Every finding on record at Mesa Hills Post Acute

Based on interviews and record reviews, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical status for 1 (Resident #1) of 4 residents reviewed for resident rights.The facility failed to ensure LVN D notified Resident #1's physician when his blood glucose was 412 on 08/22/26.This deficient practice could affect residents with a change of condition and result in not receiving adequate and timely invention and decline in condition.Findings included: Record review of Resident #1's admission record, dated 08/26/26, reflected a [AGE] year-old male, admitted on [DATE]. His relevant diagnoses included diabetes mellitus (chronic metabolic disease where body cannot properly process sugar, leading to high blood glucose levels), hypertension (condition where the force of blood against the artery wall is consistently too high), gastro-esophageal reflux disease (a chronic digestive condition where stomach acid frequently flows back into the tub connecting your mouth and stomach, irritating the lining), constipation (having fewer than three bowel movements a week or passing hard, dry, and painful stools), shortness of breath (the uncomfortable feeling that you cannot get enough air into your lungs), chronic respiratory failure (a long-term condition where the lungs cannot properly exchange oxygen and carbon dioxide, leading to low oxygen or high carbon dioxide levels in the blood), and gastrostomy status ( an opening made through the skin and the belly directly into the stomach). Record review of Resident #1's admission MDS assessment, undated, reflected it was still in process. Recor review of Resident #1's baseline care plan, dated 08/20/26, reflected:Focus: [Resident #1] has a diagnosis of diabetes. Date initiated 08/20/26 and revised on 08/26/26. Interventions included, administer medication as ordered. Date initiated 08/20/26. Focus: [Resident #1] has a diagnosis of diabetes. Date initiated 08/20/26 and revised on 08/26/26. Interventions included, administer medication as ordered . Date initiated 08/20/26. Record review of Resident #1's blood glucose readings on 08/22/26 at 12:04 a.m. indicated it was 412. During an observation on 08/26/26 at 10:00 a.m., Resident #1 was observed lying in bed with his eyes closed, he had a tracheotomy with an c-collar with oxygen, indwelling catheter, and was receiving nutrition via feeding tube. Resident #1 was non-verbal. In a telephone interview on 08/27/26 at 1:48 p.m., RT G said she was assigned to Resident #1's hall and worked the 6 p.m. to 6:00 a.m. shift. She said she worked on 08/21/26 and had provided oral care and had suctioned Resident #1 several times throughout her shift. She said Resident #1 did not experience any respiratory distress throughout her shift. In a telephone call on 08/27/26 at 2:48 p.m., the MD said he did not remember if he received a call from the facility regarding Resident #1's high blood glucose on 08/22/26. The MD refused to continue with the interview. In a telephone interview on 08/27/26 at 3:27 p.m., the Medical Director said he had not received a call from the facility on 08/22/26 regarding Resident #1's high glucose level. He said the nursing staff at the facility should have called Resident #1's NP or MD on 08/22/26 when his blood glucose was 412. He said if the nursing staff could not get Resident #1's NP or MD, they could have called him. The Medical Director said he has made it known to the facility's staff that he was always available for them anytime of the day. He said if Resident #1 did not have a change of condition on 08/22/26, then he would say there were no negative outcomes to Resident #1 for not receiving treatment or notifying his NP or MD on 08/22/26 when his blood glucose level was 412. During an interview on 08/27/26 at 3:07 p.m., LVN D said he worked the 6:00 a.m. to 6:00 p.m. shift. He said on 08/21/26, he was given report by the outgoing nurse that Resident #1's medication orders were still pending. He said on 08/22/26 at 12:04 a.m., he checked Resident #1's blood glucose level and it was 412. LVN D said he had not administered any medication to LVN D because he had no medication orders. LVN D said he had not called Resident #1's NP or MD because what was I going to tell them if he had no medications. LVN D said he continued monitoring Resident #1 throughout his shift and he did not have any change of conditions. LVN D said he had been in-serviced on changes of condition and knew what the facility's protocol was for when a resident's blood glucose level was over 400 but said Resident #1 did not have any medication orders in place. He said the facility's medication emergency kit was not utilized because there were no medication orders for Resident #1 at that time. LVN D said Resident #1 also received respiratory therapy throughout his shift and no change of conditions were reported by the respiratory therapist. LVN D said Resident #1 did not have any negative outcomes on 08/22/26 when his blood glucose was 412 because he did not have any change of conditions and was being monitored by himself and the Respiratory Therapist. LVN D said he had been in-serviced on the topic of reporting a change of condition and stop and watch. During an interview and observation on 08/28/26 at 11:43 a.m. the ADON said the facility's protocol when a resident's blood glucose level was 400 or above, the nurse was required to contact resident's physician. She was observed as she reviewed Resident #1's electronic medical record and said Resident #1's blood glucose level on 08/22/26 at 12:04 a.m. was 412. She said LVN D should have contacted Resident #1's MD even though his medication orders were still pending. After she reviewed Resident #1's electronic medical record, she said Resident #1 did not have any change of conditions since his admission and had received respiratory therapy during each shift. She said a Respiratory Therapist was assigned to Resident #1's hall and would have been available if he developed any signs of respiratory distress. The ADON said LVN D could have also used his nursing judgement and send Resident #1 to the hospital if he had noticed Resident #1 in any kind of distress. The ADON said a possible negative outcome to Resident #1 on 08/22/26 at 12:04 a.m., could have been that his blood glucose continued to increase but in Resident #1's case his blood glucose had decreased. During an interview and observation on 08/28/26 at 12:14 p.m. the DON said Resident #1 was admitted on [DATE] but his medication orders were not confirmed until 08/22/26. The DON said the facility's protocol when a resident's blood glucose was 400 or higher, the nursing staff was required to contact the resident's physician. The DON was observed as he reviewed Resident #1's electronic medical records and said on 08/220/26 at 12:04 a.m., Resident #1's blood glucose level was 412. The DON said there were no progress notes from LVN D attempted to contact Resident #1's NP, MD or himself. The DON said even though Resident #1's medication orders were still pending, there was no excuse for LVN D to not call his MD. The DON said a negative outcome for Resident #1 on 08/22/26 at 12:04 a.m. when his blood glucose was 412, could have been that his blood glucose could have continued to increase. He said after he reviewed Resident #1's electronic medical record that he had his blood glucose level had decreased to 363. He said Resident #1 had not had a change of condition since he was admitted and was under the care of a respiratory therapist every shift. The DON said Resident #1 did not have any negative outcomes on 08/22/26 on 12:04 a.m. when his blood glucose level was 412. The DON said all nursing staff were in-serviced on the topic of change of conditions and stop and watch regularly.

Based on observation, interview, and record review, the facility failed to have physician orders for the resident's immediate care at time of admission, for 2 of 6 residents (Resident #1 and Resident #2) reviewed for physician admission orders.1.The facility failed to have physician orders in place for Resident #1 when admitted on [DATE].2. The facility failed to have a physician order of heparin in place for Resident #2 when admitted on [DATE]. These failures could place residents at risk of not receiving appropriate care.Findings included: 1.Record review of Resident #1's admission record, dated 08/26/26, reflected a [AGE] year-old male, admitted on [DATE]. His relevant diagnoses included diabetes mellitus (chronic metabolic disease where body cannot properly process sugar, leading to high blood glucose levels), hypertension (condition where the force of blood against the artery wall is consistently too high), gastro-esophageal reflux disease (a chronic digestive condition where stomach acid frequently flows back into the tub connecting your mouth and stomach, irritating the lining), constipation (having fewer than three bowel movements a week or passing hard, dry, and painful stools), shortness of breath (the uncomfortable feeling that you cannot get enough air into your lungs), chronic respiratory failure (a long-term condition where the lungs cannot properly exchange oxygen and carbon dioxide, leading to low oxygen or high carbon dioxide levels in the blood), and gastrostomy status ( an opening made through the skin and the belly directly into the stomach). Record review of Resident #1's admission MDS assessment, undated, reflected it was still in process. Record review of Resident #1's baseline care plan, dated 08/20/26, reflected:Focus: [Resident #1] has a diagnosis of diabetes. Date initiated 08/20/26 and revised on 08/26/26. Interventions included, administer medication as ordered. Date initiated 08/20/26. Focus: [Resident #1] has a diagnosis of diabetes. Date initiated 08/20/26 and revised on 08/26/26. Interventions included, administer medication as ordered . Date initiated 08/20/26. Focus: [Resident #1] has gerd. Date initiated 08/26/26. Interventions included, give medications as ordered. Focus: [Resident #1] has a history of constipation. Date initiated 08/26/26. Interventions included, monitor medications for side effects of constipation. Record review of Resident #1's electronic medical record progress note dated 08/20/26 at 7:47 p.m., authored by RN A reflected Resident arrived to facility via EMS. AAOx3 able to voice needs and wants, c-collar noted in place. Patient placed on 40 percent tracheostomy collar by RT and tolerating well. No s/s of pain or distress noted at this time. Patients family member at bedside. Total care, requires assistance x2 for adl's/transfers due to recent surgery to left hip. Head to toe done and tolerated well. Skin is clean and dry. Surgical incision noted to left hip, and IV to right arm. NP made aware of patients arrival. Pending call back with new orders. Record review of Resident #1's electronic medical record progress note dated 08/21/26 at 2:40 p.m., authored by LVN C reflected This nurse notified NP of resident status at facility, requested order clarification and KUB order, pending call back, will inform oncoming shift of resident status. Record review of Resident #1's physician order summary, dated 08/26/26, reflected an order for: Amantadine HCI oral tablet 100 mg (amantadine HCI) give 1 tablet via G-tube two times a day for muscle spasms. Order date 08/22/26 and state date 08/22/26. Amlodipine Besylate oral tablet 5 mg (Amlodipine Besylate) give 1 tablet via G-tube one time a day for essential hypertension.order date 08/22/26 and start date 08/23/26. DuoNeb Solution 0.5-2.5 (3) mg/2ml (ipratropium-albuterol) 3 mi via trach every 6 hours for shortness of breath. Order date 08/22/26 and start date 08/22/26. Enoxaparin Sodium 100 unit/ml (enoxaparin solution) inject 30 mg subcutaneously two times a day for SP Orif for 2 weeks. Order date 08/22/26 and start date 08/22/26. Humalog Solution 100 unit/mg (insulin Lispro (Human)) inject as per sliding scale: if 0 - 150 = 0units; 151 - 200 = 2 units; 201 - 250 = 4 units; 251 -300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10units, subcutaneously every 6 hours for DM. Order date 08/22/26 and start date 08/22/26. Methocarbamol Oral Tablet 500 MG (Methocarbamol) give 1 tablet via G-Tube every 8 hours for muscle spasms. Order date 08/22/26 and start date 08/22/26. Pantoprazole Sodium Oral Packet 40 MG (Pantoprazole Sodium) Give 1 packet via G-Tube one time a day for GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS Order date 08/22/26 and start date 08/23/26. Polyethylene Glycol 3350 Powder (Polyethylene Glycol 3350 (Bulk)) give 17 gram via G-Tube one time a day for constipation. Hold for loose stool Mix with 8oz fluid. Order date 08/22/26 and start date 08/23/26. Record review of Resident #1's August 2026 eMAR dated 08/26/26 reflected Amantadine HCI oral tablet 100 mg (amantadine HCI) give 1 tablet via G-tube two times a day for muscle spasms. Start date-08/22/26 at 10:00 p.m. Amlodipine Besylate oral tablet 5 mg (Amlodipine Besylate) give 1 tablet via G-tube one time a day for essential hypertension. Start date-08/23/26 at 7:00 p.m. DuoNeb Solution 0.5-2.5 (3) mg/2ml (ipratropium-albuterol) 3 mi via trach every 6 hours for shortness of breath. Start date 08/22/26 at 1:00 p.m. Enoxaparin Sodium 100 unit/ml (enoxaparin solution) inject 30 mg subcutaneously two times a day for SP Orif for 2 weeks. Start Date 08/22/26 at 10:00 p.m. Humalog Solution 100 unit/mg (insulin Lispro (Human)) inject as per sliding scale: if 0 - 150 = 0 units; 151 - 200 = 2 units; 201 - 250 = 4 units; 251 -300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10units, subcutaneously every 6 hours for DM. Start date 08/22/26 at 12:00 p.m. Methocarbamol Oral Tablet 500 MG (Methocarbamol) give 1 tablet via G-Tube every 8 hours for muscle spasms. Start date 08/22/26 at 4:00 p.m. Pantoprazole Sodium Oral Packet 40 MG (Pantoprazole Sodium) Give 1 packet via G-Tube one time a day for GASTRO-ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS. Start date 08/23/26 at 7:00 a.m. Polyethylene Glycol 3350 Powder (Polyethylene Glycol 3350 (Bulk)) give 17 gram via G-Tube one time a day for constipation. Hold for loose stool Mix with 8oz fluid. Start date 08/23/26 at 7:00 a.m. 2. Record review of Resident #2's face sheet, dated 08/27/26, reflected an [AGE] year-old male, admitted on [DATE], diagnosis: acute and chronic respiratory failure with hypoxia (conditions where the lungs cannot supply enough oxygen to the blood, either suddenly (acute) or over time (chronic), leading to dangerously low oxygen levels). Resident #2 was discharged to the hospital on [DATE], unrelated to the resident not having admitting physician's order for heparin. Record review of Resident #2's baseline care plan, dated 08/20/26, reflected [Resident #2] was unable to respond. The baseline care plan revealed the nursing services, rehabilitative services, and food and nutrition services sections were not completed. The baseline care plan was not reviewed or signed by an RN. Record review of Resident #2's admission MDS assessment, dated 08/21/26, reflected the assessment was in progress. The BIMS was not conducted. Record review of Resident #2's hospital discharge orders, dated 08/20/26, reflected medication reconciliation form from the hospital with an order for heparin sodium (anticoagulant medication), flush with 3 ml of 100 units/ml heparin every 12 hours to each port (vascular access). Record review of Resident #2's physician's order summary report, dated 08/27/26, reflected no physician's order for heparin. During an observation on 08/26/26 at 10:00 a.m., Resident #1 was observed lying in bed with his eye closed, he had a tracheotomy with an c-collar with oxygen, indwelling catheter, and was receiving nutrition via feeding tube. Resident #1 was non-verbal. During an interview on 08/26/26 at 1:53 p.m., the Medical Records Supervisor said usually new admissions arrived at the facility with medical records which included a medication reconciliation list. She said Resident #1 was admitted on [DATE] around 2:30 p.m. She said Resident #1 was transferred from an out of town hospital which had not included his medication reconciliation list. The Medical Records Supervisor said the facility needed his medication reconciliation list which explained what medications the hospital recommended for him to continue or discontinue. She said she was informed on 08/21/26, during their morning meeting that Resident #1 had no orders. During an interview on 08/26/26 at 2:12 p.m., LVN C said he worked the 6:00 a.m. to 6:00 p.m. shift. He said Resident #1 was admitted on [DATE] at 2:30 p.m. LVN C said the facility's protocol when a resident was admitted was for the admitting nurse to contact the resident's physician/NP to reconcile orders and input them in their electronic medical record. LVN C said he was off on 08/20/26. He said he returned to work on 08/21/26 and noticed Resident #1 still had no orders. He said he sent Resident #1's NP a message at 2:40 p.m., but NP did not respond during his shift. He said he did not call Resident #1's MD or the facility's medical director and had not notified the DON. LVN C said during his shift on 08/21/26, Resident #1 had not had any respiratory distress or change of condition. LVN C said on 08/22/26 at 9:10 a.m., he contacted Resident #1's physician and said, I was finally able to clarify orders for Resident #1. LVN C said, I dropped the ball, I forgot to document I had clarified Resident #1's orders with his MD. LVN C said the facility's protocol when a resident's NP did not respond, was the nursing staff needed to call the resident's physician or the facility's Medical Director and also keep the ADON and DON informed. He said he was in-serviced on the topic of medication administration which included reconciling orders for new residents. LVN C said the negative outcome to Resident #1 not being administered the following medications when he was first admitted on [DATE] were as follows:Amantadine-muscle spasmsAmlodipine Besylate- hypertensionDuoNeb Solution- shortness of breathEnoxaparin Sodium- blood clotsHumalog Solution 100 units- blood sugar could sky rocketMethocarbamol Oral Tablet- muscle spasmsPantoprazole Sodium Oral Packet-GERDPolyethylene Glycol 3350 Powder-constipation During an interview and observation on 08/26/26 at 3:14 p.m., RT H said Resident #1 required respiratory therapy. She said the facility had standing orders for residents who needed respiratory therapy which included, suction, trach care, cannula change, oral care, equipment change and monitoring vent settings which Resident #1 received effective 08/20/26. RT H said it was the nursing staff responsibility to reconcile all medications and input all orders for new residents. She said the RT's relied on the nursing staff to acquire new orders. She said the RT's and nursing staff communicated on a daily basis and would keep each other up to date. RT H was observed as she reviewed Resident #1's electronic medical record and said Resident #1 had an order for DuoNeb Solution which she said was for shortness of breath with a start date of 08/22/26 at 1:00 p.m. RT H said Resident #1 had not had respiratory distress or change of condition since he was admitted . She said Resident #1 had been titrated (gradual adjustment of medication's dose) down from 48% to 24%, which was considered an improvement. RT H said she was not able to say if there were any negative outcomes to Resident #1 having his order for DuoNeb start on 08/22/26. During a telephone interview on 08/26/26 at 4:02 p.m., RN A said she was the admitting nurse for Resident #1 when he was admitted on [DATE] at 2:30 p.m. She said Resident #1 was transferred from an out of town hospital and his medication reconciliation lists were not provided at time of the transfer. She said after the standard assessments, RT assessed and initiated respiratory support and reviewed the hospital records sent with Resident #1. She said the packet did not include his medication reconciliation list only a list of medications he was taking while in the hospital. RN A said a medication reconciliation list was a list of medications the hospital doctor recommended for the facility to either continue or discontinue. She said the medication reconciliation list was reviewed with the resident's NP or MD and they decide which medications to continue. RN A said the facility had standing orders for new residents that included glucose checks, vital checks, and pain medication. RN A said she messaged Resident #1's NP (who was on call) on 08/20/26 (did not remember the time). RN A said Resident #1's NP responded (not sure what time) but refused to order any medication until the facility had his medication reconciliation list. RN A said she immediately notified her ADON and told her Resident #1's NP refused to order any medications until the facility received his medication reconciliation list. She said the ADON had also reviewed Resident #1's packet but did not find the medication reconciliation list. She said had followed the facility's protocol of notifying Resident #1's NP and her ADON. She said at the end of her shift, Resident #1 still had no orders. She said Resident #1 did not have any respiratory distress or change of condition during her shift. She said she saw the RT provide care to Resident #1 during her shift on 08/20/26. RN A said she passed report to LVN B who was the incoming nurse. RN A was not able to say if there were any negative outcomes to Resident #1 not having orders when he was admitted . During an interview on 08/26/26 at 4:24 p.m., the ADON said one of her responsibilities as an ADON was to review new admission's orders and to ensure they were followed. The ADON said Resident #1 was admitted on [DATE] at 2:30 p.m. and RN A was the admitting nurse. She said RN A notified her Resident #1's NP was notified of his arrival at the facility and refused to order any medications until the facility received his medication reconciliation list from the hospital. The ADON said she had instructed RN A to call Resident #1's MD but did not follow up with her. She said she assumed RN A contacted with Resident #1's MD. The ADON said the following morning (08/21/26) during their morning meeting she learned Resident #1 still had no orders. She said also in the morning meeting was medical records staff and since Resident #1 was discussed in the meeting, she assumed medical records would request his medication reconciliation list from the hospital he was discharged from. She said the DON was also in the morning meeting and he told the IDT team he would take over the responsibility of obtaining Resident #1's medication reconciliation list. The ADON said Resident #1 had missed the following doses and the negative outcomes: Amantadine-4 doses-muscle spasmsAmlodipine Besylate- 2 doses-hypertensionDuoNeb Solution- 5 doses-shortness of breathEnoxaparin Sodium-4 doses- blood clotsHumalog Solution 100 units-2 doses-high blood glucoseMethocarbamol Oral Tablet-4 doses- muscle spasmsPantoprazole Sodium Oral Packet-2 doses-GERDPolyethylene Glycol 3350 Powder-constipation The ADON said Resident #1 had not had any respiratory distress or change of condition on 08/20/26 or 08/21/26. The ADON said Resident #1's physician ordered medications were ordered the afternoon of 08/22/26; therefore, the morning medications were not initiated until the following day (08/23/26). The ADON said all nursing staff were in-serviced on the topic of medication administration which included obtaining orders. The ADON said this was the first the facility had encountered a situation in which a new resident's medications had not been ordered and administered in a timely manner. She said the DON had initiated in-services for all nursing staff. In a telephone interview on 08/27/26 at 11:30 a.m., LVN B said she worked the 6:00 p.m. to 6 a.m. shift. LVN B said the facility's admission protocol was for the admitting nurse to contact the resident's physician to inform them of the resident's admission and to reconcile medication orders. She said she had never encountered a situation where a new resident did not have a medication reconciliation sheet. She said the admitting nurse should notify the DON immediately and follow his instructions. She said she worked on 08/20/26 and was notified by RN A that Resident #1 had no medication orders yet. She said she had not attempted to contact Resident #1's NP, MD, Medical Director or DON because she assumed RN A had already contacted them. She said throughout her shift she checked on Resident #1 several times, checked glucose levels, and provided bolus nutrition. LVN B said Resident #1 had received respiratory care throughout the night also. She said Resident #1 did not have any change of conditions or respiratory distress during her shift. LVN B said she passed report to the LVN C (in-coming nurse for the 7:00 a.m. to 7:00 p.m. shift) at the end of her shift that Resident #1 still had no orders. LVN B said nursing staff were regularly in-serviced on the topic of medication administration which included obtaining medication orders for new residents. In a telephone interview on 08/27/26 at 12:06 p.m., the NP said she received a message from a facility's nurse notifying her of Resident #1's admission and orders. She said she was told Resident #1 had a list of medications he was taking in the hospital but not the medication reconciliation list. She said she required the resident's medication reconciliation list before she agreed to any orders. She said she instructed the facility's nurse to request it from the hospital. The NP said she had not followed up with the facility regarding Resident #1's orders. The NP said she received another message on 08/21/26 from the facility regarding wound care for Resident #1 and something else. The NP said, I was driving and was not going to respond. She said the facility should know that if she does not respond, they could call the other NP or the MD. During an interview on 08/27/26 at 2:25 PM, LVN F stated he input the admission orders for Resident #2 on 08/20/26. LVN F stated he did not recall if heparin was part of the list, but he followed the list that was provided by the hospital and confirmed by the NP. During an interview, on 08/27/26 at 2:45 PM, the NP stated she reconciled the orders, including medications, for Resident #2's admission on [DATE]. The NP stated she did not recall which medications he had or if heparin was ordered. The NP stated if Resident #2 had an order for heparin, then it should have been inputted and administered. The NP stated she had no knowledge of any negative outcome for Resident #2 related to heparin. In a telephone call on 08/27/26 at 2:48 p.m., the MD said he did not remember if he received a call from the facility regarding Resident #1. He said if a resident was admitted without a medication reconciliation list, then there's nothing to reconcile. He said he did not remember if he had already seen Resident #1 or if the NP had discussed Resident #1 with him. The MD said he was not able to say if there were any negative outcomes to Resident #1 starting his medications on 08/22/26, he said, I don't know, sometimes nothing happens and sometimes they can have negative outcomes. During an interview, on 08/27/26 at 3:15 PM, the MD stated he did not recall reconciliation of orders for Resident #2 or any specifics. The MD stated if Resident #2 had an order for heparin, then the facility staff should have ensured to follow the order. The MD stated he was not aware of any negative outcome for Resident #2 related to not receiving heparin. In a telephone interview on 08/27/26 at 3:47 p.m., the Medical Director said it was the facility's protocol when a new resident was admitted contacting their assigned doctor and to reconcile medications. He said he was not sure if the facility had a timeframe in which the nursing staff had to give a doctor to respond. The Medical Director said he was always available to the facility's nursing staff anytime. He said Resident #1's NP did not work for him. He said the facility should have requested Resident #1's medication reconciliation list before being admitted or ensure they were sent with him on 08/20/26. The Medical Director said the facility should have contacted Resident #1's MD or himself sooner. During an interview, on 08/28/26 at 11:30 AM, the ADON stated if heparin was on the medication list, then it should have been inputted and administered. The ADON stated heparin was an anticoagulant to prevent blood clots and a negative outcome of not receiving the medication as ordered could have been coagulations. The ADON stated she had no knowledge that Resident #2 had coagulations or symptoms. The ADON stated she followed up on admissions to ensure everything was in place, which included medication orders, but it was a team effort. The ADON stated it was important to have orders in place to ensure they provided the care as ordered. During an interview and observation on 08/28/29 at 12:14 p.m., the DON said Resident #1 was admitted on [DATE] at 2:30 p.m. He said he found out on 08/21/26 during the morning meeting that Resident #1 had been admitted without a medication reconciliation list. The DON was observed as he reviewed Resident #1's electronic medical record and said, according to his progress notes, RN A documented that she had sent his NP a message regarding his admission and orders and I guess they waited. The DON said there were no progress notes regarding Resident #1's orders until 08/22/26 by LVN C at 2:40 p.m. The DON said the facility did not have a specific timeframe for NPs to respond. He said nursing staff should have attempted to contact Resident #1's MD or the facility's Medical Director. The DON said the negative outcomes to Resident #1 not administered his medications until 08/22/26 and 08/23/26 could have been hypertension, high glucose level, and constipation. The DON said Resident #1 had not had a change of condition since he was admitted . He said ultimately, it was his responsibility to ensure Resident #1 was administered his medication in a timely manner. The DON said that this was the first time the facility had encountered a situation in which a new resident's medications had not been ordered and administered in a timely manner. He said nursing staff were in-serviced on the topic of medication administration (which included medication orders) on a regular basis. The DON said moving forward, he had instructed all nursing staff to contact him immediately when a new resident was admitted without their medication reconciliation list. He said he had also instructed all nursing staff to utilize the facility's three Medical Directors when the resident's NP or MD do not respond in a timely manner withing a couple of hours. During an interview, on 08/28/26 at 12:15 PM, the DON stated the admitting nurse input orders upon admission for the resident. The DON stated Resident #2 was admitted on [DATE]. The DON stated the hospital records and medication reconciliation had an order for heparin. The DON stated if the staff said they entered the orders as noted in the list from the hospital, then they should have included heparin. The DON stated he reviewed the order and Resident #2 missed about four doses, two on 08/21/26, and two on 08/22/26. The DON stated heparin was to prevent blood clots and he was not aware of any negative outcome for Resident #2 related to not receiving the medication. The DON stated Resident #2 was not at risk of injury because the nurses and staff knew to monitor for changes of condition. The DON stated it was a team effort to ensure the orders were in place. The DON stated it was important to have orders in place to follow the care and medications Resident #2 needed. The DON stated Resident #2 was discharged to the hospital on [DATE] due to a change of condition, unrelated to Resident #2 not receiving heparin. Record review of the facility's policy entitled admission Criteria revised March 2019, reflected:Policy Statement: Our facility admits only residents whose medical and nursing care needs can be met.Policy Interpretation and Implementation.4. Prior to or at the time of admission, the resident's attending physician provided the facility with information needed for the immediate care of the resident, including orders covering at least.b. medication orders, including (as necessary) a medicationcondition or problem associated with each medication.

Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care, for 1 of 4 residents (Resident #2) reviewed for baseline care plans. The facility failed to ensure Resident #2's baseline care plan was completed within 48 hours of admission on [DATE].This failure could place residents at risk of not receiving appropriate interventions and care to meet their needs.Findings included:Record review of Resident #2's face sheet, dated 08/27/26, reflected an [AGE] year-old male, admitted on [DATE], diagnosis: acute and chronic respiratory failure with hypoxia (conditions where the lungs cannot supply enough oxygen to the blood, either suddenly (acute) or over time (chronic), leading to dangerously low oxygen levels). Record review of Resident #2's baseline care plan, dated 08/20/26, reflected [Resident #2] was unable to respond. The baseline care plan revealed the activities and social services sections were completed. The nursing services, rehabilitative services, and food and nutrition services sections were not completed. The baseline care plan was not reviewed or signed by an RN. The baseline care plan was created by LVN F.Record review of Resident #2's admission MDS assessment, dated 08/21/26, reflected the assessment was in progress. The BIMS was not conducted.During an interview, on 08/27/26 at 2:10 PM, LVN E stated he admitted Resident #2 on 08/20/26, but did not initiate the baseline care plan because LVN F took over the admission's process. During an interview, on 08/27/26 at 2:25 PM, LVN F stated he did not recall if he initiated the baseline care plan for Resident #2. LVN F stated for a new admission, the floor nurse initiated or opened the baseline care plan and an RN completed or signed off on the baseline care plan. During an interview, on 08/28/26 at 11:30 AM, the ADON stated upon admission, the admitting nurse opened the baseline care plan. The ADON stated an RN had to sign off on the baseline care plan. The ADON stated the DON was the RN that reviewed and signed off on the baseline care plan.During an interview, on 08/28/26 at 12:15 PM, the DON stated baseline care plans were completed by the interdisciplinary team as each member had their section. The DON stated they had 48 hours from admission to complete a baseline care plan. The DON stated Resident #2 was admitted on [DATE] and the baseline care plan should have been completed by 08/22/26. The DON stated the admitting nurse initiated the baseline care plan and completed the nursing section, then everyone else was supposed to do their section. The DON stated he reviewed and signed the baseline care plans. The DON stated he reviewed Resident #2's file and verified his baseline care plan was not completed. The DON stated there was no negative outcome or risk of injury for Resident #2 as he received the care to meet his needs and staff were able to identify any change for him. The DON stated it was important to have the baseline care plan completed so that staff knew how to care for him and to follow the regulation.Record review of the facility's Care Plans - Baseline policy, dated March 2022, reflected - Policy Statement: A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission.1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: a. Initial goals based on admission orders and discussion with the resident/representative;b. Physician orders;c. Dietary orders;d. Therapy services;e. Social services.

Based on observation, interview and record review, the facility failed to ensure that the residents were free from chemical restraints not required to treat the residents' medical symptoms for 1 of 3 residents (Resident #1) reviewed for unnecessary medications.The facility failed to ensure LVN A correctly documented Resident #1's ordered medications outcome for Haloperidol and Invega on July 20, 21, 24, 25, 26, 2026 during the 7:00 a.m. to 7:00 p.m. shift. This failure could place residents at risk for adverse reactions and negative side effects from the administration of medication and dependence on unnecessary medications.Findings included:Record review of Resident #1's admission record, dated 07/29/26, reflected a [AGE] year-old male readmitted on [DATE] and initially admitted on [DATE]. His relevant diagnoses included schizophrenia (mental illness defined by delusions, hallucinations, and disorganized thinking), bipolar disorder (mental health condition defined by extreme shifts in mood, energy, and activity levels, moving between highs (mania) to los (depression), severe intellectual disabilities (IQ score between 20 and 35, major developmental delays and a need for daily supervision and assistance), and ataxia (lack of order, poor muscle control, clumsy movements, and balance issues).Record review of Resident #1's quarterly MDS assessment, dated 05/18/26, reflected a BIMS score of 05, which indicated his cognition was severely impacted.Record review of Resident #1's quarterly care plan assessment, dated 07/26/26, reflected:Focus: [Resident #1] uses psychotropic medications r/t behavior management. Date initiated 09/08/2025 and revised on 04/11/2026. Interventions included to administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Date Initiated: 09/08/2025Record review of Resident #1's physician's order summary, dated 07/29/26, reflected: An order for Haloperidol, Invega outcome codes: I=Improved, S=Same, W=Worsened. Every shift, active 07/15/2026.Record review of Resident #1's July 2026 MAR reflected: Haloperidol, Invega outcome codes: I=Improved, S=Same, W=Worsened. Every shift, start date 07/15/2026 reflected a code of 0 (zero) on July 20, 21, 24, 25, and 26 for the 7:00 a.m. to 7:00 p.m. shift.During an observation on 07/29/26 at 10:04 a.m., Resident #1 was observed lying in bed asleep. He was on a 1:1 supervision.During an interview on 07/29/29 at 4:26 p.m., LVN A said had been Resident #1's charge nurse on July 20-21, 24-26, 2026. He was observed as he reviewed Resident #1's medical electronic record and said he had entered 0 (zero) in error. LVN D said a code 0 (zero) to him meant same. LVN D said he must have gotten confused because Resident #1 also had an order to monitor his side effects of haloperidol and Invega that required a numerical code. LVN A said he understood his error and said, I need to pay more attention. LVN A said he was regularly in-serviced on medication administration. LVN A said a negative outcome to Resident #1 not having the correct cods for his haloperidol, Invega outcome order would be that his behaviors would not be able to be monitored. During an interview on 07/29/26 at 4:36 p.m., ADON B said it was her responsibility to ensure all nursing staff entered the correct codes on a resident's MAR. She said she was part of the IDT team who reviewed all resident's MAR during their morning daily meetings. She said Resident #1 had an order to be monitored for the outcomes of haloperidol and Invega per shift and the codes required to enter were I=improved, S=same, and W=worsened. She said a code 0 (zero) entered by LVN A on July 20, 21, 24, 25, 26, 2026 was not correct and that the order required an alphabetical code. ADON B said she and the IDT must have missed it, when reviewing Resident #1's July 2026 MAR. She said all nursing staff are in-serviced on the topic of medication administration on a regular basis. She was observed as she reviewed Resident #1's electronic medical record. She said a negative outcome for Resident #1 not having the correct codes entered on his MAR would be we would not monitor his behaviors correctly and not know if the mediation(s) were working.During an interview on 07/29/26 at 5:00 p.m., the DON was observed as he reviewed Resident #1's electronic medical record. He said Resident #1 had an order Haloperidol, Invega outcome codes: I=Improved, S=Same, W=Worsened. Every shift. He said the order required an alphabetical code and not a numerical code entered by LVN A on July 20, 21, 24, 25, 26, 2026. The DON said it was the responsibility of his ADONs and himself to ensure all nursing staff and medication aides enter the appropriate monitoring codes according to their orders. He said during their morning meetings, he and his ADONs would review all resident's orders to ensure they were being followed correctly. The DON said he and the facility's ADONs in-serviced nursing staff on the topic of medication administration. The DON said a negative outcome to Resident #1 not having his haloperidol and Invega outcome codes entered as ordered would be that we would not be able to monitor Resident #1's behaviors and not know if they have improved, stayed the same or worsened.Record review of the facility's Administering Medications policy, undated reflected: Policy Statement: Medications are administered in a safe and timely manner, and as prescribed.Policy Statement: .4.Medications are administered in accordance with prescriber orders, including any required time frame. Record review of the facility's Charting and Documentation policy, undated reflected:Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, function or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation .2. The following information is to be documented in the resident medical record .b. Medications administered.

Based on interviews and record reviews, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical status for 1 (Resident #1) of 5 residents reviewed for resident rights.The facility failed to ensure LVN A and LVN B notified the physician and the resident representative when there were reported scratches to Resident #1's arm and face on [DATE].This deficient practice could affect residents with a change of condition and result in not receiving adequate and timely invention and decline in condition.Findings included:Record review of Resident #1's face sheet, dated [DATE], reflected a [AGE] year-old female with an admission date of [DATE]. Her relevant diagnoses included severe intellectual disabilities (a person has major challenges learning, problem-solving, and managing daily life), cerebral palsy (lifelong condition that affects a person's ability to move, keep their balance, and control their posture), seborrheic dermatitis (chronic skin condition that causes itchy, greasy, and flaky patches of skin), psoriasis (chronic condition where the immune system mistakenly attacks healthy skin cells), enlarged hypertrophic nails (overgrown, thickened, or claw-like nails) and type 2 diabetes mellitus (body can't properly use or make the hormone insulin).Record review of Resident #1's comprehensive MDS assessment, dated [DATE], reflected her BIMS score of 00, which indicated severe cognitive impairment.Record review of Resident #1's care plan, dated [DATE], reflected Resident #1 has potential impairment to skin r/t psoriasis has potential to skin r/t psoriasis and seborrheic dermatitis. Goal: will maintain or develop clean and intact skin. Interventions: Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Monitor /document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration, etc. to MD.During an interview on [DATE] at 8:16 a.m., CNA C said she worked the 2 p.m.-10 p.m. shift on [DATE] and around 6 p.m., she took Resident #1 to the shower room and did not have marks or scratches on her arm and face. She said she returned to Resident #1's room at 7:30 p.m. and saw scant (barely sufficient or adequate) amount of smeared blood on the bed sheet that covered the resident's face. CNA C said she saw scratches on Resident #1. She said she saw died blood under Resident #1's fingernails and immediately notified LVN A.During an interview on [DATE] at 9:16 a.m., LVN A said the incident regarding Resident #1 took place during the evening shift on [DATE]. He said he was informed by the CNA at 7:30 p.m. of scratches on Resident #1's face and arm. LVN A said he assessed Resident #1 and saw small amounts of dried smeared blood on the resident's face and small amount of dried smeared blood on the part of the bed sheet that covered her chin. He said he assumed she scratched herself because she is being seen by a dermatologist for a skin condition. LVN A said Resident #1 was not in distress and cleaned her wounds. He said he got busy with other residents and did not notify the RP and the doctor to inform them of the scratches. LVN A the process to follow for residents having had a change in condition included documenting in the EMR and notifying the physician, RP, and DON. He said negative outcomes from not having documented and notified the MD and RP were increasing the family's concerns and escalating issues with the residents. He said he received an in-service on documentation and notification for changes in condition on [DATE].During an interview on [DATE] at 11:14 a.m., LVN B said he received report from LVN A in the morning on [DATE]. He said he was told by LVN A that Resident #1 had scratched herself during the evening shift. LVN B said he assumed LVN A had reported and documented the incident. He said he did not notify anyone about the incident and Resident #1 remained calm and had no further changes throughout the day. LVN B said not having made the proper notifications of change in condition might increase the residents' risk of infection. He said the nursing process for changes in condition included resident assessment, documentation, notification, and provided treatment as needed. LVN B said he received an in-service on documentation and notification of changes in condition on [DATE].During an interview on [DATE] at 11:30 a.m., the DON said during the morning meeting on [DATE], he was informed of Resident #1 scratches. He said he immediately checked the resident and informed the MD and RP and began the investigative process. He said notifications were made to the state agency within two hours. He said Resident #1's physician was in-house and ordered treatment. The DON said he performed 1:1 counseling with both nurses regarding the process when there is a change in condition and provided all staff with ANE in-services on [DATE].During an interview on [DATE] at 12:00 p.m., the Administrator said he and the leadership staff were made aware of the incident during the morning meeting on [DATE]. He said he immediately checked Resident #1 and reassigned the resident's roommate to ensure safety as the investigation proceeded. He said he directed the DON to complete a head-to-toe assessment on Resident #1 and to make the proper notifications. The Administrator said he immediately began the investigative process and notified the state agency within two hours on [DATE]. He said daily morning meetings were held with the IDT and discussed issues and resolutions, which included Resident #1's incident.Record review of facility policy titled Change in Condition, undated, stated The licensed nurse is responsible for: Notifying the physician or practitioner as required. Notifying the resident representative when appropriate. Documenting all findings and actions.

Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one (Resident #1) of five residents reviewed for ADL care.The facility failed to ensure Resident #1's nails were cleaned and did not have rough edges on 7/01/2026.These failures could place residents at risk of not receiving services or care, diminishing quality of life, and decreased self-esteem.Findings included:Record review of Resident #1's face sheet, dated 7/3/26, reflected a [AGE] year-old female with an admission date of 4/02/24. Her relevant diagnoses included severe intellectual disabilities (a person has major challenges learning, problem-solving, and managing daily life), cerebral palsy (lifelong condition that affects a person's ability to move, keep their balance, and control their posture), seborrheic dermatitis (chronic skin condition that causes itchy, greasy, and flaky patches of skin), psoriasis (chronic condition where the immune system mistakenly attacks healthy skin cells), enlarged hypertrophic nails (overgrown, thickened, or claw-like nails) and type 2 diabetes mellitus (body can't properly use or make the hormone insulin).Record review of Resident #1's comprehensive MDS assessment, dated 4/13/26, reflected her BIMS score of 00, which indicated severe cognitive impairment. Section GG- functional abilities for personal hygiene was coded at 2, which indicated the resident needed substantial/maximal assistance.Record review of Resident #1's care plan, dated 5/25/2026, reflected Resident #1 has potential impairment to skin r/t psoriasis has potential to skin r/t psoriasis and seborrheic dermatitis. Goal: will maintain or develop clean and intact skin. Interventions: Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Monitor /document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration, etc. to MD.Resident #1 has an ADL self-care performance deficit r/t impaired balance, limited mobility, unsteadiness on feet, difficulty in walking, lack of coordination. Goal: will maintain current level of function through the review date. Interventions: Personal Hygiene: The resident requires substantial/maximal assistance by one staff member with personal hygiene.During an observation on 7/03/2026 at 6:03 p.m., revealed Resident #1 was in her room eating dinner, assisted by therapy personnel. Resident #1 had brownish and whitish/yellowish substances underneath her fingernails (thumb, index finger, middle finger, and ring finger) on her left hand. She had blackish/brownish substances under her fingernail to her middle finger, yellowish substance under her fingernails (index finger, middle finger, pinky, and ring finger). The edges to all her fingernails on both hands were uneven.During an interview on 7/02/2026 at 4:15 p.m., the Activity director said nail trimming was a task she would carry out for residents that did not have a diagnosis of diabetes. She said she had not trimmed Resident #1's nails and that was a task that was carried out by the nurses.During an interview on 7/03/2026 at 11:40 a.m., The DON said it was part of activities to perform manicures and involve residents in the process. He said residents that have specific diagnoses, such as diabetes, were done by the nursing staff excluding CNAs. He said residents that had long and unkept nails were at risk of scratching themselves and could cause skin tears. The DON said the CNAs were to inquire if a resident had a diagnosis of DM before they trimmed the resident's fingernails. He said Resident #1 was calm and allowed the nurses to trim her fingernails but became easily startled when she felt the clippers on her nails. The DON said in-services for ADLs were done with the CNAs yearly and quarterly.Record review of facility policy titled Infection Control Standard Precautions, undated, stated .g. Personnel assist the residents with hand hygiene before meals, after toileting and when indicated.

Based on interviews and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #2) of six residents reviewed for infection control practices.The facility failed to ensure isolation protocols were followed when Resident #2 was newly admitted to the facility and roomed with a resident who was under droplet precautions.This failure could place residents at risk for the transmission of communicable diseases and infections.Findings included:Record review of Resident #2's face sheet, dated 7/2/26, reflected a [AGE] year-old male with an admission date of 6/24/26. His diagnoses included Alzheimer's disease (progressive brain disorder that gradually destroys memory and thinking skills), chronic kidney disease stage 3 (kidneys sustained moderate damage and filtering 30% to 59% of their normal capacity), osteoarthritis (cartilage that cushions the ends of bones gradually wears away), and peripheral vascular disease (poor blood circulation).Record review of Resident #2's Nursing Home Discharge MDS assessment, dated 6/29/2026, reflected his BIMS score was left blank.Record review of Resident #2's care plan, dated 6/25/26, reflected Resident #2 has an ADL self-care performance deficit r/t Alzheimer's, stroke. Goal: will maintain current level of function through the review date. Interventions: requires substantial/maximal assistance by staff 1-2 staff members for bathing/showering, bed mobility, and personal hygiene.Record review of Resident #2's, physician orders, dated 7/2/26, reflected orders to admit to skilled services. No order for isolation precautions.Record review of Resident #3's face sheet, dated 7/2/26, reflected a [AGE] year-old male with an admission date of 6/19/26. His pertinent diagnoses included pneumonia due to staphylococcus (lung infection caused by staphylococcus bacteria), personal history of other infections and parasitic diseases, and persistent vegetative state.Record review of Resident #3's comprehensive MDS assessment, dated 6/25/26, reflected hid BIMS score was left blank. Section GG indicated he was dependent on staff for ADLs.Record review of Resident #3's order summary, dated 7/2/26, indicated Resident #3 was transferred to the hospital for evaluation and treatment as ordered by the physician.During an interview on 7/02/2026 at 10:18 a.m., the ADON/IP said She said Resident #2 was admitted on [DATE] and was admitted to room [ROOM NUMBER]-A. She said he was not supposed to be in the same room with Resident #3 because Resident #3 was under droplet precautions. The ADON/IP said Resident #3 was admitted [DATE] and there was an order for droplet precautions on 6/21/26. She said the resident was under droplet precautions d/t MRSA. The ADON/IP said if he was under contact or droplet precautions there shouldn't have been another resident in the same room. She said if a resident was already in the room and the roommate was diagnosed with MRSA; the roommate would not be moved because he had already been exposed. The ADON/IP said Resident #2 could have been exposed to the MRSA by being in the same room with Resident #3. She said the staff wore their PPE while working with Resident #3 but, Resident #2 could have still been exposed. She said there were no negative outcomes for Resident #2 being in the same room as Resident #3. She said they were roomed together for one day because Resident #3 was sent to the hospital and Resident #2 was at the facility for a few days due to respite care and was discharged on 6/29/26. She said the last in-service on TBP was on 6/17/2026. She said annual clinics were done on infection control and TBP. She said the admissions coordinator assigned the rooms for newly admitted residents and she coordinated with admissions and informed them which rooms were under TBP precautions. She said she gave admission and dietary a list of residents under TBP. She said she could not explain why Resident #2 was admitted to the same room as Resident #3.During an interview on 7/02/2026 at 10:42 a.m., the Admissions Coordinator said rooms were assigned by the IDT. She said during morning meetings, new admissions were discussed and rooms were assigned for new residents. She said the team agreed to admit Resident #2 with Resident #3. She said she knew ahead of time which rooms were under isolation precautions. She said she was not aware Resident #3 was under droplet precautions and was not marked as isolation precautions on her roster dated 6/25/26. She said the staff discussed Resident #2's admission but somehow the isolation precaution was missed for Resident #3.During an interview on 7/03/2026 at 11:07 a.m., The DON said he did not know why Resident #2 was placed in the same room with Resident #3. He said whenever a resident was under TBP, the resident was roomed alone unless both residents had the same infection. He said the census sheet was highlighted to ensure all staff were aware of which residents were under isolation precautions. He said there was a follow up after Resident #2 was discharged and there was no negative outcome for Resident #2. He said there was ongoing in-services and training for the staff on infection control and infection control transfer sheets.Record review of facility policy untitled, undated, stated, Policy Statement- Transmission-Based Precautions shall be based upon the mode of transmission and may include: .2. Droplet precautions. 4.Droplet precautions shall be used for infections spread through respiratory droplets. Required measures- Staff and visitors shall: wear a surgical mask when entering the room, perform hand hygiene before and after contact, limit resident movement outside the room unless medically necessary, and place mask on the resident during transport when tolerated.

Based on interviews and record reviews the facility failed to ensure the residents right to be informed of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers, for 6 resident (Resident #4, Resident #56, Resident #73, Resident #82, Resident #104, and Resident #109) of 17 residents reviewed for consent for antipsychotic medications.1. The facility failed to ensure Resident #4's Consent for Antipsychotic or Neuroleptic Medication Treatment HHSC Form 3713 was correctly completed for Seroquel (an antipsychotic) as evidenced by there was no date or signature for the practitioner and there was no date after the resident's signature. 2. The facility failed to ensure Resident #56's Consent for Antipsychotic (used to treat certain mental/mood disorders) or Neuroleptic (also known as Antipsychotic) Medication Treatment HHSC Form 3713 was correctly completed for Risperdal (antipsychotic medication used to treat certain mental/mood disorders) as evidenced by there was no practitioner's signature and date. 3. The facility failed to ensure Resident #73's Consent for Antipsychotic or Neuroleptic Medication Treatment HHSC Form 3713 was correctly completed for olanzapine (an antipsychotic) as evidenced by there was no date or signature for the practitioner. 4. The facility failed to ensure Resident #82's Consent for Antipsychotic or Neuroleptic Medication Treatment HHSC Form 3713 was correctly completed for Risperidone as evidenced by there was no date after the practitioner's signature and there was no date after the resident representative's signature. 5. The facility failed to ensure Resident #104's Consent for Antipsychotic or Neuroleptic Medication Treatment HHSC Form 3713 was correctly completed for Seroquel (an antipsychotic) as evidenced by there was no date or signature for the practitioner. 6. The facility failed to ensure Resident #109's Consent for Antipsychotic or Neuroleptic Medication Treatment HHSC Form 3713 was correctly completed for Risperidone as evidenced by there was no date or signature for the practitioner and there was no date after the resident's signature. These failures could affect the right to self-determination of all facility residents who receive medication by allowing them to receive medication without their prior knowledge or consent, or that of their responsible party or emergency contacts. Findings included: 1. Record review of Resident #4's face sheet, dated 06/17/26, reflected a [AGE] year-old male, admitted on [DATE], diagnoses included: type 2 diabetes mellitus (insulin resistance and high blood sugar levels), acute kidney failure (condition that affects the kidneys' ability to filter waste from the blood), generalized muscle weakness, heart failure, bipolar disorder (mental health condition characterized by significant mood changes), depression (persistent feeling of sadness and loss of interest), generalized anxiety disorder (excessive, uncontrollable worry about every day issues), and post-traumatic stress disorder (mental health condition that's caused by an extremely stressful or terrifying event). Record review of Resident #4's MDS assessment, dated 06/14/26, reflected a BIMS score of 15, which indicated intact cognition. The MDS assessment reflected Resident #4 had active diagnoses of anxiety disorder, depression, bipolar disorder, and post-traumatic stress disorder. Record review of Resident #4's care plan, dated 06/17/26, reflected [Resident #4] had a mood problem related to bipolar disorder, generalized anxiety, and PTSD. Date initiated: 04/07/26. Interventions included: administer medications as ordered, monitor/document for side effects and effectiveness, assist the resident/family/caregivers to identify positive coping skills, and educate resident/family/caregivers regarding expectations of treatment. [Resident #4] had depression. Date initiated: 04/07/26. Interventions included: administer medications as ordered, monitor/document for side effects and effectiveness, and pharmacy review monthly or per protocol. [Resident #4] used psychotropic medications related to disease process of bipolar disorder. Date initiated: 04/07/26. Interventions included: administer medications as ordered by physician, monitor for side effects and effectiveness, and consult with pharmacy/MD to consider dosage reduction when clinically appropriate. Record review of Resident #4's order summary, dated 06/17/26, reflected an active order of Quetiapine Fumarate (Seroquel) tablet 100 MG give 1 tablet by mouth at bedtime for bipolar disorder. Start date of 04/13/26. Record review of Resident #4's consent for antipsychotic medication treatment form 3713, undated, reflected Resident #4 had bipolar disorder and Seroquel was proposed as a course of therapy. There was a printed name for the MD prescriber but no signature or date. Resident #4 signed the form but there was no date for his signature. 2. Record review of Resident #56's face sheet, dated 6/18/2026, reflected a [AGE] year-old female admitted on [DATE]. Resident #56's diagnoses included Unspecified dementia, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (early-stage memory and thinking problems that interfere with daily life, but the cause isn't known), major depressive disorder (serious mental health condition that causes persistent feelings of sadness, hopelessness, and a loss of interests in activities once enjoyed), anxiety disorder (mental health condition where the brain's danger alarm gets stuck in the on position), major depressive disorder, recurrent, severe with psychotic symptoms (intense, repeated bouts of severe clinical depression paired with a temporary loss of touch with reality, such as seeing or hearing things that aren't there), and Alzheimer's disease (progressive brain disorder that slowly destroys memory and thinking skills). Record review of Residents #56's quarterly MDS assessment, dated 6/13/2026, reflected a BIMS score of 2, which indicated severe cognitive impairment. Resident #56 was coded as having diagnoses of Alzheimer's disease, non-Alzheimer's dementia, anxiety disorder, depression, and unspecified dementia, mild without behaviors/psychotic/mood disturbances/anxiety. Resident #56 was coded as taking an antipsychotic medication. Record review of Resident #56's Order Summary Report, dated 6/18/2026, reflected an order for Risperdal 0.5 mg (Risperidone)give 1 tablet by mouth one time a day for affective mood disorder with a start date of 10/05/2025. Record review of Resident #56's Medication Administration Record, dated 6/1/26-6/30/26, indicated she received Risperdal 0.5 mg give 1 tablet by mouth one time a day for affective mood disorder on 6/1/26-6/18/26. Record review of Resident #56's Consent for Antipsychotic or Neuroleptic Medication Treatment HHSC Form 3713 reflected no signature of person prescribing medication, or person's designee or the nursing facility's medical director and no date. 3. Record review of Resident #73's admission record dated 06/18/2026, revealed a [AGE] year-old female with an admission date of 10/08/2024. Resident #73's diagnoses included dementia (a decline in mental ability - such as memory, thinking, and reasoning - severe enough to interfere with daily life) with other behavioral disturbance, bipolar disorder (a mental health condition that causes extreme, cyclical shifts in mood energy, and activity levels), psychosis (a collection of symptoms rather than a single illness where a person experiences a loss of contact with reality) not due to a substance or known physiological condition, mood disorder (a broad category of mental health conditions that primarily affect a person's persistent emotional state), schizoaffective disorder (a chronic mental health condition characterized by a combination of schizophrenia symptoms [like hallucinations or delusions] and mood disorder symptoms [like mania or depression]). Record review of Resident #73's Modification of Quarterly MDS, dated [DATE], revealed a BIMS score of 00, indicating severe cognitive impairment. Resident #73 had unclear speech, rarely/never understood others, and rarely/never was understood by others. There were psychiatric or mood disorders noted (Bipolar Disorder, Psychotic disorder other than schizophrenia, and schizophrenia). Resident #73 was dependent for showers and toileting requiring the assistance of two helpers. Resident #73 required substantial/maximal assistance for eating, toileting, and personal hygiene where the helpers provided 50% or more of the effort. Antipsychotics, antidepressants, and anticonvulsants were received on a routine basis. Record review of Resident #73's care plan, dated 04/11/2026, revealed, FOCUS: Antipsychotics: (Black Box Warning): Potential for side effects, complications or adverse reactions related to ordered use of drug, as noted by the FDA. *Adverse cardiovascular effects, risk for infections, respiratory and pneumonia, falls, blood glucose and lipid elevations, abnormal movement, stroke, sedation. Date Initiated: 06/11/2026 Revision on: 06/11/2026. GOAL: Side effects & adverse reactions will be minimized, recognized early, or prevented. Date Initiated: 06/11/2026 Target Date: 07/29/2026. INTERVENTIONS/TASKS: Administer medication/s as ordered Date Initiated: 06/11/2026 LPN LVN RN Observe for adverse effect/s (Black Box Warning) of drug therapy. BLACK BOX WARNING - Associated with increased mortality in older adult patients Date Initiated: 06/11/2026 LPN LVN RN OLANZapine Oral Tablet 2.5 MG Black Box Warning Warning: Increased mortality in elderly patients with dementia-related psychosis Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Analyses of 17 placebo-controlled trials (modal duration, 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients between 1.6 and 1.7 times the risk of death in placebo-treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was approximately 4.5%, compared with a rate of about 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (eg, heart failure, sudden death). [sic] Record review of Resident #73's antipsychotic consent form for olanzapine (antipsychotic) dated 03/09/2026 was not signed or dated by physician. Record review of Resident #73's Physician's order dated 04/23/2026, revealed OLANZapine Oral Tablet 2.5 MG (Olanzapine) Give 1 tablet orally at bedtime for MOOD DISORDER DUE TO KNOWN PHYSIOLOGICAL CONDITION WITH MIXE related to MOOD DISORDER DUE TO KNOWN PHYSIOLOGICAL CONDITION WITH MIXED FEATURES. [sic] Record review of Resident #73's April 2026 MAR revealed Resident #73 was administered Olanzapine 2.5 mg at bedtime from 04/23/2026 through 04/30/2026 without consent signed or dated by the doctor. Record review of Resident #73's May 2026 MAR revealed Resident #73 was administered Olanzapine 2.5 mg at bedtime from 05/01/2026 through 05/31/2026 without consent signed or dated by the doctor. Record review of Resident #73's June 2026 MAR revealed Resident #73 was administered Olanzapine 2.5 mg at bedtime from 06/01/2026 through 06/18/2026 without consent signed or dated by the doctor. Record review of Resident #73's Order Summary dated 06/18/2026 revealed an order for OLANZapine Oral Tablet 2.5 MG (Olanzapine) Give 1 tablet orally at bedtime for MOOD DISORDER DUE TO KNOWN PHYSIOLOGICAL CONDITION WITH MIXE related to MOOD DISORDER DUE TO KNOWN PHYSIOLOGICAL CONDITION WITH MIXED FEATURES with an order date of 04/23/2026 and a start date of 04/23/2026. [sic] 4. Record review of Resident # 82's face sheet, dated 6/18/2026, reflected an [AGE] year-old female admitted on [DATE]. Resident #82's diagnoses included unspecified dementia, mild without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (early-stage memory and thinking problems that interfere with daily life, but the cause isn't known), major depressive disorder (serious mental health condition that causes persistent feelings of sadness, hopelessness, and a loss of interests in activities once enjoyed), persistent mood [affective] disorder (long-lasting, low-level type of sadness), and unspecified dementia, unspecified severity, with other behavioral disturbance (decline in brain function that affects daily life and thinking skills.). Record review of Resident #82's quarterly MDS assessment, dated 5/19/2026, reflected a BIMS score of 1, which indicated severe cognitive impairment. Resident #82 was coded as having diagnoses of non-Alzheimer's dementia, depression, persistent mood [affective] disorder, and unspecified dementia, mild, without behaviors/psychotic/mood/anxiety. Record review of Resident #82's Order Summary Report, dated 6/18/26, reflected an order for Risperdal 0.5 mg (Risperidone) give 0.25 mg by mouth at bedtime for affective mood disorders with a start date of 8/11/25. Record review of Resident #82's Medication Administration Record, dated 6/1/26-6/30/26, indicated she received Risperdal 0.5 mg (Risperidone) give 0.25 mg by mouth at bedtime for affective mood disorders on 6/1/26-6/17/26. Record review of Resident #82's Consent for Antipsychotic or Neuroleptic Medication Treatment HHSC Form 3713 reflected no date next to the person prescribing the medication and no date next to the Resident or Resident's Representative's signature. 5. Record review of Resident #104's admission record dated 06/15/2026, revealed an [AGE] year-old female with an admission date of 08/12/2024. Resident #104's diagnoses included Alzheimer's Disease (a progressive, irreversible brain disorder that slowly destroys memory and thinking skills), and anxiety disorder (a group of mental health conditions that cause intense, persistent, and excessive fear or worry in non-threatening situations). Record review of Resident #104's Quarterly MDS, dated [DATE], revealed a BIMS score of 03, indicating severe cognitive impairment. There were psychiatric or mood disorders noted (anxiety and depression). Resident #104 required substantial/maximal assistance for eating, toileting, showering, and personal hygiene where the helpers provided 50% or more of the effort. Antipsychotics, antidepressants, anticoagulants, and anticonvulsants were received on a routine basis. Record review of Resident #104's care plan, dated 06/08/2026, revealed, FOCUS: Antipsychotics: (Black Box Warning): Potential for side effects, complications or adverse reactions related to ordered use of drug, as noted by the FDA. *Adverse cardiovascular effects, risk for infections, respiratory and pneumonia, falls, blood glucose and lipid elevations, abnormal movement, stroke, sedation. Date Initiated: 06/11/2026 Revision on: 06/11/2026. GOAL: Side effects & adverse reactions will be minimized, recognized early, or prevented. Date Initiated: 06/11/2026 Target Date: 07/29/2026. INTERVENTIONS/TASKS: Administer medication/s as ordered Date Initiated: 06/11/2026 LPN LVN RN Observe for adverse effect/s (Black Box Warning) of drug therapy. BLACK BOX WARNING - Associated with increased mortality in older adult patients Date Initiated: 06/11/2026 LPN LVN RN OLANZapine Oral Tablet 2.5 MG Black Box Warning Warning: Increased mortality in elderly patients with dementia-related psychosis Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Analyses of 17 placebo-controlled trials (modal duration, 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients between 1.6 and 1.7 times the risk of death in placebo-treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was approximately 4.5%, compared with a rate of about 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (eg, heart failure, sudden death). [sic] Record review of Resident #104's Physician's order dated 04/20/2026, revealed Seroquel Oral Tablet 25 MG Give 1 tablet one time a day for affective mood disorder. Record review of Resident #104's antipsychotic consent form for Seroquel 25 mg (an antipsychotic) dated 04/28/2026 was not signed or dated by physician. Record review of Resident #104's April 2026 MAR revealed Resident #104 was administered Seroquel 25 mg one time a day from 04/21/2026 through 04/30/2026 without consent signed or dated by the doctor. Record review of Resident #104's May 2026 MAR revealed Resident #104 was administered Seroquel 25 mg one time a day from 05/01/2026 through 05/31/2026 without consent signed or dated by the doctor. Record review of Resident #104's June 2026 MAR revealed Resident #104 was administered Seroquel 25 mg one time a day from 06/01/2026 through 06/17/2026 without consent signed or dated by the doctor. Record review of Resident #104's Order Summary dated 06/15/2026 revealed Seroquel Oral Tablet 25 MG Give 1 tablet one time a day for affective mood disorder with an order dated of 04/20/2026 and a start date of 04/21/2026. 6. Record review of Resident #109's admission record dated 06/17/2026, revealed a [AGE] year-old male with an admission date of 08/29/2018. Resident #109's diagnoses included bipolar disorder (a chronic mental health condition characterized by intense, alternating mood swings between extreme highs (mania or hypomania) and lows (depression) and schizophrenia (a chronic and severe mental brain disorder that affects a person's ability to interpret reality, think logically, regulate emotions, and relate to others). Record review of Resident #109's Quarterly MDS dated [DATE] revealed a BIMS score of 11, indicating moderate cognitive impairment. There were psychiatric or mood disorders noted (anxiety, bipolar disorder, depression, and schizophrenia). Resident #109 required substantial/maximal assistance for toileting and personal hygiene where the helpers provided 50% or more of the effort. Antipsychotics, antidepressants, hypoglycemics (including insulin), and anticonvulsants were received on a routine basis. Record review of Resident #109's care plan, dated 04/12/2026, revealed, FOCUS: Antipsychotics: (Black Box Warning): Potential for side effects, complications or adverse reactions related to ordered use of drug, as noted by the FDA: [] Prolixin [] Risperdal [] Risperdal Consta [] Risperdal M [] Seroquel [] Stelazine [] Symbyax [] Thorazine [] Trilafone [] Zyprexa [] Zyprexa Zydis [X] Other (RISPERIDONE). *Adverse cardiovascular effects, risk for infections, respiratory and pneumonia, falls, blood glucose and lipid elevations, abnormal movement, stroke, sedation. Date Initiated: 06/11/2026 Revision on: 06/11/2026 GOAL: Will be free from side effect from medication. Date Initiated: 06/11/2026 Target Date: 07/11/2026 INTERVENTIONS/TASKS: Administer medication/s as ordered Date Initiated: 06/11/2026 LPN LVN RN Attempt a gradual dose reduction as indicated/condition improves, as ordered Date Initiated: 06/11/2026 LPN LVN RN Labs as indicated, report abnormal results to physician. Date Initiated: 06/11/2026 LPN LVN RN Observe and report signs of hallucinations, headache, nervousness, talkativeness, apprehension, irritability, confusion, euphoria, relaxed feeling, weakness, tremor, lack of concentration, depression, dreaming/nightmares, insomnia, palpitations, chest pains, rapid heart rate, heartburn, nausea, vomiting, diarrhea, constipation, abdominal pain, loss of appetite, alterations in taste, difficulty urinating, dry mouth, excessive salivation, photosensitivity, tic-like movements Date Initiated: 06/11/2026 LPN LVN RN Observe for adverse effect/s (Black Box Warning) of drug therapy. BLACK BOX WARNING - Associated with increased mortality in older adult patients Date Initiated: 06/11/2026 LPN LVN RN Observe/record effectiveness of drug treatment as indicated LPN LVN. Record review of Resident #109's Physician's order dated 07/03/2024, revealed RisperIDONE Oral Tablet 1 MG Give 1 tablet by mouth two times a day for SCHIZOPHRENIA. Record review of Resident #109's antipsychotic consent form for risperidone 1 mg (an antipsychotic) not dated by the doctor or resident and was not signed by the physician. Record review of Resident #109's July 2024 MAR revealed Resident #109 was administered risperidone 1 mg two times a day from 07/01/2024 through 07/31/2024 without consent signed or dated by the doctor or dated by the resident. Record review of Resident #109's Order Summary dated 06/17/2026 revealed RisperIDONE Oral Tablet 1 MG Give 1 tablet by mouth two times a day for SCHIZOPHRENIA with an order dated of 07/03/2024 and a start date of 07/03/2024. Record review of Resident #109's Care Plan dated 04/12/2026 revealed: FOCUS: Antipsychotics: (Black Box Warning): Potential for side effects, complications or adverse reactions related to ordered use of drug, as noted by the FDA: [] Prolixin [] Risperdal [] Risperdal Consta [] Risperdal M [] Seroquel [] Stelazine [] Symbyax [] Thorazine [] Trilafone [] Zyprexa [] Zyprexa Zydis [X] Other (RISPERIDONE). *Adverse cardiovascular effects, risk for infections, respiratory and pneumonia, falls, blood glucose and lipid elevations, abnormal movement, stroke, sedation. Date Initiated: 06/11/2026 Revision on: 06/11/2026 GOAL: Will be free from side effect from medication. Date Initiated: 06/11/2026 Target Date: 07/11/2026 INTERVENTIONS/TASKS: Administer medication/s as ordered Date Initiated: 06/11/2026 LPN LVN RN Attempt a gradual dose reduction as indicated/condition improves, as ordered Date Initiated: 06/11/2026 LPN LVN RN Labs as indicated, report abnormal results to physician. Date Initiated: 06/11/2026 LPN LVN RN Observe and report signs of hallucinations, headache, nervousness, talkativeness, apprehension, irritability, confusion, euphoria, relaxed feeling, weakness, tremor, lack of concentration, depression, dreaming/nightmares, insomnia, palpitations, chest pains, rapid heart rate, heartburn, nausea, vomiting, diarrhea, constipation, abdominal pain, loss of appetite, alterations in taste, difficulty urinating, dry mouth, excessive salivation, photosensitivity, tic-like movements Date Initiated: 06/11/2026 LPN LVN RN Observe for adverse effect/s (Black Box Warning) of drug therapy. BLACK BOX WARNING - Associated with increased mortality in older adult patients Date Initiated: 06/11/2026 LPN LVN RN Observe/record effectiveness of drug treatment as indicated LPN LVN During an interview on 06/15/26 at 2:00 p.m., Resident #4 refused to speak to this surveyor. During an interview on 06/18/26 at 10:00 a.m., Resident #4 refused to speak to this surveyor and did not want this surveyor to return at a later time. During an interview on 06/18/2026 at 2:55 p.m., LVN D stated the nurse who took the order for an antipsychotic was the one responsible for getting the consent from the RP. She said the ADON oversaw the antipsychotics. She said the antipsychotic will be put on hold until consent was given. LVN D stated the antipsychotic consent sheets have the nurse's signature and RP/Resident and it would be dated. She said they would get a signature if the RP was at the facility. She said doctors/NPs do not sign the consent. She said she was not sure about signatures on the new 3713 Consent for Antipsychotics. She said the nurses were the ones who filled out the Consent for antipsychotics. She said they recently started the new 3713 Consent forms for antipsychotics. During an interview, on 06/18/26 at 3:00 p.m., the ADON stated Resident #4 was on Seroquel (Quetiapine Fumarate) since 04/13/26 and required a form 3713 (consent form) signed by the resident and physician. The ADON stated the Seroquel medication was for Resident #4's diagnosis of bipolar disorder and Seroquel was an antipsychotic medication. The ADON stated the consent form on file for the Seroquel was not signed or dated by the physician and was not dated by the resident. The ADON stated the form should have been signed and dated by both the resident and physician before administering the medication. The ADON stated the purpose of the form was so that the resident was aware of the medication, what it was for, what side effects were possible, and how it might make them feel. The ADON stated there was no negative outcome for Resident #4 as staff followed his orders, but the form was not official as it was not signed and dated by both the resident and physician. During an interview on 6/18/26 at 6:28 p.m., the ADON stated once an order for an antipsychotic medication was ordered, the nurses ensured the consent for the medication was completed. She stated consent form 3713 was completed once the MD or NP and the Resident or Resident Representative signed and dated the form. The ADON stated the DON checked the consent forms for antipsychotic medication to ensure they were completed. During an interview on 06/18/2026 at 6:43 p.m., ADON stated the ADON and DON monitored antipsychotic orders. She said they made sure the consents were signed, RP was notified, behavior monitoring was in place, and nurses were monitoring resident for 14 days. She said an antipsychotic needed the RP/Resident's and doctor's signature and the consent was dated. She said the ADON and DON reviewed orders for antipsychotics at the morning meetings Monday through Friday. She stated they ensured the order was input properly, consent was complete, and documentation was in the computer. She said consents for antipsychotics needed to be completed with signature of the RP/resident and doctor and they needed to be dated before the medication could be administered. The antipsychotic would be held until the consent was completed with dates and signatures. During an interview, on 06/18/26 at 7:45 p.m., the DON stated the physician that prescribed the antipsychotic medication would have explained the risks, benefits, and black box warning to the resident or their RP. The DON stated the 3713 form for antipsychotic medication had to be signed and dated by resident or the RP and the physician before administration of the medication. The DON stated he was aware that there was lack of coordination between the team and the forms had not been completed as required. The DON stated if the form was not fully signed with a signature or date missing, then the form was not official based on the regulations. The DON stated he had been auditing the consent forms and in-serviced nurses on antipsychotics and consents. The DON stated he last in-service was no more than two months ago. During an interview on 6/18/2026 at 8:30 p.m., the DON stated he audited consent forms daily. He said the NP or MD were supposed to educate the family or residents and initiate the consent form for antipsychotic medication. The DON said there was no coordination between the NP, MD, nurses, and resident or resident representative to initiate consent. He stated psychotropic medications were given to residents with incomplete consent forms if signatures and dates were missing. The DON said the last in-service given to the nurse on antipsychotic medication and consents was no more than two months ago. Record review of the facility's policy Antipsychotics - Consent, not dated, revealed, 1. Policy Statement [Facility] will protect each resident's right to make informed decisions regarding treatment and will not administer antipsychotic or neuroleptic medication unless legally valid consent has been obtained and documented, except in a medication-related emergency as permitted by law. Consent will be obtained in a manner that is voluntary, informed, free from coercion or undue influence, and consistent with federal and Texas requirements. [Facility] will ensure that antipsychotic medications are used only when medically necessary to treat a specific, documented condition, are not used for staff convenience or discipline and are subject to ongoing review, monitoring, and attempts at reduction/discontinuation when clinically appropriate. 2. Purpose The purpose of this policy is to: 1.Ensure compliance with Texas Health and Safety Code 242.505, 26 TAC 554.1207, and HHSC requirements for consent to antipsychotic/neuroleptic medication treatment. 2.Support compliance with CMS resident-rights and psychotropic-medication guidance applicable to nursing facilities. 3.Protect resident autonomy, safety, dignity, and person-centered decision-making. 4.Standardize the facility process for obtaining, documenting, renewing, and monitoring consent related to antipsychotic use.5.1 The prescribing practitioner, the practitioner's designee, or the facility's medical director is responsible for providing the consent information required by state law and for completion of the clinical information section of the form 3713 for antipsychotic medication treatment. 5.3 Nursing staff are responsible for: verifying that valid consent is present before administration.

Based on interview and record review, the facility failed to ensure that the residents were free from chemical restraints not required to treat the resident's medical symptoms for 5 (Resident #9, Resident #56, Resident #73, Resident #82, and Resident #104) of 11 residents reviewed for unnecessary medications. 1.The facility failed to have an adequate indication for the use of the medication olanzapine (Zyprexa) (an antipsychotic) for Resident #9 with a diagnosis of dementia.2.The facility failed to have an adequate indication for the use of the medication risperidone (Risperdal) (an antipsychotic) for Resident #56 with a diagnosis of dementia.3.The facility failed to have an adequate indication for the use of the medication olanzapine (Zyprexa) (an antipsychotic) for Resident #73 with a diagnosis of dementia.4.The facility failed to have an adequate indication for the use of the medication risperidone (Risperdal) (an antipsychotic) for Resident #82 with a diagnosis of dementia.5.The facility failed to have an adequate indication for the use of the medication Seroquel (an antipsychotic) for Resident #104 with a diagnosis of dementia. This failure could put residents at risk of harm from adverse reactions or harmful side effects. The findings included: 1. Record review of Resident # 9's face sheet, dated 6/17/26, reflected an [AGE] year-old female admitted on [DATE]. Resident #9's diagnoses include unspecified dementia, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (early-stage memory and thinking problems that interfere with daily life, but the cause isn't known), major depressive disorder (serious mental health condition that causes persistent feelings of sadness, hopelessness, and a loss of interests in activities once enjoyed), anxiety disorder (mental health condition where the brain's danger alarm gets stuck in the on position), and unspecified psychosis not due to a substance or known physiological condition (experiencing a loss of touch with reality, but doctors have not yet determined the exact mental health cause). Record review of Resident #9's quarterly MDS assessment, dated 5/13/26, reflected a BIMS score of 02, which indicated severe cognitive impairment. Resident #9 was coded as having non-Alzheimer's dementia, anxiety disorder, depression, and psychotic disorder. Section N indicated Resident #9 received antipsychotics on a routine basis. Record review of Resident #9's care plan, dated 6/02/2026, revealed, FOCUS: Resident #9 uses psychotropic medications r/t dementia. Date initiated: 4/30/24 Revision on: 4/30/24. GOAL: The Resident will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction, or cognitive/behavior impairment through review date. Date initiated 8/19/24 Revision on 8/19/24 Target date: 7/29/26 Intervention/Tasks: Zyprexa Black Box Warning. Warning: Increased mortality in elderly patients with dementia-related psychosis.Olanzapine is not approved for treatment of patients with dementia-related psychosis. Date initiated: 8/4/25. Record review of Resident #9's Order Summary Report, dated 6/17/26, reflected an order for Zyprexa 5 mg (olanzapine) give one tablet by mouth two times a day for unspecified psychosis. Start date: 5/7/26 Record review of Resident #9's Medication Administration Record, dated 6/1/26-6/30/26, indicated she received Zyprexa 5 mg (olanzapine) give one tablet by mouth two times a day for unspecified psychosis on 6/1/26-6/17/26. 2. Record review of Resident #56's face sheet, dated 6/18/2026, reflected a [AGE] year-old female admitted on [DATE]. Resident #56's diagnoses included Unspecified dementia, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (early-stage memory and thinking problems that interfere with daily life, but the cause isn't known), major depressive disorder (serious mental health condition that causes persistent feelings of sadness, hopelessness, and a loss of interests in activities once enjoyed), anxiety disorder (mental health condition where the brain's danger alarm gets stuck in the on position), major depressive disorder, recurrent, severe with psychotic symptoms (intense, repeated bouts of severe clinical depression paired with a temporary loss of touch with reality, such as seeing or hearing things that aren't there), and Alzheimer's disease (progressive brain disorder that slowly destroys memory and thinking skills). Record review of Residents #56's quarterly MDS assessment, dated 6/13/2026, reflected a BIMS score of 2, which indicated severe cognitive impairment. Resident #56 was coded as having diagnoses of Alzheimer's disease, non-Alzheimer's dementia, anxiety disorder, depression, and unspecified dementia, mild without behaviors/psychotic/mood disturbances/anxiety. Resident #56 was coded as taking an antipsychotic medication. Record review of Resident #56's care plan, dated 4/12/26, revealed, FOCUS: Antipsychotics: (Black Box Warning): Potential for side effects, complications or adverse reactions related to ordered use of drug as noted by the FDA: Risperdal. *Adverse cardiovascular effects, risk for infections, respiratory and pneumonia, falls, blood glucose and lipid elevations, abnormal movement, stroke sedation. Date initiated: 8/13/24 Revision on: 6/11/26. GOAL: Side effects & adverse reactions will be minimized, recognized early, or prevented. Date initiated 6/11/26 Target date: 7/11/26. Record review of Resident #56's Order Summary Report, dated 6/18/2026, reflected an order for Risperdal 0.5 mg (Risperidone)give 1 tablet by mouth one time a day for affective mood disorder (an inappropriate indication for a resident with Alzheimer's/Dementia to receive an antipsychotic) with a start date of 10/05/2025. Record review of Resident #56's Medication Administration Record, dated 6/1/26-6/30/26, indicated she received Risperdal 0.5 mg give 1 tablet by mouth one time a day for affective mood disorder on 6/1/26-6/18/26. 3.Record review of Resident #73's admission record dated 06/18/2026, revealed a [AGE] year-old female with an admission date of 10/08/2024. Resident #73's diagnoses included dementia (a decline in mental ability - such as memory, thinking, and reasoning - severe enough to interfere with daily life) with other behavioral disturbance, bipolar disorder (a mental health condition that causes extreme, cyclical shifts in mood energy, and activity levels), psychosis (a collection of symptoms rather than a single illness where a person experiences a loss of contact with reality) not due to a substance or known physiological condition, mood disorder (a broad category of mental health conditions that primarily affect a person's persistent emotional state), schizoaffective disorder (a chronic mental health condition characterized by a combination of schizophrenia symptoms [like hallucinations or delusions] and mood disorder symptoms [like mania or depression]). Record review of Resident #73's Modification of Quarterly MDS, dated [DATE], revealed a BIMS score of 00, indicating severe cognitive impairment. Resident #73 had unclear speech, rarely/never understood others, and rarely/never was understood by others. There were psychiatric or mood disorders noted (Bipolar Disorder, Psychotic disorder other than schizophrenia, and schizophrenia). Resident #73 was dependent for showers and toileting requiring the assistance of two helpers. Resident #73 required substantial/maximal assistance for eating, toileting, and personal hygiene where the helpers provided 50% or more of the effort. Antipsychotics, antidepressants, and anticonvulsants were received on a routine basis. Record review of Resident #73's care plan, dated 04/11/2026, revealed FOCUS: [Resident #73] has a communication problem and is at risk for delirium or an acute confusional episode r/t Acute disease process Dementia. Resident exhibits cognitive loss related to dementia. Resident is provide low stimulation activities in security unit. Sometimes [Resident #73] will carry a baby doll for a while if offered. [Resident #73] do not follow even simple directions She just stares at you and rarely follows simple instructions but she can't do any activity most of the time. Activities will continue provide with daily low stimulation activities in security unit through the next review date. Date Initiated: 04/07/2026 Revision on: 05/25/2026. [sic] FOCUS: [Resident #73] has impaired cognitive function/dementia or impaired thought processes r/t Dementia Date Initiated: 10/09/2024 Revision on: 10/09/2024. INTERVENTIONS/TASKS: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 10/09/2024 LPN RN. FOCUS: [Resident #73] is at risk for delirium or an acute confusional episode r/t Acute disease process Dementia Date Initiated: 11/01/2024 Revision on: 11/01/2024. FOCUS: [Resident #73] is at risk for a mood problem r/t Dementia with behaviors and pyschosis Date Initiated: 10/09/2024 Revision on: 10/09/2024. INTERVENTIONS/TASKS: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 10/09/2024 LPN RN Behavioral health consults as needed (psycho-geriatric team, psychiatrist etc.) Date Initiated: 10/09/2024 LPN RN. Record review of Resident #73's Physician's order dated 04/23/2026, revealed OLANZapine Oral Tablet 2.5 MG (Olanzapine)Give 1 tablet orally at bedtime for MOOD DISORDER DUE TO KNOWN PHYSIOLOGICAL CONDITION WITH MIXE related to MOOD DISORDER DUE TO KNOWN PHYSIOLOGICAL CONDITION WITH MIXED FEATURES. [sic] Record review of Resident #73's April 2026 MAR revealed Resident #73 was administered Olanzapine 2.5 mg at bedtime from 04/23/2026 through 04/30/2026 without consent signed or dated by the doctor. Record review of Resident #73's May 2026 MAR revealed Resident #73 was administered Olanzapine 2.5 mg at bedtime from 05/01/2026 through 05/31/2026. Record review of Resident #73's June 2026 MAR revealed Resident #73 was administered Olanzapine 2.5 mg at bedtime from 06/01/2026 through 06/18/2026. 4. Record review of Resident # 82's face sheet, dated 6/18/2026, reflected an [AGE] year-old female admitted on [DATE]. Resident #82's diagnoses included unspecified dementia, mild without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (early-stage memory and thinking problems that interfere with daily life, but the cause isn't known), major depressive disorder (serious mental health condition that causes persistent feelings of sadness, hopelessness, and a loss of interests in activities once enjoyed), persistent mood [affective] disorder (long-lasting, low-level type of sadness), and unspecified dementia, unspecified severity, with other behavioral disturbance (decline in brain function that affects daily life and thinking skills.). Record review of Resident #82's quarterly MDS assessment, dated 5/19/2026, reflected a BIMS score of 1, which indicated severe cognitive impairment. Resident #82 was coded as having diagnoses of non-Alzheimer's dementia, depression, persistent mood [affective] disorder, and unspecified dementia, mild, without behaviors/psychotic/mood/anxiety. Record review of Resident #82's Order Summary Report, dated 6/18/26, reflected an order for Risperdal 0.5 mg (Risperidone) give 0.25 mg by mouth at bedtime for affective mood disorders (an inappropriate indication for a resident with Alzheimer's/Dementia to receive an antipsychotic) with a start date of 8/11/25. Record review of Resident #82's Medication Administration Record, dated 6/1/26-6/30/26, indicated she received Risperdal 0.5 mg (Risperidone) give 0.25 mg by mouth at bedtime for affective mood disorders on 6/1/26-6/17/26. Record review of Resident #82's care plan, dated 6/2/26, revealed, FOCUS: Antipsychotics: (Black Box Warning): Potential for side effects, complications or adverse reactions related to ordered use of drug as noted by the FDA: Risperdal. *Adverse cardiovascular effects, risk for infections, respiratory and pneumonia, falls, blood glucose and lipid elevations, abnormal movement, stroke sedation. Date initiated: 6/11/26 Revision on: 6/11/26. GOAL: Side effects & adverse reactions will be minimized, recognized early, or prevented. Date initiated 6/11/26 Target date: 7/29/26. 5. Record review of Resident #104's admission record dated 06/15/2026, revealed an [AGE] year-old female with an admission date of 08/12/2024. Resident #104's diagnoses included Alzheimer's Disease (a progressive, irreversible brain disorder that slowly destroys memory and thinking skills), and anxiety disorder (a group of mental health conditions that cause intense, persistent, and excessive fear or worry in non-threatening situations). Record review of Resident #104's Quarterly MDS, dated [DATE], revealed a BIMS score of 03, indicating severe cognitive impairment. There were psychiatric or mood disorders noted (anxiety and depression). Resident #104 required substantial/maximal assistance for eating, toileting, showering, and personal hygiene where the helpers provided 50% or more of the effort. Antipsychotics, antidepressants, anticoagulants, and anticonvulsants were received on a routine basis. Record review of Resident #104's care plan, dated 06/08/2026, revealed FOCUS: [Resident #104] has a potential behavior problem r/t depression, anxiety and Alzheimer's Date Initiated: 06/15/2026 Revision on: 06/15/2026. INTERVENTIONS/TASKS: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 06/15/2026 LPN RN. FOCUS: [Resident #104] has impaired cognitive function/dementia and impaired thought processes r/t Dementia Date Initiated: 03/10/2026 Revision on: 06/15/2026. INTERVENTIONS/TASKS: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 03/10/2026 LPN RN. FOCUS: [Resident #104] has inattention and disorganized thinking related to Alzheimer's and Dementia Date Initiated: 08/30/2024 Revision on: 08/30/2024. FOCUS: [Resident #104] has depression/anxiety r/t Dementia Date Initiated: 08/30/2024 Revision on: 08/30/2024. INTERVENTIONS/TASKS: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 08/30/2024 LPN RN . Record review of Resident #104's Physician's order dated 04/20/2026, revealed Seroquel Oral Tablet 25 MG Give 1 tablet one time a day for affective mood disorder (an inappropriate indication for a resident with a diagnosis of Alzheimer's Disease/dementia to receive an antipsychotic). Record review of Resident #104's April 2026 MAR revealed Resident #104 was administered Seroquel 25 mg one time a day from 04/21/2026 through 04/30/2026. Record review of Resident #104's May 2026 MAR revealed Resident #104 was administered Seroquel 25 mg one time a day from 05/01/2026 through 05/31/2026 without consent signed or dated by the doctor. Record review of Resident #104's June 2026 MAR revealed Resident #104 was administered Seroquel 25 mg one time a day from 06/01/2026 through 06/17/2026 without consent signed or dated by the doctor. During an interview on 06/17/2026 at 12:17 p.m., Resident #104 stated she did not want to talk. In an interview on 6/18/26 at 3:20 p.m., LVN D stated the nurse was responsible for receiving and writing the order for a psychotropic medication. She said she would carry out the order for antipsychotics for a resident with the diagnosis of Alzheimer's Disease/Dementia unless the family did not agree with the antipsychotic and then the doctor would be notified. LVN D stated she did not question the doctor or the NP on the indication given for an antipsychotic even if the resident had a diagnosis of Alzheimer's Disease/Dementia. She stated if a resident showed signs of aggression, a antipsychotic medication was ordered with a diagnosis of psychosis. LVN D stated she would question the provider if the resident had not shown signs of aggression or other behaviors. In an interview on 6/18/26 at 6:28 p.m., the ADON stated the indications for an antipsychotic were checked and the nurses go by the doctor's diagnosis. She stated that an improper diagnosis for an antipsychotic medication was a diagnosis not listed in the residents' EMR. She said there would need to be documentation with a reason for giving the antipsychotic. The ADON stated she and the DON reviewed new order for antipsychotic medication to ensure the order was properly entered in the EMR and they reviewed the diagnosis used for the medication. She stated a negative outcome for a resident that had a diagnosis of Alzheimer's or dementia and was receiving an antipsychotic medication was worsening their behavior or dementia. During an interview on 06/18/2026 at 7:45 p.m., the DON stated an antipsychotic medication was ordered using a specific diagnosis and a specific behavior. He said when reviewing he looked specifically at the diagnosis. He said a specific diagnosis was important. He said they should start with nonpharmacological interventions that should be documented and care planned (before starting an antipsychotic). The DON stated mood disorder or affective mood disorder was not an appropriate diagnosis/indication for an antipsychotic to be given to a resident with Alzheimer's Disease or dementia because they were broad terms. He said psychosis was not an appropriate indication for an antipsychotic to be given to a resident with Alzheimer's Disease or dementia because a diagnosis of psychosis was an acute (sudden and for a short time) episode. The DON stated psychosis was not an appropriate diagnosis for Resident #9 because she had a diagnosis of dementia. The DON said there was a risk of increased mortality for a resident using an antipsychotic medication with a diagnosis of dementia. He stated the nurses were in-serviced on antipsychotics. He said the last in-service on antipsychotics was no more than two months ago. Record review of the facility's undated policy titled, Antipsychotic- Consent, reflected in part: 1. Policy Statement- The nursing facility will ensure that antipsychotic medications are used only when medically necessary to treat a specific, documented condition, are not used for staff convenience or discipline, and are subject to ongoing review, monitoring, and attempts at reduction/discontinuation when clinically appropriate. 2. Purpose- 2. Support compliance with CMS resident-rights and psychotropic-medication guidance applicable to nursing facilities. Record review of the facility's Antipsychotic Medication Use policy not dated reflected: Policy StatementAntipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. Policy Interpretation and Implementation 1.Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. 2. The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others. 3.The attending physician will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications. 4.The attending physician will and facility staff will identify acute psychiatric episodes, and will differentiate them from enduring psychiatric conditions. 6.Diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on comprehensive assessment of the resident.

Based on observation, interview and record review, the facility failed to coordinate assessments with the Pre-admission Screening and Resident Review (PASSR) program to the maximum extent practicable to avoid duplicative testing and effort for 4 (Resident #4, Resident #9, Resident #13, and Resident #28) of 12 residents reviewed for PASSR. 1. The facility failed to refer Resident #4 and Resident #28 for PASSR Level I when the facility incorrectly completed Form 1012. 2. The facility failed to refer Resident #9 and Resident #13 for PASRR Level II assessment when the resident were newly diagnosed with a mental illness. These failures could place residents at risk of not receiving a needed assessment, individualized care, or specialized services to meet their needs. Findings included: 1. Record review of Resident #4's face sheet, dated 06/17/26, reflected a [AGE] year-old male, admitted on [DATE], diagnoses included: type 2 diabetes mellitus (insulin resistance and high blood sugar levels), acute kidney failure (condition that affects the kidneys' ability to filter waste from the blood), generalized muscle weakness, heart failure, bipolar disorder (mental health condition characterized by significant mood changes), depression (persistent feeling of sadness and loss of interest), generalized anxiety disorder (excessive, uncontrollable worry about every day issues), and post-traumatic stress disorder (mental health condition that's caused by an extremely stressful or terrifying event). Record review of Resident #4's MDS assessment, dated 06/14/26, reflected a BIMS score of 15, which indicated intact cognition. The MDS assessment reflected Resident #4 had active diagnoses of anxiety disorder, depression, bipolar disorder, and post-traumatic stress disorder. Record review of Resident #4's care plan, dated 06/17/26, reflected [Resident #4] had a mood problem related to bipolar disorder, generalized anxiety, and PTSD. Date initiated: 04/07/26. Interventions included: administer medications as ordered, monitor/document for side effects and effectiveness, assist the resident/family/caregivers to identify positive coping skills, and educate resident/family/caregivers regarding expectations of treatment. [Resident #4] had depression. Date initiated: 04/07/26. Interventions included: administer medications as ordered, monitor/document for side effects and effectiveness, and pharmacy review monthly or per protocol. [Resident #4] used psychotropic medications related to disease process of bipolar disorder. Date initiated: 04/07/26. Interventions included: administer medications as ordered by physician, monitor for side effects and effectiveness, and consult with pharmacy/MD to consider dosage reduction when clinically appropriate. Record review of Resident #4's PASRR level 1 screening, dated 03/09/26, reflected a negative PL1 as there was no diagnosis of mental disorder indicated on the screening. Record review of Resident #4's Form 1012, dated 03/11/26, section C was incorrectly filled out. Form 1012 indicated if any responses were YES, the facility had to complete a new PL 1. Section C was marked as YES for number two, Mood disorder (bipolar disorder, major depression, or other mood disorder) with date of onset: 03/11/26. Section D was marked with the option the PL1 remained negative and no new PL1 needed to be completed. 2. Record review of Resident # 28's face sheet, dated 6/18/2026, reflected a [AGE] year-old female admitted on [DATE]. Resident #28's diagnoses included major depressive disorder (serious mental health condition that causes persistent feelings of sadness, hopelessness, and a loss of interests in activities once enjoyed), bipolar disorder (a mental health condition that causes extreme, uncontrollable shifts in mood, energy, and activity levels), obsessive-compulsive disorder (a mental health condition where a person gets stuck in a cycle of uncontrollable, distressing thoughts [obsession] and repetitive behaviors [compulsions] they feel driven to do to relieve the anxiety), unspecified dementia, mild, without behavioral disturbances, psychotic disturbance, mood disturbance, and anxiety (early-stage memory and thinking problems that interfere with daily life, but the cause isn't known), and dementia in other disease classified elsewhere, moderate with psychotic disturbance (moderate-stage mental decline caused by psychotic symptoms like hallucinations [seeing or hearing things that aren't real] or delusions [strong, false beliefs like paranoia]). Record review of Resident #28's quarterly MDS assessment, dated 5/12/2026, reflected a BIMS score of 12, which indicated moderate cognitive impairment. Resident #28 was coded as having non-Alzheimer's dementia, depression, bipolar disorder, major depressive disorder, and obsessive-compulsive disorder. Record review of Resident #28's care plan, dated 4/11/2026, indicated in part, Resident has potential for behavior problems r/t dementia and mdd. Interventions: anticipate and meet resident's needs, explain all procedures to the resident and allow resident to adjust to changes. Resident is at risk for decreased psychosocial well-being and adjustment issues, emotional distress and ineffective coping skills poor impulse related to bipolar disorder. Interventions include encourage to voice feelings and frustrations as indicated, encourage family and friends support visits, administer meds as ordered. Resident uses antidepressant and psychotropic medication r/t behavior management. Interventions include monitor/document/report PRN adverse reactions of psychotropic and antidepressant medication. Record review of Resident #28's PASRR Level 1 screening, dated 9/29/25, reflected a negative PL 1 as there was no diagnosis of mental disorder indicated on the screening. Record review of Resident #28's Form 1012, dated 9/30/25, section C was incorrectly filled. Form 1012 indicated if any responses were YES, the facility had to complete a new PL 1. Section C was marked as YES for number two, Mood disorder (bipolar disorder, major depression, or other mood disorder) with date of onset: 09/30/25. Section D was marked with the option the PL1 remained negative and no new PL1 needed to be completed. 3. Record review of Resident # 9's face sheet, dated 6/17/26, reflected an [AGE] year-old female admitted on [DATE]. Resident #9's diagnoses include unspecified dementia, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (early-stage memory and thinking problems that interfere with daily life, but the cause isn't known), major depressive disorder (serious mental health condition that causes persistent feelings of sadness, hopelessness, and a loss of interests in activities once enjoyed), anxiety disorder (mental health condition where the brain's danger alarm gets stuck in the on position), and unspecified psychosis not due to a substance or known physiological condition (experiencing a loss of touch with reality, but doctors have not yet determined the exact mental health cause). Record review of Resident #9's quarterly MDS assessment, dated 5/13/26, reflected a BIMS score of 02, which indicated severe cognitive impairment. Resident #9 was coded as having non-Alzheimer's dementia, anxiety disorder, depression, and psychotic disorder. Record review of Resident #9's care plan, dated 6/02/2026, indicated in part, Resident has depression and anxiety r/t depression. Interventions include administer medications as ordered, arrange for psych consult, and monitor/document/report PRN s/sx of depression. Record review of Resident #9's recent psychiatric subsequent assessment, dated 5/10/2026, reflected a diagnosis of unspecified psychosis. 4. Record review of Resident #13's face sheet, dated 06/17/26, reflected a [AGE] year-old female, admitted on [DATE], diagnoses included: unspecified dementia (decline in cognitive function severe enough to interfere with daily life affecting memory loss, language, problem solving, and other cognitive abilities), type 2 diabetes mellitus (insulin resistance and high blood sugar levels), generalized muscle weakness, hallucinations, and other schizoaffective disorders (mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression and mania). Other schizoaffective disorders had an onset date of 02/16/25. Record review of Resident #13's MDS assessment, dated 06/09/26, reflected a BIMS score of 01, which indicated severe cognitive impairment. The MDS assessment reflected Resident #13 had an active diagnosis of schizophrenia (e.g., schizoaffective disorders). Record review of Resident #13's care plan, dated 06/17/26, reflected [Resident #13] had a mood problem related to schizoaffective disorder. Date initiated: 05/25/26. Interventions included: administer medications as ordered, monitor/document for side effects and effectiveness, assist the resident/family/caregivers to identify positive coping skills, and educate resident/family/caregivers regarding expectations of treatment. [Resident #13] used psychotropic medications related to behavior management. Date initiated: 02/27/25. Interventions included: administer medications as ordered by physician, monitor for side effects and effectiveness, and consult with pharmacy/MD to consider dosage reduction when clinically appropriate. [Resident #13] had an aggressive behavior and mood problem due to dementia and mood affective disorders. Date initiated: 09/04/24. Interventions included: administer medications as ordered by physician, anticipate needs, provide opportunity for positive interaction, and monitor behaviors. Record review of Resident #13's PASRR level 1 screening, dated 08/20/24, reflected a negative PL1 as there was no diagnosis of mental illness indicated on the screening. The screening reflected Resident #13 had a primary diagnosis of dementia. Record review of Resident #13's psychiatric note, dated 02/22/25, reflected a diagnosis of schizoaffective disorder, bipolar type. During an attempted interview and observation, on 06/15/26 at 2:00 PM, Resident #4 refused to speak to this surveyor. Resident #4 was observed with no visible bruises, skin tears, or injury. During an interview and observation, on 06/15/26 at 2:35 PM, Resident #13 stated she was doing well and had no issues. Resident #13 stated the staff gave her medications and took care of her. Resident #13 stated she was not sure what she took medications for and she only remembered she had medications for diabetes. Resident #13 stated she was not injured or in pain. Resident #13 was observed with no visible bruises, skin tears, or injury. During an attempted interview, on 06/18/26 at 10:00 AM, Resident #4 refused to speak to this surveyor and did not want this surveyor to return at a later time. In an interview on 06/18/2026 at 5:30 p.m., the MDS nurse stated she reviewed and inputted the information from the PL1 when she received the PL1s from the hospital or the facility the resident was being admitted from. The MDS Nurse stated there were discrepancies on the 1012 forms that were incorrect. The MDS Nurse stated Resident #4 had a diagnosis of bipolar disorder and PTSD since admission. The MDS Nurse stated the form 1012 indicated yes on section C so then there should have been another PL1 submitted for Resident #4, but she did not submit another PL1 for him and could not explain why. The MDS Nurse stated Resident #13 initially had a negative PL1 because her primary diagnosis was dementia. The MDS Nurse stated she was unsure when Resident #13 was diagnosed with schizoaffective disorders but it was later after admission. The MDS Nurse stated it did not matter if Resident #13 had a primary diagnosis of dementia, Resident #13 should have had a new PL1 completed once she had the new diagnosis of schizoaffective disorders. The MDS Nurse stated Resident #28's form 1012 was also marked incorrectly and did not know why a new PL1 was not submitted. The MDS Nurse stated she would submit a new PL1 for Resident #28 but she knew Resident #28 was receiving services from a local counseling entity. The MDS Nurse stated she was going to follow up and review Resident #9's PL1 and the diagnosis of psychosis as she was unsure of when this change occurred. The MDS Nurse stated Resident #9 should have also had a new PL1 submitted with the new diagnosis of psychosis. The MDS Nurse stated audits were done annually, quarterly and as needed of residents which had a positive PASSR screening and were receiving services at the facility. The MDS Nurse stated the discrepancies on the forms resulted in the residents possibly not receiving additional services from PASRR screenings not submitted appropriately. The MDS Nurse stated she had not received training on PASRR services from the facility. In an interview on 6/18/2026 at 8:35 p.m., the DON stated a PASRR positive was when a resident had a mental disorder or intellectual disorder and qualified for services through the local community mental health service provider. The DON stated if residents were not screened appropriately, residents could potentially miss out on services. The DON stated the MDS Nurse completed PASRR screenings and coordinated assessments with the local community mental health service provider for additional services for the residents. Record review of the facility's undated policy titled, PASRR (Pre-admission Screening & Resident Review) reflected in part: Policy Statement- To ensure each patient in the facility is screened for a mental disorder (MD) or intellectual disability prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs. Policy Interpretation and Implementation- 3. A negative Level 1 screen permits admission to proceed and ends the pre-screening process unless possible serious mental disorder or intellectual disability arises later.

Based on observation, interviews and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #23) of 5 residents and 1 (100 hall medication room) of 2 medications storage rooms reviewed for infection control.1. The facility failed to ensure RN C disinfected the blood pressure cuff before use for Resident #23 on [DATE].2. The facility failed to ensure RN C wore a gown to give gastric tube medications to Resident #23 on [DATE].3. The facility failed to dispose of an expired COVID test that was in a cabinet in the medication room. 4. The facility failed to dispose of expired IV supplies stored on the counter and in cabinet in the medication room. 5. The facility failed to dispose of an enteral feeding pump administration set that was not in a protective wrapper in a drawer in the medication room. 6. The facility failed to ensure a soiled baby monitor type camera and screen were not stored in the medication room cabinet. 7. The facility failed to ensure a soiled enteral feeding pump was not stored in the medication room. These failures could place residents at risk of infection and receiving medications and supplies which were expired and possibly cross contaminated.The findings included:Record review of Resident #23's admission record reviewed on [DATE] reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included nontraumatic intracerebral hemorrhage in cerebellum (brain bleed not caused from trauma), essential hypertension (high blood pressure), tracheostomy (a hole made through the front of the neck into the windpipe when medical conditions make the use of a breathing machine, also known as a ventilator, necessary for an extended period of time), gastrostomy (a tube surgically implanted through the abdomen into the stomach used to provide nutrition, hydration, and medication), and persistent vegetative state (after a brain injury, a person may appear awake but is unaware of their surroundings and unable to respond to any stimulus). Record review of Resident #23's quarterly MDS dated [DATE] reflected a BIMS score of 6 which indicated severe cognitive impairment. The MDS also reflected Resident #23 received 51% or more calories and 501cc/day or more fluid intake by tube feeding.Record review of Resident #23's order summary report on [DATE] reflected the following phone order dated [DATE]: Enhanced barrier precautions during high contact resident care activities secondary to gastric tube, foley catheter every shift.During an observation on [DATE] at 8:18 am, RN C did not wipe down the blood pressure cuff between resident use before he checked Resident #23's blood pressure. During an observation on [DATE] at 8:18 am, RN C did not wear a gown during gastric tube medication administration for Resident #23. During an inspection of the facility's 100 hall medication room on [DATE] at 1:00 pm, the following were found: 1. An at home COVID test with an expiration date of [DATE] was found on the top shelf of a cabinet containing oral medications, inhalation medications and IV fluids. 2a. 1 of 15 7- inch IV extension sets with an expiration date 05/2026 was found in a bin labeled luer locks on the counter. 2b. 3 of 3 20 gauge IV catheters with an expiration date of [DATE] were found in a bin on the counter labeled 22G PIV. 2c. 17 of 27 7-inch expired IV extensions sets were found in a bag that was in a cabinet marked IV supplies. 5 had an expiration date of 01/2025, 5 had an expiration date of 03/2026, and 7 had an expiration date of 05/2026. 3. In a drawer labeled enteral administration kit, 1 of 8 enteral feeding pump administration sets was not in a protective wrapper. 4. In a cabinet labeled ostomy supplies, a baby monitor type camera, screen, and power cord were in a soiled, crumpled up bag on the top shelf. The camera, screen, and power cord all had brownish colored stains on them. 5. On the bottom shelf of a 3-shelf cart inside and to the right of the door of the medication room, there was an enteral feeding pump with tan colored spot type stains on the back of it and a long approximately 4 inch long by 1-inch-wide tan colored streak type stain down the front of it. In an interview on [DATE] at 8:37 am, RN C stated he was nervous and forgot to wipe down the blood pressure cuff or put a gown on before he checked Resident #23's blood pressure and administered his medications. RN C stated it was important to disinfect equipment between resident use because of cross contamination. He stated wiping down the blood pressure cuff was important because it touched the residents skin and if a resident had some type of skin infection, it could spread to other residents. RN C stated it was important to wear a gown when he administered medications to a resident with a gastric tube or when he did any kind of care for residents with indwelling devices because he did not want to risk spreading infection to or from those residents. In an interview with the DON on [DATE] at 2:33 pm, the DON stated EBP was used to protect staff and residents. He stated when a resident had EBPs, staff was to wear gown and gloves for any care that involved contact with the resident such as trach care, gastric tube care or feeding, and medication administration through a gastric tube. The DON stated any equipment that was used for more than one resident was to be wiped down between resident use with disinfectant wipes. The DON stated he did not know why the expired COVID test was in the storage room because they used a different test now when testing for COVID or flu. The DON stated the expired IV supplies should have been disposed of and if they were used it could cause infection or contamination, or the IVs or extension sets could fail and lead to injury to a resident. He stated the enteral feeding pump administration set should have been thrown away after it was opened and not put back into the drawer. He stated it could be contaminated and if it was used, could cause a resident to get sick. The DON stated he did not know why the baby monitor type system had been in the cabinet or how long it had been there. He stated he also did not know why the soiled enteral feeding pump was in the medication room. He stated when a resident left it was the charge nurse's responsibility to remove the equipment from a resident's room and she was supposed to give equipment to the central supply person to clean and store. The DON stated he did not know how long the pump had been in the medication room. The DON stated infection control in-services were monthly and the last one was in May. In an interview on [DATE] at 3:52 pm, LVN B stated the CS/MDS nurse was responsible for ensuring that all supplies and over the counter medications in the medication rooms were up to date. She stated when a resident was discharged , she would let the CS/MDS nurse know about it and the CS/MDS nurse would tell her where to put the equipment or what to do about. LVN B stated the nurse for the resident was responsible for cleaning equipment such as a feeding pump. In an interview on [DATE] at 4:29 pm, the CS/MDS nurse stated she did not go into the medication supply rooms; only the nurses went into them. She stated when a resident was discharged , the nurse cleaned the equipment and let her know about it. She stated the feeding pump should not have been in the medication room and should not have been dirty. She stated all enteral feeding equipment was wiped down every day by the nurses. In an interview on [DATE] at 6:42 pm, the ADON stated the nurses, ADONs and pharmacy were responsible for ensuring that medications and supplies in the medication storage rooms were not expired. She stated the nurses were supposed to clean the feeding pumps when a resident was discharged then put them in the appropriate storage area. The ADON stated if dirty equipment was stored in the medication room it could cause cross contamination. She stated they had several brands of COVID tests in the medication room, but she thought they got all of them out when they expired. The ADON stated she was unaware that test was on the top shelf. She stated she did not know how long the baby monitor had been there, but it should not have been there. The ADON stated medication room checks were done weekly by the nurses, every two weeks by the ADONs, sporadically by the DON, and once a month by the pharmacist. Record review of the facility's undated policy: Administering Medications reflected in part: 22. Staff follows established facility infection control procedures ( e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable.Record review of the facility's undated policy: Enhanced Barrier Precautions reflected in part: Policy StatementEnhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents.Policy Interpretation and Implementation1. Enhanced barrier precautions (EBPs) refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms (MDROs) during high contact resident care activities.2. Enhanced barrier precautions apply when:b. A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained; andc. Contact precautions do not otherwise apply.5. Indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheotomies.7. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply.a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room).8. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include:i. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.Record review of the facility's undated policy titled Medication Labeling and Storage reflected in part: Medication Storage 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.Record review of the facility's undated policy titled Infection Control Standard Precautions reflected in part: 5.Resident-Care Equipment b. Reusable equipment is not used for the care of more than one resident until it has been appropriately cleaned and reprocessed. 6. Environmental Control a. Environmental surfaces, beds, bedrails, bedside equipment and other frequently touched surfaces are appropriately cleaned.

Based on interviews and record reviews, the facility failed to ensure a PASRR evaluation was completed on newly admitted residents prior to admission or after admission for 1 resident (Resident #25) out of 6 residents reviewed for Preadmission Screening and Resident Review screenings. The facility failed to ensure Resident #25's PASRR L1 screening dated 03/07/25 accurately reflected her diagnoses of mental illness. There was no evidence that Resident #25 was referred to a Level 2 PASRR Screening and Evaluation having a primary diagnosis of mental illness. This failure could affect residents by placing them at risk for not receiving needed treatments and services.Findings included: Record review of Resident 25#'s admission record revealed a [AGE] year-old female with an initial admission date of 03/07/2025. Resident #25's diagnoses included schizophrenia (a chronic severe brain disorder that affects how a person thinks, feels, and acts) (primary diagnosis), dementia (a decline in mental ability - such as memory, thinking, and reasoning - severe enough to interfere with daily life) without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, anxiety disorder (a group of mental health conditions characterized by intense, excessive, and persistent fear or worry about everyday situations), and paranoid schizophrenia (a chronic mental health disorder characterized by intense, irrational suspicions, auditory hallucinations, and persecutory or grandiose delusions). Record review of Resident #25's Quarterly MDS report dated 06/15/2026 revealed a BIMS score of 12 indicating moderate cognitive impairment. No mood or behaviors were noted. A psychiatric disorder of schizophrenia was noted. Antidepressants were received on a routine basis. Record review of Resident #25's PL1 from the facility dated 03/07/2025 was negative for MI (mental illness), ID (intellectual disability), and DD (developmental disability). Resident #25's PL1 documented primary diagnosis as dementia. There were no other PL1 screenings for Resident #25. Record review of Resident #25's Form 1012 (Mental Illness/Dementia Resident Review) dated 03/07/2025 revealed No, the individual does not have a dementia diagnosis or has a dementia diagnosis, but it is not primary. Complete Section C. The physician does not need to sign Section B.1. The Form 1012 Indicated the PL1 was dated 03/07/2025. Section C. of the Form 1012 was not completed by the physician. Resident #25's Form 1012 was signed by the MDS nurse on 03/07/2025. Record review of Resident #25's Care Plan dated 04/11/2026 revealed FOCUS: [Resident #25] uses psychotropic medications (Haldol) r/t Behavior management, Dx: Schizophrenia 6/3/25 Resident has long history of having auditory hallucinations and paranoid delusions. 8/11/25 Resident has delusions and visual hallucinations. She voices seeing things that are not there. Date Initiated: 03/10/2025 Revision on: 08/11/2025. In an interview on 06/18/2026 at 5:17 p.m., the MDS nurse stated Resident #25 had dementia as her primary diagnosis on her PL1. She said the Form 1012 Review shows no diagnosis of dementia or dementia was not the primary diagnosis. The MDS nurse stated, I see the error. I will have to notify [behavioral testing facility] for a new PL1 and 1012 to correct it. The MDS nurse stated the negative effect was due to the discrepancy on the PL1 and 1012, it could change services for the resident. The MDS nurse stated she had not received training on PASRRs. During an interview on 06/18/2026 at 7:45 p.m., the DON stated if a resident was not screened properly for PASRRs, residents could be missing services. Record review of the facility's undated policy titled, PASRR (Pre-admission Screening & Resident Review) reflected in part: Policy Statement- To ensure each patient in the facility is screened for a mental disorder (MD) or intellectual disability prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs.Policy Interpretation and Implementation- 3. A negative Level 1 screen permits admission to proceed and ends the pre-screening process unless possible serious mental disorder or intellectual disability arises later.

Based on interview and record review, the facility failed to develop a comprehensive care plan for each resident, consistent with the resident's rights, that includes measurable short-term and long-term objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment for 2 (Resident #7 and Resident #116) of 5 residents reviewed for care plans. 1. The facility failed to ensure Resident #7's comprehensive care plan was updated to reflect he was on hemodialysis. 2. The facility failed to ensure Resident #116's comprehensive care plan was completed. These failures could place residents at risk of not receiving individualized care and services to attain or maintain the residents' highest practicable physical, mental, and psychosocial wellbeing.The findings included: 1. Record review of Resident #7's admission record on 06/16/26 reflected a [AGE] year-old male who was originally admitted to the facility on [DATE] and most recently admitted on [DATE]. His diagnoses included end stage renal disease (when the kidneys lose the ability to remove waste and balance fluids), dependence on renal dialysis (process of filtering blood through a machine to remove excess water and toxins in the blood when the kidneys no longer function), Guilain-Barre syndrome (a rare condition where the immune system attacks the nerves, causing muscle weakness and potential paralysis), quadriplegia (total or partial loss of movement and feeling in both arms, both legs, and the torso), tracheostomy (a hole made through the front of the neck into the windpipe when medical conditions make the use of a breathing machine, also known as a ventilator, necessary for an extended period of time), type 2 diabetes (chronic condition that happens when blood sugar levels are persistently high which can lead to heart disease, kidney disease, and stroke), and hypertension (high blood pressure). Record review of Resident #7's admission MDS dated [DATE] reflected a BIMS score of 13 which indicated he was cognitively intact. Section O- Special Treatments, Procedures, and Programs reflected Resident #7 was on hemodialysis on admission and while a resident. Record review of Resident #7's care plan dated 05/06/26 reflected a focus of, (chronic) renal failure r/t kidney disease (stage 4) (severe loss of kidney function), initiated and revised on 06/02/26. The goal was Resident #7 would be able to resume normal daily activities of daily living by the review date, initiated on 06/02/26 with target date 08/02/26. The interventions included assist with ADLs, dietary consult to regulate protein and potassium intake, give medications as ordered by physician, monitor/document/report for s/sx of acute failure, all initiated on 06/02/26. 2. Record review of Resident #116's admission record, dated 6/17/2026, reflected an [AGE] year-old female admitted on [DATE]. Resident #116's diagnoses included malignant neoplasm of pancreas (tumor in the pancreas), non-Hodgkin lymphoma (type of blood cancer that starts in the lymphatic system), hypertension (high blood pressure), anemia, thrombocytopenic purpura (blood disorder where low number of platelets cause purple bruises and tiny red spots on the skin), adrenocortical insufficiency (two small organs above the kidneys not producing enough vital hormones), and automatic (implantable) cardiac defibrillator (small device placed under the skin in the chest, continuously monitoring heartbeat, and immediately sends an electrical jolt to reset the heart). Record review of Resident #116's PPS MDS assessment, dated 5/5/2026, reflected a BIMS score of 12 which indicated moderate cognitive impairment. Record review of resident #116's comprehensive care plan, updated 4/12/2026, revealed the only areas addressed were preferences in activities, discharge/transfer preferences, witnessed fall, and code status. Record review of Resident #116's care plan, dated 6/17/2026, revealed a comprehensive care plan was reviewed and closed on 4/12/2026 due to discharge. In an interview on 06/18/26 at 2:51 pm, LVN D stated care plans could be updated by nurses, and it was the whole team's responsibility to ensure they were up to date. She stated she did not recall if she had looked at Resident #7's care plan in the last 2 months. LVN D stated when a resident was a new admission or re-admission, the assessment form did not include information on dialysis. LVN D stated she did not review Resident #116's care plan and that the IDT was responsible for implementing changes in the resident's care plan. She stated the changes in the care plan were reported to the DON, ADON, MD, and RP. LVN D stated the baseline care plan was re-triggered anytime the resident was re-admitted to the facility from the hospital. In an interview on 06/18/26 at 4:29 pm, the CS/MDS nurse stated the MDS nurse did care plans and nursing helped. She stated the MDS nurse revised, changed, or updated the care plans. The CS/MDS nurse stated Resident #7's dialysis should have been care planned and as of 06/18/26 it still was not on the care plan. The CS/MDS nurse stated she was not sure why Resident #7's dialysis was not care planned. She stated care plans told the story of the residents and their plan of care; what, who, how, when, why things were done. She stated care plans were to be seen daily and not having a completed care plan could affect resident care by causing delays or mistakes in the care being rendered by the nurses and CNAs. The CS/MDS nurse stated Resident #116 was sent to the hospital frequently and the resident care plan did not reflect the resident's care and medical needs. She stated Resident #116 was able to make her needs known but was dependent on the staff for care. The CS/MDS nurse stated she had not had a care plan in service, but she knew the facility had them. In an interview on 06/18/26 at 5:22 pm, the MDS nurse stated she was responsible for keeping care plans up to date. She stated any acute changes, such as falls, were changed and updated by the DON and/or the ADON. The MDS nurse stated unless she audited a chart or a progress note was available, no update was made to the resident's care plan. She stated Resident #7's dialysis was supposed to be care planned. The MDS nurse stated when a resident was admitted or readmitted , she went through the orders to pull her information for the care plan. She stated she must have missed the dialysis order for Resident #7 and that was why it was not on his care plan. She stated she had not completed the care plan for Resident #116. The MDS nurse stated nursing did a baseline care plan within 48 hours; the admitting nurse started it and the DON looked over it and signed off on it within 48 hours of resident entry. She stated 3 sets of eyes missed that he was a dialysis patient. The MDS nurse stated it was important to have a complete and accurate care plan, so all nursing staff were aware of interventions and monitoring that needed to be done. She stated the DON and ADONs did in-services on care plans with the nursing staff. The MDS nurses stated she had not been in-serviced on care plans, but the DON audited care plans and discussed any issues with her. The MDS nurse stated at least 6 care plans were audited weekly for the last 4 months. In an interview on 06/18/26 at 7:45 pm, the DON stated the MDS nurses were responsible for care plans. He stated he reviewed the care plan only for acute (sudden) incidents such as falls. The DON stated care plans were reviewed upon admission and during care plan meetings. He stated he could not explain why Resident #7's dialysis was not care planned for 2 months. The DON stated usually with readmitted residents, the MDS nurse activated the previous care plan and modified it as needed. He stated Resident #7's care plan should have been reviewed. He said Resident #116's care plan might not have been reviewed after re-admission to the facility. The DON stated there were no negative outcomes due to Resident #116 not having a completed care plan. The DON stated in the nurse meeting in the mornings, they discussed new orders and things that needed to be care planned and passed that information to the MDS nurse. He stated they also printed a report that was specifically for the MDS nurse to use for care plans that contained any information such as new orders or new residents. He stated the MDS nurse was the only person who reviewed care plans. He stated the MDS nurse had an assistant, but that person was part-time. He stated the nurses provided care based on the orders. The DON said he did not review care plans, and the nurses did not receive in-services or training on care plans at the facility. The DON stated the only training from corporate for RNs was whatever was online, and it did not contain care plan training. He stated, I'm pretty sure she (the MDS nurse) got training on care plans, but not from the facility. He stated the regional MDS nurse provided support for care plans that were reviewed. Record review of the facility's undated policy: Care Plans, Comprehensive Person-Centered reflected in part: Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (3) which professional services are responsible for each element of care; 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; c. when the resident has been readmitted to the facility from a hospital stay;

Based on observation, interview and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team, for 2 (Resident #11 and Resident #104) of 12 residents reviewed for comprehensive care plan revisions. 1. The facility failed to review and revise Resident #11's care plan to reflect his current diet (regular texture with thin liquids) and to reflect he had weight gain.2.The facility failed to review and revise Resident #104's care plan to reflect eating with her fingers and refusing assistance with eating. These failures could place the residents at risk of not receiving appropriate interventions and care to meet their current needs.Findings included:1. Record review of Resident #11's face sheet, dated 06/17/26, reflected a [AGE] year-old male, admitted on [DATE], diagnoses included: Autism disorder (condition related to brain development that impacts how a person perceives and socializes with others), type 2 diabetes mellitus (insulin resistance and high blood sugar levels), adult failure to thrive (syndrome of progressive decline in weight, nutrition, physical function, and cognitive or emotional health), dysphagia (trouble swallowing), generalized muscle weakness, unspecified protein-calorie malnutrition (condition characterized by inadequate intake of protein and calories), and other reduced mobility. Record review of Resident #11's MDS assessment, dated 04/16/26, reflected a BIMS score of 10, which indicated moderate cognitive impairment. The MDS assessment reflected Resident #11 had weight gain and was not on a physician prescribed weight gain regimen. The MDS assessment reflected Resident #11 was on a therapeutic diet (e.g., low salt, diabetic, low cholesterol). Record review of Resident #11's care plan, dated 06/17/26, reflected [Resident #11] was at risk for nutritional problem or potential nutritional problem related to risk for malnutrition and weight loss. Date initiated: 02/21/25. Interventions included: monitor weight loss, provide diet as ordered, and RD to evaluate and make diet change recommendations PRN. [Resident #11] had a nutritional risk related to malnutrition and limited concentrated sweets, no added salt diet, mechanical soft texture, and thin liquids consistency. Date initiated: 07/14/25. Interventions included: encourage dietary compliance, monitor tolerance to mechanical soft texture, monitor weight and report significant changes to MD. Resident #11's care plan did not reflect the current diet of limited concentrated sweets, no added salt diet with regular texture and thin liquids consistency. Resident #11's care plan did not reflect his weight gain. Record review of Resident #11's order summary, dated 06/17/26, reflected diet order of limited concentrated sweets, no added salt diet, regular texture, thin liquids consistency. Start date of 01/06/26. Record review of Resident #11's nutritional risk assessment, dated 01/26/26, reflected Resident #11 weighed 200 pounds and triggered for weight gain related to excessive energy intake and lifestyle choices. Encourage healthy food choices, consider weight loss regimen, encourage good oral intake, and RD to remain available for further assessments as needed. 2. Record review of Resident #104's admission record dated 06/15/2026, revealed an [AGE] year-old female with an admission date of 08/12/2024. Resident #104's diagnoses included Alzheimer's Disease (a progressive, irreversible brain disorder that slowly destroys memory and thinking skills), and anxiety disorder (a group of mental health conditions that cause intense, persistent, and excessive fear or worry in non-threatening situations). Record review of Resident #104's Quarterly MDS, dated [DATE], revealed a BIMS score of 03, indicating severe cognitive impairment. Resident #104 required substantial/maximal assistance for eating where the helpers provided 50% or more of the effort. Record review of Resident #104's care plan, dated 06/08/2026, revealed FOCUS: [Resident #104] has an ADL self-care performance deficit r/t Confusion, Dementia, Impaired balance, hip fracture Date Initiated: 08/30/2024 Revision on: 01/16/2025. INTERVENTIONS/TASKS: EATING: The resident is dependent on 1 staff member to eat. Date Initiated: 08/30/2024 Revision on: 06/02/2026. During an observation on 06/15/2026 at 12:05 p.m., Resident #104 was observed in the dining room eating lunch with her fingers. Resident #104 was seen emptying her bowl onto the table and scooping the food with her fingers and putting it in her mouth. During an observation and interview on 06/17/2026 at 12:17 p.m., Resident #104 was sitting at a table in the dining room. LVN F stated Resident #104 had already eaten. LVN F stated Resident #104 was assisted with eating. LVN F stated if Resident #104 was not assisted with eating, she would just play with her food. Resident #104 was clean and the table was cleaned. Resident #104 did not want to talk. During an interview and observation, on 06/18/26 at 11:30 AM, Resident #11 stated he was doing well and had no issues. Resident #11 stated he ate well, he ate on his own and he ate regular foods. Resident #11 stated he knew he could not eat too much and only ate 1 plate for breakfast, lunch, and dinner. Resident #11 stated he was told by staff to try to make healthier choices, but it was up to him what he ate. Resident #11 was observed with no visible bruises, skin tears, or injury. Resident #11 was observed to be served his lunch meal and had a regular texture meal on the tray. During an observation on 06/18/2026 at 11:47 a.m., Resident #104 was sitting at a table by herself at a dining room table. When she received her lunch tray, she used her left fingers to put food on the spoon in her right hand, alternating between her spoon and her fingers to eat. Resident #104 was observed eating pudding with her fingers only. Resident #104 would not speak. During an interview on 06/18/2026 at 12:10 p.m., LVN E stated Resident #104 could eat by herself. LVN E said she can check residents' charts to see if they needed assistance with eating. LVN E stated most the residents in the dining room were on her hall. She said they were her residents so she knew them and did not need to check their care plans. She said she made sure they were eating. During an interview on 06/18/2026 at 12:22 p.m., CNA H was assisting residents with eating in the dining room. CNA H stated she assisted residents who needed help eating. She said she knew which residents needed assistance with eating. CNA H stated Resident #104 ate by herself. She said Resident #104 was supposed to be assisted with eating but she refused to be assisted. CNA H stated she would let Resident #104 eat by herself when she refused help. She said she would notify the nurse when a resident refused help eating when they were supposed to be assisted. During an interview on 06/18/2026 at 2:55 p.m., LVN D stated a person who was care planned as a 1-person assist for eating, a CNA would feed them. She said it should be care planned if a resident ate with their fingers / refused to be assisted with eating. LVN D stated it was everyone's responsibility to ensure Care Plans were updated. She said the nurse can update, but IDT was responsible for Care Plans. During an interview, on 06/18/26 at 3:00 PM, the ADON stated she updated care plans for weight loss and weight gain. The ADON stated she or the MDS Nurse updated care plans for diet changes. The ADON stated she reviewed Resident #11's care plan and his care plan did not reflect weight gain or his current diet. The ADON stated Resident #11's care plan should have been updated to reflect his current diet of regular texture and should have also been updated from weight loss to weight gain. The ADON stated there was no negative outcome for Resident #11 as staff followed his orders, provided him with his current diet, and encouraged him to follow his diet. The ADON stated it was important to ensure the care plans were revised as needed to ensure everyone was aware of how to care for the resident. During an interview on 06/18/2026 at 4:34 p.m., CS/MDS stated the MDS Nurse handled care plans and the nurses help with the care plans. She said if any changes or updating are needed, the MDS Nurse and nurse will update the care plan. She said Resident #104 was a 1-person assist for eating. She said the care plan was there for anyone taking care of the resident. She said Resident #104 would have to be fed. CS/MDS stated if Resident #104 refused assistance with feeding, it would need to be care planned. She said the nurse or CNA would report the refusal to MDS. She said if the resident would eat with her fingers, it should be care planned as a preference. CS/MDS stated once the care plan was updated, MDS will notify the nurse. She said there was also the daily meeting where they were notified (the nurses) about care plans that had been updated. CS/MDS stated the care plans should be checked every day by the nurses especially for Resident #104, if eating with her fingers or refusal of assistance to eat was not care planned she might not be eating. She said the negative effect could be miscommunication and if the resident was eating with her fingers and it had not been care planned, the resident's preferences may not happen. During an interview on 06/18/2026 at 5:00 p.m., LVN E stated she did not look at the residents' care plans. She said she looks at the Tasks tab (CNAs). LVN E stated she did not look at the residents' MDS. She said Resident #104 eating with her fingers and refusal of assistance to eat should be care planned. During an interview on 06/18/2026 at 5:17 p.m., MDS Nurse stated she was responsible for care plan updates. She said if there were behaviors or falls, the ADON or DON would update the care plan. MDS stated Resident #104 was a 1-staff assist in the care plan and on MDS she was a substantial/maximal assist for eating needing 1 staff to assist her. She said that Resident #104 would be a 1-person task for feeding her. She said if a resident refused assistance with eating when they were a 1-person assist, the refusal should be care planned. MDS stated Resident #104's eating with her fingers was not care planned and it should be. She said anything like eating with fingers or refusal for assistance to eat, she would be notified by the ADON or DON when they had their Stand-up Meeting with nurses. She said if it was not reported to her, she would be unaware and could not update the care plan. MDS stated the negative effects could be not all staff would be aware of interventions that were to be done or monitoring of residents that should be done. She stated she had not been in-serviced on care plans. During an interview, on 06/18/26 at 5:20 PM, the MDS Nurse stated she or the ADON were responsible for updating care plans, depending on the change. The MDS Nurse stated diet changes and weight loss/weight gain should have been care planned and updated as needed. The MDS Nurse stated she had not been made aware that Resident #11's diet was changed from mechanical soft to regular texture, so it was not updated on his care plan. The MDS Nurse stated weight gain should have been updated by the ADON, but it was not updated. The MDS Nurse stated there was no negative outcome for Resident #11 as staff followed his diet orders and encouraged him to make good choices. The MDS Nurse stated it was important for the care plan to be updated accurately to ensure all staff was aware of the resident's current needs and how to care for him. During an interview, on 06/18/26 at 7:45 PM, the DON stated the MDS Nurse was responsible for developing and revising care plans. The DON stated care plans should have been updated for weight gain and diet changes such as texture upgrades. The DON stated Resident #11's diet was changed from mechanical soft to regular texture on 01/06/26. The DON stated Resident #11 was noted with weight gain on 01/26/26. The DON stated those changes should have been updated on the care plan. The DON stated there was no negative outcome for Resident #11 as staff followed the orders and interventions. The DON stated it was important for the care plan to be revised to ensure everyone was aware of changes in care. The DON stated Resident #104 was a 1-person assist for eating, her refusals for assistance should be care planned, and her eating with her fingers should be care planned. The DON stated if refusals and finger eating were not care planned, the task would not be generated on the tasks and they (nurses and CNAs) would not know the interventions. Record review of the facility's Care Plans, Comprehensive Person-Centered policy, undated, reflected - Policy: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observations, interviews and record reviews the facility failed to ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 5 residents (Resident #23) reviewed for enteral feeding tubes. The facility failed to ensure RN C followed physician ordered water flushes before and after medication administration given via the enteral feeding tube for Resident #23 on 06/17/26.This failure could place residents at risk of feeding tube obstruction and a decrease in nutrition and hydration. The findings included:Record review of Resident #23's admission record reviewed on 06/17/26 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included nontraumatic intracerebral hemorrhage in cerebellum (brain bleed not caused from trauma), essential hypertension (high blood pressure), tracheostomy (a hole made through the front of the neck into the windpipe when medical conditions make the use of a breathing machine, also known as a ventilator, necessary for an extended period of time), gastrostomy (a tube surgically implanted through the abdomen into the stomach used to provide nutrition, hydration, and medication), and persistent vegetative state (after a brain injury, a person may appear awake but is unaware of their surroundings and unable to respond to any stimulus). Record review of Resident #23's quarterly MDS dated [DATE] reflected a BIMS score of 6 which indicated severe cognitive impairment. The MDS also reflected Resident #23 received 51% or more calories and 501cc/day or more fluid intake by tube feeding.Record review of Resident #23's care plan dated 03/04/26 reflected he had potential fluid deficit, initiated on 04/14/26 and revised on 04/28/26. The goal was Resident #23 would be free of symptoms of dehydration and maintain moist mucous membranes and good skin turgor with interventions that included medications administered as ordered. Resident #23's care plan also reflected he required tube feeding, initiated on 03/10/26 with an intervention that stated, the resident was dependent with tube feeding and water flushes. See MD orders for current feeding orders.Record review of Resident #23's order summary report on 06/17/26 reflected a phone order on 02/26/26 that stated to flush gastric tube with 30ml of water before and after medication administration every shift. During an observation on 06/17/26 at 8:18am, RN C did not flush Resident #23's gastric tube with 30ml of water before or after medication administration. In an interview on 06/17/26 at 8:37am, RN C stated he forgot to flush Resident #23's gastric tube with 30ml of water before he started medication administration and after he completed medication administration. He stated it was important to flush the gastric tube to prevent the medications from clogging the tube which could cause the resident to have to go to the hospital to have the gastric tube changed out. In an interview on 06/17/26 at 2:23pm, the DON stated if there was a specific order to flush the gastric tube before and after medication administration, then it was to be flushed with the ordered amount of water. He stated if the tube was not flushed, it would cause the tube to clog. He stated a physician could change the gastric tube at the bedside, but most of the time, the resident was sent to the ER for it to be changed. The DON stated if the gastric tube clogged, it could cause the resident to not receive their prescribed nutrition or medications. He stated a clogged gastric tube could also cause leakage of tube feed outside of the tube or tube rupture if a nurse used too much pressure when they tried to give medication, nutrition, or unclog the tube. The DON stated gastric tube in-services were done annually and as needed. The DON stated the last in-service on medication administration was in March and the pharmacist also came in monthly and observed 2 medication passes each time. Record review of the facility's undated policy: Administering Medications reflected in part: Policy Statement Medications are administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation 4. Medications are administered in accordance with prescriber orders, including any required time frame.Record review of the facility's undated policy: Enteral Nutrition reflected in part: 12. The provider will consider the need for supplemental orders, including:i. flushing the tube before and after medications are administered.

Based on observation, interviews and record reviews, the facility failed to ensure residents were free of significant medication errors for 1 (Resident #76)of 5 residents reviewed for medication errors. 1. The facility failed to ensure LVN A did not administer Resident #76's 9:00 pm dose of Diltiazem (blood pressure lowering medication) on 06/09/26 when her blood pressure was not within parameters for administration.The facility failed to ensure LVN A did not administer Resident #76's 9:00 pm dose of Metoprolol Tartrate (blood pressure lowering medication) on 06/09/26 when her blood pressure was not within parameters for administration.The facility failed to ensure LVN B did not administer Resident #76's 3:00 pm dose of Diltiazem (blood pressure lowering medication) on 06/14/26 when her blood pressure was not within parameters for administration.The facility failed to ensure LVN B did not administer Resident #76's 3:00 pm dose of Metoprolol Tartrate (blood pressure lowering medication) on 06/14/26 when her blood pressure was not within parameters for administration.The facility failed to ensure LVN B administered Resident #76's Midodrine (blood pressure raising medication) on 06/14/26 at 3:00 pm when her blood pressure was within parameters for administration.The facility failed to ensure LVN A administered Resident #76's Midodrine (blood pressure raising medication) on 06/14/26 at 9:00 pm when her blood pressure was within parameters for administration. These failures could place residents at an increased risk for complications, exacerbation of symptoms and disease process, and potential hospitalization.The findings included:Record review of Resident #76's admission record on 06/16/26 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her pertinent diagnoses included metabolic encephalopathy (a chemical, or metabolic, problem in the body that can cause brain dysfunctions such as confusion, memory loss, and/or personality changes), essential hypertension (high blood pressure), end stage renal disease (when the kidneys lose the ability to remove waste and balance fluids), dependence on renal dialysis (process of filtering blood through a machine to remove excess water and toxins in the blood when the kidneys no longer function), quadriplegia (total or partial loss of movement and feeling in both arms, both legs, and the torso), and aphonia (loss of voice, unable to speak). Record review of Resident #76's admission MDS dated [DATE] reflected a cognitive skills for daily decision making score of 3 (severely impaired) which indicated she rarely or never made decisions. Record review of Resident #76's physician order summary on 06/16/26 reflected the following orders: Diltiazem HCI Oral Tablet 90 mg. Give 1 tablet via PEG-Tube (feeding tube) three times a day for HTN/AFIB. Do not administer if BP is <100/60 and HR <60. Ordered on 06/04/26.Metoprolol Tartrate Oral Tablet 25 mg. Give 1 tablet via PEG-Tube three times a day for HTN. Hold if BP is <100/60 and/or HR is <60. Ordered on 06/04/26. Midodrine HCI Oral Tablet 10 mg. Give 1 tablet via PEG-Tube every 6 hours as needed for Hypotension (low blood pressure). Hold if SBP >110. Ordered on 06/11/26.Record review of Resident #76's June 2026 MAR reflected the following:On 06/09/26 at 9:00 pm LVN A documented Resident #76's blood pressure as 98/50. LVN A documented Resident #76's Diltiazem and Metoprolol were both administered outside of parameters for administration per the physician's orders.On 06/14/26 at 3:00 pm, LVN B documented Resident #76's blood pressure as 93/58 and pulse 117 for Resident #76's Diltiazem and blood pressure 93/58 and pulse 76 for her Metoprolol. LVN B documented Resident #76's Diltiazem and Metoprolol were both administered outside of parameters for administration per the physician's orders. LVN B did not administer Resident #76's Midodrine when her blood pressure was within the parameters for admission per the physician's orders. On 06/14/26 at 9:00 pm, LVN A documented Resident #76's blood pressure as 101/59. LVN A documented Resident #76's Diltiazem and Metoprolol were not administered due to her blood pressure was outside of parameters for administration per the physician's orders. LVN A did not administer Resident #76's Midodrine when her blood pressure was within the parameters for admission per the physician's orders. In an interview on 06/17/26 at 8:47 am, LVN B stated she spoke to the NP about Resident #76's blood pressure and heart rate and was told to give the Diltiazem if the pulse was over 100, so she gave the Diltiazem on 06/14/26 at 3:00 pm. LVN B stated she documented 114 for Resident #76's pulse on the MAR for her Diltiazem but documented 76 for her pulse on the MAR because that was the last one that was recorded and she did not change it. She stated she did not think to give the Midodrine. LVN B stated it was important to not give blood pressure lowering medications if the blood pressure was below parameters because it could cause the resident to be hypotensive (low blood pressure) and go to the hospital. She stated it was important to give Midodrine to raise the blood pressure to prevent complications from hypotension. LVN B stated check offs for medication administration were every 6 months and the last one was about a month ago. She stated the last in-service on medication administration was about a month ago also. In an interview on 06/17/26 at 2:23pm, the DON stated he would clarify the Diltiazem order with the physician because that medication was only to control heart rate. He stated because it only affected heart rate, LVN A was right to give the Diltiazem on 06/09/26 because Resident #76's heart rate was 68 and LVN B was right to give it on 06/14/26 because Resident #76's heart rate was 117. The DON stated Resident #76's Metoprolol should have been held on both dates because Metoprolol affected both blood pressure and heart rate. He stated the Midodrine should have been given on both 06/09/26 and 06/14/26 when Resident #76's blood pressure was low. The DON stated if antihypertensive (blood pressure lowering) medications were given outside of parameters, it could lower the blood pressure more and lead to hypotensive (low blood pressure) complications and the same was true for Midodrine not being given when the resident was hypotensive. The DON stated the last in-service on medication administration was in March and the pharmacist also came in monthly and observed 2 medication passes each time. Record review of the facility's undated policy: Administering Medications reflected in part: Policy Statement Medications are administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation 4. Medications are administered in accordance with prescriber orders, including any required time frame.

Based on observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food additives in accordance with professional standards for food service safety for 1 of 2 medication storage rooms (100 hall medication room) reviewed for storage of medications and food additives.The facility failed to label an opened container of food thickener stored in a cabinet with the date it was opened. This failure could place residents at risk of receiving medications and food additives that were expired.The findings included:During an inspection of the facility's 100 hall medication room on 06/17/26 at 1:00 pm, the following was found: 1 of 2 containers of food thickener stored on a shelf in a cabinet labeled enteral and milks was opened and did not have an open date on the container. In an interview on 06/17/26 at 2:23 pm, the DON stated he was not sure how long the container of food thickener had been in the cabinet, as they did not even use it anymore because only dietary was trained and allowed to thicken foods and drinks. In an interview on 06/18/26 at 3:52 pm, LVN B stated the CS/MDS nurse was responsible for ensuring that all supplies and over the counter medications in the medication rooms were up to date.In an interview on 06/18/26 at 4:29 pm, the CS/MDS nurse stated she did not go into the medication supply rooms; only the nurses went into them.In an interview on 06/18/26 at 6:42 pm, the ADON stated the nurses, ADONs and pharmacy were responsible for ensuring that medications and supplies in the medication storage rooms were not expired. The ADON stated medication room checks were done weekly by the nurses, every two weeks by the ADONs, sporadically by the DON, and once a month by the pharmacist. Record review of the facility's undated policy titled Medication Labeling and Storage reflected in part: Medication Storage 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

Based on interview and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 2 of 6 residents (Resident #6 and Resident #76) reviewed for medical records. 1. The facility failed to ensure RN C failed to remove contact precautions from the MAR for Resident #6 after receiving verbal orders from the physician to discontinue contact precautions. 2. The facility failed to ensure LVN B and LVN D documented Resident #76's information accurately on her pre-dialysis forms in the facility's electronic medical record. This failure could place residents at risk of errors in care and treatment. The findings included: 1. Record review of Resident #6's admission record, dated 06/17/26, reflected a [AGE] year-old male admitted on [DATE]. Resident #6's diagnoses included tracheostomy status (surgically created hole in the neck that leads directly to the windpipe [trachea]), severe sepsis without septic shock (body overreacts to a common infection, causing widespread inflammation leading to organ failure), pneumonia (infection of the lung causing air sacs to swell and fill with fluid or pus), and persistent vegetative state (awake but completely unaware), Record review of Resident #6's quarterly MDS assessment, dated 04/29/26, reflected a BIMS score was left blank which indicated it could not be completed. Record review of Resident #6's nursing progress note, dated 05/11/26 at 12:05 pm, indicated, discontinue contact precautions due to ATB completed. Record review of Resident # 6's MAR, dated 05/01/26-05/31/26, reflected, Isolation with: contact precautions related to e. Coli and ESBL to urine. Every shift start date 04/27/26 D/C date 05/11/26 and indicated check marks by the nurses for 7A-7P and 7P-7A shifts, from 05/01/26-05/11/2026. Record review of Resident #6's MAR, dated 05/01/26-05/31/26, reflected, Isolation with: contact precautions related to ESBL to urine. May cohort. Every shift start date 04/24/26 and indicated check marks by the nurses for 7A-7P and 7P-7A shifts, from 05/01/26-05/31/26. Record review of Resident #6's MAR, dated 06/01/26-06/30/26, reflected, Isolation with: contact precautions related to ESBL to urine. May cohort. Every shift start date 04/24/26 and indicated check marks by the nurses for 7A-7P and 7P-7A shifts, from 06/01/26-06/15/26. 2. Record review of Resident #76's admission record on 06/16/26 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her pertinent diagnoses included metabolic encephalopathy (a chemical, or metabolic, problem in the body that can cause brain dysfunctions such as confusion, memory loss, and/or personality changes), essential hypertension (high blood pressure), end stage renal disease (when the kidneys lose the ability to remove waste and balance fluids), dependence on renal dialysis (process of filtering blood through a machine to remove excess water and toxins in the blood when the kidneys no longer function), quadriplegia (total or partial loss of movement and feeling in both arms, both legs, and the torso), and aphonia (loss of voice, unable to speak). Record review of Resident #76's admission MDS dated [DATE] reflected a cognitive skills for daily decision making score of 3 (severely impaired) which indicated she rarely or never made decisions. Record review of Resident #76's order summary report reflected the following telephone order dated 06/10/26: Avoid taking blood pressure, performing venipuncture (blood draw), giving injections, strenuous activity, or applying restrictive clothing or restraints on the AV site extremity. (Left Upper Extremity) every shift. Record review of Resident #76's pre-dialysis forms in the facility's electronic medical records reflected the following: On 06/05/26 at 10:26 am, LVN D documented Resident #76's most recent blood pressure: 110/59 on 06/04/26 at 8:36 pm (approximately 14 hours before the documented assessment time), most recent temperature: 97.8 on 06/04/26 at 4:43 pm (approximately 17 hours before the documented assessment time), and most recent pulse: 128 on 06/05/26 at 8:12 am. On 06/08/26 at 10:09 am, LVN B documented Resident #76's most recent temperature: 97.6 on 06/08/26 at 5:57 am (approximately 4 hours before the documented assessment time), most recent pulse: 107 on 06/08/26 at 7:17 am (approximately 3 hours before the documented assessment time), and most recent oxygen saturation: 97% on 06/08/26 at 7:17 am. LVN B also documented she checked Resident #76's blood pressure on her left arm. On 06/09/26 at 9:44 am LVN B documented Resident #76's most recent blood pressure: 110/61 on 06/09/26 at 3:08 pm (approximately 5 hours AFTER the documented assessment time), most recent temperature: 97.6 on 06/08/26 at 5:57 am (approximately 3.5 hours before the documented assessment time), most recent pulse: 88 on 06/09/26 at 4:13 pm (approximately 6 hours AFTER the documented assessment time), most recent respiration: 18 on 06/09/26 at 4:13 pm, and most recent oxygen saturation: 98% on 06/09/26 at 4:13 pm. LVN B also documented she checked Resident #76's blood pressure on her left arm. On 06/16/26 at 10:11 am, LVN D documented Resident #76's most recent blood pressure: 126/65 on 06/15/26 at 9:36 pm (approximately 12.5 hours before the documented assessment time), most recent temperature: 97.6 on 06/12/26 at 9:40 am (4 days before the documented assessment time), most recent pulse: 86 on 06/16/26 at 4:02 am (approximately 6 hours before the documented assessment time), most recent respiration: 06/15/26 at 7:15pm (approximately 15 hours before the documented assessment time), and most recent oxygen saturation: 98% on 06/16/26 at 4:01 am. On 06/17/26 at 9:46 am, LVN B documented Resident #76's most recent blood pressure: 96/60 on 06/17/26 at 3:18 pm (approximately 6.5 hours AFTER the documented assessment time), most recent temperature: 97.6 on 06/12/26 at 9:40 am (5 days before the documented assessment time), most recent pulse: 103 on 06/17/26 at 3:18 pm, most recent respirations: 18 on 06/17/26 at 1:52 pm (approximately 3 hours AFTER the documented assessment time), and most recent oxygen saturation: 98% on 06/17/26 at 1:52 pm. LVN B also documented she checked Resident #76's blood pressure on her left arm. In an interview on 06/15/26 at 3:16 pm, LVN G said he had been signing the MAR for contact precautions for May and June. He said the resident had an order to discontinue contact precautions from05/11/26, and that he and the nurses were made aware of it. He said the order for contact precautions was not removed from the EMR and the nurses continued signing for contact precautions after the order was discontinued. In an interview on 06/17/26 at 4:11 pm, RN C said he had received a verbal order from the NP to discontinue contact precautions for Resident #6 in May. He said once he received the order to discontinue contact precautions, he was supposed to remove the order from the EMR but did not. He said the MAR indicating contact precautions continued to be checked off by the nurses. RN C said he had an in-service for documentation upon hire, but no recent education or in-services were received. He said inaccurate documentation could have caused a negative outcome for the resident; the resident would have not been able to room with another resident due to contact precautions. In an interview on 06/18/26 at 2:51 pm, LVN D stated Resident #76 was supposed to have a pre-dialysis form completed in the EMR every time she went to dialysis. She stated the pre-dialysis form in the EMR would automatically add the most recently documented vital signs and she would have to put in the new vital signs. She stated she was not sure why she did not put the correct vital signs in that form. She stated she filled out the handwritten paper dialysis communication form every morning and that was the form to go by. LVN D stated she was not sure why the facility did both the electronic and paper forms. She stated it was important that vital signs matched on both the handwritten form and the electronic form and were most recent to paint a complete picture of the resident and to avoid confusion. LVN D stated she was not sure if anyone looked at the electronic pre-dialysis forms, but she thought the DON might. She stated if the vital signs were not accurate the resident possibly would not receive accurate treatment. LVN D stated it had been a while since the last in-service on documentation. In an interview on 06/18/26 at 3:52 pm, LVN B stated when Resident #76 went to dialysis, they checked her vital signs, disconnected her tube feeding, moved her bed and vent over to the dialysis area, then hooked her back up to everything. She stated the nurses filled out the pre and post dialysis forms in the EMR as well as on the handwritten paper dialysis communication form. She stated the pre-dialysis forms were completed right before the resident went to dialysis. LVN B stated if the form was completed after the resident returned, the documentation would not be accurate. She stated the handwritten dialysis communication form was the most accurate form. LVN B stated she thought they used the electronic dialysis forms because it was company policy. She stated medical records and the ADONs looked at those forms and they were supposed to be accurately documented. LVN B stated she documented she checked the blood pressure on Resident #76's left arm by accident. She stated it was important not to check a blood pressure on the same arm as the fistula (the site used for dialysis) because it could damage the fistula. LVN B stated if inaccurate information was documented it could cause the resident to not receive appropriate care and confusion between staff members and other entities. She stated they received in-services on documentation about once a month and it was mostly about resident behavioral documentation. In an interview on 6/18/2026 at 8:50 pm, the DON stated the expectation was accurate and timely documentation from the nurses. He stated he constantly provided guidance and education to the nurses regarding documentation and described timely as documentation within one hour. The DON stated the negative outcome from inaccurate documentation was not rendering proper care to the residents. Record review of the facility's undated policy titled Charting and Documentation reflected in part: Policy Statement All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation 2. The following information is to be documented in the resident medical record: a. Objective observations; c. Treatments or services performed; 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 7. Documentation of procedures and treatments will include care-specific details, including: a. the date and time the procedure/treatment was provided; 8. Timeliness Standards a. Documentation must be completed: 3. Treatment records: At the time of treatment or immediately after.

Based on interview and record review, the facility failed to ensure residents had the right to be free from abuse for one (Resident #2) of 5 residents reviewed for abuse. The facility failed to protect Resident #2 from Resident #1's physical abuse on 04/13/26 at around 11:00 PM. This failure could lead to residents suffering physical injuries and fear.The findings included:Record review of Resident #1's face sheet dated 04/30/26 revealed a [AGE] year-old male with an original admission date of 02/18/26 and a current admission date of 04/06/26. Pertinent diagnoses included Personal History of Other Mental and Behavioral Disorders. Record review of Resident #1's admission MDS assessment dated [DATE] revealed a BIMS score of 12 indicating moderate cognitive impairment. Further review revealed Resident #1 had not displayed any physical or verbal behaviors towards others. Record review of Resident #1's Comprehensive Care Plan dated 04/30/26 revealed the focus [Resident #1] is physically aggressive r/t Anger, Poor impulse control. He throws items at dietary staff, etc initiated on 03/03/26 and revised on 04/07/26. An intervention listed for the focus included When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later initiated on 03/03/26. Further review revealed another focus [Resident #1 has a behavior problem r/t MDD (resident will have verbal outburst with staff, and other residents initiated and revised on 04/07/26. An intervention listed for the focus included Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed initiated on 04/07/26. Record review of Resident #2's face sheet dated 04/30/26 revealed a [AGE] year-old male with an admission date of 03/09/26. Pertinent diagnosis included bipolar disorder (chronic mental health condition characterized by intense, fluctuating mood shifts, ranging from high-energy, euphoric, or irritable manic/hypomanic episodes to deep depressive episodes.) Record review of Resident #2's Comprehensive MDS assessment dated [DATE] revealed a BIMS score of 15 indicating his cognition was intact. Further review revealed Resident #2 had not displayed any physical or verbal behaviors towards others. Record review of Resident #2's Comprehensive Care Plan dated 04/30/26 revealed the focus [Resident #2] is verbally aggressive r/t Ineffective coping skills, Poor impulse control, dx: anxiety, bipolar disorder initiated on 03/16/26 and revised on 04/07/26. An intervention listed for the focus included When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later initiated on 03/16/26. Record review of nurse's progress notes on 04/30/26 revealed a progress note written on 04/14/26 at 3:19 AM stated [Resident #1] was seen talking to [Resident #2] in hallway in front of his room in normal tone of voice. Both residents went into 213 and [Resident #2] exited [Resident #1's] room and loud voices heard in hallway from both residents. [Resident #2] went to the patio. SN went in to talk to resident, very upset. [Resident #1] got long grabber tool and wheeled himself to hallway between Unit 200 and 300. Being loud, angry toward [Resident #2](.) [Resident #2] heard him and came into hallway and started being loud and using profanity and [Resident #1] got long grabber tool and hit [Resident #2] on his left forearm, causing a bruise. SN called [ADM] and made aware of situation. [ADM] informed me to call police. Both residents kept apart. [ADM] and police arrived at facility. PCP was informed of incident. In an interview with Resident #1 at 9:25 AM on 04/29/26, Resident #1 stated Resident #2 was very argumentative. Resident #1 stated he did not hit Resident #2 with the reaching aid. Resident #1 stated Resident #2 tried to take his reaching aid from him, and in the scuffle, he may have bumped Resident #2 with the reaching aid. Resident #1 stated he was defending himself. Resident #1 stated Resident #2 had never hit him before, but he had called him a faggot and a cripple. Resident #1 stated he made amends with Resident #2, and they were back to being friends. During an observation in Resident #1's room at 9:25 AM on 04/29/26, a reaching aid was seen on a table near his bed. In an interview with Resident #2 at 10:21 AM on 04/29/26, Resident #2 stated Resident #1 swung his reaching aid at him. Resident #2 stated he blocked the blow with his forearm. Resident #2 stated he had a bruise from the blow after the incident. Resident #2 stated his arm had healed and the bruise was now gone. Resident #2 stated Resident #1 threatened to hit him before with the reaching aid, but this was the first time he followed through with the threat. Resident #2 stated he made peace with Resident #1, and they were fine at this point. In an interview with the ADON at 3:41 PM on 04/29/26, the ADON stated she was familiar with Resident #1. The ADON stated Resident #1 had a short fuse. The ADON stated Resident #1 made racist comments to staff. The ADON stated she had seen Resident #1 be physically aggressive with another resident one time before the incident between Resident #1 and Resident #2. The ADON stated she witnessed Resident #1 shake another resident's wheelchair after he thought the other resident called him a name. The ADON stated the incident between Resident #1 and Resident #2 was the first time she had heard of Resident #1 using the reaching aid as a weapon. The ADON stated it would not surprise her if Resident #1 was involved in another physical altercation with a resident in the future. The ADON stated every resident had the right to be free from abuse at the facility. In an interview with LVN A at 5:04 PM on 04/29/26, LVN A stated Resident #1 had been very edgy, had no patience, and was verbally aggressive towards staff and residents. LVN A stated Resident #1 had a short fuse. LVN A stated Resident #1 told her to get off her lazy ass before and check his glucose or blood pressure. LVN A stated Resident #1 calmed down since he first arrived at the facility. LVN A stated Resident #1 threatened to get her fired. LVN A stated it did not surprise her when she learned that Resident #1 had hit another resident. LVN A stated every resident had the right to be free from abuse. In an interview with the DON at 8:57 AM on 04/30/26, the DON stated he witnessed Resident #1 be physically aggressive with another resident one time. The DON stated he saw Resident #1 grab onto another resident's wheelchair and shake it. The DON stated he would describe Resident #1 as having a short fuse. The DON stated Resident #1 generally behaved better now than when he first arrived at the facility. The DON stated after the incident between Resident #1 and Resident #2, they placed Resident #1 on a one-to-one and had psychiatry evaluate him. The DON stated Resident #1 was no longer on a one-to-one and was back to normal rounding times. The DON stated they did lab tests, but they did not reveal any infection in Resident #1. The DON stated Resident #2 moved rooms to be further away from Resident #1 for a few days, but then he moved back. The DON stated he did believe it was abuse when Resident #1 hit Resident #2 with the reaching aid. The DON stated all residents at the facility had the right to be free from abuse. In an interview with LVN B at 10:12 AM on 04/30/26, LVN B stated he witnessed the incident between Resident #1 and Resident #2. LVN B stated the incident occurred at around 11:00 PM on 04/13/26. LVN B stated both residents yelled profanities at each other in the hall. LVN B stated Resident #1 claimed Resident #2 shook his chair. LVN B stated both residents stated fuck you to each other. LVN B stated Resident #1 grabbed the reaching aid on the back of his wheelchair and swung it at Resident #2. LVN B stated Resident #2 blocked the blow with his left arm. LVN B stated Resident #2 took the reaching aid and tried to break it. LVN B stated he took the reaching aid from Resident #2. LVN B stated he performed the skin assessment on Resident #2 after the incident and discovered a minor bruise less than an inch in diameter to his posterior left forearm. LVN B stated the incident he witnessed was physical abuse. LVN B stated every resident in the facility had the right to be free from abuse. In an interview with the ADM at 12:26 PM on 04/30/26, the ADM stated he first learned about the incident between Resident #1 and Resident #2 at around 11:00 or 11:30 PM on 04/13/26. The ADM stated he came up to the facility and arrived at about the same time the police did. The ADM stated he spoke to both residents after the incident. The ADM stated they implemented a one-to-one on Resident #1. The ADM stated they took the reaching aid from Resident #1 after the incident, but he ordered a new one that they had not taken from him. The ADM stated they had a discussion on whether to take the new reaching aid or not, but since Resident #1 had not displayed any behaviors since the incident, they decided to let him keep it. The ADM stated they ordered psychiatric consultations for both residents and moved Resident #2 to a different hall to separate them further. The ADM stated Resident #1 had been physically aggressive with another resident before this incident. The ADM stated he believed this incident was physical abuse. The ADM stated he felt they had put in sufficient interventions to successfully limit his future behaviors moving forward. The ADM stated every resident had the right to be free from abuse at the facility. Record review of the undated facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revealed the following: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives:Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to:.b. other residents;

Based on observation, interview and record review, the facility failed to implement written policies and procedures to report and investigate abuse of residents for 2 of 4 residents (Resident #1 and Resident #2) reviewed for incident reporting and investigating. The facility failed to follow their abuse policy when they did not report and have evidence of a thorough investigation of an allegation of abuse when Resident #1 hit Resident #2 on 04/03/26. The facility failed to follow their abuse policy when they did not report and have evidence of a thorough investigation of an allegation of abuse when Resident #1 alleged a doctor or the DON hit his left leg on the bed frame on 04/03/26, resulting in a 1 centimeter skin tear. These failures could place residents at risk of abuse and/or continued abuse and could lead to a diminished quality of life and psychosocial harm. Findings included: 1. Record review of Resident #1's face sheet, dated 04/09/26, reflected a [AGE] year-old male, admitted on [DATE], diagnoses included: type 2 diabetes (high levels of sugar in blood), osteoporosis (weak and fragile bones), hepatic encephalopathy (brain dysfunction caused by liver failure), alcoholic cirrhosis of the liver (advanced scarring of the liver caused by long-term alcohol use), major depressive disorder (mental health condition with persistent feelings of sadness, loss of interest, various emotional/physical problems), adult failure to thrive (syndrome of weight loss, decreased appetite, functional decline, and social withdrawal), and personal history of other mental and behavioral disorders. Record review of Resident #1's MDS, dated [DATE], reflected a BIMS score of 12, indicating moderate cognitive impairment. The MDS reflected Resident #1 had no physical or verbal behavioral symptoms directed towards others. Record review of Resident #1's care plan, dated 04/09/26, reflected [Resident #1] was physically aggressive related to anger and poor impulse control. Date initiated: 03/03/26. Revised: 04/07/26. Interventions included when the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Date initiated: 03/03/26. [Resident #1] has a behavior problem related to MDD (resident will have verbal outburst with staff and other residents). Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Resident on 30 minute behavior log, monitor resident behavior and document as necessary. Date initiated: 04/07/26. Record review of Resident #1's progress notes, dated 04/03/26 at 8:38 AM, revealed, [LVN A] witnessed [Resident #1] starting to verbally and physically getting aggressive with [Resident #2]. Both residents next to portable coffee stand. [Resident #1] was getting coffee. [Resident #2] asked to get a cup of coffee and [Resident #1] started yelling derogatory words towards [Resident #2]. [Resident #2] defended himself. [Resident #1] got up and started swatting [Resident #2]. This nurse and staff attempted to redirect [Resident #1]. [Resident #1] refused and kept yelling. The DON, ADM, and NP made aware. Documented by LVN A. At 12:15 PM, revealed, [Resident #1] was redirected to his room by the DON. While taking [Resident #1] back to his room, he was still yelling. Once inside his room [Resident #1] started throwing kicks and hit the frame of the bed with his left shin, as a result he had a skin tear about 1 cm long, edges well approximated. Documented by the DON. 2. Record review of Resident #2's face sheet, dated 04/09/26, reflected a [AGE] year-old male, admitted on [DATE], diagnoses included: type 2 diabetes (high levels of sugar in blood), major depressive disorder (mental health condition with persistent feelings of sadness, loss of interest, various emotional/physical problems), and unspecified dementia (decline in cognitive function, affecting memory, thinking, behavior, and ability to perform everyday activities). Record review of Resident #2's MDS, dated [DATE], reflected a BIMS score of 8, indicating moderate cognitive impairment. The MDS reflected Resident #2 had no physical or verbal behavioral symptoms directed towards others. Record review of Resident #2's care plan, dated 04/09/26, reflected [Resident #2] had impaired cognitive function/dementia or impaired thought processes related to dementia. Date initiated: 03/03/26. Record review of Resident #2's progress note, dated 04/03/26 at 2:49 PM, revealed Gave report to charge nurse of 100 hall (room change). Resident at this time has no acute distress noted and no abnormalities. Plan of care ongoing. Documented by LVN A. During an interview and observation, on 04/09/26 at 10:00 AM, Resident #1 did not wish to speak. Resident #1 was observed self-propelling in his wheelchair in the hallways and then went outside. Resident #1 had a bandage on his left shin area. During an interview, on 04/09/26 at 1:10 PM, CNA B stated she witnessed Resident #1 become aggressive towards Resident #2 when they were getting coffee. CNA B stated she assisted LVN A to intervene but Resident #1 was able to sort of push Resident #2 on his chest. CNA B stated they separated the residents and moved them away from each other. CNA B stated later on that day, Resident #1 was wheeled to his room by the DON. CNA B said she could see the doorway but did not see what happened inside the room. CNA B stated Resident #1 yelled and said he wanted the doctor to be arrested for abuse. CNA B stated Resident #1 was referring to the DON when he said the doctor. CNA B stated the ADM was aware of these incidents and spoke to the residents. During an interview, on 04/09/26 at 3:00 PM, MA D stated he saw when Resident #1 yelled at Resident #2 and called him names. MA D stated he intervened right away along with CNA B and LVN A. MA D stated later that day or the next day, Resident #1 had a bandage on his left shin area. MA D stated Resident #1 told him that he had a cut on his leg that he obtained when a doctor rolled him in a chair and banged him on the bed. MA D stated he told LVN A about what Resident #1 was saying but she was already aware because Resident #1 was telling everyone about that incident with the doctor. MA D stated the ADM already knew about what Resident #1 alleged about being banged on the bed by a doctor. During an interview, on 04/09/26 at 3:15 PM, LVN A stated on 04/03/26 in the morning, Resident #1 and Resident #2 were getting coffee and Resident #1 started cussing at Resident #2, saying that Resident #2 hated him. LVN A stated she tried to redirect them immediately and got in the middle of the residents. LVN A stated Resident #1 started swatting, trying to hit Resident #2. LVN A stated Resident #1 was able to hit Resident #2 on the arm even though she was in between them. LVN A stated she moved her arms higher so Resident #1 could not reach Resident #2 again. LVN A stated MA D and CNA B moved the residents away. LVN A stated Resident #1 and Resident #2 were not injured from the incident. LVN A stated the ADM was notified and he went to speak to the residents. LVN A stated later on that day, around lunch time, the DON took Resident #1 to his room. LVN A stated she saw the DON take Resident #1 to his room and walked away. LVN A stated she did not see the DON hurt Resident #1's leg or bang him into the bed. LVN A stated Resident #1 had a cut on his left shin after that and Resident #1 said that it was the doctor that hit him with the bed. LVN A stated there was no doctor in the facility and she did not know if Resident #1 meant the DON. LVN A stated Resident #1 had a skin tear on his left shin that was bleeding minimally and only required first aid. LVN A stated Resident #1 said that the doctor pushed him to the bed, the doctor hurt him, and that's how he got the skin tear on his leg. LVN A stated that incident was also reported to the ADM and the ADM spoke to Resident #1. During an interview, on 04/09/26 at 4:15 PM, the DON stated he was aware of the incident with Resident #1 and Resident #2 on 04/03/26 but he did not witness it. The DON stated as far as he knew, the staff intervened and separated the residents. The DON stated the residents did not hit or make any physical contact at all. The DON stated on 04/03/26 around lunch time, he wheeled Resident #1 to his room. The DON stated once in the room, Resident #1 turned his wheelchair on his own and then said, Oh my leg, my leg. The DON stated Resident #1 had a skin tear on his left leg and blamed the DON. The DON stated Resident #1 said that he pushed him into the room and pushed him against the bed. The DON stated that did not happen as he only wheeled Resident #1 into his room and left him by the bed in front of the nightstand. The DON stated when Resident #1 turned himself in the wheelchair, Resident #1 had kicked his leg and that's when he said, My leg, my leg. The DON stated when Resident #1 blamed him, LVN A and the ADON arrived to the room. The DON stated the ADM was notified and the ADM spoke to Resident #1 on his own. The DON stated Resident #1 was changing his mind and going back and forth about what he was saying. The DON stated the ADM was the abuse coordinator and he determined if something was abuse or not. The DON stated the incident with Resident #1 and Resident #2, and the incident of Resident #1 alleging he caused the skin tear to his leg were not reported to the State Survey Agency. During an interview and observation, on 04/09/26 at 6:00 PM, Resident #2 stated he was doing well. Resident #2 stated he did not have any problems. Resident #2 stated he tried to be respectful and the staff treated him with the same respect. Resident #2 stated the staff provided him with anything he needed. Resident #2 did not recall the alleged incident with Resident #1 and did not know who Resident #1 was. Resident #2 was able to communicate his needs/wants. Resident #2 was not injured or in distress. During the interview, Resident #1 passed by Resident #2 and neither reacted to one another in any way. During an interview, on 04/10/26 at 10:00 AM, the ADON stated she went to Resident #1's room on 04/03/26 and the DON was in the room with LVN A and Resident #1. The ADON stated she saw Resident #1 had a skin tear on his leg and it was bleeding slightly, well approximated, where the skin flaps were together. The ADON stated Resident #1 calmed down and he allowed them to take care of the cut. The ADON stated Resident #1 said that the DON had taken him to his room and that he hit his leg. The ADON stated Resident #1 did not directly say that the DON hurt his leg as she understood it as Resident #1 hit his leg on his own. The ADON stated the ADM was notified either way and arrived to speak to Resident #1. During an interview, on 04/10/26 at 10:35 AM, the ADM stated on 04/03/26 in the morning, there was an incident where Resident #1 was yelling at Resident #2. The ADM stated he was not sure what was said but the staff intervened immediately and separated the residents. The ADM stated he did not witness the incident but from what staff told him, there was no physical contact between the residents. The ADM stated the staff did not tell him that Resident #1 hit or made any contact with Resident #2. The ADM stated if he had known that there was a physical altercation or that Resident #1 was able to hit Resident #2, he would have reported the incident to the State Survey Agency, even though there was no injury. The ADM stated he investigated the incident and based on what the staff said to him, he did not report it. The ADM stated the progress notes documented by LVN A reflected his investigation for the incident between Resident #1 and Resident #2. The ADM stated he interviewed staff and obtained their statements but he did not have records to show. The ADM stated the progress notes did not really show his investigation process. The ADM stated he had nothing else to show he thoroughly investigated. The ADM stated there was another incident that day on 04/03/26 where Resident #1 alleged the DON had hurt his leg. The ADM stated he arrived to Resident #1's room and asked the DON to step out. The ADM stated he tried to redirect Resident #1 to calm down so he could explain to him what happened. The ADM stated Resident #1's comments were back and forth. The ADM stated he asked Resident #1 if he wanted to call the police and he said no. The ADM stated he told Resident #1 that he needed to interview him, to assess if there was abuse or not, and that he had 2 hours to report. The ADM stated Resident #1 said to just let the time lapse, that he did not want to get anyone in trouble. The ADM stated he told Resident #1 he could not do that. The ADM stated Resident #1 said that the DON had rammed him into the bed which caused the cut on his leg, but then he said that maybe he kicked the bed frame himself. The ADM stated that was why he did not report it to the State Survey Agency because Resident #1 had changed his statement. The ADM stated on 04/03/26, after Resident #1 alleged that the DON rammed him into the bed frame, he did not recall the time, but Resident #1 called the police. The ADM stated he was still at the facility and spoke to the police after they spoke to Resident #1. The ADM stated the police told him that Resident #1 said somebody had pushed him into the bed frame causing the cut on his leg. The ADM stated the police did not specify who somebody was. The ADM stated he explained to the police the version of events Resident #1 had told him earlier. The ADM stated at that point, Resident #1 was again alleging that somebody had hurt him and he should have reported it to the State Survey Agency. The ADM stated he did not further investigate when Resident #1 voiced that the DON hit his leg because he went to Resident #1's room as soon as it happened and he did not see any other staff around. The ADM stated had he seen other staff around he would have asked them about the incident. The ADM stated the facility's policy indicated to report allegations of abuse within 2 hours, investigate allegations of abuse, and to protect the residents. The ADM stated he did what he could within the regulations to protect the residents. The ADM stated Resident #1 had behaviors but all the residents still had rights. The ADM stated he believed they did enough to protect the residents in the facility and they were not at risk of negative outcomes. The ADM stated he could have done a better job in investigating. During an interview and observation, on 04/10/26 at 11:45 AM, Resident #1 stated the other day, a doctor (did not know which doctor) brought him to his room and banged his leg into the bed frame. Resident #1 stated this bed frame that he was laying on which was made of metal and it hurt. Resident #1 stated he got a cut on his leg and it was bleeding. Resident #1 stated the nurses took care of the cut. Resident #1 stated he called the cops because he wanted that doctor to be arrested but that doctor had been hiding. Resident #1 stated he did not fight or argue with anyone else. Resident #1 stated that was all that happened. Resident #1 had pants on and he did not want to show the bandage on his left leg. Resident #1 stated it was fine. Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, undated, reflected - Policy: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. 1. Protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone (facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, and/or any other individual).2. Develop and implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents;9. Investigate and report any allegations within timeframes required by federal requirements.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided for 1 of 3 residents reviewed for accidents and supervision. (Resident #1) The facility failed to ensure Resident#1 received adequate supervision to prevent elopement. Resident #1 eloped from the facility on 04/12/2024 and was found by the police department approximately 4.3 miles away from the facility. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 04/12/2024 and ended on 04/25/2024. The facility had corrected the noncompliance before the survey began. This failure could prevent residents from receiving appropriate supervision which could lead to residents sustaining serious injury, harm, or death. Findings included: Record review of Resident #1's electronic facility face sheet dated 04/15/2025, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. Diagnosis of Dementia, Schizophrenia (a mental condition that affects how people think, feel and behave), Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking), Psychosis (when people lose some contact with reality), Muscle Weakness (loss of muscle tissue), Malnutrition (poor nutrition), and Lack of Coordination. Record review of Resident #1's quarterly MDS assessment, dated 01/20/2025 revealed a BIMS score of 02 indicating Resident #1 was severely cognitive impaired and ambulates independently. No mobilities devices needed. Record review of admission progress note dated 04/01/2024, revealed the report received from hospital nurse stated Resident #1 was found wandering streets and he had been trying to elope from home and ER. Resident #1 was admitted to the secured unit. Record review of incident report dated 04/13/2024, revealed on 04/12/24 at around 06:00 pm Resident #1 eloped from their facility. Staff found out after a change of shift, past 07:00pm. LVN A notified DON E. He then called the Administrator. ADON F called the police, started a case, and shared Resident #1's picture. The administrator sent a flyer for a Silver Alert to the PD. Resident #1 was found around 09:00 pm at a gas station approximately 4.3 miles away from the facility. DON E picked up Resident #1 and brought him back safe to their facility. Resident #1 was in good spirits; no injuries found during the head-to-toe assessment. Family and doctor were notified. Record Review of CNA B written statement for incident on 04/12/2024 indicated that around 04:45-05:00 p.m. Resident #1 came up to her and asked if he could look in a bag. After CNA B went to get residents to go to the dining room and later provided incontinent care. CNA B noticed an alarm sound. She opened the room door to check, and it was the alarm from the back door. She proceeded to turn the alarm off. CNA B thought someone forgot to turn it off when they came in. She did not think of anything afterwards. Record Review of facility incident report revealed CNA B was terminated 4/17/24. Surveyor attempted to interview CNA B on 04/15/2025 at 01:53 p.m. CNA B did not answer, left voicemail to return call. In an interview on 04/15/2025 at 02:45pm with LVN A stated Resident #1 was last seen at approximately 05:00 p.m. when CNA B was getting residents ready for dinner. LVN A stated he noticed Resident #1 was not in his room during shift change at approximately 07:00 p.m. He said he called DON E and started a search with staff. Then other staff started the elopement protocol. LVN A stated Resident #1 came back to the facility at approximately 09:00 p.m. and Resident #1's family member was present at the facility at this time. In an interview on 04/15/2025 at 04:30pm with DON E stated Resident #1 was missing for about 1-1.5 hours. He notified the family and doctor. DON E stated that all staff were looking for Resident #1. He stated that CNA B was performing patient care and turned off the alarm without checking with anyone if a resident was missing. DON E stated CNA B was terminated for not following elopement protocol. He stated PD gave Resident #1 a ride to a convenient store approximately 4.3 miles away. DON E said PD who gave him a ride notified facility after hearing the Silver Alert at around 09:00 pm. He said PD told them of Resident #1's location. DON E picked him up and took him back to the facility. He stated resident was placed on a 15-minute visual checks by nurse and the code was changed to the secure unit doors. DON E stated he a wander guard was placed, and medications were reviewed. DON E stated that the facility added a camera with motion detection on the back door and a fence to the back. DON E stated that the staff had elopement in-services and drills weekly. Staff had elopement in-services and drills. In an interview on 04/16/2025 at 09:23am with Administrator stated Resident #1 probably went out through the back door. The administrator said the exit door had a code and CNA B did not follow procedure. CNA B turned the alarm off and failed to notify the nurse. This was around 05:45pm. CNA B shift change came in at 06:00 p.m. and noticed that Resident #1 was missing. The administrator stated the resident was missing for less than 2 hours. Resident #1 was returned to the facility around 09:00 p.m. He stated the code was changed to the secure unit doors, added a camera with motion detection on the back door, and a fence to the back of the facility. He stated CNA B was terminated. The administrator stated there has been no elopements since the incident on 04/12/2024. Record review of an Elopement Policy with date of 10/2023, revealed Policy: It is the policy of this facility to ensure that the facility provides a safe and secure atmosphere for all residents in the facility. Purpose: To ensure that residents a risk for elopement are properly monitored. The Administrator was notified on 04/16/2025 at 02:21 p.m., that a past noncompliance Immediate Jeopardy situation had been identified due to the above failures. It was determined these failures placed Resident #1 in an Immediate Jeopardy situation on 04/12/2024. The facility had implemented the following interventions: Resident was placed on a 15-minute visual checks by nurse for 72 hours. Wander guard. Code changed to the Secure Unit Doors. Added a camera with motion detection on the back door. Added a fence to the back of the facility for an extra layer of security. Staff were trained in elopement/supervision procedures on 04/17/2024 and 04/25/2024. The care plan was updated on 04/12/2024 to include a wander guard and medications were reviewed. During an observation on 04/15/2025 at 5:05 p.m. revealed the cameras on the back door and the fence in the back area of the facility. Record review of an In-Service Attendance Record with subject of Elopement Drill and procedure, dated 04/17/2024 and 04/25/2024, indicated that staff signed the in-service record. In interviews on 04/15/2025 at 04:00 p.m. - 04/17/2025 at 09:58 a.m., 4 CNAs from different shifts were able to identify residents at risk for elopement, she was knowledgeable of the elopement policy and procedure. They were aware of the expectations of not turning off the alarm without notifying the nurse immediately. In interviews on 04/15/2025 from 02:45 p.m. - 04/17/2025 10:09 a.m., 5 LVNs from different shifts were able to identify residents at risk for elopement, all were knowledgeable of the elopement policy and procedure. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 04/12/2024 and ended on 04/25/2024. The facility had corrected the noncompliance before the survey began.