised on 9/08/2024 reflected that she had a nutritional problem or potential nutritional problem related to dysphagia. Interventions included giving supplements as ordered. A record review of Resident #88's physician order dated 9/21/2025 reflected that she was on a pureed diet. A record review of Resident #88's weight record reflected that she weighed 124 pounds on 4/08/2026 and she weighed 126 pounds on 3/09/2026. During an observation of breakfast on 4/21/2026 at 7:23 AM, CK F was serving breakfast using a blue #16 scoop for pureed scrambled eggs and a yellow #20 scoop for pureed sausage. During an observation of lunch on 4/21/2026 at 12:27 PM, CK F was serving lunch using a green #12 scoop for pureed beef goulash, pureed squash, and pureed peppers & onions. During an observation and interview on 4/22/2026 at 8:38 AM, Resident #88 was observed lying in bed. Resident #88 stated that the food had improved in the past few months. An observation on 4/22/2026 at 9:05 AM revealed that CK F used a blue #16 scoop to serve pureed scrambled eggs. During an observation on 4/22/2026 at 10:17 AM, Resident #2 was observed lying in bed with her call light in reach. Resident #2 was non-interviewable, and she did not respond to questions. During an observation on 4/22/2026 at 12:24 PM, Resident #23 was observed lying in bed with his lunch in front of him on a bedside table. Resident #23 was non-interviewable and did not respond to questions. An observation of lunch on 4/22/2026 at 12:33 PM revealed CK F served lunch using a green #12 scoop for pureed vegetables. An observation on 4/23/2026 at 12:02 PM revealed that CK F was serving lunch using a green #12 scoop for pureed spinach and a yellow #20 scoop for pureed bread. An observation of the kitchen on 4/23/2026 at 12:03 PM revealed a chart with different scoop sizes, their number, their volume, and their color number was posted on the wall of the kitchen. The chart reflected the following:A yellow #20 scoop had a capacity of 1 and 5/8 ounces. A blue #16 scoop had a capacity of 2 ounces. A green #12 scoop had a capacity of 2 and 2/3 ounces. A tan #10 scoop had a capacity of 3 ounces. A grey #8 scoop had a capacity of 4 ounces. A white #6 scoop had a capacity of 5 and 1/3 ounces. During an interview on 4/23/2026 at 12:59 PM, the DS stated that cooks knew which scoop to use based on the diet spreadsheet. The DS stated, we have a sheet posted with the color of the scoop. The DS said the scoop color corresponded to its size, and the scoop number was written on the back of the scoop. The DS stated that she taught staff how to read the number on the scoop and which color corresponded to which size. The DS stated, every day I tell them to check the diet spreadsheet and said she monitored staff every day. When asked how residents could be affected if the incorrect scoop size was used, the DS stated, they won't have what they need and they could lose weight. During an interview on 4/23/2026 at 1:45 PM, the DON stated that kitchen staff should follow the menu, and she did not know much about serving sizes. The DON stated that the DS was responsible for monitoring staff. When asked how residents could be affected if portions were not adequate, the DON stated, weight loss. The DON stated that Resident #23's weight loss was probably related to his recent hospitalization, and she was not sure what Resident #2's and Resident #88's weight loss was related to. During an interview on 4/23/2026 at 3:15 PM, the ADM stated the facility had just changed dietary companies and the menus had recently changed. The ADM stated that the sizes were a hair different on the new menu. When asked how residents could be affected by receiving in adequate portions, the ADM stated they could not get the nutrients they needed and weight loss. A record review of the facility's cycle menu reflected that the following menu items were to be served: Week 3 Day 17 (Tuesday, 4/21/2026) -Breakfast: a #8 scoop for pureed eggs and a #16 scoop for pureed sausage. -Lunch: a #6 scoop for pureed beef goulash, #10 scoop for pureed squash, and a #10 scoop for pureed soft, cooked vegetables. Week 3 Day 18 (Wednesday, 4/22/2026) -Breakfast: a #8 scoop for pureed egg -Lunch: a #10 scoop for pureed soft-cooked vegetables. Week 3 Day 19 (Thursday, 4/23/2026) -Lunch: a #10 scoop for pureed spinach and a #10 scoop for pureed honey kissed roll. A record review of the facility's policy titled Food and Nutrition Service Menus dated September 2017 reflected the following: PolicyIt is the policy of this facility to ensure that menus are developed and prepared to meet the nutritional needs of the residents and resident choices including their nutritional, religious, cultural, and ethnic needs while using established national guidelines.Procedure.5. Menus shall provide a variety of foods and indicate standard portions at each meal.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for 2 (Resident #51 and Resident #88) of 10 residents reviewed for medication administration. The facility failed to ensure Resident #51 took her medication while staff were present. Staff left Resident #51's medication on her bedside table for her to take. Resident #51 had not been assessed for self-administration.The facility failed to put Resident #88's inhaler back in the medication cart.The failure placed residents at risk of not taking their medication, or another resident getting the medication and taking the pills or the inhaler.Findings included: Record review of Resident #51's face sheet, dated 04/23/2026, reflected an [AGE] year-old female, admitted [DATE] with diagnoses that included dementia (memory, thinking, difficulty), muscle weakness, age-related cognitive decline, unsteadiness on feet, dysphagia oropharyngeal phase (inability to empty from the throat to the esophagus), muscle wasting, and need for assistance with personal care.Record review of Resident #51's quarterly MDS dated [DATE], reflected a BIMS Score of 11, which indicated moderate cognitive impairment.Record review of Resident #51's Care Plan, dated 04/15/2026, reflected Resident #51 did not have anything on her care plan related to her being able to self-administer medications. Record review of Resident #51's Assessments revealed the resident did not have a Medication Self-Administer Assessment. Record review of Resident #88's face sheet, dated 04/22/2026, reflected a [AGE] year-old female, admitted [DATE] with diagnoses that included dementia (memory, thinking, difficulty), muscle weakness, unsteadiness on feet, dysphagia oropharyngeal phase (inability to empty from the throat to the esophagus), muscle wasting, respiratory failure, hearing loss, and need for assistance with personal care.Record review of Resident #88's quarterly MDS dated [DATE], reflected a BIMS Score of 15, which indicated intact cognitive response.Record review of Resident #88's Care Plan, dated 02/09/2026, reflected Resident #88 did not have anything on her care plan related to her being able to self-administer medications. Record review of Resident #88's Assessments revealed the resident did not have a Medication Self-Administer Assessment. Observation of Resident #51 on 04/22/2026 at 8:45a.m., revealed she was eating her breakfast and had a cup with three white pills and one brown pill sitting on her bedside table. During an interview with Resident #51 on 04/22/2026 at 8:45a.m., she said the nurse that gave her the medication left it for her so she could eat her breakfast and take her pills. She would not answer if the staff left her pills all the time. She said she did not have any concerns and would not talk about the pills. During an observation of Resident #88 on 04/22/2026 at 8:46a.m. revealed she had an Albuterol HFA (used to treat breathing problems) on her bedside table. During an interview with Resident #88 on 04/22/2026 at 8:46a.m., revealed staff left it with her. She said she did not know the name of the staff member, but it was one on the overnight shift. She said staff normally did not leave medication with her. During an interview with MA E on 04/23/2026 at 8:30 AM, she said she was trained on medication administration. She said the policy for medication administration was to let the resident know what medication the resident was being given. She said staff were not allowed to leave medication with the resident. She said staff must watch and make sure the resident took the medication. She said the MA was responsible for making sure the resident took their medication. She said she did not have any residents who could self-administer their own medication. She said if medication was left without watching the resident take the medication, staff would not know if the resident took the medication. She added the resident may even throw the medication away. She said the nurse on the hall monitored to ensure the MA was not leaving medication with the residents. She said the nurse monitored through observations. She said the training MA took Resident #51 her medication and the resident told her she would take them with breakfast and leave the medication. She said the training MA did not inform her that she left the medication. Attempted interview with LVN B on 04/23/2026 at 12:19p.m., was unsuccessful. Left voicemail for a return call and did not get a call back. During an interview with the DON on 04/23/2026 at 2:00p.m., she said she had been trained on medication administration. She said the policy for medication administration was that staff were not to leave the medication with the resident and staff needed to watch the resident take the medication. She said the nurses and the MA were responsible for giving the residents their medication. She said there were probably some residents who could self-administer their medication, but they have not had the assessments done. She said because the self-administer assessments have not been done the facility did not have any resident that could self-administer the medication. She said if the medication was left in the resident's room, another resident could take the medication or throw the medication away. She said the DON and ADON and nurses should be checking on the MAs and monitor to ensure staff were not leaving medication. She said the DON, ADON and nurses monitored by doing observation rounds. She said the new MA told her the resident asked her to leave the medication. She said the new MA did not communicate that with MA E. She said the nurse on the overnight shift sat the inhaler down and forgot to get it when she left the room. During an interview with the ADM on 04/23/2026 at 3:17p.m., revealed he had been trained on medication administration. He said the policy for administering medication was that staff were not to leave medication with the resident. He said the MAs and nurses are responsible for ensuring the resident got their medication. He said he did not have any residents that self-administered medication. He said many things could happen if medication was left with a resident. He said if not secure someone could take the medication. He said all the nursing administration staff monitored to ensure staff were not leaving medication with the resident. He said if a staff saw someone leaving medication with a resident that staff member should say something to a nurse. He said nursing administration monitored through observation or doing room rounds. He said he did not know why the staff member left the medication with Resident #51 and Resident #88. Record review of Oral Medication Administration Procedure Policy dated 11/13/2018 revealed Administer medication and remain with resident while medication is swallowed.

Based on Observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 1 of 15 residents (Resident #79) reviewed for ADLs. The facility failed to ensure Resident #79 was provided with incontinent care after staff got her out of bed.This failure could place residents at risk of not receiving care services, diminished quality of life, and decreased self-esteem.Findings Included: Record review of Resident #79's face sheet, dated 04/22/2026, reflected a [AGE] year-old female, admitted [DATE] with diagnoses that included respiratory failure, heart failure, non-pressure chronic ulcer of skin of other sites with muscle involvement without evidence of necrosis (chronic skin loss often on the limbs extending to the muscle layer without tissue death), resistance to multiple antimicrobial drugs (when pathogens like bacteria, viruses, fungi or parasites no longer respond to several antimicrobial treatments), reduced mobility, morbid obesity with alveolar hypoventilation (severe obesity that causes breathing difficulty resulting in low oxygen and high carbon dioxide while awake), muscle weakness and irritable bowel syndrome (chronic function disorder of the large intestine causing abdominal pain, cramps bloating and diarrhea or constipation). Record review of Resident #79's quarterly MDS dated [DATE], reflected a BIMS Score of 15, which indicated intact cognitive response. The MDS also indicated that the resident did not have behavior of rejecting care. The resident was dependent on staff for toileting hygiene, bed mobility, and transfers.Record review of Resident #79's Care Plan, dated 02/17/2026, reflected Resident #79 Has potential for pressure ulcer development related to incontinence. The goal was Will have intact skin, free of redness, blisters or discoloration by/through review date. Interventions were Educate resident, family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. During an interview with Resident #79 on 04/21/2026 at 11:55a.m., she said that staff get her up around 10:30a.m. She said once staff got her up staff would not provide her with incontinent care until she laid back down. She said she usually did not get back in bed until the 2-10 shift. She said there were times she asked to be changed and staff told her she had to wait for the next shift. During an interview with CNA D on 04/21/2026 at 1:58 p.m. he said that he changes the residents every two hours. He said he would put residents back down after lunch. He said with Resident #79 he would get her up around 10:30 a.m. or 11:00 a.m. He said if he could not get her up by that time he would let her know. He said once he got Resident #79 out of her bed and in her wheelchair he does not change her again for the rest of his shift. He said he did not know what time the second shift would change her. He said Resident #79 does not ask him to change her. He said the expectation was for him to change Resident #79 every two hours. During an interview with the DON on 04/22/2026 at 9:43a.m., she said Resident #79 preferred to get up around 11:00a.m. She said she would inform the nurse when Resident #79 was getting up so the nurse could watch incontinent care. During an observation of Resident #79 on 04/22/2026 at 11:11a.m., she was provided with incontinent care and transferred into her wheelchair. During an interview with Resident #79 on 04/22/2026 at 2:13pm., she said she was not feeling good and wanted to go back to her room and lay down. During an observation of Resident #79 on 04/22/2026 at 2:21p.m., revealed she was provided with incontinent care and put back in her bed. During an interview with CNA D on 04/23/2026 at 10:15a.m., he said he had been trained on incontinent care. He said the policy was staff were to change the residents every two hours or more if needed. He said the CNAs were responsible for providing incontinent care to the residents. He said if incontinent care was not provided regularly the resident could have skin breakdown or get a rash. He said the nurse monitored to ensure the CNAs were providing the residents with incontinent care. He said the nurses monitored by doing observations on the halls and looking at the residents. He said he did not change Resident #79 because she would be moving around the facility or in an activity. He said because of her being in an activity or moving around the facility Resident #79 would have to wait until the next shift to get changed. He also said he did not ask the resident if she needed to be changed. During an interview with the DON on 04/23/2026 at 2:17p.m., she said she had been trained on incontinent care. She said the policy for incontinent care was the staff needed to provide the service to meet the needs of the resident. She said staff were supposed to check the resident every two to three hours to see if they needed to be changed. She said some urinate more frequently and staff needed to change the resident accordingly. She said the CNAs and nurses were responsible for providing incontinent care. She said if staff did not provide incontinent care the resident could get an infection or a pressure sore. She said the staff need to change the residents when they are wet and need to at least offer to change them. She said all staff monitored to ensure staff are giving incontinent care. She said she monitored by looking at her pressure sores report. She said she did not know why CNA D would not change Resident #79 after he got her up from her bed. During an interview with the ADM on 04/23/2026 at 3:11p.m., revealed he had been trained on incontinent care. He said the policy for incontinent care was the staff should be checking on the residents and changing them when needed. He said all nursing staff was responsible for providing incontinent care. He also said that all staff should be monitored to ensure the residents were being changed. He said the resident could have skin breakdown if the staff did not provide incontinent care. He said he did not know why CNA D did not provide incontinent care to Resident #79 after he got her out of bed. Record review of Policy/Procedure- Nursing Administration- Nursing Services- ADL Policy dated 05/2007 revealed Nursing service staff cares for its residents in manner and in an environment that promotes maintenance or enhancement of each residents' quality of life and promotes care for residents in a manner and in an environment that maintains or enhance each resident's dignity and respect in full recognition of his or her individuality.Each Resident:Receives or is provided the necessary care and services enabling him/her to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.Residents receive assistance as needed to manage their physical needs which includes personal hygiene grooming, dressing, toileting, transferring, ambulating, and eating.

Based on observation, interview, and record review, the facility failed to ensure that residents received proper treatment and care to maintain mobility and good foot health for 1 (Resident #67) of 8 residents reviewed for foot care. The facility failed to obtain podiatry services for Resident #67. This failure placed residents at risk for toenail loss, pain, and infection.Findings included: A record review of Resident #67's face sheet dated 4/23/2026 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of acute and chronic respiratory failure, morbid (severe) obesity, primary osteoarthritis (deterioration of cartilage), hypertensive heart and chronic kidney disease with heart failure, obstructive sleep apnea (sleep disorder), gout (form of arthritis), difficulty walking, unsteadiness on feet, cognitive communication deficit (difficulty communicating) and need for assistance with personal care. A record review of Resident #67's MDS assessment dated [DATE] reflected a BIMS score of 15, which indicated no cognitive impairment. A record review of Resident #67's care plan revised on 3/23/2026 reflected that he had potential for skin breakdown. Interventions included daily body checks and a weekly head-to-toe assessment. A record review of Resident #67's physician orders reflected an order dated 3/20/2026 that reflected 'May consult Podiatry service of resident choice'. A record review of Resident #67's progress note dated 3/23/2026 reflected very long toenails. During an interview and observation on 4/21/2026 at 9:10 AM, Resident #67 was observed lying in bed. Resident #67 stated that he had not been doing physical therapy due to foot pain. Resident #67 stated he had not seen a podiatrist in the past, but that the facility told him he would see one. Resident #67 stated, I don't know if I just missed him, or what. During an interview and observation on 4/21/2026 at 1:47 PM, Resident #67 was lying in bed. Resident #67's toenails extended at least one inch past the edge of the nailbed. Resident #67 stated that his foot pain was a 10 out of 10, but he was not sure how much it was related to his toenails and said he did not know if trimming his nails would help. Resident #67 stated that the NP was working with the SW to get him scheduled with podiatry, but no they did not give him a timeframe. During an interview on 4/22/2026 at 3:41 PM, the SW stated that the Podiatrist came to the facility twice a month and Resident #67 was referred to podiatry upon admission. The SW stated the process of referring residents to podiatry involved obtaining consent, having the resident sign, and forwarding it to the podiatry so the resident could start services The SW stated she was having a hard time with Resident #67's primary insurance because they were not authorizing podiatry services. The SW stated that the last option she had was to talk with the ADM to see if they could pay for Resident #67 to see the Podiatrist because he needed services. The SW stated that Resident #67 had not seen the podiatrist since he was admitted . The SW stated that she had seen Resident #67's toenails and he really needs the service. The SW stated they looked like they had been neglected for a long time and were in growing. The SW stated she began the back-and-forth with Resident #67's insurance on 3/27/2026. The SW stated that she had never encountered an insurance plan that denied podiatry services and that Resident #67's insurance was not contracted with the facility. During an interview on 4/22/2026 at 3:23 PM, LVN A stated she had seen Resident #67's toenails and said she could not cut his nails because of the thickness. LVN A stated she was pretty sure she notified the SW about the issue with Resident #67's nails. LVN A stated, he must be on the waiting list. LVN A stated that if residents were not used to having long nails, it could make them uncomfortable. LVA A stated she did not think that Resident #67's foot pain was related to his toenails. During an observation and interview on 4/22/2026 at 4:06 PM, CNA C was observed walking into Resident #67's room. CNA C put gloves on and examined Resident #67's feet. CNA C stated that Resident #67 had two toenails on the left foot and one toenail on the right foot that were curved over into the skin. During an interview on 4/23/2026 at 10:51 AM, the NP stated she told the SW to put Resident #67 on the top of the list for podiatry. The NP stated she usually wrote a progress note when it was that bad. The NP stated she first requested that Resident #67 be seen by a podiatrist on 3/25/2026 when she sent an email to the SW. The NP stated that Resident #67 had refused showers and had psych issues, but she did not think he had refused podiatry care. During an interview on 4/23/2026 at 10:45 AM, the Podiatrist stated that Resident #67's toenails were 5 inches long, extremely thick, and he could not wear his socks because the toenails were too long. The Podiatrist stated that Resident #67 had onychomycosis (fungal infection causing the toenails to become thick). The Podiatrist stated that the left second toe was curled over and there was an indentation on the skin, but no breakage. The Podiatrist stated that there was potential for Resident #67's toenails to get caught on a sock and he could have a traumatic avulsion (injury in which a body part or tissue is forcibly torn away). The Podiatrist stated that Resident #67 complained of right great toe pain, but she thought it was tendonitis. The Podiatrist stated that risks associated with traumatic avulsion included pain and infection. The Podiatrist stated that it was her first time seeing Resident #67 that day (4/23/2026) and there was an insurance problem. During an interview on 4/23/2026 at 1:45 PM, the DON stated that residents were assessed for the need for podiatry when they came in, it was communicated to the SW, and the SW made the referral. The DON stated that when the Podiatrist came in on 4/10/2026, Resident #67's insurance had not been verified. The DON stated that the Podiatrist came in that day (4/23/2026) and the facility paid to have Resident #67's toenails taken care of. The DON stated it looked like 10 years of growth. The DON stated that nails could get torn off if they were too long, and that could be painful. During an interview on 4/23/2026 at 3:15 PM, the ADM stated that he would expect residents to receive podiatry services as soon as possible. The ADM stated that if anyone was not covered, he paid for it. The ADM stated that Resident #67 missed the Podiatrist's visit last month and his VA insurance would not allow him to see the in-house Podiatrist. The ADM stated that once he was made aware of an issue, there was no delay. When asked what a clinical implication of long, thick toenails was, the ADM stated infection. A record review of the Podiatrist's schedule for 4/23/2026 reflected a list of residents scheduled to be seen by the Podiatrist on 4/23/2026. Resident #67 was not on the list, and he had a 'do not treat' note dated 3/27/2026 that reflected Cannot verify appropriate insurance information. A record review of the facility's policy titled Nursing Services - ADLs dated May 2007 reflected the following: Policy: Nursing service staff cares for its residents in manner and in an environment that promotes maintenance or enhancement of each residents' quality of life and promotes care for residents in a manner and in an environment that maintains or enhance each resident's dignity and respect in full recognition of his or her individuality.Each resident.-Residents receive assistance as needed to manage their physical needs which includes personal hygiene, grooming, dressing, toileting, transferring, ambulating, and eating.

Based on observations, interviews and record reviews the facility failed to ensure the facility did not use physical abuse for 1 of 2 Residents. The facility failed to ensure Resident #1 was free from abuse when CNA A and CNA B were changing the briefs of Resident # 1 on 08/17/2025. This failure could place residents at risk for serious psychosocial harm from abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life.Findings included: Record review of Resident #1's admission Record, dated 09/03/25, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Unspecified Dementia, moderate (This is when symptoms become more severe, and the individual's ability to perform daily tasks declines significantly.), Hypertensive Heart (refers to heart conditions caused by high blood pressure.) and Chronic Kidney Disease (Gradual loss of kidney function.). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 4 indicating severe cognitive impairment. The MDS revealed Resident # 1 was dependent on staff for all ADLs. Record review of Resident #1's care plan dated 07/02/2025 revealed Resident #1 had potential to demonstrate physical behaviors related to dementia. Goal: Will not harm self or others through the review date. Interventions: Analyze key times, places, circumstances, triggers, and what de-escalates behavior and document. Record review of Resident # 1's Weekly Skin Assessment on 08/15/2025 at 12:54 PM reflected left great toe abrasion and lateral ankle trauma wound present and no other skin issues noted. Record review for Change of Condition for Resident # 1's Skin Assessment on 08/17/2025 at 3:05 PM documents [NAME] Record review for Change of Condition for Resident # 1's Skin Assessment on 08/17/2025 at 3:05 PM documents Bruise and swelling to right thumb.Record Review of Provider Investigation Report dated 8/18/2025 reflected, CNA B upon getting resident up in her wheelchair, she noticed her right thumb was swollen and was unable to hold her phone while receiving a call from son.The Provider Investigation Report does did not indicate how this injury occurred. The Provider Investigation Report stated incident occurred 08/17/25 at 11:50 AM and assessment was done on 08/17/2025 @ at 3:35 PM. The assessment reported Bruising and edema to right thumb. 08/18/2025 Resident # 1 was transferred at 10:30 AM offsite to [local hospital]. Incident was reported by ED to Texas Health and Human Services Complaint and Incident Intake via email on 08/18/2025 at 7:20 PM. Record review of CNA B's statement revealed on 08/17/2025 CNA A assisted CNA B in changing Resident # 1's brief. CNA B stated, I assisted Resident # 1 by crossing her arms across her chest to roll her onto her left side. Record review of ER medical report for Resident # 1 Sservice date 08.18.25 at 12:56 PM. Findings:Xray Impression: Comminuted (bone that is broken in at least two places) ( mildly displaced fracture of the base of the right first digital proximal phalanz (most basal bones of each digit,)with extension to the first digit joint time stamped 08.18.25 @ at 13:57 pm, reported signed by Doctor. Interview &observation of Resident # 1 on 09/03/2025 at 10:35 AM. revealed Resident #1 lying in bed, she raised her right hand and arm exposing a bruised on the lower right thumb. Resident #1 stated 0on 08/17/2025 early in the morning she was awakened by CNA A. Resident #1 stated, I told them I wanted to sleep and I'll do it later. She stated CNA B joined CNA A in the room and CNA B (who was the smaller CNA) grabbed my right hand, she pulled my thumb backwards and I screamed. Resident stated, The CNA's came around dinner time and they put me in the wheelchair that's when I noticed my right thumb and right wrist were swollen. Resident # 1 stated, daughter told the staff to send me to the hospital. Interview on 09/03/2025 at 10:40 AM with Residents # 3 (Resident # 1's roommate). Resident # 3 stated, she was in the room and awake at the time of the incident and it was around 7 AM. Resident # 3 stated, Tthere were 2 CNAs in the room that morning. She stated, tThe smaller one came in to help and that's when I heard a loud cry from (Resident # 1). and I couldn't see anything because the curtain was pulled closed but, I knew (Resident # 1) was in pain by the sound of her scream. Interview on 09/03/2025 at 10:50 AM with CNA C she stated, I had cared for (Resident #1) the week before on Thursday, August 14th, 2025, and Friday, August 15th, 2025 and she had no injuries then. He stated, On Monday, August 18th, 2025 (Resident # 1's) hand looked very different than last week, so I knew something was wrong. I immediately told the Nurse about (Resident # 1's) hand. He stated, a Staff Nurse came down to the room to see the resident's injury. He stated, They called Emergency Services came and took her to the hospital, and I didn't see her again until the next day. Interview on 09/03/2025 at 12:29 PM with Family member of Resident # 1. He stated, We had a recording of the morning of the incident, but we could not see the incident because the Aids pulled the curtain around the entire bed. He stated, All I could here is mother yelling and screaming and when they opened the curtain, you can see mom holding her hand. He stated, the family had put a screw on the curtain track to prevent the curtain from being pulled because the staff continued to try and hide from the camera. He stated his mom has dementia and that she doesn't remember details. During an interview with CNA A on 09/04/2025 at 12:35 PM, CNA A said she was suspended due to Resident #1 having a bruise on her left thumb. CNA A said that she had not hurt Resident #1 or any other residents. She said she did not report the injury because it was CNA B who found the injury. She said Resident #1 did not complain of pain to her finger. Observation of Video on 09/03/2025 at 3:10 PM with ADM and DON. ADM shared an approximate 5 minutes of video recorded on 08/17/2025 at 7:11 AM. The video reveals 2 CNA's entering Resident # 1's bed area. CNAs were identified by the ADM and the DON as CNA A and CNA B. CNA A was observed pulling the curtain from the right side of the bed to the left side of Resident # 1's bed. The curtain served to block the view from the camera of the care being performed to Resident # 1. Per the audio of the video, Resident # 1 was heard to be shouting stop . Resident was also heard to scream loudly in a sharp, high pitch. When CNA A reopened the curtain, Resident #1 was observed to have on different clothing and Resident # 1 was positioned on her left side facing the window. CNA A and CNA B were observed to be holding soiled briefs and other soiled items. Observation shows both CNA's leaving the room and the video ended. During an interview with LVN A on 09/15/2025 at 12:36 PM revealed that on the day 08.17.2025 around lunch time, she was on the hallway when CNA B brought Resident #1 to LVN A at the nurse's station. CNA B told her; the resident was not able to use her hand to pick up her personal phone. She said CNA B also told her Resident # 1 could not use her hand properly. LVN A said that CNA B did not know how the injury to Resident #1 occurred. LVN A said she observed the resident's' right hand, and she saw a bruise on the upper part of the resident's right thumb. She said she asked Resident # 1, what happened? Resident # 1 said she did not know what happened and she did not remember. LVN A said she tried to assess the hand, but Resident #1 would not let her touch it. Resident #1 said she was in pain. LVN A said that CNA B told her she did not know what caused the bruises to Resident #1. Record review of the facility's Abuse, Neglect, and Exploitation, dated 11/2017, reflected: Training d. Reporting abuse, neglect, exploitation, and misappropriation of residents property, including injuries of unknown sources, and to whom and when staff and others must report their knowledge related to any alleged violation without fear of reprisal. and Abuse: Prevention of and Prohibition Against; Reporting reasonable suspicion of a crime against a resident in accordance with Section 1150B of the social security Act.This was determined to be an Immediate Jeopardy (IJ) on 09/15/2025 at 5:54 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 9/15/2025 at 5:55 p.m. The ADM was asked to submit a Plan of Removal. The following Plan of Removal submitted by the facility was accepted on 09/16/2025 at 4:33 pm.Date of IJ Notification: 09/15/2025 Date/Time IJ Identified by Surveyor: 09/15/2025 at 5:55 PMPlan of Removal - F600 (Abuse) Deficient Practice: The facility failed to ensure that Resident # 1 free from physical abuse. This resulted in the resident having a mildly displaced fracture of the base of the right first digital proximal phalanz with extension to the first digit. Immediate Actions Taken (Date: 09/16/2025):Charge nurse will assess Resident #1 for complications after hospitalization and return from dialysis. Completion date 9/10/2025 Action: CNA A and CNA B suspended pending investigationStart Date: 8/18/2025Completion Date: To be determined when suspension has ended.Responsible: Director of Nurses/Designee Action: Skin Assessments conducted on all residentsStart Date: 8/19/2025Completion Date: 8/19/2025Responsible: DON/Designee Action: Medical Director, Nurse Practitioner and Physician Assistant notification of immediate jeopardy and plan of removal discussed. Start Date: 9/15/2025Completion Date: 9/15/2025Responsible: Executive Director Action: Ad hoc QA meeting. Attendees included ED, DON, Clinical Resource, Clusters Partners, Medical Director. Meeting included the Plan of Removal and interventions.Start Date: 9/15/2025Completion Date: 9/15/2025Responsible: Executive Director Action: Inservice Director of Nursing and Executive Director on Abuse and Neglect Policy Start Date: 9/15/2025Completion Date: 9/15/2025Responsible: Clinical Resource, MSN, Ed, DON Action: Inservice Director of Nursing and Executive Director on Resident Rights Start Date: 9/15/2025Completion Date: 9/15/2025Responsible: Clinical Resource, MSN/Ed, DON Action: Inservice initiated to all staff on Abuse and Neglect Policy to be conducted prior to start of next shift.Start Date: 9/15/2025Completion Date: 09/19/2025 Responsible: DON Action: Safe Surveys conducted on all residents.Start Date: 9/15/2025Completion Date: 9/15/2025Responsible: DON/Designee Action: Inservice of CNA A and CNA B on Abuse and Neglect with knowledge retention demonstrated with post-testStart Date: 9/15/2025Completion Date: 9/15/2025Responsible: DON/Designee Action: Inservice of CNA A and CNA B on Abuse and Neglect with knowledge retention demonstrated with post-testStart Date: 9/15/2025Completion Date: 9/15/2025Responsible: DON POR monitoring conducted on 9/16/2025 and 9/17/2025. Record review of IJ Binder on 9/16/2025 CNA A and CNA B have been terminated, and the termination is in the binder. Copies have been scanned. The Abuse Policy for Freedom from abuse, neglect, & exploitation, Residence, rights & responsibilities were in the binder. Verified that the email was sent to the ombudsman notifying them of the IJ. Verified that QAPI was done with the executive director, Director of Nursing, and clinical resources, and signed by each of them Residence safety surveys were completed In service on resident rights and abuse and neglect was given to the administrator in the DON by MSN/ED, RN clinical resources. In-service training completed by all staff on abuse and neglect, and resident rights. All staff or quiz on resident rights, abuse and neglect Staff contacted the resident #1s daughter to verify that they had notified her of the immediate jeopardy During an Interview with Resident #14 at 12:12 PM Resident # 14 Revealed he has never been injured by a staff member when he is getting care. Resident #14 said he has no concerns about the staff and that they treat him well. Resident #14 likes it at the facility. There were no other concerns at the time. During an interview with Resident #18 at 12:16 PM , He revealed he felt safe at the facility. Resident #18 said he has never been abused or injured by any staff at the facility. Resident #18 said that all the staff treat him well. Resident #18 said that he likes the care he is getting at the facility. During an interview with Resident #10 at 12:25 PM he revealed he feels safe at the facility. Said he has never been abused or injured by the staff. Resident #10 said that he likes the care that he is getting, and it is better than the care he was getting at the last facility. There were no other concerns at the time. During an interview on 09/17/2025 3:21 PM, ADM revealed per Abuse policy, suspected abuse should be reported immediately to him. If ADM is not available, staff member who could report it to ADON, DON, or management. LMS education portal before they start, and continuing education quizzes and refreshers. It was serviced yesterday. Has not witnessed any abuse in the facility. ADM said to prevent this from happening, he has staff get extra training and keep telling them about abuse. During an interview on 09/17/2025 3:04 PM, DON revealed, the facility is to use the provider letter when it is reportable and follow the 24-hour guidelines. All staff are required to notify the DON or the Nurse, and they will tell ADM. If there is an allegation pending investigation. Upon hire, reliance training it covers abuse and neglect. And that covers dementia care. All the training is annual. In-service on abuse yesterday, and before that was in August. Payday in-service for abuse. Has not witnessed abuse in the facility. More training on residents' rights and the right to refuse care and more training on that and cooperative residents. During an interview on 9-17-2025 at 2:15 PM RN said that if there is abuse, then is should be reported immediately. RN said abuse should be reported to the ADM or the DON. RN said that they get in-service training on abuse and neglect through videos, in person, and emails. The last in-services on abuse and neglect were 9-16-2025 and 9-16-2025. RN has not witnessed any abuse or neglect in the facility. During an interview on 09/17/2025 2:26 PM, CNA D said that if she sees abuse in the facility, then she is to report it immediately to the ADM, who is the abuse and neglect coordinator. CNA D has not witnessed abuse or neglect in the facility. CNA D said that she had in-service training on abuse and neglect, and the last time was 9-16-2025. CNA D said that she gets in-service training regularly for abuse and neglect. videos and meetings. CNA D has not witnessed abuse or neglect in the facility. During an interview on 09/17/2025 2:00 PM LVN B said if she sees abuse in the facility, she reports it immediately to the ADM, who is the abuse and neglect coordinator. LVN B said she has not witnessed any abuse in the facility. LVN B said that she gets in-service regularly on abuse. LVN B said the last time she had abuse training was 9-16-2025. LVN B said that get in-service training in person and videos. During an interview on 09/17/2025 2:06 PM, CNA 5 said she has not witnessed abuse or neglect in the facility. CNA 5 said if she sees abuse in the facility, then she tells the ADM. CNA 5 said the last time she had in-service training on abuse was on 9-16-2025. CNA 5 said she gets in-service training by video and in person. CNA 5 said that there is usually a test after. Training Monday, test Tuesday, and last week, and the video was at the beginning of the month. During an interview on 09/17/2025 2:00 PM, ADON revealed that abuse should be reported immediately to the ADM. If the ADM is not available, then it would be reported to the DON ADON stated that they he has received training on abuse regularly and the last time was on 9/16/2025. ADON stated he gets training in person, online, and they watch videos. To prevent abuse Human Resources does a background check on new employees. ADON said he has not witnessed any abuse or neglect in the facility. An IJ was identified on 09/15/2025. The Administrator was notified and an IJ Template was provided on 09/15/2025 at 5:55 p.m. While the Immediate Jeopardy was removed on 09/17/2025 at 4:33 pm, The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property for one of one resident (Resident #1) reviewed for abuse, neglect, and exploitation. The facility failed to implement their policies and procedures to ensure Resident #1 was free from abuse when the facility failed to have effective interventions and services in place to address the resident's care, which resulted in Resident #1 sustaining Comminuted (bone that is broken in at least two places),(mildly displaced fracture of the base of the right first digital proximal phalanz (most basal bones of each digit.)with extension to the first digit joint time stamped 08.18.25 @ at 13:57 pm, reported signed by Doctor. An IJ was identified on 09/15/2025. The Administrator was notified and an IJ Template was provided on 09/15/2025 at 5:55 p.m. While the Immediate Jeopardy was removed on 09/16/2025 at 4:33 pm, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.The failure could place residents at risk for serious injuries, hospitalization, and death. Finding includes:Record review of Resident #1's admission Record, dated 09/03/25, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Unspecified Dementia, moderate (This is when symptoms become more severe, and the individual's ability to perform daily tasks declines significantly.), Hypertensive Heart (refers to heart conditions caused by high blood pressure.) and Chronic Kidney Disease (Gradual loss of kidney function.). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of was 4 indicating severe cognitive impairment. The MDS revealed Resident # 1 was dependent on staff for all ADLs. Record review of Resident #1's care plan dated 07/02/2025 revealed Resident #1 had potential to demonstrate physical behaviors related to dementia. Goal: Will not harm self or others through the review date. Interventions: Analyze key times, places, circumstances, triggers, and what de-escalates behavior and document. Record Review of Resident # 1's Weekly Skin Assessment on 08/15/2025 at 12:54 PM reflected left great toe abrasion and lateral ankle trauma wound present and no other skin issues noted.Record review for Change of Condition for Resident # 1's Skin Assessment on 08/17/2025 at 3:05 PM documents Bruise and swelling to right thumb.Record review for Change of Condition for Resident # 1's Skin Assessment on 08/17/2025 @at 3:05 PM documents Record review for Change of Condition for Resident # 1's Skin Assessment on 08/17/2025 @at 3:05 PM documents Bruise and swelling to right thumb.Record Review of Provider Investigation Report on dated 8/18/2025 reflected, that CNA B upon getting resident up in her wheelchair, she noticed her right thumb was swollen and was unable to hold her phone while receiving a call from son. The Provider Investigation Report does did not indicate how this injury occurred. The Provider Investigation Report stated incident occurred 08/17/25 at 11:50 AM and assessment was done on 08/17/2025 @ at 3:35 PM. The assessment reported bruising and edema to right thumb. 08/18/2025 Resident # 1 was transferred at 10:30 AM offsite to [St. [NAME] local hospital]. Incident was reported by ED to Texas Health and Human Services complaint and Incident Intake via email on 08/18/2025 at 7:20 PM.Record review of CNA B's statement revealed on 08/17/2025 CNA A assisted CNA B in changing Resident # 1's brief. CNA B stated, I assisted Resident # 1 by crossing her arms across her chest to roll her onto her left side. Record review of ER medical report for Resident # 1 service date 08.18.25 at 12:56 PM. Findings:Xray Impression: Comminuted (bone that is broken in at least two places) ( mildly displaced fracture of the base of the right first digital proximal phalanz (most basal bones of each digit,)with extension to the first digit joint time stamped 08.18.25 @ at 13:57 pm, reported signed by Doctor. Interview & Observation of Resident # 1 on 09/03/2025 at 10:35 AM. revealed Observed Resident #1 lying in bed, she raised her right hand and arm exposing a bruised on the lower right thumb. Resident #1 stated 0on 08/17/2025 early in the morning she was awakened by CNA A. Resident #1 stated, I told them I wanted to sleep and I'll do it later. She stated CNA B joined CNA A in the room and CNA B (who was the smaller CNA) grabbed my right hand, she pulled my thumb backwards and I screamed. Resident stated, the CNA's came around dinner time and they put me in the wheelchair that's when I noticed my right thumb and right wrist were swollen. Resident # 1 stated, My daughter told the staff to send me to the hospital. Interview on 09/03/2025 at 10:40 AM with Residents # 3 (Resident # 1's roommate). Resident # 3 stated, she was in the room and awake at the time of the incident and it was around 7 AM. Resident # 3 stated, There were 2 CNAs in the room that morning. She stated, the smaller one came in to help and that's when I heard a loud cry from (Resident # 1). and I couldn't see anything because the curtain was pulled closed but, I knew (Resident # 1) was in pain by the sound of her scream. Interview & Observation of Resident # 1 on 09/03/2025 at 10:35 AM. revealed Observed resident #1 lying in bed, she raised her right hand and arm exposing a bruised on the lower right thumb. Resident #1 stated 0on 08/17/2025 early in the morning she was awakened by CNA A. Resident #1 stated, I told them I wanted to sleep and I'll do it later. She stated CNA B joined CNA A in the room and CNA B (who was the smaller CNA) grabbed my right hand, she pulled my thumb backwards and I screamed. Resident stated, the CNA's came around dinner time and they put me in the wheelchair that's when I noticed my right thumb and right wrist were swollen. Resident # 1 stated, My daughter told the staff to send me to the hospital. Interview on 09/03/2025 at 10:40 AM with Residents # 3 (Resident # 1's roommate). Resident # 3 stated, she was in the room and awake at the time of the incident and it was around 7 AM. Resident # 3 stated, There were 2 CNAs in the room that morning. She stated, the smaller one came in to help and that's when I heard a loud cry from (Resident # 1). and I couldn't see anything because the curtain was pulled closed but, I knew (Resident # 1) was in pain by the sound of her scream. Interview on 09/03/2025 at 10:50 AM with CNA C. CNA C he stated, I had cared for her (Resident #1) the week before on Thursday, August 14th, 2025, and Friday, August 15th, 2025 and she had no injuries then. He stated, on Monday, August 18th, 2025 (Resident # 1's) hand looked very different than last week, so I knew something was wrong. I immediately told the Nurse about (Resident # 1's) hand. He stated, A a Staff, Nurse came down to the room to see the resident's injury. He stated, They called Emergency Services came and took her to the hospital, and I didn't see her again until the next day. Interview on 09/03/2025 at 12:29 PM with Family member of Resident # 1. He stated, we had a recording of the morning of the incident, but we could not see the incident because the Aids pulled the curtain around the entire bed. He stated, all I could here is mother yelling and screaming and when they opened the curtain, you can see mom holding her hand. He stated, the family had put a screw on the curtain track to prevent the curtain from being pulled because the staff continued to try and hide from the camera. He stated his mom has dementia and that she doesn't remember details. During an interview with CNA A on 09/04/2025 at 12:35 PM revealed that CNA A said she was suspended due to Resident #1 having a bruise on her left thumb. CNA A said that she had not hurt Resident #1 or any other residents. She said she did not report the injury because it was CNA B who found the injury. She said Resident #1 did not complain of pain to her finger. Observation of Video on 09/03/2025 at 3:10 PM with.During an Interview with ADM and DON., ADM shared an approximate 5 minutes of video recorded on 08/17/2025 at 7:11 AM. The video reveals 2 CNA's entering Resident # 1's bed area. CNAs were identified by the ADM and the DON as CNA A and CNA B. CNA A was observed pulling the curtain from the right side of the bed to the left side of Resident # 1's bed. The curtain served to block the view from the camera of the care being performed to Resident # 1. Per the audio of the video, Resident # 1 was heard to be shouting stop . Resident was also heard to scream loudly in a sharp, high pitch. When CNA A reopened the curtain, Resident #1 was observed to have on different clothing and Resident # 1 was positioned on her left side facing the window. CNA A and CNA B were observed to be holding soiled briefs and other soiled items. Observation shows both CNA's leaving the room and the video ended. During an interview with LVN A on 09/15/2025 at 12:36 PM revealed that on the day 08.17.2025 around lunch time, she was on the hallway when CNA B brought Resident #1 to LVN A at the nurse's station. CNA B told her, She noticed the resident was not able to use her hand to pick up her personal phone. She said CNA B also told her Resident # 1 could not use her hand properly. LVN A said that CNA B did not know how the injury to Resident #1 occurred. LVN A said she observed the resident's' right hand, and she saw a bruise on the upper part of the resident's right thumb. She said she asked Resident # 1, what happened? Resident # 1 said she did not know what happened and she did not remember. LVN A said she tried to assess the hand but Resident #1 would not let her touch it. Resident #1 said she was in pain. LVN A said that CNA B told her she did not know what caused the bruises to Resident #1. Record review of the Facility's Abuse, Neglect, and Exploitation, dated 11/2017, reflects: each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment. It is also the policy of this Facility to recognize the resident right to personal privacy and confidentiality of their physical body, personal care, and personal space or accommodations. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. This also includes the taking, keeping, using or distributing photographs or video recordings off residents in any manner that would demean or humiliate a resident, regardless of consent provided or the residents cognitive status. The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the facility, deliver care and services in a way that promotes and respects the rights of the resident to be free from abuse, neglect, misappropriation of resident property, exploitation, or use of technology that would infringe on the residents right to personal privacy.The following Plan of Removal submitted by the facility was accepted on 09/16/2025 at 4:33 pm.Action: CNA A and CNA B Suspended pending investigation on 08/18/2025.Completion date 8/18/2025 CNA A and CNA B were terminated. Responsible: Director of Nurses/Designee Action: Skin Assessments conducted on all residentsStart Date: 8/19/2025Completion Date: 8/19/2025Responsible: DON/Designee Action: Medical Director, Nurse Practitioner and Physician Assistant notification of immediate jeopardy and plan of removal discussed. Start Date: 9/15/2025Completion Date: 9/15/2025Responsible: Executive Director Action: Ad hoc QA meeting. Attendees included ED, DON, Clinical Resource, Clusters Partners, Medical Director. Meeting included the Plan of Removal and interventions.Start Date: 9/15/2025Completion Date: 9/15/2025Responsible: Executive Director Action: Inservice Director of Nursing and Executive Director on Abuse and Neglect Policy Start Date: 9/15/2025Completion Date: 9/15/2025Responsible: Clinical Resource, MSN, Ed, DON Action: Inservice Director of Nursing and Executive Director on Resident Rights Start Date: 9/15/2025Completion Date: 9/15/2025Responsible: Clinical Resource, MSN/Ed, DON Action: Inservice initiated to all staff on Abuse and Neglect Policy to be conducted prior to start of next shift.Start Date: 9/15/2025Completion Date: 09/19/2025 Responsible: DONAction: Safe Surveys conducted on all residents.Start Date: 9/15/2025Completion Date: 9/15/2025Responsible: DON/Designee Action: Inservice of CNA A and CNA B on Abuse and Neglect with knowledge retention demonstrated with post-testStart Date: 9/15/2025Completion Date: 9/15/2025Responsible: DON/Designee Action: Inservice of CNA A and CNA B on Abuse and Neglect with knowledge retention demonstrated with post-testStart Date: 9/15/2025Completion Date: 9/15/2025Responsible: DON POR monitoring conducted on 9/16/2025 and 9/17/2025. Record review of IJ Binder on 9/16/2025 CNA A and CNA B have been terminated, and the termination is in the binder. Copies have been scanned. The Abuse Policy for Freedom from abuse, neglect, & exploitation, Residence, rights & responsibilities were in the binder. Verified that the email was sent to the ombudsman notifying them of the IJ. Verified that QAPI was done with the executive director, Director of Nursing, and clinical resources, and signed by each of them Residence safety surveys were completed In service on resident rights and abuse and neglect was given to the administrator in the DON by MSN/ED, RN clinical resources. In-service training completed by all staff on abuse and neglect, and resident rights. All staff or quiz on resident rights, abuse and neglect Staff contacted the resident #1s daughter to verify that they had notified her of the immediate jeopardy During an Interview with Resident #14 at 12:12 PM Resident # 14 Revealed he has never been injured by a staff member when he is getting care. Resident #14 said he has no concerns about the staff and that they treat him well. Resident #14 likes it at the facility. There were no other concerns at the time. During an interview with Resident #18 at 12:16 PM , He revealed he felt safe at the facility. Resident #18 said he has never been abused or injured by any staff at the facility. Resident #18 said that all the staff treat him well. Resident #18 said that he likes the care he is getting at the facility. During an interview with Resident #10 at 12:25 PM he revealed he feels safe at the facility. Said he has never been abused or injured by the staff. Resident #10 said that he likes the care that he is getting, and it is better than the care he was getting at the last facility. There were no other concerns at the time. During an interview on 09/17/2025 3:21 PM, ADM revealed per Abuse policy, suspected abuse should be reported immediately to him. If ADM is not available, staff member who could report it to ADON, DON, or management. LMS education portal before they start, and continuing education quizzes and refreshers. It was serviced yesterday. Has not witnessed any abuse in the facility. ADM said to prevent this from happening, he has staff get extra training and keep telling them about abuse. During an interview on 09/17/2025 3:04 PM, DON revealed, the facility is to use the provider letter when it is reportable and follow the 24-hour guidelines. All staff are required to notify the DON or the Nurse, and they will tell ADM. If there is an allegation pending investigation. Upon hire, reliance training it covers abuse and neglect. And that covers dementia care. All the training is annual. In-service on abuse yesterday, and before that was in August. Payday in-service for abuse. Has not witnessed abuse in the facility. More training on residents' rights and the right to refuse care and more training on that and cooperative residents. During an interview on 9-17-2025 at 2:15 PM RN said that if there is abuse, then is should be reported immediately. RN said abuse should be reported to the ADM or the DON. RN said that they get in-service training on abuse and neglect through videos, in person, and emails. The last in-services on abuse and neglect were 9-16-2025 and 9-16-2025. RN has not witnessed any abuse or neglect in the facility. During an interview on 09/17/2025 2:26 PM, CNA D said that if she sees abuse in the facility, then she is to report it immediately to the ADM, who is the abuse and neglect coordinator. CNA D has not witnessed abuse or neglect in the facility. CNA D said that she had in-service training on abuse and neglect, and the last time was 9-16-2025. CNA D said that she gets in-service training regularly for abuse and neglect. videos and meetings. CNA D has not witnessed abuse or neglect in the facility. During an interview on 09/17/2025 2:00 PM LVN B said if she sees abuse in the facility, she reports it immediately to the ADM, who is the abuse and neglect coordinator. LVN B said she has not witnessed any abuse in the facility. LVN B said that she gets in-service regularly on abuse. LVN B said the last time she had abuse training was 9-16-2025. LVN B said that get in-service training in person and videos. During an interview on 09/17/2025 2:06 PM, CNA 5 said she has not witnessed abuse or neglect in the facility. CNA 5 said if she sees abuse in the facility, then she tells the ADM. CNA 5 said the last time she had in-service training on abuse was on 9-16-2025. CNA 5 said she gets in-service training by video and in person. CNA 5 said that there is usually a test after. Training Monday, test Tuesday, and last week, and the video was at the beginning of the month. During an interview on 09/17/2025 2:00 PM, ADON revealed that abuse should be reported immediately to the ADM. If the ADM is not available, then it would be reported to the DON ADON stated that they he has received training on abuse regularly and the last time was on 9/16/2025. ADON stated he gets training in person, online, and they watch videos. To prevent abuse Human Resources does a background check on new employees. ADON said he has not witnessed any abuse or neglect in the facility. An IJ was identified on 09/15/2025. The Administrator was notified and an IJ Template was provided on 09/15/2025 at 5:55 p.m. While the Immediate Jeopardy was removed on 09/17/2025 at 4:33 pm, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources were reported immediately, but no later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse to the Administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 1 of 6 residents ( Resident # 1 reviewed for abuse and neglect. The facility failed to report to HHSC when Resident #1 was found to have a significant bruise and swelling to right thumb of unknown origin on 08/17/25 at 3:03PM. This failure to report could place the residents at risk for abuse. Findings included:Record review of Resident #1's admission Record, dated 09/03/25, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Unspecified Dementia, moderate (This is when symptoms become more severe, and the individual's ability to perform daily tasks declines significantly.), Hypertensive Heart (refers to heart conditions caused by high blood pressure.) and chronic kidney disease (Gradual loss of kidney function.).Record review of Resident #1's quarterly MDS Assessment, Section V- Care Area Assessment summary dated 06/06/25, reflected her BIMS Score was 4 (indicates severe cognitive impairment, suggesting that the individual may require comprehensive assistance and specialized care approaches.).Record review of MDS, Section GG- Functional Abilities for Mobility Resident #1 needs Wheelchair.Record review of MDS, Section GG- Functional Abilities for self -care of Resident # 1 is 1(Dependent - Helper does ALL the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity.) Record review of Resident #1's care plan, revised 07/02/25, reflected: Focus: has Potential to demonstrate physical behaviors related to Dementia. Goal: Will not harm self or others through the review date. Interventions: Analyze key times, places, circumstances, triggers, and what de-escalates behavior and document. Record Review of resident # 1's Weekly Skin Assessment on 08/15/2025 at 12:54 PM reflected L great toe abrasion and lateral ankle trauma wound present and no other skin issues noted. Record review for Change of condition for resident # 1's Skin Assessment on 08/17/2025 at 3:05 PM documents Bruise and swelling to right thumb. Record Review of Provider Investigation Report on 8/18/2025 reflects that Aid notified this nurse that upon getting resident up in her wheelchair, she noticed her right thumb was swollen and was unable to hold her phone while receiving a call from son. The Provider Investigation Report does not indicate how this injury occurred. The Provider Investigation Report stated incident occurred 08/17/25 at 11:50 AM and assessment was done on 08/17/2025 at 335 PM. The assessment reported Bruising and edema to right thumb. 08/18/2025 Resident # 1 was transferred at 10:30 AM offsite to St. [NAME]. Incident was reported by ED to Texas Health and Human Services complaint and Incident Intake via email on 08/19/2025 at 12:19 AM Interview & Observation of Resident # 1 on 09/03/2025 at 10:35 AM. Observed resident lying in bed, she raised her right hand and arm exposing a bruised on the lower right thumb. Resident stated 0n 08/17/2025 early in the morning she was awakened by CNA A. Resident #1 stated, I told them I wanted to sleep and I'll do it later. She stated CNA B joined CNA A in the room and CNA B (who was the smaller CNA) grabbed my right hand, she pulled my thumb backwards and I screamed. Resident stated, they came around dinner time, and they put me in the wheelchair that's when I noticed my right thumb and right wrist were swollen. Resident # 1's stated, my daughter told the staff to send me to the hospital. Interview on 09/03/2025 @ 10:40 AM with Resident # 2 (Resident # 1's roommate). Resident # 2 stated, she was in the room and awake at the time of the incident and it was around 7 AM. Resident # 2 stated, there were 2 CNAs in the room that morning. She stated, the smaller one came in to help and that's when I heard a loud cry from Resident # 1 and I couldn't see anything because the curtain was pulled closed but, I knew Resident # 1 was in pain by the sound of her scream. Interview on 09/03/2025 @ 10:50 AM with CNA C. CNA C stated, I had cared for her the week before on Thursday and Friday and she had no injuries then. He stated, on Monday, Resident # 1's hand looked very different than last week, so I knew something was wrong. I immediately told the Nurse about Resident # 1's hand. He stated, A Staff, Nurse came down to the room to see the resident's injury. He stated, They called EMS and took her to the hospital, and I didn't see her again until the next day.Interview on 09/03/2025 at 12:29 PM with son of Resident # 1. He stated, we had a recording of the morning of the incident, but we could not see the incident because the Aids pull the curtain around the entire bed. He stated, all I could here is mother yelling and screaming and when they opened the curtain, you can see mom holding her hand. He stated, the family had put a screw on the curtain track to prevent the curtain from being pulled because the staff continued to try and hide from the camera. He stated his mom has dementia and that she doesn't remember details.Interview on 09/03/2025 @ 12:29PM with DON. She stated Resident # 1's son provided the video of the incident on 08/17/2025 but we could not see actual injury occurring, we just heard voices. Interview and observation of video on 09/03/2025 @ 1:15 PM. ED and DON provided a video recording of the incident on 08/17/2025. Video revealed CNA B rotated a privacy curtain all around the entire bed. Video did not reveal an incident of abuse. DON provided Police Report # Service request number 25-00281397.Call placed to [NAME] Policy Depart [PHONE NUMBER] was transferred to [PHONE NUMBER] Extension# 51038 requested copy of police report number 25-00281397. DON stated, both CNA's involved in this incident have been put on suspension.Record review of the Facility's Abuse, Neglect, and Exploitation, dated 11/2017, reflects: each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment. It is also the policy of this Facility to recognize the resident right to personal privacy and confidentiality of their physical body, personal care, and personal space or accommodations. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. This also includes the taking, keeping, using or distributing photographs or video recordings off residents in any manner that would demean or humiliate a resident, regardless of consent provided or the residents cognitive status. The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the facility, deliver care and services in a way that promotes and respects the rights of the resident to be free from abuse, neglect, misappropriation of resident property, exploitation, or use of technology that would infringe on the residents right to personal privacy.and Abuse: Prevention of and Prohibition AgainstReporting reasonable suspicion of a crime against a resident in accordance with Section 1150B of the Social Security Act.

Based on observation, interview, and record review, the facility failed to ensure accurate resident identification before transport for outside medical appointments for 1 (Resident #10) of 3 sampled residents. The facility failed to ensure that Resident #10 made it to his scheduled surgical appointment, and the facility sent the wrong resident in his place. This finding could place residents at risk for missing medical treatments. Record review Resident #10's medical diagnosis shows that Resident #10is diagnosed with hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side (paralysis), heart failure, and major depressive disorder, recurrent moderate (depression). Resident #10 MDS showed that he had a BIMS of 10, which indicates moderate cognitive impairment. Resident #10.Interview on 9-17-2025 at 10:20 AM, an interview with Resident #10 said he did not make it to his cataract surgery, and he doesn't know what happened. Resident #10 told staff that he was scheduled to have an appointment. Resident #10 said that a CNA told him last night that the appointment was rescheduled. Resident #10 said he was going to have cataract surgery on his left eye. Resident #10 said that he had already had the surgery on his right eye. Resident #10 said that things happen, and he will have it done when it is rescheduled. Interview on 9-17-2025 at 12:16 PM, an interview with DR said that he has been doing this job for a couple of weeks. DR said that Resident #10 had the first appointment of the day. DR said that he pointed at a resident and asked a CNA on the floor if that was Resident #10. DR said he thought the CNA responded that was Resident #10, so DR said he then took that resident and not Resident #10 to the appointment. DR stated that ADON called him and told him he had the wrong resident. DR said that he took that resident back to the facility. DR said he is supposed to look at the face sheet before taking a resident to their appointments, and he did not. DR said he was in-serviced on resident identification the day it happened. DR said it could negatively impact a resident by a resident having a procedure that should not have happened. Interview on 9-17-2025 at 2:00 PM, with the ADON said he realized that the driver took the wrong resident to the appointment. ADOON said he called the DR to let him know that he had the wrong resident. ADON said the DR returned the resident to the facility. ADON stated that the DR is supposed to bring the face sheet with the resident's information to the room to verify that it was the resident he was supposed to take to the appointment. On 9-17-2025 at 3:04 PM, an interview with the DON said that DR is supposed to have the face sheet of the resident when they are being taken to appointments. DON said the DR should check in PCC and check with the floor nurse. The DR is trained to get on PCC to verify the resident. DON said the DR asked the CNA in the hall if that was Resident #10, and the DR said that he thought the CNA told him it was Resident #10. DON said that DR should be asking a nurse on the floor if they have the right resident, along with having the face sheet to verify he has the right resident. DON said that Resident #10 could have missed an important surgery. DON said that the procedure was rescheduled. On 9-17-2025 at 2:00 PM an interview with the ADM said that DR should verify which resident they have with the face sheet to make sure he has the right resident. ADM said that staff are trained on PCC and should know where to find the resident's Face sheet. ADM said the ADON is the one who discovered that the wrong resident was taken and called DR. ADM said that the DR will now be checking with the nurse in the hall to verify. ADM said the resident could have had the wrong procedure. ADM said the DR was counseled and trained on making sure he has the right resident. The facility did not have a written Policy on what the driver was supposed to do when verifying they have the correct resident when taking residents to outside doctors' appointments.

Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that facility was free of pests and rodents for 1 of 7 bedrooms reviewed for physical environment. The facility failed to ensure that Resident #2's bedroom was free from ants. This finding could place residents at risk for bug bites, unsanitary environment and emotional distress. RR of Resident #2's face sheet revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #2 had diagnoses of Parkinson's Disease, Chronic Kidney Disease, and Muscle Weakness. RR of Resident #2's care plan dated 06/08/2023 revealed Resident #2 was at risk for impaired communication function/dementia r/t short term memory loss. RR of Resident #2's hospital record dated 08/14/2025 which triggered a visit for infected insect bite or sting. The record indicated a prescription for Cephalexin 500 MG CAP oral every 6 hours 10 days and Loratadine 10 MG tab oral daily. An observation was conducted on 09/03/2025 at 3:09PM in Resident #2's bedroom. It was observed in the room that an ant was observed. An interview was conducted on 09/03/2025 at 3:09PM with Resident #2. Resident #2 reported that a couple of weeks ago in his bedroom there were some ants crawling from the frame of the door. Resident #2 stated he touched the ants and then went to bed. Resident #2 said about 2-3 hours later, he started feeling sharp points on the sides of his body. He stated that he believed he got bites from the ants. He stated that they were still there, and the facility was aware of it. Resident #2 stated that he believed his room was the only area affected by the ants. Resident #2 stated that the facility has had pest control come and spray for the ants, but the system does not work. Resident #2 stated that the ants bother him as well as make him uncomfortable and itchy. An interview was conducted on 09/04/2025 at 2:50PM with the MD revealed MD had been employed at the facility for 7 years. The MD stated he had received training on resident rights which included the residents had the right to decline services they provide, right to their privacy and right to have their own stuff. The MD stated he received training on pest control. The MD stated that there was an issue with ants in the facility while he was on vacation and when he returned, he heavily treated the area with pest control services. The MD stated the policy for pests in the facility was to report it if they were observed in the facility. The MD stated that pest control services come out at least 2 time a month in the summer times. The MD stated that the main manager was in charge of pest control services. The MD stated a negative effect of having bugs and insects in the facility was that residents would have a low quality of life. The MD stated that he believes ants were in the facility because of the weather. The MD confirmed that there were complaints about ants in the facility in Resident #2's bedroom. An interview was conducted on 09/04/2025 at 3:10PM with the DON, the DON said she had received trainings on Resident Rights which included the right to make decisions. The DON stated that she had received training for pest control services which included how to identify and prevent bugs from coming into the facility. The DON stated the expectation for identifying bugs in the facility was if staff sees any ants, they should log it into the pest control book located at the nurse's station. The DON stated the MD will receive these notifications. The DON stated pest control services come out 2x a month and as needed. The DON stated that the MD was in charge of pest control services and bug prevention. The DON stated a negative affect it could have on residents if there were bugs and insects in the facility was the potential for residents to be bit or live in fear. An interview was conducted on 09/04/2025 at 4:30PM with the ADM who reported working at the facility for 2.5 years. The ADM stated he had received training for resident rights which included that the facility was the resident's home. The ADM stated that the MD was in charge of pest control services but that the whole facility was a team, who all have to help, if they see something they need to report it. The ADM stated that pest control services come out every other week. The ADM stated that the resident had spots on his body, and they sent him to the ER to be checked for infectious diseases such as smallpox. The ADM stated that the resident #2 had bites/spots on his body and was unsure where it came from. The ADM stated he had not seen any ants in the facility. RR of an undated document provided by the facility titled Pest Control the following information was included in the document:1. It is the policy of this facility to utilize pesticides and rodenticides in a safe and efficient manner to control pests with the least amount of contamination to the environment.2. When pests are sighted, determine why the infestation is occurring and advise department head on preventive measures.3. Report insect or pest sightings to the housekeeping/maintenance supervisor immediately.

Based on interviews and record reviews, the facility failed to ensure each resident had the right to access personal and medical records pertaining to himself or herself within 24 hours and allow the resident to obtain a copy of the records or any portions thereof upon request for 1 (Resident #1) of 6 residents reviewed for resident rights. The facility failed to provide a copy of Resident #1's medical records to Resident #1's RP after requesting the records on 02/21/25. This failure could place residents at risk of not having access to records when requested. Findings include: Review of Resident #1's Face Sheet, dated 04/28/25, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] and discharged from the facility on 01/13/25. Resident #1 was her own financial RP and care conference person and had someone designated as a financial RP and care conference person. Review of Resident #1's Admission Record, dated 04/28/25, reflected she had diagnoses including unspecified dementia and cognitive communication deficit. Review of Resident #1's Quarterly MDS Assessment, dated 10/25/24, reflected she had a BIMS score of 1, which indicated she had severe cognitive impairment. Review of Resident #1's Care Plan, revised 10/28/24, reflected she was at risk for impaired cognitive function. Review of HIM's Email Thread, reviewed on 04/28/25, reflected the HIM emailed and asked Resident #1's RP to fill out and return the Authorization for Release of Information document on 02/25/25. Resident #1's RP emailed a completed Authorization for Release of Information document to the HIM, SW, ADM, and DON on 03/03/25. HIM emailed Resident #1's RP's completed Authorization for Release of Information document to the facility's legal team, ADM, and DON on 03/04/25. The facility's legal team emailed and informed the ADM and DON to release of Resident #1's medical records to Resident #1's RP on 03/05/25. During an interview on 04/28/25 at 9:08 p.m., the HIM stated she was responsible for receiving and processing residents' or RP's medical records requests. The HIM stated it took her three days to process a resident's or RP's medical records request. The HIM stated she sent Resident #1's RP's medical records request to the facility's legal team because Resident #1's RP informed her that they had a lawyer. The HIM could not recall when Resident #1's RP sent her a medical records request. The HIM stated she could not recall if Resident #1's RP received a copy of Resident #1's medical records. An attempt to interview Resident #1's RP was made on 04/28/25 at 9:24 a.m. and 10:06 a.m. A voicemail and call back number were left. Resident #1's RP did not return the surveyor's calls before exit. During an interview on 04/28/25 9:58 a.m., the SW stated the HIM was responsible for receiving and processing residents' or RP's medical records requests. The SW stated Resident #1's RP emailed her and requested a copy of Resident #1's medical records in March 2025. The SW stated she forwarded Resident #1's RP's medical records request to the HIM. The SW stated she did not know if Resident #1's RP received a copy of Resident #1's medical records. During an interview on 04/28/25 at 10:08 a.m., the DON stated the HIM was responsible for receiving and processing residents' or RP's medical records requests. The DON stated the HIM received a medical records request from Resident #1's RP in February 2025. The DON stated Resident #1's RP's medical records request was sent to the facility's legal team. The DON stated she did not know if Resident #1's RP's medical records request was fulfilled or denied by the facility's legal team. During an interview on 04/28/25 at 10:12 a.m., the ADM stated the HIM was responsible for receiving and processing residents' or RP's medical records requests. The ADM stated the facility waited for the facility's legal team to advise before releasing a copy of the residents' medical records to the resident or RP. The ADM stated he expected the facility to provide residents or RPs with a copy of the resident's medical records within 30 days. The ADM stated Resident #1's RP requested a copy of Resident #1's medical records on 02/21/25. The ADM stated Resident #1's RP was cleared by the facility's legal team to receive a copy of Resident #1's medical records about one week ago from the time of the interview. The ADM stated he did not know why the HIM had not sent a copy of Resident #1's medical records to Resident #1's RP. During a group interview on 04/28/25 at 10:26 a.m., the DON stated the HIM told her that she did not receive a follow-up email from the facility's legal team regarding Resident #1's RP's medical records request being cleared for release after 03/04/25. The DON stated her and the ADM reviewed the email thread regarding Resident #1's RP's medical records request on 04/28/25 and found out the HIM was not included on the facility's legal team's email response regarding the approved release. The DON and ADM stated they did not follow-up with the HIM regarding Resident #1's RP's medical records request because they thought the HIM was included on the email with the facility's legal team and sent the medical records to Resident #1's RP. Review of the facility's Content of Medication Record policy, revised on 08/2007, reflected there was no medical record request procedures and processing time frames indicated. Review of the facility's Resident Rights policy, revised 12/2023, reflected there was no resident right to receive a copy of medical records listed.

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 3 (Resident #20, Resident #49, and Resident #51) of 15 resident reviewed for dignity. The facility failed to ensure Resident #49, and Resident #51 received their meal with other residents at their table. The facility failed to ensure that Resident #20 was assisted with feeding when his meal tray was delivered to his room. This failure could place residents at risk of diminished dignity and affect their quality of life. Findings included: Record review of Resident #20's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of cerebral palsy (a group of conditions that affect movement and posture), epilepsy (seizure disorder), spastic quadriplegic cerebral palsy (paralyzed due to cerebral palsy), aphasia (a disorder that affects how you communicate and comprehend), dysphagia (difficulty swallowing), difficulty walking, seasonal allergies, and constipation. Review of Resident #20's Quarterly MDS assessment, dated 01/03/2025 reflected a BIMS score of 0 indicating severe cognitive impairment. MDS further reflected Resident #20 was dependent on staff for eating. Review of Resident #20s care plan, dated 12/05/2024, reflected Resident #20 was total dependent on staff for eating. Resident #20 had a swallowing problem related to dysphagia (difficulty swallowing). Resident #20 had potential nutritional problem related to diet restrictions of honey thicken liquids and puree diet and need for staff assistance with po intake. Record review of Resident #49's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of traumatic brain injury (injury caused by external force), major depressive disorder, hypertension (high blood pressure), epilepsy (seizure disorder), contracture right elbow and right wrist (permanently bent), dysphagia (difficulty swallowing), abnormal posture, need for assistance with personal care, muscle wasting, unsteadiness on feet, and lack of coordination. Review of Resident #49's Quarterly MDS assessment, dated 01/03/2025 reflected a BIMS score of 3 indicating severe cognitive impairment. MDS further reflected Resident #49 needed supervision or touching assistance for eating. Review of Resident #49s care plan, dated 01/30/2025, reflected Resident #49 needed one staff participation to eat. The care plan also revealed that the resident had potential nutritional problems related to puree diet and thin liquids. Record review of Resident #51's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses dementia (memory, thinking, difficulty), muscle wasting, muscle weakness, difficulty walking, unsteadiness on feet, cognitive communication deficit (problems with communication), need for assistance with personal care, dry eye, COVID 19, and dysphagia (difficulty swallowing). Review of Resident #51's Quarterly MDS assessment, dated 10/08/2024 reflected a BIMS score of 1 indicating severe cognitive impairment. MDS further reflected Resident #51 needed set up and clean up assistance for eating. Observation of hall trays being passed on 02/18/2025 at 12:20pm revealed that staff took Resident #20's meal tray to his room and sat it down in front of the resident on his bedside table. At 12:45pm staff went back into the room to feed the resident. Observation of dining room meal trays being passed on 02/18/2025 at 12:30pm revealed that Resident #49 got his meal tray at 12:38pm and Resident #51 did not get her meal tray until 12:47pm while their table mate got her tray at 12:35pm. During an interview with Resident #20 on 02/17/2025 at 12:00pm was unsuccessful due to resident being nonverbal During an attempted interview with Resident #49 on 02/18/2025 at 1:00pm was unsuccessful. Resident would not say anything he would just look at surveyor. During an interview with Resident #51 on 02/18/2025 at 1:04pm revealed that she was fine. She said she had a good lunch. She said she got her food. She would not answer questions about not getting her food. During an interview with CNA D on 02/20/2025 at 1:21pm revealed that she had been trained on resident rights. She said the policy for meal tray pass was that the nurse checks the meal trays and pass the meal trays according to tables. She said if all the residents at one table do not have their meal tray, then the staff should not pass trays to other tables until everyone at the same table had their food. She said if all the residents at the same table did not get their meal tray at the same time the resident could get upset, or think they were not going to get food. She said that the nurse was supposed to watch to make sure that everyone at the same table got their meal tray. She said that the nurse monitored meal trays by watching each table as trays were handed out. She said she did not know why any of the residents had to wait for their meal tray and why staff passed trays to other tables. During an interview with MA H on 02/20/2025 at 1:35pm revealed that she had been trained on resident rights. She said that the policy for passing meal trays was that all residents at the same table get their meal tray at the same time. She said staff were not supposed to move on to the next table until all residents at the previous table had their meal tray. She said the nurses and the CNA's were responsible for monitoring to ensure all residents got their meal tray. She also said for a resident who needed assistance eating that staff were not supposed to sit a meal tray in front of a resident and walk off. She said the resident could get burned or choke on the food. She said that the policy was if staff take a tray to a resident that needs assistance eating, that the staff sit down and feed the resident. She did not know why staff put the meal tray in front of Resident #20 and walked off. During an Interview with the ADM on 02/20/2025 at 1:42pm revealed that he was trained on resident rights. He said that they cover resident rights with the staff monthly. He said the policy for meal tray pass was that everyone at the same table had to be fed at the same time. He said if one person at that table does not have their tray it was unacceptable. He said staff should not move on to another table and that if a table was not ready to be served staff were to come back to that table when all the trays were ready. He also said that all staff in the dining room was responsible for ensuring every resident at the same table had their meal tray. He said that it was a hundred percent wrong and may feel like they are not going to be served. He said that staff were not supposed to put a tray down in front of a resident that needed assistance eating and walk away. He also said that was grounds for a write up because every resident is different and could choke. He said he does not know why staff did not serve all residents at the same table or why they put the food down in front of Resident #20. During an interview with DON on 02/20/2025 at 2:45pm revealed that she had been trained on resident rights. She said that the policy was that the whole table was served at one time so that nobody was sitting at the table without food. She said that ensuring every resident had their meal tray was a team effort between nursing and dietary. She said that staff were not to put food in front of a resident who needed assistance. she said that the resident could knock the tray over, the food could get cold, or they could choke. She said that if a resident did not get their meal tray at the same time as their tablemates the resident could feel left out. She said nursing and dietary were responsible for monitoring to ensure all residents had their meal tray. She said she did not know why the meal tray was left in front of Resident #20. Record review of Policy/Procedure-Nursing Clinical Meal Serving Policy revised on 05/2021 revealed make sure all residents are served. Record review of Federal Residents Rights Policy revised 2/24/2022 revealed residents have the right to be treated with respect and dignity.

Based on observations, interview, and record review the facility failed to provide a resident who is unable to carry out activities of daily living the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 4 of 20 residents (Resident #64, Resident #42, Resident #31, and Resident #104) reviewed for Activities of Daily Living's. The facility failed to ensure Resident #64, Resident #42, Resident #31, Resident #and Resident #104's fingernails were trimmed 02/18/2025 through 02/20/2025. The facility failed to ensure that Resident #28 was free from foul odors by providing incontinent care and ADL assistance. This failure could place residents at risk of not receiving services or care, diminished quality of life, and decreased self-esteem. Findings included: Resident #64 Resident #64 is a [AGE] year-old male admitted on [DATE] with pertinent diagnoses of Parkinson's Disease (a neurological brain disease that causes muscle tremors and degeneration), chronic kidney disease (a progressive disease of the kidneys that leads to organ degradation), generalized weakness, and a need for assistance with personal care. Resident #64's MDS dated [DATE] indicates a BIMS score of 03 indicating moderate to severe cognitive impairment and a need for set up or clean up assistance with personal hygiene. Resident #64's care plan states they are at risk for an ADL self-care deficit related to disease process and to check nail length and trim and clean on bath day and as necessary. Observation of Resident #64's nails on 02/18/25 at 10:30 am revealed untrimmed fingernails on both hands that were approximately 3 millimeters in length beyond the nailbed. In an interview with Resident #64 on 02/19/25 at 01:20 PM he stated it has been 4 months since someone had clipped his nails. He previously had a pair of nail clippers, but they went missing and he has been unable to clip his nails himself. He stated he did not like his nails long and wanted his nails trimmed. He stated the nurse used to do it but has not done it in a while. Resident #42 Resident #42 is an [AGE] year-old female admitted on [DATE] with pertinent diagnoses of Type 2 diabetes (blood sugar dysregulation that causes weakness and disorientation, a need for assistance with personal care, unspecified dementia (a degenerative brain disease), and muscle wasting. Resident #42's MDS dated [DATE] a BIMS score of 08 which indicates moderate cognitive impairment and complete dependance on caregivers for personal hygiene needs. Resident #42's care plan indicates she is completely dependent for ADL performance and caregivers should encourage participation in ADL care and anticipate meeting her needs. Observation of Resident #42 on 02/18/25 at 1:30 pm revealed 4 fingernails that were long, 4 fingernails that had an unknown black substance under the nailbed, and one nail that was yellow in color and detached from the entire length of the nailbed on the left side. In an interview with Resident #42 1:30 pm she stated that they have not offered her nail care since she has been there. She did not think to ask, but stated her memory is bad and she would like to remember to ask them. She stated she always previously cared for her nails, and it made her feel pretty when they were done. In an interview with RN F on 02/20/25 at 10:25 AM, she stated that CNAs were responsible for cutting nails after showers. If a resident has a diabetes diagnosis the CNAs were only allowed to file, the nails and a nurse should cut their nails. The residents should be offered nailcare 3x a week and if the nurse or CNA has identified a need. If another staff member identified the nails should be cut, but they had diabetes, they should communicate with the nurses. The nails should have been cut to their fingertips. When asked about Resident #64 and Resident #42 she stated that she had not checked on their nails recently. She stated Resident #42 should have had her nails trimmed by a nurse and Resident #64 should have had help trimming his nails. She was trained on nail care and other ADL's when she was hired. She stated if residents do not have their nails trimmed, they could get dirty or sustain a cut. Interview with CNA A, on 02/20/25 at 11:45 am she stated that she was trained on ADL's when she was hired. The policy was to provide nail care as needed and after showers. She stated that she could not perform nail care on Resident #42 because she had diabetes. She stated Resident #64 frequently refused help with ADLs, but she would check with him that day. She stated that the residents could scratch themselves and the wound could be infected if it was dirty. Resident #31 Record review of Resident #31's Face Sheet dated 01/15/2025 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (insufficient production of insulin, causing high blood sugar), schizoaffective disorder (mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder), acute respiratory failure with hypoxia (it occurs when there is inadequate oxygen exchange between the pulmonary capillaries and the alveoli), acute embolism and thrombosis (both conditions affecting blood flow through blood vessels), dysphagia (difficulty swallowing), muscle weakness (lack of muscle strength), and cognitive communication deficit (a person's ability to communicate effectively). Record review of Resident #31's Minimum Data Set assessment dated on 01/27/2025 reflected a BIMS score of 09 indicating moderate cognitive impairment. Section GG functional abilities reflected toileting to be Dependent helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. Shower/bathing to be substantial/maximal assistance helper does MORE THAN HALF the effort helper lifts or holds trunk or limbs and provides more than half the effort. Oral hygiene, setup or clean-up assistance helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. Upper body dressing states to be partial/moderate assistance helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. Lower body dressing states to be Substantial/maximal assistance helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort, and personal hygiene, the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene) stated to be Partial/moderate assistance helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. Record review of Resident #31's Care Plan last revised on 02/04/2025 reflected a focus on Resident #31 had an Activities of Daily Living Self Care Performance Deficit. Resident #31 would maintain or improve current level of function in personal hygiene. Will safely perform bed mobility, transfers, eating, dressing, grooming, toilet use and personal hygiene with supervision, independence, or modified independence. Record review of Resident #31 Activities of Daily Living Nail Care was conducted in which it states nail care to be completed as necessary and there was no documented data found showing nail care was completed in the last 30 days. In an observation and interview on 02/18/2025 at 10:48 AM with Resident #31, an observation was made of the resident's hands which revealed long fingernails that have not been trimmed. Resident # 31 fingernails were observed to be approximately half an inch long. Resident #31 stated he gets bathed, groomed, and fingernail trimming, but his fingernails are long in which he has not gone to get them trimmed during the designated times the facility does it. He wants them trimmed but has not had assistance. In an observation on 02/19/2025 at 3:00 PM of Resident #31, he was seen sleeping in his room with fingernails still untrimmed and not maintained. Resident #104 Record review of Resident #104's Face Sheet dated 07/16/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included essential hypertension (high blood pressure), hyperlipidemia (abnormally high levels of fats in the blood, including cholesterol and triglycerides), dyspnea (shortness of breath or awareness of one's own breathing),hyperplasia without lower urinary tract symptoms (benign prostatic hyperplasia, nonmalignant adenomatous overgrowth of the periurethral prostate gland), unspecified protein calorie malnutrition (state of inadequate intake of food), muscle wasting and atrophy (the loss of muscle mass and strength), difficulty in walking, not elsewhere classified, muscle weakness, need for assistance with personal care, cognitive communication deficit, dysphagia (difficulty swallowing), oropharyngeal phase (part of the swallowing process), and unsteadiness on feet (feeling unstable or losing balance when walking) Record review of Resident #104's Minimum Data Set assessment dated on 01/22/2025 reflected a BIMS score of 10 indicating moderate cognitive impairment. Section GG functional abilities reflected toileting to be substantial/maximal assistance helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. Shower/bathing to be substantial/maximal assistance helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. Oral hygiene, Setup or clean-up assistance helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. Upper, lower body dressing, and personal hygiene states to be substantial/maximal assistance helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. Record review of Resident #104's Care Plan last revised on 07/17/2024 reflected a focus on Resident #104 had an Activities of Daily Living Self Care Performance Deficit weakness, impaired mobility, and impaired circulation. Resident #104 will safely perform bed, mobility, transfers, eating, dressing, grooming, toilet use and personal hygiene with assistance. Record review of Resident #104 Activities of Daily Living Nail Care was conducted in which it states nail care to be completed as necessary and there was no documented data found showing nail care was completed in the last 30 days. Resident #28 During a record review on 02/18/2025 at 2:10PM, Resident #28's diagnosis indicated a primary diagnosis of Dementia with other behavioral disturbance and a secondary diagnosis of Schizophreniform disorder (mental disorder characterized variously by hallucinations, delusions and disorganized thinking and behavior). During a record review on 02/20/2025 at 11:10AM, Resident #28's care plan indicated Resident #28 had a focused area of ADL self-care performance Deficit related to impaired mobility. Resident #28's care plan indicated that Resident #28 requires 1 person assist with toileting and toileting hygiene initiated on 05/24/2018. During a record review on 02/20/2025 at 11:30AM, Resident #28's MDS record dated 10/01/2024, indicated a BIMS of 01 which indicated severely impaired cognitive ability. Resident #28's MDS indicated a toileting assistance number 4, meaning Resident #28 requires Supervision and touching assistance. In an observation and interview on 02/18/2025 at 10:33 AM with Resident #104, an observation was made of the resident's hands which revealed unmaintained long fingernails in which were approximately an inch long. Resident #104 stated he gets bathed and groomed, but his fingernails are long in which it's been a while since they have been trimmed by staff and he doesn't remember the last time his fingernails have been maintained. Resident #104 stated he has been wanting his fingernails to be trimmed. In an observation and interview on 02/19/2025 at 11:52 AM, it was observed Resident #104 was receiving nail treatment after previous observation of him having long fingernails. I observed nail care taking place by Registered Nurse A. Register Nurse A stated to be the Minimum Data Staff Coordinator and that normally she is not the one that does nail treatment. Registered Nurse A stated it is her understanding that nail treatment is to be completed once a week and as needed. During an observation on 02/20/2025 at 2:36PM, Resident #28 was walking down the hall with their walker, and a strong urine odor came from the resident. During this observation, staff members had walked by and/or talked to Resident #28 without offering assistance for toileting. During an interview on 02/20/2025 at 10:15 AM with CNA B, he stated when the State is here, everything is perfect, and all staff helps, or the hire ups start to help more than usual. He has been a Certified Nurse Assistant since 2011. He has been working here for 2 years and has been covering the 300 hall for the same amount of time in which Resident #31 and Resident #104 are on. He is trained in Activities of Daily Living's and nail care. Resident showers are 3 times a week. He stated nail treatment and grooming is once a week. He offers the residents, but it is their right to refuse or want treatment a certain way. He will first ask his nurse if the resident is diabetic so he can step in and provide nail treatment for that resident since nurses are required to do it if the resident is diabetic. His expectation is making sure residents do not have dirty nails, that they are maintained, and that residents are well groomed. During an interview on 02/20/2025 at 10:35 AM with DON, she stated she has been a Director of Nursing for [AGE] years. She has been here for 7 years. She is trained in Activities of Daily Living's. She stated upon hire, all staff are trained for Activities of Daily Living's. She stated all staff go through orientation, skills check training to watch them go through the process, in-services if there is an issue or if something comes up, and annual training. Her expectations for nail treatment are making sure nails are checked, maintained, cleaned, offer the resident to do nail treatment, and if the resident is diabetic then nurses conduct nail treatment. She stated if she sees that a resident does not have nails treated, she will speak to the Certified Nurse Assistant or Nurse and have nail treatment done immediately. She stated if nail treatment is not done, a resident may scratch themselves. She stated if the resident did want nails trimmed, then it could affect their quality of life. During an interview on 02/20/2025 at 10:46 AM with ADM, he stated all staff go through Activities of Daily Living in-service trainings and reeducate them if there are concerns, annual trainings in which they are switching to doing it 2 or 3 times a year now, implementing daily practices, and bringing in 3rd party resources to help. His expectations are for facility staff to take care of the residents when it comes to grooming or nail treatment. He stated if a resident comes in with long nails, they first make sure that the resident does not have a medical issue and have the proper staff to treat them as well as follow safety. He stated it is not just his role but all managers role, they talk about Activities of Daily Living's at morning meetings, but it is everyone's expectation to jump in and help the residents with nail treatment if a resident is seen with untreated nails. He stated that he does not want any staff member to say that is not their job and not help a resident. He stated if a resident has not had their nails trimmed in a long period of time, it can affect their quality of life and needs to be fixed. During an interview on 02/20/2025 at 2:40PM, M A G stated that they have worked at the facility for 5 years. MA G stated they could smell a strong odor of urine on Resident #28. MA G stated that the CNA on the designated hall should be providing toileting assistance for Resident#28. MA G stated that Resident #28 receives showers on Mondays, Wednesdays and Fridays. MA G stated that a negative impact that could cause a resident is embarrassment. During an interview on 02/20/2025 at 2:50PM, CNA C stated that they had worked at the facility for 2 years now. CNA C stated that there is documentation of toileting on the charting system on the computer. CNA A stated she worked with Resident #28. CNA C stated that they would toilet the resident at the beginning of the shift and at the end of the shift, including sometimes in between. During an interview on 02/20/2025 at 3:10PM, the DON stated they had worked at the facility for 7 years. The DON stated the expectation for toileting residents is to meet the resident's needs and to ensure they are clean and dry. The DON stated the expectation is that CNA and qualified staff should assist with toileting at necessary. The DON identified nurses, aides and therapy as qualified staff. The DON stated that the expectation for staff if they smelled a resident that has an odor is to take the resident to their room and check them. The DON stated that Resident #28 typically does not smell like urine. The DON reported the care plan should say 2 person assist for Resident #28's toileting assistance. The expectation for staff to toilet residents is every 2 hours or as needed. The DON stated a negative impact this could cause the resident, is psychosocial embarrassment. The DON reported that trainings are provided on Relias yearly for staff. During an interview on 02/20/2025 at 03:30PM, the ADM stated that staff should be providing toileting needs every 2 hours but there is no policy on it. The ADM stated that Medication Aides, CNA's, and Nurses should provide toileting assistance. The ADM stated that nobody is above providing assistance. The ADM stated that residents should not be walking around the facility smelling like urine. The ADM stated that staff should immediately offer assistance to the resident if changing is necessary. The ADM stated showers should be provided to each resident when scheduled. The ADM stated that a Resident could smell like urine if they are wet. The ADM stated trainings for ADL and toileting is typically provided by the staffing coordinator, ADON, DON and everybody should be providing assistance with trainings. The ADM stated a negative impact it could cause a resident would be a social impact, other residents could smell the urine, and insecurities could arise for the resident. The ADM stated Resident #28 is demented and requires minimal assistance with toileting. Record Review of Nursing Services-ADL policy provided by the facility, dated 05/2007, revealed Nursing service staff cares for its residents in 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 each residents' dignity and respect in full recognition of his or her individuality. Bullet point in this policy stated Residents receive assistance as needed to manag3e their physical needs which includes personal hygiene grooming, dressing, toileting, transferring, ambulating and eating. Record review of the facility Legend Oaks Healthcare and Rehabilitation Nursing Services Activities of Daily Living's policy with revised date 05/2007 stated the following: Nursing service staff cares for its residents in manner and in an environment that promotes maintenance or enhancement of each residents' quality of life and promotes care for residents in a manner and in an environment that maintains or enhance each resident's dignity and respect in full recognition of his or her individuality. Each resident: o Receives or is provided the necessary care and services enabling him/her to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehension assessment and plan of care. o Resides and receive services in the facility with reasonable accommodations of individual needs and preferences, except when the health or safety of the individual or other residents would be endangered. o Retains and uses personal possessions including furnishings, and appropriate clothing as space permits, unless to do so would infringe on the rights or health and safety of other residents. o Residents receive assistance as needed to manage their physical needs which includes personal hygiene grooming, dressing, toileting, transferring, ambulating and eating. o Chooses activities, schedules, and health care consistent with his or her interest, assessments and plans of care and makes choices about aspects of his or her life in the facility that are significant to the resident. o Ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the resident's clinical demonstrate that diminution was unavoidable. o Each Resident is assessed for their ability to perform Activities of Daily Living is and the assistance needed, and a plan of care is developed, and interventions are implemented based on their needs, goals of care and preferences. o Each resident receives adequate supervision and assistive devices as needed. o Resident or his/her representative has the right to refuse care and treatment. Refusal of care will be documented in the clinical record with a plan to minimize or decrease functional loss. Residents may refuse or resist care due to dementia. Attempts will be made to identify cause for refusal and alternate ways to provide care as appropriate. 51115 Based on observations, interview, and record review the facility failed to provide a resident who is unable to carry out activities of daily living the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 4 of 20 residents (Resident #64, Resident #42, Resident #31, and Resident #104) reviewed for Activities of Daily Living's. The facility failed to ensure Resident #64, Resident #42, Resident #31, and Resident #104's fingernails were trimmed 02/18/2025 through 02/20/2025. This failure could place residents at risk of not receiving services or care, diminished quality of life, and decreased self-esteem. Findings included: Resident #64 Resident #64 is a [AGE] year-old male admitted on [DATE] with pertinent diagnoses of Parkinson's Disease (a neurological brain disease that causes muscle tremors and degeneration), chronic kidney disease (a progressive disease of the kidneys that leads to organ degradation), generalized weakness, and a need for assistance with personal care. Resident #64's MDS dated [DATE] indicates a BIMS score of 03 indicating moderate to severe cognitive impairment and a need for set up or clean up assistance with personal hygiene. Resident #64's care plan states they are at risk for an ADL self-care deficit related to disease process and to check nail length and trim and clean on bath day and as necessary. Observation of Resident #64's nails on 02/18/25 at 10:30 am revealed untrimmed fingernails on both hands that were approximately 3 millimeters in length beyond the nailbed. In an interview with Resident #64 on 02/19/25 at 01:20 PM he stated it has been 4 months since someone had clipped his nails. He previously had a pair of nail clippers, but they went missing and he has been unable to clip his nails himself. He stated he did not like his nails long and wanted his nails trimmed. He stated the nurse used to do it but has not done it in a while. Resident #42 Resident #42 is an [AGE] year-old female admitted on [DATE] with pertinent diagnoses of Type 2 diabetes (blood sugar dysregulation that causes weakness and disorientation, a need for assistance with personal care, unspecified dementia (a degenerative brain disease), and muscle wasting. Resident #42's MDS dated [DATE] a BIMS score of 08 which indicates moderate cognitive impairment and complete dependance on caregivers for personal hygiene needs. Resident #42's care plan indicates she is completely dependent for ADL performance and caregivers should encourage participation in ADL care and anticipate meeting her needs. Observation of Resident #42 on 02/18/25 at 1:30 pm revealed 4 fingernails that were long, 4 fingernails that had an unknown black substance under the nailbed, and one nail that was yellow in color and detached from the entire length of the nailbed on the left side. In an interview with Resident #42 1:30 pm she stated that they have not offered her nail care since she has been there. She did not think to ask, but stated her memory is bad and she would like to remember to ask them. She stated she always previously cared for her nails, and it made her feel pretty when they were done. In an interview with RN F on 02/20/25 at 10:25 AM, she stated that CNAs were responsible for cutting nails after showers. If a resident has a diabetes diagnosis the CNAs were only allowed to file, the nails and a nurse should cut their nails. The residents should be offered nailcare 3x a week and if the nurse or CNA has identified a need. If another staff member identified the nails should be cut, but they had diabetes, they should communicate with the nurses. The nails should have been cut to their fingertips. When asked about Resident #64 and Resident #42 she stated that she had not checked on their nails recently. She stated Resident #42 should have had her nails trimmed by a nurse and Resident #64 should have had help trimming his nails. She was trained on nail care and other ADL's when she was hired. She stated if residents do not have their nails trimmed, they could get dirty or sustain a cut. Interview with CNA A, on 02/20/25 at 11:45 am she stated that she was trained on ADL's when she was hired. The policy was to provide nail care as needed and after showers. She stated that she could not perform nail care on Resident #42 because she had diabetes. She stated Resident #64 frequently refused help with ADLs, but she would check with him that day. She stated that the residents could scratch themselves and the wound could be infected if it was dirty. Resident #31 Record review of Resident #31's Face Sheet dated 01/15/2025 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (insufficient production of insulin, causing high blood sugar), schizoaffective disorder (mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder), acute respiratory failure with hypoxia (it occurs when there is inadequate oxygen exchange between the pulmonary capillaries and the alveoli), acute embolism and thrombosis (both conditions affecting blood flow through blood vessels), dysphagia (difficulty swallowing), muscle weakness (lack of muscle strength), and cognitive communication deficit (a person's ability to communicate effectively). Record review of Resident #31's Minimum Data Set assessment dated on 01/27/2025 reflected a BIMS score of 09 indicating moderate cognitive impairment. Section GG functional abilities reflected toileting to be Dependent helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. Shower/bathing to be substantial/maximal assistance helper does MORE THAN HALF the effort helper lifts or holds trunk or limbs and provides more than half the effort. Oral hygiene, setup or clean-up assistance helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. Upper body dressing states to be partial/moderate assistance helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. Lower body dressing states to be Substantial/maximal assistance helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort, and personal hygiene, the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene) stated to be Partial/moderate assistance helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. Record review of Resident #31's Car Plan last revised on 02/04/2025 reflected a focus on Resident #31 had an Activities of Daily Living Self Care Performance Deficit. Resident #31 would maintain or improve current level of function in personal hygiene. Will safely perform bed mobility, transfers, eating, dressing, grooming, toilet use and personal hygiene with supervision, independence, or modified independence. Record review of Resident #31 Activities of Daily Living Nail Care was conducted in which it states nail care to be completed as necessary and there was no documented data found showing nail care was completed in the last 30 days. In an observation and interview on 02/18/2025 at 10:48 AM with Resident #31, an observation was made of the resident's hands which revealed long fingernails that have not been trimmed. Resident # 31 fingernails were observed to be approximately half an inch long. Resident #31 stated he gets bathed, groomed, and fingernail trimming, but his fingernails are long in which he has not gone to get them trimmed during the designated times the facility does it. He wants them trimmed but has not had assistance. In an observation on 02/19/2025 at 3:00 PM of Resident #31, he was seen sleeping in his room with fingernails still untrimmed and not maintained. Resident #104 Record review of Resident #104's Face Sheet dated 07/16/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included essential hypertension (high blood pressure), hyperlipidemia (abnormally high levels of fats in the blood, including cholesterol and triglycerides), dyspnea (shortness of breath or awareness of one's own breathing),hyperplasia without lower urinary tract symptoms (benign prostatic hyperplasia, nonmalignant adenomatous overgrowth of the periurethral prostate gland), unspecified protein calorie malnutrition (state of inadequate intake of food), muscle wasting and atrophy (the loss of muscle mass and strength), difficulty in walking, not elsewhere classified, muscle weakness, need for assistance with personal care, cognitive communication deficit, dysphagia (difficulty swallowing), oropharyngeal phase (part of the swallowing process), and unsteadiness on feet (feeling unstable or losing balance when walking) Record review of Resident #104's Minimum Data Set assessment dated on 01/22/2025 reflected a BIMS score of 10 indicating moderate cognitive impairment. Section GG functional abilities reflected toileting to be substantial/maximal assistance helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. Shower/bathing to be substantial/maximal assistance helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. Oral hygiene, Setup or clean-up assistance helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. Upper, lower body dressing, and personal hygiene states to be substantial/maximal assistance helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. Record review of Resident #104's Care Plan last revised on 07/17/2024 reflected a focus on Resident #104 had an Activities of Daily Living Self Care Performance Deficit weakness, impaired mobility, and impaired circulation. Resident #104 will safely perform bed, mobility, transfe[TRUNCATED]

Based on observation, interview and record review the facility failed to ensure each resident bedside and toilet and bathing facilities were adequately equipped to allow all residents to call for staff assistance through a communication system that would relay the call directly to a staff member or a centralized staff work area for 1of 14 residents (Resident #102 and Resident # 34) reviewed for resident call system . The facility failed to provide a working communication system, that was easily at reach, that would allow Resident #102 the ability to safely call for staff for assistance. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they needed support for daily living. Findings include: Review of the face sheet for Resident #102 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included congestive heart failure (when your heart can't pump blood well enough to give your body a normal supply), chronic kidney disease (longstanding disease of the kidneys leading to renal failure), hypertension (high blood pressure), diabetes mellitus type 2, unspecified visual loss, muscle wasting and atrophy (loss of muscle mass and strength, typically caused by a lack of physical activity, injury, malnutrition, or certain medical conditions, leading to a decrease in muscle size and function), difficulty walking, right femur fracture, and need for assistance with personal care. Review of Resident #102's Quarterly MDS dated [DATE] reflected a BIMS Score of 12, which indicated he had a mild cognitive impairment. The MDS also reflected Resident #102 required partial to moderate assistance for ADLs, including bed to chair transfers. Record review of Resident #102's Care Plan dated 12/09/24 reflected a focus area of being at high risk for falls related to a recent fall with right femur fracture. The goal indicated Resident #102 would not sustain serious injury through the review date, and an intervention reflected to be sure the call light was within reach and encourage to use it to call for assistance as needed. The Care Plan further indicated a focus area for ADL self-care performance deficit related to right femur fracture. The goal and interventions were for Resident #102 to safely perform bed mobility, transfers, eating, dressing, grooming, toilet use and personal hygiene with assistance of one staff member through the review date. An observation and interview on 02/18/25 at 10:24 AM revealed Resident #102 was sitting up in his wheelchair on the right side of his bed. He was wearing sunglasses due to low vision. Resident #102's call light was wrapped around the bedrail on the left side of bed and out of reach. Resident #102 stated he could not reach the call light that was wrapped around the left bedrail. An observation and interview on 2/19/25 at 10:10 AM revealed Resident # 34 was sitting up in bed. Resident states her call light was not within reach and that her call light is frequently put not within reach by the staff. Observation of call light dangling from bedside on left side near handrail and looped around handrail once. Resident has contractures of right hand and limited ROM for left hand. Interview on 2/19/25 at 2:55 PM the DON was asked,: Should residents have access to their call lights? Yes, always. Who is responsible for ensuring residents have access to their call lights? Everyone How often are residents checked to ensure their call light is within reach? All the time and but minimum of best practice of every 2 hours. Can it negatively affect a resident if they do not have access to their call light? Yes How can it negatively affect a resident if they do not have access to their call light? Their needs could not be met. Interview on 2/20/25 at 1:15 AM the SW was asked: Should residents have access to their call lights? Yes always. Who is responsible for ensuring residents have access to their call lights? All staff are responsible. How often are residents checked to ensure their call light is within reach? Every shift and best practice of every 2 hours. Can it negatively affect a resident if they do not have access to their call light? Yes physically, mentally, psychologically. Interview on 2/20/25 at 1:41 PM the MA H was asked Should residents have access to their call lights? Yes Who is responsible for ensuring residents have access to their call lights? First off CNA's and then all other staff. Anybody can answer a call light. How often are residents checked to ensure their call light is within reach? Every 2 hours, beginning of shift, end of shift, all times. Can it negatively affect a resident if they do not have access to their call light? Yes. How can it negatively affect a resident if they do not have access to their call light? The resident can feel neglected emotionally and physically. Interview on 2/20/25 at 2:40 PM CNA E was asked: How often are trainings held? Monthly and sometimes biweekly Should residents have access to their call lights? Yes Who is responsible for ensuring residents have access to their call lights? All staff How often are residents checked to ensure their call light is within reach? All the time Can it negatively affect a resident if they do not have access to their call light? Yes How can it negatively affect a resident if they do not have access to their call light? The resident could need help and not receive it, or an accident could occur. Interview on 2/20/25 at 2:46 PM CMA was asked: Should residents have access to their call lights? Yes Who is responsible for ensuring residents have access to their call lights? CNA's How often are residents checked to ensure their call light is within reach? Every 2 hours or more often if the resident needs more often can it negatively affect a resident if they do not have access to their call light? Yes How can it negatively affect a resident if they do not have access to their call light? If the resident needs help or possible accidents occur. Interview on 2/20/25 at 2:50 PM CNA I was asked: Should residents have access to their call lights? Yes, always. Who is responsible for ensuring residents have access to their call lights? CNA's and then all staff How often are residents checked to ensure their call light is within reach? All the time and every 2 hours Can it negatively affect a resident if they do not have access to their call light? Yes How can it negatively affect a resident if they do not have access to their call light? Resident could not receive the services they need such as toileting, water, pain medication. Interview on 2/20/25 at 3:00 PM the ADM was asked: Should residents have access to their call lights? Yes, always. Who is responsible for ensuring residents have access to their call lights? All staff How often are residents checked to ensure their call light is within reach? As frequent as possible but at minimum every 2-3 hours can it negatively affect a resident if they do not have access to their call light? Yes How can it negatively affect a resident if they do not have access to their call light? It could make the resident feel like nobody is paying attention. How are staff trained about respect and dignity, ADL's, call lights? I am very big on training lots of customer service training. Immediately after an incident occurs and at least monthly in-service trainings. Review of the facility Policy & Procedure for Call Light/Bell dated May 2007 reflected, It is the policy of this facility to provide a means of communication with nursing staff. 1. Answer the light/bell within a reasonable time. 2. Turn off the call light/bell. 3. Listen to the president's request/need. 4. Respond to the request. If the item is not available or you are not able to assist, explain to the resident and notify the charge nurse for further instruction. 5. Leave the resident comfortable. Place the call device within the resident's reach before leaving room.

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 2 of 4 residents (Resident #1 and Resident #2,) reviewed for infection control. CNAs B, C, and D failed to properly perform incontinent care on Residents #1 and 2. CNA D failed to perform hand hygiene while performing incontinent care on Resident #2. The facility failed to wear PPE when providing high contact resident care (dressing, bathing, transfers, wound care, device) to Resident #2. The facility failed to have signage on resident door that reflected PPE was required for high contact care for Resident #2. These failures could place residents at risk for infection, hospitalization , or death. Findings included: Review of the undated face sheet for Resident #1 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included dementia, cognitive communication deficit, and need for assistance with personal care. Review of the quarterly MDS assessment for Resident #1 dated 10/25/24 reflected a BIMS score of 1, indicating severe cognitive impairment. It reflected she was totally dependent on staff for toileting hygiene. Review of the care plan for Resident #1 revised 04/24/24 reflected the following: [Resident #1] has ADL Self Care Performance Deficit, will maintain current level of functioning in Bed Mobility, Transfers, Eating, Toileting. Toilet use: requires assistance, extensive X1 person. Observation of a closed-circuit video dated 01/08/2025 at 1:30 pm revealed CNA C began peri care (know as perineal care-involves cleaning the private areas of a patient/Resident) on Resident #1, with gloved hands, CNA C took wipes from the packet, wiped Resident #1's left groin (located at the junction where the upper body or the abdomen meets the thighs) area down and vaginal area with the same wipes 3 times without folding or changing wipes. CNA C did not separate Resident #1's labium (the inner and outer folds of the vulva, at either side of the vagina) to clean properly. CNA C did not clean Resident #1's right groin area. CNA C then rolled Resident #1 over on her left side, wiped Resident #1's buttocks in an upward motion multiple times with the same wipes without changing or folding the wipes. Observation of a closed-circuit video dated 01/08/2025 at 1:30 pm revealed CNA B began peri care on Resident #1, with gloved hands, CNA B took wipes from the packet, wiped Resident #1's lower abdominal area from left to right and down to Resident #1's vaginal area with the same wipes without folding or changing the wipes. CNA B then rolled Resident #1 over on her left side, removed soiled brief, wiped Resident #1's buttocks in an upward motion 2 times with the same wipes without changing or folding the wipes. Review of the undated face sheet for Resident #2 reflected an [AGE] year-old female admitted to the facility on [DATE] with readmitted [DATE]. Her diagnoses included metabolic encephalopathy (a condition where problems with metabolism cause brain dysfunction, can lead to symptoms such as confusion and memory loss) urinary tract infection and need for assistance with personal care. Review of the quarterly MDS assessment for Resident #2 dated 02/03/25 reflected a BIMS score of 0, indicating severe cognitive impairment. Staff assessment reflected short and long-term memory problems. Section H (bladder and Bowel) reflected Resident #1 had indwelling catheter (also a foley catheter, a thin, flexible tube inserted into the bladder for an extended period to allow urine to flow freely for collection or testing). Review of the care plan for Resident #2 revised 01/06/25 reflected the following: [Resident #2] has ADL Self Care Performance Deficit, will safely perform Bed Mobility, Transfers, Eating, dressing, grooming personal hygiene and Toileting. Toilet use: incontinent to bowel and bladder, requires total assistance X2 person with incontinent care. It was also reflected, Resident #2 had pressure ulcer or potential for pressure ulcer development (SPECIFY location) related to admitted with Stage 4 to the sacrum, Use Enhanced Barrier Precautions. Review of Resident #2's current physician order reflected the following: CATHETER TYPE: 16FR # 10 ML TO CLOSED URINARY DRAINAGE SYSTEM - DIAGNOSIS FOR USE: neurogenic bladder every shift dated 01/31/2025. ENHANCED BARRIER PRECAUTIONS: PPE required for high resident contact care activities. Indication: Wounds, Urinary Catheter dated 02/03/2025 SACRAL WOUND- Cleanse with Dakins soaked gauze, pat dry, apply collagen flakes to the wound bed, then skin prep around the area, peri wound, place peel and place dressing in place, connect to NPWT continuous at 125mmHg bridge to adjacent anterior lateral left or right if needed. Every day shift every Mon, Wed, Fri for Stage 4 dated 02/05/2025. Observation on 02/05/2025 at about 12:00 noon, revealed CNA C and CNA D went to perform peri care on Resident #2. The was no signage at Resident #2's door or bin containing PPE to indicate Resident #2 was on EBP. It was observed both CNAs did not wear gown to perform incontinent care on Resident #2. CNA D performed hand hygiene, donned clean gloves, and began wiping Resident #2's front. CNA D wiped Resident #2's left groin area multiple times, upward and backward with same wipes, and moved to right side. CNA D removed gloves, no hand hygiene, donned clean gloves, and wiped Resident #2's vaginal area. CNA D then rolled Resident #2 to the right side, wiped Resident #2's buttocks in an upward and downward motion, same wipes without folding the wipes. CNA D then removed gloves, no hand hygiene and donned clean gloves. It was observed Resident #2 had a foley catheter draining, wound at coccyx area with dressing soiled with BM and excoriations at upper thighs. CNA D applied barrier cream to excoriated area at upper thighs, with the same gloved hands CNA D touched the curtains in Resident #2's room. CNA D removed gloves, walked into Resident #2's bathroom, without hand hygiene, touched Resident #2's personal items in a sealed bag, and then washed CNA D hands. During an interview on 02/05/2025 at 1:46 pm, CNA D stated she had been trained on infection control. CNA D stated hand washing was performed just before resident's care and after care, and after changing gloves 2-3 times. She stated you can sanitize your hands with gloves changes, but she did not have sanitizer. CNA D stated, when performing incontinent care, staff were supposed to wipe from front to back and the staff could fold the same wipe and use again. CNA D stated when wiping the buttocks area, staff were to wipe in an upward motion, but with resident #2, due to the wound it was hard to wipe her. CNA D stated she had worked with Resident #2 before and was aware she had a foley catheter and wound. CNA D stated she was trained on EBP, if residents had wounds and foley catheter they were supposed to wear gown, but Resident #2 did not have sign on the door or PPE next to the door. CNA D stated they had to wear gowns to prevent the spread of infection, to protect the residents. During an interview on 02/05/2025 at 2:01 pm, CNA C stated she was trained on infection control, hand hygiene, donning PPE. CNA C stated hand hygiene was performed when entering a resident's room, when leaving the room, before and after feeding a resident, and with gloves changes. CNA C stated during incontinent care on Resident #2, when CNA D changed gloves, she should have used a sanitizer, but CNA D did not have a sanitizer. CNA C stated CNA D wiped back and forth because Resident #2 had too much cream sticking on her buttocks area. CNA C stated, when cleaning a resident's front during incontinent care, staff were supposed to wipe downward, and at the back you wipe upward to prevent infection. CNA C stated she was aware Resident #2 had a foley catheter and wounds. She also stated they were trained to wear gown when providing care for residents with foley catheter, wounds, or feeding tube to prevent the spread of infection to and from residents. CNA C stated there were no signage or PPE bin at Resident #2's door that was why they didn't wear gowns. During an interview on 02/05/2025 at 4:00 pm, the Central Supply staff stated she was responsible to ensure residents who met EBP criteria had signage at the door along with bin containing PPE. She stated residents with wounds, foley catheters, or dialysis catheters met EBP criteria. She stated usually it was discussed in the morning meetings, but she was not made aware of Resident #2 needing signage and PPE set up at her door. The Central supply staff stated not having the signage and PPE bin at the doors of residents who met EBP criteria would endanger the residents by exposing them to infection. During an interview on 02/05/2025 at 4:22 pm the DON stated the entire management team was responsible to ensure a residents who met the criteria for EBP got signage and PPE bins were at the door to alert staff. The DON stated upon admission, the team discuss in their morning meetings. The DON stated they had bins and signage setup and ready for backup for the nursing staff for Residents with wounds, foley catheters, GT, etc. The DON stated she was made aware that Resident #2 did not have signage and PPE set up at the door. The DON stated Resident #2 required EBP because of her wounds and foley catheter. The DON stated EBP was to prevent the transmission of infection to the residents. The DON stated hand hygiene should be performed when soiled, when in contact with residents, when moving from dirty to clean, with gloves change . The DON stated it was her expectation for staff to perform peri care according to the facility's peri care procedure. The DON stated staff were not supposed to wipe from the side and same wipe in the vagina area that was exposing the resident to infection. The DON stated staff were not supposed to double wipe or scrub up and down, going in the opposite direction. CNA B was not available for interview. Review of a performance review dated 09/11/2024 and signed by CNA C and the Central Supply staff reflected CNA C received her approval for all aspects of her performance of Hand Hygiene, PPE-DON and Doff, and Peri care-female. Review of a performance review dated 01/07/2025 and signed by CNA B and the Medical Record/Staffing coordinator reflected CNA B received her approval for all aspects of her performance of Peri care-female. Review of a performance review dated 07/24/2024 and signed by CNA D and the Medical Record/Staffing coordinator reflected CNA D received her approval for all aspects of her performance of Peri care-female. Review of facility's policy titled infection Prevention and Control Program revised 10/2022 reflected: Policy The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. The elements of the infection prevention and control program consist of coordination/oversight, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. The program will be carried out by the facility infection preventionist. It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene based on accepted standards. Goal o Decrease the risk of infection to residents and personnel. o Recognize infection control practices while providing care. o Identify and correct problems relating to infection control. o Ensure compliance with state and federal regulations related to infection control o Promote individual resident's rights and well-being while trying to prevent and control the spread of infection. o Monitor personnel health and safety. Review of facility's policy titled Hand Hygiene revised 12/2023 reflected: Policy It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene, which is one of the most effective measures to prevent the spread of infection, based on accepted standards. Residents, family, and visitors will be encouraged to practice hand hygiene. Hand hygiene is a general term that applies to hand washing, antiseptic hand wash, and alcohol-based hand rub. 2. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: g. Before handling clean or soiled dressings, gauze pads, etc.; h. Before moving from a contaminated body site to a clean body site during resident care; i. After contact with blood or bodily fluids; j. After handling used dressings, contaminated equipment, etc.; k. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; .After removing gloves; m. Before and after entering isolation precaution settings; n. Before and after eating or handling food; o. Before and after assisting a resident with meals; and p. After personal use of the toilet or conducting your personal hygiene. q. After removing and disposing of personal protective equipment. Review of facility's titled Policy/Procedure-Nursing Services: Quality of Care revised 01/2023 reflected: POLICY: It is the policy of this facility that residents are given the appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care. Review of facility's skill checkoff titled Peri Care-Female reflected: Implementation .put on clean gloves. .assemble supplies on clean appropriate surface and allow Resident to test temperature of water (if using) .assist resident into comfortable position with bed at a comfortable level. .ensure pad or linen protector is appropriately under the patient before washing. .apply soap to wet washcloth (skip step if using wipes) .wash genital area moving from front to back, using a clean part of the washcloth for each stroke or a clean wipe for each stroke. .using a clean washcloth, rinse soap from genital area, moving from front to back, using a clean area of the washcloth for each stroke (skip if using wipe) .after cleaning genital area, assist Resident on the side .if using wipe use a clean wipe to clean rectal area, moving from front to back, dry with towel. Review of the Virginia Department of Health - Enhanced Barrier Precautions in Nursing Homes Algorithm, dated 06/2024, reflected in part, EBP are indicated for the following residents who are: Known to be colonized or infected with a multidrug-resistant organism (MDRO) when contact precautions do not otherwise apply; At increased risk of MDRO acquisition (e.g., resident has a wound or indwelling medical device) . In addition to standard precautions, gowns and gloves should be worn during the following high-contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, wound care . Steps to Implementation: With implementation, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. 1. Post clear signage on the door or wall outside of the resident room indicating the type of precautions and required personal protective equipment (PPE) (e.g., gown and gloves). For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of a gown and gloves. 2. Make PPE, including gowns and gloves, available immediately outside of the resident room .

Based on observation, interviews, and record review, the facility failed to ensure the resident environment was as free from accident hazards as possible for 1 of 4 residents (Resident #1) reviewed for accidents. The facility failed to ensure Resident #1 was transferred safely when CNA A transferred her by mechanical lift by herself on 01/10/2025. This failure placed residents at risk of injury. Findings included: Review of the undated face sheet for Resident #1 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included dementia, cognitive communication deficit, and need for assistance with personal care. Review of the quarterly MDS assessment for Resident #1 dated 10/25/24 reflected a BIMS score of 1, indicating severe cognitive impairment. It reflected she was totally dependent on staff for every kind of transfer. Review of the care plan for Resident #1 revised 04/24/24 reflected the following: [Resident #1] has ADL Self Care Performance Deficit, will maintain current level of functioning in Bed Mobility, Transfers, Eating, Toileting. TRANSFER; Requires Mechanical lift and assistance of 2 staff members for all transfers. Observation of a closed-circuit video dated 01/10/2025 at 6:31 pm revealed CNA A began a transfer with Resident #1 using full body patient lift to move Resident #1 from her wheelchair to her bed. The entire transfer was performed alone by CNA A with no presence of any other staff person in the room. No impacts or falls were observed during the transfer, and Resident #1 did not give any verbal or nonverbal indications of distress . During an interview on 09/10/24 at 03:49 PM, the DON stated all mechanical lift transfers required the participation of two staff members in the facility for the safety of residents. She stated they had trained every staff person who had any involvement in mechanical lift transfers and had recently run a return demonstration skills test for all CNAs to ensure they knew how to implement a safe transfer. She stated she, the ADON, and the entire team were responsible for ensuring transfers were done safely. She stated a potential negative outcome to residents of not transferring properly with a mechanical lift was falls and injury. The DON stated the facility was made aware by Resident #1's family of the improper transfer. The DON stated CNA A was written up and was trained by the staff developer personnel. The DON stated random training mechanical transfers were being done by the management staff. During interviews on 02/05/2025 from 11:53 am to 4:22 pm, CNAs C, B and E, RNA F, RN G, the Staffing Coordinator, the Wound Care nurse and the Central Supply, all staff stated 2 persons were required for mechanic lift transfer for Residents safety. Staff stated they have completed checkoffs on mechanical lift transfers. On 02/05/2025 CNA A was unavailable for interview due to travel status. Review of CNA A's personnel file reflected: Counseling/Disciplinary Notice dated 01/12/2025, written warning reason---failure to perform duties directly related to or engaging in conduct that in any way compromises the safety, health and/or physical comfort and well-being of a Resident. Corrective action-skills checkoff on mechanical lift transfer. It was also reflected the document was signed by CNA A. Review of a performance review dated 01/12/2025 and signed by CNA A and the Medical Record/Staffing coordinator reflected CNA A received her approval for all aspects of her performance of a mechanical lift transfer, including the following: Gather assistance of at least one staff member prior to beginning, transfer and communicating expectations of transfer, prearranged signals, and plan to complete transferred together. Review of the facility's policy dated June 2018 titled Fall Management System reflected the following: The facility is committed to providing resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practical level of function through providing the resident adequate supervision, assistive devices and functional programs as appropriate to prevent accidents.

Based on interview and record review, the facility failed to immediately notify the resident's physician when there was a significant change in the resident's physical status for one (Resident #1) of four residents reviewed for resident rights. The facility failed to ensure Resident #1's NP was notified that she began consistently refusing and/or spitting out her medications in the middle of December 2024. This failure placed residents at risk of medical diagnoses not getting treated and a decreased quality of life. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including essential hypertension (high blood pressure), dysphagia (difficulty swallowing), type II diabetes, and dementia. Review of Resident #1's quarterly MDS assessment, dated 10/25/24, reflected a BIMS score of 1, indicating she had severe cognitive impairment. Section K (Swallowing/Nutritional Status) reflected she had a history of coughing or choking during meals or when swallowing medications. Review of Resident #1's quarterly care plan, dated 10/28/24, reflected no focus or interventions related to refusing and/or spitting out her medications. Review of Resident #1's MARs, December of 2024 and January of 2025, reflected around 12/14/24, her medication administrations were being marked either 1 or 5 on a consistent basis. 1 indicated the drug was refused, and 5 indicated she spit the medication out. From 12/14/24 - 12/31/24, there were three instances she refused her medications and seven where she spit them out. From 01/01/25 - 01/12/25, there were seven instances where she refused her medications and five where she spit them out. During an interview on 01/17/25 at 11:02 AM, Resident #1's NP stated she last saw her on 12/20/24. She stated she was not made aware of Resident #1 refusing and/or spitting out her medications. She stated she would expect to be notified in that case. She stated she would expect for the nurses to document the refusals, keep trying, or try other interventions. During an interview on 01/17/25 at 1:02 PM, LVN A stated Resident #1 had been refusing (by not opening her mouth) or spitting out the pudding (with her crushed medications) for at least a month. He stated the medication aides would tell him when that would happen, and he would attempt to get her to swallow as much as he could. He stated he did not specifically tell the NP about that but believed she knew. During an interview on 01/17/25 at 1:15 PM, LVN B stated Resident #1 had, for a while, been refusing or spitting out her medications. She stated she would keep her at the nursing station and would encourage her. She stated sometimes she would gradually swallow the pudding. She stated she thought the NP was aware of that behavior, but could not remember if she had told her. During an interview on 01/17/25 at 3:05 PM, the DON stated the NP should be notified by the nurse if a resident had multiple refusals of their medication. She stated it was important for the NP to be aware so they could discuss and determine what the next steps could be or what needed to be done. She stated a negative outcome of the NP not being involved was everyone not being involved in the residents' care . Review of the facility's Notification of Physician Policy, revised 08/2007, reflected the following: 1. The Nurse Supervisor will notify the resident's attending physician when: . D. The resident repeatedly refuses treatment or medications (i.e. two (2) or more consecutive times. Review of the facility's Administration of Medication Policy, revised 06/2022, reflected the following: It is the policy of this facility that medications shall be administered as prescribed by the attending physician.

Based on observations, interviews, 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 (Resident #1 and Resident #2) reviewed for infection control, as indicated by: The facility failed to ensure CNA A and CNA B performed infection control practices during peri care. These failures could place the residents at risk of transmission of diseases and infection. The findings included: Record review of Resident #1's face sheet on 11/08/24 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses were hypertension, muscle weakness, cognitive communication deficit, chronic kidney disease, difficulty in walking, paranoid schizophrenia, hemiplegia and hemiparesis (weaknesses or paralysis of one side of the body), and need for assistance with personal care. Record review on 11/08/24 of Resident #1's initial MDS assessment, dated 09/26/24 revealed a BIMS score of 04 indicating his cognition was severely impaired. Record review on 11/08/24 of Resident #1's care plan dated 09/13/24 indicated he had bowel/bladder incontinence r/t impaired mobility and a relevant intervention was checking for incontinence, wash, rinse, and dry perineum as required, and change clothing PRN after incontinence episodes. During an observation on 11/08/24 at 3:20pm CNA A provided peri care to Resident #1. CNA A put on a new pair of gloves. She did not wash or sanitize her hands before donning the gloves. CNA A removed the old brief and cleaned Resident #1's front and back with wet wipes. She then changed gloves and continued cleaning with wipes and with the same pair of gloves she handled the new brief. She was taking out wet wipes directly from the packet for cleaning and during that process she handled the wet wipe packet with soiled gloves. After the completion of peri care, she removed her gloves and went out for getting a new set of bed sheets. She did not sanitize or wash her hands before leaving the room . CNA A then stored the contaminated wet wipe packet on the side table for future use. She then assisted the Resident #1 to get transferred from the bed to his wheelchair. She removed a pair of shoes that were sitting on the wheelchair; however, did not sanitize the wheelchair surface after removing the shoes and before transferring the resident to the wheelchair. CNA A transported the resident out of his room on the wheelchair, without washing or sanitizing her hands. During an interview on 10/29/24 at 11:15am CNA A requested the state investigator to walk through the peri care process so that she would be able identify the mistakes. She stated she should have washed and sanitized her hands at appropriate times and should not have handled the wet wipe packet with dirty gloves. She stated she knew washing hands before and after the peri care was instructed at the facility; however, forgot to practice it at the time of peri care. CNA A stated she never thought of the contamination of the wheelchair by placing the shoes on that and stated that she realized it was necessary to sanitize the wheelchair surface before transferring the resident. She said her wrong nursing practices could promote spreading various diseases. Record review of Resident #2's face sheet on 11/08/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses were hypertension, dementia, cognitive communication deficit, muscle weakness, type 2 diabetes, chronic kidney disease, and need for assistance with personal care. Record review on 11/08/24 of Resident #2's initial MDS assessment, dated 10/25/24 revealed a BIMS score of 01 indicating her cognition was severely impaired. Record review on 11/08/24 of Resident #2's care plan dated 10/28/24 had ADL Self Care Performance Deficit and relevant intervention was extensive assistance with ADLs including toileting. During an observation on 11/08/24 at 3:40pm CNA B was performing peri care for Resident #2. She started with donning a pair of gloves without sanitizing her hands, opened the brief, and cleaned the front and back of the resident with wet wipes. She took the wipes directly from the packet with her soiled gloves. After the completion of the task, she placed the contaminated wet wipe packet with remaining wipes, on the side table. After the completion of the peri care, CNA B left the room without washing or sanitizing her hands. In that process, she contaminated the new brief, wet wipe packet, bed sheet, and the blanket by touching or handling them with the soiled gloves. During an interview on 11/08/24 at 4:45pm CNA B stated she was nervous and forgot to follow the infection control protocol while providing peri care. When the state investigator walked through the process, CNA B was able to identify the mistakes and stated she should have washed her hands before and after the peri care. She stated she contaminated the wet wipe packet by handling it with soiled gloves. CNA B said, since the wet wipe packet was contaminated, she should have thrown it away. CNA B said unhygienic practices caused contamination that eventually spread germs. CNA B said she worked at the facility for many years and received training on infection control often. She stated she could not remember when was the last in-service on peri care or infection control. During an interview on 11/08/24 at 5:00pm, the DON stated she expected the staff to wash or sanitize their hands and clean the relevant surfaces before and after any nursing care like wound care, peri care, between passing food trays, and when preparing and administering medications. She stated not sanitizing hands and equipment appropriately could cause spread of infections and diseases. The DON said the facility conduct skill check at least every year and on PRN basis. She stated in-services on infection control conducted frequently when any incompetent practices were observed. Record review of the facility policy Infection Control-Hand Hygiene revised on 10/02/22 reflected: Hand hygiene is one of the most effective measures to pr vent the spread of infection. Studies show that effective hand decontamination can significantly reduce the rate of healthcare associated infection. All personnel shall follow the handwashing/hand hygiene procedure to help prevent the spread of infections to other personnel, residents, and visitors . 1. Wash hands with soap and water for the following situations: a. When hands are visibly soiled (e.g., blood, body fluids) 2. Use an alcohol-based hand rub . b. Before and after direct contact with residents g. Before handling clean or soiled dressings, gauze pads, etc. Before moving from a contaminated body sit to a clean body site during resident care after contact with a resident's intact skin. j. After contact with blood or bodily fluids. k. After handling used dressings, contaminated equipment, etc. m. After removing gloves.

Based on observation, interview, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of their needs and preferences for 3 of 11 residents (Residents #2, 3, and 4) reviewed for resident rights. The facility failed to ensure call buttons were in reach for Residents #2, 3, and 4 on 09/10/24. This failure placed residents at risk of not having their needs met. Findings included: 1. Review of the undated face sheet for Resident #2 reflected, a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hemiplegia and hemiparesis (paralysis on one side of the body), chronic respiratory failure, atrial fibrillation (irregular heartbeat), need for assistance with personal care, muscle weakness, muscle wasting and atrophy, lack of coordination, and cognitive communication deficit. Review of the admission MDS assessment for Resident #2 dated 08/05/24 reflected a BIMS score of 06, indicating severe cognitive impairment. It reflected she required staff assistance for ADLs. Review of the care plan for Resident #2 dated 07/30/24 reflected the following: [Resident #2] has ADL Self Care Performance Deficit r/t HEMIPLEGIA AND HEMIPARESIS FOLLOWING CEREBRAL INFARCTION AFFECTING RIGHT DOMINANT SIDE. Will safely perform Bed Mobility, Transfers, Eating, Dressing, Grooming, Toilet Use and Personal Hygiene) with extensive assistance through the review date. It also reflected the following: [Resident #2] is at risk for falls r/t Weakness. Will not sustain serious injury through the review date. Be sure the call light is within reach and encourage to use it to call for assistance as needed. 2. Review of the undated face sheet for Resident #3 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included schizoaffective disorder, pain in right wrist, muscle wasting and atrophy, muscle weakness, need for assistance with personal care, cognitive communication deficit, and low back pain. Review of the quarterly MDS assessment for Resident #3 dated 06/16/24 reflected a BIMS score of 15, indicating intact cognition. It reflected she required staff assistance for ADLs. Review of the care plan for Resident #3 dated 10/03/22 reflected the following: [Resident #3] has ADL Self Care Performance Deficit r/t Impaired Mobility. Will safely perform ADL's with staff assistance through the review date. Encourage to participate to the fullest extent possible with each interaction. It also reflected the following: .At risk for falls r/t gait, Balance. Will not sustain serious injury through the review date. Be sure the call light is within reach and encourage to use it to call for assistance as needed. 3. Review of the undated face sheet for Resident #4 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included flaccid hemiplegia affecting right dominant side, vascular dementia, muscle wasting and atrophy, muscle weakness, lack of coordination, need for assistance for personal care, cognitive communication deficit, and depression. Review of the quarterly MDS assessment for Resident #4 dated 07/19/24 reflected a BIMS score of 09, indicating moderate cognitive impairment. It reflected he required staff assistance for ADLs. Review of the care plan for Resident #4 dated 05/10/23 reflected the following: [Resident #4] has ADL Self Care Performance Deficit r/t Generalized Muscle Weakness, Hemiplegia. Will safely perform ADL's with staff assistance through the review date. Encourage to participate to the fullest extent possible with each interaction. It reflected the following: at risk for falls r/t R Sided Paralysis. Will be free of falls through the review date. Be sure the call light is within reach and encourage to use it to call for assistance as needed. Observation and interview on 09/10/24 at 12:00 PM revealed Resident #2 seated in her wheelchair in her room with her call button on the floor next to her wheelchair. She stated she was not feeling well and would have used the call button to reach out to staff, but did not know where the call button was. She stated she could not have bent down to reach the call button on the floor next to her. During an interview on 09/10/24 at 12:02 PM, the TXN stated the call button should have been in place for Resident #2 and she noticed it was not. She stated she was doing rounds to make sure the residents had what they needed, but she did not usually do rounds on that hall. Observation and interview on 09/10/24 at 12:10 pm revealed Resident #3 seated in her wheelchair in her room. The cord for her call button came out of the wall and was wrapped around her mattress with the fitted bed sheet made up over the rest of the cord and the call button itself, which was under the mattress. She stated she used her call button, but not very frequently. She stated she did not know where the button was. She stated she would come out of her room and go to the nurse's station if she needed something and could not find her call button. When asked what she would do if she were in pain or could not self-ambulate in her wheelchair, she stated she did not know. During an interview on 09/10/24 at 12:14 PM, the TXN stated she found the call button for Resident #3 under the fitted sheet and under the mattress and could not imagine how it had gotten there. She stated CNAs were who made the beds. Observation and interview on 09/10/24 at 12:18 PM revealed Resident #4 seated in his wheelchair on one side of his bed, which was parallel to the privacy curtain between his side of the room and his roommate's. His call button cord was on the other side of his bed from him next to the privacy curtain and was on the floor out of view. He stated his call button was usually next to his bed and looked for it on the side of the bed closest to him. He pointed across his bed and stated it was over there and he could not have reached it if he needed it. During an interview on 09/10/24 at 01:30 PM, CNA C stated she made beds on the hall for Residents #2, 3, and 4. She stated she did not know how the call buttons got out of reach and she always made sure the call buttons were in place when she left the residents. During an interview on 09/10/24 at 03:49 PM, the DON stated the call buttons should have always been in reach. She stated the entire nursing department was responsible for ensuring call buttons were accessible to the residents. She stated they conducted in-servicing on call buttons in reach and answering call lights. She stated a potential impact of a call button not being in reach was the resident might not have their needs met. Review of the facility's policy dated 02/24/22 and titled Federal Resident Rights reflected the following: Respect and dignity. 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 in danger or other resident's health or safety.

Based on observations, interviews, and record reviews the facility failed to prevent the use of verbal, mental, physical abuse, and/or corporal punishment for 2 of 3 residents (#24 and #75) reviewed for abuse. 1. Resident #24 experienced a fractured wrist when CNA A attended her bedside. The facility did not assess all residents for safety. The facility did not in-service all staff for abuse, neglect, exploitation prevention. 2. Resident #75 was a victim of verbal/mental abuse that resulted in Resident #75 being sent to the hospital via ambulance and received medications. An IJ was identified on 10/14/2022. The IJ began on 10/3/2022 and removed on 10/4/2022. The facility took action to remove the IJ before the survey began. While the IJ was removed on 10/4/2022, the facility remained out of compliance at a scope of isolated and a severity level of actual harm because all staff had not been trained on abuse and neglect policies and procedures. These failures could place residents at risk for harm by physical, verbal, mental, abuse. The findings include: A record review of Resident #24's admission record, dated 10/14/2022, revealed an admitted [DATE] with diagnoses which included vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to the brain), hemiplegia and hemiparesis (a complete loss of strength or paralysis on one side of the body), displaced oblique fracture of shaft of left ulna (a broken forearm where the break is at an angle and the bone has moved out of alignment). A record review of Resident #24's annual MDS assessment, dated 8/05/2022, revealed, Resident #24 was [AGE] years old resident, who had been residing at the facility for the past 6 years. Resident #24 had no hearing difficulties, used glasses, had clear speech and could make themselves understood as well as could understand others. Resident #24 had upper mobility limitations and required extensive 2 person assist with activities of daily life. Resident #24 required a wheelchair and could not walk. During a record review of the facilities provider investigation report dated 10/03/2022 revealed the statement made by LVN B, statement from LVN B 7P-7 A 10/3/2022 at 4:00 AM resident was yelling from her room business went to resident room approximately at 4:00 AM, 10/3/2022 resident in bed supine position. I asked resident if anything wrong. residents start complaining that CNA that black lady she came and changed my brief she punched my mouth and twisted my left arm. resident mouth had dry blood and lips. assessment done head to toe. fresh blood on left side upper gum noted and dry blood on lips. no other bruises of redness noted. Resident Evil to move upper and lower extremities except pain to left forearm and left wrist. CNA removed from room and sent home. deal when and RN C in facility notified. on call nurse practitioner notified and new orders received for staff X-ray left shoulder, elbow, and wrist. family brother notified and situation explained to brother. in addition to my statement; approximately at 4:00 AM when this nurse went to the residence room due to resident yelling out, I entered room I asked Resident #24 what's wrong and she told me black lady came changed my brief and punched me in my mouth and twisted my left arm. while this nurse was talking to resident CNA A came in room and telling patient, you accusing me I punched you and hurt you. I haven't even made it into your room. I didn't change you yet. I asked her CNA A what time you came last time and CNA A said, around 1:00 AM to 1:30 AM I haven't changed her and she's accusing me, I'm gonna lose my job. CNA A said, let me change her. this nurse told CNA A let me check her and you can go. when this nurse opened patients brief the brief was completely dry. During an interview on 10/12/2022 at 10:20 AM the ADON stated the facility learned of an allegation of physical abuse incident on the early morning of 10/3/2022 involving Resident #24 and CNA A. The ADON stated the facility initiated an investigation which resulted in the termination of CNA A. The ADON stated he was responsible for assessing Resident #24's peers for safety and assessed 4 residents on Resident #24's hallway, 400-Hall, after the report of the abuse allegation, Residents #16, #38, #52, and #66. The ADON stated no other residents were assessed for safety. The ADON stated CNA A routinely worked on the hallway Resident #24 resided on. A record review of the facility's 10/2/ to 10/3/2022 staff schedule revealed CNA A was assigned CNA duties on 400-hall. Further reviews of the facility's schedules revealed CNA A was assigned 100-hall and also 400-hall CNA duties the previous week. During an interview on 10/12/2022 at 11:10 AM the DON stated the facility learned, early in the morning of 10/3/2022, Resident #24 alleged CNA A hurt her. The DON stated the facility maintained cameras with recording capabilities on the hallway Resident #24 resided on (400-hallway). The DON stated she reviewed the recordings which reflected 10/03/2022 02:00 AM to 06:00 AM. The DON stated the footage revealed CNA A checked on Resident #24 several times prior to 05:00 AM, in refute to CNA A claims she had not. The DON stated the recording revealed just prior to 05:00 AM CNA A made a body gesture prior to entering the room which was interpreted by the DON as a deep breath motion with hand gestures, entered the room and after a couple of minutes exited the room and entered the adjacent room across the hallway, left the door ajar, and watched Resident #24's door. The DON stated at this time in the timeline Resident #24 began loudly calling out for help to which LVN B came to Resident #24's bedside. The DON stated while LVN B was attending Resident #24 and receiving report CNA A entered the room and began yelling at Resident #24, why are you lying! .i have not been in your room! . The DON stated LVN B de-escalated the incident and removed CNA A from the room, CNA A was asked to leave the room and CNA A wrote a statement. The DON stated LVN B reported Resident #24 claimed CNA A hit her. The DON stated LVN B reported the incident to RN C and RN C reported the allegation to her, DON. The DON stated she had CNA A clock out and suspended CNA A pending an investigation. The DON stated the Administrator was given a report and the Administrator reported the incident to the state agency. The DON stated the investigation revealed CNA A was inconsistent with her accounts of the incident, Resident #24 was diagnosed with a left ulna, forearm, fracture, and CNA A was terminated on 10/6/2022. The DON stated 4 residents were assessed for safety and an in-service for abuse, neglect, and exploitation prevention was prepared and all staff were in the process of receiving the in-service. The DON stated the in-service record was in the in-service logbook at the nurse's station. The DON stated the ADON also in-serviced staff at a staff meeting on 10/7/2022. The DON stated not all staff had been in-serviced but were being in-serviced as they reported to work. A record review of Resident #35's admission record revealed an admitted [DATE], with diagnoses which included moderate dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), hypertension (high blood pressure), and osteoarthritis (the protective cartilage that cushions the ends of the bones wears down over time). During an observation and interview on 10/12/2022 at 1:48 PM Resident #35 stated, she was an auditory witness to the alleged abuse of her roommate Resident #24 on the early morning on 10/3/2022. Resident #35 stated CNA A had been in their room several times that early morning. Around 5:00 AM she heard CNA A and Resident #24 yelling out. I heard her (CNA A) yell at her (Resident #24), cuss at her, and I heard them wrestling; with Resident #24 crying out and yelling back STOP HITTING ME .OWW!, CNA A yelled back at her MOVE YOUR HAND! Resident #24 yelled I CAN'T!. Resident #35 stated she heard CNA A leave and Resident #24 continued to cry out for help. LVN B entered the room and received report from Resident #24 that she had been hit by CNA A. Resident #24 stated, that black B**** hit me!. CNA A entered the room and Resident #24 identified CNA A as hitting her. CNA A continued yelling at Resident #24 and accused Resident #24 of lying and left the room. During an observation and interview on 10/13/2022 at 01:12 PM Resident #24 was in her room seated in her wheelchair. Resident presented with a soft cast to her left wrist. Resident #24 stated someone hit her [when she referred to her soft cast] but could not remember any further details. During an interview on 10/14/2022 at 11:45 AM Resident #24's Representative stated the facility's SW called him on in the morning of 10/03/2022, between 7-9 AM. The SW said there was an incident, [Resident #24] was screaming and when the nurse went into Resident #24's room, Resident #24 stated CNA A twisted her arm, slapped her face, and covered her mouth. Resident #24's representative stated the SW reported they found blood in Resident #24's mouth. Resident #24's representative stated the DON called him later that day (10/3/2022), she told me they were investigating and getting x-ray's .I called her back and she told me CNA A was fired. Resident #24's representative stated the x-rays revealed Resident #24 had a fractured left forearm bone and Resident #24 was sent to the hospital for treatment of the broken forearm. Resident #24's representative stated, he and Resident #24 attended an orthopedic specialist appointment after the fracture was discovered, The doctor reported Resident #24 received the fracture from a grabbing twisting motion, not consistent with a fall. A record review of the facility's human resources employee time records during the period 10/3/2022 to 10/10/2022 revealed 109 employees worked in the facility. A record review of the facility's in-service logbook revealed an abuse, neglect, exploitation prevention in-service dated 10/3/2022, indicated only 26 unique staff signed they received the in-service. A record review of the facility's in-service logbook revealed an abuse, neglect, exploitation prevention in-service dated 10/7/2022, indicated only 27 unique staff signed they received the in-service. A record review of the facility's 400-hall (the hall Resident #24 resided on), census dated 10/3/2022 revealed, the facility's 400-hall had 29 available beds with only 1 bed empty. Personnel file for CNA A reviewed, no concerns regarding checks completed and no disciplinary action occurred prior to this event. Record review of Resident #24's medical records revealed x-rays images, dated 10/3/2022, which revealed a fracture to Resident #24's left Forearm at the wrist. During an interview on 10/16/2022 at 01:37 PM the administrator stated, The question on why the IJ happened, I don't believe the in servicing was effective to reach all levels of staff, prior t the IJ. The Administrator stated more residents who were cared for by CNA A, could have been assessed for safety. 2. Record review of Admission Record, printed 10/14/2022 at 3:36 PM, revealed Resident #75 was a [AGE] year-old-female, admitted [DATE] with the following diagnoses: conversion disorder with seizures or convulsions [mental condition in which a person experiences neurologic symptoms not associated to illness or injury; symptoms are real and beyond the persons control]; chest pain; non-ST elevation myocardial infarction [less damage causing form of a heart attack]; coronary artery disease [major blood vessels of the heart narrow] without angina pectoris [chest discomfort or shortness of breath]. Record review of Brief Interview for Mental Status (BIMS) single page form, dated 7/28/2022 signed by the SLP, revealed a BIMS score of 14/15 for Resident #75 [indicative of intact cognition]. Record review quarterly MDS [Minimum Data Set] dated 7/31/2022 revealed, Resident #75 had a Summary BIMS score of 10, indicative of moderately impaired cognition with fluctuating disorganized thinking and received psychological therapy on 2 days for at least 15 minutes in the 7 days prior to the MDS submission. Record review of Nursing Progress Note written by LVN JJ on 7/26/2022 at 7:16 AM revealed Resident #75 had complaints of chest pains, received 2 doses of 0.4 [Nitrostat] with no resolution of pain; sent to emergency room via emergency medical services. Record review of Medication Administration Record for July 2022 revealed Resident #75 received 2 doses of Nitrostat Sublingual 0.4 milligram on 7/25/2022 . Record review of hospital Discharge Instructions dated 7/27/2022 revealed Resident #75 had troponin levels less than 0.1 nanograms per milliliter [elevated troponin levels, greater than 0.4 nanograms per milliliter indicate a cardiac event]. admitted [DATE] at 2:57 AM. Reason for visit listed as CP [chest pain]. In addition to laboratory results, documentation revealed Resident received a chest x-ray and an abdominal ultrasound [reports not included]. Record Review of Nursing Progress Note written by LVN JJ on 7/28/2022 at 7:40 AM revealed Resident #75 was readmitted to facility. Record review of Psychological Services Progress Note dated 7/29/2022 at 5:20 PM by PSY D [Psychology Doctor] revealed documentation that Resident #75 expressed anxiety associated with a recent encounter with nursing staff. Record Review of email dated 7/29/2022 at 5:15 PM from PSY D to the ADM [Administrator], the SW [Social Worker], and the DON [Director of Nursing] revealed notification of Resident #75 concern that her recent hospitalization was prompted by an argument Resident #75 had with an unnamed nursing staff. Record review of single page In-Servicing dated 7/29/2022 signed by CNA E indicates topics presented by the ADON included: Talk to residents with dignity and respect; Ensure appropriate communication with family and residents; Continue to provide excellent care to residents; Try to keep your voice at a modest level when talking with residents; Keep them informed with what is going on. Simple comments like I'll be back in 5 minutes to check on her goes a long way. In a group interview on 10/13/2022 at 10:58 AM with the DON and ADON, the ADON stated their policies and procedures to prevent abuse begins at recruiting, we check employees backgrounds, EMR [Employee Misconduct Registry], OIG [Office of Inspector General], checking references and skills check offs. The DON stated the facility reinforced training and education via [computer-based training] courses completed within the first 21 days of employment, Abuse/Neglect/Exploitation, reporting burnout, On-The-Job training and the administrative staff was on the floor and met residents, talked to staff, managed burn out by giving staff positive feedback, providing morale boosters. The DON stated the facility reinforced training for reporting immediately any allegations of Abuse/Neglect/Exploitation and identified to all staff the Abuse Prevention coordinator as the ADM. The DON stated the SW has also provided reinforced training for reporting any grievances. In an interview on 10/13/2022 at 1:45 PM, Resident #75 stated she was speaking with her roommate's family regarding care not provided timely to the roommate when an unnamed CNA rushed into the room, and yelled, You don't need to telling (sp ) about other residents! Resident #75 clutched one hand at the base of her throat when she relayed, This startled me and scared me. Resident #75 stated she started having chest pains after that. Resident #75 reported having chest pains to the nurse on duty and received 2 doses of Nitroglycerin. Resident #75 stated the pain continued and an ambulance was called to take her to the hospital. Resident #75 stated she knew it wasn't a real heart attack when the chest pain evaporated as soon as the ambulance pulled into the hospital parking lot. It was like I just needed to get away from here. Resident #75 stated she was embarrassed she was taken by ambulance to the hospital and, It wasn't a real emergency. Resident #75 further stated that she felt that the unnamed CNA tore her up for speaking out of turn even though the family of her roommate specifically asked her to keep an eye on their loved one. Resident #75 stated this had occurred several months ago, and that she had no problems with the CNA since then . Resident #75 could not recall the name of the CNA. Resident #75 stated the CNA was still working, but she had not seen her for several days. Resident #75 provided description: female, big butt. In an interview on 10/13/2022 at 7:30 PM, the DON recalled being notified afterhours that Resident #75 had some issue regarding an interaction with staff. The DON stated she tasked the ADON with speaking with resident about the situation. The DON stated the focus was more on the fact that Resident #75 was relaying HIPAA type information about other residents and should not be responsible for relaying details to the family members. The DON stated Resident #75 had a big heart and was very protective of her peers, especially her roommate. The DON stated at the time, the events did not rise to the level of an allegation of abuse. In an interview on 10/14/2022 at 9:25 AM the DON stated Resident #75 was assessed on the evening of 10/13/2022 and had no signs or symptoms of distress. The DON stated that the allegation of abuse was reported within 1 hour of learning about Resident #75's recollection of the event on 10/13/2022. The DON stated that upon further review and through their internal investigation the alleged perpetrator was CNA E, who was currently on leave. The DON stated the Nurse on duty had quit and did not return any of the facility phone calls. The DON provided telephone contacts for both CNA E and LVN JJ. [Neither CNA E nor LVN JJ returned phone calls for interviews prior to exit of survey.] In an interview on 10/14/2022 at 10:42 AM, the ADON stated he had assessed Resident #75 back then at the time she returned from the hospital, as instructed by his DON and the event was not recalled in a way that rose to the level of an allegation of abuse. The ADON stated he provided an on-the-spot In-Servicing on customer service to CNA E. In a group interview on 10/14/2022 at 11:19 AM, with the ADM, DON and ADON present, the DON stated the incident occurred towards the end of July 2022. The DON stated the ADM, the DON, and the SW were made aware via an email from the Psychologist that Resident #75 was upset about an interaction with nursing staff causing Resident #75 being sent to the hospital. The DON then notified the ADON to assess Resident #75. The ADON stated the allegation was not reported as it did not rise to the level of verbal abuse based on the assessment at the time. The DON stated the alleged staff member continued to work, after being in-serviced. The DON stated the alleged staff member was not currently working as she was on leave, out of state for a funeral. The DON stated the last time the alleged staff member worked was more than a week prior to survey entrance. In a group interview on 10/14/2022 at 11:27 AM with the SW, DON and ADM, the ADM stated she had reported to state on 10/13/2022 for possible abuse based on the 10/13/2022 conversation with Resident #75. The DON stated the resident indicated she felt startled. The DON stated she did not feel it was verbal abuse, but the resident seemed intimidated by the loud volume, and harsh tone of voice CNA E used. The DON stated the CNA would be trained upon return to work. The DON stated an additional training course would be provided to all staff entitled, Trust Building Through Effective Communication. The ADM added she concurred with the DON and ADON responses to questions and added, we don't put anybody on the floor without the training needed; and I supervise my staff. In an interview on 10/14/2022 at 2:30 PM, the PsyD stated Resident #75 expressed being embarrassed for being sent to the hospital after having an altercation with the CNA that triggered chest pain. The PsyD stated the session was on 7/29/2022 between 4:40 and 5:20 PM. The PsyD stated after reviewing the notes she made at the time, she characterized the event as an argument. The PsyD stated Resident #75 would initially minimize her emotional state but would eventually accurately report her state of mind after some rapport building. PsyD stated since that event, Resident #75 had not displayed any increase in maladaptive behaviors or reported a decrease in engaging in coping mechanisms. PsyD stated Resident #75 had not reported increased intensity or frequency of anxiety. PsyD stated she immediately reported the concerns via email to the ADM, the SW and the DON. In an interview on 10/16/2022 at 11:03 AM Resident #75 stated she had been checked on by facility staff but could not recall any of the questions they might have asked. Resident #75 stated she had no concerns with abuse or neglect and had no fear of staff or residents at this facility. Resident #75 reiterated she had a problem when one staff member tore me up one side and down another, a few months back when she was overheard responding to her roommates' family when they asked how the roommate was being treated. Resident #75 stated tore me up meant the staff scolded her loudly for providing information to the family. Resident #75 stated at the time, it made her mad because she felt she was doing the right thing for her roommate, then it made her feel bad, as if she had done something wrong to upset her care providers. Resident #75 reiterated that this was the event that sent her to the hospital unnecessarily a few months back. Resident #75 stated she was embarrassed she used up all those resources and it was just a panic attack. Record review of Nursing Administration Policy/Procedure under Leadership section, and Nursing Services subject, revised 05/2007, revealed Each Resident is free from verbal, sexual, physical or mental abuse, corporal punishment, and involuntary seclusion. Record review of Policy/Procedure-Administration under Section: Resident Rights and Subject: Abuse - Prevention of And Prohibition Against, revised 11/28/2017, revealed, it is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Further under section C Training, topics included prohibiting and preventing all forms of abuse .; identifying what constitutes abuse .; recognizing signs of abuse .; reporting abuse .; procedures for reporting incidents; understanding behavior symptoms of residents that may increase the risk of abuse and neglect and how to respond. These symptoms include . aggressive and or catastrophic reactions of residents. Under section D - Prevention, the facility will take action to prove protect and prevent abuse . By supervising staff to identify and correct any inappropriate or unprofessional behaviors. Under section E identification the facility will assist staff in identifying abuse . including mental slash verbal abuse . In addition, under Section I - Definitions, abuse is defined as willful infliction of entry, unreasonable confinement, intimidation . with resulting physical harm pain or mental anguish. Willful as used in this definition of abuse means individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. During an interview on 10/16/2022 at 01:37 PM the administrator stated, The question on why the IJ happened, I don't believe the in servicing was effective to reach all levels of staff. Due to the above failures this was determined to be an Immediate Jeopardy (IJ) on 10/14/2022. The administrator was notified. The Administrator was provided with the IJ template on 10/14/2022 at 05:40 PM. The facility's Plan of Removal was accepted on 10/15/2022 at 10:00 AM and included: Verification -of the facility's Plan of Removal for Legend Oaks North Austin and surveyors monitoring: Immediate Action Medical Director / Resident's physician notified of IJ. During an interview on 10/15/2022 4:16 PM the medical Director stated the facility reported the incident on 10/3/2022 where Resident #24 was diagnosed with a left wrist ulna fracture allegedly by CNA A's mistreatment. The Medical Director stated he reviewed the Plan of Removal and was satisfied and had no new orders. In-service with quiz was started on 10-14-22 for employees. The in-service will include: a. Types of abuse with definitions, b. Contact and name of Abuse Coordinator c. Timeframes for reporting RN Clinical Resource to review facility ANE policy with leadership team. During an interview on 10/15/2022 at 4:02 PM the DON stated she, and the facility's leadership received training from the facility's RN Clinical Resource Nurse to include the HHSC Power Point presentation Abuse, Neglect, and Exploitation (ANE) in long-Term Care. A record review of the facility's IJ Plan of removal in service records, dated 10/15/2022, revealed Abuse, Neglect, Exploitation Post Test: 1. Abuse can be willful and negligent physically, emotionally and sexually. True / False; 2. Give 3 examples ____; 3. One of the signs of neglect is you forgot to give the Resident a toast on her breakfast tray. True / False .(etc ). A record review of the facility's IJ in-service training, dated 10/15/2022, revealed the facility utilized the HHSC Abuse, Neglect, and Exploitation (ANE) in long-Term Care, Power Point training. Further review revealed an attendance sign in sheet which included: LNFA Administrator RN DON RN CR During an interview on 10/15/2022 at 4:20 PM the DON and the Administrator stated the residents were assessed for Brief Mental Interview Statuses and assessed for safety and injury, 100% of the residents who were scored between 12-15, no mental cognitive impairment. A record review of the facility's Resident Safe Survey records, dated 10/14/2022 through 10/15/2022, revealed 100% of the residents who had no mental cognition impairment, were assessed for safety and injury, Here at [Facility] has a staff member ever been rough with you or hurt you? Made you feel afraid or humiliated / degraded? Said mean things to you, hurt you (hit, slapped, shoved, handled you roughly) made you feel uncomfortable (touched you inappropriately)? .[etc.,] ED, DON or designee will oversee completion of training and conduct training Completion of training will be 10/15 and those on leave have been contacted and instructed to complete training prior to working assigned shift. All new hires will complete training during orientation and before working first shift. During observations, interviews, and record reviews from 10/14/2022 to 10/16/2022 surveyors interviewed all staff, who were not on leave, regarding ANE training and reviewed records regarding ANE in-service training. During an Interview on 10/16/2022 at 4:30 PM the DON stated she and her ADON and charge nurses had supervised and ensured all employees completed the in-service training to include Abuse, Neglect, Exploitation Prevention and Reporting. Interviews for 06:00 AM to 2:00 PM work shift: During an interview on 10/15/2022 at 12:30 PM CNA Z stated she works on the 6:00 AM to 2:00 PM shift. CNA Z stated she received in-service training on the evening of 10/14/2022 in a staff meeting where she was given instructions on who was the abuse, neglect exploitation coordinator, the administrator, and educated on the different types of abuse, sexual, physical, mental, and verbal. CNA Z stated she was to immediately report any allegations of ANE. During an interview on 10/15/2022 at 12:30 PM CNA F stated she works on the 6:00 Am to 2:00 PM shift. CNA F stated she received in-service training on the evening of 10/14/2022 in a staff meeting where she was given instructions on who was the abuse, neglect exploitation coordinator, the administrator, and educated on the different types of abuse, sexual, physical, mental, and verbal. CNA F stated she was to immediately report any allegations of ANE. During an interview on 10/15/2022 at 1:30 PM CNA FF stated she works on the 6:00 Am to 2:00 PM shift. CNA FF stated she received in-service training on the evening of 10/14/2022 in a staff meeting where she was given instructions on who was the abuse, neglect exploitation coordinator, the administrator, and educated on the different types of abuse, sexual, physical, mental, and verbal. CNA FF stated she was to immediately report any allegations of ANE. Interviews for 02:00 PM to 10:00 PM work shift: During an interview on 10/15/2022 at 02:43 PM MA BB stated he works on the 6:00 Am to 2:00 PM shift. MA BB stated he received in-service training on the evening of 10/14/2022 in a staff meeting where she was given instructions on who was the abuse, neglect exploitation coordinator, the administrator, and educated on the different types of abuse, sexual, physical, mental, and verbal. MA BB stated she was to immediately report any allegations of ANE. During an interview on 10/15/2022 at 03:57 PM LVN CC stated he works on the 02:00 PM to 10:00 PM shift. LVN CC stated he received in-service training on the evening of 10/14/2022 in a staff meeting where he was given instructions on who was the abuse, neglect exploitation coordinator, the administrator, and educated on the different types of abuse, sexual, physical, mental, and verbal. LVN CC stated he was to immediately report any allegations of ANE. During an interview on 10/15/2022 at 08:57 PM CNA Y stated he works on the 02:00 PM to 10:00 PM shift. CNA Y stated he received in-service training on the evening of 10/14/2022 in a staff meeting where he was given instructions on who was the abuse, neglect exploitation coordinator, the administrator, and educated on the different types of abuse, sexual, physical, mental, and verbal. CNA Y stated he was to immediately report any allegations of ANE. In an interview on 10/15/22 at 7:15 p.m. with CNA O stated she work the day and evening shift (6-2 shift and 2-10 shift). CNA O stated she was in-serviced on 10/14/22 on abuse, the different types of abuse, reporting abuse, and signs of abuse. The CNA O was able to state the different types of abuse, signs of abuse and would report abuse right away to the Administrator who was the Abuse Coordinator. Interviews for the 10:00 PM to 06:00 AM shift: During an interview on 10/15/2022 at 03:23 PM CNA DD stated he works on the 10:00 PM to 06:00 AM shift. CNA DD stated he received in-service training on the evening of 10/14/2022 in a staff meeting where he was given instructions on who was the abuse, neglect exploitation coordinator, the administrator, and educated on the different types of abuse, sexual, physical, mental, and verbal. CNA DD stated he was to immediately report any allegations of ANE. In a telephone interview on 10/15/2022 at 8:46 PM, CNA K, who works overnights, stated In-Servicing occurred within the previous 24-hour period that included the types of abuse, neglect, exploitation, and mistreatment; how to recognize abuse or neglect to include allegations; who to report to, and the time frame to report. In a telephone interview on 10/15/2022 at 9:30 PM, LVN N, who works overnights, stated In-Servicing occurred within the previous 24-hour period that included the types of abuse, neglect, exploitation, and mistreatment; how to recognize abuse or neglect to include allegations; who to report to, and the time frame to report. Interviews for the 07:00 AM to 07:00 PM work shift: During an interview on 10/15/2022 at 1:30 PM LVN AA stated she works on the 7:00 AM to 7:00 PM shift. LVN AA stated she received in-service training on the evening of 10/14/2022 in a staff meeting w [TRUNCATED]

Based on interview and record review, the facility failed to ensure each resident was free from neglect, for one Resident (#1) of ten residents reviewed for neglect. The facility failed to provide and administer [MEDICATION NAME] 500 mg every 12 hours for [MEDICAL CONDITION] control to Resident #1 from July 11th to July 27th, 2017. This failure could place all 11 residents who are prescribed anticonvulsant medications for [MEDICAL CONDITION] disorders at risk for neglect. The findings were: Record review of Resident #1's Face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's medical record, revealed care planning for [MEDICAL CONDITION] and anticonvulsant administration and monitoring. Review of Resident #1's consolidated physician's orders [REDACTED].#1 was prescribed two anticonvulsants for [MEDICAL CONDITION] management. These were [MEDICATION NAME] and [MEDICATION NAME]. Review of Resident #1's Medication Administration Record [REDACTED]. Review of Resident #1's Medication Administration Record [REDACTED]. Review of Resident #1's physician's triplicate orders, revealed no discontinuation order for [MEDICATION NAME]. Review of a discharge summary by the NP dated 7/27/17, revealed Resident #1 was to be transferred to the emergency room for clustered [MEDICAL CONDITION] activity. The [MEDICAL CONDITION] activity began on 7/25/17. The NP wrote that Resident #1 was supposed to be taking both [MEDICATION NAME] and [MEDICATION NAME], but the Medication Administration Record [REDACTED]. Record review of the facility's Incident and Accident log for the last quarter revealed no documentation related to the sixteen days Resident #1 missed the twice daily [MEDICATION NAME] dose. Review of the drugs for destruction revealed only a used blister pack for [MEDICATION NAME] 500 mg that had been filled on 6/10/17 for a 30 day supply; but no [MEDICATION NAME] for July 2017. In an interview on 8/3/17 at 10:30 a.m., Resident #1's daughter stated Resident #1 had become unresponsive and started having [MEDICAL CONDITION] on 7/25/17. The daughter stated Resident #1 was still in the intensive care unit on a ventilator. The daughter stated that Resident #1's neurologist is the only provider who changes her anticonvulsant orders and Resident #1 had not had an appointment with the neurologist to discontinue the [MEDICATION NAME]. In an interview on 8/3/17 at 11 a.m., Resident #1's NP stated there was no order to discontinue the [MEDICATION NAME] and that the last [MEDICATION NAME] dose that Resident #1 received was the morning of July 11th 2017. In an interview on 8/3/17 at 11:45 a.m., the CPhT at Resident #1's pharmacy, stated the last full card of [MEDICATION NAME] had been filled on 6/10/17 for [MEDICATION NAME] 500 mg for a 30 day supply. The CPhT stated Resident #1 would have been out of [MEDICATION NAME] around 7/10/17, and the [MEDICATION NAME] order was not refilled or renewed. In an interview on 8/3/17 at 12 p.m., MA (for Resident #1's hall) stated Resident #1 had only been taking the [MEDICATION NAME] because the [MEDICATION NAME] had been discontinued. In an interview on 8/3/17 at 12:35 p.m., the hospital SW stated Resident #1 had been admitted from the emergency room to the neurology unit; but went into [DIAGNOSES REDACTED] (continuous [MEDICAL CONDITION] activity) and needed continuous EEG monitoring and to be intubated so Resident #1 was transferred to the intensive care unit and has been there since. The SW stated Resident #1 is on a ventilator and the family will need to decide whether to place Resident #1 on palliative care or take more aggressive measures with a permanent tracheotomy and PEG tube. In an interview on 8/3/17 at 2:30 p.m., the DON stated the facility was able to identify who had entered into the Medication Administration Record [REDACTED]. The DON stated there was an order on 7/11/17 to change a [MEDICATION NAME] dose and believes the nurse who entered the order erroneously discontinued the [MEDICATION NAME] instead of the [MEDICATION NAME]. The DON stated the medication error was discovered after the NP alerted the facility on 7/27/17. The DON acknowledged the incident was not reported in the facility incidences, but stated it had been documented as a medication error. Record review of the facility's Abuse and Neglect Prohibition Policy and Procedure last revised 5/2007 defined neglect as action or inaction that avoids or prevents physical, mental harm, pain, demonstrates disregard or consequences that may constitute a clear and present danger. The facility provided a list of residents on anticonvulsants, 11 of which were noted to be prescribed anticonvulsants for [MEDICAL CONDITIONS], or convulsions.

Based on interview and record review, the facility failed to provide necessary care and services to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care, for one Resident (R#1) of ten residents reviewed for care. The facility failed to provide and administer [MEDICATION NAME] 500 mg every 12 hours for [MEDICAL CONDITION] control to Resident #1 from July 11th to July 27th, 2017. This failure could place all 11 residents who are prescribed anticonvulsant medications for [MEDICAL CONDITION] disorders at risk for not attaining or maintain the highest practicable well-being. The findings were: Record review of Resident #1's Face sheet, revealed an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's medical record, revealed care planning for [MEDICAL CONDITION] and anticonvulsant administration and monitoring. Review of Resident #1's consolidated physician's orders [REDACTED].#1 was prescribed two anticonvulsants for [MEDICAL CONDITION] management. These were [MEDICATION NAME] and [MEDICATION NAME]. Review of Resident #1's Medication Administration Record [REDACTED]. Review of Resident #1's Medication Administration Record [REDACTED]. Review of Resident #1's physician's triplicate orders, revealed no discontinuation order for [MEDICATION NAME]. Review of a discharge summary by the NP dated 7/27/17, revealed Resident #1 was to be transferred to the emergency room for clustered [MEDICAL CONDITION] activity. The [MEDICAL CONDITION] activity began on 7/25/17. The NP added that Resident #1 was supposed to be taking both [MEDICATION NAME] and [MEDICATION NAME], but the Medication Administration Record [REDACTED]. Record review of the facility's Incident and Accident log for the last quarter revealed no documentation related to the sixteen days Resident #1 missed the twice daily [MEDICATION NAME] dose. Review of the drugs for destruction revealed only a used blister pack for [MEDICATION NAME] 500 mg that had been filled on 6/10/17 for a 30 day supply, but no [MEDICATION NAME] for July 2017. In an interview on 8/3/17 at 10:30 a.m., Resident #1's daughter stated Resident #1 had become unresponsive and started having [MEDICAL CONDITION] on 7/25/17. The daughter stated Resident #1 was still in the intensive care unit on a ventilator. The daughter stated that Resident #1's neurologist is the only provider who changes her anticonvulsant orders and Resident #1 had not had an appointment with the neurologist to discontinue the [MEDICATION NAME]. The daughter stated the facility did not explain to her why the [MEDICATION NAME] was discontinued. In an interview on 8/3/17 at 11 a.m., Resident #1's NP stated there was no order to discontinue the [MEDICATION NAME] and that the last [MEDICATION NAME] dose that Resident #1 received was the morning of July 11, 2017. In an interview on 8/3/17 at 11:45 a.m., the CPhT at Resident #1's pharmacy, stated the last card of [MEDICATION NAME] had been filled on 6/10/17 for [MEDICATION NAME] 500 mg for a 30 day supply. The CPhT stated Resident #1 would have been out of [MEDICATION NAME] around 7/10/17, and the [MEDICATION NAME] order was not refilled or renewed. In an interview on 8/3/17 at 12 p.m., MA (for Resident #1's hall) stated Resident #1 had only been taking the [MEDICATION NAME] because the [MEDICATION NAME] had been discontinued. In an interview on 8/3/17 at 12:35 p.m., the hospital SW stated Resident #1 had been admitted from the emergency room to the neurology unit but went into [DIAGNOSES REDACTED] (continuous [MEDICAL CONDITION] activity) and needed continuous EEG monitoring and to be intubated so Resident #1 was transferred to the intensive care unit and has been there since. The SW stated Resident #1 is on a ventilator and the family will need to decide whether to place Resident #1 on palliative care or take more aggressive measures with a permanent tracheotomy and PEG tube. In an interview on 8/3/17 at 2:30 p.m., the DON stated the facility was able to identify who had entered into the Medication Administration Record [REDACTED]. The DON stated there was an order on 7/11/17 to change a [MEDICATION NAME] dose and believes the nurse who entered the order erroneously discontinued the [MEDICATION NAME] instead of the [MEDICATION NAME]. The DON stated the medication error was discovered after the NP alerted the facility on 7/27/17. The DON acknowledged the incident was not reported in the facility incidences, but stated it had been documented as a medication error. Review of the Policy Nursing Services last revised October 2007, provided by the Administrator revealed It is the policy of this facility to provide services by sufficient number, provide nursing care to all residents in accordance with resident care plans to meet residents' needs for nursing care in a manner and in an environment which promotes each resident's physical, mental, and psychosocial well-being. The facility provided a list of residents on anticonvulsants, 11 of which were noted to be prescribed anticonvulsants for [MEDICAL CONDITIONS], or convulsions.

Based on observation, interview and record review one (1) of two (2) Licensed Vocational Nurses (LVN A) failed to provide services that meet professional standards of practice for one (1) of 3 bedfast residents reviewed for mobility who sustained bilateral femoral (upper leg bone) fractures when she fell out of bed while being repositioned without assistance of another staff member. Resident #1 , a bedfast female who is dependent on staff for mobility, sustained femoral (upper leg bone) fractures to both legs when Licensed Vocational Nurse (LVN) A attempted to reposition her while in bed without assistance from another staff member. LVN A did not review the Resident #1's care plan or Minimum Data Set Assessment (MDS) to determine the level of assistance required to move and reposition Resident #1 safely while in bed. Resident #1 fell out of bed onto the floor landing on her knees as she was not properly centered in bed before LVN A instructed the Resident to hold onto the quarter siderail on the bed while she (LVN A) pulled and lifted the incontinence pad from underneath her. Resident #1's family and physician made the decision not to surgically repair the fractures because Resident #1 is a surgical risk due to her multiple diagnoses. This deficient practice contributed to Resident #1 falling out of bed and sustaining bilateral leg fractures and has potential to place the additional two residents who are bedfast at risk for injury. Findings include: During an observation on 12/29/11 at 9:00 AM at a local hospital, Resident #1 was alert, oriented, and receiving [MEDICAL TREATMENT]. Her legs were slightly elevated and she had knee immobilizers applied to both legs. During an interview on 12/29/11 at 9:15 AM Resident #1 stated that while at the nursing home, on 12/16/11, LVN A came into her room alone and informed her that she was there to do a skin assessment. Resident #1 stated that this was unusual because she always required two people to assist her with bed mobility and treatments. She further stated that LVN A stood facing her at the bedside, and attempted to reposition her onto her left side facing the window. Resident #1 stated that she was near the edge of the bed towards the window and needed assistance to be repositioned to the center of the bed prior to being turned however, LVN A did not do that. She further stated that while she held onto the side rail, LVN A held the incontinence pad that was underneath her, pulled and lifted the pad causing her to "flip out of the bed" landing on her knees on the floor between the bed and the window. Resident #1 stated that LVN A tried to get her up unassisted by other staff and that she insisted that LVN A leave her on the floor and get help. Review of local Hospital notes dated 12/16/11, reflected Resident #1 is a bedfast, [AGE] year old female with a history of End Stage [MEDICAL CONDITION] and requires dialyses, [MEDICAL CONDITION], history of Stroke, Obesity, [MEDICAL CONDITIONS] and a history of [MEDICAL CONDITION] Infarction, Congestive [MEDICAL CONDITION], Diabetes, and Spinal Stenosis with [MEDICAL CONDITION]. The hospital notes revealed, " While at the nursing facility the resident was undergoing wound care and was too close to the edge of the bed, and rolled out of the bed. Clinical indication from radiology report: Bilateral femur fractures." Review of local Hospital notes dated 12/17/11 reflected, chief compliant: Resident #1 who is bed bound, fell out of her bed yesterday. She has pain in both knees and right ankle. There is tenderness to palpation of the knee and ankle. Range of motion could not be assessed secondary to pain. Review of local Hospital Progress Notes dated 12/17/11, reflected, Assessment/plan: Resident #1 has bilateral femur fractures. Spoke with Resident #1, and her family regarding the risk and benefits of surgery. Because Resident #1 had no functional ability to ambulate prior to the fall, and has no current potential for ambulation, the risk outweighs the benefits and will opt for non- operative management of both fractures. Risk of death during surgery was explained. Review of the Minimum Data Assessment ((MDS) dated [DATE] reflected, Resident #1 was alert, oriented and was cognitively independent. Her decision making ability was consistent and reasonable. She was bedfast and unable to reposition herself. Bed mobility: The Resident required extensive assistance to move to, and from lying positions, turning side to side; and positioning her body while in bed. Transfers: The Resident was totally dependent on staff to move between surfaces including to and from bed, chair, and wheelchair. The Resident requires two persons to assist her with bed mobility and transfers. Walk in room/ and or corridor: The resident is paraplegic, does not bear weight and is non-ambulatory. Locomotion on and off the unit: The Resident is totally dependent on staff to move between locations in her room, various locations such as the dining room, activities or treatments and away from the facility. Dressing: The Resident is totally dependent on staff for activities of daily living (ADLs), with the assistance to two staff members. Review of the Care Plan dated 12/2011, revealed that Resident #1 required assistance of 1-2 persons for bed mobility. The Resident's Care Plan lacked the specific conditions which warranted one or two person assistance to ensure the safe positioning of the Resident when in bed. Resident #1's [MEDICAL TREATMENT] renders her too weak and behavior issues frequently rendered her unwilling to participate when she required repositioning therefore requiring the assistance of 2 staff members. In an interview on 12/28/11 at 12:45 PM LVN A stated that prior to entering Resident #1's room on 12/16/11 to perform a skin assessment she did not seek the advice or assistance of other staff. She stated she did not review the Resident's clinical records and/or plan of care, to determine the appropriateness of providing bed mobility or a skin assessment without assistance. LVN A stated that she was aware that Resident #1 could participate with bed mobility by holding on to the quarter side rail, and assumed she would be fine. LVN A stated that when the resident began to fall from the bed, she climbed onto the bed, and grabbed the resident under her arms and guided her to the floor. She left the resident alone to call for help. In an interview on 12/28/11 at 1:00 PM Certified Nurse Aide (CNA) B stated that she was at the opposite end of the hallway when LVN A called for assistance. Upon her arrival to Resident #1's room she observed the resident on the floor between the bed and window. CNA B stated that direct care staff was well aware that the Resident #1 required two persons to assist with bed mobility. She stated that the nurses usually request assistance when providing care or treatments to Resident #1. In an interview on 12/28/11 at 1:30 PM. LVN C stated that she was the Charge Nurse for Resident #1 at the time of the incident on 12/16/11. She stated that LVN A did not usually provide skin assessment and most likely did not know that Resident #1 required the assistance of two staff members. She further stated that the usual practice was to provide two persons to assist Resident #1 with bed mobility, skin assessments and/ or treatments because the Resident was a [MEDICAL TREATMENT] patient and weak. She further stated that Resident #1 frequently refused to participate with care. LVN C stated that the nursing staff should never chance providing care to Resident #1 alone due to her medical condition and behaviors. In an interview on 12/28/11 at 1:45 PM the Director of Nurses (DON) stated that although Resident #1's Care Plan indicates that she requires 1- 2 persons to assist with bed mobility, the nurses are required to use their judgment to determine the Resident's needs because of her medical condition and behaviors, she may require the assistance of two. The DON stated that the Resident's current plan of care does not include concerns specific to the Resident medical conditions, that she is a [MEDICAL TREATMENT] patient and may be too weak to assist in her care and she may refuse to participate in her care due to behavioral issues, both of which warrant two persons to assist with care. Review of facility Nurses' Notes dated 12/16/11 at 1:00 PM, reflected 'Resident #1 was being turned and she grabbed the left side rail to assist. The Resident went off of the bed. Her torso began to roll off of the bed. Licensed Vocational Nurse (LVN) A grabbed under the Resident ' s arm and lowered her to the floor. LVN A called for help to assist the Resident back into bed. When returned to bed, the resident began to complain of pain. Resident sent to hospital per her request.' Review of a facility Incident Report dated 12/16/11 reflected, 'While Resident #1 was being turned, the Resident grabbed the left side of the side rail to assist with turning while lying on her left side. The resident's right leg fell off of the bed and then her torso began to fall off of the bed. LVN A grabbed the Resident and lowered her to the floor. An ice pack and pain medication was offered due to complaint of pain to her bilateral knees. The resident was sent to hospital for an evaluation. Recommended steps to prevent reoccurrence: The nurse will have assistance with all bed mobility.' In an interview on 12/29/11 at 8:15 PM Resident #1's attending Physician at a local hospital, stated Resident #1's bilateral femur fracture was not the result of the Resident's current or past medical condition, but was directly due to the impact of the fall which occurred at the nursing home as indicated by the Resident. The Standard of Nursing Practice that was breached by LVN A while providing care for Resident #1 is referenced from the following: Texas Administrative Code; Title 22 Examining Boards; Part II Texas Board of Nursing; Chapter17 Licensure, Peer Assistance and Practice; Rule 217.11 Standards of Practice (1) Standards Applicable to All Nurses. (B) Implement measures to promote a safe environment for clients; (2) Standards Specific to Vocational Nurses. The licensed vocational nurse shall assist in the determination of predictable healthcare needs of clients within healthcare settings;

Based on observation, interview and record review, the facility failed to ensure 1 of 4 residents (Resident #3) reviewed for pressure ulcers received necessary treatment and services to promote healing and prevent new sores from developing. The facility failed to initiate aggressive preventative treatment of [REDACTED].#3 developed a Stage I on her spine and the pressure ulcer progressively worsened. Resident # 3's pressure ulcer deteriorated from a Stage I, 2.0 centimeter (cm) x 1.5 cm on 10/15/10 to unstageable 2 cm x 2 cm on 10/18/10. The wound was assessed on 10/25/10 as a Stage III and measured 3.5 cm x 2.5 cm. The resident's Comprehensive Care Plan identified on 08/06/10 a low air loss mattress for the resident after the resident was admitted to the facility with a pressure ulcer on the right heel and at high risk for developing pressure ulcers. The deficient practice could affect 52 residents. This failure could cause the development and deterioration of pressure ulcers to residents identified by the facility at possible risk for developing pressure ulcers. The findings include: Review of Resident #3's clinical record revealed she was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #3's initial minimum data set ((MDS) dated [DATE] revealed the following in Section M - Skin Condition - one (1) stage IV pressure ulcer. Section M - Treatments - a. pressure leaving devices for chair, b. pressure leaving devices for bed, c. nutritional, d. nutrition or hydration intervention to manage skin problems and for ulcer care. All these boxes were checked. Review of the facility Wound Skin Record, dated 08/06/10, revealed Resident #3 was admitted with a right heel pressure ulcer. The facility assessed the pressure ulcer as unstageable 4.0 x 3.5 centimeter (cm), no exudate, no odor, wound bed black with eschar (dry scab or slough over wound). Review of the facility Braden Scale (measure for pressure sore risk) for Resident #3 revealed the following risk scores on the following dates: On 08/06, 08/13, 08/20 and 08/27/10, scored #11, #9, #9 and #9, respectively. A total score of 12 or less represents high risk for skin breakdown. Review of the facility initial Healthcare Plan, dated 08/06/10, revealed the following: Resident was admitted with impaired skin integrity, pressure ulcer to right heel. It was also noted Resident #3 required full staff assistance for all Activities of daily living (ADL ' s) and reposition every two hours. Review of Resident #3's Comprehensive Care Plan dated 08/06/10 identified Resident #3 was at risk for skin breakdown and listed the following approaches: a hand writing note reflecting for pressure reducing " LAL (low air loss) " mattress and positioning devices on the resident's bed and wheelchair. The word "cushion" was added to the approaches. Documentation reflected the resident was on a "Panacea" mattress upon admission (08/06/10) until the LAL mattress was applied to the resident's bed on 10/19/10. Review of the facility provided manufacturer insert from the panacea mattresses in use at the facility revealed the following in small print at the bottom of the page: "May be appropriate for Stage II wounds, mattress wound stage ratings are general usage guidelines. Resident - specific assessment could alter your particular usage of this mattress " . Review of Resident #3's Comprehensive Care Plan dated 10/15/10 revealed: Pressure area on the spine - Stage I, unblanchable [DIAGNOSES REDACTED]. Goals: Occupational Therapy (OT) Screen Resident for positioning. Approach: pressure reducing (LAL (low air loss mattress)) device for bed and wheelchair. Review of the facility Wound/Skin Healing Record for Resident #3 revealed the following assessment dated [DATE]: The wound presented as a stage I, 2.0 x 1.5 cm. No exudate (discharge), odor, wound bed (handwritten) purple. Skin color surrounding the area bright red, surrounding tissue wound area, normal. Review of the facility Wound/Skin Healing Record for Resident #3 revealed the following assessment dated [DATE]: unstageable wound, 2.0 x 2.0 cm with serous (serum, watery) and serosanguineous ( serum and blood) exudates, slight to no odor, small amount of exudate, wound bed - slough and black-brown with eschar, surrounding skin area - pink, surrounding tissue wound area edges - hardened. Review of the physician telephone order located in Resident #3's clinical record dated 10/18/10, revealed the following instructions: 1. cleanse open area on spine with normal saline solution, apply Santyl, and cover with foam dressing every day as standing order. 2. Pro-Stat 101 30 cc by mouth every day (protein supplement) 3. Start [MEDICATION NAME] ES 625 milligrams (mg) (med to increase appetite) once a day when out of 400 mg. 4. [MEDICATION NAME] 100 mg (antibiotic) twice a day times seven days for wound care. Review of a typed-written statement dated 11/09/10 provided by the Director of Nurses (DON) revealed the following: The low air loss (LAL) mattress was a facility owned mattress. The mattress had been applied to Resident #3 (on 10/19/10) from another bed in the facility due to non-use by another resident . The wound to Resident #3's spine was classified as unstageable on this day. As an intervention, the low air loss mattress was applied to provide assistance with wound healing. The typed-written statement was signed by the DON. Review of the telephone order dated 10/20/10 revealed the following instructions: 1. add [MEDICATION NAME] powder to Santyl during dressing changes. Review of the nursing progress notes in Resident #3 ' s clinical record dated 10/20/10 at 9:15 AM revealed: patient started on antibiotic therapy [MEDICATION NAME] for unstageable wound to spine, dressing changed, wound intact, redness surrounding wound, and drainage. Will not get patient out of bed until we receive a chair cushion for it due to pressure on spine and wound, keeping patient turned every two hours off of back. The resident's Comprehensive Care Plan dated 08/06/10 reflected a "cushion" for the resident's bed and wheelchair. Review of the physician progress notes [REDACTED]. The patient was started on [MEDICATION NAME]. Order: Add [MEDICATION NAME] powder to Santyl. Comments: pressure ulcer to spine lumbar area, slough is visible, macerated boarder areas, but has no rounded edges surrounding [DIAGNOSES REDACTED] and pyrexia. Continued review of the Comprehensive Care Plan revealed the following items added: 10/22/10 pressure area on the, spine 2.0 x 2.0 cm. On 10/29/10, stage III, 3.5 x 2.5 cm. On 11/05/10, stage III spine, 3.2 x 2.2 cm. Review of the facility Wound/Skin Healing Record for Resident #3 revealed the following assessment dated [DATE]: stage III, 3.5 x 2.5 cm with a moderate amount of serosanguineous exudate, no odor, wound bed - slough, . bright red. Review of the Occupational Therapy (OT) evaluation dated 10/27/10, revealed the following: Skin breakdown, [MEDICATION NAME] spine. Medical history: Fracture of left femoral head, hypertension, atria fibrillation, [MEDICAL CONDITION], GERD. Precautions / Complications: skin and falls. Balance and Fall Risk: Yes, from seated position. Short-term goal: 1. wheelchair positioning 2. Appropriate cushioning for back wound 3. Implement positioning plan. Review of the physician progress notes [REDACTED]. Review of the October and November 2010 recapitulated orders and telephone physician orders [REDACTED]. Observation on 11/09/10 at 9:50 AM the surveyor observed the Treatment Nurse providing Resident #3 wound treatment on her spine, heel, and leg. During the observation the Treatment Nurse described the wound to the spine as 3.5cm x 2.5cm, nonblanchable, slough, granulation drainage, moderate odor. Further observation the Treatment Nurse mixed the [MEDICATION NAME] with the Santyl, and provided treatment for [REDACTED]. In an interview on 11/11/10 10:50 PM, the DON provided a copy of the admission/discharge census report which verified the date the previous resident that was using the LAL mattress was discharged . The DON stated they moved the LAL mattress to Resident #3's bed on 10/19/10. The facility identified 52 residents at risk for developing pressure ulcers.