Every finding on record at Los Arcos Del Norte Care Center

Based on record review and interview the facility failed to maintain an effective training program for all new and existing staff providing services for 2 of 8 employees (ADON and LVN L) reviewed for training completion.-The facility failed to ensure the ADON received annual training for 1 training related to restraints reviewed on 05/21/2026.-The facility failed to ensure LVN L received annual training for 1 training related to restraints reviewed on 05/21/2026.-The facility failed to ensure that all staff employed by the facility received any training for usage of companion portable oxygen tanks.This failure could placed all residents at risk who are receiving oxygen as well as residents at risk of receiving services or care from staff who was not adequately trained.In an interview on 05/21/2026 at 9:25 AM, Central Supply Staff stated he had been employed for approximately one year. He stated that the staff had not received training on the portable tanks other than basic internal walkthroughs. He demonstrated how to check and refill the tanks, noting that they only lasted 2 hours when full. He indicated that an external Durable Medical Equipment (DME) respiratory technician was scheduled to arrive the following day (05/22) to finally train the staff. Observation on 05/21/2026 at 9:45 AM, the DON demonstrated how to refill the tanks and stated that staff only received training upon hire amongst the CNAs training during initial competencies, with no annual refresher or ongoing training. No Training has been provided by DME company as far as her knowledge. In an interview on 05/21/2026 at 09:45 AM, the Staffing Coordinator stated that portable tanks lasted approximately 2 hours and were refilled at the start of shifts. He stated there was no formal, systematic process in place for monitoring or checking the tank levels throughout the shift. In an interview on 05/21/2026 at 11:24 AM, the ADON said that the facility had nothing in place regarding oxygen training and could not provide any training documentation showing that staff were taught how to properly fill and check portable oxygen canisters. He acknowledged that competency checklists used during hire and annually contained no references to oxygen management. In an interview on 05/21/2026 at 03:07 PM, the DON reiterated that oxygen training was restricted to initial hire orientation. She stated that floor staff were expected to check canisters every 2 hours, noting that a reactive in-service had just been implemented on 05/20/2026 following the surveyor's observations. The DON identified clinical risks of this training deficit as resident hypoxia, confusion, shortness of breath, and lack of oxygen. Record Review on 05/21/2026 at 02:00 PM, the HR Coordinator provided a completed document of 8 employees sampled for personnel files reviewed. The document named Personnel Files Worksheet Form CMS-807, revealed:- ADON had a hire date of October 2024 and was missing Restraint Reduction.- LVN L had a hire date of February 2025 and was missing Restraint Reduction. Amounting to a total of 4 incomplete training courses from ADON and LVN L. In an interview on 05/21/2026 at 2:30 PM, the HR Coordinator stated she did not have documentation of completed trainings for ADON and LVN L. She stated it was not acceptable for staff to be working without complete annual training. She stated that the training needed to be completed annually to ensure staff were refreshed and competent on the regulations and policies of the facility. She stated it affected residents if staff were not up to date on their training because it posed a risk on the care they provided and staff knowledge of their actions, decisions, and procedures. She stated the ADON is the one responsible for whom employees reported to for ensuring employees were up to date on training and he can add and remove trainings at any point on Reliance (online learning management system) as well as corporate. In an interview on 05/21/2026 at 03:07 PM, the DON stated that online reliance trainings were done monthly or as needed, as well as annually. In-services are conducted anytime something comes up that needs addressing, as well as upon hire. The DON stated that corporate are the ones responsible for assigning online training for staff, as well as the ADON. The DON stated that restraint trainings are conducted upon hire and yearly or as needed. The DON stated the risk to the residents for trainings not being done yearly, staff may not understand what a restraint is, and it could cause harm to residents if staff do not understand and get frustrated with the residents. In an interview on 05/21/2026 at 03:45 PM, the ADON stated that he was not aware that they needed restraint training since they are a restraint free facility. The ADON pulled the online reliance up and stated that the program had removed all restraint trainings and will need to get with corporate to ensure that all staff will be educated on restraint training and to see why it wont allow him to add the restraint training for his staff. The ADON stated that it was his responsibility to ensure that employees had completed all training and may cause a risk to residents because staff may not be equipped with the proper knowledge on restraints. In an interview on 05/21/2026 at 04:05 PM, corporate stated she was unaware of why it would not allow the ADON to assign the trainings for restraints on reliance and will have to look into it, and was also not aware that Texas required restraint training to be conducted annually. In an interview on 05/21/2026 at 04:19 PM, the Administrator stated that trainings are to be conducted yearly. He stated that Corporate was responsible for unlocking and scheduling trainings for the staff. He stated the risk to the residents are staff could be uninformed on policy and procedures that pertain to resident safety and wellbeing. Record Review of the facility's policy titled Staff Education/Orientation policies and Procedures Annual General Orientation revision 01/12/2024, did not [NAME] any annual trainings for Restraints or any trainings listed for oxygen or portable oxygen training. Record review of the facility's policy titled Respiratory treatment care and services program revision on May 5, 2023, revealed The facility ensures a safe appropriate and effective provision of respiratory therapy care and services in accordance with professional standards of practice the residents plan of care and personal choice. Record Review of the facility's policy titled In-Service training and Education dated 03/2006 revised 01/2007, revealed Employees will receive necessary training to perform job responsibilities. Training and education will be provided to meet the entity's procedures and will comply with any applicable licensing or accrediting body regulations or state and federal mandates. Record Review of the facility's policy named Staff Education/Orientation Policies and Procedures; subject: Staff development for nursing employees revised 01/12/2024, revealed 1.) Staff development and managing through ongoing education, including in servicing training and other activities that improve staff confidence will be offered according to facility policies and procedures. 2.) the nursing staff will receive initial job training and in assessment of their ability to perform specific job duties as well as an understanding of the facility. 3) Licensed nurses will have a specific competencies and skill set necessary to care for residents these as identified through assessment and described in the plan of care providing care including its but is not limited to assessing evaluating planning and implementing resident care plans and responding to residents needs. 4.) proficiency of nurse aids will demonstrate competency in skills and techniques necessary to care for residents needs as identified through the facility assessment resident assessment and described in the plan of care. Purpose: To ensure that all nursing staff possesses the appropriate competencies and skill set necessary to provide nursing and related services to meet the residents needs safely and in a manner that promotes each resident's rights physical mental and cytological well-being all nursing staff will also meet the specific competency requirements as part of their license and certification requirements defined under state laws or regulations. 7.) Nursing Assistance from us would be performance review at least every 12 months and must receive regular in service education based on the outcome of these reviews but not less than 12 hours per year and or the facility states Pacific requirements and according to the through the assessment. 8.) nursing personnel providing care to patients slash residents with cognitive impairments receive in services about care for such patients slash residents. 9.) nursing personnel attend in services and other educational programs that include specific clinical information on all categories of patients slash residents admitted into their setting. Record review of the facility's instructions from HME Specialists LLC DME company titled Filling Instructions for the Companion Portable was reviewed. Explained the filling instructions for the companion portable oxygen tanks. Record Review of the facility's in services and training, dated 01/2026 to 05/2026 revealed no training was provided to any staff on how to maintain portable oxygen and when to check or how to check if the companion portable is full.

Based on observations, interviews, and record review, the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 3 of 24 residents (Resident #11, Resident #71 and Resident #84) reviewed for ADL care. The facility failed to ensure Resident #11's nails wered trimmed, filed, and clean on 05/19/2026. The facility failed to ensure Resident #71's nails were trimmed, cleaned, and filed on 05/20/2026. The facility failed to ensure Resident #84's facial hair was shaved on 05/20/2026. These failures could place residents at risk of loss of dignity, risk for infections, and a decreased quality of life.Resident # 11 Record review of Resident #11's face-sheet dated 05/20/2026 revealed the resident was a [AGE] year-old female with admission date 10/10/2025. Record review of Resident #11's history and physical dated 10/10/2025 revealed a medical history of the following: Diabetes Mellitus, type 2 (a chronic condition in which the body either doesn't produce enough insulin or can't use it effectively, leading to high blood sugar); and Seizure disorder (Epilepsy is a chronic brain disorder characterized by recurrent, unprovoked seizures caused by abnormal electrical activity in the brain). Record review of Resident #11's Quarterly MDS dated [DATE] revealed a BIMS score of 5, indicating the resident had severe cognitive impairment. Under Section GG- Functional Abilities, the MDS revealed Resident #11 required partial/moderate assistance with personal hygiene, meaning the helper does less than half the effort to complete the task. Record review of Resident #11's care plan dated 03/25/2026 revealed Resident #11 required assistance with ADL tasks related to muscle weakness and lack of coordination. An observation was made on 05/19/2026 at 8:43 AM of Resident #11's nails of both hands. The fingernails of both hands were observed and 4 millimeters of the white rim of the nail was observed, jagged and with black debris underneath the nails of both hands. Resident #11 was unable to answer this HHSC Surveyor's questions regarding her nails. During an interview on 05/21/2026 at 10:20 AM with the DON, she stated the nurses were responsible for monitoring and maintaining residents' nails. The DON stated the CNAs provided nail trimming and grooming during shower days or as needed, such as residents being observed with long nails. She stated the potential risk of long and dirty fingernails included risk of injury from scratching selves or others, and it could be a potential portal of entry for bacteria which could place residents at risk for infections. Resident #71Record review of Resident #71's face sheet dated 05/21/2026 revealed a [AGE] year-old male with an admission date of 01/09/2026.Record review of history and physical dated 01/07/2026 for Resident #71 revealed diagnoses of traumatic subdural hemorrhage with loss of consciousness (bleeding in the brain after trauma), hydrocephalus (fluid buildup in the brain), acute respiratory failure (inability to breathe adequately), anxiety disorder (persistent excessive worry), bipolar disorder (mental health condition with mood swings), cognitive communication deficit (difficulty understanding or expressing thoughts), depression (persistent sadness), insomnia (difficulty sleeping), and generalized muscle weakness (overall body weakness).Record review of Quarterly MDS dated [DATE] for Resident #71 revealed a BIMS score of 15, which indicated the resident was cognitively intact. Under section GG for functional abilities, the MDS revealed Resident #71 had impairment for both, upper and lower extremities, Resident #71 was dependent on staff, meaning staff did all the effort for the resident, for eating, oral hygiene, toileting hygiene, shower, upper and lower body dressing, putting and taking off footwear. Resident #71's MDS revealed he needed substantial to maximal assistance, meaning the staff needed to do more than half the effort for the resident, with rolling left to right on bed, sit to lying, lying to sitting on side of bed, sit to stand, chair to bed and bed to chair transfer and toileting transfer.Record review of care plan dated 04/09/2026 for Resident #71 revealed the resident required assistance with bilateral resting hand splints related to bilateral hand contractures (permanent tightening of muscles and joints causing the hands to become stiff). The care plan revealed staff were instructed to inspect the skin for breakdown, monitor for pain or muscle spasms during range of motion exercises, and apply bilateral resting hand splints for 30 minutes or as tolerated. Resident #71's care plan revealed the resident required dependent assistance with bed mobility, repositioning, transfers, eating, and drinking related to impaired mobility (difficulty moving independently) and cognitive impairment (difficulty with thinking and understanding).During an observation and interview on 05/20/2026 at 12:46 p.m., Resident #71's fingernails were about 3 centimeters long and had a yellowish color. Both Resident #71's hands were contracted, and his nails were pressing against the palms of his hand. Resident # 71 stated he had not asked staff for assistance, and he would wait until family visited him. Resident# 71 stated he did not want to bother the staff to assist him with trimming his nails. During an interview on 05/20/2026 at 2:40 PM, LVN B stated CNAs, LVNs, and RNs were responsible for monitoring resident hygiene, including fingernail care. She stated long fingernails on residents with contractures could dig into the skin and potentially cause injuries, bleeding, or infections. During an interview on 05/20/2026 at 2:58 PM, CNA D stated it was not acceptable for a resident with hand contractures to have long fingernails due to the risk of skin injury which could cause bleeding and infection. CNA D stated it was mainly the responsibility of CNAs to monitor fingernails length when they are assisting residents with ADLs or helping with showering a resident. CNA D stated if a resident refuses or had a preference for who would trim their fingernails, it needed to be noted on their care plan. During an interview on 05/21/2026 at 10:15 AM, the ADON stated fingernails were expected to remain trimmed because long fingernails could dig into the resident's skin and present an infection control concern. The ADON stated staff such as CNAs, LVNs and RNs were expected to assess residents' fingernails during showers or as needed and notify nursing staff, the nurse practitioner, or family members if residents refused nail care. During an interview on 05/21/2026 at 10:47 AM, CNA C stated that CNAs, LVNs, and RNs were responsible for ensuring residents' fingernails remained trimmed. She stated long fingernails could break the skin, cause bleeding, and lead to infections. She stated staff were expected to monitor residents' fingernails during hygiene assistance. CNA C stated it was not acceptable for Resident #71 to have long fingernails because of his contracted hands; there was a potential risk of him digging into his skin and getting an infection. During an interview on 05/21/2026 at 11:09 AM, the DON stated staff were expected to monitor residents for long fingernails and involve therapy services if splints were needed. The DON stated long fingernails on residents with contractures such as Resident #71's hands could cause pain, bleeding, and infections if the nails dug into the skin. During an interview on 05/21/2026 at 2:51 PM, the Administrator stated charge nurses and staff providing care to residents were responsible for ensuring residents' fingernails remained trimmed and filed. The Administrator stated residents with contractures such as Resident #71 were at risk of skin breakdown, bleeding, and infection if fingernails were not properly maintained. The Administrator stated residents were expected to be checked at least weekly for nail care needs and to write progress notes if the resident refused nail care. Resident #84. Record review of Resident #84's face sheet dated 05/21/2026 revealed an [AGE] year-old female resident with an original admission date of 07/14/2016 and a readmission date of 05/03/2026.Record review of Resident #84'S history and physical dated 06/04/2024 revealed diagnoses of dementia (memory and cognitive impairment), arthritis (joint inflammation causing pain and stiffness), major depressive disorder with psychosis (depression with altered thoughts or perception), muscle weakness (decreased body strength), epilepsy (seizure disorder) and anxiety (persistent excessive worry).Record review of Resident #84's quarterly MDS dated [DATE] revealed the resident had a BIMS score of 00, which indicated severe cognitive impairment. Under Section GG for functional abilities, the MDS revealed Resident #84 was dependent on staff meaning staff did all the effort for Resident #84's personal hygiene, oral hygiene, upper and lower body dressing, bathing, toileting hygiene, showering, bed mobility, transfers, and personal care.Record review of care plan dated 05/07/2026 for Resident #84 revealed the resident required staff assistance with activities of daily living, hygiene care, incontinence care, bathing, dressing, and grooming related needs. The care plan revealed staff interventions included providing assistance with personal hygiene, monitoring skin integrity, providing incontinence care, repositioning, and monitoring for signs of dehydration and decline in physical condition. The care plan revealed Resident #84 required interventions related to dementia (memory and cognitive impairment), wheelchair dependence, dysphagia (difficulty swallowing), fall prevention, and pressure ulcer prevention.During an observation on 05/20/2026 at 9:06 a.m. Resident #84 was observed sitting on her wheelchair in the common area of the facility watching television with other residents. Resident #84 had long facial hair on her chin of approximately two centimeters in length.During a phone interview on 05/20/2026 at 3:04 p.m., a family member stated they had visited Resident #84 approximately two weeks before. The family member stated they sometimes shaved Resident #84's facial hair during visits because they did not want her to feel embarrassed or self-conscious about her appearance. The family member stated they believed unmanaged facial hair could negatively impact Resident #84's self-esteem and emotional well-being. The family member stated they had not previously asked staff for assistance because they did not want to feel like they were burdening staff; however, they stated they would appreciate staff assisting Resident #84 with facial hair grooming. The family member stated comments made by others regarding Resident #84's facial hair or her seeing herself in the mirror could potentially hurt her feelings and make her feel depressed. During an interview on 05/21/2026 at 2:57 p.m. CNA D stated that if a female resident had facial hair and had been refusing to be shaved by staff, it needed to be included in the resident's progress notes and that RN, DON and NP needed to be made aware. CNA D stated that if Resident #84's facial hair was not shaved, it could give the family the impression that the resident was not being well taken care of and stated there was a possibility that other residents or visitors made negative comments about her facial hair which could make Resident #84 sad or self-conscious. During an interview on 05/21/2026 at 10:19 a.m., the ADON stated female residents with unmanaged facial hair could experience negative effects on self-esteem and could lead family members or other residents to believe the resident was not being properly cared for. The ADON stated it was all staff responsibility to check all residents for hygiene and grooming and especially CNAs when they aid with ADLs and showers. During an interview on 05/21/2026 at 10:50 a.m., CNA C stated CNA staff were expected to monitor and assist female residents with facial hair grooming for hygiene and dignity purposes. CNA C stated unmanaged facial hair could negatively affect the resident's self-esteem and could cause family members, visitors, or other residents to believe the resident was not receiving appropriate care. During an interview on 05/21/2026 at 11:13 a.m., the DON stated staff were expected to monitor hygiene needs, including facial hair grooming for female residents. The DON stated failure to address those concerns could impact the resident's dignity and self-esteem and could lead others to believe staff were not attentive to the resident's care needs. During an interview on 05/21/2026 at 1:16 p.m., the Administrator stated that it was the expectation for all staff who assisted the residents with ADLs to make sure every resident was groomed and clean. The Administrator stated it was not acceptable for Resident #84 to have facial hair because it could potentially make her or her family feel like the facility was not paying attention to her. The Administrator stated the facility sometimes received visitors, which could also see it as something negative. The Administrator stated that the potential negative outcome for Resident #84 could be that she could feel ashamed, and it could negatively impact her self-esteem. Record review of the facility's policy and procedure titled Resident Rights, not dated, stated in part:Resident Rights Under Federal Law The facility protects and promotes the rights of each resident in our care. The following is a summary of your rights as a nursing home resident pursuant to Part 42 of the Federal Public Health Code of Regulations (See 42 CFR S483.10 for a full description). In addition to the following rights, you will also be provided with a separate summary of your rights under applicable state laws.48. Quality of Life. Each resident must receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. 49. Resident Dignity. The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment, that maintains or enhances his/her quality of life, recognizing each resident's individuality. Record review of the facility's policy and procedure titled Activities of Daily Living, Optimal Function, revised on May 5, 2023, read in part: Nursing Policies and Procedures SUBJECT: ACTIVITIES OF DAILY LIVING, OPTIMAL FUNCTION DEFINITION:Activities of daily living (ADLs), refer to tasks related to personal care including, grooming, dressing, oral hygiene, transfer, bed mobility, eating, bathing and communication system. POLICY:The Facility provides care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. The Facility provides necessary care to all residents that are unable to carry out activities of daily living on their own to ensure they maintain proper nutrition, grooming, and hygiene.PROCEDURES:1. Facility staff recognize and assess an inability to perform ADLs, or a risk for decline in any ability to perform ADLs by reviewing the most current comprehensive or most recent quarterly assessment.2. Facility staff to monitor conditions which may cause an unavoidable decline in the resident's ability to perform ADLs:A. Natural progression of a debilitating diseaseB. Onset of an acute episode causing physical or mental disabilityC. Resident's or his/her representative's decision to refuse care and treatment offered to restore/maintain functional abilities after the facility has informed and educated about the benefit/risks of the proposed care and treatmentD. Signs and symptoms of depression and pain even if not indicated on his/her MDS3. Facility staff develop and implement interventions in accordance with the resident's assessed needs, goals for care, preferences and recognized standards of practice that address the identified limitations in ability to perform ADLs.4. Facility staff provides assistive devices to maximize independence, including but not limited to the following:A. Grooming- built up grooming aids.

Based on 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 with 1 of 2 medication carts reviewed for timely identification and removal (from current medication supply) of medications for disposition.The facility failed to ensure the Hall 100 Nurse Medication Cart was free of expired eye drops.This failure could place residents at risk for not receiving the intended therapeutic response of prescribed medications and drug diversion of controlled substances.Findings included: During an observation on 05/20/2026 at 9:15 AM of the Hall 100 Nurse Medication Cart with LVN E present revealed the following: -Systane eyedrops, open, and noted with open date 03/01/2026; -Lumigan eye drops, open and date 01/16/2026. In an interview on 05/20/2026 at 9:17 AM with LVN E, it was the nurse's responsibility to go through the medication carts and dispose any expired medications. LVN E stated eye drops were to be dated on the day they were opened and disposed of 30 days after opening. LVN E stated the nurses or medication aides assigned to the medication cart was responsible for the medication cart and maintained for cleanliness and free of expired medications, every shift. LVN E stated the DON was responsible for monitoring the medication carts. LVN E stated the potential risks of having eye drops that were not dated or past the 30 days could potentially not be as effective, which affected resident care. In an interview on 05/21/2026 at 10:22 AM with the DON, she stated that the assigned nurse or medication aide to the Medication Cart was responsible for that cart. The DON stated that the assigned nurse or medication aide would review the medication cart at least once a shift. The DON stated there was an assigned CMA that reviewed medication carts monthly and the staff from the Pharmacy that provide the Nursing Facility medications also audited the Medication Carts on a quarterly basis. The DON stated nursing staff were to date eyedrops when opened so staff could be aware. The DON stated she was not sure when eyedrops were to be disposed of after opening. The DON stated that opened and undated eyedrops were to be disposed of. The DON stated the potential risk of using undated or expired eyedrops could mean it is not as effective. Record review of the Nursing Facility's Pharmacy Services Policies and Procedures, title Medication Storage, dated 04/17/2024, read in part under Procedures: 7. Once any multi-dose packaged medication or biological is opened, nursing will mark multi-dose products (e.g. inhaers, insulin, opthalmics, otics, and the like) with the date opened and follow manufacturer/supplier guidelines with respect to expiration dates. It also read, 14. Facility should ensure that medications and biologicals for expired and/or discharged residents are stored seperately, away from use, until destroyed or returned to the provider.

Based on observations, interviews, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 2 medication carts (Hall 100 Nurse Med Cart) reviewed for medication storage. The facility failed to ensure open eye drops containers were labeled with their open date in the Hall 100 Nurse Medication Cart when reviewed on 05/20/2026.This failure could place residents at risk of not receiving the therapeutic benefit of medications or adverse reactions to medications. Findings included: During an observation on 05/20/2026 at 9:15 AM of the Hall 100 Nurse Medication Cart with LVN E present revealed the following: -Latanoprost eyedrops, opened and with no date; -Latanoprost eye drops, opened and with no date.In an interview on 05/20/2026 at 9:17 AM with LVN E, it was the nurse's responsibility to go through the medication carts and dispose any expired medications. LVN E stated eye drops were to be dated on the day they were opened and disposed of 30 days after opening. LVN E stated the nurses or medication aides assigned to the medication cart was responsible for the medication cart and maintained for cleanliness and free of expired medications, every shift. LVN E stated the DON was responsible for monitoring the medication carts. LVN E stated the potential risks of having eye drops that were not dated or past the 30 days could potentially not be as effective, which affected resident care. In an interview on 05/21/2026 at 10:22 AM with the DON, she stated that the assigned nurse or medication aide to the Medication Cart was responsible for that cart. The DON stated that the assigned nurse or medication aide would review the medication cart at least once a shift. The DON stated there was an assigned CMA that reviewed medication carts monthly and the staff from the Pharmacy that provide the Nursing Facility medications also audited the Medication Carts on a quarterly basis. The DON stated nursing staff were to date eyedrops when opened so staff could be aware. The DON stated she was not sure when eyedrops were to be disposed of after opening. The DON stated that opened and undated eyedrops were to be disposed of. The DON stated the potential risk of using undated or expired eyedrops could mean it is not as effective. Record review of the Nursing Facility's Pharmacy Services Policies and Procedures, title Medication Storage, dated 04/17/2024, read in part under Procedures: 7. Once any multi-dose packaged medication or biological is opened, nursing will mark multi-dose products (e.g. inhaers, insulin, opthalmics, otics, and the like) with the date opened and follow manufacturer/supplier guidelines with respect to expiration dates. It also read, 14. Facility should ensure that medications and biologicals for expired and/or discharged residents are stored seperately, away from use, until destroyed or returned to the provider.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Residents #79) reviewed for transmission-based precautions. LVN F failed to wear PPE when administering Resident #35's IV antibiotic on 05/20/2026. The deficient practice could place residents at risk of infections. The findings included: Record review of Resident #35's face sheet revealed an [AGE] year-old female with admission date of 05/12/2026. Record review of Resident #35's history and physical dated 05/12/2026 revealed medical history of Bacteremia (presence of bacteria in the blood). Record review of Resident #35's physician order with received date of 05/12/2026, and start date of 05/13/2026, read: Cefazolin in 0.9% sodium chloride, 2 G/100 ML, 2G to be administered IV (intravenous, It refers to the medical process of delivering fluids, medications, nutrients, or blood products directly into a person's bloodstream through a small tube (catheter) inserted into a vein), every 8 hours for 6 weeks, for Bacteremia. An observation on 05/20/2026 at 2:00 PM, LVN F performed hand hygiene via hand sanitizer and donned gloves while introducing self to resident and explained the process of the antibiotic administration via IV, which Resident #35 agreed. LVN F prepped and disinfected the tray table located next to Resident #35 to place the IV antibiotic while she assessed Resident #35's left arm where the IV access was located. LVN F was observed using a new syringe to pull and confirm blood was observed in the IV for placement. LVN F was observed reconstituting (Reconstituting an IV medication involves dissolving a powdered or crystalline drug with a specified diluent to create a solution ready for injection or infusion) the 0.9% Sodium Chloride solution with the Cefazolin medication powder. LVN F failed to don the PPE-gown throughout the IV-antibiotic administration. There was PPE observed located outside of Resident #35's room, including gowns and gloves, and had an EBP Precautions sign posted on Resident #35's door. In an interview on 05/20/2026 at 2:10 PM with LVN F, she stated she forgot to don a gown, but she should have used PPE during IV administration. LVN F stated that all nurses were responsible for donning PPE while administering IV medications due to infection control concerns. LVN F stated residents were at risk for infections because there was the resident's blood involved, leaving the resident open for infection. She stated she had received in-service training regarding EBP during IV medication administration and was aware Resident #35 required EBP precautions due to her medical history and IV access. In an interview on 05/21/2026 at 10:23 AM with the DON, she stated that every nurse was responsible for donning PPE while administering IV medications. The DON stated residents with IV antibiotics were placed on Enhanced Barrier Precautions (EBP) because there was a portal of entry to the resident, and the EBP was to protect the resident. The DON stated the potential risks for residents of staff not wearing PPE, including the disposable gown, while administering IV medications, included an infection control issue. Record review of the Nursing Facility's Infection Prevention and Control Policies and Procedures, dated 05/15/2023, read in part under Procedures: 1. Enhanced Barrier Precautions- expand the use of PPE (gowns and gloves) during high-contact resident care activities that provide opportunities for transfer Multidrug-resistant Organisms to staff hands and clothing. A. EBP will be implemented for all residents with the following: 1) Infection or colonization with an MDRO when Contact Precautions do not otherwise apply. 2)Wounds and/or indwelling medical devices (central lines, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status. It also read, C. EBP requires the following PPE: 1. Gloves, 2. Gown.

Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 2 (Resident #28, Resident#33) of 7 residents observed for oxygen management.: 1. Resident #28 was not receiving oxygen according to physician orders. 2. Resident #33 was not receiving oxygen according to physician orders. This failure could place resident #33 on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health. Resident #28 Record review of Resident #28's face sheet dated 05/21/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #28's diagnoses included Dementia (a decline in memory, language, problem-solving, and other thinking skills), behavioral Disturbance (Persistent patterns of disruptive), psychotic disturbance (break with reality), mood disturbance (extreme sadness), anxiety (body's natural response to stress), Hyperlipidemia (too much fat in the blood), diabetes mellitus (body struggles to manage blood sugar levels), Shortness of breath, Dysphagia (difficulty swallowing), pharyngoesophageal phase (involuntary Stage of Swallowing), Cognitive communication deficit (difficulty with speaking, listening, or understanding caused by problems with thinking skills). Record review of Resident #28's MDS dated [DATE], reflected a BIMS score of 05, which indicated severe cognitive impairment. Resident #28 had impairment on both sides of upper extremity ([NAME], elbow, wrist, hand), and impairment on both sides to lower extremities (Hip, Knee, Ankle, Foot). Oxygen Therapy was left blank. Record review of Resident #28's Order Summary Report dated 05/21/2026, stated: -May apply and titrate 02 to maintain SPO2 above 90% as needed every shift- PRN. -O2 at 1-4 liters per minute via nasal cannula as need for SOB or SP02 under 90%. -02 Stats every shift. Record review of Resident #28's History and Physical dated 03/09/2026 revealed a [AGE] year-old female diagnosed with Multiple Sclerosis (chronic autoimmune disease of the central nervous system), Hypertension (blood pushing against the artery wall), and Hyperlipidemia (high levels of fats). Record review of Resident #28's Care Plan dated 05/21/2026, revealed [Resident #28] is on oxygen at 1-4LPM via NCas needed for SOB or SPo2 under 90%., with a goal [Resident #28] will not exhibit or develop Respiratory distress as evidenced by no SOB O2 stat or above 90%. Apply O2 as ordered. Change O2 tubing/nasal cannula/mask/humidification system weekly. Change tubing/mask weekly. Keep O2 cannula/mask/tubing and bagged when not in use. Elevate head of bed as needed. Monitor respiratory status daily during treatmentperiod. Respiratory distress s/sx: Shortness of breath. Fast breathing, or taking lots of rapid, shallow breaths. Fast heart rate. Coughing that produces phlegm. Blue fingernails or blue tone to the skin or lips. Extreme tiredness. Fever. Crackling sound in the lungs. Observation and interview on 05/19/2026 at 09:30 AM, Resident #28 was observed in her wheelchair in the hallway, resident is unable to communicate or verbalize any understanding of why she has on her nasal cannula and how often she is to have it on. Resident #28 did not exhibit any distress. Resident #33 Record review of Resident #33's face sheet dated 05/21/2026, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #33's diagnoses included Dementia (a decline in mental abilities severe enough to interfere with daily life), behavioral Disturbance (extreme aggression, defiance, or impulsivity that disrupts daily life), psychotic disturbance (experiencing a break from reality), mood disturbance (emotional state-such as extreme sadness, irritability, or high energy is persistent, intense, and interferes with daily life), anxiety (body's natural response to stress), Chronic obstructive pulmonary disease (long-term lung condition that makes it hard to breathe), hypertension (blood pushing against your artery walls is consistently too high), Atherosclerotic heart disease of native coronary artery without angina pectoris (hardened or clogged original heart arteries), hyperlipidemia (to much fat in the blood), lacrimal gland (primary tear gland a small almond-sized organ), asthma (long-term lung condition where your airways become swollen, inflamed, and narrow). Record review of Resident #33's MDS dated [DATE], reflected a BIMS score of 02, which indicated severe cognitive impairment. Resident #33 had no impairment to upper extremity ([NAME], elbow, wrist, hand), and impairment on both sides to lower extremities (Hip, Knee, Ankle, Foot). Oxygen therapy is marked b.)While a Resident ( Performed while a resident of this facility and within the last 14 days). Record review of Resident #33's Order Summary Report dated 05/21/2026, stated: O2 at 2 liters per minute via nasal cannula, to maintain SPO2 above 90%. Special instructions Notify MD if SPO2 is below 90% every shift, first, Second, Third. Record review of Resident #33's History and Physical dated 03/09/2026 revealed an [AGE] year-old female diagnosed with Hypertension (High blood pressure), coronary artery disease (narrowing or blockage of the major blood vessels), Osteoarthritis (wear and tear of the cartilage), anemia of chronic disease (autoimmune or other illness). Record review of Resident #33's Care Plan dated 05/21/2026, revealed Resident is at risk for respiratory distress/SOB due to DX of: Chronic Obstructive Pulmonary disease. Requires supplemental Oxygen, Goal; Resident will not exhibit or develop respiratory distress as evidenced by no SOB, O2 sat at or above 90%, Approach: Apply O2 as ordered.Change O2 tubing/nasal cannula/mask/humidification system weekly. Change tubing/mask weekly. Keep O2 cannula/mask/tubing and bagged when not in use. Monitor respiratory status daily during treatmentperiod. Respiratory distress s/sx: Shortness of breath. Fast breathing, or taking lots of rapid, shallowbreaths. Fast heart rate. Coughing that produces phlegm. Blue fingernails or blue tone to the skin or lips. Extreme tiredness. Fever. Crackling sound in the lungs. Resident is receiving: O2 at 2liters per minute via nasal cannula, To maintain SPO2 above 90%. Observation and interview attempt on 05/19/2026 at 09:30 AM, Resident #33 was observed in her wheelchair in the hallway, resident is unable to communicate. Resident #33 did not exhibit any distress. Observation on 05/19/2026 at 09:30 am revealed Resident #33 and Resident # 28 were both observed in hallway 300 both with nasal cannulas on and attached to the portable oxygen canisters. An inspection of both portable canisters revealed they were empty. Observation on 05/19/2026 at 9:30 AM, revealed RN M was requested to assess both residents' oxygen saturation levels. Resident #33's initial oxygen saturation reading was 87%, which subsequently rose to and plateaued at 89%. Resident #28's oxygen saturation level was recorded at 92%. In an interview and observation on 05/19/2026 at 09:34 am, RN M stated that Resident #33 had an ongoing behavior of removing her oxygen cannula, which was why she was positioned near the nurse's desk for observation. RN M confirmed that Resident #28's oxygen was ordered on a PRN basis. Upon reviewing the active electronic records, RN M verified that Resident #33 lacked a care plan addressing the behavior of removing her oxygen equipment. RN M requested the fill of oxygen canister from a CNA near by and the canister was connected to resident and oxygen was checked again and above 90%. In an interview on 05/19/2026 at 10:01 AM, LVN L demonstrated the operation of the portable oxygen tanks, noting they only lasted approximately 4 hours. LVN L stated that staff were trained to fill them at the beginning of the shift but admitted that because they empty quickly, staff must constantly check them. In an interview on 05/21/2026 at 03:07 PM, the DON reiterated that oxygen training was restricted to initial hire orientation. She stated that floor staff were expected to check canisters every 2 hours, noting that a reactive in-service had just been implemented on 05/20/2026 following the surveyor's observations, and a system of implementation was placed for all nursing staff to check the canisters every 2 hours and sign off to assure residents are constantly having oxygen as ordered. The DON identified clinical risks of this training deficit as resident hypoxia, confusion, shortness of breath, and lack of oxygen. In an interview on 05/21/2026 at 05:08 PM, LVN N stated she had worked at the facility since November 2025. She stated a CNA had informed her that Resident #33 frequently removed her oxygen cannula, though she had never personally witnessed it or documented it. LVN N stated she did not know how to fill the portable oxygen tanks and reported that a CNA had to show her because the facility had not provided training. She was unfamiliar with the operational duration of the tanks and did not know how frequently they were supposed to be monitored. She also stated she was unaware of how long those portable tanks last without them needing to be refilled. Record review of facility's policy titled Oxygen Therapy Revision date 02/12/2024 reflected it mandated that the licensed nurse must verify the oxygen flow port in accordance with the provider's order, confirm specific timelines for usage, and document pulse oximetry readings to monitor the resident's clinical response. Record Review of the facility's in services and trainings revealed, no training was provided to any staff on how to maintain portable oxygen and when to check or how to check if the companion portable is full.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and interventions to meet the resident's identified needs. This deficient practice was identified for 1 (Resident#33) of 7 residents reviewed. The facility failed to ensure the development and implementation of a comprehensive care plan for Resident #33's behavior which was removing her nasal cannula. This failure placed residents at risk for unmet care needs, potential decline in health status, and complications related to inadequate care planning and coordination of services.Record review of Resident #33's face sheet dated 05/21/2026, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #33's diagnoses included Dementia (a decline in mental abilities severe enough to interfere with daily life), behavioral Disturbance (extreme aggression, defiance, or impulsivity that disrupts daily life), psychotic disturbance (experiencing a break from reality), mood disturbance (emotional state-such as extreme sadness, irritability, or high energy is persistent, intense, and interferes with daily life), anxiety (body's natural response to stress), Chronic obstructive pulmonary disease (long-term lung condition that makes it hard to breathe), hypertension (blood pushing against your artery walls is consistently too high), Atherosclerotic heart disease of native coronary artery without angina pectoris (hardened or clogged original heart arteries), hyperlipidemia (to much fat in the blood), lacrimal gland (primary tear gland a small almond-sized organ), asthma (long-term lung condition where your airways become swollen, inflamed, and narrow). Record review of Resident #33's MDS dated [DATE], reflected a BIMS score of 02, which indicated severe cognitive impairment. Resident #33 had no impairment to upper extremity ([NAME], elbow, wrist, hand), and impairment on both sides to lower extremities (Hip, Knee, Ankle, Foot). Oxygen therapy is marked B.) While a Resident (Performed while a resident of the facility and within 14 days). Rejection of care is coded 1. (Behavior of this type occurred 1 to 3 days). Record review of Resident #33's Order Summary Report dated 05/21/2026, stated: O2 at 2 liters per minute via nasal cannula, to maintain SPO2 above 90%. Special instructions Notify MD if SPO2 is below 90% every shift, first, Second, Third. Record review of Resident #33's History and Physical dated 03/09/2026 revealed an [AGE] year-old female diagnosed with Hypertension (High blood pressure), Coronary Artery Disease (narrowing or blockage of the major blood vessels), Osteoarthritis (wear and tear of the cartilage), anemia of chronic disease (autoimmune or other illness). Record review of Resident #33's Care Plan dated 05/21/2026, reflected it had no focus, goal, or interventions/task for resident's behavior of removing her nasal cannula. Observation and interview attempt on 05/19/2026 at 09:30 AM, Resident #33 was observed in her wheelchair in the hallway, resident is unable to communicate. Resident #33 did not exhibit any distress. In an interview and observation on 05/19/2026 at 09:34 am, RN M stated that Resident #33 had an ongoing behavior of removing her oxygen cannula, which was why she was positioned near the nurse's desk for observation. Upon reviewing the active electronic records, RN M verified that Resident #33 lacked a care plan addressing the behavior of removing her oxygen equipment. RN M requested the fill of oxygen canister from a CNA near by and the canister was connected to resident and oxygen was checked again and above 90%. In an interview on 05/21/2026 at 03:00 pm, DON stated that Care plans were living documents intended to reflect a resident's current status. It is noted and implemented to staff that baseline care plans were to be implemented upon admission, followed by a comprehensive assessment within 14 days, and updated quarterly during MDS reviews or as needed. The DON stated that the interdisciplinary team and MDS Coordinators were supposed to update the care plans during morning meetings when nursing staff verbally reported behaviors. The DON acknowledged that nursing staff failed to document these specific behaviors in the medical record, stating it would have been verbalized but not recorded. The DON stated that the risk without these directives on the care plan was, staff would not know to watch the resident to ensure compliance with oxygen therapy. In an interview on 05/21/2026 at 3:41 PM with MDS S outlined the care plan update process, stating that repeated behaviors brought up in morning meetings or found in documentation should trigger a care plan intervention. MDS S stated they were unaware of Resident #33's oxygen-removal behavior and noted that while there was a care plan for the resident removing her hearing aids, there was none for the oxygen. MDS S confirmed that any nursing staff could initiate a care plan and stated that if the ADON or floor nurses were aware of the behavior, they should have documented it and initiated a care plan. The risk for not doing so is that staff are unaware of these behaviors and staff would lack supervision regarding Resident #33 receiving oxygen as ordered. In an interview on 05/21/2026 at 3:49 PM, ADON, stated he had spoken with the morning floor nurse, who confirmed that Resident #33 regularly removed her oxygen nasal cannula. The ADON confirmed that the floor nurse failed to document the behavior or implement a corresponding care plan. In an interview on 05/21/2026 at 04:19 PM, Administrator stated that the interdisciplinary team was expected to address resident needs as they arose. He acknowledged that the failure to update care plans created a risk of failing to provide proper care, leading to insufficient oxygenation or unmonitored of resident removing her oxygen. Record review of the facility policy named Care plan Revision date May 5,2023 revealed Resident will develop and implement A baseline and comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the residents that meet professional standards of quality care. The services provided or arranged by the facility as outlined by the comprehensive person-centered care plan will meet professional standards of quality the facility will coordinate the development of the presenting a care plan within the required time frame. Through ongoing assessment the facility will initiate person centered care plans when the residents clinical status or change of condition dictates the need such as but not limited to falls and pressure ulcer.

Based on observation, interview and record review, the facility failed to ensure residents were provided services with reasonable accommodation of needs and preferences for 1 (Resident #4) of 8 residents reviewed for call light placement. The call light was beside Resident #4's bed close to the floor and tangled with other cables and not within reach of the resident. This failure placed the resident at risk of having needs unmet by not being able to contact staff for assistance.Findings included: Record review of Resident #4's face sheet dated 05/21/2026 revealed an [AGE] year-old male resident with an original admission date of 09/04/2024 and a readmission date of 04/14/2026. Record review of history and physical dated 03/09/2026 for Resident #4 revealed diagnoses of aortic valve replacement (replacement of a heart valve), brain bleed status post MMA embolization (bleeding in the brain treated with a blood vessel procedure), chronic subdural hematoma (collection of blood on the brain), dementia (memory and cognitive impairment), cardiomyopathy (weakness of the heart muscle), bradycardia (slow heart rate), glaucoma (eye disease that damages the optic nerve), insomnia (difficulty sleeping), and physical debility (general physical weakness). Record review of the admission MDS dated [DATE] for Resident #4 revealed a BIMS score of 03, which indicated severe cognitive impairment. Under Section GG for functional abilities, the MDS revealed Resident #4 required partial to moderate assistance, meaning staff needed to complete less than half the effort for the resident, with toileting hygiene, shower, upper and lower body dressing and putting on or taking off footwear. Under Section GG for functional abilities in range of motion revealed the resident had impairment on both lower extremities and needed a manual wheelchair to ambulate. Record review of care plan dated 05/19/2026 for Resident #4 revealed the resident had impaired vision related to glaucoma (eye disease that damages the optic nerve). The care plan revealed staff interventions included ensuring the resident's call light remained within reach at all times, ensuring the floor remained clear of liquids and hazards, and assessing for limitations in peripheral vision (difficulty seeing objects to the side). The care plan also revealed Resident #4 required interventions for behavioral symptoms, insomnia, and urinary tract infection prevention. Resident #4's care plan revealed the resident was at fall risk due to muscle weakness, unsteady feet, lack of coordination, abnormalities of gait and mobility and called for an approach by always keeping the call light within reach.During an observation on 05/19/2026 at 9:28 a. m. Resident #4 was asleep in bed, his call light was not within reach, and it was observed towards the head of his bed, near the floor tangled with other cables by his nightstand.During an observation on 05/19/2026 at 2:40 p.m. Resident #4 was asleep in bed; the call light was still not within reach, and it was observed in the same location to the head of his bed, near the floor tangled with other cables. During an interview and observation on 05/20/2026 at 10:22 a.m. with Resident #4, he was lying in bed, his call light was within reach pinned to his bed sheet. Resident #4 said he called staff to help him get to the bathroom every day, multiple times a day and that if he could not use the call light or he could not find it, he would go to the bathroom on his own and then pull the cord in the bathroom for staff to assist him. Resident #4 stated he needed his call light within reach at all times. During an interview on 05/21/2026 at 10:11 AM, the ADON stated call lights were intended for residents to request assistance and were expected to remain visible and within the resident's reach while the resident was in the room. The ADON stated call lights were generally clipped to the resident's lap or bedsheet. The ADON stated residents would not be able to request assistance or could potentially fall while attempting to reach the call light if it was not accessible which could potentially result in them getting injured. During an interview on 05/21/2026 at 10:52 AM, CNA C stated call lights were expected to remain within the resident's reach to allow residents to request assistance when needed and that all the staff who worked with the residents were responsible for conducting rounds to ensure all residents had their call light within reach while in their rooms. CNA C stated residents could sustain injuries or experience delays in assistance if call lights were not accessible and within reach. During an interview on 05/21/2026 at 10:56 AM, CNA D stated that when residents were in their room, their call light needed to be within reach and staff including CNAs, LVNs and RNs were responsible for walking the hallways to make sure the residents could reach their call lights. CNA D stated the potential negative outcome from a resident not being able to use their call light could be they may try to get up from bed or do any activity on their own, without help, which could lead to them falling and getting injured. During an interview on 05/21/2026 at 11:00 AM, the DON stated call lights were expected to remain within reach of residents whenever they were in their rooms. The DON stated call lights should not be left near the floor and instead should be clipped to the blanket or positioned near the bed to remain accessible. The DON stated residents could fall or experience delays in assistance if call lights were not reachable and that all CNAs, LVNs, RNs, ADON or DON were responsible for conducting rounds to ensure residents had their call lights within reach. During an interview on 05/21/2026 at 2:47 PM, the Administrator stated call lights were expected to be answered within five minutes unless the call light originated from the bathroom, which required immediate attention. The Administrator stated that all staff, including CNAs, LVNs, RNs, and management staff, were responsible for ensuring call lights remained within reach after assisting residents to their rooms. The Administrator stated residents could experience delays in assistance if call lights were not accessible and that residents could potentially sustain a fall that could result in injuries if care was delayed and they attempted to get off from bed without assistance. Record review of the facility's policy and procedure titled Nursing Policy and Procedures: Call lights, responding to revised on 11/15/2025, read in part: NURSINGPOLICY AND PROCEDURES SUBJECT: CALL LIGHTS, RESPONDING TO POLICY:The staff will respond to call lights or other requests for assistance to meet the patient's/resident's needs. PROCEDURES:1. Respond to call lights and requests for assistance as quickly as practicable.2. Staff respond to emergency lights immediately.3. Staff knock on the patient or resident room door before entering to promote privacy and dignity.4. Staff will cancel the call light to notify others that the resident is being assisted.5. If unable to complete the requested task, inform the patient/resident/family and notify the appropriate discipline. Call lights should not be canceled until the resident's need has been addressed.6. When leaving the patient or resident room, ensure the call light is placed within the patient's/resident's reach.

Based on observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 12 residents (Resident #71) reviewed for dignity. The facility failed to knock on Resident #71's door before going into his room on 05/20/2026. This failure could place residents at risk of diminished quality of life.Findings included: Record review of face sheet dated 05/21/2026 for Resident #71 revealed a [AGE] year-old male with an admission date of 01/09/2026.Record review of history and physical dated 01/07/2026 for Resident #71 revealed diagnoses of traumatic subdural hemorrhage with loss of consciousness (bleeding in the brain after trauma), hydrocephalus (fluid buildup in the brain), acute respiratory failure (inability to breathe adequately), anxiety disorder (persistent excessive worry), bipolar disorder (mental health condition with mood swings), cognitive communication deficit (difficulty understanding or expressing thoughts), depression (persistent sadness), insomnia (difficulty sleeping), and generalized muscle weakness (overall body weakness).Record review of Quarterly MDS dated [DATE] for Resident #71 revealed a BIMS score of 15, which indicated the resident was cognitively intact. Under section GG for functional abilities, the MDS revealed Resident #71 had impairment for both, upper and lower extremities, Resident #71 was dependent on staff, meaning staff did all the effort for the resident, for eating, oral hygiene, toileting hygiene, shower, upper and lower body dressing, putting on and taking off footwear. Resident #71's MDS revealed he needed substantial to maximal assistance, meaning the staff needed to do more than half the effort for the resident, with rolling left to right on bed, sit to lying, lying to sitting on side of bed, sit to stand, chair to bed and bed to chair transfer and toileting transfer.Record review of care plan dated 04/09/2026 for Resident #71 revealed the resident required assistance with bilateral resting hand splints related to bilateral hand contractures (permanent tightening of muscles and joints causing the hands to become stiff). Resident #71's care plan revealed the resident had cognitive communication deficits (difficulty understanding or expressing thoughts) related to hydrocephalus (fluid buildup in the brain) and intracranial injury (brain injury). The care plan revealed staff interventions included obtaining the resident's attention before speaking, repeating or rephrasing statements as needed, and speaking clearly.During an observation and interview on 05/20/2026 at 12:46 p.m. this surveyor was interviewing Resident #71 in his bedroom; Resident #71 was only wearing sweatpants and socks. CNA A went into Resident #71's bedroom without knocking and without announcing herself. CNA A placed Resident #71's meal tray on his side table and explained she was there to deliver lunch. CNA A stated she should have knocked on the resident's door before going inside and stated Resident #71 could have potentially felt embarrassed because he was talking to the surveyor and stated he could feel as if his privacy did not matter to the staff from the facility. During an interview on 05/20/2026 at 2:02 p.m. with Resident #71, he stated staff sometimes went into his room without knocking and sometimes he did not know they were there because he was listening to music. Resident #71 stated he had been startled before because by the time he noticed, staff was already placing food next to him, and he had knocked things to the floor in the past. Resident #71 stated he would appreciate it if staff would let him know when they were going into his room. During an interview on 05/20/2026 at 2:40 PM with LVN B, stated staff were expected to knock before entering a resident's room because residents had a right to privacy and their privacy needed to be respected. LVN B stated the rooms of the residents were considered their home and all staff who went in needed to knock and announce themselves, letting them know the purpose of their visit. LVN B stated that not knocking on Resident #71's door before going into his room could potentially make him feel his rights were not being respected, and staff did not care for his privacy. During an interview on 05/21/2026 at 10:09 AM, the ADON stated resident rooms were considered the residents' home and staff were expected to announce themselves and explain the reason for entering the room. The ADON stated failing to do so could cause residents to become startled, feel their privacy was not respected, and feel more as though they were in a medical facility rather than their home. During an interview on 05/21/2026 at 10:44 AM, CNA C stated all staff were expected to knock, introduce themselves, and explain the purpose for entering the resident's room. CNA C stated it was inappropriate for staff to enter a resident's room without first announcing themselves because it invaded the resident's privacy and could make the residents feel the facility did not care about their rights. During an interview on 05/21/2026 at 11:06 AM, the DON stated all staff, including CNAs, LVNs, RNs, and management staff, were expected to knock and introduce themselves prior to entering a resident's room. The DON stated staff were expected to slowly open the door, ask permission to enter, and explain the assistance they intended to provide. The DON stated failure to do so could embarrass residents and violate their privacy. During an interview on 05/21/2026 at 2:40 PM, the Administrator stated staff were expected to knock on the resident's door, announce themselves, explain the reason for entering, and wait for the resident's permission before entering the room. The Administrator stated it was not acceptable for any staff member or volunteer to enter a resident's room without their permission and stated the potential negative outcome could be that residents felt that the facility staff did not honor their individuality or they did not respect their privacy. Record review of the facility's policy and procedure titled Resident Rights, not dated, stated in part: Resident Rights Under Federal LawThe facility protects and promotes the rights of each resident in our care. The following is a summary of your rights as a nursing home resident pursuant to Part 42 of the Federal Public Health Code of Regulations (See 42 CFR S483.10 for a full description). In addition to the following rights, you will also be provided with a separate summary of your rights under applicable state laws.15. Privacy. Each resident has the right to privacy with regard to accommodations, treatment, communications, personal care, visits and meetings of family and resident groups.

Based on observation, interview and record review the facility failed to ensure medical records, in accordance with accepted professional standards and practices, were maintained on each resident that were accurately documented for 1 of 6 residents (Resident #2) reviewed for medical records. The facility failed to ensure Resident #2's facility provider report to the state agency failed to accurately document the treatment and administration in the record for perineal care for Resident #2. This failure could place residents at risk of having incomplete and inaccurate medical records possibly resulting in inadequate treatment/care. Findings include:Record review of Resident #2's face sheet dated 08/21/25, revealed, admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #2's history and physical dated 5/15/25 revealed diagnoses of Hemiplegia, affecting left non-dominant side (means there is paralysis (loss of movement) on the left side of the body. Since most people are right-handed, the left side is considered the non-dominant side.), Unspecified dementia (a condition that affects memory, thinking, and daily functioning. Unspecified means the exact type of dementia (like Alzheimer's or vascular dementia) has not been clearly identified), Unspecified abnormalities of gait and mobility (means the person has trouble walking or moving around normally, but the exact cause or type of walking problem hasn't been clearly described), and Muscle wasting and atrophy (refers to the muscles getting smaller, weaker, and thinner over time, often because they are not being used enough or due to a medical condition). Record review of Resident #2's annual MDS dated [DATE], revealed, an intact cognition with no impairment BIMS score of 15 to be able to recall or make daily decisions. ADLs for toileting was partial/moderate assistance (Staff does less than half the effort). Resident was always incontinent for bowel and bladder. Record review of Resident #2's care plan dated 06/19/25, revealed, Problem: Family frequently voices concern that resident was not being changed or cared for adequately, despite care being provided per facility protocols. Document all care provided.Record review of Resident #2's facility provider report dated 06/26/25, revealed, Resident #2's family member #1 stated in a grievance that he submitted on 6/19/25 that I feel that the patients are being neglected again and that the progress the staff was making has faltered. Skin sweeps conducted on hall, changed tray times on 400 hall, implemented an order for resident to be changed before meals. In-service on Abuse and Neglect, Residents rights and Dignity, Compassionate and timely Incontinent Care. Notification to Family, Physician/NP, Ombudsman, and state. Facility conclusion was inconclusive. Record review of Resident #2's progress notes generated by LVN H dated 06/19/25, revealed, LVN H asked Resident #2 if she felt neglected while residing in the facility. Resident #2 denied any feelings of neglect and stated, I really like it here. The staff are so nice and attentive to me. LVN H further inquired if the resident's needs were being met and the resident responded, Yes, I am very comfortable here. When asked if she felt safe in the facility, the resident stated, Yes, I feel very safe here. LVN H provided education to the resident about having a CNA assist with changing her brief prior to all meals. The resident verbalized understanding of this process. Additionally, the resident was informed that meal tray delivery will be adjusted to allow for brief changes before trays are served in the hallway. This change was in alignment with CMS and state infection control guidelines. On 08/20/25 a documentation policy was requested but one was not provided by the facility. During an interview on 08/20/25 at 1:56 PM, with the DON, she stated the Suggest Questions for Accused was provided to CNA C, CNA D, and LVN F but they were not being accused of any allegations. The DON stated they were given that documents form to gather information as it was being investigated as a concern and grievance from family member #1 for Resident #2. The DON stated the form should have been adjusted to say something different other then, Suggest Questions for Accused. The DON stated it was a documentation error and all staff have been trained on how to documents properly. The DON stated the negative outcome of improper documentation would be failure in documenting of the care and what was done for the resident. During an interview on 08/21/25 at 9:21 AM, CNA C stated family member #1 had voiced that Resident #2 was not being changed. CNA C stated they were changing Resident #2 and were marking the changes down on a log every time they changed her. CNA C stated she was called into the office and was asked to fill out a document. CNA C stated she does not read English and was not told that the documents title was Suggested Questions for Accused was accusing her of the allegation. CNA C stated if she would have known she would have not filled out and signed the document.During an interview on 08/21/25 at 9:52 AM, with CNA D, she stated family member #1 was complaining that staff were not changing Resident #2. CNA D stated CNA C and her were told to go to the DON's office to fill out the Suggest Questions for Accused documentation. CNA D stated she was informed that the Suggest Questions for Accused was an attention to a concern with a resident and not a write up. CNA D stated she did not read English and did not know what she was filling out other then what she was being told. During an interview on 08/21/25 at 3:33 PM, with LVN F, she stated Resident #2's family member #1 had made a complaint that staff was not changing Resident #2. LVN F stated she filled out the Suggest Questions for Accused but did not realize what she was signing. LVN F stated the staff were not suspended as it was not a write up but only information that the facility was requesting for the investigation. LVN F stated if she would have paid better attention to the document that she would have questioned it. LVN F stated the nursing staff was providing perineal care all the time. During an interview on 08/22/25 at 11:05 AM, with the Administrator, he stated the title Suggested Questions for Accused documents where the nursing staff had filled out, was a template that was given to them by corporate and should have had the part of accused being changed to something else as the nursing staff was not being accused of anything. The Administrator stated that staff are trained on documenting. The Administrator stated the nursing staff should have known how to document, clearly, and to be able to capture what was being done. The Administrator stated the negative impact would affect reimbursement and not knowing what the residents' needs are if not documented accurately and correctly.

Based on observation, interview, and record review the facility failed to assess the resident for risk of entrapment from an enabler (bed rail) prior to installation or review the risks prior to installation for 1 (Resident #3) of 4 residents reviewed for enablers (bed rails). The facility failed to ensure that Resident #3 had a Scoop/Booster Mattress Assessment done to ensure the scoop/booster mattress was appropriate for use as an enabler.The facility failed to ensure that Resident #3 had orders for the scoop/booster mattress (enablers) use. The facility failed to obtain a Consent for use of the scoop/booster mattress for Resident #3. This failure could place residents who have scoop/mattresses (enablers) at risk of having inappropriate or unnecessary enablers in place increasing their risk of injury.Findings include:Record review of Resident #3's face sheet dated 08/21/25, revealed, admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #3's facility history and physical dated 07/08/25, revealed, an [AGE] year-old male diagnosed with Dementia and Diabetes, right humeral neck fracture, left intertrochanteric femur fracture as well as a chronic right humerus head fracture with possible new medial displacement. Record review of Resident #3's quarterly MDS dated [DATE], revealed, a severe impaired cognition BIMS score of 2 to be able to recall or make daily decisions. Resident #3's functional ability was substantial/maximal assistance (staff does more than half the effort) for roll left and right, sit to lying, lying to sitting on side of bed, and chair/bed to chair transfer. Resident #3 was not coded in section P - Restrains and Alarms: P0100. Physical Restraints (Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body) for used in bed. Record review of Resident #3's care plan dated 07/10/25, revealed, Problem: Risk for injury related to impaired mobility and recent left hip fracture. Approach: Place resident on scoop mattress as ordered to assist with proper positioning, reduce pressure points, and prevent further injury. Record review of Resident #3's orders reviewed on 08/21/25, revealed, there was no orders for the use of a scoop/booster mattress for Resident #3. Order dated 02/05/25, revealed, bed mobility with assist of 1 person. Record review of Resident #3's Consent reviewed on 08/21/25, reviewed, there were no consent for use of scoop/booster mattress. Record review of Resident #3's PT Evaluation & Plan of Treatment dated 07/09/25-09/06/25, revealed, Reason for Referral / Current illness: Resident #3 was a LTC resident referred to skilled PT services due to an unwitnessed fall resulting to a left femur fracture and re-fracture of right upper extremity. Right Lower extremity strength was impaired, left lower extremity was impaired, hip impaired, knee impaired, and ankle impaired. Bed mobility was max, supine was max, sit was max, transfers was max. Gross motor was impaired. Clinical Impression: Resident #3 exhibits weakness, balance deficits and decrease activity tolerance. Resident #3 requires encouragement for participation; requires MAX Assistance for functional mobility, per nursing report, resident #3 was easily agitated and can be aggressive. Record review of Resident #3's OT Evaluation & Plan of Treatment dated 07/09/25-09/06/25, revealed, Reason for Referral /Current illness: Resident #3 referred to OT due to exacerbation (a sudden worsening or flare-up of symptoms of a chronic disease) of decrease in functional mobility, decrease in range of motion, decrease in strength, reduced dynamic balance, reduced static balance (having a decreased ability to hold a stable, fixed body position without moving) and reduced ADL participation. Right Upper Extremity ROM was impaired, shoulder was impaired, right upper extremity was impaired. Toileting was dependent, upper body dressing was Max assistance, lower body dressing was total dependence. Clinical Impressions: upon evaluation Resident #3 demonstrates significant deficits affecting selfcare tasks and functional mobility. During an interview on 08/20/25 at 2:02 PM, with the DON, she stated Resident #3 was a high fall risk. The DON stated Resident #3 had a scoop/booster mattress to help repositioning, to help find the borders for him, and to prevent him from rolling off the bed. The DON stated Resident #3 was able to get in and off the bed by himself. The DON stated Resident #3 was evaluated for the scoop/booster mattress but did not know if he was evaluated to see if he was able to in and out of bed. The DON stated she could not recall if there was a physician order for the scoop/booster mattress. The DON stated there was no physician order seen for the scoop/booster mattress. The DON stated Resident #3 was care planned for the scoop/booster mattress. The DON stated the care plan mentioned to place resident on scoop mattress as ordered. The DON stated there would have to be an order for use of the scoop/booster mattress. The DON stated there was no consent form seen for use of the scoop/booster mattress. The DON stated the nurses were responsible for getting the orders and the consent for use. During an interview on 08/21/25 at 10:25 AM, with the DOR, he stated the therapy had done their own evaluation of Resident #3 but do not do evaluation on residents to see if they are able to use bed rails or scoop/booster mattress to see if they can use them as enablers. The DOR stated Resident #3's PT evaluation for bed mobility stated he was a max assistance and also with transfers. The DOR stated Resident #3 was unable to walk. The DOR stated Resident #3 would not be able to use the scoop/booster mattress to get out of bed or help him use it as an enabler. The DOR stated he did not see the negative outcome of Resident #3 using the scoop/booster mattress. The DOR stated if there were an emergency Resident # would not be able to get out of bed on his own. During an interview on 08/22/25 at 11:24 AM, with the Administrator, he stated a scoop/booster mattress was ordered for Resident #3. The Administrator stated Resident #3 did not have a physician order, nor consent form for use of the scoop/booster mattress, and no therapy or nursing assessment conducted to see if Resident #3 was able to use the scoop/booster mattress. The Administrator stated the purpose of the therapy/nursing assessment was to make sure the scoop/booster mattress fit Resident #3 and was an enabler as not doing so could be a risk of entrapment. During an interview on 08/22/25 at 1:32 PM, NP B stated he was not too familiar with the scoop/booster mattress. NP B stated there were no orders for the scoop/booster mattress as he did not give any nor were any asked by the facility to him. NP B stated as per policy the negative outcome would be that the scoop/booster mattress would be not appropriate for Resident #3's use. Record review of the facility Bed Rails and Side Rails, installation and use Policy, dated 05/05/25, revealed, Policy - The facility will attempt to use appropriate alternatives prior to installing a side or bed rail. The facility will ensure the correct installation, use and maintenance of bed rails/side rails when their use was determined to be appropriate for the patient/resident. Procedures: Acceptable alternatives will be considered prior to the installation of bed rails. Alternatives include but are not limited to roll guards, foam bumpers, lowering the bed and using concave mattresses that can help reduce rolling off the bed. -The resident will be evaluated for the risk of entrapment prior to installation.

Based on interview and record review the facility failed to ensure the prompt resolution of all grievances to include ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the residents' concerns, a statement as to whether the grievance was confirmed, any corrective action or to be taken by the facility as a result of the grievance, and the date when the decision was issued for 1 (Resident #2) of 8 residents reviewed for resident rights. The facility failed to complete a grievance for Resident #2 RP who requested Resident #2 to be changed during a mealtime. This failure could place residents at risk for grievances not being addressed or resolved promptly. Record review of Resident #2's face sheet dated 08/21/25, revealed, admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #2's history and physical dated 5/15/25 revealed diagnoses of Hemiplegia, affecting left non-dominant side (means there is paralysis (loss of movement) on the left side of the body. Since most people are right-handed, the left side is considered the non-dominant side.), Unspecified dementia (a condition that affects memory, thinking, and daily functioning. Unspecified means the exact type of dementia (like Alzheimer's or vascular dementia) has not been clearly identified), Unspecified abnormalities of gait and mobility (means the person has trouble walking or moving around normally, but the exact cause or type of walking problem hasn't been clearly described), and Muscle wasting and atrophy (refers to the muscles getting smaller, weaker, and thinner over time, often because they are not being used enough or due to a medical condition). Record review of Resident #2's annual MDS dated [DATE], revealed, an intact cognition with no impairment BIMS score of 15 to be able to recall or make daily decisions. ADLs for toileting was partial/moderate assistance (Staff does less than half the effort). Resident was always incontinent for bowel and bladder. Record review of Resident #2's care plan dated 6/24/25 revealed a focus for requires assist to complete ADL tasks due to impaired cognition, impaired mobility and incontinence with goal of will maintain a sense of dignity by being clean, dry, odor free and well-groomed thru the next review date and interventions included toileting- partial/moderate assistance. Record review of Resident #2's grievance dated 6/18/25 revealed it was written by Resident #2Resident #2's RP and it was communicated to the DON, Administrator, and SW. The grievance was communicated verbally, and the concern was mistreatment. The concern in detail read patients not being changed in a timely manner and left soiled through lunch. Separate sheet with details. the Documentation investigation and post investigation follow up were left blank and it was only signed by Resident #2Resident #2's RP. Record review of Resident #2's grievance typed report (which was referred to above as separate sheet with details) dated 6/18/25 written by Resident #2 RP revealed On 05/02/2025 Around 11:45 AM. I went to DON office to get assistance to have someone change [Resident #2] who was soiled, call light was on for about 20 minutes, no one was around the hall nor in the nurse's station. I asked DON if she can have someone change my [Resident #2], she then in turn tells me that they can't right now because it's lunch time and that state regulations or law prohibits them to do so during lunch because it's unsanitary. [Resident #2] sat through lunch soiled for almost an hour. I spoke to [Administrator] about what had transpired with DON, and he tells me pretty much the same thing agreeing with what DON told me. I replied, that if not changing [Resident #2] who was soiled is not sanitary during lunch, is it sanitary for the patients to sit through lunch soiled? Would any of them sit through lunch soiled? I also told him that I had asked before lunch not during lunch. 15, 20 minutes before lunch. [Administrator] said that he would talk to DON to see if they can come up with a solution. 06/09/2025 At 11:17 AM, [Resident #2] tells me she needs to be changed because she pooped, I press the call switch the light goes on. Shortly afterwards [SW] walks in and asked who needed assistance, I responded that [Resident #2] needed to be changed. She said she would get someone and left the room, shortly she returns saying in an apologetic manner that [Resident #2] could not be changed at the moment cause the food trays were going to be distributed to the residents. I feel that the patients are being neglected and the progress of the staff was making has faltered. I have reached out to [Ombudsman] about what the Administrator and DON said about the regulations or law about changing patients at lunch or before lunch. His response was I have sought out law or regulation about patients being changed during lunch, before or after and have reached out to an Investigator of Health and Human Services, and found this information is baseless and suggested I file a grievance report. During an interview on 8/20/25 at 9:12 am, Resident #2 stated she needed assistance with toileting and wore briefs. She stated that if she was soiled, she had to ask in advance because if it was close to mealtime, she had to wait until after she finished eating. She stated she was not given a reason for this but was told it was just how the facility operated. She stated there were times she sat in soiled briefs during meals and that it was uncomfortable, embarrassing, and irritating. She stated she had not told anyone because she was informed by staff that she had to wait and assumed it was the norm at the facility. During an interview on 8/20/25 at 1:33 pm, the DON stated the Social Worker and Administrator conducted the investigation. The DON stated that for a typical grievance, the process would be completed online; however, since this was reportable, the investigation continued and was resolved. The DON stated they completed the investigation but did not document it. She explained the risk of not completing the documentation was that if it was not documented, it did not happen, and without follow-up it could not be supported.During an interview on 8/20/25 at 3:39 pm, the SW stated she had received the grievance from Resident #2's RP. The SW stated she had reviewed the notes and the additional page where the RP mentioned [Resident #2] being neglected, which led her to determine it was reportable. The SW stated that whenever a grievance mentioned neglect or resident rights not being met, it was considered reportable, and a self-report required to the state office. The SW stated the Administrator then took over and conducted the report but emphasized that the complaint itself was still her responsibility. She stated it was not completed because it was reportable. The SW stated she had reviewed the policy with the surveyor on 8/20/25 and identified that nothing in the policy reflected that the grievance form should not be completed due to a self-reportable. The SW stated that although she had access to the policy, she had not reviewed it prior to that day. The SW stated that if it had not been reported to the state, the grievance could have fallen through the cracks. The SW stated that even with the self-report, there could be a negative outcome because without proper documentation, there was no way to confirm if it was resolved or who had investigated it.Record review of the facility's Complaint/ Grievances Process policy dated 10/23/19 read in part Procedures: 2- Upon receipt of the grievance/ complaint the receiver completes and signs all appropriate sections of the current complaint/grievance form; 4- The SW/ designee ensures all sections of the Complaint/grievance report are completed appropriately and signed by the staff completing the investigation and developing the resolution. Ensure any supportive documentation related to the grievance is attached.

Based on interview and record review the facility failed to ensure that each resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident for 1 of 8 residents (Resident #2) reviewed for self -determination. The facility failed to ensure that Resident #2 received incontinence care before or during mealtimes when requested. This failure could place residents at risk for avoidable discomfort, compromised dignity, and potential complications such as urinary tract infections and skin breakdownFindings included: Record review of Resident #2's face sheet dated 08/21/25, revealed, admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #2's history and physical dated 5/15/25 revealed diagnoses of Hemiplegia, affecting left non-dominant side (means there is paralysis (loss of movement) on the left side of the body. Since most people are right-handed, the left side is considered the non-dominant side.), Unspecified dementia (a condition that affects memory, thinking, and daily functioning. Unspecified means the exact type of dementia (like Alzheimer's or vascular dementia) has not been clearly identified), Unspecified abnormalities of gait and mobility (means the person has trouble walking or moving around normally, but the exact cause or type of walking problem hasn't been clearly described), and Muscle wasting and atrophy (refers to the muscles getting smaller, weaker, and thinner over time, often because they are not being used enough or due to a medical condition). Record review of Resident #2's annual MDS dated [DATE], revealed, an intact cognition with no impairment BIMS score of 15 to be able to recall or make daily decisions. ADLs for toileting was partial/moderate assistance (Staff does less than half the effort). Resident was always incontinent for bowel and bladder. Record review of Resident #2's care plan dated 6/24/25 revealed a focus for requires assist to complete ADL tasks due to impaired cognition, impaired mobility and incontinence with goal of will maintain a sense of dignity by being clean, dry, odor free and well-groomed thru the next review date and interventions included toileting- partial/moderate assistance. Record review of Resident #2's grievance dated 6/18/25 revealed it was written by Resident #2's RP and it was communicated to the DON, Administrator, and SW. The grievance was communicated verbally, and the concern was mistreatment. The concern in detail read patients not being changed in a timely manner and left soiled through lunch. Separate sheet with details. the Documentation investigation and post investigation follow up were left blank and it was only signed by Resident #2's RP. Record review of Resident #2's grievance typed report (which was referred to above as separate sheet with details) dated 6/18/25 written by Resident #2 RP revealed On 05/02/2025 Around 11:45 AM. I went to DON office to get assistance to have someone change [Resident #2] who was soiled, call light was on for about 20 minutes, no one was around the hall nor in the nurse's station. I asked DON if she can have someone change my [Resident #2], she then in turn tells me that they can't right now because it's lunch time and that state regulations or law prohibits them to do so during lunch because it's unsanitary. [Resident #2] sat through lunch soiled for almost an hour. I spoke to [Administrator] about what had transpired with DON, and he tells me pretty much the same thing agreeing with what DON told me. I replied, that if not changing [Resident #2] who was soiled is not sanitary during lunch, is it sanitary for the patients to sit through lunch soiled? Would any of them sit through lunch soiled? I also told him that I had asked before lunch not during lunch. 15, 20 minutes before lunch. [Administrator] said that he would talk to DON to see if they can come up with a solution. 06/09/2025 At 11:17 AM, [Resident #2] tells me she needs to be changed because she pooped, I press the call switch the light goes on. Shortly afterwards [SW] walks in and asked who needed assistance, I responded that [Resident #2] needed to be changed. She said she would get someone and left the room, shortly she returns saying in an apologetic manner that [Resident #2] could not be changed at the moment cause the food trays were going to be distributed to the residents. I feel that the patients are being neglected and the progress of the staff was making has faltered. I have reached out to [Ombudsman] about what the Administrator and DON said about the regulations or law about changing patients at lunch or before lunch. His response was I have sought out law or regulation about patients being changed during lunch, before or after and have reached out to an Investigator of Health and Human Services, and found this information is baseless and suggested I file a grievance report. During an interview on 8/19/25 at 2:08 pm, the Ombudsman stated that Resident #2's RP called him and reported that staff were not taking care of her. The Ombudsman stated he had not seen any regulation that prevented residents from being changed, but the RP stated the facility told him that per state regulations residents were not to be changed prior to and during meals due to infection control concerns. The Ombudsman stated this was concerning because it involved residents remaining in soiled briefs before and during meals, having to wait until after meals to be changed. During an interview on 8/20/25 at 9:07 am, Resident #2 stated she needed help with toileting. She stated she wore briefs and was changed approximately every two-three hours. She stated that on one occasion she asked to be changed and was told she had to wait until after the meal. She stated she was told this was due to hygienic concerns with the meal being at bedside. She could not remember the CNA's name but stated her RP was present when this occurred. She stated she was eventually changed but could not recall how long after her request. She stated she felt very uncomfortable waiting in her soiled brief and that her RP reported the concern, but she did not know to whom. During an interview on 8/20/25 at 9:12 am, Resident #2 stated she needed assistance with toileting and wore briefs. She stated that if she was soiled, she had to ask in advance because if it was close to mealtime, she had to wait until after she finished eating. She stated she was not given a reason for this but was told it was just how the facility operated. She stated there were times she sat in soiled briefs during meals and that it was uncomfortable, embarrassing, and irritating. She stated she had not told anyone because she was informed by staff that she had to wait and assumed it was the norm at the facility. During an interview on 8/20/25 at 9:17 am, LVN F stated CNAs did not change residents' briefs during meal tray delivery. She stated CNAs were not to change residents' briefs per facility practice until after the meal. When asked about policy, she could not recall which policy it was. LVN F stated the reason provided was to prevent cross-contamination. When asked if CNAs were washing their hands before and after providing incontinence care, she stated yes. When asked how that would be considered cross-contamination, she stated, I don't know how to answer that. When asked if it was the residents' right to be changed, she stated that it was but could not explain why it was not being done and only reiterated that it was for cross-contamination prevention. LVN F stated she had not received complaints from residents about not being changed. LVN F stated the only complaint came from Resident #2 RP, who had requested Resident #2 to be changed. LVN F stated Resident #2 was eventually changed, but it occurred after the meal. When asked why care was delayed until after the meal, she hesitated and stated again it was to prevent cross-contamination. When asked about resident rights, she could not answer directly. During an interview on 8/20/25 at 9:26 am, CNA I stated that residents were not changed if they became soiled before or during meals. CNA I stated that if a resident requested to be changed during that time, she would encourage the resident to wait until they were done eating. She stated the reason given to staff was to prevent cross-contamination. When asked if she washed her hands before and after providing incontinence care, she stated yes. When asked how cross-contamination would occur if staff followed hand hygiene and infection control practices, she stated she did not know how to answer that question. During an interview on 8/20/25 at 10:07 am, the ADON (who is also the Infection Prevention nurse) stated residents were changed before meal trays were passed out and after they were done eating, but not during meals. She stated she had spoken with the DON and reviewed documentation. She stated the practice was due to infection control best practice. When asked if staff washed their hands and followed standard infection control procedures, she stated they did. She then stated the concern was also about dignity, as it was inappropriate for a roommate to eat while another resident was being changed. She acknowledged dignity issues could include odor, irritation, risk of urinary tract infections, or skin breakdown. During an interview on 8/20/25 at 1:33 pm, the DON stated Resident #2 RP approached her and requested his mother be changed while trays were out in the hall. She stated the facility's best practice was not to perform incontinence care in the unit while meal trays were actively being served and consumed. The DON stated there was no written policy, only best practice. The DON stated CNAs washed their hands, but if a roommate was eating in the room while another resident was being changed, it violated dignity for the roommate. The DON stated staff were trained to wash their hands after care per standard precautions, so cross-contamination should not be a concern, stated she did not initially think of it in that way. The DON stated she had previously referenced regulations but upon review had not found any supporting regulation. The DON stated she reviewed infection control policy the day prior (8/19/25) and did not find anything that prohibited changing during meals. The DON stated the risk of delaying care was skin breakdown, infection, and resident discomfort. During an interview on 8/20/25 at 4:08 pm, the SW stated she had heard of the concept that CNAs could not change a resident during mealtime due to concerns of cross-contamination and dignity, and because the odor might be unpleasant for the roommate and cause nausea or loss of appetite. The SW stated she was not aware if residents had been asked whether they were comfortable being changed during meals or if they had been offered the option to step out during the brief change. The SW stated that if it had been her in that situation, and she had to wait to be changed for the sake of her roommate's dignity, she would have felt dirty having to eat her meal while soiled. When asked about cross-contamination, she stated she did not know much about it and referred the question to the nursing staff. During an interview on 8/22/25 at 9:02 am, the NP stated that usually when residents were eating, staff were also busy cleaning trays in the hallway and attending to other tasks. He stated that residents should be cleaned when needed and thought it was unusual that staff did not change residents' minutes before or during meals. He stated he did not believe there was significant risk if the wait was less than two hours, but if it exceeded two hours, then it became a concern. During an interview on 8/22/25 at 11:05 am, the Administrator stated that the facility does not have a written policy that prevents residents from being changed minutes before or during meals. The Administrator explained that some staff may believe this practice relates to infection control, particularly if a resident has an explosive bowel movement, but stated that delaying care could have a negative emotional impact on residents. The Administrator clarified that he has never told staff that this was a regulation or requirement, nor has he heard the Director of Nursing communicate such a rule. Record review of the facility's Patient/Residents Rights dated 2023 read in part Policy: The Facility employs measures to ensure patient and resident personal dignity, well-being, and self-determination are maintained and will educate patients and residents regarding their rights and responsibilities. Resident rights: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section; A resident must receive and consent with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality; The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. Record review of the facility's Infection Prevention and Control Program and Plan policy dated May 15, 2023, revealed there was nothing that indicated staff could not provide soiled brief changes minutes prior and during meals due to cross contamination concerns.

Based on interview and record review the facility failed to ensure medical records, in accordance with accepted professional standards and practices, were maintained on each resident that were accurately documented for 2 of 3 residents (Resident #3, Resident #8) reviewed for medical records. The facility failed to ensure that the incident on 04/25/25, with Resident #3 who alleged ST had said something negative was documented in the resident's chart. The facility failed to ensure that the incident on 05/14/25, with Resident #8 who alleged that someone stole $40 out of his wallet was documented in the resident's chart. These failures could place residents at risk of records being inaccurate and not receiving potential needed services due to documentation errors. Finding included: Resident #3 Record review of Resident #3's face sheet dated 06/11/25, revealed, admission on [DATE] and re-admission on [DATE] to the facility. Resident #3 was a [AGE] year-old female diagnosed with depression and dementia. Record review of Resident #3's quarterly MDS dated [DATE], revealed, little to no impairment cognition BIMS of 15 to be able to recall and make daily decisions. Record review of Resident #3's care plan dated 04/03/25, revealed, Resident #3 was having mood and behavior needs as evidence by periods of refusing facility transportation to appointments. Care plan dated 01/31/24, revealed, has socially inappropriate/disruptive behavioral symptoms as evidenced by failure to adapt to other residents in room and in dining areas, yelling at staff and residents. Record review of Resident #3's Facility Self-Report to state dated 04/28/25, revealed, Resident #3 claimed that the ST said that she was an evil person during activities. Immediately suspended ST and notified the physician and NP. Investigation was conducted and was unconfirmed. Record review of Resident #3's Progress Notes were reviewed on 06/12/25 revealing, that the incident had not been documented and or recorded on the residents' chart. During an interview on 06/10/25 at 9:25 AM, with Resident #3, she stated she was in the activities room with other resident playing the loteria game (a traditional Mexican board game of chance, similar to bingo, but played with a deck of cards instead of numbered balls). Resident #3 stated the ST came into the activities room and did not know why she was there. Resident #3 stated she did not know anything about the ST telling her about her telling or calling her evil. During an interview on 06/10/25 at 10:18 AM, with Resident #3 stated she remembered now what the state was talking about and stated that the ST had told her she was evil. Resident #3 stated she had reported it and did not know why she was being called evil. During an interview on 06/10/25 at 11:03 AM, with DOR , he stated the ST had an incident with Resident #3 in which it was claimed by Resident #3 that the ST had called her evil. The DOR stated he received a statement from the ST. The DOR stated ST went into the activities room and was asked by the activities director to take over the Loteria Game that residents were playing. The DOR stated she was then suspended pending the conclusion of the investigation which was unconfirmed. During an interview on 06/10/25 at 11:24 AM, with the Activities Director, she stated she was working the day of the incident and did not hear ST say anything bad to Resident #3. The Activities Director stated that Resident #3 had claimed that the ST had told her she was evil. During an interview on 06/10/25 at 11:50 AM, with the ST, she stated she entered the activities room to help out a resident when the Activities Director was called out of the activities room. The ST stated she took over calling out the cards for the loteria game that the residents were playing. The ST stated Resident #3 was getting upset with her and not to be calling out the loteria. The ST stated she claimed she was not doing it right and not calling the cards from the bottom of the stack. The ST stated Resident #13 joined the game late and she was trying to catch him up when Resident # 3 got upset again and told her not to catch him up. The ST stated that Resident #13 won the game and Resident #3 got more upset. The ST stated she tried accommodating everything that Resident #3 wanted but it was not good enough. During an interview on 06/10/25 at 1:36 PM, with the SW, she stated the ST went into the activities room. The SW stated Resident #3 claimed ST had called her evil in which she took it personal. The SW stated that ST was not supposed to say that. The SW stated she reported it to the Administrator. The SW stated she interviewed Resident #14 and Resident #15 who both were present in the room sitting in front of Resident #3. The SW stated both resident (14 & 15 ) did not hear ST say anything of that sort or anything bad. During an interview on 06/11/25 at 8:53 AM, with Resident #14, she stated there was one resident who was getting upset with the ST. Resident #14 stated she did not know the name of the resident. Resident #14 stated at no time did the ST say anything bad to Resident #3. During an interview on 06/12/25 at 10:21 AM, with Resident #15, he stated the ST was calling out the cards for the loteria game. Resident #15 stated at no time was the ST telling anybody anything bad. During an interview on 06/13/25 at 10:24 AM, with the DON, she stated the ST was in the activities room hovering over the residents. The DON stated that Resident #3 had told the ST why she was in Resident #3's space and that the ST told her she was an evil person. The DON stated the ST was participating in the activities with the residents. The DON stated this incident should have been documented in the Resident #3's chart. The DON stated it was not documented. The DON stated the nurses were responsible for documenting. The DON stated the reason for documenting was to show they were providing care to the resident and continuation of the care. The DON stated the impact of not documenting was omissions and lack of continuity of resident care. During an interview on 06/13/25 at 4:00 PM, with the Administrator, he stated the ST was in the activities room helping out. The Administrator stated that Resident #3 had claimed that the ST had called her evil. The Administrator stated anytime there were incidents with the residents it does need to be documented . The Administrator stated the negative outcome of not documenting would be the information not being passed and could affect resident care. Resident #8 Record review of Resident #8's face sheet dated 06/12/25, revealed admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #8's facility history and physical dated 10/21/24, revealed, a [AGE] year-old male diagnosed with metabolic encephalopathy versus TIA (Encephalopathy is a broad term for brain dysfunction, often due to metabolic or systemic issues, while a TIA is a temporary interruption of blood flow to the brain, causing transient neurological deficits) Record review of Resident #8's quarterly MDS dated [DATE], revealed, a BIMS score of 8 indicating moderate impairment of cognition. Record review of Resident #8's care plan dated 12/01/23, revealed, impaired decision-making and impaired communication related to dementia. Monitor behaviors and assess for pain. Record review of Resident #8's Progress Notes were reviewed on 06/12/25 with no documentation of the incident of 05/14/25. Record review of Resident #8's Facility self-report to state dated 05/22/25, revealed, Resident #8 claimed that someone came into his room while he was napping and took his wallet out of his pants pocket that he was wearing and stole $40 from it and then put his wallet back into his pant pocket. Residents room and wallet were searched with residents' permission. Notified family and local police. Investigation was conducted and was unconfirmed. During an interview on 06/11/25 at 10:32 AM, with the ADON, she stated Resident #8 claimed that someone had taken his money. The ADON stated that he was very forgetful, had impaired judgment, and was always saying he was missing money. The ADON stated the facility offered to hold his money but refuses and was consistently re-direct when leaving his money laying on the meal tray. During an interview on 06/11/25 at 11:59 AM, with LVN G, she stated Resident #8 had gone to the nurse's station and told her someone had stolen money from him two days ago. LVN G stated this was reported to the Administrator. LVN G stated she went to look with Resident #8 in his room into his drawers and did not find the $40. During an interview on 06/13/25 at 11:33 AM, with the DON, she stated Resident #8 had voiced to LVN G that someone had taken his $40 two days ago. The DON stated the Administrator went to go assess Resident #8's wallet with the permission of Resident #8 to see if he might have misplaced it. The DON stated the incident should have been documented by the nurses who were responsible for documenting. The DON stated the impact would be the continuity of care to the resident if it was not documented. During an interview on 06/13/25 at 3:25 PM, with the Administrator, he stated Resident #8 was asleep in his bed with his wallet in his pocket. The Administrator stated he interviewed the family member who stated she had given him some money. The Administrator stated the facility would hold on to the money to keep it safe for him and he refused. The Administrator stated the incident should have been documented by the nursing staff. The Administrator stated not documenting could affect the resident care depending on the situation. Record review of the facility Documentation Guidelines dated 05/05/23, revealed, Policy - documentation guidelines pertinent to good clinical record practice will be followed by all individuals who document in the medical record.

Based on observation, interview, and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs for 4 of 6 residents (Resident #1, Resident #6, Resident #10, Resident #12) reviewed for care plans. The facility failed to implement a comprehensive person-centered care plan that addressed Resident #1's refusal of showers. The facility failed to implement a comprehensive person-centered care plan that addressed Resident #6's wandering into other resident rooms. The facility failed to implement a comprehensive person-centered care plan that addressed Resident #10 ' s sexual inappropriateness. The facility failed to implement a comprehensive person-centered care plan that addressed Resident #12 ' s sexual inappropriateness. These failures could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. Findings included: Resident #1 Record review of Resident #1's face sheet dated 06/11/25, revealed admission on [DATE] to the facility. Record review of Resident #1's facility history and physical dated 05/21/25, revealed, an [AGE] year-old female diagnosed with chronic skin condition versus staphylococcal scalded skin syndrome (MSSA bacteremia - a bloodstream infection caused by the bacteria Staphylococcus aureus, which are susceptible to methicillin and other beta-lactam antibiotics). Record review of Resident #1's MDS dated [DATE] revealed BIMS score of 11, indicating her cognition was moderately impaired ADLs for shower was marked 88 Not attempted due to medical condition or safety concerns. Record review of Resident #1's care plan dated 6/6/25 revealed no focus area or interventions for Resident #1's refusal to shower. Record review of Resident #1's progress note dated 6/6/25 revealed Resident was asking for lotion this morning; resident was asked if she wanted a shower and resident refused and even dismissed the idea of a shower. Resident had a shower over a week ago and has not received one since then. - Progress note dated 5/27/25 revealed refused shower despite multiple attempts this shift and previous shift. - Progress note dated 5/25/25 revealed Resident refused shower to take place multiple times on 5/24. Resident finally agreed 2-10 shift for shower.5/24. - Progress note dated 5/22/25 revealed family member reported patient had been without a shower for a year. During an interview on 06/10/25 at 1:27 PM, with the wound Care Nurse, she stated she asked Resident #1 if she would take a shower and afterwards, she would perform the wound care and that way she would be clean. The Wound Care Nurse stated Resident #1 had agreed to shower. The Wound Care Nurse went ahead and told the CNAs that she would be taking a shower. During an interview on 6/11/25 at 11:15 am, CNA A stated she often refused showers and had a history of declining hygiene care. CNA A stated that he was aware Resident #1 frequently refused showers and that staff had documented multiple refusals since her admission. CNA A described Resident #1 as having extremely dry skin and noticeable body odor, which he attributed to her ongoing refusal to shower. CNA A stated that this was Resident #1's first shower since admission and that it required a two-person assist due to her physical limitations. CNA A explained that morning staff would typically offer showers to Resident #1 because prior attempts during the evening shift had been unsuccessful due to her refusals. During an interview on 6/11/25 at 1:51 pm, CNA B stated that it was her first time working with Resident #1 and that she had been informed by staff that the resident had repeatedly refused showers since admission. CNA B stated that Resident #1 had a strong body odor and that she only agreed to the shower after speaking with the wound care nurse and a friend or family member, who helped encourage her to accept hygiene care. During an interview and observation on 6/11/25 at 2:16 pm, Resident #1 stated she only remembered receiving one shower approximately three or four weeks ago and recalled being taken in on a gurney. Resident #1 stated she felt scared because it was the first time someone had showered her in that manner and stated she told staff she would call the police. Resident #1 stated that since that time, she had been showered in different shower rooms and was now able to shower herself with minimal assistance. Resident #1 was observed with hair that appeared disheveled and uncombed, and had visible white, flake-like substances on her skin. A strong body odor was also noted during the observation. During an interview on 6/12/25 at 9:37 am, the Staff Coordinator stated that CNA A had approached him for assistance with showering Resident #1, noting that she had been refusing showers since admission and had developed a strong body odor as a result. The Staff Coordinator stated that he was aware family permission had been obtained to encourage hygiene care due to ongoing refusals and concerns about Resident #1's hygiene and skin condition . During an interview on 6/12/25 at 10:16 am, LVN D stated, Resident #1 had been at the facility for approximately ten days and had refused all showers during that time. LVN D stated that staff were aware Resident #1 had a history of going up to six months without accepting a shower, as reported by her family. LVN D stated Resident #1's skin appeared scaly and extremely dry, and she had a strong body odor, which staff attributed to her repeated refusal of hygiene care. LVN D stated that she agreed to a shower on 5/28/25 after persistent attempts by staff and encouragement from the wound care nurse and family. During an interview on 6/12/25 at 12:05 pm, The DON stated that she did not observe a care plan addressing Resident #1's refusal of showers. She stated that such a plan should have been developed to identify interventions that had been effective, evaluate their outcomes, and determine if alternative strategies were needed. She described this as initial care planning and stated that the failure to include refusals in the care plan represented a violation of Resident #1's rights, safety, and continuity of care. The DON stated that nursing and MDS staff were jointly responsible for completing and updating care plans. She further stated that a comprehensive care plan was required within seven days of admission, and based on the timeline, the facility should have already identified Resident #1's pattern of shower refusals and incorporated that information into her care plan. The DON stated she was not involved in the development of Resident #1's care plan. She reported that the most recent care conference on file occurred on 5/28/25. During an interview on 6/12/25 at 12:13 pm, the ADON stated that all members of the nursing department were expected to follow best practices, which involve breaking down the care plan into specific domains such as medical management, ADLs, medications, and therapies. She stated that a proper care plan would include clearly defined ADL goals and interventions, and that failure to do so poses a risk to continuity of care. During an interview on 6/13/25 at 2:55 pm, The Administrator stated he was made aware that Resident #1 had a history of refusing care, including showers. The Administrator stated that such behaviors should have been care planned to reflect the resident's specific needs. The Administrator stated there was a risk in not being fully informed of Resident #1's behavioral patterns, including how she responds to care interventions. The Administrator stated it was important to identify what strategies work for each resident and ensure appropriate interventions are in place. The Administrator stated that care approaches and planning are typically handled on a case-by-case basis . Resident #6 Record review of Resident #6's face sheet dated 06/12/25, revealed, admission on [DATE] and re-admission on [DATE] to the facility. Record review of Resident #6's hospital history and physical dated 12/09/24, revealed, a [AGE] year-old female diagnosed with Alzheimer's Disease (a progressive brain disorder that gradually destroys memory and thinking skills, eventually impacting the ability to carry out even the simplest tasks) and depression. Record review of Resident #6's care plan reviewed on 06/12/25, revealed wandering to be care planned for wandering regarding gait. Care plan did not address Resident #6 wandering into resident rooms . Record review of Resident #6's Facility self -report to state dated 05/01/25, revealed, Resident #7 hit call light and notified the RN E of incident which occurred. RN E notified RN F that Resident #6 entered room of another resident and attempted to remove Resident #7's graham crackers from her room. Resident #6 had the graham crackers slapped out of her hand. Head to toe assessment provided for both Residents. RN E and RN F at bedside with Resident #7 having no pain to left wrist/hand. Resident #6 was assessed left wrist/hand with no bruising, redness, or irritation . ROM present in all upper and lower extremities. Emotional, physical, and mental state, assessed, stable. Investigation was conducted confirmed. Other facility self-report dated 05/1/25, revealed, Resident #5 reported the incident. Resident #6 was noted rummaging through Resident #5's personal belongings. RN E notified RN F that Resident #6 entered room of another resident and attempted to remove Resident #5's belongings from her room. Resident #5 came out of the bathroom and noted Resident #6 touching her belongings. Resident #5 then pushed Resident #6 on the back and then Resident #6 turned around and scratched Resident #5 on the right hand. Pain medication was offered and head to toe assessments were conducted for both residents. Back noted with no bruises, redness, or irritation. ROM present in all upper and lower extremities for both residents. No emotional distress noted. Investigation was conducted and confirmed. Record review of Resident #6's Progress Notes generated by RN F dated 04/26/25, revealed, At 1:40 PM - Resident #7 had hit the call light and notified RN F of the incident which had occurred. Resident #6 entered room of another resident and attempted to remove Resident #7's crackers from her room. Crackers were slapped out of Resident #6's hand and wrist were grabbed. Resident #6 exited room. At 1:16 PM - Resident #6 entered room of another resident and attempted to remove Resident #5's belongings. Resident #5 then pushed resident on the back. Resident #6 turned around and scratched other resident on the right hand. Resident #6 exited room. During an interview on 06/10/25 at 2:05 PM, with the SW, she stated Resident #6 entered Resident #5's room going through her belongings. The SW stated Resident #5 had reported this to the nurse. The SW stated Resident #6 did not remember the incident and Resident #5 did not want Resident #6 going into her room. During an interview on 06/12/25 at 9:06 AM, with RN F, she stated Resident #6 had a habit of going into resident rooms to get stuff. RN F stated later in the day Resident #6 entered another resident room. RN F stated Resident #6's care plan should have addressed wandering and or going into residents' room. RN F stated care planning was so that nursing staff knew what kind to provide care for the resident. During an interview on 06/12/25 at 10:14 AM, with RN E, she stated she was told by Resident #7 that Resident #6 had gone into her room to try to take her graham crackers. RN E stated Resident #6 had a lot of behaviors and goes into other resident rooms. RN E stated the staff were constantly having to re-direct her and take her to the activities room. RN E stated it was care planned to go into other resident rooms. During an interview on 06/13/25 at 11:07 AM, with the DON, that this was Resident #6's normal behavior of going into other residents' rooms. The DON stated Resident #6 was placed on q15s and referred to psych (a primary care physician or other healthcare provider has recommended that a patient see a psychiatrist or other mental health specialist for further evaluation and treatment of a mental health concern) . The DON stated Resident #6 then went into another resident room. The DON stated Resident #6 went into Resident #5's room and was going through her stuff. The DON stated Resident #6 did not have anything care planned for wandering, going into resident rooms, or any focus area for behaviors. The DON stated it should have been addressed in Resident #6's care plan. The DON stated not care planning it could negatively impact the safety of the resident, violation of resident rights, and injuries to the residents to include her. The DON stated it was everyone responsibility to ensure it was care planned. During an interview on 06/13/25 at 3:41 PM, with the Administrator stated he could not confirm if it was care planned for Resident #6 on wandering and going into resident rooms. The Administrator stated it should have been care planned if it was not there. Resident #10 Record review of Resident #10 ' s face sheet dated 06/12/25, revealed, admission on [DATE] to the facility. Record review of Resident #10 ' s hospital history and physical dated 10/30/24, revealed, a [AGE] year-old male diagnosed with Parkinson ' s Disease, parkinsonism (a group of neurological conditions characterized by similar movement symptoms) and depression. Resident #10 did not have any diagnoses of sexual behaviors and or inappropriate behaviors. Record review of Resident #10 ' s quarterly MDS dated [DATE], revealed, a moderate impairment of cognition BIMS score of 9 to be able to recall or make daily decisions. No coding was noted for Mood or behaviors. Record review of Resident #10 ' s care plan dated 04/30/25, revealed, mood and behavior need as evidence by periods of refusing medications related to moderately impaired cognition. If resident was hallucinating to not argue or try to reason, assure him of his safety. Notify nursing. There was not focus area, goal, or interventions in the Resident #10 ' s care plan for sexual inappropriate behavior. Record review of Resident #10 ' s Facility self-report to the state dated 04/23/25, revealed, Resident #9 claimed that Resident #10 had come into her room on Tuesday (05/20/25) and exposed himself. Room change was offered to Resident #9, q15s was placed on Resident #10, psychosocial assessment was conducted on Resident #9, and psych refer was ordered for both residents. Investigation was conducted and was inconclusive. Record review of Resident #10 ' s Progress Notes generated by the DON dated 05/23/25, revealed, NP in facility, to evaluated resident as per incident. NP gave orders Ativan - 1 mg/1 tablet Q8 hours as needed. Behavior monitoring for 5 days. If increased behaviors or aggression it was okay to send to hospital. NP to evaluate resident for inappropriate behavior. During an interview on 06/10/25 at 2:28 PM. The SW stated Resident #10 lowered his pants and showered Resident #9 his private parts. The SW stated Resident #9 was given a room change and Resident #10 was referred to psych. The SW stated that sexual inappropriate behavior was not in his care plan. The SW stated it should have been care planned. The SW stated the risk of not care planning was not knowing he was capable of these behaviors and could do it again. During an interview on 06/13/25 at 12:12 PM, with the DON, he stated Resident #10 exposing himself was a new behavior. The DON stated she was informed that Resident #10 un-zipped his pants and exposed himself to Resident #9. The DON stated labs were ordered, referred to psych, room change, and placed on q15s. The DON stated it should have been care planned for sexual inappropriate or a new behavior. The DON stated not care planning places Resident #10 at risk of his safety and injury. The DON stated the nurses were responsible for care planning it. During an interview on 06/13/25 at 3:11 PM, The Administrator stated Resident #10 should have been care planned so everyone would know his behaviors to better provide care for him. Resident #12 Record review of Resident #12 ' s face sheet dated 06/12/25, revealed, a [AGE] year-old male diagnosed with anxiety and major depressive disorder, who was admitted on [DATE]. Resident #12 did not have diagnoses of sexual behaviors and or inappropriate behaviors. Record review of Resident #12 ' s quarterly MDS dated [DATE], revealed, a BIMS score of 11 indicating moderate impaired cognition. Resident #12 was not coded for mood or behaviors. Record review of Resident #12 ' s care plan dated 01/19/25, revealed, Resident #12 has physical interaction with another resident. Resident was receiver. Resident #12 will be encouraged for communication to report all changes and deviations from mood of others and self. There was nothing care planned for sexual inappropriateness or a focus on behaviors related to sexual inappropriateness. Record review of Resident #12 ' s progress notes generated by SW late entry on 06/09/25 for dated 06/03/25, revealed, SW visited with Resident #12 after reported allegation. Resident #12 informed SW that he had been in a relationship with a woman for 3-4 months and now she was trying to turn everything. SW attempted to re-orient Resident #12 to know that the Relationship might not have been that long as Resident #11 had not been at the facility that long. SW asked Resident #12 if the Resident #11 had ever told him to stop doing what he was doing, to which he stated No. Resident #12 stated she never told him to stop. Record review of Resident #12 ' s Facility self-report to the state dated 06/10/25, revealed, Resident #12 was witnessed by staff touching the breast of Resident #11. Resident #11 was given a head-to-toe assessment with no injuries. Resident #11 was not in distress nor pain. Resident #12 was placed on q15s, psychosocial assessments conducted, and referred to psych. Investigation was conducted and was confirmed. During an interview on 06/10/25 at 3:13 PM, with the SW, she stated Resident #12 told her that they were in a relationship and did not know why Resident #11 had turned her back on him. The SW stated Central Supply had witnessed Resident #12 reach out and grab Resident #11 ' s breast. The SW stated they immediately separated both of them and assessed them with no injuries. SW stated that both residents were referred to psych. SW stated they had increased monitoring on Resident #12. The SW stated there was a care plan meeting for Resident #12 to discuss the situation, but it was not care planned in the care plan. The SW stated it should have been care planned to prevent this from happening again. The SW stated the risk was another incident happening again. During an interview on 06/13/25 at 2:19 PM, with the Administrator, stated he could not confirm if Resident #12 was care planned for inappropriate behavior. The Administrator stated it should have been care planned. Record review of the facility's Care Plan Process, Person- Centered Care dated 5/5/23 revealed 6- The Interdisciplinary Team (IDT) will review for effectiveness and revise the person-centered care plan after each assessment. This includes both the comprehensive and quarterly assessments. For the comprehensive assessment the review will be completed within seven (7) days of V0200B2 and no more than 21 days after admission. 11- The person-centered care plan includes: A. Date B. Problem C. Resident goals for admission and desired outcomes D. Time frames for achievement E. Interventions, discipline specific services, and frequency F. Refusal of services and/or treatments: 1) Evaluation of resident's decision-making capacity; 2) Educational attempts; 3) Attempts to find alternative means to address the identified risk/need G. Discharge plans: 1) Resident's preference and potential for future discharge; 2) Resident's desire to return to the community and any referrals to local contact agencies and/or other appropriate entities, for this purpose. H. Resolution/Goal Analysis.

Based on observation, interview, and record review the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents for 1 of 7 (Resident #1) residents reviewed for abuse. The facility failed to follow their abuse policy when they did not perform a skin assessment following an incident. This failure placed Residents at risk for abuse and neglect. Findings included: Record review of Resident #1's face sheet dated 06/11/25, revealed admission on [DATE]. Record review of Resident #1's facility history and physical dated 05/21/25, revealed, an [AGE] year-old female diagnosed with chronic skin condition versus staphylococcal scalded skin syndrome (MSSA bacteremia - a bloodstream infection caused by the bacteria Staphylococcus aureus, which are susceptible to methicillin and other beta-lactam antibiotics). Record review of Resident #1's MDS dated [DATE] revealed BIMS score of 11, indicating her cognition was moderately impaired. Record review of Resident #1's care plan dated 6/6/25 revealed no focus area or interventions for Resident #1's refusal to shower. Record review of Resident #1's progress notes dated 5/28/25- 5/29/25 revealed there was no skin assessment documented following her behavior and/or allegation of mistreatment. Record review of Resident #1's skin assessment dated [DATE] did not specify reason for assessment and no abnormalities were found. During an interview on 6/11/25 at 11:15 am, CNA A stated that he was informed Resident #1 had alleged that he beat her up during a shower while she was on the gurney. CNA A stated that CNA B had asked him to assist with the shower. CNA A stated that he retrieved soap and began scrubbing the resident's back and hair due to visible dandruff. CNA A stated that midway through the shower, Resident #1 began saying that her cellphone had no battery and that she would call 911. CNA A stated that Resident #1 was not screaming and remained compliant until the water was applied, which he described as warm. CNA A stated after the shower, LVN D assisted him in transferring her back to bed after the shower and no cocnerns were voiced at that time, she had already been calm. CNA A described Resident #1 as having extremely dry skin and noticeable body odor, which he attributed to her refusal to shower. CNA A believed that Resident #1 became upset because she was given a shower. CNA A stated that this was the resident's first shower since admission and that she required a two-person assist. During an interview on 6/11/25 at 1:51 pm, CNA B stated that it was her first time working with Resident #1 and that she had not worked with her since, as she had not been scheduled to that hall. CNA B stated that CNA A assisted with turning on the water and waited for it to get warm, and once the water made contact with Resident #1, she began to scream, so they stopped. CNA B stated that she did not understand what Resident #1 was saying because she was speaking in Spanish. CNA B estimated they were in the shower room for approximately 8 to 10 minutes and attempted to complete the shower as quickly as possible. CNA B denied hitting Resident #1. During an interview and observation on 6/11/25 at 2:16 pm, Resident #1 was alert and oriented to person, place, and event. Resident #1 was observed with hair that appeared disheveled and uncombed, with strands scattered in multiple directions. Resident #1 had a strong body odor and visible white, flake-like substances on her skin. Resident #1 stated she only remembered receiving one shower approximately three or four weeks ago. Resident #1 stated she was taken into the shower on a gurney and that staff were putting water all over her in all directions. Resident #1 stated she felt scared because it was the first time someone had done this. Resident #1 stated she told staff she was going to call the police but ultimately did not. Resident #1 stated she could not recall the staff involved and was unable to describe them. Resident #1 stated that since then, she had been showered in different shower rooms and only required assistance with adjusting the water temperature. Resident #1 stated she was able to shower herself and now felt safe but still wanted to leave the facility. Resident #1 stated her most recent shower occurred three days ago. During an interview on 6/12/25 at 10:16 am, LVN D stated Resident #1's skin appeared very scaly and dry, and she had a strong body odor. LVN D stated that on the day of the incident (5/28/25), Resident #1 agreed to a shower. LVN D stated that once the shower was completed, he assisted with transferring Resident #1 back to bed. He stated that Resident #1 did not voice any concerns or make any statements upon returning from the shower. LVN D stated he was not made aware of any allegations until the following day when nursing administration brought it to his attention. He stated that no skin assessment was requested or conducted, and no staff reported any concerns to him at the time. During an interview on 6/12/25 at 11:41 am, The DON stated she was first notified of the allegation involving Resident #1 on 5/28/25 in the afternoon, after the morning shift had ended that Resident #1 had said she had been hit during the shower the day before. The DON stated she did not recall who initially reported the concern but believed it may have been either the floor nurse or the wound care nurse. The DON stated she was told that Resident #1 voiced that someone had scrubbed her too hard during the shower and that both hot and cold water were used. The DON stated she reviewed the documentation and found no progress notes or skin assessments completed on the day of the allegation, 5/28/25. The DON stated the only available skin assessment was timestamped 5/30/25 and did not specify that it was related to the allegation. The DON stated that, per facility policy, a progress note should have been completed to document both the skin assessment and the incident. The DON stated that the failure to document the assessment following the allegation was a failure to provide adequate care, ensure continuity of care, and properly intervene. During an interview on 6/12/25 at 12:13 pm, the ADON stated she was notified of the incident by the morning nurse (LVN D) the day after the shower (5/29/25), which occurred on 5/28/25. The ADON stated she was aware that staff had been attempting to get Resident #1 to accept a shower for several days and that the resident had finally agreed. The ADON stated that Resident #1 expressed in Spanish to her that she had been scrubbed too hard during the shower, which was the only concern initially verbalized . The ADON stated that after the concern was brought to her attention, she went to speak with Resident #1, who was with her family member at the time. The ADON stated that Resident #1 did not disclose any additional information other than saying she did not like the shower. The ADON stated that a skin assessment was attempted, but the resident initially refused due to being upset. The ADON stated she had to wait until the next day, when the resident's family member was present, to follow up. The ADON stated that a skin observation was conducted on the day of the shower and that she later completed a follow-up assessment. The ADON stated that the initial attempt to complete the skin assessment was not documented in the clinical record because it was considered part of the internal investigation. The ADON stated she declined to answer specific questions regarding documentation, noting that showers were considered part of direct care and routine treatments. During an interview on 6/13/25 at 2:55 pm, The Administrator stated the DON notified him of Resident #1's incident but he could not recall the exact date. The Administrator stated the DON conducted an investigation. The Administrator stated that following the incident, body assessment should've been completed. The Administrator stated that the risk of not completing a skin assessment after the incident would be the inability to determine if any injuries occurred. The Administrator stated the ADON and DON should have been following up to ensure all required documentation was in place. The Administrator stated that education on documentation was provided on a case-by-case basis. Record review of the facility's Abuse, Neglect, Exploitation, or Mistreatment policy dated 11/1/2017 read in part on page #7 7. Guidelines for Investigation: A. Immediately assess the resident/patient at the time of discovery of alleged abuse. B. Document assessment in the medical record.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation and food storage. -The facility failed to ensure the kitchen staff used beard restraints to prevent food contamination. -The facility failed to keep a deep fryer covered, free of food particles and burnt oil. -The facility failed to store opened food containers in the food preparation area and dry storage room in sealed containers. -The facility failed to label, and date opened foods stored in the dry storage room and refrigerator. These failures could place residents at risk of food borne illnesses. Findings included: Observation on 03/11/25 at 7:50 a.m. with the Dietary Manager revealed [NAME] D had a short beard and no beard restraint while he was serving breakfast. The Deep Fryer was uncovered, contained burnt oil and the deep fryer basket had food particles around the edges; white plastic container labeled Thickener stored in the food preparation area was not completely sealed; opened thickened milk container stored in the refrigerator was not dated; opened bag of noodles stored in a plastic bag that was not sealed; opened box of tea that was not dated when opened; large bag of peeled garlic bulbs stored in a plastic bag that was not sealed; Hashbrown and Potato bags stored in refrigerator were not dated; bag of cauliflower was not dated. The Dietary Manager said dietary staff had been trained to store opened food containers in sealed plastic bags or sealed plastic food containers to prevent food contamination to prevent exposing the food to dust, and pests. The Dietary Manager said dietary staff had also been trained to label and date food containers when food was removed from the original containers and to date food containers upon delivery and when opened. Observation on 03/13/25 at 7:50 a.m., revealed [NAME] D was serving breakfast and did not have a beard restraint. The Dietary Manager was in her office located in the kitchen directly across the serving line and cook preparation without a hairnet, while the cook was serving breakfast. In an interview on 03/13/25 at 10:24 a.m., the Dietary Manager said the dietary staff had been trained 4 months ago on the importance of using hairnets and beard restraints while working in the kitchen to prevent hair from contaminating food and food-contact surfaces, thereby ensuring food safety and hygiene. Observation 03/13/25 at 10:51 a.m., [NAME] D revealed he was preparing food in the food preparation area, by the serving line without beard restraint. Interview on 03/13/25 at 10:57 a.m., [NAME] D revealed he had been employed at the facility for 7 months and he had been trained to use hairnets and beard restraints when working in the kitchen to prevent food contamination. He said I use a beard cover most of the time. I have not had time to shave off the beard, so I don't have to use a beard cover. He said the dietary staff had been trained to put opened food containers in sealed plastic bags and/or sealed plastic containers to prevent food contamination. Record review of the Food Code 2022 reflected the following: (C) Packaged Food shall be labeled as specified in law, including 21 CFR 101 Food Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S 3-202.18. 3-202.15 Package Integrity. Food packages shall be in good condition and protect the integrity of the contents so that the FOOD is not exposed to ADULTERATION or potential contaminants. Record Review of the facility's Policy and Procedure on Food Safety in Receiving and Storage dated 06/20/23 revealed, General Food Storage Guidelines: Store food in its original packaging is clean, dry, and intact. Place food that is repackaged in leak-proof, non-absorbent, sanitary container with a tight-fitting lid. Dry Storage Guidelines: Tightly seal opened packages to prevent contamination or place food in covered containers. Refrigerated Storage Guidelines: Separate unwashed produce from washed fruits and vegetables and other ready to eat foods. Refrigerated, ready to eat foods are properly covered, labeled, dated with a use-by-date, and refrigerated immediately. Review of the facility's policy and procedures on Safe Food Handling dated 06/20/2023 revealed, Subject: Safe Food Handling. Policy: Food acquisition, and distribution will comply with accepted food handling practices. Food/Beverages Prepared and Served by Facility Staff for Patients or residents: General Requirements: Anyone working in the kitchen during normal food preparation hours are expected to wear appropriate hair restraints (such as hats, hair covers or nets, beard restraints).

Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 1 of 1 meal viewed for food temperatures. -The facility failed to maintain food hot on diet serve test trays. This failure could place residents at risk of weight loss, altered nutritional status, and diminished quality of life. Findings included: Observation and interview on 03/11/25 at 12:17 p.m., with the DON revealed a mobile Sheet Pan Rack covered with a clear trash plastic bag that contained lunch meal trays in the 200 Hall. When the state surveyor asked the DON, how was the food kept warm? The DON did not reply. Observation and interview 03/11/25 at 12:50 PM, with the DON revealed another mobile Sheet Pan Rack was in resident hallway covered with a clear plastic trash bag that contained lunch meal trays. The DON said the mobile Sheet Pan Rack were covered with a clear plastic trash bag to keep the meal trays warm. Interview on 03/12/25 at 12:00 p.m., with Dietary Manager said the mobile Sheet Pan Rack used to transport meal trays to the resident halls were covered with clear plastic trash bags to help keep the food hot in the meal trays. Sampling of the test trays on 13/14/25 at 12:17 p.m. through 12:29 p.m., in the conference room, with the Dietary Manager revealed the following: The Regular Diet Tray: *Pot Roast with brown, gray was 135-degree Fahrenheit; *Peas 133 degrees Fahrenheit; *Mashed potatoes with brown, gray was 123-degree Fahrenheit; *Cream Pie 19-degree Fahrenheit. The Mechanical Diet Tray: *Pot Roast with brown, gray was 133.7-degree Fahrenheit, *Peas 132.7-degree Fahrenheit; *Mashed potatoes with brown, gray was 131.5-degree Fahrenheit. The Pureed Diet Tray: Pot Roast with brown, gray was 125.9-degree Fahrenheit; *Peas 135.6-degree Fahrenheit; *Mashed potatoes with brown, gray was 124.7-degree Fahrenheit; *Bread 130.5-degree Fahrenheit. The Dietary Manager confirmed that several of the temperatures on the test trays were cold. She said foods that are below the required temperature will be reheated for 15 seconds in the microwave or until the food was reheated to 165 degrees Fahrenheit prior to serving to the residents. The Dietary Manager said the facility only had 2 insulated meal carts and 2 metal meal carts since she started working at the facility in 2021. She said that occasionally the residents in the 300 and 400 halls complained that food was served cold. She said, The food might get cold, depending on when the CNAs pass out the meal trays. She said that hot foods should be 140-164-degree Fahrenheit and cold food below 40-degree Fahrenheit. Review of facility's policy and procedures on Safe Food Handling dated 06/20/2023 revealed, Subject: Safe Food Handling. Policy: Food acquisition, and distribution will comply with accepted food handling practices. Food/Beverages Prepared and Served by Facility Staff for Patients or residents: All food are stored, prepared, and served at temperatures that prevent bacterial growth. Hot foods are maintained at 135 degrees Fahrenheit or higher and cold foods are maintained at 40 degrees Fahrenheit or below at point of service. At point of delivery, hot foods and cold foods should be palatable and consumed within 2 hours or discarded.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, safe and secure storage of medications for 3 of 4 medications carts (Hall 100 medication cart, Hall 200 medication cart and Hall 300 treatment cart ) reviewed for medication storage. -The facility failed to ensure liquid medication stored in medication cart did not have dried drippings on the sides of the bottles in the 100 Hall. - The facility failed to ensure the bottle of Betadine stored in the treatment cart and in medication cart (Hall 300) was free of dried drippings. -The facility failed to ensure a bottle of Chlorhexidine Gluconate solution stored in medication cart (hall 200) was free of dried drippings. This failure could result in drug diversion of controlled substances. These failures could affect residents that received medications at the facility by placing them at risk of not having prescribed medications and cross contamination. The findings included: An observation of the 200-hall medication cart on 03/12/25 at 11:11 a.m. revealed a bottle of Betadine Iodine and a bottle of Chlorhexidine Gluconate solution with dried drippings running down the side of the bottle. Hall 100 An observation of the 100-hall medication cart on 03/12/25 at 2:30 p.m. revealed a bottle of pro-stat liquid medication with dried drippings running down the bottle. An observation of the (hall #300) treatment cart on 03/12/25 at 11:37 a.m. revealed a bottle of Betadine Iodine with dried drippings running down the bottle. Interview on 3/12/25 at 2:30 p.m. with LVN B revealed that all medication bottles needed to be clean after each use because storing dirty bottles could lead to cross contamination. Interview on 3/13/25 at 9:30 a.m. with LVN A revealed all medication bottles needed to be clean. He stated they should be cleaned after every use before being put away. He stated since it was an iodine bottle, and since it is hard to keep clean because it runs everywhere, it was not a big deal. He stated that storing dirty bottles can lead to cross contamination. Interview on 3/13/25 at 2:38 p.m. DON stated that medication bottles should have been stored up right and clean. She stated staff were trained to clean bottles after each use to prevent cross contamination. She stated that she was unsure of when the last training was done for staff. Interview on 3/14/25 at 9:55 a.m. with regional nurse revealed that medication bottles should be cleaned after each use. She stated that it was hard to keep bottles clean because Iodine stains easily and pro-stat medication was very sticky. She stated storing medication bottles like this would lead to cross contamination with other medications in the cart. Record Review of facility policy Medication Management Program dated 7/1/16 revealed no specific instructions on keeping bottles clean and free of dried drippings.

Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for 2 of 12 residents (Resident #48 and Resident #146) reviewed for environment, including but not limited to receiving treatment and supports for daily living safely. The facility failed to ensure Resident# 48's belongings were not damaged when moved from rooms. Resident# 48's portable closet was broken by the facility staff and was not replaced. The facility failed to ensure Resident # 146 resided in a room with a homelike environment by aiding with personalization of the side of his room with personal items. These failures placed residents and staff at risk of living, working and visiting in an uncomfortable environment and a decreased feeling of well-being and satisfaction within their physical surroundings. Findings include: Resident # 48 Record Review of Resident # 48's Admission Record dated 01/22/2025 revealed she was a [AGE] year-old female admitted on [DATE]. Her diagnosis included toxic liver disease with hepatitis, unspecified lack of coordination, personal history of COVID-19, muscle wasting and atrophy. Record Review of Resident # 48's quarterly MDS dated [DATE] reflected a brief interview for mental status score of 15 (cognitively intact). It revealed she required limited assistance with bed mobility and transfer. Record Review of Resident # 48's Care Plan created on 2/13/25 reflected Resident# 48's had to be oriented to changes in environment such as new furniture and room changes. It revealed Resident# 48 was having periods of moods and behaviors by refusing facility transportation to appointments and the staff needed to attempt non-pharmacological interventions and document interventions on the Behavior Monitoring Flow Record, Non-pharmacological interventions included meeting her physical needs, activity programs (music therapy, exercise, outdoor time), quiet time and rest (reducing disruptive stimuli), redirection/ reassurance, increased observation, validation, consistent caregivers and psychological services. It revealed that the facility needed to communicate with the resident and made sure Resident# 48 understood prior to beginning any task. The facility was to inform the resident of intent, offer verbal one step directions for tasks, maintain a calm and slow approach, to not argue with the resident and to allow extra time for her to communicate her needs. It stated the facility needed to notify families of changes in resident status or of new or escalated behaviors to get their input as to suggestions or recommendations of interventions and approaches. It stated Resident# 48 was at risk of negative outcomes of her psychological wellbeing related to difficulty in nursing home placement. During an Observation and Interview on 03/11/25 at 10:22 AM, Resident# 48 stated her concerns of being moved from rooms without her consent and the facility breaking a portable closet that she had bought when her belongings were transferred from one room to the other. Resident# 48 said she had spoken to the Social Worker and asked to be moved to a different room. The Social Worker advised the resident she would discuss the possibility of moving her with the IDT (Inter Disciplinary Team). Resident# 48 explained one day after a doctor's appointment, she returned to the facility after 5:00 PM and her belongings had been moved to a different room. Resident# 48 stated she was upset because she had not been informed of the room changes and because she found her portable closet broken. Resident# 48 said she felt her rights had been violated for not including her on planning and making decisions as to when and where she was going to be moved. The portable closet was observed in Resident# 48's room. The closet had the resident's clothes hanging inside. The closet was bent to the front towards the opening of the plastic doors. In an interview on 03/12/25 at 02:12 PM with LVN I, she stated she was informed of Resident# 48's room change by the previous ADON in the month of January 2025 but did not recall the exact date. LVN I said after the resident's belongings were moved and she had come back from an appointment in the evening, Resident# 48 approached her and voiced she was upset that she was not notified about her transfer and from the facility touching her belongings without her being present. LVN I stated she apologized to the resident and told her she did not know the facility had not informed her about the transfer. LVN I said she reported Resident# 48's concerns to the ADON as she had been trained to do. LVN I stated the potential outcome of the facility transferring a resident to a different room without their consent could result in residents feeling angry and making them think the facility does not take them into consideration when making decisions. LVN I said Resident# 48 was alert and oriented and should have been included in making those decisions. In an interview on 03/12/25 at 02:39 PM with the Administrator, he stated he was not working for the facility when Resident# 48 was transferred to a different room. He stated he did not know if the resident was given notice prior to getting relocated. The Administrator said he had received a report at the end of February 2025 of Resident# 48's closet being broken when her belongings were moved, and he was going to replace it immediately. The Administrator stated he had not been able to replace the closet because he had to leave the facility for ten days. He stated the potential outcome of a resident not being notified or being able to participate in making decisions of when and where they will be moved could result in residents feeling like their opinion did not matter to the facility. In an interview on 03/12/25 at 03:26 PM with the DON, she stated that for room transfers, the residents or responsible parties needed to be notified before they are moved. The DON said the Social Worker would be responsible for handling a room change and would need to talk to the resident or their representative about the room transfer. The DON stated she had heard in a morning meeting some days ago that Resident# 48 had voiced concerns for not being taken into consideration when she was transferred to a different room and the resident being upset about a broken item. The DON said the Administrator and Social Worker stated during the morning meeting they would talk to Resident# 48 to address her concerns. The DON said that after that meeting, she did not hear anything else about the concerns expressed by Resident# 48 and she had assumed the concerns from the resident had been addressed. The DON said by the facility not including a resident on making decisions about transferring rooms, could result in them feeling angry and frustrated and feeling they do not matter to the facility. In an interview on 03/12/25 at 04:07 PM with Social Worker L, stated that during a morning meeting she presented the request to relocate Resident# 48 to a different to the IDT and they approved the transfer. Social Worker L said that a day passed without the resident being moved so the following day at the 3:00 PM IDT meeting, she reminded the members of team about Resident# 48's transfer and requested an update. Social Worker L stated that the previous DON appeared to be frustrated and asked the IDT who would volunteer to move Resident# 48's belongings after the meeting was concluded and several members volunteered to complete the task, including Social Worker L. She stated that those who volunteered moved Resident# 48's belongings to a different room while she was out at a doctor's appointment and when the resident returned to the facility, she was informed of the transfer. Social Worker L said Resident# 48 became upset and expressed her concerns to her stating her rights had been violated for touching her belongings without her consent and for moving her without giving her notice. Social Worker L said Resident# 48 also reported to her that the portable closet in her room had been damaged during the transfer of her belongings and requested for it to be replaced. Social Worker L stated she agreed Resident# 48's right had been violated due to the facility's failure to follow their policies and procedures for room changes. Social Worker L stated moving a resident from rooms without them being notified or included in the process could lead to residents feeling angry, frustrated or disregarded. Record Review of the facility's Grievance Summary dated 1/17/25 completed by the Social Worker stated Patient would like to submit a formal grievance for having her room changed without notification. Patient reports her closet was also damaged by staff member during room change, due to it no longer standing straight, adding that it now slants to the side. Record Review of the Resident Rights document provided to Resident# 48 by the Ombudsman stated in part: You have the right to keep and use your own property if the property is not harmful to others. Examples of your personal property include . furniture . The facility must have policies to protect your personal property from loss, damage, theft, or misuse. Resident # 146 Record Review of Resident # 146's Admission Record dated 03/13/2025 revealed she was an [AGE] year-old male admitted on [DATE]. His diagnosis included unspecified dementia, anxiety, pain disorder exclusively related to psychological factors, Alzheimer's disease, attention and concentration deficit and cognitive communication deficit. Record Review of Resident # 146's quarterly MDS assessment dated [DATE] reflected a BIMS score of 04 (severe cognitively impaired). It revealed he required limited assistance with bed mobility, transfers, eating and toilet use. Record Review of Resident # 146's Care Plan created on 3/11/25 reflected Resident# 146 wondered around the facility and entered other resident's private spaces. It stated the facility's approach as attempting to identify patterns of increased wandering when there were change of shifts or after his family had visited him. It stated Resident# 146 needed to be assessed for activities as a potential intervention. It stated the resident was having mood and behavior needs evidenced by periods of physical aggression. In an observation on 03/11/25 at 10:30 AM revealed Resident #146 was not in his, room [ROOM NUMBER]. The bed lacked linens, and the room was empty. There were no signs of residency except for snacks on the nightstand. The walls were bare, lacking any personal touches. In an interview on 03/11/25 at 2:43 PM with Resident #146, he stated it would be nice to have pictures or a plant in my room. The resident was confused and after the statement he walked away. In an interview on 03/12/25 at 01:58 PM with CNA H she stated that it was important for the residents to feel like their room was their home. She said it was the responsibility of all staff from the facility to ensure the residents felt comfortable and safe. She stated the potential negative outcomes of a resident living in a room without any personal items or personalization could result in the resident feeling lonely or as if they did not belong. In an interview on 03/12/25 at 02:19 PM with LVN I stated Resident #146 had been moved to his current room around January 2025. LVN I said she knew Resident #146 had dementia and to her knowledge, only a family member visited him about once a month. She stated she did not know why his room lacked personal items. LVN I said the potential negative outcome for not personalizing a resident's room could result on them feeling loneliness and feelings of not belonging. In an interview on 03/12/25 at 02:51 PM with the Administrator said he was familiar with Resident #146 but not with his room's details. The Administrator stated the lack of a homelike environment could potentially result in the resident feeling isolated and could contribute to his feelings of anxiety or depression. In an interview on 03/12/25 at 03:34 PM with the DON, she stated it was important for residents to have personal belongings so they felt at home and avoid seclusion. She did not know who was responsible for ensuring room personalization. The DON said she did not know Resident #146's room was bare and lacked personal items in the room. The DON said the potential negative outcome for the facility failing to ensure a resident's room looked homelike could result in them feeling isolated and for them to feel they did not belong in the facility. In an interview on 03/13/25 at 03:14 PM with Social Worker L stated that Resident #146 had been at the facility for two years. She said the resident was diagnosed with dementia, Alzheimer's, and was cognitively impaired. Social Worker L said that in her interactions with Resident #146, he voiced that he believed he was at work most of the time. She said the resident's family member visited twice a month, and Resident #146 carried photos of his family members in his pockets. Social Worker L said she had consulted with Resident #146's family member and had been able to corroborate the people in the pictures as his family members. Social Worker L stated she thought it would be good if he had those pictures posted on the walls of his room, as it could potentially help reduce his wandering behaviors. Social Worker L stated she believed the facility should encourage room decorations, and that not having a more personalized environment could lead to residents feeling alone, abandoned, or like they didn't belong. She said that by not personalizing the resident's room it could also contribute to wandering and promote anxiety and depression. On 03/13/25, Resident# 146's emergency contact and responsible party was attempted to be contacted for an interview at 2:49 PM and 3:25 PM without success. Identification and contact information were left in her voicemail and a call back was requested. On 03/14/25, Resident# 146's emergency contact and responsible party was attempted to be contacted for an interview at 2:21 PM without success. Identification and contact information were left in her voicemail and a call back was requested. Record Review of the facility's policy revised on 11/1/2027 titled Resident Room, Environmental, stated in part: The facility provides the resident/patient with an environment that preserves dignity, privacy and contributes to a positive self-image. Resident rooms are designed and equipped for adequate nursing care comfort and privacy for residents. Promoting and preserving resident independence and self-sufficiency should be considered when arranging the resident living space .

Based on record review, interview and observation, the facility failed to ensure residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 4 residents reviewed for pressure ulcers. - The facility failed to perform wound care according to physician orders for Resident #1 on 09/02/23 and 09/03/23 that lead to worsening of the wounds. Resident #1's stage IV pressure sore on his left hip increased in size and depth and left heel unstageable (full-thickness pressure injuries in which the base is obscured by slough and/or eschar) pressure sore increased in size. - The facility failed to perform repositioning and offloading for Resident #2 on 10/06/23, 10/09/23, 10/10/23, and 10/11/23. This failure affects residents by placing them at risk of developing pressure ulcers/wounds, worsening pressure ulcers/wounds, and could cause pain, infection, or hospitalization Findings included: Resident #1 Record review of Resident #1 ' s face sheet dated 10/05/23 revealed a [AGE] year-old male admitted on [DATE] to the facility. Resident #1 was diagnosed with pressure ulcer with unspecified site (skin or soft tissue injuries that form due to prolonged pressure exerted over specific areas of the body and the condition is unknown at the time of coding), unstageable (a type of bed sore that occurs due to prolonged pressure on a specific area of the skin, resulting in the lack of blood flow and oxygen to the tissue), disruption (the act or process of breaking apart or rupturing) of wound. Resident #1 had passed away a week earlier unrelated to pressure ulcers. Record review of Resident #1 ' s admission MDS dated [DATE] revealed Resident #1 had a brief interview score of 6 for mental cognition which indicated severe impairement. Resident #1 required extensive assistance with one person for bed mobility and extensive assistance with two person transfers and personal hygiene. Resident #1 was at risk for the development of pressure ulcers and uses pressure reducing device for chair and bed. Record review of Resident #1 ' s care plan dated 09/12/23 revealed decreasing size of pressure ulcer(s), goal was to do wound care as ordered. CNAs too inspect skin daily during bathing and licensed nurse to do skin check weekly. Record review of Wound Care Administration History with a print date of 9/14/23 indicated the following orders Metronidazole gel 0.75% amount to administer; 1 application; topical once a day apply thin layer to left hip ulcer for a diagnosis of pressure ulcer of unspecified site unstageable with a start day of 8/29/23-9/11/23 (DC Date) Record review of Wound Care Administration History with a print date of 9/14/23 indicated the following orders Metronidazole gel 0.75% amount to administer; 1 application; topical once a day apply thin layer to left hip ulcer for a diagnosis of pressure ulcer of unspecified site unstageable with a start day of 9/11/23-open ended. Record review of Resident #1 's administration report dated 09/02-09/03 revealed wound care for both heels was not done, daily wound treatment was not done as indicated by x marks, daily wound treatment to the left hip was not done, right hip apply foam dressing was not done, saline wound wash was not marked, Santyl was not given. Record review of Resident #1's 10/05/23 reflected left hip pressure ulcer stage IV (Full thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bone, or supporting structure (such as tendon, or joint capsule) for 08/31/23 measured 3 cm by 3 cm by 1.5 cm. Measurements taken on 09/06/23 for left hip measured 5.3 cm by 3.8 cm by 2 cm. The left heel pressure ulcer for 08/31/23 measured 4 cm by 4.5 cm by 1 cm. Measurements taken on 09/06/23 for left heel measured 5 cm by 6.3 cm by 1 cm indicating the wound had worsen. Confidential interview on 10/04/23 at 10:16 AM the Confidential caller stated they had received a call from the facility Wound Care Nurse letting them know that wound care had not been performed for Resident #1 on 09/02-09/03/23. Confidential caller stated the wound care nurse told the facility nurses that she had left all the wound care supplies to be able to perform wound care for the residents. Confidential caller stated they had sent the facility wound care orders and educational material on how to perform wound care. Confidential caller stated the wound care nurse told them the floor nurses were able to perform the wound care. Confidential caller stated Resident #1 was brought into their facility to be checked out and revealed Resident #1 ' s pressure ulcers had worsened. Confidential caller stated Resident #1 ' s wounds already had a foul smell and combined with not changing the dressings the pressure wounds had grown in size. Interview on 10/04/23 at 1:30 PM with LVN Q stated she was not trained to conduct wound care on Resident #1 as far as what needed to be done and what had to be done for Resident #1. LVN Q stated she conducted wound care on Resident #1 on the weekend of 09/02-09/03/23. LVN Q stated she received no one's help and used the basic supplies to change the pressure dressings. LVN Q stated she managed to change Resident #1's pressure wound dressing. LVN Q stated she documented the change of dressing on a late entry on 10/14/23. LVN Q did not indicated the time and date she changed Resident #1's wound dressing. Interview on 10/04/23 at 3:22 PM with Wound Care Nurse stated weekend nurses are able to change residents wound dressings. The Wound Care Nurse stated Resident #1 ' s wound care was not performed for 09/02-09/03/23 by the weekend nurse. The Wound Care Nurse stated she told the facility staff where the wound care cart keys were, and hallway 300 nurse had a key as well. The Wound Care Nurse stated she notified the Managed care and provider of medical services for Resident #1 that wound care had not been done for the resident. Wound Care Nurse stated she knew the wound care had not been done because it was not documented in the system and the dressings were not labeled/dated plus there was more drainage on the dressing. The Wound Care Nurse stated she reported to the ADON/Interim Wound Care Nurse E and the managed care and provider of medical services for Resident #1 wound care had not been done and filled out a grievance form. The Wound Care Nurse stated from the time she started working at the facility two months ago to 09/29/23 Resident #1s pressure ulcers were getting worse. The Wound Care Nurse stated it was expected if the orders stated for the resident to have wound care done daily that it needed to be done. The Wound Care Nurse stated the risk of not doing wound care could be infection and more macerated (occurs when skin is in contact with moisture for too long). Interview on 10/05/23 at 2:21 PM with the ADON/Interim Wound Care Nurse E stated according to the facility documentation, family, and managed care and provider of medical services Resident #1 had not received wound care on 09/02-09/03/23 as ordered. The ADON/Interim Wound Care Nurse E stated the facility confirmed there was not documentation indicating there had been any wound care done for Resident #1. The ADON/Interim Wound Care Nurse E stated the floor nurses and weekend supervisor confirmed that wound care had not been done for Resident #1 on 09/02-09/03/23. The ADON/Interim Wound Care Nurse E stated it was expected for the nurses to conduct wound care on residents that need to have wound care done. The ADON/Interim Wound Care Nurse E stated if wound care was not done then the resident was at risk of the wound getting worse and infected. The ADON/Interim Wound Care Nurse E stated all nursing carts have wound supplies and have the keys to be able to open the wound care cart. The ADON/Interim Wound Care Nurse E stated LVN Q would have had the basic supplies to do wound care except the antibiotic, which was a powder and was only in the wound care cart and no other carts. The ADON/Interim Wound Care Nurse E stated every nurse should know where to document for wound care and the risk of not documenting would be like it was not done. The ADON/Interim Wound Care Nurse E stated due to this incident 3 nurses and a weekend supervisor were written up, skin sweep was done in which the facility identified 3 new residents with skin issues, and resident audits. Interview on 10/11/23 at 3:42 pm with MD MM stated if a resident (generalized not to specific resident) missed a wound care for even two days that it would contribute to pressure wound worsening. Resident #2 Record review of Resident #2' s face sheet dated 10/05/23 revealed Resident #2 was admitted on [DATE] to the facility. Record review of Resident #2's history and physical dated 10/28/22 revealed a [AGE] year-old male diagnosed with muscle weakness (a lack of strength in the muscles), liver cirrhosis (a condition in which the liver is scarred and permanently damaged), and Alzheimer ' s disease with behaviors (decline in memory, thinking, and getting upset, worried, and angry more easily). Record review of Resident #2 ' s significant change MDS assessment dated [DATE] revealed a brief interview score of 3 for mental cognition which indicated severe impairment. Resident #2 ' s activities of daily livening for bed mobility and transfer was extensive with one person assistance. Resident #2 was at risk for developing pressure ulcers and used a pressure reducing device, turning/reposition program, pressure ulcer/injury care, nutrition or hydration intervention, applications for non-surgical dressings and ointments/medications. Record review of Resident #2 ' s Wound Management dated 10/05/23 revealed an identified sacrum wound stage IV on 08/31/23 to be 4.2 cm by 3 cm by 2.5 cm and on 09/06/23 it measured 5.3 cm by 3.8 cm by 2 cm worsening. On 08/31/23 an unstable left heel wound measured 3.5 cm by 6 cm by 0 cm and on 09/06/23 it measured 5 cm by 6.3 cm by 1 cm worsening or growing bigger. Record review of Resident #2 ' s Care plan dated 12/24/22 revealed risk of skin breakdown due to history of immobility and pressure ulcers. Keep off his back and turn frequently. Turn and reposition frequently. Observation on 10/06/23 at 9:20 AM revealed Resident #2 was laying down in air mattress evaluated with pillow placed in back of the head. Resident was facing upwards. Semi-covered with blue cushion boots on both feet. Observation on 10/06/23 at 10:50 AM revealed Resident #2 was on his back evaluated in air mattress with pillow behind his head. Semi covered as before with blue cushion boots on. Observation on 10/06/23 at 3:08 PM revealed Resident #2 was laying down evaluated on his back covered up wearing his cushion boots as they stuck out of the cover. Observation on 10/09/23 at 8:34 AM revealed Resident #2 was laying on his back semi covered with his cushion boots on. Pillow in back of head, do not see pillow underneath his back to ensure resident was offloaded. Interview on 10/09/23 at 9:10 AM with CNA U stated the residents are to be repositioned every two hours when CNAs are doing their rounds. CNA U stated the risk of not repositioning could be the residents could get injuries. Interview on 10/09/23 at 9:15 AM with CNA JJ stated she always checks on the residents every one to two hours. CNA JJ stated residents are to be turned or repositioned every two hours to prevent pressure ulcers from forming. Observation on 10/09/23 at 10:01 AM revealed Resident #2 was on his back lying in his bed with the pillow behind his head in same position, covered with his cushion boots. Observation on 10/09/23 at 11:31 AM revealed Resident #2 remains on his back lying in air mattress in the same position as before with pillow behind head, covered with cushion boots showing. Interview on 10/09/23 at 11:35 AM with LVN I stated facility staff have been trained to reposition the residents. LVN I stated the risk of not repositioning residents could result in the resident(s) getting hurt. Observation on 10/09/23 at 1:37 PM revealed Resident #2 was lying down on his back with pillow behind head. Green cushion boots on and a pillow towards his right foot. Observation on 10/09/23 at 3:01 PM revealed Resident #2 was on his back on his air mattress with his cushion boots on. Pillow was placed behind his head and covered in the same position as before. Observation on 10/09/23 at 4:55 PM revealed Resident #2 was lying on his back awake looking up with pillow on his back of head. Cushion boots on. Not covered, no pillow seen underneath his back. Observation on 10/10/23 at 10:07 AM revealed Resident #2 was lying in air mattress on his back with pillow behind head and cushion boots on. Interview on 10/10/23 at 10:46 AM CNA II stated they had to reposition the residents every two hours. Observation and Interview on 10/10/23 at 11:47 AM with LVN N. Resident #2 was lying on his back with pillow behind head, cushion boots on and pillow on the tray table. No pillow or wedge seen behind back to offload resident. LVN N stated she there was no pillow(s) to offload Resident #2's back. LVN N stated offloading meant placing a pillow or wedge to get the resident off the wound. LVN N stated the purpose of repositioning Resident #2 was so there would be no skin break down, to prevent pressure ulcers, and prevent contractures. LVN N stated everyone was responsible for ensuring the residents were repositioned. LVN N stated she was unsure if the nursing staff were following Resident #2 ' s care plan of turning and repositioning him. LVN N stated not following the care plan could place the resident at risk of dying if the pressure ulcer gets infected and gets worse and not healed. Observation on 10/11/23 at 9:24 AM revealed Resident #2 observed to be laying down in bed. There is no pillow or wedge observed under resident. Legs are off-loaded with boots and pillow under legs. ADON turned resident to right side, and no pillow/wedge was observed under resident. Residents ' back is red/pink and shoulder bony prominence is also pink. Observation on 10/11/23 at 11:27 AM revealed Resident #2 on his back with pillow behind head. Cushion boots on and covered up. Pillow was underneath back and in between legs. Interview on 10/14/23 at 11:35 AM with the DON. The DON stated a resident ' s care plan needed to be followed. The DON stated if the care plan stated there needed to be repositioning then the nursing staff needed to follow it. The DON stated there could be a negative outcome of not following the care plan for repositioning. The DON did not state what the negative outcome would be. Interview on 10/09/23 at 2:16 PM with the DON stated the facility did not have a repositioning policy. Record review of the facility pressure ulcer policy dated 09/07/17 revealed pressure ulcers will be evaluated and treated in accordance with professional standards of practice and prevent pressure ulcers unless clinically unavoidable. Record review of the facility staff development for nursing employees dated 01/18/13 revealed: licensed nurses will have the specific competencies and skill sets necessary to care for resident ' needs as identified through resident assessments and described in the plan of care. Providing care includes but was not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident ' s needs. Proficiency of nurse aides. Nurse aides will demonstrate competency in skills and techniques necessary to care for the residents ' needs, as identified through the facility assessment, resident assessments, and described in the plan of care.

Based on Observation, interview and record review the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #2) of 7 reviewed for pain management residents by 3 of 4 staff members (LVN C, LVN B, and LVN F). A. LVN C did not reassess Resident # 2 on 9/26/21 on the evening shift when resident continued to have unrelieved pain to the left leg that worsen with minimal movement. B. LVN B did not assess or medicate Resident #2 for pain on 9/26/21 when resident continued to have unrelieved pain to the left leg throughout the day shift that worsen with minimal movement. C. LVN F did not administer pain medication on 9/27/21 on the evening shift when resident's pain level was 9-10, 10 being the worst pain while awaiting transport to ER for evaluation of dislocation of the left hip joint prosthesis and a fracture of the left thighbone just above the knee joint. This failure could place residents at risk for unnecessary pain, discomfort and decreased quality of life. The findings include: Review of undated Resident Face Sheet documented Resident #2 was admitted on [DATE] and readmitted on [DATE] from acute care hospital. Review of Quarterly Minimum Date Set (MDS) dated [DATE] for Resident #2 documented in part: Makes self-understood, usually understands others, BIMS score 9 (moderately cognitive impaired); ADLS-Extensive of two person with bed mobility, transfers; extensive assistance of one person with locomotion on and off unit, dressing, toilet use, and personal hygiene, total assistance of one person with bathing; no functional limitation in Range of Motion to upper & lower extremities; uses wheelchair; incontinent of bowel & bladder; no pain. Interview and Record Review 10/27/21 7:30 PM with DON in the presence of LVN N Medical Records reported undated Care Plan for Resident #2, documented admitted : 05/20/21: Care Plan did not address the resident had a non-surgical procedure to align a fracture of the tibia and fibula to the left leg and history of hip surgery with left leg internally rotated and shorter than the right leg. The DON stated, Care Plan was not updated when resident #2 was readmitted from the hospital on 09/29/21 with a dislocation of the left hip joint prosthesis and fracture of the left shinbone. Review of Hospital History and Physical dated 09/28/21 for Resident #2 documented in part: Chief Complaint: Pt. brought in from nursing home for left hip dislocation as per EMS no trauma. History of Present Illness: [AGE] year-old female with dementia, [CONDITION(S)], who was brought to the Emergency Department from nursing home after increasing left extremity pain for the past 24 hours. She denies any trauma, falls, or abuse. Per nursing home past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse states that during report her leg pain became suddenly severe. medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Uses a wheelchair. Past Surgical History: Surgical History of tibia & fibula with a procedure to line up the ends of a broken bone 05/01/2015. History of hip surgery 04/28/15. Review of Systems: Musculoskeletal: Left Leg Pain, tender to palpation at tibia, extremity internally rotated and adducted. Neurologic: Alert & oriented x 2. Not oriented to date or location. Assessment & Plan: CT left lower extremity a break in the shinbone just below the knee upper portion of the bone where it widens to help form the knee joint. [CONDITION(S)] affecting all three parts of left knee. Mild accumulation of fluid and swelling around the knee joint. The patient was given [MEDICATION(S)] in the Emergency Department and her condition improved. Ortho plan to treat nonoperatively. [MEDICATION(S)] for pain management, wean off to Tylenol 3 if possible. Consult PT after procedure. Review of SBAR Communication Form dated 09/27/21 written by LVN F for Resident #2 documented in part: Situation: Change in condition, symptoms observed and evaluated are pain inter-rotation, length discrepancy. This started on 09/26/21. Since this started it has stayed the same. Symptoms worsen with movement. Things that make the symptoms better are [MEDICATION(S)]. These symptoms have not occurred before. Background: Primary Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient unable to move lower left leg due to pain. Pain Evaluation: Resident has new complain of pain to left lower extremity below the knee. Intensity of pain (rate on scale of 1-10, with 10 being the worst): 6-7. Non-verbal signs of pain-grimacing. Appearance: Patient complaining of left lower extremity pain below the knee, stat x-ray showed hip dislocation and fracture to left thighbone near hip joint. NP notified 09/27/21 at 4:40 PM. Recommendations: Send out through EMS. Review of Radiology Report with DON on 11/09/21 at 11:00 AM, for Resident #2 documented: Date of Service: 09/27/21. Report Date: 9/27/21 9:57 AM. Left Hip one View: Results: There is dislocation of the left hip joint prosthesis. Conclusion: Dislocation. Left Knee 2 Views: There is a fracture of the left shinbone just above the knee joint. Electronically signed by MD 9/27/2021 9:57 AM MDT. Review of EMS Care Report dated 09/27/21 for Resident #2 documented in part: At Scene: 4:58 PM. Urgency: Immediate. LVN F on site reported they had called EMS due to patient having a dislocated left side of hip and fracture to left knee. NP at facility advised them to take x-ray due to patient pain stating a 2-10 pain scale and increases to a 10 -10 pain scale when touched or moved. Initial assessment left leg was rotated inward. Pt. had no other medical complaint. Transferred to Local Hospital ER. Interview on 10/26/21 at 11:26 AM CNA A reported Resident #2 was confused, able to voice needs, requires extensive assistance of one person with ADLs, incontinent of bowel and bladder, sits in a wheelchair, able to propel self for short distances, risk for falls, low bed with floor mat, is able to assist with turning & repositioning by using the grab bars on the sides of the bed. On Sunday 09/26/21, at the start of the shift resident was lying in bed complaining of pain to the left leg. When I attempted to pull the sheets back the resident asked me not to touch her because she was having a lot of pain to the left leg. I immediately went to report this to LVN B the nurse on duty. I remember CNA G who worked on the day shift on 9/25/21 told me resident was having a lot of pain to the left leg on her shift and had left resident in bed on that day. The resident usually complains of pain to the left leg when she is turned & repositioned, but on that day the pain was worse. Resident usually needs extensive assistance of one person to turn & reposition in bed using the grab bars but on Sunday 09/26/21 two of us had to assist the resident with turning because minimal movement made the pain worse and she yelled loudly, moaned, and had a facial expression of severe pain. I remember reporting to LVN B at least 2 more times during the shift on that day that resident continued to complain of severe pain to the left leg with minimal movement when we changed her brief. The resident always eats her meals in the main dining room but on that day, she ate her meals in bed because she was in a lot of pain. I do not know if LVN B assessed the resident or gave the resident something for pain on that day. CNA denied seeing any bruises or swelling to the resident's left lower extremity on Sunday 09/26/21. CNA reported they had been trained to immediately report any changes in condition to the nurse and not to move a resident when they complain of pain. Observation and interview on 10/26/21 at 11:31 AM, Resident #2 was sitting in a wheelchair listening to music in the main dining room. Resident was confused, only oriented to person, was only able to answer simple questions. Noted left knee was swollen and left leg had internal rotation. Resident gently touched her left knee and denied having pain. Resident was not able to remember is she had sustained a fall. Resident said, I hurt my leg, but do not know how it happened. Interview and Record Review on 10/26/21 at 5:02 PM with LVN F reported that he had worked on Monday 09/27/21 on the evening shift when Resident #2 was sent to the hospital for evaluation of pain to the left leg. I was assigned to the resident on Friday 09/24/21 on the evening shift and she was her usual self, no complaints of pain and sat in her wheelchair for meals. When I returned to work on Monday 09/27/21 the LVN B the 6-2 nurse reported at the change of shift that they had kept resident in bed on his shift, because she was having a lot of pain to the left leg. LVN B reported the night nurse LVN D had reported to the NP on 9/26/21 resident was complaining of pain and ordered a stat x-ray of the left leg which was done on the morning shift and results were still pending at the start of my shift. I went to the resident's room to assess the resident and she was lying in bed, which was very unusual for her because she is always sitting in her wheelchair at the start of shift. Upon assessment the resident, yelled out very loud, facial expression of severe pain, grimacing, with slight movement, very painful to touch and had [CONDITION(S)] to left knee. This was a new change in condition, the pain level was at 9-10, 10 being the worst pain upon assessment. The resident's baseline was an internal rotation and shortening of the left leg related to a hip fracture from previous admission. I got the x-ray report at approximately 3:00 PM - 3:30 PM, on that day that a hip dislocation of the left hip and a fracture of the thighbone above the knee joint. I immediately reported this to the NP, and he gave orders to send the resident to the hospital for evaluation. In an interview on 10/26/21 at 5:23 PM CNA H on the 2:00 PM-10:00 PM shift reported that Resident #2 usually requires one person to turn & reposition in bed using her grab bars on the side of the bed. CNA stated, I remember that I worked on the evening shift on 09/26/21 and had to ask another CNA to help me turn the resident to her side to change her brief because the resident could not assist with turning because she was having a lot of pain to the left leg with minimal movement. I noted that the left leg was turning inward, and the pain that she was having was very different from her usual complain of pain to the left leg. I had never seen her left leg turning inward until that day. She always sits in a wheelchair for meals and eats in the dining room. On that day we left her in bed because she was in a lot of pain. She would moan loudly, had facial grimacing when we touched her left leg to move her. We make rounds every two hours to check residents for incontinence and to turn & reposition. We only checked the resident #2 three times on that day because she was in a lot of pain and did not want us to touch her. I immediately reported this to LVN C the nurse. We have been trained to immediately report to the nurse when a resident complains of pain. I did not see if the nurse medicated the resident for pain on that day. Interview on 10/26/21 at 5:31 PM, CNA I, on the 2:00 PM-10:00 PM shift reported Resident #2 is confused, requires extensive assistance of one person with ALDS, incontinent of bowel & bladder, sits in a wheelchair for meals and can propel self for short distances. CNA stated Resident usually complains of pain to the left leg and the leg is turned inward. On Monday 09/27/21 she was in bed at the beginning of the shift in a hospital gown which was very unusual for her because she is always sitting in her wheelchair at the start of the shift. She does not like to stay in bed. The resident kept telling me that her left leg was hurting really, really, bad had facial grimacing, and did not want me to pull her sheets back because she kept saying that she was having real bad pain. The resident appeared to very anxious and restless moving her arms and upper body in bed. I immediately went to report this to LVN F. I remember that the nurse sent the resident to the hospital right away. In an interview 10/27/21 at 11:31 AM, with CNA G on the 6:00 AM-2:00 PM CNA G reported Resident #2 was confused, required extensive assistance of one person with ADLs, incontinent of bowel & bladder and uses disposable briefs. Her lower left has always been turning inward and cannot extend the leg. I worked on Sunday 09/26/21 on the evening shift and assisted another CNA to turn the resident to change her brief because resident was having a lot of pain with minimal movement. Resident was having a lot more pain to the left leg than usually, so we left her in bed on that day. I immediately reported to LVN C and told her that the resident needed something for pain. I do not know if LVN C gave the resident something for pain. I remember that I reported to LVN C two times on 9/26/21 during my shift that resident continued to complain of pain to the left leg with minimal movement. The resident did not eat much on that day because of the pain. She usually eats 100 % of her meals. She continued to complain of pain until the end of my shift. CNA A and I reported to LVN B the day nurse on Monday 09/27/21, that the resident was having a lot more pain to the left leg than on Sunday, and she would not even let us touch her. On Monday 9/27/21 the resident required two people to slightly turn her to the side to change the and she would yell loudly. Before this change of condition, the resident assisted to turn by using the grab bars on the side of the bed and only required one person assist. I remember that we reported to LVN C two more times during our shift that the resident was still having a lot pain to the left leg with minimal movement and did not want us to even touch her. I do not know if he went to assess the resident or if he gave her anything for pain. We have been trained not to move a resident when a resident is having a lot of pain until the Nurse has checked the resident. That is why we reported to [NAME] at the start of shift that the resident was yelling and saying that she was in a lot pain when we had attempted to move her. Interview and Record Review 10/26/21 at 7:07 PM with DON of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated, LVN C did not document in the Resident Progress dated 9/26/21 if the pain medications were effective or ineffective. I do not know why she did not document her pain assessment in the Resident Progress Note or that she had re-assessed the resident after administering pain medication the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Telephone interview 10/27/21 at 6:31 PM, LVN C reported she was assigned to Resident #2 on Saturday 09/25/21 and Sunday 09/26/21. Reported she works weekends from 6:00 AM - 6:00 PM. I remember that on Sunday 9/26/21 LVN K night nurse reported at the change of shift Resident #2 had been complaining of pain to the left leg during his shift. I medicated the resident with Tylenol for pain at the start of my shift, since nothing had been administered for pain by the night nurse during his shift. I remember that the CNAs reported to me on Sunday 9/26/21 during the morning shift resident was having a lot of pain to the left leg with minimal movement and did not want to get out of bed that morning. Resident had her meals in bed on that day, which is very unusual for her because she always sits in a wheelchair and eats in the dining room. The CNAs reported to the on-coming CNAs on the evening shift at the start of shift resident had stayed in bed all day, because she was having a lot of pain to the left leg. The resident continued to complain of pain to the left leg throughout the day, so I called NP late evening to report unrelieved pain with Tylenol and he gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . We have been trained to re-assess the resident after administering pain medication to see if the medication was effective and document assessment in resident progress notes. I do not remember if I documented my assessment in the resident's progress note on that day. We have a lot of problems with the x-ray company taking too long to come and do stat x-rays and getting x-ray results on a timely time frame. We have reported this concern to the DON & ADON, but the problem continues. Interview and Record Review 10/27/21 at 7:07 PM with DON of Resident Progress Note for Resident #2 dated 09/26/21 - 09/27/21 documented the following: -Review of Resident Progress Note written on 9/26/21 by LVN C documented at 6:37 AM, previous nurse LVN K reported Resident #2 was complaining of pain to left lower extremity the previous shift. Resident was administered PRN Tylenol at this time to help elevate pain. DON stated, LVN C did not documented in the Resident Progress Note or MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . -Review of Resident Progress Note written on 09/26/21 written by LVN C documented at 3:30 PM, Tylenol was ineffective Resident #2 continues with pain. Notified NP, new order for Tylenol #3 every 6 hours as needed. DON stated LVN C had not documented if she had assessed the resident prior to administering Tylenol #3 for pain or after administering Tylenol #3 to reassess if medication was effective. DON reported LVN #C had not document her pain assessment, time NP was notified of change in condition, and re-assessment to evaluate effectiveness of Tylenol #3. DON stated, LVN C should have also completed a PAINAD (Pain Assessment in Advanced Dementia) for Resident #2 on 09/26/21 when resident had a change in condition, was complaining of pain to the left leg and prescribed pain medication was ineffective. The nurses have been trained to complete a PAINAD for residents with dementia, when a resident has a significant change in condition and are complaining of pain. I do not know why LVN C did not complete a PAINAD for resident #2. -Review of Resident Progress Note written on 09/26/21 10:52 PM by LVN D documented (Recorded as Late Entry on 09/27/21 at 3:37 AM), Notified by incoming shift patient #2 complain of severe pain to her left leg. Patient assessed noticed left leg internally rotated, extremity shorter to opposite one, and complains of pain with minimal touch. Notified NP and requested x-rays to hip and knee to verify if any new or progression of old injury was possible. Orders received for the X-rays. Order X-ray stat, pending to be completed. DON reported LVN D had not documented if she had assessed and/or medicated the resident for pain on that day. -Review of Progress Note written on 09/26/21 10:54 PM by RN E Resident in bed with head of bed elevated, complaining of pain to left lower extremity pain. Upon assessment noted left kneecap to be internally rotated and leg shorter in length than right leg. Pain upon flexion and extension of left foot. Resident unable to tolerate movement of extremity. Charge Nurse (LVN D) notified. NP notified new orders for hip x-ray 2 views and knee x-ray. Charge Nurse (LVN D) to call in order. Will continue to monitor. -Review of Resident Progress Note written 09/27/21 on 2:06 PM, by LVN B documented X-rays were taken this shift. Pending results. Resident #2 remains in bed resting. DON reported there was no documentation in the Resident Nurses Progress Note that LVN B had followed up on x-ray results on his shift, or that he had assessed resident for pain and/or medicated resident for pain according to physician orders. -Review of Resident Progress Note written 09/27/21 9:37 PM, by LVN F documented Received report from LVN B morning nurse that the patient #2 had left lower extremity pain yesterday and that x-rays were pending results. Retrieved results from contracted x-ray company and it showed left hip joint prosthesis dislocation and fracture of the shin bone just above the knee. On assessment, patient in bed, alert x self, able to voice needs, good appetite. She continues with moderate/severe pain to left lower leg around knee area only with movement, she continues with her baseline internal rotation and length discrepancy (shorten) of left limb, left knee area with mild [CONDITION(S)], skin warm and area painful to touch, NP notified of findings, N.O. to send out by EMS for evaluation and treatment, daughter notified by phone as well, Paramedics arrived at 4:30 PM and took resident to ER. Physician, I explained that Patient's Daughter stated that her Ortho was not able to reduce dislocation years ago after total hip replacement because it could damage her bones, s/s of dislocation were her baseline, patient left facility alert, not complaining of pain unless limb was moved, vitals stable. DON reported that there was no documentation in the Resident Progress Notes of what time x-ray results were received from the x-ray company or that LVN F had medicated the resident for pain according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurses have been trained to document the time that the x-ray was taken and what time x-ray results are received, document their assessments in the Resident Progress Notes or the SBAR form if resident has had a new change in condition, document on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There is no documentation on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . I do not know why the Nurses did not document their pain assessments in the Resident Progress Notes or on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] Review of MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Check Resident for Pain utilizing numeric rating scale 0-10 or verbal descriptor scale (M) Mild, (Mo) Moderate, (S) Severe, (VS) Very Severe at 7:00 AM, 3:00 PM, and 11:00 PM. -09/27/21 LVN B E at 7:00 AM Resident #2 had no pain. -09/27/21 LVN F E at 3:00 PM Resident #2 had no pain. Telephone interview on 10/27/21 at 7:26 PM, with LVN D stated that she was assigned to Resident #2 on 09/26/21 on the night shift from 10:00 PM to 6:00 AM. I remember that during the change of shift, LVN C reported to me that Resident #2 was have pain to the left leg. I do not remember what her pain level was on a scale from 1-10, 10 being the worse pain. I called the NP on that day, because resident had been complaining of unrelieved pain to the left leg for a couple of days. Upon assessment I noted the left leg was internally rotated, left extremity was shorter than the right leg, and complained of pain when touched. I called the NP to report that pain medication was not effective, and he gave order for a stat x-ray. I placed the order for the stat x-ray 9/26/21 and was still pending to be done at the end of my shift. I reported this to the on-coming day nurse LVN C on at the change of shift on 9/27/21. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Start Date: 09/26/21 Acetaminophen with [MEDICATION(S)] 300-30 mg one tablet by mouth every six hours as needed for pain. Review of STATSAFE (automated medication management system) used for stat dose process documented on 09/26/21 at 9:00 PM Acetaminophen/[MEDICATION(S)] #3 one was removed by LVN D for Resident #2. Review of MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -09/25/21 LVN K documented at 11:00 PM Resident #2 had no pain. -09/26/21 RN E documented at 7:00 AM Resident #2 had no pain. -09/26/21 LVN C documented at 3:00 PM Resident #2 had no pain. -09/26/21 LVN D documented at 11:00 PM Resident #2 had no pain. -09/27/21 LVN B documented at 7:00 AM Resident #2 had no pain. -09/27/21 LVN F documented at 3:00 PM Resident #2 had no pain. Review of Radiology Order dated 09/26/21 received by LVN D at 11:00 PM, documented Lt. Hip 2 View; Lt. Knee 2 View STAT, order given by NP. Interview and record review 11/09/21 at 10:23 AM with LVN B on the morning shift confirmed he documented on the 24 Hour Report Sheet dated 09/27/21 that x-ray results of left hip & knee were pending and resident was complaining of pain. LVN C stated I remember that LVN D who worked on 09/26/21 on the night shift reported to me at the change of shift resident had been complaining of pain to the left hip and left knee over the weekend, NP was notified and she had placed the order for a stat x-ray that was pending to be done at the start of my shift on 9/27/21. I know that the x-ray was done sometime after breakfast on that day. It takes about 4 hours for the x-ray to be done and one hour to receive x-ray results. Sometimes it takes longer, but if they see any abnormality on the X-ray, they will call us right away. Surveyor asked, Did you follow up on the status of x-ray report? No. Since the x-ray company did not call, I assume the x-ray was normal. I honestly do not remember if I re-assessed the resident for pain on 9/27/21 when I went to check on her multiple times during my shift on that day because I did not document anything in Resident Progress Notes. I do remember that we left her in bed on that day because she was having a lot of pain to the left leg and she did not want the staff to touch the left leg because pain worsen with minimal movement. The resident would not complain of pain is she was not moved. I have been assigned to Resident #2 for approximately two years and she has never had pain like she did on 9/27/21. I don't know why I did not report the change of condition to the physician on that day. Maybe I was having a busy day. Interview and Record Review on 11/09/21 at 3:35 PM, NP stated Hospital History and Physical dated 09/28/21 for Resident #2 documented surgical history a procedure to line up the ends of a broken tibia and fibula 05/01/2015. History of hip surgery to the left hip 04/28/15. Resident was brought to the ED after complaining of severe left leg pain for 24 hours per nursing home. Resident had left leg pain, tender to palpation at tibia, extremity internally rotated and adducted. CT of left lower extremity documented a break in the shinbone just below the knee upper portion of the bone where it widens to help form the knee joint. [CONDITION(S)] affecting all three parts of left knee with mild accumulation of fluid and swelling around the knee joint. The patient was given [MEDICATION(S)] in the Emergency Department and her condition improved. Ortho plan to treat nonoperatively. [MEDICATION(S)] for pain management, wean off to Tylenol 3 if possible. Consult PT after procedure. NP reported that resident #2 was at risk of fractures due to having [CONDITION(S)]. [CONDITION(S)] means porous bone, which causes bones to become weak & brittle. NP stated The Nurses should call me right away if the ordered pain medication is ineffective or if the pain worsens with movement. I do not remember the Nurses calling me to report that the resident started to have pain to the left leg on 9/25/21. I do remember the nurses called me several times on 9/26/21 to report Tylenol 650 mg was ineffective and I gave orders Tylenol #3, but the nurses did not call me back to report that the Tylenol #3 was ineffective on that day. I got another call on 9/26/21 from the night nurse to report that the resident was complaining of severe pain to the left leg, so I gave orders for a stat x-ray. I would expect the nurses to notify me if they are having problems getting the x-ray done on a timely manner when stat orders are given so I can send the resident to the hospital for evaluation as soon as possible. On 9/27/21 I remember the nurse in the evening calling me to report the x-ray was showing there was dislocation of the left hip joint prosthesis and a fracture to the left shinbone, so I gave orders to send the resident to the hospital for evaluation. Review of PAINAD dated 11/09/21 completed by DON for Resident #2 documented a Total Score: 6.00 Level: Moderate Pain. PAINAD Scale-Breathing Independent of Vocalization: Normal (0 points), Negative Vocalization: None (0 points), Facial Expression: Smiling or inexpressive (0 points), Body Language: Relaxed (0 points), Consolability: No need to console (0 points). Scoring: The total score ranges from 0-10 points. A possible interpretation of the scores is: 1-3=mild pain; 4-6=moderate pain; 7-10 =severe pain. These ranges are based on a standard 0-10 scale of pain but have not been substantiated in the literature for this tool. Telephone interview on 11/10/21 at 1:12 PM CNA J, stated, I worked on 09/25/21 with LVN K on that night. I changed Resident #2, three times on that day and she was able to assist with turning & repositioning in bed using the grab bars on the side of the bed. The resident did not complain of pain and I did not see any bruises or swelling on the lower extremities when I went to change her brief on that night. At approximately 5:15 AM - 5:30 AM it was close to the end of the shift, I heard Resident #2 yelling very loud, so I went to the room to check on her. The resident was lying in bed yelling and pointing to her left leg. We have been trained not to ask the residents if they are in pain. The resident understands some English and I speak very little Spanish, so that is why I immediately went to tell LVN K that the resident was yelling and pointing to the left leg. LVN K went to the room to check the resident. I do not know if he gave the resident something for pain. I remember that the resident was sound asleep at end of the shift. Telephone interview on 11/10/21 at 4:22 PM RN E reported she works double shifts on the weekends as the RN weekend supervisor. RN E stated I assessed the resident when nurses report a significant change in condition. On 9/26/21 LVN C reported to me that Resident #2 did not want to get up on that day because she was complaining of pain to the left leg. This was very unusual for her because she always sits in a wheelchair for meals. When I went to assess the resident, she was lying in bed and was able to verbalize that she was having pain to the left leg. Upon assessment noted left kneecap appeared to be internally rotated and leg shorter in length than the right leg. The resident has very minimal communication skills. Resident was able to verbalize that she was having pain to the left leg. The resident was having a lot of pain with movement and was moaning. Pain level was at 6-8 in scale of 10. I remember that LVN C called the NP several times on 9/26/21 to report Tylenol was ineffective and got orders for Tylenol #3. I remember that LVN D on the night shift, called in the stat order to the x-ray company on 9/26/21. We have been trained to immediately notify physician if pain medication is ineffective. If new pain medication is ineffective, the nurse will reassess the resident and notify the physician to see what else they want to do for the resident. We have also been trained to report to the physician if x-rays cannot be done on a timely basis. Interview and Record Review on 11/15/21 at 4:54 PM CNA

Based on observation, interview and record review, the facility failed to ensure each resident received supervision to prevent elopement and accidents for 3 (Resident #1, #2 and #3) of 14 residents reviewed for elopement risk. -The facility failed to provide supervision to prevent an elopement by Resident #1, who had been assessed to be at high risk for elopement. Resident #1 eloped from the facility on 12/12/19 and was out of building for approximately 15 minutes. Facility staff were not aware that she had exited the building through the front door until Witness B, a visitor, made nurse aware. Resident #1 did not know Witness B, a visitor, and got into visitor's truck. Resident #1 was found walking on sidewalk in front of building. - RN [NAME] failed to check the function and placement of wander guards for two elopement risk residents, Resident # 2 and Resident #3. An IJ was identified on 12/12/19. While the IJ was lowered on 12/16/19 the facility remained out of compliance of potential for more than minimal harm at a scope identified as isolated due to the facility's need to monitor its corrective action for effectiveness, and to ensure all staff received all scheduled training. This failure could place residents at risk of leaving the facility unsupervised and place them in situations that could result in serious injury or death. Findings Included: Resident #1 Review of Resident #1's face sheet dated 12/13/19 documented in part; Resident #1 was a [AGE] year-old female admitted to facility on 02/13/19. Review of Resident #1's Physician order [REDACTED]. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] documented in part; -The Brief Interview for Mental Status (BIMS) summary score was 5 which indicated at the time of the MDS the resident was severely impaired. -Alarms - Wander/elopement alarm Review of Resident #1's Elopement Risk assessment dated [DATE] documented in part; - Is the patient/resident alert& oriented to person, place & time? No -Does the patient/resident have a history of wandering? Yes -Has the patient/resident attempted to leave the health care center? Yes -does the patient/resident express a desire to leave the health care center? Yes -Does the patient/resident have a [DIAGNOSES REDACTED]. Intervention - Wander guard in place. Review of Resident #1's Care Plan dated revised on 12/13/19 documented in part; -Behavioral Symptoms wander guard in place. -Elopement risk: Yes/interventions diversion activities. Review of Resident #1's Physician order [REDACTED]. -start date 05/15/19 Wander guard check placement every shift First, Second, Third -start date 05/15/19 Wander guard check for function everyday every shift; First, Second, Third 0bservation on 12/12/19 at 5:10 PM, Investigator did not find Resident #1 in dining area, 100 hall, 200 hall, 300 hall, and 400 hall. Investigator did not hear front door alarm activate. LVN A was observed looking for Resident #1 inside building then proceeded to exit through front door to look outside. LVN A walked back in and was stopped by Witness B and LVN A went back outside. Investigator exited facility after LVN A and saw Resident #1 on sidewalk next to parked cars in parking lot. Resident #1 was observed to be anxious. She was gathering her items in her room together, and she was pacing. LVN B re-directed Resident #1 to walk with him and re-entered facility through 100 hall, through back of facility. Investigator requested LVN A to take Resident #1 to front door to test wander guard. Resident #1 had wander guard on her ankle and it did not activate when close to door. Wander guard was tested with Wander band test box and activated. Currently the receptionist was no longer present at the area. Investigator observed two staff members in the rotunda area with their backs to the front door. In an interview on 12/12/19 at 5:15 PM, Witness B stated Resident #1 got into his truck sat for a while. Witness B stated Resident #1 told him she had escaped the facility and wanted him to take her to see her son. Witness B stated he observed staff outside looking for someone, so he convinced her to wait and she would get her son to take her home. He stated he flagged down the LVN A and told him that Resident #1 had escaped and the staff went to get her. By that time, she had gotten out of the truck and was on sidewalk in front of building. In observation on 12/12/19 at 5:25 PM, LVN A walked with Resident #1 on sidewalk in front of building and entered through 100 hall. Resident #1 was taken to front door to test wander guard and it did not function at the front door. Present was LVN A and ADON C. In an interview on 12/12/19 at 5:25 PM, LVN A stated he did not see Resident #1 in hallway and started to look for her in the facility. He stated when he did not notice her in the facility he immediately went to look outside of building. He stated he did not hear the front door alarm ring that would set off wander guard. He tested Resident #1's wander guard at the front door and did not set off alarm. LVN A stated Resident #1 has had exit seeking behaviors while at the facility. In an observation and interview on 12/12/19 at 5:25 PM, ADON C confirmed the wander guard for Resident #1 did not set off alarm when Resident #1 was walked to the front door to test her wander guard. (Investigator requested that Resident #1's wander guard be checked.) ADON C was aware that Resident #1 had exit seeking behaviors. In an interview on 12/12/19 at 6:13 PM, Administrator stated the wander guard device was delayed in picking up signal and will be contacting company to fix the front door alarm system. The Investigator on 12/12/19 at 6:15 PM intervened and initiated the wander guard system check of the residents with wander guards by the facility staff. In an interview on 12/12/19 at 7:39 PM, LVN D stated he was sitting at the rotunda area documenting and did not hear the front door alarm activate. He stated his back was towards front door and did not notice Resident #1 leave the facility. In an interview on 12/12/19 at 7:40 PM, LVN F stated she was at the rotunda area and did not hear the front door alarm ring. She stated her back was towards the front door and did not see Resident #1 exit the facility. LVN F stated Resident #1 has exit seeking behaviors and LVN F has on occasion redirected Resident #1 back to her room. Resident #2 Review of Resident #2 face sheet dated 12/13/19 documented in part; Resident #2 was a [AGE] year-old female admitted to facility on 10/20/16. Review of Resident #2's Progress Notes dated 08/01/19 documented in part the following diagnoses; nausea, [MEDICAL CONDITION], hypertension, anorexia, and dementia. Review of Resident #2's Minimum Data Set (MDS) assessment dated [DATE] documented in part; -The Brief Interview for Mental Status (BIMS) summary score was 5 which indicated at the time of the MDS the resident was severely impaired. -Alarms - Wander/elopement alarm Review of Resident #2's Elopement Risk assessment dated [DATE] documented in part; - Is the patient/resident alert& oriented to person, place & time? No -Does the patient/resident have a history of wandering? Yes -Has the patient/resident attempted to leave the health care center? Yes -does the patient/resident express a desire to leave the health care center? Yes -Does the patient/resident have a [DIAGNOSES REDACTED]. Intervention - Continue with wanderguard Review of Resident #2's Care Plan dated revised on 12/13/19 documented in part; -Behavioral Symptoms wander guard in place. Approach- Wander guard in place used as an enabler to freely and safely move throughout facility independently by utilizing safe parameters. Every shift: first, second, third Discipline: all Review of Resident #2's Physician order [REDACTED]. -start date 06/10/19 Wander guard check placement q shift First, Second, Third -start date 06/10/19 Wander guard check for function q day check expiration date once a day; 06:00 - 14:00 Observation on 12/12/19 at 6:15 PM, revealed ADON C tested wander guard for Resident #2 in TV area and did not function. In an interview on 12/12/19 at 6:35 PM, RN [NAME] stated she had checked all residents for wander guards at 4:00 PM. She was not aware Resident #2 had a wander guard. She stated she was not on her list for wander guard checks. RN [NAME] identified through Resident #2's MAR indicated [REDACTED]. RN [NAME] commented to ADON C I should have checked it yesterday. Review of Resident #2's MAR indicated [REDACTED]. Resident #3 Review of Resident #3 face sheet dated 12/13/19 documented in part; Resident #3 was a [AGE] year-old female admitted to facility on 04/18/19. Review of Resident #3's History and Physical dated 04/26/19 documented in part the following diagnoses; fall at home had left thalamus hemorrhage, diabetes, hypertension, dementia, and protein calorie malnutrition. Review of Resident #3's Minimum Data Set (MDS) assessment dated [DATE] documented in part; -The Brief Interview for Mental Status (BIMS) summary score was 15 which indicated at the time of the MDS the resident was cognitively intact -Alarms - Wander/elopement alarm Review of Resident #3's Elopement Risk assessment dated [DATE] documented in part; - Is the patient/resident alert& oriented to person, place & time? No -Does the patient/resident have a history of wandering? Yes -Has the patient/resident attempted to leave the health care center? Yes -does the patient/resident express a desire to leave the health care center? Yes -Does the patient/resident have a [DIAGNOSES REDACTED]. Intervention - Continue with wander guard Review of Resident #3's Care Plan dated revised on 11/06/19 documented in part; -Behavioral Symptoms currently an elopement risk and wears a wander guard for resident safety. Review of Resident #3's Physician order [REDACTED]. -start date 09/10/19 Wander guard check placement q shift -start date 09/10/19 Wander guard check function and expiration q shift Observation on 12/12/19 at 7:00 PM, revealed ADON C tested wander guard for Resident #3 located on her wheelchair and it did not function. In an interview on 12/12/19 at 7:16 PM, RN [NAME] stated she had checked all residents for wander guards at 4:00 PM. She stated she did not check wander guard for function or placement. RN [NAME] stated she did not go and see the wander guard for Resident #3. RN [NAME] stated she just checked the MAR indicated [REDACTED]. She stated this can put a resident at risk of leaving the facility without getting noticed. RN [NAME] stated it can be a safety concern and resident can get hurt. Review of Resident #3's MAR indicated [REDACTED]. In an interview on 12/13/19 at 3:09 PM, ADON G stated for training, all floor nurse's shadow another nurse for 3 to 5 days on what to do and documentation. She stated documentation training includes; first do the task on order's then check that it was done. ADON G stated all residents that have a wander guard are considered high wander risk residents and should be monitored appropriately. In an interview on 12/13/19 at 4:05 PM, ADON C stated the physician orders [REDACTED]. She stated the wander guard function and placement need to be done according to orders. She stated when wander guards are in MARS nurse needs to check every shift for function and that resident has the device on person or wheelchair. In an interview on 12/14/19 at 6:18 PM, Administrator verified that Resident #1 had eloped the facility and two wander guards were not functioning. Administrator stated the front door alarm system is delayed in picking up signal of wander guards. He stated nursing staff are to document on MAR indicated [REDACTED]. Review of facility's Provider Investigation Report dated 12/12/19 at 11:25 PM revealed in part; confirmed Resident #1 was outside of building. Resident #1 had an active wander-guard and was outside the front of the building. Repeated testing of wander-guard door disclosed that on occasion the alarm/maglock occurred too slowly for a quick resident. Two wander-guards for residents on same hallway were found to be inactive. Record review of facility's policy on Elopement Risk assessment dated revision 11/01/17 documented in part; The licensed nurse document in the nurses' notes and behavior monitoring flow record any exit seeking behavior on on-going basis and interventions are adjusted as needed. Review of facility's policy on Nursing Policies and Procedures dated revision 07/01/16 documented in part; Policy: Documentation guidelines pertinent to good clinical record practice will be followed by all individuals who document in the medical record. Guidelines - Entries are factual -Do not document an action that did not take place. An IJ was identified on 12/12/19 at 9:30 PM and Administrator was informed. IJ Template provided to the Administrator. The Plan of Removal was accepted on 12/13/19 and it included the following: Plan of Remediation - Wander Management System dated (MONTH) 13, 2019 The following actions have been completed by facility to assure compliance and protection of residents. 1. Affected Resident #1 was assessed by a licensed nurse following elopement. 2. Elopement Report completed 3. Resident Wander Reassessment completed for Resident #1 4. Resident Wander Re-assessment conducted for each of 14 other current residents identified for risk for wandering and with assistive device. 5. Wander band Assistive Device for Resident #1 tested and validated. 6. Wander bands for all other residents with orders for wander band assistive devices tested and validated. 7. Wander management device at front entry door tested and verified. All other doorways with emergency exit alarms and security verified. 8. 24-hour staffing of front entry door. Wander management keypad code changed. 9. Qualified alarm and wander management vendor testing of only wander management and all emergency exit doors. 10. Back up wander bands in inventory and wander-band testing devices. 11. Re-education of all facility staff on duty in door security requirements. 12. Re-education of all nurses in testing of wander band assistive devices. Other areas addressed: [NAME] All residents with Assistive Devices were promptly visited in the facility (with surveyor present). Additionally, a census headcount of all residents was immediately completed by the Assistant Director of Nursing. B. The policy was reviewed and utilized for staff re-education. C. Continuous rounding of wander risk residents has been added to ensure adequate supervision. In addition, the front main entrance is the only wander management door in the facility. This door has 24-hour uninterrupted staffing since 8pm on 12/12 provides continuous supervision of any possible exit from the building. Monitoring will continue until the alarm is in operable condition, at which point the door will be monitored by the receptionist each day until 5 pm, then the door will lock, and the key pad will be utilized. All other exits are fully alarmed emergency exits that were verified as alarmed with surveyor prior to 8pm on 12/12. D. The Medication Administration Record [REDACTED] validated the presence, functioning and expiration date of the three wander-bands on residents in this hallway. This nurse has been suspended, pending further investigation. This nurse suspension is noted in facility response in HHSC Provider Self Report #SR20- 3 noted in Plan of Remediation. E. Please see Action #12 of Plan of Remediation - Re-education of all Nurses in testing of wander-band assistive devices. Re-education of every on-duty Nurse in procedure to testing of wander-band assistive devices, with return demonstration of competency, including recording or results in MAR, and responding to any failed assistive device. Each Nurse has a competency record for return demonstration following re- education. Staff not on shift are being called in and re-education continues each shift, each day until 100% of staff re-educated. Clinical management will conduct random device checks and compare with resident MAR. Findings to be discussed during clinical stand-up. Any areas of concern will be addressed upon discovery. F All staff received re-education and the facility implemented the following plan: Continuous observation and redirection of wander risk residents found wandering near exit doors and notification of behavior to nursing staff immediately. Additionally, staff are to remain alert for guest use of keypad and shall report any resident/guest attempts to remove wander-bands. Additional supervision includes 24-hour uninterrupted supervision of the only exit from the building with wander management system. All other exits are fully alarmed emergency exits. Nursing re-education includes assessments, close observation/frequent checks on elopement risk residents. [NAME] HHSC Provider Self Report of Incident #SR20- 3 is noted in the Plan of Remediation #2. Please note that the time of the on-line report is CST. On 12/14/19 and 12/15/19 the Investigator confirmed by observations and interviews with nursing and administrative staff and by record review that nursing staff were continuously in-serviced on the above and were knowledgeable about changes in procedures. Investigator observed the 14 residents in the facility with wander guards and ensured that their wander guards were working. Three LVNs on the 6:00 a.m. to 2:00 p.m. shift, five LVNs on the 2:00 p.m. to 10:00 p.m. shift, and 4 CNAs on the 6:00 a.m. to 2:00 p.m. shift were interviewed. Two ADONs were also interviewed. Some of the questions that were asked included the following: What signs do you look for in residents that are at risk of elopement? How do you test the wander guards? Where do you document checking the wander guards? The alarm management system was verified by Investigator on 12/15/19 to activate with wander guard. On 12/15/19 at 2:30 PM the Administrator was informed the IJ was lowered. While the IJ was lowered on 12/16/19 the facility remained out of compliance of potential for more than minimal harm at a scope identified as isolated due to the facility's need to monitor its corrective action for effectiveness, and to ensure all staff received all scheduled training.

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychological well-being, in accordance with the comprehensive assessment and plan of care for 2 (ID#2, ID#4) of 5 sampled residents as evidenced by: A. The Licensed staff failed to follow up with the attending physician for resident #2 when the consulting physician gave order on 9/02/11 for [MEDICATION NAME] for neck pain. This resulted in the resident not receiving his pain medication as ordered by the consulting physician. Resident #2 was admitted from the hospital on [DATE] with a [DIAGNOSES REDACTED]. B. The Licensed staff to administer the prescribed medication ordered for constipation for resident #2 according to physician's orders. Resident #2 was afraid to take his pain medication for fear of getting constipated. C. The facility failed to administer the [MEDICATION NAME] IV (intravenous medication) according to physician orders which resulted in uncontrolled pain. Resident #4 was admitted from the hospital on [DATE] with a [DIAGNOSES REDACTED]. D. Licensed staff failed to notify the attending physician that resident #4 was refusing to take her blood pressure medications as ordered. This failure could affect 63 resident at the facility by not providing the residents with the necessary care and services to meet the individual needs of each resident. The findings include: RESIDENT #2: Hospital Consultation Report for resident #2 dated 8/01/11 documented in part: [AGE] year old male admitted for therapy for [REDACTED]. Today he underwent [REDACTED]. Past Medical History-Hypertension, [MEDICAL CONDITION], on Chronic [MEDICAL TREATMENT] 3 times a week, [MEDICAL CONDITIONS], status [REDACTED]. Record review of the facility's Face Sheet documented resident #2 was admitted on [DATE] from the hospital. Review of History & Physical dated 8/18/11 for resident #2 documented in part: [AGE] year old male with [MEDICAL CONDITION], CAD, here after cervical spine surgery, underwent decompression of C4-C5 and Fusion of C3-C6. Here for continuation of therapy. Pain in legs and overall body. In an interview on 9/13/11 at 8:40 AM, resident #2 reported that he had had a spinal injury and had surgery on his back. "I have pain all over. I'm just fed up because my back hurts. I got an order for [REDACTED]. They said something about having problems with the pharmacy. I also have been having horrible abdominal pain because the pain medications make me very constipated. It takes a long time for me to have a bowel movement even after they give me the suppository. When I get like that, the pain in my belly is horrible because I cannot have a bowel movement." In an interview on 9/13/11 at 10:38 AM, resident's wife reported that the consulting physician had ordered a pain patch for her husband. "This was approximately two weeks ago. When the attending physician came to see my husband, he asked the doctor about his pain patch. The doctor told my husband that she was not aware of any orders written by the consulting physician for a pain patch. Nothing was ever done to get his pain patch, all I know is that now it has been discontinued." The wife reported that resident #2 was taking [MEDICATION NAME] for his pain but he got very constipated. "My husband will yell loudly when the pain in his belly gets very bad because of the constipation." Record review revealed a prescription dated 9/02/11 written by the consulting physician for resident #2 for [MEDICATION NAME] Patch 12 mcg/hr apply Q (every) 72 hours for pain to neck. Review of Physician's Telephone orders dated 9/03/11 for resident #2 documented, that the consulting physician had ordered [MEDICATION NAME] 12 mcg/hr apply Q 72 hours Quantity 12, no refills. Pain to neck. Record review on 9/13/11, with the Director of Nurses (DON) revealed that the Daily Skilled Nurses Notes for resident #2 dated 9/02/11 through 9/10/11 did not have any written documentation that the Licensed Staff had consulted with the attending physician regarding the new order for the [MEDICATION NAME] that was ordered on [DATE] by the consulting physician. Record review revealed Physician's Telephone orders dated 9/11/11 for resident #2 documented, D/C (discontinue) [MEDICATION NAME] Patch 12 mcg/hr ordered by consulting physician. In an interview on 9/15/11 at 1:32 PM, Registered Nurse (RN) #B reported that he did not know why resident #2 had not received his [MEDICATION NAME] for nine days according to doctor's orders. I think that the physician discontinue the [MEDICATION NAME] because the resident did not want anymore pain medication. "He's afraid of getting constipated." RN #B reported that the primary attending physician needs to approve all orders written by consulting physicians before the medications is ordered from the pharmacy. Record review with (RN) #B on 9/16/11 reported that he had written a late entry on 9/15/11 in the Daily Skilled Nurse's Notes dated 9/07/11 for resident #2 that documented the attending physician was notified about the [MEDICATION NAME] order written by the consulting physician on 9/02/11. "The attending physician verbalized that she would be coming to the facility to talk with resident #2 about his pain management and then would make a decision to approve the order for [MEDICATION NAME]. She verbalized that she would be here this week to talk to resident." Telephone interview on 9/16/11 at 2:36 PM, RN #A reported that he had called the attending physician for resident #2 on 9/03/11 and had left a message to call him back regarding the prescription written on 9/02/11 by the consulting physician. RN #A stated, "I worked that weekend and the attending physician never returned my call." RN #A reported that resident #2 had kept the prescription for the [MEDICATION NAME] in a drawer in his room for several days. RN #A stated, "the resident told me about the prescription on Saturday or Sunday, I don't remember. I do remember that I found the prescription in a drawer in his room. I also know that on Monday RN #B tried to fill the prescription but we need to get a triplicate prescription from the doctor. A week later, I called the attending physician to inform her that the [MEDICATION NAME] had not been administered as ordered because we never got the triplicate prescription from her. I do not remember if I documented this in the resident's clinical record. I was not aware that resident #2 never got his pain patch. All I know, is that no one followed up on the [MEDICATION NAME] order during the week." Record review of the facility's 24 Hour Report Sheets dated 9/02/11 and 9/08/11 did not have any written documentation for resident #2 that reflected the Licensed staff had called the attending physician for to inform her of the new order for the [MEDICATION NAME]. In an interview on 9/16/11 at 4:15 PM, attending physician for resident #2 stated, "I was not called on 9/3/11 by RN #A on the weekend about the new order for the [MEDICATION NAME]. If the Nurse had called me, I would have faxed a copy of the triplicate to the pharmacy and later bring the triplicate to the facility. I came to see the resident, I don't remember when and he reported no pain. That is when I gave orders to discontinue the [MEDICATION NAME]. I will always call the nurses back when the nurses call me and leave a message. I also have a fax machine at my home where the nurses can fax information to me at anytime and I will call them back as soon as possible. I would expect the nurses to call me and inform me of any problems with getting medications from the pharmacy or if they need a triplicate prescription to fill a prescription. I was not aware that resident #2 complained of getting more constipated with his pain medications. I would expect the nurses to report things like this to me right away. Especially if the resident is afraid to take his pain medication for fear of getting constipated." Review of Physician's Progress Note dated 9/09/11 for resident #2 documented in part: Denies any pain. Does not want to have more pain medication. In an interview on 9/19/11 at 8:24 AM, Director of Nurses (DON) reported that all orders from the consulting physicians must be verified with the primary attending physician prior to ordering the medication from the pharmacy. "We do not have a written Policy & Procedure on this, we just do that. RN #A reported that he had tried calling the primary attending physician on the weekend to get approval for the [MEDICATION NAME] and the physician did not call him back. RN #A wrote this on the 24 hour report sheet for follow up by the day nurse. The nurses should document in the Nurses Notes when telephone calls are placed to the physicians." Record review revealed Physician Telephone Order dated 8/20/11 at 3:00 PM for resident #2 documented, [MEDICATION NAME] 100 mg Po (by mouth) Bid (twice a day). [MEDICATION NAME] is a stool softener. Senna 3 tablets PO daily PRN as needed. Senna is a laxative. Record review revealed Physician Telephone Order dated 8/21/11 at 12:00 PM for resident #2 documented #2 [MEDICATION NAME] suppository rectal one daily PRN constipation. Record review of the Medication Administration Record dated August 2011 for resident #2 documented in part: Senna 3 tabs daily po prn constipation had been administered daily from August 20-31, 2011 in the morning at 8:00 AM. The MAR did not document if the Senna was effective. Review of the Daily Skilled Nurse's Notes dated 8/19/11 did not document if Senna was effective. Review of the Daily Skilled Nurse's Note dated 8/20/11 documented [MEDICATION NAME] suppository was administered. The Nurse's Notes did not have any documentation if the suppository was effective. Review of the Daily Skilled Nurse's Notes dated 8/21/11 through 8/26/11 and 8/28/11 through 8/31/11 for resident #2 did not document on page 2 if the Senna was effective. The Daily Skilled Nurse's Notes for these dates did not document on page 1 that resident was having problems with constipation. Record review of the Medication Administrator Record (MAR) dated September 2011 for resident #2 documented in part: Senna 3 tabs daily PO PRN. There was no documentation on the MAR dated September 2011 that reflected that the Senna was administered to the resident. The MAR documented [MEDICATION NAME] Suppository was administered on 9/01/11 on the day shift. The MAR and the Nurse Notes dated 9/01/11 did not document if the suppository was effective. Record review revealed an undated care plan for resident #2. The care plan did not have any written information that documented resident was having pain or problems with constipation. No additional information was brought forth during the investigation process. RESIDENT #4: Hospital Consultation Report dated 5/10/11 for resident #4 documented in part: Admission Diagnoses: [REDACTED]. History of Present Illness: [AGE] year old, female with a history of status [REDACTED]. Hospital Physician's Orders dated 5-22-11 for resident #4 documented in part: [MEDICATION NAME] 1 mg IV every 3 hours scheduled for pain. Hold medication if patient is sedated. Hospital Interdisciplinary Progress Note dated 5/26/11 for resident #4 documented in part: [AGE] year old female with Chronic Pai[DIAGNOSES REDACTED], S/P Right Hip ORIF and RLE (right lower extremity) Osteo. Currently pain adequately controlled. No prescriptions for pain meds needed for D/C (discharge). Closed record review revealed Face Sheet for resident #4 documented she was admitted to the nursing facility on 5/30/11 from the hospital. Resident was discharged home on[DATE]. Review of History & Physical Dated 5/30/11 written by the attending physician at the nursing facility for resident #4 documented in part: Reason for visit-Admission H & P, Debility, Right Foot OM, S/P ID (incision & drainage), S/P Right Hip Fx ORIF, S/P Right Knee Meniscal Tear, Chronic Pai[DIAGNOSES REDACTED]/back, Acute Pain Foot/Hip, Hx Throidectomy secondary to [MEDICAL CONDITION]. HPI: [AGE] year female with Chronic Pain secondary to back pain, Narcotic Dependent was on [MEDICATION NAME] q 3 hrs 1 mg IV scheduled. A/P documented in part: Acute/on Chronic Pain (back, feet, hip, knee), pt. stated only [MEDICATION NAME] 1 mg works IV Q 3 hrs, Don't have IV [MEDICATION NAME], will start po (see orders), No 1 mg tab available (per RN) only 2 mg tabs, Narcotic Dependent, Hypertension stable. Record review of the admission orders [REDACTED]. Resident #4 had orders for sliding scale coverage with [MEDICATION NAME]. [MEDICATION NAME] is used to treat insulin dependent diabetes mellitus. Metroprolol 25 mg PO Q 12 hours. Metroprolol is used to treat high blood pressure. [MEDICATION NAME] 20 mg one tablet PO q 12 hours. [MEDICATION NAME] is used to treat hypertension. [MEDICATION NAME] 5 mg one tablet PO Q 12 hours. [MEDICATION NAME] is used to treat hypertension. [MEDICATION NAME] 100 mg PO daily. [MEDICATION NAME] Sodium is a stool softener. [MEDICATION NAME] 325 mg PO BID. Bactrim DS one tablet x 30 days. Bactrim was an antibiotic that was ordered to treat the Osteo[DIAGNOSES REDACTED] of the right foot . [MEDICATION NAME] 350 mcg PO daily. Record review revealed Physician's Telephone order dated 5/31/11 at 3:30 AM for resident #4 documented, Change order for [MEDICATION NAME] 2 mg tab Q 3 hrs to 4 mg Q 3 hrs. Increase to 6 mg if needed. Record review revealed a fax dated 5/31/11 for Triplicate Request for [MEDICATION NAME] 4 mg tablets one tablet by mouth every 3 hours as needed for pain. Record review revealed Physician's Telephone order dated 5/31/11 for resident #4 documented, Hydromorphen 1 mg IV Q 3 hrs PRN. Record review revealed Physician's Telephone order dated 5/31/11 for resident #4 documented, Clarification for Hydromorphen 1 mg IV Q 3 hrs PRN to be administered for 3 days only when med is available. Record review revealed Physician's Telephone order dated 5/31/11 for resident #4 documented, Pt. VS (vital signs) to be checked 30 min. after each pain med admis. physician progress notes [REDACTED]. She stated only [MEDICATION NAME] IV q 3 hrs works. Trying [MEDICATION NAME] po 6 mg Q 3 hrs and she stated not enough has seen pain Doctor in hospital. A/P: Acute/Chronic Pain referred to pain specialist, [MEDICATION NAME] PO, IV follow up appointment with pain. Record review revealed Physician Telephone Order dated 6/2/11 for resident #4 documented [MEDICATION NAME] 100 mg soft gel PO Bid (twice a day) for constipation. Record review of the Social Service Progress Notes dated 6/03/11 at 3:00 PM, documented in part: "Social met with resident and mother for initial assess. Plan was short-term care 20 days only, per pt. request due to financial limitations. Pt. stated she was unable to pay AI rate and refused treatment after 20 th day." Record review revealed Physician's Telephone order dated 6/08/11 for resident #4 documented, [MEDICATION NAME] 2 mg/6 mg po Q 3 hrs PRN pain. [MEDICATION NAME] 1 mg IV Q 3 hrs PRN pain. Record review revealed Physician's Telephone order dated 6/11/11 for resident #4 documented, [MEDICATION NAME] 1 mg IM q 3 hrs. PRN for pain. Review of Physician's Progress Note dated 6/13/11 documented in part: Reason for visit-F/U pain. A/P Acute Chronic Pain. Unable to control her pain acutely(sic). Tried PO, IM, [MEDICATION NAME], No IV access. Offered other options ([MEDICATION NAME], Tylenol #3). Unable to continue IV pain [MEDICATION NAME] q 3 hrs at Nursing Home/SNF. Agreed to accept to manage acute pain with pain doctor consult. Transfer to hospital. Record review revealed Physician's Telephone order dated 6/13/11 for resident #4 documented, D/C Hospital Transfer Orders. [MEDICATION NAME] PO or IM q 3 hrs. PRN. Tylenol #4 1-2 tablets po Q 4 hrs. prn pain. Discharge Planning Friday (6/17/11). Review of Physician's Progress Note dated 6/17/11 documented in part: Acute Pain secondary to OM. Resident refusing Accu Checks and blood pressure medications. Difficult to control pain with [MEDICATION NAME] PO/IM/IV, but better, OK with Tylenol #4. Tried to transfer to hospital regarding pain management but refused. Record review revealed Physician's Telephone order dated 6/17/11 for resident #4 documented, [MEDICATION NAME] 1 mg IV/IM Q 3 hours prn (as needed) pain. Record review revealed Daily Skilled Nurses Notes dated 6/05/11 at 1:30 PM, resident & mother requesting information if any RN on duty during PM shift to administer IV med, amount of time required to replenish prescription. Patient informed PO dose of med available increase to 6 mg. Pt. responded all other routes of administration uneffective to relieve pain at which time pt. began to sob loudly over care provided by facility. Phone call placed to MD answer service pending call back. Pt informed of status. Patient refused noon meds and complained of constipation. MD contacted new orders received for [MEDICATION NAME] supp and Psych consult. Stated he would be in 6/06/11. At 8:00 PM, IVP [MEDICATION NAME] 1/2 [MEDICATION NAME] for 10/10 pain. Resident expressed disapproval of not having RN to continue her IVP meds throughout night. Explained that she has other forms of pain medications available and should take advantage during the time, she says she won't because they don't work. Record review revealed Daily Skilled Nurses Notes no time documented dated 6/06/11 Patient complained of back, leg pain [MEDICATION NAME] po given. Pt. upset because her IV supply is no longer available. At 6:00 PM, given last dose of IM or IV med available. PO pain meds remain unavailable. Record review revealed Daily Skilled Nurses Notes dated 6/12/11 at 1:50 PM, Patient activated call button requesting PRN pain med. Resident informed that staff was awaiting DON (Director of Nurses) arrival to facility to replenish med supply and offered tablet form of medication. Patient then became SOB (short of breath). Patient's mother arrived to facility demanding information regarding medication. Family notified by weekend supervisor that the DON enroute to facility. Both mother & daughter verbalized dissatisfaction with care provided. Pain level 10 in a scale from 1-10. The 10 being the worst pain. At 6:00 PM, Patient requested prn pain medication given via IV by weekend supervisor. Resident continues to refuse medications. DON in facility spoke briefly to mother and patient. Review Nurses Note date 61/12/11 at 3:10 PM, written by DON documented in part: Arrived at facility at 2:50 PM to deliver 2 vials of IV [MEDICATION NAME]. Spoke to resident & mother who were very upset about resident having to wait to receive pain med IV, apologized & explained that she could have taken po pain meds while she waited for IV dose. She stated she does not like PO meds because they do not work due to her history of [MEDICAL CONDITION]. She stated she could not believe we do not have RN available 24 hours a day, explained this not required. Mother stated, "it is not her fault she is addicted to pain meds, its hospice's fault, when she [MEDICAL CONDITION]. Again apologized for inconvenience & reassured her she had enough pain meds to last until Friday, voiced understanding. Stated she wanted number to Ombudsman and facility corporate office. Numbers provided to resident and mother. In an interview on 9/19/11 with Licensed Vocational Nurse (LVN) #H reported that resident #4 had orders for IV [MEDICATION NAME] (Intravenous medication is administered directly into the vein) every 3 hours. "We did not always have an RN (Registered Nurse) at night when I worked so the IV medication was not administered when it was requested by the resident. I also remember that resident #4 liked her IV pain medication and would tell me that the oral and IM medications were not effective to manage her pain. Resident #4 would constantly ask for pain medication. The resident was also refusing to take her blood pressure medication as ordered. I do not remember if I charted in her chart that I notified the physician. In an interview on 9/19/11 at 2:01 PM, DON confirmed that the facility did not have any [MEDICATION NAME] on hand to administer to resident #4 IV when the resident complained of pain. "I went to the local pharmacy to pick up to vials of the [MEDICATION NAME]. In the beginning we were having problems with getting the [MEDICATION NAME] because the pharmacy did not have enough of the medication to administer according to the doctor's orders. The resident kept asking as for IV [MEDICATION NAME] every 3 hours like in the hospital. She was refusing her PO meds ordered for pain because she would say that only the IV were effective to control her pain. We are not required to have RNs twenty four hours a day. That is why we did not have an RN at times to administer the IV [MEDICATION NAME] but we had the PO or IM [MEDICATION NAME] on hand. The resident just wanted her IV pain medication all of the time. The DON confirmed that the facility did not have any written documentation in the resident's clinical record that documented the attending physician had been notified of the resident complaining of abdominal pain, constipation, not sleeping, crying and that she was distressed when her pain level was a a 10 and the IV medication was not readily available to administer to the resident. Eventually we started to get the multi-dose vials. I think that on that day, resident #4 ran out of the [MEDICATION NAME] on Sunday. Record review of the facility's undated Medication Process for Charge Nurse Orientation provided by DON documented in part: PAIN-New medication require a new pain assessment. Must utilize a pain management flow sheet until medication is made routine and noted relief x 72 hours will with dosing schedule. If med remains prn the flow sheet is always going to be in use. NEW UNCONTROLLED PAIN-pain meds per order. Complete pain assess. Initiate pain flow sheet. Notify MD?NP of findings and if acceptable level met. Record review revealed a Pain Evaluation dated 5/30/11 for resident #4 documented in part: "Does the resident have any [DIAGNOSES REDACTED].? Yes. [MEDICAL CONDITION], joint pain to knee. Type of Pain: Splitting/Sharp pain. Additional symptoms associated with Pain: Anxiety. Pain is increased by: nothing specific. Times when pain is worse: Early morning, Morning, and Night. Type of Pain-Internal/Chronic. Pain rate in a scale of 1-10, 10 being the worse pain. Resident's pain level 10. How much of the time you experienced pain or hurting over the last 5 days? Site A-right knee (1) almost constantly. Site B-lower back (1) almost constantly. Site C right ankle (2) Frequently. Pain Effect on Function-Has the resident had any following changes in daily activities or habits? Participation in activities and Changes in mood/emotions. Nonverbal /Noncognitive Signs of Pain-was blank. Relief of Pain-was blank. Conclusion: Pain management intervention is necessary, refer to resident plan of care. Record review revealed Care Plan Conference Attendance Record dated for resident #4 was dated 6/16/11. Resident declined to attend Care Plan conference. Record review revealed Immediate Needs Care Plan dated 6/02/11 for resident #4 documented in part: "Frequent pain to lower extremity. Resolution: Diminished ability to perform ADLs(activities of daily living). Loss of appetite. Goal: Resident #4 will have pain rate < (less) than 4. Interventions: Administer PRN meds [MEDICATION NAME] as directed. Monitor pain level & response to pain med. Patient wanting only IV pain med. States she has tried all other pain meds and IV [MEDICATION NAME] is the only one that works. Patient does better with ADLs and Therapies if they are done immediately after she is medicated for pain. " Record review revealed Immediate Needs Care Plan dated 6/08/11 for resident #4 documented in part: "Non-complaint with care. Resolution: Medications and treatments being refused. Goal: Patient will accept medications & treatments as ordered. Interventions: Patient tends to focus on her pain medication-be prompt in administering it prn. Allow her to participate in the timing of when events will occur. Explain consequences of her refusals so she makes informed decisions. No additional information was brought forth during the investigation process. Record review revealed Care Plan dated 6/10/11 for resident #4 documented in part: Poor appetite with frequent meal refusals. Goal: Patient will eat 100 % of at least one meal a day. Interventions: Multiple Vitamin with minerals as ordered. Refuses supplemental shakes. Record review of facility's undated policy & procedure on Medication Administration Record provided by the DON documented in part: Policy: To maintain current and accurate documentation of medications, and method of administration in the resident's clinical record. All spaces are completed with the initials of the nurse/medication aide giving the medication, immediately after the medication has been received by the resident. Refused medications is noted by circling the nurse's initials and writing an explanation on the back of the form. If the medication is refused, the physician is notified. This is to be recorded in the nurse's notes. Record review of the facility's undated Medication Process for Charge Nurse Orientation provided by DON documented in part: MISCELLANEOUS need to knows-If non-pertinent meds (i.e. vitamins, stool softeners, etc) are refused 3 days in a row the MD/NP and family must be notified. If pertinent meds (i.e. medications treating a [DIAGNOSES REDACTED]. Record of the facility's policy & procedure dated 02/01/00 on RESIDENT REFUSAL OF MEDICATIONS, TREATMENT AND/OR SERVICES provided by the DON documented in part: The resident will be informed by appropriate personnel (ex. P.T., O.T., Nurse, Physician, etc.) of the health and safety consequences of such refusal, and availability of any therapeutic alternative that might exits. The interdisciplinary team will review and address noncompliance in the care planning process. The universe was selected from a census sheet and list of discharged residents provided by the DON and Administrator on 9/13/11.

Based on interview and record review the facility failed to consult with the attending physician for 2 (ID #2, ID #4) 4 sampled residents when there was a need to alter the treatment as evidenced by: A. The attending Physician was not consulted when the facility was unable to fill the prescription for the [MEDICATION NAME] (use to treat pain) ordered on [DATE] for resident #2 by the consulting physician. The attending physician became aware of the new order, 8 days later when she came to see the resident at the facility. B. The facility failed to consult with the attending physician when resident #2 was not willing to take his prescribed pain medications for fear of getting constipated. C. The Physician was not consulted when resident ID #4 was refusing to take her prescribed medications and refusing to have her accu checks (used to check blood glucose levels) done according to doctor's orders since admission to the nursing facility on 5/30/11. This failure could affect 63 residents at the facility by not consulting with the attending physician when residents refuse to allow the staff to check accu checks and administer medications according to doctor's orders. The findings include: RESIDENT #2: Hospital Consultation Report for resident #2 dated 8/01/11 documented in part: [AGE] year old male admitted for therapy for [REDACTED]. Today he underwent [REDACTED]. Past Medical History-Hypertension, [MEDICAL CONDITION], on Chronic [MEDICAL TREATMENT] 3 times a week, [MEDICAL CONDITIONS], status [REDACTED]. Record review of the facility's Face Sheet documented resident #2 was admitted on [DATE] from the hospital. Review of History & Physical dated 8/18/11 for resident #2 documented in part: [AGE] year old male with [MEDICAL CONDITION], CAD, here after cervical spine surgery, underwent decompression of C4-C5 and Fusion of C3-C6. Here for continuation of therapy. Pain in legs and overall body. In an interview on 9/13/11 at 8:40 AM, resident #2 reported that he had had a spinal injury and had surgery on his back. "I have pain all over. I'm just fed up because my back hurts. I got an order for [REDACTED]. They said something about having problems with the pharmacy. I also have been having horrible abdominal pain because the pain medications make me very constipated. It takes a long time for me to have a bowel movement even after they give me the suppository. When I get like that, the pain in my belly is horrible because I cannot have a bowel movement." In an interview on 9/13/11 at 10:38 AM, resident's wife reported that the consulting physician had ordered a pain patch for her husband. "This was approximately two weeks ago. When the attending physician came to see my husband, he asked the doctor about his pain patch. The doctor told my husband that she was not aware of any orders written by the consulting physician for a pain patch. Nothing was ever done to get his pain patch, all I know is that now it has been discontinued." The wife reported that resident #2 was taking [MEDICATION NAME] for his pain but he got very constipated. "My husband will yell loudly when the pain in his belly gets very bad because of the constipation." Record review revealed a prescription dated 9/02/11 written by the consulting physician for resident #2 for [MEDICATION NAME] Patch 12 mcg/hr apply Q (every) 72 hours for pain to neck. Review of Physician's Telephone orders dated 9/03/11 for resident #2 documented, that the consulting physician had ordered [MEDICATION NAME] 12 mcg/hr apply Q 72 hours Quantity 12, no refills. Pain to neck. Record review on 9/13/11, with Director of Nurses (DON) revealed that the Daily Skilled Nurses Notes for resident #2 dated 9/02/11 through 9/10/11 did not have any written documentation that the Licensed Staff had consulted with the attending physician regarding the new order for the [MEDICATION NAME] that was ordered on [DATE] by the consulting physician. Record review revealed Physician's Telephone orders dated 9/11/11 for resident #2 documented, D/C [MEDICATION NAME] Patch 12 mcg/hr ordered by consulting physician. In an interview on 9/15/11 at 1:32 PM, Registered Nurse (RN) #B reported that he did not know why resident #2 had not received his [MEDICATION NAME] for nine days according to doctor's orders. I think that the physician discontinue the [MEDICATION NAME] because the resident did not want anymore pain medication. "He's afraid of getting constipated." RN #B reported that the primary attending physician needs to approve all orders written by consulting physicians before the medications is ordered from the pharmacy. Record review with (RN) #B on 9/16/11 reported that he had written a late entry on 9/15/11 in the Daily Skilled Nurse's Notes dated 9/07/11 for resident #2 that documented the attending physician was notified about the [MEDICATION NAME] order written by the consulting physician on 9/02/11. "The attending physician verbalized that she would be coming to the facility to talk with resident #2 about his pain management and then would make a decision to approve the order for [MEDICATION NAME]. She verbalized that she would be here this week to talk to resident." Telephone interview on 9/16/11 at 2:36 PM, RN #A reported that he had called the attending physician for resident #2 on 9/03/11 and had left a message to call him back regarding the prescription written on 9/02/11 by the consulting physician. RN #A stated, "I worked that weekend and the attending physician never returned my call." RN #A reported that resident #2 had kept the prescription for the [MEDICATION NAME] in a drawer in his room for several days. RN #A stated, "the resident told me about the prescription on Saturday or Sunday, I don't remember. I do remember that I found the prescription in a drawer in his room. I also know that on Monday RN #B tried to fill the prescription but we need to get a triplicate prescription from the doctor. A week later, I called the attending physician to inform her that the [MEDICATION NAME] had not been administered as ordered because we never got the triplicate prescription from her. I do not remember if I documented this in the resident's clinical record. I was not aware that resident #2 never got his pain patch. All I know, is that no one followed up on the [MEDICATION NAME] order during the week." Record review of the facility's 24 Hour Report Sheets dated 9/02/11 and 9/08/11 did not have any written documentation for resident #2 that reflected the Licensed staff had called the attending physician for to inform her of the new order for the [MEDICATION NAME]. In an interview on 9/16/11 at 4:15 PM, attending physician for resident #2 stated, "I was not called on 9/3/11 by RN #A on the weekend about the new order for the [MEDICATION NAME]. If the Nurse had called me, I would have faxed a copy of the triplicate to the pharmacy and later bring the triplicate to the facility. I came to see the resident, I don't remember when and he reported no pain. That is when I gave orders to discontinue the [MEDICATION NAME]. I will always call the nurses back when the nurses call me and leave a message. I also have a fax machine at my home where the nurses can fax information to me at anytime and I will call them back as soon as possible. I would expect the nurses to call me and inform me of any problems with getting medications from the pharmacy or if they need a triplicate prescription to fill a prescription. I was not aware that resident #2 complained of getting more constipated with his pain medications. I would expect the nurses to report things like this to me right away. Especially if the resident is afraid to take his pain medication for fear of getting constipated." Review of Physician's Progress Note dated 9/09/11 for resident #2 documented in part: Denies any pain. Does not want to have more pain medication. In an interview on 9/19/11 at 8:24 AM, Director of Nurses (DON) reported that all orders from the consulting physicians must be verified with the primary attending physician prior to ordering the medication from the pharmacy. "We do not have a written Policy & Procedure on this, we just do that. RN #A reported that he had tried calling the primary attending physician on the weekend to get approval for the [MEDICATION NAME] and the physician did not call him back. RN #A wrote this on the 24 hour report sheet for follow up by the day nurse. The nurses should document in the Nurses Notes when telephone calls are placed to the physicians." No additional information was brought forth during the survey process. Record review revealed Physician Telephone Order dated 8/20/11 at 3:00 PM for resident #2 documented, [MEDICATION NAME] 100 mg Po (by mouth) Bid (twice a day). [MEDICATION NAME] is a stool softener. Senna 3 tablets PO daily PRN as needed. Senna is a laxative. Record review revealed Physician Telephone Order dated 8/21/11 at 12:00 PM for resident #2 documented #2 [MEDICATION NAME] suppository rectal one daily PRN constipation. Record review of the Medication Administration Record dated August 2011 for resident #2 documented in part: Senna 3 tabs daily po prn constipation had been administered daily from August 20-31, 2011 in the morning at 8:00 AM. The MAR did not document if the Senna was effective. Review of the Daily Skilled Nurse's Notes dated 8/19/11 did not document if Senna was effective. Review of the Daily Skilled Nurse's Note dated 8/20/11 documented [MEDICATION NAME] suppository was administered. The Nurse's Notes did not have any documentation if the suppository was effective. Review of the Daily Skilled Nurse's Notes dated 8/21/11 through 8/26/11 and 8/28/11 through 8/31/11 for resident #2 did not document on page 2 if the Senna was effective. The Daily Skilled Nurse's Notes for the above dates did not document on page 1 that resident was having problems with constipation. Record review of the MAR dated September 2011 for resident #2 documented in part: Senna 3 tabs daily PO PRN. There was no documentation on the MAR dated September 2011 that reflected that the Senna was administered to the resident. The MAR documented [MEDICATION NAME] Suppository was administered on 9/01/11 on the day shift. The MAR and the Nurse Notes dated 9/01/11 did not document if the suppository was effective. RESIDENT #4: Hospital Consultation Report dated 5/10/11 for resident #4 documented in part: Admission Diagnoses: [REDACTED]. History of Present Illness: [AGE] year old, female with a history of status [REDACTED]. Hospital physician's orders [REDACTED]. Hold medication if patient is sedated. Hospital Interdisciplinary Progress Note dated 5/26/11 for resident #4 documented in part: [AGE] year old female with Chronic Pai[DIAGNOSES REDACTED], S/P Right Hip ORIF and RLE (right lower extremity) Osteo. Currently pain adequately controlled. No prescriptions for pain meds needed for D/C (discharge). Closed record review revealed Face Sheet for resident #4 documented she was admitted to the nursing facility on 5/30/11 from the hospital. Resident was discharged home on[DATE]. Record review revealed History & Physical Dated 5/30/11 by the attending physician at the nursing facility for resident #4 documented in part: Reason for visit-Admission H & P: Debility, Right Foot OM (Osteo[DIAGNOSES REDACTED]), S/P ID (incision & drainage), S/P Right Hip Fx ORIF, S/P Right Knee Meniscal Tear, Chronic Pai[DIAGNOSES REDACTED]/back, Acute Pain Foot/Hip, Hx Throidectomy secondary to [MEDICAL CONDITION]. HPI: [AGE] year female with Chronic Pain secondary to back pain, Narcotic Dependent was on [MEDICATION NAME] q 3 hrs 1 mg IV scheduled. A/P documented in part: Acute/ Chronic Pain (back, feet, hip, knee), pt. stated only [MEDICATION NAME] 1 mg works IV Q 3 hrs, Don't have IV [MEDICATION NAME], will start po (see orders), No 1 mg tab available (per RN) only 2 mg tabs, Narcotic Dependent, Hypertension stable. Record review of the admission orders [REDACTED]. Resident #4 had orders for sliding scale coverage with [MEDICATION NAME]. [MEDICATION NAME] is used to treat insulin dependent diabetes mellitus. Metroprolol 25 mg PO Q 12 hours. Metroprolol is used to treat high blood pressure. [MEDICATION NAME] 20 mg one tablet PO q 12 hours. [MEDICATION NAME] is used to treat hypertension. [MEDICATION NAME] 5 mg one tablet PO Q 12 hours. [MEDICATION NAME] is used to treat hypertension. [MEDICATION NAME] 100 mg PO daily. [MEDICATION NAME] Sodium is a stool softener. [MEDICATION NAME] 325 mg PO BID. Bactrim DS one tablet x 30 days. Bactrim was an antibiotic that was ordered to treat the osteo[DIAGNOSES REDACTED] of the right foot.. [MEDICATION NAME] 350 mcg PO daily. Record review revealed Physician Telephone Order dated 6/2/11 for resident #4 documented [MEDICATION NAME] 100 mg soft gel PO Bid (twice a day) for constipation. Record review of the Social Service Progress Notes dated 6/03/11 at 3:00 PM, documented in part: "Social met with resident and mother for initial assess. Plan was short-term care 20 days only, per pt. request due to financial limitations. Pt. stated she was unable to pay AI rate and refused treatment after 20 th day." Record review of Physician's Progress Notes dated 6/17/11 for resident #1 documented in part: Reason for visit-Discharge Planning: Resident has refused accu checks.[MEDICAL CONDITION]("?unclear history came in with meds"). Denied B/P meds. A/P documented in part:[MEDICAL CONDITION]? "She denies high blood pressure 20 xs refusing B/P meds." Record review of the Medication Administration Record (MAR) dated May 2011 for resident #4 documented in part: Resident refused to take the Metroprolol 25 mg on 5/31/11 at 8:00 AM and 8:00 PM. Record review of the MAR dated June 2011 for resident #4 documented in part that she had refused to take the following: [MEDICATION NAME] 5 mg was refused 22 times from June 1-15, 2011. The MAR had blanks in documentation for the [MEDICATION NAME] on 6/1/11 at 9:00 AM, 6/9/11 at 9:00 AM, 6/13/11, 6/16/11 and 6/17/11 at 9:00 AM and 9:00 PM. [MEDICATION NAME] 20 mg was refused 22 times from June 1-15, 2011. The MAR had blanks in documentation for the [MEDICATION NAME] 20 mg on 6/1/11 at 9:00 AM, 6/9/11 at 9:00 AM, 6/13/11 at 9:00 AM and 9:00 PM, 6/15/11 at 9:00 AM, 6/16/11 and 6/17/11 at 9:00 AM and 9:00 PM. Metroprolol 25 mg was refused 22 times from June 1-15, 2011. The MAR had blanks in documentation for Metroprolol 6/1/11 at 9:00 AM, 6/9/11 at 9:00 AM, 6/13/11 at 9:00 AM and 9:00 PM, 6/15/11 at 9:00 AM, 6/16/11 and 6/17/11 at 9:00 AM and 9:00 PM. [MEDICATION NAME] was refused 25 times from June 1-15, 2011. The MAR had blanks in documentation for [MEDICATION NAME] 6/13/11, 6/16/11, 6/17/11 at 8:00 AM and 4:00 PM. Bactrim DS one tablet PO bid x 30 days. Bactrim DS was refused two times on 6/5/11 and 6/7/11. The MAR had blanks in documentation for the Bactrim DS for 6/13/11 and 6/16/11. [MEDICATION NAME] 350 mcg was refused 6 times from June 6-17, 2011. [MEDICATION NAME] was refused 10 times from June 1-17, 2011. The MAR had blanks in documentation 6 blanks in documentation for the [MEDICATION NAME] from June 1-17, 2011. Record review revealed a Physician's Telephone Order dated 6/7/11 for resident #4 documented, Fleet enema x 1 for constipation. If no BM 10 mg [MEDICATION NAME] PO. If no still call attending physician (sic). Record review of the Daily Skilled Nurse's Note dated 6/07/11 at 8:00 AM, documented in part: resident #4 in chair very tired and hasn't been able to sleep due to severe constipation. She refuses to take any medications including anything to help with constipation. At 10:45 AM, resident was very stressed, crying, stating she was in a lot of pain because she was so constipated, She asked what she could do to help. I explained to have a suppository and agreed to take it. At 5:00 PM, resident laying in bed considering taking an enema. At 8:35 PM, resident refused PRN constipation medications. The Skilled Nurses Notes dated 6/07/11 did not have any written documentation that reflected the Fleets enema had been administered or if the resident had a bowel movement. No additional information was brought forth during the investigation process. Record review of the Medication Administration Record dated June 2011 for resident #4 did not document the order for the Fleets enema. In an interview on 9/19/11 at 12:14 PM, with Licensed Vocational Nurse (LVN) #H reported that resident #4 refused to take her blood pressure medications as ordered. I do not remember if I charted in her chart that I notified the physician. Record review on 9/19/11 at 1:36 PM with the Director of Nurses (DON) confirmed that the facility did not have any written documentation in Daily Skilled Nurses Notes for resident #4 that documented the refusal of the [MEDICATION NAME] on 6/6/11 at 8:00 AM, 6/7/11 at 4:00 PM, 6/8/11 at 4:00 PM, 6/14/11 at 4:00 PM, 6/15/11 at 4:00 PM, 6/16/11 at 4:00 PM, 6/17/11 at 8:00 AM. The DON stated, "The nurses should have notified the attending physician of all the medications that are documented as refused on the MAR dated June 2011 for resident #4." Telephone interview on 9/19/11 at 3:50 PM, attending physician stated, " I was not informed by the nursing home staff that resident #4 was refusing to take her medications as ordered. I found out when I came to see her on one occasion, because the resident told me that she was refusing to take her blood pressure medications. This is something that I would expect for the nursing home staff to inform me of. I also was not aware that the nursing home did not have RNs twenty four hours a day to administer IV pain medications, until I was informed by the resident and her mother. So I had to give orders for IM/PO pain medications. At that time I also suggested to the resident for me to send her to the hospital for IV pain management but she refused." Record review revealed a Pain Evaluation dated 5/30/11 for resident #4 documented in part: "Does the resident have any [DIAGNOSES REDACTED].? Yes. [MEDICAL CONDITION], joint pain to knee. Splitting/Sharp pain. Additional symptoms associated with Pain: Anxiety. Pain is increased by: nothing specific. Times when pain is worse: Early morning, Morning, and Night. Type of Pain-Internal/Chronic. Pain rate in a scale of 1-10, 10 being the wrose pain. Resident's pain level 10. How much of the time you experienced pain or hurting over the last 5 days? Site A-right knee (1) almost constantly. Site B-lower back (1) almost constantly. Site C right ankle (2) Frequently. Pain Effect on Function-Has the resident had any following changes in daily activities or habits? Participation in activities and Changes in mood/emotions. Nonverbal /Noncognitive Signs of Pain-was blank. Relief of Pain-was blank. Conclusion: Pain management intervention is necessary, refer to resident plan of care. Record review revealed Care Plan Conference Attendance Record dated for resident #4 was dated 6/16/11. Resident declined to attend Care Plan conference. Record review revealed Immediate Needs Care Plan dated 6/02/11 for resident #4 documented in part: Frequent pain to lower extremity. Resolution: Diminished ability to perform ADLs(activities of daily living). Loss of appetite. Goal: Resident #4 will have pain rate < (less) than 4. Interventions: Administer PRN meds [MEDICATION NAME] as directed. Monitor pain level & response to pain med. Patient wanting only IV pain med. States she has tried all other pain meds and IV [MEDICATION NAME] is the only one that works. Patient does better with ADLs and Therapies if they are done immediately after she is medicated for pain. Record review revealed Care Plan dated 6/8/11 for resident #4 documented in part: Potential for constipation due to increased use of pain medication. Goal: Patient will have a bowel movement at leat every three days. Approaches/Intervention: Administer [MEDICATION NAME] bid as ordered. Administer [MEDICATION NAME] prn as ordered. Document BMs on CNA flow sheets. Record review revealed Care Plan dated 6/10/11 for resident #4 documented in part: Poor appetite with frequent meal refusals. Goal: Patient will eat 100 % of at least one meal a day. Interventions: Multiple Vitamin with minerals as ordered. Refuses supplemental shakes. No additional information was brought forth during the investigation process. Record review of facility's undated policy & procedure on Medication Administration Record provided by the DON documented in part: Policy: To maintain current and accurate documentation of medications, and method of administration in the resident's clinical record. All spaces are completed with the initials of the nurse/medication aide giving the medication, immediately after the medication has been received by the resident. Refused medications is noted by circling the nurse's initials and writing an explanation on the back of the form. If the medication is refused, the physician is notified. This is to be recorded in the nurse's notes. Record review of the facility's undated Medication Process for Charge Nurse Orientation provided by DON documented in part: MISCELLANEOUS need to knows-If non-pertinent meds (ie vitamins, stool softeners, etc) are refused 3 days in a row the MD/NP and family must be notified. If pertinent meds (ie medications treating a [DIAGNOSES REDACTED]. Record of the facility's policy & procedure dated 02/01/00 on RESIDENT REFUSAL OF MEDICATIONS, TREATMENT AND/OR SERVICES provided by the DON documented in part: The physician will be notified of repeated medication refusals. In reference to calling on laxatives, vitamins, antacids (unless the refusal of these medications could cause serious medical consequences), the physician will be called and future instructions in reference to calling of these medications will be documented on the physician's orders [REDACTED]. The universe was selected from a census sheet provided by the DON on 9/13/11.