Every finding on record at Paradigm at The Pines

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 3 hallways (D Hall) and 1 of 1 (Resident #16) reviewed for infection control practices. 1. The facility failed to ensure LVN E performed hand hygiene between each meal tray while passing the lunch meal trays on 12/08/25. 2. The facility failed to ensure CNA D changed her gloves and performed hand hygiene during Resident #16's incontinent care on 12/09/25. These failures could place residents at risk for cross contamination and an increased risk of infection, or the spread of infection. The findings included: 1. During an observation on 12/08/25 between 11:17 AM and 11:25 AM, LVN E checked the meal trays on D Hall and started passing them. LVN E passed the meal tray to room D1, set up the tray and exited the room; LVN E passed the meal tray to room D3, set up the tray and exited the room; LVN E passed the meal tray to room D10, set up the tray and exited the room; LVN E passed the meal tray to room D4, she moved the covered and rearranged items on the bedside table, she set up the tray and exited the room; LVN E passed the meal tray to room D6, set up the tray and exited the room; LVN E passed the meal tray to room D8, set up the tray and exited the room; LVN E passed the meal tray to room D9, she moved the blankets, readjusted the bed, setup the tray, then left the room. LVN E did not sanitize her hands or perform hand hygiene between each meal tray. During an interview on 12/08/25 beginning at 11:28 AM, LVN E stated she normally sanitized her hands between each resident's room when she passed meal trays. LVN E stated she did not have her hand sanitizer in her pocket, and the facility just added the sanitizer pumps in the hallway, so she forgot to use them. She stated she was also nervous because this was her first experience with a health inspection. LVN E stated it was important to ensure hand hygiene was performed during meal services to prevent contamination and the spread of infection. 2. Record review of the face sheet, dated 12/10/25, reflected Resident #16 was a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses of chronic respiratory failure (long-term condition in which the lungs cannot adequately exchange oxygen and carbon dioxide, leading to decreased oxygen levels and increased carbon dioxide levels in the body) and morbid obesity (a body mass index higher than 40). Record review of the quarterly MDS assessment, dated 10/22/25, reflected Resident #16 had clear speech, was understood by others, and was able to understand others. Resident #16's BIMS score was 1, which indicated severe cognitive impairment. Resident #16 had inattention and disorganized thinking, which came and went. The MDS reflected Resident #16 had physical, verbal, and other behaviors 1 to 3 days during the look-back period. Resident #16 was usually dependent on staff for toileting hygiene. Resident #16 was always incontinent of bladder. The MDS reflected Resident #16 had no active infections within the last 30 days. Record review of the comprehensive care plan, dated 10/10/25, reflected Resident #16 had bladder incontinence related to weakness mobility deficits. The interventions included: educate the resident and responsible party/family on proper perineal hygiene practices, monitor resident for signs or symptoms of UTI, perform routine rounding to include incontinence care and brief changes, and report any changes in skin integrity to the charge nurse. During an observation on 12/09/25 beginning at 3:50 PM, CNA D washed her hands and applied an isolation gown and gloves. She set up her supplies and started incontinent care. She cleaned Resident #16 from the front, rinsed, and dried. CNA D turned Resident #16 to the back and cleaned, rinsed, and dried. CNA D adjusted Resident #16's covers, then removed her gloves. CNA D used the same pair of gloves and did not perform hand hygiene during the whole incontinent care observation. During an interview on 12/10/25 beginning at 12:50 PM, CNA D stated she normally worked Resident #16's hallway. CNA D stated she should have changed her gloves and performed hand hygiene when she went from the front to the back and before she went from dirty to clean. She said she should have removed her gloves before touching anything that was clean. She stated she was checked off on incontinent care and usually did it correctly. She stated she was just nervous because the state surveyor was observing her. She stated it was important to ensure infection control practices were followed during incontinent care to prevent bacterial contamination. During an interview on 12/10/25 beginning at 2:03 PM, the DON stated she expected staff to ensure hand hygiene was performed during meals when trays were passed and during incontinent care when going from dirty to clean, and from the front to the back. The DON said she expected staff to ensure their gloves were changed when they were soiled. She said nursing management was responsible for ensuring infection control practices were followed during mealtimes and incontinent care. She stated it was important to follow infection control procedures to prevent harm or sickness from infections. During an interview on 12/10/25 beginning at 2:22 PM, the Administrator stated he expected the staff to ensure infection control policies and procedures were followed. He stated the infection control preventionist was responsible for monitoring to ensure the staff followed infection control practices. The Administrator stated it was important to ensure infection control policies and procedures were followed to stop the spread of infection. Record review of the Perineal Care policy, revised December 2023, reflected the facility will provide perineal care in a manner that maintains privacy, reduces the risk of infection, and promotes skin integrity.preparation.wash hands thoroughly and apply gloves. applying clean brief. remove soiled gloves and dispose of them properly, perform hand hygiene thoroughly, apply new clean gloves. Record review of the Infection Control Program policy, revised June 2024, reflected the facility is dedicated to maintaining a safe and healthy environment by implementing an effective infection control program that adheres to state and federal regulations and follows evidence-based practices recommended by the CDC. The policy did not specifically address hand washing or hand hygiene.

Based on observation, interview and record review, the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 8 of 16 residents (Resident #15, Resident #20, Resident #24, Resident #27, Resident #37, Resident #38, Resident #48 and Resident #49) reviewed for food and nutrition services. 1. The facility failed to ensure residents received food that tasted good. 2. The facility failed to ensure residents received food with an appetizing appearance, texture, and appropriate temperature. These failures could place residents at risk of weight loss, altered nutritional status and diminished quality of life. 1. Record review of a face sheet, dated 12/08/25, revealed Resident #15 was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including major depressive disorder (a serious mood disorder causing persistent sadness, loss of interest, and impaired daily functioning, stemming from a mix of genetic, biological, environmental, and psychological factors), anxiety and depression. Record review of a quarterly MDS assessment, dated 10/29/25, revealed Resident #15 was understood and understood others. The MDS revealed Resident #15 had a BIMS score of 15, which indicated intact cognition. During an interview on 12/08/25 at 8:59 a.m., Resident #15 said the food was too salty when one person cooked and when another person cooked they don't know what salt is. She said the facility did not serve gravy and the meat was so dry. During an observation and an interview on 12/08/25 at 12:07 p.m., Resident #15 was in bed with her meal tray in front of her. She removed the cover from the plate, and she said, it does not smell good and looks horrible. She tasted the chicken dish. She said it had no flavor. She said the tortillas in the chicken casserole were tough. She said the cornbread looked under baked. She said it was warm. She tasted the cornbread. She said, it could have cooked a few more minutes. She tasted the green beans and said they were bland. She said she was not excited about the diced peaches. She said they served a lot of canned fruits. She tasted the peaches and said they tasted like canned peaches. She said she was just tired of canned fruits. She tasted the iced tea and said, it could be stronger, It is very watery. She said watery tea was a common thing. During an interview on 12/10/25 at 8:29 a.m., Resident #15 said this morning (12/08/25) her scrambled eggs were dry. She said she preferred fried eggs over easy. She said she was able to get them for a few months. She said now she was told by staff that she could only have fried eggs on fried egg day. She said she did not even know when fried egg day was and she felt she should be able to have fried eggs if she wanted them. She said she had been getting them until two weeks ago. She said at lunch, on 12/09/25, the Shepherd's Pie had no flavor, and her honey dew melon was not ripe. She said the facility were wasting their money buying honey dew melons because it was never good. She said sometimes food was burned on the bottom. 2. Record review of a face sheet, dated 12/08/25, revealed Resident #20 was a [AGE] year-old male and who was admitted to the facility on [DATE] with diagnoses including major depressive disorder (persistent sadness or loss of interest, significant changes in sleep/appetite, fatigue, feelings of worthlessness, difficulty concentrating, and thoughts of death or suicide, lasting nearly every day for at least two weeks and affecting daily life), dysphagia (difficulty swallowing), and anxiety disorder.Record review of an annual MDS assessment, dated 11/23/25, revealed Resident #20 was understood and understood others. The MDS revealed Resident #20 had a BIMS score of 11, which indicated the resident had moderately impaired cognition.During an interview on 12/08/25 at 9:25 a.m., Resident #20 said the food was terrible. He said some days it was too salty and sometimes not salty enough. He said the pancakes were hard on the morning of 12/08/25. During an observation on 12/08/25 at 11:32 a.m., Resident #20 was served his lunch tray. The cornbread appeared pale in color and looked under cooked. During an observation and an interview on 12/08/25 at 11:42 a.m., Resident #20 said there was a piece of plastic in his peaches. There was a small piece of plastic lying on the table near his plate. Staff offered him more peaches. He said he did not want them or anything else. 3. Record review of a face sheet, dated 12/08/25, revealed Resident #24 was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing), anxiety, and major depressive disorder (persistent sadness or loss of interest, significant changes in sleep/appetite, fatigue, feelings of worthlessness, difficulty concentrating, and thoughts of death or suicide, lasting nearly every day for at least two weeks and affecting daily life). Record review of a quarterly MDS assessment, dated 09/05/25, revealed Resident #24 was usually understood and usually understood others. The MDS revealed Resident #24 had a BIMS score of 09, which indicated the resident had moderately impaired cognition. During an interview on 12/08/25 at 8:42 a.m., Resident #24 said the food was bad. She said the food did not taste good. She said the food was too salty. 4. Record review of a face sheet, dated 12/08/25, revealed Resident #27 was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including depressive episodes, anxiety disorder, and muscle weakness. Record review of a quarterly MDS assessment, dated 10/31/25, revealed Resident #27 was understood and understood others. The MDS revealed Resident #27 had a BIMS score of 13, which indicated the resident had intact cognition. During an interview on 12/08/25 at 9:12 a.m., Resident #27 said the food did not taste good. She said the food was either too salty or not salty enough. She said this morning (12/08/25) they served rubber pancakes. She said the pancakes were hard. 5. Record review of a face sheet, dated 12/08/25, revealed Resident #37 was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including generalized anxiety disorder, heart failure, and depression. Record review of a MDS assessment, dated 11/17/25, revealed Resident #37 was understood and understood others. The MDS revealed Resident #37 had a BIMS score of 14, which indicated the resident had intact cognition. During an interview on 12/08/25 at 8:34 a.m., Resident #37 said the food was cold and tasted like slop. 6. Record review of a face sheet, dated 12/08/25, revealed Resident #38 was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including stroke (when the blood supply to part of the brain is blocked or reduced), depressive episodes, and major depressive disorder (persistent sadness or loss of interest, significant changes in sleep/appetite, fatigue, feelings of worthlessness, difficulty concentrating, and thoughts of death or suicide, lasting nearly every day for at least two weeks and affecting daily life). Record review of a MDS assessment, dated 11/22/25, revealed Resident #38 was usually understood and usually understood others. The MDS revealed Resident #38 had a BIMS score of 12 which indicated the resident had moderately impaired cognition.During an interview on 12/08/25 at 9:25 a.m., Resident #38 said the eggs were cold and the food tasted like poop. 7. Record review of face sheet, dated 12/08/25, revealed Resident #48 was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including recurrent depressive disorder, anxiety and muscle weakness. Record review of MDS assessment, dated 11/23/25, revealed Resident #48 was understood and understood others. The MDS revealed Resident #48 had a BIMS score of 14, which indicated the resident had intact cognition.During an interview on 12/08/25 at 11:40 a.m., Resident #48 said the food was not good. She said she did not like the lunch (on 12/08/25) and would not eat it. She said she did not want a substitute. She said the food was horrible. 8. Record review of a face sheet, dated 12/08/25, revealed Resident #49 was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including anxiety disorder, heart failure, and protein-calorie malnutrition. Record review of a MDS assessment, dated 07/10/25, revealed Resident #49 was understood and understood others. The MDS revealed Resident #49 had a BIMS score of 14, which indicated the resident had intact cognition.During an interview on 12/08/25 at 9:20 a.m., Resident #49 said the morning of 12/08/25 he was served cold eggs and hard pancakes. He said sometimes the food was too salty. During an observation and interview on 12/09/25 at 12:12 p.m., a lunch meal tray was sampled with three state surveyors and the Dietician. The tray consisted of Shepherd's Pie, carrots in butter, biscuit, honey dew melon, and diced canned peaches. The Dietician said she could taste the potatoes, meat, and vegetables in the Shepherd's Pie. The surveyors' observation was that the potatoes in Shepherd's Pie were bland with not much flavor. The honey dew melon was crunchy and hard. The biscuit was warm, but was slightly dry and crumbly, the peaches tasted like canned peaches. The Dietician said fruit was served as a dessert for almost every meal. During an interview on 12/09/25 at 2:12 p.m., the Dietician said typically there was a fruit as a dessert on the menu every day. She said if the Dietary Manager had a complaint, they should educate their cook and make sure they were following recipes. Then they should follow up with the residents to see how they felt about the food. She said a resident who did not like their food could cause them to have a poor outlook. During an interview on 12/09/25 at 2:56 p.m., the Dietary Manage said she did notice the pancakes served on 12/08/25 were hard. She said they were pre-cooked, and she discussed with staff that next time they just needed to be re-heated. She said she made food rounds every Thursday. She said she heard complaints about the food being too salty. She said she discussed food complaints with her staff when she heard them. She said she educated staff. She said she had not completed any written in-services. She said she had just verbally educated the staff. She said the menu was new. She said she tried to find what the residents actually liked and what they wanted. She said she did not want any resident to get sick or lose weight.During an interview on 12/10/25 at 9:10 a.m., CNA A said she heard food complaints. She said she heard things like the food was never good, there were small portions, the grits were watery, and the food did not look appetizing. She said when she heard complaints, she reported it to the nurse or DON. She said when she went to the kitchen, she went to ask them for something else. She said there were other options available in the kitchen. She said a resident who did not like the food could make them frustrated and not want to eat at all. During an interview on 12/10/25 at 9:25 a.m., RN B said she heard food complaints from the residents. She said, they just don't like it, they did not get enough and they were not children. She said she reported food complaints to the kitchen all the time. She said some residents complained about small portions. She said residents who did not like their food could cause malnutrition, unhealed wounds, not getting enough protein, and grouchiness. During an interview on 12/10/25 at 9:36 a.m., the DON said if she heard a food complaint, she would ask if she could get the resident something else. She said she wanted them to eat. She said she then let the dietary staff know about the complaints. She said she heard the food was bland. She said she reported this to the Dietary Manager. She said she bought burgers for residents. She said she heard complaints about small portions. She said she was told they were using the right scoops. She said residents could ask for seconds. She said a resident who did not like their food could cause them not to eat, get depressed, or lose weight. During an interview on 12/10/25 at 9:48 a.m., the Administrator said he made rounds during the week and observed meals during the day. He said they started menu at a glance where the Dietary Manager went over the menu with the resident council. The Dietary Manager went over the next week's menu with the residents. He said sometimes changes could be made as long as it kept the nutritional value. He said he heard no recent complaints. He said a few months ago they made adjustments as they could. He said dietary staff followed the recipes. He said residents not liking their food could cause general discomfort and stress. Record review of a Resident Council Concern Follow-Up Form, dated 10/09/25 at 2:00 p.m., indicated Chili on 10/07/25 was way to spicy (hot). The action taken indicated, I will re-educate the staff on seasoning use. To make sure they follow the recipe and reading the preference. The form was signed by the Administrator on 10/09/25. Record review of a Concern Form, dated 11/10/25, indicated the Dietary Manager was the staff receiving the grievance. The summary of the grievance was the resident doesn't like the chicken over fried rice & (and) spicy. The steps taken were the Dietary Manger talked to the cook and resident. The resolution indicated, I will re-educate staff and make sure we have Asian soy sauce we been use. Record review of a Meal Quality facility policy, last revised 06/2019, indicated .Meals are served attractively and at the correct temperature to enhance patient/resident acceptance and provide a pleasant homelike dining experience.serve foods that meet the patient's/resident's individual food preferences.

Based on interviews and record review, the facility failed to consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility for 16 out of 16 anonymous residents during a confidential meeting who were reviewed for resident rights. The facility failed to ensure the resident council food grievances were promptly resolved. This failure could place residents at risk for a decreased quality of life.The findings included: Record review of the Resident Council Meeting Minutes, dated 09/11/25, reflected New Business. C. Dietary - see form. The dietary form attached to the resident council minutes reflected .seasons food good.residents would like fried and boiled eggs, wheat bread for diabetics, toast is being made too hard. Record review of the Resident Council Meeting Minutes, dated 10/09/25, reflected New Business. C. Dietary - see form. The dietary form attached to the resident council minutes reflected .Chili on 10/07/25 was way too spicy (hot).residents requesting fried eggs, not scrambled. Record review of the Resident Council Meeting Minutes, dated 11/13/25, reflected New Business. C. Dietary - see form. The dietary form attached to the resident council minutes reflected certain residents were receiving fried eggs, and some still were not receiving fried eggs. The form reflected New Administrator was made aware of 'Menu at a Glance' on Thursday morning and about residents asking for real fried chicken, cottage cheese, and fried fish fillet. During a confidential interview on an undisclosed date and time, there were 16 Anonymous residents who attended the confidential interview. All 16 Anonymous residents indicated they felt their grievances about the food were not addressed or resolved promptly. The anonymous residents stated the food quality was terrible. They said the food was bland, cold, and they were served the same things over and over. All 16 anonymous residents agreed the food was discussed during every resident council meeting, and they felt like the food has not gotten any better. During an interview on 12/10/25 beginning at 1:21 PM, the AD stated she normally facilitated the resident council meetings at the residents' request. She said the food was a constant issue discussed in resident council meetings. She said she attempted to offer solutions such as education and purchasing specific food items or spices for the Bingo carts. The AD stated the previous administrator had talked about a spice rack for the dining room, but that had not been implemented. The AD stated none of the residents had asked for the spice rack. The AD stated every Thursday the Dietary Manager held a Menu at a Glance meeting so residents were able to voice their concerns. She said it was important to ensure the resident council concerns were addressed promptly so the residents felt like they had a voice and were able to make decisions for themselves. During an interview on 12/10/25 beginning at 2:22 PM, the Administrator stated the AD was responsible for facilitating the resident council meetings. He stated he had only been invited to one resident council meeting, and the food was discussed as a concern. He said a grievance form was completed and he felt like it was addressed. The Administrator stated there were general complaints about seasoning, but the facility erred on the cautions of less seasoning. He said it was hard to please everyone when it came to food complaints. He stated the dietary staff followed the recipes from the dietitian. He stated it was important to ensure resident council concerns were addressed so the residents felt like they had a voice. During an interview on 12/10/25 beginning at 3:11 PM, the Administrator stated he felt like the facility attempted to address the resident council concerns by completing grievance forms. He said he wanted it to be noted that the previous Dietary Manager had been replaced within the last 60 days. Record review of the Resident Council policy, revised June 2019, reflected The Nutrition/Culinary Services Director/Designee receives a copy of the Council meeting minutes and responds in writing to concerns identified and actions taken. A separate food committee can be formed at the discretion of the facility. The food committee reviews menus, makes menu suggestions, and helps plan meals for special events and holidays.

Based on observation, interview, and record review, the facility failed to ensure that a resident is offered sufficient fluid intake to maintain proper hydration and health for 1 of 16 resident (Resident #39) reviewed for hydration. The facility failed to ensure Resident #39 had a water pitcher at his bedside on 12/08/25, 12/09/25, and 12/10/25. This failure could place residents at risk for decreased quality of care and dehydration. The findings included: Record review of the face sheet, dated 12/10/25, reflected Resident #39 was a [AGE] year-old male who admitted to the facility on [DATE], with diagnoses of rhabdomyolysis (rare and life-threatening condition where your muscles break down and release toxins into your blood and kidneys), heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's need for blood and oxygen), and chronic kidney disease (kidneys are damaged over time, leading to a decline in their ability to filter blood effectively). Record review of the admission MDS assessment, dated 11/08/25, reflected Resident #39 had clear speech, was understood by others, and was able to understand others. Resident #39 had a BIMS score of 5, which indicated severe cognitive impairment. Resident #39 had no behaviors or refusal of care during the look-back period. The MDS reflected Resident #39 usually required supervision or touching assistance with eating, which included liquids. Resident #39 received parenteral/IV feeding while a resident, on admission, and while not a resident. Resident #39 received 500 mL/day or less by IV or tube feeding. Record review of the comprehensive care plan, dated 11/13/25, reflected Resident #39 required regular/thin consistency liquids for nutritional support and was at risk for unplanned weight loss and nutritional complications. The goal was Resident #39 would have adequate nutritional/fluid intake and would be free from unplanned weight loss or other nutritional complications over the next 90 days. The interventions included: assist with eating as indicated. Record review of the comprehensive care plan, dated 11/13/25, reflected Resident #39 had a history of hypertension (high blood pressure). The interventions included: encourage fluid intake within dietary limits. Record review of the comprehensive care plan, dated 11/13/25, reflected Resident #39 had a history of constipation. The interventions included: encourage fluid intake within dietary limits. Record review of Resident #39's physician orders list reflected an order for a Regular diet, regular texture, regular/thin consistency liquids, which was revised on 12/10/25. During an observation and interview on 12/08/25 beginning at 8:54 AM, Resident #39 was sitting up on the side of his bed, facing the window. His bedside table was in reach and did not have a water pitcher on it. He stated the facility staff took his water pitcher out last week and never brought it back. During an observation on 12/09/25 at 8:33 AM, Resident #39 was lying in bed facing the window. There was no water pitcher at the bedside. During an interview on 12/10/25 beginning at 12:50 PM, CNA D stated she did not normally work Resident #39's hall. She said she provided ice water at the beginning of her shift daily and then again toward the end of her shift. She stated if a resident did not have an ice pitcher, she was supposed to have gotten one from dietary. CNA D stated she was unsure if Resident #39 had a water pitcher. She stated some residents did not like the facility water pitchers and preferred to use their own, but she was unfamiliar with Resident #39 and his hall. CNA D stated it was important to ensure the residents had access to water so they could stay hydrated and drink if they were thirsty. During an observation and interview on 12/10/25 beginning at 12:58 PM, CNA F stated she normally worked on Resident #39's hallway. She stated she passed ice water at the beginning of her shift and then as needed throughout the day. She stated she had already passed ice this morning on her hallway, which included Resident #39. She said if a resident did not have a water pitcher, then she would have gotten one from the kitchen. The state surveyor and CNA F went into Resident #39's room and there was no water pitcher. CNA F explained she had not been in Resident #39's room and saw him up wheeling around the facility. CNA F stated she was going to get him a water pitcher after our conversation. CNA F said it was important to ensure Resident #39 had a water pitcher to prevent dehydration and UTIs. During an interview on 12/10/25 beginning at 1:12 PM, the Treatment Nurse stated CNAs should have been passing ice at the beginning of their shift and then again toward the end of their shift, since they work 12 hours. She stated night shift frequently picked up all the water pitchers to be washed and then they were replaced in the morning to maintain sanitization. The Treatment Nurse stated she was unaware Resident #39 did not have a water pitcher at his bedside. She stated she would provide education to the facility staff and ensure he got one. The Treatment Nurse stated having a water pitcher at the bedside was important to prevent dehydration, which also helped with the skin and kidney function. During an interview on 12/10/25 beginning at 2:03 PM, the DON stated she expected all the residents to have a water pitcher unless they could not have anything by mouth. The DON stated water pitchers were picked up and cleaned during the night shift at least 3 times a week and then passed back out the next morning. The DON stated the staff were supposed to pass fresh ice water in the morning and in the evening. The DON stated the nurses were responsible for monitoring to ensure ice water pitchers were at the bedside. The DON stated it was important to ensure ice water was at the bedside to ensure the residents stayed hydrated. During an interview on 12/10/25 beginning at 2:22 PM, the Administrator stated he expected the staff to follow the hydration policy. The Administrator stated he was unsure who was responsible for monitoring to ensure water pitchers were at the bedside. He said he needed to review the policy. The Administrator stated it was important to ensure water pitchers were at the bedside to maintain hydration. Record review of the Water Pitchers/Cups policy, revised June 2019, reflected It is the policy of this facility that the staff will clean reusable water pitchers and glasses according to facility practice guidelines. when supplies are available, return the water pitcher, drinking cup, and tray (if applicable) to the resident's room. fill pitcher with ice water. note: if resident is on thickened liquid, no water is placed at the bedside. if the resident is on fluid restriction refer to his/her specific plan of care.

Based on observation, interview and record review the facility failed to ensure each resident received and the facility provided food that accommodated the resident allergies, intolerances and preferences 1 of 16 residents (Resident #19) reviewed for food and nutrition services. The facility failed to ensure Resident #19's food preferences and listed food allergy were honored. This failure could place residents at risk for dissatisfaction, poor intake, and/or weight loss.Record review of a face sheet, dated 12/08/25, revealed Resident #19 was [AGE] years old and admitted to the facility on [DATE] with diagnoses including dementia , paranoid schizophrenia (a disorder with a common presentation where paranoia, intense delusions [like persecution], and vivid hallucinations [often auditory] dominate, while other cognitive functions remain relatively intact), and major depressive disorder (a serious mood disorder causing persistent sadness, loss of interest, and impaired daily functioning, stemming from a mix of genetic, biological, environmental, and psychological factors). Record review of a quarterly MDS assessment, dated 09/05/25, indicated Resident #19 was understood and understood others. The MDS indicated Resident #19 had a BIMs of 13, which indicated her cognition was intact. The MDS indicated Resident #19 required setup or clean-up assistance with eating. Record review of Care Plan, last revised 09/28/25, indicated Resident #19 was at risk for allergic reaction due to allergies to eggs and yeast. There was an intervention to review diet for food allergies. Record review of an Order Summary, dated 12/08/25, for Resident #19 indicated an order for a regular diet with regular texture. The orders did not indicate any food allergies. Record review of the Electronic Medical Record for Resident #19, accessed 12/08/25 - 12/10/25, indicated allergies of egg and yeast. Record review of a Progress Note for Resident #19 dated 12/09/25 at 10:15 a.m., indicated Spoke with RP (representative).and he verified that (Resident #19) is not allergic to eggs or yeast. He told us she will think she is allergic to stuff and tell you, but she was not allergic to anything that he knew of. The Progress Note was signed by the DON. During an interview on 12/08/25 at 9:08 a.m., Resident #19 said she could not eat eggs and the kitchen kept sending her eggs. During an observation and interview on 12/09/25 at 8:18 a.m., Resident #19 was sitting on the side of her bed with her breakfast tray in front of her. She said there were eggs on her tray. She said she was served eggs every morning. She said she was told not to eat eggs or yeast. She said she had not had a reaction, and she just did not eat the eggs. There were scrambled eggs on her plate with sausage mixed in. The meal ticket on her tray indicated the resident was served egg and sausage casserole and did not indicate an egg allergy. She said she was told as a child that if she ate eggs, it would kill her. She said she was just eating the cereal on her tray and that was all she wanted. During an interview on 12/09/25 at 2:12 p.m., the Dietician said she would expect adequate communication between nursing staff and dietary concerning allergies and preferences. She said typically upon admission preferences were obtained. She said the dietary manager sometimes rounded in the dining room to obtain preferences and they liked to see preferences obtained quarterly from each resident. She said the outcome of a resident being served a food they were allergic to could be a number of things. During an interview on 12/09/25 at 2:56 p.m., the Dietary Manager said when a resident admitted to the facility nurses were supposed to send a paper to dietary listing allergies and food preferences. She said she also visited each new resident to discuss food allergies and food preferences. She said Resident #19 was admitted 2 years ago and her dietary card had not been updated. She said she talked to Resident #19, and she did not have an actual allergy to eggs but did not want to be served eggs. She said residents being served food they had an allergy to, could cause itching or difficulty breathing. During an interview on 12/10/25 at 9:10 a.m., CNA A said Resident #19 had been served eggs. She said they found out she was truly not allergic, but it was charted that she was. She said the resident had told her she was hoodooed (hexed) when she was a child and could not eat eggs. CNA A said she told the kitchen in the past, but eggs were still served. She said Resident #19 did not want eggs on her plate. She said in the past Resident #19 had eaten fried eggs and had no reaction. She said Resident #19 did not eat cheese either. She said there were just foods Resident #19 did not like. During an interview on 12/10/25 at 9:25 a.m., RN B said Resident #19 just did not like eggs. She said it depended on how the eggs were served to her. RN B said it had to do with her religion and her beliefs. She said if Resident #19 did not want eggs she should not be served eggs. She said all she had to do was tell them and they would get her something else. She said she never told the kitchen Resident #19 was served eggs because she had not made her complaint known to her. During an interview on 12/10/25 at 9:36 a.m., the DON said if Resident #19 did not want eggs, she did not want them. She said the only time she should be served eggs was when she asked for them. She said there were times she asked for them. She said she spoke to Resident #19's family member and he said she was not allergic to eggs. She said food preferences not being honored could cause residents to not want to eat their food and lose weight. She said a resident with an actual allergy could be caused harm if served the food they were allergic to.During an interview on 12/10/25 at 9:48 a.m., the Administrator said he expected staff to not serve food a resident was allergic to or food the resident preferred not to have. He said the Dietary Managers addressed food preferences on admission. He said allergic reactions could have a wide range from mild discomfort to a rash. He said a residents' food preference, not being honored, could lead to emotional discomfort.Record review of a Food Allergies facility policy, last revised 06/2019, indicated, .Patients/residents with food allergies will be provided with safe food/fluids, and appropriate substitutions to maintain their health.identified food allergies are documented in the medical record and communicated to the appropriate departments and personnel.the diet order must include the primary diet order and a listing of all known food allergies.When food allergies are listed as part of the diet order the Nutrition/Culinary Services Director. dietitian, or designee will interview the patient/resident to clearly identify and confirm all food allergies.The words allergic to may be printed on the meal ticket using dietary notes.Record review of a Meal Quality facility policy, last revised 06/2019, indicated, .serve foods that meet the patient's/resident's individual food preferences.

Based on interview and record review the facility failed to provide pharmaceutical services including procedures that assured the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals to meet the needs of each resident and determined that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for 1 of 3 residents (Resident #46) reviewed for pharmacy services. The facility failed to ensure Resident #46's as needed Tylenol #3 (narcotic pain medication) was signed out in the electronic medical record, when it was given on 12/02/25, 12/04/25, and 12/06/25. This failure could place residents at risk for medication errors and loss of medications through drug diversion. The findings included: Record review of the face sheet, dated 12/10/25, reflected Resident #46 was a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses of osteoarthritis (degenerative joint disease characterized by the progressive deterioration of the cartilage around the joints) and pain. Record review of the quarterly MDS assessment, dated 09/30/25, reflected Resident #46 had clear speech, was understood by others, and was able to understand others. Resident #46 had a BIMS score of 11, which indicated moderately impaired cognition. Resident #46 had no behaviors or refusal of care during the look-back period. The MDS reflected Resident #46 received as needed pain medications. Resident #46 stated he had occasional pain that occasionally effected sleep, therapy activities, and normal day-to-day activities. Resident #46 rated his worst pain at a 4 on a 0-10 pain scale. Record review of the comprehensive care plan, last reviewed 08/29/25, reflected Resident #46 complained of pain and was at risk for further episodes of increased pain. The interventions included: utilize numbers scale to assess pain level, observe for signs and symptoms of increased pain, assess resident for possible causes of pain and give pain medications, treatments, and relaxation modalities, check for effectiveness, and monitor for side effects of pain medication and report to the physician if noted. Record review of Resident #46's physician order listed an order for Acetaminophen-Codeine Tablet 300 mg - 30 mg (Tylenol #3, a narcotic pain medication) - Give 1 tablet by mouth every 6 hours as needed for pain, which started on 02/12/25. Record review of the Controlled Drug Administration Record for Resident #46's Tylenol #3 reflected the following:1. On 12/02/25 at 4 PM, one tablet was given by LVN G.2. On 12/04/25 at 8 PM, one tablet was given by LVN H.3. On 12/06/25 at 8 AM, one tablet was given by LVN G. Record review of the MAR, dated December 2025, reflected Resident #46's Tylenol #3 was not signed out on 12/02/25, 12/04/25, or 12/06/25. During an interview on 12/08/25 beginning at 1:26 PM, Resident #46 stated he had Tylenol #3 prescribed as needed every six hours for pain if he needed it. He stated that he normally received his pain medication when he requested it. During an interview on 12/10/25 beginning at 9:31 AM, the DON stated the process for administering narcotic medications included signing off the medication on the electronic MAR and the narcotic count sheet. She said she expected the nurses to give the medication and then document they gave the medication. She said the facility had a process for monitoring the nurses to ensure they were signing off on the MAR, but she and the ADON were working the floor, so monitoring was not completed. She stated it was important to ensure the nurses were signing out narcotic pain medications on the electronic MAR to prove they did not take the drug and to ensure residents were not in pain. During an interview on 12/10/25 beginning at 1:29 PM, LVN G stated when a resident complained of pain, she first performed a pain assessment and asked the resident to rate the pain. LVN G stated if the resident requested medication for pain, it should have been signed out on the narcotic count sheet, and then the electronic MAR. LVN G stated she did not always sign out Resident #46's narcotic pain medication administration in both places. She said by the time she got to the computer to sign the medication out, she got distracted and forgot. She stated it was important to ensure narcotic pain medications were accurately reconciled to prevent Resident #46 from receiving too many pills and to ensure an accurate record was kept. During an attempted telephone interview on 12/10/25 at 1:43 PM, LVN H did not answer the phone, and no return call was received before exiting the facility. During an interview on 12/10/25 beginning at 2:22 PM, the Administrator stated he expected staff to ensure narcotic pain medications were signed out as they were given. The Administrator stated the nursing management was responsible for monitoring to ensure narcotic pain medications were reconciled appropriately. He said it was important to ensure narcotic pain medications were reconciled appropriately for proper medication administration. Record review of the Medication Administration and Management policy, revised June 2019, reflected .Authorized licensed or certified/permitted medication aide or by state regulatory guidelines staff must understand. the '8 Rights' for administering medication.6) the right charting.medications are prepared, administered, and recorded by the same authorized medical/licensed staff. the authorized licensed or certified/permitted medication aide or by the state regulatory guidelines staff member documents that the medication is given in the correct slot of MAR, before going to the next patient/resident.

Based on observation, interview, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as was possible for 1 of 3 Halls (Hall C) reviewed for accidents and supervision. The facility failed to ensure an unsecured shower room did not contain bath wash, disinfectant, which was labeled Keep out of the reach of children and a package of disposable razors This failure could place residents at risk for accidents that could lead to injuries. Findings include: During an observation on 12/08/2025 at 8:15 a.m., revealed the shower room on C hall was not locked. The shower room contained a plastic cabinet approximately 6 feet tall and was missing 1 of the 2 doors. The cabinet contained 2-6 ounce bottles of body wash and were labeled to keep out of reach of children. There was a package of disposable razors noted in the cabinet. There were no residents, or staff near the shower door at this time. During an observation on 12/08/25 at 9:17 a.m., revealed the doorknob was set to lock, but the door was not latched and pushed opened. The shower room contained a plastic cabinet approximately 6 feet tall and was missing 1 of the 2 doors. The cabinet contained 2- 6-ounce bottles of body wash and labeled to keep out of reach of children. There was a package of disposable razors noted in the cabinet. There was a 32-ounce clear bottle which contained approximately 14 ounces of yellow liquid. The bottle was labeled disinfectant and labeled to keep out of reach of children. During an interview on 12/08/25 at 9:38 a.m., CNA C and CNA D said the shower room was to be locked when not in use. CNA D said the cabinet was not broken on Friday (12/05/25) and they would also lock the cabinet. CNA C and CNA D said the residents could wander in the shower room and get hurt, injured with the chemical or the razors. The CNAs said they were trained in preventing accidents . CNA C and CNA D said they were unsure why the door was not locked and could be just pushed open. During an interview on 12/08/25 at 9:45 a.m., the Director of Support Services said the hall 200's shower door was not latching properly and was not reported to her. She said there was a lock on the cabinet in the shower. The Director of Support Services walked into the shower room and said no one had reported the cabinet door was broken off the cabinet. She said the supplies must be secured to prevent accidents. During an interview on 12/08/25 at 10:00 a.m., the DON said her expectations were when doors were broken to report to the Director of Support Services and herself immediately. The DON said the cabinet must be kept locked unless the staff were giving a shower. Record review of the Policies and Procedures Housekeeping Chemical Storage & Security Policy, dated 2/2022, indicated . the facility ensures all housekeeping chemicals are safely stored and secured to prevent resident, visitor, or unauthorized staff access. Chemicals must remain locked in carts, storage rooms, and closets at all times when not actively in use. 2. Chemical Closets / Storage Rooms All chemical storage areas must remain locked at all times. Only authorized staff may access these areas. After removing or returning supplies, staff must close and secure the door.

Based on observation, interview, and record review, the facility failed to ensure the resident had the right to a safe, clean, and comfortable homelike environment for 1 of 16 residents (Resident #40) reviewed for physical environment. The facility failed to ensure Resident #40's room was cleaned and in good repair. This failure could place residents at risk for a decreased quality of life and an unsanitary environment. The findings included: Record review of the face sheet, dated 12/09/25, reflected Resident #40 was an [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of cancer of the tongue. Record review of the MDS tab in the electronic charting system, reflected Resident #40's admission MDS assessment was in progress and had not been completed yet. Record review of the baseline care plan, initiated on 12/02/25, reflected Resident #40 was new to the nursing facility and required adjustment. Record review of the nursing progress notes, dated between 12/01/25 and 12/10/25, reflected Resident #40 was alert, and oriented to person, place, time, and her situation. There were no cognitive concerns documented. During an interview and observation on 12/09/25 beginning at 11:34 AM, Resident #40 stated the toilet in her bathroom was constantly running. She said every time she washed her hands; her shirt became wet from the spray of the faucet. She said her window was opened on Saturday and it was filthy. She said her walls had missing paints. The state surveyor observed Resident #40's back wall beside her bed had a small area with missing paint and deep gouges in the sheetrock near the floor. The blinds were open; they were warped and appeared wavy. The window was slightly raised. There was a thick layer of brown gritty substance and dark brown gritty clumps between the outside screen and window. The state surveyor turned on the faucet in the bathroom and the state surveyors name badge became wet. The toilet was running. Resident #40 said she reported the issues to staff but stated no one tried to fix it yet. Resident #40 stated it made her feel disappointed with the facility because things were not completed the way she did them at her own home. During an interview on 12/10/25 beginning at 12:58 AM, CNA F stated Resident #40 reported her toilet was running, but she jiggled the handle, and it stopped. CNA F stated she instructed Resident #40 to jiggle the handle. CNA F stated she did not notice Resident #40's walls, blinds, windowsill, or the faucet spray. CNA F stated if issues with the room maintenance were reported or observed she would have notified the Director of Support Services verbally. CNA F stated it was important to ensure the room was cleaned and in good condition to ensure a sanitary and homelike environment was maintained. During an interview on 12/10/25 beginning at 1:12 PM, the Treatment Nurse stated she was also the unit manager for Resident #40's hallway. She stated Resident #40 had not reported any concerns about her room, toilet, or faucet to her knowledge. She said there was an electronic system that created work orders for environmental, or maintenance issues and the staff would also verbally notify the Director of Support Services. The Treatment Nurse stated it was important to ensure the rooms were cleaned and in good repair so the residents might feel more at home. During an interview on 12/10/25 beginning at 1:55 PM, the Director of Support Services stated if a resident reported or staff observed an environmental or maintenance concern, they placed it in the electronic system that created a work order. She stated she spoke with Resident #40 on 12/09/25 but had not received any work orders. The Director of Support Services stated Resident #40 reported her sink was messing up and she became wet every time she washed her hands. She said performed rounds on the rooms scheduled to be deep cleaned. She said she looked at things like the walls, the bathrooms, and general cleanliness and repairs needed during the rounds, but did not notice the concerns in Resident #40's room. The Director of Support Services stated rooms were prepared when one resident was discharged and another resident was ready for admission. She stated she usually knew when residents were admitted but did not always know which room they were going into. She said it was important to ensure rooms were cleaned and in good repair for resident safety and to maintain a homelike environment. During an interview on 12/10/25 beginning at 2:22 PM, the Administrator stated Resident #40's family opened the window on the previous weekend, and the facility staff were unaware of the dirt buildup. The Administrator stated that was absolutely not something they would monitor on a regular basis. The Administrator stated he expected the housekeeping staff to follow the room ready checklist but was unsure what that entailed. He stated he expected the checklists, policy, and protocols to have been followed for cleaning rooms, and getting them ready for new residents. The Administrator stated it was important to ensure the rooms were cleaned and in good repair to provide a homelike environment. Record review of the maintenance logs for December 2025, reflected no entries for Resident #40's room. Record review of the Dignity: Resident's Rights for policy, revised June 2019, reflected .create a home-like environment for the resident that includes: .clean, orderly, comfortable, safe environment.

Based on observations, interviews, and record review, the facility failed to establish policies, in accordance with applicable, Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents for 1 of 2 residents (Resident #5) reviewed for smoking and smoking policy. The facility failed to complete a quarterly smoking assessment for Resident #5 per facility policy. This failure could place residents at risk of an unsafe smoking environment and injury. Findings included: Record review of Resident #5's smoking - safety screen indicated the last and only assessment was completed on 04/16/24 and indicated she was a safe smoker. Record review of Resident #5's admission record, dated 12/10/25, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had diagnose which included dementia (decline in memory, judgment and thinking), bipolar (extreme mood swings) and seizures (temporary disruption of brain activity). Record review of the facility's, undated, Smokers list provided by the facility, identified Resident #5 as a smoker. Record review of Resident #5's comprehensive MDS assessment, dated 04/03/24, indicated a [AGE] year-old female. Resident #5's BIMS score was 15, which indicated she was intact with cognition. She used tobacco. Record review of Resident #5's care plan, dated 09/17/25, indicated she was a tobacco smoker and was at risk for injury. Resident #5 was a smoker and had the potential for injury related to smoking. The care plan indicated smoking assessment was completed on 04/16/24 deemed her safe smoker. Staff were to provide adequate supervision as indicated. Routinely complete Safe Smoking risk assessments to assess for safe smoking status, supervision required, and any assistive devices needed Safe Smoking will occur during designated safe smoking times and in the designated safe smoking areas safe to smoke with supervision. During an interview and observation on 12/08/25 at 12:30 p.m., Resident #5 was sitting outside with a staff member, and she was smoking without assistance. During an interview on 12/09/25 at 1:00 p.m., the DON said she and the management team were responsible for completing the smoking assessment every quarterly review. She said the electronic system would alert her when assessments were due. She said the only smoking assessment was completed on 04/16/24 in Resident #5's electronic records. She said the assessments had to be completed quarterly in case the residents required more assistance with smoking to prevent accidents. She said the electronic system did not alert her the assessment needed to be completed. Record review of the facility's Policies and Procedures Safe Smoking, dated March 2024 . Residents who desire to smoke will be assessed using the safe smoking screen, document in (electronic record). Assessments will be conducted at admission and quarterly.

Based on 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 of 5 residents (Resident #1 and Resident #2) reviewed for medical records accuracy. The facility did not accurately document every time Resident #1, and Resident #2 was provided with incontinent care or checked for incontinence on the CNA flow sheet dated November 2025. This failure could affect residents whose records are maintained by the facility and could place them at risk for not receiving needed care and treatment. The findings included: Record review of Resident #1's face sheet indicated she was admitted on [DATE] was a [AGE] year-old female with diagnosis including stroke and high blood sugar. Record review of the significant change MDS assessment dated [DATE] indicated Resident #1 required total care for toileting hygiene per staff. She was always incontinent with bowel and bladder. Resident #1's BIMS was 03 which indicated severely impaired cognition. Record review of Resident #1's care plan dated 10/13/25 indicated she was incontinent of bladder and bowel and required routine rounding to include incontinence care and brief changes. Record review of Resident #1's November 2025 CNA flowsheet had documentation to indicated she was frequently checked however with no documentation to indicate she was provided with incontinent care. Record review of Resident #2's face sheet indicated a [AGE] year-old female admitted to facility on 11/30/2018, with diagnosis including stroke and gastric tube feedings. Record review of the annual MDS assessment dated [DATE] indicated Resident #2's BIMS score was 00, which indicated severe impairment for cognitive abilities. Resident #2 required total care for toileting hygiene per staff. She was always incontinent with bowel and bladder. Record review of Resident #2's care plan dated 08/05/25 indicated a history of bladder and bowel incontinence and required routine rounding to include incontinence care and brief changes. Record review of Resident #2's CNA flowsheet dated November 2025 indicated interventions of clean peri-area with each incontinent episode, check resident frequently and assist with toileting as needed and provide peri care after each incontinent episode. During an interview and record review on 11/24/25 at 1:00 p.m., CNA A said she checked Resident #1 and Resident #2 every 2 hours and provided incontinent care as needed and said there was no place to chart each. She said you could chart one or two times per shift. She said there had been updates to electronic records in the past few months and she was not sure when it changed. She said she never asked about where to chart. During an interview on 11/24/25 at 1:30 p.m., the DON said the electronic record program had updates and incontinent care must have been removed. She said she was not sure how long the CNAs was not able to chart their checks every 2 hours for incontinent episodes and when they provided incontinent care. She said she was responsible for ensuring medical records were complete and accurate. She would have get with technical support to fix it so the CNAs would be able to chart the care given to the residents so the record would reflect care. Record review of the undated policy Electronic Medical Records indicated Electronic medical records are an acceptable form of medical record management and should be used in lieu of paper records when applicable.

Based on interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 3 residents reviewed for accidents and supervision. (Resident #1)The facility failed to provide adequate supervision for Resident #1 who was assessed as a high risk for elopement. On 03/23/25 CNA B who was assigned to cover the unit left the unit leaving the residents unattended. Resident #1 eloped from the unit and was found at his previous home address sitting on the porch steps approximately 1 mile from the facility. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 03/23/25 and ended on 03/27/25. The facility had corrected the non-compliance before the survey began. This failure could prevent residents from receiving appropriate supervision which could lead to resident sustaining serious injury or harm. Findings included: Record review of a face sheet dated 09/09/25 indicated Resident #1 was a [AGE] year-old male admitted on [DATE]. His diagnosis included dementia (loss of cognitive functioning), hypertension (a condition in which the force of the blood against the artery walls is too high), type 2 diabetes (a chronic condition that affects the way the body processes blood sugar), anxiety (persistent and excessive worry that interferes with daily activities) , and depression (mental illness that negatively affects how you feel, the way you think and how you act). Record review of a Baseline Care Plan dated 03/17/25 indicated Resident #1 resided on the secured unit with an intervention to conduct frequent checks on the resident, especially during high-risk times and he was at risk for elopement with an intervention to monitor resident. Record review of a Clinical Risk assessment dated [DATE] the Elopement Risk section indicated Resident #1 was a high risk. Record review of an admission MDS form dated 03/27/25 indicated Resident #1 had a BIMS score of 07 indicating he had severely impaired cognition. He had clear speech and understood others. He had other behavioral symptoms not directed towards others that occurred 1 to 3 days during the lookback period. He had no impairment of the upper and lower extremities. He used no mobility devices. The Functional self-care assessment indicated supervision/touching assistance with most ADLs. The Functional mobility assessment indicated he required supervision/touching assistance with ambulation. Record review of Nurse Notes for Resident #1 indicated the following:* an entry on 3/21/25 at 05:56 a.m., Resident restless this shift. Residing on memory care unit, attempted to follow RCS off unit and began banging on the double doors. Resident had been observed pacing from double doors back to room stating that he needs to go home. Resident upset that he is locked behind double doors. Writer was able to talk to and calm resident at this time.* an entry on 3/22/25 at 06:00 a.m., Resident resides on memory care unit. Resident does not understand why he is locked up and wants to go home and will stand at double doors in an attempt to walk out with someone.* an entry on 3/23/25 at 05:02 p.m., Patient was observed being aggressive today, patient banged on doors today. Nurse observed patient throwing belongings on the floor, when asked patient what was wrong, patient stated aggressively to leave him alone and to get out the room. Nurse was able to give patient his morning medications. Nurse continued to monitor and do routine rounds on patient. Patient continued to bang on unit doors, nurse redirected patient and explained to patient that he couldn't bang on doors, patient started hallucination sand told nurse that his mother was on the other side, and he needed to get to her. Nurse went to do routine round on patient, patient was not in room or any of the available beds on the unit, nurse notified administrator, DON, ADON to let them know that patient was not on the unit. Observed findings of a chair near fence that is said to believe what patient used to climb over fence, available Staff immediately took action, loaded cars to look for patient. Patient was found at last known address sitting on his porch, patient was not hurt, no bruising noted. Patient was accompanied by three staff members, patient refused to load the vehicle, after advising him that we need to get him home to safety, patient reconsidered and got in the vehicle. Patient was transported back to facility and was assessed by nurse, patient does not c/o any pain at this time, when asked patient what he was doing out he said that he needed to go to his mother house and cook for tomorrow, but he is back to facility now. Family Notified and is fully aware and was not upset about the situation. Family agreed to send patient out.Record review of a Provider Investigation Report dated 03/27/25 indicated the following:* LVN C reported that she saw Resident #1 at approximately 3:00pm and he was banging on the locked doors. She went to the door and calmed him down by talking to him.* At about 3:15pm, LVN C rounded on the unit and did not find Resident #1. LVN C and LVN F went directly to the unit to check on the two residents that were residing in the unit. They couldn't find Resident #1 in his room on the locked unit. They proceeded to search for Resident #1 in every room on the unit. They alerted all staff that she had a missing resident. Staff searched the facility. In the courtyard of the locked unit there was a chair in the corner fence area with a red garbage can on top of the chair. Resident #1's cane was found outside the fence in the area the chair was found at on the inside of the fence. LVN C noted maglock not locking when she went into the courtyard.* At 3:15 pm search initiated.* At 3:17 pm Sign-out book checked* At 3:16 pm Announcement made over intercom* 3:28 pm LVN F notified ADON* 3:29 pm ADON notified Administrator.* 3:30 pm Administrator notified DON* 3:31 pm Administrator notified DSS* 3:32 pm ADON notified the local Police Department. Report number 2251465* 3:40 pm Administrator notified the VPO and the Regional Nurse Consultant; and* 3:43 pm DSS found Resident #1 sitting on his porch steps of his house.* Resident #1 admitted to Behavioral hospital on [DATE].* 03/24/2025 No patients on the locked unit. Closed the locked unit.* 03/25/2025 Active Elopement Drill done with staff.* 03/26/2025 Active Elopement Drill done with staff* 03/27/2025 Staff Town Hall active elopement drill performed, and staff trained on elopement policy. During a phone interview on 09/09/25 at 12:10 p.m., HA A said he started his shift on 03/23/25 at 06:00 a.m. on the secured unit. He said there were only 2 residents on the unit at the time. He said they did everything for themselves so all he had to do was to monitor them so they would not elope. He said CNA B came on shift at 02:00 p.m. and LVN C told CNA B to relieve him so he could take a lunch. He said he did not think CNA B had went to the unit because he saw her sitting the nurse's station playing on her phone when he went into the break room. He said a short time later CNA B went into the break room and sat down. He said one of the nurses had come into the break room and ask if both HA A and CNA B were on break then who was on the unit. He said the nurse left the break room and went to the secured unit. He said Resident #1 was not found on the unit but a chair with a trash can on it was by the fence in the courtyard of the unit. During an interview on 09/09/25 at 06:30 p.m., LVN C said she told CNA B when she came on duty at 02:00 p.m. to relieve HA A on the secured unit so he could take a lunch break. She said she had issues with CNA B staying on the secured unit because she would leave to go to her car and then she left and went to the break room. She said Resident #1 had been at the double doors banging on them about 03:00 p.m. prior to him eloping that day, so she went to talk with him and calm him down. She said when she made rounds on the secured unit at 03:15 p.m. he was not located, and CNA B was not on the unit. An attempt was made to contact CNA B on 09/09/25 at 12:19 p.m., 12:25 p.m., and 01:05 p.m. but a recording indicated the phone number had been changed or no longer in service on all 3 attempts. During an interview on 09/09/25 at 01:08 p.m., the HKS said she was the DSS at the time of Resident #1's elopement. She said when she received the call about him missing, she was familiar with him, so she thought to go check at his house to see if he was there. She said he was sitting on the front porch steps at his house about a mile from the facility. She said she called the DON to let him know where he was and 3 staff came to get him. She said at first, Resident #1 did not want to get into the vehicle but eventually they were able to talk him into it and he was taken back to the facility. During an interview on 09/09/25 at 04:45 p.m., the DON said CNA B was told by LVN C to cover the secured unit so HA A could take a lunch break. She said it was found that CNA B did not go to the secured unit like she was told and Resident #1 eloped while not being attended. She said Resident #1 was sent to the behavioral hospital the next day. She said he was allowed to return with one-on-one monitoring until he was discharged to another facility out of town so he would not try to go home again. She said the secured unit was shut down the day after the incident. During an interview on 09/09/25 at 05:24 p.m., the Administrator said Resident #1's family placed him at the facility and had him placed on the secured unit because they said there had been an issue with him wandering off from his home. She said the secured unit was closed the day after Resident #1 had eloped. She said when the resident was found and returned to the facility, he was placed on one-on-one supervision until he was discharged to a sister facility out of town. She said they did the elopement drills with staff after the incident until 03/27/25 so they would ensure to have all most all the staff from different shifts in-serviced. Observations during the investigation from 09/08/25 through 09/10/25 indicated Hall A, previously designated as the Memory Care Secured Unit, was not utilized as a secured unit. Unable to interview Resident #1, he no longer resided at the facility. Record review of a Disciplinary Action Form dated 03/23/35 indicated CNA B was not on the unit as assigned by her charge nurse. CNA B was suspended while investigating the incident. CNA B was terminated after the investigation. The form was signed by the Administrator and DON on 03/27/25. Record review of an Education In-Service Attendance Record with subject of Elopement dated 03/23/25, indicated that 18 staff members (1 HA, 7 LVNs, 1 MA, 8 CNAs and 1 therapist) signed the in-service record regarding elopement policy. Record review of an Education In-Service Attendance Record with subject of Staff on Unit dated 03/23/25, indicated that 16 staff members (1 HA, 6 LVNs, 1 MA, and 8 CNAs) signed the in-service record regarding the unit must have a staff member on it at all times; assigned nurse is to make frequent rounds on the unit during their shift; and assigned nurse is to assign relief for assigned staff to take a break/lunch. Record review of a Wander/Elopement Drill Report dated 03/25/25 indicated a mock elopement/missing resident drill was conducted at 10:18 a.m. and 16 staff (admission Coord, AD, MDS Nurse, SW, Laundry staff, 2 CNAs, 3 LVNs, and 6 other staff) participated. Some were staff who were not listed on the other trainings on 03/23/25. Record review of a Wander/Elopement Drill Report dated 03/26/25 indicated a mock elopement/missing resident drill was conducted at 11:06 a.m. and 22 staff (ADON, admission Coord, MDS Nurse, Transportation, DSS, 1 hskp, 1 dietary, 1 laundry, 1 HA, 1 MA, 6 CNAs, and 3 LVNs) participated. Some were staff who were not listed on the other trainings on 03/23/25 and drill on 03/25/25. Record review of a Wander/Elopement Drill Report dated 03/27/25 indicated a mock elopement/missing resident drill was conducted at 02:13 p.m. and 15 staff (DSS, Director of Rehab, SLP, SW, 1 dietary, 1 laundry, 2 hskp, 1 HA, 1 MA, 1 CNA, and 3 LVNs) participated. Some were staff who were not listed on the other trainings on 03/23/25 and drills on 03/25/25 and 03/26/25. Record review of the Employee Staff List indicated all but 1 prn staff member had been trained on Elopement. Record review of facility incident reports from 03/24/25 through 09/08/25 indicated there were no elopements. During a phone interview on 09/09/25 at 12:10 p.m. HA A said he had received in-service on 03/23/25 and participated in elopement drills several times after the elopement. During an interview on 09/09/25 at 01:08 p.m. the HKS said she was the DSS at the time of Resident #1's elopement. She said she had received in-service and participated in elopement drills several times after the elopement. During an interview on 09/09/25 at 02:10 p.m. LVN E said he had received in-service and had participated in elopement drills they had conducted several times after the elopement. During an interview on 09/09/25 at 03:30 p.m. the UM said in-service and elopement drills had been received from 03/23/25 through 03/27/25. During an interview on 09/09/25 at 06:00 p.m.:* CNA D said she was the receptionist at the time of the elopement but had received in-service and participated in elopement drills several times after the elopement.* CNA G said she received elopement training while she was in the CNA class at the facility.* CNA H and CNA J said they received elopement training when they were hired by the facility. During interviews on 09/10/25:* at 10:20 a.m. CNA N said she had received in-service and participated in elopement drills several times after the elopement.* at 10:25 a.m. CNA O said she had received in-service and participated in elopement drills several times after the elopement.* at 10:28 a.m. CNA R said she had received in-service and participated in elopement drills several times after the elopement. Record review of the Elopement policy revised 05/2024 indicated: Policy:The Facility will engage in active elopement prevention measures to mitigate the occurrence of elopement incidents. The Facility will deploy a prompt investigation and search if a resident is considered missing.Elopement Mitigation StrategiesThe Facility will implement the following mitigation strategies: Appropriateness of resident placement within the facility upon a::Jmission and during their stay. Completion of routine elopement risk assessments. Providing the resident with appropriate supervision. Completing environmental modifications as needed. Ensuring the resident's care plan is up to date. Conducting routine elopement drills. Having a resident photo in the electronic health record. Providing education for families, visitors, and volunteers. Conducting routine alarm checks/inspections. Initiate a manual monitoring system during power failure. On 09/09/25 at 05:40 p.m., the Administrator was informed of the Immediate Jeopardy. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 03/23/25 and ended on 03/27/25. The facility had corrected the noncompliance before survey began.

Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from physical abuse for 4 of 6 residents (Resident #2, Resident #3, Resident #4 and Resident #5) reviewed for abuse. 1. The facility failed to ensure Resident #2 was free from physical abuse when Resident #2 was slapped on the neck by Resident #3 on 01/21/2025. 2. The facility failed to ensure Resident #2 was free from physical abuse when Resident #2 was punched on the arm by Resident #3 on 05/18/2025. 3. The facility failed to ensure Resident #5 was free from physical abuse when Resident #4 pushed Resident #5 causing him to fall on 07/02/2025. These failures could place residents at risk for emotional distress, fear, decreased quality of life and further abuse.Findings included: Resident #2Record review of Resident #2's admission Record dated 09/08/2025 indicated she was a [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses which included Huntington's disease (causes nerve cells in the brain to decay over time and the disease affects a person's movements, thinking ability and mental health), bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), schizoaffective disorder (mental health condition with a combination of symptoms of schizophrenia and mood disorder), anxiety disorder (persistent and excessive worry that interferes with daily activities), and muscle spasms. Record review of Resident #2's quarterly MDS assessment, dated 04/09/2025, indicated resident had a BIMS score of 07 which indicated she had severely impaired cognition and was sometimes able to make self-understood and usually understood others. She had no behaviors indicated. The functional abilities self-care indicated she required partial assistance with eating, oral care, upper body dressing and required maximal assistance with shower/bathing, lower body dressing, putting on/taking of footwear and personal hygiene. The Functional abilities mobility indicated she required maximum assistance with all tasks except walking greater than 50 feet which required totally dependent and used a manual wheelchair for mobility. Record review of Resident #2's care plan, dated 02/04/2025, indicated she had diagnosis of schizophrenia of a bipolar type with psychotic features, Huntington's disease and is at risk for disturbed thought processes, and alteration in mood or exhibitions of behavioral symptoms. She has potential for impaired skin related to risk of falls, involuntary movements related to Huntington's Disease and alteration in musculoskeletal status related to Huntington's Disease. Interventions included communication techniques, effective strategies, monitor for confounding problems, frustration levels, physical/nonverbal indications, monitor and document behaviors, 1:1 interaction as needed, administer medications as needed, referrals for therapy and psych services and report to MD if changes were identified. Resident #3Record review of Resident #3's admission Record dated 09/09/2025 indicated he was a [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnoses which included including Alcohol induced Dementia (loss of cognitive functioning), psychosis disorder (a severe mental condition in which thoughts and emotions are so affected that contact is lost with external reality), chronic obstructive pulmonary disease (a lung disease that blocks airflow making it difficult to breathe), diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), anxiety disorder (persistent and excessive worry that interferes with daily activities) and depressive disorder (mental illness that negatively affects how you feel, the way you think and how you act). He was discharged on 06/11/2025 to an acute care behavioral hospital. Record review of Resident #3's quarterly MDS assessment, dated 05/08/2025, indicated he had a BIMS score of 03 which indicated he had severely impaired cognition and was sometimes able to make self-understood and sometimes understood others. He had behaviors of inattention and disorganized thinking which fluctuates (comes and goes, changes in severity). The functional abilities self-care indicated he required set-up or clean up assistance (helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) with eating, oral care, upper body dressing, shower/bathing, lower body dressing, putting on/taking of footwear and personal hygiene. The Functional abilities mobility indicated he required set-up or clean up assistance with all tasks and used a manual wheelchair for mobility. Record review of Resident #3's care plan, dated 02/04/2025, indicated he had episodes of inappropriate behaviors and is at risk for further increased episodes and injury related to dementia with behaviors and psychosis. Interventions included communication techniques, redirection, effective strategies, monitor for confounding problems, frustration levels, physical/nonverbal indications, monitor and document behaviors, 1:1 interaction as needed, administer medications as needed, referrals for behavioral hospitals and psych services and report to MD if changes were identified. 1. Record review of provider investigation report dated 01/27/2025 for Resident-to-Resident incident between Resident # 2 and Resident #3 indicated Resident #3 hit Resident #2 on the right side of her neck and pulled her hair on 01/21/2025. An assessment was conducted on Resident #2 and indicated she had a small pink/red area noted to the right side of neck and no pain and there were no bruising or other injuries to her neck. On 01/22/2025 a skin assessment on Resident #2 was clear, no redness noted at right side of neck. Resident #3 was placed on 1:1 monitoring until transferred to behavioral hospital for evaluation and treatment. Record review of Resident #2's incident report and nurses progress note dated 01/21/2025 indicated on 01/21/2025 at 9:50 a.m., LVN C was down the hallway and noticed Resident #2 screaming: while looking down the hall LVN C witness Resident #2 being hit by Resident #3. Resident #3 was seen hitting Resident #2 in the face on the right side of her neck and pulling her hair. LVN C immediately intervened and separated the residents. Resident #2 was assessed and had redness noted to neck, no other injuries or bruising, and reported no pain when asked if she was hurting. RP, DON, ADON and the administrator were notified of the incident. During an observation and interview on 09/08/2025 at 11:30 a.m., Resident #2 wheeled to the dining room in manual wheelchair. She appeared well groomed with no foul odors and no signs of abuse or neglect were identified. Resident #2 interacted with facility staff with no indication of fear or discomfort. Resident #2 does not recall the incidents and denied any current abuse or neglect from facility staff or other residents. Unable to interview Resident #3, he no longer resides at the facility. During an interview on 09/08/2025 at 6:00 p.m., LVN C said she was the nurse that witnessed the incident between Resident #2 and Resident #3 on 01/21/2025. She said she was walking down hall and heard Resident #2 scream, looked down hallway and saw Resident #3 hit Resident #2 one time around face on right side of her neck and pulled her hair. Both residents were in wheelchairs in the hallway. She said she immediately intervened and separated the residents. She said Resident #3 was returned to his room, placed in bed, assessed with no injuries and initiated 1:1 monitoring until he was transported to behavioral hospital for evaluation. She said Resident #2 was assessed with redness to her neck with no additional injuries or bruising noted. She said she reported the physical abuse incident to RP, DON, ADON and the administrator/AC. She said that Resident #2 has Huntington's disease, and she has involuntary movements (flinging her arms and legs) and could startle other residents and visitors. She said that Residents #2 and #3 had a history of Resident-to-Resident incidents and staff were aware to monitor them closely for incidents or behaviors. 2. Record review of an incident report and nurses progress note dated 05/18/2025 indicated on 05/18/2025 around 1:00 p.m., LVN F observed Resident #2 and Resident #3 both in wheelchairs in the hallway. Resident #2 raised arms, not in an aggressive way, and Resident #3 punched Resident #2 in the arm. Residents were separated and Resident #3 was taken back to his room and staff assisted him to bed. Resident #2 was assessed and had no notable redness, injuries or bruising, and reported no pain when asked if she was hurting. DON, ADON and the administrator were notified of the incident. During an interview on 09/09/2025 at 11:39 a.m., LVN F said she was the nurse that witnessed the incident between Resident #2 and Resident #3 on 05/18/2025. She said she was walking up the hall and saw Resident #2 and Resident #3 in their wheelchairs in the hallway. Resident #2 was raising her arm, involuntary movement from her Huntington's disease, and Resident #3 intentionally punched Resident #2 in the arm. She said she immediately separated the residents and Resident #3 was returned to his room, placed in bed, assessed with no injuries and initiated monitoring. She said Resident #3 punched Resident #2, so she reported the physical abuse incident to DON, ADON and the administrator/AC. She said she worked until 6:00 p.m. the day of the incident and continued to monitor both Resident #2 and Resident #3 with no further incidents or negative effects identified and reported the incident to the oncoming staff. Resident #4 Record review of Resident #4's admission Record dated 09/08/2025 indicated he was a [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnoses which included including vascular dementia (loss of cognitive functioning caused by brain damage from impaired blood flow), diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), anxiety disorder (persistent and excessive worry that interferes with daily activities) and depressive disorder (mental illness that negatively affects how you feel, the way you think and how you act). Record review of Resident #4's quarterly MDS assessment, dated 04/25/2025, indicated resident had a BIMS score of 06 which indicated he had severely impaired cognition and was able to make self-understood and understood others. He had no behaviors indicated. The functional abilities self-care indicated he required supervision or touching assistance with eating, oral care, upper body dressing, shower/bathing, lower body dressing, putting on/taking of footwear and personal hygiene. The Functional abilities mobility indicated he required supervision or touching assistance with all tasks and ambulated independently.Record review of Resident #4's care plan, dated 03/19/2025, indicated he had episodes of behaviors and is at risk for further increased episodes and had an altercation with another resident on 07/02/2025. Interventions included communication techniques, redirection, effective strategies, monitor for confounding problems, frustration levels, physical/nonverbal indications, monitor and document behaviors, 1:1 interaction as needed, administer medications as needed, referrals for behavioral hospitals and psych services and report to MD if changes were identified. Resident #5 Record review of Resident #5's admission Record dated 09/08/2025 indicated he was a [AGE] year-old male who was readmitted on [DATE] and initially admitted to the facility on [DATE] with diagnoses which included including post-traumatic stress disorder (a mental health condition that's triggered by a terrifying event - either experiencing it or witnessing it), Alzheimer's disease (progressive disease that destroys memory and other important mental functions), diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), anxiety disorder (persistent and excessive worry that interferes with daily activities) and depressive disorder (mental illness that negatively affects how you feel, the way you think and how you act). Record review of Resident #5's quarterly MDS assessment, dated 05/25/2025, indicated he had a BIMS score of 11 which indicated he had moderately impaired cognition and was able to make self-understood and understood others. He had no behaviors indicated. The functional abilities self-care indicated he was independent with eating, oral care, upper body dressing, lower body dressing, putting on/taking off footwear and setup or clean-up assistance with shower/bathing and personal hygiene. The functional abilities mobility indicated he is independent with all tasks and used a walker for mobility. Record review of Resident #5's care plan, dated 02/04/2025, indicated he had episodes of inappropriate behaviors and is at risk for further increased episodes and injury related to post traumatic stress disorder, bipolar disorder and Alzheimer's Disease. Interventions included communication techniques, redirection, effective strategies, monitor for confounding problems, frustration levels, physical/nonverbal indications, monitor and document behaviors, 1:1 interaction as needed, administer medications as needed, referrals for behavioral hospitals and psych services and report to MD if changes were identified. 3. Record review of provider investigation report dated 07/09/2025 for Resident-to-Resident incident between Resident #4 and Resident #5. Resident #4 pushed Resident #5 causing him to fall on 07/02/2025. An assessment was conducted on Resident #5 indicated he had no injuries noted. Resident #4 was placed on 1:1 monitoring until transferred to behavioral hospital for evaluation and treatment. Record review of Resident #4's incident report and nursing progress note dated 07/02/2025 indicated on 7/02/2025 at 9:30 a.m., LVN C heard a resident falling in the dining room, LVN C went to check on Resident #4 and Resident #5 and found Resident #5 on the floor upset because Resident #4 had pushed him down. Residents were separated and Resident #4 was taken back to his room and placed on 1:1 monitoring. Residents #4 & #5 were assessed and had no redness, injuries or bruising. RN, DON, ADON and administrator were notified of the incident. During an observation on 09/08/2025 at 11:45 a.m., Resident #5 was ambulating with walker independently throughout the facility. He appeared well groomed with no foul odors and no signs of abuse or neglect were identified. During an observation and interview on 09/08/2025 at 11:50 a.m., Resident #4 was in his room resting. He appeared well groomed with no foul odors and no signs of abuse or neglect were identified. He said he was going to lunch and got up independently, walked to the dining room and sat at a dining table alone. He interacted with facility staff members passing lunch trays. During an interview on 09/08/2025 at 1:00 p.m., Resident # 5 said he recalled the incident with Resident #4, he was in the dining room, spoke to Resident #4 does not recall conversation and Resident #4 pushed him causing him to fall on the floor. He said he was not injured in the fall, but the nurses checked him over. He said he was upset at the time and may have cussed at Resident #4 after he pushed him down for no reason but now, he just avoids him and does not interact with him. He denied wanting to fight Resident #4 or making any negative comments toward Resident #4 the day of the incident. He said he has not had any other interactions with Resident #4 since the incident and feels safe at the facility. He said that he has arthritis and has frequent pain, but the medications administered by staff help the pain. He denies injuries during the incident and demonstrates he can move all extremities without increased pain or discomfort. During an interview on 09/08/2025 at 1:15 p.m., Resident #4 said he did not recall the incident with Resident #5 and denied pushing or hitting other residents. During an interview on 09/09/2025 at 10:30 a.m., contracted lab technician said he was at the facility on 07/02/2025 to collect blood specimens for ordered labs and around 9:30 a.m. he witnessed Resident #4 and Resident #5 standing in dining room having what appeared to be a normal conversation, then Resident #4 pushed Resident #5 and Resident #5 lost his balance and fell to the floor landing on his bottom/back. He said LVN C saw Resident #5 had fallen and immediately responded and separated the two residents. He said LVN C talked with him regarding what he saw that day. He said he did not hear here the conversation between the residents, just saw from a distance Resident #4 push Resident #5 and Resident #5 lost his balance and fell backwards. He said Resident #5 did not hit his head; he caught himself as he was falling backward. During an interview on 09/08/2025 at 6:30 p.m., LVN C said she was sitting at the nurses' station on 07/02/2025 at 9:30 a.m. and heard a patient fall and commotion, she looked up and immediately intervened. She said Resident #5 was sitting on the floor in front of Resident #4 in the dining room. She said Resident #5 was cussing that Resident #4 just pushed him down for no reason. She said she immediately separated the residents and Resident #4 was returned to his room and placed on 1:1 monitoring until transferred to behavioral hospital later that evening. LVN C said Resident #4 said he thought Resident #5 wanted to fight so he was defending himself, but Resident #5 denied making any negative comments or attempting to fight. During an interview on 09/09/2025 at 1:30 p.m., UM M said Resident #4 would ambulate around the facility sometimes but usually stayed in room, came to dining room for meals and activities. She said she had not had any issues or incidents with Resident #4 since he returned from the behavioral hospital and had medication adjustments. During an interview on 09/09/2025 at 2:10 p.m., the DON said she expected staff to prevent residents from being abused. She said they could not control a resident's unexpected behaviors or reactions to other residents' actions. She said the aggressive resident in an incident would be placed on 1:1 monitoring until released by psych services or transferred to behavioral hospital for evaluation. She said staff should be alerted to identify behaviors and to attempt to deescalate or redirect to prevent incidents if possible. She said resident abuse could place residents at risk for emotional distress, fear, and further abuse. During an interview on 09/10/2025 at 2:00 p.m., the Administrator said she expected facility residents to remain free from abuse and neglect and for staff to follow policies and procedures to prevent abuse and neglect. She said staff should be alerted to identify behaviors and to attempt to deescalate or redirect to prevent incidents if possible. She said resident abuse could place residents at risk for emotional distress, fear, and further abuse. Record review of the facility's policy Abuse, Neglect, Exploitation Prevention Policy and Procedure, date revised 09/10/2020, indicated Policy statement Our facility prohibits the abuse, mistreatment, neglect, and/or exploitation of residents. We believe that all residents have the right to be free from such actions by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving our community, family members or legal guardians, friends, or any other individuals. Therefore, our facility abuse, neglect, and exploitation prevention policy and procedure include the following seven components: Pre-Employment screening, ANE Training, ANE Prevention, ANE Identification, Investigation of ANE, Protection from ANE and Reporting/Response of ANE. The facility administrator, or his/her designee, will be designated as the facilities ANE coordinator and will be responsible for overseeing the ANE Prevention Program and directing any such investigation. Definitions: .Abuse is defined as the willful infliction of injury. Physical Abuse includes hitting, slapping, pinching and/or kicking.Reporting 1. It is the responsibility of all individuals who witness, or have knowledge of, an event regarding the abuse, neglect, and/or exploitation of any resident, regardless of the length of time between the actual event and his/her coming to knowledge of it, to immediately report it to the Administrator and/or Director of Nursing. If the Administrator or Director of Nursing is not present in the facility at the time, he/she should be contacted regardless of the time of day and made known of the event. The Administrator, Director of Nursing, or his/her will notify corporate director of clinical services and chief operating officer of any allegation or event concerning abuse, neglect, and/or exploitation. The Administrator, Director of Nursing, or his/her designee shall report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required and take all necessary corrective actions depending on the results of the investigation.

Based on interviews, and record review, the facility failed to review and revise resident's comprehensive care plans by the interdisciplinary team after each assessment to reflect the current condition for 2 of 12 (Resident #2 and Resident #3) residents reviewed for comprehensive care plans. The facility failed to ensure Resident #2's care plan was updated to indicate Resident #2 had received aggression during a resident-to-resident incident on 01/21/2025 and 05/18/2025. The facility failed to ensure Resident #3's care plan was updated to indicate Resident #3 had an incident of resident-to-resident aggression on 01/21/2025 and 05/18/2025. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs. The findings included: Resident #2Record review of Resident #2's admission Record dated 09/08/2025 indicated she was a [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses which included Huntington's disease (causes nerve cells in the brain to decay over time and the disease affects a person's movements, thinking ability and mental health), bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), schizoaffective disorder (mental health condition with a combination of symptoms of schizophrenia and mood disorder), anxiety disorder (persistent and excessive worry that interferes with daily activities), and muscle spasms. Record review of Resident #2's quarterly MDS assessment, dated 04/09/2025, indicated she had a BIMS score of 07 which indicated she had severely impaired cognition and was sometimes able to make self-understood and usually understood others. She had no behaviors indicated during the 7 day look back period prior to completing the MDS assessment. The functional abilities self-care indicated she required partial assistance with eating, oral care, upper body dressing and required maximal assistance with shower/bathing, lower body dressing, putting on/taking of footwear and personal hygiene. The Functional abilities mobility indicated she required maximum assistance with all tasks except walking greater than 50 feet which required totally dependent and used a manual wheelchair for mobility. Record review of Resident #2's care plan, dated 02/04/2025, indicated she had history of alteration in mood or exhibition of behavioral symptoms related to bipolar disorder, major depressive disorder, anxiety, schizoaffective disorder and behavioral problems regarding smoking and smoking times. Interventions included communication techniques, effective strategies, monitor for confounding problems, frustration levels, physical/nonverbal indications, monitor and document behaviors, 1:1 interaction as needed, administer medications as needed, referrals for therapy and psych services and report to MD if changes were identified. The care plan did not indicate Resident #2 had an updated or revised care plan for receiving aggressive behavior from another resident during a resident-to-resident aggression on 01/21/2025, 05/18/2025 and/or updated or revised care plan for behavior problems of voicing suicidal ideation related to smoking break omitted due to weather conditions Resident #3Record review of Resident #3's admission Record dated 09/09/2025 indicated he was a [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnoses which included including Alcohol induced Dementia (loss of cognitive functioning), psychosis disorder (a severe mental condition in which thoughts and emotions are so affected that contact is lost with external reality), chronic obstructive pulmonary disease (a lung disease that blocks airflow making it difficult to breathe), diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), anxiety disorder (persistent and excessive worry that interferes with daily activities) and depressive disorder (mental illness that negatively affects how you feel, the way you think and how you act). He was discharged on 06/11/2025 to an acute care behavioral hospital. Record review of Resident #3's quarterly MDS assessment, dated 05/08/2025, indicated he had a BIMS score of 03 which indicated he had severely impaired cognition and was sometimes able to make self-understood and sometimes understood others. He had behaviors of inattention and disorganized thinking which fluctuates (comes and goes, changes in severity). The functional abilities self-care indicated he required set-up or clean up assistance (helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) with eating, oral care, upper body dressing, shower/bathing, lower body dressing, putting on/taking of footwear and personal hygiene. The Functional abilities mobility indicated he required set-up or clean up assistance with all tasks and used a manual wheelchair for mobility. Record review of Resident #3's care plan, dated 02/04/2025, indicated he had episodes of behavioral problems at times and see another resident [Resident #2] with voluntary movements as aggressive behavior.Interventions included communication techniques, redirection, effective strategies, monitor for confounding problems, frustration levels, physical/nonverbal indications, monitor and document behaviors, 1:1 interaction as needed, administer medications as needed, referrals for behavioral hospitals and psych services and report to MD if changes were identified. The care plan did not indicate Resident #3 had an updated or revised care plan for aggressive behavior incident of resident-to-resident aggression on 01/21/2025 and 05/18/2025. Record review of provider investigation report dated 01/27/2025 for Resident-to-Resident incident between Resident #2 and Resident #3. Resident #3 hit Resident #2 on the right side of her neck and pulled her hair on 01/21/2025. An assessment was conducted on Resident #2 indicated she had a small pink/red area noted to the right side of neck and no pain and there were no bruising or other injuries to her neck and on 01/22/2025 skin assessment on Resident #2 was clear, no redness noted at right side of neck. Resident #3 was placed on was placed on 1:1 monitoring until transferred to behavioral hospital for evaluation and treatment. Record review of Resident #2's incident report and nurses progress note dated 01/21/2025 indicated on 01/21/2025 at 9:50 a.m., LVN C was down the hallway and noticed Resident #2 screaming: while looking down the hall LVN C witness Resident #2 being hit by Resident #3. Resident #3 was seen hitting Resident #2 around face on the right side of her neck and pulling her hair. LVN C immediately intervened and separated the residents. Resident #2 was assessed and had redness noted to neck, no other injuries or bruising, and reported no pain when ask if she was hurting. RP, DON, ADON and the administrator were notified of the incident. Record review of Resident #2's nursing process behavioral note dated 01/22/2025 at 5:31 a.m. indicated Resident #2 exhibited behaviors after being informed that the morning smoke break was omitted due to outside temperature below 20 degrees and stated, send me to the behavior center, I don't want to stay here. Resident was grabbing at medication cart looking for a trash bag, stated I will put a trash bag over my head before I stay here. Resident then requested a family member be contacted and staff obliged and left message. Monitoring initiated and all bags and harmful objects removed from the room. NP notified and order received to send referral to behavioral hospital. Record review of an incident report and nurses progress note dated 05/18/2025 indicated on 05/18/2025 around 1:00 p.m., LVN F observed Resident #2 and Resident #3 both in wheelchairs in the hallway. Resident #2 raised arms, not in an aggressive way, and Resident #3 punched Resident #2 in the arm. Residents were separated and Resident #3 was taken back to his room and staff assisted him to bed. Resident #2 was assessed and had no notable redness, injuries or bruising, and reported no pain when asked if she was hurting. DON, ADON and the administrator were notified of the incident. During an interview on 09/09/2025 at 11:39 a.m., LVN F said she was the nurse that witnessed the incident between Resident #2 and Resident #3 on 05/18/2025. She said she was walking up the hall and saw Resident #2 and Resident #3 in their wheelchairs in the hallway. Resident #2 was raising her arm, involuntary movement from her Huntington's disease, and Resident #3 intentionally punched Resident #2 in the arm. She said she immediately separated the residents and Resident #3 was returned to his room, placed in bed, assessed with no injuries and initiated monitoring. She said Resident #3 punched Resident #2, so she reported the physical abuse incident to DON, ADON and the administrator/AC. She said she worked until 6:00 p.m. the day of the incident and continued to monitor both Resident #2 and Resident #3 with no further incidents or negative effects identified and reported the incident to the oncoming staff. She said when residents have incidents or changes in condition that the care plans or revised or updated by the MDS Coordinator or DON. During an interview on 09/10/2025 at 11:30 a.m., MDS Coordinator U stated she was the MDS Coordinator for the facility hired in March 2025 but did not start completing assessment until June 2025 after receiving training at sister facility and corporate MDS nurse. She said she participates in morning meetings and incident reports and allegations are discussed during the morning meeting, if residents care plans require updating and/or IDT care plan meeting scheduling required it is completed if applicable. She said she was not involved in the incidents with Resident #2 and Resident #3 but with the scenarios provided the care plans should have been updated to reflect the current resident needs and a Significant Change in Status Assessment completed if warranted. During an interview on 09/10/2025 at 2:20 p.m., the DON said that all incidents and allegations are discussed during morning meetings (including herself, administrator, department heads, MDS Coordinator, Unit Manager, corporate staff via phone at times) and the MDS Coordinator is notified of any incidents requiring care plan revisions and she was responsible for updating the care plans. She stated new interventions should be added to the care plan regarding recurrent resident-to-resident altercations. She stated she did not know why the care plans and interventions for Residents #2 and #3 had not been updated and/or revised after the alleged incidents. She said the MDS Coordinator is responsible for updating and revising the care plan as indicated. She said she was responsibility for monitoring and ensuring that the care plans were completed and updated by the MDS Coordinator. The DON said the current MDS Coordinator was not here during the time of those incidents, and she recalled directing the old MDS Coordinator to make those updates on the care plans during a morning meeting but did not go back into the care plans to ensure the changes were made. She said if care plans were not updated or revised, the care plan would not reflect the current resident's needs. Record review of the facility's policy Care Plan Revisions, date revised 05/2022, indicated Policy: The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents within the facility. Guidelines: 1. The comprehensive care plan will be reviewed and revised every quarter, when a resident experiences a status change and as deemed necessary. 2. Procedure for reviewing and revising the care plan is as follows: a. Upon identification of a change in status, the nurse will notify the MDS Coordinator, the physician, and the resident representative, if applicable. b. The MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options. c. The care plan will be updated with the new or modified interventions. d. Staff involved in the care of the resident will report resident response to new or modified interventions. e. Care plans will be modified as needed by the MDS Coordinator or other designated staff member. f. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs. 3. The MDS Coordinator will determine whether a Significant Change in Status Assessment is warranted. If so, the assessment will be completed according to established procedures.

Based on interview and record review, the facility failed to have evidence that all allegations of abuse, neglect, exploitation, or mistreatment, were thoroughly investigated for 4 of 6 residents (Resident #2, Resident #3, Resident #4 and Resident #5) reviewed for abuse and neglect. 1. The facility did not thoroughly investigate an incident in which Resident #2 was slapped on the neck by Resident #3 on 01/21/2025. 2. The facility did not investigate an incident in which Resident #2 was punched on the arm by Resident #3 on 05/18/2025. 3. The facility did not thoroughly investigate an incident in which Resident #4 pushed Resident #5 causing him to fall on 07/02/2025. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm. The findings included: Resident #2Record review of Resident #2's admission Record dated 09/08/2025 indicated she was a [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses which included Huntington's disease (causes nerve cells in the brain to decay over time and the disease affects a person's movements, thinking ability and mental health), bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), schizoaffective disorder (mental health condition with a combination of symptoms of schizophrenia and mood disorder), anxiety disorder (persistent and excessive worry that interferes with daily activities), and muscle spasms. Record review of Resident #2's quarterly MDS assessment, dated 04/09/2025, indicated resident had a BIMS score of 07 which indicated she had severely impaired cognition and was sometimes able to make self-understood and usually understood others. She had no behaviors indicated. The functional abilities self-care indicated she required partial assistance with eating, oral care, upper body dressing and required maximal assistance with shower/bathing, lower body dressing, putting on/taking of footwear and personal hygiene. The Functional abilities mobility indicated she required maximum assistance with all tasks except walking greater than 50 feet which required totally dependent and used a manual wheelchair for mobility. Record review of Resident #2's care plan, dated 02/04/2025, indicated she had diagnosis of schizophrenia of a bipolar type with psychotic features, Huntington's disease and is at risk for disturbed thought processes, and alteration in mood or exhibitions of behavioral symptoms. She has potential for impaired skin related to risk of falls; involuntary movements related to Huntington's Disease and alteration in musculoskeletal status related to Huntington's Disease. Interventions included communication techniques, effective strategies, monitor for confounding problems, frustration levels, physical/nonverbal indications, monitor and document behaviors, 1:1 interaction as needed, administer medications as needed, referrals for therapy and psych services and report to MD if changes were identified. Resident #3Record review of Resident #3's admission Record dated 09/09/2025 indicated he was a [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnoses which included including Alcohol induced Dementia (loss of cognitive functioning), psychosis disorder (a severe mental condition in which thoughts and emotions are so affected that contact is lost with external reality), chronic obstructive pulmonary disease (a lung disease that blocks airflow making it difficult to breathe), diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), anxiety disorder (persistent and excessive worry that interferes with daily activities) and depressive disorder (mental illness that negatively affects how you feel, the way you think and how you act). He was discharged on 06/11/2025 to an acute care behavioral hospital. Record review of Resident #3's quarterly MDS assessment, dated 05/08/2025, indicated resident had a BIMS score of 03 which indicated he had severely impaired cognition and was sometimes able to make self-understood and sometimes understood others. He had behaviors of inattention and disorganized thinking which fluctuates (comes and goes, changes in severity). The functional abilities self-care indicated he required set-up or clean up assistance (helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) with eating, oral care, upper body dressing, shower/bathing, lower body dressing, putting on/taking of footwear and personal hygiene. The Functional abilities mobility indicated he required set-up or clean up assistance with all tasks and used a manual wheelchair for mobility. Record review of Resident #3's care plan, dated 02/04/2025, indicated he had episodes of inappropriate behaviors and is at risk for further increased episodes and injury related to dementia with behaviors and psychosis. Interventions included communication techniques, redirection, effective strategies, monitor for confounding problems, frustration levels, physical/nonverbal indications, monitor and document behaviors, 1:1 interaction as needed, administer medications as needed, referrals for behavioral hospitals and psych services and report to MD if changes were identified. 1. Record review of provider investigation report dated 01/27/2025 for Resident-to-Resident incident between Resident # 2 and Resident #3 indicated Resident #3 hit Resident #2 on the right side of her neck and pulled her hair on 01/21/2025. The investigation summary and provider actions taken post-investigation indicated staff interviews, skin assessments of involved residents, aggressor transferred to behavioral hospital but does not indicate evidence (safe surveys) that other residents were interviewed following an allegation of abuse to ensure their safety and wellbeing. 2. Record review of an incident report and nurses progress note dated 05/18/2025 indicated on 05/18/2025 around 1:00 p.m., LVN F observed Resident #2 and Resident #3 both in wheelchairs in the hallway. Resident #2 raised arms, not in an aggressive way, and Resident #3 punched Resident #2 in the arm. Residents were separated and Resident #3 was taken back to his room and staff assisted him to bed. Resident #2 was assessed and had no notable redness, injuries or bruising, and reported no pain when asked if she was hurting. DON, ADON and the administrator were notified of the incident. Record review of Texas Unified Licensure Information Portal (TULIP) on 08/09/2025 at 1:50 P.M. indicated no self-reported incidents or provider investigation report regarding allegations of abuse were reported for Resident # 2. During an interview on 09/09/2025 at 11:39 a.m., LVN F said she was the nurse that witnessed the incident between Resident #2 and Resident #3 on 05/18/2025. She said she was walking up the hall and saw Resident #2 and Resident #3 in their wheelchairs in the hallway. Resident #2 was raising her arm, involuntary movement from her Huntington's disease, and Resident #3 intentionally punched Resident #2 in the arm. She said she immediately separated the residents and Resident #3 was returned to his room, placed in bed, assessed with no injuries and initiated monitoring. She said Resident #3 punched Resident #2, so she reported the physical abuse incident to DON, ADON and the administrator/AC. She said she worked until 6:00 p.m. the day of the incident and continued to monitor both Resident #2 and Resident #3 with no further incidents or negative effects identified and reported the incident to the oncoming staff. She said the DON interviewed her during the investigation process and asked her to change her documentation from punched to tapped since they had missed the 2-hour window to report the incident to the state agency. Resident #4 Record review of Resident #4's admission Record dated 09/08/2025 indicated he was a [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnoses which included including vascular dementia (loss of cognitive functioning caused by brain damage from impaired blood flow), diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), anxiety disorder (persistent and excessive worry that interferes with daily activities) and depressive disorder (mental illness that negatively affects how you feel, the way you think and how you act). Record review of Resident #4's quarterly MDS assessment, dated 04/25/2025, indicated resident had a BIMS score of 06 which indicated he had severely impaired cognition and was able to make self-understood and understood others. He had no behaviors indicated. The functional abilities self-care indicated he required supervision or touching assistance with eating, oral care, upper body dressing, shower/bathing, lower body dressing, putting on/taking of footwear and personal hygiene. The Functional abilities mobility indicated he required supervision or touching assistance with all tasks and ambulated independently. Record review of Resident #4's care plan, dated 03/19/2025, indicated he had episodes of behaviors and is at risk for further increased episodes and had an altercation with another resident on 07/02/2025. Interventions included communication techniques, redirection, effective strategies, monitor for confounding problems, frustration levels, physical/nonverbal indications, monitor and document behaviors, 1:1 interaction as needed, administer medications as needed, referrals for behavioral hospitals and psych services and report to MD if changes were identified. Resident #5 Record review of Resident #5's admission Record dated 09/08/2025 indicated he was a [AGE] year-old male who was readmitted on [DATE] and initially admitted to the facility on [DATE] with diagnoses which included including post-traumatic stress disorder (a mental health condition that's triggered by a terrifying event - either experiencing it or witnessing it), Alzheimer's disease (progressive disease that destroys memory and other important mental functions), diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), anxiety disorder (persistent and excessive worry that interferes with daily activities) and depressive disorder (mental illness that negatively affects how you feel, the way you think and how you act). Record review of Resident #5's quarterly MDS assessment, dated 05/25/2025, indicated he had a BIMS score of 11 which indicated he had moderately impaired cognition and was able to make self-understood and understood others. He had no behaviors indicated. The functional abilities self-care indicated he was independent with eating, oral care, upper body dressing, lower body dressing, putting on/taking off footwear and setup or clean-up assistance with shower/bathing and personal hygiene. The functional abilities mobility indicated he is independent with all tasks and used a walker for mobility. Record review of Resident #5's care plan, dated 02/04/2025, indicated he had episodes of inappropriate behaviors and is at risk for further increased episodes and injury related to post traumatic stress disorder, bipolar disorder and Alzheimer's Disease. Interventions included communication techniques, redirection, effective strategies, monitor for confounding problems, frustration levels, physical/nonverbal indications, monitor and document behaviors, 1:1 interaction as needed, administer medications as needed, referrals for behavioral hospitals and psych services and report to MD if changes were identified. 3. Record review of provider investigation report dated 07/09/2025 for Resident-to-Resident incident between Resident #4 and Resident #5 indicated Resident #4 pushed Resident #5 causing him to fall on 07/02/2025. The investigation summary and provider actions taken post-investigation indicated staff interviews, skin assessments of involved residents, aggressor transferred to behavioral hospital but does not indicate evidence (safe surveys) that other residents were interviewed following an allegation of abuse to ensure their safety and wellbeing. During an interview on 09/09/2025 at 11:10 a.m., the Social Worker said she was the part time social worker for the facility for the last few months. She said she was not involved with the indicated allegation of abuse investigation with Resident #2 being hit by #3, and Resident #4 pushing Resident #5 causing him to fall. She said she was not the active social worker at the time of these incidents. She said she visits the facility and sister facility 2-3 times a week to provide services. She said if she is aware of abuse or neglect allegation and is at the facility or called to the facility, that she provides safe surveys after the incidents or allegations. She said she interviewed other residents to make sure the residents feel safe and there were no adverse effects from the incident. She said each incident is different so her safe surveys may be done by halls, interactions with accused residents, or staff. She said safe surveys need to be provided after allegations to identify other residents involved and to make sure residents feel safe at the facility. During an interview on 09/09/2025 at 2:00 p.m., the DON said she was aware of the incident on 05/18/2025 between Resident #2 and Resident #3 and during her investigation she identified that Resident #2 denied being hit/punched by Resident #3. Resident #2 said [Resident #3] just moved her arm out of his face and did not hit her. The DON said she reported the incident to the administrator and corporate nurse and was advised that the incident was not a reportable event. The DON acknowledges that the facility policy identifies physical abuse includes hitting, slapping, pinching and/or kicking and the alleged physical abuse should have been reported to the administrator/abuse coordinator for submission to the state agency within 2 hours of the allegation and then investigated for confirmation. The DON said that during the investigation process of incidents (including the indicated allegations between Resident #2 & #3 and Resident #4 & #5) she does speak to other residents and interviews for involvement and safety, but usually the social worker conducts safe surveys after allegations. She said that she does not document her interviews with other residents during the investigation process because she thought the social worker would document with safe survey interviews. She said the facility must not have had an available social worker during the indicated incidents to perform safe surveys. She said when no social worker was available, she or the administrator should have conducted safe surveys and completed the documents and submitted with the provider investigation report. She said she does facility rounds multiple times a day and feels if residents did not feel safe or had concerns with an incident, they would notify her. She said not completing safe surveys could possibly miss a resident involved with an incident or have a negative outcome (fear, unreported abuse) on a resident. During an interview on 09/10/2025 at 2:00 p.m., the Administrator said was notified by the DON regarding the incident on 05/18/2025 between Resident #2 and Resident #3 and the ADON and DON investigated and identified that Resident #2 denied being punched/hit by Resident #3. She said after a review of the incident by corporate, the corporate nurse advised that the incident was not a reportable event. The administrator acknowledges that the facility policy identifies physical abuse includes hitting, slapping, pinching and/or kicking and the alleged physical abuse should have been reported to the state agencies within 2 hours of the allegation, investigated, and provided an investigation report to the state agency within 5 working days. She said the facility must not have had an available social worker during the indicated incidents (including the indicated allegations between Resident #2 & #3 and Resident #4 & #5) to perform safe surveys. She said it was the responsibility of the social worker to perform safe surveys after abuse allegations and if the social worker is not available to provide safe surveys, she, the DON or designee should have performed safe surveys and completed documents and submitted with the provider investigation report. She said not completing safe surveys could possibly miss a resident involved with an incident or have a negative outcome (fear, unreported abuse) on a resident. Record review of the facility's policy Abuse, Neglect, Exploitation Prevention Policy and Procedure, date revised 09/10/2020, indicated Investigation Process: 16. The individual conducting the investigation will, as a minimum: j. review the completed documentation forms; k. review the resident's medical records to determine events leading up to the incident; j. interview the person(s) reporting the incident; m. interview any witnesses. n. interview the resident.o. interview the resident's, attending physician. p. interview staff members . q. interview resident roommates, family, r. interview other residents. s. review all events leading up the alleged incident. 20. The facility investigation will be documented on the required state investigation form. 21. The administrator will provide the facility's completed investigation including witness statements and other supporting documentation to the state survey and certification agency with five (5) working days of the reported incident.

Based on interview and record review, the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 4 residents (Resident #6) reviewed for controlled medications. * LVN X and RN Y did not count the narcotic medications during the shift change to ensure the count was correct and all narcotics had an Inventory Sheet. * Resident #6's hydrocodone 5 mg /acetaminophen 325 mg (narcotic pain medication for moderate or severe pain) were not counted and did not have an Inventory Sheet on 10/04/24. This failure could place residents at risk for medication overdose, medication under-dose, ineffective therapeutic outcomes, and drug diversion. Findings included: Record review of the face sheet dated 09/10/25 indicated Resident #6 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included fracture of the hip (broken bone in the hip). Record review of the MDS dated [DATE] indicated Resident #6 was able to hear without difficulty, able to be understood and could understand others, had clear speech, had severely impaired cognition, and received opioid medications. Record review of the September and October 2024 physician orders indicated Resident #6 had an order for hydrocodone 5 mg /acetaminophen 325 mg. Record review of the September and October 2024 MARs indicated Resident #6 had received hydrocodone 7.5mg /acetaminophen 325 mg. Record review of the Provider Investigation Report dated 10/09/24 indicated: .On 10/04/24 at 1:00 p.m., the Administrator was notified that we had an alleged drug diversion involving Resident #6's hydrocodone 5/325, per [RP]'s statement to Administrator and DON, he stated he brought the pills up to the building on 09/29/24, the pills were counted by charge nurses LVN W and UM and there were 84 total pills and narcotic sheet was created. We received the blister pack for the resident's pain medication and only one has been given from it and there is a [narcotic] sheet for them. And this pill is accounted for. Furthermore, the [RP] stated he had received a call yesterday to come pick up the bottle of pills and today at around 10:30 am, he asked the nurse for the pills. The resident's [RP] counted the pills at the nurses' station after the nurse LVN X stated she counted 62 pills, and he counted 42. So initially, we were missing 20 pills. Further investigation revealed, LVN W in her statement said there were 76 on 10/3/24 when she counted with RN Y. Again, according to LVN W she stated the count yesterday was 76; however, the MAR only shows 5 given out of the bottle. The [narcotic] sheet is missing for the bottle of pills, but it was in the building yesterday per LVN W and RN Y who counted together last night on 10/03/24. RN Y stated she did not count with the nurse, LVN X day charge nurse on 10/04/24. But she stated she did count with LVN W. Hence, there is a discrepancy of 76 minus 42 is 34 missing pills, yet 84 minus 5 which show on the MAR is 79, but the count was 76. Hence, the total number of pills missing from the pill bottle is 37. The bottle was signed back to the [RP] and taken home with him. During an interview on 09/09/25 at 02:05 p.m. the UM said she and LVN W had counted Resident #6's hydrocodone/acetaminophen when the resident's husband brought them the bottle to the facility. She said she made a count sheet since it was from an outside pharmacy and did not have a count sheet. She said she remember there was eighty something tablets in the bottle. During an interview on 09/09/25 at 02:35 p.m. the DON said during the investigation RN Y admitted she did not count with LVN X at shift change but accepted the keys for the narcotics. She said both nurses were drug tested and suspended. She said RN Y was negative, but LVN X tested positive for other substances than the opioid. She said LVN X quit. She said she expected nurses to always count the narcotics before accepting the keys to the cart. She said not counting them could lead to medication not being administered to the resident. She said not having the Inventory Sheet for a narcotic could lead to drug diversion. During an interview on 09/09/25 at 04:25 p.m. the Administrator said she expected staff to follow policy regarding narcotic medications to prevent drug diversions and ensure residents receive their medication. Attempts were made to contact LVN X but recording indicated the caller was not taking calls. Attempts were made to contact RN Y and a message was left with no return call. Record review of the Narcotic Count policy revised 11/22 indicated the following: Policy: It is the policy of this facility to mitigate the risk of drug diversion by developing, implementing, and maintaining a narcotic count process. Procedures: The Narcotic Count and Inventory: 1. Controlled drugs will be counted every eight (8) - or twelve (12) -hour shift by authorized staff reporting on duty with the authorized staff reporting off duty.2. The inventory of controlled substances/drugs will be recorded on the Narcotic Records and signed for correctness of count.Process:1. At the end of every eight (8) - or twelve (12) -hour shift the authorized staff member reporting on duty and the authorized staff member reporting off duty meet at the designated medication cart or storage area to count controlled substances/drugs.2. The off-going authorized staff member reads down the controlled substance/drug Inventory Sheet one drug at a time.3. The oncoming authorized staff member counts the number of remaining controlled substance/drug and announces that number out loud.4. The off going authorized staff member checks this number against the Inventory Sheet. The remaining number is carried over to the controlled substance/drug Inventory Sheet for the new shift.5. Steps two (2) through four (4) are repeated for each controlled substance/drug in the inventory.

Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse were reported, immediately but not later than 2 hours after the allegation was made, if the events that cause the allegation involves abuse or results in serious bodily injury, to the State Survey Agency for 1 of 5 residents (Residents #2) reviewed for reporting allegations of abuse. The facility failed to report an allegation of abuse to the state agency within 2 hours after Resident #3 punched Resident #2 in the arm on 05/18/2025. The failures could place residents at risk of not having allegations reported within the required timeframes. Findings included: Record review of Resident #2's admission Record dated 09/08/2025 indicated she was a [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses which included Huntington's disease (causes nerve cells in the brain to decay over time and the disease affects a person's movements, thinking ability and mental health), bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), schizoaffective disorder (mental health condition with a combination of symptoms of schizophrenia and mood disorder), anxiety disorder (persistent and excessive worry that interferes with daily activities), and muscle spasms. Record review of Resident #2's quarterly MDS assessment, dated 04/09/2025, indicated she had a BIMS score of 07 which indicated she had severely impaired cognition and was sometimes able to make self-understood and usually understood others. She had no behaviors indicated. The functional abilities self-care indicated she required partial assistance with eating, oral care, upper body dressing and required maximal assistance with shower/bathing, lower body dressing, putting on/taking of footwear and personal hygiene. The Functional abilities mobility indicated she required maximum assistance with all tasks except walking greater than 50 feet which required totally dependent and used a manual wheelchair for mobility. Record review of Resident #2's care plan, dated 02/04/2025, indicated she had diagnosis of schizophrenia of a bipolar type with psychotic features, Huntington's disease and is at risk for disturbed thought processes, and alteration in mood or exhibitions of behavioral symptoms. She has potential for impaired skin related to risk of falls; involuntary movements related to Huntington's Disease and alteration in musculoskeletal status related to Huntington's Disease. Interventions included communication techniques, effective strategies, monitor for confounding problems, frustration levels, physical/nonverbal indications, monitor and document behaviors, 1:1 interaction as needed, administer medications as needed, referrals for therapy and psych services and report to MD if changes were identified. Record review of Resident #3's admission Record dated 09/09/2025 indicated he was a [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnoses which included including Alcohol induced Dementia (loss of cognitive functioning), psychosis disorder (a severe mental condition in which thoughts and emotions are so affected that contact is lost with external reality), chronic obstructive pulmonary disease (a lung disease that blocks airflow making it difficult to breathe), diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), anxiety disorder (persistent and excessive worry that interferes with daily activities) and depressive disorder (mental illness that negatively affects how you feel, the way you think and how you act). He was discharged on 06/11/2025 to an acute care behavioral hospital. Record review of Resident #3's quarterly MDS assessment, dated 05/08/2025, indicated he had a BIMS score of 03 which indicated he had severely impaired cognition and was sometimes able to make self-understood and sometimes understood others. He had behaviors of inattention and disorganized thinking which fluctuates (comes and goes, changes in severity). The functional abilities self-care indicated he required set-up or clean up assistance (helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) with eating, oral care, upper body dressing, shower/bathing, lower body dressing, putting on/taking of footwear and personal hygiene. The Functional abilities mobility indicated he required set-up or clean up assistance with all tasks and used a manual wheelchair for mobility. Record review of Resident #3's care plan, dated 02/04/2025, indicated he had episodes of inappropriate behaviors and is at risk for further increased episodes and injury related to dementia with behaviors and psychosis. Interventions included communication techniques, redirection, effective strategies, monitor for confounding problems, frustration levels, physical/nonverbal indications, monitor and document behaviors, 1:1 interaction as needed, administer medications as needed, referrals for behavioral hospitals and psych services and report to MD if changes were identified. During an observation and interview on 09/08/2025 at 11:30 a.m., Resident #2 wheeled to the dining room in manual wheelchair. She appeared well groomed with no foul odors and no signs of abuse or neglect were identified. Resident #2 interacted with facility staff with no indication of fear or discomfort. Resident #2 does not recall the incident. Record review of an incident report and nurses progress note dated 05/18/2025 indicated on 05/18/2025 around 1:00 p.m., LVN F observed Resident #2 and Resident #3 both in wheelchairs in the hallway. Resident #2 raised arms, not in an aggressive way, and Resident #3 punched Resident #2 in the arm. Residents were separated and Resident #3 was taken back to his room and staff assisted him to bed. Resident #2 was assessed and had no notable redness, injuries or bruising, and reported no pain when asked if she was hurting. DON, ADON and the administrator were notified of the incident. Record review of Texas Unified Licensure Information Portal (TULIP) on 08/09/2025 at 1:50 P.M. indicated no self-reported incidents regarding allegations of abuse were reported for Resident # 2. During an interview on 09/09/2025 at 11:39 a.m., LVN F said she was the nurse that witnessed the incident between Resident #2 and Resident #3 on 05/18/2025. She said she was walking up the hall and saw Resident #2 and Resident #3 in their wheelchairs in the hallway. Resident #2 was raising her arm, involuntary movement from her Huntington's disease, and Resident #3 intentionally punched Resident #2 in the arm. She said she immediately separated the residents and Resident #3 was returned to his room, placed in bed, assessed with no injuries and initiated monitoring. She said Resident #3 punched Resident #2, so she reported the physical abuse incident to DON, ADON and the administrator/AC. During an interview on 09/09/2025 at 2:00 p.m., the DON said she was aware of the incident on 05/18/2025 between Resident #2 and Resident #3 and during her investigation she identified that Resident #2 denied being hit/punched by Resident #3. Resident #2 said [Resident #3] just moved her arm out of his face and did not hit her. The DON said she reported the incident to the administrator and corporate nurse and was advised that the incident was not a reportable event. The DON acknowledges that the facility policy identifies physical abuse includes hitting, slapping, pinching and/or kicking and the alleged physical abuse should have been reported and then investigated for confirmation. During an interview on 09/10/2025 at 2:00 p.m., the Administrator said she was notified by the DON regarding the incident on 05/18/2025 between Resident #2 and Resident #3 and the ADON and DON investigated and identified that Resident #2 denied being punched/hit by Resident #3. She said after a review of the incident by corporate, the corporate nurse advised that the incident was not a reportable event. The administrator acknowledges that the facility policy identifies physical abuse includes hitting, slapping, pinching and/or kicking and the alleged physical abuse should have been reported to the state agencies within 2 hours of the allegation of abuse and then investigated for confirmation. Record review of the facility's policy Abuse, Neglect, Exploitation Prevention Policy and Procedure, date revised 09/10/2020, indicated Definitions: .Abuse is defined as the willful infliction of injury. Physical Abuse includes hitting, slapping, pinching and/or kicking.Reporting 1. It is the responsibility of all individuals who witness, or have knowledge of, an event regarding the abuse, neglect, and/or exploitation of any resident, regardless of the length of time between the actual event and his/her coming to knowledge of it, to immediately report it to the Administrator and/or Director of Nursing. If the Administrator or Director of Nursing is not present in the facility at the time, he/she should be contacted regardless of the time of day and made known of the event. The Administrator, Director of Nursing, or his/her will notify corporate director of clinical services and chief operating officer of any allegation or event concerning abuse, neglect, and/or exploitation. The Administrator, Director of Nursing, or his/her designee shall report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required and take all necessary corrective actions depending on the results of the investigation.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions for 1 of 1 kitchen reviewed for dietary services. The facility failed to ensure food items were properly labeled with product and expiration date in the freezers. The facility failed to properly close items stored in the freezers. These failures could place residents, who ate meals prepared in the kitchen, at risk for food borne illness. Findings included: During an observation and interview with the Dietary Manager on [DATE] at 8:52 a.m. the following were observed: -Freezer #1 contained: A large, opened bag of okra that was not labeled or dated. An opened sleeve of waffles that was not labeled or dated. A large, opened bag of corn that was not labeled or dated. An opened bag of squash that was not labeled or dated and had not been properly closed and was exposed to air. Pieces of frozen squash were scattered throughout the freezer. -Freezer #2 contained: An open bag of okra that was not labeled or dated and had not been properly closed and okra was exposed to air. An open bag of riblets that was not labeled or dated and had not been properly closed and riblets were exposed to air. The Dietary Manager said all opened foods in the freezer should be labeled with the date opened and closed properly to prevent freezer burn of the food, cross contamination, and serving expired food to residents. He removed all unlabeled foods from the freezers and threw them away. During an interview on [DATE] at 3:45 p.m., the Administrator said he was the supervisor of the Dietary Manager. He said he expected for all foods in the kitchen to be stored properly including labeling and dating. He said food not being labeled and dated and stored properly could result in expired foods being served to residents. Record review of a facility policy titled Food Storage revised [DATE], indicated . Store frozen foods in moisture-proof wrap or containers that are labeled and dated. Record review of the 2022 Food Code dated [DATE] indicated ,d+[DATE].11 Food shall be protected from contamination by storing the food: . (2) Where it is not exposed to splash, dust, or other contamination. XXX,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date. Date marking is the mechanism by which the Food Code requires active managerial control of the temperature and time combinations for cold holding. Industry must implement a system of identifying the date or day by which the food must be consumed, sold, or discarded. Date marking requirements apply to containers of processed food that have been opened and to food prepared by a food establishment, in both cases if held for more than 24 hours, and while the food is under the control of the food establishment. This provision applies to both bulk and display containers. It is not the intent of the Food Code to require date marking on the labels of consumer size packages. A date marking system may be used which places information on the food, such as on an overwrap or on the food container, which identifies the first day of preparation, or alternatively, may identify the last day that the food may be sold or consumed on the premises. A date marking system may use calendar dates, days of the week, color-coded marks, or other effective means, provided the system is disclosed to the Regulatory Authority upon request, during inspections.

Based on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food prepared by methods that conserve nutritive value, flavor, and appearance and were palatable, attractive, and at a safe and appetizing temperature for 1 of 1 kitchen reviewed for food and nutrition services. The facility did not ensure the chicken wrap and potato salad served for lunch on 10/01/24 were palatable. These failures could place the residents at risk of a decline in their satisfaction and weight loss. Findings included: During confidential interviews on initial rounds on 9/30/24 from 9:38 a.m. to 11:00 a.m., the residents complained about the food tasting bad and not being edible at times. During an observation and interview on 10/01/24 at 1:14 p.m., the test tray contained a chicken ranch wrap, potato salad and pear crisp with topping. The chicken wrap was not wrapped and appeared to be a taco. The meat in the tortilla was breaded and appeared soggy, lettuce appeared fresh, tomatoes appeared canned, with ranch dressing. The meat did not taste like chicken, and it was wet, soggy, and jelly like. The inside of the patties tasted burnt and appeared grey in color. The potato salad had a strong unsavory flavor of garlic. The DM said he did not taste the food when preparing it and he did not follow the recipes. He refused to taste the food because he said he did not eat those foods. The Dietician said the food tasted fine, but the recipes should have been followed. The Administrator said the food tasted off and were not pleasing. During an interview on 10/01/24 at 2:10 p.m., the DM said when making the chicken wraps, he used breaded chicken patties because he did not receive chicken in his delivery yesterday. He said he omitted the American cheese from the wraps and substituted fresh tomatoes with canned diced tomatoes. He said when making the potato salad he omitted the hard-boiled eggs and pickle relish and added garlic which was not in the recipe. He said not following the recipes could result in residents not receiving the dietician approved recipes, decrease the nutritional value of the foods, and alter the taste of the food. During an interview on 10/01/24 at 2:20 p.m., Resident #48 said he did not eat lunch today because the chicken wrap was not a wrap and it tasted bad. He said the potato salad did not taste like potato salad. During an interview on 10/01/24 2:22 p.m., Resident #28 said lunch was terrible today. She said she didn't know what that was in the wrap, but it wasn't chicken. She said the potato salad did not taste like any potato salad she had ever tasted, and she couldn't eat it. During an interview on 10/01/24 at 2:24 p.m., Resident #51 said the chicken in the wrap was overcooked and soggy and tasted bad. He said he could not eat the potato salad because it tasted bad. During an interview on 10/02/24 at 3:45 p.m., the Administrator said his expectations were for the menus and the recipes to be followed and if they were not followed, it could cause the residents to not receive a nutritionally balanced diet. He said if foods were not received as ordered they could be purchased with the company credit card and the DM should have reported not receiving all ordered foods required for the recipes to him so the food could be purchased. Record review of a Food Preparation policy revised 0/2019 indicated: Policy- Food is to be prepared by methods that conserve nutritive value, flavor, and appearance .

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 17 residents. (Resident #5) The facility failed to develop a care plan for Resident #5's anticoagulant (blood thinner) medication, Eliquis. This failure could place the residents at risk of not receiving care and services to maintain their highest level of well-being. Findings included: Record review of a face sheet dated 10/02/24 indicated Resident #5 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included embolism (sudden blocking of an artery) and thrombosis (formation of a blood clot inside a blood vessel) of her left lower extremity on 02/20/24. Record review of physician's orders dated 10/02/24 indicated Resident #5 was prescribed Eliquis 2.5 mg two times a day with a start date of 02/08/24. Record review of Resident #5's September 2024 MAR indicated she received Eliquis 2.5 mg two times a day for venous thrombosis with a start date of 02/08/24. Record review of the most recent annual MDS assessment date 07/17/24 indicated Resident #5 had a BIMS score of 14 indicating cognitively intact but did not indicate that she received an anticoagulant medication during the last 7 days. Record review of Resident #5's care plans revised 07/29/24 did not indicate Resident #5 received the anticoagulant medication. During an observation 09/30/24 at 11:00 a.m., Resident #5 was lying in bed with no observed bruising. She said she received an anticoagulant medication but was unsure which one. During an interview on 10/02/24 at 09:46 a.m., the MDS Nurse said she was responsible for all care plans in the facility. She said she was educated on completion of care plans and accuracy. She said Resident #5 was not care planned for the anticoagulant, Eliquis she received and should have been. The MDS nurse said she would care plan it now. The MDS nurse said she had no back up to double check her care plans for accuracy, but she could call the Regional Reimbursement Director for questions. She said the care plan was overlooked. The MDS nurse said the risk of Resident #5's anticoagulant not being care planned was not following policy. She said the nurses documented monitoring for side effects for Resident #5's anticoagulant. During an interview on 10/02/24 at 9:57 a.m., Regional Reimbursement Director said the MDS nurse was responsible for all care plans in the facility. She said she could fill in for the MDS nurse if needed but she did not monitor care plans for accuracy. The Regional Reimbursement Director said the MDS nurse was educated on care plans completeness and accuracy and could call her for questions or advice. The Regional Reimbursement Director said the risk of Resident #5's anticoagulant overlooked care planned was not following policy due to Resident #5's MAR indicated the nurses monitored Resident #5 for side effects. During an interview on 10/02/24 at 10:07 a.m., the DON said the MDS Nurse was responsible for care plans in the facility and was educated on accuracy and completeness of care plans. She said Resident #5's anticoagulant care plan was overlooked and should have been care planned. The DON said the Regional Reimbursement Director was a backup for the MDS nurse that she was unaware was not double-checking care plans for accuracy. The DON said she would start double-checking care plans for accuracy and completeness. She said the resident risk of receiving an anticoagulant and it not being care planned was possible side effects not being monitored. The DON said her expectation was anticoagulants were care planned on all residents that received anticoagulants. During an interview on 10/02/24 at 10:15 a.m., the Administrator said the MDS Nurse was responsible for care plans in the facility and was educated on accuracy and completion of care plans. He said he was unaware the Regional Reimbursement Director did not check the care plans for accuracy and the DON would now start double checking them. The Administrator said Resident #5's care plan was overlooked. He said the resident risk of a care plan not including anticoagulant medication the resident had received was the resident may not receive services required. He said his expectation was 100 percent compliance going forward with everything care planned and individualized to each resident. Record review of a facility policy titled, Nursing Policies and Procedures revised 06/2019 indicated: .Subject: CARE PLANNING . It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident.

Based on observation, interview, and record review, the facility failed to ensure residents received an accurate assessment, reflective of the resident's status for 2 of 17 residents reviewed for accuracy of assessments. (Resident #s 5 and 54) The facility did not accurately complete the MDS assessment to indicate Resident #5 was receiving an anticoagulant medication. The facility did not accurately complete the MDS assessment to indicate Resident #54 was receiving an anticoagulant medication. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: 1. Record review of a face sheet dated 10/02/24 indicated Resident #5 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included embolism (sudden blocking of an artery) and thrombosis (formation of a blood clot inside a blood vessel) of her left lower extremity on 02/20/24. Record review of the physician's orders dated 10/02/24 indicated Resident #5 was prescribed Eliquis 2.5 mg two times a day for venous thrombosis (blood clot in a vein) with a start date of 02/08/24. Record review of Resident #5's September 2024 MAR indicated she received Eliquis 2.5 mg two times a day for venous thrombosis with a start date of 02/08/24. Record review of the most recent annual MDS assessment dated [DATE] indicated Resident #5 had a BIMS score of 14 indicating cognitively intact but did not indicate that she received an anticoagulant medication during the last 7 days. Record review of Resident #5's care plans revised 07/29/24 did not indicate Resident #5 received the anticoagulant medication. During an observation on 09/30/24 at 11:00 a.m., Resident #5 was lying in bed with no observed bruising. She said she received an anticoagulant medication but was unsure which one. 2. Record review of a face sheet dated 10/02/24 indicated Resident #54 was a [AGE] year-old-female admitted [DATE] with a diagnosis of venous thrombosis (blockage in a vein) and embolism. Record review of physician's orders dated 10/02/24 indicated Resident #54 was prescribed apixaban 5 mg two times a day for heart failure (the heart does not pump blood as well as it should) with a start date of 06/13/24. Record review of Resident #54's September 2024 MAR indicated she received apixaban 5 mg two times a day for heart failure with a start date of 06/13/24. Record review of the most recent quarterly MDS assessment dated [DATE] indicated Resident #54 had a BIMS score of 5 indicating severely impaired of cognition but did not indicate that she received an anticoagulant medication during the last 7 days. Record review of Resident #54's care plan revised 07/03/24 indicated Resident #54 received an anticoagulant medication for heart failure. During an observation and interview on 09/30/24 at 10:00 a.m., Resident #54 was sitting in a wheelchair with no observed bruising. Resident #54 said she received an anticoagulant medication but was unsure which one. During an interview on 10/02/24 at 09:47 a.m., the MDS nurse said she was responsible for all MDSs in the facility. She said she was educated on completion of MDSs for accuracy. She said Resident #5's and #54's MDSs were not coded for receiving an anticoagulant medication and should have been. The MDS nurse said she had no back up to double check her MDSs for accuracy, but she could call the Regional Reimbursement Director for questions. She said Resident #5's and #54's MDSs not coded for received anticoagulant medication were overlooked. She said the risk of the MDSs not being accurately coded was not following policy, an inaccuracy that she would correct. The MDS nurse said the nurses had documented monitoring for side effects for the residents and were aware of the anticoagulant medication they received. During an interview on 10/02/24 at 9:59 a.m., the Regional Reimbursement Director said the MDS Nurse was responsible for all MDSs in the facility. She said she could fill in for the MDS nurse if needed but she did not monitor all MDSs for accuracy. She said she did occasional reviews for accuracy when needed and the MDS Nurse could call for questions or advice. The Regional Reimbursement Director said the MDSs not captured for the received anticoagulant medication were overlooked. She said the MDS Nurse was educated on MDS completeness and accuracy. She said a residents' MDSs not captured for receiving an anticoagulant did not increase or decrease money. She said the risk of an MDS not captured for received anticoagulant medication was an inaccuracy of coding that could be modified and corrected. The Regional Reimbursement Director said since the nurses had monitored the anticoagulant medication for side effects and the anticoagulant was care planned it was no risk to the resident. During an interview on 10/02/24 at 10:09 a.m., the DON said the MDS Nurse was responsible for all MDSs in the facility and was educated on accuracy and completeness of MDSs. She said Resident #5's and #54's anticoagulants should have been captured on the MDSs but were overlooked. The DON said the Regional Reimbursement Director was a backup, but she was unaware the Regional Reimbursement Director was not double checking MDSs for accuracy. The DON said she would start double checking the MDSs for accuracy and completeness. She said the risk of an MDS not captured when the resident received an anticoagulant was possible side effects not monitored. The DON said her expectation was all MDSs be completed and thorough. During an interview on 10/02/24 at 10:20 a.m., the Administrator said the MDS Nurse was responsible for all MDSs in the facility and had received education on completion of MDSs. He said he was unaware the Regional Reimbursement Director did not check the MDSs for accuracy so the DON would start double checking them for accuracy. The Administrator said the resident risk of an MDS not including anticoagulant medication the resident received was the resident may not receive services required. He said his expectation was 100 percent compliance going forward with everything documented on the MDS and individualized to the resident. Record review of the facility policy revised June 2019, titled, Subject: Minimum Data Set indicated, .An MDS, which is a comprehensive, accurate, standardized reproducible assessment will be completed for each resident, using the RAI process. Record review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2023 indicated, . N0415: High-Risk Drug Classes: Use and Indication 1. Is taking: Check if the resident is taking any medication by pharmacological classification, not how it is used during the last 7 days or since admission/ reentry or reentry if less than 7 days. N0415E1. Anticoagulant (eg., warfarin, heparin, or low-molecular weight heparin): Check if an anticoagulant medication was taken by the resident at anytime during the 7- day look back period.Coding Tips and Special Populations . Do not code antiplatelet medication such as aspirin/ extended release, dipyridamole, or clopidogrel as N0415 E, Anticoagulant.

Based on observation, interview, and record review, the facility failed to provide pain management, consistent with professional standards of practice, for 1 of 6 residents reviewed for pain. (Resident # 1) The facility did not provide effective pain control when Resident #1 complained of excruciating pain during care for two weeks, until x-rays revealed a [MEDICAL CONDITION]. Resident #1 required surgery to repair the fracture. This failure could place 48 residents on a pain management program at risk for unrelieved pain, decreased functioning and social interaction. Findings included: Consolidated physician orders, dated 07/01/17 - 09/30/17 indicated Resident #1 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 demonstrated no inappropriate behaviors, was cognitively impaired, had the ability to understand others, had clear speech, and was usually understood. The assessment indicated Resident #1 was totally dependent upon 2 staff members for bed mobility and transfers. The MDS indicated Resident #1 did not complain of pain, and there were no orders for pain medication. According to the MDS, Resident #1 participated in a turning/repositioning program. A nursing note dated 08/28/17 at 1:41 a.m., indicated Resident #1 had increased signs of pain and discomfort. The note indicated Resident #1 complained of hurting all over, and new orders were received for a chest x-ray and laboratory tests. A nursing note dated 08/28/17 at 6:04 a.m., indicated laboratory testing and a chest x-ray ordered for Resident #1 were postponed due to weather conditions. A Communication Form and Progress note dated 08/28/17 at 4:00 p.m., indicated Resident #1 complained of right knee pain during ADL care that worsened with movement. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A new order for a Salonpas pain relief patch, with a start date of 8/28/17, indicated the pain relief patch was to be applied to the right knee once every day for pain. The MAR indicated [REDACTED]. There was no documentation to indicate the effectiveness of the pain relief patch. A nursing note dated 09/01/17 indicated Resident #1 complained of aching, and indicated laboratory tests would be done when the weather permitted. Resident #1's MAR indicated [REDACTED]. There was no documentation to indicate the effectiveness of the patch. A nursing note and a communication/progress note, both dated 09/05/17 at 10:03 a.m., indicated Resident #1 hollered when the CNAs touched her right leg. This note indicated Resident #1 reported her knee hurt, and a new order for an x-ray for Resident #1's right lower extremity was to be completed that day. The note indicated Resident #1's pain relief patch was in place. There was no documentation to indicate the effectiveness of the medication. A nursing note dated 09/05/17 at 3:45 p.m. indicated Resident #1 was in bed, complained her right lower extremity and knee were tender to the touch said she doesn't feel well. A nursing note dated 09/05/17 at 6:27 p.m. indicated Resident #1 was administered Tylenol for right leg pain. A new order was received for [MEDICATION NAME] for pain, every 6 hours. Physicians orders for September 2017 indicated Resident #1 was ordered an x-ray of her right femur, knee, tibia and fibula on 09/05/17. This order was discontinued 09/10/17. During an interview on 09/26/17 at 9:39 a.m., the DON said on 9/5/17, the x-ray technicians told him they could not do the mobile x-ray because Resident #1 was so contracted and her joints were too stiff. The DON said they notified the physician and were told to monitor Resident #1 for pain. During an interview on 09/26/17 at 9:35 a.m., the administrator said Resident #1 had no documented falls. She said on 08/28/17, Resident #1 began complaining of pain and was rubbing her knee. The administrator said x-rays were attempted on 09/05/17, but were unsuccessful due to Resident #1's contractures. Resident #1's September MAR indicated [REDACTED]. The [MEDICATION NAME] was first administered on 09/06/17. There was no documentation to indicate the effectiveness of the [MEDICATION NAME]. A nursing note for Resident #1 dated 09/06/17 at 7:56 a.m. indicated the NP provided a clarification order for Resident #1's [MEDICATION NAME] 50 mg, to be given routinely morning and evening, and every six hours as necessary, for pain. Physician orders [REDACTED].#1's [MEDICATION NAME] tablet was to be administered twice daily for pain, and as needed, with a start date of 09/06/17. A NP provider note dated 09/06/17 at 12:24 p.m., indicated Resident #1 was at risk for falls, had joint stiffness, and muscle weakness, dementia and pain in right lower leg. The NP ordered an x-ray to determine the cause for the leg pain, and noted Resident #1 was given [MEDICATION NAME] twice daily and as needed. A nursing note dated 09/06/17 at 5:58 p.m. indicated Resident #1 complained of her right foot hurting and was medicated as per orders. The note indicated staff would continue to monitor. There was no documentation to indicate the effectiveness of the medication. Resident #1's MAR indicated [REDACTED]. [MEDICATION NAME] was administered. There was no documentation to indicate the effectiveness of the medication. A nursing note dated 09/07/17 at 3:45 p.m. indicated Resident #1 was still complaining of pain to her lower right extremity and was medicated as ordered for pain. Will continue to monitor. There was no documentation to indicate the effectiveness of the medication. Resident #1's MAR indicated [REDACTED]. There was no documentation to indicate the effectiveness of the medication. A nursing note dated 09/08/17 at 8:17 a.m. indicated Resident #1 had no adverse reactions to [MEDICATION NAME] given twice daily and as needed, but noted Resident #1 continued to complain of right knee pain during transfers and ADLs. The note indicated therapy was to evaluate and treat. A nursing note dated 09/08/17 at 2:28 p.m. indicated Resident #1 continued to complain of right lower extremity pain and was medicated per physician order. Will continue to monitor. There was no documentation to indicate the effectiveness of the medication. A nursing note dated 09/09/17 at 2:39 a.m. indicated Resident #1 continued to complain of right hip pain and was medicated as ordered. This note indicated an x-ray of Resident #1's right hip was scheduled for 09/11/17. A nursing note dated 09/09/17 at 9:37 p.m. indicated Resident #1 complained of leg pain when transferred. Physician orders [REDACTED].#1's right hip for 09/11/17. A nursing note dated 09/11/17 at 12:59 p.m. indicated Resident #1 complained of right lower extremity pain and [MEDICATION NAME] 50 mg PRN was administered. A nursing note dated 09/11/17 at 6:20 p.m. indicated Resident #1 had a right [MEDICAL CONDITION] and the pain was being managed with [MEDICATION NAME]. This note indicated the family and NP were notified, but the family did not want the resident sent to the ER. A nursing note dated 09/12/17 at 1:00 a.m. indicated Resident #1 was moaning and asking for God to help her during patient care. The nursing note indicated Resident #1's pain level was at 6, [MEDICATION NAME] was administered and at 2:54 a.m., Resident #1 still complained of pain at a level of 3. A nursing note dated 09/12/17 at 8:17 a.m. indicated Resident #1 complained of right lower extremity pain during ADLs, but denied pain while resting. A nursing note dated 09/12/17 at 9:37 p.m. indicated Resident #1's family was present in the facility and demanded she be sent to the hospital, and Resident #1 was sent to the ER. A Resident Event document dated 09/12/17 indicated Resident #1 suffered an unexplained injury in her room at 7:30 p.m. on 09/12/17. The incident/accident description findings section indicated Resident #1 complained of right leg pain, an x-ray was done which showed a [MEDICAL CONDITION] hip. Resident #1 was sent to the hospital. During interview on 09/26/17 at 10:04 a.m., Resident #1 said she felt much better now but had been in pain every day before being sent to the hospital. Resident #1 said it hurt every time the staff moved her and they all knew it. Resident #1 said there was nothing done about her pain until her daughter got involved. Resident #1 said she was given her routine pain medications but they didn't help, and said she had to have surgery. She could not remember how her hip got broken. Resident #1 said she stopped getting out of bed because she could not stand the pain. A physical therapy discharge summary dated 09/12/17 indicated Resident #1 exhibited a decrease in pain in her right hip when the resident was at rest, with pain level described as 5 on a scale of 1 to 10. Resident #1's baseline pain while at rest was described as 7 out of 10 on 09/08/17. This same discharge note indicated Resident #1 exhibited a decrease in pain with movement to an 8 out of 10 in the right hip. Resident #1's baseline pain was described as 10 out of 10 on 09/08/17. The therapy summary indicated Resident #1 was seen three times between 09/08/17 and 09/12/17. A care plan revised 09/15/17 addressed Resident #1's severe cognitive and self-help deficits. According to this care plan, Resident #1 required total assistance with bed mobility, transfers - fluctuates between extensive and total with 2 person assist bathing, toileting and dressing . The care plan addressed pain and discomfort related to her chronic disease process and contractures to upper and lower extremities with interventions including: .3. Implement pain management flow sheet as indicated. 4. Monitor for signs and symptoms of pain including verbal expressions and nonverbal expressions every two hours and as needed. 5. Notify physician if interventions are not consistently effective . Physician orders [REDACTED]. The [MEDICATION NAME] order was discontinued on 9/18/17. During an interview on 09/26/17 at 9:35 a.m., the administrator said Resident #1 was treated with a pain relief patch and [MEDICATION NAME] until the x-ray on 09/11/17 revealed a [MEDICAL CONDITION]. The administrator said Resident #1 was not sent to theER on [DATE] after the mobile unit could not complete the x-ray in the facility, because the doctor or NP did not order an x-ray. She said the NP was in the facility 09/06/17 and clarified the [MEDICATION NAME] order. The administrator said Resident #1 was referred to therapy for pain management. During an interview on 09/26/17 at 9:39 a.m., the DON said Resident #1 complained of pain the majority of the time. He said Resident #1's pain management program included the pain relief patch, and [MEDICATION NAME] routine and as needed. He said Resident #1's pain management program was not ineffective, it just wasn't effective long term. The DON said Resident #1 was not in constant pain. The DON said Resident #1's physician was notified when she first complained of pain, and when Resident #1's pain increased, but they did not notify the physician each time she complained of pain. He said x-rays were finally done on 09/11/17, and it was discovered Resident #1 had a [MEDICAL CONDITION]. A nursing note dated 09/12/17 at 1:00 a.m. indicated Resident #1 was moaning and asking for God to help her during patient care. The nursing note indicated Resident #1's pain level was at 6, [MEDICATION NAME] was administered and at 2:54 a.m., Resident #1 still complained of pain at a level of 3. A nursing note dated 09/12/17 at 8:17 a.m. indicated Resident #1 complained of right lower extremity pain during ADLs, but denied pain while resting. A nursing note dated 09/12/17 at 9:37 p.m. indicated Resident #1's family was present in the facility and demanded she be sent to the hospital, and Resident #1 was sent to the ER. A Resident Event document dated 09/12/17 indicated Resident #1 suffered an unexplained injury in her room at 7:30 p.m. on 09/12/17. The incident/accident description findings section indicated Resident #1 complained of right leg pain, an x-ray was done which showed a [MEDICAL CONDITION] hip. Resident #1 was sent to the hospital. During an interview on 09/25/17 at 4:13 p.m., RN E said Resident #1 was bed bound and totally dependent upon staff for bed mobility and ADL care. She said Resident #1 reported she was dropped at the nursing home and had been hurting real bad since then. RN E said Resident #1 told her nothing helped to ease the pain. RN E said every time Resident #1 had to be moved, repositioned or touched on her right leg she would wince or moan in pain, and sometimes yell out. RN E said Resident #1 told her she was in constant pain for several days before she was sent to the hospital. A hospital CT scan report dated 09/12/17 at 11:49 p.m. indicated Resident #1 was admitted due to right hip pain after a fall. The results indicated Resident #1 had a [MEDICAL CONDITION] hip extending into the intertrochanteric region (upper part of the thigh bone). A hospital consultation dated 09/13/17 indicated Resident #1 fell at the nursing home within the last three weeks and had been in persistent pain since. According this note, Resident #1 was seen in the ER and found to have a right [MEDICAL CONDITION]. A hospital record dated 09/14/17 indicated Resident #1 had a right hip arthroplasty (surgery) for [MEDICAL CONDITION]. A nursing note dated 09/15/17 indicated Resident #1 returned to the facility with [MEDICATION NAME] sulfate solution 20mg ordered every 2 hours as needed for pain. According to nursing documentation, from 9/6/17 through 09/12/17, the NP or physician were not notified of Resident #1's continued complaints of pain during ADL care, movement and transfers on 09/06/17, 09/07/17, 09/08/17, 09/09/17, 09/11/17 and 09/12/17. There were no additional efforts or new pain management interventions attempted in addition to the [MEDICATION NAME] from 09/06/17 - 09/12/17 according to documentation. A September 2017 MAR indicated [REDACTED] -[MEDICATION NAME] hcl tablet 50 mg every 6 hours as needed on 09/07/17, 09/11/17 and 09/12/17 -[MEDICATION NAME] hcl tablet 50 mg twice daily 09/06/17-09/12/17 -Salonpas pain relief patch was applied daily from 09/01/17-09/12/17 During an interview on 09/26/17 at 11:06 a.m., the ADON said Resident #1 first complained of ankle pain and then she complained of right leg pain whenever she was moved. She said x-rays were ordered 09/05/17 but the technicians were unable to complete the x-ray successfully. The ADON said x-rays were finally done 09/11/17, because that was the first day the therapist was back in the facility to assist with proper positioning of Resident #1. The ADON said Resident #1 was not sent to the ER for x-rays on 09/05/17 because the physician did not order it. She said Resident #1's complaints of pain increased. The ADON said Resident #1 was given [MEDICATION NAME], but nothing else was attempted when the resident's complaints of pain persisted. She said the physician was not notified when the [MEDICATION NAME] was not effective. The ADON said the facility did not monitor the effectiveness of routine pain medication, but only monitored the effectiveness of pain medication given as needed. The ADON said the facility did not have a system for determining whether routine pain medication was effective. She said if a resident could not express their level of pain there was no way to determine if the pain medication was effective. The ADON said it was possible some residents were getting unnecessary or ineffective pain medications, because they did not monitor the effectiveness of routine pain medication. During an interview on 09/26/17 at 11:40 a.m., LVN J said routine and PRN pain management medications should always be monitored for effectiveness one hour after administration, but the facility's system only prompts for PRN pain management follow up. LVN J said Resident #1's pain management program was effective at times but as Resident #1's pain increased, there were no changes to her pain management program, and no new interventions were attempted to decrease the resident's pain and the physician was not notified. LVN J said Resident #1 complained of pain after [MEDICATION NAME] was administered, but the physician was not notified. LVN J said the pain assessment on the MAR indicated [REDACTED]. During an interview on 09/26/17 at 12:38 p.m., LVN O said she initially learned of Resident #1's severe pain on 09/05/17, and she ordered x-rays that day. She said she was not aware the x-rays were not done until she returned to work at the facility on 09/09/17. LVN O said she rescheduled Resident #1's x-rays for Monday, 09/11/17, when the therapist would be present to assist. LVN O said she knew the [MEDICATION NAME] was not effective, and could tell there was something more wrong with Resident #1, which was the reason she persisted with getting the x-rays. LVN O said Resident #1 would cry out for help and say oh baby please no when she had to be provided care or repositioned. She said Resident #1 never complained, so she knew there must be a reason. LVN O said the [MEDICATION NAME] was administered, but did not monitor the effectiveness of routine pain medications. LVN O said the pain management regimen for Resident #1 was ineffective because she continued to complain of pain. She said that [MEDICATION NAME] did not touch her pain. LVN O said she thought Resident #1 should have been sent to theER on [DATE] when the in-house mobile x-ray unit was unsuccessful at obtaining the x-rays, because Resident #1 appeared to be in a lot of pain, a lot. LVN O said, I don't know why she had to wait so long. She said the facility implemented no new interventions in an effort to address Resident #1's pain. She said the x-rays showed Resident #1 sustained a [MEDICAL CONDITION]. During an interview on 09/26/17 at 1:25 p.m., CNA B said Resident #1 told her the pain worsened every day. CNA B said the pain got so severe Resident #1 refused to get out of bed, and prior to that time, the resident was up all day. CNA B said Resident #1's social interaction decreased because she was hurting. CNA B said she reported to the nurses every day that Resident #1 was in pain, every time they provided care or moved her. CNA B said they tried to tell me it was arthritis, but I knew it more serious because of how she (Resident #1) would call on God and holler out. CNA B said it got so bad she took Resident #1 up front to the Administrator and DON and told them they had to do something to help this woman, she's hurting and that medicine ain't touching her pain. CNA B said they would give Resident #1 pain pills and she would continue to complain. CNA B said she had worked with Resident #1 for five years and Resident #1 never complained about anything. CNA B said for Resident #1 to complain, she had to really be hurting. During an interview on 09/26/17 at 2:00 p.m., LVN G said she had been Resident #1's charge nurse for three years. She said Resident #1 complained of pain to her right knee, so an x-ray was ordered. She said Resident #1's contractures prevented the x-ray technicians from obtaining the x-ray, so the pain relief patch and [MEDICATION NAME] were ordered for pain management. LVN G said Resident #1 continued to complain of pain to her right knee and right hip. She said Resident #1 could not be moved or provided incontinent care without increased pain. She said the orders for Resident #1's pain medication never changed, and there was no way to tell if routine pain medications were effective. She said only pain medications given as needed were monitored. LVN G said she did not know why Resident #1 was not sent to the ER for x-rays on 09/05/17, instead of having to wait until 09/11/17 in almost continuous pain. LVN G said [MEDICATION NAME] was only effective for Resident #1's knee pain, but did not help the pain associated with her hip. She said no other pain interventions were implemented, even when Resident #1 repeatedly complained she was hurting, especially during ADL care. LVN G said she would assist the CNAs with providing care, and Resident #1 would yell when being repositioned. LVN G said she spoke with Resident #1's family on 09/12/17, and they requested Resident #1 be sent to the hospital for treatment. During an interview on 09/26/17 at 2:15 p.m., the ADON said as of 09/05/17 Resident #1's pain started getting really bad. She said the physician and NP were not notified of Resident #1's increased pain from 09/06/17-09/11/17. The ADON said an x-ray was done 09/11/17 which revealed the [MEDICAL CONDITION] of unknown origin. The ADON said Resident #1 continued to complain of pain, and the facility did not attempt changes to medications or new interventions to manage the pain. The ADON said unrelieved pain is considered to be a change in condition, and the physician should have been notified. During an interview on 09/26/17 at 4:23 p.m., LVN T said staff were monitoring Resident #1's pain. She said no new approaches were tried when Resident #1 continued to complain of pain, and since they had no system for monitoring the effectiveness of routine pain medications, the physician should have been notified of the persistent pain and that the [MEDICATION NAME] was not working. During an interview on 09/26/17 at 4:27 p.m., LVN J said Resident #1 was referred to therapy for pain management, but the therapist wanted the results of the x-rays before they would work with her. LVN J said Resident #1 had a [MEDICAL CONDITION] and transferred to the hospital before therapy implemented any approaches for pain management. During an interview on 09/27/17 at 3:41 p.m., the administrator said their computer system does not prompt the staff to follow up for the effectiveness of pain medications. She said Resident #1's pain started 08/28/17. She said the pain was scored when pain medication was administered, but staff were not required to assess the resident's pain after the pain medicine was given. The administrator said it's not like we were all standing around listening to her holler and doing nothing. She said they were following doctor's orders. A pain assessment policy dated 11/11/16 indicated a pain assessment should be performed .if the patient demonstrates signs of pain or is subjected to a presumably painful event .in an intervention is performed, the pain level should be assessed before the intervention and within one (1) hour after the intervention to assess the patient's response .pain affects the degree of independence, level of need for caregivers and overall quality of life. A pain assessment, long-term care policy dated 08/18/17 indicated Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage .it's crucial for nurses to communicate with health care providers and address residents' pain .pain is commonly undertreated in residents with cognitive impairments such as dementia. The facility CMS 802 dated 09/26/17 indicated there were 48 residents on a pain management program.

Based on observation, interview, and record review, the facility failed to ensure each resident was provided with the necessary care and services to attain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive plan of care for 1 of 6 residents reviewed for change in condition. (Resident #5) LVN A did not assess the resident or notify the physician when Resident #5 exhibited a decreased level of consciousness and gurgling respirations on [DATE] at approximately 6:30 a.m. LVN A did not check the resident again for approximately 5 hours and, at that time, the resident Cheyne-Stokes respirations (indicative of impending death). Resident #5 died about 1 hour later. This failure created an Immediate Jeopardy situation. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at isolated actual harm with the potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the census of 56 residents at risk for delay in treatment or death. Findings included: Physician orders [REDACTED].#5, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The orders included "Do Not Resuscitate". The most recent MDS assessment dated [DATE] indicated Resident #5's cognitive status was moderately impaired and he required extensive assistance with transfers, dressing, toileting, and personal hygiene. A nursing care plan dated [DATE] indicated the physician was to be notified with changes in physical or mental status as needed. During an interview on [DATE] at 12:00 p.m., LVN A said she performed a blood sugar check on Resident #5 on [DATE] between 6:30 a.m. - 6:45 a.m. He did not move when she stuck him, which she said was unusual. She said he made a gurgling sound and thought he might be getting pneumonia again because he had recently had it. She started a breathing treatment and removed the mask fifteen minutes later. He continued to be non-responsive. She did not assess him or notify the physician because he was [AGE] years old and on hospice. She said she did not think much about it and she still had several blood sugar checks to do. LVN A said when she got "caught up" she went back to check on Resident #5 and do his noon blood sugar check between 11:30 a.m. - 12:00 p.m. His eyes were rolled back in his head and she asked the RN to check on him. During an interview on [DATE] at 1:00 p.m., RN C said she overheard CNA B say on the morning of [DATE], Resident #5 was not alert enough to eat in the dining room. She was going to assist him with breakfast in his room. RN C said Resident #5 usually ate in the dining room, but she did not question what was wrong with the resident or assess him. RN C said around 12:00 noon, LVN A asked her to check on Resident #5. RN C said Resident #5 was pale, mumbling, and exhibiting Cheyne-Stokes breathing. RN C said she notified the family and informed them of his impending death. She did not notify the physician because he had do not resuscitate orders. During an interview on [DATE] at 1:05 p.m., MA E said she administered Resident #5's medications around 7:00 a.m. and he was squirming as if in pain. Resident #5's roommate said he overheard Resident #5 say he was in pain earlier, so she gave him a [MEDICATION NAME] ,[DATE] mg (pain) She said he never opened his eyes, but opened his mouth to take his medication. MA E said Resident #5 was usually up and talkative. During an interview on [DATE] at 1:10 p.m., CNA B said on [DATE], she attempted to assist Resident #5 with his breakfast. He ate a couple of bites of food and took a sip of fluid. She said he would not open his eyes and was mumbling. CNA B said Resident #5 usually got up every morning and went to the dining room for breakfast. She reported Resident #5's condition and staying in bed for breakfast to LVN A. During an interview on [DATE] at 1:30 p.m., RA D said she weighed Resident #5 on [DATE] between 6:30 a.m. - 6:45 a.m. using a Hoyer lift scale. RA D said Resident #5 was unable to assist turning himself as he normally did. He was talking and when she asked him who he was talking to, he seemed not to hear her and kept talking. RA D was unable to understand what he was saying. RA D said Resident #5 normally was smiling, talkative, and could assist with turning. She said she did not report the change to LVN A. During an interview on [DATE] at 1:15 p.m., the ADON said Resident #5 was not on hospice or palliative care. She said the resident should have been assessed and the physician notified of his change in condition. She said Resident #5 was normally up in his wheelchair, alert and talkative. During an interview on [DATE] at 1:18 p.m., CNA F said she was Resident #5's CNA on the 10:00 p.m. - 6:00 a.m. shift on [DATE]. She said he was unable to assist with turning, repositioning, and was not talkative. He would only answer questions when asked, which was unusual for him. She did not report it to the charge nurse (LVN A) because she thought he was just tired. During an interview on [DATE] at 1:55 p.m., the DON said LVN A should have assessed Resident #5 and notified the physician when she observed he had a change in condition. She said Resident #5 was not on hospice or palliative care. During an interview on [DATE] at 8:50 a.m., Rehab assistant G said Resident #5 did not like to stay in bed and was usually up in his wheelchair. Resident #5's nursing notes dated [DATE] at 12:00 p.m. indicated he was lethargic, had Cheyne-Stokes respirations, skin pale/clammy. His pulse was 64, oxygen on at 3 liters per nasal cannula. The daughter was notified of signs/symptoms of impending death. At 12:28 p.m., resident had no respirations, blood pressure, or pulse and was pronounced deceased . The Change of Condition policy dated [DATE] indicated the following: "...for life threatening events call 911 if initial assessment indicates such action necessary" "...assess and document changes in condition in an efficient and effective manner" Provide assessment information to the physician. "...before calling physician, evaluate the resident, check vital signs and review chart." The administrator and DON were notified on [DATE] at 2:00 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 5:50 p.m. and included: "Identified resident is no longer at the facility; therefore, there is no further action that can be accomplished for this resident. The nurse responsible for the overall care of the resident on the day of the issue will be terminated for lack of assessing the resident The resident care specialist that did not report a change on the day of the issue will be re-educated for lack of reporting the change to the nurse. She will not be permitted to resume floor responsibilities until training has been completed. All residents will be assessed for a change of condition by the DON to be completed by 10:00 p.m. on [DATE]. If a change of condition is identified, a Change of Condition/SBAR (situation, back ground, assessment and request) will be completed and Physician will be notified immediately. All licensed staff will be educated on policy for Change of Condition, Change of Condition/SBAR, and on assessing a patient by the Administrator/DON/ADON. Staff will not be permitted to resume floor responsibilities until training has been completed. Initiated [DATE] and will be completed by [DATE]. All Resident Care Specialist, Restorative Aides, and Medication Aides will be educated on the policy for reporting a change of condition, utilizing the INTERACT/Stop and Watch (stop, observe the resident, and report what you see), and communicating with license nurse by the Administrator/DON/ADON. Initiated [DATE] and will be completed by [DATE]. All residents are monitored every shift for change of condition and communicated utilizing the 24-Hour Report. This will be monitored by the Administrator/DON/ADON every day during the morning stand up meeting and the weekend supervisor will monitor on weekends. Initiated on [DATE] and will be ongoing. The Quality Assurance Committee designee will review 24-hour report and monitor monthly. Administrator/DON/ADON will audit the patient charts and determine which patients are hospice or palliative care. A list will be provided for the nurses and posted at the nurses' station and updated as needed, but will be evaluated weekly for accuracy by the DON/ADON. Initiated [DATE] and will be ongoing. The Quality Assurance Committee designee will review Hospice/Palliative care list and monitor monthly. Administrator/DON/ADON will provide a census which identifies hospice patients with the 24-hr report book daily and any palliative care patients will be identified on the 24 hour report sheet. Initiated [DATE] and will be ongoing. The Administrator/DON/ADON will review 24-hr report book every day in the stand-up meeting and the weekend supervisor will monitor on weekends. The Administrator will monitor 24-hr report book during Quality Assurance Meeting monthly. Upon identification of a resident experiencing a change of condition, the resident will be monitored by a licensed nurse every 4 hours for a minimum of 72 hours. Change of Condition will be identified on the 24-hour report book and the DON/ADON will review the 24-hour report book daily in the stand-up meeting and the weekend supervisor will monitor on weekends." The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Four CNAs were interviewed and said they were in-serviced on reporting resident change of condition to the nurse immediately and on the stop and watch program. Two MAs were interviewed and said they were in-serviced on reporting resident change of condition to the nurse immediately and on the stop and watch program. Three nurses were interviewed and said they in-serviced on location of list on residents on hospice/palliative care, assessing residents when they had a change of condition and physician notification. Residents who had a change in condition was to be monitored every 4 hours for 72 hours. Five residents who were assessed by the DON were observed and the assessment matched the residents' conditions. The new policy for Change of Condition dated [DATE] contained the required revision of utilizing the "stop and watch" (stop, observe the resident and report what you see), residents with a change of condition be placed on the 24 hour report, list of hospice/palliative care residents at the nursing station and 4 hour charting for 72 hours would be done when a resident had a change in condition. On [DATE] at 9:30 a.m. the administrator and DON were informed the Immediate Jeopardy was removed, but the facility remained out of compliance at isolated actual harm due to the facility's need to complete inservice training and evaluate the effectiveness of the corrective systems. The CMS 2567 dated [DATE] indicated the census was 56.

Based on interview and record review, the facility failed to consult with the physician for 1 of 6 residents reviewed for change in condition. (Resident #5) LVN A did not notify the physician when Resident #5 exhibited a decreased level of consciousness and gurgling respirations on [DATE] at approximately 6:30 a.m. LVN A did not check the resident again for about 5 hours and at that time the resident had Cheyne-Stokes respirations (indicative of impending death). Resident #5 died about 1 hour later. This failure created an Immediate Jeopardy situation. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at isolated actual harm with the potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the census of 56 residents at risk for delay in treatment or death. Findings included: Physician orders [REDACTED].#5, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The orders included "Do Not Resuscitate". The most recent MDS assessment dated [DATE] indicated Resident #5's cognitive status was moderately impaired and he required extensive assistance with transfers, dressing, toileting, and personal hygiene. A nursing care plan dated [DATE] indicated the physician was to be notified with changes in physical or mental status as needed. During an interview on [DATE] at 12:00 p.m., LVN A said she performed a blood sugar check on Resident #5 on [DATE] between 6:30 a.m. - 6:45 a.m. He did not move when she stuck him, which she said was unusual. She said he made a gurgling sound and thought he might be getting pneumonia again because he had recently had it. She started a breathing treatment and removed the mask fifteen minutes later. He continued to be non-responsive. She did not assess him or notify the physician because he was [AGE] years old and on hospice. She said she did not think much about it and she still had several blood sugar checks to do. LVN A said when she got "caught up" she went back to check on Resident #5 and do his noon blood sugar check between 11:30 a.m. - 12:00 p.m. His eyes were rolled back in his head and she asked the RN to check on him. During an interview on [DATE] at 1:00 p.m., RN C said she overheard CNA B say on the morning of [DATE], Resident #5 was not alert enough to eat in the dining room. She was going to assist him with breakfast in his room. RN C said Resident #5 usually ate in the dining room, but she did not question what was wrong with the resident or assess him. RN C said around 12:00 noon, LVN A asked her to check on Resident #5. RN C said Resident #5 was pale, mumbling, and exhibiting Cheyne-Stokes breathing. RN C said she notified the family and informed them of his impending death. She did not notify the physician because he had do not resuscitate orders. During an interview on [DATE] at 1:05 p.m., MA E said she administered Resident #5's medications around 7:00 a.m. and he was squirming as if in pain. Resident #5's roommate said he overheard Resident #5 say he was in pain earlier, so she gave him a [MEDICATION NAME] ,[DATE] mg (pain) She said he never opened his eyes, but opened his mouth to take his medication. MA E said Resident #5 was usually up and talkative. During an interview on [DATE] at 1:10 p.m., CNA B said on [DATE], she attempted to assist Resident #5 with his breakfast. He ate a couple of bites of food and took a sip of fluid. She said he would not open his eyes and was mumbling. CNA B said Resident #5 usually got up every morning and went to the dining room for breakfast. She reported Resident #5's condition and staying in bed for breakfast to LVN A. During an interview on [DATE] at 1:30 p.m., RA D said she weighed Resident #5 on [DATE] between 6:30 a.m. - 6:45 a.m. using a Hoyer lift scale. RA D said Resident #5 was unable to assist turning himself as he normally did. He was talking and when she asked him who he was talking to, he seemed not to hear her and kept talking. RA D was unable to understand what he was saying. RA D said Resident #5 normally was smiling, talkative, and could assist with turning. She said she did not report the change to LVN A. During an interview on [DATE] at 1:15 p.m., the ADON said Resident #5 was not on hospice or palliative care. She said the resident should have been assessed and the physician notified of his change in condition. She said Resident #5 was normally up in his wheelchair, alert and talkative. During an interview on [DATE] at 1:18 p.m., CNA F said she was Resident #5's CNA on the 10:00 p.m. - 6:00 a.m. shift on [DATE]. She said he was unable to assist with turning, repositioning, and was not talkative. He would only answer questions when asked, which was unusual for him. She did not report it to the charge nurse (LVN A) because she thought he was just tired. During an interview on [DATE] at 1:55 p.m., the DON said LVN A should have assessed Resident #5 and notified the physician when she observed he had a change in condition. She said Resident #5 was not on hospice or palliative care. During an interview on [DATE] at 8:50 a.m., Rehab assistant G said Resident #5 did not like to stay in bed and was usually up in his wheelchair. Resident #5's nursing notes dated [DATE] at 12:00 p.m. indicated he was lethargic, had Cheyne-Stokes respirations, skin pale/clammy. His pulse was 64, oxygen on at 3 liters per nasal cannula. The daughter was notified of signs/symptoms of impending death. At 12:28 p.m., resident had no respirations, blood pressure, or pulse and was pronounced deceased . The Change of Condition policy dated [DATE] indicated the following: "...for life threatening events call 911 if initial assessment indicates such action necessary" "...assess and document changes in condition in an efficient and effective manner" Provide assessment information to the physician. "...before calling physician, evaluate the resident, check vital signs and review chart." The administrator and DON were notified on [DATE] at 2:00 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 5:50 p.m. and included: "Identified resident is no longer at the facility; therefore, there is no further action that can be accomplished for this resident. The nurse responsible for the overall care of the resident on the day of the issue will be terminated for lack of assessing the resident The resident care specialist that did not report a change on the day of the issue will be re-educated for lack of reporting the change to the nurse. She will not be permitted to resume floor responsibilities until training has been completed. All residents will be assessed for a change of condition by the DON to be completed by 10:00 p.m. on [DATE]. If a change of condition is identified, a Change of Condition/SBAR (situation, back ground, assessment and request) will be completed and Physician will be notified immediately. All licensed staff will be educated on policy for Change of Condition, Change of Condition/SBAR, and on assessing a patient by the Administrator/DON/ADON. Staff will not be permitted to resume floor responsibilities until training has been completed. Initiated [DATE] and will be completed by [DATE]. All Resident Care Specialist, Restorative Aides, and Medication Aides will be educated on the policy for reporting a change of condition, utilizing the INTERACT/Stop and Watch (stop, observe the resident, and report what you see), and communicating with license nurse by the Administrator/DON/ADON. Initiated [DATE] and will be completed by [DATE]. All residents are monitored every shift for change of condition and communicated utilizing the 24-Hour Report. This will be monitored by the Administrator/DON/ADON every day during the morning stand up meeting and the weekend supervisor will monitor on weekends. Initiated on [DATE] and will be ongoing. The Quality Assurance Committee designee will review 24-hour report and monitor monthly. Administrator/DON/ADON will audit the patient charts and determine which patients are hospice or palliative care. A list will be provided for the nurses and posted at the nurses' station and updated as needed, but will be evaluated weekly for accuracy by the DON/ADON. Initiated [DATE] and will be ongoing. The Quality Assurance Committee designee will review Hospice/Palliative care list and monitor monthly. Administrator/DON/ADON will provide a census which identifies hospice patients with the 24-hr report book daily and any palliative care patients will be identified on the 24 hour report sheet. Initiated [DATE] and will be ongoing. The Administrator/DON/ADON will review 24-hr report book every day in the stand-up meeting and the weekend supervisor will monitor on weekends. The Administrator will monitor 24-hr report book during Quality Assurance Meeting monthly. Upon identification of a resident experiencing a change of condition, the resident will be monitored by a licensed nurse every 4 hours for a minimum of 72 hours. Change of Condition will be identified on the 24-hour report book and the DON/ADON will review the 24-hour report book daily in the stand-up meeting and the weekend supervisor will monitor on weekends." The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Four CNAs were interviewed and said they were in-serviced on reporting resident change of condition to the nurse immediately and on the stop and watch program. Two MAs were interviewed and said they were in-serviced on reporting resident change of condition to the nurse immediately and on the stop and watch program. Three nurses were interviewed and said they in-serviced on location of list on residents on hospice/palliative care, assessing residents when they had a change of condition and physician notification. Residents who had a change in condition was to be monitored every 4 hours for 72 hours. Five residents who were assessed by the DON were observed and the assessment matched the residents' conditions. The new policy for Change of Condition dated [DATE] contained the required revision of utilizing the "stop and watch" (stop, observe the resident and report what you see), residents with a change of condition be placed on the 24 hour report, list of hospice/palliative care residents at the nursing station and 4 hour charting for 72 hours would be done when a resident had a change in condition. On [DATE] at 9:30 a.m. the administrator and DON were informed the Immediate Jeopardy was removed, but the facility remained out of compliance at isolated actual harm due to the facility's need to complete inservice training and evaluate the effectiveness of the corrective systems. The CMS 2567 dated [DATE] indicated the census was 56.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent worsening of pressure ulcers for 1 of 3 residents reviewed for pressure ulcers. (Resident #1) Resident #1 was admitted [DATE] with a Stage II pressure sore that worsened to unstageable. The physician was not consulted regarding this pressure sore until surveyor intervention on 11/26/13, 13 days after admission. This failure contributed to the worsening of an existing pressure sore for Resident #1. This failure could place 2 other residents with pressure sores at risk of a delay in medical evaluation and treatment. Findings included: Physician orders [REDACTED]. There was no diagnosis or treatment orders for pressure sores. A Braden scale assessment (a tool for assessing pressure sore risk) dated 11/13/13 indicated Resident #1 was at high risk for skin breakdown. A weekly pressure sore report dated 11/13/13 indicated Resident #1 was admitted with a Stage II pressure sore on the sacrum. A pressure sore care plan dated 11/13/13 indicated staff were to provide Resident #1 incontinent care every two hours and as needed, turn and reposition in bed and chair every two hours and as needed, and refer to registered dietician as needed. The nurse practitioner's "acute progress note" dated 11/14/13 indicated the only skin issue was the wound to the right lower abdomen and referred to the wound care center to assess the wound. There was no documentation of a pressure sore. laboratory results dated [DATE] indicated Resident #1 had a low [MEDICATION NAME] (protein indicator) of 2.5 (reference range 3.5-5.0). The most recent MDS assessment dated [DATE] indicated Resident #1 required extensive assistance with bed mobility, had a catheter, and was incontinent of bowel. The resident had minimal mental status problems and no behavior problems. The assessment indicated Resident #1 had one Stage II pressure sore. There was no dietary assessment for Resident #1 in the clinical record. During an observation on 11/26/13 at 6:30 a.m., Resident #1 was in bed lying on her right side. She had an ulcer on her sacrum that had yellow slough (dead, necrotic tissue). There was no dressing on the wound. During an interview on 11/26/13 at 8:35 a.m., the interim DON said she did an assessment on the sacral wound on or around 11/19/13. She said the buttocks were red and inflamed with a Stage II pressure sore in the middle. She said she could not find her written assessment. She said the Dietician had not seen the resident. The Dietician was at the facility on 11/05/13. During an interview on 11/26/13 at 9:50 a.m., the nurse practitioner said she was not aware Resident #1 had a sacral pressure sore. She said she thought the resident was going to the wound care center due to the abdominal wound. During an interview on 11/26/13 at 10:10 a.m., LVN #A said the yellow slough in Resident #1's wounds had been there for a while. She said she had not talked to the physician or nurse practitioner about the wound. She said they had only been applying [MEDICATION NAME] cream (steroid) and [MEDICATION NAME] (antifungal cream) to her buttocks, per her physician orders. There were no other orders for the pressure ulcer. She said the residen had an appointment to go to the wound care center. During a treatment observation and interview with LVN #A on 11/26/13 at 11:15 a.m., Resident #1 had a pressure sore to her sacral area measuring 4.5 cm x 3.2 cm with yellow slough measuring 2.5 cm x 3.0 cm in the center. The whole sacral area was red/excoriated. There was also a non-pressure wound on her right lower abdomen that measured 3.5 cm x 2.5 cm. It had yellow slough with red edges. The abdominal area was treated with triple antibiotic ointment and a dry dressing. LVN #A applied [MEDICATION NAME] cream and [MEDICATION NAME] cream to the buttocks, then covered the wound with a dressing. She said they were not able to get the cream compounded, so they applied them separately. She said Resident #1 was admitted with the abdominal wound. She said it was about the same. LVN #A said she had not talked to the physician about the pressure sore. The National Pressure Ulcer Advisory Panel website http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/ accessed 12/02/13 indicated: Category/Stage II: Partial thicknessPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous (serum with blood) filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation. Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknownFull thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed." A "Skin Management" policy with a revision dated August 2012 indicated: "12. A nutritional evaluation will be completed within 7 days of admission on alll residents identified at risk or with compomised skin integrity. 13. A Registered Dietitian will assess all residents identified with skin impairment for nutritional staus in a timely manner." The CMS 672 dated 11/26/13 indicated 3 residents had pressure sores.

Based on observation, interview, and record review, the facility failed to consult with the physician about the presence and deterioration of a pressure sore for 1 of 3 residents reviewed for pressure sores. (Resident #1) Resident #1 was admitted [DATE] with a Stage II pressure sore that worsened to unstageable. The physician was not consulted regarding this pressure sore until surveyor intervention on 11/26/13, 13 days after admission. This failure contributed to the worsening of an existing pressure sore for Resident #1. This failure could place 2 other residents with pressure sores at risk of a delay in medical evaluation and treatment. Findings included: Physician orders [REDACTED]. There was no diagnosis or treatment orders for pressure sores. A Braden scale assessment (a tool for assessing pressure sore risk) dated 11/13/13 indicated Resident #1 was at high risk for skin breakdown. A weekly pressure sore report dated 11/13/13 indicated Resident #1 was admitted with a Stage II pressure sore on the sacrum. A pressure sore care plan dated 11/13/13 indicated staff were to provide Resident #1 incontinent care every two hours and as needed, turn and reposition in bed and chair every two hours and as needed, and refer to registered dietician as needed. The nurse practitioner's "acute progress note" dated 11/14/13 indicated the only skin issue was the wound to the right lower abdomen and referred to the wound care center to assess the wound. There was no documentation of a pressure sore. laboratory results dated [DATE] indicated Resident #1 had a low [MEDICATION NAME] (protein indicator) of 2.5 (reference range 3.5-5.0). The most recent MDS assessment dated [DATE] indicated Resident #1 required extensive assistance with bed mobility, had a catheter, and was incontinent of bowel. The resident had minimal mental status problems and no behavior problems. The assessment indicated Resident #1 had one Stage II pressure sore. There was no dietary assessment for Resident #1 in the clinical record. During an observation on 11/26/13 at 6:30 a.m., Resident #1 was in bed lying on her right side. She had an ulcer on her sacrum that had yellow slough (dead, necrotic tissue). There was no dressing on the wound. During an interview on 11/26/13 at 8:35 a.m., the interim DON said she did an assessment on the sacral wound on or around 11/19/13. She said the buttocks were red and inflamed with a Stage II pressure sore in the middle. She said she could not find her written assessment. She said the Dietician had not seen the resident. The Dietician was at the facility on 11/05/13. During an interview on 11/26/13 at 9:50 a.m., the nurse practitioner said she was not aware Resident #1 had a sacral pressure sore. She said she thought the resident was going to the wound care center due to the abdominal wound. During an interview on 11/26/13 at 10:10 a.m., LVN #A said the yellow slough in Resident #1's wounds had been there for a while. She said she had not talked to the physician or nurse practitioner about the wound. She said they had only been applying [MEDICATION NAME] cream (steroid) and [MEDICATION NAME] (antifungal cream) to her buttocks, per her physician orders. There were no other orders for the pressure ulcer. She said the residen had an appointment to go to the wound care center. During a treatment observation and interview with LVN #A on 11/26/13 at 11:15 a.m., Resident #1 had a pressure sore to her sacral area measuring 4.5 cm x 3.2 cm with yellow slough measuring 2.5 cm x 3.0 cm in the center. The whole sacral area was red/excoriated. There was also a non-pressure wound on her right lower abdomen that measured 3.5 cm x 2.5 cm. It had yellow slough with red edges. The abdominal area was treated with triple antibiotic ointment and a dry dressing. LVN #A applied [MEDICATION NAME] cream and [MEDICATION NAME] cream to the buttocks, then covered the wound with a dressing. She said they were not able to get the cream compounded, so they applied them separately. She said Resident #1 was admitted with the abdominal wound. She said it was about the same. LVN #A said she had not talked to the physician about the pressure sore. The National Pressure Ulcer Advisory Panel website http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/ accessed 12/02/13 indicated: Category/Stage II: Partial thicknessPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous (serum with blood) filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation. Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknownFull thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed." The CMS 672 dated 11/26/13 indicated 3 residents had pressure sores.