Every finding on record at Life Care Center of Haltom

Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for 1 of 3 resident (Resident #1) reviewed for accident and supervision.The facility failed to ensure Resident #1 was provided with adequate supervision on 07/03/2026 to prevent the resident from remaining outside unattended in heat for and extended time and being found unresponsive. Resident #1 was transported to the hospital via EMS and expired on 07/14/2026. The noncompliance was identified as PNC. The IJ (Immediate Jeopardy) began on 07/03/2026 and ended on 07/08/2026. The facility had corrected the noncompliance before the survey began. These failures could place all residents at risk for accidents that could lead to serious injury, harm, impairment, or death. Findings included: Record review of Resident #1's admission MDS Assessment, dated 06/12/26, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. The MDS Assessment under Section C-Cognitive Patterns reflected Resident #1 had a BIMS score of 15, which indicated the resident was cognitively intact and had no cognitive impairment. The MDS Assessment under Section E-Behavior reflected Resident #1 did not present any behaviors. The MDS Assessment under Section GG-Functional Abilities reflected Resident #1 used an electric wheelchair for mobility, and he required substantial assistance with most ADLs. The MDS Assessment under Section I-Active Diagnoses reflected Resident #1's active diagnoses included: anemia (blood lacks enough healthy red blood cells), Orthostatic hypertension (your blood pressure spikes too high when you stand up), ESRD (kidney failure), acute osteomyelitis right femur (a sudden, severe bacterial or fungal infection of the bone), and quadriplegia (partial or total paralysis of all four limbs arms and legs or torso.). Record review of Resident #1's CP, revised 06/12/2026 reflected Resident #1 presented as high risk for hyperthermia (a condition where your body temperature rises dangerously high (typically above 100.4 F or 38 C).), heat stroke (severe heat related illness), dehydration, and severe sunburns (inflamed or burned skin from over exposure to the sun) related to his daily preference of sitting outside in a wheelchair under direct sunlight. The resident is non-compliant with sun safety protocols, routinely refusing sunscreen application and exceeding the recommended limit of 1 hour of daily sun exposure.To maintain the goal of keeping the resident free from life-threatening hyperthermia complications staff will limit outdoor time to 30-60 minutes per interval, frequently prompt the resident to come inside to cool down, provide regular meals, and offer hydration. Nursing staff will monitor and assess for sunburns and provide ongoing education regarding heat-illness risks. Staff will maintain high vigilance for acute signs of hyperthermia, including core temperatures over 104 F (40 C), hot or dry skin, lack of sweating, rapid heart rate (fast heartbeats), tachypnea (abnormal, shallow breathing) hypotension (low blood pressure), muscle cramps (painful tightening of the muscle), severe headache (intense head pain), dizziness (unsteadiness feeling of lightheadedness), nausea (unpleasant feeling of sickness in stomach), profound fatigue (extreme lack of physical energy, confusion (mentally disoriented), seizures (uncontrolled surge of electrical activity in the brain), or coma (state of deep unconsciousness.) Record Review of Resident #1's CIC dated 07/03/26 at 3: 28 PM, completed and signed by RN-P reflected his most recent BP was 110/60 (mmHg, it Is a standard unit of measurement for pressure.). Position: Lying r/arm.3. Most Recent Pulse: 110 (bpm)Pulse Type: Irregular - new onset. Apical Heart Rate (number of heart beats) (bpm) 110; RES 14 (Breaths/min) Weight: 131.1 (Lbs.) Scale: Wheelchair.O2 sats: 81 (%) (measuring percentage of oxygen in blood.) Method: Room Air.Other respiratory changes. shallow breathing. Record review of Resident #1's PN dated 07/03/2026 at 3:10 PM by RN-P reflected [ LATE ENTRY] Note Text: Previous Nursing note contained an incorrect charted time. Patient was found unresponsive outside seated in a motorized chair. Immediate assessment was initiated. Patient was noted to have shallow, labored respiration. Staff remained with the patient, assessed airway, breathing and circulation and continued to closely monitor the patient's condition. Due to the patient's unresponsive state, EMS was activated and the patient was transported to [hospital] for further evaluation and treatment. NP and DON were notified of the patients change in condition and transfer, [FM] was left with voicemail message informing her of [Resident #1's] condition and transfer to the hospital. No return call has been received at this time.Record review of the ADM documentation of the incident dated 07/07/2026 reflected [ADM] received a notification from [DON] that [Resident #1] was transferred to the hospital on [DATE] at 3:31 PM due to being located unresponsive with shallow respirations at approximately 2:40 PM to 2:50 PM. [RECP] seen him about 1:02 PM. [RECP] stated she got busy and remembered he was outside, so [RECP] went outside at approximately 2:50 PM, and Resident #1 was not responding. [RECP] then paged for a nurse STAT (immediately) to come check on him.[DON] reported [RN-P] told her [Resident #1] was admitted for low blood pressure.on 07/04/2026 [ADM] asked for [FL], to request an update on Resident #1 from the hospital. [FL] reported Resident #1 was on life support. [ADM] contacted [FM] 07/04/2026 at 11:30 AM for a medical status update, and [FM] reported [Resident #1] was Not going to survive this! [ADM] notified DON and ADON of the report from. [ADM] stated the outside temperature was 95 degrees. [ADM] requested for DON to obtain statements from staff involved. On 07/06/2026 at 7:30 AM [ADM] arrived at the facility and began reviewing the footage from 07/03/2026 11:00 AM. [ADM] observations were this: 12:05 pm, [Resident #1] exited the front door of the building. He turned right as he left the door and went to the west side of the front of the building. I was not able to see him on camera from that point forward.Several associates had noticed [Resident #1] sitting outside when they were entering and exiting the building. At 1:55 PM, [C.N.A.-H], reported she saw Resident #1repositioning his wheelchair. He was awake and alert, but she did not have a conversation with him or notice anything unusual.At 2:44, [LVN-E] stated the last time he saw Resident #1 at 1:45 PM.DON and I interviewed [C.N.A.-W] on 07/06/2026. She stated Resident # 1 last seen around 12:00 PM when he was heading towards the nurse station. Record review of Resident #1's case 2611405 on the medical examiner's website on 07/23/2026 revealed the resident expired on 07/14/2026, and the cause of death was pending. During an interview on 07/09/2026 at 9:30 AM, the ADM stated that on 07/03/2026 the DON notified him that Resident #1 was sent to the hospital after being found unresponsive by the RECP. ADM reviewed the camera footage and concluded Resident #1 was observed exiting the front entrance in his wheelchair at 12:05 PM. The staff did not conduct skin assessment when Resident #1 was found unresponsive on 07/03/2026. The ADM proceeded to interview staff about the incident and determined that the following staff: (C.N.A-H, RN-O, LVN-A, C.N.A.-L, RECP, and AA.) last observed Resident #1 inside of the building between 11:00 AM-12:00 PM, and multiple other staff observed the resident outside between 1:02 PM to approximately 1:55 PM on 07/03/2026. AA reported observing Resident #1 upon returning from break (time unknown) with sweaty arms. ADM reported that AA asked RECP how long he had been outside, and RECP went to check on Resident #1. Administrator stated that the resident was alert and oriented with a BIMS score of 15, and able to return inside independently. ADM stated that based on his investigation, there was no indication that the LVN-A or RN-P conducted skin assessments or CPR (is an emergency procedure used during cardiac or respiratory arrest that involves chest compression (push hard and fast in a specific way on the center of a person's chest.). LVN-A and RN-P admitted to conducting temperature, pulse, respirations, and blood pressure. EMS was called immediately and transported to the hospital Staff notified the MD. ADM proceeded with the investigation and all staff were educated on heat-related protocols and heat safety, risk of dehydration, signs and symptoms of dehydration, and hydration protocol. Alert residents were educated on the location, as well as accompanying resident to observe the locations of the hydration stations. Residents and staff were shown the location of digital thermometers at the nursing station and reception area to monitor outside heat temperatures. Staff were advised to conduct resident rounds at the top of the shift, and frequently thereafter. All staff are responsible for supervising their residents, reporting concerns, and offering residents water frequently. Staff were expected to notify leadership and MD when residents refuse to comply with remaining inside during high temperatures. Residents that are not cognitively alert and have a BIMS score below 13 must be accompanied by staff or family member. Family members received a notice about the protocols. Residents with a BIMS score higher than 13, were educated on heat safety, remain in a shaded area, communicate preference, symptoms, and risk of remaining outside in the heat, limiting time outside in the heat, hydration, and communicating changes. During an interview on 07/09/2026 at 3:30 PM, the DON stated Resident #1 was cognitively intact and made his own decisions. On July 3, 2026, staff were not conducting rounds outside or offering water to the resident, though this was a common protocol for residents. Several staff observed the resident during shift change, and RECP saw him upon arriving to work at 1:02 PM and failed to follow up until 2:40 PM. DON said the charge nurse RN-P observed the resident passing the nursing station at 12:00 PM and failed to conduct rounds during her shift. ADON and DON educated all staff on heat safety, signs of heat illnesses, conducting rounds and offering fluids, reporting changes, and notifying the receptionist when residents are going outside. During an interview on 07/09/2026 at 8:55 AM FM stated that a friend of Resident #1 ([NAME]) observed an EMS vehicle outside of the facility when she was leaving on 07/03/2026 on 07/03/2026 near the locations where Resident #1 was observed earlier. [NAME] asked the facility staff if the EMS was here for Resident #1. [NAME] said the staff said no. [NAME] told the staff that it was too hot for Resident #1 to be outside, and she notified the nurse upon entering to check on the resident. During an interview on 07/09/2026 at 11:15 AM WITH [NAME] she arrived at the facility on 07/03/2026 at approximately 1:50 PM and observed Resident #1 sitting outside in his wheelchair. [NAME] stated the outside temperatures were in the 90's. [NAME] spoke to Resident #1, but he did not respond. [NAME] notified a nurse upon entering the facility, (name unknown) to check on Resident #1. [NAME] continued in the building and remained for about 1.50 hours. Upon departing (exact time unknown), [NAME] observed nursing staff, the EMS vehicle, and several staff in the location she observed Resident #1 earlier. [NAME] asked the staff if the Ambulance was there for Resident #1, and they said no. [NAME] was unsure how long Resident #1 was outside prior to her arrival and if staff checked on him, offered him water, or the resident refused to come inside. During an interview 07/09/2026 at 11:39 AM LVN-D stated she last worked with Resident #1 on 07/02/2026. Resident #1 was cognitively alert and communicated to the nursing staff when he was going outside and nurse and RECP communicated and rounded on the residents for safety. She was not working on 07/03/2026 when the incident occurred. LVN-D said she attended training on hydration stations, heat related illnesses, resident monitoring, rounds, and changes. Alert residents were educated and encourage to remain in the shade and return after 30 minutes due to the heat. Residents that are not alert must be accompanied outside by staff or family. All staff must conduct rounds on residents that are spending time outside and offer hydration. During a hospital observation on 07/09/2026 at 12:38 PM, Resident #1 was observed lying on his back with his eyes closed. His breathing was labored. Resident was not observed with dryness around his mouth nor blisters on his head, arms, or legs. Resident was not interviewable at the time of visit. His skin had darkened from his baseline color to darker tone. During a second interview on 07/09/2026 at 12:40 PM, FM stated that she was notified that he was sent to the hospital. She said this could have been avoided if the staff had checked on him outside. She stated that he was not on palliative care, and he was not expected to live. During an interview on 07/09/2026 at 1:40 PM with the hospital nurse RN-S, she stated that the resident was receiving care through hospice and the social worker was not available. RN-S stated she would notify SW to return call. The hospice SW was not interviewed as she did not return call. During an interview on 07/09/2026 at 3:14 PM with C.N.A.-W he stated that on 07/03/2026 at approximately 1:40 PM he observed Resident #1 outside from the parking lot in his wheelchair. C.N.A.-W said he did not have a conversation with Resident #1, and the last time he observed the resident was when EMS arrived and transported him to the hospital. C.N.A.-W stated he was educated on heat-related protocols to follow, hydration protocol, accompany residents outside and conduct routine rounds. Educate the residents on risk of heat and offer hydration and fluids frequently. Residents that were not alert must be accompanied by staff outside. Hydration stations throughout the building are accessible for alert residents. During an interview on 07/09/2026 at 3:33 PM with the RN-P she stated on 07/03/2026 Resident # 1 told her he was going outside about 12:00 PM. RN-P was busy with other residents and care tasks and RN-P said she assumed Resident #1 was in the television room. RN-P stated she received a page from the RECP at approximately 2:00 PM to come to the front immediately. LVN-A was assessing the resident. RN-P called 911 and they arrived in 2 minutes. Resident #1's Respiration was 14 to 16, and she observed him with shallow breathing. RN-P last saw Resident #1 before lunch at about 12:05 PM. RN-P did not observe skin issues related to heat such as blistering. Facility education was conducted and she attended. Expectations are to conduct frequent resident rounds and provide hydration to the residents to prevent heat exhaustion. She attended education on heat safety, assessments, reporting abuse, and neglect, offering fluids to residents often, education on heat risk, and encourage to remain in the shade and return every 30 minutes. During an interview on 07/09/2026 at 3:40 PM RN-D reported she does not work with Resident #1, however she attended the education on heat safety and dangers of Residents being exposed to heat. The staff are expected to educate each resident on the risk of heat strokes, including offering hydration and fluids to resident, conducting resident rounds and assessments for residents outside to prevent them from overheating and illnesses. Residents were encouraged to notify the charge nurse with change in conditions of nausea, dizziness, cramps. RN-D said residents exposed to heat are at risk of heat stroke, dehydration, and shallow breathing. Facility hydration stations and thermometer for nursing to be aware of outside temperatures were installed and hydration side effect posters were posted for alert residents and families. During a phone interview on 07/09/2026 at 3:50 PM AA stated she observed Resident #1 as she was returning from break at approximately 2:30 PM. He was positioned in the sun and observed with sweaty arms. She notified the RECP of her observations and inquired how long he had been outside. During an interview on 07/09/2026 at 3:55 PM with LVN-B the treatment nurse, she reported being out of the office from when the incident occurred. LVN-B said when on duty, she conducts frequent checks on Resident #1 and encourages fluids. She attended the education and stated that all nursing staff were responsible for conducting resident rounds, monitoring hydration and signs and symptoms of heat risk. During a phone interview on 07/09/2026 at 4:10 PM with LVN-A she stated she recalled observing Resident #1 in his wheelchair out front near the west door at 1:35 PM upon arriving to her shift. LVN-A observed from the parking lot so there was no communication or direct observation of the resident. Around 2:50 PM she heard a page announcement requesting a nurse to assist up front. She immediately responded to the front of the facility finding Resident #1 in his wheelchair with his eyes partially closed, skin warm to touch, and sweating. She said a view of his chest revealed shallow breathing. Additional staff and his assigned nurse RN-P arrived and attempted to move the wheelchair out of the sun to further assess him. LVN-A said Resident #1 was not responding to his name. She called 911 and they arrived in 2 minutes. She provided a summary of her findings to the EMS, and he was transported via EMS to the hospital. LVN-A reported no observations of Resident #1 having blisters from heat exposure or dryness on his lips. During an interview on 07/09/2026 at 4:15 PM RN-O stated that she observed Resident #1 on 07/03/2026 at 1:43 PM from the parking lot adjusting his legs while sitting in the wheelchair. RN-O could not provide further observations as she did not move closer to the resident to communicate or assess further. RN-O was not sure how long the resident had been outside. RN-O attended the facility education that addressed heat related illnesses, residents with multiple diagnosis and medication treatments being at risk of heat related illnesses that could result in death. She said failing to monitor and hydrate residents could result in heat stroke and other illnesses. Residents with BIMS scores lower than 13 must be accompanied by staff or relative outside. Facility education provided consisted of monitoring outside heat, educate and encourage the resident to remain inside for safety, and hydrate. During a phone interview on 07/09/2026 at 4:30 PM RECP stated she entered the facility at 1:00 PM on 07/03/2026 and observed Resident #1 outside on the west side of the front porch. She entered the facility for duties, with the intention of coming back to check on Resident #1. RECP said she was distracted by clerical tasks and failed to return outside to check on Resident #1 until AA notified her at approximately 2:40 PM. RECP exited to check on the resident, and he was found unresponsive in his wheelchair. She immediately conducted a page for a nurse STAT Nurse meaning a resident needs immediate attention. Resident eyes were closed and he was sweating. LPN-E arrived with other staff immediately, 911 was called, and the resident was transported to hospital. She stated that all staff were trained on heat related illness, hydration, monitoring and educating residents on heat. She has a log that documents when the residents exit the building and notified the nurse. RECP and staff were expected to round and monitor residents out front. An observation and review of the log reflected a chart for the resident to use to sign out for outside time included the name of the resident, the time the resident went outside, the time the resident was checked on and the residents initial. During an interview on 07/09/2026 at 4:22 PM with ADON, she stated that the assigned nurse was expected to notify the receptionist when resident was going outside, monitor for safety, vitals, and hydration. Nursing staff were educated to encourage the resident to remain inside and offer other activities due to the heat index being unsafe. ADON said on 07/03/2026 she did not observe the resident outside, nor did she conduct rounds. The facility education that was conducted after the incident included all resident's receiving a BIMS assessment to determine their independent cognition for decisions and education. Upon completions of assessments, residents with a BIMS score of 13-15 were deemed appropriate to go outside and understand the risk to heat. The alert Residents were educated to remain inside during high temperatures to prevent heat related illnesses, and drink plenty of water. taken to observe the hydration station and asked to preferably remain inside. Residents that had a BIMS scores of 12 and under must be accompanied by staff or relative outside, The staff were educated on hydration protocols, location of thermometers, rounds, limiting outside time to a minimum of 30 minutes, and the risks to residents remaining outside resulting in heat related illnesses, hospitalizations, and other hazardous conditions. During an interview on 07/09/2026 at 4:49 PM with the NP, she stated she was notified that Resident #1 was sent to the hospital. She stated that the resident was noncompliant with remaining inside during high temperatures. The staff were expected to monitor him frequently or every hour. NP stated that resident received ongoing education from NP and MD to remain inside during hot temperatures. NP stated Resident #1's symptoms of shallow breathing and respiratory issues could be signs of wound infections and along with HX of low blood pressure.NP said that resident's unresponsiveness could have been related to many illnesses that he was dealing with, such as wound infections, poor food and water intake, low blood pressure, and possibly dehydration from being outside for long periods of time. NP had educated Resident #1 on hydration and limiting outside time to prevent illnesses. During a second interview on 07/09/2026 at 8:40 PM Administrator stated several staff had checked on Resident #1 while he was outside, and there were no concerns regarding heat related illnesses. ADM said it was his expectation for staff to follow new protocol for resident safety and report concerns immediately to leadership and MD. Observations of the thermometers, posters, and hydration stations were conducted on 07/09/2026 at 10:00 AM, 3:00 PM and 6:00 PM. The hydration station had large clear water container with cucumbers and ice with a dispenser and small blue disposable cups. The thermometer was observed in view of the receptionist staff and nursing station staff. Record review BIMS assessment of a score of 13-15 indicating they were alert included the following: alert Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, 24, #25, and #26. The following alert residents: Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, 24, #25, and #26 were provided education and literature on this referenced website: https://www.nia.nih.gov/health/safety/staying-safe-hot-weather) . Describing heat symptoms and illnesses with images and signing the document.Observation of hydration posters in Resident 's #2, #8, #14, and #22 rooms were observed and they all confirmed being educated, understanding the risk heat related illnesses and limited time outside. Record review of the local weather on the day of 07/03/2026 reflected the following temperatures: 12:53 PM 95 F; 1:53 PM 96 F, 2:53 PM 97 , and 3:53 PM 98 referenced website https://www.wunderground.com/history/daily/us/tx/fort-worth/KFTW/date/2026-7-3. Record review of facility actions and education documents provided by the Administrator, dated 07/06/2026. The training included encouraging residents not to go outside in the heat but if the residents want to go outside to check on them frequently and provide hydration and encourage them to sit in shaded areas.A hydration station was placed at the entrance with water and cups to offer residents water if going outside.Residents with BIMS under 13 have to be accompanied by staff when going outside.Families were notified of these changes.Residents with a BIMS of 13-15 were educated on safety precautions related to being outside and told to come inside if feeling nauseated or heated.They were shown the hydration station inside the entrance and advised to remain inside or limit time to 30 minutes or less. A record review of ADM investigation questions on 07/07/2026 and 07/08/2026 reflected the following: Date Incident Type, the name, title, address, and phone number of the witnesses. The following is a statement of the facts as reported by the above-named witnesses When was the last time you saw Resident #1? What was he doing? Did you notice anything unusual? The administrator was asked to provide the policy for accidents and supervision on 07/09/2026 and it was not provided.

Based on interview and record review the facility failed to ensure that an alleged violation involving neglect was reported immediately to Health and Human Services State Survey Agency, but not later than 2 hours after the allegation was made for 1 of 3 residents (Resident #1) reviewed for abuse, neglect, exploitation, or mistreatment. The Administrator failed to notify Health and Human Services State Survey Agency of an incident of neglect that occurred on 07/03/2026 when Resident #1 was found outside at 2:40 PM unresponsive with shallow breathing in his motorized wheelchair. This failure could place residents at risk for continued neglect and harm. Findings included:Record review of Resident #1's admission MDS Assessment, dated 06/12/26, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE]. The MDS Assessment under Section C-Cognitive Patterns reflected Resident #1 had a BIMS score of 15, which indicated the resident was cognitively intact and had no cognitive impairment. The MDS Assessment under Section E-Behavior reflected Resident #1 did not present any behaviors. The MDS Assessment under Section GG-Functional Abilities reflected Resident #1 used an electric wheelchair for mobility, and he required substantial assistance with most ADLs. The MDS Assessment under Section I-Active Diagnoses reflected Resident #1's active diagnoses included: Anemia (blood lacks healthy red blood cells), Orthostatic hypertension (your blood pressure spikes too high when you stand up), Quadriplegia (partial or total paralysis of all four limbs arms and legs or torso.). Record review of Resident #1's CP, revised 06/12/2026 reflected resident was at risk of hyperthermia (a condition where your body temperature rises dangerously high (typically above 100.4 F or 38 C). Resident enjoys sitting outside in wheelchair in direct sunlight daily. acute signs of hyperthermia, including core temperatures over 104 F (40 C), hot or dry skin, lack of sweating, rapid heart rate (fast heartbeats), tachypnea (abnormal, shallow breathing) hypotension (low blood pressure), muscle cramps (painful tightening of the muscle), severe headache (intense head pain), dizziness (unsteadiness feeling of lightheadedness), nausea (unpleasant feeling of sickness in stomach), profound fatigue (extreme lack of physical energy, confusion (mentally disoriented), seizures (uncontrolled surge of electrical activity in the brain), or coma (state of deep unconsciousness.) Record review of the facility Inservice dated 07/06/2026, 07/07/2026, and 07/08/2026 with all staff by the DON and ADON reflected education on reporting abuse and neglect immediately to the ADM.During an interview on 07/09/2026 at 9:30 AM, with the ADM stated that on 07/03/2026 he was notified by the DON that Resident #1 was sent to the hospital after being found unresponsive by the RECP. ADM stated he had not reported the incident as the resident was alert and oriented with a BIMS score of 15 and able to independently move in and outside in his power chair. During a second interview on 07/09/2026 at 12:40 PM, FM stated that she was notified that he was sent to the hospital. She stated that he was not on palliative care, and he was not expected to live. During a hospital observation on 07/09/2026 at 12:38 PM, Resident #1 was observed lying on his back with his eyes closed. His breathing was labored. Resident was not interviewable at the time of visit. His skin had darkened from his baseline color to darker tone.During an interview on 07/09/2026 at 3:33 PM with the RN-P she stated on 07/03/2026 Resident # 1 told her he was going outside about 12:00 PM. RN-P stated she received a page from the RECP at approximately 2:00 PM to come to the front immediately. RN-P said the She and RECP notified the DON that the resident was found unresponsive. DON reported the incident and that the resident was located unresponsive outside and sent to the hospital. RN-P reported Resident #1's condition to the FM and MD. During an interview on 07/09/2026 at 4:22 PM with ADON, she stated that the nurse was expected to notify the receptionist when resident was going outside, monitor for safety, vitals, and hydration. ADON stated that they were educated on reporting neglect. RN-P notified the FM and MD.During a phone interview on 07/09/2026 at 4:30 PM RECP stated that Resident #1 was found at approximately 2:40 PM unresponsive in his wheelchair. She immediately conducted a page for a nurse STAT Nurse meaning a resident needs immediate attention. DON was notified and she notified the ADM. EMS arrived and transported the resident to the hospital.During an interview on 07/09/2026 at 4:49 PM with the NP, she stated she was notified that Resident #1 was sent to the hospital. She stated that Resident #1 was sent out to ER for further evaluation. The staff were expected to monitor him frequently or every hour. During a second interview on 07/09/2026 at 8:40 PM ADM stated he did not report the Incident to the State Survey Agency, because the resident was alert and able to make his own decisions. He received notification from the DON on 07/03/2026 that Resident #1 was found unresponsive by RECP and sent to the hospital for further evaluation.Observations of the thermometers, posters, and hydration stations (facility interventions) were conducted on 07/09/2026 at 10:00 AM, 3:00 PM and 6:00 PM. The hydration station had large clear water container with cucumbers and ice with a dispenser and small blue disposable cups. The thermometer was observed in view of the receptionist staff and nursing station staff. The facility provided the following policy related to the incident titled Abuse - Reporting and Response.Revised: 04/09/2024; Reviewed: 05/07/2025 Policy The facility will ensure reporting reasonable suspicion of crimes against a resident or individual receiving care from the facility within prescribed timeframes to the appropriate entities, consistent with Section 1150B of the Elder Justice Act.The facility will ensure that all covered individuals, i.e., the owner, operator, employee, manager, agent or contractor, report reasonable suspicion of crimes, as required by Section 1150B of the Elder Justice Act.The facility will provide annual notification to each covered individual of their obligation to comply with the reporting requirements under section 1150B(b) of the Elder Justice Act Serious bodily injury - Means an injury involving extreme physical pain, substantial risk of death, protracted loss or impairment of the function of a bodily member, organ, or mental faculty, or requiring medical intervention such as surgery, hospitalization, or physical rehabilitation.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 3 residents (Resident #15, Resident #27 and Resident #33) reviewed for comprehensive care plans. 1. The facility failed to develop a comprehensive care plan for Resident #15 that addressed the cleaning and storage of BIPAP machine (a noninvasive ventilatory device that helps patients breathe by delivering two levels of air pressure: higher during inhalation and lower during exhalation to include cleaning or storage of the machine) and equipment.2. The facility failed to develop a comprehensive care plan for Resident #27 that addressed the changing and labeling of her oxygen tubing and water bottle. 3. The facility failed to develop a comprehensive care plan for Resident #33 that addressed her use of a BIPAP machine.These failures could place residents at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs. 1. Record review of Resident #15's quarterly MDS dated [DATE] revealed he was a [AGE] year-old male that was admitted on [DATE]. His BIMS score was 12 which indicated a moderately cognitive impairment. The MDS indicated Resident #15 required Partial/moderate assistance for ADL care due to a deficient r/t multiple diagnosis. Resident #15's active DX: Obstructive sleep Apnea (adult) (is when you stop breathing during sleep because of a blockage in your windpipe.) Section O-Special Treatments, procedures, and programs addressed respiratory therapy. Record review of Resident #15's care plan dated 12/09/2025 reflected that he has altered respiratory status/difficulty breathing r/t Sleep Apnea. Goal: The resident will have no s/sx of poor oxygen absorption through the review date. Interventions included assist resident with putting on and taking off BIPAP mask every night at bedtime and remove every morning. Resident #15's BIPAP use, storage, and cleaning were not addressed in her care plan.Record review of Resident 15's MD order dated 08/15/2025 reflected Oxygen with BIPAP: Large Mask with heated humidification at IPAP 19 EPAP 14 cm H2O every shift for Sleep apnea.BIPAP on while sleeping/napping and off while awake . BIPAP mask with warm soapy water, rinse and air dry as needed for sleep apnea BIPAP Clean reservoir with warm soapy water, rinse; set out to dry every day shift every 7 day(s) for sleep apnea.During an observation and interview with Resident #15 on 03/05/2026 at 10:40 AM resident was in his wheelchair watching television. His BIPAP mask was observed on his nightstand. The mask cushions and hose were observed with small greasy and cloudy film from facial daily use lying on his nightstand with other stored items. Resident #15 stated that the staff removed this mask this morning.2. Record review of Resident #27's admission MDS Assessment, dated 02/26/2026, reflected that she was [AGE] years old and was admitted on [DATE]. Resident #27 had a BIMS score of 12, which indicated she was moderately impaired cognitively. Resident #27 was dependent on staff and required maximal assistance with ADLs r/t musculoskeletal impairment (Musculoskeletal impairment refers to conditions affecting muscles, bones, joints, and connective tissues, resulting in pain, reduced mobility, and limited functions.) and femur (thigh bone) fracture that was obtained prior to admissions. Resident 27's active DX included unspecified fracture of left femur, subsequent encounter for closed fracture with routine healing, unspecified displaced fracture of surgical neck of right humerus, subsequent encounter for fracture with routine healing. wedge compression fracture of first thoracic vertebra, subsequent encounter for fracture with wedge compression fracture of first thoracic vertebra, subsequent encounter for fracture with routine healing, wedge compression fracture of second thoracic vertebra, subsequent encounter for fracture with routine healing, contusion of other part of head, subsequent encounter, and Chronic Obstructive Pulmonary Disease a progressive, incurable lung disease-primarily caused by smoking-that causes severe breathing problems due to damaged airways and trapped air). The MDS Assessment indicated in Section O-Special Treatments, procedures, and programs addressed respiratory oxygen treatments.Goal: The resident will display optimal breathing patterns daily through review date. Record review of Resident #27's admission care plan, 02/21/2026, reflected that the resident was diagnosed with COPD (is a progressive, incurable lung disease-primarily caused by smoking-that blocks airflow and makes breathing difficult), (with respiratory failure Goal: the resident will display optimal breathing patterns daily through review dated. Interventions and Task: Head of bed elevated during episodes of difficulty breathing. Observe and report PRN any s/sx of respiratory infection: Fever, Chills, increase in sputum (thick mucus) (document the amount, color and consistency), chest pain, increased difficulty breathing, increased coughing and wheezing.Observe for s/sx of acute respiratory insufficiency (not enough): Anxiety (excessive worrying), Confusion, Restlessness (unable to rest), SOB at rest. oxygen settings: 02 via nasal prongs @4L/M. Resident #27's care plan did not address the frequency of oxygen tube changing or labeling. Record review of Resident #27's MD order dated 02/20/2026 reflected Oxygen at 4 liters/minute continuously per nasal cannula. Document every shift. MD order dated 03/05/2026 at 1:15 PM reflected Change oxygen tubing, nebulizer circuit and humidifier bottle every night shift every Sun Label when changed and every 24 hours as needed when visibly soiled. Label when changed Oxygen sat rates every shift Oxygen sat rates every shift may titrate to keep above 90%.During an observation and interview on 03/05/2026 at 10:35 AM, Resident #27 was observed lying awake in bed wearing an undated nasal cannula. Resident #27 denied having any concerns with oxygen machines. 3. Record review of Resident #33's 's admissions MDS Assessment, dated 02/22/2026 and completed on 02/28/2026reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. The resident had a BIMS score of 14, which indicated her cognition was intact. Resident #33 used a wheelchair and walker for mobility. She was dependent on staff for ADL care of Toileting Hygiene showers, dressing, putting on and taking off footwear, and transfers. The MDS indicated that Resident #33's active diagnoses included: Obstructive sleep apnea (ADULT), unspecified asthma (a chronic respiratory disease that causes inflammation, swelling, and tightening of the airways.), Asthma, (inflamed lungs). Record review of Resident #33's 's care plan dated 02/20/2026 reflected the resident has hypertension Give anti-hypertensive medications as ordered. Observe for side effects such as LPN orthostatic hypotension and increased heart rate and effectiveness. Obtain blood pressure readings prior to administering medications. Section O-Special Treatments, Procedures, and Programs. Resident #33's BIPAP use, storage, and cleaning were not addressed in her care plan.Record review of Resident #33's MD orders dated 02/18/2026 Monitor every shift. Does resident experience S/SX of Shortness of Breath (SOB) when lying flat or avoid lying flat due to S/SX of SOB? (increased respiratory rate, pursed lip breathing, a prolonged expiratory phase, audible respirations, gasping for air, interrupted speech pattern, use of accessory muscles, anxiety, restlessness etc.). Order dated 02/18/2026 Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083% (Albuterol Sulfate) 3 ml inhale orally via nebulizer every 6 hours as needed for Shortness of Breath: Wheezing. Order dated 02/27/2026 BIPAP 12/6 rate of 10, apply upon availability.During an interview on 03/05/2026 at 5:45 PM the DON stated the Clinical staff were responsible for updating the care plans and DON reviews for accuracy. The DON stated that the EMR provides prompts for updates. The DON stated she expected the care plan to be updated when at admissions and as needed as resident individual plan changes. The DON stated an accurate care plan was important because it individualized the resident's care. The DON did not state that the resident should have been addressed in the care planned when asked. The DON did not provide an explanation for missing respiratory treatments in the care plan for Residents #15, # 27, and #33, however, she acknowledged that the residents were receiving respiratory treatments per MD orders.During an interview on 03/05/2026 at 5:55 PM the Administrator stated the DON was responsible for monitoring and ensuring resident care tasks are addressed and accurate. The Administrator stated care plans address the residents' individual medical needs and treatments. The Administrator did not provide additional information in the interview for non-compliance with care plans. Record review of a facility policy, titled Comprehensive Care Plans and Revision dated 03/02/2022 and reviewed on 08/29/2025 reflected The facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care.Procedure The facility should monitor the resident over time to help identify changes in the resident condition that may warrant an update to the person-centered plan of care. 2. When these changes occur, the facility should review and update the care plan to reflect the changes to care delivery, this can include a. Additional interventions on existing problems, b. Updating goal or problem statements c. Adding a short-term problem, goal, and interventions to address a time limited condition.

Based on observation, interviews, and record reviews the facility failed to ensure a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 3 of 4 residents (Residents #15, #27, and #33) reviewed for respiratory care.1. The nursing facility failed to clean, store, and document the use of a BIPAP (a noninvasive ventilatory device that helps patients breathe by delivering two levels of air pressure: higher during inhalation and lower during exhalation) for Resident #15 and Resident #33. 2. LVN-E failed to change and label Resident #27's nasal cannula (a tube with two prongs used to deliver supplemental oxygen to patients) and water bottle on 03/05/26. These failures could place residents at risk for respiratory infections. Resident #15Record review of Resident #15's quarterly MDS dated [DATE] revealed he was a [AGE] year-old male that was admitted on [DATE]. His BIMS score was 12 which indicated a moderately cognitive impairment. The MDS indicated Resident #15 required Partial/moderate assistance for ADL care due to a deficient r/t multiple diagnosis. Resident #15's active DX: Obstructive sleep Apnea (adult) (is when you stop breathing during sleep because of a blockage in your windpipe.).Record review of Resident #15's care plan dated 12/09/2025 reflected that he has altered respiratory status/difficulty breathing r/t Sleep Apnea. Goal: The resident will have no s/sx of poor oxygen absorption through the review date. Interventions included assist residents with putting on and taking off BIPAP mask every night at bedtime and remove every morning. BIPAP Settings: BIPAP (noninvasive ventilator used to assist breathing) with medium/large face mask with heated humidification IPAP 19 EPAP (BIPAP devices deliver separately adjustable inspiratory positive airway pressure (IPAP) and expiratory positive airway pressure (EPAP). The IPAP and EPAP levels are adjusted to maintain upper airway patency, and the pressure support (PS = IPAP-EPAP) augments ventilation.) 14CM H2O (H O is the chemical formula for water.).Elevate head of bed at least 30 degree's when sleeping.Observe for changes in orientation, increased restlessness, anxiety, and air hunger.Observe for s/sx of respiratory distress and report to MD PRN: Increased Respirations; Decreased Pulse oximetry (measures oxygen and saturation) (Saturation means reaching a point where something is filled completely and can't absorb more); Increased heart rate, Restlessness; Confusion; Cough. Record review of Resident #15's MD order dated 08/15/2025 reflected Oxygen with BIPAP: Large Mask with heated humidification at IPAP 19 EPAP 14 cm H2O every shift for Sleep apnea.BIPAP on while sleeping/napping and off while awake . BIPAP mask with warm soapy water, rinse and air dry as needed for sleep apnea BIPAP Clean reservoir with warm soapy water, rinse; set out to dry every day shift every 7 day(s) for sleep apnea.During an observation and interview with Resident #15 on 03/05/2026 at 10:40 AM resident was in his wheelchair watching television. His BIPAP mask was observed unbagged lying on top of his nightstand with other resident property. Observation of the mask revealed greasy substance. Resident #15 said the staff removed his mask this morning and placed it on his nightstand. Resident #15 said the staff did not clean his mask and store it in a bag. Resident #15 denied having any concerns with her BIPAP machine. Resident #27Record review of Resident #27's admission MDS Assessment, dated 02/26/2026, reflected that she was a 66-years-old and was admitted on [DATE]. Resident #27 had a BIMS score of 12, which indicated she was moderately impaired cognitively. Resident #27 was dependent on staff and required maximal assistance with ADLs r/t musculoskeletal impairment (Musculoskeletal impairment refers to conditions affecting muscles bones, joints, and connective tissues, resulting in pain, reduced mobility, and limited functions.) and femur (thigh bone) fracture that was obtained prior to admissions. Resident 27's active DX included unspecified fracture of left femur, subsequent encounter for closed fracture with routine healing, unspecified displaced fracture of surgical neck of right humerus, subsequent encounter for fracture with routine healing. wedge compression fracture of first thoracic vertebra, subsequent encounter for fracture with wedge compression fracture of first thoracic vertebra, subsequent encounter for fracture with routine healing, wedge compression fracture of second thoracic vertebra, subsequent encounter for fracture with routine healing, contusion of other part of head, subsequent encounter, and Chronic Obstructive Pulmonary Disease a progressive, incurable lung disease-primarily caused by smoking-that causes severe breathing problems due to damaged airways and trapped air). The MDS Assessment indicated in Section O-Special Treatments, procedures, and programs addressed respiratory oxygen treatments.Goal: The resident will display optimal breathing patterns daily through review date. Record review of Resident #27's admission care plan, 02/21/2026, reflected that the resident was diagnosed with COPD (is a progressive, incurable lung disease-primarily caused by smoking-that blocks airflow and makes breathing difficult), (with respiratory failure Goal: the resident will display optimal breathing patterns daily through review dated. Interventions and Task: Head of bed elevated during episodes of difficulty breathing. Observe and report PRN any s/sx of respiratory infection: Fever, Chills, increase in sputum (thick mucus) (document the amount, color and consistency), chest pain, increased difficulty breathing, increased coughing and wheezing.Observe for s/sx of acute respiratory insufficiency (not enough): Anxiety (excessive worrying), Confusion, Restlessness (unable to rest), SOB at rest. oxygen settings: 02 via nasal prongs @4L/M. Resident #27's care plan did not address the frequency of oxygen tube changing or labeling. Record review of Resident #27's MD order dated 02/20/2026 reflected Oxygen at 4 liters/minute continuously per nasal cannula. Document every shift. MD order dated 03/05/2026 at 1:15 PM reflected Change oxygen tubing, nebulizer circuit and humidifier bottle every night shift every Sun Label when changed and every 24 hours as needed when visibly soiled. Label when changed Oxygen sat rates every shift Oxygen sat rates every shift may titrate to keep above 90%.Record review of Resident #27's TAR for March 2026 reflected that the resident tubing had not been changed on the following dates 03/01/2026, 03/02/2026, 03/03/2026, 03/04/2026. Record review of Resident #27's March 2026 TAR reflected LPN-E had changed Resident #27's oxygen tubing and water on 03/05/2026 at 1:15 PM. During an observation and interview on 03/05/2026 at 10:35 AM, Resident #27 was observed lying awake in bed wearing an undated nasal cannula. An observation of the oxygen concentration water bottle revealed the saline bottle was un-dated. Resident #27 stated that the tube had not been changed since being admitted . Resident #27 denied having any concerns with oxygen machines. During a second observation on 03/05/2026 at 1:35 PM, Resident #27's oxygen tubing was dated 03/05/2026.Resident #33Record review of Resident #33's 's admissions MDS Assessment, dated 02/22/2026 reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE].the resident had a BIMS score of 14, which indicated her cognition was intact. Resident #33 used a wheelchair and walker for mobility. She was dependent on staff for ADL care of Toileting Hygiene showers, dressing, putting on and taking off footwear, and transfers. The MDS Assessment did not indicate that Resident #33 received oxygen therapy. Active Diagnosis: Obstructive sleep apnea (ADULT), unspecified asthma (a chronic respiratory disease that causes inflammation, swelling, and tightening of the airways.)Record review of Resident #33's 's care plan dated 02/20/2026 reflected she the resident has hypertension Give anti-hypertensive medications as ordered. Observe for side effects such as LPN orthostatic hypotension and increased heart rate and effectiveness. Obtain blood pressure readings prior to administering medications. Section O-Special Treatments, Procedures, and Programs did not address Resident #33's BIPAP use, storage, and cleaning in her care plan.Record review of Resident #33's MD orders dated 02/18/2026 Monitor every shift. Does resident experience S/SX of Shortness of Breath (SOB) when lying flat or avoid lying flat due to S/SX of SOB? (increased respiratory rate, pursed lip breathing, a prolonged expiratory phase, audible respirations, gasping for air, interrupted speech pattern, use of accessory muscles, anxiety, restlessness etc.). Order dated 02/18/2026 Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083% (Albuterol Sulfate) 3 ml inhale orally via nebulizer every 6 hours as needed for Shortness of Breath: Wheezing. Order dated 02/27/2026 BIPAP 12/6 rate of 10, apply upon availability. There were no MD orders addressing resident BIPAP cleaning frequency and storage when not in use.Record review of Resident #33's February 2026 TAR reflected she was assessed for S/SX of Shortness of Breath on 02/18/2026 night shift and every shift on the following dates: 02/19/2026, 02/20/2026, 02/21/2026, 02/22/2026, 02/23/2026, 02/24/2026, 02/25/2026, 02/26/2026, 02/27/2026, and 02/28/2026 by nursing staff.Record review of Resident #33's March 2026 TAR reflected she was assessed for s/sx of Shortness of Breath.every shift on March, 03/01/2026, 03/02/2026, 03/03/2026, 03/04/2026, and 03/05/2026 day shift. During an observation and interview on 03/05/2026 at 12:30 PM with Resident #33 revealed she was sitting in her wheelchair watching television. Resident #33's BIPAP mask was observed in the top drawer of her nightstand. The Mask was observed with oil build-up, with moisture and oil build up, and cloudy in appearance and the mask was not bagged for sanitation and infection prevention. Resident #33 stated that she did not know when the mask was last cleaned. Resident #33 stated she uses the mask during naps and at night when sleeping. Resident #33 denied having any concerns with her BIPAP machine.During an interview on 03/05/2026 at 1:05 PM with LPN-T, she stated that nursing conducts rounds to assess and monitor resident change, device tubing and ensure BIPAP and oxygen settings were correct, cleaned and bagged. LPN-T stated that nursing protocol included bagging the BIPAP mask when not in use. LPN-T said nursing staff were responsible for cleaning BIPAP masks and machines as often as needed. LVN-T said residents were at risk of respiratory infections from cross-contamination when the BIPAP machines were not cleaned weekly and the mask bagged when not in use.During an interview on 03/05/2026 at 1:35 PM with LVN-E he stated that he completes rounds every 2 hours to assess resident changes in care, safety precautions, and assess resident devices for connections and operations. LVN-E stated that he changed Resident #27's NC today during his resident rounds. He could not recall the time. LVN-E said he was not aware that Resident #33's mask was not stored for sanitation. He stated that the protocol was to store the BIPAP mask in a plastic bag with date to ensure sanitation. LVN-E said the risk of not being bagged could result in infections. LVN-E said he did not know if Resident #33's BIPAP machine was cleaned. During an observation on 03/05/2026 at 1:45 PM, with LPN-E assessed resident's BIPAP equipment. LPN-E was observed sanitizing his hands before entering and placing the BIPAP mask in a bag. Resident #33 asked LPN-E to water the machine as it was empty. During an interview on 03/05/2026 at 5:45 PM the DON stated it was standard practice for oxygen equipment to be changed and dated once a week and as needed. The DON stated it was important to check the equipment, keep it clean and ensure that it was working properly. The DON stated it was the nurses' responsibility to check and change the oxygen equipment once a week and as needed, as well as cleaning and storing mask to prevent cross-contamination and illnesses to the residents. The DON stated the expectation was for all nurses to check the BIPAP and oxygen equipment daily, during each shift. The DON stated not changing out the equipment at least once a week could place the residents at risk of infection. The DON stated that it was ultimately her responsibility to ensure residents received correct treatment and cleansing of devices.During an interview on 03/05/2026 at 5:55 PM with the Administrator, he stated it was standard practice for BIPAP equipment to be cleaned according to manufacturer's recommendations, and he will provide that information. The Administrator further stated it was standard practice for oxygen equipment to be changed and dated once a week and as needed. The Administrator stated the risk to residents when protocol was not followed could result in a change in the resident's health. He did not specify or elaborate. The Administrator stated that it was ultimately the responsibility of the DON to ensure residents received correct treatment and cleansing of devices.Record review of the facility's Policy titled BIPAP / CPAP Administration Policy Revised: 02/03/2026 reflected Policy The facility will ensure that each resident receives necessary respiratory care and services (BIPAP/CPAP) that are in accordance with professional standards of practice, the resident's care plan, federal, and state regulations. Definitions: Bi-level positive airway pressure (BIPAP) - is a non-invasive ventilation machine that is capable of generating two adjustable pressure levels Expiratory Positive Airway Pressure (EPAP) - is a therapeutic, non-invasive method that uses resistance during exhalation to create backpressure, keeping the airways open and preventing collapse in conditions like obstructive sleep apnea (OSA - is when you stop breathing during sleep because of a blockage in your windpipe.) Unlike CPAP, EPAP devices often use small, disposable, adhesive valves placed over the nostrils, allowing easy inhalation while creating resistance upon breathing out .Inspiratory Positive Airway Pressure (IPAP) - is the higher, specifically timed pressure delivered by a bilevel ventilator (BIPAP/NIV) when a resident inhales It supports breathing by reducing the workload on respiratory muscles, aiding in ventilation, and helping to clear CO2 (a colorless, odorless, non-flammable gas essential for life but also a major greenhouse gas.) .Infection Control To reduce the risk of waterborne illnesses associated with BIPAP/CPAP machines, the CDC (CDC is the nation's leading science-based, data-driven, service organization that protects the public's health.) recommends that opened containers of water in nursing homes should be covered, labeled, and used within 24 hours to prevent contamination. Water should be stored in clean, sealed containers, and any unused water should be discarded to reduce the risk of waterborne illnesses. Single use 100 ml containers of sterile water are recommended.To clean face mask, alcohol prep pads or warm soapy water can be used as needed .a. If mask/tubing are washed with warm soapy water, they should be air dried completely before use.

Based on interview and record review the facility failed to ensure that an alleged violation involving abuse was reported immediately, but not later than 2 hours after the allegation was made for 1 (Resident #1) of 10 residents reviewed for abuse, neglect, exploitation, or mistreatment. LVN B failed to immediately report an allegation of sexual abuse on 02/17/26 at 3:00 AM after Resident #2 wandered into the wrong room, and Resident #3 alleged that Resident #1 was molested by Resident #2. The Administrator was made aware of the allegation by Resident #3 on 02/17/26 at 11:00 AM and reported it to the state agency at that time. This failure could place residents at risk for continued abuse.Findings included: Record review of Resident #1's Discharge MDS Assessment, dated 02/17/26, reflected the resident was an [AGE] year-old female who admitted to the facility on [DATE] and discharged on 02/17/26. The resident's BIMS score was not indicated. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #1 required maximal assistance with most ADLs. The MDS Assessment under Section I-Active Diagnoses, reflected Resident # 1's active diagnoses included: hypertension (high blood pressure), acute embolism and thrombosis (sudden onset of blood clots), acute respiratory failure (sudden onset of lungs inability to adequately transfer oxygen to the blood or remove carbon dioxide), dysphasia (language impairment), and reduced mobility (difficulty walking or standing). Record review of Resident #1's Care Plan, dated 01/30/26, reflected the resident had a BIMS score of 10, which indicated cognition was moderately impaired, with interventions that included: asking yes/no questions to determine needs, using consistent and simple communication, cueing and reorienting as needed, keeping consistent routines, a referral to speech language pathology, and using step-by-step tasks. Record review of Resident #2's Discharge MDS Assessment, dated 02/19/26, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE] and discharged on 02/19/26. The resident's BIMS score was not indicated. The MDS Assessment under Section B-Hearing, Speech, and Vision, reflected no indication of any deficits. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #2 required supervision or touch assistance with most ADLs. The MDS Assessment under Section I-Active Diagnoses, reflected Resident # 2's active diagnoses included: diabetes mellitus (body's inability to control blood glucose levels), chronic kidney disease (long-term loss of kidney function), hypertension (high blood pressure), vascular dementia (progressive cognitive decline caused by reduced blood flow to the brain, often due to stroke), delirium (severe confusion). Record review of Resident #2's Care Plan, revised 02/18/26, reflected the resident was at risk for elopement, with interventions that included: using activities to divert the resident from exit-seeking behavior and provide for safe wandering. The care plan also reflected Resident #2 wandered into a female's room and was noted to be touching resident by straightening her blanket while she was lying on bed, with no noted injuries and interventions that included: anticipating Resident #2's needs, intervening as necessary to protect the rights and safety of others, and providing one-on-one care until further notice. Record review of Resident #3's Discharge MDS Assessment, dated 02/20/26, reflected the resident was an [AGE] year-old female who admitted to the facility on [DATE] and discharged on 02/20/26. The resident's BIMS score was 11, which indicated cognition was moderately impaired. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #3 required setup or clean-up assistance with most ADLs. The MDS Assessment under Section I-Active Diagnoses, reflected Resident # 3's active diagnoses included: diabetes mellitus (body's inability to control blood glucose levels), myocardial infarction (heart attack), dysphasia (language impairment), muscle weakness (reduction in strength). Record review of Resident #3's Care Plan, dated 12/31/26, reflected there was no focus that indicated the resident made false allegations. Record review of an intake investigation worksheet (incident), dated 02/17/26, reflected in part the following: Incident informationDate and Time of the Incident: 2/17/2026 3:00 AM Date facility first learned of Incident? 2/17/2026 11:00 AM Who made or reported the allegation: Resident/Client Other who made/reported the allegation:Incident Category: Abuse On what shift incident occur? Night . Narrative of The Incident A resident [Resident #3] reported during the night, a male resident [Resident #2] entered her room, went to her roommate [Resident #1] and molested her. The female resident [Resident #1] allegedly molested, had no memory of the event or no new acute psychologic symptoms noted. Roommate [Resident #3] placed call light on and staff came to room. Upon entrance, it was noted the female resident [Resident #1] was resting with eyes closed and blankets were pulled up to her clavicle (collarbone) and were still in an orderly fashion, not disturbed.As staff redirected male resident [Resident #2] out of room, the roommate [Resident #3] followed the staff out and said to the staff, He molested her. Actions and Notifications Skin assessments completed and no new areas of concern were noted. There also were no psychological changes were noted. 1:1 started with male resident [Resident #2]. During an interview on 03/05/26 at 12:42 PM, LVN B stated she worked at the facility since 07/15/25. She stated she worked with Resident #1 on 02/17/26, when there was an incident of alleged sexual abuse. LVN B stated Residents #1 and #3 were roommates, and Resident #2 resided on the same hall. LVN B stated she was doing rounds at approximately 3:00 AM when she noticed the bathroom light on in Residents #1 and #3's room, and she went in to find Resident #2 feeling around on Resident #1's bed like he was trying to find his way back to bed. She stated Resident #2 was visually impaired and would often wake up in the middle of the night to use the bathroom and wander into the wrong room. LVN B stated as she and the aide escorted Resident #2 back to his room, Resident #3 followed behind them and started yelling He molested my roommate. LVN B stated when she checked on Resident #1, she was sound asleep with the covers pulled all the way to her neck and undisturbed. LVN B stated Resident #1 was very sensitive and would have been hollering in discomfort if her sleep had been disturbed in any way. She stated overnight was not her normal shift and there was a lot going on that night, so it slipped her mind to report the allegation to the Administrator; however, she did write it down on a note pad. LVN B stated she had been a nurse for a long time and was also trained on abuse and neglect at the facility, so she knew the protocol for reporting abuse. LVN B also stated based on her observations, she did not feel Resident #1 had been sexually abused. LVN B stated she did not complete a head-to-toe assessment of Resident #1 to check for any injuries or signs of abuse and only took a general inspection of the resident's state. LVN B stated later that morning during the shift change meeting, she heard that Resident #3 reported the allegation to someone and that was when she remembered that she forgot to tell the Administrator. LVN B stated not reporting allegations could place residents at risk of harm and she was suspended from work for not doing so. During an interview on 03/05/26 at 1:45 PM, Resident #2's RP stated Resident #2 was currently at a different nursing facility with a secured unit due to his wandering. The RP stated Resident #2 had vision loss due to complications from diabetes and a stroke, and he would often get lost while wandering around trying to find his room or the bathroom. The RP stated Resident #2 did not have a history of aggression or sexually inappropriate behaviors and would not harm anyone. An attempted interview on 03/05/26 at 2:10 PM with Resident #3's RP was unsuccessful due to no response to call. During an interview on 03/05/26 at 3:31 PM, the DON stated she learned of the alleged incident from the Administrator. The DON stated she told LVN A, who was the wound care nurse, to complete a head-to-toe assessment on Resident #1 and there were no findings of any injuries. The DON stated Resident #2 was visually impaired and had a history of wandering into the wrong room; however, the resident did not have a history of having sexually inappropriate behaviors. The DON stated she was shocked by the allegation. The DON stated she trained all staff on recognizing and reporting abuse and neglect at least monthly, so LVN B should have known to report the allegation immediately or within the 2-hour timeframe. The DON stated LVN B did not report the allegation, it was reported by Resident #3. During an interview on 03/05/26 at 4:20 PM, the Administrator stated he was informed that Resident #3 wanted to speak with him in her room. The Administrator stated he went to speak with Resident #3, and she informed him that Resident #2 wandered into her room and was rubbing on Resident #1. The Administrator stated Resident #3 demonstrated by rubbing up and down on the front of her thighs and waist area. The Administrator stated Resident #3 told him that she turned on her call light and before she could get out of bed and into her wheelchair, staff were in the room. The Administrator stated this was reported to him on 02/17/26 at approximately 11:00 AM and the alleged incident occurred at approximately 3:00 AM. The Administrator stated he immediately started an investigation and reported the allegation to the state agency. The Administrator stated LVN B reported when she entered Residents #1 and #3's room, she found Resident #2 feeling around on Resident #1's bed near her legs and the covers were pulled up to her neck. The Administrator stated LVN B informed him that Resident #1 did not appear to be disturbed; however, Resident #3 was yelling that Resident #1 had been molested by Resident #2. The Administrator stated Resident #2's RP informed that when the resident was home, he would often wander during the night, get confused and end up trying to get in her bed; however, Resident #2 did not have any inappropriate behaviors. The Administrator stated even with the alleged incident occurring at 3:00 AM, the expectation was for LVN B to notify him immediately, especially for an allegation of sexual abuse. The Administrator stated LVN B reported that her observations did not indicate that the allegation occurred and this was based on the condition Resident #1 was found in and Resident #2's history of wandering. However, the Administrator stated it was not for LVN B to make that determination as it was his responsibility to investigate allegations. The Administrator stated LVN B was suspended for 3 days and given a final warning because that was not her first time being slow to report an incident. The Administrator stated it was important to report alleged abuse within the specified timeframe to prevent further abuse and protect the integrity of the investigation. During an interview on 03/05/26 at 5:00 PM, LVN C stated she worked at the facility for about 7 months. She stated she was trained on abuse and neglect prevention upon hire and several times monthly. LVN C was able to describe abuse and neglect and stated she would report an allegation of abuse to the Administrator, who was the abuse coordinator, immediately no matter what time it occurred. LVN C stated she worked overnights and had called the Administrator during the middle of the night or early morning to report incidents before. During further interview on 03/05/26 at 5:45 PM, the Administrator stated it was his understanding that the timeframe for reporting alleged abuse did not start until he was notified; however, his expectation was for staff to report it to him immediately. The Administrator reiterated that he reported the allegation to the state agency as soon as he was made aware of it. He also stated LVN B's reason for not reporting the allegation was because she did not have cause to suspect that the abuse really occurred. During an interview on 03/10/26 at 12:23 PM, Resident #1's RP returned the surveyor's call and stated the facility notified her of the alleged incident on 02/17/26. The RP stated Resident #1 was visited by family that morning and she reported that a male entered her room, but she did not know what he wanted. The RP stated Resident #1 was very coherent and would have reported to the family if she was abused in any way. The RP stated she had no concerns for Resident #1 being abused at the facility. Record review of the facility's Chapter 3: Abuse, Neglect, and Exploitation policy, dated 10/04/22 and reviewed 06/17/24, reflected in part the following: Abuse - Identification of Types PolicyIt is the policy of this facility to identify abuse, neglect, and exploitation of residents and misappropriation of resident property. This includes but is not limited to identifying and understanding the different types of abuse and possible indicators. Procedure The facility will apply the following definitions to identify abuse, neglect, and exploitation. 2. Facility staff should report any suspected abuse, neglect, or exploitation noted based on thebelow definitions to the Executive Director or Director of Nursing. Refer to the Abuse -Reporting and Response Policy for additional direction.Risk Factors that May Provoke Reactions in Residents, Staff, or Visitors The risk for abuse may increase when a resident exhibits a behavior(s) that may provoke areaction by staff, residents, or others, such as: .e. Wandering into other's rooms/space; . Record review of the facility's policy titled Chapter 3: Abuse, Neglect, and Exploitation, dated 10/04/2022, revised 04/09/2024, and reviewed 06/17/2024, reflected in part the following: Abuse - Reporting and Response - Suspicion of a Crime PolicyThe facility will ensure reporting reasonable suspicion of crimes against a resident or individualreceiving care from the facility within prescribed timeframes to the appropriate entities, consistentwith Section 1150B of the Elder Justice Act The facility will ensure that all covered individuals, i.e., the owner, operator, employee, manager,agent or contractor, report reasonable suspicion of crimes, as required by Section 1150B of theElder Justice Act. The facility will provide annual notification to each covered individual of their obligation tocomply with the reporting requirements under section 1150B(b) of the Elder Justice Act.Reporting Procedures 1. Once an associate or other covered individual at the facility (e.g., medical director) forms areasonable suspicion that a crime has been committed against a resident or other individualreceiving services at the facility, he or she must immediately notify the Executive Directorof their suspicion. 2. The Executive Director must then notify Law Enforcement and the applicable State SurveyAgency of the suspected crime within the time period as indicated above.

Based on observation, interview and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 1 of 1 resident (Resident #13) reviewed for enteral nutrition.The facility failed to include Resident #13's down time in the physician orders for enteral feeding. The facility failed to include Resident #13's down time from enteral feeding on her Medication Administration Record. These failures could affect residents receiving enteral nutrition/hydration and place them at risk of health complications and decline in nutrition.Findings included:Record review of Resident #13's Quarterly MDS dated [DATE] revealed the resident was a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE]. Resident BIMS score was 00 (which indicates severe thinking and cognitive function). Resident #13's cognitive skills for daily decision making indicated severely impaired. The assessment reflected Resident #13's diagnoses included diabetes mellitus (a disorder of carbohydrate metabolism marked by impaired ability to produce or respond to insulin and maintain blood glucose levels), malnutrition (the condition that develops when the body does not get the right amount of the vitamins, minerals, and other nutrients it needs to maintain healthy tissue and organ function). The MDS reflected Resident #13 received her nutrition via tube feeding. Record review of Resident #13's undated care plan revealed the following: Resident #13 requires tube feeding related to Dysphagia (difficulty swallowing) and is at risk for complications related to placement. Goal: The resident will remain free of side effects or complications related to tube feeding. The resident will maintain adequate nutritional and hydration status aeb weight stable, no signs or symptoms of malnutrition or dehydration. The resident will be free of aspiration (fluid or solid enter the airways or lungs, leading to airway blockage or pneumonia). Interventions included resident needs the head of bed elevated 45 degrees during and thirty minutes after tube feed. Observe and report as needed any signs or symptoms of: Aspiration- fever, short of breath, Tube dislodged, Infection at tube site, Self-extubation (removing their own tubing), Tube dysfunction or malfunction, Abnormal breath/lung sounds, Abnormal lab values, Abdominal pain, distension (enlarged/bloated), tenderness, Constipation or fecal impaction, Diarrhea, Nausea/vomiting, Dehydration. Registered Dietician to evaluate quarterly and as needed. Make recommendations for changes to tube feeding as needed.Record review of Resident #13's physician orders included the following: 1.NPO diet NPO texture, NPO consistency Active with start date:10/16/252.Enteral Feed Order as needed Enteral access site care; verify tube securement is in place Active with start date: 10/17/253.Enteral Feed Order as needed Verify position of Enteral Access Device prior to feeding/medication administration, compare documented length or numerical marking at the exit site to the previously documented length. If changes have occurred/ concern for migration, contact provider Active with start date 10/16/254.Enteral Feed Order every 4 hours Verify position of Enteral Access Device by comparing the documented length or numerical marking at the exit site of the device to the previously documented length. If changes have occurred and concern for migration exist, contact provider. Active with start date 10/16/255.Enteral Feed Order every day shift Assess the tube exit site for new or increasing pain and signs of skin breakdown, redness, edema (fluid trapped in tissues that cause swelling) , leakage, induration (thickening of soft tissue), bleeding, and wear and tear. Active with start date 10/17/256.Enteral Feed Order every day shift Enteral access site care; verify tube securement is in place. Active with start date 10/17/257.Enteral Feed Order every shift At least 15 ml purified water flush before and after medication administration. Active with start date 10/16/258. Enteral Feed Order every shift Glucerna 1.5 at 55ml/hour x 22 hours via pump for a total amount of 1200 ml. Flush with 125 ml purified water every 4 hours. Active with start date 11/06/259. Enteral Feed Order every shift Head of bed elevated at least 30 degrees. Active with start date 10/16/2510. Enteral Feed Order every shift If PEG tube bumper not snugly against the skin, hold tube firmly with one hand and slide the bumper against the ABD with the other. DO NOT place bumper too tightly against skin as it will result in skin breakdown. Active with start date 10/16/2511. Enteral Feed Order every shift Verify position of external bumper on PEG tube. Bumper to remain snugly flush against ABD with dry slit gauze placed underneath. Active with start date 10/16/25Record review of Resident #13's January 2026 MAR did not reflect any down time for the tube feedings.Observations on 01/13/26 from 10:00 AM-12:00 PM, of Resident #13 revealed she was disconnected from the feeding pump, which meant the formula was not infusing.Observations on 01/14/26 from 10:00 AM-12:00 PM, of Resident #13 revealed she was disconnected from the feeding pump, which meant the formula was not infusing.Observations on 01/15/26 from 10:00 AM-12:00 PM, of Resident #13 revealed she was disconnected from the feeding pump, which meant the formula was not infusing. Interview on 01/15/26 at 12:47 PM with RN C revealed she worked morning shift with Resident #13. RN C stated Resident #13 was on 22 hours of continuous tube feedings, and the resident received Glucerna 1.5, 125 flush of water every 4 hours. RN C stated Resident #13 was disconnected at 10:00 AM and reconnected at 12:00 PM to give her a break from the machine and to aide with digesting the formula. RN C stated she was not able to locate where the order read to disconnect Resident #13 for 2 hours continuously or if the two hours should allow for therapy or incontinent care. RN C stated Resident #13 was previously scheduled for surgery, and the orders may not have carried over upon her return. RN C stated it was the responsibility of the nursing staff to ensure orders were entered upon admission, and the ADON and the DON would audit the orders to ensure all orders were entered correctly. RN C stated not having an understanding of Resident #13's feeding orders placed her at risk of weight loss, hunger, or malnutrition. RN C stated the order should include Resident #13's down time, so that all staff would be aware of her feeding schedule.Interview on 01/15/26 at 1:18 PM with the ADON revealed she knew Resident #13 received Glucerna 1.5 by tube feeding machine for 22 hours continuously. The ADON stated Resident #13 was disconnected for two hours during the morning shift between 10:00 AM until 12:00 PM with RN C. The ADON stated she did not see the order that indicated Resident #13 would disconnect from the machine for 2 hours however RN C was aware to disconnect Resident #13 at that time. She further stated the MAR should alert RN C to do so. The ADON stated she did not see a risk for Resident #13 if her order did not indicate specific details for her down time from her feeding. The ADON stated Resident #13 was on continuous feedings for 22 hours, and it just so happened that Resident #13's down time was with RN C. The ADON stated RN C was very knowledgeable about her hallway and the residents, who resided on the hall. Interview on 01/15/26 at 2:35 PM with the DON revealed Resident #13 was on 22 hours of continuous feeding, with 125 ml flushes of water every 4 hours. The DON stated Resident #13 is doing well with no concerns of weight loss. The DON stated nurses on duty with Resident #13 were expected to record the orders as they come in and follow them. The DON stated if orders did not indicate a down time, nurses should contact the physician to ensure orders were complete and in this case to indicate when the down time was to be completed. The DON stated not having complete orders placed Resident #13 at risk of weight loss. Record review of the facility's Enteral Nutrition Therapy (Continuous) policy, revised 09/03/24, reflected: The facility will provide continuous enteral nutrition therapy in accordance with physician orders and professional standards of practice.Assisted Nutrition and hydration, based on a resident's comprehensive assessment, the facility must ensure that a resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 6 medication carts (Hall B cart) reviewed for pharmacy services. The facility failed to ensure one bottle of zinc, with an expiration date of November 2025, had been removed from the Hall B medication cart. This failure could place residents at risk of receiving expired medications that were ineffective. Findings included: Observation on 01/14/26 at 12:39 PM of the Hall B MA cart with MA A revealed one bottle of zinc 50 mg (medication to help with zinc deficiency and used to help the body's immune system fight infections and heal wounds) with an expiration date of 11/2025. Interview on 01/14/26 at 12:51 PM with MA A confirmed the zinc expired in November 2025. MA A stated she checked her carts every 2 weeks for expired medications, but she would review the medications daily as well. She stated she just checked for expired medications the previous week, but she did not see the zinc. MA A stated it was all nurse's responsibility to ensure there were no expired medications, but it was her fault since it was her medication cart. MA A stated by failing to remove the expired medication, the medication could be administered, and the dose could cause a reaction. MA A stated she had done training on checking for expired medications and reviewing the carts. Interview on 01/15/26 at 12:50 PM with Facility Physician B revealed the risk of having expired zinc on the medication cart was the medication could be administered, causing an upset stomach, vomiting, and it could affect the effectiveness of the medication. Interview on 01/15/26 at 1:03 PM with The ADON revealed she expected her nurses and medication aides to review the carts every day. She stated the staff should be looking over the medications during administration. The ADON stated she would go behind the staff and look through the medication carts every few days to check to ensure the carts were being reviewed. The ADON stated she checked carts last week and must have accidentally looked at the open date, not the expiration date. She stated she just missed it. The ADON stated the risk of having expired medications on the cart was that they could be administered to residents and not be effective or cause an adverse reaction. The ADON stated she was stepping up to review the medication carts daily and in-servicing on medication administration/carts. The ADON stated it was all the nurse's responsibility to ensure there were no expired medications. Interview on 01/15/26 at 2:37 PM with the DON revealed that she expected her staff to review all their carts daily. The DON stated she also had 3 nurse managers that covered 2 hallways and were monitoring the medication carts weekly and as needed. The DON stated it was the nursing team's responsibility to ensure there were no expired medications on the carts. She stated the risk of not checking the medication carts for expired medications was the medication could be given and not be effective. The DON stated she was providing in-services and education on properly checking for expired medications. Record review of the facility's Storage and Expiration Dating of Medication and Biologicals policy, revised on 06/30/25 reflected the following: .10. Facility should ensure medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier.22. Facility should destroy or return all discontinued, outdated/expired, or deteriorated medications of biological in accordance with pharmacy return/destruction guidelines and other applicable laws. 23. Facility personnel should inspect nursing station storage areas for proper storage compliance on a regular basis.

Based on observation, interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 3 residents (Resident #13) reviewed for hospice services. The facility failed to obtain Resident #13's physician's order for hospice services. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs.Findings included: Record review of Resident #13's admission MDS Assessment, dated 10/30/25, reflected she was an [AGE] year-old female who was admitted to the facility on [DATE]. She had a BIMS score of 14 indicating no cognitive impairment. Her active diagnoses included Alzheimer's Disease (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain) and malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat). Her MDS indicated she received hospice care while a resident. Record review of Resident #13's physician's orders, dated 01/14/26, reflected there was not an order for hospice services. Record review of Resident #13's care plan, revised 01/06/26, reflected the following: Focus: [Resident #13] has a terminal prognosis.Interventions: Work cooperatively with hospice team to provide resident's spiritual, emotional, intellectual, physical and social needs. Observation and attempted interview on 01/13/26 at 10:36 AM revealed Resident #13 was asleep in her bed, and the resident did not rouse when spoken to and asked questions. Observation and attempted interview on 01/15/26 at 11:40 AM revealed Resident #13 was asleep in her bed, and the resident did not rouse when spoken to and asked questions. Interview on 01/15/26 at 9:17 AM with LVN B revealed she only worked PRN at the facility, but she knew Resident #13 received hospice services. LVN B said the resident should have an order in her chart for hospice services. She stated the admitting nurse should have included the order in the resident's chart. LVN B said since she was PRN that was all she knew. Interview on 01/15/26 at 2:41 PM with the DON revealed Resident #13 should have had an order to be admitted to hospice in her chart. The DON said usually the nurse, who admitted the resident, would have added it. She stated she chose random charts each week to audit and check for accurate orders. The DON said the purpose of having the order was to make sure everyone was aware the resident was receiving hospice services, so they could communicate with the hospice agency to ensure a collaborative effort and proper care was being provided to the resident. The DON said if the order was missing from the resident's chart, it could potentially cause an issue with her palliative care. Record review of the facility's Hospice Coordination of Care policy, revised 09/03/25, reflected: The facility provides hospice care under a written agreement and must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 3 of 5 residents (Residents #2 and #3, and #4) Record reviewed for abuse.1. The facility failed to ensure Resident #1 did not verbally abuse Resident #2 on 03/18/25 .2. The facility failed to ensure Resident #1 did not verbally abuse Resident #3 on 06/28/25. 3. The facility failed to ensure Resident #4 had the right to be free from abuse when CNA A threatened to hit the resident back on 06/06/25. This failure could place residents at risk for abuse.Findings included:1. Record review of Resident #1's quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included non-Alzheimer's dementia (various types of dementia that do not involve Alzheimer's disease, including dementia with Lewy bodies, vascular dementia, and frontotemporal dementia), anxiety disorder (mental health issues characterized by excessive fear and anxiety that interferes with ADLs), and depression (a mood disorder characterized by persistent feelings of sadness and loss of interest). Resident #1 had a BIMS of 15 which indicated his cognition was intact. The MDS further reflected the resident did not exhibit physical or verbal behaviors. Record review of Resident #1's care plan initiated on 06/28/25 reflected the resident was at risk for behaviors related to history of initiating verbal aggression toward previous roommate. Interventions included to educate the resident on boundaries related to appropriate communication techniques, problem solving, techniques, and who to discuss with, without becoming verbally aggressive with people. Other interventions included to take resident triggers into consideration with considering roommate placement. Record review of Resident #2's annual MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] and his diagnoses included non-Alzheimer's dementia. Resident #2 had a BIMS of 9 which indicated his cognition was moderately impaired. The MDS further reflected the resident did not exhibit physical or verbal behaviors. Record review of undated Resident #2's current care plan did not reflect any physical or verbal behaviors. Record review of Resident #2's progress noted dated 03/18/25 documented by LVN B reflected the following: This nurse went to picked [sic] up morning trays after resident ate breakfast from [hall] and heard both resident [sic] were exchanging words. This nurse went to resident's room and asked both of them to stop. [Resident #1] was verbally abusing his roommate and stated he will knock him out. This nurse told him to moved [sic] back to his space and to stopped [sic] verbally abusing and threatening his roommate. This nurse moved the other resident out of the room an brought him to the nursing station.Observation and interview on 08/06/25 at 10:25 AM with Resident #1 revealed he was in his room sitting on his rolling walker and did not have a roommate at the time. The resident said he had trouble with previous and stated Resident #2 alleged Resident #1 had threatened to kill him but that never happened. Resident #1 further stated he now had a room to himself and hope he would not get a new roommate because he like it peaceful. Observation and interview on 08/07/25 at 12:47 PM with Resident #2 revealed he was in his recliner and appeared to be hard of hearing. The resident was asked about the incident with Resident #1 (03/18/25), and Resident #2 said it has occurred a long time ago. Resident #2 said he and Resident #1 argued about the room temperature and Resident #1 had threatened him, but he did not recall what was said. Resident #2 said he was not scared at the time because he knew Resident #1 was just talking to talk and he knew how to defend himself if he needed to. Resident #2 stated he was moved to another room, and he did not have any concerns and felt safe at the facility. Interview on 08/06/25 at 1:26 PM with LVN B revealed Resident #1 did not like to have roommates and he had been moved a couple of times due having issues with prior residents. LVN B said she was making rounds, did not recall how long ago, when she heard Residents #1 and #2 argue and when she entered the room Resident #2 wanted to turn the AC up because he was cold, and Resident #1 did not want that. LVN B said she told both residents to calm down and Resident #2 said he was going to punch the shit out of him. LVN B said she separated both residents and took Resident #2 to another room and also said Resident #2 did not appear to be afraid with the threat. LVN B stated she had never seen Resident #1 have any behaviors towards others and he only bickered with roommates because he wanted a room to himself. Interview on 08/06/25 at 1:17 PM with LVN D revealed Resident #1 was pleasant and socialized with others, staff and residents. LVN D stated she had never heard Resident #1 be verbally abusive towards other and the resident normally stayed in his room on his computer. Interview on 08/06/25 at 1:44 PM with the ADON revealed she recalled the incident Resident #1 and #2 but she did not recall the details or what words were exchanged between both residents. Interview on 08/06/25 at 3:32 PM with the Previous DON revealed she recalled there had been an incident between Resident #1 and #2, but did not recall how long ago, where the residents had argued about the room temperature. The Previous DON stated she did not recall Resident #1 had threatened to punch Resident #2. 2. Record review of Resident #3's admission MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included non-Alzheimer's dementia, Parkinson's disease, anxiety disorder and depression. Resident #3 had a BIMS of 15 which indicated his cognition was intact. The MDS further reflected Resident #3 did not exhibit physical or verbal behaviors. Record review of Resident #3's undated current care plan did not reflect any physical or verbal behaviors. Record review of the facility's Provider Investigation Report dated 07/09/25 reflected the following: [Resident #1] did stand over [Resident #3] and yelled at him because he was snoring. [Resident #3] does have a history of snoring. Safe surveys were completed and no concerns were noted by other residents.Record review of Resident #1's progress notes dated 06/28/25 documented by LVN C reflected the following: This unit nurse was called to the patient's room to address threats made by the patient towards his roommate regarding the roommate's loud snoring. The threats included the statement that if the roommate did not stop snoring loudly, [Resident #1] would ‘knock the snore out of him.' The patient expressed significant frustration and irritation, stating he had been unable to sleep for four consecutive nights and had reached his limit. The patient was transferred to [another hall] to an empty room to be by himself.Observation and interview on 08/06/25 at 10:25 AM with Resident #1 revealed he was in his room sitting on his rolling walker and did not have a roommate at the time. The resident said he had trouble with a previous roommate, and he stated Resident #3 snored very loudly, and he told Resident #3 to hush, but the Resident #3 kept snoring. Resident #1 denied threatening Resident #3 or telling him he would plug his nose up. Resident #1 further stated he now had a room to himself, and he stated he hoped he would not get a new roommate because he liked it peaceful.Observation and interview on 08/06/25 at 9:53 AM of Resident #3 revealed he was in his room sitting in his wheelchair and appeared to be pleasant. Resident #3 was asked about the incident, 06/26/25, with Resident #1 and he said the end of June his roommate (Resident #1) woke him up and told him he was snoring like a pig. Resident #3 said he told Resident #1 he could not stop, and he did not recall the exact words but Resident #1 told Resident #3 he was going to plug his nose to shut him up and he was going to kick his ass. Resident #3 said he did not feel safe at the time and reported the incident to the charge nurse. Resident #3 said he was moved to another room and did not see Resident #1 anymore. Resident #3 further stated he currently felt safe at the facility and was not scared of Resident #1. Interview on 08/06/25 at 3:42 PM with LVN C revealed she recalled Resident #1 was upset with Resident #3 and stated if Resident #3 did not quiet his snoring, he was going to do something physical to him but did not recall what his exact words were. Resident #3 told LVN C he could not control his snoring and did not feel safe in the room with Resident #1 at that time. Resident #3 was then transferred to another hall. LVN C said she believed Resident #3 had made false threats as he was usually pleasant when he was around other residents. Interview on 08/06/25 at 3:23 PM with the ADON revealed she was told Resident #1 had said something to Resident #3 about his loud snoring, but she did not recall what was said between both residents. The ADON said Resident #3 was in a room alone and there were no current behavioral issues with the resident. Interview on 08/07/25 at 1:48 PM with the Administrator revealed Resident #1 had some past verbal behaviors. The Administrator said he knew Resident #1 and Resident #2 has argued about the room temperature back in March, but he was not aware #1 had threatened Resident #2. The Administrator further stated there had been an incident where Resident #1 had become upset at Resident #3's snoring. The residents were separated, and Resident #1 did better with no roommates. 3.Record review of Resident #4's quarterly MDS assessment reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, non-Alzheimer's anxiety disorder, and depression. Resident #4 had a BIMS of 4 which indicated her cognition was severely impaired. The MDS also reflected Resident #4 usually understood others. The MDS further reflected the resident had physical behaviors 4 to 6 days a week and verbal behaviors towards others 1 to 3 days a week. Resident #4. The resident also required substantial/maximal assistance for bathing/showers. Record review of Resident #4's care plan revised on 05/24/23 reflected the resident was resistive to care, refused to take showers, and became very angry yelling at staff that she cannot take a shower because she is going to fall. Interventions included to allow the resident to make decision about treatment regime and assist or offer the resident a bed bath when she refused showers. If the resident resist ADL's reassure the resident, leave for 5-10 minutes and try again later. Record review of the facility's Provider Investigation Report dated 06/06/25 reflected the following: CNA was providing a shower to resident and was being hit by resident. CNA was overheard stating ‘You are not going to hit me. I am not the person you want to do that. If you hit me again, I will not give you [soda] or candy bar'.Observation and interview on 08/06/25 at 9:50 AM of Resident #4 revealed she was in bed with her eyes open. She was asked how he was doing and she responded with good and did not answer any follow-up questions and appeared confused as she pulled her covers over her face. Interview on 08/06/25 at 2:19 PM with the Housekeeping Supervisor revealed she was making round around 3:00 PM (06/06/25) when she overheard commotion and when she walked past the shower room she heard an aide (CNA A) yell at Resident #4 don't hit me, I'm not the one and I will hit you back and also said he she did not behave the resident would not get a [candy bar] or soda. Resident #4 was heard repeatedly saying no, no, no. At that time the Housekeeping Supervisor went to get the DON, and the DON went to the shower room where she stood for a moment to listen to what was being said and the CNA continued to yell at the resident, but the Housekeeping Supervisor was not able to make out what was said. The DON then opened the door, asked the Housekeeping Supervisor to stay as a witness and the aide was told to get her things and leave the facility. The Housekeeping Supervisor stated Resident#4 usually yelled out stating she wanted candy and soda and had never heard any other staff yell at the resident. Interview on 08/06/25 at 3:32 PM with the Previous DON revealed the Housekeeping Supervisor reported she heard what she thought was verbal abuse. The DON said she then went to the shower room and when she entered CNA A was assisting the resident with her shower and there was BM on the resident. The DON said she did not hear verbal abuse when she stood at the door but only heard CNA A say she could not have something until the resident was nice. The DON said CNA A was not yelling but felt like the acoustics in the shower room made it appear as thought she was yelling. The DON said the resident was yelling out someone's name which she said was her baseline and did not appear distressed. The DON stated she had CNA A sent home and had another staff member finish Resident #4's shower. The DON further stated CNA A has recently been hired and did not have previous complaints about her and said she did not get to talk to the CNA A as she had to leave out of town shortly after and the Administrator had taken over the investigation. Interview on 08/06/25 at 3:23 PM with the ADON revealed she was made aware by the Previous DON of the incident between Resident #4 and CNA A. The ADON said she had only conducted staff interview as part of the investigation. The ADON stated Resident #4 had severe dementia and was combative during care and at times there were periods when the resident would become very confused. The ADON said CNA A was new to the facility and had only been out of training for about two weeks and no staff nor resident has complained about her. Interview on 08/07/25 at 1:48 PM with Administrator revealed the Housekeeping Supervisor overhead and aide (CNA A) speak to Resident #4 in an abusive manner so the Housekeeping Supervisor reported the incident to the Previous DON. The Previous DON then suspended CNA A pending the investigation and the CNA A did not return to work. The Administrator said he spoke to CNA A about the incident and the aide had denied the allegation. The Administrator further stated CNA A had not worked at the facility long and he did not have any issues or concerns with CNA prior to the incident. Record review of the facility's policy titled Abuse-Prevention Record reviewed on 05/06/25 reflected the following: PolicyIt is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation or resident property, and exploitation.The resident has the right to be free from abuse, neglect, misappropriation of resident property.

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 infections for 2 of 3 residents (Residents #5 and #7) reviewed for infection control.1. CNA G failed to wear a PPE when she provided Resident #5, who was on enhanced barrier precautions, with incontinence care on 08/06/2025 with a physician order for PPE dated 07/16/2025. 2. CNA H failed to perform proper hand hygiene practices to include changing her gloves and washing/sanitizing her hands when she provided Resident #7 incontinence care on 08/07/2025.These failures placed residents at risk of cross contamination and the spread of infection.1.Record review of Resident #5's entry MDS assessment dated [DATE] reflected the resident was a [AGE] year-old female, who admitted to the facility on [DATE] and readmitted on [DATE]. The resident had moderate cognitive impairment with a BIMS score of 11, and her diagnoses included diabetes mellitus, and the MDS reflected she had a Stage 4 pressure ulcers.Record review of Resident #5's care plan dated 06/26/25 reflected: Focus: Resident#5 has actual impairment to skin integrity. admitted with Stage 4 pressure ulcer to sacrum Goal: [Resident #5] Risk for developing new pressure ulcers will be minimal with nursing interventions through the Record review date. Interventions: Enhanced barrier precaution.Record review of Resident #5's physician order dated 07/16/25 reflected: Enhanced barrier precautions for wound requiring dressing.Observation on 08/06/25 at 03:29 PM revealed CNA G was preparing to provide Resident #5 with incontinent care. Resident #5's door had the following sign: enhanced barrier precautions -providers and staff must also wear Gown and Gloves. There was PPE hanged on the door. CNA G performed hand hygiene and donned a pair of gloves. She put all the supplies together and without putting on a PPE gown, CNA G then provided Resident #5 with incontinent care. Interview via phone on 08/07/25 at 11:32 AM, CNA G stated she did not know whether Resident #5 was on enhanced barrier precautions. She stated she was aware that PPE was supposed to be worn during care for residents on precautions. She stated she knew she did wear a gown while providing the resident incontinence care, but she did not explain why she did not wear a gown. She stated she was aware Resident #5 had wounds. She stated the risk of not putting on PPE was that it could lead to the spread of infection. She stated she had done training on enhanced barrier precautions for residents with wounds, gastronomy tubes, and Foley catheters.2. Record review of Resident #7's comprehensive MDS assessment dated [DATE] reflected the resident was [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. The resident's cognition was severely impaired with a BIMS score of 0. The resident's diagnoses included hypertension (high blood pressure) and aphasia (a language disorder that affects a person's ability to communicate). Record review of Resident #7's care plan dated 05/10/2025 reflected: Focus: Resident#7 was incontinent of bladder and bowel rule out dementia. Goal: Resident will be clean, dry and odor free with no occurrence of skin impairment through next Record review date Interventions: Observe for non-verbal cues resident may need to use the toilet.Observation on 08/07/25 at 10:03 AM revealed CNA H providing Resident #7 with incontinence care after the resident had had a bowel movement. CNA H cleansed the resident's abdominal folds and the perineal area inside out. She helped the resident to turn using the draw sheet. She cleansed the resident's buttocks while still using one hand to hold the resident in place. She did not change her gloves after cleansing bowel movement on Resident #7. She went directly to applying a clean brief without changing her gloves or performing hand hygiene. She left resident comfortable and then removed her gloves and washed her hands.Interview on 08/07/25 at 10:15 AM with CNA H revealed she was supposed to change her gloves and perform hand hygiene after cleansing the bowel movement and before applying a clean brief, but she did not. She stated she forgot, and she knew she was supposed to remove her soiled gloves and wash her hands while moving from a dirty to clean environment. She stated changing gloves and performing hand hygiene during incontinence care would prevent contamination which could cause infection. She stated she had done training on infection control, to include changing gloves and hand washing.Interview on 08/07/25 at 1:04 PM, the ADON stated she expected staff to wear a gown and gloves while providing care to a resident, who was on enhanced barrier precautions. She stated she was not sure of what the facility policy reflected regarding when providing incontinence care on resident with wounds. She stated she expected when staff saw the PPE by a resident's door they should wear the PPE. She stated wearing PPE would prevent cross contamination and infection. She also revealed her expectation was for the staff to remove their gloves and perform hand hygiene with contamination. The ADON stated the staff was supposed to remove her gloves and wash her hands after cleansing bowel movement and before putting a clean brief on Resident #7. The ADON stated the risk of not changing gloves and performing hand hygiene during the incontinence care was that it could lead to cross contamination and then infection. She stated she had provided training on enhanced barrier precautions, perineal care, and infection control; however, no record of the training was provided. Record review of training on enhanced barrier precautions, dated 07/18/25, reflected CNA G was not in attendance.Record review of training on donning(put on) and doffing (remove) of PPE, dated 07/18/25, reflected CNA H was not in attendance.Record review of the facility's Enhanced Barrier Precautions in Nursing Homes policy, dated March 2024, reflected: Enhanced barrier precautions (EBP) are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following:Infection or colonization with CDC targeted MDRP when contact precautions do not otherwise apply or;Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO.For residents for whom EBP are indicated is employed when performing the following high contact resident activities: Changing briefs or assisting with toileting.Record review of the facility's Infection Control policy, revised August 2024, reflected: . perform hand hygiene. after contact with blood, body fluids, or contaminated surfaces; when you are moving your hands from a contaminated body site to a clean body site during resident care.

Based on observation, interview, and record review, the facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin source and misappropriation of resident property are reported immediately but not later than 2 hours after the allegation is made to the administrator of the facility and to other officials (including to the State Survey Agency) for 1 of 5 residents (Resident #2) Record reviewed for reporting. The facility failed to report to the Administrator when Resident #1 verbally threatened Resident #2 on 03/18/25. This failure places residents at risk for further abuse. Findings included:Record review of Resident #1's quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included non-Alzheimer's dementia, anxiety disorder, and depression. Resident #1 had a BIMS of 15 which indicated his cognition was intact. The MDS further reflected the resident did not exhibit physical or verbal behaviors. Record review of Resident #1's care plan initiated on 06/28/25 reflected the resident was at risk for behaviors related to history of initiating verbal aggression toward previous roommate. Interventions included to educate the resident on boundaries related to appropriate communication techniques, problem solving, techniques, and who to discuss with, without becoming verbally aggressive with people. Other interventions included to take resident triggers into consideration with considering roommate placement. Record review of Resident #2's annual MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] and his diagnoses included non-Alzheimer's dementia. Resident #2 had a BIMS of 9 which indicated his cognition was moderately impaired. The MDS further reflected the resident did not exhibit physical or verbal behaviors. Record review of Resident #2's undated current care plan did not reflect any physical or verbal behaviors. Record review of Resident #2's progress noted dated 03/18/25 documented by LVN B reflected the following: This nurse went to picked [sic] up morning trays after resident ate breakfast from [hall] and heard both resident were exchanging words. This nurse went to resident's room and asked both of them to stop. [Resident #1] was verbally abusing his roommate and stated he will knock him out. This nurse told him to moved [sic] back to his space and to stopped [sic] verbally abusing and threatening his roommate. This nurse moved the other resident out of the room an brought him to the nursing station.Observation and interview on 08/06/25 at 10:25 AM with Resident #1 revealed he was in his room sitting on his rolling walker and did not have a roommate at the time. The resident said he had trouble with previous and stated Resident #2 alleged Resident #1 had threatened to kill him but that never happened. Resident #1 further stated he now had a room to himself and hope he would not get a new roommate because he like it peaceful. Observation and interview on 08/07/25 at 12:47 PM with Resident #2 revealed he was in his recliner and appeared to be hard of hearing. The resident was asked about the incident with Resident #1 (03/18/25), and Resident #2 said it has occurred a long time ago. Resident #2 said he and Resident #1 argued about the room temperature and Resident #1 had threatened him, but he did not recall what was said. Resident #2 said he was not scared at the time because he knew Resident #1 was just talking to talk and he knew how to defend himself if he needed to. Resident #2 stated he was moved to another room, and he did not have any concerns and felt safe at the facility. Interview on 08/06/25 at 1:26 PM with LVN B revealed Resident #1 did not like to have roommates and he had been moved a couple of times due having issues with prior residents. LVN B said she was making rounds, did not recall how long ago, when she heard Residents #1 and #2 argue and when she entered the room Resident #2 wanted to turn the AC up because he was cold, and Resident #1 did not want that. LVN B said she told both residents to calm down and Resident #2 said he was going to punch the shit out of him. LVN B said she separated both residents and took Resident #2 to another room and also said Resident #2 did not appear to be afraid with the threat. LVN B stated she had never seen Resident #1 have any behaviors towards others and he only bickered with roommates because he wanted a room to himself. Interview on 08/06/25 at 1:17 PM with LVN D revealed Resident #1 was pleasant and socialized with others, staff and residents. LVN D stated she had never heard Resident #1 be verbally abusive towards other and the resident normally stayed in his room on his computer. Interview on 08/06/25 at 1:44 PM with the ADON revealed she heard both residents had to be separated because they were not getting along but did not recall the details. The ADON said she did not report the incident to the Administrator but assumed he had been told about the incident by the Previous DON.Interview on 08/06/25 at 3:32 PM with the Previous DON revealed she recalled there had been an incident between Resident #1 and #2, but did not recall how long ago, where the residents had argued about the room temperature. The Previous DON stated she did not recall Resident #1 had threatened to punch Resident #2 and she believed the Administrator has been made aware. Interview on 08/07/25 at 1:48 PM with the Administrator revealed he was made aware Resident #1 and Resident #2 did not get along and at one time Resident #1 was upset about the temperature in the room he shared with Resident #2. The Administrator said he was not aware Resident #1 had verbally threatened Resident #2 during the room temperature incident. The Administrator stated he was the abuse coordinator, and the verbal threat should have been reported to him and all allegations of abuse should be reported to state office. Record review of the facility's Abuse-Conducting an Investigation policy, dated May 2025, reflected the following: PolicyIt is the policy of this facility that allegations of abuse (abuse, neglect, mistreatment, including injuries of unknown origin, exploitation, and misappropriation of property) are promptly and thoroughly investigated.Complaints and grievances will be investigated as outlined in the.and will be reported immediately if the investigation reveals any alleged violation involving neglect, abuse, (including injuries of unknown source), and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State Law.3. When an incident or suspected incident of resident abuse and/or neglect, injury of unknown source, exploitation, or misappropriation of resident property is reported, the administrator/designee will investigate the occurrence.

Based on observation, interview, and record review the facility failed to have evidence that all alleged violations in response to allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for 1 of 5 residents (Resident #5) Record reviewed for abuse.The facility failed to thoroughly investigate and an incident when CNA A asked Resident #5 for $0.50 to buy a soda on 07/23/2025. This failure places the residents at risk for misappropriation and exploitation. Findings included:Record review of Resident #5's quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included non-Alzheimer's dementia, anxiety disorder, and depression. The resident had a BIMS of 14 which indicated her cognition was intact. Record review of Resident #5's care plan dated 05/06/25 reflected the resident was noted to be making false accusations against staff, stating staff are not answering her call light or attending to her needs, states they make her stay in wet brief for hours when staff are in the room every time she puts call light on and at least every hour to attend to her needs. Interventions included anticipate and meet the resident's needs and if reasonable, discuss the resident's behaviors and reinforce why behavior is inappropriate and/or acceptable to the resident. Record review of the facility's Provider Investigation Report dated 07/30/25 reflected the following: When was the allegation made?07/23/25Investigation SummaryCNA stated she did request $.50 for drink from resident. CNA provided ED with $.50 and the money was returned to resident. CNA was terminated.Action to prevent recurrence CNA was suspended pending outcome of investigation and safety rounds were completed on residents on D Hall.Agency Action Post-Investigation Associate was terminated and education was completed regarding ANE prevention and reporting.Further review of the provider investigation report revealed there was no evidence of staff education and/or interviews and there was no evidence and other resident interviews were submitted during the time of the incident. Observation and interview on 08/06/25 at 10:07 AM with Resident #5 revealed she was in bed watching TV and when asked if staff has asked her for money recently, she said aide (CNA E) asked her for $.50 and she (Resident #5) did not know what to do so she just gave it to her. Resident #5 said she did not want to give her the money but felt like she had to so after that Resident #5 said she reported it to the Administrator. Resident #5 said that was the first time CNA E has asked her for money and no one else has done so since. Resident #5 said the Administrator took care of the issue and she felt safe at the facility. Interview on 08/06/25 at 10:07 AM with the Administrator revealed Resident #5 called him (07/23/25) and said CNA E asked to borrow $.50 and it sounded like the resident did not want to but felt forced. The Administrator said he spoke with CNA E who admitted asking Resident #5 for the money and also said she knew it was wrong. CNA E was suspended pending the investigation and later terminated for the incident. Interview on 08/07/25 at 2:03 PM with CNA E revealed she did not ask Resident #5 for $.50 (07/23/25) but it was the resident who wanted to give her $1 for a soda. CNA E said that she already had $.50 on her and only accepted $.50 from the resident so she could buy her soda but had planned to pay the resident back. CNA E admitted knowing it was wrong to accept the money from Resident #5 but because she knew she was going to pay her back CNA E did not think much about it. The following day after the incident, the Administrator approached her (CNA E) to ask about the money and she told him she had taken the money and also said she had the money in her pocket to pay Resident #5 back so the Administrator took the money from her and said he would give it back to the resident. Interview on 08/07/25 at 2:09 PM with the Interim Social Worker revealed she only did 2 safe surveys with residents and was told to stop by the Administrator because she had new admissions to work on. Further interview on 08/07/25 at 1:48 PM with the Administrator revealed his investigation with Resident #5 and CNA E was complete because the aide had admitted to asking and taking money from Resident #5 and there was nothing else to complete. The Administrator said the facility held fire drills around the same time as the incident so during the fire drill staff were talked to about taking money from residents. Record review of documentation provided by the Administrator on 08/06/25 reflected there was a fire drill completed on 07/31/25. Record review of an email sent by the Administrator on 08/11/25 reflected there 8 resident safe surveys conducted on 07/29/25 in which one of the questions included: Has an associate asked to borrow your personal belongings including money for their own use? with no concerns. Record review of the facility's Abuse-Conducting an Investigation policy, dated May 2025, reflected the following: PolicyIt is the policy of this facility that allegations of abuse (abuse, neglect, mistreatment, including injuries of unknown origin, exploitation, and misappropriation of property) are promptly and thoroughly investigated.

Based on observation, interview, and record review, the facility failed to ensure resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 5 residents (Resident #5) reviewed for wound care . The facility failed to ensure Resident #5's stage 4 pressure ulcer wound her sacrum was covered with a dressing.This failure could place residents at risk of severe pain, and lead to systemic infections causing harm for residents.Record review of Resident #5's entry MDS assessment dated [DATE] reflected the resident was a [AGE] year-old female, who admitted to the facility on [DATE] and readmitted on [DATE]. The resident had moderate cognitive impairment with a BIMS score of 11, and her diagnoses included diabetes mellitus, and the MDS reflected she had a Stage 4 pressure ulcers.Record review of Resident #5's care plan dated 06/26/25 reflected: Focus: Resident#5 has actual impairment to skin integrity. admitted with Stage 4 pressure ulcer to sacrum. Goal: [Resident #5] Risk for developingnew pressure ulcers will be minimal with nursing interventions through the Record review date. Interventions: Assess location, size and treatment of skin injury. Report abnormalities, failure to heal, sign and symptoms of infection and maceration. Treatment as ordered.Record review of Resident #5's physician order dated 07/23/25 reflected: Cleanse Sacrum with NS, pat dry, apply Santyl, and cover with gauze island with border dressing everyday shift AND as needed if soiled or dislodged.Observation and interview on 08/07/24 at 9:12 AM with the Wound Care Nurse of Resident #5's Stage 4 pressure ulcer on her sacrum revealed the pressure ulcer did not have a wound care dressing. The Wound Care Nurse asked Resident #5 what happened to the wound dressing, and the Wound Care Nurse told the resident to let somebody know when the dressing fell off. The Wound Care Nurse stated she was not aware Resident #5 did not have a dressing on. Observation of the pressure ulcer revealed there were no signs of infection noted. Interview on 08/07/25 at 9:32 AM revealed Resident #5 was lying in bed. Resident #5 stated she was doing well. Resident #5 stated she admitted to the facility with wounds on her sacrum. Resident #5 stated she was not aware the dressing was off. She stated CNA K performed incontinence care on her around 8:00 AM to 8:30 AM. Interview on 08/07/25 at 9:39 AM with CNA K revealed she was the CNA assigned to Resident #5. She stated she had provided incontinence care to Resident #5. She stated she noticed the resident's dressing was peeling off, and it had fecal matter on it, so she removed the dressing. She did not recall the time when she provided Resident #5 with incontinence care. She stated she knew she was supposed to notify the nurse or the treatment nurse about the soiled dressing, but she did not. She stated it had slipped her mind, and she forgot to notify the nurse. She stated she was in a hurry to finish giving another resident a shower on another hall because that resident had an early pick up of around 8:30 AM for appointment. She stated she was aware she was not allowed to remove dressings, and she knew she was supposed to call the nurse to come and replace the soiled peeling dressing with a clean dressing but not for her to remove it. She stated Resident #5 did not complain of pain. CNA K stated she should have notified the nurse. She stated the risk of not having a dressing on would be infection and wound getting bigger. She stated she had done training on calling the nurse if a dressing had become soiled and not to removing the dressing. Interview on 08/07/25 at 9:48 AM with the Wound Care Nurse revealed Resident #5 had a physician's order to cleanse and cover the wound daily and an order for as needed in case the dressing get soiled or dislodged. She stated she was not made aware that Resident #5's dressing had come off. She stated when she completed wound care yesterday (08/06/25) on Resident #5, she had applied a dressing over it. She stated her expectations were for the nurses to monitor the dressing every shift and if the dressing came off, they had as needed treatment orders to follow. She stated C N A's were not supposed to touch or remove the dressing. She stated her expectation was for CNA K to call her or the nurse to replace the soiled dressing. She stated the potential risk if the dressing comes off would be a decline in the wound status and infections. She stated she prefer the C N As to notify the nurses because they could leave the wound open and the resident happen to have a bowel movement and that also predisposes Resident#5 to the risk of infection. She stated she had provided staff with training regarding turning and repositioning. She provided a training record dated 02/21/25, which reflected CNA K was not in attendance as she was newly hired to the facility in April.Interview on 08/07/25 at 9:54 AM with the RN J, who was the charge nurse, revealed she was not made aware that Resident #5's dressing had come off. She stated her expectation was for CNA K to report to her so that she could replace the soiled dressing with a clean dressing when she was performing incontinent care on Resident #5. She stated the risk of removing dressing and not replacing with a clean one was infection. She stated she had done training on dressing change.Interview on 08/07/25 at 1:12 PM with the ADON revealed her expectations were for her staff to follow orders and as needed orders. If the dressing came off or it was soiled when completing peri care, she expected CNA K to stop care and notify the nurse, and the nurses were to apply a new dressing. The ADON stated CNAs were not supposed to remove the soiled dressing and if it fall off they should also notify the nurse. She stated the risk of not notifying the nurse and of not having a dressing could lead to, an infection and wound margins increasing. She stated wound care nurse had completed in-services on wound care with staffs.Record review of training on turning and repositioning, dated 02/21/25, reflected CNA K was not in attendance.The training addressed resident not having dressing or dressing are soiled they should notify nurse immediately so that a new dressing may be applied. CNAs are not to touch /remove dressings.Record review of facility policy wound care management, long term care revised June 2025, Did not address soiled and fall off dressings.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of six residents (Resident #2 and #3) residents reviewed for infection control. 1. The facility failed to provide Enhanced barrier precaution signage and PPE outside of Resident#2 door. 2. The facility failed to provide PPE inside and/or outside of Resident# 3 room. These failures could place residents at risk for infection. Findings include: 1. Record review Resident #2's face sheet, dated 05/06/25, reflected the resident was admitted to the facility on [DATE]. Resident #2 was diagnosed with Urinary tract infection,)( a very common type of infection in your urinary system) site not specified, unspecified protein-calorie malnutrition,( reduced availability of nutrients leads to changes in body composition and function) adult failure to thrive (Older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal), Dementia (General decline in cognitive abilities that affects a person's ability to perform everyday activities), unspecified convulsions (rapid involuntary muscle contractions), type 2 diabetes mellitus without complications (chronic condition characterized by insulin resistance and elevated blood sugar levels), contracture of muscle (Condition where muscle fibers permanently shorten, leading to stiffness and reduced flexibility), right and left upper arm, Record review of Resident #2's admission MDS Assessment, dated 04/02/25, reflected she had a BIMS score of 0, which indicated severe cognitive impairment. Resident #2 did not have a wound infection (other than the foot). Resident#2 was at risk of pressure ulcers/injuries, Resident #2 had one or more unhealed pressure ulcers. Resident #2 had 7 stage 2 pressure ulcers at entry, Stage 2 pressure ulcers meant Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister. Resident #2 had 1 stage 4 pressure ulcer at entry which meant stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Resident #2 MDS had 1 unstageable pressure injury presented as deep tissue on entry. Resident #2's skin and ulcer/injury treatments included: pressure reducing device for bed and pressure ulcer/injury care. Record review of Resident #2 care plan goals, initiated on 04/02/25, reflected: Minimize risk for symptoms of infection through next review. Resident #2's interventions revised on 05/02/25 reflected enhanced barrier precautions .weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Record review of Resident #2 care plan, initiated on 04/23/25 and revised on 05/02/25, reflected: Resident #2 had pressure ulcers: DTI to left, proximal, lateral heel DTI to left, distal, lateral foot DTI to left, lateral, fifth toe, Stage IV to left, medial foot (3-28-25) Placing her at risk for complications and developing new pressure ulcers r/t immobility, hx of ulcers, contractures Record review of Resident #2's MAR, dated 05/06/25, reflected an active order, dated 04/11/25, which indicated enhanced barrier precautions for skin opening requiring a dressing every shift. Record review of Resident #2's census reflected she transferred rooms on 04/15/25. 2. Record review of Resident #3's face sheet reflected the resident was admitted to the facility on [DATE]. Resident #3 was diagnosed with diabetes mellitus (insulin deficiency or resistance) due to underlying condition with diabetic neuropathy (nerve damage) unspecified, acquired absence of other right toe's, acquired absence of left leg below knee and end stage renal disease (Kidney failure). Record review of Resident #3's admission MDS Assessment, dated 04/10/25, revealed she had a BIMS score of 15, which indicated no cognitive impairment. Resident #3 was at risk for developing pressure ulcers. Record review of Resident #3's care plan, dated 05/06/25, reflected Resident#3 had break in skin integrity initiated on 04/08/25. Minimize risk for symptoms of infection .Interventions included treatments as ordered. Record review of Resident #3's MAR, dated 05/06/25, reflected an active order dated 04/11/25, which reflected enhanced barrier precautions for skin opening requiring a dressing every shift. Record review of Resident #3's MAR reflected an active order, dated 04/07/25, which indicated monitor for s/s of infection to shunt/fistula site every shift. Observation and interview on 05/06/25 at 9:43 AM revealed Resident #2 did not have an enhanced barrier precaution sign and did not have PPE inside or outside Resident#2 door. The resident did not have PPE inside of her room. Observed CNA A start to move Resident #2 and the WCN told her to stop because they needed a gown and gloves to provide wound care. The WCN stated Resident #2 had just transferred rooms and she should be on enhanced barrier precautions because of her wounds. The WCN stated wearing PPE helped protect the residents from bacteria and cross-contamination. CNA A returned to Resident #2's room with PPE. Observation on 05/06/25 at 10:00 AM revealed Resident #2 had an enhanced barrier precaution sign outside the door which reflected enhanced barrier precautions everyone must: Clean their hands, including before entering and when leaving the room. Wear gloves and gown for the following high-contact residents care activities: Wound care any skin opening requiring a dressing. Interview on 05/26/25 at 10:02 AM, CNA A stated staff should use hand sanitizer before entering the room wash hands before exiting. CNA A stated PPE was used to protect the residents and staff . CNA stated PPE is usually located outside the residents doors. Interview on 05/26/25 at 2:37 PM, the staffing coordinator stated it was important to put on PPE because we have bacteria that could infect residents at any point of entry. Interview on 05/06/25 at 2:40 PM, the IP stated the sign and PPE outside of door reminded staff to put on PPE before high contact care. Resident #2 was transferred over to a different hall and the ending nurse and receiving nurse should have been responsible for putting the sign back up and PPE outside of the resident room. The IP stated, I'm ultimately responsible to check to make sure PPE is available and signage was up. The IP stated she would hook the PPE storage on Resident #3's room and then someone would take it down and she did not know who. IP stated nursing staff could find additional PPE central supplies. The IP stated she was responsible for providing training to the staff. The IP stated it was important to protect the residents from cross contamination . Interview on 05/06/25 at 2:53 PM, CNA B stated staff and visitors should wear PPE according to the sign outside the resident door. Each precaution was used to help prevent infection. Interview on 05/06/25 at 3:12 PM, the DON stated PPE was used to prevent residents with artificial opening from getting anything (bacteria, infection) in them. Record review of in-service on 03/28/25 by IP titled Enhanced Barrier Precautions: Enhanced barrier precautions were implemented for all residents who have PICC line, feeding tube, foley catheter, .a wound that requires a dressing. Please remember to wear your PPE during all required activities while caring for these residents. This is done to decrease the spread of MDROs (Multidrug-Resistant Organisms) from resident to resident that may be present on our clothing. This protects you as well as the resident. Record review of the facility's policy, titled Enhanced barrier precautions revised 04/25 reflected EBP are indicated for residents with any of the following . 2. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO .a) Wounds generally include chronic wounds, not shorter lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds and venous stasis ulcers .Enhanced Barrier Precautions (EBP)- refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. Record review of the facility's policy titled Infection Prevention and Control Program (IPCP) and plan, revised 06/24 reflected: 16. Provide Supplies Necessary to Adhere to Recommended Infection Prevention and Control Practices. c. Personal Protective Equipment (PPE)

Based on observation, interview and record review the facility failed to ensure based on the comprehensive assessment of a resident, the facility ensured a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable; and a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 6 residents (Resident #1 and Resident#2) reviewed for pressure ulcers/injuries. The facility failed to provide pressure relieving devices to support the residents being repositioned on their side. This failure could place residents at risk of complications such as pain, acquiring new wounds, worsening of existing wounds, and infection. Findings include: 1. Record review of Resident #1's face sheet, dated 05/06/25, reflected the resident was admitted to the facility on [DATE]. Resident #2 was diagnosed with cellulitis of left lower limb (bacteria infection of the skin and the tissue beneath the skin.) contusion (bruise, occurs when blood vessels are damaged due to trauma) of left lower leg and Crohn's disease (inflammatory bowel disease (IBD) that causes chronic inflammation of the gastrointestinal (GI) tract, which can affect any part from the mouth to the anus). Record review of Resident #1's admission MDS Assessment, dated 03/03/25, reflected she had a BIMS score of 8, which indicated moderate cognitive impairment. Resident#1 did not have a wound infection (other than the foot). Resident#1 was at risk of pressure ulcers/injuries, Resident #1 had one or more unhealed pressure ulcers. Resident #1 had 1 stage 2 pressure ulcer at entry, Stage 2 pressure ulcers meant Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister. Resident #1's skin and ulcer/injury treatments included: pressure ulcer/injury care, application of nonsurgical dressings and applications of ointments/medications. Record review of Resident#1 care plan, initiated on 02/27/2025, reflected: Resident#2's focus reflected, the Resident was admitted with a stage II pressure ulcer, and continued to have a potential for pressure ulcer development r/t cognitive deficits, impaired mobility, incontinence, history of ulcer, dislocation or fright shoulder, arthritis (swelling and tenderness of one or more joints), and osteoporosis ( a condition that weakens bones and increases the risk of fractures.). Initiated on 02/27/2025. Resident #1's goal reflected, the resident would have intact skin, free of redness, blisters or discoloration by/through review, initiated on 02/27/2025. Educate the 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. Assist resident to turn and reposition self at least every 2 hours. Record review of Resident#1 progress note dated 04/30/25 by WCN reflected, Patient seen by [NAME] physician this morning and daughter notified of the status and progression of wound and exacerbated due to generalized decline of patient. Patient is non-compliant with offloading wounds as well as turning and repositioning. patient education provided to patient with the help of staff translating the importance of offloading wounds, patient verbalized understanding. Record review of Resident#1 wound report dated 05/06/05 reflected assessment date of 04/30/25 with an acquired onset date of 4/16/25, sacrum pressure that was unstageable. Sacrum ulcer had a length of 19, width of 11 and depth of 0.1. Resident#1 wound status for sacrum was classified as deterioration. Observation on 05/06/25 at 9:07 AM revealed Resident #1 was laying on her back with no support. There was a wedge on the dresser. Attempted to interview resident#2 on 05/06/25 at 9:10 AM and resident#2 did not answer surveyor. 2. Record review Resident #2's face sheet, dated 05/06/25, reflected the resident was admitted to the facility on [DATE]. Resident #2 was diagnosed with Urinary tract infection,)( a very common type of infection in your urinary system) site not specified, unspecified protein-calorie malnutrition,( reduced availability of nutrients leads to changes in body composition and function) adult failure to thrive(Older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal), Dementia (General decline in cognitive abilities that affects a person's ability to perform everyday activities), unspecified convulsions (rapid involuntary muscle contractions), type 2 diabetes mellitus without complications (chronic condition characterized by insulin resistance and elevated blood sugar levels), contracture of muscle (Condition where muscle fibers permanently shorten, leading to stiffness and reduced flexibility) in the right and left upper arm, Record review of Resident #2's admission MDS Assessment, dated 04/02/25, reflected she had a BIMS score of 0, which indicated severe cognitive impairment. Resident #2 did not have a wound infection (other than the foot). Resident#2 was at risk of pressure ulcers/injuries, Resident #2 had one or more unhealed pressure ulcers. Resident #2 had 7 stage 2 pressure ulcers at entry, Stage 2 pressure ulcers meant Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister. Resident #2 had 1 stage 4 pressure ulcer at entry which meant stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Resident #2 MDS had 1 unstageable pressure injury presented as deep tissue on entry. Resident #2's skin and ulcer/injury treatments included: pressure reducing device for bed and pressure ulcer/injury care. Record review of Resident #2 care plan goals, initiated on 04/02/25, reflected: Minimize risk for symptoms of infection through next review. Resident #2's interventions revised on 05/02/25 reflected enhanced barrier precautions .weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Record review of Resident #2 care plan, initiated on 04/23/25 and revised on 05/02/25, reflected: Resident #2 had pressure ulcers: DTI to left, proximal, lateral heel DTI to left, distal, lateral foot DTI to left, lateral, fifth toe, Stage IV to left, medial foot (3-28-25) Placing her at risk for complications and developing new pressure ulcers r/t immobility, hx of ulcers, contractures Record review of Resident #2's progress notes reflected, on 04/29/25 by LVN D .reposition every 2 hours and PRN. With bilateral boots on. With multiple wounds. Wound treatment done by the treatment nurse. With diagnosis of end stage skin failure. Resident[sic] is aware of his mother condition but refused all the other alternatives. Record review of Resident #2's MAR, dated 05/06/25, reflected active order date of 04/11/25 which indicated enhanced barrier precautions for skin opening requiring a dressing every shift. Record review of Resident #2's wound report, dated 05/06/05, reflected assessment date of 04/30/25 with admitted on set on 03/28/25, sacrum pressure that was a stage 4. The Sacrum ulcer had a length of 9, width of 6.2 and depth of 0.1. Resident #2's wound status for sacrum was classified as other-not at goal. Observation on 05/06/25 at 9:44 AM revealed Resident #2 was laying on her back with no support. Observed wedge on top of her dresser. Attempted to interview Resident#2 and was not able to make out her words. Interview on 05/06/25 at 10:00 AM, the WCN stated residents were supposed to be on their side not laying on their back and applying pressure to the sacrum wounds. The WCN stated sometimes Resident #1 would refuse to be repositioned if she had pain. The WCN stated the resident was monitored for pain and given pain medications as needed and scheduled. The WCN stated she did training about repositioning residents, using pressure relieving devices. The WCN stated she was one person, and it took the whole nursing team to help residents wounds heal. Interview on 05/06/25 at 2:53 PM, CNA B stated she repositioned residents every 2 hours to prevent pressure sores, bed sores and to keep the blood flowing. CNA B stated she had just finish Resident #2's bath and did not want to keep moving her because she knew the WCN was coming to do wound care. CNA B stated she did not place wedge since she would be moved again. CNA B stated staff wear PPE to prevent the spread of bacteria. Interview on 05/06/25 at 3:06 PM, LVN C stated she usually worked over night and would reposition residents every 2 hours with the wedge to put them on their side. Interview on 05/06/25 at 3:12 PM, the DON stated Resident # 1 and Resident #2 could be repositioned on one side, then back and to the opposite side every 2 hours. The DON stated Pressure relieving devices are used to help promote healing. DON stated, Blood vessels are like hoses and when you are seating on the skin the blood vessel is closed, and oxygen cannot come through and cannot prevent cell and tissue death. Record review of the facility's policy titled skin integrity and pressure ulcer/injury prevention and management, revised, 07/09/24, reflected Measures to protect the resident against the adverse effects of external mechanical forces, such as pressure, friction, and shear are implemented in the plan of care:a. reposition at least every 2-4 hours (per NPIAP standards) as consistent with overall patient goal and medical condition. b. utilizes positioning devices to keep bony prominences from direct contact. c. ensure proper body alignment when side-lying;

Based on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, for 1 of 3 residents (Resident #2) reviewed for abuse. The facility failed to implement the abuse and neglect policy and procedure regarding reporting an injury of unknown origin for Resident #1 to the Administrator or HHSC. These failures could place the residents at an increased risk for abuse and neglect. Findings included: Record review of the facility policy for Abuse, Neglect, and Exploitation, dated 06/17/24, indicated the following: The facility will report alleged violations related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property and report the results of all investigations to the proper authorities within prescribed timeframes. For those allegations that meet the definition of a crime, the facility should refer to the Abuse - Reporting and Response - Suspicion of a Crime Policy. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Record review of Resident #2's Admission Record, dated 03/11/25, reflected the resident was an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #2's quarterly MDS Assessment, dated 02/20/25, reflected diagnoses included muscle weakness, dysphagia (difficulty swallowing), unilateral primary osteoarthritis (degenerative joint disease), vascular dementia, hemiplegia and hemiparesis (muscle weakness/partial paralysis on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side. Resident #1's BIMS score of 3 indicating his cognition was severely impaired. The MDS further revealed Section GG - Functional Abilities for Mobility Resident #1 needed partial/moderate assistance for chair/bed-to-chair transfer. Record review of Resident #2's care plan, revised 02/17/25, reflected: Focus: Patient with left side weakness following a CVA. Goal: The resident will maintain optimal status and quality of life within limitations imposed by Hemiplegia/Hemiparesis through review date. Interventions/Tasks: Reposition/Ambulate as tolerated and at least every 2 hours. Record review of Resident #2's EHR revealed no progress notes or assessments completed on 01/24/25. Record review of Resident #2's X-Ray dated 01/25/25 reflected the following: LEFT Elbow X-Ray 2 Views: BONES: No acute fracture or focal osseous lesion. Diffuse osteopenia is seen. JOINTS: No dislocation. Osteoarthritis is identified. SOFT TISSUES: The soft tissues are unremarkable. IMPRESSION: No acute osseous process. LEFT FOREARM X-RAY 2V: BONES: No acute fracture or focal osseous lesion. Diffuse osteopenia is seen. JOINTS: No dislocation. Osteoarthritis is identified. SOFT TISSUES: The soft tissues are unremarkable. IMPRESSION: No acute osseous process. Interview on 03/11/25 at 8:43 AM with Resident #2's Family Member B revealed on 01/24/25 a bruise was noticed on Resident #2's left forearm. Family Member B stated Resident #2 was unable to state how it happened and resident unable to move his left arm due to paralysis. Family Member B stated the bruise was reported to the DON and RN D on 01/24/25 and she followed-up with an email to the DON on 01/25/25 with no response. Family Member B stated it was unknown how the resident sustained the bruise. Family Member B stated x-rays were completed with no findings of fractures or dislocations. Family Member B stated a picture was taken on 01/25/25 a day after it was noticed. Family Member B stated visits were completed prior to 01/24/25 and no bruising was noticed on his left forearm. Record review of a picture of Resident #2's left forearm provided by Family Member B on 03/11/25 reflected a significant dark red/purple bruising on resident left forearm. Bruise started from left mid forearm to elbow. Observation on 03/11/25 at 9:08 AM of Resident #2 awake and in bed. Resident #2 was not a good historian and was unable to answer questions. Observed Resident #2 skin color to be light skinned with light brown spots. No visible marks or bruises observed on Resident #2 left arm. Interview on 03/11/25 at 11:29 AM with LVN A revealed she was the nurse assigned to Resident #2 during the morning shift. She stated she could not recall the exact date, but Resident #2 family member had notified her about a bruise on Resident #2's left forearm. She stated she could not recall much of what happened; however, an x-ray was completed, and no fractures noted. LVN A stated prior to Resident #2 family member notifying her of the bruise, no one else had mentioned anything to her or any incidents. She stated Resident #2 was known to be combative but was unsure how the resident sustained the bruise. Interview on 03/11/25 at 2:45 PM with RN D revealed he was the nurse assigned to Resident #2. RN D stated about a month ago on 01/24/25, he was notified Resident #2 had a bruise on his left forearm. He stated he could not recall if it was a family member or DON who informed him about the bruise. RN D stated prior to 01/24/25 he was never informed of the bruises and none of his staff had reported to him of the bruise. RN D stated it was a significant bruise to the mid left forearm, approximately measuring 2x2 cm maybe a little bigger. RN D stated after he was notified, he obtained orders to complete an x-ray. He stated results were negative for any acute fractures. RN D stated he could not recall being told Resident #2 was being combative during showers. Interview on 03/11/25 at 4:44 PM with the DON revealed she was notified of Resident #2's bruise by Resident #2's family member. She stated after she interviewed the staff that had worked with Resident #2 it was informed Resident #2 had been combative during showers and resident was swinging his arms. She stated it appeared that was how the resident sustained the bruises. The DON stated Resident #2's left arm was not completely paralyzed and resident could still move it. She stated anyone was responsible for reporting to the state any alleged abuse, neglect concerns. The DON stated Resident #2's bruise was not suspicious of any abuse because Resident #1 was being combative during showers. She stated she could not recall but she believed it was reported to the Administrator. The DON stated Resident #2's bruise should have not been reported to the state. Interview on 03/11/25 at 5:33 PM with the Administrator revealed any concerns of abuse or neglect he was expected to be notified. He stated he was notified of Resident #2's bruise today (03/11/25). He stated the DON was made aware of Resident #2's bruise on January 24th. He stated he went back and looked at his emails and noticed he had an email on 01/27/25 regarding the bruise but was not sure if he read it. He stated based on the DON's investigation Resident #2's bruise did not meet the criteria for it to be reported. He stated an x-ray was completed and results were negative. He stated the bruises on Resident #2 arm could had been from Resident #2 being combative or different things of nature. The Administrator stated Resident #2's bruises was not considered an injury of unknown origin due to Resident #2 being known to be combative.

Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source 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 3 residents (Resident #2) reviewed for abuse and neglect. The facility failed to report to HHSC when Resident #2 was found to have a significant bruise of unknown origin on his left forearm on 01/24/25. This failure to report could place the residents at risk for abuse. Findings included: Record review of Resident #2's Admission Record, dated 03/11/25, reflected the resident was an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #2's quarterly MDS Assessment, dated 02/20/25, reflected his diagnoses included muscle weakness, dysphagia (difficulty swallowing), unilateral primary osteoarthritis (degenerative joint disease), vascular dementia, hemiplegia and hemiparesis (muscle weakness/partial paralysis on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side. Resident #1's BIMS score of 3 indicating his cognition was severely impaired. The MDS further revealed Section GG - Functional Abilities for Mobility Resident #1 needed partial/moderate assistance for chair/bed-to-chair transfer. Record review of Resident #2's care plan, revised 02/17/25, reflected: Focus: Patient with left side weakness following a CVA. Goal: The resident will maintain optimal status and quality of life within limitations imposed by Hemiplegia/Hemiparesis through review date. Interventions/Tasks: Reposition/Ambulate as tolerated and at least every 2 hours. Record review of Resident #2's EHR revealed no progress notes or assessments completed on 01/24/25. Record review of Resident #2's X-Ray dated 01/25/25 reflected the following: LEFT Elbow X-Ray 2 Views: BONES: No acute fracture or focal osseous lesion. Diffuse osteopenia is seen. JOINTS: No dislocation. Osteoarthritis is identified. SOFT TISSUES: The soft tissues are unremarkable. IMPRESSION: No acute osseous process. LEFT FOREARM X-RAY 2V: BONES: No acute fracture or focal osseous lesion. Diffuse osteopenia is seen. JOINTS: No dislocation. Osteoarthritis is identified. SOFT TISSUES: The soft tissues are unremarkable. IMPRESSION: No acute osseous process. Interview on 03/11/25 at 8:43 AM with Resident #2's Family Member B revealed on 01/24/25 a bruise was noticed on Resident #2's left forearm. Family Member B stated Resident #2 was unable to state how it happened and resident unable to move his left arm due to paralysis. Family Member B stated the bruise was reported to the DON and RN D on 01/24/25 and she followed-up with an email to the DON on 01/25/25 with no response. Family Member B stated it was unknown how the resident sustained the bruise. Family Member B stated x-rays were completed with no findings of fractures or dislocations. Family Member B stated a picture was taken on 01/25/25 a day after it was noticed. Family Member B stated visits were completed prior to 01/24/25 and no bruising was noticed on his left forearm. Record review of a picture of Resident #2's left forearm provided by Family Member B on 03/11/25 reflected a significant dark red/purple bruising on resident left forearm. Bruise started from left mid forearm to elbow. Observation on 03/11/25 at 9:08 AM of Resident #2 awake and in bed. Resident #2 was not a good historian and was unable to answer questions. Observed Resident #2 skin color to be light skinned with light brown spots. No visible marks or bruises observed on Resident #2 left arm. Interview on 03/11/25 at 11:29 AM with LVN A revealed she was the nurse assigned to Resident #2 during the morning shift. She stated she could not recall the exact date, but Resident #2 family member had notified her about a bruise on Resident #2's left forearm. She stated she could not recall much of what happened; however, an x-ray was completed, and no fractures noted. LVN A stated prior to Resident #2 family member notifying her of the bruise, no one else had mentioned anything to her or any incidents. She stated Resident #2 was known to be combative but was unsure how the resident sustained the bruise. Interview on 03/11/25 at 2:45 PM with RN D revealed he was the nurse assigned to Resident #2. RN D stated about a month ago on 01/24/25, he was notified Resident #2 had a bruise on his left forearm. He stated he could not recall if it was a family member or DON who informed him about the bruise. RN D stated prior to 01/24/25 he was never informed of the bruises and none of his staff had reported to him of the bruise. RN D stated it was a significant bruise to the mid left forearm, approximately measuring 2x2 cm maybe a little bigger. RN D after he was notified, he obtained orders to complete an x-ray. He stated results were negative for any acute fractures. RN D stated he could not recall being told Resident #2 was being combative during showers. Interview on 03/11/25 at 4:44 PM with the DON revealed she was notified of Resident #2's bruise by Resident #2's family member. She stated after she interviewed the staff that had worked with Resident #2 it was informed Resident #2 had been combative during showers and resident was swinging his arms. She stated it appeared that was how the resident sustained the bruises. The DON stated Resident #2's left arm was not completely paralyzed and resident could still move it. She stated anyone was responsible for reporting to the state any alleged abuse, neglect concerns. The DON stated Resident #2's bruise was not suspicious of any abuse because Resident #1 was being combative during showers. She stated she could not recall but she believed it was reported to the Administrator. The DON stated Resident #2's bruise should have not been reported to the state. Interview on 03/11/25 at 5:33PM with the Administrator revealed any concerns of abuse or neglect he was expected to be notified. He stated he was notified of Resident #2's bruise today (03/11/25). He stated the DON was made aware of Resident #2's bruise on January 24th. He stated he went back and looked at his emails and noticed he had an email on 01/27/25 regarding the bruise but was not sure if he read it. He stated based on the DON's investigation Resident #2's bruise did not meet the criteria for it to be reported. He stated an x-ray was completed and results were negative. He stated the bruises on Resident #2 arm could had been from Resident #2 being combative or different things of nature. The Administrator stated Resident #2's bruises was not considered an injury of unknown origin due to Resident #2 being known to be combative. Record review of the facility's Abuse, Neglect, and Exploitation, dated 06/17/24, reflected: The facility will report alleged violations related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property and report the results of all investigations to the proper authorities within prescribed timeframes. For those allegations that meet the definition of a crime, the facility should refer to the Abuse - Reporting and Response - Suspicion of a Crime Policy. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision and assistive devices to prevent accidents for 2 of 5 residents (Resident #1 and Resident #2) reviewed for accidents. 1. The facility failed to ensure Resident #1 was provided with adequate supervision to prevent falls when Resident #1 fell when attempting to self-transfer, due to staff not returning to assist her. 2. CNA E failed to obtain assistance from another staff member when using a mechanical lift to transfer Resident #2 from his geri chair to his bed on 01/21/25. Agency CNA failed to obtain assistance from another staff member when using a mechanical lift to transfer Resident #2 from the shower chair to his bed on 1/23/25. This failure could place residents at risk for accidents and injuries. Findings included: 1. Record review of Resident #1's Admission Record, dated 03/11/25, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #1's quarterly MDS Assessment, dated 02/24/25, reflected her diagnoses included unspecified dementia, history of falling, difficulty in walking, muscle weakness, essential hypertension (high blood pressure) and chronic kidney disease. Resident #1's BIMS score of 7 indicating her cognition was severely impaired. The MDS further revealed Section GG - Functional Abilities for Mobility Resident #1 needed partial/moderate assistance for chair/bed-to-chair transfer. Record review of Resident #1's care plan, revised date 01/16/25, reflected the following: Focus: ADL Assistance and Therapy Services needed to maintain or attain highest level of function. Goal: Resident has a goal to be independent with ambulation by completion of skilled services. Resident wishes to attain prior level of function. Interventions/Tasks: Assist with mobility and ADLs as needed. Use [ mechanical] lift for transfers. Focus: Resident is at risk for falls r/t impaired mobility/balance, cognitive deficits, history of falls, malnutrition, arthritis, DMII , and receiving antidepressant medication. 2/24/25 Unwitnessed fall attempting to transfer self without calling for assistance. Goal: Resident's risk for falls will be minimal with fall interventions through review date. Interventions/Tasks Staff will monitor resident when up in w/c for tiredness and assist her to bed in a timely manner. Call light within reach. Record review of Resident #1's Incident Report dated 02/24/25 05:15 PM reflected: Un-witnessed Fall. Incident Description: CNA notified this nurse that resident is on the floor. upon entry resident room noted she is lying on the floor on her left side close to her bed. resident wheelchair was behind her and was on locked. Skin assessment done, noted hematoma to left side of her head with 2 small laceration. range of motion done, neuro checks done. resident [mechanical] lift from the floor to bed. resident stated she try to go to bed and fall. Immediate Action Taken: skin assessment, range of motion and neuro checks done. resident [mechanical] lift by staff to bed. ice pack applied. Injuries Observed at Time of Incident: No injuries observed at time of incident. Mental Status: Oriented to Person/Oriented to Place. Notes: 2 small laceration to left side of her head. Record review of Resident #1's progress notes dated 02/24/25 21:13 [9:13PM] by LVN A reflected: CNA notified this nurse that resident is on the floor. upon entry resident room noted she is lying on the floor on her left side close to her bed. resident wheelchair was behind her and was on locked. Skin assessment done, noted hematoma to left side of her head with 2 small laceration. range of motion done; neuro checks done. resident [mechanical] lift from the floor to bed. Notified DON and family member while this nurse was in resident room taking care of her. Her [family] request for her mother to transfer to hospital. Notified NP about resident and her [family] requested. Order to transfer resident to hospital. resident transfer to [hospital name] by [ambulance] around 6:40pm. Record review of Resident #1's hospital discharge summary, dated 2/28/25, reflected the following: Patient is a 87 y.o. female with past medical history significant for T2DM (type 2 diabetes mellitus), HTN (high blood pressure), CKD stage IV (Chronic Kidney Disease), gout, dementia, CVA (cerebrovascular accident), and HLD (hyperlipidemia) who was brought to [hospital name] ED [emergency department] after a mechanical GLF (Ground Level Fall) while she was trying to transfer from her wheelchair to the bed. Patient hit her had but no LOC (Level of Consciousness). Denies prodromal symptoms. Since falling she has been experiencing headache and right thigh pain. She has felt overall weak for the last several weeks. CT head and cervical spine and XR pelvis/hips neg (negative) for acute injury - Discharge to long term care facility Record review of video footages reflected the following: Dated 02/24/25 at 20:59 [8:59 PM] Resident #1 was observed sitting in her wheelchair watching television. CNA C entered the room to ask resident if she was doing okay and if she needed anything. Resident #1 is heard saying she wanted to go to bed, CNA C stated okay and told Resident #1 she would return. Dated 02/24/25 at 22:44 [10:44 PM] Resident #1 was observed sitting in her wheelchair, leaning forward against her bed and then falling to the floor. -Video does not show Resident #1 hitting her head, it only showed resident's bottom hitting the floor and then her upper body landed underneath her bed. Dated 02/24/25 at 23:08 [11:08 PM] LVN A observed to enter the room asking Resident #1 how she ended up on the floor and then LVN A exited the room. Dated 02/24/25 at 23:11[11:11 PM] LVN A, CNA B and CNA C were observed in the room checking resident and with a mechanical lift. Dated 02/24/25 at 23:13 [11:13 PM] LVN A, CNA B and CNA C were observed transferring Resident #1 back in bed via mechanical lift. Interview on 03/05/25 at 10:12 AM with Resident #1 Family Member A revealed there was video footage of Resident #1 asking a staff she wanting to go to bed, staff took too long to return, so resident attempted to transfer by herself and ended up falling. Family Member A stated the video footage time stamps were incorrect, she stated it happened in the afternoon. She stated on 02/24/25 at 2:39PM Resident #1 asked the staff that she wanted to be put to bed and then at 4:44 PM Resident #1 had the fall. Family Member A stated Resident #1 laid on the floor for about 23 minutes before someone came to the room to assist her. Family Member A stated resident was transported to the hospital for further evaluation. Family Member A stated there was no fractures. Observation and interview on 03/05/25 at 10:33 AM revealed Resident #1 in bed, she stated she was doing well. Resident #1 stated she had a fall a couple of weeks ago, could not recall the exact date or time. She stated she was in her wheelchair, and she had told someone she wanted to go to bed. Resident #1 could not recall the name of staff she asked. She stated it took about 23 minutes for some to come in the room, she stated she tried to get in bed by herself and she fell to the floor. She stated she hit her head but does not recall having any injuries. Interview on 03/11/25 at 11:29 AM with LVN A revealed Resident #1 had an unwitnessed fall in her room while resident was trying to self-transfer from her wheelchair to bed. She stated upon entry of Resident #1's room she observed Resident #1 on the floor, wheelchair was behind the resident and locked. She stated she asked Resident #1 what happened, and Resident #1 stated she wanted to go to bed. She stated Resident #1 had a small hematoma, and two tiny superficial laceration on the head. She stated Resident #1 refused to go to the hospital, but family requested resident to go. Interview on 03/11/25 at 12:47 PM with CNA B revealed she was working the day Resident #1 had a fall from her wheelchair. She stated she could not recall the exact date; however, she came in for her 2PM-10PM shift. She stated she was not assigned to Resident #1, but she still went over to check on resident to see how she was doing. She stated she checked on Resident #1 around 2:45 PM, and resident was sitting in her wheelchair. CNA B stated Resident #1 did not mentioned anything about wanting to go to bed. She stated she asked Resident #1 who she wanted to work with that day, and CNA C was standing at the door and CNA C stated she was assigned to Resident #1. CNA B stated around dinner time before 5PM, she was called to the nurses' station by LVN A to assist with Resident #1. She stated herself, LVN A and CNA C went to Resident #1 and Resident #1 was observed to be on the floor. She stated Resident #1 stated she was trying to transfer herself to the bed. Interview on 03/11/25 at 1:19 PM with CNA C revealed about 2 weeks ago, unknown of the exact date, Resident #1 had a fall. CNA C stated she came in for her 2-10PM shift, she was the CNA assigned to Resident #1. She stated she was doing her arounds and she got to Resident #1's room between 2:00PM-2:30PM. She stated Resident #1 told her she wanted to go to bed, she stated Resident #1 was a mechanical lift transfer. CNA C stated she went out to get the mechanical lift and to request assistance to transfer Resident #1. She stated when in route she was stopped by LVN A, LVN A told her Resident #1 had been reassigned to CNA B. She stated after she was told Resident #1 was no longer assigned to her, she went to go check on her other residents. CNA C stated she observed CNA B in Resident #1's room and assumed Resident #1 might had told her to put her to bed. CNA C stated she did not follow up to ensure if Resident #1 was transferred to bed and she did not notify anyone Resident #1 had requested to be put to bed because she was reassigned. CNA C stated between 3:45 PM- 4PM, she was gathering the residents to transfer them to the dining area for dinner, she went to the room across from Resident #1 room. She stated she looked over to Resident #1's room and noticed Resident #1 was not in the room. She stated she did not enter the room, she looked inside the room from the hallway. She stated she walked to the nurse's station and asked LVN A where was Resident #1. She stated LVN A went to Resident #1's room and noticed resident was on the floor. She stated she assisted LVN A, CNA B with picking up Resident #1 via mechanical lift. She stated CNA B thought Resident #1 was assigned to her; however, she thought Resident #1 was assigned to CNA B. CNA C stated it was a miscommunication between LVN A, CNA B, and herself on who was assigned to Resident #1. Follow-up interview on 03/11/25 at 2:02 PM with LVN A revealed when Resident #1 had the unwitnessed fall, Resident #1 was initially assigned to CNA C but then CNA B told her that Resident #1 requested CNA B to be her CNA. LVN A stated CNA B stated the DON was made aware of the change and for her to notify CNA C. She stated she notified CNA C of the reassignment at around 2:30PM-3PM. She stated CNA C never mentioned anything about Resident #1 wanting to go to bed. She stated there was a miscommunication between the CNAs on who was assigned to Resident #1. She stated CNA B thought Resident #1 remained assigned to CNA C and CNA C thought Resident #1 was reassigned to CNA B. However, if Resident #1 asked CNA C to put her to bed, it was the responsibility for CNA C to complete the task or notify someone about it and then continue with her work. She stated it was Resident #1 right to be put to bed when requested. LVN A stated CNA C failed to obey request. She stated the potential risk would be resident falling. Interview on 03/11/25 at 4:44 PM with the DON revealed she was not present at the time of Resident #1's fall; however, it was reported Resident #1 had asked an aide to put her to bed. She stated the aide had left the room to go get help. She stated she was not sure of about the details; however, there was a miscommunication on who was assigned to Resident #1. She stated Resident #1 was first assigned to CNA C but then was reassigned to CNA B. She stated she notified LVN A of the change and the LVN A notified the CNAs of the reassignments. The DON stated Resident #1 had told CNA C to put her to bed but did not. She stated Resident #1 did not get transfer back to bed in which Resident #1 attempted to self-transfer and fell . The DON stated her expected time for when a resident request to be put to bed should not be more than 15 minutes, depending on how busy they are. The DON stated CNA C failed to communicate Resident #1 request to be put to bed, she stated it should had been reported to the nurse or task should had been completed. She stated the potential risk on this incident would have been resident not receiving care. Interview on 03/11/25 at 5:33 PM with the Administrator revealed he was made aware of Resident #1's fall by the resident's family. He stated Resident #1's family observed resident on the floor via video footage and did not notify anyone about it until when they arrived at the facility. The Administrator stated when he asked the family why they did not report the fall to the facility, the family response was We just wanted to see how long it would take for the staff to enter the room. He stated Resident #1 had asked CNA C to put her in bed but did not. He stated there was some miscommunication on who was assigned to Resident #1. He stated the expectation was for CNA C to complete the task and put Resident #1 to bed. He stated everything was a risk if not completing a task. 2. Record review of Resident #2's Admission Record, dated 03/11/25, reflected the resident was an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #2's quarterly MDS Assessment, dated 02/20/25, reflected his diagnoses included muscle weakness, dysphagia (difficulty swallowing), unilateral primary osteoarthritis (degenerative joint disease), vascular dementia, hemiplegia and hemiparesis (muscle weakness/partial paralysis on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side. Resident #1's BIMS score of 3 indicating severe. The MDS further revealed Section GG - Functional Abilities for Mobility Resident #1 needed partial/moderate assistance for chair/bed-to-chair transfer. Record review of Resident #2's care plan, revised date 02/17/25, reflected: Focus: Patient with left side weakness following a CVA. Goal: The resident will maintain optimal status and quality of life within limitations imposed by Hemiplegia/Hemiparesis through review date. Interventions/Tasks: Reposition/Ambulate as tolerated and at least every 2 hours. Focus: Patient with impaired mobility/balance, poor safety awareness requiring total assist with ADLs. Goal: The resident maintain his current level of function as possible. Interventions/Tasks: Transfers - total assist X 2 with use of [mechanical] lift. Record review of video footage dated 01/21/25 at 15:44 [3:44 PM] it was observed Resident #2 being transferred via mechanical lift by CNA E. Resident #2 was observed to be on the sling and being lowered to the bed. Record review of video footage dated 01/23/25 at 12:37 PM it was observed Resident #2 to be on the shower chair. Resident #2 was transferred via mechanical lift from shower chair to bed by Agency CNA. Interview on 03/11/25 at 8:43 AM with Resident #2's Family Member B revealed there was video footage of facility staff completing a mechanical lift transfer by one person. Family Member B stated it had been brought up to the facility attention but was unknown if it was addressed. Family Member B stated there had been on incident from the one person transfers. Observation on 03/11/25 at 9:08 AM of Resident #2 awake and in bed. Resident #2 was not a good historian and was unable to answer questions. Interview on 03/11/25 at 3:55 PM with CNA E revealed she had been employed for about 2 months. She stated she had assisted with Resident #2 mechanical lift transfers. She stated Resident #2 required a mechanical lift for transfers and was a two person assist. CNA E stated she had not completed Resident #2 transfer by herself. CNA E reviewed video footage and stated she was the one completing the transfer but could not recall why she did it by herself. She stated she had always done two-person transfer. She stated she was in-serviced on mechanical lift transfer but could not recall the exact date of when it was completed. She stated the potential risk of transferring a resident via mechanical lift by one-person could lead to resident falling. Interview on 03/11/25 at 4:16 PM with ADON revealed when a resident transfers via mechanical lift there should be two staff completing the transfer. She stated her expectation was for two staff to complete the transfer from beginning to end. She stated the risk would be a safety risk of resident falling. Interview on 03/11/25 at 4:44 PM with the DON revealed the facility expectation was for two staff to complete a transfer via mechanical lift. The DON reviewed both video footage, she stated one of the CNAs was CNA E and the other CNA was an Agency CNA. She stated the Agency CNA no longer worked at the facility. She stated she was unaware of the video footage and was never informed Resident #2 had been transferred via mechanical lift by one person. She stated her staff should know better and should never complete a transfer by themselves when using a mechanical lift. She stated it was not safe to do a one person transfer via mechanical lift and it was not the facility policy. Follow-up interview on 03/11/25 at 5:40 PM the DON revealed she was unable to obtained Agency CNA's contact information. Record review of CNA E Total Mechanical Lift Competency Checklist was completed on 01/04/25. Record review of the facility's Fall Management policy, revised 11/25/2024, reflected the following: To promote patient safety and reduce patient falls by proactively identifying, care planning and monitoring of patients' fall indicators . Each resident receives adequate supervision and assistance devices to prevent accidents. Record review of the facility's Transfer with a mechanical lift, long-term care policy, revised 05/20/2024, reflected the following: The facility will ensure that two associates should be present during the transfer of residents who require a mechanical lift .

Based on observation, interview and record review the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 3 residents (Resident #2) reviewed for accuracy of medical records. The facility failed to ensure a bruise found on Resident #2's left forearm was documented accurately and completely in the resident's EHR when it was noticed on 01/24/25. This failure could place the residents at risk for incomplete and inaccurate clinical records which could lead to miscommunication or a delay in services. Findings included: Record review of Resident #2's Admission Record, dated 03/11/25, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #2's quarterly MDS Assessment, dated 02/20/25, reflected his diagnoses included muscle weakness, dysphagia (difficulty swallowing), unilateral primary osteoarthritis (degenerative joint disease), vascular dementia, hemiplegia and hemiparesis (muscle weakness/partial paralysis on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side. Resident #1's BIMS score of 3 indicating his cognition was severely impaired. The MDS further revealed Section GG - Functional Abilities for Mobility Resident #1 needed partial/moderate assistance for chair/bed-to-chair transfer. Record review of Resident #2's care plan, revised date 02/17/25, reflected: Focus: Patient with left side weakness following a CVA. Goal: The resident will maintain optimal status and quality of life within limitations imposed by Hemiplegia/Hemiparesis through review date. Interventions/Tasks: Reposition/Ambulate as tolerated and at least every 2 hours. Record review of Resident #2's EHR revealed no progress notes or assessments completed on 01/24/25 of resident bruise. Record review of Resident #2's X-Ray dated 01/25/25 reflected the following: LEFT Elbow X-Ray 2 Views: BONES: No acute fracture or focal osseous lesion. Diffuse osteopenia is seen. JOINTS: No dislocation. Osteoarthritis is identified. SOFT TISSUES: The soft tissues are unremarkable. IMPRESSION: No acute osseous process. LEFT FOREARM X-RAY 2V: BONES: No acute fracture or focal osseous lesion. Diffuse osteopenia is seen. JOINTS: No dislocation. Osteoarthritis is identified. SOFT TISSUES: The soft tissues are unremarkable. IMPRESSION: No acute osseous process. Interview on 03/11/25 at 8:43 AM with Resident #2's Family Member B revealed on 01/24/25 a bruise was noticed on Resident #2's left forearm. Family Member B stated Resident #2 was unable to state how it happened and resident unable to move his left arm due to paralysis. Family Member B stated the bruise was reported to the DON and RN D on 01/24/25 and she followed-up with an email to the DON on 01/25/25 with no response. Family Member B stated it was unknown how the resident sustained the bruise. Family Member B stated x-rays were completed with no findings of fractures or dislocations. Family Member B stated a picture was taken on 01/25/25 a day after it was noticed. Family Member B stated visits were completed prior to 01/24/25 and no bruising was noticed on his left forearm. Record review on 03/11/25 of a picture of Resident #2's left forearm reflected a significant dark red/purple bruising on resident left forearm. Bruise started from left mid forearm to elbow. Observation on 03/11/25 at 9:08 AM of Resident #2 awake and in bed. Resident #2 was not a good historian and was unable to answer questions. Observed Resident #2 skin color to be light skinned with light brown spots. No visible marks or bruises observed on Resident #2 left arm. Interview on 03/11/25 at 2:45 PM with RN D revealed he was the nurse assigned to Resident #2. RN D stated about a month ago on 01/24/25, he was notified Resident #2 had a bruise on his left forearm. He stated he could not recall if it was a family member or DON who informed him about the bruise. RN D stated prior to 01/24/25 he was never informed of the bruises and none of his staff had reported to him of the bruise. RN D stated it was a significant bruise to the mid left forearm, approximately measuring 2x2 cm maybe a little bigger. RN D after he was notified, he obtained orders to complete an x-ray. He stated results were negative for any acute fractures. Interview on 03/11/25 at 4:44 PM with the DON revealed when an incident occurs, a skin injury was noted or a change of condition happens her expectations was for her staff to document in the progress notes, complete an incident report, document that all parties had been notified and assessments to be completed. She stated she was aware RN D had not documented in the Resident #2's chart regarding the bruise. She stated she had been clear with her staff regarding her expectations regarding documentation. She stated the potential of not documenting could lead to not knowing if things were being done. Follow-up interview on 03/11/25 at 5:28 PM with RN D revealed he could not recall being told Resident #2 was being combative during showers. RN D stated he failed to document the bruise on Resident #2's clinical records. He stated he should had completed an incident report, assessments, document that the family and doctor were made aware. He stated the potential risk of not documenting can lead to something coming back and not knowing what happened. Interview on 03/11/25 at 5:33 PM with the Administrator revealed he was notified of Resident #2's bruise today (03/11/25). He stated there was no documentation regarding Resident #2's bruise. He stated it was the responsibility of the charge nurses to document in the resident's progress notes, complete an incident report and to complete assessments. Record review of the facility's Nursing Documentation policy, revised 09/05/2024, reflected the following: This facility will ensure nursing documentation is consistent with professional standards of practice, the state nurse practice act, and any state laws governing the scope of nursing practice. Medical Records: The medical record shall reflect a resident's progress toward achieving their person-centered plan of care objectives and goals and the improvement and maintenance of their clinical, functional, mental and psychosocial status. Staff must document a resident's medical and non- medical status when any positive or negative condition change occurs, at a periodic reassessment and during the annual comprehensive assessment. The medical record must also reflect the resident's condition and the care and services provided across all disciplines to ensure information is available to facilitate communication among the interdisciplinary team. The medical record must contain an accurate representation of the actual experience of the resident and include enough information to provide a picture of the resident's progress, including his/her response to treatment and/or services, and changes in his/her condition, plan of care goals, objectives and/or interventions.

Based on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 4 residents (Resident #20) reviewed for dialysis. The facility failed to ensure post-dialysis assessments were completed for Resident #20 after returning from dialysis treatment. This failure could place residents at risk of inadequate post dialysis care. Findings included: Record review of Resident #20's EHR reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #20 had a diagnosis of end stage renal disease (a chronic condition that occurs when the kidneys can no longer filter waste from the blood and requires long-term dialysis or a kidney transplant to maintain life). Record review of Resident #20's quarterly MDS assessment, dated 08/23/24, reflected a BIMS score of 0, which indicated his cognition was severely impaired. The MDS reflected Resident #20 received dialysis. Record review of Resident #20's care plan, dated 09/24/24, reflected Resident #20 needed hemodialysis (medical procedure that filters blood to remove waste and extra fluid when the kidneys are no longer functioning properly). Resident #20 will have no signs of complication from dialysis through next review. Facility will send completed dialysis communication sheet/book with resident. Staff will obtain completed dialysis communication sheet from dialysis center. Record review of Resident #20's July 2024 physician's order reflected orders for post dialysis monitoring, assess bruit/thrill upon return from dialysis. Check site for bleeding, and infection. Record review of Resident #20's EHR reflected no nursing documentation regarding Resident #20's post-dialysis vital signs on the missing forms. Record review of Resident #20's dialysis communication forms from 08/22/24 to 10/10/24 reflected dialysis communication forms with resident assessment and observation post-dialysis section for August on 08/26/24 and 08/28/24, for September on 09/02/24, 09/06/24 and 09/20/24 and for October on 10/02/24 and 10/09/24 all the other dialysis dates of the month of August,September and October were missing communication forms totalling to one day in August, eleven days in September and two days in October. Interview on 10/08/24 at 10:14 AM with Resident #20 revealed he went for dialysis Monday, Wednesday, and Friday. He stated he got a form that he took to dialysis and brought back to facility. Interview on 10/11/24 at 01:04 PM with LVN D revealed she was aware she was supposed to send Resident #20 with the dialysis communication form when he left for dialysis and then collect the form when the resident returned from dialysis. LVND stated she knew she was supposed to monitor the dialysis access site for the bruit thrill (a vibration caused by blood flowing through the fistula and can be felt by placing your fingers just above incision line), dressing for bleeding and vital signs when Resident #20 was back from dialysis. She stated it was all nurse's responsibility to update the dialysis communication form when Resident#20 came back and, they give them to RN H who was responsible of ensuring they are given to medical records for uploading to electronic health records. LVN D stated failure to fill the communication form after dialysis they could miss the orders from dialysis and if not monitoring after dialysis Resident #20 post dialysis put him at risk of low blood pressure, infection, and bleeding. She stated she had done trainings, on dialysis communication form. Interview on 10/10/24 at 02:05 PM with the RN H revealed all nurses were responsible for filling out the forms pre- and post-dialysis. She stated it was her responsibility to ensure the staff completed post-dialysis communication forms when Resident #20 returned to the facility. RN H stated she went through the dialysis communication forms after dialysis. She stated the nurses were supposed to put the forms in her office or in the resident binder. She stated she then collected them and went through them, from there go through forms before she giving to the medical record for uploading. She stated she did not document what she had received and what was missing, so she could not tell whether there some that were missing. RN H stated the communication forms were important to ensure the vital signs were stable, check for bleeding and it was the communication between dialysis and the facility. She stated the risk for not assessing the vitals was Resident #20's vital signs could be unstable leading to change of condition and the nurses could miss orders from dialysis H stated she did in-service training with staffs on 9/13/24. Interview on 10/10/24 at 02:16 PM with the DON revealed her expectation was for the nurses to perform post-dialysis assessments when residents returned from dialysis, and document on dialysis communication forms on dialysis days. She stated RN H from management and her were responsible of following up with nurses and ensuring the post dialysis monitoring was being done and documented, on the dialysis communication form. She stated RN H was supposed to check and follow up with nurses. The DON stated failure to monitor the vital signs after dialysis would lead change of condition, bleeding, and unstable vital signs and they could miss important orders form dialysis center. She stated facility had done training with staff and the last in-service was in September 2024. Record review of the facility trainings reflected the facility had done training on the Dialysis communication form on 09/13/24. Record review of the facility's Hemodialysis offsite policy, dated 08/23/23, reflected the following: Day of dialysis, .2 observe vascular access site prior to dialysis and initiate the pre/post dialysis communication form to be sent to the dialysis clinic with the resident. (med pass form #LCCA-528). Post dialysis Obtain vital signs of resident upon return from dialysis and complete the pre/post dialysis communication form. (med pass form #LCCA-528).