Every finding on record at Patriot Heights Health Care Center

Based on observations, interviews and record reviews, the facility failed to ensure assessments accurately reflected thestatus of the residents for 1 of 6 residents (Resident #1) reviewed for MDS assessments. The facility failed to ensure Resident #1s accurate number of falls which were two, were reflected on the admission MDS assessment dated [DATE] and quarterly MDS assessment dated [DATE]. This deficient practice could place residents at risk of inadequate care. The findings include: Record review of Resident #1's electronic face sheet dated 08/12/2026 reflected an [AGE] year-old male admitted on [DATE]. He had a diagnosis of history of falling. Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected Review of his quarterly MDS assessment dated [DATE] reflected he could usually understand and usually be understood. He scored 12 of 15 on the BIMS which signified his cognitive status was intact. He required maximum assistance with his ADLs. No fall within the previous assessment period was noted. Record review of Resident #1's previous admission MDS assessment dated [DATE] reflected Resident #1 had a history of one fall within the previous month of February. Record review of Resident #1's comprehensive care plan dated 02/09/2026 reflected Focus, had an actual fall with poor balance x2 on 02/09/2026, witness fall, patient lost balance when standing at bedside, no injury, 02/09/2026, found lying on abdomen on floor next to bed, no injury, Interventions, scoop mattress, bed in lowest position. Record review of Resident #1's Progress Notes dated 04/22/2026 and 04/25/2026 reflected Resident #1 had sustained falls on these dates. Observation on 08/12/2026 of Resident #1's room, because the resident was involved in activities revealed a low bed, scoop mattress, body pillow, and a floor mat next to the bed. During an interview on 08/12/2026 at 3:03 p.m., the MDS nurse stated she was new at the facility and was working with the regional consultant. She confirmed the falls were not documented accurately on Resident #1's admission and quarterly MDS assessment. She stated the MDS nurse was accountable for the accuracy of the MDS's and stated that an inaccurate MDS assessment could affect the facility quality rating and care could be missed. During an interview on 08/12/2026 at 3:13 p.m., the ADON stated the MDS needed to be accurate to show what care a resident needed and it could be miscommunicated or not communicated to direct care staff if it was wrong. During an interview on 08/12/2026 at 4:38 p.m., the ADM stated the MDS accuracy was important to reflect and communicate care needed or the care could be missed. Record review of the facility's policy and procedure titled Resident Assessments dated 04/2025 reflected An accurate comprehensive assessment will be made of the resident's needs, strengths, goals, life history and preferences, using the RAI. Record review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.20.1, dated October 2025 reflected The RAI process has multiple regulatory requirements. Federal regulation required the assessment accurately reflects the resident's status.

Based on observation, interviews, and record reviews, the facility failed to develop and implement a comprehensiveperson-centered care plan for each resident, consistent with the resident rights, which includes measurable objective andtimes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 Resident (Resident #2) of 6 residents reviewed for care plans. The facility failed to accurately reflect Resident #2's prevention intervention of a floor fall mat positioned next to his bed. This deficient practice could place residents at risk of missed or miscommunicated care.The findings include: Record review of Resident #2's electronic face sheet dated 08/12/2026 reflected a [AGE] year-old male admitted on [DATE]. His diagnoses included: paroxysmal atrial fibrillation (irregular, fast heart rhythm), type 2 diabetes mellitus (chronic condition where the body cannot use insulin properly), and acute and chronic respiratory failure with hypoxia (long-standing breathing impairment suddenly worsens (acute), causing low levels of oxygen in the blood). Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected he could understand and be understood. He scored 9 of 15 on the BIMS which signified his cognitive status was moderately impaired. Resident #2 was dependent on staff for ADLs. He was noted to have 2 falls with no injury.Record review of Resident #2's comprehensive care plan dated 02/05/2026 reflected Focus, at risk for falls r/t: muscle weakness, poor balance, endurance and safety awareness. Further review reflected interventions listed did not include a floor mat. Observation on 08/12/2026 at 10:30 a.m. of Resident #2 revealed he was lying in a low bed, skid strips on the floor on the left side of the bed and a floor mat was located on the right side. During an interview on 08/12/2026 at 11:13 p.m., RN A stated Resident #2 had fall interventions in place and stated that he had a low bed, fall mat on the right side of the bed on the floor, and anti-skid tape. She stated he had those fall interventions for over a couple of months, and a couple of new ones were added such as a reach bar (pole with grab handle to reach things) and basket at his bedside which had items he could reach easily. During an interview on 08/12/2026 at 3:03 p.m., the MDS nurse stated she was new at the facility and was working with the regional consultant. She stated the fall mat should have been listed in Resident #2's care plan under interventions for fall prevention. She stated the care plan needed to reflect residents' needs and care required or something could be missed. During an interview on 08/12/2026 at 3:13 p.m., the ADON stated the comprehensive care plan needed to reflect what the resident required for quality care and care could be missed if the plan was not accurate. During an interview on 08/12/2026 at 4:38 p.m., the ADM stated the care plan was important because it showed what a resident needed for care and was a communication tool for others to use who cared for the resident. Record review of the facility's policy and procedure titled Comprehensive Person-Centered Care Planning dated 04/2025 reflected It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observations, interviews and record reviews, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1(Resident #3) of 1 resident reviewed for nebulizer treatment. The facility failed to ensure LVN B placed Resident #3's nebulizer mask and tubing into a protective bag after use observed on 08/12/2026. This deficient practice could place residents on oxygen treatments at risk for respiratory distress.Record review of Resident #3's electronic face sheet dated 08/12/2026 reflected a [AGE] year-old male admitted on [DATE]. His diagnoses included: malignant neoplasm of esophagus and bone (esophagus and bone cancer), schizoaffective disorder (mental health condition characterized by hallucinations or delusions and mood disorder symptoms) and cognitive communication deficit (impairment in the mental processes that support effective communication). Record review of Resident #3's quarterly MDS assessment dated [DATE] reflected he was able to understand and to be understood. He scored 13 of 15 on the BIMS which signified his cognitive status was intact. He was dependent on staff for ADLs. He received enteral feedings via G-tube (tube surgically inserted into the stomach for administration of feeding and medication). Record review of Resident #3's comprehensive care plan dated 06/04/2026 reflected Focus, has ADL self-care performance deficit r/t generalized weakness, cancer (disease in which the body's cells grow uncontrollably and spread to other parts of the body), anemia (deficiency of healthy red blood cells or hemoglobin) and pneumonia (lung infection). Record review of Resident #3's Active Orders as of: 08/12/2026 reflected he received nebulizer treatments every 6 hours as needed for SOB or wheezing with a start date of 08/11/2026. Record review of Resident #3's MAR dated 08/1/2026 to 08/31/2026 reflected he received one nebulizer treatment on 08/11/2026 at 10:13 p.m. administered by LVN B. Observation on 08/12/2026 at 11:00 accompanied by the ADON in Resident #3's room revealed he was on EBP with signage and PPE available in a bin outside of his room. Resident #3's nebulizer mask and tubing were lying on a table unbagged. Resident #3 was not available for an interview. During an interview on 08/12/2026 at 12:10 p.m. with LVN B, he stated he administered the breathing treatment to Resident #3 on the evening shift of 08/11/2026 and he remained with the resident throughout the treatment. He stated he did not place the nebulizer mask and tubing in a bag as he was trained to do. He stated the importance of protecting the nebulizer mask and tubing between treatments was to prevent dust and dirt particles and bacteria from entering the equipment. He stated cross contamination or respiratory distress could happen if anything was in the mask or tubing and the resident inhaled the substance. He stated he was trained to put the equipment in a bag between uses. During an interview on 08/12/2026 at 3:13 p.m., the ADON stated the nebulizer equipment, mask and tubing needed to be placed in a protective bag between uses. She stated cross contamination or infection could occur. During an interview on 08/12/2026 at 4:38 p.m., the ADM stated Resident #3's nebulizer mask and tubing needed to be placed in a bag between uses to prevent cross contamination which could result in infection. Record review of LVN B's Respiratory System, Proper Nebulizer Treatment Administration Post-Test Exam dated 08/03/2026 reflected he passed the written part and met the competency demonstration. Record review of the facility's policy and procedure titled Small Volume Nebulizer dated 07/2026 reflected Replace nebulizer in identified patient bag, at patient's bedside to keep from contamination of the nebulizer.

Based on observation, interview, and record review the facility failed to ensure that the resident's environment remained free of accidents and hazards as was possible and each resident received adequate supervision to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents.The facility failed to ensure Resident #1's fall mat was utilized per the comprehensive care plan.This failure could place residents at risk for accidents and injuries related to risk of falls.The findings included:Record review of Resident #1's face sheet dated 5/5/26 reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, anxiety disorder, and history of falling.Record review of Resident #1's most recent admission MDS assessment dated [DATE] reflected the resident was severely cognitively impaired for daily decision-making skills, required substantial/maximal assistance with mobility, and had reports of falls without injury.Record review of Resident #1's comprehensive care plan with revision date 3/12/26 reflected the resident had an ADL self-care deficit related to muscle weakness, poor endurance, and cognitive impairment with interventions that included the resident was dependent on staff with bed mobility, and transfers. Record review of Resident #1's comprehensive care plan reflected the resident had an actual fall with poor balance, poor communication/comprehension, unsteady gait with interventions that included the resident's bed placed in lowest position, a scoop mattress, room change closer to the nurse's station, and the use of fall mats.Record review of Resident #1's Fall Risk Evaluation dated 4/25/26 reflected the resident had a history of falls and had 3 or more falls in past 3 months, was disoriented at all times, chairbound, incontinent, and required the use of assistive devices. Record review of the facility document titled Ambassador/Guardian Angel Room Rounds dated 5/5/26 reflected Resident #1 looks good; fall prevention put in place.During an observation and interview on 5/5/26 at 9:09 a.m., Resident #1 was observed sitting up in a low bed, and a folded-up fall mat was observed propped up against the wall at the foot of the bed. Resident #1 stated he had never had any falls and denied needing help to get out of bed. Resident #1 stated he could show the State Surveyor that he was able to get out of bed without help and attempted to get up but was told not to. During an observation on 5/5/26 at 9:16 a.m. the call light to Resident #1's room was observed activated and at 9:22 a.m., the BOM entered the resident's room and asked the resident if he had activated his call light. The call light to Resident #1's room was turned off and the BOM exited Resident #1's room. The fall mat was observed folded up against the wall at the foot of the bed.During an observation on 5/5/26 at 9:31 a.m., CNA A was observed entering Resident #1's room and informed the resident she was going to change him. The resident's fall mat was folded up against the wall at the foot of the bed. CNA A closed the resident's door behind her.During an observation on 5/5/26 at 9:37 a.m., CNA A was observed exiting Resident #1's room with Resident #1 sitting up in a wheelchair. CNA A placed Resident #1 behind the nurse's station and returned to the resident's room.During an interview on 5/5/26 at 9:38 a.m., CNA A stated her shift began at 6:00 a.m. and she made rounds of the unit every two hours, and sometimes more often. CNA A stated she passed Resident #1's room often because the resident would try to get up out of bed by himself. CNA A stated Resident #1 was supposed to have a fall mat in place while in bed, but she forgot to put the fall mat back in place after serving him breakfast. CNA A stated she went to help another resident on the unit and forgot to put the fall mat back for Resident #1. CNA A stated Resident #1 could have an injury if he should have a fall if the fall mat was not in place. CNA A stated she was aware Resident #1 was supposed to have the fall mat in place while the resident was on the bed and it was care planned. CNA A stated she was not the only person responsible for ensuring the resident's fall mat was in place, it was everybody's responsibility.During an interview on 5/5/26 at 9:51 a.m., the BOM stated she was part of a team assigned to resident rooms that consisted of making general rounds and checking on the residents to ensure their rooms were clean, the call lights were in place and asking the residents if they needed anything. The BOM stated nursing staff would often inform the staff regarding residents who were at risk for falls and interventions in place such as fall mats. The BOM stated Resident #1 was not on her rotation but was simply answering his call light. The BOM stated she was not aware if Resident #1 was a fall risk and did not notice the fall mat folded up against the wall at the resident's foot of the bed. The BOM stated, if Resident #1 was a fall risk and he had a fall mat, it should be utilized because if he should have a fall, the fall mat could help cushion the fall and prevent injury. During a joint interview on 5/5/26 at 10:36 a.m. with ADON B and ADON C, ADON B stated it was her expectation that fall mats that were implemented for a resident with a fall risk were supposed to be utilized because it helped to prevent injury. ADON B stated that the CNA staff and nursing staff should check for placement of the fall mat as well. ADON B stated she felt it was a Team effort to ensure safety, and we all do rounds to check on Resident #1. ADON C stated, staff were assigned to a unit to make rounds to ensure the residents were provided with hydration, to ensure the beds were in a safe low position, and the call lights were within the resident's reach. ADON C stated the routine for staff rounding the units was an established process and a check-off list was given to the assigned staff to complete while making rounds. ADON C stated the check-off list was reviewed by management during the morning meetings and were checked for any concerns made by a resident for items such as food requests or activity requests. Record review of the facility document titled Fall Management System with review date 10/25 reflected in part, .This facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision, assistive devices and functional programs as appropriate to prevent accidents.It is the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs.Resident with high risk factors identified on the Fall Risk Evaluation will have an individualized care plan developed that includes measurable objectives and timeframes. The care plan interventions will be developed to prevent falls by addressing the risk factors and will consider the particular elements of the evaluation that put the resident at risk.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access for 1 of 5 Residents (Resident #2) reviewed for medication storage:The facility failed to ensure Resident #2 did not have a container of antifungal powder at the bedside.This deficient practice could affect residents who received medications in the facility and place them at risk for not receiving the correct medications, medication misuse or drug diversion.The findings included:Record review of Resident #2's face sheet dated 5/5/26 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included cellulitis of right lower limb, morbid obesity due to excess calories, bacterial infection, and age-related physical debility.Record review of Resident #2's comprehensive care plan with revision date 4/23/26 reflected the resident had fungal moisture associated skin damage under both breasts and abdominal folds with interventions that included to administer treatments as ordered.Record review of Resident #2's Order Summary Report dated 5/5/26 reflected the following:- Nystatin External Powder 100,000 Unit/GM, apply to groin topically two times a day for fungal infection for 7 days with order date 4/29/26 and end date 5/6/26During an observation and interview on 5/5/26 at 9:57 a.m., Resident #2 was observed on the bed wearing a hospital gown and her lower extremities were bandaged from her feet up to her ankles. Resident #2 stated she did not have any wounds on her buttocks and was not allowed to administer medications to herself because the facility did not allow the residents to administer their own medications. Resident #2 was observed with a 3-ounce bottle of antifungal powder at the bedside. The antifungal powder did not have a pharmacy label and indicated it was used for skin with a fungal infection. Resident #2 stated she had a fungus under her belly and was given the antifungal powder observed on the bedside by an unknown staff. Resident #2 stated, they left the antifungal powder at the bedside, but the staff applied it on her.During an observation on 5/5/26 at 2:06 p.m. Resident #2 was observed in the bed and the 3-ounce bottle of antifungal powder was observed at the bedside. During an observation and interview on 5/5/26 at 2:11 p.m., ADON C observed the 3-ounce bottle of antifungal powder at Resident #2's bedside and stated it was a stock bottle used by the nurse aides. ADON C stated, Resident #2 was not supposed to have the antifungal powder at the bedside because the resident could not treat herself. ADON C stated the resident required a physician's order and an assessment to show the resident could safely treat herself to keep the antifungal powder at the bedside. ADON C stated, Resident #2 could have an adverse reaction or further skin issues if the resident was trying to treat other areas of her skin. ADON C stated she would investigate who would have given Resident #2 the antifungal powder.During a follow-up interview on 5/6/26 at 7:54 a.m., ADON C stated she had interviewed CNA staff about providing Resident #2 with the antifungal powder and determined the CNA staff did not have access to antifungal powder and the medication was not part of their medication stock.During an interview on 5/6/26 at 8:22 a.m., RN D stated the CNA staff did not have access to topical medications other than moisturizers. RN D stated there were no residents in the facility who were allowed to medicate or treat themselves with medication. RN D stated residents would not be allowed to have medications at the bedside because they could be used improperly, consume it or other residents could wander into the room and take it. RN D stated the CNA staff were not even allowed to have barrier cream, and it had to be used on the residents, the nurse would have to apply it.During an interview on 5/6/26 at 9:33 a.m., CNA A stated she was not allowed to apply barrier cream or any other topical medication on the residents unless she was given permission by the nurse. CNA A stated fungal powder was not supplied to the CNA staff.Record review of the facility document titled Medication Access and Storage with revision date 5/2007 reflected the following, .It is the policy of this facility to store all drugs and biological in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.Only licensed nurses, the consultant pharmacist and those lawfully authorized to administer medications (e.g., medication aides) are allowed access to medications.

Based on observation, interview and record review, the facility failed to ensure the resident had the right to be free from abuse and neglect for 2 of 6 residents (Resident #1 and Resident #2) reviewed for resident abuse. The facility failed to ensure a safe environment free from sexual abuse when Resident #1, who had a history of alleged sexual behaviors, placed his mouth on Resident #2's breast on 10/28/2025 at 04:15 p.m. The noncompliance was identified as past non-compliance IJ. The IJ began on 10/28/2025 and ended on 10/29/2025. The facility had corrected the noncompliance before the investigation began, 10/29/2025 at 12:30 p.m. This failure could place residents at risk of physical harm, pain, mental anguish, and/or emotional distress. The findings included: Resident #1 Record review of Resident #1's admission Record, dated 10/29/2025, revealed a [AGE] year-old male admitted on [DATE]. Resident #1 was noted to have two contacts listed, including his [family member]. MD C was noted as his attending physician. Record review of Resident #1's Medical Diagnosis tab on the EMR, undated and accessed 10/29/2025 at 03:26 p.m., revealed diagnoses including traumatic subdural hemorrhage (a type of bleeding near your brain due to a traumatic head injury which could impact memory, motor skills, physical mobility, and ability to speak and language processing), functional quadriplegia (complete inability to move due to severe disability or frailty), and vascular dementia (a change in thinking and memory that occur when the brain experiences a disruption in blood flow) with mood disturbance. Record review of Resident #1's quarterly MDS, dated [DATE], revealed Resident #1 had a BIMS score of 06, indicating he had severe cognitive impairment. He had not exhibited physical, verbal, or other behavioral symptoms over the 7 days reviewed. He used a wheelchair for mobility and could wheel himself with supervision or touching assistance. Record review of Resident #1's Care Plan Report, undated and accessed 10/29/2025 at 03:28 p.m., revealed the following focuses and interventions:- [Resident #1] engages in sexually inappropriate remarks and uninvited physical contact with female staff members. He has a traumatic brain injury and displays poor impulse control and decision-making.10/28/25: Resident was seen by staff inappropriately touching a resident's breast.Psych services and PCP have noted that resident will not benefit from psychotropic medications because his behaviors are caused by his TBI., date initiated 04/21/2025 and revised on 10/29/2025 with interventions: - If reasonable, discuss behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable., date initiated 04/21/2025. - Remain calm and professional and gently yet firmly redirect the behavior by telling him it is inappropriate and unacceptable, date initiated 04/21/2025. - A care plan meeting will be conducted with the resident and responsible party to assess inappropriate behaviors and ensure the safety of other residents., date initiated 08/25/2025. - Psych Services as needed, date initiated 08/25/2025. - Firmly and respectfully redirect the resident away from the inappropriate behavior and set clear, consistent boundaries using simple language, date initiated 08/25/2025 and revised on 09/22/2025. - An additional staff member must accompany female employees to prevent inappropriate comments or actions directed at them when assisting resident., date initiated 09/22/2025. - 1:1 staff observation of resident while out of his room, date initiated 10/28/2025 and revised on 10/29/2025. - Expedited discharge to another SNF initiated, date initiated 10/29/2025. - New Psych referral requested:Psych services and PCP have noted that resident will not benefit from psychotropic medications because his behaviors are caused by his TBI., date initiated 10/29/2025 and revised on 10/29/2025. - Sent to ER for evaluation, date initiated 10/28/2025 and revised on 10/29/2025.- [Resident #1] is at risk for aggressive behaviors with staff, family and other resident r/t Poor impulse control and cognitive status., date initiated 05/12/2025 and revised on 05/14/2025 with interventions: - Analyze key times, places, circumstances, triggers, and what de-escalates behavior and document., date initiated 05/12/2025. - Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation., date initiated 05/12/2025. - Document observed behavior and attempted interventions., date initiated 05/12/2025. Record review of Resident #1's Order Summary Report, active orders as of 10/29/2025, revealed:- [psychiatry/psychology company name] for Eval and Treat, order status noted as Active with order dated, 05/13/2025.- Send to [local hospital name] ER for eval/treat per Dr. [MD C], order status noted as Active with order dated 10/28/2025.- Refer to [psychiatry/psychology company name] for Eval and treat, order status noted as Active with order dated 10/29/2025. Record review of Resident #1's [psychiatry/psychology company name] visit note, encounter dated 10/21/2025, Patient reports to 'fine' Staff report no worsening behaviors.Inappropriate behaviors is likely due to hx of TBI and vascular dementia s [sic]- facility to continue to implement safety measures.Cognition: Attention span and concentration was faire. Patient was oriented to person, place, and year. Recent memory was mildly impaired. Remote memory was mildly impaired. Fund of knowledge was mildly impaired. On examination, patient exhibited Slowed of thought. Patient denies auditory/visual hallucinations, no delusional content noted. Patient's insight was poor. Judgment was poor. Patient is at little to no risk of aggression. Record review of Resident #1's Progress Notes, dated 10/29/2025 at 03:32 p.m. for effective date range: 10/22/2025 to 10/30/2025, revealed: - Nursing note, dated 10/28/2025 at 04:17 p.m. by the ADON: [LPN B] approached ADON this nurse regarding incident with resident A [Resident #2]. residents [sic] were separated and taken to room for further evaluation and treatment resident was evaluated no injuries, open skin or bruises noted. Administrator [ADMIN], DON and SW [SW F] all notified of incident family contacted [Resident #1 family member] and made aware of occurrence. New orders from [MD C] to refer to Psych services for further evaluation. Psych services unable [sic] to meet with patient until AM. Orders were given to transport resident to hospital for further evaluation and treatment. Resident placed on 1-1 for monitoring due to behaviors.- Social Services note, dated 10/28/2025 at 05:18 p.m. by SW F: Social worker was informed of an incident that occurred between this resident and a female resident where a staff member witnessed this patient with his mouth on the other residents [sic] bare breast. Staff member immediately separated the patients [sic] and this patient stated, 'She said it was okay'. Both patients are cognitively impaired. Social worker, along with ADON contacted patients [family member] to inform them of the incident. Family stated, 'I didn't know [Resident #1] could move around that much'. SW [SW F] and ADON informed family [sic] of residents [sic] behaviors and reminded them of the conversation regarding moving him to another facility. [Family member] stated they had toured 2 facilities that they liked but could not remember the name and they were told by 'some little girl that works [sic] there' that the facilities did not want him. This social worker informed the family that she had sent referrals to 3 locations who had informed her they accepted him but had not heard from family. The locations were [3 nursing facilities named]. [Family member] stated 'it must have been the other social worker or girl who helps with sending the referrals' [sic]. This writer is the only social worker and is the one who sends referrals. Social worker informed family that we would send out the referrals again and request the facilities to only contact [family member]. Family in agreement that they would pick a new facility for patient to live.- Nursing note, dated 10/28/2025 at 09:35 p.m. by LPN B: Housekeeper [HK A] presented to nurses' station to report [Resident #1] was found sitting next to Resident A [Resident #2] with mouth on breast with R [right] hand holding shirt in dining room. resident [sic] was removed from dining room and taken to nurses [sic] station until time for supper. resident [sic] was put on 1:1.- Nursing note, dated 10/28/2025 at 11:10 p.m. by LPN D: [name of transport services company] arrived to transport resident to [local hospital]. Resident left facility via stretcher with 2EMTs @ 2235 [10:35 p.m.]. - Nursing note, dated 10/29/2025 at 06:39 a.m. by LPN D: Follow up call from [local hospital] with nurse [local hospital nurse named], @2330 [11:30 p.m.] stated that resident would get tested for UTI, then once cleared from psych that he would be sent back to facility. [Resident #1] arrived to facility at 0400 [04:00 a.m.], orders to follow up with [medical doctor named]. No report given before resident arrived from hospital. Final paperwork for psych clearance from medical records is pending. - Administrative Note, dated 10/29/2025 at 09:50 a.m. by ADMIN: We spoke with [Resident #1 family member]. She is actively looking for placement to better suite [Resident #1]. She stated that she would let the SW [SW F] know asap of the facility that they would choose for him to DC to. She is aware of the need for immediate DC. We let her know that we spoke with the Ombudsman and PM from the state.- Nursing note, dated 10/29/2025 at 10:13 a.m. by the ADON: Psych appointment follow up. Called [psychiatry/psychology company name] to discuss options for follow up and process for Behavioral health care. Per [psychiatry/psychology company staff member] [ SW G] will be present today to do an onsite evaluation and follow up.- Nursing note, dated 10/29/2025 at 11:06 a.m. by the DON: This nurse spoke to resident regarding incident. Resident stated female resident showed him her breast, he asked if he can touch it and she said yes. Resident stated he believed it was okay because she gave permission. Resident was reeducated on keeping hands to self and stated understanding.- Nursing note, dated 10/29/2025 at 12:17 p.m. by the ADON: [SW G] with [psychiatry/psychology company name] called to confirm visit for follow up this afternoon and will review resident's current feelings and concerns. [Resident #1 family member] aware and notified of pending appointment this afternoon. [MD C] notified of confirmation of visit. Record review of Resident #1's Skin Evaluation - PRN/ Weekly, dated 10/28/2025 at 04:15 p.m. and signed by LPN B, revealed no skin issues noted. Record review of Resident #1's SNF-NF to Hospital Transfer Form by LPN B, dated 10/28/2025 at 06:40 p.m., revealed Reason(s) for transfer noted as Other: sexually inappropriate with another resident/unable to see psych service until tomorrow. Date and time of transfer noted as 10/28/2025 at 06:00 p.m. with resident noted as alert, oriented, and able to follow instructions. Record review of Resident #1 [local hospital] documentation, dated admission [DATE] at 10:57 p.m., revealed the reason for visit noted as psych evaluation. History of present illness noted as [AGE] year-old male who stays at skilled nursing facility presenting Emergency Department for psychiatric evaluation.he was sent here by the nursing staff because he had groped another skilled nursing resident in the shared dinner space, reportedly.PSYCHIATRIC: Cooperative. Appropriate mood and affect.Patient is alert, oriented, denies any significant medical complaints at this time, denies any significant psychiatric complaints at this time. Nursing staff reportedly sent him here because he may have sexually assaulted another resident, will request psychiatric assessment since that is when he was sent here for. A blood alcohol concentration lab was run with a concentration at 4 mg/dL, under a level indicating alcohol consumption or clinical influence. A specimen for urinalysis was taken but cancelled without notation of why the lab was cancelled. Notes from a psychiatric evaluation were not included in the documentation. Record review of Resident #1's [psychiatry/psychology company name] visit note, encounter dated 10/29/2025, Patient is being seen today for anxiety and dementia.Patient reports to 'I'm just fine.' Staff report patient was involved in a resident-resident incident yesterday where patient touched and put his mouth on another resident's breast in the dining room. Staff immediately separated residents and patient was evaluated by facility SW. Patient informed SW that the other resident told him it was okay, SW contacted patient's family to inform them of incident. Patient's family and facility SW working to find a facility that would be a better fit for patient. Patient was sent to the hospital for further evaluation with no new orders.Met with patient via telemedicine with the assistance of facility ADON.Patient is calm and does not appear to be in acute distress.Patient states 'I'm just fine.' Patietn [sic] does recall going to the hospital yesterday following an incident and states the other resident told him he could touch her breast. Clinician reminded patient the importance of respecting others and keeping his hands to himself. Patient states he feels safe at teh [sic] facility and staff help him with his needs. Patient denies depression or anxiety symptoms. Patietn [sic] denies issues sleeping or with his appetite.10/29/25: Patient evaluated today due to a resident-resident incident that occurred yesterday. Patient was evaluated at the hospital following incident with no new orders. Patient's inappropriate behaviors are likely due to hx of TBI and vascular dementia and there is no specific medication for these behaviors. Patient is not in acute distress today and feels safe during evaluation. Facility is implementing safety measures, counseling services to evaluate patietn [sic] later today, and patient's family, with the help of facility SW, is looking for a better fit placement for patient. Psychiatric medications were reviewed to determine if benefit outweighs risk.Speech was fluent. Mood was neutral. Affect was mood congruent. Cognition: Attention span and concentration was fair. Patient was oriented to person, place and year. Recent memory was mildly impaired. Remote memory was mildly impaired. Fund of knowledge was mildly impaired. On examination, patient exhibited Slowed of thought. Patient denies auditory/visual hallucinations, no delusional content noted. Patient's insight was poor. Judgment was poor. Patient is at little to no risk of aggression. Record review of Resident #1's Social Services note by SW F, dated 10/31/2025 at 10:10 a.m., revealed: Patient will be discharged to [nursing facility name] at/around 10:20am via [transport company] EMS. Resident #2 Record review of Resident #2's admission Record, dated 10/29/2025, revealed a [AGE] year-old female initially admitted on [DATE] and re-admitted on [DATE]. Resident #2 was noted to be her own responsible party with a friend noted for her emergency contact. MD C was noted as her attending physician. Record review of Resident #2's Medical Diagnosis tab on the EMR, undated and accessed 10/29/2025 at 04:03 p.m., revealed diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness of one side of the body) following cerebral infarction (a disruption of the brain's blood flow) affecting left non-dominant side, bipolar II disorder (a mental illness characterized by alternating periods of elation and depression), dementia (a general term for impaired ability to remember, think, or make decisions), and generalized anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness). Record review of Resident #2's modification of quarterly MDS, dated [DATE], revealed Resident #2 had a BIMS score of 06, indicating she had severe cognitive impairment. She had not exhibited physical, verbal, or other behavioral symptoms over the 7 days reviewed. She used a wheelchair for mobility and was dependent on helper assistance to wheel any distance. Record review of Resident #2's Care Plan Report, undated and accessed 10/29/2025 at 04:15 p.m., revealed the following focuses and interventions:- [Resident #2] is at Risk for Re-traumatization r/t history of trauma d/t Adverse Childhood ExperienceHistory of trauma: As a child I was physically and mentally abused by my mother. She reported being sexually assaulted by two different strangers on two different occasions when she was working and going to school at [local college]. After experiencing sexual abuse in the past, [Resident #2] views accidental contact in personal areas as triggering event. Due to her cognitive impairments, she struggles to control her impulses, which can lead to unpredictable behavior when triggered., date initiated 05/01/2025 and revised on 08/28/2025 with interventions: - Explain that trauma responses are normal and provide reassurance to reduce anxiety, date initiated 08/25/2025. - For assistance with trauma processing, refer the patient to a qualified mental health practitioner as needed., date initiated 08/28/2025.- [Resident #2] has the potential for a psychosocial well-being problem as a result of another resident's inappropriate touching of her breast., date initiated and revised 10/29/2025 with interventions: - Allow time to answer questions and to verbalize feelings perceptions, and fears., date initiated 10/29/2025. - Provide the resident with a calm, safe environment and allow her to vent/share feelings., date initiated and revised on 10/29/2025. - Psych services to follow up with resident, date initiated 10/29/2025. - Psychosocial monitoring is in place, date initiated 10/29/2025. - Send to ER for evaluation, dated initiated and revised 10/29/2025. - [Resident #2] demonstrates physical behaviors such as self inflicting [sic] bruises AEB pt observed pinching self.Resident has self inflicted [sic] bruising to her breast., date initiated 07/26/2024 and revised on 10/29/2025 with interventions: - Analyze key times, places, circumstances, triggers, and what de-escalates behavior and document., date initiated 07/31/2024. - Gently redirect the resident from self-harm when seen., date initiated 10/29/2025. - [Resident #2] has been noted with physical behaviors that affect other residents and staff r/t poor impulse control.Resident has a self-inflicted bruise on her left breast and has been seen lifting her shirt to display to staff., date initiated 02/05/2025 and revised on 10/29/2025 with intervention: - Gently redirect and discourage the resident from lifting her shirt and revealing intimate areas in common areas in front of other residents., date initiated and revised 10/29/2025. Record review of Resident #2's Order Summary Report, active orders as of 10/29/2025, revealed: - Refer to [psychiatry/psychology company name] for evaluation and treat., order status noted as Active with order dated 04/03/2025.- Assess changes in skin status: appearance, color, decline in wound healing, and/or s/sx of infection. Notify MD of changes. every [sic] shift for skin maintenance for 7 Days, order status noted as Active with order dated 10/24/2025, order start date as 10/24/2025, and order end date as 10/31/2025. - Send to [local hospital name] ER for treat/eval., order status noted as Active with order dated 10/28/2025. - [psychiatry/psychology company name] to Eval and treat., order status noted as Active with order dated 10/29/2025. Record review of Resident #2's [psychiatry/psychology company name] visit note, encounter dated 10/27/2025, Patient reports to 'good' Staff report no behavioral problems.Appetite, mood and sleep were reported as good. She denied current anxiety, depression and its reported that she is taking medications and has no side effects.Speech was monotone, slow and soft. Mood was neutral. Affect was mood congruent. Cognition: Attention span and concentration was good. Patient was oriented to person, month and year. Recent memory was intact. Remote memory was intact. On examination, patient exhibited logical thought process. Patient denies auditory/visual hallucinations, no delusional content noted. Patient's insight was good. Judgement was good. Patient is at little to no risk of aggression. Record review of Resident #2's Skin Evaluation- PRN/ Weekly, dated 10/21/2025 at 10:02 a.m., revealed Skin is clean, dry, intact, and warm to touch old bruise to left breast yellow in color. Record review of Resident #2's Skin Evaluation- PRN/ Weekly, dated 10/28/2025 at 03:25 p.m., revealed CURRENT SKIN CONDITION: 1. Skin is clean, dry, intact, and warm to touch with resolving bruise to the breast. Record review of Resident #2's Skin Evaluation- PRN/ Weekly, dated 10/28/2025 at 04:20 p.m. and signed by the ADON, revealed L breast old yellow bruising, no open skin noted. Denies pain or discomfort. Record review of Resident #2's Progress Notes, dated 10/29/2025 at 04:10 p.m. for effective date range: 10/22/2025 to 10/30/2025, revealed: - [Program name] SBAR Summary for Providers note, dated 10/28/2025 at 04:15 p.m. by LPN B: The Change In Condition/s reported on this CIC Evaluation are/were: Other change in condition. - Mental Status Evaluation: No changes observed.Nursing observations, evaluation, and recommendations are: resident to resident incident resident not in any distress noted head to toe assessment done no new skin issues noted only noted old bruising to (L) breast. [MD C] notified of incident andFamily [sic] friend listed as contact for resident was notified of incident.Recommendations: per [MD C] recommendation new order for psych eval until to see psych services referred to hospital for eval/treat.- Nursing note, dated 10/28/2025 at 04:18 p.m. by the ADON: [LPN B] approached ADON this nurse regarding incident in dining room with resident B [Resident #1]. [Resident #2] was immediately evaluated by [LPN B] and ADON head to toe assessment complete no new bruising open skin or injuries were noted. Resident was asked if she was ok and resident replied she was in no distress SW [SW F] approached resident during evaluation and monitoring. Psych services were contacted and are unable to see resident till 10.29 [10/29/2025] in AM. [MD C] notified and Friend [Resident #2 emergency contact], orders were given to send resident to hospital for further evaluation and treatment. [Local police department] was contacted [local police officer name, badge number, and case number noted]. Patient to be sent to [local hospital name] hospital for further evaluation.- Social Services note, dated 10/28/2025 at 04:57 p.m. by SW F: Social worker was informed of an incident involving this resident and a male resident. It was reported that a staff member witnessed the male resident with his mouth on this residents [sic] bare breast. Staff member immediately separated patients and stated this resident did not appear to be in distress at that time. Abuse coordinator made aware of incident. Social worker approached this resident and asked her how her day was going. Resident responded 'good' as social worker was talking with resident, the resident lifted her shift multiple times to shower this writer the bruise on her breast. Social worker assisted in lowering her shirt stating, Oh lets put this down to not show everyone our breast, but what happened Patient stated, 'I don't know it's just a bruise'. This writer then asked patient if anything occurred with another resident, patient stated, 'That man touched my breast' social worker asked how that made patient feel, she stated 'Not good' Social worker explained to patient that we want to make sure she feels safe and cared for and asked patient if she would like for us to call the police to which she responded yes. Social worker asked if she would like to go to the hospital she responded 'I would'. Social worker informed nursing of the requests. Friend [Resident #2's emergency contact] informed of incident.- Nursing note, dated 10/28/2025 at 09:39 p.m. by LPN B: Housekeeper approached nurses' station to report resident B [Resident #1] was witnessed near [Resident #2] when housekeeper approached residents. Resident B [Resident #1] was witnessed with R hand on [Resident #2] lifting shirt and mouth around L breast.- Nursing note, dated 10/28/2025 at 11:15 p.m. by LPN D: Resident arrived to facility @2248 [10:48 p.m.] with [transport company name] via stretcher, accompanied with 2 EMTs.- Nursing note, dated 10/29/2025 at 03:16 a.m. by LPN D: Follow up: Resident arrived to facility @2248 [10:48 p.m.] with [transport company name] via stretcher, accompanied with 2 EMTs. [NP E] notified of arrival. Resident was restless during the shift, continued to yell at roommate. Resident stated her hip and left breast was hurting. Discoloration to left nipple noted. APAP given for pain. Resident appears confused when asked why did she go to the hospital. Resident was awake most of the night.- Nursing note, dated 10/29/2025 at 03:40 a.m. by LPN D: Apap for pain was effective. Resident was able to sleep, without labored breathing. [Resident #2] was yelling at roommate to be quiet due to her roommate talking out loud, resident noted to not be upset/crying throughout shift. Resident was able to sleep after roommate fell asleep and Apap was effective.- Nursing note, dated 10/29/2025 at 10:14 a.m. by the ADON: Psych appointment follow up. Called [psychiatry/psychology company name] to discuss options for follow up and process for Behavioral health care. SN communicated patients' [sic] current feelings and concerns for follow up. Resident voiced difficulty sleeping Per [psychiatry/psychology company staff member name] [SW G] will be present today to do an onsite evaluation and follow up.- Nursing note, dated 10/29/2025 at 11:14 a.m. by the DON: This nurse visited with resident regarding incident. Resident with no s/s of distress. Emotional wellbeing WNL for resident. This nurse asked resident how she was and stated 'good' this nurse asked resident if anything has happened and she stated 'yes, a man touched my breast' this nurse asked resident if that was okay with her and she did not answer. This nurse asked with what/how her breast was touched and stated 'with his hand.' This nurse asked resident if she felt safe in facility and stated 'yes.' Resident denied pain when asked. Resident declined feeling sad or angry when asked.- Nursing note, dated 10/29/2025 at 12:16 p.m. by the ADON: Received call from [SW G] regarding visit today and will be in this afternoon for follow up. SN explained residents' feelings and difficulties throughout the night. [SW G] to follow up and discuss with resident her current concerns. [MD C] notified of expected appointment. [Resident #2 emergency contact] notified of set follow up with [psychiatry/psychology company name]. Record review of Resident #2's SNF-NF to Hospital Transfer Form by LPN B, dated 10/28/2025 at 07:30 p.m., revealed Reason(s) for transfer noted as Other: for sexual assault- no penetration. Date and time of transfer noted as 10/28/2025 at 07:05 p.m. with resident noted as alert, oriented, and able to follow instructions. Record review of Resident #2 [local hospital] documentation, dated admission and discharge 10/28/2025, revealed the chief complaint as complaint of being sexually assaulted by another resident. Pt states the resident fondle her breasts, hips and touched her vagina. The history of present illness notes per the report the Patient denies any vaginal penetration, no actual sexual contact. Only unwanted sexual advances. Psychiatric:[Normal mood], [normal affect], [normal concentration]. Differential diagnosis noted as Screening examination, sexual assault, sexual harassment. Nurse screening noted Abuse/Neglect Screen: No evidence of abuse/neglect. Under Pain Present: No actual or suspected pain. Notes from a psychiatric evaluation were not included in the documentation. Record review of Resident #2's [psychiatry/psychology company name] visit note, encounter dated 10/29/2025, Patient is being seen today for depression/sadness.Patient reports to 'I'm fine' Staff report three was a resident-resident incident yesterday where the other resident, a male, touched and put his mouth on patient's breast while in the dining room. Staff witnessed the incident and immediately separated residetns [sic] and patietn [sic] was evaluated with no injuries. SW evaluated patient and patient wanted to go to the hospital for further evaluation. No new orders were sent from hospital following evaluation. Patient has been sitting next to nurses' station today in no acute distress.Met with patient via telemedicine with the assistance of facility ADON.Patient is calm and does not appear to be in acute distress. Patient states 'I'm fine'. Patietn [sic] does recall the incident that occurred yesterday and states 'a man touched my breast' and states she feels sad because that happened. Patient states she did go to the hospital to get further evaluated and felt safe to return to the facility. Patient states she still feels safe at teh [sic] and staff are helping patient with her needs. Patient denies worsening of her depression or anxiety symptoms. Patient denies issues with her sleep.Patient reports she feels safe at facility.10/29/2025: Patient was evaluated today as patient was involved in a resident-resident incident yesterday. Patient states she went to the hospital after incident and felt safe to return to the facility. Patient reports felling safe right now and that staff are helping her with her needs. Patietn [sic] is not in acute distress during evaluation. Continue psych medications unchanged. Counseling services to evaluate patietn [sic] this afternoon and patient agrees to talk with counselor.Speech was monotone, slow and soft. Mood was neutral and depressed. Affect was mood congruent. Cognition: Attention span and concentration was good. Patient was oriented to person, place and day. Recent memory was intact. Remote memory was intact. On examination, patient exhibited logical thought process. Patient denies auditory/visual hallucinations, no delusional content noted. Patient's insight was good. Judgement was good. Patient is at little to no risk of aggression. During an observation and interview on 10/29/2025 at 01:18 p.m., a staff member was noted to be sitting in a chair outside Resident #1's door. Resident #1's room was noted to be at the end of a different hall than Resident #2. Upon entry to room, Resident #1 was lying down in bed watching television and did not appear to have injuries or be in distress prior to and during the interview. Resident #1 appeared to have difficulty hearing or understanding questions during interview. The resident was asked a series of questions, and his responses were as follows: - When Resident #1 was asked if he felt safe in the facility, he responded Yes, a lot of people here. They are old but you know. - When asked if he recalled an interaction he had with another resident the day prior, he replied, There was a lady that was lifting her blouse, and I asked if I could taste and she said okay. - When asked where this occurred, he replied In the lunchroom. - When asked if he knew the lady, he replied, She was following me wherever. I don't know her name. - When asked if she was a friend, he replied I guess. - When asked if facility staff were present when this occurred and what happened next, he replied There was a nurse in there. This happened two days ago I think. - When asked how the lady responded to his touching her, he responded After I left, I don't know if she got upset. She was happy. - When asked if he had interacted or seen the lady since the interaction, he responded Everyone was finishing up eating, but I didn't see her there. Staff said to stay away from her, but they will find a way. - When asked who

Based on interview and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for 3 of 6 residents (Resident #19, Resident #51, and Resident #55) who were reviewed for resident assessments. 1. The facility failed to document Resident #19's use of pain medication on the MDS assessment.2. The facility failed to document Resident #51's use of hypoglycemic medication on the MDS assessment.3. The facility failed to document Resident #55's use of antiplatelet medication on MDS assessment.This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.The findings included:1. Record review of Resident #19's admission sheet dated 10/08/24 with an original date of 6/23/21 documented a [AGE] year-old female with diagnoses including cerebral infarction (stroke), hyperlipidemia (high cholesterol), seizures, dementia, hypothyroidism (when the thyroid gland does not produce enough hormone leading to a slowdown in metabolism), anxiety, and depression.Record review of Resident #19's MDS dated [DATE] documented a BIMS of 8 indicating moderate cognitive impairment and recorded the use of antidepressant, opioid, and anticonvulsant medications. Further review of Resident #19's MDS documented in section J0.100 Pain Management, an answer of 0 to the question At any time in the last 5 days, has the resident: A. Received scheduled pain medication regimen? 0. No 1. Yes.Record review of Resident #19's order summary documented an active order for Tylenol (a non-opioid analgesic and antipyretic indicated for the treatment of pain and fever).Record review of Resident #19's July 2025 MAR documented the resident had been receiving Tylenol as prescribed. Further review of the July MAR documented Tylenol was ordered as Tylenol 325mg, Give 2 tablet by mouth three times a day for pain.Record review of Resident #19's care plan documented the resident had chronic pain r/t hx of Lumbar fx, muscle wasting and atrophy with interventions including Anticipate need for pain relief and respond immediately to any complaint of pain. Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM, withdrawal or resistance to care. Pain assessment every shift. Report to Nurse any change in usual activity attendance patterns or refusal to attend activities related to s/sx or c/o pain or discomfort.2. Record review of Resident #51's admission sheet dated 8/20/25 with an original date of 4/20/22 documented a [AGE] year-old female with diagnoses including diabetes mellitus, Alzheimer's disease, dementia, anxiety, hyperlipidemia, depression, and hypertension (high blood pressure).Record review of Resident #51's MDS dated [DATE] documented a BIMS of 10 indicating moderate cognitive impairment and recorded the use of antianxiety, antidepressant, antiplatelet, and anticonvulsant medications. Further review of Resident #51's MDS documented in section N0350. Insulin recorded an answer of 2 to the question A. Insulin Injections-Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days. The use of hypoglycemic medications was not recorded on the resident's MDS.Record review of Resident #51's order summary documented an active order for Basaglar ([insulin glargine] a long-acting human insulin analog indicated to improve glycemic control in diabetes mellitus).Record review of Resident#51's August 2025 MAR documented the resident had been receiving Basaglar as prescribed. Further review of the August MAR documented Basaglar was ordered as Basaglar 100units/mL, Inject as per sliding scale: if 1-119=0 units; 120-400=25 units, subcutaneously at bedtime for long-acting insulin. Further review of the Augus MAR documented the resident received 25 units of Basaglar on 8/21/25 for a blood glucose of 185 and 25 units of Basaglar on 8/22/25 for a blood glucose of 178.Record review of Resident #51's care plan documented the resident is at risk for infection, skin impairment, hypo/hyperglycemia, and multi-organ complications r/t DMT2 and Will have no complications related to diabetes.3. Record review of Resident #55's admission sheet dated 12/13/24 documented an [AGE] year-old male with diagnoses including cerebral infarction, dementia, hypertension, diabetes mellitus, and hyperlipidemia.Record review of Resident #55's MDS dated [DATE] documented a BIMS of 9 indicating moderate cognitive impairment and recorded an answer of None of the above in section N0415 High-Risk Drug Classes: Use and Indication 1. Is taking. Further review of the MDS revealed no drug classes were marked in section N0415 including the medication class Antiplatelet.Record review of Resident #55's order summary documented an active order for Clopidogrel (a platelet inhibitor indicated for acute coronary syndrome, recent MI [myocardial infarction or heart attack], recent stroke, or established peripheral arterial disease).Record review of Resident #55's June 2025 MAR documented the resident had been receiving Clopidogrel as prescribed. Further review of the July MAR documented Clopidogrel was ordered as Clopidogrel 75mg, Give 1 tablet by mouth one time a day for prevention of blood clots.Record review of Resident #55's care plan documented the resident Is on antiplatelet therapy and is at risk for bleeding and bruising and Will be free from discomfort or adverse reactions related to antiplatelet use.During an interview with the MDS Coordinator on 9/3/25 at 11:35 AM, the MDS Coordinator stated it was important for the MDS to be accurate, because they need an accurate description of the resident and the level of care they need. During an interview with the DON on 9/3/25 at 2:38 PM the DON stated her expectation for the MDS assessments was that they should be accurate, and that the facility should be looking at all the documentation and records when developing the MDS. The DON further stated it was important for the MDS to be accurate for correct reimbursement and for continuity of care of the resident.Record review of the facility policy titled Resident Assessments with a revision date of 4/2025 noted Comprehensive Assessment: includes the completion of the MDS (Minimum Data Set)as well as the CAA (Care Area Assessment) process, followed by development and/or review of the comprehensive care plan. and An accurate Comprehensive Assessment wil be made of the resident's needs, strengths, goals, life history and preferences, using the RAI (Resident Assessment Instrument) and will include at least the following: Medications.

Based on observations, interviews, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 1 (West Hall) of 8 shower rooms observed for environment. The facility failed to ensure resident shower room on the [NAME] Hall was clean, safe, and in good repair. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment. Findings included: Observations made on 9/2/2025, 9/4/2025 and 9/4/2025 of resident room shower in the west hall revealed a missing shower tile in the resident room shower. The Maintenance Director interviewed on 9/4/2025 at 10:40 am. They stated that whoever sees an issue that requires maintenance attention, a work order is supposed to be entered, and that they also inform them verbally, then a work order was issued and completed. They stated that resident rooms should be inspected daily. They stated that the issue with missing tile was it could lead to structural damage if not fixed. Interview with the Administrator on 9/4/2025 at 11:00 am, he stated that for maintenance issues, maintenance should be given a work order to get it fixed. He stated that the residents shower room should not have missing tile, it could lead to damage to the wall structure. Record review of the facility policy titled, Preventive Maintenance Program, showed, Work orders are inputted by all staff which notified Plant manager of any non-working system. The TELS or equivalent will notify the plant manager weekly on inspections and monthly inspections.

Based on interview and record review, the facility failed to ensure that all allegations misappropriation were reported to the State Survey Agency no later than 24 hours after misappropriation was alleged for 1 of 8 residents (Resident #1) reviewed for misappropriation of resident property. The facility failed to report to HHSC when Resident #1's lost gold wedding ring, which was reported missing on [DATE], a replacement was provided on 04-09-2025 the facility did not report to HHSC within 24 hours. This failure could place residents at risk of misappropriation of money, possessions, and feelings of loss.The findings included:Record review of Resident #1's Face Sheet, dated [DATE], reflected a [AGE] year-old resident with an initial admission date of [DATE], with a most recent admission on [DATE], and diagnoses including Chronic Obstructive Pulmonary Disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe), acute and chronic respiratory failure with hypercapnia (respiratory failure which leads to high volumes of carbon dioxide in the body), and type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Further review reflected that Resident #1 expired on hospice at the facility on [DATE]. Record review of Resident #1's MDS Assessment, dated [DATE], reflected Resident #1 had a BIMS score of 7, indicating severe cognitive impairment. Record review of Resident #1's Comprehensive Person-Centered Care Plan, undated, reflected, [Resident #1] has age related cognitive decline and requires assistance and reminders at times to make needs known or complete tasks. Record review of Facility Grievance Resolution Form, for Resident #1 dated [DATE], reflected a summary statement of the grievance, Patient's [family member] reported she noticed residents' gold wedding band was missing from his hand when she went to wash his hands for lunch. With a Summary of Findings and Resolution, SW & wound care nurse searched residents' room & belongings. Maintenance director searched laundry services. SW spoke to CNA's who reported they had not seen the ring while providing care that morning. With corrective action, Checking in laundry and continuing to look for ring. Ordered a replacement ring. Outcome is satisfactory per spouse.Record review of Resident #1's Inventory of Personal Effects, dated [DATE], reflected that Resident #1 admitted with a gold wedding ring.Record review of email invoice dated [DATE] at 9:42 AM reflected that the Administrator bought a replacement ring for Resident #1. Record review of local police department incident report reflected that the Administrator reported to the local police department Resident #1's missing wedding ring on [DATE] at 12:34 PM. Interview on [DATE] at 12:42 PM, LSW stated that she was unsure of where Resident #1's ring went, but that Resident #1 had come back from the hospital 4 days prior to Resident #1's family member noticing his wedding ring was missing and they were uncertain if he was wearing his wedding ring when he was readmitted to the facility. LSW stated that she asked CNA's and Hospice Aides, who had visited earlier in the morning on [DATE] if they had seen Resident #1's ring. LSW stated no one had seen Resident #1's ring after Resident #1 had come back from the hospital. LSW stated that they did not think it needed to be reported, as Resident #1's family member made it seem as though it could possibly be at home, and they replaced the ring immediately which Resident #1's member was satisfied with. Interview on [DATE] at 2:34 PM, the DON stated the missing wedding ring was not reported to the State Survey Agency (Texas HHSC) because Resident #1's family member did not state the ring was stolen, only that she could not locate the ring and thought it was misplaced. The DON stated that the Administrator ordered a replacement and reported the missing ring to the local police department within 24 hours of the grievance describing that Resident #1's wedding ring was missing. The DON stated their expectation, as administration of the facility, was to report misappropriation of resident property to the state survey agency within the timeframe required. Interview on [DATE] at 9:15 AM, the Administrator stated that their top priority was finding the ring when the facility was notified it went missing, and once it was unable to be located, the next priority was providing Resident #1 with a replacement ring. The administrator stated it was not reported sooner due to Resident #1's family member not stating it was stolen, but only that she was unable to locate the ring. The Administrator stated his expectation was to report misappropriation to the state survey agency within 24 hours. Record review of Facility Policy, undated, titled, Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment reflected, In response to allegations of abuse, neglect, exploitation, or mistreatment, the Facility will: Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately but.not later than twenty-four (24) hours if the events that cause the allegation does not involve abuse and does not result in serious bodily injury.

Based on observations, interviews, and record reviews, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys, for 1 of 4 medication carts (treatment cart) reviewed for drug security and 2 of 13 residents (Resident #16 and Resident #41) reviewed for medications at the bedside. 1. Facility treatment cart was left unattended and unlocked at the North-hall on [DATE] at 9:52 a.m. 2. Resident #16's Triad Hydrophilic wound dressing cream was left unattended and unsecured on the nightstand at the resident's bedside. 3. South-hall nursing cart had Resident #41's insulin pen with open date [DATE], but DON said Novolog insulin pen should have been discarded after 28 days once it was opened. This failure could place residents at risk for misappropriation of property and could place residents at risk for accidents, hazards, and not receiving therapeutic effects. The findings included: 1. Observation on [DATE] at 9:52 a.m. revealed treatment cart was located at the North-hall, and the cart was left unattended and unlocked. Nobody was around the cart, and there were many wound dressings, gauzes, ointments, and cream for wound care inside the cart. Interview on [DATE] at 9:53 a.m. RN B stated facility treatment cart was left unattended and unlocked. The cart was opened, and RN B stated the cart should have been locked all the time. RN B did not know what reason the treatment cart was left unattended and unlocked. Usually treatment nurse used the cart, but [DATE] was Sunday, so the floor charge nurses might unlock the cart after using it. It was nurses' responsibility to lock the cart all the time, and the potential harm was residents could have taken some creams or ointments from the cart, and it could cause harm to residents. Interview on [DATE] at 5:42 p.m. DON stated all facility medication carts and treatment cart should be locked all the time when the carts were left unattended. 2. Record review of Resident #16's electronic face sheet, dated [DATE], reflected the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses included: parkinsonism (clinical syndrome characterized by tremor), hypertension (high blood pressure), muscle wasting and atrophy (the decrease in size and wasting of muscle tissue), and difficulty in walking. Record review of Resident #16's quarterly MDS assessment with an ARD of [DATE] reflected the resident scored an ,d+[DATE] on her BIMS which signified the resident had moderately cognitive impairment, and the resident needed to have setup or clean-up assistance (helper sets up or cleans up) for eating and dependent (helper does all of the effort) for hygiene, shower/bathe, and transfer. Record review of Resident #16's physician order, dated [DATE], reflected Triad Hydrophilic wound dress external paste (Wound dressings) - Apply to bilateral buttock topically every shift for prevention cleanse skin completely with peri wipes, pat dry. Mix Triad and antifungal ointment together then apply. Record review of Resident #16's MAR, dated from [DATE] to [DATE], reflected Resident #16 received her Triad Hydrophilic wound dress external paste (Wound dressings) cream to her buttock area every morning, evening, and night shift as ordered. Observation on [DATE] at 10:36 a.m. revealed in Resident #16's room, Triad Hydrophilic wound dress external paste (Wound dressings) cream was on the nightstand at the resident's bedside unattended. Resident #16 was not in her room and attending in the activity. Interview on [DATE] at 10:41 a.m. with ADON and RN B stated Resident #16's Hydrophilic wound dress external paste (Wound dressings) cream was on the nightstand at the resident's bedside unattended. Further interview with ADON and RN B stated it was medication. All medications should not be in resident's room. They did not know what reason the medication was on the nightstand unattended in Resident #16's room. Nurses might forget putting the medication in the cart after using it. The potential harm was that Resident #16 or other residents might use the medication incorrectly even though the resident was alert and oriented and had no roommate. Interview on [DATE] at 5:42 p.m. DON stated all medications should not be in resident's room unattended per the facility policy. 3. Record review of Resident #41's electronic face sheet, dated [DATE], reflected the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses included: malignant neoplasm of prostate (Prostate cancer), dementia (a group of symptoms affecting memory, thinking and social abilities), type 2 diabetes mellitus (trouble controlling blood sugar), and hypertension (high blood pressure). Record review of Resident #41's admission MDS assessment with an ARD of [DATE] reflected the resident scored an ,d+[DATE] on his BIMS which signified the resident had severe cognitive impairment, and the resident needed to have supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for eating and dependent (helper does all of the effort) for hygiene, shower/bathe, and substantial/maximal assistance (helper does more than half the effort) for transfer. Record review of Resident #41's physician order, dated [DATE], reflected NovoLoG FlexPen Subcutaneous Solution Pen injector 100 unit/ml. Inject as per sliding scale: if ,d+[DATE] = 0 unit; ,d+[DATE] = 2 unites. If greater than 400 administer 2 units and notify physician for type 2 diabetes mellitus. Record review of Resident #41's MAR, dated from [DATE] to [DATE], reflected Resident #41 received his NovoLoG FlexPen Subcutaneous Solution Pen injector 100 unit/ml as per sliding scale by scheduled 6:30 am, 11:30 am, and 4:30 pm as ordered. Observation on [DATE] at 3:27 p.m. revealed there was Resident #41's Novolog Flex pen with open date [DATE] inside South-hall nursing cart. Interview on [DATE] at 3:40 p.m. ADON stated Resident #41's Novolog Flex pen with open date [DATE] was inside South-hall nursing cart. Further interview with the ADON stated Novolog insulin pen should have been discarded after 28 days once it was opened. The ADON did not know what reason this insulin pen was inside the cart. The potential harm was Resident #41 might have ineffective therapeutic drug result. Interview on [DATE] at 5:42 p.m. DON stated Resident #41's Novolog insulin pen should have been discarded after 28 days once it was opened. Record review of the facility policy, titled Medication Access and Storage, undated, reflected . 2. Only licensed nurses, the consultant pharmacist and those lawfully authorized to administer medications are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. 6. Except for those requiring refrigeration, medications intended for internal use are stored in a medication cart or other designated area. Record review of health direct pharmacy services' standard of care for insulin pen, dated [DATE], reflected For Novolog Flex pen was expired after 28 days upon opening.

Based on observation, interviews, and record reviews, the facility failed to ensure residents were free of any significant medication errors for 1 of 5 residents (Resident #1) reviewed for medication administration. During medication administration observation on 07/30/2024, MA hold Resident #1's Metoprolol Tartrate 25 mg because of low blood pressure (118/50), but the MA did not notify holding the medication to the charge nurse, LVN D. This failure could place residents at risk for not receiving the therapeutic effects of their prescribed medications. The findings included: Record review of Resident #1's electronic face sheet, dated 07/31/2024, reflected the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses included: urinary tract infection (bladder infection), type 2 diabetes mellitus (trouble controlling blood sugar), hypertensive (high blood pressure), chronic atrial fibrillation (abnormal heart rhythm), chronic kidney disease state 3 (damage to or disease of a kidney), and hyperlipidemia (high levels of fat). Record review of Resident #1's significant change MDS assessment with an ARD of 06/24/2024 reflected the resident scored an 8/15 on his BIMS which signified the resident had moderately cognitive impairment, and the resident needed to have setup or clean-up assistance (helper sets up or cleans up) for eating and dependent (helper does all of the effort) for hygiene, shower/bathe, and transfer. Record review of Resident #1's physician order, dated 06/21/2024, reflected Metoprolol Tartrate tablet 25 mg - give 1 tablet by mouth two times a day related to hypertensive (high blood pressure). Hold for SBP [systolic blood pressure] less than 110 or pulse less than 60. Record review of Resident #1's MAR, dated from 07/01/2024 to 07/31/2024, reflected Metoprolol Tartrate tablet 25 mg - give 1 tablet by mouth two times a day related to hypertensive (high blood pressure). Hold for SBP [systolic blood pressure] less than 110 or pulse less than 60 - Scheduled AM 07 [from 7 am to 11 am] and PM 15 [from 3 pm to 7 pm]. Observation on 07/30/2024 at 9:12 a.m. revealed MA C took Resident #1's blood pressure before giving the resident's medications, and the blood pressure was 118 (systolic blood pressure) / 50 (diastolic blood pressure) and pulse 62 per minute. MA C held Resident #1's Metoprolol Tartrate tablet 25 mg by saying holding this medication because the resident's diastolic blood pressure was low as 50. Further observation on 07/30/2024 at 9:29 a.m. revealed the MA C did not notify holding Resident #1's Metoprolol Tartrate tablet 25 to the charge nurse. Interview on 07/30/2024 at 2:21 p.m. with MA C stated Resident #1 did not receive his Metoprolol Tartrate tablet 25 mg one tablet because of his low diastolic blood pressure as 50, and MA C did not notify holding this medication due to low diastolic blood pressure to the charge nurse. MA C stated she knew she could hold Resident #1's Metoprolol Tartrate tablet 25 mg when his SBP [systolic blood pressure] less than 110 or pulse less than 60 per the physician order. However, MA C thought that she should hold it because Resident #1's diastolic blood pressure was low as 50. Further interview with the MA C stated she should have notified to the charge nurse immediately and followed the charge nurse's directions. MA C stated she was aware of notifying the charge nurse immediately but totally forgot because she was very nervous. Interview on 07/30/2024 at 2:30 p.m. the DON stated Resident #1 should have received his Metoprolol Tartrate tablet 25 mg because his systolic blood pressure was 118 (more than 110), and his pulse was 62 (more than 60). If MA C thought she should hold the medication because Resident #1's diastolic blood pressure was low as 50, she should have notified it to the charge nurse immediately and followed the charge nurse's directions. Medication aide could not hold medications without nurse's directions and physician orders. It was medication error. Record review of the facility policy, titled Medication Administration, undated, revealed It is the policy of this facility that medications shall be administered as prescribed by the attending physician. 2. Medications must be administered in accordance with the written orders of the attending physician.

Based on interviews and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1) of 13 residents reviewed for accuracy and completeness of clinical records. LVN D did not document Resident #1's refusal of wound care on 07/04/2024 to the resident's treatment administration record. This failure placed facility residents at risk for lack of wound care or incorrect wound care due to misinformation by incomplete and inaccurate medical record. Findings included: Record review of Resident #1's electronic face sheet, dated 07/31/2024, reflected the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses included: urinary tract infection (bladder infection), type 2 diabetes mellitus (trouble controlling blood sugar), hypertensive (high blood pressure), chronic atrial fibrillation (abnormal heart rhythm), chronic kidney disease state 3 (damage to or disease of a kidney), hyperlipidemia (high levels of fat), and peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Record review of Resident #1's significant change MDS assessment with an ARD of 06/24/2024 reflected the resident scored an 8/15 on his BIMS which signified the resident had moderately cognitive impairment, and the resident needed to have setup or clean-up assistance (helper sets up or cleans up) for eating and dependent (helper does all of the effort) for hygiene, shower/bathe, and transfer. Further record review of the MDS Section M (Skin Conditions) revealed to the question (M0210 - Does this resident have one or more unhealed pressure ulcers/injuries? the answer was Yes, and Resident #1 had one state 3 pressure ulcer (full thickness tissue loss) to left ischium (left buttock area). Record review of Resident #1's physician order, dated 06/26/2024, reflected Left ischium - state 3 - clean with wound cleanser, gently pat dry, apply skin prep to peri wound. Apply Anasept mixed with collagen sprinkles to wound bed, cover with calcium alginate, and secure with bordered foam dressing - every day. Record review of Resident #1's treatment administration record, dated from 07/01/2024 to 07/31/2024, revealed Left ischium - state 3 - clean with wound cleanser, gently pat dry, apply skin prep to peri wound. Apply Anasept mixed with collagen sprinkles to wound bed, cover with calcium alginate, and secure with bordered foam dressing - every day was scheduled to Day, and Resident #1 received the wound care as ordered every day, except 07/04/2024. There was a hole (empty space) on 07/04/2024 to Resident #1's treatment administration record for July 2024. Record review of facility 24-hour nursing report, dated 07/04/2024, revealed 6 am to 2 pm shift nurse documented [Resident #1] refused wound care. Patient stated to tired, and 2 pm to 10 pm nurse documented [Resident #1] refused wound care and patient stated tomorrow. Interview on 07/31/2024 at 4:17 p.m. LVN D stated she worked for Resident #1 on 07/04/2024 from 6 am to 10 pm, and when the LVN D tried to provide the wound care to Resident #1 in the daytime, the resident refused and tried one more time the evening time, but the resident refused again. The LVN D also confirmed LVN D did not document regarding the resident refused wound care on 07/04/2024 in the resident's treatment administration record because wound care nurse usually provided the care to Resident #1, but on 07/04/2024 was holiday, so the wound care nurse did not work. For this reason, LVN D was very busy and totally forgot documenting on the treatment administration record. However, LVN D documented it to the 24-hour nursing report. Further interview with the LVN D stated LVN D should have documented Resident #1's refusal for wound care on the treatment administration record because it was official medical record. Potential harm was Resident #1 could have incorrect wound care or received same wound cares twice because of no charting. Interview on 07/31/2024 at 5:42 p.m. DON stated LVN D should have documented Resident #1's refusal for wound care on 07/04/2024 to the resident's treatment administration record, and the treatment administration record should have been accurate because it was a medical record. Record review of the facility policy, titled Medication Administration, undated, reflected . 13. The nurse must enter an explanatory note on the medication/treatment administration record when drugs are withheld, refused, or given other than at scheduled times.

Based on observation, interview, and record review, the facility failed to enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 1 (Resident #1) of 13 residents reviewed, in that: Resident #1's personal refrigerator located in his room was observed on 07/28/2024, and there was a small plastic container inside the refrigerator with olives, but no date on the plastic container. The findings included: Record review of Resident #1's electronic face sheet, dated 07/31/2024, reflected the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses included: urinary tract infection (bladder infection), type 2 diabetes mellitus (trouble controlling blood sugar), hypertensive (high blood pressure), chronic atrial fibrillation (abnormal heart rhythm), chronic kidney disease state 3 (damage to or disease of a kidney), and hyperlipidemia (high levels of fat). Record review of Resident #1's significant change MDS assessment with an ARD of 06/24/2024 reflected the resident scored an 8/15 on his BIMS which signified the resident had moderately cognitive impairment, and the resident needed to have setup or clean-up assistance (helper sets up or cleans up) for eating and dependent (helper does all of the effort) for hygiene, shower/bathe, and transfer. Observation on 07/28/2024 at 11:38 a.m., revealed Resident # 1 was watching on television on the bed, and there was a personal refrigerator in room with undated olives inside a small plastic container on bottom shelf. Interview with Resident # 1 on 07/28/2024 at 11:39 a.m., stated that the olives were brought in by his son and could not recall how long ago that was. Interview on 07/28/2024 at 11:50 a.m. with RN B stated there were seven olives inside a small plastic container in Resident # 1's personal refrigerator, and they should have been thrown out by nursing staff because it was undated. Interview on 07/31/2024 at 5:42 p.m. DON stated night nurses were responsible for overseeing Resident's personal refrigerators and also responsible for monitoring it daily, and the potential harm was Resident # 1 risked possible food - illness by consuming undated food in personal refrigerator. Record review of the facility policy, titled Resident personal food storage, revised 01/2022, revealed 4. Resident and individuals bringing food in from outside sources will be educated on safe food handling and storage techniques by designated facility staff as needed.

Based on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 13 Residents (Resident #4) whose MDS records were reviewed for accuracy. The facility failed to ensure Resident #4's quarterly MDS assessment, dated 06/17/2024, accurately reflected the resident had a significant weight loss. This failure could place residents at risk for inadequate care due to inaccurate assessments. The findings included: Record review of Resident #4's electronic face sheet, dated 07/31/2024, reflected the resident was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4's diagnoses included: urinary tract infection (bladder infection), protein-calorie malnutrition (the state of inadequate intake of food as a source of protein, calories, and other essential nutrients), kidney failure (kidneys stop working), hypokalemia (below normal in potassium), and dementia (a group of symptoms affecting memory, thinking and social abilities). Record review of Resident #4's quarterly MDS assessment with an ARD of 06/17/2024 reflected the resident scored an 1/15 on his BIMS which signified the resident had severe cognitive impairment, and weight loss (loss of 5% or more in the last month or loss of 10% or more in last 6 months) in the section K (Swallowing/Nutritional status) was marked as No or unknown. Record review of Resident #4's comprehensive care plan revised on 06/10/2024 reflected [Resident #4] has unplanned/unexpected weight loss related to recent hospitalization on [DATE] - significant weight loss to 17.3 pounds (11%) for 6 months and for interventions Labs as ordered. Report results to physician and ensure dietician is aware, Med pass 120 milliliters by mouth two times a day added, monitor and evaluate any weight loss, and monitor and record food intake at each meal. Record review of Resident #4's weight log revealed the resident weighed 157.3 pounds on 12/06/2023 and 140.0 pounds on 06/03/2024 which the resident had a -11.00% significant weight loss for 6 months. Record review of Resident #4's nutrition assessment, dated on 04/15/2024, revealed At risk of dehydration due to dementia; offer fluids frequently. Weight loss related to inadequate oral intake as evidenced by weight loss for two weeks. Goal - gradual, non-significant weight gain towards ideal body weight. Recommendation - discontinue Renal diet restrictions and add Med Pass 120 milliliters two times a day. Record review of Resident #4's MAR, dated from 07/01/2024 to 07/31/2024, revealed Resident #4 received Med Pass 120 milliliters two times a day as ordered. Interview with the MDS nurse RN A on 07/31/2024 at 5:14 p.m. confirmed Resident #4 had a -11.00% significant weight loss from 12/06/2023 to 06/03/2024, and the quarterly MDS assessment with an ARD of 06/17/2024's weight loss in the section K (Swallowing/Nutritional status) should have been marked as Yes to Loss of 5% or more in the last months or loss of 10% or more in last 6 months. The MDS nurse RN A stated she did not know the reason it was marked No.; it was mistake because the MDS nurse RN A started working as a MDS nurse four months ago and was still on learning processes about MDS. Further interview with the MDS nurse RN A stated the potential harm was Resident #4 might have more weight loss because of no interventions by inaccurate MDS. Record review of the facility's policy, titled Nursing Administrative, undated, revealed To complete a comprehensive assessment of the resident's needs which are based on the State's specific Resident Assessment Instrument and the facility's interdepartmental assessment form, To assess the resident's capability to perform daily functions and significant impairments on function capacity, and this facility will assure the completion of the resident assessment process enabling the development of an individualized comprehensive care plan for residents. Record review of the CMS MDS 3.0 Manual dated October 2023 revealed in part, .The OBRA regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents. The Resident Assessment Instrument (RAI) process is the basis for the accurate assessment of each resident. The MDS 3.0 is part of that assessment process and is required by CMS .

Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 1 of 2 residents (Residents #11) reviewed for respiratory treatment in that: Resident #11's nebulizing mask and tubing were observed on 07/28/2024, and it was covered in a plastic bag but dated on 05/12/2024. This failure could affect residents who received nebulizing treatment by placing them at risk for respiratory infections. The findings included: Record review of Resident #11's electronic face sheet, dated 07/31/2024, reflected the resident was admitted to the facility on [DATE] with diagnoses included: cerebral infarction (damage to tissues in the brain), dementia (a group of symptoms affecting memory, thinking and social abilities), atherosclerotic heart disease (damage or disease in the heart's major blood vessels), asthma (a person's airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe), and sleep apnea (potentially serious sleep disorder in which breathing repeatedly stops and starts). Record review of Resident #11's quarterly MDS assessment with an ARD of 04/27/2024 reflected the resident scored an 10/15 on his BIMS which signified the resident had moderately cognitive impairment, and the resident needed to have supervision or touching assistance to all activities of daily living such as eating, dressing, showering, and transferring. Record review of Resident #11's physician orders, dated 05/11/2024, reflected Ipratropium-Albuterol Solution 0.5 - 2.5 (3) mg/3 ml - 3 milliliters inhale orally every 4 hours as needed for short of breathing or wheezing through nebulizer. Observation on 07/28/2024 at 11:43 a.m. revealed Resident #11's nebulizer was on the nightstand connected to a tubing and mask, and the tubing and mask were covered in a plastic bag. The plastic bag was dated on 05/12/2024. Interview on 07/28/2024 at 11:48 a.m. with RN B saw Resident #11's tubing and mask and confirmed the tubing and mask connected to Resident #11's nebulizer were covered in a plastic bag, and the bag was dated on 05/12/2024. RN B stated Resident #11 used sometimes the nebulizer and mask for breathing treatment. Further interview with the RN B confirmed per the facility policy nurses should have changed a tubing and mask for breathing treatment weekly, and RN B did not know what reason nurses did not change them weekly. The potential harm was Resident #11 might have respiratory infection due to old tubing and mask. Interview on 07/31/2024 at 5:42 p.m. with DON stated facility nurses should have changed Resident #11's tubing and mask for breathing treatment weekly. Record review of the facility policy, titled Nebulizer, undated, reflected . 5. Nebulizer tubing to be changed and dated weekly and kept bagged when not in use.

Based on observation, interview and record review the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents goals and preferences for 2 of 5 residents (Resident #2 and #3) reviewed for respiratory care. 1. The facility failed to ensure Resident #2's oxygen tubing and concentrator humidifier with connected tubing was not on the floor. 2. The facility failed to ensure Resident #3's oxygen tubing was not on the floor. These deficient practices could place residents at risk of cross contamination, infections, receiving incorrect or inadequate oxygen support and could result in a decline in health. The findings were: 1. Record review of Resident # 2's face sheet reflected he is a [AGE] year old male with an admitted [DATE] and a readmitted [DATE]. Resident #2 had diagnoses which included chronic pain syndrome (pain that encompasses a range of symptoms that impact daily life), peripheral vascular disease (circulation disorder that affects any blood vessel outside of the heart), type II diabetes mellitus with hyperglycemia (causes high blood sugar due to the pancreas not producing enough insulin), pleural effusion (collection of fluid around the lungs), diabetic neuropathy (nerve damage caused by diabetes), depression (mood disorder characterized by persistent feelings of sadness, emptiness and loss of joy), anxiety disorder (intense, excessive and persistent worry and fear about everyday situations), chronic kidney disease (gradual loss of kidney function) and chronic atrial fibrillation(a disease of the heart characterized by irregular and often faster heartbeat). Record review of Resident # 2's consolidated physician orders for February 2024 reflected orders for O2 at 2 L/MIN continuous every shift (order date 12/27/2023). Further review of the consolidated orders reflected an order to change O2 tubing and humidifier bottle every night shift every Sunday (order date 12/27/2023). Record review of Resident #2's care plan, revised on 11/16/2023, reflected Resident #2 has shortness of breath related to acute respiratory failure due to parotitis (inflammation of one or both parotid glands) and aspiration pneumonia. The goal was he would have no complications related to SOB through the review date and would not have a rehospitalization within 30 days. The interventions reflected check and record O2 saturations as needed for SOB, Cyanosis(a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood.), respiratory distress, labored breathing and O2 at 2-4 L/MIN via NC to maintain O2 greater than 92%. Record review of Resident #2's MDS, dated [DATE], reflected a BIMS score of 9, indicating moderately impaired cognition. Resident #2 was on oxygen therapy for respiratory failure. Observation on 02/14/2024 at 11:32 AM revealed Resident # 2's oxygen tubing and concentrator humidifier with connected tubing was on the floor. Resident #2 was observed lying in bed watching TV with his nasal cannula in his nose, the oxygen tubing was lying on the floor, beside the bed and the humidifier bottle sat on the floor in front of the concentrator. Observation on 02/15/2024 at 11:10 AM revealed the oxygen tubing on the floor while Resident #2 was lying in bed. During an interview on 2/14/24 at 1:35 PM with Resident #2, he stated he was on oxygen and he was not aware the tubing and humidifier were on the floor. He stated he did not put the tubing on the floor and said the nurses assisted him with administering the oxygen. During an interview on 02/15/2024 at 12:45 PM with LVN B, LVN B stated oxygen tubing on the floor could cause a resident to get sick from dirty floors or cleaning supplies. She stated she received training on oxygen equipment and tubing and said it was the Charge Nurse and CNA's responsibility to ensure the tubing was not touching the ground. During an interview on 02/15/2024 at 1:00 PM with the ADON, the ADON stated he witnessed the oxygen tubing and the humidifier for the concentrator on the floor the morning of 02/14/2024. The ADON stated he observed the tubing on the floor, picked it up and replaced it with new tubing. The ADON stated the concentrator humidifier attachment was broken and he switched out the concentrator and replaced the humidifier with a new one. The ADON stated this deficient practice could cause bacteria, cross contamination or respiratory infections. He stated staff received training on oxygen equipment and he believed it included not having oxygen tubing touch the floor. 2. Record review of Resident #3's face sheet reflected he is a [AGE] year old male with an initial admitted [DATE] and a readmitted [DATE]. Resident #3 had diagnoses which included sepsis (the body's extreme response to an infection), acute respiratory failure with hypoxia (a condition where the body cannot respond to O2), aphasia (a comprehension and communication disorder resulting from damage or injury to a specific area of the brain) following cerebral infarction (stroke)and dementia. Record review of Resident #3's MDS, dated [DATE], reflected a BIMS of 6 indicating severely impaired cognition and oxygen therapy with a diagnosis of respiratory failure. Record review of Resident #3's care plan, dated 02/08/24, reflected has altered respiratory status/difficulty breathing related to acute and chronic respiratory failure with hypoxia(below normal levels of oxygen in the blood). The goal was will have no complications related to SOB through the review date. Interventions included provide oxygen as ordered. Observation on 02/14/24 at 11:28 AM revealed Resident #3's oxygen tubing was on the floor. Resident #3 was observed lying in bed watching TV with a nasal canula in his nose. The connected oxygen tubing was lying on the floor beside his bed. During an interview on 02/14/24 at 11:28 AM with Resident #3, he indicated he did not know his oxygen tubing was on the floor. During an interview on 2/14/2024 at 12:11 PM with LVN A, she revealed she received training on oxygen equipment and storage of tubing. She also revealed tubing should not be on the ground because it could get contaminated or get kinked which could reduce oxygen flow. She revealed contamination could introduce a bacterium into the resident's lungs and cause a respiratory infection. During an interview on 02/15/24 at 11:00 AM with LVN A, she revealed she picked up the oxygen tubing off of the floor and changed the tubing on the morning of 02/14/2024 after she observed it on the floor. She stated it was the responsibility of the Charge Nurse and CNA to ensure the oxygen tubing was not on the floor. During an interview on 2/15/24 at 12:10 PM with the DON, the DON stated oxygen tubing should be kept off the ground. She stated oxygen tubing touching the ground could cause infections, trip hazard and kinking in the oxygen line which could lead to a reduced amount of O2 being administered. She stated everyone was responsible for ensuring the tubing was not touching the floor and stated the staff have received training on oxygen equipment and tubing. Record review of the facility's policy on Oxygen Equipment, dated 05/2007, reflected it was the policy of the facility to maintain all oxygen therapy equipment in a clean and sanitary manner and the facility will maintain clean tanks, connectors and concentrators.

Based on interview and record review the facility failed to immediately consult with the resident's physician and notify, consistent with his or her authority, the resident representative when there was an accident with potential for requiring physician intervention for 1 of 6 Residents (Resident #1) whose records were reviewed for accidents. LVN A failed to notify Resident #1's physician and representative when he had a fall on 9/18/23 which resulted in a delay of care. The facility failed to consult the physician when the mobile x-ray did not arrive timely to take the x-ray resulting in Resident #1 waiting 15 1/2 hours for his x-ray to be taken. Resident #1 was hospitalized on [DATE], was diagnosed with a right hip fracture and admitted for surgery. The noncompliance was identified as past noncompliance Immediate Jeopardy (IJ). The noncompliance began on 9/18/23 and ended on 11/30/23. This deficient practice could contribute to residents not receiving the medical care and treatment needed and a decline in physical condition. The findings were: Review of Resident #1's face sheet, dated 9/20/23, revealed he was admitted to the facility on [DATE] with diagnoses including unspecified Dementia (decline in cognitive abilities that impacts a person's ability to perform everyday activities) and Parkinson's (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves). Further review revealed Resident #1 had a family member who was his Emergency Contact #1. Review of Resident #1's quarterly MDS assessment, dated 8/31/23, revealed he required extensive assistance by 1 person for bed mobility, transfers ambulation and locomotion. He used a walker and wheelchair for locomotion. Further review revealed Resident #1's level of cognition and level of pain was not assessed; he had 1 fall since admission, 2 falls with no injuries and 1 fall with injury but not a major injury. Review of Resident #1's change of condition MDS assessment, dated 10/24/23, revealed his BIMS was 1 of 15 indicative of severe cognitive impairment. Further review revealed Resident #1 used a walker and manual wheelchair for mobility and was admitted with diagnosis which included hip fracture; a pain assessment was not completed, and it reflected that he required major surgery prior to admission to the facility which included a hip replacement. Review of Resident #1's Care Plan revised on 11/28/23 revealed he had self-performance deficit related to Dementia and Parkinson's. He required limited to extensive assistance by 1 or 2 persons with bed mobility and transfers. Further review revealed Resident #1 was a risk for falls reason to unsteady gait/balance, Dementia and Parkinson's. Some of the interventions included to anticipate and meet needs and follow facility fall protocol. Review of Resident #1's fall risk assessment, dated 8/14/23, revealed his score was 16 indicating he was a high fall risk. Review of Resident #1's fall risk assessment, dated 10/18/23, revealed his score was 18 indicating he was a high fall risk. Review of an incident report, dated 9/18/23 at 9:30 AM, revealed that LVN A was passing by Resident #1's room; she saw him sitting on his walker. He bent forward to pick up a wrapper from the floor. The walker started to roll backwards, and she responded, tried to hold him up by his waistline, but was not able to hold him up and lowered him to the floor. LVN A went to get MA B to help transfer Resident #1 safely into his bed. Further review revealed LVN A assessed Resident #1 for range of motion and pain. Assessment was done before and after moving Resident #1 into the bed. Results were within his normal limits. No injuries were observed at the time of incident or post incident. Review of Resident #1's progress note, dated 9/18/23, written by LVN A revealed it was a late entry note. The note reiterated Resident #1 had a fall per the incident report. Further review revealed LVN A did not contact Resident #1's physician or family representative. Review of the SBAR communication form written by LVN A, dated 9/19/23, revealed the change of condition, symptoms or signs observed and evaluated was Pain (uncontrolled). She noted changes in the last week for Resident #1 included mobility decreased and a skin tear (right knee). LVN A conducted a pain evaluation which revealed Resident #1 had a new onset of pain as evidenced by grimacing when attempted to stand, occasional moan and groan, level of speech with negative or disapproving quality, tense, distressed pacing, fidgeting and distracted. Further review revealed a new order for an x-ray of the pelvis and right knee. In addition, it was noted LVN A notified the physician for Resident #1's change of condition on 9/19/23 at 8:35 AM and the family representative on 9/19/23 at 9:00 AM. Review of a an eMAR administration note effective dated 9/19/23 at 12:25 PM revealed LVN A administered Acetaminophen 325 mg., give two tablets every 4 hours as needed for pain. It was noted at 13:27 (1:27 PM) PRN administration was ineffective. Follow up pain scale was: 6. Review of Radiology report, examination dated 9/20/23 at 01:09 (1:09 AM), revealed Single view of the pelvis. Findings: Acute dislocated fracture involving the right femoral neck (right hip fracture). Ortho consultation recommended. Diffuse Osteopenia present. Right Knee X-ray, 2 views of the right knee. Findings: There are no visualized fracture. Review of Provider Investigation Report, dated 9/27/23, revealed that on 9/18/23 Resident #1 was assessed by LVN A. LVN A found there was no pain immediately post fall. Further assessment shows that ROM was not significantly different than baseline. On 9/19/23, LVN A completed another assessment which revealed Resident #1 was showing signs of guarding his right side. Physician notified; new order given to have x-ray of resident's right side. Results showed fracture in right femoral neck. Provider Response: 1. Incident Report Completed 2. Interview Staff 3. Safe Survey 4. In-service staff - Abuse/Neglect, Pain assessment, Fall Risk Assessment, Incident Report, Documentation, Interventions 5. Notified Family 6. Notified Physician 7. Nurse Suspended pending investigation Summary: Upon investigation and completing staff interviews on 9/19/23, it was discovered the nurse did not report the fall when it occurred on the 18th. The nurse was suspended during investigation. Family was notified on the 19th and an x-ray was ordered. Results of x-ray led to resident being sent to the hospital. Staff was in-serviced on incident reports, pain assessment, fall risk assessment, interventions, reporting falls, fall documentation and on abuse and neglect. Review of an in-service dated 9/21/23 related to reporting falls revealed thirteen staff signatures. Further review revealed the in-service was continued on 9/22/23 which revealed fourteen staff signatures. Review of an in-service dated 9/21/23 related to pain/assessment revealed thirteen staff signatures. Further review revealed the in-service was continued on 9/22/23 which revealed thirteen staff signatures. Review of an in-service dated 9/22/23 related to fall interventions/documentation revealed thirty-two staff signatures. Further review revealed the in-service was continued on 9/22/23 which revealed eight staff signatures. Review of an in-service dated 9/22/23 related to falls assisted and unassisted/documentation revealed thirty-two staff signatures. Further review revealed the in-service was continued on 9/22/23 which revealed nine staff signatures. Review of an in-service dated 9/22/23 related to Abuse, Neglect and Reporting revealed ninety-nine staff signatures. Review of a statement, undated, titled Conversation with [name of LVN A] read: I was walking past the room when I noticed resident was sitting on rolling walker, he was bending down to pick up candy wrapper off the floor, I was worried he was going to fall over so I went to the room, the walker was rolling away and he started falling, I grabbed him from the waistband and assisted him to the floor. He was sitting upright on the floor, so I went to get help and when we returned, he was on the right side stretched out. [name of MA B] the med aide helped assist him get back into bed. Did not verbalize pain. Vitals were taken and charted. On Tuesday, he didn't' want to get up, acted stiff, not moving freely, and moaning. I went to check on him, he was guarding his right side. No visible signs of injuries. No edema (swelling) no bruising. PRN medication given at 8:30 am notified [name of NP C] NP, ordered x-ray. I called [name of Emergency Contact #1) and let her know. 9:30 called x-ray, did not come in during 6 to 2 shift. Results did not come in until overnight. Interview on 1/3/24 at 2:21 PM with MA B, he stated Resident #1 was a fall risk. He stated LVN A asked him to help transfer Resident #1 back into bed after he fell and subsequently was diagnosed with a right broken hip. He stated upon entering Resident #1's room, Resident #1 was on the floor. Resident #1 was grimacing and LVN A conducted an assessment. LVN A then administered PRN pain medication. MA B stated it would be LVN A's responsibility to call the physician and responsible party to inform them of the fall and the details of the incident. MA B verbalized the understanding of the facility fall precautions, preventions and protocols to follow. Interview on 1/3/24 at 4:20 PM with LVN D revealed he worked 2 to 10 PM on 9/18/23. He stated LVN A did not report to him that Resident #1 had fallen. He stated it was the following day that LVN A reported Resident #1 had fallen the day before because on this date, 9/19/23, Resident #1 was complaining of pain to his right side. LVN D stated there was no documentation in the 24-hour report, there was no progress note and he did not know anything about an X-ray order which should be noted in the nursing documentation. LVN D stated after a fall, the charge nurse was responsible for notifying the physician, in-house administrative staff and the resident's responsible party. Further interview revealed LVN D verbalized the understanding of the facility fall precautions, preventions and protocols to follow. Interview on 1/3/24 at 7:54 PM with LVN A revealed she worked 6 AM to 2 PM on 9/18/23. She reiterated the details of the incident report and her statement r/t Resident #1's fall. She stated on the morning of 9/18/23 she saw Resident #1 sitting on the rolling walker as she was passing his room. He bent over to pick up a piece of paper from the floor. He was holding onto the handles which engaged the walker and it started to roll backwards. Resident #1 was very unsteady, and it looked like he was going to fall. She stated she assisted him to the floor, and he did not at any point make contact with the floor. She stated she was able to straddle the walker and held Resident #1 up from under his arm pits. She stated he was too heavy and could not hold him up and lowered him down her legs and he came to a sitting position on her feet. LVN A stated he never hit the floor and at the time she did not perceive it as a fall. She stated she had MA B help her transfer Resident #1 back to bed. She stated Resident #1 was able to stand and lift his legs onto the bed. Resident #1 did not exhibit any signs of pain during assessment. He mumbled no and shook his head when she asked about pain. LVN A further stated Resident #1 did not complain of pain the remaining of the shift. LVN A stated the following day on 9/19/23 Resident #1 was in bed asleep when she rounded on him upon starting her shift at 6 AM. She stated later the same morning, Resident #1 complained of excruciating pain when the aides tried to get him up from bed after breakfast. She stated she tried to give him PRN medication, but he would not take it. She stated she called NP C who ordered mobile X-rays. She then called the responsible party and stated the responsible party did not say anything about sending Resident #1 to the hospital. LVN A stated when she talked to the DON about the incident, the DON was upset with her because she did not report the incident the day before. LVN A stated at this point it was clear to her that an assisted fall was considered a fall. The DON instructed her to complete an incident report, enter late entries into the nurse's progress notes and complete a change of condition risk management form r/t Resident #1 complaining of pain. LVN A stated in retrospect, she believed she mishandled the incident and although she did not perceive it as a fall, it was clearly an incident and should have followed protocol by reporting the incident to the physician, responsible party and administrative staff. Then followed up with documenting the incident. The only person she stated she told about the fall was the 2 to 10 PM shift nurse reporting to work on 2/18/23. LVN A stated on 9/20/23 she learned mobile x-ray did not complete imaging until about 1 AM and then he was sent out later that early morning on the 10 PM to 6 AM shift. LVN A stated the X-Ray confirmed he had a right broken hip. Interview on 1/4/24 at 10:16 AM with the previous DON E revealed LVN A did not report Resident #1's fall on the date of the fall. She learned about it when LVN A was completing a Change of Condition report the day after the fall because he was complaining of pain to his right side. The previous DON E confirmed per LVN A's interview, that LVN A did not report the incident to administrative staff, did not call the physician and did not call the family member on the date of the incident. The previous DON E stated it was necessary to follow fall protocol because the physician might have provided orders on the date of the fall which would then delay care. The previous DON E stated Resident #1 sustained a right hip fracture and required surgery. She stated Resident #1 was transferred to a higher level of care acute post op facility for rehabilitation before transferring back to the nursing facility. Further interview revealed the previous DON E stated staff was provided with extensive training related to facility policy and protocols regarding falls including identifying a fall, reporting the fall, preventions, precautions, assessing pain and documentation. DON E further stated she was terminated as the DON. Attempted telephone call on 1/4/24 at 11:22 AM to Resident #1's Emergency Contact. Left a voicemail requesting she return the call. Interview on 1/4/24 at 11:53 AM with the Interim ADM revealed after Resident #1's fall, facility staff followed protocol when Resident #1 experienced a change of condition; he was experiencing pain on 9/19/23. He stated LVN A called the physician, she obtained an order for X-rays, she administered PRN pain medication and nursing staff sent Resident #1 to the hospital once the X-ray results were obtained. The ADM stated he expected nursing staff to use their best nursing judgement to follow up with a call to the physician when asked about the amount of time it took the X-rays to be completed and provided to the facility. The ADM further stated the previous DON remained in communication with the family representative who elected to have Resident #1 returned to the facility and the facility completed extensive training for all nursing staff regarding facility fall protocols. Telephone interview on 1/5/24 at 12:38 PM with Resident #1's Emergency Contact revealed LVN A called her the day after Resident #1 fell (9/19/23). LVN A reported to her Resident #1 was in pain and she called the physician and X-rays were ordered. She stated she asked LVN A if she needed to pick Resident #1 up and take him to the hospital and stated LVN A downplayed it and commented, It's not that serious. Resident #1's Emergency Contact stated she was upset that LVN A did not call her on the date of the fall; that LVN A downplayed it and that it took about 16 hours before the X-ray's were completed while he laid in bed in pain. Resident #1's Emergency Contact stated she had told nursing staff Resident #1 had a high tolerance for pain and again stated she was so upset that it took 2 days to send him out to the hospital. She stated she expressed how unhappy she was with how staff handled Resident #1's incident during a discussion with the previous DON and the Operations Manager after he was released from the hospital. She stated she decided not to transfer Resident #1 because he had Dementia, was comfortable and did not want to disrupt his placement. Review of facility policy, Resident Rights, undated, read It is the policy of this facility that all resident rights be followed per state and federal guidelines as well as other regulative agencies. 26. To be informed of any accident involving Resident resulting in injury or requiring physician intervention, any significant change in Resident's condition, or need to alter treatment significantly. Review of facility policy, Quality of Care, Incident Accident Reporting, revised 05/2007, read 3. Incident/Accident Reports involving residents will have notations in the nurses' notes for a minimum of seventy-two (72) hours, or longer as appropriate, until such time as the resident is deemed stable and/or has returned to their previous level of functioning. Report Incident/Accident 1. The charge nurse on the shift when the incident/accident is discovered is required to complete the incident/accident report, before the end of shift. Notification to the resident's appropriate representative and to the attending physician are to be included on this report. Reviews: 1.Fall policy stated Attending physician and Resident Representative shall be notified. 2.Inservice completed on 9/21/23 -The provider either NP or physician and RP will be notified. 3.Inservice completed on 9/22/23-The DON, MD/NP and RP will be notified. 4.NEW DON -Inservice done on 10/16/23- RP, MD and the DON must be notified. 5.Inservice completed on 11/3/203- RP, MD and the DON must be notified. 6.Inservice completed on 11/16/2023- order x-rays, follow up with needed x-rays and calling for reports and follow up. 7.Inservice completed on 11/30/23- RP and MD notified of Change of Condition (COC). Further review of in-services revealed out of 44 nursing employees (nurses and aides) 41 had signed in-service on fall management. Two staff were no longer working at the facility, and 1 was prn and had not worked. The noncompliance was identified as past noncompliance IJ. The noncompliance began on 9/18/23 and ended on 11/30/23 when all staff had been in-serviced on fall management to include notifying the MD and RP. LVN A resigned, and the DON was terminated prior to surveyor entrance. The facility corrected the noncompliance before survey began.

Based on interviews and record reviews the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 6 Residents (Resident #1) reviewed for treatments and services. LVN A failed to ensure Resident #1 received appropriate assessments and interventions when he had a fall on 9/18/2023, which she did not report as a fall to an oncoming nurse, DON or Administrator. The facility failed to consult the physician when the mobile x-ray did not arrive timely to take the x-ray resulting in Resident #1 waiting 15 1/2 hours for his x-ray to be taken. Resident #1 was hospitalized the following day on 9/19/2023 and diagnosed with a right hip fracture. The noncompliance was identified as past noncompliance Immediate Jeopardy (IJ). The noncompliance began on 9/18/2023 and ended on 11/30/23. This deficient practice could contribute to residents not receiving the necessary medical assessment and treatment and a decline in physical condition. The findings were: Record review of Resident #1's electronic medical record face sheet dated 1/10/2024 revealed a [AGE] year-old male with an initial admitted [DATE] and a re-admitted [DATE] with diagnoses to include encounter for closed fracture with aftercare, Parkinson's Disease(a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves.), dysphagia(difficulty with speech), cognitive communication deficit, history of falling, and unspecified dementia(decline in cognitive abilities that impacts a person's ability to perform everyday activities). Review of Resident #1's change of condition MDS assessment, dated 10/24/23, revealed his BIMS score was 1 of 15 indicative of severe cognitive impairment. Further review revealed Resident #1 used a walker with a seat and a manual wheelchair for mobility, he had 3 falls since admission with no injuries and 1 fall with injury but not a major injury. Record review of Resident #1's care plan date initiated 7/18/2023 and revision date of 11/28/2023 revealed Resident #1 was at risk for falls. Interventions were adaptive devices as recommended by therapy or the MD. Monitor for risk of falls. Monitor/document ability to perform ADL's. Report any improvement or decline to the MD. Monitor/document/report to the MD PRN signs or symptoms of Parkinson's complications such as poor balance, poor coordination, gait disturbances, and decline in range of motion. Follow the facility fall protocol. Review of Resident #1's fall risk assessment, dated 8/14/23, revealed his score was 16 indicating he was a high fall risk. Review of Resident #1's fall risk assessment, dated 10/18/23, revealed his score was 18 indicating he was a high fall risk. Review of an incident report, dated 9/18/23(no time documented), revealed that LVN A was passing by Resident #1's room; she saw him sitting on his walker. He bent forward to pick up a wrapper from the floor. The walker started to roll back wards and she responded, tried to hold him up by his waistline, but was not able to hold him up and lowered him to the floor. LVN A went to get MA B to help transfer Resident #1 safely into his bed. Further review revealed no injuries were observed at the time of incident or post incident. Record review of Resident #1's EMR revealed documentation authored by LVN A on 9/18/2023 at 9:30 am of Resident #1's fall. There was documentation of an assessment and responsible party and physician were notified of the fall. There was no documentation for the following shifts on 1/18/2024 on the 2:00 PM-10:00 PM shift or the 10:00 PM-6:00 am shift. Review of the SBAR(Situation-Background-Assessment-Recommendation) communication form written by LVN A, dated 9/19/23, revealed that on 9/18/23 Resident #1's mobility decreased and he had a new onset of pain as evidenced by grimacing when attempted to stand, occasional moan and groan; level of speech with negative or disapproving quality, tense, distressed pacing, fidgeting and distracted. Further review revealed a new order for an x-ray of the pelvis and right knee. Review of a medication administration note effective dated 9/19/23 at 13:27 PM (1:27 PM) revealed LVN A administered Acetaminophen 325 mg., give two tablets every 4 hours as needed for pain for Resident #1's right hip pain, PRN administration was ineffective. Follow up pain scale was: 6. Review of the radiology report, examination date 09/20/23 at 01:09 (1:09 AM), revealed Single view of the pelvis. Findings: Acute dislocated fracture involving the right femoral neck(is a break in the bone that connects the hip joint to the thigh bone). Ortho consultation recommended. Diffuse Osteopenia(means your bones are thinner than normal, but not as weak as osteoporosis) present. Right Knee X-ray, 2 views of the right knee. Findings: There are no visualized fracture( a break in the bone.). Review of a statement, undated, titled Conversation with [name of LVN A] revealed: I was walking past the room when I noticed resident was sitting on rolling walker, he was bending down to pick up candy wrapper off the floor, I was worried he was going to fall over so I went to the room, the walker was rolling away and he started falling, I grabbed him from the waistband and assisted him to the floor. He was sitting upright on the floor, so I went to get help and when we returned, he was on the right side stretched out. [Name of MA B] the med aide helped assist him get back into bed. Did not verbalize pain. Vitals were taken and charted. On Tuesday(9/19/2023), he didn't' want to get up, acted stiff, not moving freely, and moaning. I went to check on him, he was guarding his right side. No visible signs of injuries. No edema (swelling) no bruising. PRN medication given at 8:30 am notified [Name of NP C] NP, ordered x-ray. I called [name of Emergency Contact #1) and let her know. 9:30 am called x-ray, did not come in during 6:00 am to 2:00 PM shifts. Results did not come in until overnight(9/19/2023). Interview on 1/3/24 at 4:20 PM with LVN D revealed he worked 2 to 10 PM on 9/18/23. He stated LVN A did not report to him that Resident #1 had fallen. LVN D stated there was no documentation in the 24-hour report, there was no progress note and he did not know anything about an X-ray order which should be noted in the nursing documentation. During an interview on 1/3/24 at 7:54 p.m.LVN A stated the following day on 9/19/23 Resident #1 was in bed asleep when she rounded on him upon starting her shift at 6 AM. She stated later the same morning, Resident #1 complained of excruciating pain when the aides tried to get him up from bed after breakfast. During a phone interview on 1/10/24 at 9:20 a.m. with the family member of Resident #1, stated the facility did not know that Resident #1 had a right hip fracture on 09/19/2023 until x-ray results were obtained. She further revealed she did not know how long Resident #1 had a fracture to his right hip. During an interview on 1/10/2024 at 1:45 PM with Medication Aide B revealed he worked on 9/18/2023 with LVN A. He stated he was called to assist her in a resident's room (Resident #1) but couldn't recall time, to help get the resident to back to bed. He stated the resident complained of some pain in his right knee and he left to do his medication pass. Medication Aide B was not asked by the nurse to give any pain medications. All staff receive in-services frequently at the facility on falls reporting abuse and neglect by management. Medication Aide B said (Resident #1) stayed in bed the following day as he was not wanting to get up. During an interview on 1/10/2024 at 1:59 PM with Certified Nurse Aide C revealed he worked on 9/18/2023 during the 2-10 PM shift. He stated he was familiar with Resident #1. He stated during the evening of 9/18/2023 he was sleepy, but he did not recall him complaining of pain. Certified Nurse Aide C stated Resident #1 did not want to get out of bed. He stated he usually would walk with a walker and assistance of one staff, or he could fall as he was a fall risk. Certified Nurse Aide C stated he did not remember anything else and could not recall the next day if the resident was in the hospital or at facility. During an interview on 1/10/2024 at 2:56 PM the Director of Rehabilitation revealed Resident #1 was a fall risk due to Parkinson's Disease and dementia(inability to recall) therefore he used a walker while ambulating. During a phone interview on 1/11/2024 at 1:04 p.m. LVN A revealed she was working as a charge nurse on the 6:00 am to 2:00 PM shift, Monday through Friday on 09/18/2023. She stated she was no longer working at the facility as she decided to resign. She further revealed on 09/18/2023 she was walking past Resident #1's room when she noticed Resident #1 was sitting on the seat of his rolling walker, he was bending down to pick up a candy wrapper off the floor. She stated, I was worried he was going to fall over so I went to the room, the walker was rolling away and he started falling. I grabbed him from the waistband and assisted him to the floor. He was sitting upright on the floor, so I went to get help and when we returned, he was on his right side stretched out. She stated [name of MA B] the med aide helped me assist him get back into bed. LVN A said Resident #1 did not verbalize any pain to her at that time. LVN A further revealed she finished the assessment of checking his body for any injuries on the resident and took his vital signs and she charted them. LVN A stated Resident #1 had no complaints of pain during the rest of her shift. She stated she reported to the oncoming nurse(LVN A stated she could not remember who the nurse was) the resident had not had a fall but to watch him in case he sat on floor again. LVN A confirmed on the following day she was working as the charge nurse on the 6 am to PM shift, when she went to check on Resident #1. LVN A stated, He didn't' want to get up, acted stiff, not moving freely, and moaning. There were no visible signs of injuries, no edema (swelling), and no bruising to his right leg or hip. LVN A further revealed she notified the nurse practitioner who ordered an x-ray. She further revealed she notified Resident #1's responsible party. LVN A revealed she should have reported the incident with Resident #1 as a fall to the DON. She stated, The reason I did not is because I did not think it was a true fall, but thinking back I should have treated it like one. LVN A said if a resident had a fall then nurses were to assess them and then follow up by calling the doctor and follow any new orders, the responsible party, and notify the DON. Documentation was done in the resident's electronic medical record and in the 24-hour report. During an interview on 1/10/2024 at 9:40 am with DON she revealed she was not working at the facility during the time when Resident #1 had a fall on 9/18/2023 During an interview on 1/10/2024 at 9:55 am the facility Administrator confirmed he was the Administrator when Resident #1 had a fall on 9/18/2023. He further revealed that LVN A should have notified the DON and Administrator when the fall occurred on 9/18/2023 Record Review of Provider Investigation Report, dated 9/27/23, revealed that on 9/18/23 Resident #1 was assessed by LVN A. LVN A found there was no pain immediately post fall. Further assessment showed that ROM was not significantly different than baseline. On 9/19/23, LVN A completed another assessment which revealed Resident #1 was showing signs of guarding his right side. Physician notified and new order given to have x-ray of residents right side. Results showed fracture in right femoral neck. Provider Response: 1. Incident Report Completed 2. Interviews of Staff 3. Safe Survey with residents 4. In-service staff - Abuse/Neglect, Pain assessment, Fall Risk Assessment, Incident Report, Documentation, Interventions 5. Notified Family 6. Notified Physician 7. Nurse Suspended pending investigation. Summary: Upon investigation and completing staff interviews on 9/19/23, it was discovered that the nurse did not report the fall when it occurred on the 18th. The nurse was suspended during investigation. Family was notified on the 19th and an x-ray was ordered. Results of x-ray led to resident being sent to the hospital. Staff was in-serviced on incident reports, pain assessment, fall risk assessment, interventions, reporting falls, fall documentation and on abuse and neglect. Review of the facility policy titled Significant Change of Condition, Response, dated 05/2007 with revision dates of 06/2019, 01/2022, and 12/2023 revealed: It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practible physical mental and psychological well-being in accordance with the interdisciplinaty comprehensive assessment and plan of care. 4. The Medical Director shall be notified in the evenrt that the Attending Physician or on-call Physician cannot be reached. Review of the facility policy titled Fall Management System, dated 06.2018 with revision dates of 1.2022; and 12.2023, revealed: Policy: It is the policy of the facility to provide an environment that remains as free of accident hazards as possible. It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. Definition: Fall: refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (e.g., resident pushes another resident).An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. Procedure section 3. When a resident sustains a fall, a physical assessment will be completed by a licensed nurse, with results documented in the medical record. b. Follow up documentation will be completed for a minimum of 72 hours following the incident. The facility course of action prior to surveyor entrance included: LVN A resigned before she was terminated. The previous DON was terminated. Review of in-services on notifying the MD in the event of a fall, change of condition, and ordering x-rays, follow up with needed x-rays and calling for reports and follow up were completed between 9/21/2023-11/30/23. Review of an in-service, dated 9/21/23 related to reporting falls revealed thirteen staff signatures. Further review revealed the in-service was continued on 9/22/23 which revealed fourteen staff signatures. Review of an in-service, dated 9/21/23 related to pain/assessment revealed thirteen staff signatures. Further review revealed the in-service was continued on 9/22/23 which revealed thirteen staff signatures. Review of an in-service, dated 9/22/23 related to fall interventions/documentation revealed thirty-two staff signatures. Further review revealed the in-service was continued on 9/22/23 which revealed eight staff signatures. Review of an in-service, dated 9/22/23 related to falls assisted and unassisted/documentation revealed thirty-two staff signatures. Further review revealed the in-service was continued on 9/22/23 which revealed nine staff signatures. Review of an in-service, dated 9/22/23 related to Abuse, Neglect and Reporting revealed ninety-nine staff signatures. Review of an in-service , dated 10/16/23 related to reporting falls revealed fourty-eight staff signatures. Review of an in-service , dated 11/3/2023 related to falls and pain management revealed twenty-nine staff signatures. Review of an in-service , dated 11/16/2023 related to order xrays, follow up with needed xrays and calling for reports and follow up revealed fourteen staff signatures. Review of an in-service , dated 11/30/23 related to RP and MD notified of COC revealed nineteen staff signatures. Interviews with 27 employees who consisted of LVNs, RNs, MA, and CNAs from 1/23/24 at 10:00 a.m. to 1/25/24 at 10:30 a.m. revealed that had received in-services on fall management, identifying change of conditions to include pain and behavior, who to notify (DON, doctor, and RP), delay in tests, and abuse and neglect. The noncompliance was identified as past noncompliance IJ. The noncompliance began on 9/18/2023 and ended on 11/30/23 when all staff had been in-serviced on fall management, notifying the MD and RP, pain management, and x-ray ordering/follow-up. LVN A resigned and the DON was terminated before surveyor entrance. The facility had corrected the noncompliance before the survey began.

Based on interview and record review, the facility failed to establish and follow a written policy on permitting residents to return to the facility after being hospitalized for 1 of 7 residents (Resident #2) reviewed for transfer/discharge. The facility failed to readmit Resident #2 after an acute care hospital stay resulting in Resident #2 not being permitted to stay in the facility pending placement or appeal. This deficient practice could place residents at risk of being discharged and not allowed to return to the facility causing a disruption in their care and services and potential decline in health. Findings included: Record review of Resident #2's face sheet dated 1/4/24 revealed an [AGE] year old male resident admitted on [DATE] with diagnoses of unspecified cirrhosis of the liver (scarring of the liver interfering with liver function), major depressive disorder (a mental health disorder of persistent depressed mood), and suicidal ideations (thinking about or planning suicide). Record review of Resident #2's MDS completed on 8/20/23 revealed a BIMS score of 11 (a test of mental competency indicating moderate cognitive impairment). Record review of Resident #2's progress notes revealed there was a physician order to send resident to the hospital on 08/30/23 for evaluation due to the resident's suicidal statements with a plan. The resident's progress notes had no entry that the resident would not be allowed to return to the facility after the hospital stay. During an interview with the Administrator and Operations Manager on 1/4/24 at 10:30am the Administrator stated that an interdisciplinary team had met with a decision to not accept the Resident #2's return to the facility from his last hospital stay. The Administrator stated that the resident had made statements about not wanting to stay at the facility, knowing how to hurt other residents due to his military training, and had a stated plan for suicide. The Administrator stated that the team meeting that generated the decision was not documented. During an interview with the hospital social worker on 1/4/24 at 1:15pm stated that the facility staff had communicated that a 72-hour time frame was needed for further hospital treatment before a decision to return the resident to the facility would be made. The Social Worker stated that on 9/6/23 the facility's DON did advise by phone that the resident would not be accepted back to the facility based on his not wanting to live at the facility and his statements of potential harm to others and himself. The Social worker stated that no written documentation was provided from the facility regarding the decision to not accept the resident back to the nursing facility. During an interview with the Administrator on 1/4/24 at 3:40pm he stated that the facility did not send a written notice to the hospital regarding the return decision. He stated that since the resident was a skilled resident with coverage days remaining, he felt the hospital would be able to place the resident in another nursing facility. During an interview with the DON and Admissions Director on 1/4/24 at 4:25pm, the DON stated that her understanding was that the facility wound not send a discharge notice to a resident who was in the hospital and who was not being returned to the facility after the hospital stay. Record review of the facility's policy entitled Admission, Transfer, and Discharge which was revised on 11/2016 reflected that a copy of the resident's discharge summary and any other documentation to ensure a safe and effective transition of care was to be given to the receiving provider. .

Based on interview and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, which were complete and accurate for two of five residents (Residents #1 and #2) reviewed for accuracy of records, in that: 1. Resident #1's physician orders for [DATE] had both full code and DNR listed as the resident's code status. 2. Resident #2's consent for the anti-depressant medication Sertraline was placed in Resident #1's EMR. These failures could place residents at risk of not having accurate medical records and could create confusion in services provided or needed to be provided. The findings included: 1. Closed record review of Resident #1's face sheet, accessed on [DATE], and EMR revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: Quadriplegia (a symptom of paralysis that affects all a person's limbs and body from the neck down), pneumocystosis (fungal infection that causes cough, difficulty breathing and fever, and can lead to respiratory failure), and a Stage 3 pressure ulcer (a deep wound that affects the top two layers of skin, as well as fatty tissue). Closed record review of Resident #1's hospital discharge summary dated [DATE] revealed his BIMS was 15, indicating he was cognitively intact. Closed record review of Resident #1's Care Plan, reviewed on [DATE], revealed no code status was listed as a focus area. Closed record review of Resident #1's admission packet revealed a document entitled Advance Directive Acknowledgement dated [DATE]. The document stated: Please circle the items that apply and listed the options DNR, Directive to Physician and Medical Power of Attorney. None of these options were circled. There was an X in the box next to the statement: Upon my admission, I do not have an Advance Directive. I have been provided information about Advance Directives, if requested, and have had the opportunity to ask questions about Advance Directives. I understand that I may execute these documents at any time so that my health decisions will be followed should I become incapacitated. I can contact the facility Social Worker to assist with these documents. The document was signed by Resident #1 on [DATE] and a facility representative. Closed record review of Resident #1's physician orders revealed under the following order: DNR. The order was confirmed on [DATE], signed by Resident #1's physician on [DATE], and under End was the word Indefinite. The order was confirmed by LVN A. There was also an order for Full Code: Use AED (Automated External Defibrillator) with CPR during sudden cardiac arrest signed by Resident #1's physician on [DATE] with an end date of [DATE]. The order was confirmed by ADON B. During an interview on [DATE] at 11:30 a.m. with the DON she stated that the DNR order was an error. LVN A, who admitted Resident #1 on [DATE], saw a document from another state that the resident had signed prior to his admission. This document was not an Out Of Hospital Do Not Resuscitate form. It was entitled Orders For Life-Sustaining Treatment and not valid documentation for a DNR order. In addition, LVN A had put the order in the wrong category when completing the resident's orders in the EMR. She put the order in the other category instead of the area specifically designated for the resident's code status. As a result, when a nurse reviews the resident's orders, they do not see this order. The DON further stated she contacted LVN A when the error was discovered but LVN A returned the call on [DATE]; she was given an inservice over the phone at this time. The DON stated she understood the confusion having two different code status in a resident's orders could cause and the potential life-threatening repercussions of this error. Interview on [DATE] at 5:04 p.m. with ADON B revealed he was off for a few days and when he returned on [DATE], he reviewed the EMRs for all the new admissions as he always did. ADON B discovered that Resident #1 did not have code status in his EMR, so he put a full code status in the resident's orders. ADON B further stated he spoke with Resident #1, who was alert and oriented, and confirmed with the resident that he desired to be a full code and he knew the paperwork he had brought with him from another state was temporary. The ADON stated he did not see the DNR order in Resident #1's orders. During an interview on [DATE] at 1:20 p.m. with the Administrator he acknowledged Resident #1's orders listed both full code and also DNR and this was an error; when it was discovered Resident #1's desired code status was a full code, the DNR code status should have been removed from Resident #1's orders so there was no confusion regarding the correct code status. 2. Record review of Resident #2's face sheet, accessed on [DATE], revealed an [AGE] year old male admitted to the facility on [DATE] with diagnoses including: Acute kidney failure (a condition when an abrupt reduction in kidneys' ability to filter waste products occurs within a few hours or a few days), Type II diabetes (a condition results from insufficient production of insulin, causing high blood sugar, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #2's EMR revealed Resident #2's BIMS was 13, indicating the resident was cognitively intact. Record review of Resident #2's care plan, accessed on [DATE], revealed the following: Focus - Resident #2 is taking Sertraline related to depression. Date initiated: [DATE]. Record review of Resident #2's physician orders revealed an order for: Sertraline HCL Tablet 25 mg - Give 1 tablet by mouth one time a day for depression. The order was dated [DATE] and started [DATE]. Record review of Resident #2's MAR for the month of [DATE] revealed Resident #2 was administered Sertraline as ordered daily from [DATE] - [DATE] except for [DATE] when he was absent from the facility. Record review of Resident #2's EMR revealed a progress note signed by LVN C indicating Resident #2 was taking Sertraline 25 mg for depression, the consent was in place, and the resident was being seen by Psych services. Record review of the Misc. section of Resident #2's EMR indicated there was no consent form for Sertraline. Closed record review of the Misc. section of Resident #1's EMR revealed a form entitled, Psychoactive Medication Therapy Informed Consent Form. The name listed on the form was Resident #2's name. The medication listed was Sertraline for the diagnosis of depression. The form indicated that Resident #2 had given verbal consent for this medication on [DATE]. During an interview on [DATE] at 3:20 p.m. with the Administrator and DON they both acknowledged that Resident #2's consent for the medication Sertraline was improperly placed in Resident #1's EMR, it was done in error, and could result in confusion regarding whether an appropriate consent was in place for Resident #2 to receive a psychoactive medication. During an interview on [DATE] at 3:30 p.m. with the Medical Records Clerk, she stated she uploaded Resident #2's consent for Sertraline in Resident #1's EMR in error. She stated she sometimes receives stacks of consents to upload in residents' medical records and probably had the EMRs of both Resident #1 and Resident #2 open. The Medical Records Clerk claimed she was trained by the medical records clerk of a sister facility and she can always contact her if she has questions. Record review of facility policy Medical Record, Content of revised ,d+[DATE] revealed, Policy: It is the policy of this facility that a separate medical record shall be maintained for each resident admitted to the facility and the resident's name will be placed on all medical record forms. All physicians, nursing staff and other health care professionals involved in the resident's care will be responsible for making prompt, appropriate entries in the record. Procedures: 4. Consents/Authorizations/Acknowledgements. Appropriate consent forms, authorizations and acknowledgements signed by the resident or legal representative and entered in the medical record .these include, but are not limited to, the following: Consents for care and treatment, consent for generic drug use, acknowledgement of receipt of advance directive information. 6. List of contents of the medical record: Consent forms (not included in the admission consent); advance directive acknowledgement. Record review of facility policy Advance Directives revised ,d+[DATE] revealed, Policy: It is the policy of this facility that a resident's choice about advance directives will be respected. Procedures: 5. If advance directive documents were developed in another state, the resident must have such documents reviewed and revised by legal counsel in this state before the facility may honor such directives.

Based on interview and record review the facility failed to implement their policies and procedures to prohibit neglect for 1 of 4 residents reviewed for neglect (Resident #4). Resident #4 was administered [MEDICATION NAME] (blood thinner) 4.5 mg without physician ordered INR (to test the effectiveness of the blood thinner [MEDICATION NAME]) laboratory monitoring for a 19 day period when INR's could have been monitored, resulting in above therapeutic INR level of greater than 10. Resident #4 was admitted to the hospital and diagnosed with [REDACTED]. This was determined to be past non-compliance due to the facility's implementation of actions that corrected the non-compliance prior to the current survey. The facility was out of compliance from 3/30/15 through 4/20/15. The facility's corrected action was completed on 4/20/15. The deficient practice resulted in Resident #4's above therapeutic INR blood levels resulting in a subdural hematoma and could have contributed to her death and could affect 2 residents in the facility that were prescribed [MEDICATION NAME] and required INR monitoring, placing them at risk for uncontrolled bleeding and death. Findings were: Review of a face sheet revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of change in condition MDS, dated [DATE], revealed cognition score of 15 which indicated Resident #4 was alert and oriented with no cognitive deficits. Review of the physical function section of the MDS revealed Resident #4 required limited to extensive assistance with activities of daily living. Review of a physician's order, dated 9/26/15, revealed an order for [REDACTED]. Review of physician's order, dated 10/1/14, revealed and an order to add PT/INR to Monday am labs with CBC Q Monday. Review of Mosby's Diagnostic and Laboratory Test Reference, sixth edition, page 731, Table 17, revealed when monitoring [MEDICATION NAME] preferred INR for [MEDICAL CONDITION] was 1.5 - 2.0 and 2.0 - 3.0 for treatment of [REDACTED]. Review of Resident #4's physician's consolidated orders, dated 3/1/15 - 3/31/15, revealed an order for [REDACTED]. Review of Resident #4's physician's order dated 3/19/15 revealed an order to hold [MEDICATION NAME] and check INR in AM. Review of lab report revealed Resident #4's INR on 3/20/15 was 5.0 and a handwritten note on the lab report indicated Held [MEDICATION NAME] 2.5 mg yesterday C/O INR 4.8. Review of physician's order, dated 3/20/15, revealed an order to hold [MEDICATION NAME] and INR in AM. Review of lab report, dated 3/21/15, revealed INR of 3.5. Review of Physician's order, dated 3/21/13, revealed an order to continue to hold [MEDICATION NAME] and INR on 3/23/15. Review of lab report dated 3/23/15 revealed INR of 1.6 with a hand written note, on [MEDICATION NAME] 4 mg since 3/19/15. Also written on the lab was an order to increase [MEDICATION NAME] to 4.5 mg every night. Review of physician's order, dated 3/23/15, revealed an order D/C [MEDICATION NAME] 4 Mg Start [MEDICATION NAME] 4.5 mg po qd written by LVN B. Review of Resident #4's physician's orders from 3/23/15 through 4/12/15 revealed no change in the dose of [MEDICATION NAME]. Review of Resident #4's physician's consolidated orders for 4/1/15 - 4/30/2015 revealed an order for [REDACTED]. Review of laboratory results for 3/23/15 through 4/12/15 revealed no INR levels were requested or monitored. INR labs ordered for 3/30/15, 4/1/15, 4/3/15, 4/6/15, 4/8/15 and 4/10/15 were not drawn or completed. Review of the March 2015 MARS revealed Resident #4 was administered [MEDICATION NAME] 4.5 mg from March 23-31, 2015. Review of the 4/15 MARS revealed Resident #4 was administered [MEDICATION NAME] 4.5 mg from April 1-11, 2015. Review of a document titled, SBAR Communication Form and Progress Note, dated 4/12/15, documented by LVN A, revealed Resident #4 was alert to verbal stimuli, unable to respond appropriately, bleeding from mouth and was found with dry blood around lips. The form indicated Resident #4 was sent to a local hospital for evaluation. Review of a hospital history and physical, dated 4/12/15, revealed Resident #4 was admitted to the local hospital for altered mental status. Review of the hospital CAT scan, dated 4/12/15, revealed a [DIAGNOSES REDACTED]. Review of the hospital laboratory results, dated 4/12/15 revealed an INR, greater than 10. Nurse's notes dated 4/15/15 indicated Resident #4 was readmitted to the facility unresponsive and was under the care of a Hospice agency. Nurse's notes dated 4/20/15 revealed Resident #4's respirations and pulse stopped at 2200 and was pronounced by Hospice RN. Review of physician's history and physical, dated 4/16/15, revealed Resident #4 as readmitted from the hospital. Resident #4 was found unresponsive on 4/12/15 by facility nurse and transferred to emergency room . CT of the head revealed acute left subdural hematoma with midline shift. The INR was > 10. Resident #4 was intubated by physician and administered fresh frozen plasma for coagulopathy (impairment of the bloods ability to clot). Family did not want to pursue aggressive measures. Resident #4 returned to the facility on Hospice. General exam conducted by the physician revealed Resident #4 was unresponsive to sternal rub. During an interview on 4/24/15 at 2:50 pm with the Executive Director (ED)and the Administrator they confirmed Resident #4 was administered [MEDICATION NAME] 4.5 mg and there were no INR lab monitoring for Resident #4 from 3/23/15 - 4/12/15. The ED stated the INR's for Resident #4 were not completed as prescribed by the physician. During an interview on 4/24/15 at 6:15 pm, with LVN F, he stated when he wrote an order for [REDACTED]. During an interview on 4/24/15 at 6:25 pm, with the Laboratory Company phlebotomist, responsible for obtaining the facility's physician ordered lab, he stated he did not receive any requisition/orders for Resident #4's INR levels to be drawn between the period of 3/23/15 - 4/12/15. During an interview with the Interim DON, RN E, on 4/27/15 at 2:36 she stated she would be monitoring the [MEDICATION NAME] flow sheets daily and had conducted training with the facility nurse's on the monitoring of [MEDICATION NAME] and the flow sheet. During an interview with RN E on 4/27/15 at 3:07 pm she stated all regular facility staff have had training on use of the [MEDICATION NAME] and INR flow sheet and the facility would not allow any nurse to provide care to the residents until the nurse received the training. During an interview with the Administrator on 4/27/15 at 3:10 pm he stated RN E would be monitoring the [MEDICATION NAME] flow sheets daily. Review of the facility policy for anticoagulation -Clinical protocol, (Nursing Services Policy and Procedure - 2005 Medpass revised April 2013), revealed the physician would order appropriate lab testing to monitor anticoagulation therapy and staff should use a [MEDICATION NAME] flow sheet or comparable monitoring tool to follow trends in anticoagulation dosages and response. The facility's Success Plan included: 1. Incident on Resident #4 4/12/15 transferred to hospital approximately 11:00 am 2. Investigation began 4/13/15. 3. Suspended LVN A pending investigation 4/13/15 4. Initiated identification of resident who receive anticoagulation therapy prior to lab audit. 5 Lab audit complete 4/20/15 7. Audit for HMP and progress notes on 4/17/15 8. Weekly audits of lab orders initiated on April 17, 2015 9. Educated staff on 4/13/15 on local pharmacy ordering protocol. Ongoing 10. Educated staff on 4/14/15 on new admission orders [REDACTED] 11. Educated staff on 4/17/15 on lab/radiology follow-up. Ongoing 12. Educated licensed staff from 4/15/15 on PT/INR flow sheet. Ongoing 13. Terminated LVN C on 4/9/15 and referral of license Texas Board of Nursing 4/22/15. 14. Terminated LVN B on 4/16/15 and referral of license Texas Board of Nursing 4/22/15. 15. Terminated LVN A on 4/24/15 by phone and referral of license Texas Board of Nursing 4/22/15. 16. Resignation of Director of Nursing RN D effective 4/16/15 17. Corrective action for RN E effective 4/27/15. 18. Educated IDT on Quality of Care Meeting and held on 4/22/15. Ongoing 19. New admissions/Readmissions/Change in condition are reviewed in morning meeting 20. Will review at QAPI. Ongoing Review of the facility policy for abuse and neglect, dated 4/1/2011, indicated the facility definition of neglect was the failure of a caregiver or fiduciary to provide the goods or services that are necessary to maintain the health and safety of an elder. Review of the facility policy for anticoagulation -Clinical protocol, (Nursing Services Policy and Procedure - 2005 Medpass revised April 2013), revealed the physician would order appropriate lab testing to monitor anticoagulation therapy and staff should use a [MEDICATION NAME] flow sheet or comparable monitoring tool to follow trends in anticoagulation dosages and response. Review of facility documentation revealed a resident lab audit was completed on 4/20/15 and staff training on [MEDICATION NAME] & PT/INR flow sheet which was conducted on 4/17/15. Review of a list provided by the facility revealed 2 current residents were prescribed [MEDICATION NAME].

Based on interview and record review the facility failed to implement their written policies and procedures to prohibit neglect for 1 of 4 residents reviewed for neglect (Resident #4). Resident #4 was administered [MEDICATION NAME] (blood thinner) 4.5 mg without physician ordered INR (to test the effectiveness of the blood thinner [MEDICATION NAME]) laboratory monitoring for a 19 day period when INR's could have been monitored, resulting in above therapeutic INR level of greater than 10. Resident #4 was admitted to the hospital and diagnosed with [REDACTED]. This was determined to be past non-compliance due to the facility's implementation of actions that corrected the non-compliance prior to the current survey. The facility was out of compliance from 3/30/15 through 4/20/15. The facility's corrected action was completed on 4/20/15. The deficient practice resulted in Resident #4's above therapeutic INR blood levels resulting in a subdural hematoma and could have contributed to her death and could affect 2 residents in the facility that were prescribed [MEDICATION NAME] and required INR monitoring, placing them at risk for uncontrolled bleeding and death. Findings were: Review of the facility policy for abuse and neglect, dated 4/1/2011, indicated the facility definition of neglect was the failure of a caregiver or fiduciary to provide the goods or services that are necessary to maintain the health and safety of an elder. Review of the facility policy for anticoagulation -Clinical protocol, (Nursing Services Policy and Procedure - 2005 Medpass revised April 2013), revealed the physician would order appropriate lab testing to monitor anticoagulation therapy and staff should use a [MEDICATION NAME] flow sheet or comparable monitoring tool to follow trends in anticoagulation dosages and response. Review of a face sheet revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of change in condition MDS, dated [DATE], revealed cognition score of 15 which indicated Resident #4 was alert and oriented with no cognitive deficits. Review of the physical function section of the MDS revealed Resident #4 required limited to extensive assistance with activities of daily living. Review of a physician's order, dated 9/26/15, revealed an order for [REDACTED]. Review of physician's order, dated 10/1/14, revealed and an order to add PT/INR to Monday am labs with CBC Q Monday. Review of Mosby's Diagnostic and Laboratory Test Reference, sixth edition, page 731, Table 17, revealed when monitoring [MEDICATION NAME] preferred INR for [MEDICAL CONDITION] was 1.5 - 2.0 and 2.0 - 3.0 for treatment of [REDACTED]. Review of Resident #4's physician's consolidated orders, dated 3/1/15 - 3/31/15, revealed an order for [REDACTED]. Review of Resident #4's physician's order dated 3/19/15 revealed an order to hold [MEDICATION NAME] and check INR in AM. Review of lab report revealed Resident #4's INR on 3/20/15 was 5.0 and a handwritten note on the lab report indicated Held [MEDICATION NAME] 2.5 mg yesterday C/O INR 4.8. Review of physician's order, dated 3/20/15, revealed an order to hold [MEDICATION NAME] and INR in AM. Review of lab report, dated 3/21/15, revealed INR of 3.5. Review of Physician's order, dated 3/21/13, revealed an order to continue to hold [MEDICATION NAME] and INR on 3/23/15. Review of lab report dated 3/23/15 revealed INR of 1.6 with a hand written note, on [MEDICATION NAME] 4 mg since 3/19/15. Also written on the lab was an order to increase [MEDICATION NAME] to 4.5 mg every night. Review of physician's order, dated 3/23/15, revealed an order D/C [MEDICATION NAME] 4 Mg Start [MEDICATION NAME] 4.5 mg po qd written by LVN B. Review of Resident #4's physician's orders from 3/23/15 through 4/12/15 revealed no change in the dose of [MEDICATION NAME]. Review of Resident #4's physician's consolidated orders for 4/1/15 - 4/30/2015 revealed an order for [REDACTED]. Review of laboratory results for 3/23/15 through 4/12/15 revealed no INR levels were requested or monitored. INR labs ordered for 3/30/15, 4/1/15, 4/3/15, 4/6/15, 4/8/15 and 4/10/15 were not drawn or completed. Review of the March 2015 MARS revealed Resident #4 was administered [MEDICATION NAME] 4.5 mg from March 23-31, 2015. Review of the 4/15 MARS revealed Resident #4 was administered [MEDICATION NAME] 4.5 mg from April 1-11, 2015. Review of a document titled, SBAR Communication Form and Progress Note, dated 4/12/15, documented by LVN A, revealed Resident #4 was alert to verbal stimuli, unable to respond appropriately, bleeding from mouth and was found with dry blood around lips. The form indicated Resident #4 was sent to a local hospital for evaluation. Review of a hospital history and physical, dated 4/12/15, revealed Resident #4 was admitted to the local hospital for altered mental status. Review of the hospital CAT scan, dated 4/12/15, revealed a [DIAGNOSES REDACTED]. Review of the hospital laboratory results, dated 4/12/15 revealed an INR, greater than 10. Nurse's notes dated 4/15/15 indicated Resident #4 was readmitted to the facility unresponsive and was under the care of a Hospice agency. Nurse's notes dated 4/20/15 revealed Resident #4's respirations and pulse stopped at 2200 and was pronounced by Hospice RN. Review of physician's history and physical, dated 4/16/15, revealed Resident #4 as readmitted from the hospital. Resident #4 was found unresponsive on 4/12/15 by facility nurse and transferred to emergency room . CT of the head revealed acute left subdural hematoma with midline shift. The INR was > 10. Resident #4 was intubated by physician and administered fresh frozen plasma for coagulopathy (impairment of the bloods ability to clot). Family did not want to pursue aggressive measures. Resident #4 returned to the facility on Hospice. General exam conducted by the physician revealed Resident #4 was unresponsive to sternal rub. During an interview on 4/24/15 at 2:50 pm with the Executive Director (ED)and the Administrator they confirmed Resident #4 was administered [MEDICATION NAME] 4.5 mg and there were no INR lab monitoring for Resident #4 from 3/23/15 - 4/12/15. The ED stated the INR's for Resident #4 were not completed as prescribed by the physician. During an interview on 4/24/15 at 6:15 pm, with LVN F, he stated when he wrote an order for [REDACTED]. During an interview on 4/24/15 at 6:25 pm, with the Laboratory Company phlebotomist, responsible for obtaining the facility's physician ordered lab, he stated he did not receive any requisition/orders for Resident #4's INR levels to be drawn between the period of 3/23/15 - 4/12/15. During an interview with the Interim DON, RN E, on 4/27/15 at 2:36 she stated she would be monitoring the [MEDICATION NAME] flow sheets daily and had conducted training with the facility nurse's on the monitoring of [MEDICATION NAME] and the flow sheet. During an interview with RN E on 4/27/15 at 3:07 pm she stated all regular facility staff have had training on use of the [MEDICATION NAME] and INR flow sheet and the facility would not allow any nurse to provide care to the residents until the nurse received the training. During an interview with the Administrator on 4/27/15 at 3:10 pm he stated RN E would be monitoring the [MEDICATION NAME] flow sheets daily. The facility's Success Plan included: 1. Incident on Resident #4 4/12/15 transferred to hospital approximately 11:00 am 2. Investigation began 4/13/15. 3. Suspended LVN A pending investigation 4/13/15 4. Initiated identification of resident who receive anticoagulation therapy prior to lab audit. 5 Lab audit complete 4/20/15 7. Audit for HMP and progress notes on 4/17/15 8. Weekly audits of lab orders initiated on April 17, 2015 9. Educated staff on 4/13/15 on local pharmacy ordering protocol. Ongoing 10. Educated staff on 4/14/15 on new admission orders [REDACTED] 11. Educated staff on 4/17/15 on lab/radiology follow-up. Ongoing 12. Educated licensed staff from 4/15/15 on PT/INR flow sheet. Ongoing 13. Terminated LVN C on 4/9/15 and referral of license Texas Board of Nursing 4/22/15. 14. Terminated LVN B on 4/16/15 and referral of license Texas Board of Nursing 4/22/15. 15. Terminated LVN A on 4/24/15 by phone and referral of license Texas Board of Nursing 4/22/15. 16. Resignation of Director of Nursing RN D effective 4/16/15 17. Corrective action for RN E effective 4/27/15. 18. Educated IDT on Quality of Care Meeting and held on 4/22/15. Ongoing 19. New admissions/Readmissions/Change in condition are reviewed in morning meeting 20. Will review at QAPI. Ongoing Review of facility documentation revealed a resident lab audit was completed on 4/20/15 and staff training on [MEDICATION NAME] & PT/INR flow sheet which was conducted on 4/17/15. Review of a list provided by the facility revealed 2 current residents were prescribed [MEDICATION NAME].

Based on interview and record review the facility failed to ensure for 1 of 4 residents drug regimen ([MEDICATION NAME]) was adequately monitored to prevent adverse consequences. (Resident #4). Resident #4 was administered [MEDICATION NAME] (blood thinner) 4.5 mg without physician ordered INR (to test the effectiveness of the blood thinner [MEDICATION NAME]) laboratory monitoring for a 19 day period when INR's could have been monitored, resulting in above therapeutic INR level of greater than 10. Resident #4 was admitted to the hospital and diagnosed with [REDACTED]. This was determined to be past non-compliance due to the facility's implementation of actions that corrected the non-compliance prior to the current survey. The facility was out of compliance from 3/30/15 through 4/20/15. The facility's corrected action was completed on 4/20/15. The deficient practice resulted in Resident #4's above therapeutic INR blood levels resulting in a subdural hematoma and could have contributed to her death and could affect 2 residents in the facility that were prescribed [MEDICATION NAME] and required INR monitoring, placing them at risk for uncontrolled bleeding and death. Findings were: Review of a face sheet revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of change in condition MDS, dated [DATE], revealed cognition score of 15 which indicated Resident #4 was alert and oriented with no cognitive deficits. Review of the physical function section of the MDS revealed Resident #4 required limited to extensive assistance with activities of daily living. Review of a physician's order, dated 9/26/15, revealed an order for [REDACTED]. Review of physician's order, dated 10/1/14, revealed and an order to add PT/INR to Monday am labs with CBC Q Monday. Review of Mosby's Diagnostic and Laboratory Test Reference, sixth edition, page 731, Table 17, revealed when monitoring [MEDICATION NAME] preferred INR for [MEDICAL CONDITION] was 1.5 - 2.0 and 2.0 - 3.0 for treatment of [REDACTED]. Review of Resident #4's physician's consolidated orders, dated 3/1/15 - 3/31/15, revealed an order for [REDACTED]. Review of Resident #4's physician's order dated 3/19/15 revealed an order to hold [MEDICATION NAME] and check INR in AM. Review of lab report revealed Resident #4's INR on 3/20/15 was 5.0 and a handwritten note on the lab report indicated Held [MEDICATION NAME] 2.5 mg yesterday C/O INR 4.8. Review of physician's order, dated 3/20/15, revealed an order to hold [MEDICATION NAME] and INR in AM. Review of lab report, dated 3/21/15, revealed INR of 3.5. Review of Physician's order, dated 3/21/13, revealed an order to continue to hold [MEDICATION NAME] and INR on 3/23/15. Review of lab report dated 3/23/15 revealed INR of 1.6 with a hand written note, on [MEDICATION NAME] 4 mg since 3/19/15. Also written on the lab was an order to increase [MEDICATION NAME] to 4.5 mg every night. Review of physician's order, dated 3/23/15, revealed an order D/C [MEDICATION NAME] 4 Mg Start [MEDICATION NAME] 4.5 mg po qd written by LVN B. Review of Resident #4's physician's orders from 3/23/15 through 4/12/15 revealed no change in the dose of [MEDICATION NAME]. Review of Resident #4's physician's consolidated orders for 4/1/15 - 4/30/2015 revealed an order for [REDACTED]. Review of laboratory results for 3/23/15 through 4/12/15 revealed no INR levels were requested or monitored. INR labs ordered for 3/30/15, 4/1/15, 4/3/15, 4/6/15, 4/8/15 and 4/10/15 were not drawn or completed. Review of the March 2015 MARS revealed Resident #4 was administered [MEDICATION NAME] 4.5 mg from March 23-31, 2015. Review of the 4/15 MARS revealed Resident #4 was administered [MEDICATION NAME] 4.5 mg from April 1-11, 2015. Review of a document titled, SBAR Communication Form and Progress Note, dated 4/12/15, documented by LVN A, revealed Resident #4 was alert to verbal stimuli, unable to respond appropriately, bleeding from mouth and was found with dry blood around lips. The form indicated Resident #4 was sent to a local hospital for evaluation. Review of a hospital history and physical, dated 4/12/15, revealed Resident #4 was admitted to the local hospital for altered mental status. Review of the hospital CAT scan, dated 4/12/15, revealed a [DIAGNOSES REDACTED]. Review of the hospital laboratory results, dated 4/12/15 revealed an INR, greater than 10. Nurse's notes dated 4/15/15 indicated Resident #4 was readmitted to the facility unresponsive and was under the care of a Hospice agency. Nurse's notes dated 4/20/15 revealed Resident #4's respirations and pulse stopped at 2200 and was pronounced by Hospice RN. Review of physician's history and physical, dated 4/16/15, revealed Resident #4 as readmitted from the hospital. Resident #4 was found unresponsive on 4/12/15 by facility nurse and transferred to emergency room . CT of the head revealed acute left subdural hematoma with midline shift. The INR was > 10. Resident #4 was intubated by physician and administered fresh frozen plasma for coagulopathy (impairment of the bloods ability to clot). Family did not want to pursue aggressive measures. Resident #4 returned to the facility on Hospice. General exam conducted by the physician revealed Resident #4 was unresponsive to sternal rub. During an interview on 4/24/15 at 2:50 pm with the Executive Director (ED)and the Administrator they confirmed Resident #4 was administered [MEDICATION NAME] 4.5 mg and there were no INR lab monitoring for Resident #4 from 3/23/15 - 4/12/15. The ED stated the INR's for Resident #4 were not completed as prescribed by the physician. During an interview on 4/24/15 at 6:15 pm, with LVN F, he stated when he wrote an order for [REDACTED]. During an interview on 4/24/15 at 6:25 pm, with the Laboratory Company phlebotomist, responsible for obtaining the facility's physician ordered lab, he stated he did not receive any requisition/orders for Resident #4's INR levels to be drawn between the period of 3/23/15 - 4/12/15. During an interview with the Interim DON, RN E, on 4/27/15 at 2:36 she stated she would be monitoring the [MEDICATION NAME] flow sheets daily and had conducted training with the facility nurse's on the monitoring of [MEDICATION NAME] and the flow sheet. During an interview with RN E on 4/27/15 at 3:07 pm she stated all regular facility staff have had training on use of the [MEDICATION NAME] and INR flow sheet and the facility would not allow any nurse to provide care to the residents until the nurse received the training. During an interview with the Administrator on 4/27/15 at 3:10 pm he stated RN E would be monitoring the [MEDICATION NAME] flow sheets daily. Review of the facility policy for anticoagulation -Clinical protocol, (Nursing Services Policy and Procedure - 2005 Medpass revised April 2013), revealed the physician would order appropriate lab testing to monitor anticoagulation therapy and staff should use a [MEDICATION NAME] flow sheet or comparable monitoring tool to follow trends in anticoagulation dosages and response. The facility's Success Plan included: 1. Incident on Resident #4 4/12/15 transferred to hospital approximately 11:00 am 2. Investigation began 4/13/15. 3. Suspended LVN A pending investigation 4/13/15 4. Initiated identification of resident who receive anticoagulation therapy prior to lab audit. 5 Lab audit complete 4/20/15 7. Audit for HMP and progress notes on 4/17/15 8. Weekly audits of lab orders initiated on April 17, 2015 9. Educated staff on 4/13/15 on local pharmacy ordering protocol. Ongoing 10. Educated staff on 4/14/15 on new admission orders [REDACTED] 11. Educated staff on 4/17/15 on lab/radiology follow-up. Ongoing 12. Educated licensed staff from 4/15/15 on PT/INR flow sheet. Ongoing 13. Terminated LVN C on 4/9/15 and referral of license Texas Board of Nursing 4/22/15. 14. Terminated LVN B on 4/16/15 and referral of license Texas Board of Nursing 4/22/15. 15. Terminated LVN A on 4/24/15 by phone and referral of license Texas Board of Nursing 4/22/15. 16. Resignation of Director of Nursing RN D effective 4/16/15 17. Corrective action for RN E effective 4/27/15. 18. Educated IDT on Quality of Care Meeting and held on 4/22/15. Ongoing 19. New admissions/Readmissions/Change in condition are reviewed in morning meeting 20. Will review at QAPI. Ongoing Review of facility documentation revealed a resident lab audit was completed on 4/20/15 and staff training on [MEDICATION NAME] & PT/INR flow sheet which was conducted on 4/17/15. Review of a list provided by the facility revealed 2 current residents were prescribed [MEDICATION NAME].

Based on interview and record review the facility failed to ensure laboratory services were accurate and timely for 1 of 4 residents reviewed for physician ordered lab monitoring. (Resident #4). The facility failed to provide laboratory monitoring that was necessary to maintain the health and safety of Resident #4. Resident #4 was administered [MEDICATION NAME] (blood thinner) 4.5 mg without physician ordered INR (to test the effectiveness of the blood thinner [MEDICATION NAME]) laboratory monitoring for a 19 day period when INR's could have been monitored, resulting in above therapeutic INR level of greater than 10. Resident #4 was admitted to the hospital and diagnosed with [REDACTED]. This was determined to be past non-compliance due to the facility's implementation of actions that corrected the non-compliance prior to the current survey. The facility was out of compliance from 3/30/15 through 4/20/15. The facility's corrected action was completed on 4/20/15. The deficient practice resulted in Resident #4's above therapeutic INR blood levels resulting in a subdural hematoma and could have contributed to her death and could affect 2 residents in the facility that were prescribed [MEDICATION NAME] and required INR monitoring, placing them at risk for uncontrolled bleeding and death. Findings were: Review of a face sheet revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of change in condition MDS, dated [DATE], revealed cognition score of 15 which indicated Resident #4 was alert and oriented with no cognitive deficits. Review of the physical function section of the MDS revealed Resident #4 required limited to extensive assistance with activities of daily living. Review of a physician's order, dated 9/26/15, revealed an order for [REDACTED]. Review of physician's order, dated 10/1/14, revealed and an order to add PT/INR to Monday am labs with CBC Q Monday. Review of Mosby's Diagnostic and Laboratory Test Reference, sixth edition, page 731, Table 17, revealed when monitoring [MEDICATION NAME] preferred INR for [MEDICAL CONDITION] was 1.5 - 2.0 and 2.0 - 3.0 for treatment of [REDACTED]. Review of Resident #4's physician's consolidated orders, dated 3/1/15 - 3/31/15, revealed an order for [REDACTED]. Review of Resident #4's physician's order dated 3/19/15 revealed an order to hold [MEDICATION NAME] and check INR in AM. Review of lab report revealed Resident #4's INR on 3/20/15 was 5.0 and a handwritten note on the lab report indicated Held [MEDICATION NAME] 2.5 mg yesterday C/O INR 4.8. Review of physician's order, dated 3/20/15, revealed an order to hold [MEDICATION NAME] and INR in AM. Review of lab report, dated 3/21/15, revealed INR of 3.5. Review of Physician's order, dated 3/21/13, revealed an order to continue to hold [MEDICATION NAME] and INR on 3/23/15. Review of lab report dated 3/23/15 revealed INR of 1.6 with a hand written note, on [MEDICATION NAME] 4 mg since 3/19/15. Also written on the lab was an order to increase [MEDICATION NAME] to 4.5 mg every night. Review of physician's order, dated 3/23/15, revealed an order D/C [MEDICATION NAME] 4 Mg Start [MEDICATION NAME] 4.5 mg po qd written by LVN B. Review of Resident #4's physician's orders from 3/23/15 through 4/12/15 revealed no change in the dose of [MEDICATION NAME]. Review of Resident #4's physician's consolidated orders for 4/1/15 - 4/30/2015 revealed an order for [REDACTED]. Review of laboratory results for 3/23/15 through 4/12/15 revealed no INR levels were requested or monitored. INR labs ordered for 3/30/15, 4/1/15, 4/3/15, 4/6/15, 4/8/15 and 4/10/15 were not drawn or completed. Review of the March 2015 MARS revealed Resident #4 was administered [MEDICATION NAME] 4.5 mg from March 23-31, 2015. Review of the 4/15 MARS revealed Resident #4 was administered [MEDICATION NAME] 4.5 mg from April 1-11, 2015. Review of a document titled, SBAR Communication Form and Progress Note, dated 4/12/15, documented by LVN A, revealed Resident #4 was alert to verbal stimuli, unable to respond appropriately, bleeding from mouth and was found with dry blood around lips. The form indicated Resident #4 was sent to a local hospital for evaluation. Review of a hospital history and physical, dated 4/12/15, revealed Resident #4 was admitted to the local hospital for altered mental status. Review of the hospital CAT scan, dated 4/12/15, revealed a [DIAGNOSES REDACTED]. Review of the hospital laboratory results, dated 4/12/15 revealed an INR, greater than 10. Nurse's notes dated 4/15/15 indicated Resident #4 was readmitted to the facility unresponsive and was under the care of a Hospice agency. Nurse's notes dated 4/20/15 revealed Resident #4's respirations and pulse stopped at 2200 and was pronounced by Hospice RN. Review of physician's history and physical, dated 4/16/15, revealed Resident #4 as readmitted from the hospital. Resident #4 was found unresponsive on 4/12/15 by facility nurse and transferred to emergency room . CT of the head revealed acute left subdural hematoma with midline shift. The INR was > 10. Resident #4 was intubated by physician and administered fresh frozen plasma for coagulopathy (impairment of the bloods ability to clot). Family did not want to pursue aggressive measures. Resident #4 returned to the facility on Hospice. General exam conducted by the physician revealed Resident #4 was unresponsive to sternal rub. During an interview on 4/24/15 at 2:50 pm with the Executive Director (ED)and the Administrator they confirmed Resident #4 was administered [MEDICATION NAME] 4.5 mg and there were no INR lab monitoring for Resident #4 from 3/23/15 - 4/12/15. The ED stated the INR's for Resident #4 were not completed as prescribed by the physician. During an interview on 4/24/15 at 6:15 pm, with LVN F, he stated when he wrote an order for [REDACTED]. During an interview on 4/24/15 at 6:25 pm, with the Laboratory Company phlebotomist, responsible for obtaining the facility's physician ordered lab, he stated he did not receive any requisition/orders for Resident #4's INR levels to be drawn between the period of 3/23/15 - 4/12/15. During an interview with the Interim DON, RN E, on 4/27/15 at 2:36 she stated she would be monitoring the [MEDICATION NAME] flow sheets daily and had conducted training with the facility nurse's on the monitoring of [MEDICATION NAME] and the flow sheet. During an interview with RN E on 4/27/15 at 3:07 pm she stated all regular facility staff have had training on use of the [MEDICATION NAME] and INR flow sheet and the facility would not allow any nurse to provide care to the residents until the nurse received the training. During an interview with the Administrator on 4/27/15 at 3:10 pm he stated RN E would be monitoring the [MEDICATION NAME] flow sheets daily. Review of the facility policy for anticoagulation -Clinical protocol, (Nursing Services Policy and Procedure - 2005 Medpass revised April 2013), revealed the physician would order appropriate lab testing to monitor anticoagulation therapy and staff should use a [MEDICATION NAME] flow sheet or comparable monitoring tool to follow trends in anticoagulation dosages and response. The facility's Success Plan included: 1. Incident on Resident #4 4/12/15 transferred to hospital approximately 11:00 am 2. Investigation began 4/13/15. 3. Suspended LVN A pending investigation 4/13/15 4. Initiated identification of resident who receive anticoagulation therapy prior to lab audit. 5 Lab audit complete 4/20/15 7. Audit for HMP and progress notes on 4/17/15 8. Weekly audits of lab orders initiated on April 17, 2015 9. Educated staff on 4/13/15 on local pharmacy ordering protocol. Ongoing 10. Educated staff on 4/14/15 on new admission orders [REDACTED] 11. Educated staff on 4/17/15 on lab/radiology follow-up. Ongoing 12. Educated licensed staff from 4/15/15 on PT/INR flow sheet. Ongoing 13. Terminated LVN C on 4/9/15 and referral of license Texas Board of Nursing 4/22/15. 14. Terminated LVN B on 4/16/15 and referral of license Texas Board of Nursing 4/22/15. 15. Terminated LVN A on 4/24/15 by phone and referral of license Texas Board of Nursing 4/22/15. 16. Resignation of Director of Nursing RN D effective 4/16/15 17. Corrective action for RN E effective 4/27/15. 18. Educated IDT on Quality of Care Meeting and held on 4/22/15. Ongoing 19. New admissions/Readmissions/Change in condition are reviewed in morning meeting 20. Will review at QAPI. Ongoing Review of facility documentation revealed a resident lab audit was completed on 4/20/15 and staff training on [MEDICATION NAME] & PT/INR flow sheet which was conducted on 4/17/15. Review of a list provided by the facility revealed 2 current residents were prescribed [MEDICATION NAME].