Every finding on record at Southpark Meadows Nursing and Rehabilitation Cente

Based on record review and interview, the facility failed to ensure the required documentation in the resident's medical record made by the physician for a safe and effective transition of care 1 (Resident #1) of 5 residents reviewed for transfer or discharge. The facility discharged Resident #1 on 06/03/26 without physician documentation in the EMR. This failure could place residents at risk for inappropriate discharge resulting in psychological harm due to feelings of anger and sadness.Findings included: Record review of Resident #1's face sheet, dated 06/19/26, reflected a [AGE] year-old male, admitted [DATE], with diagnosis that included unspecified dementia- unspecified severity-without behavioral disturbance- psychotic disturbance- mood disturbance and anxiety (group of symptoms affecting memory, thinking, and social abilities), cognitive communication deficit, cerebral palsy (group of conditions that affect movement and posture caused by brain damage before birth), unspecified intellectual disabilities, and schizophrenia (serious mental health condition affecting how people think, feel, and behave). The face sheet reflected Resident #1 was discharged [DATE] to other nursing home/SNF. Record review of Resident #1's Discharge Return Not Anticipated MDS assessment, dated 06/03/26, reflected a discharge date of 06/03/26. Cognitive patterns reflected a BIMS score of 0, indicating severe cognitive impairment, and the resident was rarely/never understood. Active diagnosis reflected schizophrenia (serious mental health condition affecting how people think, feel, and behave) and dementia (group of symptoms affecting memory, thinking, and social abilities). Record review of Resident #1's care plan, reflected a focus initiated on 05/26/26 , Resident #1 has been identified as having PASRR positive status related to ID due to cerebral palsy and intellectual debility. with interventions that included .coordinate services with a representative from the local authority. Another focus initiated on 05/24/26 included, Resident #1 has behavior problem. He was noted to have inappropriately touched a female resident r/t poor impulse control d/t intellectual disability. with interventions that included .1:1 monitoring by staff member, intervene as necessary to protect the rights and safety of others, divert attention, remove from situation and take to alternate location as needed, monitor behavior episodes and attempt to determine underlying cause. The care plan indicated on a focus initiated 11/21/25 Resident #1 had impaired cognitive function or impaired thought process related to schizophrenia and was being seen by psychiatric services. Record review of Resident #1's progress notes reflected the following:SW note, dated 05/24/26 at 12:38 PM, indicated, attempted to talk to Resident #1 regarding alleged incident that occurred earlier. Resident was found sitting with his 1:1. Resident won't answer any questions or maintain eye contact, just keeps looking away when asked questions. Resident is developmentally delayed and this is not uncommon behavior for him. also notified psychiatry of alleged incident.A nursing note, dated 5/24/26 at 01:00 PM, indicated, aggressor: staff member reported seeing this resident touch a female resident both breasts, staff member states she called out for him to stop, resident immediately stopped, she called out for another staff member, aide, and nurse. Residents separated immediately, administrator notified, [city police] called, reported to HHSC, 1:1 monitoring initiated immediately, notifications to RP/NP.A nursing note, dated 6/3/26 at 10:50 AM, indicated, transportation arrived from [receiving SNF] medications and belongings taken. Pt noted pleasant, no s/s of distress noted. Record review of Resident #1's psychiatric provider assessment note, dated 06/01/26 by PMHNP, reflected: Pt with PMH dementia insomnia and schizophrenia. Pt seen for medication management and inappropriate behavior. Nursing reported he groped another resident. On exam, he is seen in room, with obvious aphasia and cognitive deficits. Chart and MAR reviewed, pt with intellectual disabilities. Nursing reports intermittent behaviors, but no other inappropriate behaviors or increase in elopement attempts. Pt unable to recall events, likely due to impulsiveness and not malicious behaviors. Record review of a FRI, received 5/24/26 (with follow up provider investigation attached 6/2/26), reflected the following documentation:Incident date of 5/24/26: Incident reported to ADM r/t Resident #1 found touching another resident on her breast over her clothes. Residents were separated and assessed, no injuries noted, Resident #1 was placed on 1:1 monitoring.Eight resident safe surveys, dated 05/24/26 conducted by the SW, reflected that they denied anyone touching them inappropriately.Eleven staff members' written statements, all dated 05/26/26, indicated they had not seen any previous history of Resident #1 touching other residents inappropriately.In a report by the ADM, signed 5/29/26, after the incident indicated: Officers visited but the residents did not recall the event and no distress observed from either resident. Review of the care plans had not shown any history of those behaviors. Neither residents have had any previous similar interactions with each other nor other residents since the date of both of their admissions. Record review of Resident #1's EMR, accessed 06/19/26 reflected there was no documentation by Resident #1's physician documenting the basis for the transfer or the danger that the failure to transfer or discharge the resident would pose and if failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. During an interview on 06/19/26 at 10:42 A.M., Resident #1's family member stated she was alerted by the facility of the incident that occurred Sunday 5/24/26 and that she was told they immediately wanted to get rid of him by Monday 5/25/26. She stated the first few facilities the current SNF tried to move him to denied him, then he was accepted into an all-male facility and officially d/c on 6/3/26. She stated she was not provided with options of where to place the resident, she was not given a formal written notice with information to the ombudsman, the LIDDA (resident was PASRR positive) or information on appeal rights. She stated this was not a behavior the resident had ever had before, and that her biggest issue was the rush the facility placed on displacing him. She stated she did not speak to the provider or was provided with documentation indicating the basis of the discharge. During an interview on 06/19/26 at 12:31 P.M. the SW stated she did not issue the d/c notices that they were completed by the ADM. She stated that a 30-day notice was typically required unless a resident presented a risk of harm to other residents or the facility. She stated in those cases the incident would need to be documented, the history of behaviors by the provider (MD or NP) that sees the resident. She stated the reason for Resident #1's discharge was the incident that occurred on 05/24/26 with him touching another resident inappropriately. She stated he did not have similar behaviors or a history of these behaviors at the facility. She stated Resident #1 or his RP were not provided a written discharge notice. She stated she did not see documentation in the resident's chart made by a physician with the basis of the discharge and need for emergency discharge and the danger the failure to transfer or discharge would pose. During an interview on 06/19/26 at 01:07 PM, the DON stated the facility's SW and ADM were responsible for discharges. She stated if there were negative behaviors the facility got with psychiatric services to make a determination if they needed to discharge a resident. She stated if a resident was discharged by the facility, it could be a 30-day notice or less, if the resident presented with negative behaviors. She stated the reason for Resident #1's discharge was he was groping one of the females. She stated he was immediately placed on 1:1 and did not have a history of these behaviors. She stated he was not able to be interviewed about the events due to his cognition and diagnosis. She stated she could not find documentation in the chart from a physician detailing the safety concerns or provider notes indicating the behavior that warranted the discharge. She stated, based on the policy and regulation, the discharge process was not followed. During an interview on 06/19/26 at 01:40 PM with the ADM, he stated the reason for discharge of Resident #1 was the behavior he had on 05/24/26 r/t inappropriate behavior with another resident. He stated Resident #1 did not have a history of those behaviors. He stated Resident #1 was not intervieable due to his cognition and diagnosis, he could not complete sentences. The ADM stated he handles the final discharges of residents. He stated he was unsure of there being any provider notes indicating the basis of the discharge. Record review of the facility policy titled, Transfer and Discharge (including AMA), dated 3/5/25 reflected: Policy:It is the policy of this facility to permit each resident to remain in the facility and not transfer or discharge the resident from the facility, except in limited circumstances. This policy applies to all residents regardless of their payment source.Policy Explanation and Compliance Guidelines:The facility will evaluate and determine the level of care needed for the resident prior to admission to ensure the facility's ability to meet the resident's needs.Once admitted , the resident has the right to remain at the facility unless their transfer or discharge meets one of the following specified exemptions: c. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident.The facility will obtain a physician's order for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis.If the resident chooses to appeal the discharge, the facility will allow the resident to return to his or her room or an available bed in the nursing home during the appeal process, unless there is documented evidence that the resident's return would endanger the health or safety of the resident or other individuals in the facility.

Based on interview and record review, the facility failed to notify the resident and resident's representative(s) of the discharge, reasons for the move, and right to appeal in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 (Resident #1) of 5 residents reviewed for discharge planning. The facility failed to notify Resident #1 and Resident #1's RP of Resident #1's discharge, reasons for the move, and right to appeal in writing, in a language and manner they understand, and at least 30 days before Resident #1 was discharged from the facility on 06/03/26 in a facility-initiated discharge to another skilled nursing facility.The facility failed to send a copy of the notice to the facility's Ombudsman before Resident #1 was discharged from the facility on 06/03/26 and failed to notify the LIDDA (Resident #1 was PASRR positive). This failure could place residents at risk of being discharged without alternative placement, discharge options, their rights to appeal and access to advocacy services.Findings included: Record review of Resident #1's face sheet, dated 06/19/26, reflected a [AGE] year-old male, admitted [DATE], with diagnosis that included unspecified dementia- unspecified severity-without behavioral disturbance- psychotic disturbance- mood disturbance and anxiety (group of symptoms affecting memory, thinking, and social abilities), cognitive communication deficit, cerebral palsy (group of conditions that affect movement and posture caused by brain damage before birth), unspecified intellectual disabilities, and schizophrenia (serious mental health condition affecting how people think, feel, and behave). The face sheet reflected Resident #1 was discharged [DATE] to other nursing home/SNF. Record review of Resident #1's discharge return not anticipated MDS assessment dated [DATE] reflected a discharge date of 06/03/26. Cognitive patterns reflected a BIMS score of 0 resident is rarely/never understood indicating severe cognitive impairment. Active diagnosis reflected schizophrenia and dementia. Record review of Resident #1's care plan revised 06/17/26 reflected a focus of Resident #1 has been identified as having PASRR positive status related ID due to cerebral palsy and intellectual debility with interventions that included coordinate services with a representative from the local authority. Another focus included Resident #1 has behavior problem. He was noted to have inappropriately touched a female resident r/t poor impulse control d/t intellectual disability with interventions that included 1:1 monitoring by staff member, intervene as necessary to protect the rights and safety of others, divert attention, remove from situation and take to alternate location as needed, monitor behavior episodes and attempt to determine underlying cause. The care plan indicated resident had impaired cognitive function or impaired thought process related to schizophrenia and was being seen by psychiatric services. Record review of Resident #1's progress notes reflected the following:SW note, dated 05/24/26 at 12:38 PM, indicated, attempted to talk to Resident #1 regarding alleged incident that occurred earlier. Resident was found sitting with his 1:1. Resident won't answer any questions or maintain eye contact, just keeps looking away when asked questions. Resident is developmentally delayed and this is not uncommon behavior for him. also notified psychiatry of alleged incident.A nursing note, dated 5/24/26 at 01:00 PM, indicated, aggressor: staff member reported seeing this resident touch a female resident both breasts, staff member states she called out for him to stop, resident immediately stopped, she called out for another staff member, aide, and nurse. Residents separated immediately, administrator notified, [city police] called, reported to HHSC, 1:1 monitoring initiated immediately, notifications to RP/NP.A nursing note, dated 6/3/26 at 10:50 AM, indicated, transportation arrived from [receiving SNF] medications and belongings taken. Pt noted pleasant, no s/s of distress noted. Record review of Resident #1's psychiatric provider assessment note dated 06/01/26 by PMHNP reflected: Pt with PMH dementia insomnia and schizophrenia. Pt seen for medication management and inappropriate behavior. Nursing reported he groped another resident. On exam, he is seen in room, with obvious aphasia and cognitive deficits. Chart and Mar reviewed, pt with intellectual disabilities. Nursing reports intermittent behaviors, but no other inappropriate behaviors or increase in elopement attempts. Pt unable to recall events, likely due to impulsiveness and not malicious behaviors. Record review of a FRI received 5/24/26 (with follow up provider investigation attached 6/2/26) reflected the following documentation:Incident date of 5/24/26: Incident reported to ADM r/t Resident #1 found touching another resident on her breast over her clothes. Residents were separated and assessed, no injuries noted, Resident #1 was placed on 1:1 monitoring.8 resident safe surveys were reviewed dated 05/24/26 conducted by the SW and reflected they denied anyone touching them inappropriately.11 staff members written statements all dated 05/26/26 indicated they had not seen any previous history of Resident #1 touching other residents inappropriately.In a report by the ADM signed 5/29/26 it reflected after the incident: Officers visited but the residents did not recall the event and no distress observed from either resident. Review of the care plans had not shown any history of those behaviors. Neither residents have had any previous similar interactions with each other nor other residents since the date of both of their admissions. Review of Resident #1's EMR accessed on 06/19/26 reflected there was no documentation by Resident #1's physician documenting the basis for the transfer or the danger that the failure to transfer or discharge the resident would pose if failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. There was no record of a discharge notice to the resident in writing, contact to the state long term care ombudsman or the LIDDA. During an interview on 06/19/26 at 10:42 AM with Resident #1's family member, she stated she was alerted by the facility of the incident that occurred Sunday 5/24/26 and that she was told they immediately wanted to get rid of him by Monday 5/25/26. She stated the first few facilities the current SNF tried to move him to denied him, then he was accepted into an all-male facility and officially d/c on 6/3/26. She stated she was not provided with options of where to place the resident, she was not given a formal written notice with information to the ombudsman, the LIDDA (resident was PASRR positive) or information on appeal rights. She stated this was not a behavior the resident had ever had before, and that her biggest issue was the rush the facility placed on displacing him. She stated she did not speak to the provider or was provided with documentation indicating the basis of the discharge. During an interview on 06/19/26 at 12:31 PM with the SW she stated she did not issue the d/c notices that they were completed by the ADM. She stated that a 30-day notice is typically required unless a resident presents a risk of harm to other residents or the facility. She stated in those cases the incident would need to be documented, the history of behaviors by the provider that sees the resident. She stated the reason for Resident #1's discharge was the incident that occurred on 05/24/26 with him touching another resident inappropriately. She stated he did not have similar behaviors or a history of these behaviors at the facility. She stated Resident #1 or his RP were not provided with a written discharge notice. She stated she did not see documentation in the residents' chart made by a physician with the basis of the discharge and need for emergency discharge and the danger the failure to transfer or discharge would pose. The SW stated notification of the d/c needs to be made to the MD or NP, the patient and their RP. She stated, you probably should notify the ombudsman. She stated the LIDDA would also need to be notified if the resident is PASRR positive. She stated the purpose of notifying the ombudsman is to ensure the residents' rights are being followed and PASRR residents need the LIDAA notified to ensure they are sending the resident to an appropriate facility. She stated the notifications needed to be made before the discharge. She stated a negative outcome of not making the notifications would be residents had the potential to be discharged to an inappropriate facility. The SW stated Resident #1 was not issued a written 30-day notice with the information to the ombudsman or the LIDDA, or his right to appeal. She stated she did not personally contact the ombudsman or LIDDA and believed the ADM would be the one to do that. During an interview on 06/19/26 at 01:07 PM with the DON she stated the facility SW and ADM are responsible for discharges. She stated if there were negative behaviors the facility gets with psychiatric services to make a determination if they need to discharge a resident. She stated if a resident is discharged by the facility, it can be 30-day notice or less if the resident presents with negative behaviors. She stated the reason for Resident #1's discharge was he was groping one of the females. She stated he was immediately placed on 1:1, he did not have a history of these behaviors. She stated he was not able to be interviewed about the events due to his cognition and diagnosis. She stated she could not find documentation in the chart from a physician detailing the safety concerns or provider notes indicating the behavior that warranted the discharge. She stated, based on the policy and regulation, the discharge process was not followed. The DON stated parties that needed to be notified of a d/c included the MD, the resident or resident RP, if they were PASRR positive the LIDDA would need to be notified as well. The DON stated the Ombudsman needed to be notified of all discharges but doesn't know why. She stated if those parties were not notified it could negatively affect the services the residents were to receive. The DON stated she could not find any documentation indicating the LIDDA or Ombudsman were notified. During an interview on 06/19/26 at 01:40 PM with the ADM, he stated the reason for discharge of Resident #1 was the behavior he had on 05/24/26 r/t inappropriate behavior with another resident. He stated Resident #1 did not have a history of those behaviors. He stated Resident #1 was not interviewable due to his cognition and diagnosis, he could not complete sentences. The ADM stated he handles the final discharges of residents. He stated he was unsure of there being any provider notes indicating the basis of the discharge. The ADM stated that for Resident #1's d/c the ombudsman was not notified, he stated that if a resident was on PASRR that they would need to be included in the process, denied the LIDDA being contacted. He stated the purpose of notifying the ombudsman was they are an advocate for the residents and help them address any discharge concerns they have, he stated notifying the LIDDA would ensure continuity of services. He stated failing to notify the ombudsman or LIDDA of a resident discharge would be the advocacy component is not there, and the continuation of services would not be there. He stated there was no documentation of them being notified. Record review of the facility Transfer and Discharge (including AMA) policy dated 3/5/25 reflected: Policy:It is the policy of this facility to permit each resident to remain in the facility and not transfer or discharge the resident from the facility, except in limited circumstances. This policy applies to all residents regardless of their payment source.Policy Explanation and Compliance Guidelines:The facility will evaluate and determine the level of care needed for the resident prior to admission to ensure the facility's ability to meet the resident's needs.Once admitted , the resident has the right to remain at the facility unless their transfer or discharge meets one of the following specified exemptions: c. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident.The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: The specific reason and basis for transfer or discharge.The effective date of transfer or discharge.The specific location (such as the name of the new provider or description and/or address if the location is a residence) to which the resident is to be transferred or discharged .An explanation of the right to appeal the transfer or discharge to the State.The name, address (mailing and email) and telephone number of the State entity which receives such appeal hearing requests.Information on how to obtain an appeal form.Information on obtaining assistance in completing and submitting the appeal hearing request.The name, address (mailing and email), and phone number of the representative of the Office of the State Long-Term Care Ombudsman.For nursing facility residents with intellectual and developmental disabilities (or related disabilities) or with mental illness (or related disabilities), the notice will include the name, mailing and e-mail addresses and phone number of the state agency responsible for the protection and advocacy of these populations.Generally, the notice must be provided at least 30 days prior to a transfer or discharge of the resident. Exceptions to the 30-day requirement apply when the transfer or discharge is affected because:The health and/or safety of individuals in the facility would be endangered due to the clinical or behavioral status of the resident;In these exceptional cases, the notice must be provided to the resident, resident's representative if appropriate, and LTC ombudsman as soon as practicable before the transfer or discharge.The facility will maintain evidence that the notice was sent to the Ombudsman.The facility will obtain a physician's order for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis.If the resident chooses to appeal the discharge, the facility will allow the resident to return to his or her room or an available bed in the nursing home during the appeal process, unless there is documented evidence that the resident's return would endanger the health or safety of the resident or other individuals in the facility.

Based on observations, interviews and record review, the facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 4 of 7 residents (Resident #59, Resident #23, Resident #46, and Resident #29) reviewed for infection control. 1. The facility failed to properly use personal protective equipment during wound care for Resident #23.2. The facility failed to follow hand hygiene procedure during direct care for Resident #59, Resident #46, and Resident #29.This failure could place residents at risk for infection transmission, sepsis, and hospitalization. Findings included:Observation on 10/01/2025 at 9:59 AM revealed LVN B did not remove personal protective equipment (gown) after she removed contaminated wound dressing, cleaned the wound and forgot the Topical Antibiotic Ointment on her treatment cart outside of Resident's #23's room. She removed gloves, sanitized her hands, but did not remove the gown. LVN B exited Resident #23's room, opened the treatment cart, removed medication and came back to Resident #23's room wearing the same gown. Record review of Resident #23's face sheet, dated 10/03/2025, revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included idiopathic gout (a form of inflammatory arthritis (conditions that cause inflammation and damage to the joints)) caused by the accumulation of uric acid crystals in the joints), chronic kidney disease (condition in which the kidneys gradually lose their ability to filter waste products from the blood, leading to damage and dysfunction), venous thrombosis (a condition where a blood clot forms in a vein, typically in the deep veins of the legs or arms) and embolism (a medical condition where a foreign object or clot travels through the bloodstream and blocks a blood vessel). Record review of Resident #23's Annual MDS assessment, dated 09/21/2025, with BIMS score 15 indicated the Resident #23 had intact cognitive functions. Record review of Resident #23's orders dated 09/16/2025, indicated wound care order to left calf venous ulcer clean area with wound cleanser, pat dry, apply topical antibiotic to wound bed, cover with dry dressing two times a day every other day for wound care and as needed for if soiled or dislodged following enhanced barrier precautions.Interview on 10/01/2025 at 10:15AM of LVN B revealed she was trained on hand hygiene and infection control policy. This training included the proper application and removal of personal protective equipment (PPE) before and after existing the room of residents. LVN B was certified as an infection preventionist and wound care nurse at the facility. LVN B stated she completed in-service training in following enhanced barrier precautions last month. She stated that following proper infection control procedures protects residents and staff from getting sick and prevents the spread of infection. LVN B stated she forgot to remove the PPE gown when exited resident's room due to being too nervous while observed by state surveyor.Observation on 10/01/25 at 11:15 AM revealed LVN A performed blood sugar check for Resident #46. He did not change gloves after completing blood sugar check and touched the doorknob to open the door and nursing cart when exited Resident #46's room. Record review of Resident #46's face sheet, dated 10/03/2025, revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included hemiplegia (paralysis of one side of the body) following cerebral infarction (a condition where blood flow to the brain is interrupted, leading to tissue damage) affecting left non-dominant side, type 2 diabetes mellitus (a chronic condition in which the body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest).Record review of Resident #46's Quarterly MDS assessment, dated 08/21/2025, with BIMS score 10 indicated moderate cognitive impairment.Record review of Resident #46's Care Plan, dated 10/10/24, reflected thatResident #46 had diagnosis of Diabetes Mellitus and risk for hyper/hypoglycemia.An interview of LVN A on 10/01/25 at 11:21 AM, revealed he was trained in hand hygiene and infection control policy. LVN A stated he was supposed to take gloves off after completing direct patient care including blood sugar check procedure. He stated that not removing contaminated gloves could cause cross contamination and spread infection to other residents. Record review of Resident #46's face sheet, dated 10/03/2025, revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included hemiplegia (paralysis of one side of the body) following cerebral infarction (a condition where blood flow to the brain is interrupted, leading to tissue damage) affecting left non-dominant side, type 2 diabetes mellitus (a chronic condition in which the body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels), and depression (mood disorder that causes a persistent feeling of sadness and loss of interest).Record review of Resident #46's Quarterly MDS assessment, dated 08/21/2025, with BIMS score 10 indicated moderate cognitive impairment.Record review of Resident #46's Care Plan, dated 10/10/24, reflected thatResident #46 had diagnosis of Diabetes Mellitus and risk for hyper/hypoglycemia.Observation on 10/01/2025 at 12:31 PM of CNA A performed peri-care for Resident #29. CNA A did not remove contaminated gloves after performing peri-care and cleaning urinary catheter. She pulled Resident's #29's clothes and transferred resident to the wheelchair without removing the gloves. Interview on 09/24/25 at 12:51 PM with CNA A revealed she had hand hygiene and peri-care training provided monthly. CNA A stated she forgot to remove gloves after completing Resident #29's peri care. CNA A stated not removing contaminated gloves she could make residents sick.Record review of Resident #29's face sheet, dated 10/03/2025, revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included sepsis with an unspecified organism (a systemic infection where the specific organism causing the infection is unknown), macular degeneration (eye disease that affects the macula, the central part of the retina responsible for sharp, central vision), type 2 diabetes mellitus (a chronic condition in which the body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels), and dementia (a general term for a group of conditions that cause a decline in cognitive functions, such as memory, thinking, reasoning, and problem-solving, severe enough to interfere with daily life).Record review of Resident #29's admission MDS assessment, dated 09/15/25, with BIMS score 14 indicated intact cognitive functions.Record review of Resident #29's Care Plan, dated 09/25/2025, reflected thatResident #29 had Self Care Performance Deficit and indwelling catheter in place.Observation on 10/03/2025 at 8:38 AM revealed CNA B performed peri-care for Resident #59. CNA B did not remove contaminated gloves between providing peri care of front and back peri area. CNA touched and removed wipes from the package with contaminated gloves. An interview on 10/03/2025 at 8:55 AM, revealed CNA B had infection control and hand hygiene training a week ago. She stated that she was trained in removing gloves between dirty and clean areas to prevent spreading infection to residents. She stated that she forgot to do it while performing direct care to Resident #59.Record review of Resident #59's face sheet, dated 10/03/2025, revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included spastic quadriplegic cerebral palsy (a severe form of cerebral palsy that affects all four limbs, the trunk, and often the face), dementia (a general term for a group of conditions that cause a decline in cognitive functions, such as memory, thinking, reasoning, and problem-solving, severe enough to interfere with daily life), and gastroparesis (a condition where the stomach empties food into the small intestine too slowly).Record review of Resident #59's Quarterly MDS assessment dated [DATE] revealed a BIMS Score of 2, which reflected severe cognitive impairment. Record review of Resident #59's Care Plan dated 06/11/2025 reflected:Resident #59 had self-care performance deficit and risk for impaired skin integrity due to bladder and bowel incontinence. In interview on 10/03/2025 at 3:40 PM DON stated DON, infection preventionist nurse and charge nurses were responsible for ensuring staff were conducting proper hand hygiene/following infection control measures when providing care for the residents. She stated she conducts weekly routine checks and in-services. She stated the policy on hand hygiene, providing peri-care, wound care, and foley catheter care was to conduct hand hygiene before going in the room, between changing gloves and front/back peri-cares and when coming out of the room. The DON stated the last training on infection control and hand hygiene was conducted last month and during annual skills training sessions, weekly audits, and in huddles. The DON stated a potential negative outcome for the residents would be the cross contamination.Interview on 10/03/2025 at 3:35PM with the ADM, who stated that hand hygiene and wearing/changing gloves is one of most important requirements for staff in this facility to prevent risk of infection. He stated that nursing staff, including himself, received in-services on hand hygiene policy. Review of Infection Control Policy, dated 10/24/2022, reflected: The fundamental of infection control precautions is hand hygiene before and after direct resident contact, before and after assisting a resident with personal care, before and after changing a dressing, after removing gloves, after handling soiled equipment. Record review of Hand Hygiene Policy dated 10/24/2022 indicated that All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors.Record review of Perineal Care policy dated 10/4/2022 indicated in (10) re-position resident, change gloves if soiled and continue with perineal care.

Based on interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 2 of 4 residents (Resident #45, and Resident #105) reviewed for accuracy of assessments. 1. The facility failed to ensure Resident #45's admission MDS, dated [DATE], accurately reflected his smoking status. 2. The facility failed to ensure Resident #105's annual MDS, dated [DATE], accurately reflected his smoking status.These failures could place residents at risk of inadequate supervision due to an inaccurate assessment of smoking status. Findings Included:1. Record review of Resident #45's dated 10/03/2025 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #45 had a diagnosis which included lack of coordination, muscle wasting, attention and concentration deficit (ongoing problems with focus, organization, and impulsiveness), cognitive communication deficit (problems with communication), pulmonary embolism without acute cor pulmonale (blood clot in the lungs without difficulty breathing) and hemiplegia and hemiparesis following cerebral infraction affecting right dominant side (paralysis and weakness on right side after stroke).Record review of Resident #45's admission MDS dated [DATE] revealed Resident #45 had a BIMS of 12 which indicated moderate impairment. The MDS also revealed current tobacco use was marked as no.Record review of Resident #45's care plan dated 09/21/2025, revealed Resident #45 was a smoker. The goals in place were that the resident would not smoke without supervision through the review date. The resident would not suffer injury from unsafe smoking practices through the review date. Interventions were instruct resident about smoking risks and hazards and about smoking cessation aids that are available. Observe clothing and skin for signs of cigarette burns. The resident requires SUPERVISION while smoking.Record review of Resident #45's Smoking Safety Screen dated 10/02/2025, revealed Resident #45 had dexterity (skill in performing tasks, especially with the hands). The smoking safety screen also stated the resident was to be supervised while smoking. 2. Record review of Resident #105's dated 10/03/2025 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #105 had a diagnosis which included lack of coordination, muscle wasting, altered mental state, personal history of traumatic brain injury (usually a violent blow to the head), cognitive communication deficit (problems with communication), seizures, and repeated falls.Record review of Resident #105's annual MDS dated [DATE] revealed Resident #105 had a BIMS of 11 which indicated moderate impairment. The MDS also revealed current tobacco use was marked as no.Record review of Resident #105's care plan dated 09/21/2025, revealed Resident #105 was a smoker. The goals in place were that the resident would not smoke without supervision through the review date. The resident would not suffer injury from unsafe smoking practices through the review date. Interventions were instruct resident about smoking risks and hazards and about smoking cessation aids that are available. Observe clothing and skin for signs of cigarette burns. The resident requires SUPERVISION while smoking.Record review of Resident #105's Smoking Safety Screen dated 10/02/2025, revealed Resident #105 was to be supervised while smoking. During an interview with the MDS Nurse on 10/03/2025 at 10:56am it was revealed that she had been trained on MDS. She said the policy for MDS was that staff had 14 days to complete the MDS. She said a resident's pain, ADLs, medication, and therapy go on the MDS. She said the MDS was to be updated quarterly. She said she was responsible for doing the MDS. She said that she was usually notified that a resident was a smoker by the smoking assessment and the morning meeting. She said a resident's smoking status was to be on the MDS. She said she and the social worker were responsible for putting the smoking status on the MDS. She said a lot of different things could happen if a resident's smoking status was not on the MDS. She said a resident could have short breath and staff would not know it was due to smoking. She said she did not know why Resident #105 and Resident #45 did not have the smoking status on their MDS. During an interview with the SW on 10/03/2025 at 11:18am it was revealed she had been trained on MDS. She said the MDS policy was that the MDS had to be done within 14 days. She said the SW, the MDS nurse and the ADM were responsible for doing the MDS. She said everything the resident does, and all the help the resident needs were to be put on the MDS. She said the MDS was to be updated annually and quarterly or when the resident had a significant change. She said she did not know if the resident's smoking status went on the MDS. She said she was notified that the resident was a smoker by the resident, or a caregiver taking care of the resident. She said that she did not inform the MDS nurse of a resident who was a smoker. She said she did not know how it would affect the resident if the smoking status was not on the MDS or not correct on the MDS. She also said she did not know why Resident #105 and Resident #45 did not have their smoking status on the MDS.During an interview with the ADM on 10/03/2025 at 2:04pm it was revealed he had been trained on MDS. He said the policy was that the MDS was to be done on admission, quarterly, annually, and when there was a significant change. He said the MDS Nurse was responsible for completing the MDS. He said information that was on the MDS was the resident's ADLs, therapy, and discharge. He said a resident's smoking status should be on the resident's MDS. He said the MDS nurse was responsible for updating the MDS. He said the MDS nurse was notified of a resident's smoking status through discussion with management, and there was a smoking assessment that was done on the resident. He said if a resident smoking status was not documented on the MDS staff would not be able to get an accurate picture of the plan of care for the resident. He said that he did not know why Resident #105 and Resident #45's smoking status was not on the MDS. When asked for the MDS policy he said they did not have a policy they just follow the RAI. Record review of Centers for Medicare and Medicaid Services Long-Term Care Facilities: RAI 3.0 User's Manual dated October 2025 revealed: J1300: Current Tobacco Use Item Rationale Health-related Quality of Life The negative effects of smoking can shorten life expectancy and create health problems that interfere with daily activities and adversely affect quality of life. Planning for Care This item opens the door to negotiation of a plan of care with the resident that includes support for smoking cessation. If cessation is declined, a care plan that allows safe and environmental accommodation of resident preferences is needed. Steps for Assessment 1. Ask the residents if they used tobacco in any form during the 7-day look-back period. 2. If the resident states that they used tobacco in some form during the 7-day look-back period, code 1, yes. 3. If the resident is unable to answer or indicates that they did not use tobacco of any kind during the look-back period, review the medical record and interview staff for any indication of tobacco use by the resident during the look-back period. Coding Instructions Code 0, no: if there are no indications that the residents used any form of tobacco. Code 1, yes: if the resident or any other source indicates that the resident used tobacco in some form during the look-back period.

Based on interview and record review, the facility failed to provide accurate PASRR screenings for individuals with a mental disorder for 1 (Resident #5) of 7 residents reviewed for PASRR.The facility failed to complete an accurate PASRR level one screening after Resident #5 was admitted with a negative PASRR Level 1 screening but had a mental illness.The failure could place residents at risk of not receiving or benefiting from specialized therapy and equipment services they may require. Findings included:Record review of Resident #5's undated face sheet, revealed a [AGE] year-old woman admitted to the facility on [DATE]. Resident #5 had diagnosis of hemiplegia and hemiparesis following cerebral infarction (hemiplegia and hemiparesis following cerebral infarction), bipolar disorder unspecified (chronic mental health condition characterized by extreme mood swings between mania) , and major depressive disorder (common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities). Record review of Resident #5's quarterly MDS assessment, dated 08/27/2025, did not reflect a diagnosis for requiring a PASSAR II screening. Record review of Resident #5's care plan dated last revised 07/30/2025 revealed Resident #5 has potential for a behavior problem r/t dx bipolar disorder, depression. Resident #5 had a care area resident had e antipsychotic medications r/t Bipolar Disease.Record review of Resident #5's PASRR Level 1 screening, dated 10/16/2024 conducted by director of social services, reflected Resident #5 was negative for mental illness, intellectual disability, and developmental disability. Interview on 10/03/2025 at 1:15PM with MDS A who revealed that the outside facilities are responsible for PASSAR screening before the resident enters the facility. MDS A said that the MDS team is responsible for verifying the information on the PASSAR 1 screenings. MDS A said a diagnosis that would indicate a positive level 1 PASSAR would be any mental illness, bipolar, schizophrenia, IDD diagnosis. MDS A stated a resident that came into the facility with a negative PASSAR 1 and had a diagnosis would indicate the need for a new PASSAR screening. MDS A said an incorrect level 1 PASSAR screening could negatively affect a resident by not receiving the services that they may qualify for. Interview on 10/03/2025 at 1:43PM with the DON revealed she had r3eceived training on resident rights which include the right to refuse services and make informed decisions. The DON said that the MDS team is responsible for inputting PASSAR screenings, as well as to ensure that the screening was correct. Interview on 10/03/2025 at 2:30PM with the ADM revealed he had received training on resident rights which include the right to privacy, the right to be informed, the right to know, and the right to a dignified existence. The ADM said the policy on PASSAR is to obtain a PL1 for anybody coming into the facility from the referring entity. The ADM stated the MDS would put the screening into the system. The ADM said that depending if it is negative or positive will determine if they will come out and assess for a PL2. The ADM said the MDS team is responsible for ensuring the screening is correct. The ADM said a diagnosis of major depressive disorder, an ID or DD would indicate a positive level 1 PASSAR screening. The ADM stated a new diagnosis would require a new PASSAR screening to initiate. The ADM stated if the level 1 PASSAR was incorrect, then the residents could be negatively affected by not receiving a level 2 screening for potential related services.

Based on observation, interview and record review, the facility failed to ensure residents receive drinks including water and other liquids consistent with need and preference and sufficient to maintain hydration for 2 of 5 residents reviewed for hydration. (Resident #s 36 and #110).The facility failed to provide water at the bedside for Resident's # 36 and # 110.On multiple occasions throughout the survey process, Resident #36's water pitcher was sitting on her nightstand (approximately 3-5 feet beyond Resident's reach).This failure placed 2 residents at risk for thirst, dehydration, UTI's, and decreased quality of life and could place the residents who were reviewed for hydration at risk for thirst, dehydration and decreased quality of life. Findings included:Record review of Resident #36's Face sheet revealed she is a [AGE] year-old female that was admitted on [DATE]. She has the following diagnoses: Alzheimer's Disease with late onset, (Can Cause memory and cognition issues, impaired judgement, and other symptoms as it progresses.), Type 2 Diabetes Mellitus, (characterized by high levels of sugar in the blood.),Congestive Heart Failure, (a long- term condition where the heart cannot pump blood effectively, leading to fluid accumulation in the lungs and legs.).Record review of Resident # 36's revised care plan dated 09/11/2025 revealed, Regular diet, Pureed texture and regular liquid to be served. intake and record and approach included offer extra fluids with and between meals and to monitor fluid intake. Resident # 36 is at high risk for falls related to confusion, gait and balance problems. Fall mats at bedside when resident is in bed.Record review of the most recent MDS (Minimum Data Set) dated 08/20/2025 indicated Resident #36 had BIMS score of 99 (resident was unable to complete the interview.) Staff Assessment for Mental Status revealed residents were severely impaired and never/rarely made decisions. The MDS indicated he required extensive assistance with bed mobility and ADLs.During an observation on 09/30/2025 at 10:52 am., Resident #36 was lying in bed, she was confused, sleepy and unable to answer questions. Her lips were dry. There was a water pitcher and an empty glass on a dresser table 5-6 feet from the resident's bed. A fall mat was observed between the resident's bed and the dresser tableDuring an observation on 10/03/2025 at 8:15 AM, Resident # 36 was lying in her bed, and no hydration was located within reach of residents. Cup was less than 1/8 filled with water and is 5-6 feet from the resident's bed. Record review of resident # 110's face sheet dated, 10/02/2025 revealed she is an [AGE] year-old female that was admitted on [DATE]. She has the following diagnoses: Acute Kidney Failure, (happens when your kidneys suddenly stop working.), Vascular Dementia, Moderate (moderate dementia is the fourth stage of vascular dementia and is when many people get a diagnosis as the symptoms become more prominent.), Major Depressive Disorder, ( Is also known as Clinical depression, its symptoms are feelings of sadness, tearfulness, emptiness or hopelessness.).Record review of Resident # 110's care plan dated 09/17/2025 revealed, the resident has impaired visual function, (resident is blind in 1 eye), The resident has an ADL self-care performance deficit (patient who is not adequately performing the activities of daily living (ADLs).Record review of the most recent MDS (Minimum Data Set) dated 09/22/2025 indicated Resident #110 had BIMS score of 05 (A BIMS score of 5 indicates severe cognitive impairment). The MDS indicated Resident # 110 is dependent regarding mobility, (Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the residents to complete the activity. MDS indicates Resident #110 is independent with eating and drinking (Resident completed all the activities by themself, with or without an assistive device, with no assistance from a helper.). During an observation on 09/30/2025 @ 10:30 AM. Resident was lying in bed looking up to the ceiling. The residents would intermittently shout unrecognizable words. Resident # 110 was not interviewable. A bed table was located approximately 4 feet to the right of a resident's bed. No water cups or fluid containers were present in resident # 110's room. The room was not homelike; no personal items were observed in this room.During an observation on 10/02/2025 12:45 P.M, residents #110 was sitting in a wheelchair in the facility dining room. Resident # 110 was observed to be feeding herself and during the lunch meal, independently. Resident #110 was also observed lifting a cup of iced tea to her mouth and drinking independently.During an observation on 10/03/2025 at 2:10 PM, resident # 110 was sitting in her wheelchair in the hallway outside her room. Observation of the interior of room # 110 revealed a cup of water was located approximately 4 feet from resident # 110's bed and it was out of reach of the resident. On 10/03/2025 at 2:20 p.m., the surveyor interviewed CNA C, said she has been trained on resident rights. CNA C stated residents have the right to a dignified existence and their care should include eating and drinking as much as they want. CNA C stated the CNAs are responsible for insuring residents have drinks. She stated the CNA staff should check as often as possible to see if residents have enough to drink. She stated fluids should be on the table close to the resident so they can reach it. CNA C stated dehydration could occur if residents don't have water available to them. CNA C stated she does not know why Resident # 36 water was not within reach of her. In an interview on 10/03/2025 at 2:35 p.m., CNA D said, she has been trained on resident rights and residents have the right to have water and to be paid attention to. CNA D stated the staff should look in on residents every 30 minutes and residents should have liquids within reach of them all the time. She stated CNAs are responsible for insuring residents have drinks. CNA D stated residents could become dehydrated if they don't have water to drink. CNA D stated she has read the facility policy for water and it says they need it! CNA D stated residents should be given water between each meal, in the morning and in the evening. CNA D stated, I don't know why water was not within reach of residents 36 and # 110.In an interview on 10/03/2025 at 3:15 p.m., the Director of Nursing (DON) stated every resident has the right to a dignified existence. Residents have a right to make choices which include the amount of food and drink they want to consume. DON stated she completed online training as a requirement for employment. She stated, I have been trained on resident rights and abuse and neglect. She stated that if a resident does not get enough fluid the resident could become dehydrated, get UTI's and could have altered mental status. DON stated the CNAs are responsible for ensuring residents have drinks and are hydrated. DON stated, residents should be monitored 2 times a day to confirm fluids are available and are within the residents' reach. Monitoring is done by physically observing the room when we do our hydration rounds. DON stated fluids should be placed on a bedside table and moved close to the residents.DON stated she does not know why resident, 36 did not have drinks within reach. DON stated, I think that Resident # 36 may have just been taken to her room after lunch when you looked in on her. She stated resident # 36 is well hydrated during her meals.DON revealed that Resident # 110 often hits her water cups, and they spill on the ground. DON is not aware of any other reason why water was not available to Resident # 110.During an interview with ADM on 10/03/2025 at 3:45 PM, ADM revealed that he has been trained on Abuse, Neglect and resident rights. ADM stated he is the Abuse Coordinator for the facility and all staff should report to him if they suspect abuse. ADM stated, residents have the right to choose what food they eat, and residents have rights to snacks throughout the day. ADM stated, residents should have a dignified existence. He stated, residents could feel discouraged or upset if their needs are not met. ADM stated that the responsibility for ensuring residents have drinks is a collective effort. ADM stated, my expectation is that Department Heads are responsible for doing rounds to monitor the hydration for each resident. ADM revealed, that dehydration, UTI's and other medical complications could occur if residents don't have adequate fluids. ADM stated, water should be provided after meals and at the med pass. ADM stated the nurse is responsible for monitoring staff. ADM stated, I have no Incite as to why resident # 36 and resident # 110 did not have drinks within reach in their rooms. ADM revealed that Resident # 110 has anxiety issues, and it may be more detrimental for her and for others if she has water near to her.Record review of a facility policy, titled Diets, Nutrition and Hydration last revised on 10/24/2022 revealed: 1. Fluid should be available for residents between meals for additional hydration. Fluids will be delivered and/or refreshed a. prior to each meal b. between meals during snack/hydration.

Based on interviews and record review, the facility failed to maintain medical records on each resident that are- (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized for 1 of 5 residents (Resident #86) reviewed for pharmacy services. 1. The facility did not follow up on pharmacy consultant recommendation and physician order dated 08/14/2025 to discontinue Hydroxyzine 25mg q24h prn (as needed) for Resident #86.This failure could place the residents at risk for medication errors, unnecessary medications, and incorrect administration. Findings include:Record review of Resident #86's face sheet, dated 10/03/2025, revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included dementia (a progressive and irreversible brain disorder that causes memory loss, cognitive decline, and changes in behavior and personality), chronic kidney disease (condition where the kidneys gradually lose their ability to filter waste products from the blood and maintain fluid balance), and depression (mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities).Record review of Resident #86's quarterly MDS assessment, dated 8/26/2025, revealed a BIMS score of 2 which indicate severe cognitive impairment. Record review of Resident #86's care plan dated 08/16/2025, revealed the resident used anti-anxiety medication related to anxiety disorder. Record review of Resident #86's order summary dated 10/2/2025 revealed an active order for Hydroxyzine HCl Oral table 25 mg (Hydroxyzine HCL) give 1 tablet by mouth every 24 hours as needed for anxiety given prior to personal care ordered on 7/30/2025. Record review of Resident #86's Consultant Pharmacist-Physician Communication dated 07/17/2025 revealed Patient has been taking Hydroxyzine 25mg q24h prn for anxiety since 7/30/2025. PRN orders for psychotropic drugs are limited to 14 days. If the physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she must document rationale and indicate the duration for the PRN order. The box next to Physician/Prescriber response was marked agree with order to discontinue this medication signed and dated by physician on 8/14/2025. Record review of Resident #86's medication administration record for months of August and September 2025 revealed Hydroxyzine HCl Oral table 25 mg (Hydroxyzine HCL) give 1 tablet by mouth every 24 hours as needed for anxiety given prior to personal care was not discontinued and identified as an active order, but medication was not administered to Resident #86 during that time. An interview on 10/03/2025 at 12:27 PM with RP revealed he audited the medication records in the facility monthly around 3rd week of the month and made recommendations. He followed up on any changes transcribed to residents' medical records per physician's response to his recommendations. He stated that Hydralazine HCl 25mg for Resident #86 is as needed medication (PRN) and would not be given to her if she does not have signs and symptoms of agitation, so not transcribing the updated order from the physician in this case was a clerical issue. The RP stated that this error did not have potential detrimental effects to the president's health.An interview on 10/03/2025 1:22 PM with ADON revealed he was responsible for transcribing the medication orders from Pharmacist-Physician Communication forms to residents' electronic medical records in the facility. ADON stated that the potential risk from not accurately transcribing the updated order to Resident #86's medication record was a medication error and potential harm with severity depended on medication. An interview on 10/03/2025 1:45 PM with DON revealed the potential risk for not properly transcribing medication orders to residents' medical administration records could lead to medication errors. The DON stated Resident #86 could become over sedated and could be on medications that are no longer indicated. DON stated that ADON was responsible for reviewing Consultant Pharmacist-Physician Communication forms transcribing new orders to residents' medical records. DON stated that new order for Resident #86 to discontinue Hydroxyzine 25mg Q24H prn was not transcribed accurately.An interview on 10/03/2025 2:15 PM with ADM revealed he expected the pharmacy consultants and physician orders to be accurately transcribed to residents' medical records and followed. He stated not accurately transcribing medication orders could potentially harm residents.Record review of Documentation in Medical Record policy dated 10/24/2022 revealed Documentation should be timely and accurate.

Based on interview and record review, the facility failed to immediately notify the resident's physician when there was a significant change in the resident's physical status for one (Resident #1) of three residents reviewed for resident rights. The facility failed to notify Resident #1's NP when she was diagnosed with C. diff (a bacterium that causes diarrhea and inflammation of the colon) twice in May of 2025 which caused increased diarrhea and her laxative was not discontinued. This failure placed residents at risk of excessive diarrhea, weight loss, infection, and pain. Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including multiple fractures of pelvis, dementia, urinary tract infections, and muscle wasting and atrophy (wasting away). Review of Resident #1's admission MDS assessment, dated 05/05/2025, reflected a BIMS score of 3, indicating she was severely cognitively impaired. Section H (Bladder and Bowel) reflected she was always incontinent of bowel . Review of Resident #1's admission care plan, dated 05/05/25, reflected she had a potential for fluid deficit with an intervention of notifying the physician if she had persistent symptoms of diarrhea. Review of Resident #1's lab results, dated 05/11/25, reflected she was diagnosed with C. diff. Review of Resident #1's lab results, dated 05/28/25, reflected she was diagnosed with C. diff. Review of Resident #1's physician order, dated 05/06/25, reflected Bisacodyl oral tablet delayed release - 5 MG - Give 2 tablets by mouth one time a day for constipation. Review of Resident #1's May 2025 and June 2025 MARs, reflected she was administered Bisacodyl every day of the month . During a telephone interview on 06/13/25 at 9:04 AM, Resident #1's RP stated he was aware she had been diagnosed with C. diff twice while at the facility. He stated she had increased stomach issues which caused her to dump all of the time. He stated her brief was always full of diarrhea. He stated he was not aware she was on a laxative as she had never been on one in her life. During a telephone interview on 06/13/25 at 11:55 AM, Resident #1's NP stated she was not notified of her increased diarrhea or that she was still being administered a laxative. She stated if she had been notified, she would have discontinued the laxative to ensure she did not experience weight loss or an electrolyte imbalance. During an interview on 06/13/25 at 12:48 PM, CNA A stated he remembered Resident #1 having huge amounts of diarrhea every day and it got progressively worse. He stated it was so much that it would come out of her brief and drip down her wheelchair to the floor. He stated the staff were constantly changing her brief. He stated he knew the nurse was aware. During an interview on 06/13/25 at 1:01 PM, MA B stated Bisacodyl was for constipation. She stated she knew Resident #1 was having diarrhea, but she administered it to her because it was on her MAR. She stated she told LVN C about her concern, but she did not remember what she said about it specifically. She stated she thought LVN C would have reached out to the NP. During an interview on 06/13/25 at 1:27 PM, LVN C stated she was aware of Resident #1's increased diarrhea and that she was on a laxative. She stated she was admitted with the order for the laxative and did not think to notify the NP when her diarrhea increased, and she believed it was okay for her to be on a laxative with diarrhea since she had C. diff. During an interview on 06/13/25 at 1:45 PM, the DON stated she would expect the nurses to notify the NP immediately if a resident was experiencing excessive diarrhea. She stated the NP should have also known she was still being administered a laxative. She stated the NP could have adjusted Resident #1's treatment/medication plans accordingly. She stated a negative outcome of not notifying the NP was she (NP) not being involved of all aspects of a resident's care and possibly developing dehydration and/or malnutrition. Review of the facility's Notification of Changes Policy, dated 10/24/22, reflected the following : The purpose of this policy is to ensure the facility promptly informs the resident, consults with the resident's physician when there is a change requiring notification. Definition: Need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences.

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of three residents reviewed for quality of care. The facility failed to discontinue Resident #1's laxative when she was diagnosed with C. diff (a bacterium that causes diarrhea and inflammation of the colon) twice in May of 2025 which caused increased diarrhea, dehydration, elevated troponin (a protein that indicates heart damage or injury), and a weight loss of 25 pounds (27.8% weight loss) from 04/30/25 - 06/11/25. This failure placed residents at risk of an increased quality of life, weight loss, pain, and hospitalization. Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including multiple fractures of pelvis, dementia, urinary tract infections, and muscle wasting and atrophy (wasting away). Review of Resident #1's admission MDS assessment, dated 05/05/25, reflected a BIMS score of 3, indicating she was severely cognitively impaired. Section H (Bladder and Bowel) reflected she was always incontinent of bowel. Review of Resident #1's admission care plan, dated 05/05/25, reflected she had a potential for fluid deficit with an intervention of notifying the physician if she had persistent symptoms of diarrhea. Review of Resident #1's lab results, dated 05/11/25, reflected she was diagnosed with C. diff. Review of Resident #1's lab results, dated 05/28/25, reflected she was diagnosed with C. diff. Review of Resident #1's physician order, dated 05/06/25, reflected Bisacodyl oral tablet delayed release - 5 MG - Give 2 tablets by mouth one time a day for constipation. Review of Resident #1's May 20205 and June 2025 MARs, reflected she was administered Bisacodyl every day of the month. Review of Resident #1's weights reflected the following: 04/27/25 - 109.7 lbs (at hospital) 05/01/25 - 107.8 lbs 05/05/25 - 108.0 lbs 05/22/25 - 103.0 lbs 06/06/25 - 100.4 lbs 06/11/25 - 84.7 lbs (at hospital) Review of Resident #1's hospital records, dated 06/11/25, reflected an onset date of 06/11/25 for diagnoses of an AKI, dehydration, uremia, and a UTI. - Troponin levels were elevated at .94 ng/ML (reference range: <=0.04 ng/mL). Likely result of demand ischemia from volume depletion - Recent C Diff infection - Elevated Creatinine - 2.3 mg/dL (reference range: .59 - 1.04 mg/dL) Likely prerenal due to volume depletion. Resident #1 presented with profound hypotension that corrected after 1 L fluid bolus. - Acute Kidney Injury - Prerenal, secondary to dehydration. Improved with IV fluids. - BMI - 16.53 kg/m2 (reference range: 18.5 - 24.9) During a telephone interview on 06/13/25 at 9:04 AM, Resident #1's RP stated he was aware she had been diagnosed with C. diff twice while at the facility. He stated she had increased stomach issues which caused her to dump all of the time. He stated her brief was always full of diarrhea. He stated he took her home on [DATE] and later that day her blood pressure dropped so he took her to the ER where she was diagnosed with a UTI and dehydration. He stated Resident #1 lost a lot of weight and he was not sure if it was due to her not liking the facility's food or the increased diarrhea. He stated he did not know she was on a laxative or why they would continue administering it to her when she was having diarrhea. During an interview on 06/13/25 at 11:38 AM, the SC stated she conducted the weekly weights for the residents. She stated she gave the weights to the ADONs, she did not notify the NP of any weight loss herself. She stated if a resident lost eight pounds in a month, that would be a lot. She stated anything over three pounds in a month she would consider to be too much. During a telephone interview on 06/13/25 at 11:55 AM, Resident #1's NP D stated she was not notified of her increased diarrhea or that she was still being administered a laxative. She stated if she had been notified, she would have discontinued the laxative to ensure she did not experience weight loss or an electrolyte imbalance. She stated in the geriatric population, she would consider losing 8-10 pounds in a month to be a lot and would expect to be notified by the facility within a month. She stated if a resident lost over 20 pounds in a month, her first thought would be, we need to re-weight them. She stated that would be a very significant weight loss but knew that scales were not always accurate. She stated a negative outcome of losing that amount of weight so quickly could cause dehydration, a decline in health, or organ failure. She stated Resident #1 had diarrhea and lot of fluid loss coupled with poor nutrition so she could understand if she had lost weight. She stated losing that kind of weight that fast even from diarrhea could cause troponin levels to elevate. During an interview on 06/13/25 at 12:48 PM, CNA A stated he remembered Resident #1 having huge amounts of diarrhea every day and it got progressively worse. He stated it was so much that it would come out of her brief and drip down her wheelchair to the floor. He stated the staff were constantly changing her brief. He stated he knew the nurse was aware. During an interview on 06/13/25 at 1:01 PM, MA B stated Bisacodyl was for constipation. She stated she knew Resident #1 was having diarrhea, but she administered it to her because it was on her MAR. She stated she told LVN C about her concern, but she did not remember what she said about it specifically. She stated she thought LVN C would have reached out to the NP. During a telephone interview on 06/13/25 at 1:08 PM, NP E stated she was covering for NP D while she was on vacation. She stated if a resident had C. diff/diarrhea for a month, she stated that could definitely cause a 20-plus pound weight loss. She stated she would want to check for dehydration their electrolyte level. She stated losing that much weight in such a short timeframe could cause troponin levels to be elevated because it was an inflammatory response. During an interview on 06/13/25 at 1:27 PM, LVN C stated she was aware of Resident #1's increased diarrhea and that she was on a laxative. She stated she was admitted with the order for the laxative and did not think to notify the NP when her diarrhea increased, and she believed it was okay for her to be on a laxative with diarrhea since she had C. diff and that was normal. She stated she was not aware Resident #1 was losing weight. She stated if a resident lost between 3-5 pounds in a week, she would notify the NP. During an interview on 06/13/25 at 1:45 PM, the DON stated she would expect the nurses to notify the NP immediately if a resident was experiencing excessive diarrhea or weight loss. She stated the NP should have also known she was still being administered a laxative. She stated the NP could have adjusted Resident #1's treatment/medication plans accordingly. She stated a negative outcome of not notifying the NP was she not being involved of all aspects of a resident's care and possibly developing dehydration and/or malnutrition. She stated if she would have known Resident #1 was on a laxative while she had C. diff, she would contacted the NP to get it discontinued as it could cause more diarrhea which could put a resident a risk of dehydration or weight loss. She stated she was not aware of her weight loss but could see her weight fluctuating due to the diarrhea she had been experiencing. During a telephone interview on 06/17/25 at 9:15 AM, Resident #1's PCP stated the laxative may have contributed but it was not the cause of all of her ER diagnoses. He stated it had not been a negligence situation on the facility's part. He stated she had a history of IBS with diarrhea and constipation and was on a long-term laxative to manage those symptoms. He stated the laxative should have been stopped, but it was not the cause of what was already going on with her. Review of the facility's Notification of Changes Policy, dated 10/24/22, reflected the following: The purpose of this policy is to ensure the facility promptly informs the resident, consults with the resident's physician when there is a change requiring notification. Definition: Need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences. Review of the facility's undated Weight Monitoring Policy reflected the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for one (Resident #1) of five residents reviewed for care plans, in that: 1. The facility failed to care plan for Resident #1's 05/11/25 orthopedic ordered left arm sling prescribed for comfort, no discontinue date. 2 The facility failed to care plan Resident #1's history of refusal of care and medication from 12/07/2024 and 05/09/25. This failure placed residents at risk of not receiving the benefit of prescribed orthopedic equipment, risk of pain and discomfort and a lack of goals and interventions for the residents' individual needs for person-centered care. Findings included: Review of Resident #1's face sheet dated 06/06/25 reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body), cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery (a type of stroke caused by reduced or blocked blood flow to the brain), and other cerebral infarction due to occlusion or stenosis of small artery ( ischemic strokes, caused by the blockage or narrowing of smaller arteries within the brain). Review of Resident #1's quarterly MDS assessment, dated 05/12/25, reflected a BIMS score of 13, indicating no cognitive impairment. Section GG (Functional Abilities) reflected he was impaired on one side of both upper and lower extremities. Review of Resident #1's care plan reflected no identified problems, goals, or interventions for his prescribed left arm sling or his history of refusal of care and medication. Record review on 06/06/25 of Nurses Progress Note by LVN A dated 12/07/2024 reflected, notified by CNA staff was in room to adjust pt in bed and to be check and change if needed pt refuse c/not [sic] right now maybe later Record review on 06/06/25 of Nurses Progress Note by LVN A dated 12/08/2024 reflected, Enoxaparin Sodium Injection Solution Prefilled Syringe (prefilled syringe is a medication used to prevent and treat blood clots) 30 MG/0.3ML Inject 1 dose subcutaneously (under the skin) every 12 hours for anticoagulant (medications that prevent blood clots from forming) [Resident #1] refuse c/o too much medication has been given and will make him sick Record review on 06/06/25 of Nurses Progress Note by LVN A dated 01/05/25 reflected, give 12 grams by mouth two times a day constipation Mix with 4-8 oz of liquid resident refuse Record review on 06/06/25 of Nurses Progress Note by LVN A dated 01/21/25 reflected Np on call notified resident refuse 10 units of Lantus (insulin) this am Record review on 06/06/25 of Nurses Progress Note by LVN A dated 03/28/25 reflected, resident refuse dinner wife @ bedside alternate taken to room (steak fingers) refuse yelling @ nurse, 'I don't want that' Record review on 06/06/25 of Nurses Progress Note by LVN A dated 04/10/25 reflected pain medication was offered to Resident #1 and he stated, I don't want noting. I don't want anything from you. i don't want anything from anybody I'm fine. Record review on 06/06/25 of Nurses Progress Note by LVN A dated 05/09/25 reflected Resident #1 refusal for staff to assist pt back in bed. Record review on 06/06/25 of Nurses Note by the DON dated 05/09/25 reflected, Apply left arm sling for comfort as tolerated. one time a day for Left arm healing Record review on 06/06/25 of Resident #1's order dated 05/11/25, entered by the DO reflected Apply left arm sling for comfort as tolerated. one time a day for Left arm healing. Record review on 06/06/15 of Nurses Note by LVN A dated 05/25/25 reflected, Apply left arm sling for comfort as tolerated. one time a day for Left arm healing. Interview on 06/06/25 at 12:24 pm with Resident #1 reflected he had a sling for his left arm, but they did not put it on him. He said they used to, but they did not put it on him anymore he said his left arm hurt a lot. Interview on 06/06/25 at 4:05 with LVN B reflected she put Resident #1's left arm sling on him daily if he wanted her to. She said, at times, he would agree to wear it, and the next time she entered his room, he would have removed it. She said he was, not a very big fan for it. She said that he had two or three left arm slings, and there is one he liked better than the other. She said the one he liked was blue and soft and in the neck area there was some padding, and that was the one he would be more compliant to wear. She said there had been times when Resident #1 had refused to wear the left arm sling. She said he would say, maybe later or that thing just does not work. She said she attended facility daily staff morning meetings, and they discussed Resident #1 and his left arm sling. She said Resident #1's left arm sling was discussed more when it was first introduced and not very much after, maybe because he was not wearing it as much. LVN B said the care plan contained the interventions for the residents to be at their best functioning. She said she did not look at care plans every day, but she found them helpful. She said that if a resident had an order for equipment, it should be included in the care plan. She said she did not think Resident #1's left arm sling was helping him, and because it was not helping him, it did not need to be included in the care plan. She said the social worker, the MDS Coordinator and the DON were responsible for the care plans. She said care plans were not the responsibility of the floor nurses. She said that resident noncompliance should be included in the care plan and Resident #1's noncompliance with his left arm sling should have been included in the care plan. She said, in the past, Resident #1 had refused to take his medications and had a history to telling the staff No to care. Interview on 06/06/25 at 3:10 pm with LVN/MDSC revealed she was responsible for care plans and the updating of care plans, and stated that resident diagnoses, resident behaviors, and resident orthotics should be care planned. She said she was not a floor nurse, but she got information for care planning during the facility daily staff morning meetings. She said floor nurses would provide updates regarding behaviors from the previous day that needed to be added to the care plan. She said she relied on the floor nurses, the nurse manager, the DON, and the ADONs to help with the information to update care plans. She said a care plan was a tool used to determine a problem and it has a set of goals and interventions for the resident needs. She said the floor staff knew best know how to care for a resident. She said a care plan was necessary because it let the team know what the residents' needs were. She said if someone had a sling, it should be included in the care plan. She said the possible negative outcome, if care plans were not updated, was that certain care might not be provided to the resident, or the nurses might not know how to manage a problem. She said Resident #1's refusal to wear the sling should definitely be care planned. She said the sling was prescribed for comfort and to hopefully minimize some of Resident #1's pain. Interview on 06/06/25 at 4:52 pm with the Administrator reflected a care plan was the comprehensive tool used to direct specific resident centered care. He stated the MDS nurses are responsible for the care plans. He said the MDS Coordinators were not floor nurses, and they received the information to updated residents' care plans from information received from resident care reports facility daily staff morning meetings, and talking to the floor nurses. The Administrator revealed that Resident #1's left arm sling should have been included in the care plan. He said it was the responsibility of the MDS Coordinators to make sure residents have everything in the care plan. It was the responsibility of the DON or the regional care management specialist to make sure the care plan was accurate. The negative effects of not having a complete care plan were that the resident could receive inadequate care. Interview on 06/06/25 at 1:29 pm with the DON reflected Resident #1 had a specific sling that he liked to use when he allowed staff to put his left arm sling on for him. The DON said that more than 50% of the time, Resident #1 did not allow staff to put the sling on Resident #1. The DON said that during the facility daily morning staff meetings, it had been discussed that Resident #1 either refused to wear the left arm sling or removed the left arm sling, and it ended up on the floor. The DON stated that Resident #1's prescribed arm sling should be care planned. The possible outcome of Resident #1 not wearing his sling was discomfort and improper healing. She stated that it was upsetting and bothersome that Resident #1's left arm sling is not care planned, and that his refusal to wear his sling was not care planned. The DON said the importance of a care plan was that it set forth the care for the resident that included a resident's medical and behavioral orders how orders should be followed. She stated that if Resident #1 choses the use of one specific left arm sling over another left arm sling, this information should have been in the care plan. The DON said Resident #1 preferred the sling that had the pad on the strap towards the back, but that was not the sling that was in his room. She said the care plan was the responsibility of the MDS Coordinator, and the MDS Coordinator was not a floor nurse but Resident #1's non-compliance with his sling usage was discussed in the facility morning meetings when the MDS coordinator was present. The DON said Resident #1's other non-compliant behaviors were discussed in the facility morning meetings when the MDS Coordinator was present. She said she believed Resident #1's non-compliance with his left arm sling was discussed about 3 times during morning meeting, and his other non-compliance behaviors were discussed pretty frequent. She said it was the responsibility of the DON to follow up and make sure resident care plans were complete with information that was discussed during morning meetings. The DON said that if a care plan was not updated, resident care could be neglected and not carried out for both the resident's mental and physical needs. Interview on 06/06/25 at 3:51 pm with the NP revealed Resident #1 had an old fracture to his left elbow and the issue with his left arm sling was Resident #1's lack of compliance. She said the nurses would put the sling on him and Resident #1 would remove it and shove it in a drawer. She said that he had told her that no one was giving him his left arm sling to wear. She said the order for the left arm sling was given to Resident #1 by the by the orthopedic doctor for comfort. Review of the facility's policy, Comprehensive Care Plans dated 10/24/22, reflected it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent, with resident rights that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Person centered means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives. The comprehensive care plan will include measurable objectives and time frames to meet the residents needs as identified in the residents' comprehensive assessment. The objectives will be utilized to monitor the residents' progress. Alternative interventions will be documented, as needed.

Based on observations, interviews, and record review the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 8 of 8 residents (Resident #8, Resident #11, Resident #18, Resident #38, Resident #52, Resident #62, Resident #76, and Resident #80) reviewed for resident rights. The facility failed to ensure Resident #8, Resident #11, Resident #18, Resident #38, Resident # 52, Resident #62, Resident #76 and Resident #80's call lights was within reach on 08/20/2024. This failure could place residents at risk of needs not being met. Findings included: Record review of Resident #8's Admission Record dated 08/21/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included frontotemporal neurocognitive disorder (type of memory), severe protein calorie malnutrition, thalassemia (inherited blood disorder), dementia (memory, thinking, difficulty), dysphagia (difficulty swallowing), type 2 diabetes mellitus without complications (high blood sugar), hyperlipidemia (high cholesterol), constipation, hypertension (high blood pressure), muscle wasting, unsteadiness on feet, lack of coordination, anxiety order, and adjustment disorder. Record review of Resident #8's Quarterly MDS dated [DATE] revealed that resident is rarely/never understood. Resident #8 did not have a BIMS score due to not being able to complete assessment. The MDS also revealed that the resident is dependent on toileting, and bathing. Resident #8 was also substantial/maximal assistance. Record Review of Resident #8's care plan dated 08/12/2024 revealed that staff were to encourage resident to use bell to call for assistance. Record review of Resident #11's Admission Record dated 08/20/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (a progressive disorder that affects the nervous system), type 2 diabetes mellitus with diabetic kidney disease (kidney damage due to diabetes), hypertension (high blood pressure), osteoarthritis (joint disease), heart failure, heart disease, hyperlipidemia (high cholesterol), schizophrenia (mental disorder), type 2 diabetes mellitus with diabetic neuropathy (nerve damage due to diabetes), muscle wasting, unsteadiness on feet, lack of coordination, migraines, Presbyopia (gradual loss of eye focus), malaise (feeling of general discomfort), cognitive communication deficit (problems with communication), bipolar (extreme mood swings), and dementia (memory, thinking, difficulty). Record review of Resident #11's Quarterly MDS dated [DATE] revealed Resident #11 had a BIMS score of 13, indicating that the resident could understand and make self-understood. The MDS also revealed that needed supervision or touching assistance with toileting. Record Review of Resident #11's care plan dated 07/12/2024 revealed the resident needs a safe environment, a working and reachable call light. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Record review of Resident #18's Admission Record dated 08/21/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included dementia (memory, thinking, difficulty), type 2 diabetes mellitus without complications (high blood sugar), hypertension (high blood pressure), hyperlipidemia (high cholesterol), atrial fibrillation(abnormal heart rhythm), depressive episodes, anxiety, pain, malignant neoplasm of brain (cancer of the brain), osteoarthritis (joint disease), hypermetropia (near objects are blurry in the eyes), missing organs, history of falling, muscle wasting, unsteadiness on feet, weakness, lack of coordination, adjustment disorder, insomnia (difficulty sleeping), edema (swelling), and age related physical debility. Record review of Resident #18's Quarterly MDS dated [DATE] revealed Resident #18 had a BIMS score of 1, indicating the resident rarely understood and rarely made self-understood. The MDS also revealed that Resident #18 was dependent with eating, toileting, and bed mobility. Record Review of Resident #18's care plan dated 07/26/2024 revealed encourage the resident to use bell to call for assistance. Record review of Resident #38's Admission Record dated 08/22/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included heart failure, heart disease, atrial fibrillation(abnormal heart rhythm), pulmonary embolism (blood clot in the lungs), hyperlipidemia (high cholesterol), hyperthyroidism (excessive production of thyroid hormones), muscle weakness, intellectual disabilities, schizoaffective disorder depressive type (mental disorder), unsteadiness on feet, lack of coordination, muscle weakness, chronic bladder pain, dysphagia (difficulty swallowing), and cognitive communication deficit (problems with communication). Record review of Resident #38's Quarterly MDS dated [DATE] revealed Resident #38 had a BIMS score of 10, indicating the resident could understand and made self-understood. The MDS also revealed that Resident #38 was substantial/maximal assistance with toileting, bed mobility and transfers. Record Review of Resident #38's care plan dated 06/20/2024 revealed encourage the resident to use bell to call for assistance. Record review of Resident #52's Admission Record dated 08/20/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus with hyperglycemia (high blood sugar), Parkinson's disease (a progressive disorder that affects the nervous system), hypertension (high blood pressure), muscle wasting, difficulty walking, unsteadiness on feet, lack of coordination, cognitive communication deficit (problems with communication), dysphagia (difficulty swallowing), long term use of insulin, and muscle wasting. Record review of Resident #52's Quarterly MDS dated [DATE] revealed Resident #52 had a BIMS score of 08, indicating the resident could understand and made self-understood. The MDS also revealed that Resident #52 was substantial/maximal assistance with toileting, bed mobility and transfers. Record Review of Resident #52's care plan dated 08/04/2024 revealed encourage the resident to use bell to call for assistance. Record review of Resident #62's Admission Record dated 08/21/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included dementia (memory, thinking, difficulty), anemia (not enough healthy red blood cells), convulsions, hypertension (high blood pressure), chronic pain, hyperthyroidism (excessive production of thyroid hormones), dysphagia (difficulty swallowing), pain in right arm, history of falling, anxiety, muscle wasting, unsteadiness on feet, lack of coordination, aphasia (unable to comprehend due to damage to the brain), morbid obesity, kidney failure, adjustment disorder, reduced mobility, post-traumatic stress disorder, major depressive disorder, and malaise (feeling of general discomfort). Record review of Resident #62's Quarterly MDS dated [DATE] revealed Resident #62 had a BIMS score of 06, indicating the resident could understand and made self-understood at times. The MDS also revealed that Resident #62 was substantial/maximal assistance with toileting, bed mobility and transfers. Record Review of Resident #62's care plan dated 08/04/2024 revealed encourage the resident to use bell to call for assistance. Record review of Resident #76's Admission Record dated 08/20/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (a progressive disorder that affects the nervous system), kidney disease, ulcerative colitis (swelling in the bowels), lack of coordination, muscle wasting, repeated falls, weakness, unsteadiness on feet, cognitive communication deficit (problems with communication), dysphagia (difficulty swallowing), and dementia (memory, thinking, difficulty). Record review of Resident #76's Quarterly MDS dated [DATE] revealed Resident #76 had a BIMS score of 12, indicating the resident could understand and made self-understood. The MDS also revealed that Resident #76 was substantial/maximal assistance with toileting. Resident #76 was partial/moderate assistance for bed mobility and transfers. Record Review of Resident #76's care plan dated 06/21/2024 revealed be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. A working and reachable call light. Record review of Resident #80's Admission Record dated 08/20/24 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included cerebral atherosclerosis (arteries in the brain become thick, hard and narrowing), heart failure, atrial fibrillation(abnormal heart rhythm), protein calorie malnutrition, cardiomegaly (enlarged heart), heart disease, muscle wasting, malaise (feeling of general discomfort), lack of coordination, dysphagia (difficulty swallowing), cognitive communication deficit (problems with communication), pain due to trauma, and oxygen. Record review of Resident #80's Quarterly MDS dated [DATE] revealed Resident #80 had a BIMS score of 3, indicating the resident could not understand and could not make self-understood. The MDS also revealed that Resident #80 was substantial/maximal assistance with toileting, transfer and bed mobility. Record Review of Resident #80's care plan dated 07/12/2024 revealed encourage the resident to use bell to call for assistance. An observation of Resident #76's room on 08/20/2024 at 7:41am revealed the resident's call light was hanging on the privacy curtain approx. 3 feet from the resident. An interview with Resident #76 on 08/20/2024 at 7:41am revealed that the call light was not in the reach of the resident most of the time. An observation of Resident #38's call device on 08/20/2024 at 7:54am revealed that his call light was sitting on the table approx. 3 feet from him where he could not reach the call light. A interview with Resident #38 on 08/20/2024 at 7:54am revealed that most of the time he has his call light. He stated that there are times that he must look for his call light. A observation of Resident #52's call device on 08/20/2024 at 8:36am revealed that her call light was wrapped around the bedrail that is lowered to the down position. The resident could not reach the call light. A interview with Resident #52 on 08/20/2024 at 8:36am revealed she normally does have her call light in reach but there were times that staff would not give the call light to her. An observation of Resident #80's call device on 08/20/2024 at 8:41am revealed Resident #80's call light was clipped to the privacy curtain that was against the wall. Resident #80 could not reach the call light while she was sitting in her wheelchair. A interview with Resident #80 on 08/20/2024 at 8:41am revealed she could not reach her call light. She stated that most of the time it is not in reach. An observation of Resident #11's call device on 08/20/2024 at 8:44am revealed that the resident's call light was wrapped around his bed rail that was in the down position. The resident was sitting at the end of the bed. An interview with Resident #11 on 08/20/2024 at 8:44am revealed that he did not know where his call light was. He said that he rarely used his call light. An observation of Resident #8 on 08/21/2024 at 9:07am revealed that the resident was approx. 2 feet from the call light. Resident #8 could not reach the call light to call for help. The resident was yelling for help. An observation of Resident #18's call light on 08/21/2024 at 9:51am revealed that the call light was hanging on the back of the wheelchair down to the floor. The resident could not reach the call light. An interview with LVN A on 08/22/2024 at 11:27am revealed that she had been trained on resident rights. She stated that the call light should always be within the resident's reach. She said that all staff are responsible for ensuring that the call light was in the resident's reach. She said that the call light should be in the residents always in reach because that is how they let staff know when they need help. She said that if the call light were not in the resident's reach the resident would not be able to get ahold of staff if they need something. She stated she did not know why the call lights were not in reach of the residents. An interview with the DON on 08/22/2024 at 11:32am revealed she had been trained on resident rights. She stated the call lights were to be always in the reach of the resident. She said that the call light should be next to the resident or clipped to their clothes. She said that CNAs were responsible for ensuring that the call lights were in the resident's reach. She said the call light needed to be in the reach of the resident so that the resident could get their needs met. She said if the call light were not in reach the resident could not get their needs met and the resident may fall. She stated she did not know why the call lights were not in reach of the residents. She also said that it could have been the student aides could be forgetting. An interview with CNA F on 08/22/2024 at 11:38am revealed she had been trained on resident rights. She stated the call light had to be always in the reach of the resident. She also said that if a resident is weaker on one side the call light was supposed to go on the resident's stronger side. She said CNAs were responsible for ensuring that the call lights were always in reach of the residents. She said that the call light is important because that was how residents called staff if they needed them or in case of an emergency. She also said if the call light were not in reach of the resident it could be detrimental to the resident. She said the resident could have a life threating issue and not be able to call for help. She also said she did not know why the call lights were not in reach of the resident. An interview with ADM on 08/22/2024 at 11:44am revealed staff has been trained on resident rights. He stated call lights should be placed in the resident's reach when the resident was in the room. He said all staff were responsible for answering and call light placement. He said it was important for the call light to be in the resident's reach so that the resident could get his or her needs meet. He also said if the call light was not in the reach of the resident, their needs cannot be met. He stated he did not know why the call lights were not in the reach of the residents. He also said that the facility does a lot of CNA training, and the students could just be forgetting to put them in the reach of the residents. Record Review of Call Lights: Accessibility and Timely Response Policy dated 10/13/2022 revealed staff was to ensure the call light was within reach of the resident and secured as needed. They call system will be accessible to the residents while in their bed or other sleeping accommodations within the resident's room.

Based on observation, interview and record review, the facility failed to ensure the residents' right to privacy including leaving electronic medical records out for public view for 1 (Resident #4) of 4 residents reviewed for privacy and protected HIPPA information. 1) The facility failed to ensure nursing staff locked the computer screen when it was unattended, which had displayed Resident #4's personal medical information during medication administration while RN C was away from the computer administering medication to Resident #4 at 07:56 AM on 8/16/2024. 2) On 08/20/24 at 08:13 AM RN C once again left Medication Cart A unattended and Resident #4's personal medical information open on computer screen. These failures could allow residents' protected HIPPA information to be shared with individuals who do not have a need or right to know, resulting in facility staff not honoring the resident's privacy, including during visits, treatment, or leaving medical records out for public view. The findings include: Record review of Resident #4's undated admission record revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included, but were not limited to Cerebral infarction (Stroke), Flaccid hemiplegia affecting right dominant side (weakness or paralysis on one side of the body), Need for assistance with personal care, Hypertension, Lack of coordination, Vascular dementia, Pain in joints right hand, Major depressive disorder, Epileptic seizures, Chronic pain syndrome, and Cognitive communication deficit. Record review of Resident #4's Annual MDS dated [DATE] and a Discharge MDS dated [DATE] revealed her BIMS assessment was not completed. Record review of Resident #4's Care Plan dated 08/14/24 reflected the resident had impaired cognitive function/dementia or impaired thought processes related to dementia, impaired decision making, long-term memory loss, short-term memory loss and CVA (Stroke), and the relevant interventions were: 1. Administer medications as ordered. Monitor/document for side effects and effectiveness. 2. Ask yes/no questions in order to determine resident's needs. 3. Communication - use the resident's preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. 4. Cue, reorient and supervise as needed. 5. Review medications and record possible causes of cognitive deficit: new medications or dosage increases; anticholinergics, opioids, benzodiazepines, recent discontinuation, omission or decrease in dose of benzodiazepines, drug interactions, errors or adverse drug reactions, drug toxicity. 6. The resident needs assistance with all decision making. Observation on 08/20/24 at 07:56 AM revealed RN C walked away from medication cart and went into Resident #4's room. RN C left Resident #4's medical information up on screen. RN C then returned to the medication cart and retrieved a sanitizing wipe and sanitized the blood pressure cuff. RN C then walked back into the Resident #4's room to check her oxygenation level with a pulse oximeter and left Resident #4's information visible on the screen. Observation on 08/20/24 08:13 AM revealed RN C had again left Resident #4's medical information visible on the screen. Interview on 08/20/24 at 08:11 AM with RN C revealed he had worked at the facility for 2 months in PRN status. RN C stated he should have turned Resident #4's privacy screen off when he stepped away from the medication cart to administer Resident #4's medications. RN C further stated leaving a resident's medical information visible to other residents and visitors was a HIPPA violation. During an observation and interview on 08/20/24 at 08:21 AM revealed Resident #4 was sitting in her bed and was awake and alert. She was sharing her room with another resident. Resident #4 resided to the left side of the room when facing her from the entrance door. Her roommate who resided at the right side of the room, was not in the room during medication administration. RN C was the designated nurse providing medications to Resident #4 on this day. During an attempted interaction by the investigator, Resident #4 was not able to answer questions about her right to have privacy. Interview on 08/22/24 at 02:26 PM with the DON who revealed protecting resident information was very important, as someone could steal their information. The DON stated this was the first and last time RN A would work as a medication aide and probably would no longer be utilized. The DON also stated her expectation was for all nurses and medication aides to keep the screen secured at all times. The DON stated she had started in-servicing her staff on locking the resident's privacy screen on 08/20/24. Interview on 08/22/24 at 03:30 PM with the ADM revealed the privacy screen not on Resident #4's electronic health record and keys left on top of the cart should not have happened and was a HIPPA violation. Record review of the facility's undated policy titled Resident Rights reflected: The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States . . The resident has a right to be treated with respect and dignity .

Based on observation, interview and record review, the facility failed to assure that medications were secured and inaccessible to unauthorized staff and residents for 1 of 8 medication carts (Medication Cart A), and that supplies in the medication room were not expired for medication storage and labeling. 1) Facility staff failed to ensure Medication Cart A was locked while administering medications to Resident #4 at 8:13 AM on 8/16/2024. 2) On 08/20/24 at 08:13 AM staff left Medication Cart A unlocked again and left a set of keys on top of the cart. 3) Observation on 08/21/24 at 01:45 PM in the medication room revealed 12 IV Start Kits with an expiration date of 05/19/24. 4) A resident (Resident #151) had prescription medications in his room sitting on the windowsill. These failures could lead to others accessing and ingesting medications that could cause clinically significant adverse consequences necessitating hospitalization to stabilize the resident and/or drug diversion. The findings included: Record review of Resident #4's undated admission record revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included, but were not limited to Cerebral infarction (Stroke), Flaccid hemiplegia affecting right dominant side (weakness or paralysis on one side of the body), Need for assistance with personal care, Hypertension, Lack of coordination, Vascular dementia, Pain in joints right hand, Major depressive disorder, Epileptic seizures, Chronic pain syndrome, and Cognitive communication deficit. Record review of Resident #4's Annual MDS dated [DATE] and a Discharge MDS dated [DATE] revealed her BIMS assessment was not completed. Record review of Resident #4's Care Plan dated 08/14/24 reflected the resident had impaired cognitive function/dementia or impaired thought processes related to dementia, impaired decision making, long-term memory loss, short-term memory loss and CVA (Stroke), and the relevant interventions were: 1. Administer medications as ordered. Monitor/document for side effects and effectiveness. 2. Ask yes/no questions in order to determine resident's needs. 3. Communication - use the resident's preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. 4. Cue, reorient and supervise as needed. 5. Review medications and record possible causes of cognitive deficit: new medications or dosage increases; anticholinergics, opioids, benzodiazepines, recent discontinuation, omission or decrease in dose of benzodiazepines, drug interactions, errors or adverse drug reactions, drug toxicity. 6. The resident needs assistance with all decision making. Record review of Resident #151's undated admission record revealed an [AGE] year-old male was recently admitted to the facility on [DATE] with diagnoses that included, but were not limited to Anxiety disorder, depression, Hypertension, Hypokalemia (low serum potassium), Urinary tract infection, and Benign prostatic hypertrophy with urinary tract symptoms ( enlarged prostate gland with urinary tract symptoms). Record review of Resident #151's Comprehensive MDS dated [DATE] revealed his BIMS assessment had not been completed. Record review of Resident #151's Care Plan dated 08/14/24 reflected the resident was a smoker. Goal - the resident will not smoke without supervision through the review date and the resident will not suffer injury from unsafe smoking practices through the review date. Instruct the resident about smoking risks and hazards and about smoking cessation aids that are available and observe clothing and skin for signs of cigarette burns. Observation on 08/20/24 at 07:56 AM revealed RN A walked away from Medication Cart A and went into Resident #4's room. RN A left Medication Cart A unlocked . RN A did not press the lock button on Medication Cart A when he went into Resident #4's room. RN A then returned to Medication Cart A and retrieved a sanitizing wipe and sanitized the blood pressure cuff. RN A then walked back into the Resident #4's room to check her oxygenation level and Medication Cart A was still left unlocked, and a set of keys were sitting on top of Medication Cart A. Observation on 08/20/24 08:13 AM revealed RN A had again left Medication Cart A unlocked, and a set of keys were left on top of the cart. Interview on 08/20/24 at 08:11 AM with RN A revealed he had worked at the facility for 2 months in PRN status. RN A stated he should have locked Medication Cart A when he walked away from Medication Cart A to administer Resident #4's medications. RN A further stated leaving Medication Cart A unlocked put residents at risk of someone taking their medications. Observation of the medication room on 08/21/24 at 01:45 PM revealed 12 IV Start Kits with PVP Prep Pad with an expiration date of 05/19/24 in the bottom drawer of a 3-drawer plastic bin. Observation on 08/21/24 at 03:28 PM revealed there were 3 prescription medications sitting on Resident #151's windowsill. Resident #151 was not in the room at the time. The medications had Resident #151's name on them, and the label on each bottle reflected a prescription for Escitalopram 10mg, Chlordiazepoxide 5mg, and Fluticasone Propionate nasal spray 50mcg. Resident #151's roommate was bedbound and required a mechanical lift transfer to get up to his wheelchair. Interview on 08/21/24 at 4:26 PM with LVN A revealed she had not noticed Resident #151 had medications sitting on his windowsill, and she had worked the past weekend. LVN A further stated had she seen the medications she would have confiscated them and ensured they were locked up. Interview on 08/22/24 at 9:28 AM with Resident #151 revealed he had asked his friend to bring the medications that were on his windowsill and some clothing to him so he could talk to the NP at the facility about them. Resident #151 further stated he did not intend any harm and had not thought about the possibility of another resident getting his medications and wanted to cooperate with the facility rules. Resident #151 stated the facility had taken the medications and locked them up. Interview on 08/22/24 at 02:26 PM with the DON revealed she was responsible for overlooking the expired IV start kits when she checked the medication room. The DON stated she was responsible for rotating the items in medication room and removing expired medications and supplies. The DON stated the medication carts should always be locked when staff step away, to prevent anyone from going into the medication cart and grabbing things from it. The DON stated her expectation was to keep medication carts locked at all times when unattended. The DON further stated she did go around and check the carts, at least twice per week, and when a medication cart was found unlocked, she would lock the cart in her office. The DON stated Resident #151 had a visitor who he had asked to bring clothing and the medications to review with the NP. The DON stated she would expect the charge nurse to notice the medications. The DON further stated the charge nurse had been a nervous wreck during state observation of g-tube care for Resident #151's roommate and had not seen the meds in the window. The DON stated the medications on the windowsill should have been confiscated by the charge nurse and locked up. Interview on 08/22/24 at 03:30 PM with the ADM revealed he had gone to look in Resident #151's room in the afternoon of 08/21/24 and found medications on his windowsill. The ADM further stated they had confiscated the medications after Resident #151 was present and communicated to Resident #151 the medications had to be locked up. The ADM stated Resident #151 had felt badly about the medication incident, and he had wanted to talk with the NP about them. The ADM stated the potential impact of a resident having access to medications the facility was not aware of could cause an undesirable interaction for the resident, and also the possibility of another resident taking the medications. The ADM stated the expired IV start kits found in the medication room and medication cart left unattended, and keys left on top of the cart should not have happened. The ADM stated the nurse and nurse management were responsible for ensuring resident medications were secured, and that all medications and IV tubing in the medication room were removed if expired. The ADM further stated no medications should be at bedside unless approved by a physician and the resident was self-administering their medications. Review of facility Policy and Procedure titled, Expiration Dating and Expired Medications: dated 10/01/19 reflected, The facility is to strictly adhere to the expiration dating and It is the responsibility of all nurses who administer medications to monitor the expiration dates of the medications. Expired medications will not be administered in the facility. All expired medications will be disposed of per Facility policy.

Based on interview and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented for 4 of 32 residents (Residents #8, #81, #206, and #217) reviewed for clinical records. 1. The facility failed to ensure a legal MPOA was in the clinical record for Resident #8. 2. The facility failed to ensure a legal OOH-DNR was in the clinical record for Resident #81. 3. The facility failed to ensure the code status for Resident #206 was evident in the clinical record. 4. he facility failed to ensure medical documents for Resident #217 were filed in the correct clinical record. This failure placed residents at risk of having their confidentiality and their rights violated. Findings included: 1. Review of the undated face sheet for Resident #8 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included frontotemporal neurocognitive disorder (type of memory), severe protein calorie malnutrition, thalassemia (inherited blood disorder), dementia (memory, thinking, difficulty), dysphagia (difficulty swallowing), type 2 diabetes mellitus without complications (high blood sugar), hyperlipidemia (high cholesterol), constipation, hypertension (high blood pressure), muscle wasting, unsteadiness on feet, lack of coordination, anxiety order, and adjustment disorder. Review of Resident #8's quarterly MDS assessment dated [DATE] reflected the resident was rarely/never understood. Resident #8 did not have a BIMS score due to not being able to complete assessment. Review of the miscellaneous documents section for Resident #8 reflected the MPOA that had been uploaded had no date, signature, or notary seal. 2. Review of the undated face sheet for Resident #81 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included fracture of neck of right femur (broken thigh bone), anemia (low blood iron), hypertension (high blood pressure), weakness, arthritis, history of breast cancer, urinary tract infection, muscle wasting and atrophy, unsteadiness on feet, lack of coordination, cognitive communication deficit (difficulty communication due to cognitive impairment), and cerebral aneurysm (bulge or ballooning in a blood vessel in the brain that can rupture and cause a brain bleed). Review of Resident #8's admission MDS assessment dated [DATE] reflected a BIMS score of 02, indicating severely impaired cognition. Review of the profile information for Resident #81, which included the date of admission, code status, and primary diagnosis and appeared at the top of every section of the EMR, reflected a code status of DNR. Review of the physician's order summary for Resident #81 reflected the following order dated 07/23/24: DNR (Do Not Resuscitate). Review of the miscellaneous documents section for Resident #81 reflected no OOO-DNR form present. During an interview on 08/22/24 at 01:17 PM, the SW stated she thought Resident #8's family member sent the wrong MPOA form, and somebody uploaded the form by accident. She stated the BOM was the person who uploaded the MPOA for Resident #8 into the clinical record, and she was out on leave. She stated she did not know if she was responsible for uploading the OOH-DNR for Resident #81, but usually it was tied to the code status order being placed in the order list at admission. The SW stated she could not enter orders, as she was not a nurse or a nurse practitioner. She stated a potential negative impact of the failures related to the MPOA and the OOH-DNR was residents might not receive the care they wanted. An attempt was made on 08/22/24 at 03:04 PM to interview the BOM but she did not answer her phone or return contact. 3. Review of the undated face sheet for Resident #206 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included muscle wasting and atrophy, hypertension (high blood pressure), hyperlipidemia (high cholesterol), type two diabetes mellitus(high blood sugar), obstructive sleep apnea (sleep-related breathing disorder), atrial fibrillation (irregular and often very rapid heartbeat), and insomnia. Review of the MDS assessments for Resident #206 reflected he did not have any complete assessments. Review of the physician's order summary for Resident #206 reflected an order dated 08/19/24 for code status to be full code. Review of the profile information for Resident #206 reflected his code status was not present in the heading at the top of the page. This profile information included the date of admission and primary diagnosis and appeared at the top of every section of the EMR, but the area reserved for code status did not clarify a code status. During an interview on 08/22/24 at 12:04 PM, LVN E stated she had admitted Resident #206 and should have entered his code status so that it could be seen at the top of the page in his clinical record in the EMR. She stated she was very busy that night and must have forgotten. She stated it was her responsibility. She stated she did not think it would have a negative impact, because he had a full code status, and they would always treat a resident as a full code if there was a question about their code status. 4. Review of the undated face sheet for Resident #217 reflected a [AGE] year-old male admitted to the facility on [DATE] and discharged on [DATE]. His diagnoses included urinary tract infection, cellulitis of right, lower limb, methicillin susceptible staphylococcus aureus infection (infection caused by bacteria commonly found on the skin), emphysema (destructive disease of the lung), obstructive and reflux uropathy (when urine can't flow through the ureter, bladder, or urethra due to some type of obstruction), anemia, anxiety disorder, acute kidney failure, chronic kidney disease stage four, and hyperkalemia (high blood potassium). Review on 08/21/24 of the miscellaneous documents section of the clinical record for Anonymous Resident #1 reflected Resident #217's hospital records from 07/29/24 had been uploaded to Anonymous Resident #1's clinical record. Review on 08/22/24 of the miscellaneous documents section of the clinical record for Anonymous Resident #2 reflected Resident #217's hospital records from 07/13/24 had been uploaded to Anonymous Resident #2's clinical record. Both Anonymous Residents #1 and #2 were currently residing in the facility during the time Resident #217's records were found in their charts. During an interview on 08/22/24 at 12:54 PM, the MR stated she was responsible for uploading documents to the EMR and had uploaded the two hospital documents for Resident #417 into the wrong clinical records. She stated she was not sure why the documents were filed incorrectly, but it might have been because they were sent to other departments to view, sent back to her, and were stacked with a different resident. She stated a potential impact of the document being uploaded in the wrong record was a provider who was looking might also have missed the name and thought they were looking at clinical information about the patient they were treating and give them the wrong care, or it could have been a violation of HIPAA. During an interview on 08/22/24 03:15 PM, the ADM stated he had determined there were three aspects of the same clinical records issue. He stated with Resident #8, the BOM had been assisting the family with getting him on Medicaid, and the MPOA document that was provided by the MPOA was the one that was uploaded and sent to Medicaid. The ADM stated Medicaid was approved, so the person who reviewed the Medicaid application obviously did not check closely the MPOA, either. He stated in that situation, the BOM was responsible for uploading the correct, legal document in the chart. The ADM stated the issue with Resident #217's documents being placed in the wrong clinical records was because of the high number of admissions they had at the facility, as they admitted and discharged many short-term skilled residents each week. He stated the stacks of information coming from all the disciplines were so many documents, that the MR simply misfiled a couple. Related to the issue of Resident #206 not having his code status clearly printed in his chart at the top of his profile information, he stated that was because there was a drop-down menu nurses had to use to enter a code status after they entered orders, and the admitting nurse must have forgotten. He stated the oversight could have resulted in Resident #206 not receiving emergency treatment as quickly as possible as the staff would have to dig into the record to find the information. He stated the records being filed under the wrong resident chart could have had the impact of violating HIPAA or of clinicians not getting the correct clinical information about the patient they were looking up. He stated a potential impact of a resident not having a legal MPOA was that it could have been a rights violation if the person claiming MPOA did not have a full and legal designation. He stated a potential impact of not having a legal OOH-DNR in the clinical record was the resident might not have had her wishes observed. He stated the SW should have been responsible for checking the legal documents and ensuring they were available, and the MR was responsible for ensuring they went into the correct chart. He stated the nurses and nurse management were responsible for ensuring the code status was entered into the EMR profile. Review of a document provided by the ADM on 08/21/24 reflected a legal MPOA dated 01/24/24 for Resident #8 delegating his FM as his MPOA. Review of a document provided by the ADM on 08/21/24 reflected a legal OOH-DNR for Resident #81 dated 07/23/24. Review of the facility policy dated 10/24/22 and titled Documentation in the Clinical Record reflected the following: Each resident's medical record should contain accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Review of facility policy dated 10/24/22 and titled Residents' Rights Regarding Treatment and Advance Directives reflected the following: It is our policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and formulate an advanced directive. 3. Upon admission, should the resident have an advanced directive, copies will be made and placed on the chart as well as communicated to the staff.

Based on observation, interview, and record review, the facility failed to ensure residents who entered the facility with indwelling catheters received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #203) reviewed for catheter. The facility failed to ensure orders were entered related to Resident #203's Foley catheter at his admission on 08/15/24. This failure placed residents at risk of UTI and other catheter-related complications. Findings included: Review of the undated face sheet for Resident #203 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included urinary tract infection (UTI) and sepsis ( a serious condition in which the body responds improperly to an infection). Review of of the MDS assessments for Resident #203 reflected none had been completed for Resident #203. Review of the baseline care plan for Resident #203 dated 08/15/24 and completed by LVN D reflected he had an indwelling catheter. It reflected the following care planning options related to his indwelling catheter, each with buttons next to them that indicated they could be checked/triggered, but none of them were checked: Problem: The resident has (SPECIFY: Condom/Intermittent/Indwelling Suprapubic) Catheter: Goal: The resident will be/remain free from catheter-related trauma through review date. Goal: The resident will show no s/sx of Urinary infection through review date. Intervention: CATHETER: last changed: (SPECIFY Date). Change catheter (FREQ). (SPECIFY Size) (SPECIFY Type) Intervention: CATHETER: The resident has (SPECIFY Size) (SPECIFY Type of Catheter). Position catheter bag and tubing below the level of the bladder and away from entrance room door. Intervention: Check tubing for kinks [# TIMES] each shift. Intervention: Monitor and document intake and output as ordered Intervention: Monitor for s/sx of discomfort on urination and frequency. Intervention: Monitor/document for pain/discomfort due to catheter. Intervention: Monitor/record/report to MD for s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Problem: The resident has (SPECIFY: Condom/Intermittent/Indwelling Suprapubic) Catheter. Review of the physician's order summary for Resident #203 pulled from the EMR on 08/22/24 at 12:55 PM reflected no orders related to an indwelling catheter. Observation on 08/22/24 at 10:02 AM revealed Resident #203 had a foley catheter tube emerging from his penis and connected to a plastic bag partially filled with yellow liquid. He did not respond to any efforts to converse with him. During an interview on 08/22/24 at 01:05 PM, LVN D stated she had been the nurse on duty when Resident #203 was admitted to the facility and had entered his orders and processed his admission paperwork on 08/15/24. She stated she knew Resident #203 had a catheter, and if he did not have orders for the catheter entered into the MAR, it was probably because she had made a mistake. She stated, as the admitting nurse, entering the orders for Resident #203 had been her responsibility. LVN D stated it was important to have orders related to catheters because a lack of orders in the system could cause new staff not to know he had a catheter. She stated if the catheter was not monitored for placement, patency, and quality of the urine. During an interview on 08/22/24 at 02:34 PM, the DON stated when a new resident admitted , the admitting nurse should have entered orders right then and there. She stated the orders should have been entered immediately, and if they were not, the team looked at the admission the next day in morning meeting and caught the omission. The DON stated she did not know why the missing catheter orders for Resident #203 were not caught in the morning meeting. She stated there had been no negative impact, because she had assessed him when they learned the orders had not been entered, and his urine was clear and yellow, not cloudy or tinged, and placement of the catheter was good. The DON stated the admitting nurse was responsible for entering the orders, and she and her ADONs were responsible for following up to ensure it was done. During an interview on 08/22/24 at 03:15 PM, the ADM stated there needed to be orders related to a resident's catheter. He stated it was the responsibility of the charge nurse for the resident and nurse management to ensure those orders were in place. He stated a resident could have negative outcomes without catheter orders, but he did not elaborate. A policy on catheters was requested from the ADM on 08/22/24 at 03:34 PM but not provided by the time of exit.

Based on observation, interview, and record review, the facility failed to provide routine and emergency drugs to its residents for 1 of 8 residents (Resident #206) reviewed for administration of medication. The facility failed to ensure Resident #206's medication orders were entered immediately upon his admission, and he did not receive his temazepam for insomnia his first night in the facility, 08/19/24. This failure placed residents at risk of insomnia and discomfort. Findings included: Review of the undated face sheet for Resident #206 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included muscle wasting and atrophy, hypertension (high blood pressure), hyperlipidemia (high cholesterol), type two diabetes mellitus(high blood sugar), obstructive sleep apnea (sleep-related breathing disorder), atrial fibrillation (irregular and often very rapid heartbeat), and insomnia. Review of the MDS assessments for Resident #206 reflected he did not have any complete assessments. Review of the physician's order summary for Resident #206 reflected an order dated 08/19/24 for Temazepam Oral Capsule 15 MG (Temazepam) Give 1 capsule by mouth at bedtime for INSOMNIA with a start date of 08/20/24. Observation and interview on 08/20/24 at 09:00 AM, revealed Resident #206 was seated in a chair next to his bed, awake and alert. He stated he was alright except that his medications did not come in the night before, and he had gone without the medicine he took to help him sleep. He stated it was not a very welcoming experience. He stated he had asked the nurse, whose name he did not know, for his temazepam, but she told him the pharmacy had not delivered it. He stated he had arrived at the facility at 06:00 PM the night before, on 08/19/24, and he did not understand why there was not communication between the hospital and the nursing facility to ensure he got his night medications. He stated the sleep medication was the only medication he took at night. He stated he did not sleep well after not receiving his medication, but he was not in very much distress about it. During an interview on 08/22/24 at 12:04 PM, LVN E stated she had admitted Resident #206 on the night of 08/19/24. She stated when she had an admission in the evening, she first did everything on her hall for her residents before she sat down and did the admission in the computer. She stated she finished all her work the night of Resident #206's admission and then sat down and began entering his information into the computer, including orders. She stated when she finished the admission, she went to visit him and offered him a temazepam from the emergency kit. She stated she did that because she saw he had a nighttime medication and the aides said he had been asking the aides for it. She stated he declined the medication from the emergency kit and said he would start the medication the following day. She stated it was 01:00 AM or 02:00 AM at that point. LVN E stated she had not documented anywhere that it was that late in the night, but she agreed it might be too late for someone to feel comfortable taking a sleeping medication. She stated it might have affected his night of sleep and might have made his first night in the facility unpleasant. During an interview on 08/22/24 at 02:46 PM, the DON stated the procedure should have been the admitting charge nurse for a new resident placed medication orders immediately in the EMR as soon as they were obtained by the referral and the resident arrived. She stated if the admission was after 05:00 PM, they would not have been able to receive the medications by their 08:00 PM pharmacy delivery, but if the orders were entered, the resident could have received the medication form the emergency kit. The DON stated her expectation was the nurse who admitted a resident entered medication orders immediately and not after completing all the work on their hall. The DON stated LVN E should have prioritized putting the medication orders in for Resident #206. She stated Resident #206 should have received his medication for sleep the night of his admission on 08/19/24. She stated she thought his experience was not very favorable if he did not receive his sleeping medication. She stated it was the admitting nurse's responsibility to ensure medication orders were entered immediately upon resident admission, and it was nurse management's During an interview on 08/22/24 at 03:15 PM, the ADM stated medication orders should have been entered at admission to avoid residents missing medications. The ADM stated it was primarily the admitting nurse's responsibility to ensure the medication orders were entered, but nurse management oversaw the system for compliance. He stated a potential negative impact of not receiving his nighttime medications for Resident #206 was poor sleep. A policy on Entering/Following Physician Orders was requested from the ADM on 08/22/24 at 03:34 PM but was not provided by the time of exit.

Based on observation, interview, and record review, the facility did not provide pharmaceutical services to meet the needs of each resident for one (Resident #1) of four residents reviewed for pharmaceutical services, in that: The facility failed to ensure Resident #1 was administered her prescribed Clonazepam (for anxiety), Duloxetine (for depression), Zyprexa (for agitation), and Melatonin (for insomnia) for four days after admission on 05/22/24. This caused her symptoms of confusion and agitation to exacerbate causing distress. This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements or could result in worsening or exacerbation of chronic medical conditions. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including agitation, anxiety disorder, depression, stroke, and cognitive communication deficit. Review of Resident #1's EMR, on 05/26/24, reflected her 5-day MDS assessment had not been completed. Review of Resident #1's BIMS, dated 05/23/24, reflected a BIMS of 11, indicating a moderate cognitive impairment. Review of Resident #1's admission care plan, dated 05/22/24, reflected it had nothing related to her diagnoses or behaviors. Review of Resident #1's hospital records, dated 05/18/24, reflected the following: Called by RN as [Resident #1] was throwing food, water, meds . security called . Zyprexa 2.5 mg IV ordered . AMS/Agitation . Zyprexa BID, E sitter ordered . Review of Resident #1's hospital records, dated 05/19/24, reflected the following: [Resident #1] with waxing/waning MS . change Zyprexa to 2.5 mg PO Q6 hours PRN . has E sitter (cannot go to SNF with E sitter) . Disposition - to SNF once MS improved . Review of Resident #1's hospital records, dated 05/20/24, reflected the following: Remove sitter at 3 PM if [Resident #1] is oriented and alert . PT/OT - resume therapy today . Review of Resident #1's hospital records, dated 05/21/24, reflected the following: Stop sitter at 3 PM today . less confused . Anticipate SNF discharge tomorrow afternoon. Review of Resident #1's discharge medications in her hospital records, dated 05/22/24, reflected the following: Clonazepam - 0.5 mg - po BID Duloxetine - 20 mg - po BID Zyprexa - 2.5 mg - po qhs Melatonin - 10mg - po qhs Review of Resident #1's MAR, May of 2024 on 05/26/24, reflected she received her first dose of Clonazepam and Duloxetine on the morning of 05/26/24. She had not received any doses of Melatonin or Zyprexa since she was admitted on [DATE]. From 05/23/24 - 05/25/24, LVN D marked 9, which was defined as Other/See Progress Notes. Review of Resident #1's progress notes, from 05/23/24 - 05/25/24, reflected no progress notes documented by LVN D related to medications. Review of Resident #1's progress notes in her EMR, dated 05/25/24 at 6:27 PM and documented by RN A, reflected the following: Day shift nurse reports [Resident #1] refused all three meals today but did accept a health shake. Review of Resident #1's progress notes in her EMR, dated 05/25/24 at 7:22 PM and documented by RN A, reflected the following: . [Resident #1] began using racial slurs, throwing items in her room . Review of Resident #1's progress notes in her EMR, dated 05/26/24 at 4:30 AM and documented by RN A, reflected the following: Staff reports that [Resident #1] was cursing and shoving furniture in her room and throwing items. Review of Resident #1's progress notes in her EMR, dated 05/26/24 at 5:31 AM and documented by RN A, reflected the following: [Resident #1] near the nurse's station uses her cell phone to call (city) police department. Reports someone stole her phone charger and she believes she is being mistreated. During an observation and interview on 05/26/24 at 9:47 AM revealed Resident #1 ambulating with her walker slowly around the nurses' station. She was agitated and distressed and stated she had not slept in two days and she had no idea what was going on. She repeatedly laid her head on the desk of the nurses' station, moaning that she was so tired. LVN B redirected Resident #1 towards her room and stated they had been waiting on some of her medications to arrive and she had gone without several medications and that was why she had been anxious, agitated, and not sleeping well. During an interview on 05/26/24 at 10:40 AM, RN A stated Resident #1 had not slept last night and was more agitated than usual. She stated she was throwing furniture and yelling at staff. She stated she had not worked in a few days and it looked like her medications were still pending delivery from the pharmacy but she utilized the e-kit for her morning medications. She stated she had already called the pharmacy to try and get an update. During an interview on 05/26/24 at 10:47 AM, CNA C stated Resident #1 had been more confused and agitated since she was admitted . She stated she was restless and anxious all night and did not sleep. During an interview on 05/26/24 at 11:11 AM, the ADON stated the nurse management team was responsible for ensuring medications were in house and readily available upon residents' admission. He stated if there were not medications available for a resident, he would it was the nurse's responsibility to contact the DON and NP or call the pharmacy for a stat delivery. He stated their pharmacy makes deliveries twice a day and it would be unacceptable for any resident to go multiple days without their scheduled medications. He stated if a resident went days without medications such as Duloxetine, Zyprexa, and Clonazepam, it could cause increased anxiety and could affect all aspects of their mental health. He stated he was not aware Resident #1 had gone multiple days without these medications. He stated he was not sure if those particular medications (Duloxetine, Clonazepam, Zyprexa, and Melatonin) were in their emergency medication kit. On 05/26/24 multiple telephone calls were made to LVN D. A returned phone call was not received prior to exiting. Review of the facility's Medication Orders Policy, revised 10/01/19, reflected the following: Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. Verbal orders are received only by the licensed nurses or pharmacists and confirmed in writing by the prescriber within 48 hours. . C. Emergency Medication Order: (Medication NOT contained in emergency medication supply) An emergency order is placed with the provider pharmacy, and the medication is scheduled to be given as negotiated with the pharmacy and based on logistics and applicable regulations. Stat orders always require direct communication between a nurse and a pharmacist to adequately assess the situation and define a resolution.

Based on observation, interview, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment, in safe operating condition, for 1 of kitchen reviewed for essential equipment. 1. The facility failed to ensure that the dishwasher dispensed the correct amount of chlorine to properly sanitize dishes. 2. The facility failed to ensure the freezer was free from leaks. 3. The facility failed to ensure the coffee machine was in good working condition. This failure could place residents at risk of being exposed to food-borne illnesses from equipment that does not function properly. The findings included: Observation on 06/13/23 at 09:00 AM during initial walkthrough of the kitchen revealed: Coffee maker spout/spigot leaking - had serving tray under front feet of machine with towels and a metal bowl directly under the spout to catch the dripping coffee and the towels were wet with coffee. The large 2-door freezer had a 2-inch-deep baking pan sitting on top of boxes of food. The baking pan was on the top shelf with a layer, approximately 0.5 to 0.75 inch thick, of ice in it that appeared to be from a leak at the top of the freezer at a 2-inch metal bracket which also had a small amount of ice collection noted. In an interview on 06/13/23 at 09:15 AM Dietary Aid D stated that the coffee pot in the kitchen had been leaking since she started working here and it had been serviced several times by the contract company. She stated that the maintenance man said it was fixed but it kept leaking from the spout, so they left the bowl under it to catch the dripping coffee and emptied it when it got full. She stated that the freezer was leaking a while ago, she couldn't remember how long, and the maintenance man worked on it, but they had put the pan on the top shelf to catch the leaking water and decided to leave it there in case it started to leak again. Observation on 06/13/23 at 09:35 AM revealed that after Dietary Aid E had run a cycle on the dishwasher, the water was tested with a chlorine strip and the strip read 10 ppm chlorine. The reading was verified with Dietary Aid E and Cook F. Review of the June 2023 Daily Dish Machine Temperature and Sanitizer Log hanging on the wall opposite the dishwasher revealed that all chlorine levels were 50 ppm, and were checked at breakfast, lunch, and dinner. Observation and interview on 06/13/23 at 09:40 AM with Dietary Aid E and Cook F, Dietary Aid E ran the dishwasher again with no dishes and used test strips on outside water where sanitizer mixes into machine and inside the dishwasher and both strips read at 10 ppm chlorine. Verified the strip reading with Dietary Aid E and Cook F. Dietary Aid E stated that when she ran that test that morning the strip read at 50 ppm but she agreed that the current strip did not look the same. Cook F stated that they thought there was an issue with the pipe or hose that connected the sanitizers to the machine coming loose or not being secure and that the machine had been serviced recently. Cook F stated they had not had any issues with the reading in the past that she was aware of. Dietary Aid E stated that before she logged the reading every morning, she had to run two cycles to let the sanitizer get to the right mixture, but after that she never had a problem with the readings. Dietary Aid E went to the connection and attempted to push it back into place more securely. Another cycle was run without dishes in the machine and the test strip was dipped in the water inside the dishwasher and continued to read at 10 ppm. The strips were then shown to the Food Service Manager and the situation was explained to her. The Food Service Manager stated that she would look into when that last time the machine was serviced was and find out exactly what was done to the machine at that time. The Food Service Manager also confirmed that the strips were showing 10 ppm chlorine and that was below that acceptable level for sanitizing dishes. Observation on 06/13/23 at 10:00 AM the Food Service Manager ran the dishwasher without dishes and dipped a test strip in the water inside the machine and the strip read at 10 ppm chlorine. Observation and interview on 06/13/23 at 10:40 AM the Food Service Manager and surveyor ran dishwasher without dishes and tested water inside machine and outside machine where sanitizer mixes and strip read at 10 ppm chlorine. The Food Service Manager stated that she had already contacted the company that services the dishwasher to come check it out and they would be there that day. She stated that the chlorine content in the dishwasher was a sanitization issue and if the dishes, pots, pans and utensils were not sanitized correctly residents could get sick, so the machine needed to be fixed immediately. In an interview on 06/13/23 05:50 PM with the Administrator, he stated that company who serviced the dishwasher had been notified of sanitizer not mixing correctly and they would send a technician to check on it that day if they had not already done so. When he was informed of the leaking coffee machine and leaking freezer, he stated that the coffee pot had been fixed in the past due to what sounded like the same issue. He was unaware that there had been a leak in the freezer, but he would have the maintenance supervisor investigate it that day. In an interview on 06/15/23 at 09:37 AM with the Maintenance Supervisor, he stated the leak in the freezer was from the condenser hose that ran from the inside of the unit to a drain pan in the back of the unit. He stated the leak started 8 months to a year ago when the hose separated from the drain connection inside the freezer. He stated when the leak started, he reattached the hose and the leak had stopped. The Maintenance Supervisor stated that as far as he was aware it had been working without any leaks. He was made aware of the leak by the Administrator the previous day (6/14/23). He stated he was able to secure the hose with a bracket and it should not leak again. He stated the coffee maker in the kitchen had also been repaired previously. He stated that in March 2022 the handle on the spout broke and began leaking due to the spring wearing out from use. He stated it was a very simple thing to fix if he was made aware of it. He stated the part had already been ordered and it would be fixed by the end of the week. He stated the facility used a computer program to put in work orders for him to know when something is broken so he could order parts or call someone to do work. He stated he never received a work order about the coffee pot or the freezer, but the Food Service Manager was new, so she did not know how to put the work order in the system. He stated he did not do any work on the dishwasher and that it was all done by the contract company. The Maintenance Supervisor was able to provide invoices from the contract company for the dishwasher to show it had been serviced 1/25/23, 4/19/23 and 6/14/23. In an interview on 06/15/23 at 10:00 AM the Administrator stated that the facility did not have a written policy on essential equipment.

Based on observation, interview, and record review the facility failed to treat residents with respect, dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 9 of 9 residents in the confidential group interview, and one individual resident (Resident #27). Staff used cell phones in residents' presence causing residents to feel disrespected. (Resident #27 and 9 residents in the Resident Council Meeting) This failure resulted in a diminished quality of life for the identified residents and could affect additional residents by causing a loss of self-esteem and increased isolation. The findings included: Observation on 6/13/23 at 10:10 a.m. revealed the medication cart was in the hall and the MA was standing in the doorway of room [ROOM NUMBER], with her back facing into the room and her arms stretched out onto the medication cart, texting. When the MA saw the Surveyor, she immediately put the phone in her pocket. Resident #18 was in the room at the time of this observation but was not interviewed. Review of Resident #27's Admission Record, dated 6/14/23, revealed she was [AGE] year-old female admitted to the facility on [DATE] with diagnoses including stroke and paralysis of the right side. Review of Resident #27's quarterly MDS Assessment, dated 4/24/23, revealed she had long and short-term memory impairment Interview on 6/13/23 at 11:33 AM Resident #27 said the nurses were not nice to her. When asked for details, Resident #27 made a gesture like holding a phone to her ear. The Surveyor asked if that meant the staff used their cell phones when providing care for her, Resident #27 nodded her head yes. Resident #27 pointed at the A side of bedroom, and the Surveyor asked if Resident #27 meant the staff were hiding on the A-side of the room on the phone and Resident #27 nodded her head yes. The Surveyor asked how it made her feel and Resident #27 made a fist and shook it at the A side. The Surveyor confirmed that meant it made Resident #27 angry and Resident #27 nodded her head yes. Interview on 6/14/23 at 9:52 AM during the confidential Resident Council meeting, nine residents said staff were on their cell phones while providing care to residents. The residents explained staff were on their cell phones while passing pills, feeding residents, or in the shower. One resident said they wished the staff would not pass pills while on the phone because divided attention is no attention. The residents said sometimes the phone calls were long, especially while feeding the residents. One resident shared that while they did not need assistance with being fed, the roommate did and when that happened all the roommate could do was scream in the dining room. Interview on 6/15/23 at 9:13 AM the Administrator said the facility had done several in-services on cell phone use. He said he would feel less than attended to if staff were on their phone while providing care which would not feel good. He was informed of the Surveyor's observations and interviews with individual residents as well as the Resident Council. He stated Resident #27 was with it enough to communicate what was going on. The Administrator stated that cell phone use was an ongoing issue in the facility. He stated that the management staff had addressed it on several occasions through in-services and would continue to do so. Interview on 6/15/23 at 11:38 AM the DON said she would be ticked off if staff were on their phone while taking care of her. Review of the facility's in-services, dated 5/24/23 and 1/2/23, revealed: Cell phones are not to be used while working, no cell phones are allowed while in hallways or resident rooms. In case of emergency let your charge nurse know and step into break room. Employee handbook F-4 - Employees are not permitted to use their personal cell phones while on work duty, including during the care of residents, except in emergency situations.

Based on, interview, and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care and the facility failed to ensure the baseline care plan was developed within 48 hours of a resident's admission for 4 of 8 residents (Residents #100, #262, #265, #267) reviewed for baseline care plan. The facility failed to ensure Resident #100 had a baseline care plan that addressed his ADL status, cognitive ability, urinary incontinence, pain management, falls or breathing treatments. The facility failed to ensure Resident #262 had a baseline care plan that addressed his PEG tube (feeding tube), diabetes mellitus, pneumonitis, ADL decline, falls, and pain. The facility failed to ensure Resident #265 had a baseline care plan that addressed his wound care, osteomyelitis, and pain. The facility failed to ensure Resident #267 had a baseline care plan that addressed his end stage renal failure, intravenous antibiotic therapy, dialysis and shunt (a catheter that aids the connection from dialysis access to a major artery) care, and fluid restriction. This failure could place residents at risk of not receiving the care and services and continuity of care. Findings include: Record review of Resident #100's face sheet, dated 6/14/23, revealed an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe), atherosclerosis (a buildup of fats, cholesterol plaque in the walls of arteries), dementia (a group of conditions that impairs memory and judgement), atrial fibrillation (irregular heart rate that causes poor blood flow), and muscle wasting (decreased muscle tissue). Review of Resident #100's MDS section of the chart, reflected her admission MDS was not completed yet. Review of Resident #100's Order Summary Report, dated 06/06/23, revealed orders: Tramadol 50 MG, give 1 tablet by mouth every 8 hours as needed for pain. Rosuvastatin Calcium 5 mg tablet, give 1 tablet by mouth at bedtime for HDL cholesterol. Ipratropium 0.5 mg inhale orally via nebulizer four times a day for shortness of breath. Lidocaine Patch 4 %, apply 1 patch transdermally one time a day for pain. Quetiapine Fumarate (used to treat schizophrenia, bipolar disorder) 25 mg, give 1 tablet by mouth two times a day for (no diagnosis given). Review of Resident #100's undated care plan reflected no baseline care plan for ADL status, cognitive ability, urinary incontinence, pain management, falls, breathing treatments. Review of Resident 100's admission notes, revealed that resident was incontinent, was at risk for falls, needed assistance with pain management and ADL's. Record review of Resident #262's face sheet, dated 6/14/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included pneumonitis (inflammation of lung tissue), cancer, gastrectomy (removal of all or part of stomach), diabetes mellitus, hypertension, severe protein calorie malnutrition, muscle wasting and difficulty walking. Review of Resident #262's MDS section of their chart reflected her admission MDS was not completed yet. Review of Resident #262's Order Summary Report, dated 06/10/23, revealed orders: Hydrocodone-Acetaminophen tablet 10-325 mg via PEG-tube, give as needed for pain. Hydromorphone Oral Tablet 2mg, give1 tablet via PEG-tube for pain. Insulin Aspart Injection ,100 UNIT/ml, Inject as per sliding scale for diabetes mellitus. Enteral Feed, one time a day Jevity 1.2 via PEG-tube. Review of Resident #262's undated care plan revealed no baseline care plan for PEG tube, diabetes mellitus, pneumonitis, ADL decline, falls, and pain. Review of Resident 262's admission notes, revealed that resident was admitted with a diagnosis of pneumonitis, diabetes mellitus, was at risk for falls, needed assistance with pain management, ADL's and a PEG tube. Record review of Resident #265's face sheet, dated 6/14/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included osteomyelitis of vertebra (bone infection of vertebra), stimulant drug abuse, and neuropathy (disease of peripheral nerves, causing numbness). Review of Resident #265's MDS section of their chart revealed her admission MDS was not completed yet. Review of Resident #265's Order Summary Report, dated 06/06/23, revealed orders: Oxycodone 5 mg, give 1 tablet by mouth every 4 hours as needed for pain. Nafcillin Sodium, give12 gram intravenously one time a day for osteomyelitis. Wound care: Clean area with normal saline, pat dry, apply anasept gel, apply collagen, cover with xeroform ABD, secure with Kerlix daily. Review of Resident #265's undated care plan revealed no baseline care plan for wound care, osteomyelitis, and pain. Review of Resident 265's admission notes, revealed that resident was admitted with osteomyelitis of vertebra, needed assistance with pain management and wound care. Record review of Resident #267's face sheet, dated 6/14/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included end stage renal disease (kidney function has ceased), and acute respiratory failure with hypoxia (not enough oxygen in tissues). Review of Resident #267's MDS section of their chart revealed her admission MDS was not completed yet. Review of Resident #267's Order Summary Report, dated 06/08/23, revealed orders: Tramadol 50 mg tablet, give 1 tablet by mouth every 4 hours as needed for moderate to severe pain. Sevelamer Carbonate 800 mg, give 3 tablets by mouth with meals for end stage renal failure. Dialysis: check shunt for signs/symptoms of infection or bleeding every shift. A/V shunt restrictions: no heavy lifting, no blood pressure, and no blood draws to arm, every shift. Renal diet, regular texture, regular liquids, fluid restriction of 1500 ml's. Cefazolin Sodium, give 2 grams antibiotic intravenously in the evening every Monday and Wednesday Review of Resident #267's undated care plan revealed no baseline care plan for end stage renal failure, intravenous antibiotic therapy, dialysis and shunt care, fluid restriction. Review of Resident 267's admission notes, revealed that resident was admitted with a diagnosis of end stage renal failure. Review of Residents 267's orders revealed resident was on intravenous antibiotic therapy, required dialysis, shunt care, and fluid restriction. Interview on 6/15/23 at 12:00 PM, the DON stated that currently the process was that the admitting nurse was responsible for ensuring the baseline care plan was initiated on admission. If the admitting nurse was unable to initiate, then the MDS nurse would be next in line to initiate the baseline care plan. If neither one was able to initiate the baseline care plan, then the ADON would step in. DON stated that it was her responsibility to review new admission charts to ensure that baseline care plans were initiated. The DON stated that she failed review these charts and therefore failed to initiate the baseline care plan for these residents. Record review of the facility's, Care Plans- Baseline policy, dated 10/22/22 revealed: The facility will develop and implement a baseline 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. 1.The baseline care plan will: a. be developed within 48 hours of a resident admission. b. include the minimum healthcare information necessary to properly care for a resident, including but not limited to: i. Initial goals based on admission orders. ii. Physician orders. iii. Dietary orders. iv. Therapy services. v. Social services. vi. PASARR recommendations. 2. The admitting nurse, or supervising nurse on duty, shall gather information from admission physical assessment, hospital transfer information, physician orders, and discussion with the resident and resident representative, if applicable. a. Once gathered, initial goals shall be established that reflect the residents stated goals and objectives. b. Interventions shall be initiated that address the residents current needs including: i. Any health and safety concerns to prevent decline or injury, such as elopement, fall, or pressure injury risk. ii. Any identified needs for supervision, behavioral interventions, and assistance with activities of daily living. iii. Any special needs such as for IV therapy, dialysis, or wound care. 3. A supervising nurse shall verify within 48 hours that a baseline care plan has been developed. 4. A written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident/representative can understand. The summary shall include, at a minimum, the following: a. The initial goals of the resident. b. A summary of the residents medications and dietary instructions. c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.

Based on interview and record review, the facility failed to implement policies and procedures that prohibit neglect for 1 of 22 residents reviewed for abuse and neglect (Resident #14). Resident #14 was afraid to go to the dining room for meals, or attend other activities, after witnessing an argument between two CNAs on 1/12/16. The facility failed to further address Resident #14 ' s verbalization of fear, which caused reduced social interaction, increased anxiety, and a new order for anti-anxiety medication. This deficient practice has the potential to cause increased anxiety, decreased social interaction and increase of [MEDICAL CONDITION] medication use in 24 residents with a [DIAGNOSES REDACTED]. Findings include: Review of Resident #14 ' s face sheet revealed she was [AGE] years old, admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #14 ' s most recent quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, indicating she was cognitively intact. Further review of the MDS revealed no indicators of depressed mood or psychosocial disturbances. Resident #14 ' s response to the interview for Activity Preferences, as documented on the annual MDS dated [DATE], was very important for her to do things with groups of people. In an interview during an initial tour on 2/2/16 at 10:40 a.m., Resident #14 stated she used to go to the dining room to eat her meals, but now she is too scared to go. Resident #14 stated two aides got into a fight on 1/12/16, and the aide she is scared of is still working on the 2 - 10 p.m. shift. Resident #14 also stated she no longer goes to activities outside her room and no longer eats in the dining room since she is scared. In an interview on 2/4/16 at 2:50 p.m., Resident #14 stated she heard a male and female aide yelling and screaming at each other on 1/12/16 at the end of the 2 - 10 p.m. shift. Resident #14 stated she could not understand what they were yelling about because it was in Spanish. Resident #14 stated the aides were in front of her door, and she saw the female aide back up against the wall. Resident #14 stated she saw the male aide with his hands up against her and it looked like he was trying to choke her. Resident #14 stated she asked them to stop repeatedly, and leave each other alone. Resident #14 stated the nurse came in her room to comfort her, and told her the Administrator was on his way. The Administrator came to her room that night around 11 p.m., and told her the employees had left the building, and would not return until they investigated what happened. Resident #14 stated they fired the female employee because she instigated the argument. Resident #14 also stated she did not know how scared she was until she saw the male employee walk into the dining room about a week after the incident. Resident #14 stated she told the Administrator, as well as the DON, when she saw the male employee in the dining room that she was scared. Resident #14 stated she was crying the other day, and the Administrator came to talk to her again, telling her the male employee was assigned to the other side of the building, and will not be working much because he will be going to nursing school (the nurse was still on schedule). Resident #14 then stated, there is nothing to keep him from coming to this side, and into my room. Resident #14 stated They didn ' t care at all about how she feels. Resident #14 stated the psychologist and psychiatrist came to see her, and starting giving her a medication for her not to cry, but she does not like to take medication. Resident #14 stated she told both the psychologist and the psychiatrist that she was scared of the employee, but they said she would be fine with the new medication to calm her down. Resident #14 described the male employee as having a bad temper (related to the altercation), and stated she was still afraid. The resident she had to change her way of living since it took so long and the employee still worked there. In an interview on 2/4/16 at 5:40 p.m., the Administrator stated he investigated the argument between the employees, and reviewed security tape. The Administrator stated the tape showed the female aide instigated the incident, so she was terminated. The Administrator stated he did not know if another incident happened near or in Resident #14 ' s room that would increase her fear. The Administrator stated he requested psychological services visit with Resident #14 after the incident to make sure she was ok. The Administrator stated he did follow-up with the resident and did not realize she quite going to the dinning room and activities due to fear. The Administrator also stated the male aide is about to leave for nursing school, and did not think he had been working much lately. The Administrator stated that he should have visited with the resident and followed-up with her more. Review of the Daily Schedule Sign-In sheets for the male aide that was in the argument revealed he had worked the 2 - 10 p.m. shift the following days after the incident: 1/15 - 18/16; 1/22 - 25/16; and 1/27 - 30/16, for a total of 12 days. Review of Mental and Behavioral Health Visit note dated 1/19/16, documented Resident #14 ' s mood as depressed, anxious and tearful. Further review, Emergency session to address anxiety and panic associated with events of the past week. Description of this session documented Resident #14 described her desire not to live in fear by modifying her eating schedule, and may search for a new facility in which to live. Increased anxiety is a barrier to continued progress .Frequency of therapeutic support will increase due to her increased anxiety. Review of previous Mental and Behavioral Health Visit note dated 11/13/15, documented no depression, anxiousness or tearfulness of Resident #14 ' s mood, only some homesickness noted. Review of NP Progress Note dated 1/20/16, documented Resident #14 was very anxious about an incident that happened in her room recently in which she felt a CNA was pushed by another CNA .she reports now being afraid of the CNA and does not want to come out of her room for meals as she is worried she will see him. Discussed with DON who is handling the incident and staff. Resident reports feeling very anxious and nervous about the incident. Assessment and Plan: 1)anxiety/depression: order [MEDICATION NAME] (antianxiety) as needed, psych following as well. Review of Resident #14 ' s physician orders [REDACTED]. Further review of Resident #14 ' s physician orders [REDACTED]. In an interview on 2/4/16 at 9:30 a.m., CNA Z stated Resident #14 used to go to the dining room for meals, but stopped about two weeks ago. CNA Z stated Resident #14 told her she was terrified of an employee that had gotten into a fight with another employee in her room, and that staff member is no longer assigned to her hall. CNA Z stated she did report to her charge nurse that Resident #14 was scared, but could not remember which nurse she told. In an interview on 2/5/16 at 10:15 a.m., LVN A stated she was not working when the argument occurred between two aides, but the night nurse told her about it during report. LVN A stated the night nurse told her the CNAs were in or near Resident #14 ' s room and arguing very loud, upsetting the residents. LVN A stated Resident #14 used to go to the dining room for all her meals, but after this event she stopped going. LVN A stated CNAs have told her Resident #14 is scared, and she has told Resident #14 that aide is no longer assigned to her hall. LVN A also stated Resident #14 is now on a new medication for anxiety and asks for it every morning. LVN A also stated she encourages her to go but it is sad that she does not go to social events any longer, and has to take a [MEDICAL CONDITION] medication. In a telephone interview on 2/5/16 at 2:00 p.m., RN B stated she was working the night the two aides got into an argument. RN B stated they were very loud and disturbing the residents, and she asked them to go outside but they did not. RN B stated Resident #14 even came out of her room to ask them to be quiet at some point. RN B stated she did not see the beginning of the argument and she asked if she could help resolve the issue, but they did not want her to be involved. RN B stated near the end of the shift at 10 p.m., she was coming around the corner from another hall, and saw the two aides in the hallway yelling and standing inches apart from each other, and that is when she went down the hall and insisted they go outside. RN B stated she checked on the residents, and called the Administrator, who arrived very quickly. RN B stated she did not see if the male aide pushed or touched the female aide, but she would not be surprised if it happened because of how angry they were and how close they were standing to each other. In an interview on 2/5/16 at 4:05 p.m., the DON stated she was not aware Resident #14 was scared to go to the dining room. The DON stated Resident #14 told them after the incident that she was angry that they terminated the female employee because she felt the female employee needed her job. When asked about the documentation from the NP on 1/20/16, the DON stated they did not discuss Resident #14 being afraid, they discussed the staffing issue. In an interview on 2/5/16 at 9:20 a.m., the LMSW stated Resident #14 told her about the drama and noise the morning after the argument between the two aides. When asked to clarify what drama Resident #14 reported, the LMSW stated Resident #14 told her one CNA choked another CNA in her room during the argument. The LMSW stated Resident #14 decided to eat in her room after the incident. The LMSW also stated the fact that Resident #14 was no longer coming to the dining room was discussed in a small group that included the Administrator and DON. In an interview on 2/5/16 at 9:35 a.m., the AD stated Resident #14 did like to play BINGO, but does not attend as frequently as she used to. The AD stated Resident #14 used to come to the dining room for meals, but has not been lately. The AD stated she was not sure why Resident #14 wanted to stay in her room now, but thought it was to keep her belongings safe. The AD added that is was strange for Resident #14 to stay in her room so much because she enjoyed the social activities. Review of Resident #14 ' s Care Plan for Activities dated 12/3/15: she would be interested in BINGO, socials, special events. Approaches included: invite to cooking club, crafts, music listening; invite to van trips to shop/lunch; invite to socials, parties, special events, bake sales and resident council meetings. Review of the facility ' s Abuse Prohibition Policy and Procedure, dated 6/2015: Signs and symptoms of abuse: 1) emotionally upset; 5) isolating his/her self from others . Component III - Prevention: Under general circumstances, the facility ' s Quality Assurance Team will consider the following factors .3) Review of staff supervision to identify inappropriate behaviors of staff members that may be signs of potential abuse. Component IV - Identification: The facility will use reasonable efforts to develop systems to identify events, occurrences, patterns and trends that constitute or may be a precursor to abuse, neglect or exploitation to help minimize the threat or occurrence of abuse. Component VI - Protection: The facility will use reasonable efforts .to minimize harm to residents. The DON provided a list of 24 residents with a [DIAGNOSES REDACTED].

Based on interview and record review, the facility failed to implement policies and procedures that prohibit neglect for 1 of 22 residents reviewed for abuse and neglect (Resident #14). Resident #14 was afraid to go to the dining room for meals, or attend other activities, after witnessing an argument between two CNAs on 1/12/16. The facility failed to further address Resident #14 ' s verbalization of fear, which caused reduced social interaction, increased anxiety, and a new order for anti-anxiety medication. This deficient practice has the potential to cause increased anxiety, decreased social interaction and increase of [MEDICAL CONDITION] medication use in 24 residents with a [DIAGNOSES REDACTED]. Findings include: Review of the facility ' s Abuse Prohibition Policy and Procedure, dated 6/2015: Signs and symptoms of abuse: 1) emotionally upset; 5) isolating his/her self from others . Component III - Prevention: Under general circumstances, the facility ' s Quality Assurance Team will consider the following factors .3) Review of staff supervision to identify inappropriate behaviors of staff members that may be signs of potential abuse. Component IV - Identification: The facility will use reasonable efforts to develop systems to identify events, occurrences, patterns and trends that constitute or may be a precursor to abuse, neglect or exploitation to help minimize the threat or occurrence of abuse. Component VI - Protection: The facility will use reasonable efforts .to minimize harm to residents. Review of Resident #14 ' s face sheet revealed she was [AGE] years old, admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #14 ' s most recent quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, indicating she was cognitively intact. Further review of the MDS revealed no indicators of depressed mood or psychosocial disturbances. Resident #14 ' s response to the interview for Activity Preferences, as documented on the annual MDS dated [DATE], was very important for her to do things with groups of people. In an interview during an initial tour on 2/2/16 at 10:40 a.m., Resident #14 stated she used to go to the dining room to eat her meals, but now she is too scared to go. Resident #14 stated two aides got into a fight on 1/12/16, and the aide she is scared of is still working on the 2 - 10 p.m. shift. Resident #14 also stated she no longer goes to activities outside her room and no longer eats in the dining room since she is scared. In an interview on 2/4/16 at 2:50 p.m., Resident #14 stated she heard a male and female aide yelling and screaming at each other on 1/12/16 at the end of the 2 - 10 p.m. shift. Resident #14 stated she could not understand what they were yelling about because it was in Spanish. Resident #14 stated the aides were in front of her door, and she saw the female aide back up against the wall. Resident #14 stated she saw the male aide with his hands up against her and it looked like he was trying to choke her. Resident #14 stated she asked them to stop repeatedly, and leave each other alone. Resident #14 stated the nurse came in her room to comfort her, and told her the Administrator was on his way. The Administrator came to her room that night around 11 p.m., and told her the employees had left the building, and would not return until they investigated what happened. Resident #14 stated they fired the female employee because she instigated the argument. Resident #14 also stated she did not know how scared she was until she saw the male employee walk into the dining room about a week after the incident. Resident #14 stated she told the Administrator, as well as the DON, when she saw the male employee in the dining room that she was scared. Resident #14 stated she was crying the other day, and the Administrator came to talk to her again, telling her the male employee was assigned to the other side of the building, and will not be working much because he will be going to nursing school (the nurse was still on schedule). Resident #14 then stated, there is nothing to keep him from coming to this side, and into my room. Resident #14 stated They didn ' t care at all about how she feels. Resident #14 stated the psychologist and psychiatrist came to see her, and starting giving her a medication for her not to cry, but she does not like to take medication. Resident #14 stated she told both the psychologist and the psychiatrist that she was scared of the employee, but they said she would be fine with the new medication to calm her down. Resident #14 described the male employee as having a bad temper (related to the altercation), and stated she was still afraid. The resident she had to change her way of living since it took so long and the employee still worked there. In an interview on 2/4/16 at 5:40 p.m., the Administrator stated he investigated the argument between the employees, and reviewed security tape. The Administrator stated the tape showed the female aide instigated the incident, so she was terminated. The Administrator stated he did not know if another incident happened near or in Resident #14 ' s room that would increase her fear. The Administrator stated he requested psychological services visit with Resident #14 after the incident to make sure she was ok. The Administrator stated he did follow-up with the resident and did not realize she quite going to the dinning room and activities due to fear. The Administrator also stated the male aide is about to leave for nursing school, and did not think he had been working much lately. The Administrator stated that he should have visited with the resident and followed-up with her more. Review of the Daily Schedule Sign-In sheets for the male aide that was in the argument revealed he had worked the 2 - 10 p.m. shift the following days after the incident: 1/15 - 18/16; 1/22 - 25/16; and 1/27 - 30/16, for a total of 12 days. Review of Mental and Behavioral Health Visit note dated 1/19/16, documented Resident #14 ' s mood as depressed, anxious and tearful. Further review, Emergency session to address anxiety and panic associated with events of the past week. Description of this session documented Resident #14 described her desire not to live in fear by modifying her eating schedule, and may search for a new facility in which to live. Increased anxiety is a barrier to continued progress .Frequency of therapeutic support will increase due to her increased anxiety. Review of previous Mental and Behavioral Health Visit note dated 11/13/15, documented no depression, anxiousness or tearfulness of Resident #14 ' s mood, only some homesickness noted. Review of NP Progress Note dated 1/20/16, documented Resident #14 was very anxious about an incident that happened in her room recently in which she felt a CNA was pushed by another CNA .she reports now being afraid of the CNA and does not want to come out of her room for meals as she is worried she will see him. Discussed with DON who is handling the incident and staff. Resident reports feeling very anxious and nervous about the incident. Assessment and Plan: 1)anxiety/depression: order [MEDICATION NAME] (antianxiety) as needed, psych following as well. Review of Resident #14 ' s physician orders [REDACTED]. Further review of Resident #14 ' s physician orders [REDACTED]. In an interview on 2/4/16 at 9:30 a.m., CNA Z stated Resident #14 used to go to the dining room for meals, but stopped about two weeks ago. CNA Z stated Resident #14 told her she was terrified of an employee that had gotten into a fight with another employee in her room, and that staff member is no longer assigned to her hall. CNA Z stated she did report to her charge nurse that Resident #14 was scared, but could not remember which nurse she told. In an interview on 2/5/16 at 10:15 a.m., LVN A stated she was not working when the argument occurred between two aides, but the night nurse told her about it during report. LVN A stated the night nurse told her the CNAs were in or near Resident #14 ' s room and arguing very loud, upsetting the residents. LVN A stated Resident #14 used to go to the dining room for all her meals, but after this event she stopped going. LVN A stated CNAs have told her Resident #14 is scared, and she has told Resident #14 that aide is no longer assigned to her hall. LVN A also stated Resident #14 is now on a new medication for anxiety and asks for it every morning. LVN A also stated she encourages her to go but it is sad that she does not go to social events any longer, and has to take a [MEDICAL CONDITION] medication. In a telephone interview on 2/5/16 at 2:00 p.m., RN B stated she was working the night the two aides got into an argument. RN B stated they were very loud and disturbing the residents, and she asked them to go outside but they did not. RN B stated Resident #14 even came out of her room to ask them to be quiet at some point. RN B stated she did not see the beginning of the argument and she asked if she could help resolve the issue, but they did not want her to be involved. RN B stated near the end of the shift at 10 p.m., she was coming around the corner from another hall, and saw the two aides in the hallway yelling and standing inches apart from each other, and that is when she went down the hall and insisted they go outside. RN B stated she checked on the residents, and called the Administrator, who arrived very quickly. RN B stated she did not see if the male aide pushed or touched the female aide, but she would not be surprised if it happened because of how angry they were and how close they were standing to each other. In an interview on 2/5/16 at 4:05 p.m., the DON stated she was not aware Resident #14 was scared to go to the dining room. The DON stated Resident #14 told them after the incident that she was angry that they terminated the female employee because she felt the female employee needed her job. When asked about the documentation from the NP on 1/20/16, the DON stated they did not discuss Resident #14 being afraid, they discussed the staffing issue. In an interview on 2/5/16 at 9:20 a.m., the LMSW stated Resident #14 told her about the drama and noise the morning after the argument between the two aides. When asked to clarify what drama Resident #14 reported, the LMSW stated Resident #14 told her one CNA choked another CNA in her room during the argument. The LMSW stated Resident #14 decided to eat in her room after the incident. The LMSW also stated the fact that Resident #14 was no longer coming to the dining room was discussed in a small group that included the Administrator and DON. In an interview on 2/5/16 at 9:35 a.m., the AD stated Resident #14 did like to play BINGO, but does not attend as frequently as she used to. The AD stated Resident #14 used to come to the dining room for meals, but has not been lately. The AD stated she was not sure why Resident #14 wanted to stay in her room now, but thought it was to keep her belongings safe. The AD added that is was strange for Resident #14 to stay in her room so much because she enjoyed the social activities. Review of Resident #14 ' s Care Plan for Activities dated 12/3/15: she would be interested in BINGO, socials, special events. Approaches included: invite to cooking club, crafts, music listening; invite to van trips to shop/lunch; invite to socials, parties, special events, bake sales and resident council meetings. The DON provided a list of 24 residents with a [DIAGNOSES REDACTED].

Based on interview and record review the facility failed to implement policies and procedures that prohibit neglect for one (1) of six (6) residents reviewed for Full Code status Advance Directives (Resident #1). On [DATE] LVN A failed to comply with Resident #1's Advance Directive when the resident was found unresponsive without a pulse or respirations and did not initiate CPR. This was determined to be past-non-compliance at the IJ level that occurred on [DATE] through [DATE] for Resident #1. This deficient practice could place 45 residents with Advance Directives for Full Code Status at risk for prolonged lack of oxygen to the brain, brain death and death if [MEDICAL CONDITION] should occur and CPR is not initiated. The Findings Include: Review of a Face Sheet for Resident #1 reflected she was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an Acknowledgment of Advance Care Planning document for Resident #1 dated [DATE], and signed by Resident #1 ' s daughter, reflected the following area of the form was initialed by the daughter: " For Full Code Status please initial the following: I/Family do not wish to make a decision at this time and understand that should [MEDICAL CONDITION] occur, every measure will be taken to resuscitate. I reserve the right to execute an Advance Directive at a later time. RESIDENT IS FULL CODE STATUS. " Review of a care plan for Resident #1 dated [DATE] reflected "Resident is Full Code Status- Will comply with Resident's/Family Wishes." Review of an agreement for hospice services for Resident #1 dated [DATE] reflected the family wished for Resident #1 to remain on Full Code Status. During an interview on [DATE] at 4:00 pm CNA Z stated she had worked the 2:00 pm to 10:00 pm shift the evening of [DATE] and had gone into Resident #1's room with CNA Y around 8:00 pm to turn and reposition her. Resident #1 was found to be cold to touch, her eyes were open without blinking and she wouldn ' t respond to her name being called. CNA Z then went to get the nurse on duty, LVN A, who checked Resident #1 for a ' heartbeat and breathing " . CNA Z stated when LVN A didn ' t hear a heartbeat or breath sounds for Resident #1 she left the room and did not initiate CPR. CNA Z stated she was instructed by LVN A to temporarily move Resident #1 ' s roommate to another room until the hospice RN arrived, the family visited and the body was released to the funeral home. CNA Z stated the last time she provided care for Resident #1 prior to finding her unresponsive was at approximately 6:30pm. During an interview on [DATE] at 4:16 pm LVN A stated she had worked at the facility since ,[DATE]. LVN A further stated on [DATE] she had given Resident #1 her scheduled medications via her PEG tube at approximately 6:15 pm and her condition was at baseline of answering to her name and totally dependent on staff for all activities of daily living. At approximately 8:05 pm CNA Z came to get her because Resident #1 was unresponsive. LVN A immediately went to Resident #1 ' s room and found her to be unresponsive. Her eyes were open and her body was cold to touch, pale and the lower extremities were stiffening. LVN A stated she assessed Resident #1 and she could not hear a heartbeat and there were no respirations. LVN A then left Resident #1 ' s room and telephoned the DON who informed her to call the hospice service RN for the death pronouncement. LVN A stated the DON asked to speak to another nurse on duty, LVN E, and informed him to help her complete the necessary paperwork for Resident #1 ' s body to be picked up by the funeral home. LVN A stated this was the first death she had been involved in since becoming a nurse and it was upsetting for her. LVN A stated she had been trained during orientation to verify code status when a resident becomes unresponsive and without a pulse and/or respirations, but in the midst of everything she had made the assumption that Resident #1 ' s code status was DNR because she was receiving hospice services and did not initiate CPR. In a continued interview on [DATE] LVN A stated she telephone the hospice RN on call at approximately 8:15 pm and she arrived at the facility at 9:05 pm. LVN A went into the room with the hospice RN to observe her assess Resident #1 and she pronounced her dead at 9:10 pm. LVN A stated immediately afterwards the hospice RN went to the nurses station to chart on Resident #1 ' s pronouncement of death and at that time the hospice RN informed her Resident #1 ' s chart reflected she was a Full Code status. LVN A stated after learning from the hospice RN that Resident #1 was a Full Code status she called the DON to inform her she had not verified the code status or initiated CPR after finding her unresponsive. During an interview on [DATE] at 4:35 pm the DON stated on [DATE] she had just arrived home from the facility around 8:00 pm when she received a call from LVN A stating Resident #1 was found unresponsive, cold to touch and without a pulse or respirations. The DON further stated LVN A told her Resident #1 was on hospice and she instructed her to telephone the hospice RN on call to make the pronouncement of death. The DON stated she did not ask LVN A about Resident #1 ' s code status or if she had verified the status when she found her unresponsive. In a continued interview on [DATE] with the DON she stated she received another phone call from LVN A on [DATE] around 9:15 pm stating she just realized Resident #1 had been a Full Code status and she had not verified the code status or initiated CPR. The DON immediately returned to the facility and called her nurse managers to come in to in-service staff on verification of code status when a resident is found unresponsive without a pulse and/or respirations. The DON also stated she and the nurse managers conducted a complete audit of all the residents ' charts to ensure the code status documentation was accurate. The DON went on to say the facility does not have a policy on Full Code status, but it is the expectation of the licensed staff if they find a resident unresponsive to verify the code status and initiate CPR if indicated; followed by calling EMS and then notify the physician and DON after EMS arrives and takes responsibility. The DON further stated part of the licensed staff orientation checklist includes death procedures and verifying code status when a patient becomes unresponsive without a pulse and/or respirations. The DON stated there had been multiple in-services on abuse and neglect in the past 12 months but none specific to code status verification until [DATE]. During an interview on [DATE] at 4:48 pm the hospice RN stated she was called about Resident #1 at 8:15 pm and she arrived to the facility at 9:05 pm and pronounced her dead at 9:10pm. She stated Resident #1 was cold to touch, her eyes were open and glossed over, her lips were white and her lower extremities were stiffened. In a continued interview on [DATE] the hospice RN stated after pronouncing Resident #1 ' s death she went to the nurses ' station to document in the chart and it was at that time she realized Resident #1 was a Full Code status and questioned LVN A if she was aware of this. She stated LVN A was very upset and told her she had assumed Resident #1 was a DNR due to she received hospice services. Review of the Texas Board of Nurses Scope of Practice for Licensed Vocational Nurses 15.2 reflected: "LVNs do not have the authority to legally determine death, diagnose death, or otherwise pronounce death in the State of Texas. Regardless of practice setting, the importance of initiating CPR in cases where no clear Do Not Resuscitate (DNR) orders exist is imperative. " Review of the facility's Abuse Neglect Policy dated ,[DATE] reflected the following: Component II: Training- All facility employees will be given orientation and on-going training regarding abuse/neglect prohibition practices. The facility ' s orientation program pertaining to abuse prevention will generally include the following: 1. Review of the Resident Right ' s as published in the Medicare/Medicaid Requirements of participation. Review of the facility ' s RN/LVN Orientation Skills Checklist revealed the following: " Facility Death Procedures/Post Mortem Care; Education on CPR for Residents and Families: Many health problems are so serious that they can cause your heart to stop beating. This is called [MEDICAL CONDITION]. When this happens you stop breathing. When your heart stops beating your body and brain do not get the oxygen for you to live. CPR is a choice-it is not a treatment everyone must have. Some people want everything done to keep them alive if their heart stops beating. " Review of an undated facility policy titled ' Advance Directive Guidelines ' reflected the following: Upon admission please review the following- Code Status (acknowledgement form and MD order must match), upon readmission orders [REDACTED]. There was no facility policy available for implementation of Advanced Directives. It was determined these failures placed Resident #1 in a past IJ situation from [DATE] to [DATE]. The facility Administrator, DON and Regional Vice President were notified of the past non-compliance at an IJ level on [DATE] at 6:00 pm. The facility completed the following in-services to correct the non-compliance as follows: Review of facility in-services dated [DATE] and [DATE] reflected the following: Summary of Training- ? Advance Directives ? Code Status verification ? Acknowledgement of Advance Care Planning ? OOHDNR (Out of Hospital Do Not Resuscitate) ? Physician Orders Observations and interviews with licensed staff on [DATE] during initial tour and throughout the investigation from [DATE] to [DATE] revealed staff were knowledgeable regarding Advance Directives and verification of code status when a resident is found unresponsive. Staff was able to demonstrate the ability to verify code status in the electronic record and the paper chart. Review of LVN A's personnel file reflected she was terminated on [DATE]. The LVN was suspended pending investigation on [DATE]. The DON provided a list of 45 residents with Advance Directives for Full Code.

Based on observation, interview and record review the facility failed to implement written policies and procedures that prohibit neglect of residents for residents for one (1) of six (6) residents reviewed for Full Code status Advance Directives (Resident #1). On [DATE] LVN A failed to comply with Resident #1's Advance Directive when the resident was found unresponsive without a pulse or respirations and did not initiate CPR. This was determined to be past-non-compliance at the IJ level that occurred on [DATE] through [DATE] for Resident #1. This deficient practice could place 45 residents with Advance Directives for Full Code Status at risk for prolonged lack of oxygen to the brain, brain death and death if [MEDICAL CONDITION] should occur and CPR is not initiated. The Findings Include: Review of the facility's Abuse Neglect Policy dated ,[DATE] reflected the following: Component II: Training- All facility employees will be given orientation and on-going training regarding abuse/neglect prohibition practices. The facility ' s orientation program pertaining to abuse prevention will generally include the following: 1. Review of the Resident Right ' s as published in the Medicare/Medicaid Requirements of participation. Review of an undated facility policy titled ' Advance Directive Guidelines ' reflected the following: Upon admission please review the following- Code Status (acknowledgement form and MD order must match), upon readmission orders [REDACTED]. There was no facility policy available for implementation of Advanced Directives. Review of the Texas Board of Nurses Scope of Practice for Licensed Vocational Nurses 15.2 reflected: "LVNs do not have the authority to legally determine death, diagnose death, or otherwise pronounce death in the State of Texas. Regardless of practice setting, the importance of initiating CPR in cases where no clear Do Not Resuscitate (DNR) orders exist is imperative. " Review of a Face Sheet for Resident #1 reflected she was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a care plan for Resident #1 dated [DATE] reflected "Resident is Full Code Status- Will comply with Resident's/Family Wishes." Review of an Acknowledgment of Advance Care Planning document for Resident #1 dated [DATE], and signed by Resident #1 ' s daughter, reflected the following area of the form was initialed by the daughter: " For Full Code Status please initial the following: I/Family do not wish to make a decision at this time and understand that should [MEDICAL CONDITION] occur, every measure will be taken to resuscitate. I reserve the right to execute an Advance Directive at a later time. RESIDENT IS FULL CODE STATUS. " Review of an agreement for hospice services for Resident #1 dated [DATE] reflected the family wished for Resident #1 to remain on Full Code Status. During an interview on [DATE] at 4:00 pm CNA Z stated she had worked the 2:00 pm to 10:00 pm shift the evening of [DATE] and had gone into Resident #1's room with CNA Y around 8:00 pm to turn and reposition her. Resident #1 was found to be cold to touch, her eyes were open without blinking and she wouldn't respond to her name being called. CNA Z then went to get the nurse on duty, LVN A, who checked Resident #1 for a "heartbeat and breathing ". CNA Z stated when LVN A didn't hear a heartbeat or breath sounds for Resident #1 she left the room and did not initiate CPR. CNA Z stated she was instructed by LVN A to temporarily move Resident #1 ' s roommate to another room until the hospice RN arrived, the family visited and the body was released to the funeral home. CNA Z stated the last time she provided care for Resident #1 prior to finding her unresponsive was at approximately 6:30pm. During an interview on [DATE] at 4:16 pm LVN A stated she had worked at the facility since ,[DATE]. LVN A further stated on [DATE] she had given Resident #1 her scheduled medications via her PEG tube at approximately 6:15 pm and her condition was at baseline of answering to her name and totally dependent on staff for all activities of daily living. At approximately 8:05 pm CNA Z came to get her because Resident #1 was unresponsive. LVN A immediately went to Resident #1 ' s room and found her to be unresponsive. Her eyes were open and her body was cold to touch, pale and the lower extremities were stiffening. LVN A stated she assessed Resident #1 and she could not hear a heartbeat and there were no respirations. LVN A then left Resident #1 ' s room and telephoned the DON who informed her to call the hospice service RN for the death pronouncement. LVN A stated the DON asked to speak to another nurse on duty, LVN E, and informed him to help her complete the necessary paperwork for Resident #1 ' s body to be picked up by the funeral home. LVN A stated this was the first death she had been involved in since becoming a nurse and it was upsetting for her. LVN A stated she had been trained during orientation to verify code status when a resident becomes unresponsive and without a pulse and/or respirations, but in the midst of everything she had made the assumption that Resident #1 ' s code status was DNR because she was receiving hospice services and did not initiate CPR. In a continued interview on [DATE] LVN A stated she telephone the hospice RN on call at approximately 8:15 pm and she arrived at the facility at 9:05 pm. LVN A went into the room with the hospice RN to observe her assess Resident #1 and she pronounced her dead at 9:10 pm. LVN A stated immediately afterwards the hospice RN went to the nurses station to chart on Resident #1 ' s pronouncement of death and at that time the hospice RN informed her Resident #1 ' s chart reflected she was a Full Code status. LVN A stated after learning from the hospice RN that Resident #1 was a Full Code status she called the DON to inform her she had not verified the code status or initiated CPR after finding her unresponsive. During an interview on [DATE] at 4:35 pm the DON stated on [DATE] she had just arrived home from the facility around 8:00 pm when she received a call from LVN A stating Resident #1 was found unresponsive, cold to touch and without a pulse or respirations. The DON further stated LVN A told her Resident #1 was on hospice and she instructed her to telephone the hospice RN on call to make the pronouncement of death. The DON stated she did not ask LVN A about Resident #1 ' s code status or if she had verified the status when she found her unresponsive. In a continued interview with the DON 0n [DATE] she stated she received another phone call from LVN A on [DATE] around 9:15 pm stating she just realized Resident #1 had been a Full Code status and she had not verified the code status or initiated CPR. The DON immediately returned to the facility and called her nurse managers to come in to in-service staff on verification of code status when a resident is found unresponsive without a pulse and/or respirations. The DON also stated she and the nurse managers conducted a complete audit of all the residents ' charts to ensure the code status documentation was accurate. The DON went on to say the facility does not have a policy on Full Code status, but it is the expectation of the licensed staff if they find a resident unresponsive to verify the code status and initiate CPR if indicated; followed by calling EMS and then notify the physician and DON after EMS arrives and takes responsibility. The DON further stated part of the licensed staff orientation checklist includes death procedures and verifying code status when a patient becomes unresponsive without a pulse and/or respirations. The DON stated there had been multiple in-services on abuse and neglect in the past 12 months but none specific to code status verification until [DATE]. During an interview on [DATE] at 4:48 pm the hospice RN stated she was called about Resident #1 at 8:15 pm and she arrived to the facility at 9:05 pm and pronounced her dead at 9:10pm. She stated Resident #1 was cold to touch, her eyes were open and glossed over, her lips were white and her lower extremities were stiffened. In a continued interview the hospice RN stated after pronouncing Resident #1 ' s death she went to the nurses ' station to document in the chart and it was at that time she realized Resident #1 was a Full Code status and questioned LVN A if she was aware of this. She stated LVN A was very upset and told her she had assumed Resident #1 was a DNR due to she received hospice services. Review of the facility ' s RN/LVN Orientation Skills Checklist revealed the following: " Facility Death Procedures/Post Mortem Care; Education on CPR for Residents and Families: Many health problems are so serious that they can cause your heart to stop beating. This is called [MEDICAL CONDITION]. When this happens you stop breathing. When your heart stops beating your body and brain do not get the oxygen for you to live. CPR is a choice-it is not a treatment everyone must have. Some people want everything done to keep them alive if their heart stops beating. " It was determined these failures placed Resident #1 in a past IJ situation from [DATE] to [DATE]. The facility Administrator, DON and Regional Vice President were notified of the past non-compliance at an IJ level on [DATE] at 6:00 pm. The facility completed the following in-services to correct the non-compliance as follows: Review of facility in-services dated [DATE] and [DATE] reflected the following: Summary of Training- ? Advance Directives ? Code Status verification ? Acknowledgement of Advance Care Planning ? OOHDNR (Out of Hospital Do Not Resuscitate) ? Physician Orders Observations and interviews with licensed staff on [DATE] during initial tour and throughout the investigation from [DATE] to [DATE] revealed staff were knowledgeable regarding Advance Directives and verification of code status when a resident is found unresponsive. Staff was able to demonstrate the ability to verify code status in the electronic record and the paper chart. Review of LVN A's personnel file reflected she was terminated on [DATE]. The LVN was suspended pending investigation on [DATE]. The DON provided a list of 45 residents with Advance Directives for Full Code.

Based on interview and record review the facility failed to provide services that meet professional standards of quality for one (1) of six (6) residents reviewed for Full Code status Advance Directives (Resident #1). On [DATE] LVN A failed to comply with Resident #1's Advance Directive when the resident was found unresponsive without a pulse or respirations and did not initiate CPR. This was determined to be past-non-compliance at the IJ level that occurred on [DATE] through [DATE] for Resident #1. This deficient practice could place 45 residents with Advance Directives for Full Code Status at risk for prolonged lack of oxygen to the brain, brain death, and death if [MEDICAL CONDITION] should occur and CPR is not initiated. The Findings Include: Review of the Texas Board of Nurses Scope of Practice for Licensed Vocational Nurses 15.2 reflected: "LVNs do not have the authority to legally determine death, diagnose death, or otherwise pronounce death in the State of Texas. Regardless of practice setting, the importance of initiating CPR in cases where no clear Do Not Resuscitate (DNR) orders exist is imperative. " Review of a Face Sheet for Resident #1 reflected she was [AGE] years old and admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an Acknowledgment of Advance Care Planning document for Resident #1 dated [DATE], and signed by Resident #1 ' s daughter, reflected the following area of the form was initialed by the daughter: " For Full Code Status please initial the following: I/Family do not wish to make a decision at this time and understand that should [MEDICAL CONDITION] occur, every measure will be taken to resuscitate. I reserve the right to execute an Advance Directive at a later time. RESIDENT IS FULL CODE STATUS. " Review of a care plan for Resident #1 dated [DATE] reflected "Resident is Full Code Status- Will comply with Resident's/Family Wishes." Review of an agreement for hospice services for Resident #1 dated [DATE] reflected the family wished for Resident #1 to remain on Full Code Status. During an interview on [DATE] at 4:16 pm LVN A stated she had worked at the facility since ,[DATE]. LVN A further stated on [DATE] she had given Resident #1 her scheduled medications via her PEG tube at approximately 6:15 pm and her condition was at baseline of answering to her name and totally dependent on staff for all activities of daily living. At approximately 8:05 pm CNA Z came to get her because Resident #1 was unresponsive. LVN A immediately went to Resident #1 ' s room and found her to be unresponsive. Her eyes were open and her body was cold to touch, pale and the lower extremities were stiffening. LVN A stated she assessed Resident #1 and she could not hear a heartbeat and there were no respirations. LVN A then left Resident #1 ' s room and telephoned the DON who informed her to call the hospice service RN for the death pronouncement. LVN A stated she had been trained during orientation to verify code status when a resident becomes unresponsive and without a pulse and/or respirations, but in the midst of everything she had made the assumption that Resident #1's code status was DNR because she was receiving hospice services and did not initiate CPR. In a continued interview on [DATE] LVN A stated she telephone the hospice RN on call at approximately 8:15 pm and she arrived at the facility at 9:05 pm. LVN A went into the room with the hospice RN to observe her assess Resident #1 and she pronounced her dead at 9:10 pm. LVN A stated immediately afterwards the hospice RN went to the nurses station to chart on Resident #1 ' s pronouncement of death and at that time the hospice RN informed her Resident #1 ' s chart reflected she was a Full Code status. LVN A stated after learning from the hospice RN that Resident #1 was a Full Code status she called the DON to inform her she had not verified the code status or initiated CPR after finding her unresponsive. LVN A stated this was the first death she had been involved in since becoming a nurse and it was upsetting for her. During an interview on [DATE] at 4:35 pm the DON stated on [DATE] she had just arrived home from the facility around 8:00 pm when she received a call from LVN A stating Resident #1 was found unresponsive, cold to touch and without a pulse or respirations. The DON further stated LVN A told her Resident #1 was on hospice and she instructed her to telephone the hospice RN on call to make the pronouncement of death. The DON stated she did not ask LVN A about Resident #1 ' s code status or if she had verified the status when she found her unresponsive. In a continued interview with the DON on [DATE] she stated she received another phone call from LVN A on [DATE] around 9:15 pm stating she just realized Resident #1 had been a Full Code status and she had not verified the code status or initiated CPR. The DON immediately returned to the facility and called her nurse managers to come in to in-service staff on verification of code status when a resident is found unresponsive without a pulse and/or respirations. The DON also stated she and the nurse managers conducted a complete audit of all the residents ' charts to ensure the code status documentation was accurate. The DON went on to say the facility does not have a policy on Full Code status, but it is the expectation of the licensed staff if they find a resident unresponsive to verify the code status and initiate CPR if indicated; followed by calling EMS and then notify the physician and DON after EMS arrives and takes responsibility. The DON further stated part of the licensed staff orientation checklist includes death procedures and verifying code status when a patient becomes unresponsive without a pulse and/or respirations. The DON stated there had been multiple in-services on abuse and neglect in the past 12 months but none specific to code status verification until [DATE]. During an interview on [DATE] at 4:48 pm the hospice RN stated after pronouncing Resident #1 ' s death she went to the nurses ' station to document in the chart and it was at that time she realized Resident #1 was a Full Code status and questioned LVN A if she was aware of this. She stated LVN A was very upset and told her she had assumed Resident #1 was a DNR due to the fact she received hospice services. Review of the facility ' s RN/LVN Orientation Skills Checklist revealed the following: " Facility Death Procedures/Post Mortem Care; Education on CPR for Residents and Families: Many health problems are so serious that they can cause your heart to stop beating. This is called [MEDICAL CONDITION]. When this happens you stop breathing. When your heart stops beating your body and brain do not get the oxygen for you to live. CPR is a choice-it is not a treatment everyone must have. Some people want everything done to keep them alive if their heart stops beating. " It was determined these failures placed Resident #1 in a past IJ situation from [DATE] to [DATE]. The facility Administrator, DON and Regional Vice President were notified of the past non-compliance at an IJ level on [DATE] at 6:00 pm. The facility demonstrated the following corrective measures to correct the non-compliance as follows: Review of facility in-services dated [DATE] and [DATE] reflected the following: Summary of Training- ? Advance Directives ? Code Status verification ? Acknowledgement of Advance Care Planning ? OOHDNR (Out of Hospital Do Not Resuscitate) ? Physician Orders Observations and interviews with licensed staff on [DATE] during initial tour and throughout the investigation from [DATE] to [DATE] revealed staff were knowledgeable regarding Advance Directives and verification of code status when a resident is found unresponsive. Staff was able to demonstrate the ability to verify code status in the electronic record and the paper chart. Review of LVN A's personnel file reflected she was terminated on [DATE]. The LVN was suspended pending investigation on [DATE]. The DON provided a list of 45 residents with Advance Directives for Full Code.

Based on observation, interview, and record review, the facility failed to maintain proper hydration for one (1) of 11 residents reviewed for hydration. (Resident #1) The facility failed to ensure Resident #1 consumed sufficient oral intake to prevent dehydration and did not monitor the residents intake.Resident #1 was admitted to the hospital on [DATE] with symptoms of severe dehydration, acute kidney injury, and [MEDICAL CONDITION] due to volume depletion. This deficient practice could affect the 75 residents who the facility identified as being at risk for signs and symptoms of dehydration such as [MEDICAL CONDITION] (increased blood potassium levels), decreased Blood Pressure (BP), dizziness, stroke, and possible death. Findings include: Review of Resident #1 ' s facesheet reflected an [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1 ' s most recent Quarterly Minimum Data Set ((MDS) dated [DATE] reflected: - C0500: Brief Interview of Mental Status (BIMS) score of 10; - G0110H1: Resident #1 is able to feed herself independently; - J1550Z: Problem conditions: none of the above (fever, vomiting, dehydrated, internal bleeding); - K0510C2: Resident #1 receives a mechanically altered diet; - L0200A: Loosely fitting dentures. Review of Resident #1 ' s Current Care Plan reflected Task Completion of Care with a problem onset date of 09/26/13 with an approach to provide a supplement of Magic Cup (a high calorie dietary supplement) with breakfast, lunch, and dinner, offer fluids, supper/dinner intake, and snacks. Also, Resident #1 is at risk for [MEDICAL CONDITIONS] with a problem onset date of 09/13/13 with an approach to encourage Resident #1 ' s adequate fluid intake. It further reflected Resident #1 is experiencing fluctuating/unstable BP with a problem onset date of 09/13/13 with an approach to obtain and evaluate Resident #1 ' s BP every shift (QS) and monitor Resident #1 for headaches and dizziness. It also reflected a problem of Resident #1 is occasionally incontinent of urine with a problem onset date of 09/13/13 with an approach to evaluate Resident #1 ' s fluid intake and hydration status, ongoing assessment of color, clarity and character of urine, assess Resident #1 ' s symptoms of UTI, provide verbal cueing, and observe Resident #1 for acute behavioral changes that may indicate UTI. It further reflected a problem of Resident #1 has difficulty recalling recent evens with a problem onset date of 01/25/14 with an approach to give resident verbal cues/reminders when cannot remember. Review of Resident #1 ' s Situation Background Assessment Request (SBAR) Note dated 01/15/14 reflected a [DIAGNOSES REDACTED]. " Review of Resident #1 ' s Physician's Progress Note dated 02/07/14 reflected " patient also states staff lost her lower dentures several months ago and have not been replaced, patient unable to eat and maintain proper intake. " Further review reflected a plan of " poor by mouth (po) intake related to loss of dentures, dental consult as soon as possible (ASAP). " Review of Resident #1 ' s Nurse ' s Notes reflected: 02/20/14, 5:13 pm: Continue antibiotics for UTI, continue to encourage by mouth (po) fluids, patient verbalized understanding, no sign of distress noted at this time. 02/25/14 9:49 pm: Resident resting comfortably in bed, BP 88/56, alert and able to verbalize pain, denies pain or discomfort at this time. Appointment today and admitted to hospital while at doctor ' s appointment. Review of Resident #1 ' s Hospital Preliminary Report dated 02/25/14 18:14 Central Standard Time (CST) reflected that Resident #1 was in the waiting room of a local clinic at approximately 3:50 pm on 02/25/14 and was noted to have worsening of her left facial droop and almost complete left-sided [MEDICAL CONDITION] (paralysis of the arm, leg, and trunk on same side of the body). With Emergency Medical Services (EMS) on arrival, her BP was 70/40 millimeters mercury (mmHg) and glucose was 200 milligrams/deciliter (mg/dL). It further reflected an [AGE] year old female with right sided [MEDICAL CONDITION] with residual left-sided weakness worsening of her symptoms acutely and was found to be hypotensive (low BP) who improved rapidly with stabilization of her vital signs. Likely this is worsening of her previous stroke symptoms with the hypoperfusion (decreased blood flow through an organ), which could have also resulted in a small new infarct (tissue death caused by local lack of oxygen due to an obstruction of the tissue's blood supply). She admits to being dehydrated and has poor by mouth (po) water intake. It further reflected recommendations of fluid/bolus replacement. Review of Resident #1 ' s Hospital Preliminary Report dated 02/25/14 20:15 CST reflected Resident #1 was transported to the emergency room (ER) where she was found to have continued [MEDICAL CONDITION] which did respond to a bolus of normal saline. Laboratory revealed a metabolic acidosis (when the kidneys are not removing enough acid from the body) with a pH (measure of acidity in the blood) of 7.19, acute kidney injury with a creatinine (Cr) of 5.4 mg/dL and [MEDICAL CONDITION] with a potassium of 6.6 milliequivalents/liter (mEq/L) and a serum [MEDICATION NAME] of 13 mEq/L. Further review of the Preliminary Report reflected that Resident #1 denies any fever, night sweats, or chills and has not been eating very well and is positive for anorexia. It also reflected Blood Urea Nitrogen (BUN) of 107mg/dL and Cr 5.4 mg/dL, potassium 6.6 mEq/L, and serum [MEDICATION NAME] 16 mEq/L. Resident #1 had acute kidney injury, possible on top of chronic; looked dehydrated, no evidence of fluid overload, and in fact looked volume depleted. Urine electrolytes were sent to confirm suspicion that it may be pre-renal azotemia (when BP or flow through the kidney drops, filtering of the blood decreases; waste products stay in the blood and little or no urine is formed, even though the kidney itself is working). Review of Global RPh: The Clinician's Ultimate Reference (http://www.globalrph.com/labs.htm) on 03/10/14 reflected normal ranges of: - Cr 0.5 - 1.4 mg/dL - BUN 7 - 20 mg/dL - Potassium 3.5 - 5.2 mEq/L - Blood Glucose 2 hours post-prandial (after eating) up to 140 mg/dL Review of Resident #1 ' s Hospital Summary of Current Orders dated 02/28/14 reflected that during the 24 hour window on 02/25/14 while at the hospital, Resident #1 had a total fluid intake of 3376 milliliters (mL) and her total urine output was 110 (mL). It further reflected a BP of 79/41mmHg on 02/26/14. On 02/25/14, Resident #1 ' s potassium level was 6.6 and 7.0 mEq/L, BUN was 107 and 96 mg/dL, Cr was 5.2 and 5.4 mg/dL. It further reflected that on discharge on 02/28/14, Resident #1 improved to potassium of 3.9 mEq/L, BUN of 29 mg/dL, and Cr of 1.4 mg/dL. Review of Resident #1 ' s Hospital Final Report dated 02/27/14 reflected and Impression and Plan of [MEDICAL CONDITION] (TIA) more likely, [MEDICAL CONDITION] from volume depletion, sudden onset of left facial droop and other neurological changes. It further reflected acute [MEDICAL CONDITION]ly, [MEDICAL CONDITION], Cr dramatically improved, she has [MEDICAL CONDITION], and urinalysis negative for UTI so pre-renal is likely in setting of recurrently [MEDICAL CONDITION]; [MEDICAL CONDITION] and metabolic acidosis resolved. During an interview on 03/01/14 at 12:40 pm, the ER physician stated that Resident #1 came into theER on [DATE] because of altered mental status (AMS). She further stated that she was going to a doctor ' s appointment with her daughter that morning when they noticed her left-sided face droop. They brought her to the ER because of low BP where they found she had acute kidney injury, severe dehydration, and Resident #1 came back to baseline when given fluids. She further stated that because of Resident #1 ' s neurological checks, they think she had a TIA and was weak because of the dehydration. The ER physician then stated that Resident #1 was not eating or drinking well. She further stated that the [MEDICAL CONDITION] is caused by not taking in enough nutrients, Resident #1 has Adult Failure to Thrive (AFTT) but she is not depressed and wants to be alive. She then stated that Resident #1 ' s dentures were misplaced about four weeks ago and she has not been able to eat well since. The ER physician then said that Resident #1 and her daughter told numerous people at the facility who kept saying that they would take care of her dentures but never did. She then stated that she had called the facility and they did not know Resident #1 lost her dentures but further added that Resident #1 ' s daughter was not paying the nursing home fees on a regular basis so there may be problems there. During an interview on 03/01/14 at 3:00 pm, Resident #1 ' s daughter stated that the resident moved to another facility after she was hospitalized for [REDACTED].#1 and something did not seem right. She then got a CNA who said they would get a nurse to check on her. The daughter then stated that she had to leave so she was not sure if a nurse came to check on Resident #1 on 02/24/14. She further stated that the next day at the doctor ' s office, Resident #1 was cold, clammy, and stated she was sick to her stomach. They called EMS and Resident #1 went to the hospital. The daughter then stated that Resident #1 ' s lower dentures have been missing for about one month and it could have caused dehydration because she is not eating as well. She further stated that one month prior, Resident #1 was lying in bed, gave her lower dentures to a CNA who put them in a tissue and placed them on the bedside table, not in the blue container where they are normally stored. She further stated that Resident #1 stated the tissue with the dentures was not on the bedside table the next morning and thinks staff threw it away when cleaning. The daughter then stated that Resident #1 just takes a few sips of drinks and needs to be reminded to take in fluids. She then stated that she told the Administrator, the Social Worker (SW), and the Administrator in Training (AIT) about the lost dentures immediately after her mother told her they went missing. The daughter then said that the Administrator said that sometimes dentures are misplaced and they would look for them. The daughter then said she gave the facility one week to look but then followed up to see if they were found and they were not. During an interview on 03/01/14 at 4:50 pm, Resident #1 stated she has not had her dentures for at least three weeks and she told the Administrator, AIT, and some CNAs that her dentures were missing. She further stated she asked a CNA to take care of her lower dentures who put them in a tissue and placed them on her bedside table, she further stated they were not in the same place the next day and she has not seen them since. Resident #1 then stated it is hard to eat or drink without her lower dentures. When asked if she knew why she was in the hospital, Resident #1 stated because she had too much potassium in her system. Resident #1 could not remember the names of the CNAs she talked to about her dentures. During an interview on 03/02/14 at 12:35 pm, the Assistant Director of Nursing (ADON) B stated that Resident #1 was always a finicky eater so they would give supplements. She further stated that Resident #1 liked coffee and would drink milk or health shakes but not a lot of water. She further stated that they had to push Resident #1 to drink fluids. During an interview on 03/02/14 at 12:45 pm, ADON A stated that Resident #1 had a doctor ' s appointment and was exhibiting stroke like symptoms so she went to the hospital. She further stated Resident #1 was not a big eater and she would get three beverages with each meal and drank all of them. She further stated that Resident #1 would ask for a health shake if she did not like the food. ADON A then stated Resident #1 was not at risk for dehydration and did not need cueing to drink. During an interview on 03/02/14 at 1:57 pm, ADON B stated they only measure input/output if a resident has a physician's order [REDACTED].#1 did not have one and was not at risk so they did not monitor her fluid intake. Review of Resident #1's Physician order [REDACTED]. Review of Resident #1 ' s Hydration Roster dated 02/01/14 - 02/28/14 reflected Resident #1 accepted all fluids offered to her. During an interview on 03/02/14 at 2:00 pm, CNA B stated that she worked with Resident #1 and she did not always accept fluids when offered. She further stated they would give her juice, water, or milk and if she did not want one, they did not offer other forms of fluids besides drinks. During an interview on 03/02/14 at 3:20 pm, ADON A stated they do a Hydration Assessment on Admission, Quarterly, and a Significant Change. She further stated that she expects staff to offer drinks with snacks three times a day and with meals. If a resident does not want water, they offer juice or milk; no other forms of fluids besides drinks are offered. ADON A further stated that Resident #1 always accepted drinks when offered and she could request them and drink herself. When asked what the signs and symptoms of dehydration are, ADON A stated dry lips, sunken eyes, AMS, poor skin turgor, high BUN/Creatinine, and low blood pressure. When asked about Resident #1 on the day she left for her appointment before she went to the hospital, ADON A stated she had low blood pressure but looked fine. During an interview on 03/02/14 at 3:30 pm, CNA C stated that she saw Resident #1 on the morning of her doctor ' s appointment and she looked very sweaty; she even stated to the van driver that her brief was dry and clean but she is just very wet because she is sweating so much. When asked if she reported it to a nurse, CNA C stated that they knew Resident #1 was sweating quite a bit. During an interview on 03/02/14 at 2:20 pm, the ER physician stated that Resident #1 ' s blood pressure was low when she came into the hospital and had to give fluids to get Resident #1 back to baseline. She further stated that she was not familiar with Resident #1 on a day to day basis but she physically looked dry and thinks the nursing home should have checked on her more and should have monitored how much fluid and nutrients Resident #1 was taking in. The ER physician then stated that the nursing home should have recognized that Resident #1 looked tired and weak before sending her to her appointment. During an interview on 03/02/14 at 2:30 pm, Resident #1's daughter stated that she visits her mother at least every other day at various times and she was there a few days before her doctor's appointment and she looked fine. She further stated Resdient #1 only takes a few sips of fluids at at time and she thinks she forgets to drink. She then stated that she has never seen a staff member offer her mother fluids outside of meals. During an interview on 03/01/14 at 2:00 pm, Resident #2 stated that it was shift change at that time and it is hard to get a staff member to refill her water pitcher because it takes a while for someone to stop by. She then stated that her pitcher was empty and asked the surveyor to fill it up in the bathroom for her because she was not sure the next time a staff member would come by. During an interview on 03/01/14 at 3:50 pm, Resident #7 stated that she has to ask for water or other drinks if she wants them. She further stated that she gets drinks when she asks for them but sometimes staff do not come by her room for a while. Observation on 03/01/14 at 3:50 pm revealed no water pitchers in Resident #7 ' s room for her or her roommate. During an interview on 03/02/14 at 11:40 am, Resident #10 stated that she has gone thirsty if staff do not stop by to get her something to drink. During an interview on 03/02/14 at 1:55 pm, Resident #11 stated that she has to ask for drinks if she wants something and sometimes that takes a while. Review of the facility ' s Hydration policy dated 07/13 reflected the facility must provide each resident with sufficient fluid intake to maintain proper hydration and health. " Sufficient Fluid " means the amount of fluid needed to prevent dehydration (output of fluids far exceeds fluid intake? And maintain health. The amount needed is specific for each resident, and fluctuates as the resident ' s condition fluctuates. The Hydration Policy further reflected that risk factors for a resident becoming dehydrated are functional impairments that make it difficult to communicate fluid needs, dementia in which residents forget to drink or refusal of fluids. Review of the facility's CMS form 802 reflected 75 residents identified with hydration problems.