Every finding on record at Richard a. Anderson (State of Texas Veterans Land

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment for 1 of 7 residents (Resident #1) reviewed for comprehensive person-centered care plans. The facility failed to ensure Resident #1's Care Plan addressed a significant change in the resident's condition related to his mental and psychosocial needs as recommended in a psychological evaluation dated 05/09/26. This failure could place residents at risk of negative impact on quality of life and quality of care. Findings include: Record review of Resident #1 admission Record dated 8/11/2026 revealed [AGE] year-old male admitted to SNF on 11/16/2022. Resident # 1 had diagnoses of Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris with onset date of 2022, Hypertension with onset date of 2022, Major Depressive Disorder; recurrent; mild with onset date of 2024, Unspecified Dementia; unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety with onset date of 2024, Insomnia with onset date of 2024, other Amnesia with onset date of 2024. Record review of Resident # 1 Care Plan dated 5/21/2026 revealed focus area of impaired cognitive function/impaired thought processes related to diagnosis of Dementia, Amnesia revised on 11/17/2025. Goal was to communicate basic needs on daily basis through review date. Interventions included administrator medications as ordered, cue, reorient and supervise as needed, monitor/document/ report as needed any changes in cognitive function, specifically changes in decision-making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status created on 6/19/2023. Further review revealed focus area of antidepressant medication related to depression and weight loss and is at risk for adverse reactions revised on 5/15/2026. Goal was to be free from discomfort or adverse reactions related to antidepressant therapy through review date. Interventions included administrator antidepressants as ordered, monitor/ document side effects and effectiveness every shift, Monitor/Document/ report as needed adverse reactions to antidepressant therapy: changes in behavior/mood/cognition; hallucinations/delusions, social isolation, suicidal thoughts, withdrawal.Observe for side effects. If side effects are observed, notify the MD and document in a progress note. Another Focus area revealed psychosocial well-being problem related to little interest in doing things revised on 5/6/2026. Goal was to identify reasons for feelings of unhappiness, isolation, anger, and loss. Interventions include allowing the resident time to answer questions and verbalize feelings, perceptions and fears as needed, consult with Pastoral Care, Social Services, Psych Services, Monitor/ document resident's feelings related to isolation, unhappiness, anger, and loss Record review of Resident # 1's MDS dated [DATE] revealed BIMs score of 7, indicates impairment with recall. Record review of Resident # 1's Psychological Evaluation dated 5/9/2026 read in part Medical Necessity: Psychological testing was deemed medically necessary based on the following: A significant change in the patient's condition. The need to evaluate a patient's capacity to function in a given situation or environment. Assessment of patient's capacity for decision-making when impairment is suspected that would affect patient care or management. This second time, by contrast, the patient requested testing himself, believing the assessment would confirm his cognitive and emotional competence allow him increased independence, thwart suspected plan to take his money, and make remarriage a possibility.Recommendations: Assist the patient to acknowledge his anxiety rather than deny or intellectualize it.Be aware of the patients use of confabulation.Avoid arguing about patients false beliefs. Consistently focus interactions on the reality-based parts of the patient's communication. Provide encouragement and positive reinforcement for even the smallest acceptance of your help Interview on 8/11/2026 at 11:09 am with Family Member, stated Resident # 1 wanted to secure marriage with a caregiver to avoid family member's management of his affairs so he can discharge from the facility. Family Member stated Resident # 1 has told his doctor, social worker, and maybe others at the facility that he wanted to get remarried. Family Member stated Resident # 1's online calendar had information on three different CNA's and their phone numbers. Family Member alerted Administrator and DON of what was found in the calendar for Resident # 1's safety. Family Member states CNA C's name was written in the calendar, and that Resident # 1 wrote about a proposal. Family Member stated Resident # 1 and another resident had to be separated because Resident # 1 felt that resident was talking to his (Resident # 1) woman. Family Member stated after informing Administrator and DON of concerns with Resident # 1 there was not resolution to address Resident #1's continued delusion ideas of marriage with someone that may work or care for Resident # 1. Interview on 8/11/2026 at 1:31 pm Resident #1 stated he got along with other residents although he had a verbal issue with another resident before. Resident # 1 did not remember the name of the other resident or what happened to start the argument. Resident # 1 stated he imagined there have been discussions about relationships with residents or staff, and that he might be in a relationship. Resident # 1 stated some residents are unable to be in a relationship due to ambulatory status, but some do not care. Resident # 1 stated he would not have CNA's or staff members phone numbers stored in his phone to avoid someone say he called them. Interview on 8/11/2026 at 1:45 pm CNA A said she was not aware of any marriage or romantic behaviors/ideas of residents in her assigned pod. CNA A said she was familiar with Resident # 1 in her assigned pod, however, was not told he wanted to be married or why he wanted to be married. CNA A said she was familiar with all the residents in her area but would ask the nurse about a resident when she was unsure. Interview on 8/11/2026 at 2:08pm CNA B, said she was familiar with the residents on her assigned pod. CNA B said she was not aware that Resident # 1 wanted a relationship with a CNA or other staff to then leave the facility. Interview on 8/11/2026 at 3:00pm CNA C, said she use to work on Resident #1's pod, however she moved to a new pod a few weeks ago. CNA C said she was not aware of inappropriate relationships with staff and residents. CNA C stated in the past residents say hey baby how you doing are you married oh too bad denied a resident asked her to marry them. CNA C stated she was familiar with Resident # 1 and that he liked to be on his phone. CNA C said she talked to him about his different personal concerns. CNA C said Resident # 1 would ask her personal questions but denied he asked he asked her to marry him. CNA C said she was not aware Resident # 1 wanted to marry a CNA or staff member and leave the facility. CNA C said she asked to return to her pervious pod but was told to wait. CNA C said residents have asked for CNA's phone numbers, however it was against policy to give their phone numbers out. Interview on 8/11/2026 at 4:37 Social Worker, said she was familiar with Resident # 1. Social Worker said Resident # 1 did not have any behaviors and had a diagnosis of Dementia however he did not act comparable to a resident with Dementia. Social Worker said Family Member was concerned Resident # 1 had a relationship with someone in his phone. Social Worker said Resident # 1 would say Hey Beautiful however she did not take it seriously as that was just the way he was. Social Worker said she told Family Member the facility could not look or take Resident # 1's phone to see if he was talking to a staff member. Social Worker said Resident # 1 would write names down on paper of staff that would come and go into his room however it was not a concern. Social Worker said the Administrator and DON completed an investigation after Family Member raised concerns however did not know the results of the investigation. Social Worker said during a care plan meeting last year Resident # 1 told them he wanted to get married but did not tell them who. Social Worker said Resident # 1 has not recently said he wanted to be married and was not actively trying to be married. Social Worker said Resident # 1 believed Family Member was against him being married and was taking his money. Social Worker stated Resident # 1 had a psychological evaluation last year and another evaluation this year to review his ability to make his own decisions. Social Worker said there were no changes or recommendations to be made since the recent evaluation this year. Interview on 8/11/2026 at 5:15pm RN A, said she was assigned Resident # 1's pod. RN A said Resident # 1 has said he wanted to marry again but did not mention who it would be. RN A said Resident # 1 stated I may marry again maybe a month ago but did not take Resident # 1 seriously. RN A said she has not seen anything inappropriate with CNA's and Resident # 1. RN said she has not gotten report from other CNA's of Resident # 1 pursuing them or a relationship. Interview on 8/12/2026 at 11:40am MDS Coordinator, said Care Plans are created with resident's current medication order and diagnosis list. MDS Coordinator said Care Plan interventions come from a library bank or she will create her own. MDS Coordinator said she heard from Family Member that Resident # 1 wanted to pursue a relationship but denied Resident # 1 said he wanted to pursue a relationship or marriage. MDS Coordinator said during a Care Plan meeting it was disclosed and expressed to the Social Worker that Resident # 1 had names of female staff members listed in his phone. MDS Coordinator said she was not aware Resident #1 wanted to be remarried as of this year or that a Psychological Evaluation with a diagnosis of Anxiety was completed. MDS Coordinator said Psychological Evaluation recommendations and any diagnoses would be added to the Care Plan. MDS Coordinator said any evaluations would go to the Social Worker for review and the care plan focus areas would include diagnoses and interventions based on the focus area or recommendations in the evaluation. MDS Coordinator said the purpose of a Care Plan was to provide goals and interventions to deliver a better quality of life and care for patients. Interview on 8/12/2026 at 12:13 pm DON, said she was told by Family Member Resident # 1 was looking for wedding rings online and had a concern that he wanted to get married to someone at the facility. DON said she was told about Resident # 1 writing out CNA's work schedules in his phone calendar. DON said Resident # 1 had not expressed marriage and that it was only a Family Member concern. DON said she last talked to staff at the beginning of the year that worked Resident # 1 pod about his interactions and if he tried to pursue them or talked about marriage to them and all the staff reported no. DON said she did not inform floor staff, CNA's, or Nurses of Resident # 1 writing names and work schedules in his phone. DON said she was informed of Resident # 1 past and that he was taken advantage financially. DON said Resident # 1 has expressed to DON what is the different of someone else taking advantage of me and his family member taking advantage of him. DON said after facility investigation CNA C was moved off pod with Resident # 1 due to him having CNA C's work schedule detailed in his phone and his want to pursue marriage. DON said social services reviewed Psychological Evaluations but was not aware of Resident # 1 request for recent Psychological Evaluations. DON said Resident # 1 did not go around just saying he wanted to get married however, he may say hey beautiful. DON reviewed Psychological Evaluation dated 5/9/2026 with diagnoses of Anxiety and. DON said she was told by Family Member that Resident # 1 gets attached to women. DON said in general they tell the staff to watch their interactions with residents. DON said a diagnosis of anxiety for Resident # 1 could be related to his fixation on marriage. DON said staff would know to report to the nurse anything about marriage. Interview on 8/12/2026 at 4:50 pm, MD stated Resident # 1 had an active diagnosis of anxiety and took a mood stabilizer for the diagnoses. Interview ended. Record review of facility policy titled Clinical Services: Care Plan and Case Management dated 6/2029 read in part The comprehensive care plan has been designed to:a. Identify care needs that include resident's strengths, history, and preferences;b. Incorporate risk factors;c. Establish goals in measurable outcomes;d. Include individualized approaches to meet resident's goals.

Based on observation, interviews and record reviews, the facility failed to ensure a resident is offered a therapeutic diet when there is a nutritional problem, and the health care provider ordered a therapeutic diet for 1 of 24 residents (Resident #4) reviewed for nutrition status. The facility failed to provide Resident #4 with a fortified meal plan as ordered by his physician between 7/22/25 and 9/11/25. This failure could affect all residents on therapeutic diets by placing them at increased risk for significant weight loss and malnutrition. The findings included: Record review of Resident #4's admission Record generated on 9/10/25 revealed he was admitted to the facility on [DATE] and had diagnoses of dementia (causes memory loss in older adults), parkinsonism ( a clinical syndrome characterized by tremor, rigidity and postural instability), weakness, gastro-esophageal reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining), diabetes type II (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) and post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing a terrifying event). He was [AGE] years of age. Record review of Resident #4's Quarterly Nutrition assessment dated [DATE] completed by the Dietician revealed he was eating about 76-100% of his meals. She indicated he was at risk of malnutrition after completing a mini nutritional assessment. Record review of Resident #4's Dietary Recommendations dated 7/17/25 revealed the dietician recommended Resident #4's physician (Physician A) to order a fortified meal plan. Physician A agreed and the document was signed on 7/22/25. Record review of Resident #4's Physician Order dated 7/22/25 revealed Physician A wrote an order for Resident #4 to receive a fortified meal plan. The order was created by the ADON. Record review of Resident #4's Care Plan dated 7/23/25 revealed he required a low concentrated sweets diet with regular texture and was on a fortified meal plan. The goal was for the resident to adhere to the diet through the next review date with a target date of 10/26/25. Record review of Resident #4's Weight Summary revealed he weighed 194.2 lbs on 7/17/25 and weighed 199.8 lbs on 9/5/25. In an interview on 9/10/25 at 3:54pm, the Dietary Manager stated a fortified meal plan help residents gain weight. She said typically, the fortified meal plan consists of oatmeal for breakfast, mashed potatoes at lunch and soup for dinner. She said they also provided an ice cream nutritional supplement. She said they saw a resident's diet or meal plan printed on the ticket. She said normally, the diets would auto-transfer to the meal tickets. She said for an unknown reason, some of the fortified meal plan orders did not always transfer to the ticket. She said she double checked the meal tickets and, in some instances, had to type a note and added the fortified meal plan indicator to the ticket. She said she would provide a list of residents who were receiving a fortified meal plan. Record review of the meal tickets provided by the Dietary Manager revealed Resident #4 was not listed as receiving a fortified meal plan. In an observation and record review on 9/10/25 at 5:15pm, Resident #4 was eating dinner in the dining room. His meal consisted of a chili hot dog with a bun, tater tots, cole slaw and apple cobbler. Record review of his meal ticket next to his tray revealed it did not indicate he received a fortified meal. In an interview on 9/10/25 at 5:22pm, the ADON stated the fortified meal plan was used for weight loss to help residents boost their weight. She said when she entered a new dietary order, they communicated the new order to the Dietary Manager by printing out the order and letting her know. She said she would review Resident #4 to determine if he had received a fortified meal plan. In an interview on 9/11/25 at 10:55am, the DON said a fortified meal plan adds more calories to a meal by adding extra butter or sugar. She said once they put the order in the system, it automatically generated on the meal ticket. She said there was an error in the system for Resident #4. She was not sure why the fortified meal order did not transfer to the meal ticket. In an interview on 9/11/25 at 11:30am, the Dietician stated when she recommended a fortified meal plan, residents are eating parts of their tray but could use extra calories to maintain nutrition status. She said sometimes, they are not eating a lot but likes to add fortified, so they get extra calories. When asked about the risk of not receiving a fortified diet when one was ordered by the physician, she said it depended on each resident's situation. She said Resident #4 was gaining weight. She said she tracked resident's weights and would have changed interventions if she noticed weights trending down. In an interview on 9/11/25 at 4:05pm, the Dietary Manager stated she could not explain why Resident #4's fortified meal plan was not listed on his meal tickets. She said when plating, the cooks would not have known to provide him with fortified foods, so he was not receiving them. Record review of a facility policy regarding Nutrition Supplementation dated 6/1/2019 stated, The facility is committed to assisting residents in maintaining and maximizing their nutritional status. Supplemental nutrition will be provided in a manner that maximizes intake of the oral diet before adding other supplementation. use of fortified foods should be used to provide additional calories and protein for residents unable to meet estimated calorie and/or protein needs with current intake.

Based on interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 of 24 residents (Resident #3) reviewed for assessments, in that: Resident #3's quarterly MDS assessment dated [DATE] inaccurately indicated he did not receive insulin injections during the lookback period of 7 days. This failure could place residents at risk of not having accurate assessments to receive care. The findings included: Record review of Resident #3's admission Record generated on 9/11/2025 revealed he was admitted to the facility on [DATE] and had diagnoses of vascular dementia (causes memory loss in older adults) and diabetes type II (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). He was [AGE] years of age. Record review of Resident #3's Care Plan dated 8/28/2023 revealed he was at risk of hyperglycemia (abnormally high level of glucose in the blood) or hypoglycemia (a condition in which the body's blood sugar level goes below the standard range) related to a diagnosis of diabetes. Interventions included administer insulin (a treatment that helps keep blood sugar under control and prevent diabetes complications) as ordered. Record review of Resident #3's physician orders dated 7/1/25 revealed an order for Insulin Glargine Solution 100 U/mL, inject 40 units subcutaneously (administering medication into the fatty tissue just underneath the skin) one time a day for diabetes. Record review of Resident #3's Medication Administration Record dated July 2025 revealed he received Insulin injections daily between 7/1/25 and 7/31/25. Record review of Resident #3's MDS assessment dated [DATE] revealed Section N0300 regarding injections indicated he received 0 injections of any type in the last 7 days. In an interview on 9/11/25 at 9:37am, MDS Coordinator A said when she completed Section N (Medications) of the MDS assessment, she reviewed the resident's medication administration record and referenced the last 7 days. She said injection medications would include insulin. When asked about Resident #3's MDS assessment, she said she would review it for accuracy. In an interview on 9/11/25 at 9:55am, MDS Coordinator A said Resident #3 received injectable insulin during the 7-day lookback period. She said the MDS was miscoded. In an interview on 9/11/25 at 10:55am, the DON said she signed the MDS assessments to indicate they were complete. She said she did not review them for accuracy. Record review of the facility policy regarding MDS Accuracy (undated) stated, Accurate MDS assessments support individualized care planning, compliance with federal and state regulations, and appropriate reimbursement under Medicare/Medicaid.It is the policy of (company) that all MDS assessments: Accurately reflect the resident's clinical status.

Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 18%, based on 5 errors out of 27 opportunities, which involved 1 of 4 residents (Resident #1) and 1 of 3 staff (MA A) observed during medication administration reviewed for medication error, in that: -MA A administered the incorrect dose of Chlor-Con (potassium chloride) to Resident #1. -MA A failed to administer 4 additional medications/supplements prior to surveyor intervention. -MA A had documented she administered the 4 medications/supplements. -The resident did not receive the medications/supplements until after surveyor intervention. These failures placed the resident at risk for inadequate therapeutic outcomes, increased negative side effects, and a decline in health. Findings include: Record review of the Admission Record (copied 08/22/24) for Resident #1 revealed he was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, congestive heart failure, atrial fibrillation (irregular heartbeat), hypokalemia (low potassium), type 2 diabetes mellitus, GERD (reflux disease), and arthritis. Record review of the admission MDS assessment dated [DATE] for Resident #1 revealed he scored 14 of 15 on the BIMS, indicative of intact cognition. Record review of the Care Plan dated 07/02/24 for Resident #1 revealed he was at risk for complications from atrial fibrillation. One intervention was reflected as Medications as ordered. Observation on 08/22/24 at 8:05 a.m. revealed MA A was at her medication cart near the entrance to Resident #1's room. Her computer screen displayed the orders for Resident #1's morning medications. Observation revealed MA A dispensed the following medications/supplements into a transparent 30 cc medication cup: Lasix 40 mg (diuretic) 1 tablet Jardiance 10 mg (for diabetes) 1 tablet Klor-Con 10 meq (potassium chloride) 1 tablet Toprol 25 mg (for blood pressure) 1 tablet Famotidine 20 mg (for GERD) 1 tablet Ranolazine ER 500 (for chest pain) 1 tablet Allopurinol 100 mg (for gout) 1 tablet Tamulosin 0.4 mg (for urinary retention) 1 tablet Aspirin 81 mg 1 tablet Continued observation revealed MA A closed the drawers of the medication cart and locked it. The surveyor asked her to count the number of medications in the cup. MA A counted the medications and said Nine. MA A administered the nine medications to Resident #1. Record review of Resident #1's August 2024 Physician's Orders revealed the resident was to receive 20 meq of potassium chloride, but was administered 10 meq. Continued review of the Orders revealed he was to receive CoQ10 100 mg (for congestive heart failure), a multivitamin, and Calcium 600 mg + vitamin D3 20 mcg (for vitamin deficiency). Those medications/supplements had not been administered. Record review of a Physician's Order dated 08/13/24 revealed Resident #1 was to receive Fexofenadine HCl 60 mg (for allergies) twice daily. The medication had not been administered. Record review on 08/22/24 at 9:00 a.m. of Resident #1's August 2024 MAR revealed MA A had initialed and checked that she had administered the CoQ10 100 mg tablet, the multivitamin, the Calcium 600 mg + vitamin D3 20 mcg, and the Fexofenadine HCl 60 mg. A copy of the MAR was made at that time. In an interview on 08/22/24 at 09:12 a.m., Resident #1 was asked if MA A had returned with additional medications. The resident said MA A had returned to let him know when he could receive a pain medication from the nurse, but she did not bring any additional medications. In an interview and observation on 08/22/24 at 09:15 a.m. MA A said she had given all of the 9:00 a.m. scheduled medications to Resident #1. The surveyor asked her to check the order for the Potassium Chloride. MA A checked the order on the computer and verified it was for 20 meq. She looked at the medication 'blister pack' which had 10 meq tablets. MA A said, Clor-con is 20. It's a 10. I need to give him another one. Observation revealed MA A dispensed and administered a 10 meq tablet to the resident. Record review on 08/22/24 at 1:00 p.m. of Resident #1's August 2024 MAR revealed the CoQ10 100 mg tablet, the multivitamin, the Calcium 600 mg + vitamin D3 20 mcg, and the Fexofenadine HCl 60 mg had been changed to a '9' (not given) instead of a check indicating they were given. In an interview on 08/22/24 at 1:10 p.m., RN B, the Unit Charge Nurse, was asked if MA A had informed her that a resident did not receive all of his medications. RN B said that MA A did not tell her she did not give some medications, but asked her to 'strike out' medications for Resident #1. She said MA A did not give a reason, and she did not ask her why. She said MA A had left the facility. In an interview on 08/22/24 at 1:40 p.m., ADON C said MA A had informed her that Resident #1 did not receive the Calcium with Vitamin D, the CoQ10, and the Fexofenadine. She said she looked at the MAR and they were coded '9', which meant the nurse was verbally informed. ADON C said she could not recall the time MA A informed her. ADON C said that she went to Central Supply, and the medications/supplements were there. The Pharmacy nurse then administered them. The surveyor informed ADON C the MAR had been signed as 'given,' then changed to a code '9'. ADON C said MA A should not have signed them as given. Record review of the the facility policy Medication Administration (no date) read, in part, .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection . Review MAR to identify medication to be administered .Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time .Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent accidents for 2 (Resident #1 and Resident #2) of 7 residents reviewed for accidents hazards/supervision in that: -Resident #1 who resided in the Memory Care Unit was let out of the facility by CNA A on 2/16/24 at 6:45 pm and located by the Resident Representative around 8:30 pm on the corner of a major high traffic street corridor approximately 1/2 mile away. -The facility failed to prevent Resident #2 in Memory Care Unit from ingesting shampoo on 5/17/24 which resulted in emergency treatment services at the local hospital. An Immediate Jeopardy was identified on 06/21/24 at 3:49 pm. The Immediate Jeopardy was removed on 06/23/24 at 12:54 pm; however, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of serious injuries or death due to lack of supervision. Findings included: 1.Record review of Resident #1's face sheet dated 6/20/24 revealed a [AGE] year-old male admitted on [DATE]. His diagnoses included dementia, abnormalities of gait and mobility, lack of coordination, adjustment disorder with anxiety (a mental health condition that can occur after a significant life change), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), hypertension, major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), post-traumatic stress disorder (PTSD), insomnia, allergic rhinitis (an allergic response causing itchy, watery eyes, sneezing, and other similar symptoms), and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). Record review of Resident #1's comprehensive MDS dated [DATE] revealed a BIMS score of 3 indicating a severe cognitive impairment. The MDS documented he had no potential indicators of psychosis, behaviors affecting others, or rejection of care. Per the MDS, Resident #1 had a wandering frequency which occurred 1 to 3 days. Record review of Resident #1's care plan dated 6/4/2024 revealed a focus on at risk for difficulty in psychosocial adjustment related to admission to facility including interventions introducing self-introduction upon each visit with resident, introduce to others who may have similar interests, notify physician as needed, observe for signs and symptoms of difficulties in psychosocial adjustment; a focus on exit seeking behavior related to dementia with interventions staff educated on resident and visitor identification prior to exiting unit, wander guard placed in veteran's trumpet bag, attempt diversional activities as needed, check functionality and visualization of wander guard, check functioning of secure alarm, check placement of secure alarm, check placement per protocol, contact physician and family of attempt to leave facility, observe and monitor frequently with redirection, personal secure alarm, routine elopement risk screens. Record review of Resident #1's progress note created by LVN A dated 2/16/2024 at 11:02 pm read this nurse was passing evening medications and did not see resident wandering around unit as he normally does. Went to look in other resident rooms and other hallways and common areas and could not locate resident. Notified all staff that resident had not been seen recently and to start checking all rooms. When notifying staff about resident CNA explained to this nurse that when she entered unit around 6:45 pm that she thought he was a visitor and opened the door to let him off the pod from the main door. This nurse notified RN supervisor and DON. All staff in building notified of elopement. All staff began looking for veteran around facility and nearby locations. Family and Administrator also notified. While searching for resident this nurse was notified by Supervisor that family found resident at 8:30 p.m. outside of facility. Resident brought back to B-pod and was sitting in the day room. Assessed for any injuries. No c/o pain. Veteran stated that he was looking for his car when asked what happened. Fluids given to resident and consumed well. Neuro checks initiated. MD notified of elopement. Record review of Resident #1's progress note created by the DON, dated 2/16/24 at 11:02 pm, labeled as Late Entry read The staff provided the Veteran with a wander guard. The elopement binder was updated. An investigation was initiated, and the staff were educated on providing properly entering and exiting the memory care unit. Interview on 6/20/24 at 10:25 a.m., with the DON, she said the wander guard for Resident #1 was in his trumpet case. She said they tried to put the wander guard on Resident #1's wrist but he would take it off. The DON said Resident #1 carried his trumpet everywhere he went. She said on the day Resident #1 eloped from the facility; he had his trumpet and case with him . Observation on 6/20/24 at 11:00 a.m., revealed Resident #1 was in the memory care dining room with a group of residents. Resident #1 had a foam tube in his hands and did stretches along with the other residents. Resident #1 did not have his trumpet case with him . Resident #1 did not have a wonder guard on him. Attempted interview on 6/20/24 at 11:54 a.m. with Resident Representative for Resident #1 was unsuccessful. Interview on 6/20/24 at 2:40 p.m. with CNA A, she said on 02/16/24 at approximately 6:45 pm, she let Resident #1 out of the memory care unit because he looked like a visitor, he had a backpack with keys in his hands and told her he needed to get back out to his car. She said Resident #1 was a new resident and staff did not inform her he was new. She said it had been 3 months since the last time she worked in the memory care unit. Attempted phone call on 6/20/24 at 2:45 p.m. and 6/21/24 at 12:22 p.m. to LVN A was unsuccessful. Observation on 6/20/24 at 4:00 p.m., CNA B located the trumpet case from Resident #1's closet to search for Resident #1's wander guard. The wander guard was tucked inside the lining of the trumpet case. ADON A entered Resident #1's room and took the trumpet case outside the memory care unit to test the wander guard. ADON A said, if a resident wanted to exit memory care, they would need to have an access card to open the doors. ADON A tested the alarms for the wander guard while standing approximately 10 feet away from the memory care entry/exit doors. The wander guard alarms proved to be working properly . Interview on 6/20/24 at 5:45 p.m. with the DON, she said the Resident Representative located Resident #1 on 2/16/24 at approximately 8:30 p.m. She said the facility did not call the police because the resident representative was able to locate him. She said Resident #1 had air pods on him and the Resident Representative was able to be tracked by GPS. The DON said the worst thing that could happen to a resident who eloped could result in death. The DON said the worst thing that could have happened for Resident #1 was getting lost. The DON said the protocol for when an elopement occurred was to start the search immediately, go room to room, do a count and talk with staff, and initiate parameters, such as code [NAME] on B pod. She said staff were supposed to get in their cars and search for residents. She said, the Administrator, DON, and family would need to be notified. The DON said she didn't call the police because the family knew how to locate him. The DON said the facility had never had an elopement in the past, until this incident occurred . 2.Record review of Resident #2's face sheet dated 6/21/24 revealed an [AGE] year-old male admitted on [DATE]. His diagnoses included dementia with agitation, fatigue, difficulty in walking, lack of coordination, dysphagia (difficulty swallowing foods or liquids), cognitive communication deficit, post-traumatic stress disorder (PTSD), congestive heart failure, major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), insomnia, malignant neoplasm of prostrate, hyperlipidemia (a condition in which there are high levels of fat particles in the blood), obstructive sleep apnea, and hypertension. Record review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS score of 00 indicating a severe cognitive impairment. The MDS documented Resident #2 had no potential indicators of psychosis, behaviors affecting others, or rejection of care; Resident #2 used a wheelchair for mobility and required one person assistance with ADLs. He was on a mechanically altered diet and antiplatelet (prevent blood clots from forming) medication. He received ST, PT, and OT services. Record review of Resident #2's care plan revised on 4/17/24 read, Focus on Resident #2 placing non-food items in mouth. Interventions: staff to ensure to keep non-food items are out of reach and not left out, room sweep of all rooms on POD to ensure all personal care items are in a secured cabinet, keep all non-food items out of resident's reach as possible, notify physician as needed, observe for signs and symptoms of aspiration. Focus: Resident #2 is at risk for aspiration pneumonia related to diagnosis of dysphagia. Interventions: diet as ordered, elevate head of bed during meals or have resident upright in chair, notify physician as needed, observe for and report signs of aspiration, thickened liquids as ordered. Focus: depression. Resident #2 at risk for mood/behavior problems. Interventions: social services as needed, observe for change in mental status, observe for signs and symptoms of depression, psyche consult as ordered. Record review of Resident #2's progress note created by LVN A dated 5/17/2024 at 7:05 am, CNA informed nurse that shampoo was seen on the floor in resident's room and shampoo bottle was sitting out on dresser. Veteran then was observed vomiting several times while sitting up in wheelchair a soapy like substance. Veteran unable to describe what happened. Veteran assessed immediately. 911 called for transport to ER. RP notified of transport. MD, RN supervisor, and DON notified. Veteran transferred to VA hospital . Interview on 6/20/24 at 2:52 p.m., with Resident #2's family member, she said on 5/17/24 there was a bottle of shampoo left on the resident's food tray and the resident drank the shampoo. She said she didn't know where the bottle of shampoo came from. She said the resident was hospitalized and was brought back to the facility same day at night. She said Resident #2 was sent back to the hospital on 5/20/24 because his health was declining. The doctor at the hospital told her Resident #2 had chemical pneumonia. She said Resident #2 came back to the facility on [DATE] and was put on a puree diet. Interview on 6/21/24 at 12:50 p.m. with the DON, she said they were unsure if Resident #2 drank the shampoo, but they assumed he drank the shampoo. She said Resident #2 was already throwing up and CNA C saw the shampoo bottle on the floor. She said they were unsure how long Resident #2 was vomiting. She said CNA C got Resident #2 up to get dressed for breakfast. She said CNA C went to another room to assist another resident and when he returned, he saw the shampoo bottle on the floor. The DON said CNA C took Resident #2 to the dining room area and the resident began vomiting. Follow-up interview on 6/23/24 at 10:00 a.m. with CNA C, he said he woke Resident #2 to get him ready for breakfast. He said he went to another resident's room to assist and when he returned Resident #2 had a white foaming substance on his mouth and his shirt that looked like shampoo and he was throwing up. He said he saw a bottle of shampoo on the floor of the resident's room, and it was not there when he left the room earlier. He said he saw the drawer by his bed open and thought Resident #2 got the shampoo out of the drawer. CNA C said he thought a family member may have brought the shampoo and put it in the drawer. On 6/21/24 at 3:49 p.m., the administrator was informed that an Immediate Jeopardy situation was identified due to the above failures and the IJ template was provided. The following Plan of Removal was submitted by the facility and accepted on 6/22/2024 at 11:49 AM: Immediate action: Upon return to facility on 2/16/2024 Resident #1 w as assessed with no injuries noted. Resident remained on 15-minute checks on secured unit until IDT felt resident was no longer at risk and/or interventions are updated and evaluated. Beginning 2/16/2024 ended 2/22/2024. Resident's Care plan was updated with new interventions wander guard added in addition to personal safety alarm. Care plan was held with resident's responsible party and IDT on 2/22/2024. Resident remains on Memory Secure Unit. Continues to have exit seeking but is redirected by staff. No further elopement incidents. Staff member who inadvertently let resident leave secure unit received counseling and training by DON on 2/16/2024 and 6/21/2024. 100% of all available staff will be trained and all other staff will be trained before their next scheduled shift on elopement procedure including calling police when resident is not located in the facility. Training completed will be done by Nurse Managers on 6/20/2024 and 6/21/2024 and ongoing until all receive the training. This training includes the following. 1. Nursing/Ancillary staff make determination that the resident is missing, and an announcement is made using facility approved protocol (CODE Brown) to alert all personnel that a search is underway. 2. DON and Administrator will be notified. 3. Resident representative notified to determine if resident is out on pass with family. 4. Each unit will send a designated person to the unit where the code was announced to gather information about the missing resident (i.e. name, description of resident). A copy of the elopement identification form will be provided from Elopement Book. 5. A person is designated as the facility person in charge of the search. They will coordinate the search to ensure that both inside and outside searches occurs. 6. Each unit or area should direct in-house staff to search room to room and all potential areas of the center: resident rooms, bathrooms, closets, laundry, under stairwells, shower rooms, under beds, utility rooms, offices, dining areas, kitchen, dayrooms, courtyards and employee lounges. 7. Facility person in charge assures all areas are being searched. 8. During open kitchen hours, the dietary staff will search the kitchen and related areas, checking the walk-in freezers/refrigerators. o A staff member is assigned to search the area if the kitchen is closed. 9. Two members of staff are assigned to search the outside perimeter. They should go out the front door, one goes to the left and one to the right and meet in the back, searching bushes, behind trees, around vehicles, dumpsters, outside buildings, etc. 10. Each designated person is to report back to the facility person in charge with the results of their search. 11. If resident has not been located police should be called. A copy of the elopement identification form will be provided from Elopement Book. 12. Notify Attending Physician. 13. Notify the Regional [NAME] President, Chief Clinical Officer and the Regional Clinical Consultant. 14. Upon return to the facility the resident is to be thoroughly assessed for any injuries or medical issues. 15. Notify search team that resident has been found. 16. Notify Resident Representative, Administrator, DON, Physician, Police, Regional [NAME] President, Chief Clinical Officer and the Regional Clinical Consultant. 17. Document incident and findings. 18. Update plan of care An Elopement Drill will be conducted on each shift starting with evening shift on 6/20/2024 and completing with day shift 6/21/2024 by administrator and nurse managers. Elopement Risk book will be reviewed and updated by social workers on 6/21/2024. This book contains identification information on residents at risk for wandering. Picture of resident as well as face sheet are included. Book is available to all staff with copy at receptionist desk and on each nursing unit. 100% of all available staff will be trained and all other staff will be trained before their next scheduled shift on 6/21/2024 by facility leadership. All doors with the wander guard system will be checked to ensure proper function on 6/21/2024 by facility maintenance staff. Signage has been placed on Memory Support Doors that no one be assisted in exiting without staff members being sure they do not reside in Memory Unit on 6/20/2024. Upon signing into the facility visitors will receive a Visitor Badge with photo. Visitors will need to show the Visitor Badge to exit the secure unit. During shift change any residents admitted since staff member last worked are to be met by secure unit staff. Staff will be educated on this process on 6/21/2024 and ongoing until all staff are educated by Facility Leadership. Elopement Risk will be assessments completed on all residents. Any resident identified with elopement risk will have interventions in place. These will include but not be limited to Wander Guard, Secure Unit, Frequent checks. Care Plan will be updated. This task will be completed by Licensed Nurses and Social Workers on 6/21/2024. A test will be utilized upon completion of training to ensure understanding of elopement process. Elopement policy was reviewed and updated on 6/20/2024 by Regional Clinical Consultant. This was included in training being provide to staff on Elopement. Policy was revised to specifically address missing resident and process. Resident #2 returned to facility on 6/4/2024 with diagnosis of aspiration pneumonia. During hospitalization diet was downgraded to pureed with thickened liquids at recommendation of Speech Therapist. Care conference was held with wife on 6/4/2024 to discuss plan of care. Resident #2 to receive PT/OT/ST. Resident #2's room was inspected on 5/17/2024 by licensed nurses to ensure all item that are keep out of reach were in locked cabinet. The remaining rooms on memory unit were also inspected on 5/17/2024 by licensed nurses to ensure all keep out of reach items were in locked cabinets. There have been no further incidents. Resident #2 currently continues PT, OT, ST. No other incidences of possible ingestion of non-food items. Care plan meeting held with wife 6/12/2024. An inspection was completed of all resident rooms by facility leadership on 6/21/2024 to ensure safe placement of keep out of reach items. No non-compliance noted. Nurse managers and social workers are reviewing all residents for any behaviors of consuming nonfood items on 6/22/2023. Any residents identified with this behavior will be care planned and have interventions to ensure they are not at risk for consuming keep out of reach items. 100% of all available staff will be trained and all other staff will be trained before their next scheduled shift on prevention and procedure when resident consumes non-food item including calling poison control and ensuring dangerous items are not available in resident areas. Training will be provided by Nurse Managers on 6/21/2024 and 6/22/2024 and ongoing until all receive the training. This training includes the following. 1. Keep out of reach items should be safety stored in cabinets. This includes any items with keep out of reach of children warning on label. 2. In Memory Unit this is a locked cabinet in each resident room to store items. 3. Any items noted out on tables or counters should be immediately stored. 4. Should it be suspected that a resident has consumed a non-food item, charge nurse and RN supervisor are to be immediately notified. 5. Poison Control will be notified. 6. Following assessment RN will contact resident's physician and carry out orders. This may include transfer to hospital for further evaluation. 7. Resident representative, DON and administrator to be notified. 8. If resident remains in facility, Poison Control directions will be followed. 9. Document incident and status of resident. 10. Update care plan. Poison Control number was posted at each nurses' station on 6/22/2024. An electronic message call was placed to all resident representatives on 6/21/24 by administrator providing information regarding placement of keep out of reach items and directing to nurse if any questions. Signage was placed on each nursing unit and at entrance to memory support unit on 6/21/2024 advising that keep out of reach items need to be safely stored, and to contact nurse if any questions. Facility Leadership will make rounds of facility daily to ensure that keep out of reach items are safely stored. This process remains as part of daily tasks indefinitely. Leadership was trained on 6/21/24 that this includes any items with keep out of reach of children warning on label. Medical Director was notified of IJ on 6/22/2024 at 5PM Facility QAPI meeting was held on 6/21/2024 at 7PM to discuss POR. Items not Allowed has been reviewed by Regional Clinical Consultant on 6/22/2024. This listing is provided to residents and families upon admission and reviewed with them when there is a concern. The document does include no keep out of reach of children items. Document has been posted at each nurse's station as well as on Memory Care entrance and exit. On 6/22/24 and 6/23/24, the surveyor confirmed the plan of removal had been implemented sufficiently to remove the Immediate Jeopardy by: Observation on 6/22/24 at 12:30 p.m., upon entrance into the facility, the sign-in station had an electronic device that printed a visitor badge with a photo for all visitors entering the facility. Observation on 6/22/24 at 12:40 p.m., the receptionist provided an elopement risk binder. Observation on 6/22/24 at 1:55 p.m. of the memory care doors revealed signage that read Please identify any unfamiliar person(s) with the charge nurse before allowing them to exit the memory care unit. All memory care veterans must be accompanied by staff/family when exiting the memory care unit. An additional sign posted on the memory care doors read Please ensure that all items labeled 'keep out of reach of children' are properly stored and secured. Please see the nurse if you have any questions. Observation and interview on 6/22/24 at 2:00 p.m., revealed Resident #2 lying in bed. He muttered we're trying to get this fixed. There were no hazardous items left out in the room or the restroom. The restroom had a keypad lock on the top cabinet and was closed shut and a keypad lock on the medicine cabinet and was closed shut. Observation on 6/22/24 at 2:05 p.m., revealed Resident #1 was sleeping in his bed. There were no hazardous items left out around his room or the restroom. The restroom had a keypad lock on the top cabinet and was closed shut and a keypad lock on the medicine cabinet and was closed shut . Resident #1 was not wearing a wander guard. Observation on 6/22/24 at 2:10 p.m. of the nurse's station in the memory care unit revealed signage that had the poison control center phone number and who to notify. Additional signage addressing items labeled keep out of reach of children were posted as well. An elopement risk binder was at the memory care's nurse's station. Observation on 6/22/24 at 2:53 p.m. of the nurse's station in Pod C revealed signage had the poison control center phone number and who to notify. Additional signage addressing items labeled keep out of reach of children was posted as well. An elopement risk binder was at the nurse's station for Pod C. Observation on 6/22/24 at 2:57 p.m. of the nurse's station in Pod A revealed signage that had the poison control center phone number and who to notify. Additional signage addressing items labeled keep out of reach of children was posted as well. An elopement risk binder was at the nurse's station for Pod A. Observation on 6/22/24 at 3:00 p.m. of the nurse's station in Pod D revealed signage that had the poison control center phone number and who to notify. Additional signage addressing items labeled keep out of reach of children was posted as well. An elopement risk binder was at the nurse's station for Pod D. Interview with LVN B on 6/22/24 at 3:31 p.m., she said she had worked at the facility since 2/13/24. LVN B said if a resident cannot be found, staff would look in the resident rooms and bathrooms from the pod that the resident came from. If the resident cannot be found in the building a Code [NAME] was called over the intercom. She said two staff members would go out the front door and one staff member would go out the left and the other to the right and both staff members would meet behind the building. She said the DON, Administrator, police, and the family members would need to be notified. LVN B said non-food items were locked away in the resident's cabinet in the restroom. She said if a family member brought cleaning supplies, they would need to return the cleaning supplies to the family. She said if a resident were to put a non-food item in their mouth and ingested it, the poison control center would need to be notified along with the DON, family, and doctor. She said she was in-serviced for elopement on 6/20/24 and the keep out of reach items on 6/21/24. Interview on 6/22/24 at 3:42 p.m. with CNA D, she said she had worked at the facility since 7/5/23. She said if a resident eloped from the facility, staff would search the inside of the facility by checking all the rooms, restrooms, and other areas of the facility. If the resident cannot be found inside the facility, then the search would be expanded to the outside. She said the police, DON, and family would need to be notified. She said an elopement drill was conducted today (6/22/24 ). CNA D said with the non-food items these need to be locked away. She said the protocol if a resident were to swallow a non-food item would be to call poison control and inform the charge nurse. She said she was in-serviced for elopement on 6/20/24 and the keep out of reach items on 6/21/24. Interview on 6/22/24 at 3:48 p.m. with CNA E, she said she worked in the Memory Care unit and has worked at the facility for 2 and half years. She said if a resident eloped, she would report to the nurse's station to see who they are looking for. She would go room to room throughout the pod, then the search would be expanded throughout the facility, then outside the facility. When the search is expanded outside the facility, 2 staff members will go out the front door and go opposite ways to circle the perimeter of the building and would meet behind the building. CNA E said the non-food items needed to be locked in cabinets. If it's an item that's not supposed to be in the resident's room such as a heating pad or cleaning supplies, these types of items need to be taken to the nurse's station. She said if a resident did drink or eat a non-food item, she would need to go to the nurse's station and the charge nurse would call poison control. She said she was in-serviced for elopement on 6/20/24 and the keep out of reach items on 6/21/24. Interview on 6/22/24 at 4:00 p.m. with CNA F, she said she worked in C pod and has worked at the facility since February 2024. She said if a resident eloped, an announcement would be made over the intercom Code Brown. She said the first thing she would need to do is look at the elopement book and find out who is missing. CNA F said the search would start inside the building and then expand outside. She said two staff members go outside the front door and go opposite ways to circle around the building. These two staff members would need to check all the porches at each pod and then meet up behind the building. She said she participated in the elopement drill the night before last (6/20/24). CNA F said any item that is labeled 'keep out of reach for children' would need to be locked up in the cabinet with the combination code. If a resident drank or ate a non-food item, she would notify the charge nurse and the charge nurse would notify the ADON, DON, physician, and family. She said she was in-serviced for elopement on 6/20/24 and the keep out of reach items on 6/21/24. Interview on 6/22/24 at 4:12 p.m. with CNA G, she said she worked in D pod and had worked at the facility for almost a year. She said if a resident eloped, the first thing she needed to do was look at the elopement book, find out which resident eloped, and make copies of the picture of the resident that eloped to pass out to other staff. She said they would need to check inside the facility and check every door that can open, such as bathrooms, storage rooms, and kitchen. If the resident cannot be found inside the building, then the search is expanded to the outside of the building. There would be 2 staff members designated to go out the front door and go opposite directions around the building and meet up behind the building. She said with non-food items, these would need to be stored in locked cabinet and would need to make sure the cabinet is secured and shut. If a resident ate or drank a non-food item, the charge nurse and poison control would need to be notified. She said she was in-serviced for elopement on 6/20/24 and the keep out of reach items on 6/21/24. Interview on 6/22/24 at 4:23 p.m. with CNA H, she said she worked in A pod and had worked at the facility since 5/7/24. She said if a resident eloped, she would need to go to the nurse's station and wait for instructions. She said the inside of the building would need to be searched first, then move to the outside of the building. She said two staff members would be designated to search outside the building. The two staff members would need to start at the front of the building and go opposite directions to meet behind the building. She said she participated in an elopement drill on 6/20/24. CNA H said items that are labeled 'keep away from children' need to be locked up. She said resident rooms need to be checked for non-food items every 2 hours and more often if time permitted. CNA H said if a resident drank or ate a non-food item, the charge nurses and poison control would need to be notified. She said she was in-serviced for elopement on 6/20/24 and the keep out of reach items on 6/21/24. Interview on 6/22/24 at 4:35 p.m. with the Maintenance Director, he said he had worked at the facility for 4 years. He said the wander guard alarms were tested on [DATE] and 6/21/24. He said the wander guards were tested weekly. The Maintenance Director said the wonder guard alarms are located at the front door, at the exit door for each patio, and along the connector/hallway going down each pod. He said was in-serviced for elopement on 6/20/24 and the keep out of reach items on 6/21/24. Observation on 6/22/24 at 4:50 p.m., the Maintenance Director had a wander guard in his hand and walked down D pod. The wander guard alarm went off as he was walking down the hallway toward D pod. The Maintenance Director went to the patio for D pod and opened the door with the wander guard in his hand and the alarm went off. Record review of the Elopement Risk binder identified 33 residents that were an elopement risk. These residents each had their face sheet and a picture to identify the resident. Record review of the Elopement Screen document dated 6/21/24 listed all residents residing at the facility were screened for elopement risk. Record review of the Elopement Drill documents revealed elopement drills were conducted on 6/20/24 for the 2 pm-10 pm shift and 10 pm-6 am shift. An elopement d [TRUNCATED]

Based on interview and record review the facility failed to ensure all alleged violations involving neglect were reported immediately or no later than 24 hours after the allegation was made for 2 of 7 residents (CR#1 and Resident #2) reviewed for reporting in that: -The facility failed to report to the State agency CR #1's fall incident with serious injury (a left distal clavicle fracture) resulting in hospitalization on [DATE]. -The facility failed to report to the State agency Resident #2's incident of ingesting a non-food item and was transported via emergency services for hospital treatment. These failures could affect all residents and could result in undetected neglect and emotional distress leading to serious harm/injury. Findings included: Record review of CR #1's face sheet dated 6/20/24 revealed a [AGE] year-old male admitted on [DATE]. His diagnoses included Parkinson's disease with dyskinesia (a disorder of the central nervous system that affects movement, often including tremors), quadriplegia, parkinsonism, cognitive communication deficit, abnormalities of gait and mobility, repeated falls, muscle wasting and atrophy, lack of coordination, major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), post-traumatic stress disorder (PTSD), attention-deficit hyperactivity disorder (ADHD), right-side maxillary fracture, right-side fracture of other specified skull and facial bones, multiple fractures of ribs left-side, insomnia, osteoarthritis of hip, depression, and orthostatic hypotension (a decrease in systolic blood pressure or a decrease in diastolic blood pressure within three minutes of standing when compared with blood pressure from the sitting position). Record review of CR #1's quarterly MDS dated [DATE] revealed a BIMS score of 13 indicating he was cognitively intact. The MDS documented he had no potential indicators of psychosis, behaviors affecting others, or rejection of care. Per the MDS CR #1 used a wheelchair for mobility. The MDS revealed he was independent for most ADL's and needed setup or clean-up assistance with eating, showering, and shower transfers. The MDS documented CR #1 had two or more falls with no injury and two or more falls with injury. Per the MDS CR #1 was on antipsychotic and antidepressant medications. The MDS documented CR #1 received OT and PT services. Record review of CR #1's care plan dated 3/22/24 revealed a focus for falls related to unsteady gait and tremors from Parkinson's disease, continued to be non-compliant with safety measure. Interventions included blood work as ordered by MD status post fall, orthostatic, take BP lying/sitting/standing x3 days, urine analysis with reflex cultures, wheelchair for long distances and walker for short distances, neuro-check, transfer to ER for evaluation, use wheelchair for safety measure, therapy to evaluate and treat as indicated, anti-tippers on wheelchair and rollator, therapy to address safety awareness while opening and closing door to exit/enter his room, encourage to use call light for staff assistance with ambulation and care needs, anti-grip high traction tape to restroom floor, remind resident to use his walker while in his room for safety precautions and staff to ensure secure/safe location to access toilet tissue within safe reach. Record review of CR #1's progress note created by RN A dated 3/5/2024 read, nurse was called into CR #1's room. CR #1 was in restroom and assisted back to bed, CR #1 verbalized 'when I tried to grab a tissue roll from the top of the cupboard, I lost balance and slipped and hit my head on the floor' He is alert and oriented. Skin tear seen on back of the head with mild bleeding. Pressure was applied using gauze dressing and bleeding was controlled. Skin tear seen on both elbows with mild bleeding. CR #1 is conscious. 911 was called and CR #1 was taken to VA hospital. NP, DON, and RP notified. Record review of incident report dated 6/21/24 revealed a fall incident for CR #1 on 3/5/24. Record review of the HHSC TULIP reporting system revealed no self-report for CR #1's fall incident on 3/5/24. Attempted interview on 6/19/24 at 3:32 p.m. to complainant was unsuccessful. Interview on 6/21/24 at 12:45 pm, with the DON, she said CR #1 had fallen many times. She said for every fall he had they would update his care plan. The DON asked this Surveyor if they were supposed to call the state for every fall. The DON said staff made sure Resident #1 was given extra toilet paper rolls to prevent him from getting up on his own. She said CR #1 was non-compliant and would not use his wheelchair. She said CR #1 tried to be independent but with his Parkinson's he would fall. The DON said the Administrator normally reported to the state. The DON said she received guidance form the Corporate Nurse and the Administrator for self-reporting. She said they normally reported injuries of unknown origin. Record review of Resident #2's face sheet dated 6/21/24 revealed an [AGE] year-old male admitted on [DATE]. His diagnoses included dementia with agitation, fatigue, difficulty in walking, lack of coordination, dysphagia (difficulty swallowing foods or liquids), cognitive communication deficit, post-traumatic stress disorder (PTSD), congestive heart failure, major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), insomnia, malignant neoplasm of prostrate, hyperlipidemia (a condition in which there are high levels of fat particles in the blood), obstructive sleep apnea, and hypertension. Record review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS score of 00 indicating a severe cognitive impairment. The MDS documented Resident #2 had no potential indicators of psychosis, behaviors affecting others, or rejection of care; Resident #2 used a wheelchair for mobility and required one person assistance with ADLs. He was on a mechanically altered diet and antiplatelet (prevent blood clots from forming) medication. He received ST, PT, and OT services. Record review of Resident #2's care plan revised on 4/17/24 read, Focus on Resident #2 placing non-food items in mouth. Interventions: staff to ensure to keep non-food items are out of reach and not left out, room sweep of all rooms on POD to ensure all personal care items are in a secured cabinet, keep all non-food items out of resident's reach as possible, notify physician as needed, observe for signs and symptoms of aspiration. Focus: Resident #2 is at risk for aspiration pneumonia related to diagnosis of dysphagia. Interventions: diet as ordered, elevate head of bed during meals or have resident upright in chair, notify physician as needed, observe for and report signs of aspiration, thickened liquids as ordered. Focus: depression. Resident #2 at risk for mood/behavior problems. Interventions: social services as needed, observe for change in mental status, observe for signs and symptoms of depression, psyche consult as ordered. Record review of Resident #2's progress note created by LVN A dated 5/17/2024 CNA informed nurse that shampoo was seen on the floor in resident's room and shampoo bottle was sitting out on dresser. Veteran then was observed vomiting several times while sitting up in wheelchair a soapy like substance. Veteran unable to describe what happened. Veteran assessed immediately. 911 called for transport to ER. RP notified of transport. MD, RN supervisor, and DON notified. Veteran transferred to VA hospital. Interview on 6/20/24 at 2:52 p.m., with Resident #2's family member, she said on 5/17/24 there was a bottle of shampoo left on the resident's food tray and the resident drank the shampoo. She said she didn't know where the bottle of shampoo came from. She said the resident was hospitalized and was brought back to the facility same day at night. She said Resident #2 was sent back to the hospital on 5/20/24 because his health was declining. The doctor at the hospital told her Resident #2 had chemical pneumonia. She said Resident #2 came back to the facility on [DATE] and was put on a puree diet. Interview on 6/21/24 at 12:50 p.m. with the DON, she said they were unsure if Resident #2 drank the shampoo, but they assumed he drank the shampoo. She said Resident #2 was already throwing up and CNA C saw the shampoo bottle on the floor. She said they were unsure how long Resident #2 was vomiting. She said CNA C got Resident #2 up to get dressed for breakfast. She said CNA C went to another room to assist another resident and when he returned, he saw the shampoo bottle on the floor. The DON said CNA C took Resident #2 to the dining room area and the resident began vomiting. Follow-up interview on 6/23/24 at 10:00 a.m. with CNA C, he said he woke Resident #2 to get him ready for breakfast. He said he went to another resident's room to assist and when he returned Resident #2 had a white foaming substance on his mouth and his shirt that looked like shampoo and he was throwing up. He said he saw a bottle of shampoo on the floor of the resident's room, and it was not there when he left the room earlier. He said he saw the drawer by his bed open and thought Resident #2 got the shampoo out of the drawer. CNA C said he thought a family member may have brought the shampoo and put it in the drawer. Record review of incident report dated 6/20/24 revealed an incident under section 'Other incidents' for Resident #2 on 5/17/24 at 6:00 am. Record review of the HHSC TULIP reporting system revealed no self-report for Resident #2's accident on 5/17/24. Interview with the Administrator on 6/23/24 at 12:40 p.m., he said the incident involving CR #1 and Resident #2 were not reported because these incidents did not meet the qualifications for reporting. He said he received guidance from Veterans Affairs (VA). He said the risk to the resident was staff would not be educated on what they were doing. Record review of the Abuse Reporting policy titled: Abuse Reporting dated October 2022 read in part . Procedure: 3. The facility will have a process in place to report allegation or abuse, neglect, exploitation, or mistreatment including injuries of unknow origin and misappropriation or resident property, and suspected crimes to the required agencies immediately or no later than two hours after the allegation is made if the event that cause the allegation involve abuse or result in serious bodily injury. 4. The facility will have a process in place to report allegations of abuse, neglect, exploitation, or mistreatment including injuries of unknown origin and misappropriation of resident property, and suspected crimes to the required agencies within twenty-four hours of identification if the event that cause the allegation do not involve abuse or result in serious bodily injury .

Based on observations, interviews, and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 12 residents (Resident #1) reviewed for quality of care. LVN A failed to ensure Resident #1's scalp wound was treated and dressed as ordered by his physician. This failure could place residents with skin injuries at risk of worsening skin injury, infection, and pain. Findings include: Record review of Resident #1's face sheet revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included sepsis (a life-threatening condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence), cognitive communication deficit (problems with communication that have and underlying), squamous cell carcinoma (abnormal, accelerated growth of squamous cells) of the skin of the scalp and neck, congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), and muscle wasting and atrophy (decrease in size of muscle tissue). Record review of Resident #1's MDS dated [DATE] revealed he had a BIMS score of 14 (cognitively intact); he had no behaviors; he required extensive physical assistance from at least two staff for bed mobility, transfers, dressing, toileting, bathing, and personal hygiene; he was wheelchair bound; he was frequently incontinent of bowel and occasionally incontinent of bladder; and he had two unhealed stage 3 pressure sores (full thickness tissue loss - subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed). Record review of Resident #1's care plan dated 07/08/2023 revealed the following care areas: *Resident had actual impairment to skin integrity of the right ear due to cancer cluster. Goals included: Resident will have no complications [NAME] to cancer cluster of the right ear. Interventions included: Apply A&D Ointment to right ear everyday for skin treatment. Monitor for side effects of the antibiotics and over-the-counter pain medications. Monitor/document location, size, and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, and maceration to doctor. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudates and any other notable changes or observations. *Resident had behavior problem: non-compliant/refusal of care at times. Goals included: Resident will have no evidence of behavior problems. Interventions included: Anticipate and meet the resident's needs. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situation. Document behavior and potential causes. *Resident had fluctuations in cognitive function/impaired thought process due to mental and behavioral disorder. Goals included: Resident will be able to communicate basic needs on a daily basis. Interventions included: Keep routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion. Ask yes/no questions to determine needs. Communicate with resident and his family/caregivers regarding his capabilities and needs. Cue, reorient, and supervise as needed. *Resident's skin was fragile, and he was at risk for skin/pressure injury due to new or worsening skin condition, immobility, and incontinence; Cancer lesion of the scalp (01/25/2023) - resident refused to see dermatology because the lesion was not bothering him. Goals included: Resident skin injury will resolve without associated complications. Interventions included: Apply treatment as ordered. Follow community's practice for assessing skin, reporting skin concerns to charge nurse, doctor, resident or representative and follow skin protocol in place as indicated. *Resident had an actual impairment to skin integrity of the scalp due to cancer lesion. Goals included: Resident will have no complications due to cancer lesion of the scalp. Interventions included: Cleanse top of the scalp with normal saline/wound cleanser, pat dry, apply A&D Ointment and cover with dry dressing PRN. Encourage good nutrition and hydration in order to promote healthier skin. Monitor for side effects of the antibiotics and over-the-counter pain medications. Monitor/document location, size, and treatment of sin injury. Report abnormalities, failure to heal, signs/symptoms of infection, and maceration to doctor. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue, and any other notable changes or observations. Observation and interview with Resident #1 on 07/21/2023 at 11:45 a.m. revealed he was alert, oriented, and very hard of hearing. Resident #1 was in bed and had a large, irregular shaped wound on the top of his head with a dark-colored scab. Further observation revealed there was no dressing covering the scalp wound. A follow-up observation and interview with Resident #1 on 07/21/2023 at 2:30 p.m. revealed his scalp wound was dressed and appropriately dated. Resident #1 stated the nurse came in a while ago to put a dressing on his head. He said he could not recall if the nurse attempted to cover his scalp wound earlier that morning (07/21/2023). Record review of Resident #1's physician's orders revealed the following orders: *Cleanse top of scalp with normal saline/wound cleanser, pat dry. Apply A&D Ointment and cover with dry dressing every MWF, every day shift every Monday, Wednesday, and Friday for wound treatment. Order date: 06/29/2023. Start Date: 06/30/2023. *Cleanse top of scalp with normal saline/wound cleanser, pat dry. Apply A&D Ointment and cover with dry dressing PRN, as needed for wound treatment. Order date: 06/29/2023. Start Date: 06/29/2023. Record review of Resident #1's TAR for July 2023, printed on 07/21/2023 at 1:44 p.m. revealed the following: Cleanse top of scalp with normal saline/wound cleanser, pat dry. Apply A&D Ointment and cover with dry dressing every MWF, every day shift every Monday, Wednesday, and Friday for wound treatment. The entry box for 07/21/2023 was checked and initialed by LVN A, indicating the treatment was completed. In an interview with LVN A on 07/21/2023 at 12:15 p.m., she stated Resident #1 had orders to apply A&D ointment and cover his scalp wound with a dressing, but if she covered it, it would get mushy and would go in the wrong direction (get worse). LVN A stated Resident #1's current orders said to put a dressing on the scalp wound all the time. She said they were leaving it open before, as previously ordered by his doctor. She said Resident #1's scalp wound, and an ear wound were reoccurring due to cancer, so she was very familiar with treatments. She said she dealt with the wound daily, so she knew when it was not good to dress it. She said it was best to leave the wound open to the air so it would not accumulate moisture. She said that was what she did with his scalp wound. She said sometimes Resident #1 wanted a dressing on the scalp wound, and sometimes he did not. She said Resident #1 would tell her what to do and to not do. She said if a resident said to stop, that was what she did. She said when she did Resident #1's wound care earlier on 07/21/2023, she cleansed the scalp wound and was about to apply the dressing when he told her to stop. She said Resident #1 did not want her to put the dressing on. She said she would leave the wound open and return before the end of her shift to complete the treatment. LVN A stated Resident #1's family member complained about the resident's scalp wound not being covered when she visited, but she (LVN A) told the family member all she (LVN A) could do was chart that he did not want the dressing on there. She said Resident #1's scalp dressing was on the majority of the time when his family member visited. She said sometimes, Resident #1 did not want the dressing on his scalp when she initially attempted, and he told her to come back later. LVN A said she documented when Resident #1 did not allow her to apply a dressing on the scalp wound all day. She said if Resident #1 initially said no but allowed her to dress the wound later in the same day, she did not document in his notes. She said she completed Resident #1's other wound care earlier (on 07/21/2023), but she would return later to complete the scalp treatment. She stated Resident #1 never experienced a negative outcome from not having his scalp wound dressed. Record review of Resident #1's progress notes in the facility's computer system for June 2023 and July 2023 on 07/21/2023 at 12:30 p.m. revealed no documentation to indicate Resident #1 refused any wound care treatment or asked LVN A to return later to complete a wound care treatment. In a telephone interview with Resident #1's family member on 07/21/2023 at 2:00 p.m., she stated she visited Resident #1 regularly and there was often no dressing on his scalp wound. She stated she spoke to LVN A about the dressing several times, but she (LVN A) fought her about it and would not but the dressing on. In an interview with the DON on 07/21/2023 at 2:45 p.m., she stated Resident #1's scalp wound should have been dressed at all times and LVN A should have documented every time the resident refused the treatment even if he allowed her to complete the treatment later in the day. She stated Resident #1 never experienced a negative outcome from not having the wound covered. Record review of facility policy titled Treatment Administration dated June 2022 revealed, Policy: Treatment Administration, Responsibility: Licensed Nurse . Purpose: To provide treatment per physician's order. Procedure: 1. Review physician's orders for treatment . 30. Document the treatment on the treatment record as indicated.

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder and had a catheter upon admission, received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 (Resident #29 and #50) of 3 residents reviewed for incontinent care. -The facility failed to ensure Resident #29's foley bag and tubing was not placed on the floor. -The facility failed to ensure CNA C followed appropriate infection control procedures during foley care for Resident #29. -The facility failed to ensure Resident #50's foley bag was positioned below the bladder. These failures could place residents at risk for pain, infection, injury, and hospitalization . Findings included: Resident #29 Record review of Resident #29's admission face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included cerebral infraction (a result of disrupted blood flow to the brain), gastrostomy (used to provide a route feeding to the stomach ) dysphagia (impairment or difficulty in swallowing) and hypertension (blood is pumping with more force than normal through arteries). Record review of Resident #29's Admission MDS assessment, dated 05/22/23, revealed the BIMS score was 00, which indicated severely impaired cognition. Further review of the MDS revealed he required extensive assistance with one to staff assist with all ADL. The resident had an indwelling catheter. Record review of Resident #29's care plan initiated 05/17/22 and revealed the following: Resident#29 have indwelling foley catheter 18fr 10cc. I am at risk for complication. Intervention: check tubing for kinks each shift. Foley catheter care with perineal wipes and/or soap and water every shift and as needed. Record review of Resident # 29's order summary report for June 2023 reflected: foley catheter 18 FR 10 cc, change monthly and PRN one time a day starting on the 20th and ending on the 20th every month related to pressure ulcer of sacral region, stage IV, date initiated 0619/23. Observation on 06/20/23 at 10:45 a.m., it revealed Resident # 29's foley bag, foley cover and tubing were on the floor. Interview on 06/20/23 at 10:51 a.m., RN P said she observed Resident #29's Foley bag and tubing on the floor. She said the bag should not touch the floor to prevent infection. She said she had skills checked off for Foley care. Interview on 06/21/23 at 12:30 p.m., the DON said Resident #29's Foley bag and tubing should not touch the floor because it was an infection control issue which could cause UTI for the resident. Observation on 06/21/23 at 2:24 p.m., Resident 29's's Foley care was provided by CNA A, and CNA C revealed CNA C did not clean the Foley catheter during Foley care. Interview on 06/21/23 at 2:50 p.m., CNA A said CNA C did not clean the catheter when they provided foley care to Resident #29. She said Resident #29 could get an infection if the germs traveled back to the resident penis because it was inserted into his penis. Interview on 06/21/23 at 2:58 p.m., CNA C said she forgot to wipe the tube inserted into Resident #29, and it would be an infection control issue. CNA C said she did the skill check-off on Foley. She said she did not know why she did not clean the tube because it could cause a severe infection for Resident #29. Resident #50 Record review of Resident #50's admission face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included multiple sclerosis (a condition that affects brain and spinal cord), neuromuscular dysfunction of bladder (ack of bladder control due to brain, spinal cord or nerve problem ) dysphagia (impairment or difficulty in swallowing) and hypertension (blood is pumping with more force than normal through arteries). Record review of Resident #50's quarterly MDS assessment, dated 05/27/23, revealed the BIMS score was 06, which indicated severely impaired cognition. Further review of the MDS revealed he required extensive assistance with one to staff assist with all ADL. The resident had an indwelling catheter. Record review of Resident #50's care plan initiated 05/12/23 and revealed the following: Resident #50 required an indwelling foley catheter 16fr 10cc related to diagnosis of neuromuscular dysfunction of bladder. Intervention: change catheter per facility protocol or physician order. Record review of Resident #50's order summary report for June 2023 reflected: Foley catheter 16 FR 10 cc, change as needed related to neuromuscular dysfunction of bladder, Observation on 06/21/23 at 7:00 a.m. revealed Resident #50's was sitting in the dining room with two other residents on the same table, and her foley bag was hung on top of her wheelchair close to the resident's upper back. Observation on 06/21/23 at 7:00 a.m., RN A said the aide had placed Resident #29's Foley on the backrest of the wheelchair. She said the bag was hung above the bladder, and urine would flow back to Resident #50's bladder, which could cause a urinary tract infection. She said she had in-service and skills checked off for Foley care. She said the nurse monitored the aides and ensured they cared for the residents. She said she was unaware the foley bag was hung on the back of the wheelchair until now. During an interview on 06/21/22 at 1:29 p.m., the DON said Resident #50's Foley bag should be hung below the bladder, not above, so the urine would not flow back to the resident's bladder, which could cause infection. She said the ADON made random checks to monitor the nurse and the aides to ensure they provided care for the residents. Record review of the facility policy on Cather care for Male Revised: March 2023 read in part . Purpose . it is the policy of this facility to ensure residents with indwelling catheters receive appropriate catheter using proper technique . Procedure #12 . anchor catheter, hold securely and cleanse the tubing from the urethral open downwards .

Based on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 4 of 6 Staff (CNA S, RN A, Dietary Aide O, and Laundry Aide H) reviewed for infection control. - The facility failed to ensure CNA S followed proper hand hygiene during hydration. - The facility failed to ensure RN A followed proper hand hygiene and infection control procedure during g- tube medication administration for Resident #29. - The facility failed to ensure RN A followed proper hand hygiene and infection control procedure during ACCU CHECK for Resident #58, Resident #75, and Resident #92. - The facility failed to ensure Dietary Aide O did not wear gloves in the hallway. - The facility failed to ensure Laundry Aide followed proper hand hygiene when he demonstrated hand washing. These deficient practices could affect residents and place them at risk for infection, and reinfection. Findings include: Observation on 06/20/23 at 9:40 a.m. revealed, CNA S came out of room [ROOM NUMBER] and went into room [ROOM NUMBER] without washing her hand. Then she came out of the room with the resident water pitcher, went into the hydration room, filled the pitcher with ice and water, and returned to room [ROOM NUMBER]. CNA S came out of room [ROOM NUMBER] and still did not sanitize her hand. Interview on 06/20/23 at 9:46 a.m., CNA S said she should have sanitized her hand when she came out of one resident room before she went into another's and before she filled the water pitcher with ice and water. She said hands are sanitized to prevent the transfer of germs from one resident to another. She said she had in service on hand washing. Observation on 06/21/23 at 7:10 a.m., RN A did not sanitize or wash her hand before she popped medications for Resident #29. Observation on 06/21/23 at 7:25 a.m., RN A did not wash her hand before she donned gloves or disinfect the stethoscope bell before she auscultated and checked for g-tube placement. After administering the medication, she washed her hands and turned off the water faucet with her wet hands. Interview on 06/21/23 at 8:00 a.m., RN A said she was nervous and forgot to wash her before she started taking medication from the container and when she assessed Resident #29 g tube before she administered the medications. She said she forgot to dry her hands before she turned off the water tap. She said she could transfer germs to Resident #29 because she did not use proper infection control measures. Observation on 06/21/23 at 8:07 a.m., RN A administered inhalation treatment to Resident #13 in his room and left the resident's room without washing or sanitizing her hands. Interview on 06/20/23 at 8:10 a.m., RN A said she forgot to wash or sanitize her hand after she provided inhalation treatment for the resident. She said she could transfer germs to another resident. Observation and interview on 06/20/23 between 8:13 a.m. and 8:29 a.m., RN A wore one set of gloves without washing her hands or changing her gloves, provided an accu-check (blood sugar check) on three residents (Resident #58, Resident #75, and Resident #92) and administered insulin to Resident #58. RN A carried a box of alcohol wipes with lancets and a container of strips, and she placed it on the residents' tables without a barrier. Interview on 06/20/23 at 8:30 a.m., RN A said she forgot and did not realize she was wearing the same gloves when she did the accu - checks for the three residents. She placed the box on the residents' table and the dining room table, which could have transferred germs from one resident to another, an infection control issue. She said she should have washed her hands and checked gloves from one resident to another and disinfected the glucometer between each resident and had a barrier on the tables. She said she had skills checked off on blood sugar checks. Interview on 06/21/23 at 12:18 p.m., the DON said RN A should sanitize or wash her hands before she pouched medication from the blister or container Resident #29. She said she contaminated her hands when she turned off the water faucet with her wet hands. She said RN A should have removed her gloves and washed her hands or sanitized them before going to another resident because of infection control. Observation on 06/21/23 at 8:52 a.m., it revealed Dietary Aide O was walking in the hallway in POD C and had gloves on her hands. Interview on 06/21/23 at 8:52 p.m., Dietary aide O said she was not supposed to wear gloves on the hall because it was an infection control issue. Dietary aide O said she had a lot of work to do, so she forgot to remove her gloves and just finished serving all three halls in POD C. She said she had in service on PPE and hand washing. Interview on 06/21/23 at 3:52 p.m., the Dietary manager said Dietary aide O should not have worn gloves on the hall because of cross-contamination. Observation and interview on 06/21/at 3:40 p.m., it was revealed Laundry aide H washed his hands and dried his hands with a paper towel. He used the same paper towel with which he dried his hands, turned off the water faucet, and continued using the same paper towel to dry his hands until he got to the trash can and disposed of the paper towel. Laundry aide H shrugged his shoulder when asked why he used the same wet paper towel and continued to use it. He also did not respond when asked if he had in-service on hand hygiene. Interview on 06/21/23 at 3:48 p.m., the Laundry supervisor said Laundry aide H should have used a dry paper towel when he turned off the water tap which would have prevented his hands from being contaminated. Observation and interview on 06/21/23 at 3:50 p.m., it revealed three clear plastic bags with red napkins and four red napkins that were not in the plastic bag on the floor in the dirty section of the laundry room. Laundry aide H said the kitchen staff placed the napkins on the floor, which should be placed in the gray bin; he said it was an infection control issue. Interview on 06/21/23 at 3:56 p.m., the Dietary manager said her staff brought the napkins to the laundry room and placed it on the floor. She said the staff should not have left it on the floor because they have a trash can (gray) for the staff to put the napkin in. She said it was an infection control issue. Interview on 06/22/23 at 4:50 p.m., the DON said CNA S should wash or sanitize her before she left a resident room and wash or sanitize when she entered another resident to prevent the spread of germs. Record review of the facility policy on hand hygiene Revised: February 2020 read in part . it is the policy of the is facility that staff will perform hand hygiene to aide in the prevention of the transmission of infection . procedure #4 . pat your hand dry with paper towel and discard . #5 . turn off the faucets with a clean, dry towel and discard . Record review of the facility policy on gastrostomy tube medication administration Revised: October 2012 read in part . procedure: . #1 . wash or sanitize your hands . #4 . clean the bell of the stethoscope with an alcohol prep . Record review of the facility competency gastrostomy tube medication revealed RN A signed the paper on 04/13/23.

Based on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 2 medication rooms (Medication Rooms) 1 out of 2 nursing medication carts (nurse medication cart for POA A), and residents reviewed for medication storage. - The facility failed to ensure nurse cart did not have discontinued, opened undated and opened medication not stored in its original packet. - The facility failed to ensure the Medication Rooms (POD D and POD C) did not contain expired medication, and unlabeled medication not stored in he delivery packet - The facility failed to ensure RN A did not leave medications in a medication cup on top of the unlocked medication cart and unattended. - The facility failed to ensure RN A did not leave breathing treatment medication for Resident #13 in room for the resident to administer himself. These failures could place residents at risk of adverse medication reactions and infections. Findings Include: Observation on 06/22/23 at 2:18 p.m. with LVN W revealed the following medication in the nurse's cart: -Albuterol sulfate metered was not in the original packet which it was delivered in, -2 Albuterol sulfate HFA was opened, and it was not dated with open date, -E Swab transport system expired 05/03/23, -Sorbitol 15 gm/60 ml was discontinued and left in the cart. Interview on 06/23 at 2:20 p.m., LVN W said discontinued medication should be taken out of the cart because you do not want to give any resident discontinued medication. She said medication should be dated when opened to prevent residents from getting expired medication. She said the test result could be affected, and it might lead to misdiagnosis. Interview on 06/22/23 at 2:23 p.m., RN M said medications are dated to prevent giving residents expired medication. He said discontinued medication should be pulled from the cart to prevent the medication from being administered by mistake, which would cause medication error or may have a negative outcome for the resident. Observation on 06/22/23 at 2:40 p.m., with LVN E and LVN L for Medication room in D POD revealed the following expired medication: -Accu-check Avia test strips expired 04/07/23 and there was 7 boxes, -Accu-check 30 strips 10 boxes expired 04/27/23, -Fluorouracil cream was discontinued and it was in the shelf in the medication room, -Diclofenac sodium topical gel was not in the delivery packet and it did not have instructions on application instruction, -Diclofenac sodium topical 1% expired 06/17/23, -Diclofenac sodium topical 1% expired 04/15/23 Interview on 06/22/23 at 2:53 p.m., LVN E said medications that were discontinued should be placed in the discontinued box, and they should not be on the shelf to prevent the medications from being administered by mistake. She said all medications should be stored in their original packets to know the instruction for use, such as the temperature. Interview on 06/22/23 at 2:56 p.m., LVN L said the ADON or the pharmacy nurse should pull expired medications from the cupboard to prevent them from being administered to the residents because the medication had lost their potency. She said when a medication was discontinued, it must be pulled from the cart and medication room and given to the pharmacy nurse or put in the discontinued bin. She said if the medication was not pulled, the staff might give it by mistake, and it becomes a medication error. She said the medication should be stored in its delivered packet because it has the resident name and instructions; if it was not in its original packet, it could be given to the resident which it did not belong or the wrong dose. LVN L said the medication would not be effective. Observation on 06/22/23 at 3:10 p.m., with LVN Y and RN T in the Medication room in C POD revealed the following expired medication: -Levetiracetam oral solution 100mg expired 04/25/23, -Ultratuss(guaifenesin) expired 05/11/23, -two Artificial tears expired 04/10/2. At the same time, the following over the counter medications were open and inside the cupboard: -Walgreen Vitamin D3, -Daily Vitamin formula and Iron, -Vitamin E 180mg(400IU), -Century 21st D3 1250 mcg (50,000IU). Interview on 06/22/23 at 3:20 p.m., RN T said expired medications should be placed in the bin or given to the pharmacy nurse. She said the charge nurse should pull the medication from the self. RN T said expired medication could be administered to a resident if it was not pulled. She said the resident could have advised reaction action depending on what the medication was and decreased effectiveness. Interview on 06/22/23 at 3:49 p.m., LVN Y said opened over-the-counter medication should not be in the medication room because they do not know when it was opened, and the facility does not every carry those brands of over-the-counter medication. Interview on 06/22/23 at 5:03 p.m., the DON said the expired medication should be placed in an expired medication bin. She said it should be pulled so the nurses would not administer expired medication. She said if the expired medication was administered to a resident, it could cause an adverse reaction depending on the medication type. She said the medication should be stored in the original delivery packet because the order, instructions, and the resident's name are printed on the packet. Observation on 06/21/23 at 7:12 a.m. revealed that RN A left medications on top of the unlocked medication cart and went to the nursing station. -7:16 a.m. RN A left the unlocked medication cart with medications on the cart and went to the nursing and got a spoon. -7:20 a.m. RN A took 1 cup of medication into the resident room three seperate times until all the medications were in Resident #29's room. During the trips to the resident's room the medication cart was unlocked and had medication on top of the cart. -7:22 a.m. RN A left the cart unlocked and left the cart. Interview on 06/21/23 at 7:53 a.m., RN A said she was nervous, so she left the cart unlocked and the medications on top of the cart. She said the residents were walking around in the dining area close to the unlocked cart and medications on top of the cart. She said any resident could have taken the medication, and it could make the resident sick. She said the cart had all the medication the nurse should give for POD A. Observation on 06/12/23 at 8:07 a.m., RN A kept ipratropium bromide and albuterol sulfate 0.5/3mg per 3ml on Resident # 13's bedside table, and the resident took it and put it in his pocket. Resident #13 said he would administer it when he wanted. Interview on 06/21 at 8:07 a.m., RN A said she was unsure if Resident #13 could administer the breathing treatment himself. However, she left the medication for the resident because the nurses had been doing that. Interview on 06/21/23 at 1:04 a.m., the DON said RN A should not have left the cart unlocked and medication on top of the cart and walked away because the residents could get into the cart or taken the medication on top of the cart. She said the resident could have several side effects, such as a lower heart rate. She said she was unsure if Resident # 13 could administer his medication. Still, RN A should not have left medication for the resident without training on self-medication administration. Record review of the facility policy Omnicare, a CVS health company for medication and expiration dating of medications read in part procedure 3.3 . facility should ensure all medications . are securely stored in a locked cart . # 4 . facility should separate expired medication and stored separate from other medications until destroyed . #5 . facility should record the date opened on the primary medication container . #6 . facility should destroy and reorder medications . damaged or missing label . #13 .1 Bedside medication storage: . facility should not administer/provide bedside medications without physician/prescriber order .

Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 10%, based on 3 errors out of 28 opportunities, which involved 1 (Residents #29) of 5 residents reviewed for medication errors. -RN A failed to administer three medications scheduled for 8:00 a.m. during Resident #29's medication administration through a g-tube. This failure could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. Findings include: Record review of Resident #29's admission face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included cerebral infraction (a result of disrupted blood flow to the brain), gastrostomy (used to provide a route feeding to the stomach) dysphagia (impairment or difficulty in swallowing) and hypertension (blood is pumping with more force than normal through arteries). Record review of Resident #29's Admission MDS assessment, dated 05/22/23, revealed the BIMS score was 00, which indicated severely impaired cognition. Further review of the MDS revealed he required extensive assistance with one to staff assist with all ADL. The resident had a g tube. Record review of Resident #29's care plan initiated 05/17/22 and revealed the following: Resident#29 required tube feeding related to dysphagia and CVA. Intervention: flush tubing with 30 cc of water before and after medication administration. Record review of Resident # 29's order summary report for June 2023 revealed -Omeprazole powder, give 40mg via g - tube imitated 05/23/23 -Vitamin C give 1 tab via g - tube one tome a day via g - tube -Lokelma oral packet 5 gram give 1 packet via g- tube one a day related to hyperkalemia-initiated date 06/01/23. Every shift administers 10 to 15 ml of water between each medication, initiated date 05/15/23. Observation on 06/21/23 at 7:10 a.m. revealed RN A prepped and administered medication for 8:00 a.m. to Resident #29 but did not administer the following three medications: Lokelma oral packet of 5 grams give one packet, vitamin C, and omeprazole 40 mg was not given because it was left in the portion cup and in the syringe which was used to administer the medications. Interview on 06/21/23 at 1:31 p.m., the DON said if the medication was not given when it was scheduled, it would be considered a medication error, and Resident #29 may not get the desired outcome. Record review of the facility gastrostomy tube medication administration revised October 2012 read in part . medication to be administered through gastrostomy tube per physician' order . Record review of the facility Omnicare, a CVS health company read in part . facility staff should also refer to the facility policy regarding medication administration . Record review of the facility medication administration competency revealed RN A signed the competency on 4/13/23.

Based on observation and interview, the facility failed to ensure the call system was accessible to the resident at each resident's bedside for one (Resident #15) of twenty-two residents reviewed for call lights. -The facility failed to ensure the call light system in Resident #15's room was in a position which was accessible. This failure could place residents at risk of being unable to obtain assistance in the event of an emergency. Findings include: Record review of Resident #15's admission record revealed a [AGE] year-old resident admitted on [DATE]. The admission record documented he had diagnoses including dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life) diagnosed [DATE], psychotic disturbance (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) diagnosed [DATE], mood disturbance (affective disorders are a set of psychiatric diseases, also called mood disorders: the main types of affective disorders are depression, bipolar disorder, and anxiety disorder) diagnosed [DATE], anxiety (characterized by excessive fear and worry and related behavioral disturbances) diagnosed [DATE], cerebrovascular disease (conditions that affect blood flow to the brain), hemiplegia (paralysis of one side of the body) and hemiparesis(weakness on one side of the body), chronic kidney disease (a gradual loss of kidney function), Wegner's granulomatosis (autoimmune multisystem disease, which causes inflammation of blood vessels in nose, sinuses, throat, lungs and kidneys) with renal (kidney) involvement, COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), anemia (deficiency of healthy red blood cells in blood), arteritis (inflammation of blood vessels), hypertension (high blood pressure), cerebral infarction (a loss of blood flow to part of the brain-a stroke), delusional disorders (fixed, false conviction in something that is not real or shared by other people), gastrointestinal hemorrhage (bleeding that occurs from the digestive tract, from the mouth to the rectum), adjustment disorder (short term condition arising due to difficulty in managing the stressful life changes), hyperlipidemia (high cholesterol), muscle weakness, lack of coordination, muscle wasting (loss of muscle leading to its shrinking and weakening Loss of muscle leading to its shrinking and weakening ) and atrophy (progressive and degeneration or shrinkage of muscles or nerve tissues), dysphagia (difficulty in swallowing food or liquid), dysarthria (difficulty in speech due to weakness of speech muscles), major depressive disorder (mental health disorder having episodes of psychological depression) diagnosed [DATE], PTSD (mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations) diagnosed [DATE], and insomnia (trouble falling and staying asleep). Record review of Resident #15's quarterly MDS dated [DATE] with an ARD of 6/10/2023 revealed a BIMS score of 13 indicating a minimal cognitive delay. The MDS revealed Resident #15 he had no behavioral indications of psychosis, behaviors affecting others, rejection of care, or wandering or elopement behaviors. Per the MDS Resident #15 required two-person extensive assistance with bed mobility, transfers, toileting, and personal hygiene, supervision and two-person assistance with locomotion, and was totally dependent on two-person assistance with dressing. Per the MDS, he was totally dependent on staff for oral hygiene, toileting, bathing, dressing, and putting on and taking off footwear. The MDS revealed he was dependent on staff for rolling, transferring from sitting to lying positions, movement from sitting to standing, transferring from bed to chair or chair to bed, and toileting transfers, and he used a wheelchair. The MDS documented Resident #15 was frequently incontinent of bladder and always incontinent of bowel, and he was not using a toileting program. Record review of Resident #15's care plan revealed a focus on his call light use with interventions including instructing him on call light use and ensuring the call lights were within reach. Interview on 6/20/2023 at 10:48 AM with CNA A revealed she had been employed by the facility for approximately two months. CNA A said her primary responsibilities as a CNA were to care for the residents, assist them with ADLs, and assist residents with showers. CNA A said the residents' call lights should be placed in a location they can reach and press the button. CNA A said the position of the call light in Resident #15's room was inappropriate. CNA A said the call light should have been placed where he could reach. CNA A said if a resident's call light was not placed in a position the resident could reach the resident may not be able to call for help in an emergency. Observation on 6/20/2023 at 9:21 AM of Resident #15 revealed he was lying in his bed watching television. Resident #15's call light was placed at the end of his bed in a position he could not reach. Interview on 6/20/2023 at 9:21 AM with Resident #15 he said the facility staff often placed his call light where he could not reach it. Resident #15 said the staff responded to call lights when he could call them. He said this made him upset and concerned his needs would not be met when he could not reach the call light. Resident #15 said he did not have other concerns at that time. Interview on 6/20/2023 at 10:51 AM with LVN A, she said a resident's call light should be placed near the resident where a resident can reach it. LVN A said if a resident could not reach a call light, he/she may not be able to call for help in an emergency, and he/she would not be able to ask for help with routine activities. LVN A said the call light in Resident # 15's room was not in a position he could reach. LVN A said the call light should have been placed on bed, near his hands. Interview on 6/21/2023 at 3:05 PM with the DON, she said call lights should be placed where a resident is able to reach them. The DON said the facility expectation was that residents would be able to reach their call lights to call for assistance. Record review of the facility's Call Light System dated October 2019 revealed that the entire facility staff was responsible for implementation. The policy read in part .a functioning call light at each resident's bedside, toilet, and bathing areas to allow residents to call for assistance ., .staff will receive education related to the mechanism of the call light system ., .residents will receive education on how to call for assistance using the call light ., .residents will be evaluated for unique needs and preferences ., .special accommodations will be reflected in the resident's plan of care ., and .staff will report noted call light system problems .

Based on observation, interview and record review, the facility failed to ensure garbage and refuse was disposed properly for 2 of 2 dumpsters reviewed for garbage disposal. -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage. Findings include: Observation on 06-20-23 at 8:30 am, with the Food Service Manager revealed the facility's dumpster area, which was in the lot behind the dietary department had a 2 commercial -size dumpsters and the lids and doors were opened. Interview on 06-20-23 at 9:00 am, with the Food Service Manager she stated the dumpster lids always must be closed to keep vermin, pests, and insects out of the dumpster and from entering the facility. She also stated that she is responsible for all requirements be met in the Food Service Department. She will in-service the dietary staff on following Policy and Procedure for Garbage Disposal Record review of the facility policy and procedure dated June 1, 2019, revealed that outdoor storage shall be constructed to have tight fitting lids, doors or covers and stored in a manner that is inaccessible to insect and rodents with doors/lids kept closed and no waste outside.

Based on observation, interview, and record review the facility failed to ensure residents who need respiratory care were provided such care, consistent with professional standards of practice for 1 (Resident #13) of 3 residents reviewed for respiratory care. - The facility failed to provide Resident #13 appropriate nasal cannula for oxygen administration to prevent the prongs from hurting the resident's nostrils. - The facility failed to prevent Resident #13 from adjusting the oxygen setting on the concentrator. These failures placed residents who received oxygen therapy at risk of respiratory complications. Findings included: Record review of Resident #13's admission face sheet revealed an [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included dementia (loss of cognitive function, thinking,), chronic obstructive pulmonary disease, chronic respiratory failure, and hypertension (blood is pumping with more force than normal through arteries). Record review of Resident #13's quarterly MDS assessment, dated 06/14/23, revealed the BIMS score was 15, which indicated intact cognition. Further review of the MDS did not indicate the resident was on oxygen. Record review of Resident #13's undated care plan revealed Resident #13 required oxygen therapy to impaired gas exchange as evidenced by diagnosis of chronic obstructive pulmonary disease. Record review of Resident #13's Nurse Administration Record for June 2023 read continuous oxygen 3 liters per N/C every shift for oxygen, nurses signed-off on it. Record review of Resident #13's order review report for June 2023 read continuous oxygen 3 liters per N/C every shift for oxygen. Observation and interview on 06/20/23 at 11:12 a.m., revealed Resident #13's oxygen was set to 3.5, and Resident #13 said his oxygen should be set on 4L. Interview on 06/21/23 at 8:10 a.m., revealed the concentrator was set at 3.5 liters. RN A said she had not checked the setting on the concentrator, and she needed to know how many liters of oxygen the resident concentrator should be set, and she would find out and get back to the surveyor. She said the nurses should check the oxygen setting on the concentrator and sign off on the MAR. During an observation on 06/22/23 at 12:11 p.m. revealed Resident # 13's O2 was set at 3.5 L on the concentrator. During an interview on 06/22/23 at 12:18 p.m., Resident #13 said he changed the settings on the concentrator because prongs on the NC hurt his nose because they are long. He said it said when they changed from the shorter prongs, and he had told the nurses, and none of them had done anything about it. He said he increased the oxygen because he did not put the prongs all the way into his nostrils. Resident #13 said he told the nurses not to change the setting until they provided the old NC, which had been months. Resident #13 said he was not sure if he was getting more oxygen or not, but he was comfortable. During an interview on 06/22/23 at 12:19 p.m. RN M said he checked Resident #13 oxygen setting this morning but needed help remembering where it was set or what his order was on the MAR. RN A checked the setting with the surveyor and said it was on 3.5 L. RN M said, Let me tell you, I just checked the concentrator, and the resident had a NC but did not notice if it was inside his nostrils. He said he was unaware the resident had a problem with NC because this was his day working on POD A. He said if the resident kept changing the oxygen to a higher setting, it could cause the resident not to clear carbon dioxide. Interview on 06/22/23 at 12:32 p.m., LVN W said nurses had a check off on their screen, showing how much oxygen Resident # 13 should be on. She said if the resident complained the NC was hurting his nose, the nurse should get him another one, and if the facility did not have it, she would get with central supply to see if the facility would buy another type of NC. LVN W said the oxygen should not change without a doctor's order because it is medication. She said if they had an emergency, they could put oxygen on a resident, call 911, and notify the doctor. She said the adverse outcome would be that if the resident could not process the 02, it would increase the C02 level. LVN W said the nurse had not told her Resident #13 was adjusting his oxygen because the nurses monitored Resident #13 oxygen each shift. Interview on 06/22/23 at 4:46 p.m., the DON said the nurses should be checking the setting on the concentrator for Resident #13 because they signed off in the MAR. She said oxygen should only be changed with a doctor's order, and the nurses should have educated Resident #13 not to adjust the setting on the concentrator and the adverse reaction. She said the nurses had not told her Resident #13 was changing the oxygen, and the NC prong was hurting his nostrils. Record review of the facility policy on oxygen administration revised: February 2015 read in part . correct technique and standards of practice will be used with oxygen administration . .

Based on interview, and record review the facility failed refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for two (Residents #15 and #32) of six residents reviewed for PASRR. The facility failed to ensure an accurate additional PASRR Level I screening was completed for Residents #15 and #32. This failure could place residents at risk of not receiving necessary care and services in accordance with individually assessed needs. Findings included: Resident #15 Record review of Resident #15's admission record revealed a [AGE] year-old resident admitted on [DATE]. The admission record documented he had diagnoses including dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life) diagnosed [DATE], psychotic disturbance (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) diagnosed [DATE], mood disturbance (affective disorders are a set of psychiatric diseases, also called mood disorders: the main types of affective disorders are depression, bipolar disorder, and anxiety disorder) diagnosed [DATE], anxiety (characterized by excessive fear and worry and related behavioral disturbances) diagnosed [DATE], major depressive disorder (mental health disorder having episodes of psychological depression) diagnosed [DATE], and PTSD (mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations) diagnosed [DATE] Record review of Resident #15's medication record revealed he had prescriptions including Lidocaine external patch applied topically every 12 hours as needed for pain, Hydralazine HCI 100mg by one tablet three times daily for blood pressure, Lasix 20mg tablet once daily for edema, and Prednisone 5mg one tablet daily for inflammation. Record review of Resident #15's quarterly MDS dated [DATE] with an ARD of 6/10/2023 revealed a BIMS score of 13 indicating a minimal cognitive delay. The MDS revealed Resident #15 he had no behavioral indications of psychosis, behaviors affecting others, rejection of care, or wandering or elopement behaviors. Per the MDS Resident #15 required two-person extensive assistance with bed mobility, transfers, toileting, and personal hygiene, supervision and two-person assistance with locomotion, and was totally dependent on two-person assistance with dressing. Per the MDS, he was totally dependent on staff for oral hygiene, toileting, bathing, dressing, and putting on and taking off footwear. The MDS revealed he was dependent on staff for rolling, transferring from sitting to lying positions, movement from sitting to standing, transferring from bed to chair or chair to bed, and toileting transfers, and he used a wheelchair. The MDS documented Resident #15 was frequently incontinent of bladder and always incontinent of bowel, and he was not using a toileting program. The MDS noted no weight gain of more than 5% in a month. The MDS revealed he was at risk of developing pressure ulcers or injuries, but he did not currently have any. Per the MDS, Resident #15 had been administered diuretic medication seven of the previous seven days. The MDS documented Resident #15 received no therapeutic services. Record review of Resident #15's care plan revealed a focus on Resident #15's psychosocial wellbeing problem related to his anxiety with an intervention of removal from conflict to a sav environment for calming and venting feelings. The care plan included a focus on his self-care deficit with interventions including assistance with bathing, bed mobility, dressing, grooming, hygiene, incontinence care, mobility, and transfers. The care plan revealed a focus on Resident #15's dementia with interventions including a consistent routing, medication administration, and use of yes or no questions. The care plan revealed a focus on his memory plan with interventions including notification of change in condition, provision of choices, ensure voices are heard. The care plan revealed a focus on Resident #15's problematic manner of behaviors characterized by ineffective coping, verbal aggression, and loss of control with interventions including provision of additional time to process directions and requests, approaching from in front, ensuring staff do not express anger or impatience, removal from aggressive situations. Record review of Resident #15's PASRR 1 evaluation dated 12/6/2019 revealed the form was completed by the individual with power of attorney. The evaluation documented he had no mental illness, intellectual disabilities, and/or developmental disability in sections C0100, C0200, and C0300 of the form. Record review of Resident #15's PASARR 1 evaluation dated 1/27/2020 revealed the form was completed by Resident #15's family member. The evaluation documented he had no mental illness, intellectual disabilities, and/or developmental disability in sections C0100, C0200, and C0300 of the form. Record review of Resident #15's PASARR 1 evaluation dated 6/11/2020 revealed the form was completed by a director of case management at an acute care facility. The evaluation documented he had no mental illness, intellectual disabilities, and/or developmental disability in sections C0100, C0200, and C0300 of the form. Record review of Resident #15's Mental Illness/Dementia Resident Review form (Form 1012) dated 6/22/2023 revealed it was completed a physician. The form documented Resident #15 was not eligible for services due to a primary diagnosis of dementia. The form further documented Resident #15 was diagnosed with another unnamed mental illness disorder on 1/27/2020 and a mood disorder such as bipolar disorder, major depression, or another mood disorder on 7/30/2020. The form's section D related to nursing facility action, but it was not completed and had no signature. Observation on 6/20/2023 at 9:21 AM of Resident #15 revealed he was lying in his bed watching television. Resident #15 appeared clean and appropriately dressed. Resident #32 Record review of Resident #32' admission record revealed a [AGE] year-old resident admitted [DATE]. The admission record documented his diagnoses included cerebral infarction (a loss of blood flow to part of the brain-a stroke), bipolar disorder (serious mental illness characterized by extreme mood swings) diagnosed [DATE], altered mental status (an abnormal state of alertness or awareness), major depressive disorder recurrent (mental health disorder having episodes of psychological depression) diagnosed [DATE], schizoaffective disorder (mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder) diagnosed [DATE], and transient ischemic attack (brief stroke-like attack wherein symptoms resolve within 24 hours). Record review of Resident #32' medication record he had prescriptions including Trazadone 50mg 1/2 tablet (25mg) once daily at bedtime for major depressive disorder related insomnia and Carbamazepine 100mg twice daily for bipolar disorder and major depressive disorder. Record review of Resident #32's orders record revealed an indefinite order for psychological treatment dated 6/22/2021. The record documented an order for Carbamazepine therapy every six months dated 12/1/2020. Record review of Resident #32's quarterly MDS dated [DATE] with an ARD of 4/20/2023 revealed a BIMS Of 15 indicating minimal to no cognitive delay. The MDS documented he had no behaviors or indications of psychosis, no behaviors affecting others, no rejection of care, and no wandering or elopement behaviors. The MDS revealed Resident #32 was administered antidepressant and diuretic medications seven of the seven days prior to the assessment. Record review of Resident #32's care plan dated 4/4/2023 revealed a focus on his risk of social isolation due to depression, PTSD, and bipolar disorder with interventions including medication administration, psychological consultations, and monitoring for signs or symptoms of depression. The care plan documented a focus on his hypnotic/sedative mediations with interventions including monitoring for side effects, education on the medication, and monitoring for the targeted behaviors. Record review of Resident #32's PL1 dated 7/22/2020 revealed it was completed by his family member. The PL1 documented he had no mental illness, intellectual disability, and developmental disability in sections C0100, C0200, and C0300 of the form. Record review of Resident #32 Mental Illness/Dementia Resident Review form (Form 1012) dated 6/22/2023 revealed it was completed by a physician. The form documented Resident #15 was eligible for services as there was not a primary diagnosis of dementia. The form further documented Resident #15 was diagnosed with another unnamed mental illness disorder on 8/9/2020, schizoaffective disorder on 8/9/2020 and a mood disorder such as bipolar disorder, major depression, or another mood disorder on 11/2/2020. The form's section D related to nursing facility action noted a new positive PL1 was submitted on 6/22/2023. Interview on 6/23/2023 at 8:41 AM with Resident #32 said he had received therapy in the past. Resident #32 said he only received therapy when it was approved by the VA. Resident #32 said the VA typically approved therapy for two weeks at a time. Resident #32 said when he received therapy it was very beneficial. Resident #32 said he was not currently receiving therapy. Resident #32 the VA had stopped his therapy benefits. Resident #32 said he would like therapy because it was helpful. Interview on 6/22/2023 at 3:02 PM with The MDS Nurse revealed she was an LVN and had been employed by the facility for a little over one month. The MDS Nurse said her primary assignments were to complete the MDS assessments, some interviews, and ensure the PASARR 1 was completed for the residents entering the facility. The MDS Nurse said the PL1 was completed prior to the resident's admission in the facility. The MDS Nurse said if the PL1 was positive for ID, MD, or DD the local health authority would evaluate the resident for any services required. The MDS Nurse said if the resident was eligible for services, she would coordinate a meeting with the resident's family to coordinate services. The MDS Nurse said if a resident received a new diagnosis of ID, MD, or DD while in care at the facility, she would complete a new Mental Illness/Dementia Resident Review (Form 1012) to determine if a new PL1 was required. The MDS Nurse said if a new PL1 was required the facility would complete it, the local authority would evaluate the resident, and services may be offered. The MDS Nurse said the Form 1012 should be completed as soon as a new ID, MD, or DD diagnosis was determined. The MDS Nurse said a new Form 1012 should have been completed for both Resident #15 and Resident #32 prior to 6/22/2023. The MDS Nurse said Resident #15 would have been ineligible for a new PL1 due to a primary diagnosis of dementia, but Resident #32 would have needed a new PL1. The MDS Nurse said if the PASARR was not completed appropriately a resident may not receive services he/she were eligible for. Interview on 6/22/2023 at 3:32 AM with the DON and Admin, the DON said if a resident was admitted with a positive PL1, it was the responsibility of the local health authority to evaluate the residents. The DON said the local health authority determines if services are needed and the facility coordinates those services. The Admin said if a resident received a new diagnosis of ID, MD, or DD, they would not be eligible for a new P1 if the Form 1012 indicated a primary diagnosis of dementia or Alzheimer's disease, The DON said if a resident did not have the PASARR process completed appropriately he/she/they may not receive services necessary. The Admin said he did not know Resident #15 and Resident #32 had required a new Form 1012 and Resident #32 required a new PL1. The Admin said the Form 1012's for both Resident #15 and Resident #32 should have been completed prior to 6/22/2023. Record review of the facility's undated Preadmission Screening and Resident Review (PASRR) policy read in part .ensure each resident in a nursing facility is screened for mental disorder (MD) or intellectual disability (ID) prior to admission and that the individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs ., .the PASRR will be completed prior to admission ., .the PASRR determines the level of services required and specialized services ., and .a positive Level 1 screen necessitates an in-depth evaluation of the individual by the state-designated authority known as Level II PASRR .

Based on observation, interviews, and record review, the facility failed to ensure each resident had the right to make choices about aspects of his or her life in the facility that were significant to the resident for 1 (Resident #38) of 22 residents reviewed for self-determination. -The facility failed to respect Resident #38's refusal for a Covid-19 test. This failure could place residents at risk for being denied the opportunity to exercise his or her autonomy regarding things that are important in their life and decrease their quality of life. The findings include: Record review of Resident #38's admission record revealed a [AGE] year-old resident admitted on [DATE]. The record documented his diagnoses included Parkinson's disease (a condition that affects the brain and causes problems with movement, balance, and coordination), weakness, repeated falls, muscle wasting (a condition where muscles lose mass and strength, often due to diseases, aging, or inactivity) and atrophy (a progressive and degeneration or shrinkage of muscles or nerve tissues), osteoarthritis (inflammation of one or more joints)of the hip, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and orthostatic hypotension (a form of low blood pressure that happens when you stand up from sitting or lying down). Record review of Resident #38's medication record revealed prescriptions including Carbidopa-Levodopa 25-100mg three tablets five times daily for Parkinson's disease, Midodrine HCI 5mg one tablet by mouth twice daily for low blood pressure administered if systolic blood pressure was less than 100, Sertraline HCL 50mg one tablet by mouth once daily for depression, Aricept 10mg one tablet once daily for dementia, and Nuplazid 34mg one capsule daily for Parkinson's Disease. Record review of Resident #38's Quarterly MDS dated [DATE] with an ARD of 6/3/2023 revealed a BIMS score of 12 indicating minimal cognitive impairment. The MDS documented he had no signs or symptoms of psychosis, behaviors affecting others, wandering or elopement behaviors, or rejection of care. Per the MDS, Resident #38 required supervision and setup assistance only for bed mobility, transfers, walking, eating, toileting, and grooming, and required supervision but had only preformed the activity once or twice in the seven days prior to the assessment. The MDS revealed he was independent in moving from lying to sitting on the bed, transitioning from sitting to standing, rolling in the bed, transferring from a chair or the toilet, and walking. The MDS documented he was always continent of bladder and bowel and was not on a toileting program. Per the MDS he had no skin tears or skin injuries. Per the MDS he was administered antidepressants seven of the seven days prior to the assessment. Record review of Resident #38's care plan updated 6/24/2023 revealed a focus on his skin tear to the right inner forearm with interventions including assessing and measuring the injury, cleansing it with saline and wound cleanser, application of antibiotic ointment, notification of the physician and resident representative, and observations for signs or symptoms of infection or pain. The care plan documented a focus on his self-care deficit, falls, and skin concerns with interventions including medication administration, ADL care assistance, hand hygiene, and monitoring and notification related to change in condition. The care plan noted a focus on his risk for falls due to Parkinson's disease and walking behind a wheelchair with interventions including anticipation of needs, ensuring his bed was at appropriate height, encouragement to sit in the wheelchair, pain medication as ordered, and therapy and evaluation to treat his falls as needed. The care plan revealed a focus on Resident #38's use of anti-depressants with interventions including appropriate medication administration, monitoring for side effects, and a referral for psychiatric services for non-pharmacological interventions. Record review of a nurse's note dated 6/7/2023 revealed Resident #38 was observed at 9:21 PM and follow-up assessments were continued following a fall. The follow-up assessments included neurological checks. Per the note Resident #38 revealed no change in condition, delayed injury, or skin issues. Record review of a nurse's note dated 6/8/2023 revealed a head-to-toe assessment was completed for Resident #38 and no injuries were observed. A nurse's note dated 6/9/2023 revealed Resident #38 was first observed with a skin tear to the right arm on 6/9/2023 . There was no documentation of how the injury occurred. Record review of Resident #38's non-pressure skin tear assessment dated [DATE] revealed Resident #38 sustained a skin tear to the right arm, and his family and physician had been notified. There was no documentation on how the injury occurred. Record review of a questionnaire completed for Resident #38 dated 6/9/2023 revealed he had received a COVID test during the night of 6/8/2023 which he did not consent to receive. The questionnaire documented Resident #38 was held down by two to three people and was forced to have the COVID test completed. Per the questionnaire, Resident #38 was asleep when two to three people came into his room and forced him to receive the COVID test. The questionnaire revealed he had been handled rough or mistreated the previous evening. Record review of the PIR documentation revealed the provider investigation report (Form 3613-A) dated 6/15/2023. The report revealed an assessment which read in part .wound care nurse observed a skin tear on Resident #38's right inner forearm, 2 open areas 1.3 x 1.1 x 0 cm, and a 3.5cm red discoloration of the whole area . The report's provider response read in part .the CNA was suspended pending the results of the investigation ., the nurse obtained orders for normal Saline-Tiple ABT with a dry dressing MWF ., and .the RP, Physician, HHSC, Ombudsman, Regional [NAME] President of Operation, and the Clinical Consultant were notified ., and .the facility performed skin rounds . The report revealed a summary which read in part .Resident #38 said the alleged perpetrator that he did not want a covid test. Resident #38 stated that while he was in bed the (CNA) held his arm and gave him the Covid test. This alleged action caused a skin tear and bruise. Resident #38 report this incident and an investigation was initiated. The CNA was suspended pending investigation . and concluded . in conclusion the community found that the CNA failed to get consent from Resident #38 prior to performing the COVID test. This action resulted in a failure to maintain Resident Rights and Resident Dignity and Respect. The CNA has been terminated . Record review of an email between a former facility employee and The Admin dated June 9, 2023, at 3:49 PM read revealed the former facility employee had completed the COVID test on resident #38 after he had a Parkinson's Disease tremor. The email noted Resident #38 had allowed the former facility employee to complete the test after the tremor. Record review of an email from The WCN to The Admin on June 15, 2023, at 5:02 PM read on Friday, 6/9/2023, I was asked to reassess the skin of Resident #38. After assessing from head-to-toe, an observation of right inner forearm, 2 open 1.3 x 1.1 x 0 cm and 0.5 x 0.4 x 3.5 cm red discoloration for whole area. I asked Resident #38 'how did this happen?' He replied 'I was in my room, and someone came to take the Covid test, and I said no I don't want to do it anymore. Then they held my arms and did it and scratched me.' I responded with an apology of the incident and administered treatment to the area. Record review of a written statement from the SW read SW was doing a Life Satisfactory Survey and resident family member was present in the room, asking Resident #38, about the incident (Covid-Test). Resident #38 said, 'Two to three people held me down, while I was sleeping in my bed. They woke me up and two people were holding my leg, and the other was holding up my arm, and I had bruises.' Record review of a written statement dated 6/9/2023 at around 1300 completed by RN A read Resident #38 stated to this nurse he was given a Covid Test late last night and that a 'big black woman held me down to get it' Complete skin assessment done at that time. Record review of staff sign-in forms dated 6/9/2023 for Abuse/Neglect: Residents have the right to be free from abuse, corporal punishment, and involuntary seclusion. Abuse: willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish. Categories: crime, exploitation, involuntary seclusion, mental abuse, misappropriation, neglect, physical sexual, verbal abuse, deprivation of goods, serious bodily harm in-service training conducted on 6/9/2023 revealed sign-in forms documented for Pods A, B, C and D, housekeeping, and therapy. Record review of Former CNA A's personnel file revealed her hire date was 5/3/2022. Former CNA A's file included an Employee Counseling Form dated 6/19/2023 which revealed it was a Written Counseling 1 form related to a Significant failure of standards of work performance or service in circumstance warranting immediate termination, Failing to treat all patients and coworkers with dignity and respect, and On 6/8/23 Former CNA A failed to provide patient care in the manner that was consistent with the HMR/VSI service standards. The counseling form documented Former CNA A refused to sign the form. The employee record revealed an employee misconduct check dated 1/12/2023 with no bars to employment and no NAR bars to employment. Per Former CNA A's personnel file, she received training on resident abuse reporting, resident rights, PTSD, and understanding the veteran on 5/3/2022. Interview on 6/21/2023 at 3:15 AM with the Admin and DON, the Admin said when the facility was notified about Resident #38's allegations that he was forced to submit to a COVID test and sustained injury, the facility initiated an investigation. The Admin said the facility staff interviewed Resident #38 and he said someone attempted to give him a COVID test. The Admin said Resident #38 alleged that he sustained a skin tear when the staff performed the skin test. The Admin said Resident #38 alleged the incident occurred while he was in bed. The Admin said the facility completed a skin assessment and social worker assessment on Resident #38 and all the residents on the pod. The Admin said Resident #38 later alleged multiple people held him down causing the injury. The Admin said there was no indication there was anyone beside the one staff identified responsible for conducting Resident #38's Covid test. The Admin said former facility employee related she had completed the test. The Admin said the facility interviewed all the other residents in the pod, and none of the other residents had an issue with the method the COVID test was performed. The Admin said the CNA was fired due to failure to ensure the resident's rights were respected. The Admin said the CNA did not ask Resident #38 permission to perform the COVID test. The Admin said the CNA said she had waited for Resident #38's Parkinson's Disease tremor to stop. The Admin said the CNA never reported asking for permission to perform Resident #38's COVID test. The DON said Resident #38 reported telling the CNA not to perform the COVID test. The Admin said when a resident consents for a procedure a consent does not need to be signed. The DON said Resident #38 was insistent that he declined the COVID test. The DON said the CNA was terminated for this incident and other activities. The DON and the Admin said there was no corroboration of any abuse, neglect, and/or exploitation of Resident #38 during the incident. The DON said there was no indication Resident #38's skin tear occurred during the COVID test. Interview on 6/23/2023 8:35 AM with MA A revealed she had been employed as a medication aid by the facility for approximately two years. MA A said residents refuse medication on occasion. MA A said if a resident refuses medication she will report that to the nurse. MA A said residents have the right to refuse medication. MA A said residents have the right to refuse any care they wish. MA A said she had never forced a resident to receive care. Interview on 6/23/2023 at 8:41 AM with Resident #38, he said he would not discuss anything to do with his recent COVID test. Resident #38 said he had received five COVID vaccination shots in the past. Resident #38 said he received the vaccinations prior to living at the facility. Resident #38 said he would not answer any other questions related to the COVID test or any other questions. Record review of the facility's PIR revealed a witness statement completed by a former facility employee on 6/19/2023. The statement was three pages of hand-written notes. The statement read in part .Wednesday, June 7, 2023, upon arrival at work 10 PM to 6 AM shift I got a report that Resident #38, was found on the floor around the patio smoking area . The statement further read .and the nurse went outside to pick Resident #38, off the floor . The statement further read .the report I got was that Resident #38, had a bruise on his arm . The statement continued by indicating Resident #38 had allowed the former facility employee to conduct the COVID test and permission was granted. Record review of the facility's Abuse policy dated October 2022 read in part .each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion ., .residents must not be subjected to abuse by anyone ., the facility will ensure the resident is free from physical or chemical restraints ., any allegation of abuse will be immediately reported to the facility administrator ., .the facility will coordinate and communicate situations of abuse, neglect, misappropriation of resident property, and exploitation with the QAPI program ., and .revising the resident's care pan preferences because of an incident of abuse will be completed by the interdisciplinary team as needed . Record review of the facility's Resident Rights policy dated October 2022 read in part .the facility will inform the resident both orally and in writing in a language that the resident understands his or her rights and rules and regulations covering resident conduct and responsibilities during the stay in the facility ., .the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility ., .the resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice ., .the resident has a right to choose activities ., and .the resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident .

Based on interview, and record review, the facility failed to ensure the resident environment was free of accident hazards and failed to ensure each resident received adequate supervision and assistance to prevent accidents for one of 10 residents (CR #1) reviewed for accidents and hazards. CR #1 who was cognitively impaired and unable to walk due to previous fall with fracture was not provided effective interventions to prevent accidents and he sustained multiple unwitnessed falls and injures of unknown origin in the facility which included head/face lacerations, subdural hematoma, skin tears, and fractured clavicle . CR #1 was observed by a nursing staff crawling out of his room on the floor and staff failed to intervene and/or provide continued supervision to ensure his safety. CR #1 was able to continue crawling out of his room, across a living area, and then outside into a courtyard area unseen by staff until he was found by a staff member crawling on his hands and knees outside with a t-shirt and brief on approximately 45 minutes later. He was then not promptly assisted to ensure his safety due to 2 CNA's recording him for approximately one minute before aiding. CR #1 was not assessed by licensed nursing staff after he was brought back into the building to ensure he hadn't sustained any injuries while crawling from his room to outside, his physician and RP were not notified of incident, and facility staff failed to make any documentation in CR #1's record regarding the incident. CR #1's incident of crawling from room to outside area was not timely investigated by facility to prevent similar incidents from happening. Facility did not begin investigation into how CR #1 got out of the building or put interventions in place to ensure safety until three days later. CR #1 was no longer in the building once the investigation began due to him sustaining another unwitnessed incident the same morning which resulted from him crawling out of his bed again. CR #1 was found out of his bed attempting to stand up from crawling position by his bathroom door, staff found him with abrasion to the back of his head that was bleeding and was noted to have dried blood in his bed and on the wall, a hole was also noted in the wall behind the bathroom door with blood stains. CR #1 was transferred to the hospital where he was diagnosed with a worsened subdural hematoma and a fractured clavicle, he remained in the hospital and expected to return to the facility. An Immediate Jeopardy (IJ) was identified on 6/10/21. While the IJ was removed on 6/13/21, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. These failures placed residents at risk of incidents such as elopement or falls which could result in physical harm, injury, emotional distress, or even death. Findings included: Record review of CR #1's facesheet revealed an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included: orthopedic aftercare, trochanteric fracture of left femur, closed fracture, dementia without behavioral disturbances, [CONDITION(S)] of native coronary artery, [CONDITION(S)], mood disorder, muscle wasting and atrophy, lack of coordination, [CONDITION(S)], laceration to scalp, difficulty in walking, and [CONDITION(S)]. Record review of CR #1's Admission assessment dated [DATE] revealed he was at risk for falls and did not display exit seeking behavior. Record review of CR #1's nurses notes dated 1/28/21 at 1:15PM revealed in part, .alert to person only. Confused attempts to respond to simple command but nurse notes word salad . Record review of CR #1 care plan initiated on 1/28/21 revealed he was at risk for falls related to cognitive and mobility impairment. He had a fall at home that resulted to having left femur fracture and recent surgery. Intervention of floor mat placed on each side of the bed was noted to begin on 1/29/21. Anticipate and meet needs and keep call bell within reach as indicated was dated 1/31/21. Keep commonly used items close to resident for easy access was dated 1/31/21. Record review of CR #1's nurses notes dated 1/29/21 at 7:30AM revealed in part, .alert/oriented X 1, confused and non-compliant with safety measures . unable to bear 50% of weight to left lower extremity . Bed in lowest position with safety mattress on both sides of bed on floor . Record review of CR #1's nurses notes dated 1/29/21 at 9:02AM revealed in part, .Nurse notes resident climbing out of bed on the floor. Floor mattress in place on both sides of bed. Staff X 2 assisted resident back to bed. Bed in lowest position with safety mattress on both sides of bed. Call light placed in reach . He shows signs of not understanding simple verbal commands . Record review of CR #1's nurses notes dated 1/29/21 at 9:19AM revealed in part, Resident continues to attempt to get out of bed without assistance. Non-compliant with safety measures. Resident assisted from bed to wheelchair and brought outside of room to table. Nurse notes resident attempting to stand up multiple times from chair without assistance. Assisted to sit per staff on multiple occasions . Record review of CR #1's nurses notes dated 1/29/21 at 9:54AM revealed in part, .Nurse, CNA, and medication aide continue to alternate Veteran due to non - compliance of safety measures . Record review of CR #1's nurses notes dated 1/29/21 at 6:05PM revealed in part, .Nurse called to room per CNA, upon arriving to the room, nurse notes resident lying on abdomen with right side of face on floor. Nurse notes blood to diaper area. Resident catheter dislodged. Nurse notes red bruising to right cheek with some swelling. No bleeding noted. Incision to left hip remains intact . Veteran alert with eye open and does not respond to verbal stimuli . ROM of Bilateral upper and lower extremities preformed with good results. Call placed to physician regarding incident. Awaiting response . Record review of CR #1's nurses notes dated 1/29/21 at 7:05PM revealed in part, . resident with new order send to hospital due to fall for cat scan and x-ray of left hip per physician, RP notified via phone . Record review of CR #1's incident report dated 1/29/21 at 6:05PM revealed he was found lying on his abdomen with right side of face on floor. CR #1 was unable to say what happened and had a bruise (location not listed). Predisposing factor was ambulating without assistance. He was transferred to the hospital. Record review of CR #1's nurses notes dated 1/30/21 at 3:23AM revealed in part, . resident returned from ER . came back with antibiotic [MEDICATION(S)] 800/160mg for UTI . Record review of CR #1's nurses notes dated 1/30/21 at 6:06PM revealed in part, . at 10am resident was trying to fall out of the bed several times. Redirected and not effective. After 2 hours he slept for 2 hours. Then he wake up and trying to get out of the bed. Resident came from the hospital (previous shift) with [MEDICATION(S)] ds 1 bid X 7days for UTI . Will continue to monitor . Record review of CR #1's nurses notes dated 1/31/21 at 6:09AM revealed in part, .Veteran is status post new admit day 3/3 resident is having some trouble adjusting to community due to his cognitive impairment . Resident is status post fall day 2/3 he was sent out to the ER for his fall to have a CT scan which came back negative . Record review of CR #1's incident report dated 1/31/21 revealed at 2:00PM a CNA found the resident on the floor. The CNA assigned to the resident stated CR #1 was sleeping. She left to go check on her other assigned resident. Assessment revealed no injuries, resident unable to say what happened, he was assisted back to bed. Record review of CR #1's nurses notes dated 2/1/21 at 2:01AM revealed in part, . at 12:15am, staff heard resident stating help me get up and staff checked and found him on the floor in prone position. He did not hit his head. He was assisted by 2 staff in the wheelchair. He has a skin tear in the R elbow and appropriate treatment applied. Neuro vital signs done. MD, RP and DON notified . Record review of CR #1's incident report dated 2/1/21 revealed at 12:15AM, heard resident calling for help and found him on the floor in his room in prone position . He was placed in a wheelchair and assessed. There was no indication he hit his head on the floor. He had a skin tear on the right elbow and treatment nurse cleaned the area and applied treatment. Resident was unable to say what happened. Record review of CR #1's Fall risk tool dated 2/1/21 revealed his risk factors were previous falls and cognitive impairment. He had two falls in the last 30 days that happened in the evening. During the resident current fall he was, sleeping in his bed and so his sitter stepped out for a minute to get a water and then that is the time staff heard him saying help me get up and he is on the floor. Record review of CR #1 care plan initiated on 1/28/21 revealed he was at risk for falls related to cognitive and mobility impairment. Care plan area indicated it was updated on 2/1/21 with added intervention of PVC bed and low bed for safety. Record review of CR #1's nurses notes dated 2/1/21 at 4:40PM revealed in part, .Nurse notes resident crawling out of bed on to safety mattress. Resident assisted up from mattress per CNA x 2 . Resident encouraged to use call light when assistance is needed. Veteran shows no signs of understanding . Record review of CR #1's incident report dated 2/3/21 at 8:45AM revealed a CNA stated she found the resident on the floor. Resident was unable to give description of what happened. An assessment was completed by nurse, and no injuries were noted. NP and RP were notified. Record review of CR #1's Fall Risk Tool dated 2/3/21 at 8:45AM revealed his risk factors were previous falls, problem with gait and balance, incontinent, upper and/or lower body weakness, and cognitive impairment and he had falls within the last 30 days. Record review of CR #1's nurses notes dated 2/3/21 at 1:28PM revealed in part, . Resident has sitter at bedside due to non - compliance with safety measures . Record review of CR #1's Admission MDS dated [DATE] revealed a BIMS score of 0 out of 15 which indicated severe cognitive impairment. Further review of the MDS revealed he required extensive assistance with bed mobility, transfers, locomotion on and off unit, dressing, eating, and personal hygiene. He used a wheelchair as a mobility device. MDS also indicated CR #1 was a fall risk and had a fall history of 2 falls without injury and 2 falls with injury not major. Record review of CR #1's nurses notes dated 2/5/21 at 4:27AM revealed in part, .at 9.30pm (on 2/4/21) sitter notified that resident is on the floor. Writer is giving care to another resident at that time. When writer enter the room at 9.35pm, resident is crawling on the floor. Floor mat present on both sides. He has his lower bed already. Sitter said resident is sleeping and snoring while he left his room. He went to check another resident who is on fall risk and on observation. Then he came back to check CR #1, he is on the floor. He notified the nurse. CNAs are giving care to other residents at this time. When writer left his room after administering his medications at 9pm, resident is sleeping without any distress/discomfort. He is on low bed, floor mat present on both sides. Call light within reach. Full assessment done; no injuries/ bruises/ pain noted. Vital signs within normal limits. Assisted him back to bed X 2 person. Neuro check initiated and in progress. Supervisor notified. Continue with 1:1 observation. Sitter continue to monitor him . Record review of CR #1's incident report dated 2/4/21 at 9:30PM revealed resident was found on the floor, when nurse got to the room to assess him, he was crawling around on the floor. Assessment revealed he had no injuries. Resident was unable to say what happened. His one on one observation with sitter continued. Record review of CR #1's Fall Risk Tool dated 2/4/21 at 9:30PM revealed he was at risk for fall because of previous falls, problems with gait and balance, and takes hypnotics, antipsychotics, anti-depressants, antianxiety or neuroleptic medications. He had 4 falls in the last 30 days. During his current fall he was noted crawling on the floor. Record review of CR #1's nurses notes dated 2/5/21 at 11:28PM revealed in part, .sitter is there to monitor him at that time . Record review of CR #1's nurses notes dated 2/6/21 at 3:45PM revealed in part, .during unexpected visit at 2am, noted that resident is trying to get out of bed and pulling his Foley catheter. Redirected him several times. After sitter left at 12am, team members alternatively doing 1:1 observation on him. He follows the instructions. Writer played Spanish songs for him. He said, I Love music and stay in bed for a while. Then again started to get up from the bed. At 2.30 am, resident assisted to wheelchair by 2 staff and be on the dining room, watching TV. snacks and juice provided. Accepted well . Record review of CR #1's nurses notes dated 2/6/21 at 8:27AM revealed in part, . Resident lying in bed, sitter at bedside . Nurse notes red abrasion to forehead/scalp area. No bleeding or swelling noted. Denies pain upon palpation . Record review of CR #1's clinical revealed no record of fall or incident on 2/6/21 that resulted to abrasion to forehead/scalp. Record review of CR #1's nurses notes dated 2/8/21 at 5:50AM revealed in part, .during unexpected visit to the resident room, writer saw that resident was trying to roll from the bed. Redirected him to stay in the bed. Resident keep on doing that, not staying in the bed. Resident assisted to wheelchair by 2 staff. Thickened fluids and soft cookies provided, accepted well. Resident is in wheelchair and sitting in the living room at this time . Record review of CR #1's nurses notes dated 2/9/21 at 4:51AM revealed in part, 2/8 @8:30 pm received resident in his room lying down on his bed ALERT . upon entering resident room for medication administration at 12:45am (2/9/21) noted a blood stain on his pillow. Total assessment done noted laceration on his back of the head. Veteran was asked what happened, resident stated he fell early yesterday at 3:30pm in his room. Veteran head clean with normal saline and cover with gauze . Vitals are stable 122/65 67 97.4, 97 RA. NP called no response, text message sent to get an order to send veteran for evaluation. Don notified. Ambulance called and arrived and transferred resident to ER. RP notified . Record review of CR #1's Fall Risk Tool dated 2/9/21 at 12:45AM revealed resident was at risk because of previous history of falls and had falls within the last 30days. Record review of CR #1's nurses notes dated 2/9/21 at 9:37AM revealed in part, . Resident came back from the hospital at 7:20AM. Has 8 staples to back of the head . Record review of CR #1 care plan initiated on 1/28/21 revealed he was at risk for falls related to cognitive and mobility impairment. Care plan area indicated it was updated on 2/9/21 with added interventions of sent out to hospital for treatment of the laceration and ensure room has adequate lighting and calm quiet setting conductive for rest. Record review of CR #1's incident report dated 2/9/21 at 6:14PM revealed the resident was in bed and his brief was changed, pain medication was given, and water given while he was trying to get out of bed. He started resting in the bed. Housekeeping Supervisor saw the resident was crawling to the dining room from his room. Resident was assessed with no visible injuries. He was assisted to his wheelchair and back to bed. NP and RP were notified. Record review of CR #1's Fall Risk Tool dated 2/9/21 at 6:14PM revealed he was at risk because of previous falls, lower body weakness, and cognitive impairment. He had 6 falls within the last 30 days. Record review of CR #1's progress notes dated 2/9/21 revealed no mention of resident crawling from his room to the dining room. Record review of CR #1's progress notes dated 2/10/21 at 1:30AM revealed in part, . writer observing the resident 1:1, after the sitter left at 12:30AM . Record review of CR #1's progress notes dated 2/10/21 at 4:00AM revealed in part, . At 4am while watching resident, resident trying to roll over the bed. He refused to stay in the bed. He hit the nurse while try to dress the resident. Call for help, CNAs was helping other residents. Assisted him to wheelchair by 2 staff. Nurse sit with him to watch, because he keeps on try to get up from the wheelchair . Record review of CR #1's progress notes dated 2/10/21 at 8:16AM revealed in part, .Non-compliant with safety measures, continues to attempt to stand without assistance. Redirected on multiple times to sit in wheelchair. Eight staples counted to top of head (scalp) . Record review of CR #1's progress notes dated from 2/10/21 - 6/1/21 revealed no further mention of CR #1 having one on one supervision or an assigned sitter. Record review of CR #1's incident report dated 2/13/21 at 5:35PM revealed in part, .Resident was sitting in wheelchair and ate the dinner, after 30 minutes around 5pm transferred to his bed. He was resting in the bed. CNA went to feed the resident and after she came back and checked resident was on the floor foot of the bed. She called the nurse. Writer came in the room; resident was on the floor noted unresponsive. Shacked and called name, no response. Vital signs within normal limits. Called 911. Before 911 reach he start to respond to talk . Resident stated to paramedics that he is not feeling good. Hurting right shoulder . 911 was called and paramedic checked resident and checked his vital signs. Paramedics spoke with the RP and he accepted to resident stay in the facility. Record review of CR #1's Fall Risk Tool dated 2/13/21 at 5:35PM revealed he was at risk for falls because previous falls, problems with gait and balance, incontinent, gets up at night to void, upper and lower body weakness, use of a wheelchair. He had had falls in the last 30 days. Record review of CR #1 care plan initiated on 1/28/21 revealed he was at risk for falls related to cognitive and mobility impairment. Care plan area indicated it was updated on 2/13/21 with added interventions of encourage activity participation during daytime hours such as planned activities that promote physical exercise and stimulation. Record review of CR #1's progress notes dated 2/14/21 at 5:07AM revealed in part, . at 6:00PM (2/13/21), resident sitting in his wheelchair after fall happened on this evening. Resident keeps on trying to get out from the wheelchair. Assisted to bed by two staff. CNA watching resident throughout the night. No changes from his baseline status . Record review of CR #1's progress notes dated 2/17/21 at 9:00PM revealed in part, .resident was found on floor at bedside via CNA at this time resident is on fall mat in room at left side of bed lying on left side of body with laceration noted to left side of forehead resident was assessed vital signs obtained assisted to wheel chair via staff X 2, resident is alert but does not know how he fell , NP and RP notified of findings new order to send to resident to hospital for observation, DON notified and aware . Record review of CR #1's incident report dated 2/17/21 revealed he was found by a CNA at his bedside on fall mat lying on his left side. He had a laceration noted to the left side of forehead. Resident was unable to give description of incident and his predisposing situation factor was ambulating without assistance. Resident was transferred to the hospital. Record review of CR #1's Fall Risk Tool dated 2/17/21 revealed he had risk factors of previous falls, problems with gait and balance, incontinent, upper and/or lower body weakness, cognitive impairment, and takes 4 or more medications. He had unknown number of falls in the last 30 days that occurred during the day and night. For the current fall the resident was trying to walk and environmental factors was a bedside table. Record review of CR #1's progress note dated 2/17/21 at 9:30PM revealed 911 arrived and he was transferred to the hospital for observation. Record review of CR #1 care plan initiated on 1/28/21 revealed he was at risk for falls related to cognitive and mobility impairment. Care plan area indicated it was updated on 2/17/21 with added interventions of provide activity baskets such as pictures, folding items, baby clothes, reminiscing items to divert attention at high risk times for falls, pressure applied to the wound, cleanse and covered with dry dressing, resident was sent to hospital for further evaluation and treatment. Further review of the care plan revealed no further updates for fall interventions. Record review of CR #1's hospital records dated 2/25/21 revealed he was admitted on [DATE] and came to the hospital after a fall at nursing facility and he was found to have head laceration. CR #1 was noted to initially be treated for [CONDITION(S)] with antibiotics which were later discontinued due to clinical improvement. CR #1 was assessed to have Dementia and recurrent falls but appeared to be back at his baseline. He had [CONDITION(S)] which required fall precautions of 1:2 sitter due to high risk for falls. Record review of CR #1's progress notes dated 2/26/21 at 6:22PM revealed he returned to the facility from the hospital. Record review of CR #1's quarterly MDS dated [DATE] revealed a BIMS score of 3 out of 15 which indicated severe cognitive impairment. Further review of the MDS revealed he required extensive assistance with bed mobility, transfer, dressing, toilet use, and personal hygiene. He required limited assistance with locomotion on and off unit. He used a wheelchair for mobility device. Further review of the MDS revealed CR #1 had no falls since reentry. Record review of CR #1's progress notes dated 3/15/21 at 9:00PM revealed in part, .resident was found on left side of bed on floor mat at bedside lying on right side of body with cut noted to right side of forehead resident stated he was trying to get out of bed and walk but would not do it again resident denies any pain or discomfort, was assessed, vital signs obtained and assisted back to bed via staff X 2, RP NP ADON aware zero new orders at this time . Record review of CR #1's incident report dated 3/15/21 at 9:00PM revealed resident was found on floor on floor mat, he had a small cut to right side of forehead. Resident said he was trying to get out of bed and walk. NP, DON and RP notified, there were no new orders. Record review of CR #1's hospital records dated 3/17/21 revealed he was admitted on [DATE] and was admitted post fall with a small scalp laceration. CT of the head demonstrated, 9mm chronic Left convexity subdural hematoma with small acute component along lateral floor of anterior cranial fossa. Further review of the hospital records revealed he was discharged on [DATE]. Record review of CR #1's nurses notes dated 3/17/21 at 10:55PM revealed in part, .resident came from hospital at 6:05pm . CT result shows stable left convexity subdural, no increase in size or acute component . Record review of CR #1's nurses notes dated 3/27/21 at 3:53PM revealed, Nurse called to room per CNA. Upon entering room nurse notes resident on floor. Alert but not responding verbally. Head to toe assessment preformed. Based on above report x-ray of the right knee ordered still awaiting x-ray technician. Record review of CR #1's clinical record revealed no incident report or fall risk tool dated 3/27/21. Record review of CR #1's nurses notes dated 3/30/21 at 3:19PM revealed x-ray to right knee free of fracture and lytic or blastic [CONDITION(S)]. Record review of CR #1's nurses note dated 4/7/21 at 4:38PM revealed in part, .Therapist found resident laying under the window. Resident's bed is in lowest position on floor. Raised scab noted to left knee. Cleaned with normal saline, [MEDICATION(S)] and dry dressing applied. ADON and wound care notified . Record review of CR #1's incident report dated 4/7/21 at 7:45PM revealed a therapist notified nurse resident was under the window. The nurse entered the room and found the resident in supine position under the window. Resident was picked up from the floor and assessed which noted a raised scab to left knee. Wound was cleaned and resident was put in a wheelchair and brought into the day area where he could be seen for close monitoring. Record review of CR #1's NP progress note dated 4/13/21 revealed in part, .Staff also noted that patient repeatedly crawls on the floor . On [MEDICATION(S)] 15MG, will continue to monitor . Record review of CR #1's physician orders revealed an order for [MEDICATION(S)] 15MG started on 3/10/21 and was received through 5/31/21. Record review of CR #1's care plan dated 2/17/21 revealed he used [CONDITION(S)] medication [MEDICATION(S)] related to disease process (psychotic disorder with hallucinations due to known physiological condition). The interventions listed were to administer medications as ordered. Monitor/document for side effects and effectiveness. Consult with pharmacy, MD to consider dosage reduction when clinically appropriate. Monitor for target behaviors/symptoms and document per facility protocol. Record review of CR #1's clinical record revealed no monitoring for risks associated with the use of antipsychotic medication [MEDICATION(S)]. Record review of website www.MedlinePlus.gov (https://medlineplus.gov/druginfo/meds/a 3.html ) revealed in part, .[MEDICATION(S)] may cause side effects . dizziness, feeling unsteady, or having trouble keeping your balance . restlessness and falling . Record review of CR #1's nurses note dated 4/26/21 at 6:29AM revealed, Resident upper lip swollen resident unable to explain what happen. Ice applied. Resident is stable will continue to monitor. Record review of CR #1's incident report dated 4/26/21 at 7:05PM revealed nurse noticed swelling to residents' upper lip. The DON and Administrator came to assess and noted 1cm length and 0.5cm. Resident could not say what happened, NP and RP notified. Record review of CR #1's nurses note dated 4/26/21 at 7:23PM revealed, Writer noticed swelling in upper lip of the resident, reported to the DON, Administrator, they came and assessed the resident and noticed 1cm length and 0.5cm width skin tear and it got infected. It has to be seen by NP. Family aware of it. Interview on 6/3/21 at 5:57PM, CR #1's RP said she was anonymously sent a video on 6/1/21 of CR #1 crawling on his hands and knees outside with just a brief and t-shirt on. She said you could hear two people talking in the background who were recording. The RP said they felt disgusted that someone recorded CR #1 in that state and let him continue to crawl around while they recorded instead of immediately going to assist him. The RP said the video was marked as being recorded on Saturday, 5/29/21 at 7:03AM. The RP said they were never notified of CR #1 getting out of the building and him being found crawling around outside. The RP said this was an incident that should have been reported to them as it was unclear from the video how or what he was doing outside. The RP said there was not a wheelchair anywhere around in the video, so she voiced concern on how the resident was able to get outside because he is unable to walk. The RP said CR #1 has had repeated falls in the facility and should be under close supervision because he had fallen in the past and sustained a subdural hematoma and lacerations to the head. The RP said last month (4/26/21) they found him with his lips swollen and he had a small cut on his lips. The RP said he also had a cut on his nose, she stated it looked like he had been punched. The RP said the facility was unable to say how he got it. The RP went on to say CR #1 was now in the hospital. She said the facility claimed he had a fall the morning of 6/1/21 and was transferred to the hospital because he had an abrasion to the back of head. She said the hospital physician reported CR #1's subdural hematoma had worsened, and he had a possible fractured clavicle. The RP said the hospital was going to contact them back after they run some test to confirm. The RP said she went up to the facility after CR #1 went to the hospital to get him some clothes and found there was a hole in the wall behind the bathroom door with blood on it, along with other blood stains on the wall near his bed and his fall mat. CR #1's RP said they were concerned the resident could have been injured from what occurred on Saturday, 5/29/21 and he was just getting medical attention on 6/1/21. The RP provided copies of video recorded of CR #1 on 5/29/21 and pictures she took of CR #1's room. The RP also provided pictures taken of CR #1 on 6/2/21 while in the hospital which showed abrasion to the scalp and swelling to right neck area. The RP said they were not told CR #1 needed one on one supervision and did not know the facility had CR #1 on one on one supervision at any time during his stay at the facility. Review of video provided by CR #1's RP dated 5/29/21 at 7:03AM revealed a recording that started a distance away from CR #1. The video shows the recorder slowly approaching CR #1 as he was in a t-shirt with a brief on and socks. CR #1 was crawling in the grass on his hands and knees when the video begins, as the video continues the recorder stops moving towards CR #1 and stands stationary recording as CR #1 crawls from the grass onto the concrete with his hands and knees sliding on the pavement. CR #1 crawls over to a brick wall and starts to attempt to stand up from standing position. One person who was recording was then heard saying, oh my god and then another voice says, umm hmm, I got it good mama and the video continues. CR #1 was observed with a bandage to his left knee that had turned black covered in dirt and also observed a bandage to his left elbow. Once CR #1 had pulled himself up to be one knee as if he about to try and stand a voice was heard saying, okay let go and the video cuts off. The video reviewed was 51 seconds long. Record review of CR #1's clinical record on 5/29/21 revealed no documentation was completed, no progress notes, no incident report, no assessments, no care plan updates, no NP/MD notes, and no neuro checks. Record review of CR #1's progress notes dated 6/1/21 at 8:16AM written by LVN B revealed, During walking rounds resident was found on his knees pulling at the restroom door. Resident unable to give description of the incident due to baseline cognitive impairment. This nurse on duty completed a full body assessment on the resident, then assisted him x2 into wheelchair. Abrasion noted to back of head. No signs of pain or distress noted or verbalized. NP, Director of Nursing, and Responsible party notified. NP gave orders to send patient out to hospital for observation. Record review of CR #1's incident report dated 6/1/21 at 7:02AM completed by LVN B revealed during walking rounds CR #1 was found in his room on his knees pulling at the restroom door. Resident was unable to say what happened. Resident was assessed and noted with a skin tear to the top of his scalp. The NP was informed, and she ordered to send him out for observation. Record review of CR #1's hospital record dated