Every finding on record at Starr County Nursing and Transitional Care

Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care was provided such care consistent with professional standards of practice for 1 of 4 (Resident #30) residents reviewed for oxygen in that:Resident #30's oxygen tubing was not connected to the concentrator. This failure could place residents who receive oxygen at risk of developing respiratory complications and a decreased quality of care. The findings included:Record Review of Resident #30's face sheet dated 1/12/2026 indicated he was a [AGE] year old male initially admitted on [DATE] and readmitted [DATE] with the diagnoses of Cerebral Infarction (condition that occurs when blood flow is disrupted causing brain tissue to die), Severe vascular dementia (brain damage caused by multiple strokes), and generalized muscle weakness. Record Review of Resident #30's significant change Minimum Data Set assessment dated [DATE] indicated he had a BIMS score of 00 (indicting he was severely impaired). He received oxygen therapy. Record review of Resident #30's comprehensive care plan dated 10/28/2025 indicated Resident #30 has oxygen therapy, Oxygen Saturation every shift, Monitor for s/sx of respiratory distress and report to MD PRN Date Initiated: 12/31/2024 Revision on: 12/31/2024 Record review of Resident #30's January 2026 physician's orders indicated OXYGEN at 4 LPM via nasal cannula continuous every shift for SOB. Observation of Resident #30 on 01/12/26 at 10:30 am revealed the oxygen tubing was not connected to the Oxygen concentrator however the concentrator was on and set at 4 liters per minute. Resident #30 was not receiving oxygen until told by the surveyor. WCN was in the room and connected the oxygen tubing to the concentrator. WCN went to get LVN A. LVN A checked Resident #30's oxygen saturation and received a reading of 92%. Interview on 1/12/2026 at 10:30am with Resident #30 revealed that he was not interviewable. Interview on 1/12/2026 at 10:30am WCN stated that nurses were responsible for checking the oxygen settings and tubing. WCN stated that she did not have the pulse oximeter with her, but she was going to get the nurse. WCN stated that the negative outcome of not receiving oxygen would be oxygen saturations would drop. Interview with LVN A on 1/12/26 at 10:33am revealed she was Resident #30's nurse and was not aware Resident #30 was not receiving oxygen until told by the WCN. LVN A stated she checked Resident #30's oxygen every chance she got. LVN A stated Resident #30 was to receive continuous oxygen at 4 liters per minute. LVN A stated the negative outcome of not receiving oxygen would be oxygen saturations would drop. LVN A said a reading of 92% oxygen saturation is within normal limits. During an interview with the DON on 01/13/26 at 6:12 PM she said LVN A was in charge to check oxygen administration at least every shift and whenever the nurse was providing care. The DON stated hypoxia (low oxygen level in the blood), and respiratory distress could occur if oxygen administration was not provided as ordered. DON stated that the facility did not have a policy on oxygen administration.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were secured and stored in accordance with currently accepted professional principles and standards for 1 of 2 medication storage rooms (200 Hall Medication Storage Room) reviewed for medication storage. The facility failed to ensure the 200 Hall Discontinued Medication cabinet was locked and secured. This failure could place the residents at risk of gaining access to unlocked medications that were not prescribed to them and place the facility at risk of drug diversion. Findings included: In an observation in the 200 hall medication room on 01/12/2026 at 4:02 p.m., a cabinet that had a sign posted that read Discontinue Medications and Medications on Hold was not locked and secured. During an interview on 01/12/2026 at 4:03 p.m., LVN D stated she knew that the cabinet that stored the discontinued medications and medications that were on hold was supposed to be locked. She stated that she had checked it this morning, 01/12/26, and was locked. She stated that the nurse from 200 hall has the key. LVN D stated that if cabinet was left unlocked anyone could have gotten into it and take medications that did not belong to them. During an interview on 01/12/2026 at 4:34 p.m., ADON E confirmed that the cabinet that stored the discontinued medications and medication that were on hold was supposed to be locked. ADON E stated that the nurses who unlock the cabinet to put the medications should lock the cabinet. She stated that she does her rounds in the mornings and the cabinet was locked this morning around six. She stated that the 200-hall nurse holds on to the key and hands it to nurse who needs it at the time. ADON E stated that the discontinued medications cabinet was to be kept locked because anyone would have access to the medications. They can steal them and take them for personal use. ADON stated that the staff were not following policy and procedures for discontinued medication storage. During an interview on 01/13/2026 at 4:56 p.m., the DON stated that the cabinet that stored the discontinued medications and medication that were on hold was supposed to be locked. She stated that 3 LVNs had the keys. She stated that they would unlock the cabinet to put the discontinued medications and lock it back up when done. The DON stated if the cabinet was kept unlocked then anyone can grab a discontinued medication and use it as a refill because it was next to the refill medications. The staff could administer discontinued medication. She stated the ADONs check that the cabinet was locked daily, and the managers check over the weekends. Record Review of the facility's Medication Storage and Disposal: Discontinued Medication policy, dated revised 10/01/19, revealed Policy When medications are discontinued by physician order, a resident is transferred or discharged and does not take mediation with him/her, or in the event of resident's death, the medications are marked appropriated and destroyed, unless unopened and/or are returnable to the pharmacy. Procedure 2. Medications awaiting disposal or return are stored in a locked secure area designated for that purpose until disposed of, or retuned to the pharmacy if credit is allowed.

Based on observation, interviews and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for storage, preparation and sanitation.The facility failed to ensure all food products in standing freezer were labeled and dated.This failure could place residents at risk for food contamination and food-borne illnesses.Findings included:Observation and initial tour of the kitchen on 01/11/26 at 9:26 a.m. revealed a 3-gallon tub of vanilla ice cream with no open date labeled.During an interview on 01/11/26 at 9:32 a.m. DA said she did not know why the tub of ice cream was not dated. She said it's supposed to be dated when it's opened. During an interview on 01/12/26 at 2:50 p.m. the DM said all food is supposed to be labeled and dated. She said ice cream is good for 6 months after date received. Record review of facility's policy: Food Storage, date revised June 1, 2019, revealed:Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines.Freezerse. Store frozen foods in moisture-proof wrap or containers that was labeled and dated.

Based on interview and record review, the facility failed to ensure that residents are free from chemical restraints for one (Resident #6) of three residents reviewed for medications. The facility failed to have an adequate indication for the use of the medication Zyprexa (Olanzapine- atypical antipsychotic) for Resident #6. This failure could put residents at risks of receiving unnecessary psychotropic medications. Record review of Resident #6's admission Record dated 01/13/26 indicated Resident #6 was an [AGE] year-old female admitted to the facility on [DATE] with an original admission date of 08/07/24. The admission record revealed Resident #6 had diagnoses of unspecified dementia (cognitive decline that significantly impairs daily life), altered mental status (a sudden change in brain function, causing confusion, disorientation, reduced awareness, or unusual behavior), cognitive communication deficit (difficulty communicating due to impaired thinking, often from neurological conditions), unspecified psychosis (psychotic symptoms such as hallucinations, delusions, and disorganized thinking), and mood disorder due to known physiological condition (a disturbance in mood like depression, mania, or irritability directly caused by another medical illness). Record review of Resident #6's MDS Resident Assessment and Care Screening dated 12/26/25 revealed Resident #6 had a BIMS score of 3 which indicated Resident #1 had severely impaired cognition. The MDS assessment also revealed Resident #1 was on a high-risk drug, an antipsychotic. Record review of Resident #6's Physician's Orders revealed an order dated 12/24/25 for Olanzapine Oral Tablet 5 mg, give one tablet by mouth at bedtime related to unspecified dementia, unspecified severity, with psychotic disturbance. The order did not indicate an end date. Side effect monitoring for Olanzapine every shift with start date of 12/26/26 25 and behavior monitoring for Olanzapine every shift with start date of 12/26/2625. Record review of Resident #6's e-MAR dated December 2025 through January 2026 revealed the medication Olanzapine oral tablet 5 mg was administered to Resident #6 effective 12/24/25 through present time. Record review of Resident #6's care plan dated 12/26/25 revealed that Resident #6 used antipsychotic medications related to Dementia with psychotic disturbances. The interventions were to administer the antipsychotic medications as ordered by physician, monitor for side effects and effectiveness every shift, and monitor/document/report PRN any adverse reactions to antipsychotic medications. Record review of Resident #6's Nursing Facility Consent for Antipsychotic or Neuroleptic Medication treatment form for Olanzapine, revealed an indication, diagnosis of Dementia with psychotic disturbances. The form was dated 12/24/25. In an interview on 01/13/26 at 7:58 pm, the DON stated Resident #1 was on Zyprexa medication. While the DON looked at her computer screen, the DON read out loud Resident #6's Olanzapine order. The DON stated the indication of dementia was allowed due to having, With psychotic disturbance attached to the indication of dementia. The DON stated, I know the indication for an antipsychotic cannot have dementia diagnosis alone, but it can be approved by adding, psychotic disturbances. In an interview on 01/13/26 at 8:06 pm, ADON F stated the in-house Psychiatric NP had visited with Resident #6 on 12/31/25. ADON F provided a copy of the psychiatric evaluation form filled out by the NP. The NP's recommendation was to keep Resident #6 on her current medication regimen. The form included the order for Zyprexa 5 mg HS with indication of psychosis. ADON F stated she was assigned to add and update antipsychotic medication orders to the resident's charts. ADON F stated she had not updated Resident #6's current order for Olanzapine. ADON F stated she was aware dementia should not be an indication but forgot to update the order after the psychiatric NP did her evaluation. Record review of Facility's undated Psychoactive Medication Management Program policy revealed:Upon noting an order for psychoactive medication on admission or initiation of therapy:1. Complete the Psychoactive Medication Evaluation at the initiation of psychoactive medication therapy.2. Complete the Consent for Use of Psychoactive Medication therapy with the resident and/or the resident representative at the initiation of psychoactive medication or off label use of a medication (i.e., Klonopin) educate on the benefits, potential negative outcomes, alternatives, and outcomes of psychoactive medication use.3. Implement the behavior monitoring/side effects monitoring in PCC on the MAR for psychoactive medications with the targeted behavior for why the resident is receiving the medication as ordered. Initial appropriate observed behaviors or no behaviors observed.4. Complete baseline Abnormal Involuntary Movement Scale (AIMS) at the initiation of psychoactive medication therapy.5. Care plan the targeted behavior for why the resident is receiving the medication.

Based on observations, interviews, and record review, the facility failed to ensure residents who entered the facility without pressure ulcers did not develop pressure ulcers and residents having pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and further development of skin breakdown or pressure ulcers for 1 (Resident #1) of 3 residents reviewed for pressure ulcers. -The facility failed to ensure Resident #1 was repositioned to promote healing. This failure placed residents at risk of developing new pressure injuries/ulcers, worsening of existing pressure injuries/ulcers, infection, experiencing pain, decreased quality of life, and death. The findings included: Record review of Resident #1's admission record dated 1/13/26 revealed an [AGE] year-old male admitted on [DATE]. Diagnoses included cerebral infraction (the death of brain tissue from a blocked vessel, depriving it of oxygen and nutrients), muscle wasting and atrophy (the loss of muscle tissue, leading to decreased muscle size, strength, and function), functional quadriplegia (complete immobility of all four limbs due to severe physical disability or frailty from another medical condition). Record review of Resident #1's care plan dated 11/19/2025 revealed Resident had an alteration in skin integrity related to the presence of an unstageable pressure ulcer on sacrum with a date of origin of 11/14/2025. Goal: the resident's pressure ulcer/injury will decrease in size measurements. Interventions: air mattress with bolsters while in bed, apply treatment as ordered. Record review of Resident #1's Comprehensive MDS dated [DATE] revealed resident had a BIMS score of 01 which indicated severe cognitive impairment. Resident #1's MDS also revealed resident was dependent (helper does all of the effort) for rolling left and right, sitting to lying, lying to sitting on side of bed. The same MDS revealed resident had a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device at the time of admission. Record review of Resident #1's Initial Wound Sheet dated 11/15/25 revealed resident had an unstageable pressure ulcer (full-thickness tissue loss where the wound bed is obscured by dead tissue) to her sacrum that measured: Length: 3.22 cm, Width: 4.08cm, Depth: 0.1cm. This Initial Wound Sheet was e-signed by the DON. Record review of Resident #1's weekly wound sheet dated 11/17/25 revealed resident had an unstageable pressure ulcer (full-thickness tissue loss where the wound bed is obscured by dead tissue) to her sacrum that measured: Length: 4.62 cm, Width: 5.58cm, Depth: 0.1cm. Order read Medihoney Wound/Burn Dressing External Paste (Wound Dressings) Apply to Sacrum topically one time a day for Unstageable pressure ulcer cleanse wound with wound cleanser, pat dry with 4x4 dry gauze, apply Medi honey to wound bed, then apply collagen sheet to bone, cover with adaptic, cover with ABD pad and secure with tape. This documentation was completed by WCN on 11/17/2025. Record review of Resident #1's weekly wound sheet dated 11/24/25 revealed resident had an unstageable pressure ulcer (full-thickness tissue loss where the wound bed is obscured by dead tissue) to her sacrum that measured: Length: 3.65 cm, Width: 3.74cm, Depth: 0.1cm. Medihoney Wound/Burn Dressing External Paste (Wound Dressings) Apply to Sacrum topically one time a day for Unstageable pressure ulcer cleanse wound with wound cleanser, pat dry with 4x4 dry gauze, apply Medi honey to wound bed, then apply collagen sheet to bone, cover with adaptic, cover with ABD pad and secure with tape. This documentation was completed by WCN on 11/24/2025. Record review of Resident #1's weekly wound sheet dated 12/8/25 revealed resident had an unstageable pressure ulcer (full-thickness tissue loss where the wound bed is obscured by dead tissue) to her sacrum that measured: Length: 3.41 cm, Width: 3.18cm, Depth: 0.2cm. Medihoney Wound/Burn Dressing External Paste (Wound Dressings) Apply to Sacrum topically one time a day for Unstageable pressure ulcer cleanse wound with wound cleanser, pat dry with 4x4 dry gauze, apply Medi honey to wound bed, then apply collagen sheet to bone, cover with adaptic, cover with ABD pad and secure with tape. This documentation was completed by WCN on 12/8/2025. Record review of Resident #1's weekly wound sheet dated 1/5/26 revealed resident had an unstageable pressure ulcer (full-thickness tissue loss where the wound bed is obscured by dead tissue) to her sacrum that measured: Length: 4.31 cm, Width: 4 cm, Depth: 3.0cm. Medihoney Wound/Burn Dressing External Paste (Wound Dressings) Apply to Sacrum topically one time a day for Unstageable pressure ulcer cleanse wound with wound cleanser, pat dry with 4x4 dry gauze, apply Medi honey to wound bed, then apply collagen sheet to bone, cover with adaptic, cover with ABD pad and secure with tape. This documentation was completed by WCN on 1/5/2026. Record review of Resident #1's Order Summary Report dated 01/13/26 revealed, Medihoney Wound/Burn Dressing External Paste (Wound Dressings) Apply to Sacrum topically one time a day for Unstageable pressure ulcer cleanse wound with wound cleanser, pat dry with 4x4 dry gauze, apply Medi honey to wound bed, then apply collagen sheet to bone, cover with adaptic, cover with ABD pad and secure with tape. During an interview with Resident #1's family member on 01/12/26 at 01:40 PM, FM stated the resident has a pressure ulcer on his buttocks. FM further stated, the provider told me they do not reposition him. FM stated the facility got Resident #1 an air mattress. During an interview with Resident #1's Provider on 01/13/26 at 10:00 AM, FM stated the resident has a pressure ulcer on her buttocks. FM further stated, they do not reposition him. FM stated the facility got Resident #1 an air mattress, she was not able to recall the date. FM stated that she got to the facility at 6:45AM and staff just came to reposition the resident. Observation of Resident #1 on 1/13/26 at 12:00 PM revealed resident lying flat on his back in bed with the head of bed elevated and his head on a pillow. At this time staff came into the room to reposition resident. Resident #1 was facing the window. Observation of Resident #1 on 1/13/26 at 2:00 PM revealed resident lying flat on his back in bed with the head of bed elevated and his head on a pillow. At this time staff came into the room to reposition resident. Resident #1 was facing the door. During an interview on 01/13/26 at 10:30 AM CNA B stated that residents are usually repositioned every two hours but that she liked to do it more frequently if residents had a pressure ulcer. CNA B stated the resident would be repositioned every time they were changed or whenever she went in to check them. In reference to Resident #1, CNA B stated that he gets repositioned every two hours, but not necessarily by her. CNA B stated, I've been here since 6 AM today. Today I did not reposition resident until 10:00 am because I did not have time, I got busy with other residents. CNA B stated that if residents are not repositioned it could result in more skin breakdown. During an interview on 01/13/26 at 10:35 AM, CNA C stated, residents are repositioned every 2 hours. I make sure I go in there every 2 hours to reposition them. CNA C stated, regarding Resident #1, he is being repositioned every 2 hours. Today I did not repositioned resident until 9:45am to 10:00am. CNA C further stated, if residents are not repositioned, they can get ulcers and skin breakdown. We get in-services quite often; I would say sometimes 2 a month, but at least once a month.During an interview on 01/13/26 at 11:47 AM, the LVN A stated, Residents are repositioned every 2 hours or as needed. If they're uncomfortable and requesting repositioning, we reposition. If residents are not repositioned, they will have breakdown, redness, pressure ulcers or they could develop respiratory issues. When asked under what circumstances staff would not reposition a resident, LVN A answered, when they're independent and can do it themselves. During an interview on 1/13/26 at 5:00 PM, DON stated, Residents are repositioned every 2 hours or as needed. If the residents are not repositioned at least every 2 hours the resident could develop a pressure ulcer or if the resident has a pressure ulcer could prevent the wound healing. Record review of facility's Turning and Repositioning Policy with implemented date 2/19/2025 revealed: It is out policy to implement turning and repositioning as part of our systematic approach to pressure injury prevention and management. This policy establishes responsibilities and protocols or turning and repositioningPolicy Explanation and Compliance Guidelines:All residents at risk of, or with existing pressure injuries, will be turned and repositioned, unless it is contraindicated due to a medical condition.

Based on interview and record review, the facility failed to ensure residents were free from any significant medication errors for one of five residents (Resident #2) reviewed for medication errors. The facility failed to administer Resident #2's clonidine (blood pressure medication) when Resident #2's blood pressure was within parameters 12 days in the months of September and October 2025. This failure could place residents at risk for complications such as increased blood pressure, exacerbation of symptoms, and potential hospitalization. The findings include:Record review of Resident #2's face sheet, dated 10/14/25, reflected a [AGE] year-old male with an admission date of 05/15/24. Resident #2's pertinent diagnosis included hypertensive heart disease with heart failure (condition in which long-term high blood pressure leads to heart failure). Record review of Resident #2's Quarterly MDS assessment, dated 09/02/25, reflected a BIMS score of 10 which indicated moderate impairment. Record review of Resident #2's comprehensive care plan, dated 10/14/25, reflected the problem [Resident #2] has hypertension. last revised on 12/26/24. An intervention listed for the problem included Give anti-hypertensive medications as ordered. initiated on 05/16/24. Record review of Resident #2's order summary reflected an active order for clonidine HCl Oral Tablet 0.1 MG. Give 1 tablet by mouth every 6 hours as needed for HTN. May administer if SBP greater than 150mmhg or DBP greater than 100mmhg initiated on 10/14/24. Resident #2 also had an active order for amlodipine besylate oral tablet 10 MG (blood pressure medication). Give 1 tablet by mouth one time a related to hypertensive heart disease with heart failure. May hold if SBP 100 or below DBP 60 or below initiated on 08/05/24. Record review of Resident #2's blood pressure log, on 10/14/25, from September and October of 2025 reflected the following blood pressures:- 10/09/25 at 09:43 AM - 152/68 mmhg- 10/07/25 at 09:50 AM - 156/84 mmhg- 10/05/25 at 09:38 AM - 158/84 mmhg- 09/25/25 at 09:07 AM - 158/88 mmhg- 09/24/25 at 09:27 AM - 168/78 mmhg- 09/20/25 at 09:35 AM - 164/92 mmhg- 09/14/25 at 09:10 AM - 153/84 mmhg- 09/13/25 at 09:44 AM - 164/86 mmhg- 09/11/25 at 09:11 AM - 164/72 mmhg- 09/08/25 at 09:45 AM - 162/96 mmhg- 09/06/25 at 09:59 AM - 152/80 mmhg- 09/04/25 at 11:03 AM - 154/86 mmhgFurther Record review of the blood pressure logs revealed Resident #2's blood pressure was only checked twice on 09/30/25 and 09/16/25. Neither of the two dates it was checked twice recorded a blood pressure above 150/100 mmhg. Record review of Resident #2's MAR for September and October 2025 reflected clonidine 0.1 mg had not been administered during those two months. Further review revealed Resident #2 had been administered amlodipine 10 mg every morning during those two months. In an interview with LVN C at 9:48 AM on 10/14/25, LVN C stated he measured Resident #2's blood pressure earlier that day. LVN C stated Resident #2's systolic blood pressure was usually in the 140's. LVN C stated Resident #2 gets his blood pressure checked in the morning when he is scheduled to receive a daily blood pressure medication. LVN C stated if he measured Resident #2's blood pressure to be above 150/100, he would wait for around one hour and recheck to see if it was still elevated, and if so, administer the clonidine. LVN C stated he did not know if Resident # 2's blood pressure was rechecked on the days it was measured to be above 150/100. LVN C stated if the blood pressure was rechecked it should have been recorded in the blood pressure log. LVN C stated it was important to administer blood pressure lowering medications as ordered to prevent the resident from having a stroke. In an interview with ADON A at 10:07 AM on 10/14/25, ADON A stated Resident #2's blood pressure should have been checked at least twice per day to know if he needed the clonidine or not. ADON A stated Resident #2's blood pressure was only being checked once per day on most days. ADON A stated if Resident #2's blood pressure was checked in the evening, and it was over 150/100 she would administer the clonidine. ADON A stated it was important to maintain a resident's blood pressure to prevent strokes. In an interview with the DON at 10:27 AM on 10/14/25, the DON stated the facility should have measured Resident #1's blood pressure every 6 hours to determine if he needed the clonidine. The DON stated if Resident #2's blood pressure was measured in the morning to be over 150/100, nurses should have administered Resident #2's other blood pressure medication, wait an hour or so, and recheck the blood pressure to see if it was still over the threshold. The DON stated she was unable to find any documentation showing Resident #2's blood pressure was rechecked on the days it was over 150/100 in the morning. The DON stated it was important to ensure Resident #2's blood pressure did not rise too high otherwise he could have a stroke. Record review of the facility's policy Medication Administration, dated 10/24/22, reflected the following policies: .8. Obtain and record vitals signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters.14. Administer medication as ordered in accordance with manufacturer specifications.

Based on observation, interviews, and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for medication administration. The facility failed to accurately document Resident #1's Medication Administration Record for Oxygen Therapy that was administered from 10/10/2025 through 10/14/2025. This deficient practice could place residents at risk of having inaccurate medical records. Findings Included:Record review of Resident #1's electronic face sheet dated 10/14/2025 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had diagnoses which included the following: Chronic Obstructive Pulmonary Disease (lung condition that damages the airways making it difficult to breathe), Muscle Wasting and Atrophy (muscles shrinking and getting weaker), Dysphagia (difficulty swallowing), Hypertension (high blood pressure), Peripheral Vascular Disease (a circulation problem that affects blood vessels outside your heart and brain, most commonly in the legs and arms), Gout (inflammatory arthritis in the joints). Record review of Resident #1's Comprehensive MDS assessment, dated 09/29/2025, reflected a BIMS score of 03, indicated her cognition was severely impaired. Special treatments, procedures, and programs reflected resident received oxygen therapy. Record review of the Physician's Order Summary dated 10/14/2025 reflected Resident #1 was prescribed Oxygen at 2LPM via nasal cannula as needed for SOB related to Chronic Obstructive Pulmonary Disease (lung condition that damages the airways making it difficult to breathe) start date 09/29/2025. Record review Resident #1 care plan, dated 10/14/2025, reflected that the resident had oxygen therapy related to COPD. Interventions reflected: administer oxygen per physician's orders, monitor for s/sx of respiratory distress and report to MD PRN: Respirations, Pulse oximetry, Increased heart rate, Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis, Cough, Pleuritic pain, Accessory muscle usage, Skin color. Record review of Resident #1's Medication Administration Record (MAR) reflected Oxygen at 2LPM via nasal PRN, had no administration entries from 10/10/2025 through 10/14/2025. Record review of Resident #1's Skilled Nurse Notes dated 10/10/2025, 10/11/2025, 10,12/2025, 10/13/2025, and 10/14/2025 reflected Resident #1 was on Oxygen @2LPM via NC. During an interview on 10/14/2025 at 10:57 a.m. RN B stated that she was the nurse for Resident #1. She stated that Resident #1 had been on oxygen since she was admitted .Follow up interview on 10/14/2025 at 3:20 p.m. RN B stated that she would document Resident #1's Oxygen saturation once a shift in the MAR. She would then document that the resident was on oxygen in the skilled nurse note. RN B was not aware that she needed to document this information in the MAR. She then stated that she would reach out to the doctor to get a continuous oxygen order. During an interview on 10/14/2025 at 2:56 p.m. with the DON stated Resident #1 oxygen therapy was ordered as needed. She stated that the oxygen should had been signed off in the MAR that it was being administered. The DON stated that it was important for the oxygen to be documented to follow doctors' orders. During an interview on 10/14/2025 at 3:25 p.m. ADON A stated the nurse who administered the oxygen was to document that it was administered in the MAR. She then confirmed that the nurse did not document in the MAR that oxygen was being administered. ADON A stated that it was important to document so that it was verified that Resident #1 was currently on oxygen. She stated that the DON and herself check the MAR's for completion and accuracy. ADON A stated that Resident #1's MAR's slipped and therefore she did not notice that it had not been documented. Record review of the facility's policy titled Medication Administration, dated 10/24/2022 revealed, Policy Explanation and Compliance Guidelines:10. Review MAR to identify medication to be administered.17. Sign MAR after administered. For those medications requiring vital signs, record vital signs on the Medication Administration Record (MAR). Record review of the facility's policy titled Documentation in Medical Record, dated 10/24/2022, revealed: Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the residents progress through complete, accurate, and timely documentation.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection for one (Resident #3) of five residents reviewed for infection control, in that:On 10/18/2025, the facility failed to ensure CNA A removed her contaminated gloves and performed hand hygiene after touching multiple surfaces prior to initiating Resident #3's perineal incontinent care These failures could place residents at risk of contamination and infection. FindingsRecord review of Resident #3's Admissions Record dated 10/18/2025 revealed Resident #3 was a [AGE] year-old-female who was initially admitted [DATE]. Resident #3 was admitted with several diagnoses including: dementia (cognitive impairment), hemiplegia (paralysis) and hemiparesis (partial weakness), and unspecified psychosis (severe mental condition in which thought and emotions are so affected that contact is lost with external reality). Record review of Resident #3's Quarterly MDS dated [DATE] revealed Resident #3 had a BIMS score of 8 which meant severe cognitive impairment and was dependent on staff for most of her ADLs. Additionally Resident #3 was coded for always urine/bowel incontinence. Record review of Resident #3's Care Plan revealed date initiated 07/24/2023 [Resident #3] has bladder incontinence r/t limited mobility. Goal: The resident will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions: Clean peri-area with each incontinence episode. Monitor/document 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. During an observation on 10/18/2025 at 2:04PM CNA A and CNA B knocked and entered Resident #3' s room. They both then notified Resident #3 of their desire to perform incontinent care, to which Resident #3 agreed to. CNA A closed Resident #3's entry door, walked into the bathroom and commenced hand hygiene utilizing soap and water for roughly 32seconds. CNA A then applied clean gloves. CNA A then retrieved Resident #3's call light remote and placed it on the side of Resident #3, then withdrew Resident #3's blankets and sheets, followed by removing Resident #3's brief and proceeded to retrieve clean wipes, and commenced incontinent care without removing the potentially contaminated gloves nor performed hand hygiene prior to commencement of incontinent care. During an interview on 10/18/2025 at 2:29PM, CNA A stated she should have removed her contaminated gloves once she touched Resident #3's call light remote and removed Resident #3's sheet and blanket. CNA A stated the reason she should have taken off the contaminated gloves and utilized ABHR, after she touched Resident #3's surroundings, was a precautionary infection control measure to ensure that any unknown microorganisms would not be introduced to Resident #3 during incontinent care. CNA A stated by not removing her contaminated gloves after she touched Resident #3's call light and linen, she may have compromised Resident #3's well-being and continued to state if the microorganisms were introduced to Resident #3, the resident could become at risk for contracting a UTI. CNA A stated she was nervous during the observation and that she had recently completed her incontinent care skills check off. During an interview on 10/19/2025 at 9:56AM, the DON stated the facility follows CDC Guidelines regarding hand hygiene. The DON stated CNA A should have removed her contaminated gloves and performed hand hygiene after touching Resident #3's surroundings. The DON stated that CNA A should have completed the glove removal and hand hygiene was to promote infection control. The DON stated by CNA A not completing the two tasks, Resident #3 could have potentially contracted an infection that could lead to a urinary tract infection which could negatively affect Resident #3's well-being. The DON stated her managerial staff facilitate random skill check offs for all CNAs and conduct monthly in-services regarding hand hygiene and infection control. Record review of the facility's CNA A's Skill Checklist dated 10/07/2025 revealed CNA A adequately was educated and completed the infection prevention portion of training regarding hand washing and stand precautions. Record review of the facility's Infection Control and Handwashing in-service on 10/01/2025 was reviewed and CNA A was in attendance. Record review of the facility's Perineal Care policy date implemented 10/24/2022 revealed it is the practice of this facility to provide perineal care to all incontinent residents during routine bath and as needed in order to promote cleanliness and comfort, prevent infection to the extent possible and to prevent and assess for skin breakdown.Record review of the facility's Infection Control Policy did not specifically detail when to perform hand hygiene during incontinent care. Record review of the CDC guidelines Clinical Safety: Hand Hygiene for Healthcare Workers dated 02/27/2024 documented recommendations for when to clean your hands after touching a patient or patient's surroundings.

Based on observation, interview and record review the facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, for 1 of 5 residents (Resident#1) reviewed for oxygen in that:The facility failed to ensure Residents #1 oxygen therapy was being properly administered.This deficient practice could place residents who receive oxygen therapy at an increased risk of developing respiratory complications and a decreased quality of care. Findings Included: Record review of Resident #1's electronic face sheet dated 10/14/2025 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had diagnoses which included the following: Chronic Obstructive Pulmonary Disease (lung condition that damages the airways making it difficult to breathe), Muscle Wasting and Atrophy (muscles shrinking and getting weaker), Dysphagia (difficulty swallowing), Hypertension (high blood pressure), Peripheral Vascular Disease (a circulation problem that affects blood vessels outside your heart and brain, most commonly in the legs and arms), Gout (inflammatory arthritis in the joints). Record review of Resident #1's Comprehensive MDS assessment, dated 09/29/2025, reflected a BIMS score of 03, indicated her cognition was severely impaired. Special treatments, procedures, and programs reflected resident received oxygen therapy. Record review of the Physician's Order Summary dated 10/14/2025 reflected Resident #1 was prescribed Oxygen at 2LPM via nasal cannula as needed for SOB related to Chronic Obstructive Pulmonary Disease (lung condition that damages the airways making it difficult to breathe) start date 09/29/2025. Record review of Resident #1 care plan, dated 10/14/2025, reflected the resident had oxygen therapy related to COPD. Interventions reflected: administer oxygen per physician's orders, monitor for s/sx of respiratory distress and report to MD PRN: Respirations, Pulse oximetry, Increased heart rate, Restlessness, Diaphoresis (excessive sweating that was not caused by typical triggers like heat or exercise), Headaches, Lethargy, Confusion, Atelectasis (partial or complete collapse of a lung or a section of a lung), Hemoptysis (coughing up blood or bloody mucus from the lungs or respiratory tract), Cough, Pleuritic pain, Accessory muscle usage, Skin color. Observation on 10/14/2025 at 10:51 a.m. Resident #1 observed in room lying in bed with her eyes closed and the head of the bed was slightly elevated. Oxygen concentrator was on and set on 2LPM. Resident #1 had oxygen tubing properly placed on her face via nasal cannula, but the oxygen tube was not connected to the concentrator. Resident #1 did not have symptoms of respiratory distress. ADON A along with RN B checked Resident #1 O2 saturation with different devices at the same time. ADON A checked it on finger, read 93% and RN B checked it on the earlobe, read 96%. During an interview on 10/14/2025 at 10:53 a.m. ADON A stated that the nurses were responsible for checking the oxygen in the morning or once per shift. She stated that Resident #1 tends to move around a lot and that was probably how it got disconnected. ADON A stated that the negative outcome was that Resident #1 oxygen can desaturate (drop in oxygen levels in the blood) and as a result can become hypoxia (condition where the body tissues don't get enough oxygen). During an interview on 10/14/2025 at 10:57 a.m. RN B stated that she was the nurse for Resident #1. She stated that Resident #1 had been on oxygen since she was admitted . RN B stated that she was in Resident #1's room around 10:15 a.m. and that at the time the tubing was connected to the oxygen concentrator. She stated that she checks Resident #1 oxygen several times during her shift due to Resident #1 getting up to use the restroom and gets SOB. RN B stated the negative outcome was that Resident #1 oxygen can desaturate (drop in oxygen levels in the blood). During an interview on 10/14/2025 at 2:56 p.m. with the DON stated that the nurses were responsible for checking oxygen and O2 saturation levels every shift and as needed throughout the day. The DON stated that the negative outcome was that Resident #1 can go into respiratory distress. Record review of the facility's Lippincott Manual of Nursing Practice 11th edition Administering Oxygen Therapy, revealed 1.Assess need for oxygen by observing for symptoms of hypoxia: . Assess the patient's current oxygenation 3.Administer oxygen in the appropriate concentration and device.c. Ensure proper use and fit of oxygen delivery device., with oxygen flow rate according to instructions.

Based on observations, interview and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preference for one (Resident #9) of three residents reviewed for call lights. The facility failed to ensure Resident #9 had the call light within reach while in bed in his room. This failure could place residents at risk of being unable to obtain assistance or help when needed and in the event of an emergency. Findings were: Record review of Resident #9's Admission record dated 02/13/24 reflected an [AGE] year-old female with diagnoses of Unspecified Dementia (decline in thinking, learning and reasoning), Unspecified Severity without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety, Heart failure unspecified, Muscle Wasting And Atrophy Unspecified Site, Anxiety (persistent and uncontrollable feelings of fear that disrupt daily living), Need for assistance with personal care, Unspecified convulsions (type of unknown seizures). Record review of Resident #9's Annual MDS dated [DATE] reflected a BIMS score of 0 indicating severe cognitive impairment. Section GG - Functional Abilities and Goals indicated Resident requires substantial /maximal assistance with upper and lower body dressing, sitting to lying on bed, rolling left and right side on bed, and toileting hygiene. Observation on 10/14/24 at 11:25 a.m., revealed Resident #9's call light device was in top of the bedside table, Resident #9 was not able to reach it. During an interview on 10/14/24 at 11:38 AM, CNA B observed Resident #9's call light device was in top of the bedside table, Resident #9 was not able to reach it. CNA B said Resident #9 was supposed to have her call light near her so she can call for help should she need to. CNA B said she usually used her call light on and off. CNA B said she checks all residents to make sure their call lights are within reach, and they are not in need of any other assistance. She said she does this at the beginning when she first begins working and throughout her shift. CNA B said a negative outcome of not having the call light within reach was that a resident could fall and the resident could not be able to call for help. During an interview on 10/14/24 at 12:00 PM, CNA C said that Resident #9 used the call light. CNA C said that Resident #9 was able to grab the call light but sometimes had difficulty pressing the call light button. CNA C said that she went to the residents room frequently, every 2 hours to check if resident needed anything. CNA C stated that a negative outcome was that Resident #9 could fall and not able to call for assistance. During an interview on 10/14/24 at 12:45 PM, LVN A said that Resident #9 did not use the call light, her cognitive status was bad. LVN A said that was important to have the call light within reach so the resident could call me, and it could take longer to check what the resident needed. LVN A said that a negative outcome was that a resident could get skin irritations, pressure ulcers and even falling. During an interview on 10/15/24 at 11:55 AM, LVN J said that Resident #9 used her call light when she needs something. She said she always makes sure she has it within reach and reminds her to use it. LVN E said that if a resident cannot reach the call light, then they cannot get help, they may have a fall and be at risk of getting hurt. During an interview on 10/15/24 at 12:00 PM, ADON D said that if call lights are not within reach, Resident #9 could have fallen when trying to get the call light. Record review of facility's policy titled Call Lights: Accessibility and Timely Response date implemented: 10/13/22 states. Policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Policy Explanation and Compliance Guidelines: 1. All staff will be educated on proper use of the resident call system, including how the system works and ensuring resident access to the call light. 2. All residents will be educated on how to call for help by using the resident call system. 5. Staff will ensure the call light is within reach of resident and secured. As needed.

Based on record review and interview the facility failed to perform preadmission screening for individuals with a mental disorder and individuals with intellectual disability prior to admission for 1 of 3 residents (Resident #67) reviewed for preadmission screening. The facility failed to perform a PASRR for Resident #67 after she was admitted on [DATE] with readmission on 12/20/23. This failure could place residents at risk of receiving inadequate care. Findings included: Record review of Resident #67's admission record revealed an [AGE] year-old female with an original admitted on 10/20/23 and a readmission on 12/20/23. Diagnoses included Bipolar Disorder Unspecified (a mental health condition characterized by extreme shifts in mood, energy, and activity levels), Unspecified Dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (a mental disorder that causes a person to lose the ability to think, remember, learn, make decisions, and solve problems, but without behavioral disturbances) Record review of Resident #67's care plan dated 10/23/23 revealed pg. 5 identified a problem dated 11/6/23 of behavior problem with diagnosis of bipolar disorder, with a goal that the resident will have fewer episodes, with interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated on 11/06/2023. Anticipate and meet the resident's needs. Date initiated on 11/6/23. Record review of Resident #67's L1 dated 10/20/23 was negative for Mental Illness or Intellectual or Developmental Disability. In an interview with MDS LVN L on 10/15/24 at 2:45 PM, she stated she did not know how she missed Resident #67's PASRR L1 that was negative on 10/20/23 and she should have sent a 1012 form used for further evaluation of mental illness. She said she overlooked the PASRR L1. She said a level 2 should be done with those diagnoses, regardless of a diagnosis of dementia. MDS LVN L said she did not have or send a 1012 for Resident #67. She stated, Because the Resident was not evaluated, resident had not received the proper care. In an interview with ADON I on 10/16/24 at 10:50 AM, she stated that if all residents with Mental Illness or intellectual or developmental disability needed to be screened when admitted . She said a form was supposed to be filled out for the evaluation for the diagnosis of bipolar disease. ADON I stated that Resident #67 was not getting the services that was appropriate for her diagnosis. During an interview on 10/16/24 at 11:00 AM, the DON stated that if a PASRR positive was received then a form was filled out for evaluation for residents to get approved for services. During an interview with the ADMIN on 10/16/24 at 11:10 AM, stated that she was not familiar with the process of the PASRR, but she thought that failing to do this process could affect the services provided to the residents. Reference: CFR S483.20(k)(2), and the resident remains in the facility longer than 30 days, the facility must screen the individual using the State's Level I screening process and refer any resident who has or may have MD, ID or a related condition to the appropriate state-designated authority for Level II PASARR evaluation and determination.

Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 5 (Resident #301) residents reviewed for respiratory care. The facility failed to ensure Resident #301's oxygen was administered at the correct setting of 2 liters per minute on 10/14/24 at 11:57 a.m. This failure places residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care. The findings included: Record review of Resident #301's face sheet dated 10/14/2024 reflected a [AGE] year-old male with an admitted [DATE]. Pertinent diagnoses included Chronic Obstructive Pulmonary Disease (chronic inflammatory lung disease that makes it difficult to breathe), Congestive Heart Failure (heart doesn't pump enough blood for your body's needs), Type 2 Diabetes, and Hypokalemia (lower than normal potassium level in the bloodstream). Record review of Resident #301's comprehensive care plan dated 10/14/2024 revealed Resident #301 has oxygen therapy related to Chronic Obstructive Pulmonary Disease with interventions to provide reassurance and allay anxiety; Have an agreed-on method for the resident to call for assistance. Stay with the resident during episodes of respiratory distress, and change residents position every 2 hours to facilitate lung secretion movement and drainage. Record review of Resident #301's physician's order summary revealed oxygen at 2LPM via Nasal cannula every shift continuously for hypoxia related to COPD, order start date 10/14/2024. During an observation of Resident #301 on 10/14/2024 at 11:57 a.m., his oxygen concentrator setting was set at 1.5 LPM via nasal cannula. Observed Resident #301 in bed, asleep. No signs of respiratory distress noted. In an interview on 10/14/2024 at 12:04 p.m. with LVN H stated, she was the nurse for Resident #301. She stated her shift started at 6 a.m. LVN H verified that the O2 setting was set at 1.5 LPM. She stated it was supposed to be at 2 LPM. She stated the O2 setting was to be checked at every shift. LVN H stated that she has not checked it for today. That she normally checks it before lunch or at the end of her shift, depends how her day was going. LVN H stated that the negative outcome of keeping Resident #301 at a lower oxygen rate than ordered would be that his oxygen level can go down and it can affect his brain or organs. She stated they had a respiratory care in-service/training about 2-3 months ago. In an interview on 10/14/2024 at 12:13 p.m. with Resident #301 stated, he was doing well. He denied any chest pain, shortness of breath or headache. He had no concerns with his oxygen. In an interview on 10/14/2024 at 12:50 p.m. with ADON I stated, she was the ADON for 300 & 400 halls. ADON I stated the nurse was responsible for checking the O2 settings once every shift and throughout their shift. She stated the managers also check in the morning and in the afternoon before they leave. ADON I stated the admissions coordinator had checked it this morning and it was at 2 LPM. She stated she checked the O2 settings at around 7:30 a.m. and did a second round when the surveyors got here. ADON I stated Resident #301 can get hypoxic (low levels of oxygen in the body) if he continued at a low O2 setting than prescribed since Resident #301 had COPD. She stated they had respiratory care in-service/training not too long ago, maybe around July 2024, they do it yearly. In an interview on 10/14/2024 at 4:28 p.m. the DON stated the nurse was responsible for checking the O2 settings every shift. She stated the ADON and herself also check it, as needed. The DON stated the if Resident #301 was not getting the full oxygen as prescribed it can cause a decrease in his oxygen saturation. She stated that respiratory care in service/training was done around July 2024, it was done yearly and as needed. Record review of the Respiratory Skills Checklist dated 06/25/24 revealed the LVN H was checked off on Respiratory Skill: Oxygen Administration, Tracheal Suctioning and Tracheostomy Trained and Returned Demonstration Performed/Passed on 6/25/24. Record review of the copy the facility provided of the Lippincott Nursing Procedures 11th edition 2016 for Administering Oxygen Therapy revealed: Nursing Assessment and Intervention 3. Administer oxygen in the appropriate concentration and device. 5. Increase or decrease the inspired oxygen concentration, as appropriate. c. Determine oxygen prescription . and . follow these flow rates.

Based on interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 4 residents (Residents #26 and #304), reviewed for pharmaceutical services. The facility failed to ensure: LVN M performed a safety check and compare physician orders against single dose bister pack prior to administering Resident #26's medication. LVN N perform a safety check and compare physician orders against single dose bister pack prior to administering Resident #304's medication . These deficient practices placed residents at risk for not receiving the therapeutic effects of their prescribed medications. The findings included: 1. A record review of Resident #26's admission record, dated 10/16/2024 revealed an admitted [DATE] with diagnoses which included type 2 diabetes (a chronic condition that affects how your body regulates blood sugar (glucose) levels), unspecified dementia (a clinical syndrome that describes dementia without a specific diagnosis), muscle wasting and atrophy (the loss of skeletal muscle mass ). A record review of Resident #26's physician's orders dated 10/16/2024 revealed an order for Nuedexta oral capsule 20-10 milligrams, one capsule to be administered via Gastrostomy tube one time per day. A record review of Resident #26's care plan dated 12/07/22 revealed, Resident #26 a behavior problem. Resident #26 will at times will have fits of crying with no apparent trigger to cause the crying. With interventions which included, Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 06/19/2023. During an observation and interview on 10/16/2024 at 08:10 AM, LVN M prepared Resident #26's medications, she removed * capsules from the single-dose blister pack containing Nuedexta 20 milligram capsules. The blister pack indicated to give one capsule via Gastrostomy tube every 12 hours. LVN M was noted to not perform a safety check to the order prior to pouring the medication. LVN M said she was unaware the dose had changed and stated when a physician order changes a change of directions sticker should have been placed in the single-dose blister pack . During an interview on 10/16/24 at 10:35 AM, LVN A stated that nurses and med aids needed to do a safety check of the physician orders against the single-dose blister pack. LVN A stated that when physician orders change, a change of directions sticker should have been placed on the blister pack or discard that blister pack because this could cause a medication error . During an interview on 10/16/24 at 10:45 AM, the DON stated that the nurse should have placed a change of direction sticker to prevent a medication error or give the wrong dose to the resident . 2. A record review of Resident #304's admission record, dated 10/16/24 revealed an admitted [DATE] with diagnoses which include type 2 diabetes (a chronic condition that affects how your body regulates blood sugar (glucose) levels), overactive bladder (a condition characterized by involuntary bladder contractions that cause a sudden, intense urge to urinate, often with little or no warning), morbid obesity (a condition characterized by an excessive amount of body fat that significantly increases the risk of serious health problems), Hypertension (a chronic condition where the force of blood against the artery walls is persistently elevated ). A record review of Resident #304's physician's orders dated 10/16/2024 revealed the physician prescribed Resident #304 was prescribed Losartan Potassium oral tablet 50 milligrams administer 1 tablet by mouth one time per day. A record review of Resident #304's care plan dated 09/30/2024 revealed, Resident #304 has hypertension HTN, see MAR for medication orders. With interventions which included, Give anti-hypertensive medications as ordered. Monitor for side effects such orthostatic hypotension and increased heart rate (Tachycardia) and effectiveness. Date Initiated: 10/01/2024 During an observation and interview on 10/16/2024 at 09:25 AM, LVN N prepared Resident #304's medication. LVN N poured * pills from a single-dose blister pack that indicated Losartan 50 milligrams give one tablet via gastrostomy tube every 12 hours. LVN N poured the medication without first performing a safety check. LVN N stated she was unaware of the order had changed and stated when a physician order changes a change of directions sticker should have been placed on the single-dose blister pack. During an interview on 10/16/24 at 10:35 AM, LVN A stated that nurses and med aids needed to do a safety check the physician orders against the single-dose blister pack. LVN A stated that when physician orders change, a change of directions sticker should have been placed on the blister pack or discard that blister pack because this could cause a medication error. During an interview on 10/16/24 at 10:45 AM, the DON stated that the nurse should have placed a change of direction sticker to prevent a medication error or give the wrong dose to the resident. A record review of the policy named Medication Administration date implemented on 10/24/22 revealed: Compare medication source (blister pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time.

Based on observation, interview, and record review the facility failed to ensure a resident, who was fed by enteral means, received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 6 residents (Resident #21) reviewed for enteral feeding. The facility failed to ensure Resident #21's head of bed was maintained at 30 degrees elevated while receiving continuous feeding. The failure could place residents at risk of aspiration (when food or liquid goes into the lungs or airway). Findings included: Record review of Resident #21's face sheet dated 10/14/24 revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (a brain disorder that gradually destroys memory and thinking skills, and eventually the ability to perform everyday tasks), Dysphagia Unspecified (difficulty swallowing), Gastrostomy complication unspecified (wound infection, Cerebrovascular Disease (a group of conditions that affect blood flow and the blood vessels in the brain). Record review of Resident #21's quarterly MDS assessment dated [DATE] revealed he was severely cognitive impaired (a condition where a person has trouble with memory, learning, concentration, and decision-making to the point that it limits their ability to function socially or occupationally), had enteral feeding while a Resident (intake of food via the gastrointestinal tract). Record review of Resident #21's care plan dated 03/2/21 revealed a focus area for requires tube feeding related to Dysphagia (difficulty swallowing) with a goal of will remain free of side effects or complications related to tube feeding through review date and interventions that included Elevate HOB (head of bed) i.e. 30-45 degrees during and i.e. 30-40 minutes after tube feeding is stopped. During an observation on 10/14/24 at 11:45AM, revealed Resident #21 was in bed with the continuous enteral feeding running at 40 milliliters per hour. Resident #21's bed was elevated at approximately 30 degrees while Resident #21's head and torso were not elevated at 30 degrees, and she was lying flat on her back. No signs of distress were noted. During an interview on 10/14/24 at 11:48 AM, revealed LVN A was called into Resident #21's room. LVN A called for help to reposition resident, LVN A stated his head of bed was elevated at 30 degrees but Resident #21 was not as she was lying on her back. LVN A stated CNAs and nurses were responsible of ensuring residents who received continuous enteral feeding like Resident #21 were repositioned with the head of bed elevated at least 30 degrees. LVN A stated CNAs and nurses conducted rounds at least every 2 hours to ensure proper positioning for residents on continuous enteral feeding. LVN A stated failure to position Resident #21 head of bed at 30 degrees placed her at risk of aspiration (occurs when contents such as food, drink, saliva, or vomit enters the lungs). During an interview on 10/16/24 at 08:00 AM, LVN J stated that residents with enteral feedings had to be with the head elevated at 30 degrees. LVN J stated that if head of bed was not elevated the residents with enteral feedings are at risk of aspiration pneumonia. During an interview on 10/16/24 at 10:00 AM. the DON stated all CNAs and nurses were responsible for ensuring residents who received continuous feedings were positioned with the head of bed elevated at least 30 degrees. The DON stated the charge nurses were responsible for ensuring proper position during their continuous rounds. The DON stated risk included aspiration pneumonia and lung congestion. Record review of Tube (enteral) Feeding General Information policy on Lippincott Manual of Nursing 11th edition reflected in part Suggested protocol for enteral tube feeding orders: elevated head of bed 30-45 degrees at all times during continuous feedings.

Based on observation, record review, and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for four (R#48, R#52, R#26 and R#53) of 24 residents that were reviewed for infection control and transmission-based precautions policies and practices, in that: 1. The facility failed to ensure Resident #48's indwelling catheter drainage bag was not touching the floor when placed behind his wheelchair. 2. The facility failed to ensure LVN M performed hand hygiene for at least 20 seconds before medication administration for Resident #52. 3. LVN M failed to properly clean a multi-use medical device between each resident during medication administration for Resident #26 and Resident #53. These failures could place residents that require assistance with personal care at risk for healthcare associated cross-contamination and infections. The findings were: 1. Record review of Resident #48's Admission Record dated 10/16/24 revealed Resident #48 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a group of symptoms affecting memory, thinking and social skills), obstructive and reflux uropathy (is when your urine can't flow through your ureter, bladder, or urethra due to some type of obstruction), age-related physical debility, muscle weakness, unsteadiness on feet, and muscle wasting and atrophy. Record review of Resident #48's quarterly MDS assessment dated [DATE] revealed: -was sometimes able to make himself understood (ability is limited to making concrete requests) -was sometimes able to understand others (responds adequately to simple, direct communication), - resident required maximum assistance for his ADLs, - did not have indwelling catheter, external catheter, ostomy or intermittent catheterization. Record review of Resident #48's comprehensive care plan initiated on 10/07/24 revealed Resident #48 had 16 Fr with 30ml bulb foley catheter r/t Obstructive Uropathy, with intervention to monitor for s/sx of discomfort on urination and frequency, monitor/document for pain/discomfort due to catheter and 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. Record review of Resident #48's physician's order summary dated 10/05/24 revealed monitor for privacy bag placement every shift related to obstructive and reflux uropathy, unspecified. Monitor that collection bag is off the floor and hung below bladder level every shift related to obstructive and reflux uropathy, unspecified. During an observation on 10/16/24 at 9:16 a.m. in the 200 hall, Resident #48 was self-propelling himself up the hall. Surveyor heard a swishing noise and looked down at the back of Resident #48's wheelchair. Resident #48 had the indwelling catheter drainage bag in a black privacy bag. The privacy bag was hung so low on the back of his wheelchair that it was dragging on the floor. Surveyor asked Resident #48 his name and Resident #48 did not respond and just looked at Surveyor and began rocking his wheelchair back and forth. In an interview on 10/16/24 at 9:17 a.m. ADON/LVN D said she was the ADON for the 200 hall. ADON/LVN said it was fine if the privacy bag was dragging on the floor because the catheter bag was in the privacy bag. The ADON/LVN D then bent down and took off the privacy bag, shortened the straps and then rehung the bag so that it was not touching the floor, stood up and then walked away. In an interview on 10/16/24 at 9:23 a.m. CNA E said the foley privacy bag should not be dragging on the floor. CNA E said the reason the foley bag should not be dragging on the floor was because of contamination to the foley. CNA E said they got in-services often on infection control and preventing contamination frequently. CNA E said they had an in-service on foley care last month. In an interview on 10/16/24 at 9:41 a.m. N.A. F said she did transfer Resident #48 to the wheelchair. The N.A. said she put the foley bag on the wheelchair. The N.A. said she did know the bag was not supposed to be dragging on the floor but did not know the reason why it was not supposed to be dragging on the floor. The Nurse Aide said she was still in training. In an interview on 10/16/24 at 4:09 p.m. the DON said the foley privacy bag can touch the floor, but it cannot drag. The CNAs are responsible to place the foley in the privacy bag and to place it on the W/C. The DON said the CNAs get instruction on how to hang the foley bag. The purpose of privacy bag is to give the resident privacy and to protect the foley bag from touching the floor. The foley bag can't touch the floor due to infection control. In an interview on 10/17/24 at 1:50 P.M. LVN G said a foley must not touch the floor. The foley touching the floor would be infection control. Record review of the copy the facility provided of the Lippincott Nursing Procedures 8th edition for Indwelling Urinary Catheter Care and Removal revealed: Implementation Inspect the catheter system for disconnections and leakage, because a sterile, continuously closed system is required to reduce the risk of CAUTI. Don't place the drainage bag on the floor, to reduce the risk of contamination and subsequent CAUTI. 2. Record review of Resident #52's Face Sheet dated 10/15/24 reflected an [AGE] year-old female with an original admitted [DATE]. Her diagnoses included unspecified dementia (decline in cognitive abilities that affects a person's ability to perform everyday activities), Diabetes Mellitus (high levels of glucose in the blood). During an observation of medication administration for Resident #52 on 10/15/24 at 7:30AM, LVN M washed her hands for 16 seconds prior to beginning medication administration and 16 seconds after medication administration was completed. During an interview on 10/16/25 at 08:00AM, CNA K stated that handwashing should be done for at least 20 seconds. CNA K stated that was important to properly wash the hands to prevent contaminate the next Resident. During an interview on 10/16/24 at 09:00AM, LVN M stated handwashing should be done for at least 20 seconds to prevent the spread of germs and infections. LVN A stated by not washing hands for 20 seconds or greater, it could lead to Resident #52's wound becoming infected. LVN M stated staff were in-serviced frequently on hand hygiene and infection control but could not remember when the last in-service was. During an interview on 10/16/24 at 10:20AM, LVN J stated handwashing should be done for at least 20 seconds to prevent the spread of infection. LVN J stated a negative outcome could be a cross contamination from one resident to another resident. During an interview on 10/16/24 at 10:35 AM, LVN A stated that handwashing should be done for at least 20 seconds with soap and water. LVN A stated if handwashing was not done correctly there was a risk of cross contamination. In an interview on 10/16/24 at 11:00AM, the DON stated handwashing should be at least 20 seconds or greater when lathering hands. The DON stated by not washing hands for 20 seconds are greater could increase the chances of spreading germs. The DON stated that a good handwashing needed to be done to prevent contamination from one Resident to another one. Record review of facility's Hand Hygiene policy revised on October 14, 2022, reflected: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Hand Hygiene technique when using soap and water: a. Wet hand with water. Avoid using hot water to prevent drying of skin. b. Apply to hands the amount soap recommended by the manufacturer. c. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. d. Rinse hands with water. e. Dry thoroughly with a single-use towel. f. Use clean towel to turn off the faucet 3. During a medication administration observation on 10/15/24 at 07:35 AM, LVN M picked up the wrist blood pressure device from the top of the medication cart and took it to the room of Resident #53 and took her blood pressure on the left wrist. She then took the wrist blood pressure device and placed it on top of the medication cart. LVN M did not sanitize the wrist blood pressure device before or after use and then went and used the blood pressure device with Resident #26. During an interview on 10/16/24 at 10:35 AM, LVN A stated she should have disinfected the blood pressure device before and after each use. LVN A stated that the staff used Micro Kill Bleach and that should let it sit for three minutes. She stated a potential negative outcome for failure to sanitize multi-use devices between residents would be the transfer of diseases and infection. During an interview on 10/16/24 at 10:45 AM, LVN J stated that multiple use blood pressure devices should be disinfected before and after each use in between residents. LVN J stated that failure to disinfect the blood pressure device was that all residents are at risk for cross contamination. During an interview on 10/16/24 at 11:11 AM, the DON stated a potential negative outcome for failure to sanitize multi-use devices between residents would be increased risk of infection to residents. Record review of the facility-provided policy titled Infection Prevention and control Program, date implemented 5/13/23, revealed: Equipment protocol: All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment. 50487

Based on interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (which included to the State Survey Agency) in accordance with State law through established procedures for 2 of 5 residents (Resident #4 and Resident #5) reviewed for reporting alleged allegation of abuse. Facility staff member, LVN A did not report to the Administrator within 2 hours when Resident #4 and Resident #5 got into an altercation. This failure could place residents at risk for undetected abuse, neglect and/or decline in feelings of safety and well-being. The findings included: Record review of Resident #4's face sheet, dated 09/26/24, reflected the resident was a [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnoses that included: Alzheimer disease (progressive disease that destroys memory and other important mental functions) with late onset, flaccid hemiplegia (one side of the body is completely and permanently paralyzed) affecting right dominant side, dysphagia oropharyngeal phase (difficulty swallowing). Record review of Resident #4's state optional minimum data set assessment (MDS), dated [DATE], reflected Resident #4 was rarely/never understood and did not have a BIMS conducted. Record review of Resident #4's care plan with an initiated date of 07/11/23 reflected 5/21/24 - [Resident #4] was pulled off from bed by resident A [SIC]. As per resident A, he felt confused while looking for his bed and pulled resident on bed B off of bed. with an initiated date of 07/21/23 and a revision date of 08/12/24. Record review of resident #4's nursing note written by LVN A with an effective date of 05/21/24 at 2:19am stated, CNA notified SN (staff nurse) that both residents in room were in a physical altercation. Sn went to room to assess. [Resident #5] was sitting on his right side of his bed. Bed at mid position with wheels locked, call light within reach. [Resident #4] was on the right side to his bed on the floor facing down with [Resident #5's] cane under him. Bed at lowest position with call light within reach. Resident is nonverbal, when asked if he hit [Resident #5] resident shook his head side to side. When asked if [resident #5] hit him, resident nodded his head up and down. When asked if [Resident #5] dragged him off of bed, resident nodded head up and down. head to toe assessment down [SIC] while resident was lying on floor. No visible injuries noted. With assistance by CNAs, readjusted resident to sitting position on floor, head to toe assessment done, noted redness to left forearm, redness to right flank, and redness to right side of face. With assistanceof cnas, transferres [SIC] resident back on to bed. Head to toe assessment done again, redness to left forearm noted, redness to right flank, and redness to right side of face noted at the time. Resident denies pain and shows no nonverbal cues of pain. Resident is smiling back at sn. Bed at lowest position with call light within reach. Pending to notify RP and PCP. Record review of Resident #4's weekly skin evaluation dated 05/21/24 reflected, redness to left knee, left hand and right hand. Record review of Resident #5's face sheet, dated 09/26/24, reflected the resident was a [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnoses that included: Blindness (lack of vision) right eye category 3 (visual acuity of worse than 3/60 and better than 1/60), blindness (lack of vision) left eye category 3 (visual acuity of worse than 3/60 and better than 1/60), paranoid schizophrenia (paranoia that feeds into delusions and hallucinations), bipolar disorder (extreme shifts in mood), current episode mixed, severe, with psychotic features, schizoid personality disorder (avoiding social activities and interacting with others) Record review of Resident #5's state optional minimum data set assessment (MDS), dated [DATE], reflected Resident #5 had a BIMS score of 06 indicating he had severe cognitive impairment. Record review of Resident #5's care plan with an initiated date of 08/11/22 reflected 5/21/24 - [Resident #5] stated he felt confused while looking for his bed and pulled resident on bed B off of the bed. with an initiated date of 06/19/23 and a revision date of 05/23/24. Record Review of Resident #5's nursing notes dated 05/21/24 stated, Sn was walking out of storage when cna notified sn that both residents in room were in a physical altercation. Sn went to room to assess. [Resident #5] was sitting on his right side of his bed. Bed at mid position with wheels locked, call light within reach. [Resident #4] was on the right side to his bed on the floor facing down with [Resident #5's] cane under him. Bed at position with call light within reach. Resident stated he was lost and confused looking for his bed, stated he got to his bed someone hit him. Resident stated he hit person back with his cane and dragged him from bed. When asked if resident also fell to the floor, resident stated yes, denies any pain, no loss of consciousness [SIC], stated he hit his right temporal. Resident fell when he pulled [Resident #4] from bed. Resident stated he got himself up and sat down to the right of his bed. Head to toe assessment done, redness to right temporal noted. No other injuries noted, denies pain or discomfort at the time. Good range of motion noted to BUE and BLE. Able to verbilize [SIC] needs at the time. Offered pain medication, denied at the time. Reoiented [SIC] and reeducated resident on the importance on not being violent and or physical. [Resident #5] denied hitting resident first after being reeducated. Pending to notify RP and PCP. Record review of Resident #5's weekly skin evaluation dated 05/21/24 reflected, redness to left temporal at the time. Record Review of TULIP (HHSC online incident reporting application) on 09/24/24 at 11:00 AM revealed a self-report received by the facility on 05/21/24 at 9:58AM regarding the altercation with Resident #4 and Resident #5, more than 2 hours after the altercation occurred. During an interview with Resident #5 on 09/24/24 at 11:10 am he stated he did not recall an incident specifically with Resident #4 or any resident. During an interview with Resident #4 on 09/24/24 at 11:42am he was unable to clearly answer questions due to limited gestures used for communication. During an interview with CNA B on 09/25/24 at 1:24pm she stated there was one night that she responded to a scream from a resident who had told her he heard Resident #5 scream and went to go check along with CNA B. CNA B stated everyone went to go assess the situation and saw Resident #5 angry and was stating that Resident #4 was in his bed, however CNA B stated at that time Resident #4 was actually in his correct bed and Resident #5 was confused. CNA B stated they had spoken to Resident #5, and he had told them the whole situation. CNA B stated they believed Resident #5 tried to push Resident #4 off the bed. CNA B stated LVN A went to assess the residents for any injuries. CNA B stated she was not sure who LVN A notified of the altercation. During an interview with LVN A on 09/25/24 at 3:36pm who stated she stated she could not recall the exact date but stated she was notified by an aide that there had been a fight with Resident #4 and Resident #5 and Resident #4 was on the floor. LVN A stated when she entered the room Resident #4 was on the floor and Resident #5 was sitting on his bed. LVN A stated Resident #4 was found to have some redness to his face, arm and somewhere on his abdomen and Resident #5 had some redness to his face. LVN A stated she completed her risk management/incident report documents for both residents and had completely forgotten to make the appropriate notifications. LVN A stated she went home and later that morning received a call from the facility after they had reviewed the risk management documents in the morning and asked her what happened. LVN A stated she had to return to the facility that morning and complete the report and notify the police and appropriate parties. LVN A stated the facility did write her up due not making the appropriate notifications. During a follow up interview with LVN A on 09/25/24 at 4:48pm who stated the abuse coordinator was responsible for training staff over abuse and the reporting process however she was unable to recall who the abuse coordinator was. LVN A stated incidents of abuse should be reported to the DON, the resident's family and the doctor. LVN A stated she considered the altercation between Resident #4 and Resident #5 as abuse and stated it should have been reported to the DON, Administrator and MD/NP. LVN A stated she had not reported it because she lost track of time and had forgotten. LVN A stated it was important to report abuse because of the change in condition to the residents and safety. LVN A stated she had been trained over the facility abuse policy both at orientation and after the altercation with Resident #4 and Resident #5 and stated it said to report immediately. LVN A stated she did not follow the facility abuse policy. LVN A stated she monitored residents to ensure they were free from abuse and neglect by completing her observations of the residents and how they get along with others and their interactions with aides and the care the aides were providing. LVN A stated not reporting incidents of abuse could negatively impact the residents because if it is not reported then no interventions would be put place, and residents can decline emotionally and physically if in an environment of abuse and neglect. During an interview with the Administrator on 09/25/24 at 5:10pm who stated staff had been trained over abuse and the reporting process by her on a regular basis. The administrator stated she was the abuse coordinator and stated staff should report incidents of abuse to her. The Administrator stated there was a resident to resident altercation with Resident #4 and #5 when Resident #5 was confused and believed he was getting into his own bed when it was Resident #4's bed. When this occurred Resident #4 became combative defending himself and he and Resident #5 got into an altercation when then Resident #5 pulled Resident #4 out of the bed and onto the floor. The Administrator stated both residents were assessed by LVN A with slight redness to left knee, left and right hand for Resident #4 and slight redness to the temporal area for Resident #5, the Administrator stated neither resident voiced pain at time of assessment. The Administrator stated LVN A completed the appropriate risk management/incident report documentation but failed to make the appropriate notifications. The Administrator stated she got report during their morning meeting on 05/21/24 at around 9:00am that an incident occurred around 2am that morning. The Administrator stated she made a self-report on 05/21/24 at 9:30am after becoming aware of incident. The Administrator stated LVN A should have reported the altercation between Resident #4 and #5 to herself and the DON. The Administrator stated she did not know why LVN A did not report the incident and stated although she was a new employee she had been trained over reporting upon orientation. The Administrator stated due to Resident #4 and Resident #5's BIMS score and confusion she did not consider the altercation between Residents #4 and #5 abuse and stated Resident #5 stated he did not mean to hurt anyone and had thought someone was in his bed and when he felt someone fight back, he became defensive. The Administrator stated it was important to report abuse to the appropriate parties to prevent abuse and ensure patient safety. The Administrator stated the facility policy was similar to the regulations in place and stated all allegations should be reported to administrator and state agencies immediately and no later than 2 hours after if it's from abuse and no later than 24 hours if the incident did not involve abuse. The Administrator stated LVN A did not follow the facility policy. The Administrator stated she monitored residents to ensure they were free from abuse by ensuring direct care staff, leadership team and the physicians completed their rounds and reported any changes. The Administrator stated residents were also educated on how to report by her and through their resident council meetings. The Administrator stated not reporting incidents of abuse could negatively impact the resident because it puts them at risk if it was not reported. During an interview with the DON on 09/25/24 at 6:45pm who stated she had started to work at the facility on 07/01/24 and was not working at the facility at time of the incident between Resident #4 and Resident #5 in May 2024. Record review of facility in-services reflected LVN A had been trained over reporting incidents on 05/06/24. Record review of a document titled, EMPLOYEE COUNSELING REPORT reflected on 05/21/24 LVN A received counseling over her failure to report an incident in a timely manner. Record review of facility policy titled Abuse, Neglect and Exploitation with an implementation date of 08/15/22 included a section titled, Reporting/Response that included the following verbiage: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on interview and record review, the facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, for 2 of 5 residents (Resident#4 and Resident #5) reviewed for abuse and neglect, in that: Facility staff member, LVN A did not implement facility abuse policy related to reporting abuse to the Administrator when Resident #4 and Resident #5 got into an altercation on 05/21/24. This failure could place residents at risk of abuse and neglect. The findings included: Record review of Resident #4's face sheet, dated 09/26/24, reflected the resident was a [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnoses that included: Alzheimer disease (progressive disease that destroys memory and other important mental functions) with late onset, flaccid hemiplegia (one side of the body is completely and permanently paralyzed) affecting right dominant side, dysphagia oropharyngeal phase (difficulty swallowing). Record review of Resident #4's state optional minimum data set assessment (MDS), dated [DATE], reflected Resident #4 was rarely/never understood and did not have a BIMS conducted. Record review of Resident #4's care plan with an initiated date of 07/11/23 reflected 5/21/24 - [Resident #4] was pulled off from bed by resident A [SIC]. As per resident A, he felt confused while looking for his bed and pulled resident on bed B off of bed. with an initiated date of 07/21/23 and a revision date of 08/12/24. Record review of resident #4's nursing note written by LVN A with an effective date of 05/21/24 at 2:19am stated, CNA notified SN (staff nurse) that both residents in room were in a physical altercation. Sn went to room to assess. [Resident #5] was sitting on his right side of his bed. Bed at mid position with wheels locked, call light within reach. [Resident #4] was on the right side to his bed on the floor facing down with [Resident #5's] cane under him. Bed at lowest position with call light within reach. Resident is nonverbal, when asked if he hit [Resident #5] resident shook his head side to side. When asked if [Resident #5] hit him, resident nodded his head up and down. When asked if [Resident #5] dragged him off of bed, resident nodded head up and down. head to toe assessment down [SIC] while resident was lying on floor. No visible injuries noted. With assistance by CNAs, readjusted resident to sitting position on floor, head to toe assessment done, noted redness to left forearm, redness to right flank, and redness to right side of face. With assistanceof cnas, transferres [SIC] resident back on to bed. Head to toe assessment done again, redness to left forearm noted, redness to right flank, and redness to right side of face noted at the time. Resident denies pain and shows no nonverbal cues of pain. Resident is smiling back at sn. Bed at lowest position with call light within reach. Pending to notify RP and PCP. Record review of Resident #4's weekly skin evaluation dated 05/21/24 reflected, redness to left knee, left hand and right hand. Record review of Resident #5's face sheet, dated 09/26/24, reflected the resident was a [AGE] year-old male who was initially admitted to the facility on [DATE] with diagnoses that included: Blindness (lack of vision) right eye category 3 (visual acuity of worse than 3/60 and better than 1/60), blindness (lack of vision) left eye category 3 (visual acuity of worse than 3/60 and better than 1/60), paranoid schizophrenia (paranoia that feeds into delusions and hallucinations), bipolar disorder (extreme shifts in mood), current episode mixed, severe, with psychotic features, schizoid personality disorder (avoiding social activities and interacting with others) Record review of Resident #5's state optional minimum data set assessment (MDS), dated [DATE], reflected Resident #5 had a BIMS score of 06 indicating he had severe cognitive impairment. Record review of Resident #5's care plan with an initiated date of 08/11/22 reflected 5/21/24 - [Resident #5] stated he felt confused while looking for his bed and pulled resident on bed B off of the bed. with an initiated date of 06/19/23 and a revision date of 05/23/24. Record Review of Resident #5's nursing notes dated 05/21/24 stated, Sn was walking out of storage when cna notified sn that both residents in room were in a physical altercation. Sn went to room to assess. [Resident #5] was sitting on his right side of his bed. Bed at mid position with wheels locked, call light within reach. [Resident #4] was on the right side to his bed on the floor facing down with [Resident #5's] cane under him. Bed at position with call light within reach. Resident stated he was lost and confused looking for his bed, stated he got to his bed someone hit him. Resident stated he hit person back with his cane and dragged him from bed. When asked if resident also fell to the floor, resident stated yes, denies any pain, no loss of consciousness [SIC], stated he hit his right temporal. Resident fell when he pulled [resident #4] from bed. Resident stated he got himself up and sat down to the right of his bed. Head to toe assessment done, redness to right temporal noted. No other injuries noted, denies pain or discomfort at the time. Good range of motion noted to BUE and BLE. Able to verbilize [SIC] needs at the time. Offered pain medication, denied at the time. Reoiented [SIC] and reeducated resident on the importance on not being violent and or physical. [Resident #5] denied hitting resident first after being reeducated. Pending to notify RP and PCP. Record review of Resident #5's weekly skin evaluation dated 05/21/24 reflected, redness to left temporal at the time. During an interview with Resident #5 on 09/24/24 at 11:10 am he stated he did not recall an incident specifically with Resident #4 or any resident. During an interview with Resident #4 on 09/24/24 at 11:42am he was unable to clearly answer questions due to limited gestures used for communication. During an interview with CNA B on 09/25/24 at 1:24pm she stated there was one night that she responded to a scream from a resident who had told her he heard Resident #5 scream and went to go check along with CNA B. CNA B stated everyone went to go assess the situation and saw Resident #5 angry and was stating that Resident #4 was in his bed, however CNA B stated at that time Resident #4 was actually in his correct bed and Resident #5 was confused. CNA B stated they had spoken to Resident #5, and he had told them the whole situation. CNA B stated they believed Resident #5 tried to push Resident #4 off the bed. CNA B stated LVN A went to assess the residents for any injuries. CNA B stated she was not sure who LVN A notified of the altercation. During an interview with LVN A on 09/25/24 at 3:36pm who stated she stated she could not recall the exact date but stated she was notified by an aide that there had been a fight with Resident #4 and Resident #5 and Resident #4 was on the floor. LVN A stated when she entered the room Resident #4 was on the floor and Resident #5 was sitting on his bed. LVN A stated Resident #4 was found to have some redness to his face, arm and somewhere on his abdomen and Resident #5 had some redness to his face. LVN A stated she completed her risk management/incident report documents for both residents and had completely forgotten to make the appropriate notifications. LVN A stated she went home and later that morning received a call from the facility after they had reviewed the risk management documents in the morning and asked her what happened. LVN A stated she had to return to the facility that morning and complete the report and notify the police and appropriate parties. LVN A stated the facility did write her up due not making the appropriate notifications. During a follow up interview with LVN A on 09/25/24 at 4:48pm who stated the abuse coordinator was responsible for training staff over abuse and the reporting process however she was unable to recall who the abuse coordinator was. LVN A stated incidents of abuse should be reported to the DON, the resident's family and the doctor. LVN A stated she considered the altercation between Resident #4 and Resident #5 as abuse and stated it should have been reported to the DON, Administrator and MD/NP. LVN A stated she had not reported it because she lost track of time and had forgotten. LVN A stated it was important to report abuse because of the change in condition to the residents and safety. LVN A stated she had been trained over the facility abuse policy both at orientation and after the altercation with Resident #4 and Resident #5 and stated it said to report immediately. LVN A stated she did not follow the facility abuse policy. LVN A stated she monitored residents to ensure they were free from abuse and neglect by completing her observations of the residents and how they get along with others and their interactions with aides and the care the aides were providing. LVN A stated not reporting incidents of abuse could negatively impact the residents because if it is not reported then no interventions would be put place, and residents can decline emotionally and physically if in an environment of abuse and neglect. During an interview with the Administrator on 09/25/24 at 5:10pm who stated staff had been trained over abuse and the reporting process by her on a regular basis. The administrator stated she was the abuse coordinator and stated staff should report incidents of abuse to her. The Administrator stated there was a resident to resident altercation with Resident #4 and #5 when Resident #5 was confused and believed he was getting into his own bed when it was Resident #4's bed. When this occurred Resident #4 became combative defending himself and he and Resident #5 got into an altercation when then Resident #5 pulled Resident #4 out of the bed and onto the floor. The Administrator stated both residents were assessed by LVN A with slight redness to left knee, left and right hand for Resident #4 and slight redness to the temporal area for Resident #5, the Administrator stated neither resident voiced pain at time of assessment. The Administrator stated LVN A completed the appropriate risk management/incident report documentation but failed to make the appropriate notifications. The Administrator stated she got report during their morning meeting on 05/21/24 at around 9:00am that an incident occurred around 2am that morning. The Administrator stated she made a self-report on 05/21/24 at 9:30am after becoming aware of incident. The Administrator stated LVN A should have reported the altercation between Resident #4 and #5 to herself and the DON. The Administrator stated she did not know why LVN A did not report the incident and stated although she was a new employee she had been trained over reporting upon orientation. The Administrator stated due to Resident #4 and Resident #5's BIMS score and confusion she did not consider the altercation between Residents #4 and #5 abuse and stated Resident #5 stated he did not mean to hurt anyone and had thought someone was in his bed and when he felt someone fight back, he became defensive. The Administrator stated it was important to report abuse to the appropriate parties to prevent abuse and ensure patient safety. The Administrator stated the facility policy was similar to the regulations in place and stated all allegations should be reported to administrator and state agencies immediately and no later than 2 hours after if it's from abuse and no later than 24 hours if the incident did not involve abuse. The Administrator stated LVN A did not follow the facility policy. The Administrator stated she monitored residents to ensure they were free from abuse by ensuring direct care staff, leadership team and the physicians completed their rounds and reported any changes. The Administrator stated residents were also educated on how to report by her and through their resident council meetings. The Administrator stated not reporting incidents of abuse could negatively impact the resident because it puts them at risk if it was not reported. During an interview with the DON on 09/25/24 at 6:45pm who stated she had started to work at the facility on 07/01/24 and was not working at the facility at time of the incident between Resident #4 and Resident #5 in May 2024. Record review of facility in-services reflected LVN A had been trained over reporting incidents on 05/06/24. Record review of a document titled, EMPLOYEE COUNSELING REPORT reflected on 05/21/24 LVN A received counseling over her failure to report an incident in a timely manner. Record review of facility policy titled Abuse, Neglect and Exploitation with an implementation date of 08/15/22 included a section titled, Reporting/Response that included the following verbiage: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on observations, interview and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preference for one (Resident #2) of four residents reviewed for call light. The facility failed to ensure Resident #2's call light was within reach. This failure could place residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings were: Record review of Resident #2's face sheet dated 07/18/2024 reflected an [AGE] year-old male with an admitted [DATE]. Resident #2's relevant diagnoses included cerebral infarction (occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it), unsteadiness on feet, need for assistance with personal care, and lack of coordination. Record review of Resident #2's quarterly MDS dated [DATE] reflected a BIMS score of 04, which indicated Resident #2's cognition was severely impaired. Record review of Resident #2's quarterly comprehensive care plan dated 04/29/24 reflected: Problem: the resident was at risk for falls related to weakness and debility. Interventions: 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 request for assistance. Date initiated: 08/12/2022. An observation on 07/17/24 at 2:45 p.m., Resident #2 was lying awake in bed, his bed was set to the lowest position. Resident #2's call light was not within reach or sight. An interview on 07/17/24 at 2:48 p.m., Resident #2 said he did not know where his call light was. He said whenever he needed assistance, he would call out for help or would wheel himself to the front of his door to get the staff's attention. Resident #2 said would rarely use the call light. An interview and observation on 07/17/24 at 2:56 p.m., CNA A said Resident #2 was able to use the call light, but he preferred calling out for help. Surveyor observed CNA A looking for Resident #2's call light and she found it inside his dresser drawer next to his bed. She said she was not sure why it was there but that it should have been within Resident #2's reach. CNA A said she would round resident's rooms every two hours or as needed. She said one of the things she checked when doing her rounds was to make sure resident's bed was set to the lowest position and their call light was within reach. CNA A said a negative outcome for Resident #2 not having his call light within reach could be not receiving the assistance he needed in case he fell . She said she had been in-serviced on making sure the resident's call light were always within reach when she was first hired and monthly after that. An interview on 07/17/24 at 3:10 p.m., CNA B said she had been assigned to Resident #2's room on 07/17/2024. She said her shift on 07/17/2024 was 6 a.m. to 6 p.m. CNA B said she had already rounded Resident #2's room between 3 to 4 times since her shift began. CNA B said Resident #2 had been showered in the morning and while he was being showered, she changed his linen. CNA B said she remembered placing Resident #2's call light inside his dresser drawer next to his bed and must have forgotten to take it out and place on his bed when she was done. CNA B said she had not noticed Resident #2's call light was not within reach the 3 other times she had gone into his room. She said Resident #2 rarely used his call light, she said he preferred calling out for help. CNA B said she had not told her charge nurse that Resident #2 did not like to use his call light. She said a negative outcome for Resident #2 not having his call light within reach could an injury. She said she had been in-serviced on making sure the resident's call light were always within reach when she was first hired and monthly after that. An interview on 07/17/24 at 3:19 p.m., LVN C said she was Resident #2's charge nurse on 07/17/24. LVN C said she and CNA's rounded each resident every 2 hours or as needed. LVN C said she had already made several rounds to resident #2's room that day and had not noticed his call light was not within reach. LVN C said Resident #2 rarely used his call light. She said when he needed something, he would yell out or wheeled himself to the door to motion a staff member. She said she had not told the DON that Resident #2 did not like to use the call light. LVN C said a negative outcome for Resident #2 not having his call light within reach could be him not receiving the care he needed. An interview and observation on 07/17/24 at 3:25 p.m., ADON/LVN D said Resident #2 was able to use the call light but preferred yelling out when he needed something. Surveyor observed ADON-LVN D ask Resident #2 to press his call light to verify that he was able to use it. Resident #2 was observed pressing the call light and saying he knew to press it when he needed assistance. ADON-LVN D said a negative outcome to Resident #2 not having his call light within reach would be staff would not know resident needed help at that moment. She said all staff are in-serviced on making sure resident's call lights are within reach when they are first hired and monthly after that. An interview on 07/18/2024 at 4:00 p.m. the Administrator said the ADON's had audited all residents on 07/17/2024 to make sure their call lights was within reach. She was not able to say what negative outcome could be if a resident did not have their call light within reach. Record review of the facility's Call Lights: Accessibility and Timely Response policy dated 10/13/2022 reflected: Policy: The purpose of this policy is ot assure the facility is adequately equipped with a call light at teach resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. Policy Explanation and Compliance Guidelines: 1. All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light 5. Staff will ensure the call light is within reach of resident and secured, as needed.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 7 residents (Resident #1 and Resident #3) reviewed for care plans, in that: 1. The facility failed to ensure Resident #1's care plan revised on 03/10/2024 reflected an injury for a witnessed fall on 02/15/2024. 2. The facility failed to ensure Resident #3's quarterly care plan dated 03/28/2024 reflected an un-witnessed fall he had on 02/29/2024. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs. The Findings included: 1. Record review of Resident #1's face sheet dated 07/18/24 reflected Resident #1 was admitted on [DATE] and was [AGE] years old. Resident #1 had diagnoses of subsequent encounter of fracture of shaft of humerus to right arm, muscle weakness, age-related osteoporosis, dementia, and mood disorder. Record review of Resident #1's Discharge MDS dated [DATE] reflected the resident: Short-term memory problem modified independence with some difficulty in new situations only. Required substantial/maximal assistance for self-care except eating and oral hygiene supervision/touching assistance, and upper body dressing partial/moderate assistance. Required substantial/maximal assistance for mobility. BIMS score of 1 which indicated Resident #1's cognition was severely impaired. Record review of Resident #1's comprehensive care plan reflected: Resident #1 had an actual fall r/t muscle wasting/atrophy, lack of coordination, and difficulty walking. 2/15/2024 1:30 witnessed fall, no injury. Date Initiated: 01/27/2024. Revision on: 03/10/2024 Interventions included: o 2/16/2024: Orthopedic Consult On 7/17/24 at 4:34 pm interviewed MDS-RN - Care Management Specialist. She said that a fall with injury should be updated on the care plan by the ADON or DON. On 7/17/24 at 5:00 pm interviewed ADON-LVN D. She said that the fall on 2/15/24 initially was care planned without injury. She said that on 2/16/24, they received results of x-rays, and the injury should have been updated on the care plan. She looked up the resident's care plan and said the injury was not updated on care plan. She said that it should have been updated to fall with injury. She said that if the MDS and care plan are not updated, staff would not know that the care plan is current with the resident needs. 2. Record review of Resident #3's face sheet dated 07/17/2024 reflected an [AGE] year-old male with an admitted [DATE] and an original admitted [DATE]. Resident #3 was discharged on [DATE]. Resident #3's relevant diagnoses included cerebral infarction (occurs because of disrupted blood flow to the brain due to problems with the blood vessels that supply it), Parkinson's Disease (a disorder of the central nervous system that affects movement), dementia (a group of thinking and social symptoms that interfere with daily functioning), diabetes (too much sugar in the blood), and lack of coordination. Record review of Resident #3's quarterly assessment dated [DATE] reflected no BIMS score which indicated Resident #3's cognition was severely impaired. Record review of Resident #3's quarterly care plan dated 03/28/2024 reflected [Resident #3] had an actual fall r/t muscle wasting/atrophy, lack of coordination, and difficulty walking on 04/01/2024 un-witnessed fall, with no injury and 04/10/2024 un-witnessed fall, laceration to posterior head. The un-witnessed fall he had on 02/29/2024 was not care planned. An interview on 07/17/2024 at 3:31 p.m., MDS-RN said she was new to her position and would rather have surveyor interview one of the facility's ADON's. An interview and observation on 07/17/2024 at 5:00 p.m., ADON-LVN D was observed checking Resident #3's electronic record and said after she reviewed his care plan that she was not sure if the un-witnessed fall Resident #3 had on 02/29/2024 had been care planned. She said the fall Resident #3 sustained on 02/29/2024 should have been care planned. ADON-LVN said she was going to check with MDS if it had been care planned. An interview on 07/17/2024 at 5:32 p.m., ADON-RD D said the un-witnessed fall Resident #3 had on 02/29/2024 had not been care planned. She was not able to say if Resident #3 had any negative outcome for the fall not being care planned because he had already been discharged . Record review of facility's Care Plan Revisions Upon Status Change policy dated 10/24/22 reflected: Policy: The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 2. Procedure for reviewing and revising the care plan when a resident experiences a status change . f. Care plans will be modified as needed by the MDS Coordinator or other designated staff member. 49301

Based on interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #1) of 3 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #1 was coded in the MDS for a fall on 2/16/24. This failure could place residents at risk of receiving care and services to meet their needs. The findings included: Record review of Resident #1's face sheet dated 07/18/24 reflected Resident #1 was admitted on [DATE] and was [AGE] years old. Resident #1 had diagnoses of subsequent encounter of fracture of shaft of humerus to right arm, muscle weakness, age-related osteoporosis, dementia, and mood disorder. Record review of Resident #1's comprehensive care plan reflected: Resident #1 had an actual fall r/t muscle wasting/atrophy, lack of coordination, and difficulty walking. 2/15/2024 1:30 pm witnessed fall, no injury. Date Initiated: 01/27/2024. Revision on: 03/10/2024 Interventions included: o 2/16/2024: Orthopedic Consult Record review of Resident #1's Discharge MDS dated [DATE] revealed: Short-term memory problem modified independence with some difficulty in new situations only. Required substantial/maximal assistance for self-care except eating and oral hygiene supervision/touching assistance, and upper body dressing partial/moderate assistance. Required substantial/maximal assistance for mobility. No falls since Admission/Entry or Reentry or Prior MDS Assessment. Record review of Resident #1's progress notes dated 2/15/2024 at 10:47 a.m., written by LVN D indicated SN was made aware by therapist that resident was on floor in dining room. SN went to assess resident and was laying supine on floor. Resident able to move all extremities with no pain or distress voiced. SN assessed head and noted no redness. As per staff, they didn't hear the fall but when they look resident was already on the floor. SN notified NP no new orders given. Neuro checks initiated. SN notified RP, but no answer. Resident unable to give description. Record review of a progress note for Resident #1 dated 2/15/2024 at 12:28 p.m., written by LVN E indicated Resident noted abnormal movements. Resident trying to get off wheelchair. Noted with uncoordinated movement. NP made aware. Neuro checks in place. New orders for Hydroxyzine 25mg q12hrs x 14day. SN will pass on report. Orders carried out. Record review of the facility's incident log not dated revealed that on 2/15/24, Resident #1 had a witnessed fall on. No other information is noted on the facility log. During an interview on 7/17/24 at 4:34 p.m., MDS-RN - Care Management Specialist said she had worked at the facility for four months. She said that a fall with a fracture should be captured on the following MDS, in this Resident's case, the Discharge MDS. She said that it had not been captured by MDS. During an interview on 7/17/24 at 5:00 p.m., ADON-LVN D said the fall should have been captured on the MDS by the MDS department. She said that the care plan and MDS are an interdisciplinary team effort. She said that if the MDS and care plan are not updated, staff would not know that the care plan is current with the resident needs. Record review of CMS's RAI Version 3.0 Manual dated 10/2023, , reflected section: J1800: Any falls since admission/entry or reentry or Prior to Assessment. Coding instructions: Code 1, yes if the resident has fallen since the last assessment. Continue to number of falls since admission/entry or reentry or prior to assessment. J1900: Any falls since admission/entry or reentry or Prior to Assessment. Coding instructions: Code 1, yes if the resident had one non-injurious fall since admission/entry or reentry or prior assessment.