Every finding on record at Mi Casita Nursing and Rehabilitation

Based on interview and record review the facility failed to ensure residents were free from abuse for 1 of 5 residents (Resident #1) reviewed for abuse in that: The facility failed to protect Resident #1 from abuse when the BOM yelled at Resident #1 and then removed Resident #1 from the BOM's office by grabbing Resident #1's walker and dragging Resident#1 out to the hallway on 7/16/26. This failure could place residents at risk of physical harm, mental anguish, and emotional distress.Findings Included: Record review of Resident #1's face sheet, dated 8/18/26, revealed a [AGE] year-old male admitted on [DATE]. Resident #1 had the following diagnoses: other Alzheimer's disease (brain disorder that destroys memory, thinking skills, and the ability to carry out simple daily tasks), dependence on renal dialysis (life-sustaining state where a person relies on regular dialysis treatments because their kidneys can no longer filter waste and extra fluid from the blood), muscle weakness, cognitive communication deficit (trouble with communication), essential hypertension (high blood pressure), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (decline in thinking skills caused by conditions like strokes that block or reduce blood flow and oxygen to the brain), unsteadiness on feet, unspecified lack or coordination, other abnormalities of gait and mobility (walking and balance difficulty). Record review of Resident #1's Brief Interview for Mental Status (3.0 BIMS) assessment, dated 7/16/26, revealed a BIMS score of 07 which indicated Resident #1 had severe cognitive impairment. Record review of Resident #1's MDS, dated [DATE], revealed Section GG- Functional Abilities, the resident used a walker for mobility. Record review of Resident #1's undated care plan revealed the following: Focus: Falls management: I am at risk for falling due to my co-morbid conditions and impaired mobility, date initiated 3/5/26.Interventions: Educate me/my family/my caregivers about safety reminders and what to do if a fall occurs, date initiated: 3/5/26. Focus: Resident had the potential for a decline in ambulation/steps, date initiated: 5/29/26. Interventions: Resident's usual performance in walk 150 feet? Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. Resident's usual performance in walking 50 feet with two turns? Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity, date initiated 5/29/26. Focus: Resident was in the BOM office, both Resident and the BOM were arguing with each other about the Resident's money. The BOM grabbed Resident's walker and forcefully pulled/dragged the resident out of the office while the resident was still holding onto his walker. When the BOM had the resident out of the office, he turned around and returned to his office. Resident had no visible injuries and walked to the north hall without incident, date initiated: 7/16/26. Interventions: All allegations of abuse/neglect will be investigated, ADM/Abuse Coordinator will be notified of all allegations/suspicion of abuse/neglect, notify Medical Doctor/Facility Nurse Practitioner, Medical Director ,and family with any findings of abuse, staff in-service on abuse and neglect, train staff to understand and manage resident's verbal aggression, date initiated: 7/16/26. Record review of Resident #1's active Physician's Orders as of 7/16/26, revealed an order with a start date of 6/24/226 for 1) PT Evaluation and Treat as indicated. 2) PT to treat 3 days per week for 30 days, 6/24/2026 through 7/23/2026, Gait Training, Manual Therapy, Group Therapy, Wheelchair Management Treatment Dx: M62.81 Muscle Weakness, R26.81 Unsteadiness on feet one time only until 07/23/2026 23:59 (11:59 PM). Record review of Physical Aggression Received Report for Resident #1, dated 7/16/26, revealed This resident refusing to exit office of BOM. Employee grabbed resident's walker and began dragging this resident out of the office into the hallway. Resident was unable to recall the incident. This nurse assessed any injuries, and a family member was informed of the incident. Facility Nurse Practitioner informed as well. No injuries at time of incident. Person Preparing report: ADON. Record Review of Provider Investigation Form, dated 7/16/26, revealed in part: Investigation Summary: 7/16/26 at approximately 11:30 AM, it was witnessed [by the MDS Coordinator] the BOM and Resident #1 in conversation in office doorway. Resident #1 was asking for money and was told that he could not have any. The conversation escalated with both the BOM and Resident #1 becoming angry. The BOM had a red face, and his voice was harsh as he again told Resident #1 that he could not have any money. Resident #1 continued to argue with the BOM at this point, the BOM grabbed the walker that Resident #1 was holding on to and began dragging him out of the office. Upon pulling/dragging Resident #1 into the hallway, the BOM turned around and went into his office leaving Resident #1 standing in the hall. Resident #1 did not have visible signs of injury. Resident #1 them walked away towards the south hall. ADON completed incident report, emotional distress and skin, no injuries, no distress. Resident #1 appeared his normal self. No other issues have occurred. Social Service visited with the resident. Facility Investigation Findings: Confirmed. Dated 7/22/26 and signed by the ADM. Record Review of Suspension Form, dated 7/16/26, revealed unpaid suspension until further notice. Compensation for suspended time will be determined based upon findings. Associate Comments: Resident #1 repeatedly asked for his balance after getting a cash withdrawal. After telling him his balance multiple times I told him I couldn't keep doing this, we needed to leave my office, as I cannot have anyone there because of petty cash. He refused to come so I pulled him with his walker to the doorway. Signed by the BOM. Record Review of Associate Separation Record Form, dated 7/20/26, revealed Associate Comments: I understand that I should not have led the resident out of my office by pulling on his walker, but he and I had a very civil conversation once we were in the hall. While in my office it was the resident who was agitated and yelling. By initialing here, I agree with this disciplinary action, the BOM signed their initials. The BOM signed the form and dated 7/20/26. During an interview on 8/18/26 at 9:04 AM, the ADM stated Resident #1 wanted some money. The ADM stated the BOM was busy and gave Resident #1 some money and then told Resident #1 to get out of his office. The ADM stated she had never seen Resident #1 walk without the walker as it was a security for him. The ADM stated she never spoke to Resident #1 about the incident, he had dementia and he did not remember. The ADM stated Resident #1 had not shown any emotional distress. The ADM stated the BOM was terminated because he mistreated Resident #1 when he yelled at him to get out of his office, his face was red, he was angry and because he put Resident #1 out of his office. The ADM stated the BOM told her he needed Resident #1 out of the office because he had the petty cash money box out. The ADM stated she told the BOM he could have verbally redirected Resident #1 out of the office. The ADM stated this occurred during regular business hours, Resident #1 did not need an appointment to speak with the BOM and ask about his balance, and there was no reason he should have gotten kicked out of the office. The ADM stated the BOM was trained on abuse and neglect. The ADM stated Resident #1 was not having a behavior during this incident. The ADM stated the BOM dragged Resident #1 out of his office by his walker, he was not led out of the office, as the BOM wrote in his suspension and separation statements. The ADM stated she was clear on that. Record review of the Staff Training Record for the BOM, dated 8/18/26, revealed the BOM was trained on Dementia Care and Abuse Prevention on 10/17/25, Preventing, Recognizing, Reporting Abuse on 4/10/25, and Customer Service Excellence on 6/10/26. During an interview on 8/18/26 at 9:23 AM, the ADON stated she was asked to complete an assessment on Resident #1. The ADON stated she did not witness the incident or hear the yelling. The ADON stated she completed the skin assessment, the emotional assessment, and asked Resident #1 how he felt. The ADON stated Resident #1 said he was fine, he did not cry, and he was not angry when she assessed him. The ADON stated she gave Resident #1 a shower afterwards and did not observe any injuries. The ADON stated Resident #1 did not tell her anything about the incident. The ADON stated she continued to monitor Resident #1 for a few days. The ADON stated Resident #1 had not said anything about the incident since it occurred. The ADON stated the BOM no longer worked there since the incident. The ADON stated the BOM was sent home shortly after the incident occurred. During an interview on 8/18/26 at 9:35 AM, the AD stated she and Resident #1 made a list of items he wanted her to buy for him from the store. The AD stated then she and Resident #1 went to the BOM's office to get the money from Resident #1's account. The AD stated the BOM asked how much was needed and gave Resident #1 some money and then Resident #1 gave her (the AD) the money ($20). The AD stated then Resident #1 asked the BOM about his account balance and she walked out of the office to give them privacy. The AD stated she heard yelling and arguing as she was walking out the front door, so she went back to see what was going on. The AD stated she saw Resident #1 outside of the BOM's office in the hallway. The AD stated she did not see the BOM drag the walker. The AD stated Resident #1's facial expressions showed he was upset but he did not say anything to her. The AD stated then Resident #1 walked down the hall afterwards. The AD stated the MDS Coordinator was there. The AD stated during her conversation with Resident #1 (prior to entering the BOM's office), Resident #1 was fine and was not having any behaviors. The AD stated she could not recall what was said during the yelling incident as it was loud and brief. The AD stated she never saw the BOM after the incident. The AD stated grabbing a resident's walker could be physical abuse if it was against their will. The AD stated when she returned from the store, she took Resident #1 the items she purchased, and he was okay and did not seem upset at all. During an interview on 8/18/26 at 11:00 AM, Resident #1 stated the office did not want to give money and he did not know why. Resident #1 stated he asked for his balance. Resident #1 stated some man dragged his walker and he did not know why. Resident #1 stated he did not fall. Resident #1 stated the man told him he could walk but he could not, he had to hold on to something. Resident #1 stated he could not walk far and could not walk without his walker. A full interview was unable to be obtained due to the resident's level of cognitive functioning. During an interview on 8/18/26 at 11:25 AM, the MDS Coordinator stated she heard arguing so she went to see what was going on. The MDS Coordinator stated once she got to the doorway of her office, she saw Resident #1 and the BOM standing side by side in the doorway of the BOM's office. The MDS Coordinator stated the BOM's office was two doors down from her office. The MDS Coordinator stated Resident #1 and the BOM argued over money. The MDS Coordinator stated the argument became heated and the BOM got angry and his face was red. The MDS Coordinator stated that the BOM stepped in front of Resident #1 and grabbed the little bar on Resident #1's walker and dragged Resident #1 out of his office into the hallway. Then the BOM turned around and sat down in his office. The MDS Coordinator stated she was sure the BOM dragged Resident #1 because Resident #1's feet shuffled very fast. The MDS Coordinator stated Resident #1 pulled back and his feet were dragging. The MDS Coordinator stated Resident #1 was pulled against his will. The MDS Coordinator stated Resident #1 did not trip or fall. The MDS Coordinator stated Resident #1 walked off towards his room, and she went to find the ADM. The MDS Coordinator stated she did not talk to the BOM because the incident happened so fast, and the BOM had already gone into his office, and it was all over and done. The MDS Coordinator stated they were not supposed to move residents by their medical equipment if they were not willing. The MDS Coordinator stated Resident #1 could have fallen and gotten hurt. During an interview on 8/18/26 at 1:43 PM, the ADM stated the policy stapled to the in-service packet titled Abuse, Neglect, change in behavior/escalation, was the policy she used for the in-service she provided to staff on 7/16/26 after the incident. Observation of the policy titled Abuse and Neglect- Clinical Protocol, revised March 2018, included information on the protocol to follow and how to assess and recognize signs of abuse, neglect, and sexual abuse. The policy did not include information on abuse, neglect, and exploitation prevention. The ADM stated she was not aware the policy did not include information on abuse, neglect, and exploitation prevention and she would look for that policy and provide a copy. During an interview on 8/18/26 at 2:39 PM, the DON stated the policy for Abuse, Neglect, and Exploitation was to immediately stop it and then notify the Abuse Coordinator/ADM. The DON stated there was a zero-tolerance policy on Abuse, Neglect, and Exploitation. The DON stated she was not aware of the incident until the ADM told her about it. The DON stated they monitored abuse, neglect, and exploitation by doing rounds on the floor and they listened and watched interactions. The DON stated they provided in-services to staff, and staff also completed mandatory training annually. The DON stated Resident #1 was allowed to ask about his balance, he did not need an appointment to talk to the BOM that day. The DON stated all staff were responsible to ensure residents were not abused, neglected, or exploited. The DON stated she expected staff to stop the abuse, neglect, and exploitation and notify the ADM immediately. The DON stated staff were not allowed to relocate residents by their medical equipment without their permission, unless it was to protect them from danger. The DON stated they tried to verbally redirect/guide residents and get them to go willingly with them. The DON stated a potential negative outcome was that the resident could have fallen. During an interview on 8/18/26 at 3:01 PM, the ADM stated abuse, neglect, and exploitation was not tolerated at all. The ADM stated they monitored for abuse, neglect, and exploitation by making rounds, they had an open-door policy to residents and family, they had resident council meetings and had daily stand-up meetings to inquire about any concerns. The ADM state staff were trained with frequent in-services, orientation training upon being hired, and mandatory annual training. The ADM stated staff were trained in abuse, neglect, and exploitation by herself or the ADON and sometimes the DON would help when needed. The ADM stated everyone was responsible for preventing abuse, neglect, and exploitation. The ADM stated she expected staff to not abuse residents and to ask for more training. The ADM stated the BOM could have stepped away from the resident if he was frustrated, or he could have asked for help from another staff. The ADM stated it was not okay for the BOM to raise his voice at the resident. The ADM stated staff were not allowed to grab resident's medical equipment and relocate them without their consent just because they did not want the residents in their office. The ADM stated she felt Resident #1 would have left on his own if the BOM had given him a few more minutes. The ADM stated potential negative outcomes were that Resident #1 could have gotten injured, Resident #1 may feel uncomfortable or no longer feel safe to go back in that office to ask for money. Record Review of facility policy titled, Abuse, Exploitation, and Misappropriation Prevention Program, revised April 2021, revealed in part: Policy Statement 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 to treat the resident's symptoms. Policy Interpretation and Implementation The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including but not necessarily limited to:A. Facility staff;B. Other residents;C. consultants;D. volunteers;E. staff from other agencies;F. family members;G. legal representatives;H. friends;I. visitors; and/orJ. any other individual.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 2 (Residents #7 and #40) of 22 residents reviewed for care plans. 1. The facility failed to develop a care plan for oxygen administration for Resident #7.2. The facility failed to implement the smoking care plan for Resident #40. This failure could place residents at risk of not receiving the care required to meet their individualized needs.1. Record review of the admission record for Resident #7, dated 03/27/26, revealed an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: chronic respiratory failure (a condition where the lungs cannot adequately supply oxygen to the blood), malignant neoplasm of the lung (lung cancer), heart failure and anemia (blood disorder leading to reduced oxygen to tissues). Record review of the significant change MDS assessment for Resident #7, dated 03/10/26, revealed Resident #7 had a BIMS score of 03 indicating she had severe cognitive impairment. Section O - Special Treatments, Procedures and Programs revealed Resident #7 used oxygen therapy while a resident. Record review of the comprehensive care plan for Resident #7, last reviewed on 03/25/26, revealed no care plan for the administration of oxygen therapy. Record review of #7's current Physician Orders dated 03/27/26 revealed the following: May use oxygen at 2L per minute via cannula (tube in nostrils)/mask by concentrator/tank, with a start date of 02/02/26. Record review of Resident #7's Nurse Administration Record dated 03/01/26-03/31/26, revealed oxygen administration was signed for daily between 03/04/26-03/27/26. Observation and interview during the initial tour on 03/25/26 at 11:06 AM, Resident #7 was not wearing oxygen, but she stated she frequently wore oxygen while in bed. An oxygen concentrator with attached tubing was observed at Resident #7's bedside. Telephone interview on 03/27/26 at 4:09 PM, the MDS Coordinator stated she was responsible for resident care plans. She stated she must have overlooked adding Resident #7's care plan for oxygen. She stated she usually checked physician's orders and the 24-hour report daily to update residents' care plans. The MDS Coordinator stated the care plan is used by all nursing staff and interdisciplinary team members to know the proper care of the resident. She stated a potential negative outcome for failure to develop a complete care plan, including oxygen therapy, was that staff may not know the resident required oxygen which could cause respiratory issues. Interview on 03/27/26 at 4:10 PM, the ADM stated she was not aware Resident #7's care plan did not include oxygen therapy. She stated the completeness of the care plan was important, so nursing staff and IDT members were aware of how to care for the resident. The ADM stated her expectation of staff was that care plans were accurate and complete. She stated a potential negative outcome for failure to include oxygen therapy in the care plan was nursing staff and IDT members may not be aware of the resident's need for oxygen. 2. Record review of the admission record for Resident #40, dated 03/25/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: chronic atrial fibrillation (irregular heart rate), acute lower respiratory infection, and chronic obstructive pulmonary disease (lung disease). Record review of the comprehensive MDS assessment for Resident #40, dated 06/06/25, revealed Resident #40 had a BIMS score of 12 indicating his cognition was intact. The MDS further revealed Resident #40 currently used tobacco. Record review of the care plan for Resident #40, last reviewed on 12/24/25, revealed, Focus: Smoker: [Resident #40] is a smoker and is safe to smoke unsupervised. Intervention/Tasks: The resident's smoking supplies are stored at the nurses' station with an initiation date 07/01/25. Interview during the initial tour on 03/25/26 beginning at 9:30 AM, Resident #40 stated he was allowed to keep a cigarette and lighter on his person and he had one in his front shirt pocket at that time. Resident #40 stated none of the staff members had told him that he was not allowed to have a cigarette and lighter on him. Observation on 03/27/26 at 9:20 AM, Resident #40 was observed to have 1 cigarette and 1 lighter in a cigarette box in his front shirt pocket. Interview on 03/27/26 at 9:23 AM, LVN B stated she had been trained to look at the Kardex which was a simplified version of the care plan, but it had been a while since her last training. LVN B stated she did not know why Resident #40 had a cigarette and lighter in the front pocket of his shirt. LVN B stated sometimes Resident #40 was non-compliant with the smoking policies in the facility. LVN B stated a potential harm to the residents was their care plan not being followed. Interview on 03/27/26 at 11:05 AM, the DON stated the staff had been trained to check the care plans for the residents. The DON stated she did not know the last time the staff had been trained on following the care plans. The DON stated she did not know why the smoking care plan for Resident #40 was not being followed. The DON stated a potential negative outcome to the residents was that the residents could not get the care they needed. In an additional interview on 03/27/26 at 3:48 PM, the DON stated she did not know why Resident #7's care plan did not include oxygen therapy. She stated the care plan should have been added when the physicians order was received. She stated she and the MDS Coordinator were responsible for the accuracy and completeness of resident care plans. The DON stated the care plan was used by all staff for information on how to care for a resident. Interview on 03/27/26 at 1:41 PM, the ADM stated she expected the nursing staff to check the care plans and follow them. The ADM stated the nursing staff was trained on care plans, but she did not know when. The ADM stated she did not know why the nursing staff did not follow the smoking care plan for Resident #40. The ADM stated there was a potential risk for danger with the smoking care plan not being followed. Record review of the undated facility-provided policy titled, Policy and Procedure Comprehensive Care Planning, revealed: Purpose: Ensure every resident has a comprehensive, complete, accurate and all inclusive specific care plan written timely to [NAME] all requirements of the RAI and regulatory process to include input from all the IDT members. Procedure.8. Every resident will have all needs/specialized services care planned.and revised routinely.

Based on observations, interviews, and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #40) reviewed for smoking. The facility failed to ensure Resident #40's smoking items were kept at the nursing station. This failures could place the residents at risk of inadequate supervision, accidents, and burns which could result in injury.Findings Included: Record review of the admission record for Resident #40, dated 03/25/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: chronic atrial fibrillation (irregular heart rate), acute lower respiratory infection, and chronic obstructive pulmonary disease (lung disease). Record review of the comprehensive MDS assessment for Resident #40, dated 06/06/25, revealed Resident #40 had a BIMS score of 12 indicating his cognition was intact. The MDS further revealed Resident #40 currently used tobacco. Record review of the care plan for Resident #40, last reviewed on 12/24/25, revealed, Focus: Smoker: [Resident #40] is a smoker and is safe to smoke unsupervised. Intervention/Tasks: The resident's smoking supplies are stored at the nurses' station with an initiation date 07/01/25. Record review of Resident #40's Safe Smoking Assessment, dated 03/11/26, revealed: .B. Summary:4. All smoking materials will be kept at the nurse's station was checked off. Interview during the initial tour on 03/25/26 beginning at 9:30 AM, Resident #40 stated he was allowed to keep a cigarette and lighter on his person and he had one in his front shirt pocket at that time. Resident #40 stated none of the staff members had told him that he was not allowed to have a cigarette and lighter on him. Resident #40 was observed with oxygen on via nasal cannula at 3 liters per minute. Observation on 03/27/26 at 9:20 AM, Resident #40 was observed to have 1 cigarette and 1 lighter in a cigarette box in his front shirt pocket. Resident #40 was observed with oxygen on via nasal cannula at 3 liters per minute. Interview on 03/27/26 at 9:23 AM, LVN B stated she had been trained on the smoking policy at the facility recently. LVN B stated she did not know why Resident #40 had a cigarette and lighter in the front pocket of his shirt. LVN B stated sometimes Resident #40 was non-compliant with the smoking policies in the facility. LVN B stated that sometimes the families will bring cigarettes to the residents and no one will tell the staff about it. LVN B stated a potential harm to the residents was possible burning themselves or combustion if a resident was on oxygen. Interview on 03/27/26 at 11:05 AM, the DON stated the staff had been trained on the smoking policy at the facility last month. The DON stated the residents were not supposed to have smoking supplies on their person, but sometimes it was difficult to manage with the independent residents who smoke. The DON stated Resident #40 probably had his smoking supplies on him because he did not give it back to the nurses. The DON stated the staff were trained to look for smoking supplies with the residents. The DON stated a potential negative outcome to the residents was they could forget and try to light a cigarette in their room. Interview on 03/27/26 at 1:41 PM, the ADM stated she expected the residents and staff to follow the smoking policies and procedures. The ADM stated all staff were responsible to monitor for smoking supplies and should know that all smoking supplies was kept in the med room at the nurse's station. The ADM stated she did not know why Resident #40 had his smoking supplies on his person, unless he did not give them back to the nurses after he went outside to smoke. The ADM stated there was a potential risk for danger with cigarettes, lighters and oxygen use. Record review of the facility in-service titled, Smoking Policy, dated 2/1/26 revealed the signature for LVN B. Record review of the facility policy titled, Smoking Policy - Residents with a revised date of 10/23 reflected the following: Policy Statement: This facility has established and maintains safe resident smoking practices. Policy Interpretation and Implementation:.14. All smoking items shall be kept at the facility designated area. This includes but not limited to lighters, cigarettes.

Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 2 (Resident #1 and #17) of 8 residents reviewed for respiratory care. The facility failed to ensure that Resident #1 and Resident #17's oxygen tubing were replaced every seven (7) days, according to physician's orders. This failure could place residents at risk for respiratory compromise and infectionResident #1 Record review of Resident # 1's face sheet dated 03/27/26 reflected a [AGE] year-old male with an original admission date of 07/14/15. Resident #1 had diagnoses which included: right heart failure (condition where the right side of the heart cannot effectively pump blood to the lungs), acute and chronic respiratory failure (condition where the lungs cannot adequately supply oxygen to the blood), peripheral vascular disease (a progressive circulation disorder), acute pulmonary edema (sudden buildup of fluid in the lungs causing severe breathing difficulties), and dependence on supplemental oxygen. Record review of Resident #1's annual MDS dated [DATE] reflected a BIMS score of 15, indicating the resident was cognitively intact. Section O - Special Treatments, Procedures and Programs revealed Resident #1 used oxygen therapy while a resident. Record review of Resident #1's comprehensive care plan, revised 02/26/26, reflected Resident #1 required oxygen therapy related to shortness of breath. Interventions included: OXYGEN SETTINGS: Oxygen: May have oxygen at 1-5L via cannula/mask by concentrator/tank. To initial when using oxygen.Record review of Resident #1's current Physician Orders dated 03/27/26 reflected the following: Oxygen: May have oxygen at 1-5L via cannula (tube in nostrils)/mask by concentrator/tank. Oxygen: To change oxygen equipment and clean filters weekly, every night shift every Sunday. Record review of Resident #1's Nurse Administration Record dated 03/01/26-03/31/26, reflected an order to change oxygen equipment and clean filters weekly, every night shift every Sunday. The following dates were initialed: 03/01/26, 03/08/26, 03/15/26, and 03/22/26. During an observation and interview on 03/25/26 at 10:55 AM, Resident #1 had oxygen being administered at 3 L/minute via nasal cannula. The oxygen tubing was dated 03/15/26. Resident #1 stated staff usually changed out his oxygen tubing, but he did not recall when staff had last changed it. During an observation on 03/26/26 at 12:15 PM, Resident #1's oxygen tubing was dated 03/15/26. Resident #17 Record review of Resident # 17's face sheet dated 03/27/26 reflected a [AGE] year-old female with an original admission date of 01/17/18. Resident #17 had diagnoses which included: chronic obstructive pulmonary disease (a progressive lung disease that causes obstructed airflow), acute and chronic respiratory failure (condition where the lungs cannot adequately supply oxygen to the blood), heart failure (a progressive condition where the heart does not pump blood efficiently), peripheral vascular disease (a progressive circulation disorder), and dependence on supplemental oxygen. Record review of Resident #17's quarterly MDS dated [DATE] reflected a BIMS score of 15, indicating the resident was cognitively intact. Section O - Special Treatments, Procedures and Programs revealed Resident #1 used oxygen therapy while a resident. Record review of Resident #17's comprehensive care plan, revised 09/09/25, reflected Resident #17 required oxygen therapy related to ineffective gas exchange. Interventions included: OXYGEN SETTINGS: Oxygen: May have oxygen at 1-5L via cannula/mask by concentrator/tank. To initial when using oxygen. Record review of #17's current Physician Orders dated 03/27/26 reflected the following: Oxygen: May have oxygen at 1-5L via cannula (tube in nostrils)/mask by concentrator/tank. Oxygen: To change oxygen equipment and clean filters weekly, every night shift every Sunday. Record review of Resident #17's Nurse Administration Record dated 03/01/26-03/31/26, reflected an order to change oxygen equipment and clean filters weekly, every night shift every Sunday. The following dates were initialed: 03/01/26, 03/08/26, 03/15/26, and 03/22/26. During an observation and interview on 03/25/26 at 11:22 AM, Resident #17 had oxygen being administered at 3L/min via nasal cannula. The oxygen tubing was dated 3/15/26. She stated that she does wear her oxygen. She stated that one staff member was really good about changing the tubing and adding water to the canister, but not all staff did. During an observation on 03/26/26 at 12:16 PM, Resident #17's oxygen tubing was dated 03/15/26. During an interview on 03/27/26 at 3:25 PM, the ADON stated she worked as the charge nurse part of the night shift on 03/22/26, which was a Sunday. She stated 03/22/26 was the scheduled date for oxygen tubing changes for Resident #1 and Resident #17. The ADON stated Sunday was the designated day for weekly oxygen equipment changes and night shift charge nurses were responsible for completing the task. She stated she took care of Resident #1 and Resident #17 during the shift, and she got busy and failed to change the oxygen tubing for Resident #1 and #17 and failed to report to the oncoming nurse that the task had not been completed. She stated a potential negative outcome for failure to change oxygen tubing, according to orders was residents could have respiratory complications. During an interview on 03/27/26 at 3:48 PM, the DON stated the facility policy was for oxygen tubing to be changed every week on Sunday. She stated the night shift charge nurses were responsible for changing tubing and documenting the tubing change. She stated nursing administration was responsible for assuring oxygen equipment was changed timely, according to orders. The DON stated oxygen tubing and equipment was spot checked by nursing administration while on rounds in the facility. She stated a potential negative outcome for failure to change oxygen tubing according to physicians orders was infection issues. During an interview on 03/27/26 at 4:10 PM, the ADM she was not aware oxygen tubing changes for Residents #1 and #17 had not been completed on the scheduled date. She stated her expectation of staff was to follow physicians orders for each resident. The ADM stated the charge nurse was responsible for oxygen tubing changes and nursing administration was responsible for monitoring the completion of the task. The ADM stated a potential negative outcome for failure to change oxygen tubing, according to orders, was infection. Record review of the facility-provided policy titled Administration of Oxygen and Maintenance of Tubing and Equipment, dated 10/2017 revealed: Administration of Oxygen 1) Oxygen will be administered per physician order. Maintenance of Tubing and Equipment. 2) Tubing will be dated, and will be changed weekly.

Based on observation, interview, and record review the facility failed to ensure that its medication error rate was less than 5 percent. The facility had a medication error rate of 6.06% based on 2 out of 33 opportunities, for 2 of 3 Residents (Residents #33 and #36) reviewed for medication administration, in that:-The facility failed to ensure Med Aide C provided a full dose of the medication Polyethylene Glycol 3350 Powder (MiraLAX) 17 grams to Resident #36. -The facility failed to ensure Med Aide C provided the correct eye drop medication to Resident #33.These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health.Findings included: Resident #36 Record review of Resident #36's admission record, dated 03/26/26, revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: pneumonia (lung infection), acute cystitis without hematuria (bladder infection), and constipation. Record review of Resident #36's physician orders, dated 03/26/26, revealed an order for Polyethylene Glycol 3350 Powder (Polyethylene Glycol 3350 (Bulk)) Give 17 gram by mouth one time a day related to constipation, mix with 4-6 oz of water with a start date of 01/08/26. During a medication administration observation on 03/26/26 at 8:14 AM, for Resident #36, Med Aide C was observed dispensing polyethylene glycol 3350 powder by filling the bottle cap half full in the white area. The powdered medication did not reach the top of the white section in the bottle cap. Med Aid C then mixed the powder with approximately 4 oz. of water and administered to Resident #36. Review of the back of the Polyethylene Glycol 3350 Powder medication label revealed the directions: Fill the provided cap to the top of the white section (marked 17g). During an interview on 03/26/26 at 8:20 AM, Med Aide C stated she did not know that the polyethylene glycol 3350 powder needed to reach the top of the white section of the bottle cap as no one had ever told her. Med Aide C stated a potential negative outcome to the resident was not getting the full effect of the medication. Resident #33 Record review of Resident #33's admission record, dated 03/26/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: fracture of coccyx, lack of coordination, and dry eye syndrome of bilateral lacrimal glands. Record review of Resident #33's physician orders, dated 03/26/26, revealed an order for Artificial Tears Ophthalmic Solution 1 % (Carboxymethylcellulose Sodium (Ophth[almic])) Instill 1 drop in both eyes three times a day for dry eyes with a start date of 07/20/24. During a medication administration observation on 03/26/26 at 8:33 AM, for Resident #33, Med Aide C was observed administering Redness relief eye drops 1 drop per eye. During an interview on 03/26/26 at 12:01 PM, Med Aide C stated she noticed the Redness relief eye drops were different than Artificial Tears eye drops. Med Aide C stated she administered the Redness relief eye drops because that was provided to her by the facility. Med Aide C stated a potential negative outcome to the resident was possible adverse reactions. During an interview on 03/27/26 at 11:05 AM, the DON stated she expected the staff to observe the 5 rights for medication administration. The DON stated Med Aide C had told her the reason she did not fill up the Polyethylene Glycol 3350 Powder to the top of the white section in the bottle cap was because she was afraid of the medication overflowing and making a mess. The DON stated the nurses and medication aides were trained on proper dosing of medications, but she did not know when the last training was. The DON stated the residents had a risk of constipation with not getting a full dose of Polyethylene Glycol 3350 Powder. The DON stated artificial tears were difficult to locate and that was why Redness relief eye drops were provided to the facility. The DON stated a potential negative outcome to the resident was the Redness relief eye drops would not help his dry eyes. During an interview on 03/27/26 at 1:41 PM, the ADM stated the DON oversees the medication administration at the facility. The ADM stated she knows the staff was trained on medication administration, but she did not know when the last training for medication administration was provided. The ADM stated Med Aide C was probably nervous. The ADM stated a potential negative outcome to the residents with not getting a full dose of medication was it could not be effective. The ADM stated a potential negative outcome to the residents with getting the wrong medication was that the resident could not get the correct effect from the medication that was needed. Record review of facility policy titled, Administering Medications with a revised date of 01/01 reflected the following: Policy Statement: Medications will be administered in a timely manner and as prescribed by the resident's attending physician or the facility's medical director. Policy Interpretation and Implementation:.8. The individual administering the medication must ensure that the right medication, the right dosage.are verified before the medication is administered (e.g. review of the drug label, physician orders, etc.)

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 2 of 4 medication carts (Med Cart A and Med Cart B) and 1 of 2 medication rooms (Med Room C) reviewed for medication storage. The facility failed to ensure Med Cart A did not have loose pills in the drawers. The facility failed to ensure Med Cart A, Med Cart B and Med Room C did not have expired medications and supplies. These failure could place residents at risk of medication errors or adverse effects. The findings included: During an observation of Med Cart A on 03/27/26 at 11:17 AM with the DON, 2 loose pills were found in the second drawer. 1 pill was oblong and was light gray in color. 1 pill was oblong and was yellow/orange in color. During an interview on 03/27/26 at 11:26 AM, the DON stated she believed the light gray pill that was found in Med Cart A was memantine and she thought the yellow/orange pill was a different dose of memantine. During an observation of Med Cart B on 03/27/26 at 11:23 AM with the DON, 32 sureprep pads with an expiration date of 11/15/25 were found in the bottom drawer, aloe vera hand sanitizer 2 fluid oz. with an expiration date of 08/22 and a 30 mL medicine cup with 15 mL full of a white powder, unlabeled was in the top small drawer and eucalyptus hand sanitizer 32 fluid oz. with an expiration date of 08/22 was sitting on top of the medication cart. During an interview on 03/27/26 at 11:29 AM, LVN D stated the medicine cup of white powder in the top drawer of Med Cart B was miralax that a resident had asked for and then refused when he took it to them. LVN D stated he did not want to waste the medication, so he put it back in the medication cart. During an observation of Med Room C on 03/27/26 at 11:35 AM with the DON revealed, 4 packs of povidone-iodine swab sticks with an expiration date of 05/25 was observed on a shelf. 4 bottles of Glucerna hunger smart shakes 10 fluid oz. with an expiration date of 07/01/25 were found in the refrigerator in Med Room C. During an interview on 03/27/26 at 11:47 AM, the DON stated the medication aides and the nurse's were responsible for ensuring loose pills and expired items were not in the medication carts or the medication rooms. The DON stated she did not know why expired items were found in Med Cart B or Med Room C. The DON stated the staff were trained on medication storage but she did not have an exact date on when the last training was. The DON stated a potential negative outcome to the residents was the expired supplies could not work as well. The DON stated a potential negative outcome to the residents with improperly labeled medications was medication errors. During an interview on 03/27/26 at 1:41 pm, the ADM stated the DON was responsible for medication storage and labeling. The ADM stated she expected for expired items to be pulled off the shelf before the expiration date. The ADM stated she did not know why some medications were not labeled properly or why some items were expired, maybe was an oversight. The ADM stated a potential negative outcome to the residents was the expired items may not be as effective. The ADM stated a potential negative outcome to the residents with unlabeled medications was the residents could be short pills. Record review of the facility policy titled, Storage of Medications with a revised date of November 2020 reflected the following: Policy heading: The facility stores all drugs and biologicals in a safe, secure, and orderly manner.Policy Interpretation and Implementation:.2. Drugs and biologicals are stored in packaging, containers or other dispensing system in which they are received. Only the issuing pharmacy is authorized to transfer medication between containers.4.Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services.1. The facility failed to ensure red onions with sprouts and mold were removed from the dry pantry.These failures could place residents at risk for foodborne illness. On 3/25/26 an initial kitchen observation tour from 9:47 AM to10:30 AM revealed the following:The dry pantry had a plastic bin dated 2/24/26 with red onions in it. There were 6 red onions found to have green sprouted shoots and were soft to touch. There were 4 red onions with dark black and grey molded areas and were soft to touch.During an interview on 3/25/26 at 10:05 AM the DS stated that staff were to check the red onions every day. She stated, it was likely the red onions had not been checked in the past couple of days. She stated that the date on the plastic bin, 2/24/26, was when the red onions were received. She stated the kitchen was very hot and the dry pantry was hot and the temperature could cause the red onions to go bad faster. She stated the red onions should have lasted 2 weeks in the dry pantry with the heat. She stated she would have a staff member sort the red onions in the bin and throw away the spoiled red onions.During an interview on 3/25/26 at 11:46 AM the DS stated all the red onions were thrown away and new red onions were ordered.During an interview on 3/27/26 at 3:55 PM Corporate Account Manager stated that the red onions should have been checked daily and dietary staff should discard any that were spoiled. She stated that the heat could cause the red onions to ruin faster as well as moisture. She stated additional education would be provided to dietary staff.During an interview on 3/27/26 at 5:00 PM the ADM stated the company had the ADM do a walk through in the kitchen every week. She had completed the walk through on Monday and did not see the spoiled red onions in the dry pantry.Record review of the facility's Use by date Guide used to determine a use by date when labeling opened and unopened food that must be used within a certain time frame.Item/Category - produce, fresh fruits and vegetables, Use By- Check daily for freshness.Record review of the facility's policy titled Food receiving and storage dated, 2001 and revised date November 2022, revealed in part:Policy Statement: Food shall be received and stored in a manner that complies with safe food handling practices.Policy Interpretation and Implementation:4. Food services, or other designated staff, maintain clean and temperature/humidity-appropriate food storage areas at all times.Dry Food Storage:4. Dry foods and goods in storage must be checked weekly for perishable or changes to the integrity of the food product. Food products in which the integrity of the food has changed since arrival must be disposed of properly.5. Dry foods that are stored in bins are removed from original packaging, labeled and dated ( use by date). Such foods are rotated using a first in - first out system

Based on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 2 (Residents #1 and #17) of 22 residents reviewed for clinical records. The facility failed to accurately document oxygen tubing changes for Residents #1 and #17 This failure could place residents at risk of inaccurate and incomplete care.Resident #1 Record review of Resident # 1's face sheet dated 03/27/26 reflected a [AGE] year-old male with an original admission date of 07/14/15. Resident #1 had diagnoses which included: right heart failure (condition where the right side of the heart cannot effectively pump blood to the lungs), acute and chronic respiratory failure (condition where the lungs cannot adequately supply oxygen to the blood), peripheral vascular disease (a progressive circulation disorder), acute pulmonary edema (sudden buildup of fluid in the lungs causing severe breathing difficulties), and dependence on supplemental oxygen. Record review of Resident #1's annual MDS dated [DATE] reflected a BIMS score of 15, indicating the resident was cognitively intact. Section O - Special Treatments, Procedures and Programs revealed Resident #1 used oxygen therapy while a resident. Record review of Resident #1's comprehensive care plan, revised 02/26/26, reflected resident #1 required oxygen therapy related to shortness of breath. Interventions included: OXYGEN SETTINGS: Oxygen: May have oxygen at 1-5L via cannula/mask by concentrator/tank. To initial when using oxygen. Record review of #1's current Physician Orders dated 03/27/26 reflected the following: Oxygen: May have oxygen at 1-5L via cannula (tube in nostrils)/mask by concentrator/tank. Oxygen: To change oxygen equipment and clean filters weekly, every night shift every Sunday. Record review of Resident #1's Nurse Administration Record dated 03/01/26-03/31/26, reflected the ADON inaccurately signed for an oxygen tubing change on 03/22/26 for Resident #1, that did not occur. During an observation on 03/25/26 at 10:55 AM, Resident #1 had oxygen being administered at 3 L/minute via nasal cannula. The oxygen tubing was dated 03/15/26. During an observation on 03/26/26 at 12:15 PM, Resident #1's oxygen tubing was dated 03/15/26. Resident #17 Record review of Resident # 17's face sheet dated 03/27/26 reflected a [AGE] year-old female with an original admission date of 01/17/18. Resident #17 had diagnoses which included: chronic obstructive pulmonary disease (a progressive lung disease that causes obstructed airflow), acute and chronic respiratory failure (condition where the lungs cannot adequately supply oxygen to the blood), heart failure (a progressive condition where the heart does not pump blood efficiently), peripheral vascular disease (a progressive circulation disorder), and dependence on supplemental oxygen. Record review of Resident #17's quarterly MDS dated [DATE] reflected a BIMS score of 15, indicating the resident was cognitively intact. Section O - Special Treatments, Procedures and Programs revealed Resident #1 used oxygen therapy while a resident. Record review of Resident #17's comprehensive care plan, revised 09/09/25, reflected Resident #17 required oxygen therapy related to ineffective gas exchange. Interventions included: OXYGEN SETTINGS: Oxygen: May have oxygen at 1-5L via cannula/mask by concentrator/tank. To initial when using oxygen. Record review of #17's current Physician Orders dated 03/27/26 reflected the following: Oxygen: May have oxygen at 1-5L via cannula (tube in nostrils)/mask by concentrator/tank. Oxygen: To change oxygen equipment and clean filters weekly, every night shift every Sunday. Record review of Resident #17's Nurse Administration Record dated 03/01/26-03/31/26, reflected the ADON inaccurately signed for an oxygen tubing change on 03/22/26 for Resident #1, that did not occur. During an observation on 03/25/26 at 11:22 AM, Resident #17 had oxygen being administered at 3L/min via nasal cannula. The oxygen tubing was dated 3/15/26. During an observation on 03/26/26 at 12:16 PM, Resident #17's oxygen tubing was dated 03/15/26. During an interview on 03/27/26 at 3:25 PM, the ADON stated she worked as the charge nurse part of the night shift on 03/22/26, which was a Sunday. She stated Sunday was the designated day for weekly oxygen equipment changes and night shift charge nurses were responsible for completing the task. She stated she took care of Resident #1 and Resident #17 during the shift and signed for oxygen tubing changes on the MAR for each of those residents and intended to change the tubing later in the shift. The ADON stated she got busy and failed to change the oxygen tubing for Resident #1 and #17 during her shift and failed to report to the oncoming nurse that the task had not been completed. She stated she had been trained during her nursing education to sign for procedures after completing the task. The ADON stated she was trying to be helpful to the oncoming nurse to get tasks completed and inadvertently failed to complete the task she signed for. She stated a potential negative outcome for inaccurate documentation was residents could have incomplete care or miss essential care that is ordered by the physician. During an interview on 03/27/26 at 3:48 PM, the DON stated she was not aware oxygen tubing changes for Residents #1 and #17 had been inaccurately documented. She stated documentation should be accurate for all residents at all times. She stated a task should be signed for only after being completed or should have a strikeout by staff if a task was not completed. She stated documentation was monitored by nursing administration and by the regional nurse during onsite visits. The DON stated a potential negative outcome for inaccurate documentation was care that was ordered for a resident could be missed if signed for and not completed. During an interview on 03/27/26 at 4:10 PM, the ADM stated she was not aware oxygen tubing changes for Residents #1 and #17 had been inaccurately documented. She stated her expectation of staff was to accurately document all care in a timely manner. The ADM stated the system for monitoring the accuracy of documentation was through random checks of the health record by nursing administration and the regional nurse. She stated a potential negative outcome for inaccurate documentation was that the resident may not get care tasks completed according to orders. Record review of the facility-provided policy titled Charting and Documentation, revised July 2017, revealed: Policy Statement .The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation. 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.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #32) reviewed for infection control. The facility failed to ensure LVN B washed her hands after entering the room to provide wound care to Resident #32. This failure could place residents at risk for cross contamination and infection. The findings included: Record review of the face sheet for Resident #32, dated 03/25/26 revealed an [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: chronic obstructive pulmonary disease (lung disease), pressure ulcer of right heel stage 3, and peripheral vascular disease (poor blood circulation). Record review of the comprehensive MDS assessment for Resident #32, dated 01/17/26 revealed Resident #32 had a BIMS score of 09 which indicates his cognition was moderately impaired. The MDS further revealed Resident #32 had a Stage 3 Pressure ulcer. Record review of the order summary report for Resident #32, dated 03/25/26, revealed an order: Tx [treatment] to right outer heel stage 3 pressure ulcer: Cleanse, pat dry, apply iodosorb and calcium alginate, clover and secure with bordered gauze. Every dayshift with a start date of 01/09/26. Record review of the care plan for Resident #32, last care plan review completed 03/05/26 revealed: Focus: The resident has actual pressure injury development to his right heel. During an observation of wound care on 03/26/27 at 10:02 AM, LVN B gathered her supplies on a tray at the wound care cart and entered Resident #32's room for wound care. LVN B set her supplies down, put on a clean gown and gloves and began performing wound care for Resident #32's Right heel wound. LVN B did not wash her hands after entering the room and before putting on clean gloves. During an interview on 03/26/27 at 10:12 AM, LVN B stated she had been trained to wash her hands before providing care to the residents. LVN B stated she was last trained a few months ago on infection control. LVN B stated she washed her hands at the sink before the surveyor began watching the wound care observation. LVN B stated it had slipped her mind to wash her hands after entering the room. LVN B stated a potential negative outcome for the residents was an increased risk for infection. During an interview on 03/27/26 at 11:05 AM, the DON stated she expected the staff to wash their hands before starting any care. The DON stated she did not know why LVN B did not wash her hands after going in the room to provide care for Resident #32. The DON stated LVN B was last trained on infection control in February of 2026. The DON stated a potential negative outcome to the residents was an infection control risks to the residents. During an interview on 03/27/26 at 1:41 PM, the ADM stated she expected the staff to wash their hands before providing care to the residents. The ADM stated the DON manages infection control concerns in the facility. The ADM stated she knows LVN B had been trained on infection control at the facility, but the DON would have that information. The ADM stated a potential negative outcome to the residents was a possible infection. Record review of the facility's in-service document titled, Handwashing/Gloves, dated 02/16/26 revealed LVN B's signature. Record review of the facility's policy titled, Policies and Practices - Infection Control with a revised date of 10/18 reflected the following: Policy Statement: This infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage the transmission of disease and infections. Record review of the facility's policy titled, Handwashing/Hand Hygiene with a revised date of 10/23 reflected the following: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.Policy Interpretation and Implementation:.2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors.Indications for Hand Hygiene:1. Hand hygiene is indicated:a. immediately before touching a resident.5. The use of gloves does not replace hand washing/hand hygiene.

Based on interviews and record reviews, the facility failed to treat each resident with respect, dignity, and care for each resident in a manner and in an environment that promotes the maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility failed to protect and promote the rights of 4 of 24 confidential residents in that: The facility failed to ensure staff were not on their personal cell phones while providing care, which included peri-care to residents. This could place residents at risk for diminished quality of life and loss of dignity and self-worth.Findings include: The four confidential residents at an undisclosed date and time four confidential residents stated the use of cell phones by CNAs while performing care made them feel ignored, not a priority, embarrassed, concerned the CNA could make a mistake due to distraction by the cell phone conversation, and, most of all, their privacy was violated. During an interview with four confidential residents stated the use of cell phones by CNAs occurred on every shift. Confidential residents also stated staff utilize their cell phones while feeding residents during meals; residents stated the use of the cell phones while feeding residents forced those residents to have significant wait times between bites. The four confidential residents stated they did not know the names of the CNAs who utilized their cell phones while performing care. The confidential residents stated cell phone usage of the CNAs while performing care happened in the facility happened so often, they said every CNA in the facility utilized their cell phone while performing care. During an interview on 03/27/26 at 3:33pm, the ADM stated residents should be provided with privacy during resident care. She stated all staff were trained on privacy, resident rights, dignity, and cell phone usage during orientation and through continuous education by department heads and the ADM. She stated staff were monitored by making rounds and correcting any issues found, and by addressing complaints and grievances concerning cell phone usage by staff while performing resident care. She stated cell phones should never be used in resident rooms, hallways, or nurses' stations. She stated the potential negative outcome could be mistakes and HIPAA violations. Record review of the undated facility policy titled Resident Rights revealed the following: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and ImplementationFederal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a dignified existence to be treated with respect, kindness, and dignityt. privacy and confidentiality

Based on observation, interview, and record review the facility failed to provide 80 square feet of floor space per resident in 10 of 40 semi-private resident rooms containing two beds (Rooms #1, 3, 5, 8, 27, 29, 30, 31, 32, and 33) in that: Rooms #1, 3, 5, 8, 27, 29, 30, 31, 32, and 33 semi- private rooms did not have 80 square feet per resident. This failure could result in overcrowding in resident rooms and possible diminished quality of life. The findings included: Record review of Texas Health and Human Services Form 3740 (Bed Classifications (Numbers and Location) dated 01/8/25 documented that rooms #1, 3, 5, 8, 27, 29, 30, 31, 32, and 33 were listed as a Title 18/19 bed classification semi-private rooms for two residents. During an interview on 03/27/26 at 10:15am with the Administrator, she was asked if she wanted to apply for the room size waiver she stated, Yes, I want to apply for the waiver. She stated rooms #1, 3, 5, 8, 27, 29, 30, 31, 32, and 33 had a waiver for years and there has been no change to the floor plan. During a general observation tour on 03/27/26 between 2:30pm and 3:00pm, it was noted that 10 of 40 semi-private rooms had 154 square feet instead of the required 160 square feet for 2 residents: (Rooms) #1, 3, 5, 8, 27, 29, 30, 31, 32, and 33. During an interview on 03/27/26 at 3:33pm with the Administrator, regarding the risk of residents not having the appropriate space, she stated there have been no issues with the room size in the past 34 plus years. She stated there was no facility policy for room size waiver.

Based on observations, interviews, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 9 of 15 confidential residents. The facility failed to ensure 9 of 15 confidential residents were provided, through postings in prominent locations, the Grievance Procedure, were provided access to the Grievance form, were provided information who the facility grievance official was, their contact information, how to file an anonymous grievance, and their right to obtain a written decision related to their grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings included: Interviews and Record Review during Resident Council on, 01/07/2024 at 1:30pm, attendees 9 of 15 confidential residents, stated they did not have access to the Grievance form, they did not know they could file a Grievance anonymously, the Grievance procedure had never been discussed in Resident Council, and they had not observed a posting of the Grievance procedure in prominent locations. Residents attending Resident Council did not know where to acquire a grievance form, who to turn the form into, and what happened once a grievance was filed. The Residents did not know they had the right to receive a written decision once their grievance was resolved. 9 Residents attended the meeting, the 9 Residents in attendance had all been Residents of the facility for 6 plus months. Observed and toured the facility; there were no Grievance forms available to Residents and there was no access to submit a Grievance anonymously. Interview with the ADM on 1/8/2024 at 1:05pm; the ADM stated she was the Grievance Officer for the facility. The ADM stated she alone reviewed Grievances, assigned the Grievance to the appropriate department head, ensured the resolution to the Grievance was documented on the Grievance form, and she followed up with the resident and their family members to inform them of the resolution to the Grievance. The ADM stated the form was kept in her office and at each of the nurses' station. The ADM stated she did not remember informing the Residents or the Activities Director of the location of the Grievance form. The ADM stated she was not aware Residents needed access to the Grievance form and she was not aware the Residents needed an avenue to submit a Grievance anonymously. The ADM stated she completed Grievance forms for residents, Residents did not ask for forms or complete them on their own. The ADM stated there were no procedures for Residents to submit Grievances anonymously. The ADM stated she addressed Grievances immediately and she expected department heads to address Grievances immediately. The ADM stated she did not know what the facility policy stated the timeframe was for Grievances to be addressed. The resolution for all Grievances were documented on the Grievance form and the completed form was submitted to the ADM for review. The ADM stated completed Grievance forms were kept in a notebook for 3 years. The ADM stated she monitored the Grievance process for success by following up with the staff member assigned to resolve the Grievance, the ADM stated she also met with the complainant to ensure they were satisfied with the resolution. The ADM stated she was responsible for ensuring staff were trained on the Grievance process. The ADM stated she was not aware the Grievance procedure was not being discussed in Resident Council. Grievance Policy Record Review indicated the policy was last revised in June 2005. Our facility investigates all grievances and complaints filed with the facility. Policy Interpretation and Implementation: 1. The ADM was assigned the responsibility of investigating Grievances and complaints. 2. Upon receiving and complaint report the ADM will investigate the allegations. The department head involved in the Grievance. 3. The Grievance Form must be filed with the ADM within 5 days of the complaint. 4. The Resident or their Representative will be informed of the findings of the investigation, as well as any corrective actions recommended within 5 working days of the filing of the complaint. 5. A copy of the Grievance form must be filed in the business office. 6. A copy of the resolution must be attached to the Grievance form and made available to the Resident and/or the Resident's representative.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. 1) The facility failed to keep refrigerator, freezer and oven handles clean. 2) The facility failed to properly store food in the pantry and refrigerator. These failures could place residents at risk for food contamination and foodborne illness. The findings include: Observation during a kitchen tour on 01/06/25 beginning at 1:54 PM revealed 3 freezer handles, 2 fridge handles and 1 oven handles that had dry, sticky substances on the outside and inside handle, a gallon sized zip lock bag of fruit loops, dated 01/02, that was not fully sealed in the pantry and bag of lunch meat, stored in a gallon sized zip lock bag, date was not legible, that was not fully sealed in the refrigerator. Interview on 01/06/25 at 2:21 PM, the DM stated she did not know why the refrigerator handles, freezer handles and oven handles were not clean. The DM stated the zip lock bags popped open easily but all food should be stored completely sealed. Interview on 01/08/25 11:52 PM, the DM stated the dietary staff usually followed a daily cleaning schedule but this week had been short staffed due to an employee quitting on 01/06/25. The DM stated there had been a lot going on in the kitchen and she did not have time to make sure kitchen items were cleaned. The DM stated all the kitchen staff had been trained on kitchen cleanliness and food storage. The DM stated the zip lock bags did not work well and they should be replaced when they did not want to shut easily. The DM stated the residents had a potential risk of getting sick due to kitchen items not being clean or food items not being stored properly. Interview on 01/08/25 at 12:30 PM, the ADM stated she expected dietary staff to follow the cleaning schedules and keep kitchen items clean. The ADM stated she expected the dietary staff to store all foods properly. The ADM stated she did not know why the refrigerator handles, freezer handles, or oven handles were not clean or why food was not stored completely sealed in the pantry or refrigerator. The ADM stated sometimes the zip lock bags do not seal correctly if the staff are in a hurry. The ADM stated the residents have a risk for cross-contamination due to food not being stored properly or kitchen items not being clean. Record review of the facility's policy and procedure title, Food Receiving and Storage with a revised date of November 2022, reflected the following: Food shall be received and stored in a manner that complies with safe food handling practices Record review of the facility's policy and procedure titled, Sanitation with a revised date of November 2022, reflected the following: Policy Statement: The food service area is maintained in a clean and sanitary manner

Based on observation, interview, and record review the facility failed to provide each resident with a diet that met his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 3 (Resident #16, Resident #40, and Resident #25) of 15 residents reviewed for dietary services. The Facility did not provide Resident #16 or Resident #25 with their dietary preferences for 1 of 2 meals reviewed (Lunch on 01/07/25). The Facility did not provide Resident #40 with double portions or his dietary preferences for 1 of 2 meals reviewed (Lunch on 01/07/25). This failure could place residents, who ate meals from the kitchen, at risk for weight loss, altered nutritional status and diminished quality of life. Findings included: Observation of the Lunch meal service on 01/07/25 that began at 11:54 AM revealed sour cream enchiladas were prepared for the main entree and there was not enough sour cream enchiladas for all the residents who requested sour cream enchiladas. Observation on 01/07/25 at 12:34 PM revealed Resident #25 sitting up in a wheelchair in the main dining room. Resident #25 was observed eating a hamburger and was served potato chips alongside the hamburger. Observation on 01/07/25 at 12:35 PM revealed Resident #40 sitting up in a wheelchair in the main dining room. Resident #40 was observed with a plate in front of him with a hamburger and potato chips. Observation on 01/07/25 at 12:38 PM revealed Resident #16 sitting up in his room. Resident #16 was observed eating a hamburger and was served potato chips alongside the hamburger. Interview on 01/07/25 at 12:23 PM, [NAME] A stated they ran out of enchiladas. [NAME] A stated the residents were provided with hamburgers or fish sandwiches to ensure all residents were provided a meal at lunch. [NAME] A stated she thinks there was a problem with the lunch meal because some residents must have changed their mind and originally wanted a hamburger but wanted enchiladas at the last minute. [NAME] A stated the CNA's could also have marked the residents choice incorrectly on the lunch meal dietary slips. Interview on 01/07/25 at 4:29 PM, [NAME] A and the DM stated they were able to see that 39 residents wanted enchiladas for lunch and each resident received 2 enchiladas as their portion. [NAME] A stated the enchiladas come to the facility pre-rolled and when she was making the recipe, she made a total of 75 enchiladas. [NAME] A stated she thought 75 enchiladas was enough for residents to get a serving if they wanted one. [NAME] A agreed 75 enchiladas was not enough for all the residents when 2 enchiladas per resident for 39 residents is a total of 78 enchiladas. Record review of Resident #25's admission record, dated 01/08/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: contracture, right knee (joints shorten and become very stiff), major depressive disorder (mood disorder), and hypokalemia (low potassium in blood). Record review of Resident #25's admission record, dated 01/08/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: contracture, right knee (joints shorten and become very stiff), major depressive disorder (mood disorder), and hypokalemia (low potassium in blood). Record review of Resident #25's significant change MDS assessment, dated 12/05/24, revealed a BIMS score of 10, indicating Resident #25's cognition was moderately impaired. The MDS further revealed Resident #25 required set-up or clean-up assistance with eating. Record review of Resident #25's order summary report, dated 01/08/25, revealed an order: Regular diet, regular texture, regular consistency with a start date of 07/14/23. During an interview on 01/08/25 at 10:28 AM Resident #25 stated he had asked for the main entree (enchiladas with rice and beans) yesterday (01/07/25) for lunch and was given an alternate meal (hamburger with chips) instead. Resident #25 stated the dietary staff told him they ran out of the main entree and that was why he received an alternate meal instead. Resident #25 stated this was the first time it happened to him. Resident #25 stated it was ok that he got a hamburger but he was looking forward to eating enchiladas. Record review of Resident #40's admission record, dated 01/08/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: major depressive disorder (mood disorder), anemia (blood disorder), and severe protein-calorie malnutrition (not getting enough nutrient from food). Record review of Resident #40's quarterly MDS assessment, dated 10/28/24, revealed a BIMS score of 09, indicating Resident #40's cognition was moderately impaired. The MDS further revealed Resident #40 required set-up or clean-up assistance with eating. Record review of Resident #40's order summary report, dated 01/08/25, revealed an order: Regular diet, Regular texture, regular consistency, Fortified foods with all meals. Large protein portions with lunch and dinner meal with a start date of 08/23/24. During an interview on 01/08/25 at 10:32 AM, Resident #40 stated he asked for enchiladas yesterday for lunch and was given an hamburger and chips. Resident #40 stated he does not know why he did not get enchiladas for lunch yesterday. Resident #40 stated sometimes the kitchen serves him something different than what he asked for and stated it does not happen often. Record review of Resident #16's admission record, dated 01/08/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: end stage renal disease (kidneys stopped working), type 2 diabetes mellitus (blood sugar problems), and cirrhosis of liver (damaged liver that does not function properly). Record review of Resident #16's quarterly MDS assessment, dated 10/03/24, revealed a BIMS score of 13, indicating Resident #16's cognition was intact. The MDS further revealed Resident #16 was independent with eating. Record review of Resident #16's order summary report, dated 01/08/25, revealed an order: Low Concentrated Sweets diet. Regular texture, regular consistency, please limit bananas, potatoes, raw tomatoes and citrus with a start date of 10/20/21. During an interview on 01/08/25 at 10:35 AM, Resident #16 stated he had wanted enchiladas for lunch yesterday and it turned into a hamburger. Resident #16 stated the dietary staff told him there was not enough enchiladas for all the residents who wanted them. Resident #16 stated the dietary [department] has been running out of food lately. Resident #16 stated he is always given food to eat, but lately it is not always what he requested. Record review of the facility's menu titled, Fall Winter 2024 Week 4 with January 7, 2025 listed in the dates. The menu for January 7, 2025 was as follows: Sour Cream Enchiladas, Spanish Rice, Refried Beans, Churro Bites, Salt/Pepper/Margarine, Choice of Beverage, and Water. Record review of the facility's document titled Meal Preferences, dated Lunch 01/07/25, revealed Resident #16, Resident #25, and Resident #40 requested the regular meal. Record review of the facility recipe titled, Chicken Enchiladas (Sour Cream Chicken Enchiladas) For Service: Week 4, Tuesday, lunch, reflected the following: Enchilada Chicken: Servings 45 - 90 each Record review of the facility document titled, Resident Council Minutes dated 07/25/24 reflected the following: Dietary - .sometimes run out of food. Record review of the facility document titled, Resident Council Minutes dated 08/22/24 reflected the following: Kitchen often runs out of food so no seconds Record review of the facility document titled, Resident Council Minutes dated 09/26/24 reflected the following: Dietary - constantly running out of food Record review of the facility document titled, Resident Council Minutes dated 10/30/24 reflected the following: Dietary is still running out of food. Bread, eggs, and milk. Record review of the facility document titled, Resident Council Minutes dated 11/29/24 reflected the following: Dietary - running out of food or dietary staff is throwing away right after they serve, so if we go back for seconds there isn't anything. Record review of the facility document titled, Resident Council Minutes dated 12/27/24 reflected the following: Dietary has improved but occasionally run out of bread, turkey, and cheese. Interview on 01/08/25 at 11:52 AM, the DM stated the cooks were trained to follow the recipes for the meals provided to the residents. The DM stated she thought [NAME] A made enough enchiladas for lunch on 01/07/25 and thought the residents changed their minds and that was why the kitchen was short on enchiladas. The DM stated a potential negative outcome was the residents families could get upset the resident was not served what they wanted. Interview on 01/08/25 at 12:30 PM, the ADM stated she did not know what happened yesterday at lunch with the enchiladas. The ADM stated she thought the staff got mixed up with who wanted hamburgers and who wanted the enchiladas. The ADM stated it was the first time the kitchen staff had a confusion like that. The ADM stated kitchen staff were trained on following the recipes for the menu. The ADM stated a potential negative outcome to the residents was they could refuse to eat the alternate that was provided. Record review of the facility policy titled, Food and Nutrition Services, with a revised date of October 2017, reflected the following: Policy Statement: Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.

Based on interviews and record review, the facility failed to ensure all residents had the right to formulate advance directives for 1 of 15 residents (Resident #11) reviewed for advanced directives. The facility failed to ensure Residents #11, who was listed as DNR (Do Not Resuscitate), had an Out-of-Hospital Do Not Resuscitate (OOH-DNR) form that did not have missed required information on the OOH-DNR. These failures could place residents at risk for not having their end of life wishes honored and incomplete records. Findings included: Resident #11 Record review of Resident #11's undated face sheet revealed a [AGE] year-old-female who was admitted to the facility on [DATE] and had diagnosisies which included Cerebral infarction (lack of blood supply to the brain), Dementia (irreversible that causes mental deterioration) and Type 2 Diabetes (problem with blood sugar). The face sheet indicated under the advance directive section - DNR-Do Not Resuscitate. Record review of Resident #11's physician order summary dated 01/08/24 reflected the following order: DNR-Do Not Resuscitate dated 05/19/23. Record review of Resident #11's care plan, dated 12/05/24, reflected care plan for DNR. Record review of Resident #11's OOH-DNR form dated 05/17/23 reflected there was no date that accompanied one of the witness's signatures. During an interview on 01/08/24 at 12:25pm with the SW, she stated OOH DNR was not valid if it's not filled out correctly. She stated she was responsible for ensuring OOH-DNRs were completed correctly. She verified missing information on OOH-DNR for Residents #11. She stated there was no system for monitoring OOH-DNRs for accuracy. She stated the reason the DNR's were not complete was human error. She stated she has been trained on OOH-DNRs. The SW stated the potential negative outcome for residents if a DNR was not completed correctly was the Resident may not have their final wishes honored and the facility may be taken to court. During an interview on 01/08/24 at 1:05PM with the ADM, she stated the OOH DNR was not valid if not filled out correctly. She stated the DON was responsible for making sure the OOH DNR was completed accurately. She stated they did not have a system in place to monitor OOH DNR for accuracy. She stated the DON should be reviewing the OOH DNRs for accuracy. She verified missing information on OOH DNR for Residents #11. She stated she did not know why the information was missing. She stated the potential negative outcome was the Resident's end of life wishes may not be honored. She stated she was trained on how to complete OOH DNR and her expectations were for them to be filled out completely and be correct. Record review of the Social Services Policies and Procedures Advanced Directives (Revised March 2021) reflected the following: Policy Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. A DNR order form must be completed and signed by the attending physician and resident or resident's legal surrogate and placed in the front of the resident's medical record. Should the resident be transferred to the hospital, a photocopy of the DNR order form must be provided to the personnel transporting the resident to the hospital. The DNR orders will remain in effect until the resident or legal surrogate provides the facility with a signed and dated request to end the DNR order. The interdisciplinary care planning team will review advance directives with the resident during quarterly care planning sessions to determine if the resident wishes to make changes in such directives. The resident's attending physician will clarify and present any relevant medical issues and decisions to the resident or legal representative as the resident's condition changes to clarify and adhere to the resident's wishes. Inquiries concerning do not resuscitate orders/requests should be referred to the administrator, director of nurses, or the social services director.

Based on observation, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 of 1 medication room reviewed for storage, in that: The facility had a Schedule IV narcotic stored improperly in the medication storage room refrigerator. This failure could result in medication diversion, leading to a resident not receiving ordered treatment, affecting the resident's treatment and care, which could result in deterioration of their health. Findings included: During an observation on 01/07/2025 at 11:05 AM of the medication storage room refrigerator, revealed an unlocked lockbox containing a prescription Lorazepam 2 MG/ML oral concentrate. The lockbox containing the narcotic was not locked, as the padlock for the lockbox was unsecured and open, hanging on the lockbox. During an interview on 01/07/2025 at 11:05 AM with LVN A revealed the following: LVN A opened the lock box in the medication storage room refrigerator and stated the medication found in the lockbox was Lorazepam 2 MG/ML. LVN A stated he was not aware the medication was in the lockbox as he thought the lock box was empty. LVN A stated the lock box should have been locked with the attached padlock since it contained the narcotic, and he was not sure why it was not locked. LVN A locked the lock box and placed it back into the refrigerator. LVN A stated Lorazepam was a medication that was required to be stored in the lockbox to prevent the medication from being stolen. LVN A stated he was not sure who placed the medication inside of the lockbox and stated he did not know how long it had been there. LVN A stated he did not have a key to the lockbox and stated the DON had the key. During an interview on 01/07/2025 at 12:06 PM with DON revealed the following: The DON stated she was not sure why the lock box was not locked inside of the medication storage room refrigerator. The DON stated the medication storage room remained locked at all times and only nursing staff and the ADM had access to the room. The DON stated Lorazepam was a narcotic and was required to be locked in the lock box, inside of the locked room, to ensure the medication was stored properly and to prevent theft of the medication. The DON stated she did not know who left the lockbox unlocked or why it was not locked. The DON stated she was unaware of the medication being stored in the lockbox and she thought the lockbox was empty. The DON stated she and the ADON had the only keys to the lockbox. During an interview on 01/08/2025 at 12:45 PM with the DON revealed the following: The DON stated that nursing staff were notified through orders of any new medications, and this was how they were usually made aware of narcotics that required additional storage restrictions. The DON stated she thought the medication was brought by Hospice for a resident and this was why it was overlooked. The DON stated it should have still been seen during nursing staff's reconciliation at the end of each shift. The DON stated all nursing staff were also required to complete counts of all medication at the end of each shift, and the nursing staff should have checked the medication storage room, including the refrigerator, to ensure all medications were stored properly. The DON stated the medication storage room door should have remained locked at all times as well as the lock box in the refrigerator. The DON stated an in-service would be completed to re-educate staff. The DON stated she was responsible for training staff and ensuring medications were stored properly. The DON stated that staff received regular in-service training pertaining to medication counting and storage, as well as training that they received when they were hired. The DON stated all narcotics had to be stored with a double locking process and had to be reconciled at every shift change. The DON stated this information was included in staff training. The DON stated all nursing staff were responsible for ensuring medications were stored properly. The DON stated there was a risk of narcotics being stolen and residents not receiving their medications as needed, if medications were not stored properly. During an interview on 01/08/2025 at 01:30 PM with the ADM revealed the following: The ADM stated all narcotics should have been under a double lock process. The ADM stated the medication storage room door remained locked at all times, and this was the first lock for the medications. The ADM stated the second lock should have been on the lockbox to properly secure the medication. The ADM stated she was not sure why this lock was not locked. The ADM stated all nursing staff were responsible for reconciling narcotics at the end of each shift. The ADM stated this training was conducted regularly by the DON as well as upon hire for nursing staff. The ADM stated both the door to the medication room as well as the pad lock on the lock box inside of the refrigerator should have been locked at all times. The ADM stated the DON and all nursing staff were responsible for ensuring medications were stored properly and narcotics were under a double lock. The ADM stated there was a potential risk of medication being stolen if they were not stored properly. Record review of the facility's policy Storage of Medications revised November 2020 revealed the following: Policy heading The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation 8. Schedule IJ-V controlled medications are stored in separately locked, permanently affixed compartments. Access to controlled medication is separate from access to non-controlled medications.

Based on observations, interviews, and record review the facility failed to ensure that its medication error rate was less than 5 percent. The facility had a medication error rate of 6.52% based on 3 out of 46 opportunities, which involved 3 of 5 residents (Residents #43, #44, and #23) reviewed for medication administration. MA A failed to administer Resident #43's ordered Fluticasone medication (given for allergies), resulting in a missed dose. MA B failed to verify the dose on Resident #44's ordered medication Gabapentin (given for nerve pain), resulting in Resident #44 being underdosed. MA B failed to properly verify and dispense Resident #23's ordered medication Methylphenidate (given for nervous system disorder). These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health. Findings included: Resident #43 Record review of Resident #43's face sheet dated 01/08/25 revealed a [AGE] year-old male with an admitted [DATE] with the following diagnoses: unspecified dementia unspecified severity with other behavioral disturbance (loss of memory, language, problem-solving and other thinking abilities), anemia (deficiency of red blood cells or hemoglobin in the blood), moderate protein calorie malnutrition (when not enough protein and calories are consumed ), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and allergic rhinitis (inflammation of the nasal passages). Record review of Resident #43's Admission MDS dated [DATE] revealed a BIMS of 13, which indicated the resident was slightly cognitively impaired. Record review of Resident #43's current physicians orders revealed an order for Fluticasone Propionate Nasal Suspension 50 MCG (Fluticasone Propionate (Nasal)) 1 spray in both nostrils one time a day for allergies . During a medication administration observation on 01/07/25 at 09:18 AM for Resident #43, MA A failed to administer Fluticasone Propionate Nasal Suspension 50 MCG/ACT (Fluticasone Propionate (Nasal)) 1 spray in both nostrils one time a day for allergies. MA A documented in the MAR that she administered this medication to Resident #43. During an interview with MA A on 01/07/2024 at 11:05 AM, she stated the MAR reflected she administered Fluticasone Propionate Nasal Suspension 50 MCG/ACT (Fluticasone Propionate (Nasal)) to Resident #43 at 9:21 AM. MA A stated she did not administer the medication to Resident #43. MA A stated she did not know why she marked the medication as being administered since it was not given to the resident. MA A stated this error could lead to Resident #43 not receiving his medication as ordered by his physician. Resident #44 Record review of Resident #44's face sheet dated 01/07/25 revealed a [AGE] year-old male originally admitted to the facility on [DATE] with the following diagnoses: Type 2 Diabetes Mellitus (disease causing blood sugar to be elevated), peripheral vascular disease (circulatory condition causing reduced blood flow to the limbs), cutaneous abscess of right foot (skin infection), hypertension (high blood pressure), complete traumatic amputation at level between left hip and knee (surgical absence of left leg above the knee and below the hip), respiratory failure with hypoxia (condition resulting in inadequate oxygen in the body's tissues), respiratory distress syndrome (breathing condition causing low oxygen in the body), and muscle weakness. Record review of Resident #44's current physician orders dated 01/07/25 revealed an order for Gabapentin Oral Capsule 100 mg (Gabapentin) Give 2 capsules by mouth three times a day related to complete traumatic amputation at level between left hip and knee. During a medication administration observation on 01/07/25 at 9:38 AM, for Resident #44, MA B dispensed one (1) Gabapentin 100 mg capsule into a 30cc clear medication cup and administered the medication, which resulted in Resident #44 being underdosed. MA B failed to verify the medication with the order prior to administering the medication. During an interview with MA B on 01/07/25 at 9:44 AM, she stated she did not administer Resident #44's medication, Gabapentin, correctly. She stated the order was for 2 capsules to be given but she dispensed and administered only one capsule. She stated it was an oversight on her part and it would be considered a medication error and she would let the DON know. MA B dispensed a second Gabapentin 100 mg capsule and administered the medication to Resident #44. She stated failure to give Resident #44 the accurate dose of Gabapentin could result in the resident having an increased level of pain. Resident #23 Record review of Resident #23's face sheet dated 01/07/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: vascular dementia with behavioral disturbance (dementia caused by impaired blood to the brain), cerebral infarction (stroke), aphasia (difficulty communicating), hemiplegia (paralysis of one side of the body), hemiparesis (muscle weakness to one side of the body), heart failure, disorder of the nervous system, and secondary hypertension (high blood pressure caused by another medical condition). Record review of Resident #23's admission MDS dated [DATE] revealed a BIMS score of 08, indicating the resident had mildly impaired cognition. Record review of Resident #23's comprehensive care plan dated 10/31/24 revealed a focus which stated The resident had a cerebral vascular accident. Medications: Topiramate, Clopidogrel, Gabapentin, Methylphenidate with Interventions/Tasks listed as: Give medications as ordered by the physician. Monitor/document side effects and effectiveness. Record review of Resident #23's current physician orders revealed an order for Methylphenidate HCl Oral Tablet 5 mg (Methylphenidate HCl) Give 1 tablet by mouth one time a day related to other post-procedural complications and disorders of nervous system During a medication administration observation on 01/07/24 at 9:48 AM for Resident #23, MA B was observed preparing morning medications for administration which included nine medications, one of which was a controlled medication. MA B placed the following nine (9) medications into a 30cc clear medication cup: Aspirin 81 mg delayed release - 1 tablet Docusate Sodium 100mg tablet - 2 tablets Multivitamin-Minerals tablet - 1 tablet Fenofibrate 54 mg tablet - 1 tablet Clopidogrel 75 mg tablet - 1 tablet Fluoxetine HCl 40 mg - 1 tablet Topiramate 25 mg tablet - 1 tablet Gabapentin 300 mg capsule - 1 capsule MA B was observed to unlock the narcotic box and open the narcotic book to Resident #23's medication count sheet for Methylphenidate 5 mg tablet (given for nervous system disorder). The count for Methylphenidate 5 mg was noted at 5 remaining tablets. MA B was observed to sign out one tablet then wrote the remaining count at 4 tablets and signed her name. A resident in the hallway asked MA B a question, and MA B directed her attention to the resident and answered the question. MA B was then observed to pick up the blister pack for the controlled medication (Methylphenidate 5 mg) and place it back into the lock box drawer, lock the box, then close the drawer to the cart. MA B failed to remove the controlled medication from the blister pack prior to placing the medication back in the cart. MA B failed to verify medications in the cup with physician's orders to verify the correct number of medications to be administered. MA B was then observed to pour water into a drinking cup, lock her medication cart, pick up the cup of medications, and began walking into Resident #23's room to administer the medications. At that time, the surveyor provided intervention and asked MA B to verify the medications in the cup with Resident #23's physician's orders. MA B then opened her computer and counted the number of medications that were to be administered and stated, There should be 10 medications in the cup. MA B counted the medications in the cup and stated, Oh, I only have 9 pills here. I don't know which one is missing. I think I'll have to go back through the medication cards and verify each one. Observed MA B pull Resident #23's medication cards from the medication cart and reconcile the medications in the cup to the orders on her computer screen. MA B was observed to check approximately half the medications, then she accidentally spilled the cup of medications on top of the cart, requiring her to place the medications back into the cup, and restart the verification process. MA B verified 9 routine medications then stated, It must be the narcotic that I missed. MA B then unlocked the narcotic box and pulled out Resident #23's Methylphenidate 5 mg medication card which was observed to have 5 remaining tablets in the blister pack. MA B stated, I guess I got distracted and didn't pop the med after I signed it out. I would have caught it at shift change when the narc count was off, but it would have been too late to give the dose by then. MA B was then observed to dispense one tablet of Methylphenidate 5 mg into the cup with Resident #23's other medications, totaling ten (10) medications. MA B administered the medications from the cup to Resident #23. During an interview on 01/07/25 at 10:28 AM, MA B stated she did not verify medications to be dispensed with physician's orders for Resident #44 and Resident #23. She stated she did not normally count the medications in the cup prior to administering the medications and she had not been trained to do so in her MA training, nor the at the facility. When asked how she would know she had administered the correct number of medications without verifying the order and the count she stated, Well, I wouldn't, but I will definitely count and verify meds going forward because it's obviously easy to make a mistake. MA B stated she worked at the facility as a medication aid as needed and did not recall receiving medication administration training in the past year. She stated she had done a skills check for medication administration with the DON approximately three (3) months ago. MA B stated a potential negative outcome for failure to verify medications with physician's orders would be a higher chance of medication errors. She stated a potential negative outcome for not receiving medications as ordered by the physician would be that a resident might have pain if they miss a pain pill or it could cause other trouble for the resident, depending on what the medication is given for. During an interview on 01/08/25 at 11:38 AM, the ADM stated she was made aware that two staff members made medication errors during medication pass observations. She stated all nursing staff were trained on proper medication administration and the facility's nursing administration was responsible for conducting training. She stated her expectation of staff for administering medications was that staff read orders, administer medications according to the MAR and contact the DON if they have any questions about a medication. The ADM stated a potential negative outcome for failure to administer medications according to physician's orders was the resident could become sick or have a decline in health. During an interview on 01/08/25 at 12:09 PM, the DON stated she was made aware that two staff members made medication errors during medication pass observations. She stated all nurses and medication aids were trained on medication administration and it was the responsibility of nursing administration to conduct training. She stated she conducted skills checks for medication administration for all staff who administer medications. She stated nursing staff were also trained via periodic computer training and medication aids attended recertification training on an annual basis. She stated a potential negative outcome for failure to dispense medications according to physicians' orders was a decline in resident outcomes and residents not being within therapeutic levels of ordered medications. Record review of the facility-provided training document for Medication Pass Competency dated 12/06/24 and marked satisfactory was signed by MA A and the ADON. Record review of the facility-provided training document for Medication Pass Competency dated 12/06/24 and marked satisfactory was signed by MA B and the ADON. Record review of facility-provided policy titled Administering Medications, dated April 2019, revealed: 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. . 10. The individual administering the medications checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. 22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next one.

Based on observation, interview and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible for 1 of 15 Residents (Resident #16). The facility failed to store Resident #16's portable oxygen tank properly when not in use. These failures could place residents at risk for avoidable injuries related to improperly storing a portable oxygen tank. The findings included: Record review of Resident #16's admission record, dated 01/08/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: end stage renal disease (kidneys stopped working), heart failure, and chronic respiratory failure (breathing problems). Record review of Resident #16's quarterly MDS assessment, dated 10/03/24, revealed a BIMS score of 13, indicating Resident #16 had intact cognition. The MDS further revealed Resident #16 used a wheelchair and was able to use his wheelchair independently. Record review of Resident #16's order summary report, dated 01/08/24, revealed an order: Oxygen: May have oxygen at 1-5L via cannula/mask by concentrator/tank. With a start date of 02/29/24. During an observation on 01/07/25 at 2:23 PM in Resident #16's room revealed 1 portable oxygen tank free-standing and resting up against the wall. The oxygen tank was stored sticking out from the wall on the bottom with the top of the oxygen tank resting up against the wall and was not secure. During an interview on 01/07/25 at 2:26 PM, the DON stated the portable oxygen tank should be stored in a secure area. The DON stated a portable oxygen tank should be kept stored in a single cart with wheels or in a cage that prevents the tank from tipping over. During an interview on 01/08/25 at 10:35 AM, Resident #16 stated the staff put a portable oxygen tank on the back of his chair when he went to dialysis. Resident #16 stated he does not take the oxygen tank on and off his wheelchair. Resident #16 stated staff took his oxygen tank on and off the back of his wheelchair and stated he could not remember which staff member took his portable oxygen tank off yesterday. Resident #16 stated sometimes staff left the oxygen tank in his room against a wall or they would take it somewhere else. During an interview on 01/08/25 at 12:24 PM, the DON stated she was not sure exactly why the portable oxygen tank was unsecured in Resident #16's. The DON stated the staff have been verbally trained on properly securing the portable oxygen tanks. The DON stated a potential risk to the residents with a portable oxygen tank not being secured was it could fall over and become a projectile missile. During an interview on 01/08/25 at 12:31 PM, the ADM stated she expected the portable oxygen tanks to be secured in holders. The ADM stated she has never seen Resident #16 take off his own portable oxygen tank from the back of his wheelchair. The ADM stated the portable oxygen tanks could also be stored in a single rack with wheels if needed. The ADM stated staff have been trained on properly storing portable oxygen tanks and she was unsure why a tank was unsecure in Resident #16's room. The ADM stated a potential risk to the resident was it could explode if it fell over. Record review of the facility's policy and procedure titled, Fire Safety and Prevention, with a revised date of May 2011, reflected the following: Policy Statement: All personnel must learn methods of fire prevention and must report condition(s) that could result in a potential fire hazard. Policy Interpretation and Implementation: .Oxygen Safety: f. Store oxygen cylinders in racks with chains, sturdy portable carts, or approved stands. Never leave oxygen cylinders free-standing. Do not store oxygen cylinders in any resident room or living area Record review of the facility's policy and procedure titled, Hazardous Areas, Devices and Equipment, with a revised date of July 2017, reflected the following: Policy Statement: All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible

Based on observations, interviews, and record reviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 (Resident #10) of 4 residents reviewed for ADL care. The facility failed to ensure Resident #10's wheelchair was clean. This deficient practice could place residents at risk of neglect, infection, and a diminished quality of life. Findings included: Review of Resident #10's admission record, dated 01/08/2025, reflected a [AGE] year-old male resident who was admitted to the facility on [DATE] with diagnoses including Sacral spina bifida (a condition that occurs when the spine and spinal cord don't form properly, type of neural tube defect) without hydrocephalus (a condition that occurs when fluid builds up in the skull and causes brain swelling), age-related nuclear catarac, bilateral (cloudy lens that hardens and turns yellowish over time, leading to decreased vision), primary optic atrophy bilateral (damage to optic nerve, which carries impulses from your eye to brain), dysphagia oropharyngeal phase ( inability to swallow food or drink due to neurological, neuromuscular, or structural impairments), paraplegia (paralysis of the legs and lower body), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of Resident #10's quarterly MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 15, indicating the resident was cognitively intact. Review of Resident #10's Care Plan dated 12/11/2015, revised on 11/19/2020, indicated the following: The focus area stated Incontinence and Mr. [NAME] has frequent bowel and bladder incontinence. The goal stated, He will reman free from skin breakdown due to incontinence. The interventions included BRIEF USE: He wears Med disposable briefs. Change every 2 hours if damp, every4 hours if dry and as needed, moisture barrier and needed or indicated. During an observation on 01/07/2025 at 09:25 AM, a motorized wheelchair was observed in the hallway, outside of Resident #10's room. The wheelchair was observed to have brown spots covering the backrest of the wheelchair as well as brown spots on the seat of the wheelchair. During an observation and interview on 01/07/2025 at 09:51 AM, the motorized wheelchair was observed in the same place, in the hallway, outside of Resident #10's room. CNA C was then observed moving the wheelchair into Resident #10's room. CNA C was asked who the wheelchair belonged to, and she stated it belonged to Resident #10. During an observation on 01/07/2025 at 12:10 PM Resident #10 was observed in his wheelchair in the dining area during lunch. During an observation on 01/07/2025 at 01:15 PM Resident #10 was observed going into his room in his wheelchair. CNA C was observed assisting Resident #10 in his room. Resident #10 was heard saying he had a blowout, and he asked CNA C, did it get on my chair?. The door to Resident #10's room was closed after they entered and the conversation could no longer be heard. During an observation on 01/07/2025 at 02:23 PM, the motorized wheelchair was observed again in the hallway, outside of Resident #10's room. The wheelchair was observed to have the same brown spots covering the backrest of the chair, as well as on the seat. During an observation and interview on 01/07/2025 at 04:40 PM, the motorized wheelchair was observed again in the hallway, outside of Resident #10's room. The wheelchair was observed to have the same brown spots covering the backrest of the chair as well as on the seat. Resident #10 was observed in his bed. Resident #10 stated his wheelchair had not been cleaned all day. Resident #10 stated he was aware the wheelchair was soiled all day. Resident #10 stated he did not know why it had not been cleaned throughout the day. Resident #10 stated it did bother him that his wheelchair was soiled, and he wanted it to be cleaned. Resident #10 stated he wanted the nursing staff to be notified that his wheelchair needed to be cleaned. During an interview on 01/07/2025 at 04:45 PM, LVN B stated the CNAs were responsible for ensuring wheelchairs were cleaned when they were soiled during their shift. LVN B stated she was not aware Resident #10's wheelchair was soiled. LVN B stated CNA C was the CNA assigned to Resident #10's room, that shift, and stated she would have CNA C clean Resident #10's wheelchair. During an interview on 01/08/2025 at 12:05 PM CNA A stated Resident #10 was incontinent and had frequent bowel movements due to the medication he was prescribed. CNA A stated it was a CNA's responsibility to clean up Resident #10 and to clean any soiled area such as bedding or Resident #10's wheelchair. CNA A stated she did not work on the previous day , but she frequently cleaned Resident #10's wheelchair during her work shifts. CNA A stated if a resident's wheelchair was left soiled with feces, it would have been unsanitary and could have been embarrassing to the resident. During an interview on 01/08/2025 at 12:15 PM CNA B stated she did not work on the previous day, and she did not see Resident #10's wheelchair soiled recently. CNA B stated Resident #10 was incontinent, and it was common for Resident #10 to defecate through his brief. CNA B stated, when this occurred, it was the CNA's responsibility to clean Resident #10 and his bedding or wheelchair. CNA B stated it was important to maintain the cleanliness of residents' wheelchairs because it was not sanitary to leave a wheelchair soiled with feces. During an interview on 01/08/2025 at 12:45 PM the DON stated Resident #10's wheelchair had to be washed frequently due to incontinence. The DON stated the nursing staff overnight was responsible for cleaning all residents' wheelchairs. The DON stated, if a wheelchair was soiled through out the day, it was the CNA's responsibility to clean the soiled wheelchair. The DON stated any staff who observed the soiled chair should have ensured it was cleaned promptly. The DON stated the CNA who transferred the resident in and out of the wheelchair should have noticed the chair and cleaned it after the resident was cleaned and situated. The DON stated there was potential for embarrassment to the resident as well as an unsanitary environment. During an interview on 01/08/2025 at 1:30 PM the ADM stated wheelchairs were cleaned during the night shift and should have been cleaned daily for every resident. The ADM stated Resident #10 was incontinent and had frequent bowel movements that would leak from his brief. The ADM stated the CNA that transferred Resident #10 should have observed the soiled wheelchair and cleaned it after the CNA cleaned up the resident. The ADM stated any staff that observed the soiled wheelchair was responsible for ensuring it was cleaned promptly. The ADM stated the resident's wheelchair should have been cleaned after every transfer since the resident had frequently soiled briefs. The ADM stated it was not sanitary to have the resident placed on a soiled wheelchair with clean clothing, and there was a risk of embarrassment to the resident which could have affected his self esteem. During an interview on 01/08/2025 at 02:30 PM CNA C stated it was the CNAs responsibility to clean a resident's wheelchair if the wheelchair was soiled. CNA C stated she was assigned on the hallway where Resident #10 resided the previous day. CNA C stated she helped transfer Resident #10 to and from his wheelchair during her shift. CNA C stated she did not see Resident #10's wheelchair soiled with feces, but she did clean Resident #10 after he was incontinent. CNA C stated Resident #10 had frequent bowel movements that leaked outside of his brief, and this got on his wheelchair at times. CNA C stated she did not know why the wheelchair was not cleaned throughout the day on the previous date. CNA C stated she was unaware that the wheelchair was soiled. CNA C stated she could not recall checking the wheelchair during the day. CNA C stated she cleaned the wheelchair after LVN B asked her to, at the end of her shift. CNA C stated the wheelchair should have been cleaned right away if it was soiled. CNA C stated the wheelchair should have been cleaned before the resident was helped back into it. CNA C stated Resident #10's wheelchair remaining soiled throughout the day could have been a sanitary concern as well as a concern for the resident's dignity. Review of the facility's policy titled Cleaning and Disinfection of Resident-Care Items and Equipment revised September 2022 revealed the following documentation: Policy Statement Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. Policy Interpretation and Implementation I. The [NAME] Classification System is used to distinguish the levels of sterilization/disinfection necessary for items used in resident care: a. Non-critical items are those that come in contact with intact skin but not mucous membranes. i. Non-critical resident-care items include bedpans, blood pressure cuffs, crutches and computers. ii. Non-critical environmental surfaces include bed rails, bedside tables, etc. iii. Non-critical items require cleaning followed by either low- or intermediate-level disinfection following manufacturers' instructions. Disinfection is performed with an EPA-registered disinfectant labeled for use in healthcare settings. All applicable label instructions on EPA registered disinfectant products are followed (e.g., use-dilution, shelf life, storage, material compatibility, safe use and disposal). 1. Low-level disinfection is defined as the destruction of all vegetative bacteria (except tubercle bacilli) and most viruses, some fungi, but not bacterial spores. Examples of low-level disinfectants include EPA- registered hospital disinfectants with a HBV and HIV label claim. Low-level disinfection is generally appropriate for most non-critical equipment. 2. Intermediate-level disinfection is traditionally defined as destruction of all vegetative bacteria, including tubercle bacilli, lipid and some nonlipid viruses, and fungi, but not bacterial spores. EPA-registered hospital disinfectants with a tuberculocidal claim are intermediate-level disinfectants. Intermediate-level disinfection is considered for non-critical equipment that is visibly contaminated with blood. However, a low-level disinfectant with a label claim against HBV and HIV may also be used.

Based on observations, interviews, and record reviews, the facility failed to ensure each resident was treated with respect, dignity, and care for each resident in a manner and in an environment that promoted the maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility failed to protect and promote the rights of the resident for 1 of 18 (Resident #33) residents reviewed for resident rights. CNA D failed to provide Resident #33 privacy during incontinent care. This failure could place residents at risk for diminished quality of life and loss of dignity and self-worth. Findings included: Record review of Resident #33's face sheet dated 01/13/24, revealed a [AGE] year-old male with an original admitted [DATE] with the following diagnoses: Type 2 Diabetes Mellitus (inability of the body to use insulin properly), cerebral infarction (stroke), diverticulosis (digestive condition), cognitive communication deficit (communication difficultly caused by cognitive impairment), dysphagia (difficulty swallowing) and anxiety. Record review of Resident #33's admission MDS dated [DATE] revealed a BIMS of 08, indicating mild cognitive impairment. Section H-Bladder and Bowel revealed Resident #33 was always incontinent of bowel and bladder. Record review of Resident #33's comprehensive care plan revised on 07/25/24, revealed the resident was incontinent with an intervention to provide incontinence care after each incontinent episode. During an incontinent care observation on 01/07/25 at 10:51 AM for Resident #33, CNA D failed to pull the privacy curtain before performing incontinent care, which placed the resident at risk of exposure if a staff member or resident opened the door. During incontinent care, CNA D left Resident #33 uncovered while he went to the resident's restroom to sanitize his hands between glove changes, which exposed the resident's lower back and buttocks areas. During an interview on 01/07/25 at 3:12 PM with CNA D, he stated he failed to properly provide privacy to Resident #33 during incontinent care by not pulling the privacy curtain and not draping the resident when he left the bedside to sanitize his hands. He stated he had been trained to provide privacy during incontinent care, but he was rushing and got in too big of a hurry. CNA D stated he had received privacy training from the DON and the ADON and through monthly training videos. He stated a potential negative outcome for failure to provide privacy during care was the resident could be exposed and have a lack of privacy. During an interview on 01/08/25 at 11:38 AM with the ADM, she stated she was not aware that staff were not providing proper privacy to residents during care. She stated all staff had been trained on privacy and dignity by nursing administration. When asked what her expectation was for staff to provide privacy during care, she stated, It is a big deal to me. A lot of people are modest, and I expect staff to always maintain the residents' privacy. The ADM stated a potential negative outcome for failure to provide privacy during care was that the resident would be embarrassed or have a decreased level of self-esteem. During an interview on 01/08/25 at 12:09 PM with the DON, she stated she was not aware that staff were not providing proper privacy to residents during care, prior to survey. She stated privacy during care should be provided to each resident by closing the door, pulling the privacy curtain, closing the blinds, and draping the resident appropriately. She stated she was responsible to assure staff were trained on providing privacy during care and training was conducted through in services as well as through monthly video trainings. The DON stated a potential negative outcome for failure to provide privacy during care was that resident dignity was not intact. Record review of the facility's policy titled; Dignity, date revised February 2021 revealed: Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation: 1. Residents are always treated with dignity and respect. 11. Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 12. Demeaning practices and standards of care that compromise dignity is prohibited. Staff are expected to promote dignity and assist residents . Record review of the facility's policy titled; Resident Rights, date revised February 2021 revealed: Policy Statement Employees shall treat all residents with kindness, respect, and dignity. Policy interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; . t. privacy and confidentiality;

Based on observation, interview, and record review, the facility failed to ensure the resident was free from any form of abuse for 7 (Resident #1, #2, #3, #4, #5, #6, #8) of 7 residents reviewed for Neglect. The facility failed to ensure residents were protected from verbal abuse by LVN A yelling and cursing at staff in front of residents and yelling and cursing at residents. This failure could affect all residents that reside in the facility placing them at risk of emotional and psychosocial abuse. On 05/22/2023 at 5:59 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 05/24/2023 at 4:38 PM, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place all residents in the facility at risk for severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being. Findings included: Resident #1: Review of Resident #1's face sheet revealed she was an [AGE] year-old female admitted to the facility on [DATE] with a primary diagnosis of diabetes mellitus due to underlying condition with neuropathy (weakness, numbness, and pain from nerve damage usually in the hands and feet), muscle weakness, lack of coordination, chronic viral hepatitis C, anemia (a condition in which the blood does not have enough healthy red blood cells), sickle cell trait, iron deficiency anemia, mild protein calorie malnutrition, schizophrenia, bipolar disorder, polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body), high blood pressure, asthma, acid reflux, rheumatoid arthritis (a chronic inflammatory disorder affecting many joints, including those in the hands and feet), hypoxemia (low level of oxygen in the blood), urinary incontinence, Bacteremia (the presence of viable bacteria in the circulating blood). Review of Resident #1's Annual Minimum Data Set, dated dated [DATE], revealed her BIMS (Brief Interview for Mental Status) was 12, suggesting that the resident's cognitive was moderately impaired. Under section B0600 for Speech Clarity revealed that Resident #1 was listed as a 0 meaning Resident #1 has clear speech-distinct intelligible words. Under section B0700 for Makes Self Understood, Resident #1 was listed as a 0 meaning resident is understood. Under section B0800 for Ability to Understand Others, Resident #1 was listed as a 0 meaning understands clear comprehension. Under section C1310 for Delirium, Resident #1 was listed as a 0 meaning from the resident's baseline there was no evidence of an acute change in mental status and did not display inattention, disorganized thinking, or altered level of consciousness. Under E0100 for Potential Indicator for Psychosis, Resident #1 was listed as a 0 meaning Resident #1 did not display hallucinations or psychosis. Under section E0200 for Behavioral Symptoms-Presence and Frequency, Resident #1 was listed as a 0 meaning Resident #1 did not display physical, verbal, or other behavioral symptoms such as: hitting, kicking, pushing, scratching, grabbing, abusing other sexually, threatening others, screaming at others, cursing at others, scratching self, pacing, rummaging, public sexual acts, disrobing in public, smearing food or bodily wastes, verbal/vocal symptoms like screaming or disruptive sounds. Interview with Resident #1 on 05/22/2023 at 3:23 pm. Resident #1 stated that she was in the dining room and did witness the fight with LVN A and Kitchen staff I. Resident #1 stated that LVN A went to the kitchen door and was yelling at Kitchen staff I. Resident #1 stated that LVN A was cursing at Kitchen staff I am saying, We only have one fucking aide, you dumb bitch. Resident #1 stated that LVN A is always cursing at staff and residents. Resident #1 stated that when Kitchen staff I told LVN A, I'm sorry I did not know, that LVN A stated, Shut your fucking mouth, I am going to the Administrator about this. Resident #1 appeared to have distress by explaining the situation of what happened in the kitchen by crying and saying that Kitchen staff I did not deserve to be treated like that and it makes me so sad to see that. Resident #1 stated that the residents in the dining room were all yelling at LVN A to stop. Resident #1 stated that she is scared that LVN A will get worse because the DON is his mother, and she does not do anything to change the situation. Resident #1 stated that LVN A even yells and curses at her while flipping her off. Resident #1 stated that when she uses her call light when she needs something and LVN A is working he will come in her room and told her, Shut up, Fucker, while flipping her off. Resident #1 stated it makes her feel like she cannot ask for help. Resident #1 stated it also makes her feel like she is below him and it does not feel too good. Resident #1 stated that when she had gone to the DON to report the situation, the DON stated, My son would not do that. Resident #1 stated that she does not feel like she can tell anyone because even the Administrator is best friends with the DON and the DON is the mother of LVN A. Resident #1 stated that not only does LVN A curse at everyone, but he does not do anything if the residents need help. Resident #1 stated that LVN A will just sit there and do nothing. Resident #1 stated that she has tried to make complaints to the DON about other things not involving LVN A and the DON would yell at her saying, Quit complaining about shit. Resident #1 stated that she has tried to go to the Administrator, and she does nothing either about LVN A. Resident #1 stated she does not like LVN A's behavior, that it is ugly and mean and makes people feel bad. Resident #2: Review of Resident #2's face sheet revealed she was an [AGE] year-old female admitted to the facility on [DATE] with a primary diagnosis of schizoaffective disorder bipolar type, muscle spasms, muscle weakness, unsteadiness on feet, abnormalities of gait and mobility, peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), anxiety, type 2 diabetes, hyperlipidemia (a condition in which there are high levels of fat particles in the blood), major depressive disorder, high blood pressure, chronic obstructive pulmonary disease (a group of lung diseases that block the airflow and make it difficult to breathe), overactive bladder, edema, need for assistance with personal care, abnormal posture, acid reflux, insomnia, abscess of bursa (septic bursitis occurs when a bursa becomes infected and inflamed), pruritus (itching). Review of Resident #2's Annual Minimum Data Set, dated dated [DATE], revealed her BIMS (Brief Interview for Mental Status) was 15, suggesting that the resident's cognitive was cognitively intact. Under section B0600 for Speech Clarity revealed that Resident #2 was listed as a 0 meaning Resident #2 has clear speech-distinct intelligible words. Under section B0700 for Makes Self Understood, Resident #2 was listed as a) meaning resident is understood. Under section B0800 for Ability to Understand Others, Resident #2 was listed as a 0 meaning understands clear comprehension. Under section C1310 for Delirium, Resident #2 was listed as a 0 meaning from the resident's baseline there was no evidence of an acute change in mental status and did not display inattention, disorganized thinking, or altered level of consciousness. Under E0100 for Potential Indicator for Psychosis, Resident #2 was listed as a 0 meaning Resident #2 did not display hallucinations or psychosis. Under section E0200 for Behavioral Symptoms-Presence and Frequency, Resident #2 was listed as a 0 meaning Resident #2 did not display physical, verbal, or other behavioral symptoms such as: hitting, kicking, pushing, scratching, grabbing, abusing other sexually, threatening others, screaming at others, cursing at others, scratching self, pacing, rummaging, public sexual acts, disrobing in public, smearing food or bodily wastes, verbal/vocal symptoms like screaming or disruptive sounds. Observations of Resident #2 during interview process on 05/18/2023 at 10:40 am. Observed Resident #2 eyes tearing up during explaining the events of the altercation that occurred with LVN A and Kitchen staff I. Observed Resident #2 showing signs of distress by means of nervousness by biting her nails and looking around to see if anyone was watching her talk to Surveyor. Interview with Resident #2 on 05/18/2023 at 10:40 am. Resident #2 stated that had been a couple of different situations in which LVN A has gotten aggressive with his mouth. Resident #2 stated that one-time LVN A had told her, Fuck you, and flipped her off. Resident #2 stated that she was scared to tell the Administrator because she did not want to get in trouble. Resident #2 stated that LVN A's mouth will really get out of hand at times. Resident #2 stated that she was in the dining room when LVN A went off on kitchen staff I. Resident #2 stated that she heard LVN A tell Kitchen staff I, shut your fucking mouth bitch. Resident #2 stated that she heard Kitchen staff I tell LVN A, Don't talk to me like that. Resident #2 stated that she heard LVN A tell Kitchen staff I, What are you going to do about it? Resident #2 stated that it was very sad, and she was crying because it made her sad to see Kitchen Staff I being treated like that. Resident #2 stated, I felt helpless. Resident #2 stated that she was scared because LVN A was capable of getting verbally aggressive badly and sometimes it will get worse. Resident #2 stated that LVN A is mouthy and thinks that he can treat people however he wants, and it is okay. Resident #2 stated that she is scared that the facility will find out that she is saying anything about it and then she will lose her cigarette break or LVN A will refuse to provide her care because he has done it before, or he will yell at her. Resident #2 stated that when she witnessed the fight it made her cry and felt nervous. Resident #2 stated, I don't want to live in chaos. Resident #3: Review of Resident #3's face sheet revealed she was an [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE] with a primary diagnosis of end stage renal disease, abnormal posture, need for assistance with personal care, viral hepatitis C, anemia in chronic kidney disease, diabetes mellitus due to underlying condition with chronic kidney disease, hypertensive emergency (an acute, marked elevation in blood pressure that is associated with signs of target-organ damage), heart failure, acid reflux, cirrhosis of the liver, muscle weakness, abnormalities of gait and mobility, lack of coordination, dependent on renal dialysis, hyperkalemia (high potassium), sepsis, unsteadiness on feet, anemia, history of pulmonary embolism (blood clot in lungs), mild protein calorie malnutrition, pure hyperglyceridemia (high concentration of triglycerides in the blood), stroke, metabolic encephalopathy, chronic respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily function), pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and heart), fluid overload, dizziness, hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone). Review of Resident #3's Minimum Data Set, dated dated [DATE], revealed his BIMS (Brief Interview for Mental Status) was 14, suggesting that the resident's cognitive was cognitively intact. Under section B0600 for Speech Clarity revealed that Resident #3 was listed as a 0 meaning Resident #3 has clear speech-distinct intelligible words. Under section B0700 for Makes Self Understood, Resident #3 was listed as a) meaning resident is understood. Under section B0800 for Ability to Understand Others, Resident #3 was listed as a 0 meaning understands clear comprehension. Under section C1310 for Delirium, Resident #3 was listed as a 0 meaning from the resident's baseline there was no evidence of an acute change in mental status and did not display inattention, disorganized thinking, or altered level of consciousness. Under E0100 for Potential Indicator for Psychosis, Resident #3 was listed as a 0 meaning Resident #3 did not display hallucinations or psychosis. Under section E0200 for Behavioral Symptoms-Presence and Frequency, Resident #3 was listed as a 0 meaning Resident #3 did not display physical, verbal, or other behavioral symptoms such as: hitting, kicking, pushing, scratching, grabbing, abusing other sexually, threatening others, screaming at others, cursing at others, scratching self, pacing, rummaging, public sexual acts, disrobing in public, smearing food or bodily wastes, verbal/vocal symptoms like screaming or disruptive sounds. Observations made of Resident #3 during the interview process on 05/18/2023 at 3:50 pm. Observed Resident #3 getting agitated talking about the incident between LVN A and Kitchen Staff I. Observed Resident #3 tightening his lips and shaking his head at one point during the interview. Observed Resident #3 showing signs of distress talking about the incident that he witnessed. Interview with Resident #3 on 05/18/2023 at 3:50 pm. Resident #3 stated that he was sitting in the dining room when LVN A came into the kitchen door and started yelling and cursing at kitchen staff member I. Resident #3 stated that LVN A told Kitchen staff I, You dumb bitch, I only have one fucking CNA. Resident #6 stated that he didn't understand why LVN A would call her that and that LVN A yelled it too. Resident #3 stated LVN A seemed angry at Kitchen staff I. Resident #3 stated that LVN A is known for being verbally aggressive towards staff and residents. Resident #3 stated that LVN A doesn't work either because he is not made to work, he's allowed to do nothing but be mean to people. Resident #3 stated that Kitchen Staff I told LVN A, Why are you cursing at me? Resident #3 stated that Kitchen Staff I said, I'm sorry I did not know that you only had one CNA. Resident #3 stated that residents were yelling at LVN A to stop and Kitchen staff I was crying. Resident #3 stated that LVN A had no reason to fly off the handle like that. Resident #3 stated that it made him feel bad for Kitchen staff I because no one should be talked to like that. Resident #3 stated that he wanted to help Kitchen Staff I. Resident #3 stated that what LVN A did made him angry, and he wanted to beat him up for what he did to Kitchen Staff I. Resident #3 stated that it was uncalled for. Resident #3 stated that he wanted to protect Kitchen staff I but couldn't do anything about it and that makes him mad. Resident #4: Review of Resident #4's face sheet revealed he was an [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE] with a primary diagnosis of psychosis not due to substance abuse, cellulitis, protein calorie malnutrition, metabolic encephalopathy, high blood pressure, polydipsia, anemia, alcohol abuse with other disorder, seizures, gout, restlessness and agitation, peripheral vascular disease, cirrhosis of the liver, muscle weakness, abnormal gait and mobility, lack of coordination. Review of Resident #4's Annual Minimum Data Set, dated dated [DATE], revealed his BIMS (Brief Interview for Mental Status) was 10, suggesting that the resident's cognitive was moderately impaired. Under section B0600 for Speech Clarity revealed that Resident #4 was listed as a 0 meaning Resident #4 has clear speech-distinct intelligible words. Under section B0700 for Makes Self Understood, Resident #4 was listed as a) meaning resident is understood. Under section B0800 for Ability to Understand Others, Resident #4 was listed as a 1 meaning usually understands-misses some part/intent of message but comprehends most conversation. Under section C1310 for Delirium, Resident #4 was listed as a 0 meaning from the resident's baseline there was no evidence of an acute change in mental status and did not display inattention, disorganized thinking, or altered level of consciousness. Under E0100 for Potential Indicator for Psychosis, Resident #4 was listed as a 0 meaning Resident #4 did not display hallucinations or psychosis. Under section E0200 for Behavioral Symptoms-Presence and Frequency, Resident #4 was listed as a 0 meaning Resident #4 did not display physical, verbal, or other behavioral symptoms such as: hitting, kicking, pushing, scratching, grabbing, abusing other sexually, threatening others, screaming at others, cursing at others, scratching self, pacing, rummaging, public sexual acts, disrobing in public, smearing food or bodily wastes, verbal/vocal symptoms like screaming or disruptive sounds. Observation of Resident #4 during interview on 05/18/2023 at 1:51 pm. Observed Resident #4 free from any kind of distress. Resident #4 did not display any distress during interview process. Interview with Resident #4 on 05/18/2023 at 1:51 pm. Resident #4 stated that he was not in the dining room when the incident occurred. Resident #4 stated that he does know LVN A. Resident #4 stated that he does curse a lot at the staff and some residents. Resident #4 stated that LVN A has cursed at him before saying, Fuck off. Resident #4 stated that he does not like it (cussing), but he was not sure if LVN A was meaning it or just playing around. Resident #4 stated that sometimes it makes him mad, but he has not fought with LVN A because of it. Resident #4 stated that he has heard LVN A tell Resident #1 to, Shut the fuck up. When she is yelling or something. Resident #4 stated, that is not nice of him. Resident #5: Review of Resident #5's face sheet revealed he was an [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE] with a primary diagnosis of type 2 diabetes, cellulitis of left upper limb, reduced mobility, long term use of anticoagulants, repeated falls, hypertensive crisis, heart disease, glaucoma, unqualified visual loss of left eye, normal vision in right eye, anemia, insomnia, hypothyroidism, hyperlipidemia, major depression disorder, high blood pressure, acid reflux, muscle weakness, end stage renal disease, unsteadiness on feet, lack of coordination, complete traumatic amputation at level between right hip and knee, need for assistance with personal care, dependent on renal dialysis. Review of Resident #5's Annual Minimum Data Set, dated dated [DATE], revealed his BIMS (Brief Interview for Mental Status) was 14, suggesting that the resident's cognitive was cognitively intact. Under section B0600 for Speech Clarity revealed that Resident #5 was listed as a 0 meaning Resident #5 has clear speech-distinct intelligible words. Under section B0700 for Makes Self Understood, Resident #5 was listed as a) meaning resident was understood. Under section B0800 for Ability to Understand Others, Resident #5 was listed as a 0 meaning understands. Under section C1310 for Delirium, Resident #5 was listed as a 0 meaning from the resident's baseline there was no evidence of an acute change in mental status and did not display inattention, disorganized thinking, or altered level of consciousness. Under E0100 for Potential Indicator for Psychosis, Resident #5 was listed as a 0 meaning Resident #5 did not display hallucinations or psychosis. Under section E0200 for Behavioral Symptoms-Presence and Frequency, Resident #5 was listed as a 1 for verbal behaviors meaning Resident #5 did display verbal symptoms directed towards others such as threatening, screaming at others, cursing at others but not physical, or other behavioral symptoms such as: hitting, kicking, pushing, scratching, grabbing, abusing other sexually, scratching self, pacing, rummaging, public sexual acts, disrobing in public, smearing food or bodily wastes, verbal/vocal symptoms like screaming or disruptive sounds. Observations made of Resident #5 during interview process on 05/18/2023 at 2:27 pm. Observed Resident #5 sitting in his wheelchair and pulled up next to his bed with his head laying on the side of the bed. Observed Resident #5 did not show distress during interview. Interview with Resident #5 on 05/18/2023 at 2:27 pm. Resident #5 stated that he has not worked with LVN A much but stated that he used to work nights and his attitude and mouth was bad at that time. Resident #5 stated that LVN A would cuss at resident's for asking for help. Resident #5 stated that he is not sure, but he does think that by LVN A moving to days has helped the situation some. Resident #5 stated that LVN A does not seem as moody as he did when he worked the night shift. Resident #5 stated that when LVN A was working nights he would not help the residents and was lazy. Resident #5 stated that he does not work with him a whole lot now. Resident #5 stated that he does not like to complain too much about anything because then you will lose your cigarette breaks. Resident #5 stated, I can't lose my breaks, it's the only thing keeping me going right now. Resident #5 stated that he has made complaints to the Administrator about people stealing money out of his room and missing vape and nothing was done but less time for breaks, so I try to not complain. Resident #6: Review of Resident #6's face sheet revealed she was an [AGE] year-old female admitted to the facility on [DATE] with a primary diagnosis of stroke, insomnia, acid reflux, cirrhosis of the liver, obstruction of bile duct, type 2 diabetes, hyperlipidemia (a condition in which there are high levels of fat particles in the blood), hypokalemia (low potassium), schizophrenia, bipolar disorder, major depression, anxiety, encephalopathy, muscle weakness, lack of coordination. Review of Resident #6's Annual Minimum Data Set, dated dated [DATE], revealed her BIMS (Brief Interview for Mental Status) was 11, suggesting that the resident's cognitive was moderately impaired. Under section B0600 for Speech Clarity revealed that Resident #6 was listed as a 0 meaning Resident #6 has clear speech-distinct intelligible words. Under section B0700 for Makes Self Understood, Resident #6 was listed as a) meaning resident is understood. Under section B0800 for Ability to Understand Others, Resident #6 was listed as a 0 meaning understands clear comprehension. Under section C1310 for Delirium, Resident #6 was listed as a 0 meaning from the resident's baseline there was no evidence of an acute change in mental status and did not display inattention, disorganized thinking, or altered level of consciousness. Under E0100 for Potential Indicator for Psychosis, Resident #6 was listed as a 0 meaning Resident #6 did not display hallucinations or psychosis. Under section E0200 for Behavioral Symptoms-Presence and Frequency, Resident #6 was listed as a 0 meaning Resident #6 did not display physical, verbal, or other behavioral symptoms such as: hitting, kicking, pushing, scratching, grabbing, abusing other sexually, threatening others, screaming at others, cursing at others, scratching self, pacing, rummaging, public sexual acts, disrobing in public, smearing food or bodily wastes, verbal/vocal symptoms like screaming or disruptive sounds. Interview with Resident #6 on 05/19/2023 at 1:55 pm. Resident #6 stated that it took her a while to get to know LVN A because he is just always sitting at the desk doing nothing. Resident #6 stated that even if the residents call for help, he will either just sit there and ignore the residents or he will cuss at them to stop using the call lights. Resident #6 stated that she thinks that the facility has not fired him yet because his mother was the DON. Resident #6 stated that the Administrator does not do anything about the situation either. Resident #6 stated that all the Administrator will do is threaten to take resident's cigarettes away if they say anything. Resident #6 stated that the Administrator threatens the residents often about taking away their cigarettes or their breaks. Resident #6 stated that she did not witness the incident in the dining room between LVN A and Kitchen Staff I but she has seen LVN A curse at residents before. Resident #6 stated that she has witnessed LVN A tell Resident #1, shut up fucker, or he has also told Resident #1, you annoying bitch. Resident #6 stated that LVN A tried talking to her like that one time, but she just stayed quiet about it because if she were to tell anyone then they get punished. Resident #6 stated that the residents will get punished especially if LVN A goes and tells because his mother who was the DON, and she always has his back. Resident #6 stated that one time when LVN A was just ignoring the residents she told him, When are you going to get up and do something? Resident #6 stated that LVN A stated, Never. Resident #6 stated that she told LVN A, Probably because your mom is the DON and she's in charge. Resident #6 stated that LVN A stated, Wouldn't you do it if your mom were in charge? So shut the fuck up now. Resident #6 stated that she does not like to hear the cursing from LVN A. Resident #6 stated that it is ugly and it's offensive to her. Resident #6 stated she has seen LVN A curse at other staff and residents before. Resident #6 stated that she was afraid that eventually he will do something bad since he is allowed to get away with the small stuff. Resident #8: Review of Resident #8's face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] with a primary diagnosis of Alzheimer's disease, peripheral vascular disease, muscle weakness, lack of coordination, unsteadiness on feet, schizoaffective disorder bipolar type, major depressive disorder, glaucoma, high blood pressure, asthma, hormone replacement therapy, Review of Resident #8's Annual Minimum Data Set, dated dated [DATE], revealed her BIMS (Brief Interview for Mental Status) was 11, suggesting that the resident's cognitive was moderately impaired. Under section B0600 for Speech Clarity revealed that Resident #8 was listed as a 0 meaning Resident #8 has clear speech-distinct intelligible words. Under section B0700 for Makes Self Understood, Resident #8 was listed as a) meaning resident is understood. Under section B0800 for Ability to Understand Others, Resident #8 was listed as a 0 meaning understands. Under section C1310 for Delirium, Resident #8 was listed as a 0 meaning from the resident's baseline there was no evidence of an acute change in mental status and did not display inattention, disorganized thinking, or altered level of consciousness. Under E0100 for Potential Indicator for Psychosis, Resident #8 was listed as a 0 meaning Resident #8 did not display hallucinations or psychosis. Under section E0200 for Behavioral Symptoms-Presence and Frequency, Resident #8 was listed as a 0 meaning Resident #8 did not display physical, verbal, or other behavioral symptoms such as: hitting, kicking, pushing, scratching, grabbing, abusing other sexually, threatening others, screaming at others, cursing at others, scratching self, pacing, rummaging, public sexual acts, disrobing in public, smearing food or bodily wastes, verbal/vocal symptoms like screaming or disruptive sounds. Observations made of Resident #8 during the interview process on 05/18/2023 at 2:27 pm. Observed Resident #8 in slight signs of distress by lowering her head and slightly shaking her head with slight tightening of the lips. Interview with Resident #8 on 05/18/2023 at 2:27 pm. Resident #8 was interviewed with Resident #5 because they shared a room together. Resident #8 stated that she had not worked with LVN A much either. Resident #8 stated that she had not had any issues with LVN A herself. Resident #8 stated that he had never cursed at her or called her named or yelled at her. Resident #8 stated that she had been in the dining room when LVN A has cursed at other staff members, but she does not remember their names because she has a hard time remembering people's names. Resident #8 stated that she had heard him one time call a female staff a, Bitch. Resident #8 stated that she does not like to talk like that, and it bothers her. Resident #8 stated she just does not like it. Resident #8 stated she does not know why people use those words. Resident #8 stated, I would not want someone talking to me like that. Resident #8 stated that she would prefer not to have to hear those words. Resident #8 did not specify if she was distressed because of the cursing, she just kept stating that she did not like to hear it. Interview with Administrator on 05/18/2023 at 10:03 am. Administrator stated that she did do an investigation for the incident that had happened in front of the residents. Administrator stated that it is just a lot of he said she said stuff. Administrator stated that she got complaints of LVN A not wanting to work and a lot of his call in's. Administrator stated that a resident had complained that LVN A is unprofessional and said the word, Shit. Administrator stated that no safe surveys were completed for residents. Administrator stated that LVN A was aware that he had been suspended pending investigation process as of 05/17/2023. Administrator stated that she does not normally get complaints from residents for anything. Administrator stated that she was told by Resident #1 and Resident #2 that they heard LVN A say the word, Shit. Administrator stated that she had called her boss (Corporate) and stated that she needed their help. Administrator stated that she does not give LVN A special treatment, but it has been said in the facility before. Administrator stated that she had not gotten any complaints from staff about LVN A cursing or not caring for the residents. Administrator stated she would just have to get through with her investigation to see what will happen with LVN A. Interview with DON on 05/18/2023 at 10:25 am. DON stated that she had not gotten any complaints about LVN A from staff or residents. DON stated that LVN A did have an altercation with the kitchen staff. DON stated that LVN A just stands up for the nurse aides because kitchen staff try to run over them. DON stated that LVN A does not put up with resident-to-resident bullying, so he does stand up for residents also. DON stated that LVN A will stand between the residents and redirect them to a different area. DON stated that she had not heard of LVN A having any kind of aggressive behavior or cursing whatsoever. DON stated that she had not gotten any complaints of LVN A not caring for the residents from residents or staff members. Interview with Kitchen staff H on 05/18/2023 at 11:33 sm. Kitchen staff H stated that Kitchen staff I had went and told LVN B to give menus to the resident. Kitchen staff H stated that the next thing she knew that LVN A had come to the kitchen and was yelling and cursing at Kitchen Staff I saying, you need to get your shit together, you dumb bitch. Kitchen staff H stated that Kitchen staff I told LVN A to stop cursing and yelling at her. Kitchen staff H stated that LVN A told Kitchen staff I, What are you going to do about it? Kitchen staff H stated that there were many residents in the dining room which witnessed the incident. Kitchen staff H stated that residents were yelling at LVN A to stop. Kitchen staff H stated then LVN A just walked away. Kitchen staff H stated that Kitchen staff I did not want to even come to work after this and neither did anyone else. Kitchen staff H stated it, made her nervous to be there. Kitchen staff H stated that she witnessed two residents crying when the incident occurred and that others were clearly concerned. Kitchen staff H stated that the two residents that were crying were Resident #1 and Resident #2. Kitchen staff H stated that it made her feel bad that they had to see all that. Interview with LVN B on 05/18/2023 at 11:56 am. LVN B stated that he was a witness to the incident that happened with LVN A and Kitchen Staff I. LVN B stated that Kitchen staff I had brought the menu choice papers to him and LVN B stated that he told her, It will be just a moment because we only have one aide. LVN B stated that CNA D had grabbed the papers from him and stated, That was kind of rude of her. LVN B stated that LVN A[TRUNCATED]

Based on interview and record review, the facility failed to, based on the comprehensive assessment of a resident, ensure that a resident (Resident #99) received care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; in that: a)The facility staff failed to provide effective and timely skin assessment to 1 of 1 residents (Resident #99) with a hard splint/cast. The ineffective and untimely assessment resulted in an in-house stage II pressure sore to the right foot. This problem could result in residents without pressure sores developing pressure sores due to ineffective skin monitoring. The findings include: Record review of the progress notes for resident #99 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. further review of the document revealed [DIAGNOSES REDACTED].(primary) hypertension, gastro-[MEDICAL CONDITION] reflux disease without esophagitis, [MEDICAL CONDITIONS], as defined in usa, nausea with vomiting, unspecified, other asthma, other chest pain, other constipation, other [MEDICAL CONDITION], other [MEDICAL CONDITIONS], other skin changes, pediculosis due to pediculus humanus capitis, pressure ulcer of unspecified buttock, stage 2, stenosis of other vascular prosthetic devices, implants and grafts, initial encounter, [MEDICATION NAME] hemorrhage, bilateral, and pressure ulcer of right heel, stage 2 (12/08/18). On 12/10/18 at 10:20 a.m. LVN #1 stated that Resident #99 was blind and had a pressure sore. On 12/10/18 at 10:47 AM, Resident #99 stated that she found out she had a sore on her foot while in the facility. The resident was noted to be obese and blind. On 12/12/18 at 2:45 PM an observation was made of Resident #99's foot with LVN #2. Observation of the wound on Resident #99 right heel revealed that it did have a slight foul odor and was approximately the size of a dime/nickel. The wound had white slough and was moist and had red areas with missing skin. The resident's right foot was swollen and dark and the resident's lower leg was a dark color. The resident skin was very dry and cracked both on top of and under the foot. The resident's toenails were thick. It was also noted that the hard, molded splint cast that had been taken off of the resident's right foot was heavily soiled and had a foul odor to it. The interior of this brace was heavily soiled with brown residue. The residents wound was determined as a stage 2 pressure ulcer by RN Surveyor. When the leg was first seen it was noted that the right foot was wrapped in an ace bandage and when it was taken off there was a molded splint/cast underneath it and that the resident had her socked foot and leg against the interior of this soiled molded splint. She did have a dressing over the pressure area on her heel. At that time LVN #2 stated that the resident's foot was not as swollen the other day. ~In-House Pressure Ulcer: ~The following documentation revealed that Resident #99 did not enter the facility with a pressure ulcer to the right heel, indicating that the pressure ulcer was developed in-house: Due to Resident #99 being a new admission, her admission MDS was in process and not completed. Record review of the 48 HOUR BASELINE CARE PLAN - V 4 for Resident #99 Effective Date: 12/04/2018 18:07 revealed that the resident had no open areas on admission and identified a fractured right ankle and a splint cast. The document stated, .N. 1. Pressure Sore / Skin at Risk GOAL: Prevent / Heal pressure sores .3. Preventive: 3a. (specify) past history of pressure sore to buttocks. no open areas at admission 4. Position: 4a. (specify) reposition q 2 hours and encourage being up . 10. Fracture/[MEDICAL CONDITION] 11. GOAL: 11a. (specify) right ankle stress fracture to heal without difficulty 12. Cast: 12a. (specify) splint cast . Record review of the Admission Record dated 12/04/18 14:52, Admission/Readmission Assessment - V 2 dated 12/04/2018 18:07 and an undated discharge information document by discharging facility LVN #3 for Resident #99 revealed that there was no documentation of a pressure sore to the right heel on admission. Record review of the admitting orders dated 12/04/18 and 12/05/18 for Resident #99 revealed no treatment orders related to a pressure ulcer to the right heel. Record review of the Daily-Skilled Nurses' Note - V 2 for Resident #99 dated Effective Date: 12/05/2018 20:41 documented, E. Skin / Skin Conditions 1. Select all that apply (Record review of this area revealed that none of the items including pressure ulcer were checked). Further record review of the form revealed the following, .L. Nursing Skill . 2. Additional information related to skilled nursing services being provided: Resident admitted with stress fracture to right ankle, resident [MEDICAL CONDITION], blind DM right ankle wrapped with ace with splint intact, resident with Diaylsis port to right [MEDICATION NAME] area dressing intact, resident needs 24 hour care needs assist with meals and monitoring BS and medication, assist with ADLS. Record review of the Weekly Skin Assessment updated - V 2 for Resident #99 dated Effective Date: 12/06/2018 21:31 documented, [NAME] Weekly Skin Assessment .h. Does the resident have a pressure, venous, arterial, or diabetic ulcer? If yes, complete The Ulcer Assessment. a. No i. Other skin findings: Resident has splint to left ankle wrapped with ace toes warm to touch. ~ Facility Discovery of Right Heel In-House Pressure Ulcer on 12/08/18: ~ Further record review revealed that a pressure ulcer to the right heel was discovered by the DON the evening of 12/08/18 after removal of the splint/cast. The documentation was as follows: Record review of Resident #99's Progress Notes revealed the following documentation, .Effective Date: 12/9/2018 00:27 Type: Nursing Progress Note Text: Late entry: at 2030, was cleaning and applying lotion to resident right leg. found stage 2 pressure ulcer measuring 3.0 x 2.5 x .1 edges to medial of wound is stage 1 for total of 5cm. called (FNP) for Physician #1, orders received to cleanse heel with NS, pat dry and apply hydrogel and cover with adhesive foam dressing. apply lotion to right leg qd day and reapply splint cast and ace wrap. Nurse performed wound care and applied lotion to right lower extremity . Author: Director of Nursing (e-SIGNED) . Record review of the Weekly Ulcer Assessment - V 3 dated Effective Date: 12/09/2018 00:18 documented the following, [NAME] Ulcer Information. 1. Location of ulcer right heel, 2. Type of Ulcer a) Pressure 3. If Pressure, what stage is the ulcer? b) II 4. Date Ulcer Identified 12/08/2018 . B. Ulcer Assessment 1. Length (cm) 3.0 2. Width (cm) 2.25 3. Depth (cm)- If unable to determine enter UTD .1 . 7. Wound bed character b. Moist 8[NAME] Wound bed margins (select all that apply) [NAME] Open . 9[NAME] Wound bed color (check all that apply) [NAME] Pink .10. Skin around wound: B. Macerated 11. Select the most severe tissue type present 2) Granulation - pink or beefy red tissue; shiny, moist, granular 13. Exudate amount 1) Light 14. Exudate color a) Yellow 15. Exudate character b) Opaque or Purulent 16. Odor 0) None . C. Interventions 1. Current wound treatment Cleanse with Ns, pat dry, apply hydrogel and cover with adhesive foam dressing. 2. Frequency of wound treatment daily 3. Frequency of turning and repositioning c) q2h 4. Pressure reducing devices in place: (select all that apply) C. Pillows to float heels 4B. Other pressure reducing device . 1. Is this a new wound, a wound that has declined, or new orders received related to this wound b) Yes 2b. Date and time of physician notification 12/08/2018 20:40 . ~ Addressing of the Unsanitary Splint/Cast Condition and Wound Culturing: ~Record review and staff interviews revealed that the unsanitary condition of the splint/cast in contact with the resident and wound culturing was not addressed until 12/11/18 and 12/12/18. The information was as follows: Record review of Resident #99's Progress Notes revealed the following documentation, .Effective Date: 12/11/2018 17:01 Type: Nursing Progress Note Called . about x rays to resident's right foot and ankle and about needing a new splint. She said to make her an appt with Hospital # 1 ortho. Will pass on in report for am nurse to call. D.O.N. is aware. Author: LVN #1 - Licensed Vocational Nurse (e-SIGNED). Record review of the duplicate verbal order dated12/12/18 15:05 revealed an order that stated, Order Summary: Wound culture to Rt. Heel wound. (MONTH) place temporary air cast on Rt foot until orthopedic appt. On 12/12/18 at 2:45 PM the Corporate RN stated, We and the PA are looking into getting another cast. On 12/12/18 at 3:05 PM the DON stated that a call had been made to the physician about Resident #99's fracture and the brace/splint now. And that the facility is trying to get another brace for the resident. ~ Staff Interviews Regarding the Right Heel Pressure Ulcer, Splint Condition, Skin Assessment: ~ Interviews with staff revealed that the skin under the splint/cast had not been assessed, since admission on 12/04/18, until 12/08/18 when the DON removed the hard splint/cast and discovered the stage 2 in-house pressure ulcer to Resident #99's right heel. The interviews were as follows: On 12/12/18 at 3:30 PM the DON was asked if she was aware of Resident #99 having a pressure sore and she stated, I saw it Saturday and it was nasty. We tried to clean it Saturday night. I got orders for wound care. She stated that the physician had been called yesterday about the ankle fracture and brace. She stated, I just now wrote an order to get an air cast for her leg. She stated that they were getting opinions to see if the resident was weight-bearing or non-weight-bearing. She stated, I wrote an order for [REDACTED].?, as she proposed ways to prevent the resident from having contact with the soiled brace/cast. She added, Saturday night I cleaned her leg and foot and applied lotion. I didn't smell it because I'm all stopped up. On 12/13/18 at 8:45 AM LVN #2 was interviewed regarding Resident #99's pressure ulcer and cast. She stated that she put gauze padding between the resident's foot and a cast today so that her foot did not contact the cast. She also stated that, I called orthopedics about the cast. She was also asked when she first knew about the pressure sore on the resident's heel. She stated, Saturday or Sunday (12/08/18 or 12/09/18). She added that prior to that, she had no knowledge of the resident having a pressure sore. She stated, We were applying a lot of cream when she first came here, to her legs. She further stated, We didn't do anything with it, (meaning the splint/cast). She also stated, The other facility said for her to wear it (splint/cast). LVN #2's stated, She came in Tuesday (12/04/18) and I was off Wednesday and Thursday. I just took it off, the wrap, not the cast. I didn't want to remove the cast. She added, The (DON) worked that night (12/08/18) and took off the cast. On 12/20/18 at 10:32 AM LVN #1 was asked if she had checked the skin on Resident #99's right foot before the discovery of the pressure sore by the DON. She stated No. The family said not to take it (splint) off because she was non-weight bearing due to the ankle fracture. We had it x-rayed and they said it was an old fracture. After (the DON) found the pressure sore, then we took the splint off and treated the ulcer. On 12/20/18 at 5:14 PM LVN #5,who conducted the admission assessment for Resident #99, was asked if she had observed the right foot of the resident during her admission assessment on 12/04/18. She stated, No I was not able to look at it since it said it was a fracture. I did see that her toes were real flakey. On 12/13/18 at 9:00 a.m. an interview was conducted with the DON. She was asked about Resident #99's pressure sore. She stated, I found it. There were no wound orders when she was admitted . There was just a discussion that there may be one (pressure ulcer). So I just wanted to inspect and I stripped it all down. I found it and cleaned it and applied lotion. We will in-service that (splints and skin assessment). The ADON stated at this time, She (Resident #99) did come in (admitted ) late. They (staff) have to get better communication. She added, We will put a plan in place. Observation on 12/13/18 at 12:18pm revealed Resident #99 had very dry, scaly skin from her right knee to her foot. She had a stage 2 pressure ulcer to the right heel where the tissue looked red and beefy. There were areas on her shin area that were beginning to ooze a serosanguinous colored fluid. Policy: Record review of the facility policy label Operational Policy and Procedure Manual 2001, Revised (MONTH) 2006 revealed the following documentation, Admissions - Admitting The Resident To The Unit / Room, Policy Statement. Facility Personnel shall greet and assist newly admitted residents to their units / rooms. Policy Interpretation and Implementation . 9. Observe the general condition of the resident (i.e., rashes, burns, bruises, sores, etc., as well as his/her reaction to the admission). Record review of the facility policy labeled Pressure Ulcer Protocols and Prevention, 10/1/2016 revealed the following documentation, Purpose. Nursing home residents, due to comorbidities and underlining clinical conditions, may develop pressure ulcers during their stay at the facility, but pressure ulcer prevention should be performed daily to deter ulcers from forming . Prevention. Prevention of pressure ulcers from farming is a priority when caring for residents. This includes all residents not just high risk for pressure ulcer residents as defined from the pressure ulcer risk assessment, but high-risk residents should be monitored closely . Process. I. Assessment of risk. All residents are considered at risk for the development of pressure ulcers. During the admission nursing assessment process, the condition of the resident's skin should be noted . IV. Documentation . Observations pertinent to the resident's skin status should be recorded in the nurse's notes as appropriate. Care plan the skin issue for the date recognized .

Based on observation, interview and record review, the facility failed to ensure that 1 of 4 sampled residents (#1) did not experience an avoidable unplanned weight loss, and maintained acceptable parameters of nutritional status, such as body weight, based on the resident's comprehensive assessment. Resident #1 weight dated 2/11/13 revealed a 12% weight loss in six months,7% loss in 3 months, and 6% loss in 1 month. Failure to ensure residents do not have unplanned, avoidable weight loss places them at risk for a decline in their health and well-being. This problem affected 1 of 4 residents sampled that experienced weight loss, (resident # 1) and had the potential to affect all 4 residents identified as having weight loss. The finds include: Review of Face Sheet revealed Resident #1 was admitted into facility on 4/7/10. His date of birth is 4/21/26. He is an [AGE] year old man. Review of Physician order [REDACTED]. Review of Resident #1's Physician order [REDACTED]. Review of the Annual Comprehensive MDS dated [DATE] indicated resident #1 had no or unknown weight loss and no or unknown weight gain. Review of the Quarterly MDS dated [DATE] also documented the resident had not experienced a weight loss or gain. Review of the Resident #1's Dietary Progress Notes revealed the following recommendations: on 10/15/12 was ordered a Pureed diet, HS snack 50 percent Protocol, and his weight at 118 lbs.; on 12/11/12 no diet changes, is fed by staff, and had a 2 lb. decrease; 1/14/13 no diet changes and he is stable (even though he lost 6.7 lbs.); on 2/16/13 increase house supplement from twice a day to 3 times a day. Review of the Consultant Dietitian Report for 12/2012 revealed the recommendation for Resident #1 to be provided with "a multivitamin with minerals, and a supplement/snack at 1000 and 1400 med pass." Review of Resident #1's Weight Change Comparison records revealed his weights as follows; on 9/03/12 weight was 121.8 pounds, on 10/03/12 weight was 117.60 lbs., on 12/05/12 weight was 116.40 lbs. on 1/5/13 weight was 114.50 lbs. and most recently on 2/14/13 weight was 107.8 pounds Current care plans revealed that there was no care plan specifically addressing weight loss. Observation of meal on 2/12/13 - lunch and 2/13/13 - lunch revealed Resident #1 ate 100% of meal with total assistance. However, no second servings were given to resident. Observation on 2/14/13 at 8:53 AM, resident #1 was observed weighed on a Detect Chair scale. He was transferred from his wheel chair to chair scale by CNA #11 and CNA #12. Both feet were placed on footrest before reading. He weighed 107.8 pounds. This loss of 6.7 pounds is categorized as severe. Interview with Food Service Supervisor on 02/20/13 @ 2:50 PM revealed that the consultant dietician has seen Resident #1 since 12/12/12. She also acknowledges no intervention seen from July to October 2012 regarding drop in Resident # 1's weight. Interview on 2/19/13 at 10:00 AM with ADON revealed Resident #1 normally eats 100% of meals. The facility offers him a second serving and Resident #1 only eats about 25% because he gets tired and stops eating. ADON also stated he did not want to eat with dentures. So he would not eat. The facility eventually removed them. She stated she had to check on the time frame. She came back with DON. Interview is as follows: Interview on 2/19/13 at 10:10 AM with DON, revealed that Resident #1's teeth were removed on 6/29/12 and was given dentures. He stopped using the dentures in July 2012. He did not like the dentures. The DON also stated that Resident #1 also has wounds that are healing. "All his nutrients are going to the healing process. He will eventually gain weight." DON also wanted to state her credentials to include Gerontologist. Review of the facility's policy regarding Weight Assessment and Intervention, revised December 2008, revealed: Communication: Any weight change of 5 % or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing. Response by Dietitian: The Dietitian will respond within 24 hours of receipt of written notification. Evaluation of Negative Trends: The Dietitian will review the unit Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for "significant" weight change has been met. Significant Changes Definition: The threshold for significant unplanned and undesired weight loss will be based on the following criteria (where percentage of body weight loss (usual weight-actual weight)/(usual weight)x 100: 1 month - 5 % weight loss is significant; greater than 5 % is severe 3 months - 7.5 % weight loss is significant; greater than 7.5% is severe. 6 months - 10 % weight loss is significant; greater that 10 % is severe." According to this policy, Resident #1's weight loss was considered severe. Review of the facility submitted CMS 802 (Roster Sample/Matrix) revealed that there was1 resident in the facility with weight loss. Resident #1 was not documented on this form as having weight loss. The facility's CMS 672 dated 2/11/13 documented 1 Resident with unplanned significant weight loss/gain. The facility's CMS 672 dated 2/11/13 documented a census of 62 residents. Refer to F314.

Based on observations, interviews, and record reviews, the facility did not ensure 2 of 4 residents (#1 & #4) with assistive devices of side rails, tab and/or pressure alarms had the alarms in use and turned on. Resident #4 had falls on 5/16/11, 5/23/11, 6/7/11 and 6/9/11. Hospice had placed a pressure alarm on the resident after the fall on 5/16/11. Resident #4' s pressure alarm was not on the bed when resident #4. Resident #4's fall on 6/9/11 resulted in multiple skin tears, lacerations and a cut to the left ear requiring sutures. Resident #4 did not have his 1/2 side rails up on the bed when he fell on [DATE] and did not have his pressure alarm on his bed when he fell on [DATE]. The facility's failure placed the 4 residents who were identified as having alarms and side rails at risk for injury from falls as staff would not be alerted to respond when the residents were attempting to move from their beds or wheelchairs without assistance. Findings include: 1. Resident #4 was observed on 6/10/11 at 2:30 PM lying in bed without the pressure bed alarm and had a ? side rail up on the bed. The resident had an abrasion to his nose, left side of his head and sutures in his left ear. The resident revealed he did not know how he fell on [DATE]. Record review of Resident #4' s clinical records revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #4 was admitted to Hospice on 3/17/11 due to a decline related to his medical diagnoses. Record review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 was receiving Hospice care and at risk for falls. Review the care plan dated 5/11/11 for Resident #4 revealed the care plan for falls was never revised/updated to reflect Resident #4' s falls and interventions of side rails and a bed pressure alarm which was provided by Hospice. The fall risk evaluation was dated 4/28/11 revealed Resident #4 was at high risk for falls. According to the incident reports and interventions the care plan should have been revised following the incidents on 5/16/11, 5/23/11, 6/7/2011 and 6/9/11. Record review of incident reports and clinical records revealed Resident #4 had his first fall on 5/16/11 at 9 PM. Resident #4 sustained multiple skin tears and a bump to his head. The incident report dated 5/16/11 revealed Resident #4 attempted to go to the restroom and was wearing socks when he slipped and fell to the floor. The incident interventions were to encourage the resident to call for assistance and the care plan was to be updated to reflect fall risk due to weakness, pain medications and dementia. Record review of the change of condition charting related to the fall on 5/16/11 revealed Resident #4 had a bed alarm on his bed on 5/20/11 on the 6p-6a shift. Review of the Hospice records dated 5/16/11 at 9:30 PM revealed a facility nurse called to report Resident #4 had a fall while attempting to get out of bed. The report indicated Resident #4 had a hematoma to the left temple, skin tears (2) to the left elbow, bruises to be left upper back and a 3 cm abrasion. The records indicated the facility nurse requested a bed alarm for Resident #4. The communication record, dated 5/16/11, revealed the Hospice RN would be notified and visit the facility in the morning on 5/17/11. An incident report dated 5/23/11 at 10 PM, revealed Resident #4 rolled off the bed and had a small 1 cm laceration to the top of his head. Interventions per incident summary were for ? side rails to bed to assist with bed mobility. The incident report summary dated 5/23/11 revealed Resident #4 was becoming weaker and on Hospice. The incident report summary revealed the care plan was to be updated for fall risk, side rails, weakness and Hospice. An incident on 6/7/11 at 11:30 AM revealed Resident #4 rolled out of bed and had a skin tear to the back of his head. The incident report revealed Resident #4 had a bed pressure alarm on at the time, but the side rails were down on resident #4' s bed. The incident report revealed Resident #4 informed staff he was turning to his side when he fell backwards onto the floor. The intervention per the incident summary was to use side rails while in bed to assist with mobility. An incident report dated 6/9/2011 at 4 PM revealed Resident #4 was found on the floor, lying on his left side. The incident report revealed Resident #4 was assessed and had lacerations to his left ear, left side of the head, multiple skin tears to face and head, abrasion to his nose was and bruising to bilateral knees. The records revealed Resident #4 had soiled (feces) himself and attempted to get out of bed without assistance. The resident was sent to the emergency room for sutures to his ear and further evaluation. The incident report under devices used at the time of the incident was blank indicating the pressure alarm was not on the resident's bed.. Environmental issues per the incident report revealed Resident #4 had climbed over the side rails. An interview with the ADON on 6/10/11 at 5 PM revealed Resident #4 had placed a pressure alarm on his bed a couple of weeks ago because she had heard the alarm go off in the past. She stated Resident #4 did not have the bed pressure alarm on his bed when he fell on ,[DATE]/ 11. The ADON stated Resident #4 had been able to self transfer until a few weeks ago. The ADON revealed staff don' t have a list to know which residents have alarms and which do not. An interview with LVN #1 on 6/10/11 at 5:20 PM revealed she was working when Resident #4 fell on [DATE] around 4 PM. LVN #1 stated Hospice had asked about the alarm when she notified them of the fall. The LVN stated she did not know about the bed alarm. LVN #1 stated one of the aides (CNA #3) had told her LVN #2 had told the aide to put Resident #4's alarm on resident #1. LVN #1 confirmed Resident #4 did not have the bed alarm on when he fell on [DATE] at 4 PM. An interview with Hospice nurse #1 on 6/13/11 at 1:10 PM revealed a pressure bed alarm was ordered from the medical supplier on May 17, 2011 and delivered to the facility for Resident #4. The Hospice nurse revealed she did not write a physician 's order for the pressure alarm. The Hospice nurse revealed she had observed Resident #4 with the pressure alarm on his bed during visits after 5/17/11. An interview with CNA #3 on 6/13/11 at 3:35 PM revealed he had informed LVN #2 Resident #1 needed a tab alarm. CNA #3 stated LVN #2 told him to put Resident #4' s alarm on resident #1 because Resident #4 had side rails and was sleeping thru the night. CNA revealed this was probably occurred on Sunday (6/5/11). An interview on 6/14/11 at 12:15 PM with the Director of Nurses (DON) confirmed Resident #4 did not have his bed pressure alarm on when the resident fell on [DATE] and did not have his side rails up when the resident fell on [DATE]. During this interview the Director of Nurses (DON) confirmed the care plan for Resident #4 had not been updated to reflect interventions for the bed pressure alarm and side rails. The DON revealed when the incident summary was completed, the form documented resident interventions and updates that need to be done for the care plans. The DON indicated the Assistant Director of Nurses (ADON) was given the incident summary so that updates would be done on resident' s care plan. An interview with the ADON on 6/14/11 at 12:20 PM confirmed the care plan was not been updated/revised for Resident #4 regarding the pressure alarm and side rails. 2. Observation of Resident #1 on 6/13/11 at 3:50 PM revealed the resident was lying in bed without a tab alarm. Review of the physician's order [REDACTED]. Review of the Care Plan for Resident #1 revealed a tab alarm when up in wheelchair and while in bed. An interview with the DON on 6/13/11 at 3:57 PM revealed she was not informed by the nurse Resident #1 did not have a tab alarm on. An tab alarm was located and placed on Resident #1 on 6/13/11 at 4 PM. 3. Further interview with the DON on 6/14/11 at 1:40 PM revealed the facility had four residents who used alarms.