Every finding on record at Sandy Lake Rehabilitation and Care Center

Based on interviews and record reviews, the facility failed to ensure the resident participated in the development and implementation of his or her person-centered plan of care, including the planning process, the right to identify individuals or roles to be included in the planning process, the right to request meetings, and the right to request revisions to the person-centered plan of care for 1 of 8 residents (Resident #5) reviewed for Care Plan development and assessments. The facility failed to ensure Resident #5 participated in the development of her Quarterly Care Plan assessment. This failure could place residents at risk of their needs not being met. Findings include:Record review of Resident #5's Face Sheet, dated 08/18/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had diagnoses of End Stage Renal Disease (Kidney failure), and heart disease. Record review of Resident #5's Quarterly MDS Assessment, dated 07/15/25, reflected Resident #5 had an intact cognitive response with a BIMS score of 15. The Quarterly MDS Assessment reflected the resident required total assistance for ADL care and a treatment of hemodialysis (blood purifying). Record review #5's Comprehensive Care Plan, dated 08/12/25, reflected the resident's last care plan conference occurring on 03/18/25. In an interview on 08/17/25 at 11:50 AM, Resident #5 stated she had not had a care plan conference meeting in quite some time. She stated she was scheduled for a conference in June 2025, but it was canceled and never rescheduled. She stated she wanted to be a part of her care planning. In an interview on 08/18/25 at 11:41 AM, MDS Nurse C stated the social worker was responsible for setting up care plan conferences, but they did not currently have one, so the MDS nurses were responsible for scheduling the conference. She was advised Resident #5 stated she had not had a recent care plan conference and records indicated her last care plan conference occurred on 03/18/25 and her next conference was scheduled for 06/18/25, but it was canceled and never rescheduled. She stated she was unsure why the resident's care plan conference was canceled, and never rescheduled. She stated the resident's care plan conference was needed to ensure the resident, or their responsible party were aware of the plan of care and to get their buy-in of the care plan. In an interview on 08/19/25 at 12:53 PM, the DON was advised Resident #5's last care plan conference occurring on 03/15/25, and the resident stating that she had not had once since then. She stated she was in the hospital at the time, and the care plan conference was never rescheduled. She stated the social worker should have rescheduled the care plan conference, but it was overlooked. She stated the previous social worker was no longer at the facility. She stated going forward the resident will get her care plan conferences. She stated the importance of the resident getting the care plan conferences allowed her to express her needs, concerns, and obtain her input. Record review of facility's policy, CARE PLAN PROCESS, PERSON-CENTERED CARE (05/05/23) reflected The facility will coordinate the development of the person-centered care plan within the required timeframes. The IDT will invite participation from the resident and the resident's legal representative (if applicable). The IDT will document an explanation in the resident's medical record of the invitation, participation, or lack of participation of the resident and their resident representative if determined not practicable for the development of the resident's person-centered care plan. Residents will remain actively engaged in the person-centered care planningprocess and has the right to participate in the development of and be informed inadvance any changes to the person-centered care plan; see the person-centeredcare plan and choose to sign the care plan after significant changes.

Based on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment, receiving housekeeping services, and supports for daily living safely for 15 of 20 resident rooms on the 300 and 400 halls (Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15) reviewed for a clean and homelike environment. The facility failed to ensure Resident rooms #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15, were thoroughly cleaned and sanitized. This failure could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.Findings include: An observation on 08/17/25 at 11:11 AM of resident room [ROOM NUMBER] reflected the air condition vents had dirt stains and dust between the vents. An observation on 08/17/25 at 11:16 AM of resident room [ROOM NUMBER] reflected the air condition vents had dirt stains and dust between the vents and the air filters had thick dust. A night light, located on the bottom of a wall near the door entrance, and thick black stains and dust on the cover. The toilet in the bathroom had brownish stains on the inside bowl. The bottom of the bed frame had dirt and light brownish stains. An observation on 08/17/25 at 11:21 AM of resident room [ROOM NUMBER] reflected the bathroom had [NAME] stains on the wall near an assist rail. The soap dispenser on the wall had dark stains on the bottom of the dispenser. A night light, located on the bottom of a wall near the door entrance, and dark stains and dust on the cover. On the bottom of the door frame were brownish spots. An observation on 08/17/25 at 11:25 AM of resident room [ROOM NUMBER] reflected a night light, located on the bottom of a wall near the door entrance, and dark stains and dust on the cover. The toilet in the bathroom had brownish stains on the inside bowl. On the bottom of the door frame were brownish spots. An observation on 08/17/25 at 11:31 AM of resident room [ROOM NUMBER] reflected the air condition vents had [NAME] stains on and between the vents. A bedside table in the room had brownish stains along the bottom of the frame. The base of the toilet had brownish stains around the bolt. The bathroom floor had dark gray and brownish stains near and around the toilet. An observation on 08/17/25 at 11:34 AM of resident room [ROOM NUMBER] reflected the base of the toilet had brownish stains around the bolt. The bathroom floor had dark gray and brownish stains near and around the toilet. An observation on 08/17/25 at 11:38 AM of resident room [ROOM NUMBER] reflected the air condition vents had [NAME] stains on and between the vents. A night light, located on the bottom of a wall near the door entrance, and dark stains and dust on the cover. An observation on 08/17/25 at 11:41 AM of resident room [ROOM NUMBER] reflected the air condition vents had [NAME] stains on and between the vents. The base of the toilet had brownish stains around the bolt. The bathroom floor had dark gray stains near and around the toilet and the corners of the floor. An observation on 08/17/25 at 11:44 AM of resident room [ROOM NUMBER] reflected the air condition vents had [NAME] stains on and between the vents. The bathroom floor had dark gray stains near and around the toilet and the corners of the floor. An observation on 08/17/25 at 12:02 PM of resident room [ROOM NUMBER] reflected the mini fridge had reddish stains and dried of food inside the bottom of the fridge. The bathroom floor had dark gray stains near and around the toilet and the corners of the floor. An observation on 08/17/25 at 12:08 PM of resident room [ROOM NUMBER] reflected the mini fridge had grayish stains inside the bottom of the fridge. A bedside table in the room had brownish stains along the bottom of the frame. The base of the toilet had brownish stains around the bolt. The bathroom floor had dark gray stains near and around the toilet and the corners of the floor. A night light, located on the bottom of a wall near the door entrance, had dark stains and dust on the cover. An observation on 08/17/25 at 12:11 PM of resident room [ROOM NUMBER] reflected the base of the toilet had brownish stains around the bolt. The bathroom floor had dark gray stains near and around the toilet and the corners of the floor. The door frame had brownish spots along the bottom portion of the frame. An observation on 08/17/25 at 12:15 PM of resident room [ROOM NUMBER] reflected the base of the toilet had brownish stains around the bolt. The bathroom floor had dark gray stains near and around the toilet and the corners of the floor. The toilet in the bathroom had brownish stains on the inside bowl. An observation on 08/17/25 at 12:17 PM of resident room [ROOM NUMBER] reflected the air condition vents had [NAME] stains on and between the vents. The base of the toilet had brownish stains around the bolt. The bathroom floor had dark gray stains near and around the toilet and the corners of the floor. An observation on 08/17/25 at 12:23 PM of resident room [ROOM NUMBER] reflected the air condition vents had [NAME] stains on and between the vents. The base of the toilet had brownish stains around the bolt. The bathroom floor had dark gray stains near and around the toilet and the corners of the floor. The room floor had brownish stains near the bed and near a nightstand. In an interview on 08/19/25 at 12:10 PM, Housekeeper E stated she had been at the facility for 18 months. She stated she was assigned to clean the 300-hall. She stated they were to clean everything in the resident room, including the bathroom and shower stall. She stated the Housekeeping Supervisor had told her that the floor techs were to clean the air condition filters. She was shown pictures of the concerns observed in Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15, and she stated housekeeping was responsible for cleaning the areas mentioned. She stated not cleaning the areas could impact the resident's breathing. In an interview on 08/19/25 at 12:22 PM, the Housekeeping Supervisor stated he had been at the facility for 9 years. He stated the housekeeping staff used a checklist to clean the resident rooms. He was shown pictures of Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15. He stated they completed deep cleans daily and he spot checked the rooms. He stated he had the floor techs clean the air filters once a week. He stated he tried to strip the floors, but they had a challenging time getting the residents out of the room. He stated not thoroughly cleaning the resident rooms could impact their breathing. In an interview on 08/19/25 at 12:36 PM, the Administrator was shown pictures of the concerns observed in Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15. She stated she expected the resident rooms to be thoroughly cleaned. She stated not thoroughly cleaning the resident rooms could cause infections. Record review of the facility's policy on Safe/Comfortable/Homelike Environment (Revised 2022) reflected Housekeeping and Maintenance services include the cleaning, sanitization, and care for rooms and common areas of the facility to ensure that the facility is safe for all who reside, work, and visit.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of hazards as was possible for 1 (Resident #28) of twelve residents reviewed for accident hazard. The facility failed to ensure that a container of germicidal (substance that destroys germs and microorganism) wipes was not left inside Residents #28's room on 08/17/2025. This failure could prevent the residents from having an environment that was free from toxic chemicals. Findings include: Record review of Resident #28's Face Sheet, dated 08/18/25, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with neoplasm (abnormal mass of tissues that could be cancerous or not) of the kidney and bone and sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep). Record review of Resident #28's Comprehensive MDS Assessment (assessment used to determine functional capabilities and health needs), dated 07/17/2025, reflected the resident was cognitively intact (resident capable of normal cognition and needs little support) with a BIMS (screening tool used to assess cognitive status) score of 15. The Comprehensive MDS Assessment indicated that the resident had cancer and sleep apnea. Record review of Resident #28's Comprehensive Care Plan, dated 07/17/2025, reflected the resident had stage 4 carcinoma and sleep apnea. Observation and interview on 08/17/2025 at 9:59 AM revealed Resident #28 was in his bed, awake. It was observed that there was a container of germicidal wipes on the resident's bedside table. It was also observed that the container of germicidal wipes was near the CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) mask that was on the table. The resident said the container of germicidal wipes had been sitting on his table for some time. He said the staff would use it to clean some of the items inside his room. Observation and interview on 08/17/2025 at 10:12 PM, ADON B stated the container of germicidal wipes should not be inside Resident #28's room or any residents' room for that matter. She said it should not be close to any items used by the resident, like the CPAP mask, because the CPAP mask had contact with the resident's face when the resident was using it. She said it should be inside the cart the nurses' cart or the MAs' carts, locked. She said maybe, it was left by a CNA because they use it to clean the room. She said she would go to Resident #28's room and will get the container of germicidal wipes. She said the germicidal wipes had chemicals in it that could cause skin irritation that was why the staff used gloves when handling the wipes. She said it could also cause eye irritation and respiratory issues. She said it could affect the resident's condition because he was already immunocompromised. She said she would find out who left it inside the room and educate them. She said she would also initiate an in-service about not leaving anything that could be unsafe to the resident. She said she would also check the rooms of the other residents to see if there were any germicidal wipes left inside the room. In an interview on 08/17/2025 at 10:29 AM, CNA L stated he did not know who left the container of germicidal wipes inside Resident #28' room. He said he did not notice the container when he did his morning round. He said the container were usually inside the carts of the nurses or the MAs. He said it should be somewhere not accessible to the residents because they might touch or put it in their mouth and could cause harm to them because the wipes have chemicals on them. In an interview on 08/19/2025 at 11:28 AM, the Administrator stated the wipes should not be inside the residents' rooms because they were used to kill bacteria. She said if the wipes had chemicals in it that could be harmful. She said confused residents might touch it or visitors unknowingly thought the wipes were ordinary wipes that could be used to wipe the face. She said the expectation was that the staff would not leave the germicidal wipes inside the residents' room and that if they saw that somebody left it inside the room, they should get it and put it where it should be. She said she would coordinate with the DON and the ADONs to make sure nothing with chemicals were left inside the room or left somewhere accessible to the residents. In an interview on 08/19/2025 at 11:43 AM, the DON stated the germicidal wipes should be locked inside the carts and not be inside the residents' rooms. She said it should be secured inside the carts so that the residents would not be able to access the wipes that had chemicals on them. She said she was not sure what chemical was on the wipes but considering the wipes were used to disinfect, then the wipes could be harmful to the residents. She said confused resident might get hold of the wipes and wipe their face and body that could result to irritations. She said the expectation was for the staff to be mindful and never leave the germicidal wipes inside the residents' room. She said she would do an in-service about not leaving anything harmful to the residents and would make sure that they understood the outcome if a resident got hold of the wipes. The DON said it should not be placed close to the CPAP mask as the CPAP mask was used by placing it in the face. Record review of the facility's policy MEDICATION STORAGE Pharmacy Services Policies and Procedures revised 04/17/2024 revealed POLICY . biologicals are stored safely, securely . the facility will store all drugs and biologicals in locked compartments . biological supply is only accessible to licensed nursing personnel, pharmacy personnel or authorized staff members . potentially harmful substances (e.g. cleaning supplies and disinfectants) are clearly identified and stored away).

Based on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three (Residents #2, #28, and #71) of twelve residents reviewed for respiratory care. 1. The facility failed to ensure an Oxygen in Use sign was placed outside Resident #2's room on 08/17/2025. 2. The facility failed to ensure Resident #28's CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) mask was properly stored when not in use on 08/17/2025. 3. The facility failed to ensure Resident #71's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was properly stored when not in use on 08/17/2025 These failures could place residents at risk for respiratory infection and not having their respiratory needs met. Findings included: 1. Record review of Resident #2's Face Sheet, dated 08/17/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with shortness of breath. Record review of Resident #2's Quarterly MDS Assessment, dated 06/03/2025, reflected the resident had moderate impairment (resident may need additional support and monitoring) in cognition with a BIMS score of 10. The Quarterly MDS Assessment indicated the resident was receiving oxygen therapy. Record review of Resident #2's Comprehensive Care Plan, dated 07/30/2025, reflected the resident was on oxygen therapy and one of the approaches was to administer oxygen as per order. Record review of Resident #2's Physician Order, dated 05/01/2025, reflected O2 at __2__ liters per minute via nasal cannula. Observation on 08/17/2025 at 9:21 AM, revealed Resident #2 was in her bed with eyes closed. It was observed that the resident was on oxygen therapy at 2 liters per minute via nasal cannula. It was also observed there was no Oxygen in Use sign outside the resident's room. Observation and interview on 08/17/2025 at 9:41 AM, LVN F stated Resident #2 was using oxygen continuously. She said that if a resident was using oxygen, there should be an Oxygen in Use sign outside the resident's door so the staff and the visitors were aware oxygen was being used in the facility. She said the sign served as a reminder that they could not initiate any flame to prevent any untoward (unfavorable)incident such as fire and explosion. She went to the storage room, took a sign, and placed it outside the resident's room. 2. Record review of Resident #28's Face Sheet, dated 08/17/2025, reflected the resident was a [AGE] year-old male admitted on [DATE]. The resident was diagnosed with sleep apnea. Record review of Resident #28's Comprehensive MDS Assessment, dated 07/17/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had sleep apnea and was using CPAP. Record review of Resident #28's Comprehensive Care Plan, dated 07/17/2025, reflected the resident had sleep apnea and one of the approaches was CPAP as ordered. Record review of Resident #28's Physician Order, dated 08/07/2025, reflected Noninvasive Ventilation via CPAP. Parameter set at 12 cm H2O on RA Via Medium sized Face Mask to be Administered with O2 2l/ml via NC QHS & PRN During Naps. Observation and interview on 08/17/2025 at 9:59 AM, revealed Resident #28 in his bed, awake. It was observed that a CPAP mask was on the resident's side table unbagged. The resident said the nurses would put it on at night and would take it off. He said he could take it off but it would be hard for him to put it on the table because the table was far from him. He said he was using the CPAP even before he was admitted to the facility. Observation and interview on 08/17/2025 at 10:12 AM, ADON B stated Resident #28 used a CPAP when he was sleeping and when he was taking a nap. She said the CPAP masks should be in a plastic bag when not in use to prevent cross contamination and respiratory infection. She went inside the resident's room and saw the CPAP mask on the side table. She said she would clean it and would put it in a bag. She said she would also find out who took it off and left it on the table so they could be reminded of bagging the CPAP mask. She said she would start an in-service about bagging the CPAP mask. 3. Record review of Resident #71's Face Sheet, dated 08/17/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with shortness of breath. Record review of Resident #71's Comprehensive MDS Assessment, dated 08/15/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 09. The Comprehensive MDS Assessment indicated the resident was on oxygen therapy. Record review of Resident #71's Comprehensive Care Plan, dated 08/14/2025, reflected the resident had COPD (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and one of the approaches was oxygen as per order. Record review of Resident #71's Physician Order, dated 08/08/2025, reflected O2 at _2-4___ liters per minute via nasal cannula Every Shift - PRN. Observation on 08/17/2025 at 9:27 AM, revealed Resident #71 was in her bed with eyes closed. An oxygen concentrator was observed at bedside with a nasal cannula connected to it. The nasal cannula was not bagged and was hanging on top of the oxygen concentrator. Observation and interview on 08/17/2025 at 9:34 AM, LVN F stated Resident #71was on oxygen therapy, as needed. She went inside the resident's room and saw the nasal cannula hanging on top of the oxygen concentrator. She said the nasal cannula, should be bagged when the resident was not using them to prevent transfer of microorganisms that could eventually cause infection. She disconnected the nasal cannula and said she would get a new one and would place them in a bag. She said she did notice that the nasal cannula was not bagged when she did her morning round. In an interview on 08/19/2025 at 6:41 AM, ADON A stated it was her fault there was no Oxygen in Use outside Resident #2's room because she was the one responsible for checking who were the residents using oxygen and then placing the sign outside the rooms of resident using oxygen. She said the purpose of the sign was to remind the staff and the visitors not to light a cigarette or even a candle because oxygen was being used in the facility. She said nasal cannula should be stored properly inside a plastic bag if the residents were not using them to prevent respiratory infections or respiratory discomforts. She said the staff were responsible for ensuring all the breathing paraphernalia were clean every time the residents used them. She said the expectation was for the staff to be mindful and bag the nasal cannula and to check if there was an Oxygen in Use sign outside the door of residents that were using oxygen. She said she would start an in-service about oxygen administration. In an interview on 08/19/2025 at 7:16 AM, the DON stated the nasal cannula and the CPAP mask should be inside a plastic bag when not in use, and not just hanging around or on top of the table, to maintain its cleanliness as well as its patency. She said bagging the nasal cannula and the CPAP mask were important to prevent development of infections. She said if a resident was using oxygen, there should be an Oxygen in Use sign outside the door. She said the sign for oxygen use was to remind the staff and visitors to be careful not to cause any ignition that could cause fire. She said she was responsible for making sure the staff were bagging the nasal cannula and the CPAP mask and that they were placing a sign outside the door. She said she would re-educate the staff about the issues discussed and her expectations was that the staff would understand the in-services and would put them in practice. In an interview on 08/19/2025 at 7:32 AM, the Administrator stated everything that the residents were using for their respiratory issues should be kept clean to prevent cross contamination and respiratory infection. She said there should be a sign outside the door if a resident was using oxygen to avert any untoward incident such as fire. She said the expectation was that the staff would be compliant with the policies. She said she would coordinate with the DON and the ADONs to provide additional in-services and monitor their compliance. Record review of the facility's policy OXYGEN THERAPY Respiratory Policies and Procedures, dated 02/24/2024, revealed PROCEDURES . C. Check the patient's/resident's room to make sure it's safe for oxygen administration, place oxygen precautions sign on the door of the patient's/resident's room. Record review of the facility's policy EQUIPMENT CHANGE SCHEDULE Respiratory Policies and Procedures, dated 02/12/2024, revealed place in clean, dry plastic bag

Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals that met the needs of each resident for one of eight residents (Resident #3) reviewed for pharmaceutical services The facility failed to dispose of Resident #3's expired Duloxetine dated 11/17/2024. This failure could place residents at risk of not receiving the medication's full therapeutic benefits and the possible side effects of taking expired medications. Findings included: Record review of Resident #3's Face Sheet, dated 08/13/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with depression (persistent feeling of sadness or loss of interest). Record review of Resident #3s Comprehensive MDS Assessment, dated 06/03/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had depression. Record review of Resident #3's Comprehensive Care Plan, dated 08/14/2025, reflected the resident had depression and was being treated with antidepressant medication to manage symptoms. Record review of Resident #3's Physician's Order, dated 05/09/2025, reflected Duloxetine HCl 30 MG Capsule delayed release particles, 1 CAPSULE BY MOUTH ONE TIME A DAY. Observation on 08/18/2025 at 12:11 PM, revealed an expired duloxetine for Resident #3 was inside the medication cart. The date on the container of the medication was 11/17/2024. In an interview on 08/18/2025 at 12:13 PM, MA G stated Resident #3 was just transferred to hall 100 and it was her first time administering her medications. She said the resident had a blister pack for her duloxetine and that was what she used when she gave her morning medication. She said the expired one should not be inside the cart so that staff administering the medication would not mistakenly use the expired one. She said the effectiveness of the medication already diminished when it was expired or there could be adverse reactions from the expired medication. She said she would audit her cart to make sure there was no expired medications. she said she was responsible in auditing the cart that she was using. Observation and interview on 08/18/2025 at 12:14 PM, revealed ADON A saw Resident #3's expired medication and stated that particular medication should not be inside the cart because the medication was already expired. She said the medication was not from their pharmacy and must have been brought from the hospital when she was admitted to the facility and was just placed inside the cart without checking the date. She said expired medication inside the carts could be erroneously used and could cause reduced effectiveness or adverse effects to the organs of the body. She said the nurses and medication aides were responsible in ensuring there were no expired medication inside the carts. She said the resident was transferred to her hall the Friday prior and her medications were also transferred with her. She said the transfer of the medications were usually done from nurse-to-nurse, then the medications would be given to the medication aide. She said there were four sets of eyes, but no one noticed that one of the medications was expired. She said it should have been caught when the medication was still on the other cart. She took the expired medication from the cart and said she would dispose of the medications. She said the expectation was for the staff to check the carts for anything expired. She said she would audit the carts and would start an in-service about the issue. In an interview on 08/19/2025 at 6:27 AM, MA H stated he would administer Resident #3's medication when the resident was still on the other hall. He said he was responsible for auditing the cart that he was using. He said he was not aware one of the medications was already expired. He said he never gave the resident a medication from the container. He said expired medication could harm the residents. In an interview on 08/19/2025 at 7:16 AM, the DON stated expired medications should not be kept inside the cart so it would not be used for the resident, purposely or accidentally. She said the risk could be that the potency of the medication was already less and there might be harmful effects when an expired medication was used. She said she would tell the nurses and the medications aides to check all the carts for any expired medications. She would also ask the ADONs to check medication room just to be sure. She said she would start an in-service that no expired medication be inside the cart and said her expectation was for the staff to make sure that the carts would be audited and that expired medications were disposed accordingly. In an interview on 08/19/2025 at 7:32 AM, the Administrator stated the expectation was that there were no expired medications inside the carts and medication rooms and that the staff would be auditing the carts. She said she was not a clinician, but one thing she knew, expired medication cannot be used. She said she would coordinate with the DON and the ADONs regarding the expired medication. In an interview on 08/19/2025 at 12:41 PM, LVN K stated she did receive Resident #3 when she was transferred to her hall the Friday prior. She said she also received the resident's medication and handed them over to MA H. She said she could not remember if they were all blister packs or if there were containers with them. She said she should have inspected the medications given her to check if there were expired medications because it could harm the residents. Record review of the facility's policy MEDICATION MANAGEMENT PROGRAM Nursing Policies and Procedures, dated 01/15/2025, revealed Administering the Medication Pass . D. Checking for expiration dates and removing any expired products. Record review of the facility's policy MEDICATION STORAGE Pharmacy Services Policies and Procedures, dated 04/17/2024, revealed PROCEDURES . 12. Outdated, contaminated, or deteriorated medications . are immediately removed . disposed of according to procedures for medication destruction.

Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for one (Resident #70) of eight residents reviewed for medication administration. The facility failed to ensure RN C would not crush or dissolve Resident #70's Venlafaxine extended-release medication on 08/18/2025. These failures placed residents at risk of not receiving the full benefit of the medication. Findings included: Record review of Resident #70's Face Sheet, dated 08/18/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing). Record review of Resident #70's Comprehensive MDS Assessment, dated 07/28/2025, reflected the resident was cognitively intact with a BIMS score of 13. The Comprehensive MDS Assessment indicated the resident had a feeding tube. Record review of Resident #70's Comprehensive Care Plan, dated 07/28/2025, reflected the resident was at risk for aspiration due to presence of feeding tube and one of the approaches was to observe for signs of aspiration. Record review of Resident #70's Physician Order, dated 07/31/2025, reflected Enteral Feeding: Flush tube with 60 cc warm water before and after medication administration; 10 - 15 cc flush between each med. Record review of Resident #70's Physician Order, dated 07/29/2025, reflected RISK: choking, swallowing, aspiration, weight loss/gain, dehydration. Record review of Resident #70's Physician Order, dated 07/25/2025, reflected Venlafaxine 150 mg ER via gastric tube two times a day. Observation on 08/18/2025 at 7:28 AM, revealed RN C was about to administer Resident #70's medication via g-tube. She said she would be administering four medications for the resident. one of the medications she prepared was Venlafaxine 150 mg ER capsule. It was observed that the content of the capsule was in granules form. She poured water on all medications and stirred them with plastic spoon one by one. In an interview on 08/18/2025 at 8:57 AM, RN C stated she had a hard time with the last medication because the granules would not pass through the syringe. She said she tried to dissolve it but it would not dissolve completely. She said she would sometimes crush the medication so it would pass through the tube easier. She read the order for the medication and saw the medication was an extended release. She said extended-release medications should not be crushed or dissolved because the medication was designed to be released in an extended period of time. She said she did not notice that the order was extended release. In an interview on 08/19/2025 at 7:02, ADON B stated extended-release medications were not crushed or dissolved because it could result to the medication being released too early or large amount released at once. She said the medication could also lose its potency. She said she already called the doctor and requested for a crushable replacement for Venlafaxine 150 mg ER. She said the order should have been checked and the medication that could not be crushed or dissolved should have been caught. She said expectation was for the orders for medications be reviewed and see if all the medications were crushable and could be dissolved. She said she would start an in-service about the issue. In an interview on 08/19/2025 at 7:16 AM, the DON stated extended release could not be crushed or dissolved because the medication was intended to be released in an extended period of time. She said dissolving the medication could affect the absorption of the medication. The DON said she would check if the nurse already called the doctor to get an order for a crushable venlafaxine. She said whoever was administering the medications should read the order to ensure accurate medication preparation. She said proper preparation should be done to prevent a medication error. The DON said the expectation was for the staff not to dissolve extended-release medications. The DON concluded she would get on top of this issue, re-educate the staff, and conduct in-services. In an interview on 08/19/2025 at 7:32 AM, the Administrator stated she would let the nurse managers take the lead about administering extended-release medications via g-tube. She said the expectation was for whatever the procedure was in giving the medications, it should be followed to prevent any errors. Record review of the facility's policy MEDICATION MANAGEMENT PROGRAM Nursing Policies and Procedures, dated 01/15/2025, revealed Administering the Medication Pass . F. Crush oral medications in accordance with facility policy.

Based on observations, interviews, and record review, the facility failed to ensure the medications for eight (Residents #2, #3, #5, #7, #49, #60, #68, and #77) of twenty-one residents were stored properly in locked compartments or provided a safe and secured storage with limited access. 1. The facility failed to ensure Resident 2's zinc oxide (cream used to treat skin irritations, diaper rash, and other skin conditions) was not left on top of the resident's side table on 08/17/2025. 2. The facility failed to ensure Resident 3's zinc oxide was not left on top of the resident's side table on 08/17/2025. 3. The facility failed to ensure Resident 5's zinc oxide was not left on top of the resident's side table on 08/17/2025. 4. The facility failed to ensure Resident 7's Theraworx (medication used for muscle cramps) was not left on top of the resident's side table on 08/17/2025. 5. The facility failed to ensure Resident #49's triple antibiotics (medication used for skin tears) was not left inside the room on 08/17/2025. 6. The facility failed to ensure Resident 60's zinc oxide in a cup was not left on top of the resident's side table on 08/17/2025. 7. The facility failed to ensure Resident 68's zinc oxide in a cup was not left on top of the resident's side table on 08/17/2025. 8. The facility failed to ensure Resident 77's zinc oxide was not left on top of the resident's side table on 08/17/2025. These failures could place the residents at risk of accidental overdose or misuse of medications. Findings included: 1. Record review of Resident #2's Face Sheet, dated 08/17/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with depression. Record review of Resident #2's Quarterly MDS Assessment, dated 06/03/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 10. The Quarterly MDS Assessment indicated the resident had depression and was incontinent for bladder . Record review of Resident #2's Comprehensive Care Plan, dated 07/30/2025, reflected the resident was at risk for pressure ulcer and one of the approaches was to use skin barrier cream for skin protection. Record review of Resident #2's Physician Order on 08/17/2025 reflected no order for zinc oxide. Observation on 08/17/2025 at 9:21 AM revealed Resident #2 was in her bed with eyes closed. A container of zinc oxide was observed on top of the resident's side table. 2. Record review of Resident #3's Face Sheet, dated 08/13/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with depression. Record review of Resident #3's Comprehensive MDS Assessment, dated 06/03/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident was incontinent for bladder and bowel. Record review of Resident #3's Comprehensive Care Plan, dated 08/14/2025, reflected the resident was at risk for pressure ulcer due to incontinence and one of the approaches was to use skin barrier cream for skin protection. Record review of Resident #3's Physician Order on 08/17/2025 reflected no order for zinc oxide. Observation on 08/17/2025 at 9:15 AM, revealed Resident #3 was in her bed with eyes closed. A container of zinc oxide was observed on top of the resident's side table. 3. Record review of Resident #49's Face Sheet, dated 08/17/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness. Record review of Resident 49's Comprehensive MDS Assessment, dated 08/14/2025, reflected the resident had a moderate impairment in cognition with a BIMS score of 11. The Comprehensive MDS Assessment indicated the resident was incontinent for bladder and bowel. Record review of Resident #49's Comprehensive Care Plan, dated 08/15/2025, reflected the resident was at risk for pressure ulcer due to decreased immobility and one of the approaches was to use skin barrier cream for skin protection. Record review of Resident #49's Physician Order on 08/06/2025 reflected, Daily Wound Treatment: Right Buttock, Cleanse with NS, PAT & DRY, Cover with dry dressing daily & PRN. Observation on 08/17/2025 at 9:31 AM, revealed Resident #49 was not inside her room. A tube of triple antibiotics was observed on top of the resident's side table. 4. Record review of Resident #77's Face Sheet, dated 08/17/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness. Record review of Resident 77's Comprehensive MDS Assessment, dated 07/21/2025, reflected the resident had a moderate impairment in cognition with a BIMS score of 12. The Comprehensive MDS Assessment indicated the resident was incontinent for bladder. Record review of Resident #77's Comprehensive Care Plan, dated 07/30/2025, reflected the resident was at risk for pressure ulcer due to decreased immobility and one of the approaches was to use skin barrier cream for skin protection. Record review of Resident #77's Physician Order on 08/17/2025 reflected no order for zinc oxide. Observation on 08/17/2025 at 9:19 AM, revealed Resident #77 was in her bed with eyes closed. A container of zinc oxide was observed on top of the resident's side table. In an interview on 08/17/2025 at 9:41 AM, LVN F stated zinc oxide and the triple antibiotics were a form of medication because zinc oxide was used to prevent skin irritation and triple antibiotics was used to treat issues like skin tears. She said both zinc oxide and the triple antibiotics should not be inside the room or should be stored where they were not accessible to the residents. She said she did notice the medications when she did her morning round. She said she was not aware how long the medications were inside the rooms of the residents. She went inside Residents #2, #3, #49, and #77's rooms and removed the zinc oxides and the triple antibiotics. She said confused residents might mistakenly consume them and might cause adverse reactions such as allergy and stomach upset. 5. Record review of Resident #5's Face Sheet, dated 08/17/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with irritant contact dermatitis (inflammation of the skin). Record review of Resident #5's Comprehensive MDS Assessment, dated 07/17/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had moisture associated skin damage. Record review of Resident #5's Comprehensive Care Plan, dated 06/17/2025, reflected the resident had a pressure ulcer and one of the approaches was to use skin barrier for protection. Record review of Resident #5's Physician Order, dated 08/12/2025, reflected Apply House Barrier Cream to buttocks as needed. Observation and interview on 08/17/2025 at 9:50 AM, revealed Resident #5 was in her bed, awake. It was observed that a tube of zinc oxide was on the resident's overbed table and was on a tray along with her snacks. She said the zinc oxide had been on the tray for quite some time. She said she was not sure if the staff saw it or not. In an interview on 08/17/2025 at 10:12 AM , ADON B said zinc oxide and triple antibiotics were medications because they were used to prevent or treat skin issues. She said those medications should not be left or stored inside the residents' rooms because the residents might administer or use them incorrectly that could result to adverse reactions. She said the medicated creams and ointments should be stored in the cart because it had chemicals that could be toxic when consumed. She said the staff could also secure them in drawers or somewhere the residents could access them. She said there should be physician orders for such medications as well. She said the expectation was for the staff to be compliant with the policies regarding medication storage to ensure that the residents would not have any access to them. She said she would go to Resident #5's room to get the zinc oxide and then would start an in-service about medication storage. 6. Record review of Resident #7's Face Sheet, dated 08/17/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with pain disorder and idiopathic neuropathy. Record review of Resident #7's Comprehensive MDS Assessment, dated 08/14/2025, reflected the resident had severe impairment in cognition with a BIMS score of 03. The Comprehensive MDS Assessment indicated the resident received scheduled pain medication. Record review of Resident #7's Comprehensive Care Plan, dated 06/17/2025, reflected the resident had nerve pain to wrist and one of the approaches was to administer pain medication as ordered. Record review of Resident #7's Physician Order on 08/17/2025 reflected no order for Theraworx (medication used for muscle cramps). Observation on 08/17/2025 at 11:35 AM revealed Resident #7 was not inside the room. A Theraworx foam spray was observed on the resident's side table. Observation on 08/18/2025 at 9:51 AM revealed the Theraworx spray was still on Resident #7's side table in plain view. Observation and interview on 08/18/2025 at 10:10, LVN E she did not see the Theraworx foam spray when she did her morning round. She said it was a form of medication because it provided relief during muscle cramps. She talked to Resident #7 and said she would get the foam spray and would put it in the cart. She also told the resident that she would get an order for the Theraworx. She said the said medication should not be inside the room because the confused resident might consume it or other confused residents might go inside the room and consume it as well. She said sometimes the family would bring some medications and would not inform them. In an interview on 08/18/2025 at 10:56 AM, Resident #7 was asked where the medication that was taken by LVN E came from, the resident did not reply. 7. Record review of Resident #60's Face Sheet, dated 08/17/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with hemiplegia and hemiparesis. Record review of Resident 60's Comprehensive MDS Assessment, dated 06/30/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 07. The Comprehensive MDS Assessment indicated the resident had a stroke. Record review of Resident #60's Comprehensive Care Plan, dated 06/25/2025, reflected the resident was at risk for pressure ulcer due to decreased mobility and one of the approaches was to use skin barrier for protection. Record review of Resident #60's Physician Order on 08/17/2025 reflected no order for zinc oxide. Observation on 08/17/2025 at 9:51 AM, revealed Resident #60 was not inside the room. It was observed that some cream on a cup was at the resident's bedside table. 8. Record review of Resident #68's Face Sheet, dated 08/17/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with overactive bladder. Record review of Resident 68's Comprehensive MDS Assessment, dated 07/01/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 07. The Comprehensive MDS Assessment indicated the resident was incontinent for bladder and bowel. Record review of Resident #68's Comprehensive Care Plan, dated 07/01/2025, reflected the resident was at risk for skin breakdown due to overactive bladder and one of the approaches was to administer medications as ordered. Record review of Resident #68's Physician Order, dated 06/17/2025, reflected Barrier cream to perineum (area between the legs) after each incontinent episode. Observation on 08/17/2025 at 9:44 AM revealed Resident #68 was not inside the room. It was observed that some cream on a cup was at the resident's bedside table. Observation and interview on 08/17/2025 at 10:29 AM, CNA L stated he did not notice the cups inside Resident #60 and Resident #68's room until his attention was called. He said the cream inside the cups was zinc oxide used when they were changing the residents. He said the cups should have been thrown away after it was used so the resident would not be able to get the cups. He said the cream might be harmful to the residents. He took the cups and threw them in the trash can. In an interview on 08/19/2025 at 6:41 AM, ADON A stated the zinc oxides, TAO, and Theraworx were medications and should not be within reach of the residents because the resident might accidentally ingest them. She said the creams, ointment, and foam had chemicals that could be toxic when ingested by anybody. She said confused residents might mistake them as toothpaste and put them in their mouth. She said the expectation was for the staff to put the said medications where the resident could not reach it, like in the carts. She said she would do an in-service pertaining to medication storage. In an interview on 08/19/2025 at 7:16 AM, the DON stated zinc oxide was used during incontinent care to prevent skin irritation, TAO was used for treatment of skin tears or abrasions, and Theraworx foam was used to provide relief during muscle cramps. She said the medications should be secured and should not be accessible to the residents because they could be harmful to the resident if they accidentally consumed them or put them in their face or eyes. She said they should be placed inside the drawer of the side tables after use. She said if the resident or a visitor ingested it, there could be adverse reactions, especially if somebody who accidentally ingested the medications were allergic to the medications. She said the expectation was the medicated cream, ointment, and foam used for treatment be placed inside the carts to secure it and that the staff would check the residents' room for medications. She said she would do an in-service making sure no medicated cream, ointment, and foam were accessible to the residents. In an interview on 08/19/2025 at 7:32 AM, the Administrator stated the expectation was that the barrier cream, triple antibiotics, and the Theraworx foam should not be inside the room or within reach of the residents to prevent accidental consumption that could result to adverse reactions like allergy, stomach upset, and irritations. She said she would coordinate with the ADONs and the DON to educate the staff about the matter. Record review of the facility's policy MEDICATION STORAGE Pharmacy Services Policies and Procedures, dated 04/17/2024, revealed POLICY . 1. Medications and biologicals are stored safely, securely . the facility will store all drugs and biologicals in locked compartments . 2. The medications and biological supply is only accessible to licensed nursing personnel, pharmacy personnel or authorized staff members.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services. 1. The facility failed to ensure foods in the freezer was concealed from air borne contaminants. 2. The facility failed to ensure food in the walk-in cooler and freezer were labeled and dated when stored. 3. The facility failed to discard molded food in the walk-in cooler. 4. The facility failed to ensure storage bins in the dry storage area were thoroughly cleaned. These failures could place residents at risk for cross contamination and air-borne illnesses.Findings include: Observations on 08/17/25 from 9:16 AM to 9:26 AM in the facility's only kitchen revealed: One zip lock bag of fish filets, located in the walk-in cooler, was not labeled with the date stored. One large container of thick substance, located in the walk-in cooler was not labeled and dated. One large bag of diced bell peppers, located in the walk-in cooler, was not labeled with the date stored. One large box of frozen lima beans, located in the freezer, was not concealed from air-borne contaminants. One large box of frozen biscuits, located in the freezer, was not concealed from air-borne contaminants. One bag of hash browns, located in the freezer, was not labeled with the date stored. Two storage bins containing sugar and flour, located in the dry storage area, had dirt stains on the outside and near the opening of the containers. One large storage bin of corn meal, located in the dry storage area, had brown stain along the inside walls of the container. One large storage bin of salt, located in the dry storage area, had a brown patch in the salt, which was later described as dried up water mixed into the salt. One large plastic bottle of sweet-and-sour sauce observed with visible mold growth around the lid and exterior of the bottle. In an interview on 08/18/25 at 11:23 AM, the Dietary Manager was advised of the findings in the kitchen. She stated the cooks label and date the food in the freezer and the walk-in cooler and Dietary Aides label and date the food in the dry storage area. She stated she normally inspect the area every morning but did not get around to doing in that morning. She stated she had a new cook, and she was trying to her to ensure that foods are labeled and dated and stored properly. She stated she had the containers cleaned at least once a week and it was just overlooked. She stated the foods in the freezer should have been covered to avoid freezer burn. She stated the risk of not addressing these concerns could result in residents getting sick. In an interview on 08/18/25 at 11:55 AM [NAME] M, was advised of the findings in the kitchen. She stated staff were trained to regularly sanitize bottles and containers, including wiping them down during line checks and before closing. She stated she understood any sign of mold or buildup, even if the contents appear unaffected, warranted immediate disposal. She stated she routinely checked the condition of frequently used squeeze bottles and condiment containers throughout the day. She was shown a picture of the container, which contained mold around the opening and stated she did not notice it and said it was an oversight. She stated the contaminated item would be thrown away immediately. She stated the need of maintaining a clean and safe food preparation environment to avoid residents getting sick. In an interview on 08/18/25 at 12:25 PM [NAME] H was advised of the findings in the kitchen. She stated food containers were wiped down regularly and labeling and dating food were part of the expected routine. She stated if any staff member observed mold or residue on a bottle, they were expected to discard the item immediately to avoid any risk to residents. She was shown the photo of the molded bottle, and she stated she hadn't noticed the issue. She stated it was an oversight and stated the bottle would be thrown out. She stated the need of food safety procedures when storing food. In an interview on 08/19/25 at 12:36 PM, the Administrator was shown pictures of the concerns observed in the kitchen area. She stated she expected the kitchen staff to follow the policy on proper food and storage and kitchen sanitation. She reinforced the importance of following established food safety policies, particularly around labeling, dating, and the general handling of kitchen containers. She emphasized that lapses in sanitation can lead to contamination, which poses a direct health risk to residents not only through illness but also by potentially affecting their nutritional intake. Record review of the facility's policy on NUTRITION ORIENTATION & COMPETENCY POLICIES AND PROCEDURES, FOOD STORAGE (07/21/2023), revealed If food is not stored properly, chances are that it will spoil quickly. Remember these pointers for storage: Label and date new food items removed from their original containers. Always cover, label and date leftovers that are to be stored. They should be date marked with the use by date. Keep all containers of food tightly covered. Keep all storage areas clean and dry. Record review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306.

Based observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for five (Resident #23, #28, #48, #70, and #71) of twelve residents reviewed for infection control. 1. The facility failed to ensure CNA J wore a gown while fixing Resident #23's beddings, who had a catheter (flexible tube inserted into the bladder to remove the urine), on 08/17/2025. 2. The facility failed to ensure RN D placed a cap ( green disinfecting caps) Resident 28's PICC line (long, flexible tube inserted into the vein used for administering intravenous medications) on 08/17/2025. 3. The facility failed to ensure LVN E performed hand hygiene and sanitized the overbed table before performing Resident #48's wound care and sanitized the scissors after getting it from her pocket on 08/18/2025. 4. The facility failed to ensure RN C wore a gown while dressing Resident #70, who had a g-tube (gastrostomy feeding tube: a tube that is surgically inserted through the skin of the belly and into the stomach), on 08/18/2025. 5. The facility failed to ensure LVN E performed hand hygiene before providing care to Resident #71 on 08/18/2025. 6. The facility failed to ensure CNA I performed hand hygiene while providing incontinent care to Resident #71 on 08/18/2025. These failures could place residents at risk of cross-contamination and development of infections. Findings included: 1. Review of Resident #23's Face Sheet, dated 08/17/2025, reflected the resident was a [AGE] year-old female admitted on the facility on 08/19/2024. The resident was diagnosed with neuromuscular dysfunction of bladder (the muscles and nerves that control the bladder do not work properly due to illness). Review of Resident #23's Comprehensive MDS Assessment, dated 06/20/2025, reflected the resident had a severe impairment (requires significant assistance and support in daily life) in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident had an indwelling catheter (device that drains urine from the urinary bladder). Review of Resident #23's Comprehensive Care Plan, dated 06/11/2025, reflected the resident required an indwelling catheter and one of the interventions was provide catheter care as scheduled. The Comprehensive Care Plan indicated the resident was on enhanced barrier precaution related to Foley catheter (device used to help drain urine from bladder). Record review of Resident #23's Physician Order, dated 08/20/2024, reflected Foley catheter care every shift. Record review of Resident #23's Physician Order, dated 06/25/2024, reflected Enhanced Barrier Precaution every shift. Observation on 08/17/2025 at 1:13 PM revealed CNA J was inside Resident #23's room and was fixing the resident's beddings. The resident was observed to have a catheter and there was a signage outside the room that the resident required enhanced barrier precaution during changing linens. In an interview on 08/17/2025 at 1:17 PM, CNA J stated Resident #23's family member asked her to fix the resident's bed. She said when she entered the room, the linens were already stripped and all she did was to put on the new beddings. She said she should have worn a gown and a pair of gloves when she was fixing the bedding because the resident was on EBP and the signage outside the room clearly stated to use EBP when changing the linens. She said the resident was not in the bed but she could introduce germs from her scrubs or she could get germs from the bed and transfer it to another resident that she would later have contact. 2. Record review of Resident #28's Face Sheet, dated 08/18/25, reflected the resident was a [AGE] year-old male admitted on [DATE]. The resident was diagnosed with local infection of the skin and subcutaneous (located under the skin) tissue. Record review of Resident #28's Comprehensive MDS Assessment, dated 07/17/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated that the resident had local infection of the skin and subcutaneous tissue. Record review of Resident #28's Comprehensive Care Plan, dated 08/07/2025, reflected the resident required IV medication for wound infections and one of the approaches was to administer medications: ABT. Record review of Resident #28's Physician Order, dated 08/07/2025, reflected IV CEFEPIME 1 GM/50 ML. 1 GM IV EVERY SIX HOURS ACTIVATE AND INFUSE IV CEFEPIME 1 GM OVER 30MINS (TOTAL VOLUME 50 ML WITH RATE OF 100 ML/HR). Observation and interview on 08/17/2025 at 9:59 AM, revealed Resident #28 in his bed, awake. It was observed that the resident had a PICC line to left upper arm. The resident said he had a PICC line because he was receiving an antibiotic for his skin infection. Observation at 08/18/2025 at 8:20 AM, revealed RN C was about to administer Resident #28's antibiotics via PICC line to his left upper arm. The end of the PICC line was not capped and was touching the resident's hospital gown. In an interview on 08/18/2025 at 8:44 AM, RN C stated she usually put a green cap on Resident #28's PICC line to prevent cross contamination. She said she did not see any green cap on the resident's side table that was why she was not able to put one on. She said she did sanitize the port of the PICC line before flushing it but since it was laying on the resident's hospital gown, one would never know if something already crept inside before it was sanitized. She said the best practice was to put a cap on the PICC line after medication administration. In an interview on 08/19/2025 at 6:33 AM, RN D said she would administer Resident #28's 2 AM antibiotics. She said she should cover the PICC once the medication was done to prevent cross contamination and infection because the resident already had an infection that was why he was receiving an antibiotic and not capping the end of the PICC line could only introduce another form of infection to the resident. 3. Record review of Resident #48's Face Sheet, dated 08/18/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with injury of unspecified body region and parkinsonism (movement disorder). Record review of Resident #48's Quarterly MDS Assessment, dated 07/23/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Quarterly MDS Assessment indicated the resident had Parkinson's disease (movement disorder). Record review of Resident #48's Quarterly Care Plan, dated 06/11/2025, reflected the resident had seizure like activity and was at risk for injury and one of the interventions was to keep the resident safe by keeping clutters away. Record review of Resident #48's Physician Order, dated 08/10/2025, reflected Treatment order for skin tear right knee. Cleanse wound with normal saline apply xeroform and cover with dry dressing daily until resolved. Observation on 08/18/2025 at 9:51 AM, LVN E was about to do Resident #48's wound care. She prepared normal saline pink bullets, 4 by 4 dressing, gauze, and xeroform (dressing used to cover wounds). She went inside the resident's room and placed the things that she prepared for wound care on top of the resident's overbed table. She did not sanitize the table. She put on a gown and a pair of gloves and proceeded with wound care. She did not do hand hygiene before putting on a pair of gloves. After cleaning the wound, she took a pair of scissors from her pocket and cut the xeroform to the desired size. She did not sanitize the pair of scissors, that was from her pocket, before cutting the xeroform. After placing the xeroform on the wound, she covered it with the 4 by 4 dressing. She cleaned the overbed table and washed her hands. In an interview on 08/18/2025 at 10:10 AM, LVN E stated she should have sanitized the table before she placed the things needed for wound care on it to make sure that the dressing, gauze, and xeroform were clean when applied to the wound. She said she should have sanitized the scissors before cutting the xeroform because it came from her pocket. She said she sanitized it before putting it in her pocket but since her pocket might be dirty then the pair of scissors was considered dirty again. She said her actions could contribute to cross contamination and development of infection. 4. Record review of Resident #70's Face Sheet dated 08/18/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing). Record review of Resident #70's Comprehensive MDS Assessment, dated 07/28/2025, reflected the resident was cognitively intact with a BIMS score of 13. The Comprehensive MDS Assessment indicated the resident had a feeding tube. Record review of Resident #70's Comprehensive Care Plan, dated 07/28/2025, reflected the resident was at risk for aspiration due to presence of feeding tube and one of the approaches was to observe for signs of aspiration. The Comprehensive Care Plan indicated the resident was on enhanced barrier precaution related to feeding tube. Record review of Resident #70's Physician Order, dated 07/25/2025, reflected The resident is on Enhanced Barrier Precautions related G-Tube. Observation and interview on 08/18/2025 at 7:28 AM revealed RN C was about to administer Resident #70's medication via g-tube. She said she would prepare the resident first. She went inside the room and assisted the resident with clothes. The resident had a g-tube and there was a sign outside the door that the resident required EBP during dressing. In interview on 08/18/2025 at 8:57 AM, RN C stated she should have worn a gown when she was assisting Resident #70 with her clothes because the resident had a feeding tube. She said she the EBP was implemented to prevent transfer of microorganism from one resident to another, especially for those residents that had feeding tubes. 5. Record review of Resident #71's Face Sheet, dated 08/17/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with shortness of breath. Record review of Resident #71's Comprehensive MDS Assessment, dated 08/15/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 09. The Comprehensive MDS Assessment indicated the resident was on oxygen therapy. Record review of Resident #71's Comprehensive Care Plan, dated 08/14/2025, reflected the resident had COPD and one of the approaches was oxygen as per order. Observation on 08/18/2025 at 9:37 AM revealed LVN E was called by Resident #71's family member and stated the resident seems to need oxygen. LVN E went inside the room, put on a pair of gloves but did not perform hand hygiene before putting on the pair of gloves. She placed the nasal cannula on the resident's nose and then said the oxygen concentrator seems to not be working. She told the family member that she would get another oxygen concentrator. She went out of the room and came back with another oxygen concentrator. She put on a pair of gloves and did not perform hand hygiene again. She connected the nasal cannula on the oxygen concentrator and put on the nasal cannula on the resident. In an interview on 08/17/2025 at 9:41 AM, LVN E stated she should have washed her hands or sanitized them before putting on a pair of gloves. She said hand hygiene was being done to make sure that the hands were clean before touching the clean pair of gloves. She said hand hygiene was being implemented to prevent transfer of microorganism and development of infections. 6. Record review of Resident #71's Face Sheet, dated 08/17/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with senile degeneration of brain. Record review of Resident #71's Comprehensive MDS Assessment, dated 08/15/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 09. The Comprehensive MDS Assessment indicated the resident was incontinent for bowel and bladder. Record review of Resident #71's Comprehensive Care Plan, dated 08/14/2025, reflected the resident was incontinent for bowel and bladder and one of the approaches was provide incontinence care after each incontinent episode. Observation on 08/18/2025 at 9:16 AM, revealed Resident #71 had just finished bowel movement and CNA I was about to put the resident's brief on but the resident asked again for her bed pan. CNA I went to the bathroom and got the resident's bed pan and placed it under the resident. When the resident said she was done, CNA I took the bed pan. She removed her gloves and put on a new pair of gloves from her pockets. She did not do hand hygiene before putting on a new pair of gloves. She cleaned the resident again. After cleaning the resident, she removed her gloves and put on a new pair of gloves. She did not perform hand hygiene before putting on the new pair of gloves and the gloves were from her pocket again. She took the brief from the resident's side, placed it under the resident, and fixed it. She removed her gloves and washed her hands. In an interview on 08/18/2025 at 9:25 AM, CNA I stated hand hygiene was important to prevent cross contamination and to prevent infection. She said she did hand hygiene before and after Resident #71's incontinent care but did not sanitized her hands when she changed her gloves. She said sanitizing the hands in between changing of gloves was done to make sure the hands were clean before touching the gloves. She said she should have taken a box of large gloves instead of hoarding them in her pocket to make sure that the gloves she would be using were clean. She said her pocket might be dirty because she would sometimes put her keys in it. She said she would be mindful the next time she does incontinent care to do hand hygiene in between changing of gloves and not to put the gloves inside her pocket. In an interview on 08/19/2025 at 6:41 AM ADON A at 6:41 AM, ADON A stated staff must perform hand hygiene before doing any care, must sanitize their hands before putting on a new pair of gloves, must not put their gloves on their pockets, must sanitize the table and the scissors before doing wound care, must place a cap at the end of the PICC line after medication administration, and must wear a gown when EBP was required. She said deviation from the said procedures could result to cross contamination and development of infection. She said the expectation was for the staff to be mindful and compliant with the policy of infection control. She said she would start an in-service about infection control. In an interview on 08/19/2025 at 7:02 AM, ADON B stated staff must wash their hands before and after any care, should sanitize their hands when changing their gloves, should not put gloves in the pockets, should make sure that the table was clean and the scissors to be used was sanitized, should place a green cap on the PICC line, and worn a gown if the resident had a catheter and a g-tube. she said all the issues discussed could contribute to cross contamination and development of probable infection. She said the expectation was for the staff to be diligent in caring for the residents and would not add another issue to their existing conditions. She said she would start an in-service about infection control and would closely monitor the staffs' adherence to the policy of infection control. In an interview on 08/19/2025 at 7:16 AM, the DON stated hand hygiene was the most effective way to prevent cross contamination and spread of infection. She said hand hygiene should be done before any care and before putting on a pair of gloves. She said gloves should not be placed on the staff's pockets because there was no assurance that their pockets were clean. She said, basically, the gloves from the pockets were deemed dirty. She said everything that would be used for wound care, like the table and the scissors should be sanitized to keep the dressing and xeroform clean when applied to the wound. She also said that the end of the PICC line should be capped to maintain a close circuit. She said the staff do sanitize the port before medication administration but what if the microorganisms already snuck inside the PICC line port. She said the purpose of the antibiotics being given was defeated. She said when a resident was on EBP, staff should wear a gown and a pair of gloves when handling the resident or the resident's beddings. She said the expectation was for the staff to be mindful with what they were doing to protect the residents from all kinds of infections. She said she would do an in-service pertaining to infection control focusing on all the issues discussed. She said she would closely monitor the staff with their compliance to the policy of infection control. In an interview on 08/19/2025 at 7:32 AM, the Administrator stated the expectation was for the staff to adhere to the policy of infection control. She said hand hygiene should be done, the PICC line should be capped, no gloves in the pockets, sanitize the table and scissors, and wear a PPE if the resident required EBP. She said the staff should always make sure that they were aware that their actions could cause infections. She said she would coordinate with the DON and ADONs to do an in-service about infection control and for them to monitor closely, and make sure the staff understood the in-services to be done. Record review of the facility's policy, HAND HYGIENE/HANDWASHING Infection Prevention and Control Policies and Procedures, dated May 15, 2023, revealed, POLICY: Proper hand hygiene/hand washing technique will be accomplished at all times that handwashing is indicated . Hand Hygiene/Hand washing is the most important component for preventing the spread of infection . PROCEDURES . 1. Hand hygiene/hand washing is done . Before . A. Before patient/resident contact . F. Before performing an aseptic task . After . A. After contact with soiled or contaminated articles . H. H. After removal of medical/surgical or utility gloves. Record review of the facility's policy, Incontinence Management, undated, revealed, Remove and discard gloves . Perform hand hygiene. Record review of the facility's policy, TRANSMISSION BASED/STANDARD PRECAUTIONS, AND ENHANCED BARRIER PRECAUTIONS Infection Prevention and Control Policies and Procedures, dated May 15, 2023, revealed, EBP will be implemented for all residents with . urinary catheter . feeding tube . EBP will be implemented during the following high contact-resident care activities . 1. Dressing . 5. Changing linens. Record review of the facility's policy Peripherally Inserted Central Catheter Use, undated revealed, Place a disinfectant-containing end cap on the needleless connector.

Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 of 8 residents (Resident #50) reviewed for dignity. CNA S failed to assist feed Resident #50 at eye level when assisting the resident with her lunch. This failure placed residents at risk of not having their right to a dignified existence maintained.Findings included: Record review of Resident #50's Face Sheet, dated 08/18/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #50 had diagnoses of severe protein-calorie malnutrition, and dysphagia (difficulty swallowing). Record review of Resident #50's Quarterly MDS Assessment, dated 07/15/25, reflected Resident #50 had severe cognitive impairment with a BIMS score of 3. The Quarterly MDS Assessment reflected the resident required total assistance for feeding. Record review of Resident #50's Comprehensive Care Plan, dated 08/14/25, did not reflect a care plan for feeding assistance. Record review of Resident #50's Physician Order, dated 08/18/25, reflected Eating with assist of X 1 Person. In an Observation and interview on 08/18/25 at 9:05 AM, CNA S was observed feeding Resident #50 her lunch, while the resident was lying in bed. CNA S was observed standing over the resident, not at eye level, feeding the resident. She was asked how she should be feeding the resident, and she stated the resident should be sitting up at a 45-degree angle. She was asked if she should be eye level with the resident and she stated she was able to see the resident's eyes, and she found no concerns with her standing over the resident while feeding her. In an interview on 08/18/25 at 9:07 AM, RN S was advised of CNA S being observed feeding Resident #50 while she was standing over the resident. RN S stated staff should ensure the resident was sitting up and staff should be at eye level to ensure the resident was not choking and for the resident's dignity. In an interview on 08/18/25 at 9:10 AM, the DON was advised of CNA S being observed feeding Resident #50 while she was standing over the resident. The DON stated staff was to be at eye level while feeding the residents because it was for the resident's dignity. The DON stated she was going to in-service the CNA on the protocol for feeding residents. Record review of facility's policy, ACTIVITIES OF DAILY LIVING, OPTIMAL FUNCTION, dated 05/05/03, revealed Activities of daily living (ADLs), refer to tasks related to personal care including, grooming, dressing, oral hygiene, transfer, bed mobility, eating, bathing and communication system. POLICY: The Facility provides care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. The Facility provides necessary care to all residents that are unable to carry out activities of daily living on their own to ensure theymaintain proper nutrition, grooming, and hygiene. Facility staff develop and implement interventions in accordance with the resident's assessed needs, goals for care, preferences and recognized standards of practice that address the identified limitations in ability to perform ADLs. Record review of facility's policy, Quality of Life - Dignity & Privacy, dated August 2009, revealed Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, privacy, respect and individuality. Residents shall be treated with dignity and respect, and resident privacy will be protected. Residents will be assisted in maintaining and enhancing his or her self- esteem and self-worth.

Based on interviews and record reviews, the facility failed to ensure resident is assessed using the standardized Quarterly Review assessment tool no less than once every 3 months between comprehensive assessments for one of six residents (Resident #54) reviewed for Resident Assessments. The facility failed to ensure Resident #54 completed a Quarterly Review assessment within 3 months of the previous completed on 04/18/25. This failure could place residents at risk of their needs not being met and addressing any potential change in condition. Findings include: Record review of Resident #54's Face Sheet, dated 08/19/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #54 had diagnoses of Dysphagia (difficulty swallowing), and Cerebral Infarction (stroke). Record review of Resident #54's Quarterly MDS Assessment, dated 04/18/25, reflected Resident #54 had an intact cognitive response with a BIMS score of 14. The Quarterly MDS Assessment reflected the resident required total assistance for ADL care and a diagnosis of muscle weakness. Record review #54's Comprehensive Care Plan, dated 08/12/25, reflected the resident's last care plan conference occurring on 05/23/25. Record Review of Resident #54's Quarterly MDS Assessment, dated 04/18/25, reflected Resident #54 had an assessment due date of 07/19/25, and it was not completed. In an interview on 08/19/25 at 9:50 AM, MDS Nurse C stated a Quarterly MDS Assessment was not completed for Resident #54. She stated she did not know how it was overlooked. She stated the Quarterly Assessment was due on 07/18/25 and it was the MDS nurse's responsibility to complete it. She stated not completing the resident's assessment could impact her overall care. In an interview on 08/19/25 at 1:07 PM, the DON was advised rResident #54 did not have an MDS Quarterly assessment completed since 04/18/25 and she stated it should have been completed by the MDS nurse. She stated the MDS nurse was new and was trying to get caught up. She stated not completing the assessment could result in missed change of conditions and care for the resident. Record review of the Facility's policy on Minimum Data Set, revise 09/28/23, reflected A licensed nurse will conduct or coordinate each assessment with the interdisciplinary team. A quarterly review assessment is completed using the standardized Quarterly review assessment tool specified by the State and approved by CMS no less than once every 3 months between comprehensive assessments.

Based on interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs were identified in the comprehensive assessment for a resident for 2 of 8 residents (Residents #1 and #50) reviewed for Care Plans. The facility failed to ensure Resident #1's usage of a BiPAP device was care planned. The facility failed to ensure Resident #50 was care planned for requiring feeding assistance. These failures could place the residents at risk of not receiving the necessary care and services required. Findings include: 1. Record review of Resident #1's Face Sheet, dated 08/18/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Relevant diagnoses included atrial fibrillation (irregular heartbeat), and heart failure. Record review of Resident #1's Quarterly MDS assessment, dated 07/25/25, reflected she had a severe cognitive impairment with a BIMS score of 3. Active diagnosis included heart failure. Record review of Resident #1's Physician orders, dated 08/18/25, reflected Noninvasive ventilation via BiPAP ST. Parameters are IPAP 8.2 CM H2O, EPAP 2.2 CM H2O on RA Via Medium Size face mask to be administered QHS & PRN during naps. Record review of Resident #1's Quarterly Care Plan, dated 07/23/25, did not reflect a care plan for the resident's use of the BiPAP machine. In an interview of 08/18/25 at 12:25 PM, ADON B stated Resident #1 had physician orders for use of a BiPAP machine. She was advised the resident's care plan did not reflect a plan of care for the BiPAP machine. She stated the resident should have been care planned for the use of the equipment to ensure the resident was receiving the care. She stated it was both the ADON and MDS nurse's responsibility to ensure the resident's use of the BiPAP machine was care planned. In an interview on 08/19/25 at 12:53 PM, the DON was advised Resident #1 did not have a care plan for the BiPAP machine, and she stated the resident should have been care planned. She stated the importance of the BiPAP machine being care planned was to avoid the resident having reparatory issues. In an interview on 08/18/25 at 1:00 PM, MDS Nurse G was advised Resident #1 did not have a care plan for the use of the BiPAP machine. She stated the resident should have had it on her care plan, because it ensured the resident received the care for use of the BiPAP machine. She stated it was MDS and the ADON's responsibility to ensure that it was care planned. Record review of Resident #50's Face Sheet, dated 08/18/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #50 had diagnoses of severe protein-calorie malnutrition, and dysphagia (difficulty swallowing). Record review of Resident #50's Quarterly MDS Assessment, dated 07/15/25, reflected Resident #50 had severe cognitive impairment with a BIMS score of 3. The Quarterly MDS Assessment reflected the resident required total assistance for feeding. Record review #50's physician order, dated 08/18/25, reflected Eating with assist of X 1 Person Record review #50's Comprehensive Care Plan, dated 08/14/25, did not reflect a care plan for feeding assistance. In an interview on 08/18/25 at 10:02 AM, MDS Nurse C was asked about Resident #50's care plan for feeding assistance. She stated the resident did have physician orders for a mechanical diet and required feeding assistance. She stated both concerns should have been care planned. She stated all care pertaining to the resident should be care planned to ensure the resident received proper care. She stated the MDS Nurse and the ADON were responsible for updating the resident's care plan. In an interview on 08/19/25 at 12:53 PM, ADON B advised Resident #50 required feeding assistance, and it should have been care planned. She stated MDS and the nursing staff was responsible for updating the care plans. She stated if the assist feeding was not care planned the resident could be at risk of weight loss. In an interview on 08/19/25 at 12:49 PM, the DON was advised of Resident #50 not being care planned for assist feeding and resident #1 should have been care planned for the use of a BiPAP machine. She stated the MDS nurse was new and was trying to get caught up with updating resident care plans. She stated not having the BiPAP machine and assist feeding care planned could result in the residents not receiving the proper care. Record review of facility's policy, CARE PLAN PROCESS, PERSON-CENTERED CARE (05/05/23) reflected The facility will develop and implement a baseline and comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Person-centered care means the facility focuses on the resident as the center of control and supports each resident in making his or her own choices. Person-centered care includes trying to understand what each resident is communicating, verbally and nonverbally, identifying what is important to each resident with regard to daily routines and preferred activities, and understanding the resident's life before coming to reside in the nursing home.

Based on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for one (Resident #70) of two residents reviewed for feeding tube (a way of providing nutrition directly to the stomach). The facility failed to ensure RN C would not use too much water to flush Resident #70's medication via g-tube (gastrostomy tube: a tube inserted through the abdomen that delivers nutrition directly to the stomach). This failure could place residents with g-tubes at risk for aspiration, discomfort, and overhydration. Findings included: Record review of Resident #70's Face Sheet, dated 08/18/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing). Record review of Resident #70's Comprehensive MDS Assessment, dated 07/28/2025, reflected the resident was cognitively intact with a BIMS score of 13. The Comprehensive MDS Assessment indicated the resident had a feeding tube. Record review of Resident #70's Comprehensive Care Plan, dated 07/28/2025, reflected the resident was at risk for aspiration due to presence of feeding tube and one of the approaches was to observe for signs of aspiration (fluid or solid substance entered the airway). Record review of Resident #70's Physician Order, dated 07/31/2025, reflected Enteral Feeding (delivery of food through feeding tube): Flush tube with 60 cc warm water before and after medication administration; 10 - 15 cc flush between each med. Record review of Resident #70's Physician Order, dated 07/29/2025, reflected RISK: choking, swallowing, aspiration, weight loss/gain, dehydration. Record review of Resident #70's Physician Order, dated 07/25/2025, reflected Venlafaxine (medication used for depression) 150 mg ER via gastric tube two times a day. Observation and interview on 08/13/2025 at 7:28 AM revealed RN C was about to administer Resident #70's medication via g-tube. She said she would be administering four medications for the resident. RN C sanitized her hands and put on a pair of gloves. She started placing the medications in a cup separately, crushed three of the medications, and returned the crushed medications to their respective small plastic cups. One of the medications, Venlafaxine 150 mg, was a capsule and RN C opened the capsule and placed its content in a cup. It was observed that the content of the capsule was in granules form. After placing the medications in the cups, she prepared two big cups of water. She said she would use the water to flush the g-tube and to dissolve the medications. She placed what she prepared on a tray, went inside the room, and placed the tray on top of the resident's overbed table. She also brought with her a plastic spoon and placed it on the tray. She raised the resident's bed and disconnected the g-tube from the formula. She then pulled the plunger (movable part of the syringe that pulls ot pushes liquid into the syringe) of a 60 ml piston syringe and connected it to the g-tube. She pushed the plunger to check the placement of the g-tube and then pulled the plunger to check for the residual. She disconnected the syringe and pulled the plunger all the way and connected the syringe without the plunger. She then put approximately 10 ml of water on each medication and stirred them using the plastic spoon. She flushed the g-tube with 60 ml of water, poured the first medication, and flushed the g-tube with 15 ml of water. She did the same procedure up to the third medication. She then poured the last medication. It was observed the granules were still intact even after she put some water on it and even after stirring it. She poured the granules with water in the syringe. The granules got stuck where the syringe was connected to the g-tube. She said she was having a hard time with the last medication because the granules did not dissolve easily and would not go through. She poured 30 ml of water in the syringe and rocked the syringe back and forth. When there was no more water in the syringe, she said she would pour another 30 ml because the granules were still in the syringe. She rocked the syringe back and forth again. She then poured some more water, approximately 15 ml, seven times until all the granules passed through the syringe. She then said since she already used a lot of water on the last medication, she would only flush the g-tube with 30 ml. After flushing the last 30 ml, she connected the g-tube to the formula, threw away the cups that she used, and washed her hands. In an interview on 08/18/2025 at 8:57 AM, RN C stated she had a hard time with Resident #70's last medication because the granules would not pass through the syringe. She said the granules did not easily dissolve and got stuck where the syringe was connected to the g-tube. She said because the granules got stuck, she had a hard time flushing because of the stuck granules. She said she used a lot of water just to flush the last medication. She said she knew she was only supposed to flush 60 ml before and 60 ml after medications and 15 ml between medications but ended up pouring too much water because she had to make sure the granules would go through. She said too much water could cause fluid overload and bloating of the stomach. In an interview on 08/19/2025 at 7:02 AM, ADON B stated it was important to flush the g-tube to prevent clogging the tubing and to make sure that the medications administered went through. She said there were certain amounts of water ordered for flushing before and after medication administration and in between medications. She said more than or less than the ordered amount of water could have an effect on the resident. She said less fluid could cause dehydration and more water could cause fluid overload, vomiting, and aspiration. She said flushing a medication with more than 100 ml of water was not right. She said she would talk with RN C to ask what happened and what could be done to prevent the issue from happening again. In an interview on 08/19/2025 at 7:16 AM, the DON stated there was a specific amount of water incorporated during medication administration via g-tube to avoid dehydration, overhydration, and aspiration. Too much water given for one flushing could lead to aspiration. She said the expectation was that the staff would use water for flushing as required. She said she would do an in-service about g-tube focusing on the amount of water needed during medication administration. In an interview on 08/19/2025 at 7:32 AM, the Administrator stated the expectation was for the staff to follow the right procedure in administering medications via g-tube. She said she was not a clinician and would let the DON and the ADONs take the lead in educating the staff about the issue. Record review of the facility's policy GASTROSTOMY TUBES Nursing Policies and Procedures, dated May 5, 2023, revealed POLICY: Gastrostomy tubes may be used for residents who require enteral feedings to maintain nutrition . electrolyte balance . resident will be offered sufficient fluids to maintain proper hydration . prevent complications of enteral feeding, like aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.

Based on observation, interview, and record review, the facility failed to ensure nurses were able to demonstrate competency in assessment related to fall risk for 1 of 23 residents reviewed for fall risk assessments (Resident # 1). The facility failed to ensure LVN B was competent to accurately assess fall risks on 04/03/2025 and 06/03/2025. This failure could place the residents at risk for insufficient assessments and insufficient interventions for fall risk. Findings included: Review of Resident #1's Face Sheet dated 06/05/2025 revealed he was a [AGE] year-old male admitted to the facility on [DATE] for hospice care. Diagnoses included narcotic poisoning (overdose,) dementia (group of symptoms affecting memory, thinking, and social abilities,) vascular dementia (dementia caused by brain damage from impaired blood flow,) contractures of left lower leg (stiffening of muscles to prevent body movement,) pain disorder (chronic pain experienced in one or more areas of the body) and glaucoma (damage to the optic nerve affecting vision.) Diagnosis related to incident included displaced intertrochanteric (points where the muscles of the thigh and hip attach) fracture of the left femur (left hip fracture) and pain in left hip. Review of Resident #1's Comprehensive Care Plan, rev. 06/04/2025, revealed: 1.Resident #1 was at risk for falling related to medication use, cognition, vision, weakness, and history of falls. He required assistance for all mobility. Interventions included: -Verbal reminders to not ambulate/transfer without assistance -Close monitoring by staff while up on chair -Keep bed in lowest position with brakes locked -Call light in reach at all times -Personal items within reach -Provide resident an environment free of clutter -Provide toileting assistance 2. Resident #1 had a fracture to his left femur and was at risk for uncontrolled pain and infection. Interventions included: -Administration and monitoring of anticoagulants -Assessment of affected area every shift for changes -Maintain body in functional alignment -Report signs of venous thrombosis (blood clot) 3.Resident had an actual fall on 01/10/2025, 02/12/2025, 03/08/2025, and 04/02/2025. Interventions included: -Wheelchair brakes locked -Keep personal items and frequently used items within reach -Occupy resident with meaningful distractions -Observe frequently and place in a supervised area when out of bed Review of Resident #1's re-admission MDS dated [DATE] revealed his BIMS score was not completed because resident was rarely/never understood. Additionally, Resident #1 was scored as having short- and long-term memory problems, and his cognitive skills for daily decision making were moderately impaired. Resident #1 was assessed as having both lower and upper impairments of his extremities; but did not use any mobility aides. Resident #1 required substantial/maximal assistance with oral hygiene, toileting, upper body dressing, personal hygiene. Resident #1 was dependent upon staff for shower/baths, lower body dressing, and putting on/taking off footwear. Review of facility's Morse Fall Scale Assessment completed by LVN B, after the fourth documented fall, on 04/03/2025 reflected she documented Resident #1 had a history of falling, was on bed rest, had a weak gait, and was oriented to his own abilities. This data scored Resident #1 as a low fall risk. Review of facility's Morse Fall Scale Assessment completed 06/03/2025 at 12:25 AM by LVN B revealed Resident #1 had a history of falling, was on bed rest, and was oriented to his own abilities. This data scored Resident #1 as a low risk for falls. Review of facility's incident report dated 06/05/2025 revealed: 01/10/2025 at 11:55 PM Resident #1 was in the dining room found on floor, with no apparent injury 02/12/2025 at 4:45 AM Resident #1 was in the TV room found on floor, with no apparent injury 03/08/2025 at 4:10 PM Resident #1 was at the nurses' station, unwitnessed fall, with no apparent injury 04/02/2025 at 3:30 AM Resident #1 was found in his room on the floor, with no apparent injury Review of facility's post-fall assessments between 01/10/2025 and 04/02/2025 for Resident #1's falls revealed no evidence of documented injuries or signs and/or symptoms of pain from each assessment. Review of facility Progress Notes on 05/28/2025 at 2:33 PM, reflected RN S wrote that [Resident #1] was on his wheelchair with his left leg turned inward and looked uncomfortable. RN S stated she tried to fix left leg but seems like resident has pain while moving leg . Resident #1's provider was notified, radiology was ordered and obtained, and results were pending. In interview with RN S on 06/06/2025 on 11:52 AM, she stated she was Resident #1's nurse on 05/28/2025 and assisted Resident #1 to the wheelchair that day without any issue. She stated later during her shift she observed Resident #1's leg turned inward while he was in his wheelchair and that he appeared to be in pain. She stated she reported this to the provider and received an order for radiology. Review of Resident #1's Final X-Ray Report, dated 05/28/2025 revealed Examination Left Hip, Pelvis . Findings . Acute, transverse intertrochanteric fracture femur . In observation of Resident #1 on 06/05/2025 at 9:36 AM, resident appeared in his bed resting, clapping his hands. Resident #1's call light was observed nearby and within reach, personal items observed nearby on his bedside table, his immediate environment was observed to be free of clutter; but Resident #1's bed was not observed in its lowest position. Additionally, no fall mat was present at this time. CNA A entered the room and lowered Resident #1's bed to its lowest position. Interview with Resident #1 was not successful due to his cognitive abilities. In interview with CNA A on 06/05/2025 at 9:40 AM, he stated he lowered Resident #1's bed to its lowest position for safety. CNA A stated Resident #1 was a fall risk; but stated Resident #1 had no history of previous falls that he was aware of. In interview on 06/05/2025 at 11:35 AM with the facility nurse who assessed Resident #1 as a low fall risk, LVN B stated her overall impression of Resident #1 was that he was alert but confused. She stated Resident #1 would get up from bed without using his call light and was known to get out of bed without assistance. When asked if Resident #1 was aware of his abilities, she stated he was not aware at all. When asked if she completed Resident #1's Morse Fall Scale Assessments on 04/03/2025 and 06/03/2025 she said that she did. When asked how she assessed the resident, she stated I need more training on the assessment tool. After reviewing the assessments, she stated the assessments were not accurate, and that he was a high fall risk. She stated it was important to complete accurate assessments for the safety of the resident so proper interventions can be put in place. She stated inaccurate assessments can lead to incidents. She stated it was her responsibility as the nurse to complete accurate assessments so sufficient safety interventions can be put into place. In interview with the DON on 06/06/2025 at 9:13 AM she stated Resident #1 was a high fall risk. When provided with facility's Morse Fall Scale Assessments from 04/03/2025 and 06/03/2025 she stated, that's not right. She stated she expected her nurses to complete accurate assessments because accurate assessments lead to appropriate interventions and good outcomes. She stated CNA A should ensure Resident #1's bed was at its lowest position for his safety and per his comprehensive care plan, and CNA A should have been aware of his fall history. She stated this information was accessible to all CNAs via the facility's POC system but this was populated from resident assessments so it might not have been indicated. DON further stated that Resident #1 had no injuries and accidents between April and the recent diagnoses of fracture, and that he probably obtained the fracture during a previous fall at the facility. She stated that the interventions the facility have implemented have been effective, but she would re-assess if a fall mat would be appropriate. In a follow up interview with the DON on 06/06/2025 at 2:41 PM she stated I think we've done everything to prevent [Resident #1's] falls. She stated that the fracture appeared to be in the healing stages and was not an acute injury. She stated she still thought it was a residual injury from the fall in April . She stated she has now implemented a fall mat for Resident #1 and will work on getting a low low bed. She stated these interventions were not in place previously but will be in place moving forward to prevent further incidents and/or injury. In interview with the facility Administrator on 06/06/2025 at 10:22 AM, she stated she felt the interventions they had in place for Resident #1 to prevent injury were effective. She stated she was not aware of what more could be implemented to prevent further falls, incidents, and injury. She stated it was the DON's responsibility to review each resident's falls and add needed interventions as necessary. She stated she expected her nurses to complete accurate assessment data and this was the responsibility of the clinical team led by the DON. Review of facility policy, Fall Management, rev. 05/05/2023, revealed The facility will identify each resident who is at risk for falls and will plan care and implement interventions to manage falls . The Fall Risk Evaluation assists in identifying the appropriate preventative interventions that will be recorded on the resident's care plan . The care plan reflects individualized interventions that are reassessed and revised as needed . Review of facility policy, Care Plan Process, Person Centered Care, rev 05/05/2023, revealed The facility will develop and implement a baseline and comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care . Thru ongoing assessment, the facility will initiate person-centered care plans when the resident's clinical status or change of condition dictates the need such as . falls.

Based on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three (Resident #1, Resident #2, and Resident #3) of eight residents reviewed for Reasonable Accommodation of Needs. The facility failed to ensure the call light system in Resident #1, Resident #2, and Resident #3's rooms were in a position that was accessible to the residents on 05/13/2025. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings included: 1. Record review of Resident #1's Face Sheet, dated 05/13/25, reflected he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included nausea with vomiting, and sepsis (complications from an infection). Record review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 03/07/25, reflected he had a BIMS score of 15 (intact cognitive response). For ADL care, it reflected the resident required extensive assistance. Record review of Resident #1's Comprehensive Care Plan, dated 03/03/2025, reflected the resident was a fall risk and one of the interventions was to be ensure the resident's call light was within reach. In an observation on 05/13/25 at 8:05 AM, Resident #1 was observed lying in bed and his call light was observed on the floor, near a wall, and out of reach for the resident. In an observation and interview on 05/13/25 at 8:07 AM, ADON F observed Resident #1's call light on the floor and out of reach for the resident's use. She stated the resident was capable of pressing the call light button whenever he needed assistance. She stated the call light should have been clipped near the resident so that he can alert staff if care was needed. She stated the risk of not having the call light near the resident could result in him having an emergency and not being able to contact anyone. She said staff should make sure the call lights were within reach of the residents before they leave the room so that the needs of the residents could be addressed and also to prevent falls. 2. Record review of Resident #2's Face Sheet, dated 05/13/25, reflected he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included vomiting, and unsteadiness on feet. Record review of Resident #2's Quarterly Minimum Data Set (MDS) assessment, dated 02/28/25, reflected he had a BIMS score of 14 (intact cognitive response). For ADL care, it reflected the resident required extensive assistance. Record review of Resident #2's Comprehensive Care Plan, dated 02/13/25, reflected the resident had a history of falls and one of the interventions was to be ensure the resident used his call light for assistance. In an observation and interview on 05/13/25 at 8:10 AM, Resident #2 was observed lying in bed and his call light pad was observed on the floor, under the bed, and out of reach for the resident. Resident #2 stated he was soak and wet earlier in the morning and could not contact staff for assistance because he could not reach his call light. The resident stated he had cerebral Palsy, which causes him to shake a lot and could fall out of the bed. In an observation and interview on 05/13/25 at 8:11 AM, RN S was shown a picture of where Resident #2's call light pad was positioned under the bed, and she stated the call light should have been clipped near him. She stated she had checked on the resident earlier in the morning and the call light pad was positioned on the bed. She stated the call light should have been clipped near the resident so that he can alert staff if care was needed. She stated the risk of not having the call light near the resident could result in him having an emergency and not being able to notify staff. 3. Record review of Resident #3's Face Sheet, dated 05/13/25, reflected he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included sepsis (complications from an infection), and unsteadiness on feet. Record review of Resident #3's Quarterly Minimum Data Set (MDS) assessment, dated 014/30/25, reflected he had a BIMS score of 13 (intact cognitive response). For ADL care, it reflected the resident required supervision or touching assistance. Record review of Resident #3's Comprehensive Care Plan, dated 04/25/25, reflected the resident was a risk for falls and needed a one person assist for ADL and mobility. In an observation on 05/13/25 at 8:20 AM, Resident #3 could be heard from the hall calling for assistance. After entering the resident's room, the call light was observed hanging on the wall, wrapped around a plugged-in air freshener, and out of reach for the resident. In an observation and interview on 05/13/25 at 8:22 AM, CNA L, RN E, and the DON was shown where Resident #3's call light was positioned hanging on the wall, and the DON stated the call light should have been placed in reach of the resident. The DON stated the resident was a fall risk and his call light She have been placed near him just in case he had a fall or needed assistance. The DON stated she was unsure how the call light was placed there. In an interview on 05/13/25 at 10:20 AM, the DON stated she had in-serviced her staff today on ensuring call lights were placed in reach of the residents, making more frequents rounds to ensure call lights were in reach, and care planned residents who had a habit of moving their call lights. She stated the risk of the call lights not being in reach of the residents could prevent them from notifying staff if there was an emergency. Record review of the facility's policy Call Lights (05/05/23), revealed When leaving the patient or resident room, ensure the call light is placed within the patient's/resident's reach.

Based on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Resident #1) of four residents reviewed for supervision. The facility failed to provide adequate supervision to prevent Resident #1, who had severe cognitive impairment from eloping from the facility on 03/21/25. The resident was found at an intersection, across the street from the facility. The resident did not sustain any injuries and was found by a pedestrian. The noncompliance was identified as PNC IJ. The noncompliance began on 03/21/25 and ended on 03/21/25. The facility corrected the noncompliance before the investigation began. This failure could place residents at risk for injury and/or death. Findings included: Review of Resident #1's Face Sheet, dated 03/21/25, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Senile Degeneration of Brain (encompasses a range of neurological disorders characterized by a progressive decline in cognitive function, impacting memory, reasoning, and the ability to perform everyday activities), Cerebral Infarction (also called ischemic stroke, a cerebral infarction occurs as a result of disrupted blood flow to the brain), Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), Dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), Anxiety Disorder (symptoms of intense anxiety or panic that are directly caused by a physical health problem), Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and Cognitive Communication Deficit (a communication difficulty caused by a cognitive impairment). Review of Resident #1's MDS (Minimum Data Set) assessment, dated 01/06/25, revealed the resident was sometimes understood by others and sometimes understood others, had a BIMS (Brief Interview for Mental Status) was 04, which indicates severe cognitive impairment, had impairment of his lower extremities and used a wheelchair to ambulate independently, able to ambulate without support from staff. Review of the Elopement Risk Observation assessment dated [DATE], identified Resident #1 as having exit-seeking behaviors, as it indicated t he had attempted to leave the healthcare facility. Review of Resident #1's Care Plan, last Care Conference dated 08/29/24, revealed the resident had cognitive loss/Dementia as evidenced by long term memory recall, inability to understand commands/communication, poor decision-making; Related to diagnoses of Dementia and Cerebrovascular Accident, also known as a stroke. Goal: Resident #1 will understand helpful reminders, will have needs met by staff as identified or anticipated, will have minimal negative emotional distress related to cognitive issues. As evidenced by documentation in the medical record. Approach: Continue to assess periodically for changes in cognition, encourage decision-making when able, reinforce use of memory cues. Review of Resident #'1's Care Plan, revised 03/21/25, revealed the resident will not have negative events related to wandering, will remine safely in the facility as evidence by documentation in the medical record. Approach: find placement for secured unit Approach: assist with 1:1 supervision at all times Approach: Attempt to identify patterns to time of increased wandering (shift change, evening, after family visits, when hungry or near mealtimes .- not if no patterns identified.) Approach: Resident will be assessed by activities and potential intervention are identified as: activities of interest include: (add preferences) The interventions will be noted on the POC. Approach: Resident will be identified to staff through the facility alert system as an elopement risk. Approach: Resident's physical needs will be met; hunger, thirst, toileting Review of Resident #1's Care Plan, last reviewed/revised on 03/25/25, revealed the Category of Behavioral Symptoms: Problem - Resident #1 wanders through out the facility, is a risk for 1. Elopement . Related to diagnosis of Dementia. Goal(s): Resident will not have negative events related wo wandering, will remain safely in the facility as evidence by documentation in the medical record. Approach(es): Resident eloped on 03/21/25. Resident receiving one and one monitoring. Social Worker working with Responsible Party to locate secure unit. Attempt to identify patters to time of increased wandering (shift change, evening, after family visits, when hungry or near mealtimes .not if no patters identified.) Resident will be assessed by activities and potential intervention are identified as: activities of interest include: The interventions will be noted on the Plan of Corrections. Resident will be identified to staff through the facility alert system as an elopement risk. Resident's physical needs will be met; hunger, thirst, toileting. Review of Resident #1's Admission Elopement Risk Observation Assessment, dated 04/30/24, revealed the resident was cognitively impaired with poor decision-making skills, confused, independent with aide (wheelchair) in mobility, and had a known history of wandering, placing him at significant risk for getting to potentially dangerous places (stairs, outside of facility). Review of Resident #1's Progress Notes, dated 03/21/25 at 3:24 PM, revealed the resident propelled himself out of the front entrance door and was noted outside the building. The resident was noted at the intersection from which the resident was assisted back to facility by responding staff. No acute s/s of distress noted. Call placed to the Responsible Party to notify. The Responsible Party stated, Resident #1 use to be in the military and is super-fast and quiet. I know he's a pain in the butt. The Responsible Party apologized and thanked this writer for notifying her. The resident is currently with the assigned charge nurse head to toe assessment, skin assessment, hydration and Activities of Daily Living care implemented. Resident is currently in line of sight, one on one supervision of 1 staff. No signs/symptoms of distress noted. Call placed to physician; no new orders received. Date & Time Template Progress Notes 4/17/25, 3:18 PM Observation of the intersection on 04/16/25 at 9:00 AM, revealed the intersection began at the corner of the parking lot's west entrance. The intersection consists of three, eastbound lanes with the outermost lane for moving straight ahead or turning right onto another street. The innermost lane being a left turning lane, which leads into the facility's parking lot's west entrance. The intersection also consists of three westbound lanes with the innermost lane being a left turning lane and the outermost lane for moving straight ahead or turning right, into the facility's parking lot's west entrance. There was a median separating the two directions of traffic and there were traffic lights for both directions of traffic. The resident would have had to exit from the parking lot's west entrance, heading southbound, cross the street, stop at the median to avoid eastbound traffic, and then cross the eastbound lanes to reach the corner where the pedestrian stopped him and kept him, until the Administrator arrived. There were businesses on the block which the pedestrian stopped the resident and across the street, west of the businesses, was a gated senior living community. The resident had to cross six lanes to get to the other side of the street. The speed limit for the lanes going east and west bound was 40 miles per hour. An interview with the Receptionist on 04/16/25 at 10:11 AM, revealed the day of Resident #1's elopement, the front area was busy with a group of residents playing a card game and staff were passing through and talking. She stated she saw Resident #1 in the lobby area; however, he was not near the entrance door at the time. She stated when the vendor came in with another resident, they stopped at the counter, and she was talking to the vendor and the resident. She stated she did not notice that Resident #1 had reached the door and exited. She stated she contacted the vendor and told them that they had to make sure the door was closed behind them, whenever they entered and exited the facility, and they stated they understood. She stated she was instructed to contact the vendor, by the Administrator. She stated that day, the orange notice was placed on the door, telling visitors and vendors to make sure the door was closed when they enter and/or exit the facility. An interview with the Director of Nursing (DON) on 04/16/25 at 5:19 PM, revealed Resident #1 was an exit-seeker, he was already in the Elopement Risk Binder prior to the incident. She stated she did not know the last time he attempted or if he had ever been successful at eloping, prior to this date. She stated he had not attempted to elope since she had been at the facility, prior to the day of the incident. She stated the Elopement Risk Binder with residents' pictures are at the reception desk, and both nurses' stations. She stated the books are reviewed when new staff start and if there was an elopement attempt on the 24-hour Report, the binders are updated, and it was discussed during their shift changes and morning meetings. She stated they had not had an elopement, since she was at the facility. She stated they had Elopement Drills monthly and as needed. She stated they monitored Elopement Risk residents for change in condition, whether they declined, or their behavior increased, she stated any change in the resident, was discussed and they would update the binder and their care plans. She stated when this incident happened, they educated the staff, and the vendor was contacted to ensure they understood to make sure the door closed behind them. An observation on 04/16/18 at 6:28 PM, revealed the facility front door, which lead to the lobby, had a bright orange sign placed at eye-level, which instructed visitors and vendors to make sure all doors were closed behind them when they entered and exited the facility, to ensure residents were not able to leave the building unassisted. Interview with the Administrator on 04/17/25 at 9:25 AM, revealed Resident #1 had eloped from the facility through the front entrance. She stated the facility received a call from a pedestrian who found the resident on the corner of the intersection, across the street from the facility. The Administrator stated she was notified and immediately told other administrative staff. She stated she exited the building and saw Resident #1 across the street. She stated she went to the resident and asked him where he was going and he replied, I was trying to get away. She stated she assessed him and did not observe any signs of injury or distress. She told him he had to go back home and that she would take him. She stated the resident agreed. She stated by then, other staff had arrived, and they all escorted the resident back to the facility. She stated resident was assessed by a nurse and no injuries or signs of distress were noted. She stated the resident was placed on 1:1 monitoring, and the monitoring continued until he was discharged . She stated the resident's physician and Responsible Party was notified. She stated they reviewed video footage to determine how the resident exited the facility, and they saw that he stopped the door from closing, after a vendor entered the facility with another resident. She stated the vendor stopped at the reception desk and as was talking to the receptionist, the resident exited without being seen. She stated a Care Conference was set up and during the Care Conference, they discussed the resident requiring a secured unit being a more suitable placement for the resident and the Responsible Party agreed. She stated the Social Worker, assisted the Responsible Party with finding a facility with a secured unit. She stated the resident was discharged to the new facility on 03/26/25. She stated on the day of the elopement, all staff were in-serviced on Elopements, and she instructed the DON to post signs telling visitors and vendors to ensure the door closes completely, behind them. Review of the facility's Elopement Policy, dated 11/01/17, revealed Policy: To safely and timely redirect patients/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing. The facility will determine a signal code, e.g. Code [NAME] to designate a missing patient/resident. Procedures: 1. Once it has been established that a patient/resident is missing, all employees are notified immediately by paging overhead Purple. 2. The DON/designee completes a missing resident profile. 3. The DON or designee organizes and institutes an immediate and thorough search of the center and surrounding grounds. The search should include but is not limited to a search of the area outside the nearest exit to the patient/resident's room or the exit where he/she was last seen, and the entire unit where the patient/resident resides or was last seen, the remainder of the facility (all rooms, closets - including storage facilities - and bathroom) and grounds, extending beyond the fence line. 4. The entire search process of the facility and grounds, from the time the patient/resident is missing, will be completed within (30) thirty minutes. 5. If the search fails to locate the missing patient/resident within (30) thirty minutes from the time the patient/resident is found missing, the Administrator or designee contacts the appropriate community agencies (Police, Local Health Department) and Administration, the patient/resident's legal representative and attending physician. Staff will provide the Police with all physical identifying information including but not limited to physical appearance, height, weight, age, sex, and clothing if known. 6. The search is continued. Two staff members search the surrounding streets by car for a (2) two-mile radius around the facility. 7. When the patient/resident is located, the Charge Nurse completes a head-to-toe assessment. The Social Services designee assesses the patient/resident for emotional distress. The Charge Nurse reports any findings to the DON or designee. The DON or designee notifies the Administrator/designee and notifies the appropriate community agencies, attending physician, and patient/resident's legal representative .11. Facilities Quality Assurance Committee investigates the incident and implements interventions to prevent reoccurrences. The Administrator and DON were notified on 04/17/25 at 4:10 PM, that a Past Non-Compliance IJ situation had been identified due to the above failures. It was determined these failures placed Resident #1 in an IJ situation on 03/21/25. The facility implemented the following interventions: Interventions initiated prior to surveyor entry on 03/25/25: * Daily inspection log of all exits beginning 03/21/25 * Elopement drills with all staff on 03/21/25 * Updated Care plan for Resident #1 on 03/21/25 * 100 % audit all residents for elopement risk. 03/21/25 * The facility conducted appropriate in-service trainings, on 03/21/25, in regard to: Elopement Risk What to do if resident is missing Abuse, Neglect, and Exploitation * Resident #1 was discharged from the facility to another facility, accompanied by a C.N.A. via transport in wheelchair. The resident departed in stable condition with all remaining belongings and medication. Copy of face sheet and Continuity of Care Documents were sent with the resident on 03/26/25. There had been no previous and no new incidents for any additional residents as of 03/21/25. Interviews: 04/16/25 at 5:41 PM with C.N.A. A, revealed Elopement In-services on checking doors to make sure they are closed. Check on the residents. They had to always try to keep residents who moved around all the time, in an area where everyone could see them and know where they were. If an alarm went off, they would check the doors to see if they could see who went out or was trying to go out. They were then supposed to go outside and look around the parking lot and the sidewalk out front, to see if they could see a resident. If no residents were found, they were supposed to come back in and locate all of their assigned residents. They would check the Elopement Binder to make sure those residents were in the building. They would report to the nurse that all of their people were in the building. She stated if a resident eloped, they would call Code Purple over the speakers. She stated they would round on their residents every 15 to 30 minutes because they had to constantly be working and making sure the residents were ok and to see if they needed something. She stated if she saw a resident going toward an Exit door, she would run and get them and redirect them. If its someone who was combative, she would call for help and then try to redirect them. She stated they were told to not give the door code to visitors and vendors. She stated they were also told to tell visitors and vendors to make sure the door closed behind them. She stated the back door was only used for staff and vendors who were bringing in supplies. She stated everyone else had to use the front door to enter and exit the building. She stated they never used the side doors that had a sign saying This is not an Exit. She stated they were for emergencies only. She stated when they were doing 1:1 monitoring, they would have to stay with that resident at all times. She stated if they need to go to the restroom, they have to get someone to sit with the resident until they get back. She stated even if the resident is asleep, they have to stay in the room with them, in case they get up. She stated 1:1 monitoring would last as long as they were told to do it. She stated she was not assigned to be on 1:1 monitoring for Resident #1. She stated she worked with Resident #1 and she never saw him trying to get out of the building. She stated if she witnessed any type of abuse, she would report it to the nurse and to the Administrator. She stated if it was resident-to-resident abuse, she would separate them and call for help, then report it. 04/16/25 at 5:38 PM with ADON R, revealed the last time they had an Elopement in-service was when they had an elopement in March. She stated they talked about what to do when an elopement occurs. She stated they were to check the doors to see if they can see who was at the door or went out of the door. She stated if they did not see anyone, they were supposed to go outside and search the parking lot and up and down the street. She stated if they did not see anyone, they were to come back in the building and search for the residents who were in the Elopement Binder, then make sure the rest of the residents were in the building. She stated once everyone had been accounted for, the aides were to report to the CNAs who would report to the ADONs The ADONs reported to the DON and Administrator. She stated the code word for an elopement was Purple. She stated in the in-service, they were told to tell visitors and vendors to make sure they physically close the door behind them, going and coming. She stated if they saw a resident attempting to exit, they would gently redirect them away from the door and would take them to where they could engage in an activity or where they could be seen by other staff. Such as at the nurses' stations. 04/16/25 at 6:12 PM with ADON S, revealed she stated they had elopement skills drills every three months. She stated if an elopement happened, they would call a code purple and everyone had to search for the missing resident. She stated some staff would ensure that all of their residents were accounted for, while also looking for the missing resident. She stated other staff would search closets, empty rooms, storage rooms, and outside. She stated once the missing resident was found, they would assess the resident and a report would be written. She stated they had to notify the physician, family, Administrator, and DON. She stated staff were to remind vendors and visitors to make sure the doors closed behind them, when they entered and exited the facility. 04/17/25 at 7:15 AM called RN E, no answer, and not able to leave a voice message. 04/17/25 at 7:25 AM called C.N.A. P, no answer, and not able to leave a voice message. 04/17/25 at 7:30 AM called LPN H, no answer, and not able to leave a voice message. 04/17/25 at 10:31 AM with LVN J, revealed in-services were done quarterly and whenever there was an elopement incident. She stated if there was an elopement, the person who noticed a resident was missing, they were to call Code Purple. She stated some of them looked for the missing resident, while the others were going room-to-room counting everyone else to make sure everyone else was accounted for. She stated they looked throughout the building and outside. She stated there were signs on the doors for the visitors or vendors know to make sure the doors close behind them before walking off. She stated this was important so residents could not get out. She stated they walked around and made sure they knew where the residents were, who were an elopement risk. She stated even residents who were not at their baseline of behaviors, she watched them more diligently to make sure they did not slip out of the building or attempt to. 04/17/25 at 11:09 AM with C.N.A. W, revealed they had an in-service no Elopement about a week ago. She stated she was not sure how often they had Elopement Drills, but they had them frequently. She stated they went around saying Code Purple, so staff had to drop everything and start looking. She stated she rounded on her residents every 30 minutes, for the bed-bound residents. She stated for residents who were an elopement risk, she looked for them frequently. She stated most of the time, they gave them a coloring book or some activity to keep them busy at the nurses' station, so they could see them at all times. She stated in the in-services, they were told to tell visitors and vendors to make sure the doors closed behind them and to make sure they did not let residents out the door, like did not hold the door open for them. 04/17/25 at 11:50 AM with LVN U, revealed the last time they had an in-service on Elopement was maybe a couple of weeks ago. She stated they had Elopement Drills quarterly, and when an elopement occurred. She stated if someone eloped, they would call a Code Purple and everyone would be hands on, looking for the missing resident. She stated staff were to round on the residents every two hours or more often if needed. She stated for residents who were elopement risk, they had to know where they were at all times. She stated they kept them busy with activities and they took them to the bathroom regularly. She stated they had Elopement books at the nurses' stations and the front desk. She stated they were to remind visitors and vendors to be mindful of residents around them and make sure the doors closed behind them, so the residents did not get out of the building. 04/17/25 at 1:44 PM called LPN K, left a voice message. 04/17/25 at 1:47 PM called RN M, left a voice message. 04/17/25 at 2:49 PM with LVN K, revealed they recently had an elopement, and they had an in-service a few weeks ago. She stated she was not sure how often Elopement Drills occurred through the week, but she knew they had them. She stated they had not had one during the weekends. She stated the code word for an elopement was Purple. She stated they were to immediately alert the staff of the Code Purple, then start searching for the resident, and they did a head count of all residents. Then once everyone was accounted for or if they still could not find the resident, they were to let the DON and Administrator know. 04/17/25 at 9:00 PM with RN K, revealed they had an in-service on Elopement about two weeks. She stated the vendors and visitors had to look at the door to make sure the door was closed so residents could not get out. She stated if there was an Elopement, they would call Code Purple, and everyone knew to start searching for the missing resident. She stated they counted to make sure everyone was there. She stated they had to report it to the DON and Administrator. She stated they had an Elopement binder at each nurses' station and at the front desk. She stated they did not have Elopement Drills on the night shift, but they had been educated on what to do. 04/17/25 at 9:11 PM with C.N.A. C, revealed the last in-service on Elopement was last month. She stated they had the in-service because a resident had eloped. She stated if they had an elopement, the staff were to make sure all staff were aware and then they all would look all over the building to make sure they saw all of the residents, while others looked outside to try to find the missing resident, if they did not find them inside. She stated once all of the residents were located, they would tell the nurse. She stated if they could not find a resident, they would call 9-1-1. She stated she was not sure what the code word was for elopement, but she knew that it was in the Elopement books which were located at both nurses' stations and at the front desk. 04/17/25 at 9:22 PM with LPN L, revealed the last in-service on Elopement was a few weeks ago. She stated they were told to tell vendors and visitors to make sure the doors closed behind them, so the residents could not get out. She stated they had Elopement binders at the front desk and at the nurses' stations. She stated if someone was missing, they would call code purple and the aides check to see if all of their people were in the building, while the nurses looked, and other staff looked outside in the parking lot and the back of the building and up and down the street. She stated once the missing resident was found, a report would be written, and the DON and Administrator would be notified. She stated they had an elopement a few weeks ago and that was why they had the in-service.

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for 1 of 3 (Resident #1) residents reviewed for Care Plans. The facility failed to ensure Resident #1's bed was in the lowest position and ensure his bedside table was in a safe location to assist in fall prevention. These failures could place residents at risk of injury. Findings include: Record review of Resident #1's Face Sheet, dated 02/27/25, reflected he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included unsteadiness on feet, dementia (cognitive decline), and muscle weakness. Record review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected, he had a BIMS score of 07 (severe cognitive impairment). For ADL care it reflected for transfers, toileting, and bathing and the resident was totally dependent for assistance. For active diagnosis it reflected muscle weakness and lack of coordination. Record review of Resident #1's Quarterly Care Plan, dated 02/13/25, reflected the resident had a history of falls and interventions were to provide a clutter free area, and bed in low position. Record review of Resident #1's progress notes dated 02/12/25, revealed the resident had a fall. An observation on 02/27/25 at 08:10 AM, revealed Resident #1 lying on his bed. He had a fall mat placed alongside his bed. His bed was not lowered to the lowest position and the bed side table was placed alongside his bed and not in an area that allows the resident to safely reach items on the bedside table. In an interview and observation on 02/27/25 at 08:12 AM, LVN J stated Resident #1 was a fall risk and his bed needed to be lowered to the lowest position and his living area needed to be free of any hazards. She stated the risk of the bedside table being placed alongside his bed could result in a form of restraint and was a fall risk for the resident. In an interview on 02/27/25 at 10:43 AM, Resident #1's family member stated she resided in the room with the resident. She stated ever since the resident had a fall, she preferred his bed to be in a low position. She stated the only time the resident's bed was in a raised position, was when he was receiving incontinent care. In an interview on 02/27/25 at 11:43 AM, the DON stated the resident, and his family member raises the bed. She stated the risk of the resident's bed not being in the lowest position and the bedside table not being in a safe location could result in the resident having a fall and injuring himself. The facility's policy Fall Management System (12/2023) reflected It is the policy of this facility to provide an environment that remains as free of accident hazards as possible. It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents' bed was free from any physical or chemical restraints imposed for purposes of discipline or convenience for 2 (Resident #1 and Resident #2) of 5 residents reviewed for physical restraints, The facility failed to obtain physician orders or a physician assessment as of 01/08/25 for Residents #1 and Resident #2 for the usage of a scoop mattress prior to installing the mattress to assist in fall prevention. This failure could prevent residents from having an environment that was free from any physical or chemical restraints. Findings included: Record review of Resident #1's Face Sheet, dated 01/09/25, reflected he was an [AGE] year-old male admitted on [DATE]. Relevant diagnoses included unsteadiness on feet, dementia, and muscle weakness. Record review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected, he had a Brief Interview for Mental Status (BIMS) score of 03, ( score of 0-7 indicates severe cognitive impairment) and for ADL care it reflected for transfers, toileting, and bathing and the resident was totally dependent for assistance. Record review of Resident #1's physician orders, dated 01/09/25, reflected no physician orders for a scoop mattress. An observation on 01/09/25 at 09:00 AM revealed Resident #1 had a scoop mattress on his bed. Record review of Resident #2's Face Sheet, dated 01/09/25, reflected he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included unsteadiness on feet, history of falls, and muscle weakness. Record review of Resident #2's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected, he had a Brief Interview for Mental Status (BIMS) score of 01, (score of 0-7 indicates severe cognitive impairment) and for ADL care it reflected for transfers, toileting, and bathing and the resident was totally dependent for assistance. Record review of Resident #2's physician orders, dated 01/09/25, reflected no physician orders for a scoop mattress. An observation on 01/09/25 at 09:00 AM revealed Resident #2 had a scoop mattress on his bed. An interview on 01/09/25 at 10:00 AM, LVN Y stated that she had been at the facility for 6 months and she had known Resident #1 and Resident #2 to both have a scoop mattress while she had been at the facility. She stated she was unsure if Resident #1 was a fall risk, but she was sure Resident #2 was a fall risk. She stated both residents should have physician orders for use of the scoop mattress. She stated she reviewed both residents' physician orders on 01/09/25, and no physician orders were found for the residents. She stated she had communicated this information to the DON for further action. She stated the risk of the residents not having physician orders for the scoop mattress could result in them injuring themselves. In an interview on 01/09/25 at 10:00 AM, the DON stated LVN Y had brought to her attention that Resident #1 and Resident #2 did not have physician orders for the scoop mattresses. She stated that physician orders were needed for both residents because the residents could injure themselves falling out of their bed. She stated she had already gotten physician orders for Resident #2 on 01/09/25 from her physician and was attempting to contact Resident #1's physician so that they could obtain physician orders for the resident to have the scoop mattress. The facility's policy Fall Management System (12/2023) reflected It is the policy of this facility to provide an environment that remains as free of accident hazards as possible. It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs.

Based on observations, interviews, and record review, the facility failed to maintain an infection control program designed to help prevent the development and transmission of disease and infection for 1 (Resident #22) of 2 residents reviewed for infection control. The facility failed to ensure Resident #22's foley catheter bag (collects urine drained from the bladder) was not touching the floor on 12/19/24. This failure could place the residents at risk for the development and transmission of infections. Review of Resident #22's Face Sheet, dated 12/19/24, reflected Resident #22 was a [AGE] year-old male admitted to the facility on [DATE] with neuromuscular dysfunction of the bladder (nerves controlling bladder function are damaged). Review of Resident #22's Comprehensive Care Plan, dated 12/02/24, reflected Resident #22 had an indwelling foley catheter and was at risk for urinary tract infections. One intervention was to always apply appropriate infection precautions during care. Record review reflected a physician's order, dated 10/03/24, for Resident #22 to have an indwelling foley catheter for a neurogenic bladder (bladder dysfunction cause by nervous system conditions) and to empty the foley catheter bag every shift and document output. Review of Resident #22's Quarterly MDS (tool to measure health status) Assessment, dated 09/29/24, does not reflect a BIMS (tool to evaluate cognitive function) score because resident refused to answer/provided nonsensical answers. Section H reflected Resident #22 had an indwelling foley catheter. During observation and interview on 12/19/24 at 09:35 AM, Resident #22 was lying in bed looking at his cell phone. Resident #22's foley catheter bag was on the floor next to the bed. Resident #22 stated he had to get the catheter a couple of months ago and that it was usually hung on the side of the bed. In an interview 12/19/24 at 09:39 AM, LVN G stated the foley bag should not have been on the floor. LVN G entered Resident #22's room and hooked the foley bag on the side of Resident #22's bed. The bottom of the foley bag was touching the floor. When asked about this, LVN G adjusted the bed height to prevent the catheter bag from touching the floor. LVN G stated it was important to keep the foley bag off the floor to prevent Resident #22 from getting an infection. In an interview 12/19/24 at 01:45 PM, the ADON stated Resident #22's foley catheter bag should not have been touching the floor. The ADON stated it was important to ensure foley catheter bags did not come in contact with the floor because that was an infection control issue. The ADON stated she was going to in-service staff about it. Review of the facility's policy Indwelling Urinary Catheter Care and Removal reflected Do not place the drainage bag on the floor, to reduce the risk of contamination and subsequent catheter associated urinary tract infections. Undated.

Based on observation, interviews, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of three residents reviewed for Respiratory Care. The facility failed to ensure Resident #1's nasal cannula was properly stored when not in use. This failure could place residents at risk for respiratory infection and not having their respiratory needs met. Findings included: Review of Resident #1's Face Sheet, dated 12/19/2024, reflected the resident was an [AGE] year-old female admitted on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of Resident #1's Quarterly MDS Assessment, dated 12/16/2024, reflected the resident was cognitively intact with a BIMS score of 13. The Quarterly MDS Assessment indicated Resident #1 was on oxygen therapy while a resident of the facility. Review of Resident #1's Comprehensive Care Plan, dated 10/10/2024, reflected the resident required oxygen therapy related to COPD and one of the interventions was administer oxygen at 2 - 3 L via nasal cannula. Review of Resident #1's Physician Order, dated 03/19/2021, reflected O2 @ 2-3L/MIN CONTINUES VIA NC. Observation on 12/19/2024 at 9:49 AM, revealed Resident #1 was not inside her room. It was observed that there was an oxygen concentrator beside her bed. A nasal cannula was attached to the oxygen concentrator. The nasal cannula was hanging on top of the oxygen concentrator and was not bagged. Observation and interview with CNA B on 12/19/2024 at 9:57 AM, CNA B said she assisted Resident #1 to transfer to her wheelchair. She said she took off the nasal cannula before she transferred her and put it on top of the oxygen concentrator. She said it should be placed inside a plastic bag to keep it clean. She looked for a plastic bag behind the oxygen concentrator but did not see one. While in the process of looking for a plastic bag, CNA B placed the nasal cannula on top of the bed. She said she would call the nurse to get plastic bag. Observation and interview with RN A on 12/19/2024 at 10:08 AM, she said the nasal should be bagged when not in use to keep it clean and prevent respiratory infection. RN A went inside Resident #1's room and saw the nasal cannula on top of the bed. She disconnected the nasal cannula and threw it in the trash can. She said she would get a new nasal cannula and a plastic bag. RN A went out of the room and returned with a new nasal cannula and a plastic bag. She said sometimes the resident would take it off but was not an excuse for her to check if the nasal cannula was bagged. In an interview with the DON on 12/19/2024 at 10:49 AM, the DON stated the nasal cannula should not be left hanging on the oxygen concentrator or placed on top of the bed to prevent respiratory infections and exacerbations of respiratory issues for those residents that already had respiratory challenges. The DON said the expectation was for the staff to make sure the nasal cannula were bagged. She said, actually, it was not the resident's responsibility to put the nasal cannula but management could educate the resident to put the nasal cannula in a bag if she would take it off. She said she do an in-service about bagging the nasal cannula and would personally monitor their adherence to the policy. In an interview with the Administrator on 12/19/2024 at 12:10 PM, the Administrator stated the nasal cannula connected to the oxygen concentrator should be in a bag when the resident was not using it to prevent cross contamination and infection. She said the expectation was the nasal cannula would be bagged when the resident was not using it. She said the DON already started an in-service to remind the staff to place a plastic bag near the oxygen concentrator and to bag the nasal cannula when not in use. Record review of facility policy, RESPIRATORY TREATMENT, CARE AND SERVICES PROGRAM Nursing Policies and Procedures revised May 5, 2023 revealed POLICY: The Facility ensures the safe, appropriate and effective provision of respiratory treatment, care and services . 5. Respiratory Equipment Maintenance . B. Handling of equipment, including cleaning, storage.

Based on interviews and record reviews the facility failed to ensure the resident received adequate supervision and assistance devices to prevent accidents for 1 (Residents #25) of 1 resident reviewed for accidents and hazards. On 04/02/24, Director of Therapy failed to utilize Resident #25's footrest when transporting her which resulted in a fracture to her left leg. This failure placed the resident at risk of further injury due to improper use of equipment. The noncompliance was identified as past noncompliance (PNC) The IJ began on 04/02/24 and ended on 04/08/24. The facility had corrected the noncompliance before the state's investigation began. Findings included: Record review of Resident #25's face sheet, dated 07/23/2024, revealed she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included diabetes (high blood sugar) and hemiplegia. Record review of Resident #25's Quarterly Minimum Data Set (MDS) dated [DATE] revealed, she had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact) and for ADL care it stated, for transfers, toileting, and bathing, the resident required moderate assistance. Record review of Resident #25's progress notes from 04/02/24 thru 04/05/24, revealed no indication of the resident complaining of pain. Pain assessments were completed, and all documentation indicated Resident Denies of Pain or Discomfort for This Shift. Record review of Resident #25's progress notes on 04/06/24 indicated that the resident had complained of pain in her left leg to LPN M, who completed a pain assessment, and notified the Nurse Practitioner who ordered an x-ray be completed of Resident #25's left leg. Further review of Resident #25's progress notes entered by LPN M dated 04/06/24 at 6:53 PM, revealed Xray diagnostic company called and reported that x-ray is positive for Left knee FX, NP notified and gave order to send out to ER, Daughter family member, Resident notified, ADON, DON and Administrator notified. PRN pain medication administered. In an interview on 07/23/24 at 01:57 PM, Resident #25 stated the Director of Therapy had caused her to break her leg. She stated the on 04/02/24 the DOT was pushing her back to her room from the dining room. She stated that on her way back to her room, her sneakers had gripped the floor, and it caused her left leg to get caught under her wheelchair. She stated the accident caused her to break her knee. She stated that she had to lay in bed for 8 weeks until she was able to sit in her wheelchair and begin moving again. She stated the facility had terminated the DOT for injuring her. She stated she was in pain when the accident occurred, and she had complained about her leg hurting her unto the weekend nurse on 04/06/24. She contacted the physician, and the physician advised the nurse to send the resident out for an x-ray, which was when she was advised that she had fractured her leg. She stated she had no concerns with staff and felt safe at the facility. In an interview on 07/24/24 at 11:31 AM, the Physical Therapist stated she had been at the facility for over 2 years. She stated she was familiar with Resident #25, but she was not at the facility when the incident occurred on 04/02/24. She stated she heard the resident was being wheeled by the Occupational Therapist Assistant, who was also the DOT, from the dining room and for some reason the DOT failed to install the footrest for the resident. She stated she heard that the resident's leg had gotten caught under the wheelchair and she injured her leg. She stated the DOT did not report the incident until the resident had complained about the injury. She stated because of this, she was terminated. The PT stated staff was in-serviced on reporting any injuries or changes in condition on 04/08/24. She stated the risk of not notifying the resident's physician could result in the resident going untreated for a severe injury. In an interview on 07/25/24 at 09:45 AM, the Regional Director of Operations, stated she had been the director since January 2024 and the Area Director prior to her new role. She stated the resident had complained of pain throughout the weekend (04/06/24 and 04/07/24), they found out about the resident being injured, and it was not reported. They stated they immediately placed the Director of Therapy on leave and removed her from all resident responsibility. She stated the team was in-serviced on transporting residents in wheelchairs, using the footrest, and reporting incidents. She stated the resident had increased pain over the weekend and it was discussed during the morning meeting on 04/08/24. The DOT did not report the incident that occurred on 04/02/24 until the morning meeting on 04/08/24. The Administrator immediately suspended her, and ultimately terminated her employment. She stated the risk of the Director of Therapy not reporting the incident until 04/08/24 could have resulted in the resident experiencing a severe injury and having pain. In an interview on 07/25/24 at 09:53 AM, RN K stated she had been at the facility for almost two years. She stated that she managed the 100-Hall, and she was familiar with Resident #25. She stated the resident only complained about her normal pain and she was not aware of any new pain the resident was having. She stated the resident did not like getting out of bed, only for special events, and the resident council meetings. She stated she was made aware of the resident's injury when she returned to work on 04/08/24. She acknowledged completing an in-service on reporting changes in condition and notifying the physician. She stated the risk of not reporting the pain the resident had could result in serious injury like a broken bone. In an interview on 07/25/24 at 10:05 AM, the ADON stated she was familiar with the incident regarding Resident #25. She stated she heard the DOT was taking the resident back to her room and she had failed to put the footrests on the resident's wheelchair and the resident injured her leg. She stated she had not heard the resident complaining of pain until 04/06/24, and the weekend nurse contacted the physician, who referred her to the hospital for x-rays. She stated she had heard a couple of days later of what happened after speaking with the resident. She stated the CNA was supposed to notify the nurse of any pain a resident was having so that the nurse can follow up with the resident to assess what was wrong. She stated she nor the nursing staff received any reports of the resident having any new pains. She stated the resident rarely got out of her bed and she had not gotten out of bed that week (04/03/24 to 04/05/24). She stated the risk of not reporting the incident could result in the resident experiencing a severe injury and having pain untreated. In an interview on 07/25/24 at 10:25 AM, the Administrator stated that he knew of the incidents that occurred with Resident #25, and he stated it should have been reported sooner, which was why he had suspended and later terminated the DOT for being neglectful. He stated he had met with all staff and had in-serviced them on reporting injuries, fall protocols, and proper wheelchair transport and positioning on 04/08/24. He stated that he decided to terminate the DOT because of her not reporting the incident and her being neglectful in not using the resident footrest. He stated he had made several attempts to contact the DOT to interview her, but she had not returned his call. He stated the risk for not using the footrest and not reporting the incident once the incident had occurred was not good for the resident because she had a serious injury that went unnoticed for several days. In an interview on 07/25/24 at 03:10 PM, the Nurse Practitioner stated he was advised of the incident that occurred with the resident on 04/06/24. He stated when he was advised that the resident was complaining of pain in her leg, he immediately had her sent out for x-rays. He stated he was made aware that there was an incident involving a wheelchair and she had twisted her left leg. He stated the resident sustained a fracture below her knee, but it did not result in her needing a cast on her leg but instead a leg immobilizer. He stated the resident rarely left her bed and could have had pain when readjusting herself in bed. Attempts were made to contact the DOT for an interview on 07/24/24 at 12:00 PM, on 07/25/23 at 11:00 AM, and on 08/06/24. Each time the phone went straight to voicemail. The noncompliance was identified as past noncompliance (PNC) The IJ began on 04/02/24 and ended on 04/08/24. The facility had corrected the noncompliance before the state's investigation began: The facility re-educated the staff on Policy and procedure for Wheelchair transport and positioning, Patient Safety and Incident Reporting; and Fall Protocol. The facility conducted an AD Hoc Quality Assurance Meeting and terminated the previous Director of Therapy prior to the beginning of the HHSC investigation on 07/22/24. The Staff confirmed when interviewed they were adequately trained to report immediately to the Administrator, if they heard or suspected abuse, neglect or exploitation.

Based on interviews and record reviews the facility failed to notify the physician of an accident that resulted in an injury and required the physician intervention for 1 (Residents #25) of 1 resident reviewed for notification of changes. The Director of Therapy failed to notify Resident #25's physician when the resident injured her left leg on 04/02/24 while being transported in her wheelchair without footrests. Resident #25 sustained a fracture which was not discovered until 04/06/24 when the NP was notified and ordered an x-ray. This failure placed the resident at risk of not receiving immediate medical attention and at risk of further damage to her leg. The noncompliance was identified as past noncompliance (PNC) The IJ began on 04/02/24 and ended on 04/08/24. The facility had corrected the noncompliance before the state's investigation began. Findings included: Record review of Resident #25's face sheet, dated 07/23/2024, revealed she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included diabetes (high blood sugar) and hemiplegia. Record review of Resident #25's Quarterly Minimum Data Set (MDS) dated [DATE] revealed, she had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact) and for ADL care it stated, for transfers, toileting, and bathing, the resident required moderate assistance. Record review of Resident #25's progress notes from 04/02/24 thru 04/05/24, revealed no indication of the resident complaining of pain. Pain assessments were completed, and all documentation indicated Resident Denies of Pain or Discomfort for This Shift. Record review of Resident #25's progress notes on 04/06/24 indicated that the resident had complained of pain in her left leg to LPN M, who completed a pain assessment, and notified the Nurse Practitioner who ordered an x-ray be completed of Resident #25's left leg. Further review of Resident #25's progress notes entered by LPN M dated 04/06/24 at 6:53 PM, revealed Xray diagnostic company called and reported that x-ray is positive for Left knee FX, NP notified and gave order to send out to ER, Daughter family member, Resident notified, ADON, DON and Administrator notified. PRN pain medication administered. In an interview on 07/23/24 at 01:57 PM, Resident #25 stated the Director of Therapy had caused her to break her leg. She stated the on 04/02/24 the DOT was pushing her back to her room from the dining room. She stated that on her way back to her room, her sneakers had gripped the floor, and it caused her left leg to get caught under her wheelchair. She stated the accident caused her to break her knee. She stated that she had to lay in bed for 8 weeks until she was able to sit in her wheelchair and begin moving again. She stated the facility had terminated the DOT for injuring her. She stated she was in pain when the accident occurred, and she had complained about her leg hurting her unto the weekend nurse on 04/06/24. She contacted the physician, and the physician advised the nurse to send the resident out for an x-ray, which was when she was advised that she had fractured her leg. She stated she had no concerns with staff and felt safe at the facility. In an interview on 07/24/24 at 11:31 AM, the Physical Therapist stated she had been at the facility for over 2 years. She stated she was familiar with Resident #25, but she was not at the facility when the incident occurred on 04/02/24. She stated she heard the resident was being wheeled by the Occupational Therapist Assistant, who was also the DOT, from the dining room and for some reason the DOT failed to install the footrest for the resident. She stated she heard that the resident's leg had gotten caught under the wheelchair and she injured her leg. She stated the DOT did not report the incident until the resident had complained about the injury. She stated because of this, she was terminated. The PT stated staff was in-serviced on reporting any injuries or changes in condition on 04/08/24. She stated the risk of not notifying the resident's physician could result in the resident going untreated for a severe injury. In an interview on 07/25/24 at 09:45 AM, the Regional Director of Operations, stated she had been the director since January 2024 and the Area Director prior to her new role. She stated the resident had complained of pain throughout the weekend (04/06/24 and 04/07/24), they found out about the resident being injured, and it was not reported. They stated they immediately placed the Director of Therapy on leave and removed her from all resident responsibility. She stated the team was in-serviced on transporting residents in wheelchairs, using the footrest, and reporting incidents. She stated the resident had increased pain over the weekend and it was discussed during the morning meeting on 04/08/24. The DOT did not report the incident that occurred on 04/02/24 until the morning meeting on 04/08/24. The Administrator immediately suspended her, and ultimately terminated her employment. She stated the risk of the Director of Therapy not reporting the incident until 04/08/24 could have resulted in the resident experiencing a severe injury and having pain. In an interview on 07/25/24 at 09:53 AM, RN K stated she had been at the facility for almost two years. She stated that she managed the 100-Hall, and she was familiar with Resident #25. She stated the resident only complained about her normal pain and she was not aware of any new pain the resident was having. She stated the resident did not like getting out of bed, only for special events, and the resident council meetings. She stated she was made aware of the resident's injury when she returned to work on 04/08/24. She acknowledged completing an in-service on reporting changes in condition and notifying the physician. She stated the risk of not reporting the pain the resident had could result in serious injury like a broken bone. In an interview on 07/25/24 at 10:05 AM, the ADON stated she was familiar with the incident regarding Resident #25. She stated she heard the DOT was taking the resident back to her room and she had failed to put the footrests on the resident's wheelchair and the resident injured her leg. She stated she had not heard the resident complaining of pain until 04/06/24, and the weekend nurse contacted the physician, who referred her to the hospital for x-rays. She stated she had heard a couple of days later of what happened after speaking with the resident. She stated the CNA was supposed to notify the nurse of any pain a resident was having so that the nurse can follow up with the resident to assess what was wrong. She stated she nor the nursing staff received any reports of the resident having any new pains. She stated the resident rarely got out of her bed and she had not gotten out of bed that week (04/03/24 to 04/05/24). She stated the risk of not reporting the incident could result in the resident experiencing a severe injury and having pain untreated. In an interview on 07/25/24 at 10:25 AM, the Administrator stated that he knew of the incidents that occurred with Resident #25, and he stated it should have been reported sooner, which was why he had suspended and later terminated the DOT for being neglectful. He stated he had met with all staff and had in-serviced them on reporting injuries, fall protocols, and proper wheelchair transport and positioning on 04/08/24. He stated that he decided to terminate the DOT because of her not reporting the incident and her being neglectful in not using the resident footrest. He stated he had made several attempts to contact the DOT to interview her, but she had not returned his call. He stated the risk for not using the footrest and not reporting the incident once the incident had occurred was not good for the resident because she had a serious injury that went unnoticed for several days. In an interview on 07/25/24 at 03:10 PM, the Nurse Practitioner stated he was advised of the incident that occurred with the resident on 04/06/24. He stated when he was advised that the resident was complaining of pain in her leg, he immediately had her sent out for x-rays. He stated he was made aware that there was an incident involving a wheelchair and she had twisted her left leg. He stated the resident sustained a fracture below her knee, but it did not result in her needing a cast on her leg but instead a leg immobilizer. He stated the resident rarely left her bed and could have had pain when readjusting herself in bed. Attempts were made to contact the DOT for an interview on 07/24/24 at 12:00 PM, on 07/25/23 at 11:00 AM, and on 08/06/24. Each time the phone went directly to voicemail. Record review of the facility policy referencing PHYSICIAN AND OTHER COMMUNICATION/CHANGE IN CONDITION dated 05/05/23, To improve communication between physicians and nursing staff to promote optimal patient/resident care, provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patient's/resident's condition, and provide guidance for the notification of patients/residents and their responsible party regarding changes in condition. The facility took the following actions to correct the noncompliance prior to the investigation: The facility re-educated the staff on Policy and procedure for Wheelchair transport and positioning, Patient Safety and Incident Reporting; and Fall Protocol. The facility conducted an AD Hoc Quality Assurance Meeting and terminated the previous Director of Therapy prior to the beginning of the HHSC investigation on 07/22/24. The Staff confirmed when interviewed they were adequately trained to report immediately to the Administrator, if they heard or suspected abuse, neglect or exploitation

Based on observation, interview and record review, the facility failed to ensure that the resident is free from physical restraints imposed for convenience and that are not required to treat the resident's medical symptoms, and the facility failed to use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. The Facility: 1. failed to assess for entrapment risks and attempt less restrictive measures prior to installing bed rails for 88 of 88 residents; 2. failed to obtain physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 3. failed to care plan for bed rails for 47 of 88 residents; and 4. failed to obtain consents for bed rails for 88 of 88 residents. These failures placed all residents at risk impaired muscle strength, increased agitation, loss of dignity, falls and entrapment resulting pain, bruising, fractures, strangulation, hanging and death. On 04/29/21 at 6:37 PM, the Administrator and the DON were notified of an identified IJ related to bed rails and the lack of assessments, orders, or consents. They were informed that the first plan of removal was due on 04/29/21 by 7:20 PM. Neither facility staff stated they had any questions and they were provided with IJ template and asked print, sign, and return original to survey team. The Immediate Jeopardy was removed 05/03/21; however, the facility remained out of compliance at a pattern of potential for more than minimal harm that was not immediate jeopardy, due to the facility's need to complete in-service training and evaluate the effectiveness of corrective systems. Findings include: In an interview on 04/29/21 at 12:30 PM, when asked for the bed rail and entrapment risk assessment for Resident #57, MDS Nurse J said they did not have any full bed rails in the facility. She stated that they only used half rails and those did not require an assessment or entrapment risk assessment for use. An observation on 04/29/21 at 12:35 PM, with MDS Nurse J and the Administrator, revealed the bed rails, when not engaged, were folded up and positioned at the head of the bed. The bed rails, when engaged, were folded down and lied laterally in the middle of the bed and left an open area between the bed rail at the head of the bed and at the foot of the bed. Whether in the engaged or not engaged position, the bed rails were present above the level of the mattress. In an interview at 04/29/21 at 12:35 PM, the Administrator was asked if the facility required bed rail assessment and entrapment risk assessments for bed rails, he stated he was unsure and would look into their policy. HHSC Surveyor requested the facility's policy on bed rails. In an interview on 04/29/21 at 2:00 PM, the Administrator provided the HHSC surveyor with the facility's bed rail policy and stated that they had not found any bed rail assessments, entrapment risk assessments, or bed rail orders for any of the residents. He also stated that the only bed rail consent they found was from 2012. He stated that all the beds come with bed rails pre-installed and these were the beds they have always had since the facility opened [AGE] years ago. He said there had not been any changes in beds and if a bed needed to be replaced, they would be replaced with the same beds with the bed rails pre-installed. He stated that even the corporate nurse wasn't aware of the assessment or consent requirements for bed rails and that if [corporate] didn't know, there was no way for us [this facility] to know. In an interview on 04/29/21 at 2:38 PM, Resident #68 stated he did not like the bed rails and that it was hard for him to scoot down to the foot of the bed to get out of bed. Resident denied having any falls or injuries related to the bed rails. Resident said, [Bed rails are] just a reminder for me to behave or they'll put it down [in the engaged position]. In an interview on 04/29/21 at 2:38 PM, CNA A said she was an agency CNA, but had worked at the facility since November 2020. When asked how many of the residents had bed rails, CNA A said, I think they all got them. She stated that the bed rails were there for the resident's safety. She said that she routinely worked double shifts (6AM to 10PM) and when she arrived in the morning the residents' bed rails were always in the engaged position. When asked when she would normally place the bed rails in the engaged position, CNA A said she would put their bed rails in the engaged position anytime I put [a resident] in bed. CNA A said she had been a CNA for [AGE] years. She stated that she was unaware if the bed rails were in each resident's plan of care, however, based on her experience she knew that if bed rails were present she would know to use them. She said, If I see [bed rails], I assume it's to be used. CNA A stated she had observed some residents scoot down to the foot of the bed to get out of bed when the bed rails where in the engaged position. She stated she had observed Resident #25 do this because she will get in and out of her bed all day. CNA A said that at another facility she was taught a few years ago bedrails were considered a restraint. This is one of the few places I've worked at that has bed rails. None of the residents can remove the bed rails on their own because the knob to pull it down is on the outside and low down. Technically I think [bed rails] would be considered a restraint. CNA A said she had observed Residents #4 and #75 go around the rails to get out bed. In an interview on 04/29/21 at 2:45 PM, Resident #9 denied having difficulty getting in and out of bed because of bed rails but said that sometimes his hand did go in between the rails at night when he slept. Resident #9 said he could not disengage the bed rails when he was in bed and had to scoot down to the foot of the bed to get out of bed. In an interview on 04/29/21 at 2:46 PM MDS Nurse J stated, We got orders for all residents to have bed rails. When asked if the doctor had approved for all 88 residents to have bed rails, MDS Nurse J stated, Yes. In an observation on 04/29/21 at 2:50 PM, MDS Nurse J asked CNA B if Resident #4 used the bed rails to transfer himself in bed. MDS Nurse J was standing at Resident #4's doorway typing into her lap top and did not enter the room, nor did she speak with Resident #4. In an interview on 04/29/21 2:58 PM, CNA B said that all residents have bed rails. CNA B said he mainly worked the 100's hallway, and his routine shift was 6am to 2pm, however, he regularly worked overtime on the 2pm to 10 pm shift. CNA B said he normally engaged the bed rails anytime a resident was in bed unless the resident said, they don't want it down. CNA B said that if residents can maneuver themselves they request to not have the bed rails down. He stated that Resident #46 was the only resident who requested not to have the bed rails engaged. When asked what the purpose of the bed rails was, CNA B said they were to guide [residents] from falling down and to keep [residents] from doing what you don't want them to do, like getting up. CNA B said that Resident #25 still thinks she can do the things like she was young, so bedrails are to keep her from getting out of bed. She tries to get out of even with the bed rails, she'll scoot to the end of the bed. When asked if Resident #25 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She falls trying to get out of bed, before you know it she is in the bed or she'll be out of bed using her wheelchair as a walker. CNA B stated he had never observed Resident #25 attempting to climb over the bed rail. CNA B said that except for residents who verbalize they do not want bed rails, the bed rails are engaged anytime a resident was in bed. CNA B said that sometimes the bed rails became loose. He said that Resident #29, would hold on to the bed rails, would shake the bed rails, and the bed rails would become loose. He stated that when he noted loose bed rails he would notify maintenance. An observation on 04/29/21 at 4:30 PM revealed all 88 residents present at the facility had beds with bed rails installed; 63 of 88 residents had at least one bed rail in the engaged position. In an interview on 04/29/21 at 5:58 PM, the DON stated she has worked at facility as DON for 2 years. The DON stated the purpose of bed rails was for residents to use for repositioning themselves. She stated that all beds in the facility had bed rails. The DON stated some of the risks of bed rails were injuries such as falls when trying to climb over rails, skin bruising/tears, strangulation, even death. In an interview on 04/29/21 6:01 PM, ADON C said she had worked at the facility for one year. She stated she was not aware of any injuries related to the bed rails. When asked what the purpose of bed rails was she stated she had previously worked in a hospital setting and it was a surprise how many things here are considered restraints and that [bed rails] are more for positioning or for [physical therapy] to work with residents on them repositioning themselves. When asked if any documentation was required prior to use of bed rails, she said that there would be an assessment of bed mobility to assess the need. She stated that would require, Getting with PT as well and collaborating with the disciplines to see where the residents is and if they even need it. She said they would also talk to the physicians to see if [there] is a concern for safety. When asked if residents were able to disengage the bed rails, ADON C said there is a knob to disengage the bed rails, and that usually very mobile residents could disengage the side rails sitting at the edge of bed. She stated that residents that used side rails due to general weakness would require help from aides to disengage the side rails. ADON C said she had never seen a resident disengage the bed rails while lying down. When asked when bed rails were used, ADON C said, We would reach out to the physician to use the bed rails to prevent falls from bed, we also have scoop mattress and fall mats to use. We use [bed rails] at night time or early in the morning if there is any disorientation [in a resident]. When asked who required bed rails, ADON C said, A large part of the population use the bed rails [in the engaged position'. Very independent residents, will have their side rails [in the disengaged position] because they are a low fall risk. Usually very ambulatory residents will not use the bed rails; however, I have seen them use them. ADON C said she was not aware of staff using the bed rails to keep the residents in bed. ADON C said that in the morning meetings when discussing falls, It's been brought up whether a bed rail contributed to a fall, but we never came to a conclusion that a bed rails contributed to a fall. When asked if there were alternative fall risk interventions other that bed rails, ADON C said, Bed in low position, floor mats. ADON C said, I have never been told that a resident has a history of attempting to climb over the bed rail. If staff was using a bed rail to keep a resident in bed, I would be concerned that I have some patients that are claustrophobic, or restraining them, or if they've had an injury due to that, or if this a method that staff are using when they can't be there like to free up their time. ADON C said that consents for bed rails were a very recent thing that we have discussed, either at the end of last year or at the beginning of this year. ADON C said that some residents can consent for themselves, I believe we have consents for the bed rails. [The DON] usually handled that area. Review of Resident #100's face sheet dated 04/30/21 reflected and birthdate of 10/19/30 and an admitted [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #100's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident requires/ requested the use of side rails. Monitor frequently and release and position PRN for toileting or Repositioning. Every shift . Resident #100 did not have a care plan for the use of side rails. Review of Resident #57's face sheet dated 04/30/21 reflected and birthdate of 01/01/37 and an admitted [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #57's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident requires/ Requested the use of side rails. Monitor frequently and release and position PRN for toileting or Repositioning. Every shift . Review of Resident #57's Care Plan dated 03/25/21, reflected, Problem .Resident requires use of quarter side rails to assist with bed mobility, and positioning .Goal .Resident will be able to reposition self in bed .Approach . Allow resident to make an effort to use side rail for help in moving self in bed .assess for need of continued use of side rail . Review of Resident #69's face sheet dated 04/30/21 reflected and birthdate of 10/07/44 and an admitted [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #69's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident request/requires positional rail to facilitate bed mobility and transfer. Every shift . Review of Resident #69's Care Plan dated 04/15/21, reflected, Problem . Resident requires use of quarter side rails to assist with bed mobility, and positioning . Goal .Resident will be able to reposition self in bed .Approach . Allow resident to make an effort to use side rail for help in moving self in bed .assess for need of continued use of side rail . Review of Resident #75's face sheet dated 04/30/21 reflected a birthdate of 01/13/34 and an admitted [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #75's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident requires/requested the use of side rails. Monitor frequently and release and position PRN for toileting or Repositioning. Every shift . Resident #75 did not have a care plan for the use of side rails. Review of Resident #58's face sheet dated 04/30/21 reflected a birthdate of 06/14/47 and an admitted [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #58's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident requires/ Requested the use of side rails. Monitor frequently and release and position PRN for toileting or Repositioning. Every shift . Resident #58 did not have a care plan for the use of side rails. Review of Resident #55's face sheet dated 04/30/21 reflected a birthdate of 12/21/26 and an admitted [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #55's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident requires/ Requested the use of side rails. Monitor frequently and release and position PRN for toileting or Repositioning. Every shift . Resident #55 did not have a care plan for the use of side rails. Review of Resident # 67's face sheet dated 04/30/21 reflected a birthdate of 10/08/31 and an admitted [DATE]. The listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #67's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident requires/requested the use of side rails. Monitor frequently and release and position PRN for toileting or Repositioning. Every shift . Review of Resident #67's Care Plan dated 04/20/21, reflected, Problem .Resident requires use of quarter side rails to assist with bed mobility, and positioning .Goal .Resident will be able to reposition self in bed .Approach . Allow resident to make an effort to use side rail for help in moving self in bed .assess for need of continued use of side rail . Review of Resident #78's face sheet dated 04/30/21 reflected a birthdate of 06/18/28 and an admitted [DATE]. The listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #78's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident requires/requested the use of side rails. Monitor frequently and release and position PRN for toileting or Repositioning. Every shift . Review of Resident #78's Care Plan dated 02/22/21, reflected, Problem .Resident requires use of quarter side rails to assist with bed mobility, and positioning .Goal .Resident will be able to reposition self in bed .Approach . Allow resident to make an effort to use side rail for help in moving self in bed .assess for need of continued use of side rail . Review of Resident #16's face sheet dated 04/30/21 reflected a birthdate of 12/29/26 and an admitted [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #16's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident requires/requested the use of side rails. Monitor frequently & release & position frequently & PRN for toileting/ Repositioning. Every shift . Review of Resident #16's Care Plan dated 11/24/20, reflected, Problem .Requires use of quarter side rails to assist with bed mobility, and positioning .Goal .will be able to reposition self in bed .Approach . Allow resident to make an effort to use side rail for help in moving self in bed .assess for need of continued use of side rail . Review of Resident #23's face sheet dated 04/30/21 reflected a birthdate of 02/15/51 and an admitted [DATE]. The listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #23's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident requires? requested the use of side rails, Monitor frequently & Release & position Frequently & PRN for toileting/ REpositioning. Every shift . Review of Resident #23's care plan for side rails reflected it was edited on 04/29/21 and included: Problem .Resident requires use of 1/3 side rails to assist with bed mobility, and positioning .Goal .Resident will be able to reposition self in bed .Approach . Allow resident to make an effort to use side rail for help in moving self in bed .assess for need of continued use of side rail . Review of Resident #17's face sheet dated 04/30/21 reflected a birthdate of 03/30/35 and an admitted [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #17's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident requires/requested the use of side rails. Monitor frequently and release and position PRN for toileting or Repositioning. Every shift . Review of Resident #17's Care Plan dated 04/29/21, reflected, Problem .Resident requires use of side rails to assist with bed mobility, and positioning .Goal .Resident will be able to reposition self in bed .Approach . Allow resident to make an effort to use side rail for help in moving self in bed .assess for need of continued use of side rail . Review of Resident #6's face sheet dated 04/30/21 reflected a birthdate of 05/09/27 and an admitted [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident requires/ Requested the use of side rails. Monitor frequently and release and position PRN for toileting or Repositioning. Every shift . Review of resident #6's Care Plan dated 04/14/21, reflected, Problem .requires use of quarter side rails to assist with bed mobility, and positioning .Goal .Resident will be able to reposition self in bed .Approach . Allow resident to make an effort to use side rail for help in moving self in bed .assess for need of continued use of side rail . Review of Resident #68's face sheet dated 04/30/21 reflected a birthdate of 03/31/49 and am admitted [DATE]. The listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #68's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident requires/ Requested the use of side rails. Monitor frequently and release and position PRN for toileting or Repositioning. Every shift . Review of Resident #68's Care Plan dated 03/22/21, reflected, Problem .Resident requires use of quarter side rails to assist with bed mobility, and positioning .Goal .Resident will be able to reposition self in bed .Approach . Allow resident to make an effort to use side rail for help in moving self in bed .assess for need of continued use of side rail . Review of Resident #101's face sheet dated 04/30/21 reflected a birthdate of 10/18/42 and an admitted [DATE]. The listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #101's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Patient/Resident requests/requires position rail to facilitate bed mobility and/or transfer. Every shift . Resident #101 did not have a care plan for the use of side rails. Review of resident #11's face sheet dated 04/30/21 reflected a birthdate of 07/30/36 and an admitted [DATE]. The listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident requires/requested the use of side rails. Monitor frequently and release and position PRN for toileting or Repositioning. Every shift . Review of Resident #11's Care Plan Dated 04/29/21, reflected, Problem . Resident requires use of side rails to assist with bed mobility, and positioning .Goal .Resident will be able to reposition self in bed .Approach . Allow resident to make an effort to use side rail for help in moving self in bed .assess for need of continued use of side rail . Review of Resident #36's face sheet dated 04/30/21 reflected a birthdate of 06/22/40 and an admitted [DATE]. The listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #36's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident requires/ Requested the use of side rails. Monitor frequently and release and position PRN for toileting or Repositioning. Every shift . Resident #36 did not have a care plan for the use of side rails. Review of Resident #75's face sheet dated 04/30/21 reflected a birthdate of 01/09/30 and an admitted [DATE]. The listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #75's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident requires/requested the use of side rails. Monitor frequently and release and position PRN for toileting or Repositioning. Every shift . Resident #75 did not have a care plan for the use of side rails. Review of Resident #102's face sheet dated 04/30/21 reflected a birthdate of 07/31/63 and an admitted [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #102's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident requires/requested the use of side rails. Monitor frequently and release and position PRN for toileting or Repositioning. Every shift . Resident #102 did not have a care plan for the use of side rails. Review of Resident #22's reflected a birthdate of 11/07/35 and an admitted [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #22's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident requires/requested the use of side rails. Monitor frequently and release and position PRN for toileting or Repositioning. Every shift . Resident #22 did not have a care plan for the use of side rails. Review of Resident #37's face sheet dated 04/30/21 reflected a birthdate of 02/07/34 and an admitted [DATE]. The listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #37's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident requires/requested the use of side rails. Monitor frequently and release and position PRN for toileting or Repositioning. Every shift . Resident #37 did not have a care plan for the use of side rails. Review of Resident #5's face sheet reflected a birthdate of 09/30/45 and an admitted [DATE]. The listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident requires/requested the use of side rails. Monitor frequently and release and position PRN for toileting or Repositioning. Every shift . Review of Resident #5's Care Plan dated 01/08/21, reflected, Problem .Resident requires use of quarter side rails to assist with bed mobility, and positioning .Goal .Resident will be able to reposition self in bed .Approach . Allow resident to make an effort to use side rail for help in moving self in bed .assess for need of continued use of side rail . Review of Resident #13's face sheet dated 04/30/21 reflected a birthdate of 10/03/56 and an admitted [DATE]. The listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, interview and record review the facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail, assess the resident for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation of bed rails for all 88 residents in the facility. The Facility: 1. failed to assess for entrapment risks and attempt less restrictive measures prior to installing bed rails for 88 of 88 residents; 2. failed to obtain physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 3. failed to care plan for bed rails for 47 of 88 residents; and 4. failed to obtain consents for bed rails for 88 of 88 residents. These failures placed all residents at risk of falls and entrapment resulting in pain, bruising, fractures, strangulation, hanging and death. On 04/29/21 at 6:37 PM, the Administrator and the DON were notified of an identified IJ related to bed rails and the lack of assessments, orders, or consents. They were informed that the first plan of removal was due on 04/29/21 by 7:20 PM. Neither facility staff stated they had any questions and they were provided with IJ template and asked print, sign, and return original to survey team. The Immediate Jeopardy was removed 05/03/21; however, the facility remained out of compliance at a pattern of potential for more than minimal harm that was not immediate jeopardy, due to the facility's need to complete in-service training and evaluate the effectiveness of corrective systems. Findings include: In an interview on 04/29/21 at 12:30 PM, when asked for the bed rail and entrapment risk assessment for Resident #57, MDS Nurse J said they did not have any full bed rails in the facility. She stated that they only used half rails and those did not require an assessment or entrapment risk assessment for use. An observation on 04/29/21 at 12:35 PM, with MDS Nurse J and the Administrator, revealed the bed rails, when not engaged, were folded up and positioned at the head of the bed. The bed rails, when engaged, were folded down and lied laterally in the middle of the bed and left an open area between the bed rail at the head of the bed and at the foot of the bed. Whether in the engaged or not engaged position, the bed rails were present above the level of the mattress. In an interview at 04/29/21 at 12:35 PM, the Administrator was asked if the facility required bed rail assessment and entrapment risk assessments for bed rails, he stated he was unsure and would look into their policy. HHSC Surveyor requested the facility's policy on bed rails. In an interview on 04/29/21 at 2:00 PM, the Administrator provided the HHSC surveyor with the facility's bed rail policy and stated that they had not found any bed rail assessments, entrapment risk assessments, or bed rail orders for any of the residents. He also stated that the only bed rail consent they found was from 2012. He stated that all the beds come with bed rails pre-installed and these were the beds they have always had since the facility opened [AGE] years ago. He said there had not been any changes in beds and if a bed needed to be replaced, they would be replaced with the same beds with the bed rails pre-installed. He stated that even the corporate nurse wasn't aware of the assessment or consent requirements for bed rails and that if [corporate] didn't know, there was no way for us [this facility] to know. In an interview on 04/29/21 at 2:38 PM, Resident #68 stated he did not like the bed rails and that it was hard for him to scoot down to the foot of the bed to get out of bed. Resident denied having any falls or injuries related to the bed rails. Resident said, [Bed rails are] just a reminder for me to behave or they'll put it down [in the engaged position]. In an interview on 04/29/21 at 2:38 PM, CNA A said she was an agency CNA, but had worked at the facility since November 2020. When asked how many of the residents had bed rails, CNA A said, I think they all got them. She stated that the bed rails were there for the resident's safety. She said that she routinely worked double shifts (6AM to 10PM) and when she arrived in the morning the residents' bed rails were always in the engaged position. When asked when she would normally place the bed rails in the engaged position, CNA A said she would put their bed rails in the engaged position anytime I put [a resident] in bed. CNA A said she had been a CNA for [AGE] years. She stated that she was unaware if the bed rails were in each resident's plan of care, however, based on her experience she knew that if bed rails were present she would know to use them. She said, If I see [bed rails], I assume it's to be used. CNA A stated she had observed some residents scoot down to the foot of the bed to get out of bed when the bed rails where in the engaged position. She stated she had observed Resident #25 do this because she will get in and out of her bed all day. CNA A said that at another facility she was taught a few years ago bedrails were considered a restraint. This is one of the few places I've worked at that has bed rails. None of the residents can remove the bed rails on their own because the knob to pull it down is on the outside and low down. Technically I think [bed rails] would be considered a restraint. CNA A said she had observed Residents #4 and #75 go around the rails to get out bed. In an interview on 04/29/21 at 2:45 PM, Resident #9 denied having difficulty getting in and out of bed because of bed rails but said that sometimes his hand did go in between the rails at night when he slept. Resident #9 said he could not disengage the bed rails when he was in bed and had to scoot down to the foot of the bed to get out of bed. In an interview on 04/29/21 at 2:46 PM MDS Nurse J stated, We got orders for all residents to have bed rails. When asked if the doctor had approved for all 88 residents to have bed rails, MDS Nurse J stated, Yes. In an observation on 04/29/21 at 2:50 PM, MDS Nurse J asked CNA B if Resident #4 used the bed rails to transfer himself in bed. MDS Nurse J was standing at Resident #4's doorway typing into her lap top and did not enter the room, nor did she speak with Resident #4. In an interview on 04/29/21 2:58 PM, CNA B said that all residents have bed rails. CNA B said he mainly worked the 100's hallway, and his routine shift was 6am to 2pm, however, he regularly worked overtime on the 2pm to 10 pm shift. CNA B said he normally engaged the bed rails anytime a resident was in bed unless the resident said, they don't want it down. CNA B said that if residents can maneuver themselves they request to not have the bed rails down. He stated that Resident #46 was the only resident who requested not to have the bed rails engaged. When asked what the purpose of the bed rails was, CNA B said they were to guide [residents] from falling down and to keep [residents] from doing what you don't want them to do, like getting up. CNA B said that Resident #25 still thinks she can do the things like she was young, so bedrails are to keep her from getting out of bed. She tries to get out of even with the bed rails, she'll scoot to the end of the bed. When asked if Resident #25 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She falls trying to get out of bed, before you know it she is in the bed or she'll be out of bed using her wheelchair as a walker. CNA B stated he had never observed Resident #25 attempting to climb over the bed rail. CNA B said that except for residents who verbalize they do not want bed rails, the bed rails are engaged anytime a resident was in bed. CNA B said that sometimes the bed rails became loose. He said that Resident #29, would hold on to the bed rails, would shake the bed rails, and the bed rails would become loose. He stated that when he noted loose bed rails he would notify maintenance. An observation on 04/29/21 at 4:30 PM revealed all 88 residents present at the facility had beds with bed rails installed; 63 of 88 residents had at least one bed rail in the engaged position. In an interview on 04/29/21 at 5:58 PM, the DON stated she has worked at facility as DON for 2 years. The DON stated the purpose of bed rails was for residents to use for repositioning themselves. She stated that all beds in the facility had bed rails. The DON stated some of the risks of bed rails were injuries such as falls when trying to climb over rails, skin bruising/tears, strangulation, even death. In an interview on 04/29/21 6:01 PM, ADON C said she had worked at the facility for one year. She stated she was not aware of any injuries related to the bed rails. When asked what the purpose of bed rails was she stated she had previously worked in a hospital setting and it was a surprise how many things here are considered restraints and that [bed rails] are more for positioning or for [physical therapy] to work with residents on them repositioning themselves. When asked if any documentation was required prior to use of bed rails, she said that there would be an assessment of bed mobility to assess the need. She stated that would require, Getting with PT as well and collaborating with the disciplines to see where the residents is and if they even need it. She said they would also talk to the physicians to see if [there] is a concern for safety. When asked if residents were able to disengage the bed rails, ADON C said there is a knob to disengage the bed rails, and that usually very mobile residents could disengage the side rails sitting at the edge of bed. She stated that residents that used side rails due to general weakness would require help from aides to disengage the side rails. ADON C said she had never seen a resident disengage the bed rails while lying down. When asked when bed rails were used, ADON C said, We would reach out to the physician to use the bed rails to prevent falls from bed, we also have scoop mattress and fall mats to use. We use [bed rails] at night time or early in the morning if there is any disorientation [in a resident]. When asked who required bed rails, ADON C said, A large part of the population use the bed rails [in the engaged position'. Very independent residents, will have their side rails [in the disengaged position] because they are a low fall risk. Usually very ambulatory residents will not use the bed rails; however, I have seen them use them. ADON C said she was not aware of staff using the bed rails to keep the residents in bed. ADON C said that in the morning meetings when discussing falls, It's been brought up whether a bed rail contributed to a fall, but we never came to a conclusion that a bed rails contributed to a fall. When asked if there were alternative fall risk interventions other that bed rails, ADON C said, Bed in low position, floor mats. ADON C said, I have never been told that a resident has a history of attempting to climb over the bed rail. If staff was using a bed rail to keep a resident in bed, I would be concerned that I have some patients that are claustrophobic, or restraining them, or if they've had an injury due to that, or if this a method that staff are using when they can't be there like to free up their time. ADON C said that consents for bed rails were a very recent thing that we have discussed, either at the end of last year or at the beginning of this year. ADON C said that some residents can consent for themselves, I believe we have consents for the bed rails. [The DON] usually handled that area. Review of Resident #100's face sheet dated 04/30/21 reflected and birthdate of 10/19/30 and an admitted [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #100's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident requires/ requested the use of side rails. Monitor frequently and release and position PRN for toileting or Repositioning. Every shift . Resident #100 did not have a care plan for the use of side rails. Review of Resident #57's face sheet dated 04/30/21 reflected and birthdate of 01/01/37 and an admitted [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #57's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident requires/ Requested the use of side rails. Monitor frequently and release and position PRN for toileting or Repositioning. Every shift . Review of Resident #57's Care Plan dated 03/25/21, reflected, Problem .Resident requires use of quarter side rails to assist with bed mobility, and positioning .Goal .Resident will be able to reposition self in bed .Approach . Allow resident to make an effort to use side rail for help in moving self in bed .assess for need of continued use of side rail . Review of Resident #69's face sheet dated 04/30/21 reflected and birthdate of 10/07/44 and an admitted [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #69's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident request/requires positional rail to facilitate bed mobility and transfer. Every shift . Review of Resident #69's Care Plan dated 04/15/21, reflected, Problem . Resident requires use of quarter side rails to assist with bed mobility, and positioning . Goal .Resident will be able to reposition self in bed .Approach . Allow resident to make an effort to use side rail for help in moving self in bed .assess for need of continued use of side rail . Review of Resident #75's face sheet dated 04/30/21 reflected a birthdate of 01/13/34 and an admitted [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #75's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident requires/requested the use of side rails. Monitor frequently and release and position PRN for toileting or Repositioning. Every shift . Resident #75 did not have a care plan for the use of side rails. Review of Resident #58's face sheet dated 04/30/21 reflected a birthdate of 06/14/47 and an admitted [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #58's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident requires/ Requested the use of side rails. Monitor frequently and release and position PRN for toileting or Repositioning. Every shift . Resident #58 did not have a care plan for the use of side rails. Review of Resident #55's face sheet dated 04/30/21 reflected a birthdate of 12/21/26 and an admitted [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #55's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident requires/ Requested the use of side rails. Monitor frequently and release and position PRN for toileting or Repositioning. Every shift . Resident #55 did not have a care plan for the use of side rails. Review of Resident # 67's face sheet dated 04/30/21 reflected a birthdate of 10/08/31 and an admitted [DATE]. The listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #67's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident requires/requested the use of side rails. Monitor frequently and release and position PRN for toileting or Repositioning. Every shift . Review of Resident #67's Care Plan dated 04/20/21, reflected, Problem .Resident requires use of quarter side rails to assist with bed mobility, and positioning .Goal .Resident will be able to reposition self in bed .Approach . Allow resident to make an effort to use side rail for help in moving self in bed .assess for need of continued use of side rail . Review of Resident #78's face sheet dated 04/30/21 reflected a birthdate of 06/18/28 and an admitted [DATE]. The listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #78's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident requires/requested the use of side rails. Monitor frequently and release and position PRN for toileting or Repositioning. Every shift . Review of Resident #78's Care Plan dated 02/22/21, reflected, Problem .Resident requires use of quarter side rails to assist with bed mobility, and positioning .Goal .Resident will be able to reposition self in bed .Approach . Allow resident to make an effort to use side rail for help in moving self in bed .assess for need of continued use of side rail . Review of Resident #16's face sheet dated 04/30/21 reflected a birthdate of 12/29/26 and an admitted [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #16's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident requires/requested the use of side rails. Monitor frequently & release & position frequently & PRN for toileting/ Repositioning. Every shift . Review of Resident #16's Care Plan dated 11/24/20, reflected, Problem .Requires use of quarter side rails to assist with bed mobility, and positioning .Goal .will be able to reposition self in bed .Approach . Allow resident to make an effort to use side rail for help in moving self in bed .assess for need of continued use of side rail . Review of Resident #23's face sheet dated 04/30/21 reflected a birthdate of 02/15/51 and an admitted [DATE]. The listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #23's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident requires? requested the use of side rails, Monitor frequently & Release & position Frequently & PRN for toileting/ REpositioning. Every shift . Review of Resident #23's care plan for side rails reflected it was edited on 04/29/21 and included: Problem .Resident requires use of 1/3 side rails to assist with bed mobility, and positioning .Goal .Resident will be able to reposition self in bed .Approach . Allow resident to make an effort to use side rail for help in moving self in bed .assess for need of continued use of side rail . Review of Resident #17's face sheet dated 04/30/21 reflected a birthdate of 03/30/35 and an admitted [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #17's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident requires/requested the use of side rails. Monitor frequently and release and position PRN for toileting or Repositioning. Every shift . Review of Resident #17's Care Plan dated 04/29/21, reflected, Problem .Resident requires use of side rails to assist with bed mobility, and positioning .Goal .Resident will be able to reposition self in bed .Approach . Allow resident to make an effort to use side rail for help in moving self in bed .assess for need of continued use of side rail . Review of Resident #6's face sheet dated 04/30/21 reflected a birthdate of 05/09/27 and an admitted [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident requires/ Requested the use of side rails. Monitor frequently and release and position PRN for toileting or Repositioning. Every shift . Review of resident #6's Care Plan dated 04/14/21, reflected, Problem .requires use of quarter side rails to assist with bed mobility, and positioning .Goal .Resident will be able to reposition self in bed .Approach . Allow resident to make an effort to use side rail for help in moving self in bed .assess for need of continued use of side rail . Review of Resident #68's face sheet dated 04/30/21 reflected a birthdate of 03/31/49 and am admitted [DATE]. The listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #68's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident requires/ Requested the use of side rails. Monitor frequently and release and position PRN for toileting or Repositioning. Every shift . Review of Resident #68's Care Plan dated 03/22/21, reflected, Problem .Resident requires use of quarter side rails to assist with bed mobility, and positioning .Goal .Resident will be able to reposition self in bed .Approach . Allow resident to make an effort to use side rail for help in moving self in bed .assess for need of continued use of side rail . Review of Resident #101's face sheet dated 04/30/21 reflected a birthdate of 10/18/42 and an admitted [DATE]. The listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #101's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Patient/Resident requests/requires position rail to facilitate bed mobility and/or transfer. Every shift . Resident #101 did not have a care plan for the use of side rails. Review of resident #11's face sheet dated 04/30/21 reflected a birthdate of 07/30/36 and an admitted [DATE]. The listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident requires/requested the use of side rails. Monitor frequently and release and position PRN for toileting or Repositioning. Every shift . Review of Resident #11's Care Plan Dated 04/29/21, reflected, Problem . Resident requires use of side rails to assist with bed mobility, and positioning .Goal .Resident will be able to reposition self in bed .Approach . Allow resident to make an effort to use side rail for help in moving self in bed .assess for need of continued use of side rail . Review of Resident #36's face sheet dated 04/30/21 reflected a birthdate of 06/22/40 and an admitted [DATE]. The listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #36's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident requires/ Requested the use of side rails. Monitor frequently and release and position PRN for toileting or Repositioning. Every shift . Resident #36 did not have a care plan for the use of side rails. Review of Resident #75's face sheet dated 04/30/21 reflected a birthdate of 01/09/30 and an admitted [DATE]. The listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #75's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident requires/requested the use of side rails. Monitor frequently and release and position PRN for toileting or Repositioning. Every shift . Resident #75 did not have a care plan for the use of side rails. Review of Resident #102's face sheet dated 04/30/21 reflected a birthdate of 07/31/63 and an admitted [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #102's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident requires/requested the use of side rails. Monitor frequently and release and position PRN for toileting or Repositioning. Every shift . Resident #102 did not have a care plan for the use of side rails. Review of Resident #22's reflected a birthdate of 11/07/35 and an admitted [DATE]. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #22's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident requires/requested the use of side rails. Monitor frequently and release and position PRN for toileting or Repositioning. Every shift . Resident #22 did not have a care plan for the use of side rails. Review of Resident #37's face sheet dated 04/30/21 reflected a birthdate of 02/07/34 and an admitted [DATE]. The listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #37's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident requires/requested the use of side rails. Monitor frequently and release and position PRN for toileting or Repositioning. Every shift . Resident #37 did not have a care plan for the use of side rails. Review of Resident #5's face sheet reflected a birthdate of 09/30/45 and an admitted [DATE]. The listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . It also reflected that on 04/29/21 the following order was entered: Resident requires/requested the use of side rails. Monitor frequently and release and position PRN for toileting or Repositioning. Every shift . Review of Resident #5's Care Plan dated 01/08/21, reflected, Problem .Resident requires use of quarter side rails to assist with bed mobility, and positioning .Goal .Resident will be able to reposition self in bed .Approach . Allow resident to make an effort to use side rail for help in moving self in bed .assess for need of continued use of side rail . Review of Resident #13's face sheet dated 04/30/21 reflected a birthdate of 10/03/56 and an admitted [DATE]. The listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision/assistance to prevent accidents for one (Resident #1) of five residents reviewed for accidents. The facility failed to ensure staff provided the appropriate level of assistance to Resident #1 when transferring the resident. On 06/24/20 CNA A transferred Resident #1 without any assistance and Resident #1 sustained a probable nondisplaced incomplete [MEDICAL CONDITION] ankle. On 01/25/21 CNA C transferred Resident #1 without any assistance and during the transfer the resident had to be lowered to floor. As a result of the transfer, Resident #1 acute fractures of the left tibia (lower front leg bone) and left fibular head (bone near the knee). Resident #1 was required to be non-weight bearing and have a cast on her left leg. An Immediate Jeopardy (IJ) was identified on 02/22/21. While the IJ was removed on 02/25/21, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility was still monitoring the effectiveness of the plan of removal. This failure placed residents at risk for serious injury, [MEDICATION NAME] physical impairment, and even death. Findings included: 1) Review of Resident #1's electronic admission record revealed the resident was a [AGE] year-old female who admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #1's quarterly MDS assessments, dated 12/08/20 and 05/13/20, revealed Resident #1 required extensive physical assistance of a least two persons for transfers. Review of the Resident #1's Care Plan, dated 12/17/19 and revised 02/04/21, revealed the risk for falls was addressed with a goal for the resident to be free from major injury related to falls. The intervention of providing two-persons to assist during transfers, due to left sided weakness and retrograde flexion (leaning backwards) was added 06/25/20. Prior to 06/25/20 the Care Plan did not identify the specific number of people Individual #1 required for assistance with transferring. Review of Resident #1's electronic Resident Profile revealed the approach for two-person transfer assistance was initiated on 06/25/20. The profile was updated on 02/24/21 to include the use of a mechanical lift. Review of the facility's Provider Investigation Report dated 06/24/20 revealed Resident #1 reported when CNA C transferred the resident from the bed to the wheelchair on the morning of 06/20/20 she and the CNA fell . The resident was assessed on 06/20/20 with a painful and swollen left ankle. The radiology exam dated 06/20/20 reflected an impression of a probable nondisplaced incomplete [MEDICAL CONDITION] medial malleolus. The investigation report further reflected staff had been educated on safe transfers to include one-on-one with CNA C regarding Resident #1's specific needs. Review of Resident #1's hospital radiology report dated 06/20/20 revealed a suspicion of a non-displaced incomplete [MEDICAL CONDITION] medial malleolus (ankle bone). The final report reflected a probable non-displaced incomplete [MEDICAL CONDITION] medial malleolus. Interview attempts with CNA C on 02/11/21 at 10:50 a.m. and 1:20 p.m. were unsuccessful as he was no longer employed by the facility and no return calls were received. Review of the facility's Provider Investigation Report dated 01/28/21 revealed Resident #1 sustained a fracture to the lower left leg when CNA A attempted to transfer the resident without the assistance of another staff as required according to the resident's assessment and care plan. The resident was transferred to the hospital for radiological studies on 01/26/21 and returned on 01/29/21 with a splint to the left lower leg and orders to be non-weight bearing. The investigation report reflected CNA A was not aware the resident required two persons to transfer. Review of Resident #1's hospital records and radiology reports dated 01/26/21 revealed an acute [MEDICATION NAME] proximal tibia and an acute non-displaced [MEDICAL CONDITION] fibular head was determined. Interview with CNA A on 02/12/21 at 3:29 p.m. revealed she had worked at the facility for approximately one month. She stated she transferred Resident #1 from the wheelchair to the commode on 01/25/21 without having assistance of another person. She stated she was unable to locate anyone to assist when the resident urgently requested to use the bathroom and she was not aware the resident required two people to transfer. She stated Resident #1was using her right hand to hold the grab bar in the bathroom and suddenly let go, raised her left foot off the floor and yelled out she was falling. The CNA stated she was unable to support the resident's weight and had to lower the resident to the floor. She stated she had never been informed Resident #1 required two staff for transfers and when she had transferred the resident alone on other occasions the resident was able to cooperate. There had been times in the past when she obtained assistance to transfer the resident but only because it was quicker with two people. She further stated during orientation she followed CNA B and transferred Resident #1 alone the same way CNA B did. Additionally, she stated she had been provided training by therapy on how to perform transfers but had not been informed or aware resident transfer needs were listed on the Resident Profile in the POC database until yesterday (02/11/21) when she was informed/instructed by another staff. Review of CNA documentation in the facility's POC database for 01/24/21 through 01/26/21 revealed CNAs documented Resident #1 received assistance by one staff for transfer assistance on five different occasions. Resident #1 was observed on 02/10/21 at 10:15 a.m. awake in bed with a splint to the left lower extremity. Attempts to interview the resident regarding the incidents were unsuccessful due to impaired cognition. A family member present at the bedside stated the resident was forgetful and not able to recall things well. The family member stated the resident had sustained two fractures while residing in the facility during staff assisted transfers. Interview with CNA B on 02/12/21 at 1:05 p.m. and 4:14 p.m. revealed he had worked at the facility for ten years and provided care for Resident #1. The CNA stated he had trained CNA A on using two people to transfer Resident #1. Resident #1 had always required one-person transfer assist unless staff were unable to perform the transfer alone. He stated he transferred the resident alone because he knew the resident well and used the Resident Profile to obtain information about new residents. He further stated he only used the POC database to document what care was provided to residents and did not use the Resident Profile Care Plan screen, as it was for the nurses, he knew most of the resident's needs and the nurse usually told him the amount of care the residents required. Interview with CNA E on 02/12/21 at 1:15 p.m. revealed she had worked at the facility for one month. She stated facility nurses informed her of resident's transfer needs. She stated there was nothing in the POC database related to a resident's transfer needs. Interview with the DON on 02/22/21 at 9:46 a.m. revealed she had an action plan to address Resident #1's 01/25/21 incident. She stated the plan had not fully been implemented due to surveyors entering the facility on 02/10/21 and the facility had been, figuring out what to do. She stated some nurses had not been consistent in providing report of resident needs to CNAs. She stated resident care needs to include transfer requirements were listed on the Resident Profile in the POC database. The facility's electronic health record system had been initiated in 2019 but no specific training had been provided to CNAs related to where to find resident information. She further stated when Resident #1 was noted with an injury after being transferred by one staff 06/20/20, her investigation did not identify the resident should have been transferred by two staff. She did not know at the time of the incident the resident required two staff for transfers. After the incident she updated the resident's Care Plan to reflect two people were required as a new intervention. Review of the facility's action plan provided by the DON on 02/22/21 revealed the plan was dated 01/29/21 and reflected review dates of 02/05/21 and 02/10/21. The identified issue was communication of lift requirements with a root cause analysis of the ability to be aware of lift status. The plan was developed in response to a fall with injury identified on 01/25/21. The plan further reflected interventions would be to review an assessment (sic) of all residents to determine lift requirements, develop a labeling system that is readily available at the door that indicates the number of people required and type of equipment needed, revitalize nursing reports to CNAs and review of lift requirements to be added to Quality of Care and report monthly at QAPI (Quality Assurance and Performance Improvement). Interview on 02/22/21 at 5:40 p.m. The DON stated Resident #1's incident was due to CNA A bypassing the use of two persons for transfer assist, lowering the resident causing the fracture. All staff had been re-educated on using the POC database but there was no documented evidence of the re-education as it had been provided by word of mouth. She stated on 1/29/21 she began developing an action plan and in-service related to transfer techniques. She stated she assumed CNA B would know Resident #1 required two persons for transfer. She never got to interviewed CNA B on what training he had provided to CNA A. CNA B was not supposed to transfer Resident #1 alone and her expectations were for staff to follow the resident's care plan and use the appropriate amount of people for transfers. Interviews were conducted on 02/22/21 with LVN F, LVN G and LVN H at 2:20 p.m., 2:32 p.m. and 2:36 p.m. respectively. The nurses stated CNAs used the POC database to obtain resident care needs to include transfers. They stated they provided resident care information to the CNAs if there was a new resident. The nurses further stated CNAs should ask the nurse or the supervisor if they did not know the care needs of the resident they were caring for. LVN G stated she was not able to tell CNAs daily what a resident's needs were and expected CNAs to use the POC database if they knew how. Interview with the DON on 02/24/21 at 3:09 p.m. revealed the previous list of residents who required two-person transfer assist was incorrect. Instead of the 9 residents more residents had been identified and currently 41 residents in the facility required two-person transfer assist. She stated she, along with other nursing administration and therapy staff had reviewed Resident Profiles and determined which residents required two-person transfer assist. The facility's policy/procedure related to transfers and updating the Resident Profile was requested from the DON on 02/25/21 at 3:20 p.m. On 02/25/21 the DON provided a one-page document from the Matrix Clinical Guide revised 01/28/2008 and entitled Resident Profile/Using the Resident Profile. She provided a policy/procedure related to mechanical lifts, wheelchair safety use and maintenance. No policy/procedure related to transfers was provided. Interview with the DON on 02/25/21 at 3:28 p.m. revealed nurses were responsible for updating the Resident Profile. She stated there were several layers to the process that included the DON, ADONs, MDS nurses and any nurse could update the profiles. She further stated during the reviews of the profiles for the POR the facility discovered the profiles had not been updated as frequently or as consistently as she wanted. She stated there was not specific policy/procedure related to who was responsible for updating the Resident Profile or the procedure/system to ensure the Resident Profile is updated. She stated the profiles should be completed on admission, quarterly, during a significant change and when orders affect residents care needs. Review on 02/25/21 of a one-page document provided by the DON from the Matrix Clinical Guide revised 01/28/2008 and entitled Resident Profile/Using the Resident Profile reflected in part: The Resident Profile provided clinical staff with a systematic process to view and communicate key resident care information. Information on the profile had been configured and included information linked from the face sheet like allergies [REDACTED]. The profile was beneficial because it included quick access and consistency of information for all clinical staff. The document reflected The CNA staff will review care delivery needs prior to working with each resident, and intermittently through the shift. As resident care issues change, remember to update resident profile items. An Immediate Jeopardy was identified on 02/22/21. The Administrator and DON, were notified of the Immediate Jeopardy on 02/22/21 and they were provided with a copy of the IJ template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Plan of Removal was accepted on 02/24/21 at 11:00 a.m. and reflected the following: Resident identified is currently a 2 person transfer and being transferred per the care plan and profile 41 residents who reside in the facility and require 2-person assist with transfers have the potential to be affected by the alleged deficient practice. Resident profiles have been updated to reflect the current transfer status. Any staff member who deviates from resident profile will receive one-on-one re-education and appropriate disciplinary action. Licensed nurses and Certified Nursing Assistants will be re-educated by the Director of Nursing / designee on the following: Resident transfers can be found on the resident profile and care plan and can be accessed in the kiosk. Resident profiles should be reviewed prior to caring for residents who require assistance with transfers. Certified Nursing Assistants are to notify the licensed nurse for assistance if a transfer cannot be performed due to no staff availability Additionally, the Licensed Nurses will be re-educated on the expectation that a shift report will be given to the Certified Nursing Assistants regarding residents who have a change in transfer status due to decline or a fall intervention. This re-education will begin on February 22, 2021 and will be completed February 23,2021. Any licensed nurse or Certified Nursing Assistant not receiving this education by this date will be educated prior to next scheduled shift. We will use an employee roster and schedule to track and document education compliance. Agency personal and or facility New Hires will receive this re-education prior to reporting for duty and will be given access to resident profiles in the kiosk. The Director of Nursing will observe a minimum of 2 resident transfers daily for 5 days to validate that residents are being transferred per the Plan of Care and question clinical staff regarding: where to access resident transfer information and to validate understanding of the education presented. The Medical Director was notified of the Immediate Jeopardy on February 22, 2021. An ad hoc Quality Assurance Performance Improvement Meeting was held on February 22, 2021 to review contents of this plan. The following observations, interviews, and record reviews conducted to verify the implementation of the facility's Plan of Removal revealed the following: Interviews conducted with 9 licensed nurses across all three shifts on 02/24/21 from 3:19 p.m. to 4:14 p.m. and 02/25/20 from 12:25 a.m. to 4:22 p.m. revealed they verbalized comprehension of the in- service training. They stated they had been in-serviced on accessing Resident Profiles in the POC database, CNAs were expected to review the profiles prior to caring for a resident and they were to provide a shift report to CNAs related to changes in resident's transfer status. Interviews conducted with 12 CNAs across all three shifts on 02/24/21 from 3:19 p.m. to 4:14 p.m. and 02/25/21 from 12:25 a.m. to 4:22 p.m. revealed CNAs verbalized comprehension of the in-service training. They stated they had received in-service training regarding how to access Resident Profiles and resident care needs. They stated they would never transfer a resident who required two-person transfer assist without obtaining help from another staff even if they had to ask the nurse for assistance. They further stated they had been instructed to check the Resident Profiles at the start of their shifts, before providing transfer assistance and anytime they needed information related to the care needs of a resident. Observations conducted during interviews with the day and evening shift CNAs revealed they were able to demonstrate the correct procedure for logging into the POC database and locating the Resident Profile and required transfer needs. Review of in-service records dated 02/22/21 revealed staff had received training on locating resident care needs on the Resident Profile in the POC database and reviewing the profiles prior to caring for residents. Training included licensed nurses providing reports to CNAs regarding residents who had change in transfer status and CNAs notifying licensed nurses if no other staff was available to assist with a two-person transfer. The Administrator was notified on 02/25/20 at 1:45 p.m. that the Immediate Jeopardy was removed. While the IJ was removed on 02/25/21, the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and a scope of isolated because the facility was still monitoring their plan of removal.

Based on observation, interview and record review, it was determined the facility failed to ensure three (Residents #1, #2 and #3) of ten residents reviewed for nutrition, maintained acceptable parameters of body weight and [MEDICATION NAME] levels. 1) Resident #1 had a 19.2 lb weight loss in three weeks (08/23/10 - 09/13/10), representing a "severe" weight loss of 12%. The resident was weighed weekly during the same time period, but no interventions were put in place to address the weight loss. The resident was sent to the hospital on [DATE] and was admitted to a local hospital with [DIAGNOSES REDACTED]. Food preferences were not utilized. 2) Resident #2 had a 14.6 lb weight loss in five weeks (8/13/10 - 9/17/10), representing a "severe" weight loss of 10%. The resident continued to lose another 2.2 lbs in the next three days. The resident was weighed frequently during this period and interventions were not planned and ordered until 09/10/10. Interventions were not followed through with as indicated by the resident not receiving the magic cup and fortified foods with meals, Protein Powders with the medication pass. There were no interventions through a dietitian consultation. Food preferences were not utilized. 3) Resident #3 had an 11.4 lb weight loss in six weeks (08/09/10 - 09/20/10), representing a "significant" weight loss of 8%. No dietary interventions were put in place until 09/13/10. The facility did not have a dietitian from 08/26/10 through 09/20/10. No dietician was consulted regarding Resident #3's 9% weight loss at any time. Resident food preferences were not completed for Resident #3. These failures resulted in Residents #1, #2 and #3 in having severe and significant weight loss and resulted in Resident #3 being sent to the hospital for treatment with further [DIAGNOSES REDACTED]. These failures could affect the facility's 76 residents, placing them at risk for weight loss and abnormal lab results to go undetected and untreated. These failures could result in the potential for a delay in healing of pressure ulcers, decreased physical stamina, and have a negative impact on the residents health and well-being resulting in exacerbation of their disease processes. Findings included: 1) Resident #1 was an [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility admission orders [REDACTED]. Laboratory orders included: complete blood count (CBC), comprehensive metabolic profile (CMP) and urinalysis with culture and sensitivity (UA with C&S). Review of the Admission Nursing assessment dated [DATE] for Resident #1 revealed his weight was 154 lbs. However the handwritten notation, " 8/25" indicated the weight assessment was actually added to the assessment two days after admission. Review of Resident #1's facility weights as documented in the weight book for the 100 Hall and 200 Hall revealed: 08/25/10 - 154 lbs; 09/02/10 - 142 lbs; 09/13/10 - 136 lbs; 09/13/10 - re-weigh 134.8. These weights reflected Resident #1 had a 19.2 lb weight loss in three weeks, representing a "severe" weight loss of 12.%. Review of the entire clinical record for Resident #1 revealed there was no dietary assessment. Review of Nurse's Notes for Resident #1 from 09/02/10 through 09/12/10 revealed no documentation of Resident #1's weight loss, or that a weight loss was reported to the physician or family. Resident #1's Nurse's Note dated 09/13/10 and signed by the DON reflected, "Received weight since admit 8/25-154, 9/2-142, 9/13-136 ordered for fortified foods, magic cup, wkly wts (weekly weights), carnation instant breakfast can supplement BID. Informed charge nurse also (physician)...." Review of Progress Notes for Resident #1 revealed he was assessed by the nurse practitioner for his attending physician on 09/07/10, 09/09/10 and 09/14/10. None of the three Progress Notes addressed the resident's weight loss. Interview on 09/18/10 at 2:45 p.m. with the DON revealed they were in the process of hiring a dietitian. She stated they had been without the dietitian for less than 30 days. Interview on 09/18/10 at 3:20 p.m. with the Dietary Manager (DM) revealed there was currently no dietitian for the facility. When asked what dietitian he consulted with regarding dietary needs, the DM stated there was not one. He added he would talk with the DON or the ADM. The DM revealed on 09/10/10, Resident #1's family talked with him regarding Resident #1's "drastic" weight loss. The family was also concerned the resident was not getting enough protein in his diet. The DM stated this was the first he had been made aware of the resident's weight loss. On 09/14/10, the DM attended the weight committee meeting. When asked what was discussed, the DM revealed Resident #1' "drastic" weight loss was discussed. The DM was queried regarding measures discussed to be implemented for Resident #1. He stated he was not sure what was to be implemented, but the DON was present during the weight committee meeting on 09/14/10. The DM was also queried regarding the dietary likes and dislikes of Resident #1. The DM stated residents' likes and dislikes were listed on the resident's meal ticket for guidance. After reviewing Resident #1's dietary information, the DM confirmed he had not completed likes and dislikes for Resident #1. Interview on 09/20/10 at 9:05 a.m. with Resident #1, at a local hospital, revealed the facility provided three meals a day, but he did not always eat what was served. He stated the food was "awful." Observation revealed Resident #1 was very thin. Interview on 09/20/10 at 10:06 a.m. with the ADM revealed she was planning to hire a new dietitian. The ADM added "if needed," she could call the dietitian, who worked at a sister facility. Interview on 09/20/10 at 10:25 a.m. with RNA A revealed he had been employed at the facility for six months. He stated he was responsible for weights. He stated when a new resident was admitted to the facility, the resident was weighed weekly for four weeks. He stated he documented all weights (monthly, weekly and daily) in the weight books located at each nurse's station. He added he would compare the current weight, with the previously documented weight. When asked what he did if a resident had weight loss, RNA A stated he reported it to the charge nurse and the DON. The weight book for the 100 Hall and 200 Hall was reviewed with RNA A at the time of the interview. When asked specifically about Resident #1's weight loss, RNA A stated he reported the weight loss to the charge nurse and the DON. He stated he could not remember who the specific charge nurse was to whom he reported it. Interview on 09/20/10 at 10:40 a.m. with ADON B revealed she had only been working in the facility for approximately three weeks. ADON B confirmed she participated in the weight committee meeting on 09/14/10. ADON B revealed the DM, the DON and the Speech Therapist were in the meeting. She stated they discussed Resident #1's weight loss and decided they would weigh him weekly for four weeks and continue his [MEDICATION NAME]. They were also going to add fortified foods and a magic cup to his meals. When queried if the DM discussed his conversation with Resident #1's family on 09/10/10 prior to the weight committee meeting (09/14/10), ADON B stated she could not remember. ADON B stated she was not aware of Resident #1's weight loss until the family brought it to her attention the day before the weight committee meeting (09/13/10). When asked if she had investigated why the weight loss was not addressed on 09/02/10, ADON B stated she had not. (Note: The facility's weight book reflected the resident had lost 12 lbs in one week when he was weighed on 09/02/10.) Interview on 09/20/10 at 11:20 a.m. with the ADM revealed a new dietitian was starting that day. The new dietitian's contract was requested for review. During an interview on 09/20/10 at 3:35 p.m. with the DON and the ADM, the DON stated she was not informed on Resident #1's weight loss until 09/13/10. The DON denied RNA A notified her on 09/02/10, and she could not recall being told of any concerns or conversations regarding Resident #1 by the DM. The ADM and DON were asked what had been done to ensure residents' weight loss was communicated effectively. The DON stated she had spoken with RNA A about the situation. When asked how it was determined to discuss weight loss in the meetings, the DON was very nonspecific in just stating residents were discussed when weight loss was found. Interview on 09/20/10 at 4:15 p.m. with the DON revealed they would have the contract for the dietitian ready on 09/21/10. During an interview on 09/21/10 at 1:35 p.m. with the ADM and the DON, they were queried as to the availability of a corporate dietitian for consultation prior to 09/18/10. The ADM stated she could check and see if anyone had been available. Interview on 09/21/10 at 2:43 p.m. with MDS Coordinator D revealed she was present during the care plan meeting on 09/08/10 with the family of Resident #1. She stated she could not recall if weight loss was discussed during the meeting. She remembered discussing Resident #1 not eating in the dining room. Review of a Care Plan Conference Summary dated 09/08/10 for Resident #1 revealed the dietary section was blank. Three family members attended the conference. Note: Resident #1 had > 10 lbs weight loss on 09/02/10. Review of a Comprehensive Plan of care dated 09/13/10 for Resident #1 revealed the resident's weight loss was identified and facility approaches included, "1) Serve residents food preferences, 2) Assess resident for food preferences..." Resident #1's weights (08/25/10 -154, 09/02/10 - 142 and 09/13/10 - 136) were handwritten on the care plan. Review of a Diet Order & Communication dated 09/13/10 for Resident #1 revealed, "...Fortified foods each meal...magic cup TID, carnation instant breakfast one can BID." Review of a physician's telephone order dated 09/13/10 for Resident #1 revealed, "1) Fortified foods, 2) Magic Cup TID, 3) Carnation instant breakfast one can BID, 4) weekly weights (times) 4." Review of Resident #1's entire clinical record revealed no likes and dislikes were documented in the record. Review of the lab section of the clinical record for Resident #1 revealed a CBC and a CMP that was collected on 08/24/10. The lab report was faxed to the facility on [DATE]. The lab results were signed off by the Nurse Practitioner on 09/14/10. Resident #1's [MEDICATION NAME] was low at 2.6 g/dL. The normal [MEDICATION NAME] was 3.4-5.0 g/dL. Review of the hospital Emergency Physician Record dated 09/14/10 for Resident #1 revealed the resident was sent to the hospital with "wt. loss." The physician's Clinical Impression was, "1) Weakness, 2) Dehydration, 30 Leukocytosis." Review of the hospital history and physical dated 09/14/10 for Resident #1 revealed, "...History of Present Illness: ...The family had concerns that the patient had loss (sic) 18 pounds since admission to that skilled nursing facility, 12 pounds in the first week...does report that he is unable to walk. He reports that he has been eating normally, but he does have dementia, and this may be inaccurate. He currently reports that he is hungry...wt 61.68 Kg (135.6 pounds)...." 2) Resident #2 was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the weight book for the 100 Hall and 200 Hall revealed the following weights for Resident #2: 08/13/10 - 136 lbs; 08/20/10 - 128.6 lbs; 09/04/10 - 125.2 lbs; 09/14/10 - 125.2 lbs; 09/15/10 - 123.4 lbs; 09/17/10 - 121.4 lbs. 09/20/10 - 119.2 lbs. These weights reflected Resident #2 had a 14.6 lb weight loss in five weeks, representing a "severe" weight loss of 10%. The resident continued to lose another 2.2 lbs in the next three days. Review of a physician's telephone order dated 09/09/10 for Resident #2 revealed, "Get up for meals to assisted dining...." Review of a physician's telephone order dated 09/10/10 for Resident #2 revealed, "...1) Fortified foods with meals, 2) Wkly weight (times) 4, 3) Ready Care 60 cc TID, 4) Magic cup lunch and dinner." Review of a Diet Order & Communication dated 09/10/10 for Resident #2 revealed, "Magic cup at lunch and dinner, Fortified foods each meal, Ready Care 2.0 60 cc po TID." Review of a physician's telephone order dated 09/14/10 for Resident #2 revealed, "...4) Protein Powder (one) scoop TID...." Observation on 09/18/10 at 1:05 p.m. revealed Resident #2 was being assisted with her noon meal in her room. Resident #2 was in bed. She consumed 41% of the noon meal, which consisted of ribs, potatoes with gravy, noodle salad, a piece of bread, beans and Jello. There was not a magic cup on the tray. Observation on 09/20/10 at 12:40 p.m. revealed Resident #2 was up in a wheelchair in the assisted dining room being assisted with the noon meal, which included ham, potatoes, cabbage, cornbread, soup, applesauce and a magic cup. Resident #2 complained of nausea and was wheeled back to her room. She consumed 8% of the meal. Review of a physician's telephone order dated 09/20/10 for Resident #2 revealed, "[MEDICATION NAME] 40 mg/10 ml po HS." Observation on 09/21/10 at 8:40 a.m. revealed Resident #2 was in her bed, being assisted with her breakfast. The meal consisted of scrambled eggs, bacon, toast and two glasses of juice. She did not have the fortified food, oatmeal, on her tray. There was a healthshake on the overbed table, however the staff member stated it was left from the previous night. The carton was warm to touch and unopened. There was an unopened cereal bar on the overbed table with a label, which reflected, "09/20/10 10 am." Observation of the medication pass on 09/21/10 at 8:40 a.m. revealed MA C prepared all of Resident #2's medications, which included Panteprazole 40 mg. After reconciling the medications, it was determined this medication was ordered to be administered at 6:30 a.m. and was to be given before meals for [MEDICAL CONDITION] Reflux. Resident #2 was also to receive Protein Powder (a supplement) three times a day. The Protein Powder was not administered. Interview on 09/21/10 at 12:30 p.m. with MA C and ADON B confirmed the Protein Powder was not administered, and the Panteprazole was not administered as ordered for Resident #2. Review of Progress Notes for Resident #2 revealed she was seen by the Nurse Practitioner on 08/24/10, 08/31/10, 09/07/10, 09/09/10 and 09/14/10. There was nothing noted on any of the five notes regarding the resident's weight loss. Review of a CMP dated 08/13/10 for Resident #2 revealed her [MEDICATION NAME] was low at 2.2 g/dL. The normal was 3.4-5.0 g/dL. The only Nutritional Evaluation for Resident #2 was dated 08/15/10 (two days after admission). There were no dietary recommendations identified on the evaluation. The RD identified the resident had a Stage II pressure ulcer on the coccyx. Review of a Nurse's Note dated 09/20/10 for Resident #2 revealed, "...spoke (with) daughter regarding weight loss...." Review of Resident #2's Diet History/Food Preference List, located in the clinical record under the dietary section, was blank. The only thing on the form was the resident's name, physician and room number. 3) Resident #3 was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the weight book for the 100 Hall and 200 Hall revealed Resident #3's weights: 08/09/10 - 142.2 lbs; 08/17/10 - 138 lbs; 09/02/10 - 137.8 lbs; 09/13/10 - 134 lbs; 09/20/10 -130.8 lbs. These weights reflected Resident #3 had an 11.4 lb weight loss in six weeks, representing a "significant" weight loss of 8%. Review of a Care Plan Conference Summary dated 08/25/10 for Resident #3 revealed, "...Dietary: wt (weight) 144.2...." (Note: weight on 08/17/10 was 138.) Review of a Care Plan initiated on 08/16/10 for Resident #3 revealed, "Altered Nutrition...Prefers Chinese Food...Approaches...Obtain food likes or dislikes...." An additional care plan dated 08/16/10 for Resident #3 revealed, "Edentulousness...Approaches: Refer to dentist...." Review of a Comprehensive Plan of Care initiated on 09/13/10 for Resident #3 revealed, "Weight loss...Approach...1) Serve resident's food preferences. 2) Assess resident for food preferences...." Review of a physician's telephone order dated 09/13/10 for Resident #3 revealed, " 1) Fortified foods each meal, 2) Magic cup BID, 3) healthy shake (NSA) (no sugar added) BID, 4) wkly weights (times) 4." Review of a Diet Order & Communication dated 09/13/10 for Resident #3 revealed, "Fortified foods with meal, magic cup BID." Review of a physician's telephone order dated 09/14/10 for Resident #3 revealed, "...2) dental consult for missing teeth, 3) (change) diet to mech soft...." Observation on 09/20/10 at 1:00 p.m. revealed Resident #3 was sitting alone at the assisted dining table. Her noon meal tray consisted of ham, beans, cornbread, cabbage, chocolate pudding, magic cup and soup. Resident #3 consumed 14% of the meal. Observation on 09/20/10 at 1:11 p.m. revealed Resident #3 was weighed by RNA A. Her actual observed weight was 130.8 pounds. Observation on 09/21/10 at 7:45 a.m. revealed Resident #3 was in the assisted dining room. Her breakfast consisted of scrambled eggs, sausage, toast, oatmeal (fortified food) and juice. She consumed 50% of the meal. Review of a Diet Order Communication, located in the dietary section of the clinical record, for Resident #3 revealed, "09/20/10 Please add rice to every meal." The last dietary consult for Resident #3 was 08/15/10. Under "ability to chew/swallow" was, "own teeth poor condition." There were no likes and dislikes documented in the clinical record for Resident #3. 4) Review of the facility's Resident Nutrition Services policy dated April 2009, provided by the DON as the current policy, revealed, "Each resident shall receive the correct diet, with preferences accommodated as feasible and shall receive prompt meal service and appropriate feeding assistance...1) The multidisciplinary staff, including nursing staff, the Attending Physician and the Dietitian AND FOOD SERVICE SUPERVISOR (FSS) will assess each resident's nutritional needs, food likes, dislikes and eating habits. They will develop a resident care plan based on this assessment. 2) Nursing personnel will ensure that residents are served the correct food tray...7) Nursing personnel, FSS AND DIETITIAN will evaluate food and fluid intake in residents with, or at risk for, significant nutritional problems...." 5) The facility census was 76, per interview with the ADM on 09/21/10 during the exit conference at 3:00 p.m.