Every finding on record at Stillhouse Rehabilitation and Healthcare Center

Based on interview, and record review the facility failed to facilitate the inclusion of the resident or resident representative in the care planning process for 3 (Resident #5, #66 and #74) of 5 residents reviewed for care plans in that: The facility failed to invite and include the input of Resident's #5, #66 and #74 or their representatives as members of the interdisciplinary team in the Care Plan conference meetings. This failure could place residents at risk of not having their needs met by depriving them of the opportunity to participate in the decision making regarding their care. The findings included:Record review of Resident #5's face sheet dated 07/17/2026 revealed a [AGE] year-old male originally admitted [DATE] with diagnoses which included chronic respiratory failure (a long-term condition where the lungs cannot maintain adequate oxygen levels), DMII (a condition that affects how the body uses insulin and sugar), hyperlipidemia (elevated levels of lipids (fats) in the blood), hypertension (high blood pressure) and major depressive disorder (a persistent feeling of sadness and loss of interest). Resident #5 was his own responsible party.Record review of Resident #5's Quarterly MDS dated [DATE] revealed no speech, communication or hearing deficits and a BIMS score of 14 which indicated intact cognition. The MDS revealed Resident #5 required the use of a walker or wheelchair for mobility, set up assistance for eating, supervision with bathing, upper body dressing and moderate assistance with toileting, lower body dressing.Record review of the Care Plan Review Summary dated 08/19/2024, 02/18/2024 and 12/30/2024 indicated that Resident #5 participated in the care plan conference and there was a corresponding Care Conference Summary which included a signature sheet which indicated attendance at the meeting. Record review of the Care Plan review Summary dated 01/09/2026, 04/09/2026 and 07/09/2026 indicated that Resident #5 participated in the care plan conference, but there was no corresponding signature sheet that indicated attendance at the meeting. During a group interview on 07/15/2026 at 3:45 p.m., Resident #5 denied attending quarterly review meetings recently, but noted he had attended in the past.Record review of Resident #66's face sheet dated 07/17/2026, revealed Resident #66 admitted [DATE] with diagnoses which included COPD (a progressive lung disease that makes it difficult to breathe), DMII (a condition that affects how the body uses insulin and sugar), Atrial fibrillation (irregular, rapid heartbeat), hyperlipidemia (elevated levels of lipids (fats) in the blood), and atherosclerotic heart disease (a condition caused by plaque buildup in the arteries). Resident #66 was his own responsible party.Record review of Resident #66's Quarterly MDS dated [DATE] revealed no speech, communication or hearing deficits and a BIMS score of 15 which indicated intact cognition. The MDS revealed Resident #66 had lower extremity range of motion impairment, required the use of a wheelchair for mobility, set up assistance in eating, maximum assistance in bed mobility and was totally dependent inon staff for toileting, bathing, dressing, and transfers.Record review of the Care Plan Review Summary dated 12/30/2025 indicated that Resident #66 participated in the care plan conference and there was a corresponding Care Conference Summary with signature sheet which indicated attendance at the meeting. Record review of the Care Plan review Summary dated 02/25/2026, 05/11/2026, and 06/02/2026 indicated that Resident #66 participated in the care plan conference, but there is no corresponding signature sheet that indicated attendance at the meeting. During a group interview on 07/15/2026 at 3:45 p.m., Resident #66 denied that he had attended quarterly review meetings recently but that he had attended in the past. Record review of Resident #74's face sheet dated 07/17/2026, revealed a [AGE] year-old male who admitted on [DATE] with diagnoses which included hypertension (high blood pressure), cardiac arrhythmia (irregular heartbeat) and depression (persistent feeling of sadness, emptiness and a loss of interest in daily activities) and anxiety (excessive or persistent feelings of fear or apprehension). Resident #74 was his own responsible party.Record review of Resident #74's Quarterly MDS dated [DATE] revealed no speech, communication or hearing deficits and a BIMS score of 12 which indicated moderate cognitive impairment. Resident #74 required the use of a wheelchair for mobility, was independent in toileting, dressing, bed mobility, transfers, and supervision in bathing. Record review of the Care Plan Review Summary dated 10/9/2025 indicated that Resident #66 participated in the care plan conference and there was a corresponding Care Conference Summary with signature sheet which indicated attendance at the meeting. Record review of the Care Plan review Summary dated 01/09/2026, 04/09/2026, and 07/09/2026 indicated that Resident #74 participated in the care plan conference, but there is no corresponding signature sheet that indicated attendance at the meeting. During a group interview on 07/15/2026 at 3:45 p.m., Resident #74 denied that he had attended quarterly review meetings recently but that he had attended in the past. In an interview on 07/16/2026 at 8:55 a.m., the Social Worker stated that she completed a Care Conference Summary which included the signature of each member in attendance to include the resident or responsible person. The Social Worker was unable to provide a Care Conference Summary for Resident #5 dated 01/09/2026, 04/09/2026 or 07/09/2026, for Resident #66 dated 02/25/2026, 05/11/2026 or 06/02/2026 and Resident #74 dated 01/09/2026, 04/09/202 or 07/09/2026. The Social Worker stated all completed Care Conference Summaries had been provided to the medical records department to be uploaded in the EMR. The SW stated she was responsible for completing the Care Conference Summary and obtaining signatures of attendance.In an interview on 07/16/2026 at 9:10 a.m., the Medical Records technician stated she had uploaded all documents and was current up to June 2026. The Medical Records technician stated she did not have any Care Conference Summaries for the identified dates that occurred for Residents #5, #66 and #74. In an interview on 07/17/2026 at 2;:24 p.m., LVN K stated that she had attended the care plan meetings in the past and that she does not recall if she signed an attendance sheet at each meeting. LVN K stated she could not recall specifically if she had attended the care plan meetings for Resident #5, Resident #66 and Resident #74. In an interview on 07/17/2026 at 3:40 p.m., the DON stated that the IDT members who attend the care plan meetings should sign in for attendance and that it was important for the resident or the responsible party to take part in the meeting either in person or by phone. The DON stated the Social Worker was responsible for completing the Care Conference Summary form which has a section for signature of attendance. The DON stated that not ensuring the resident or the responsible party were present in the care plan meeting would place the resident at risk for not having their needs accurately identified. In an interview on 07/17/2026 at 4:13 p.m., the Administrator stated that it is the Social Worker's responsibility to ensure all members who attend the care plan meeting sign the attendance sheet and that attempts to include the resident or responsible party are documented if they do not attend. The Administrator stated that he was not aware the SW was not completing the Care Conference Summary form and documenting attendance and participation. The Administrator stated it was important for the resident or the responsible party to be allowed to participate in the meeting to ensure their information was correct, that the plan of care accurately reflected the residents' needs and the plan of care would be that the meeting would not be resident centered. Record review of the facility policy titled, Comprehensive Person-Centered Care Planning, Revised 4.2025, revealed Procedure: 7. The facility IDT includes, but is not limited to the following, E. To the extent practicable, resident and/or resident representative; and 8. The facility will provide the resident and resident representative, if applicable, advance notice of care planning conference to encourage resident and/or resident representative participation. Care conference may be in the form of face-to-face meeting, conference calls or video conferencing. If not practicable, the reason will be documented in the medical record.

Based on observation, interview, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 3 of 8 medication carts (Hall B - Medication Aide Cart, Hall C - Medication Aide Cart and Hall C - Nurse Cart) reviewed for drugs and biologicals. 1. The facility failed to ensure the Timolol solution (used to lower the pressure in the eye), Brimonidine solution (eye drops used to lower the pressure in the eye), and the Prednisolone solution (eye drops used to treat swelling/injury) in the B Hall - Medication Aide Cart were dated when opened. 2. The facility did not ensure LVN G locked Hall C nurses' cart while administering medication on [DATE]. These failures could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion. Findings included: During an observation and interview on [DATE] at 09:35 a.m., Timolol solution (eye drops used to lower the pressure in the eye), Brimonidine solution (eye drops used to lower the pressure in the eye), Prednisolone solution (eye drops used to treat swelling/injury) on Hall B - Medication Aide Cart were opened and not dated. ADON E said she did not know who opened them, so she did not know why they had not put an open date on them. ADON E said the person that opened a medication was responsible for putting the open date on it. ADON E said it was important for medication to be dated when opened to prevent expiration. During an observation and interview on [DATE] at 10:11 a.m., Dorzolamide HCL solution (eye drops used to lower the pressure in the eye) on Hall C – Medication Aide Cart was opened and not dated. MA R said she was unsure if she had opened the eye drops and failed to date the eye drop medication. MA R said all medication should be dated when opened to prevent expired medication being used which may lack effectiveness. During an interview on [DATE] at 1:11 p.m., the DON said all medications should be stored and labeled per manufacturing instructions. The DON said when a medication is opened it should be labeled to prevent expiration and effectiveness of the medication. The DON said she expected all clinical staff working on the medication carts to take notice and make sure medications were labeled and dated appropriately. The DON said the ADONs were responsible for spot checking the medication carts randomly to ensure the staff was compliant with proper labeling and storage of the medication carts. During an interview on [DATE] at 4:35 p.m., the Administrator stated he expected medications to be properly labeled/dated/stored per manufacturing instructions. The Administrator stated the DON was responsible for monitoring and overseeing medication carts. The Administrator stated it was important to ensure the medications were properly labeled/dated/stored to ensure strength and effectiveness. 2. During an observation and interview on [DATE] at 12:01 p.m., LVN G left Hall C nurse's cart unlocked and out of sight, facing Resident #6's room, while washing her hands with the door shut in Resident #6's bathroom. LVN G stated she should have locked the medication cart prior to going in Resident #6's room. LVN G stated she forgot to lock the cart because she was nervous. LVN G stated it was important to ensure the medication cart was locked for residents' safety. During an interview on [DATE] at 2:34 p.m., the DON stated she expected LVN G to lock the cart anytime she stepped away from it. The DON stated she was responsible for monitoring medication carts by random spot checks. The DON stated there had not been any issues with medication carts being unlocked. The DON stated it was important to ensure the medication cart was locked while unattended for residents' safety. During an interview on [DATE] at 4:35 p.m., the Administrator stated he expected medication carts to be always locked when cart was not in use or unattended. The Administrator stated the DON was responsible for monitoring and overseeing medication carts. The Administrator stated it was important to ensure the medication cart was locked while unattended for residents' safety. Record review of the facility's policy titled Medication Access and Storage, E-Kit Access, revised 08/2019, reflected. 2. Medication.carts. are locked or attended by persons with authorized access.

Based on observation, interview, and record review, the facility failed to follow the menu as food was prepared in advance for 2 of 2 meals (the lunch meal) reviewed. 1.The facility failed to ensure [NAME] P prepared enough bell pepper for the lunch menu on 07/15/26.2.The facility failed to ensure Dietary Aide O prepared enough pie for the lunch menu on 07/16/26. These failures could place residents at risk of weight loss, not having their nutritional needs met, and a decreased quality of life. Findings included:During a kitchen observation and interview for the lunch meal served on 07/15/26 at 12:50 p.m., revealed there were not enough bell peppers to serve all the residents stuffed bell peppers for the lunch meal. [NAME] P said she did not have enough stuffed bell pepper to continue to serve the residents. Observation revealed there were about 20 residents tray cards who had not been served. The Dietary Manager looked through the tray cards and said about 10 residents already had requested alternate meals or had other diets, so 10 residents were left who were supposed to receive the regular meal of stuffed bell pepper. During an interview on 07/15/26 at 1:23 p.m., [NAME] P said she was supposed to cook 8 pans of stuffed bell pepper according to the census, but the Dietary Manger told her to only cook 6 pans. She said they usually cooked enough food. During a kitchen observation on 07/16/26 at 12:54 p.m., revealed the kitchen staff were serving ice cream as the dessert, but pie was the dessert listed on the menu. The state surveyor asked why they were serving ice cream and Dietary Aide O said they ran out of pie.During an interview on 07/16/26 at 2:10 p.m., Dietary Aide O said she did not prepare enough pie. She said she did not look at the census and just fixed what she usually fixed. She said she made 9 pies and she should have made 12 pies based on census. She said usually 1 pie made 8 slices. She said which made about 72 pies and with a census of 96 she was about 24 pies short. She said some residents did not get to have what other residents had. She said she was aware she should have looked at the census and not relied on her memory.During an interview on 07/16/26 at 2:30 p.m., Dietary Manager said [NAME] P was going to cook 8 pans of stuffed bell pepper, but she told her they did not need 8 pans because in the past they had too much food left over. She told [NAME] P to only cook 6 pans of stuffed bell pepper. She said she did not make her decision based off census but based on the last time stuffed bell pepper was prepared. She said Dietary Aide O did not make enough pie because she did not cook pie based on census. She said she was responsible for the kitchen staff and making sure they prepared enough food for all residents. She said she would make sure staff went off the census and prepared enough food for all residents. She said the risk could be a resident might not be served what was on the menu.During an interview on 07/16/26 at 2:51 p.m., the Registered Dietitian said staff should prepare enough food for all residents according to the prepared menu. She said kitchen staff should be using the spread sheet when preparing food to ensure they were following the recipe and serving size. She said the Dietary Manager was the overseer of the kitchen and should ensure enough food was cooked for each meal. The Registered Dietitian said it was important to follow the recipe when preparing food according to the census so they would have enough food for all residents.During an interview on 07/17/26 at 2:43 p.m., the DON said she expected the dietary staff to prepare enough food for each meal service. The DON said the Dietary Manager was responsible for making sure the kitchen staff followed the recipe and ensuring all residents had enough food to eat. She said failure to prepare enough food could cause residents not to receive the meal on the menu that they wanted.During an interview on 07/16/26 at 3:52 p.m., the Administrator said he expected the dietary staff to read the menu and prepare enough food for all residents. The Administrator said the Dietary Manager was responsible for ensuring the kitchen staff prepared enough food for all residents when serving the meals. The Administrator said failure to prepare food could lead to residents not receiving the food they wanted to eat.Record review of the facility's policy titled, Menu Planning, revised 02/19/18, indicated, Policy: Menus are provided to the facility by the food service contract company. Menus are planned by the contract company dietitian(s). Procedure: DSM (Dietary Services Manager) will print menus and spread sheets prior to the start of a new menu cycle. Menus will be followed and served as written. Recipes for all menu items will be placed in organized binders and/or an electronic system for ease of use by culinary staff.Record review of the facility's policy titled, Food and Nutrition Service Menus, undated 04/25, indicated, Policy: It is the policy of this facility to assure that menus are developed and prepared to meet the nutritional needs of the residents.

Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 6 of 18 residents (Resident #63, and 5 confidential residents ) and 1 of 1 lunch meals reviewed for palatability. The facility failed to provide palatable food served at an appetizing temperature or taste to Resident #63 who complained the food was unappetizing and did not taste good.The facility failed to provide palatable food served at an appetizing taste for 5 confidential residents, who complained the food served was not prepared properly, vegetables were mushy, meats were over or undercooked and food was not appealing. The dietary staff failed to provide food that was palatable for the lunch meal observed on 07/16/26.These failures could place residents at risk of weight loss, altered nutritional status, and diminished quality of life. Findings included:1.Record review of Resident #63's face sheet dated 07/14/2026 revealed a [AGE] year-old female admitted [DATE] with diagnoses which included CVA (a stroke where the blood flow to the brain is reduced and the brain is deprived of oxygen) with left sided hemiplegia (paralysis that affects one entire side of the body), hypertension (high blood pressure), atrial fibrillation (fast, irregular heartbeat), cerebral atherosclerosis (hardening and narrowing of the arteries in the brain due to plaque buildup), dysphagia (difficulty swallowing), depression (persistent feeling of sadness, emptiness and a loss of interest in daily activities) and anxiety (excessive or persistent feelings of fear or apprehension). Record review of Resident #63's quarterly MDS dated [DATE] revealed Resident #63 was usually understood by others and usually understood what was said to her, required the use of prescription glasses, had no mood or behavior concerns during the assessment period and had a BIMS score of 14 which indicated intact cognition. Resident #63 had upper and lower extremity impairment, required the use of a wheelchair for mobility, setup assistance with eating, moderate assistance with dressing, transfers and maximum assistance with bathing, toileting, bed mobility. The MDS did not indicate weight loss.Record review of Resident #63's comprehensive care plan with target date of 09/02/2026 revealed a focus area of potential for nutritional problems related to decreased mobility and swallowing problem but did not identify food preferences. During an observation and interview on 07/14/26 at 1:52 p.m., Resident #63's room revealed snack items in original packaging and personal refrigerator revealed a carton of milk (expiration date 07/21/2026). Resident #63 said she does not eat the facility food items unless she had no other options because she did not like the facilities food. Resident #63 said her family member brings food items to her or she will just eat snacks.2.During a confidential group interview on 07/15/2026 at 3:45 p.m., the 5 confidential group members said the meal items most of the time were not prepared properly, steamed vegetables were overcooked, meats were either undercooked or overcooked, and the food does not look appealing. 3.During an observation and interview on 07/16/26 at 1:04 p.m., the Dietary Manager and six state surveyors sampled a lunch tray. The sample tray consisted of fried chicken, au gratin potatoes, and sweet peas. The surveyors tasted the chicken, which was good, the au gratin potatoes were dry and when the Dietary Manager inserted her fork, they fell apart and the sweet peas were lukewarm and bland. The Dietary Manager said the sample tray had flavor and was warm. The Dietary Manager said we could not sample the pie because they had run out.During an interview on 07/16/26 at 4:36 p.m., the Dietary Manager said she had complaints about food here and there but mostly about residents' preferences. She said if the residents did not like the food, they may not eat it, which could cause weight loss.During an interview on 07/16/26 at 4:46 p.m., the Dietitian said she was not aware of any food concerns. She said if residents do not like the food it could potentially cause weight loss.During an interview on 07/17/26 at 2:43 p.m., the DON said she expected the temperature to be within parameters and taste should be palatable. She said it was the Dietary Manager's responsibility to ensure the food was palatable. She said if the residents thought the food was too cold, bland, or hard they may not consume enough which could lead to weight loss.During an interview on 07/17/26 at 3:52 p.m., the Administrator said he expected the food to be palatable. He said the Dietary Manager was responsible for ensuring the food served was palatable and served at an appetizing temperature. He said he had addressed some food complaints with grievances in the past. He said he wanted the residents to enjoy their food. He said he tasted the food out of the kitchen at least monthly and the food was okay. He said failure to serve palatable food could cause weight loss. Record review of the facility's policy titled, Food and Nutrition Service Menus, undated 04/25, indicated, Policy: It is the policy of this facility to assure that menus are developed and prepared to meet the nutritional needs of the residents.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services. The facility did not ensure:1. Food items were labeled and dated.2. Hair restraints were worn correctly. 3. Hand washing was always performed. 4. The saucers and pots/pans were cleaned.5. The microwave was clean and free of food debris6. The machine and ice scoop container were clean.These failures could place residents at risk for foodborne illness.Findings included: During the initial tour observation and interview with the Dietary Manager on 07/14/26 beginning at 10:42 a.m., revealed the following: 1 bag of breadcrumbs located in the storage room with a use by date of 6/14/261 box of bagged Kale located in the refrigerator with use by date of 7/10/261 box of shredded cabbage located in the refrigerator with a use by date of 7/10/26Cook P had hair sticking out of her hairnets while preparing food.Cook P came into the kitchen and did not wash her hands.Several saucers turned up with brown substance on it, in the clean area.1 pot with carbon build up (the Dietary Manager said they used it daily)1 of 1 microwave was dirty with red/orange substance on back wall.2 of 2 ice machine with dirty ice containers and 1 of 2 ice machine dirty on the inside and around the ledgeDuring an observation on 07/14/26 at 10:35 a.m., [NAME] P's hairnet was not covering her entire head while preparing food. There was loose hair sticking out. During an observation on 07/14/26 at 11:00 a.m., [NAME] P came in from outside and went to the prep area and started gathering utensils for the lunch meal.During an interview on 07/14/26 at 11:40 a.m., the Dietary Manager said the blacken pan should have been thrown away, the microwave should have been clean, saucers should have been turned down so things would not fall onto them, the ice machine and the ice scoop container should have been clean, all kitchen staff should have on hairnets properly covering their hair and wash their hands when working in the kitchen. She said all these things were placing residents at risk for contamination. She said it was everyone's responsibility to clean the fridge and throw away expired items. She said she had a system for checking expired items on Tuesdays and Fridays when the food truck was delivered. She said the only risk she could see from the use by date was the food would not be fresh as it should be.During an interview on 07/14/26 at 12:56 p.m., [NAME] P said she should have all her hair in the hair net. She said she did not know it was sticking out. She said she had a lot of hair, and it sometimes stuck out. She said all her hair should be completely covered with the hairnet to prevent food from getting into the food. [NAME] P said she did go out of the kitchen and returned without washing her hands. She said she knew she was supposed to wash her hand to prevent cross contamination. She said all staff were responsible for ensuring the refrigerator did not have expired food items.During an observation and interview on 07/16/26 at 1:17 p.m., the Dietary Manger came into the kitchen from the dining area and started helping [NAME] P prep for lunch without washing her hands. The Dietary Manager said she was trying to get the food prepared and forgot to wash her hands. She said she knew she was supposed to wash her hands to prevent cross contamination.During an interview on 07/16/26 at 4:06 p.m., the Dietitian said the kitchen should be clean and organized. The Dietitian said the dirty dishes should not be stored with clean dishes and the microwave should be cleaned after each use. She said pot/pans should not have black buildup on them. The Dietician said staff who entered the kitchen area should wash their hands. She said whoever put the food or items up in the refrigerator was responsible for dating them. She said this was done to prevent residents from eating or receiving expired food or items. The Dietician said hair nets should always be worn while in the kitchen and covered the entire head without loose hair sticking out. The Dietician said these failures could potentially put residents at risk for foodborne illness and cross contamination.During an interview on 07/17/26 at 2:43 p.m., the DON said cleanliness was important in the kitchen, so the staff were not spreading germs or contaminating anything. The DON said the Dietary Manager was responsible for making sure the kitchen was cleaned appropriately. The DON said all food should be dated by the date received. The DON said hair nets should be worn while in the kitchen and covering the entire head without loose hair sticking out. The DON said dirty dishes should not be stored with clean dishes. The DON said these failures could potentially put residents at risk for cross contamination and food borne illness. During an interview on 07/17/26 at 3:52 p.m., the Administrator said he expected staff to wash their hands when entering the kitchen and in between as needed, food to be dated, and hair nets to be worn without loose hair sticking out. The Administrator said he expected the kitchen to always be clean. He said clean saucers and dishes should be stored with clean dishes. He said pots/pans should not have black buildup on them. The Administrator said the Dietary Manager was responsible for monitoring and overseeing the kitchen. The Administrator said these failures could potentially put residents at risk for cross contamination, and food borne illness. Record review of the facility's policy titled, Texas Food Establishment Rules, revised 10/15, indicated, #228.43. Hair Restraints. food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles.Record review of the facility's policy titled, Equipment Cleaning Procedures, revised 07/22, indicated, Policy: It is the policy of this facility that all dietary equipment and the environment are cleaned and sanitized in a manner that meets local (if applicable), state, and federal regulations.Record review of the facility's policy titled, Food Safety and Sanitation Plan, revised 07/21, indicated, Policy: It is the policy of this facility to follow an effective, proactive food safety program that is based on preventing food safety hazards before they occur. Fundamental Information: Nursing home residents' risk serious complications from foodborne illness as a result of their compromised health status. Unsafe food handling practices present a potential source of pathogen exposure for residents. Sanitary conditions must be present in health care food service settings to promote safe food handling 2.Receiving: When food, food products or beverages are delivered to the facility, staff will inspect items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all foods stored in the refrigerator or freezer as indicated.Record review of the facility's policy titled, Dietary Hand hygiene, revised 09/14, indicated, Policy: Hand hygiene continues to be the primary means of preventing the transmission of infection. Guidelines for hand washing and gloves used to promote safe and sanitary conditions throughout the dietary department must be followed. Food employees shall clean their hands and exposed portions of their arms. Procedure: Hand washing #1. Hand washing is a priority for infection control.

Based on observation, interview, and record review, the facility failed to treat residents with respect and dignity and cared for them in a manner and in an environment that promoted maintenance or enhancement of their quality of life for 2 of 4 residents (Residents #85 and, #61) reviewed for resident rights. 1. The facility did not ensure MA Q fed Resident #85 while sitting down. 2. The facility did not ensure Resident #61 was provided with foot covers to include shoes or socks. These failures could place residents at an increased risk of embarrassment, isolation, and diminished quality of life. Findings included: 1. Record review of Resident #85's face sheet, dated 07/17/26, reflected Resident #85 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnosis which included dysarthria (difficulty speaking) following cerebral infraction (stroke). Record review of Resident #85's quarterly MDS assessment, dated 06/21/26, reflected Resident #85 usually made himself understood, and usually understood others. Resident #85's BIMS score was 11, which reflected his cognition was moderately impaired. Resident #85 required set-up clean up assistance with eating. Record review of Resident #85's comprehensive care plan, revised 05/26/22, reflected Resident #85 had ADL Self Care Performance Deficit related muscle weakness. The care plan interventions included required set-up assistance to eat. During a dining observation on 07/14/26 at 12:34 p.m., MA Q was standing up while feeding Resident #85 a spoon of rice. During an interview on 07/14/26 at 1:05 p.m., MA Q stated she knew she had to sit at eye level while feeding Resident #85, but she wanted to make sure the rice was to his likening. MA Q stated it was important to treat residents with dignity and respect. During an interview on 07/14/26 at 1:11 p.m., Resident #85 was non-interview able as evidenced by confused conversation. During an interview on 07/17/26 at 2:34 p.m., the DON stated she expected MA Q to sit at eye level while assisting Resident #85 with lunch. The DON stated rounds were made randomly during meal service to ensure dignity and respect were being provided while being assisted with meals. The DON stated there had been no issues in the past. The DON stated it was important to treat residents with dignity and respect because it was their rights. During an interview on 07/17/26 at 4:35 p.m., the Administrator stated he expected MA Q to sit at eye level while assisting Resident #85 with his meal. The Administrator stated he monitored dignity during meal service by random rounds. The Administrator stated it was important to treat residents with dignity and respect. 2. Record review of Resident #61's face sheet dated 07/17/2026 revealed a [AGE] year-old male admitted [DATE] with diagnoses which included malignant neoplasm (abnormal growth of cells) of the brain and left lung, hypertension (high blood pressure), atherosclerosis (gradual build-up of plaque), spinal stenosis (narrowing of the spinal canal that causes pressure on the spinal cord and nerves), benign prostatic hyperplasia (enlarged prostate gland), convulsions (irregular body movement caused by involuntary contractions) and transient ischemic attack (a brief blockage of blood flow to the brain that causes stroke-like symptoms). Record review of Resident #61's Quarterly MDS dated [DATE] revealed no speech or communication deficits and a BIMS score of 14 which indicated intact cognition. Resident #61 required the use of a wheelchair for mobility, set up assistance with eating, and was totally dependent on staff for toileting, bathing, dressing, bed mobility and transfers. Record review of Resident #61's care plan with target date of 09/02/2026 revealed a focus area of ADL self-care deficit with on-set date of 03/02/2026 with interventions that included dressing, putting on / taking off footwear that required two staff participation to dress and to allow sufficient time for dressing and undressing. The care plan did not indicate a focus area that Resident #61 preferred to be barefoot or had a preference not to wear shoes or socks. During an observation on 07/14/2026 at 11:25 a.m., Resident #61 was observed self-propelling in the hallway, was barefoot with no socks or shoes. During an observation and interview on 07/16/2026 at 11:02 a.m., Resident #61 was observed sitting in his wheelchair near the nurse's station and was not wearing shoes or socks. Resident #61 stated, they tell me they are going to get socks, but no one ever does. Resident #61 stated that he had one pair of shoes, but no slippers or socks. Resident #61 confirmed he would like to at least wear socks. During an observation and interview on 07/17/2026 at 10:15, Resident #61 was observed self-propelling in the hallway and was wearing yellow non-skid socks. Resident #61 stated, they gave me socks today because you asked them why I was barefoot. During a joint interview on 07/17/2026 at 10:11 a.m., with the Activity Director and LVN A, the Activity Director stated she had seen Resident #61 without shoes or socks, but she had not asked him if he wanted shoes or socks. Resident #61 stated that she thinks he does not have any shoes and that she had not reached out to his family to bring the resident shoes or socks. LVN A stated she had observed Resident #61 without shoes or socks, and she did not offer to provide shoes or socks or ask him if this was his preference. LVN A stated that Resident #61 does not ambulate, but he does use his feet to self-propel in his wheelchair and his feet do touch the floor. During an interview on 07/17/2026 at 12:55 p.m., CNA B stated that she has worked with Resident #61 and does not recall if she provided him with socks or shoes. CNA B stated that foot coverings are important to keep residents' feet clean and protected. During an interview on 07/17/2026 at 12:58 p.m., CNA C stated she had seen Resident #61 without shoes or socks but did not recall if she offered to get him shoes or socks. She stated she did not recall if she notified the nurse or if he preferred to be barefoot. During an interview on 07/17/2026 at 2:24 p.m., LVN G stated that she thought Resident #61 did not own a pair of shoes, that up until a few weeks ago, Resident #61 was bedfast and that he only recently began to get out of bed because he wanted to go on smoke breaks. LVN G stated that she had not yet, but that she would contact Resident #61's spouse to bring him shoes and socks so that he could be appropriately dressed. During an interview on 07/17/2026 at 3:40 p.m., the DON stated that it is important for the residents to be dressed appropriately to include foot coverings. The DON stated that she was not sure why Resident #61 did not wear shoes or socks and could not confirm if she had seen Resident #61 without shoes or socks. The DON stated that she expects nursing staff to intervene and provide appropriate foot coverings for all residents. The DON stated that the risks of not wearing shoes or socks would spread of infection, injury to feet and effects resident's psychosocial well-being. During an interview on 07/17/2026 at 4:13 p.m., the Administrator stated that it is very important for residents to be appropriately dressed daily and that it is the responsibility of all the staff to intervene and either assist with getting residents dressed or notify a staff member who can assist. Record review of the facility policy and procedure titled Resident Rights, Dignity and Respect, Revised 10/2015, revealed Policy, It is the policy of this facility that all residents be treated with kindness, dignity and respect, and Procedures: 3. Residents will be appropriately dressed in clean clothes arranged comfortably on their persons and be well groomed.

Based on interviews and record review, the facility failed to ensure the resident had the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers for 2 of 6 (Resident #12 and Resident #11) residents reviewed for psychoactive medications consents. 1.The facility did not ensure Resident #12 had signed a psychotropic consent for quetiapine (Seroquel) 200 mg, an antipsychotic (primarily used to treat schizophrenia, bipolar disorder, and as an add-on treatment for major depressive disorder). 2. The facility did not ensure written consent was obtained from the legal authorized representative on HHSC Form 3713 to administer Risperdal (a medication used to decrease agitation) 2 mg to Resident #11. These failures could place the residents at risk for receiving unnecessary medications, adverse side effects, and violation of the residents' rights to make informed decisions regarding their care and treatment. Findings include: 1.Record review of Resident #12's face sheet dated 07/14/26, indicated she admitted to the facility on [DATE] with diagnoses of bipolar disorder (mental health condition characterized by significant mood swings), generalized anxiety disorder (mental health condition that a constant feeling of being overwhelmed and excessive worry about everyday things), and post-traumatic stress disorder (mental health condition that's caused by an extremely stressful or terrifying event). Record review of Resident #12's annual MDS dated [DATE], reflected she made herself understood and understood others with a BIMS score of 15 which indicated her cognition was intact. The MDS indicated she had an active diagnosis of bipolar disorder. Record review of Resident #12's care plan initiated on 04/23/25 indicated Resident #12 was on anti-psychotic medication related to bipolar disorder. The interventions were for staff to document non-pharmacological interventions, approach in a calm manner, offer snacks/fluids, assess for pain, and provide a quiet environment, document side-effects: drowsiness, dry mouth, blurred vision, constipation, edema, extra pyramidal symptoms, urinary retention, stiff or tight muscles. Record review of Resident #12's order summary dated 07/14/26 indicated she had an order for Quetiapine Fumarate (Seroquel) Oral Tablet 200 MG, 1 tablet by mouth at bedtime, started on 03/13/26. Record review of Resident #12's consent for use of psychotropic medication, Seroquel 200 mg every day was not documented in her chart. During an interview on 07/17/26 at 10:20 a.m., Resident #12 said she was taking Seroquel 150mg. She said she was not aware if the dosage had changed. She said she had signed the consent for Seroquel 150mg. During an interview on 07/17/26 at 11:03 a.m., RN A said the risk of not having an updated consent on file would be the resident not knowing the possible side effects and dosage. During an interview on 07/17/26 at 2:43 p.m., the DON said consents should be signed before administering any psychoactive medication. The DON said consents were obtained to inform the family about the risks and benefits before receiving medications. The DON said the charge nurse who received the order was responsible for obtaining consents, and ADON A was the overseer. The DON said failure to obtain consents could cause the residents or families not to have all the information about the medication side effects or a choice about the resident's care. During an interview on 7/17/26 at 4:13 p.m., the Administrator said the charge nurse was ultimately who received the order, followed up with family and made sure there was a signature in place or 2 verbal consents before medication was given. He said residents and family should be aware of all medications, especially medications that require consent because of the potential side effects. 2. Record review of Resident #11's face sheet, dated 07/17/26, reflected Resident #11 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included schizophrenia (a complex, chronic brain disorder that impaired a person's ability to think, feel, and perceive reality), and anxiety (excessive worry). Record review of Resident #11's annual MDS assessment, dated 06/21/26, reflected Resident #11 made himself understood, and understood others. Resident #11's BIMS score was 5, which reflected his cognition was severely impaired. Resident #11 had an active diagnosis of anxiety, and schizophrenia. Resident #11 took an antipsychotic medication 7 out of 7 days during the look-back period. Record review of Resident #11's comprehensive care plan, revised 05/20/26, reflected Resident #11 used an antipsychotic medication related to schizophrenia. The care plan interventions included document episodes of behavior, document non-pharmacological interventions and document side effects. Record review of Resident #11's order summary report, dated 07/17/26 reflected an active physician order for Risperdal 1 mg: 1 tablet by mouth two times a day for antipsychotic related to schizophrenia. Record review of the MAR dated 07/01/26-07/31/26 reflected Resident #11 received Risperdal 1 mg orally two times a day on 07/01/26-07/17/26. Record review of the facility's electronic charting system on 07/16/26 did not reveal HHSC 3713 Form signed by the resident or resident's representative for Resident #11. During an interview on 07/16/26 at 11:14 a.m., ADON A stated she was responsible for ensuring the correct psych consents were obtained. ADON A stated the HHSC 3713 form should have been obtained within 7 days of medication administration. ADON A stated she just started learning what medications were required for the HHSC 3713 form. ADON A stated it was important to obtain consent on the new HHSC Form 3713 to ensure the correct medications were given per the diagnoses and the residents or residents' representatives were made aware of the side effects. During an interview on 07/17/26 at 2:34 p.m., the DON stated ADON A was responsible for ensuring the correct consent form was obtained for the anti-psychotic medications. The DON stated HHSC 3713 form should have been obtained for Residents #11, and #12. The DON stated she monitored consent forms to ensure the forms were kept up to date by random audits. The DON stated her last audit was done in June 2026. The DON stated it was important to obtain consent on the required HHSC form to ensure the medication was needed and the residents or residents' representatives were made aware of the side effects. During an interview on 07/17/26 at 4:35 p.m., the Administrator stated he expected ADON A to ensure HHSC Form 3713 was filled out for psychotropic medications. The Administrator stated it was important to obtain consent on the required HHSC form to ensure the residents or residents' representatives understood the benefits and risks of the medications. Record review of the facility's policy titled Psychotropic Medications last reviewed on 12/2023, reflected, 7 (f). Informed consent was obtained prior to medication use.

Based on observation, interview and record review, the facility failed to ensure the residents' right to privacy during personal care for 1 of 6 residents (Resident #81) reviewed for privacy. The facility failed to ensure LVN H provided privacy to Resident #81 when she administered Resident #81's medication via her gastronomy tube (tube placed in the stomach to administer feedings and medications) on 07/16/2026. This failure could place residents at risk of having their bodies exposed to the public, low self-esteem, and a diminished quality of life. Findings included: Record review of Resident #81's face sheet dated 07/17/2026 indicated Resident #81 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and right dominant side (weakness and paralysis after a stroke which affected the left and right side of the body) and gastrostomy status (presence of an artificial opening to the stomach and a tube is inserted to administer feedings and medications). Record review of Resident #81's Quarterly MDS assessment dated [DATE] indicated she was sometimes understood by others, and she was sometimes able to understand others. The MDS assessment indicated Resident #81 had a BIMS score of 01, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #81 was dependent on staff for all ADLs. The MDS assessment indicated Resident #81 had a feeding tube. Record review of Resident #81's Order Summary Report dated 07/17/2026 indicated Tylenol 325 mg give 2 tablets via PEG tube every 6 hours for pain with a start date of 01/06/2025. Record review of Resident #81's care plan with a target date of 09/27/2026 indicated she had a potential for acute and chronic pain and to administer pain medication as per orders. During an observation and interview on 07/16/2026 starting at 11:03 AM, LVN H went into Resident #81's room, lifted her gown, and administered 2 tablets of Tylenol 325 mg by her gastronomy tube. LVN H did not close the privacy curtain, and she did not close the door. LVN H said she should have shut the door for privacy. LVN H said she forgot to close the door. During an interview on 07/17/2026 at 01:11 PM, the DON said the staff should provide privacy when providing care. The DON said she in-serviced the staff on providing privacy, and she asked the residents to ensure the staff was providing privacy. The DON said she had no complaints about LVN H or the staff not providing privacy. The DON said it was important for the staff to provide privacy to the residents for the residents' dignity, and because the residents should have privacy in their home. During an interview on 07/17/2026 at 04:35 PM, the Administrator said he expected the staff to provide proper care and follow the proper precautions when administering medications. The Administrator said it was important for privacy to be provided during procedures to ensure the residents felt dignified in their care. Record review of the facility's Policy/Procedure-Nursing Administration, Section: Resident Rights, Subject: Dignity and Respect, revised 10/2025, indicated, Residents shall be examined and treated in a manner that maintains the privacy of their bodies. A closed door or drawn curtain shields the Resident from passers-by.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 (Resident #2) residents reviewed for comprehensive care plan.The facility did not develop and implement measurable and appropriate interventions in Resident #2's care plan to prevent falls and injury related to falls. This failure could place residents at risk of not having individual needs met, and cause residents not to receive needed services. Findings included:Record review of Resident #2's face sheet dated 07/17/2026, revealed an [AGE] year-old male admitted [DATE] with diagnoses which included left hip fracture, dementia (decline in cognitive function that affects the ability to perform daily activities), DMII (a condition that affects how the body uses insulin and sugar), hyperlipidemia (elevated lipid (fat) levels in the blood), atrial fibrillation (irregular heart rhythm), dysphagia (difficulty swallowing), and dysphonia (impaired voice quality). Record review of Resident #2's Comprehensive MDS dated [DATE] revealed no hearing, speech or communication deficits and BIMS score of 4 which indicated severe cognitive impairment. The MDS revealed Resident #2 had upper and lower extremity range of motion limitations, required the use of a wheelchair for mobility, set up assistance with eating and was totally dependent oin staff for toileting, bathing, dressing, bed mobility and transfers. The MDS indicated Resident #1 2 had a fall in the last month prior to admission which resulted in a fracture related to fall. Record review of Resident #2's care plan with target date of 08/15/2026 revealed a focus area initiated 05/10/2026 which indicated a risk for falls related to unsteady gait and muscle weakness with interventions to include avoid rearranging furniture, be sure the call light is within reach and encourage to use it to call for assistance, keep needed items in reach, maintain a clear pathway, and therapy evaluation and treatment per physician orders. Resident #2's care plan revealed a focus area initiated 07/14/2026 of an actual fall on 07/13/2026 with intervention of neuro-checks as ordered.Record review of Resident #2's order summary report printed 07/17/2026 revealed an order dated 05/09/2026 that indicated Fall Precautions.Record review of Resident #2's fall history revealed resident had a fall on 06/17/26 at 2:15 a.m. in that resident was found on the floor beside his bed resulting in a right forehead hematoma and right elbow skin tear with no documented interventions. Resident #2 had a second fall on 07/13/2026 at 9:35 a.m. in that he was found on the floor beside his bed with no injuries and post fall interventions to include Occupational Therapy services. During an observation and interview on 07/14/2026 at 11;:27 a.m., observed resident Resident #2 lying in bed, call light in reach, bed in raised position and bed control was sitting on the nightstand not in resident's reach. Observed Call Don't Fall Signs posted on the closet door. Resident #2's attempted verbalizations were nonsensical, and he could not verbalize if he knew how to call for assistance. During a phone interview on 07/14/2026 at 10:01 a.m., the responsible party stated that Resident #2 has had a lot of falls, and she does not agree with the new law that says they cannot use full side rails to keep him in bed. She Sstated she does not recall the bed in a low position close to the floor when she would visit.During an observation on 07/15/2026 at 1:00 p.m., Resident #2 was in bed eating pizza, and the bed was observed to be in raised position. Call light was in reach, and bed control was hanging on the side of the bed. During an observation 07/16/2026 at 3:16 p.m., Resident #2 was resting in bed, eyes closed, unlabored breathing and he did not respond to verbal greeting. The bed was in raised height, and mattress was positioned in an S shaped. The call light in place and bed control wrapped around the left handrail. During an observation and attempted interview on 07/17/2026 at 12:47 p.m., Resident #2 was lying in bed, awake and responded to direct questions with nonsensical communications. Observed call light to be in reach, bed control hanging between the mattress bottom and the floor and the bed was in a raised position. During an interview on 07/17/2026 at 12:55 p.m., CNA B stated that she does not usually work with Resident #2, but as fall precautions, she would place the beds in a low position and if triggered on the nurse aide documentation system, will utilize fall mats. During an interview on 07/17/2026 at 1:06 p.m., RN L stated that Fall Precautions: referred to the residents needing increased monitoring and ensure the call light was in reach. RN L stated that Resident #2 should have his bed in low position.During an interview on 07/17/2026 at 3:40 p.m., the DON stated that the care plans were reviewed quarterly and the MDS Nurse was responsible for accuracy and completion of the focus areas, goals and interventions for fall identification and interventions. The DON stated that she expects the MDS Nurse in conjunction with the IDT members to identify resident specific concerns and identify appropriate interventions to meet the resident's needs. During an interview on 07/17/2026 at 4:13 p.m., the Administrator stated that the IDT members reviewed falls to identify appropriate interventions and that the DON is ultimately responsible for ensuring the interventions are identified and implemented. The Administrator stated that he expects the IDT members to identify the root cause for all falls to ensure resident safety. Record review of the facility policy titled, Fall management system, revised 12.2023, revealed Procedure: 2.a. The care plan interventions will be developed to prevent falls by addressing the risk factors and will consider the elements of the evaluation that put the residents at risk and 6. Resident's care plan will be updated.

Based on observation, interview and record review the facility failed to ensure the resident environment remained free of accident and hazards for 1 of 5 residents (Resident #2) reviewed for accident hazards. The facility did not ensure Resident #2's bed was in the lowest position in order to prevent fall injuries. These failures could place residents at risk for significant injury and decreased quality of life. Findings included: Record review of Resident #2's face sheet dated 07/17/2026, revealed an [AGE] year-old male admitted [DATE] with diagnoses which included left hip fracture, dementia (decline in cognitive function that affects the ability to perform daily activities), DMII (a condition that affects how the body uses insulin and sugar), hyperlipidemia (elevated lipid (fat) levels in the blood), atrial fibrillation (irregular heart rhythm), dysphagia (difficulty swallowing), and dysphonia (impaired voice quality). Record review of Resident #2's Comprehensive MDS dated [DATE] revealed no hearing, speech or communication deficits and BIMS score of 4 which indicated severe cognitive impairment. The MDS revealed Resident #2 had upper and lower extremity range of motion limitations, required the use of a wheelchair for mobility, set up assistance with eating and was totally dependent in toileting, bathing, dressing, bed mobility and transfers. The MDS indicated Resident #1 had a fall in the last month prior to admission which resulted in a fracture related to fall. Record review of Resident #2's care plan with target date of 08/15/2026 revealed a focus area initiated 05/10/2026which indicated a risk for falls related to unsteady gait and muscle weakness with interventions to include avoid rearranging furniture, be sure the call light is within reach and encourage to use it to call for assistance, keep needed items in reach, maintain a clear pathway, and therapy evaluation and treatment per physician orders. Resident #2's care plan revealed a focus area initiated 07/14/2026 of an actual fall on 07/13/2026 with intervention of neuro-checks as ordered. Record review of Resident #2's order summary report printed 07/17/2026 revealed an order dated 05/09/2026 that indicated Fall Precautions. Record review of Resident #2's fall history revealed resident had a fall on 06/17/26 at 2:15 a.m. in that resident was found on the floor beside his bed resulting in a right forehead hematoma and right elbow skin tear with no documented interventions. Resident #2 had a second fall on 07/13/2026 at 9:35 a.m. in that he was found on the floor beside his bed with no injuries and post fall interventions to include Occupational Therapy services. During an observation and interview on 07/14/2026 at 11;27 a.m., observed resident lying in bed, call light in reach, bed in raised position and bed control was sitting on the nightstand not in resident's reach. Observed Call Don't Fall signs posted on the closet door. Resident #2's attempted verbalizations were nonsensical, and he could not verbalize if he knew how to call for assistance. During a phone interview on 07/14/2026 at 10:01 a.m., the responsible party stated that Resident #2 has had a lot of falls and she does not agree with the new law that says they cannot use full side rails to keep him in bed. Stated she does not recall the bed in a low position close to the floor when she would visit. During an observation on 07/15/2026 at 1:00 p.m., Resident #2 was in bed eating pizza, and the bed was observed to be in raised position. Call light was in reach, and bed control was hanging on the side of the bed. During an observation 07/16/2026 at 3:16 p.m., Resident #2 was resting in bed, eyes closed, unlabored breathing and he did not respond to verbal greeting. The bed was in raised height, and mattress was positioned in an S shaped. The call light in place and bed control wrapped around the left handrail. During an observation and attempted interview on 07/17/2026 at 12:47 p.m., Resident #2 was lying in bed, awake and responded to direct questions with nonsensical communications. Observed call light to be in reach, bed control hanging between the mattress bottom and the floor and the bed was in a raised position. During an interview on 07/17/2026 at 12;55 p.m., CNA B stated that she does not usually work with Resident #2, but as fall precautions, she would place the beds in a low position and if triggered on the nurse aide documentation system, would utilize fall mats. During an interview on 07/17/2026 at 1:06 p.m., RN L stated that Fall Precautions: referred to the residents needing increased monitoring and ensure the call light was in reach. RN L stated that Resident #2 should have his bed in low position Record review of the facility policy titled, Fall management system, revised 12.2023, revealed Procedure: 2.a. The care plan interventions will be developed to prevent falls by addressing the risk factors and will consider the elements of the evaluation that put the residents at risk and 6. Resident's care plan will be updated.

Based on interview and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 1 resident (Resident #6) reviewed for quality of care. The facility failed to ensure Resident #6's physician's order for his enteral feedings (a form of nutrition that is delivered into the digestive system as a liquid form via the feeding tube) indicated the route of the enteral feed and the specific administration method.This failure could affect residents receiving enteral nutrition and hydration and place them at risk of dehydration, weakness and malnutrition.Findings included:Record review of Resident #6's face sheet, dated 07/17/26, reflected Resident #6 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty swallowing) following cerebral infarction (stroke). Record review of Resident #6's admission MDS assessment, dated 06/29/26, reflected Resident #6 sometimes made himself understood, and usually understood others. Resident #6's BIMS score was 00, which reflected his cognition was severely impaired. Resident #6 had a feeding tube and had not had any weight loss/gain of 5% or more in the last month or 10% or more in the last 6 months. Record review of Resident #6's comprehensive care plan, revised 06/28/26, reflected Resident #6 required tube feeding related to dysphagia following CVA. The care plan interventions reflected Resident #6 was dependent on tube feeding, water flushes and monitor/document/report to MD PRN. Record review of Resident #6's physician order summary report, dated 07/15/26, reflected an active physician order for eternal feed three times a day; Jevity 1.5 250 ml three times a day. This order omitted the required route of the Jevity and the specific administration method (bolus or pump).During an interview on 07/15/26 at 12:01 p.m., after reviewing Resident #6's electronic medical record, LVN G stated the order was missing the route and administration method. LVN G stated the nurse that put the order in and the nurses that provided care to him were responsible for ensuring the route and administration method were in the order. LVN G stated the order should have specified g-tube for the route and bolus for the administration method. LVN G stated it was important that the five rights were followed through to prevent harm to the residents, medication error as well as aspiration. During an interview on 07/15/26 at 1:22 p.m., the RN Clinical Resource stated the route, and the method of administration should be added to the order. The RN Clinical Resource stated whoever put the order in and the nurses that administer the medication were responsible for ensuring the route and administration method were in the order. The RN Clinical Resource stated it was important that the five rights were followed through to prevent adverse side effects. During an interview on 07/17/26 at 2:34 p.m., the DON stated she expected the 5 rights to be followed when an order was obtained. The DON stated the nurse that obtained the order and provided care to Resident #6 were responsible for ensuring the route and administration method were in the order. The DON stated ADON E was responsible for monitoring and overseeing physician orders. The DON stated a random audit was completed a week ago but Resident #6 was not included. The DON stated not following the 5 rights could potentially cause adverse effects. During an interview on 07/17/26 at 3:51 p.m., ADON E stated she reviewed the orders in PCC (electronic health records) daily. ADON E stated she overlooked the route and method of administration. ADON E stated it was important that the five rights were followed through to prevent aspiration and fluid overload. During an interview on 07/17/26 at 4:35 p.m., the Administrator stated he expected the route and administration method to be stated on the order. The Administrator stated the person that put in the order was responsible. The Administrator stated the DON was responsible for monitoring and overseeing physician orders to ensure accuracy. The Administrator stated it was important that the five rights were followed through to prevent adverse side effects.Record review of the facility's policy Medication Administration via Feeding Tube reviewed 04/2025, reflected . It is the policy of this facility to ensure that medications administered via feeding tubes are administered safely and accurately.2. A physician's order is required for the administration of any medication via feeding tubes. The order must specify the.route.frequency.

Based on interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 1 of 7 residents (Resident #13) reviewed for laboratory services. The facility failed to ensure Resident #13's Complete Blood Count also known as CBC (is a common blood test that evaluates overall health and detects various disorders, such as anemia, infection, and leukemia), Thyroid-Stimulating Hormone also known as TSH (blood test used to screen for or monitor thyroid disorders), and Comprehensive Metabolic Panel also known as CMP (a routine blood test that measures essential information about your metabolism, fluid and electrolyte balance, and the health of your liver and kidneys) was drawn every 4 months as ordered by the physician.These failures could place residents at risk of not receiving lab services as ordered, not receiving timely diagnosis and treatment, and not receiving appropriate monitoring for certain diseases. Findings included:Record review of Resident #13's face sheet, dated 07/17/26, reflected Resident #13 was an [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included stroke, Anemia (a condition where your blood lacks enough healthy red blood cells or hemoglobin, impairing its ability to carry oxygen to your body's tissues),malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it actually consumes), dysphagia (difficulty or discomfort in swallowing), diabetes (high blood sugars), and high blood pressure. Record review of Resident #13's quarterly MDS assessment, dated 04/28/26, reflected Resident #13 made himself understood, and was understood by others. Resident #13's BIMs score was an 11 which indicated he had moderately impaired cognitive skills The MDS did not indicate any weight loss.Record review of Resident #13's physician's orders dated 09/23/23 indicated lab CMP and TSH yearly.Record review of Resident #13's physician's orders dated 03/04/24 indicated lab CBC every 3 months.Record review of Resident #13's comprehensive care plan revised 09/17/25 reflected Resident #13 had Seizure Disorder related to his stroke and received blood thinners. The care plan interventions were for staff to monitor labs as ordered and report any sub therapeutic or toxic results to the physician. Record review of Resident #13's electronic medical record did not indicate Resident #13 had a CBC, over the last 6 months nor TSH or CMP level since labs were ordered 03/04/24.During a phone interview on 07/17/26 at 3:21 p.m., the facility's physician said he expected labs to be done as ordered. He said he could not recall why the lab was ordered for Resident #13 but knew CBC, TSH and CMP was for monitoring anemia and other systems in the body. During an interview on 07/17/26 at 4:29 p.m., LVN D said when labs were ordered the nurses completed the orders in the electronic system and lab drew them. She said they placed the new order on the 24-hour report for the nurses to follow up. She said she did not know if they had a monitoring system for the labs process. She said she was not aware of Resident #13 missing any labs. She said failure to follow up on labs could potentially cause the residents to miss a medication or something else they might need.During an interview on 07/17/26 at 2:43 p.m., the DON said she expected labs to be drawn as ordered by the physician's order. The DON said the nurses were responsible for putting the order in the electronic system and placing on the 24-hour report. She said the lab provider was responsible for coming the next day to draw the lab. She said nurses could see any pending lab on their electronic system. She said she monitored the labs daily by reviewing their electronic system. The DON said she was not aware Resident #13 had missed labs. The DON said it was important to ensure labs were drawn as ordered by the physician to ensure the resident's health had been monitored by those lab values. The DON said they did not have a policy on labs but they followed the physicians orders.During an interview on 07/17/26 at 3:52 p.m., the Administrator said he expected labs to be drawn as ordered. He said the nurses were responsible for filling out the lab slip and following the physician's orders. He said nurse management were responsible for ensuring lab had been drawn as ordered. The Administrator said it was important for labs to be drawn as ordered by the physician for the welfare of the resident's health. Record review of the facility's policy titled Physician Orders, dated 09/28/21, indicated. Purpose: Policy: The policy provide guidance on receiving and following physician orders.

Based on observation, interview, and record review, the facility failed to provide food and drink that accommodated the residents' preferences for 1 of 23 residents (Resident #22) reviewed for preferences. The facility did not honor Resident #22's preference for no rice on 07/14/26.This failure could place residents at risk for a decrease in residents' choices and weight loss. Findings included: Record review of Resident #22's face sheet, dated 07/17/26, indicated a 54 -year-old male, admitted [DATE], with diagnoses including malnutrition (your body isn't getting enough calories or the right balance of nutrients to stay healthy), dementia (decline in memory loss), diabetes (high blood sugar), high blood pressure.Record review of Resident #22's quarterly MDS assessment, dated 06/09/26, indicated Resident #22 made himself understood and was understood by others. His BIMS score was 02, which indicated he was severely cognitively impaired. The MDS indicated he was dependent with eating. The MDS did not indicate any weight loss.Record review of Resident #22's comprehensive care plan, dated/revised 04/13/25, indicated Resident #22 was on a mechanical soft diet with a potential for malnutrition (undernutrition) and decreased mobility. The intervention was to honor resident rights to make personal dietary choices and provide dietary education as needed.Record review of Resident #22 's physician orders, dated 05/01/26, indicated mechanical soft texture, with thin liquids.Record review of the lunch meal ticket, dated 07/14/26, for Resident #22 indicated mechanical soft diet, and under the note section indicated dislikes rice.During an observation and interview on 07/14/26 at 12:21 p.m., Resident #22 was in the main dining room assisted by staff eating his lunch which contained rice. MA M said he had dislike of rice on his tray card. She said she did not see it on his tray card and had already given him a spoon of rice. During an observation and interview on 07/14/26 at 12:23 p.m., ADON E was in the dining room assisting staff pass out lunch trays. The surveyor and ADON B read Resident #22's meal ticket indicating Resident #22 disliked rice. The ADON E said it should have been caught when she checked the tray for Resident #22. She said she would get him a substitute for rice.During an interview on 07/14/26 at 4:05 p.m., Resident #22 said he does not like rice.During an interview on 07/15/26 at 10:00 a.m., [NAME] P said she served lunch on 07/14/26. She said she did not see Resident #22 tray card read dislikes rice. She said they were running behind in the kitchen and trying to get all resident trays out as soon as possible. She said she should honor any resident's preferences and not provide something they did not like.During an interview on 07/16/26 at 10:00 a.m., the Dietary Manager said she expected Resident #22 not to receive his dislike of rice. She said the kitchen staff were responsible for ensuring they were reading the tray card and not serving anything a resident disliked. The Dietary Manager said it was important for all residents to receive their preference of food choices so they would eat.During an interview on 07/17/26 at 4:56 p.m., the DON said if Resident #22 did not like rice, then he should never have been served them. She said the process started in the kitchen with the cook and then to the staff who served the tray. She said dietary and nursing staff were responsible for ensuring they followed Resident #22's meal ticket. She said it was important to serve the correct diet and preference to prevent weight loss.During an interview on 07/17/26 at 4:15 p.m., the Administrator said he wanted Resident #22's' preferences to be honored. The Administrator said he expected the dietary staff to prepare and serve the residents' diet and preferences. He said the nurses were responsible for ensuring staff followed the tray card directions. The Administrator said it was important for residents' food preferences to be honored so they would receive food they liked. Record review of the facility's policy titled, Food and Nutrition Service Menus, undated 04/25, indicated, Policy: It is the policy of this facility to assure that menus are developed and prepared to meet the nutritional needs of the residents and resident choices .

Based on observation, interview, and record review, the facility failed to ensure the medical record was complete and accurately documented for 1 of 4 residents (Resident #22) reviewed for resident records.The facility failed to provide documentation of Resident #22's visits done by the Habilitation Coordination. This failure could place residents at risk of not receiving appropriate care due to incomplete/inaccurate information being documented.Findings included: Record review of Resident #22's face sheet, dated 07/17/26, indicated a 54 -year-old male, admitted [DATE], with diagnoses including malnutrition (your body isn't getting enough calories or the right balance of nutrients to stay healthy), dementia (decline in memory loss), diabetes (high blood sugar), high blood pressure.Record review of Resident #22's quarterly MDS assessment, dated 01/26/26, indicated Resident #22 made himself understood and was understood by others. His BIMS score was 02, which indicated he was severely cognitively impaired. The MDS indicated he was dependent on all ADLs. Record review of Resident #22's comprehensive care plan, revised 04/08/26, reflected Resident #22 had identified that he needed specialized services due to history of intellectual disabilities (ID). The care plan interventions included: an IDT (Interdisciplinary Team) meeting would be conducted with the designated Local Intellectual and Developmental Disability Authority (LIDDA) representative annually and as needed for significant changes in status and specialized services determined to be necessary by the IDT will be initiated.Record review of the PCSP meeting dated 06/12/26 reflected that Habilitation Coordination was recommended for Resident #22. Record review of Resident #22's electronic medical records dated 03/16/26 through 07/17/26 did not reflect any documentation of Habilitation Coordination notes. During an interview on 07/16/26 at 3:43 p.m., Resident #22 was unable to answer questions when asked about habilitation services he was receiving. During an interview on 07/17/26 at 8:58 a.m., The MDS Coordinator said she was responsible for ensuring visits were conducted by the Habilitation Coordinator. The MDS Coordinator said she was not aware when the last Habilitation Coordinator came to visit. The MDS Coordinator said staff did not coordinate with habilitation after their visits. The MDS Coordinator said they did not have a system in place to ensure Resident #22 was receiving his PASRR services. The MDS Coordinator said it was important for them to receive documentation after every visit to ensure the residents were receiving services. She said residents should receive PASRR services if they qualify because it was their right and it enhanced their quality of life.During a telephone interview on 07/17/26 at 9:22 a.m., the Habilitation Coordinator said she came to the facility monthly to get a report from Resident #22 to ensure his needs were met. She said Resident #22 had a quarterly meeting on 06/12/26. She said she saw Resident #22 for a face-to-face meeting on 1/21/26, 2/9/26, 04/22/26 and 05/20/26. She said Resident #22 qualified for PASRR service, and she was required to see him monthly and with the quarterly meetings. The Habilitation Coordinator said they did not leave any documentation for the monthly visits at the facility. She said they were going to start a sign-in sheet this month (July 2026) to prove they had been at the facility to see Resident #22.The Habilitation Coordinator said she did follow up with unknown staff after each visit to see if there were any concerns with his care. During an interview on 07/17/26 at 2:43 p.m., the DON said she had seen the Habilitation Coordinator come to the facility in the past but was not sure how often she visited. She said she did expect some type of documentation to be provided after every visit to show they were in the facility. The DON said the Social Worker and the MDS Coordinator were responsible for the PASRR services. The DON said it was important to ensure residents were receiving PASRR services because they needed the service.During an interview on 07/17/26 at 3:52 p.m., the Administrator said he did not know what services Resident #22 was receiving. He said the Social Worker and the MDS Coordinator were the overseer of PASRR. The Administrator said he expected the residents to receive specialized service if they qualified for them and expected the provider to leave documentation of the services they provided. The Administrator said it was important to receive the service to maintain their baseline of activity of daily function.Record review of the facility's undated policy titled PASRR Rational, dated 01/20/26, indicated, Purpose: The aim of the PASRR program is to identify residents with Mental Illness (MI), Intellectual Disability (ID) or Developmental Disability (DD)/Related Conditions (RC) and to ensure they are properly placed , whether in community or in a Nursing Facility (NF) and to ensure they receive the services they require for their MI, or ID/DD. The IDT Meeting Process: The IDT will review and discuss the recommended Specialized Services on the PE and come to an agreement on which specialized services the resident needs. The IDT will identify the most appropriate entity to provide those services and will follow-up to ensure they are provided to the residents.

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 communicable diseases and infections for 2 of 3 residents (Resident #49 and Resident #27) reviewed for infection control. The facility failed to ensure CNA S and CNA T dispose of contaminated PPE in the biohazard prior to exiting Resident #49's room on 07/14/2026, 07/15/2026, 07/16/2026 and 07/17/2026.The facility failed to ensure CNA N wiped correctly and performed hand hygiene while providing incontinent care for Resident #27 on 07/14/26. These failures could place residents at risk for cross contamination and the spread of infection. Findings included: 1)Record review of the face sheet dated 07/17/2026 revealed Resident #49 admitted to the facility on [DATE] with the diagnosis of metabolic encephalopathy (brain doesn't work properly because of chemical imbalances in your body caused by another illness or organ problem). Record review of the comprehensive MDS dated [DATE] revealed Resident #49 had a BIMS score of 15 which indicated no cognitive impairment. The MDS indicated septicemia (infection), urinary tract infection (bladder infection), and wound infection. Record review of the care plan dated 07/06/2026 revealed Resident #49 had a care plan for infection of the left hip surgical site and MRSA (Methicillin Resistant Staphylococcus Aureus) with the intervention of contact isolation. Record review of the order summary report dated 07/17/2026 revealed Resident #49 had an order for contact isolation for diagnosis of MRSA. Observation on 07/14/2026 at 2:15 p.m., CNA S provided care to Resident #49 who was on transmission based precautions. Upon completion of care CNA S removed PPE while holding a clear trash bag. CNA S placed used PPE into the clear trash bag while holding the bag with one hand, then removed her own gown and gloves and placed them into the same bag. CNA S performed hand hygiene prior to exiting Resident #49 room. CNA S then transported the clear open trash bag containing contaminated PPE through the hallway and disposed of the bag in a regular trash receptacle in the shower room. The exterior of the clear trash bag had been handled during removal of contaminated PPE. Observation on 07/15/2026 at 9:00 a.m., CNA S and CNA T entered Resident #49 room to perform care. When walking in CNA S and CNA T put on a gown and gloves and grab a clear plastic trash bag from the PPE box on the outside of the room. Once care was completed both CNA S and CNA T took off the gown and gloves placed it in a clear trash bag contaminating it bringing it out of the room. CNA S and CNA T took the used contaminated PPE out of the room in a clear trash bag to the trash receptacle located in the shower room used for all other residents. Observation on 07/16/2026 at 9:20 a.m., revealed no biohazard bags were available for contact isolation room in Resident #49 PPE cart and Resident #49 room. CNA S and CNA T removed soiled linen and PPE from the room in a clear trash bag. CNA S and CNA T entered Resident #49 room for their round to check and change resident brief. Once care was completed both CNA S and CNA T took off the gown, placed it in one clear trash bag with CNA S holding the soiled trash bag with soiled gloves, with the same soiled gloves she used to open the door for CNA T and took the soiled PPE and linen to the shower room. Observation on 07/17/2026 at 9:30 a.m., revealed no biohazard bags were available for contact isolation room in Resident #49 PPE cart and Resident #49 room. CNA S and CNA T removed soiled linen and PPE from the room in a clear trash bag. CNA S and CNA T removed contaminated PPE while holding the clear trash bag, carried it out of the room to the shower room and touched the door handle with dirty gloves. Interview on 07/14/2026 at 1:50 p.m., the Housekeeping Supervisor stated that residents on contact isolation clothing would be placed in a biohazard bag which would remind the staff who work in the laundry to put on PPE to wash the clothes. The Housekeeping Supervisor stated that there were no contact isolation clothes in the dirty laundry at that time. The Housekeeping Supervisor stated that a bleach mixture was used additionally to clean contact isolation rooms. Interview on 07/17/2026 at 9:22 a.m., ADON E infection preventionist, revealed she expected the staff to place their PPE in a red biohazard bag and take it straight to biohazard. ADON E stated that she expected staff to gown and gloves when entering the room. ADON E stated that she expected the staff to take off the gown and gloves when exiting the room and wash hands. ADON E stated that she expected the staff to place Resident #49's laundry in biohazard bag to be separated. Interview on 07/17/2026 at 9:36 a.m., the DON said she expected staff to wear gown and glove when entering Resident #49's room. The DON stated she expected staff to remove PPE and then perform hand hygiene. The DON stated that she expected PPE to be placed in a red biohazard bag. Interview on 07/17/2026 at 9:45 a.m., the Administrator stated he expected infection precautions to be taken according to order and policy. The Administrator stated that he expected all staff to put on and take off, dispose of PPE according to the policy and CDC guidelines. The Administrator said Resident #49 could be at risk of spread of infection at risk of worsening of condition. 2) Record review of Resident #27's face sheet dated 07/17/2026 indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE]. Her diagnoses included dementia (loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life), and stroke. Record review of Resident #27's quarterly MDS assessment dated [DATE] indicated she understood others and made herself understood. The MDS also indicated she had a BIMS score of 05 which meant she was severely cognitively impaired. The MDS also indicated she was always incontinent of bowl and bladder. The MDS indicated she required maximal assistance with toileting, transfers, dressing, and bed mobility, and supervision with eating. Record review of Resident #27's comprehensive care plan last revised 10/14/25 indicated she had bowel/bladder incontinence related to impaired mobility, and stroke. She also had an ADL self-care performance deficit and was dependent on staff to assist with her ADLs which included toileting. During an observation on 07/14/26 at 1:50 p.m., Resident #27 was lying in bed while CNA N performed incontinence care. CNA N wiped Resident #27's perineal area from front to back and then assisted her to turn to her side and wiped the buttocks which contained bowel. She then removed the sling to the mechanical lift and applied her clean brief with the same dirty gloves. She then removed her gloves without hand hygiene and applied new gloves to use the remote to let the head of bed up. During an interview on 07/14/26 at 2:19 p.m., CNA N said she thought she changed her gloves but said she should have hand hygiene in between glove changes and then apply gloves to prevent cross contamination while performing care to Resident #27. During an interview on 07/17/26 at 2:43 p.m., the DON said she expected staff to provide incontinent care properly and follow in the steps. She said they should change their gloves from dirty to clean. She said she did not expect staff to touch clean objects with dirty gloves. The DON said the nurses and herself were responsible for ensuring the staff performed peri care correctly. The DON said check offs for proper incontinent care were completed periodically as well as upon hire. She said failure to properly perform hand hygiene could place residents at risk of infection and cross contamination. During an interview on 07/17/26 at 3:53 p.m., the Administrator said his expectation was for proper perineal care and proper hand hygiene to be completed by all staff. The Administrator said the nursing administration (DON, ADON) were responsible for ensuring the staff provided proper perineal care and hand hygiene. The Administrator said proficiency checks were completed upon hire and as needed. The Administrator said the failure created a risk for spread of disease. Record review of Contact Precautions signage revealed all those who enter resident room should put on and take off all PPE and discard of it prior to exiting the room. Record review of IPCP Standard and Transmission-Based Precautions policy revision date 04/2025 revealed Page Contact Precautions (Transmission-Based Precautions or TBP) are used with a known infection that is spread by direct or indirect contact with the resident or the resident's environment. (e.g. MDROs). A. Personal protective equipment (PPE):i. Wear a gown and gloves for all interactions that may involve contact with the patient orthe patient's environment.ii. [NAME] PPE upon room entry, then doff and properly discard PPE and perform handhygiene before exiting the patient room to contain pathogens. Record review of the facility's policy titled Hand Hygiene, undated, indicated: hand hygiene continuous to be the primary means of preventing the transmission of infection.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #1) reviewed for infection control. The facility failed to ensure CNA B followed enhanced barrier precautions when providing incontinent care to Resident #1 on 06/06/2026. This failure could place residents at risk for cross contamination and the spread of infection due to lack of implementation of orders. Finding include: Record review of Resident #1's face sheet, dated 06/06/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included pneumonitis (swelling and irritation of the lungs) due to inhalation of food and vomit and need for assistance with personal care. Record review of Resident #1's admission Comprehensive MDS assessment, dated 05/21/2026 revealed Resident #1 was able to make himself understood and had the ability to understand others. Resident #1 had a BIMS score of 15, which indicated no cognitive impairment. Resident #1 had urinary incontinence and an indwelling catheter, feeding tube, and pressure ulcer. Record review of Resident #1's care plan, dated 06/06/2026, revealed Resident #1 was care planned for feeding tube, pressure ulcer, and bowel and bladder incontinence with the intervention of enhanced barrier precautions with care. Record review of Resident #1's order summary report revealed Resident #1 had an order to cleanse gastronomy tube stoma with normal saline, dry with gauze and apply sponge gauze every day shift started on 06/05/2026. Order summary report indicated an order for sacrum clean with normal saline, dry with gauze, apply calcium alginate with silver, and cover with island bordered dressing every day shift started on 06/05/2026. Order summary report indicated the resident had an order for enteral feeding every shift started on 05/19/2026. During observation on 06/06/2026 at 11:30 a.m., revealed CNA A performed incontinent care on Resident #1 without donning a gown. The CNA cleaned the resident's bowel movement with open sacral wound with cleansing wipe, applied new clean brief, with one pair of gloves without changing her gloves. Observation of EBP sign on door and supplies in cart inside door of Resident #1 room. During interview on 06/06/2026 at 11:35 a.m., Resident #1 revealed he had a feeding tube, wound on his stoma, and sacral wound. Resident #1 stated staff normally wore a gown and gloves when proving care to him but sometimes they forget. During interview on 06/06/2026 at 11:40 p.m., CNA A revealed she had forgotten to wear a gown when providing care to Resident #1. CNA A stated Resident #1 had a gastronomy tube, wound on his sacrum, and wound on his tube side. CNA A stated Resident #1 was at risk of cross contamination and infection. CNA A stated she only worked as needed on the floor and she had forgotten to wear EBP. During interview on 06/06/2026 at 12:00 p.m., revealed RN B expected all nursing staff to wear EBP when providing direct contact care to Resident #1. RN B stated Resident #1 was on enhanced barrier precautions for his feeding tube and wounds to his sacrum and stoma. During interview on 06/07/2026 at 10:15 a.m., the DON stated she was told by the CNA A that she had forgotten to wear EBP when providing care to Resident #1. The DON stated she expected all staff who came in direct contact with Resident #1 to wear a gown and gloves when providing care to Resident #1. The DON stated there were signs posted on Resident #1 door and a box of supplies needed in his room. The DON stated she educated CNA A on EBP and to wear her gown and gloves. The DON stated Resident #1 was at risk for the spread of infection. During interview on 06/07/2026 at 10:30 a.m., the Administrator stated he expected all staff to follow policy and procedures regarding infection control. The Administrator stated he expected CNA A to wear a gown and gloves with providing incontinent care to Resident #1 due to his tube and wounds. The Administrator stated EBP was used to prevent the spread of infection and cross contamination. Record review of the facility's Policy and Procedure Infection Prevention Control Program Standard and Transmission-Based precautions, revised 03/2024, indicated Enhanced Barrier Protection (EBP): used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident-to-resident. (e.g., residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs). a. PPE: The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with: i. Wounds and/or indwelling medical devices regardless of known MDRO infection or colonization.

Based on interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 3 of 22 residents (Residents #10, #13 and #27) reviewed for laboratory services. 1. The facility did not obtain a physician's ordered BMP (test used to monitor the blood sugar levels, the balance of electrolytes and fluid as well as the health of kidneys) for Resident #10. 2.The facility did not obtain a physician's ordered Hgb A1C (measures the average blood sugar levels over the past 2-3 months) for Resident #13. 3. The facility did not obtain a physician's ordered CBC (used to measure different parts and features of blood) for Resident #27. These failures could place residents at risk of not receiving lab services as ordered and not managing medications at a therapeutic level. Findings included: 1. Record review of Resident #10's face sheet, dated 05/27/25, reflected Resident #10 was a [AGE] year-old female, readmitted to the facility on [DATE] with a diagnosis which included diabetes mellitus without hyperglycemia (chronic condition that affects the way the body processes blood sugar). Record review of Resident #10's annual MDS assessment, dated 04/25/25, reflected Resident #10 made herself understood, and understood others. Resident #10's BIMS score was 15, which indicated her cognition was intact. Resident #10 had a diagnosis of diabetes mellitus. Record review of Resident #10's comprehensive care plan revised on 07/21/23, reflected Resident #10 had diabetes mellitus. The care plan interventions included: diabetes medication as ordered by the doctor, monitor/document/report to MD PRN s/sx of hypo/hyperglycemia. Record review of Resident #10's physician order summary report, dated 05/22/25, reflected an active physician order for BMP every 3 months with a start date 01/16/25. Record review of Resident #10's electronic medical record indicated Resident #10 last BMP was drawn on 01/22/25. Resident #10's BMP should have been drawn for 04/25 according to the physician order. 2. Record review of Resident #13's face sheet, dated 05/27/25, reflected Resident #13 was a [AGE] year-old female, readmitted to the facility on [DATE] with a diagnosis which included diabetes mellitus without hyperglycemia (chronic condition that affects the way the body processes blood sugar). Record review of Resident #13's quarterly MDS assessment, dated 05/04/25, reflected Resident #13 made herself understood, and understood others. Resident #13's BIMS score was 15, which indicated her cognition was intact. Resident #13 had a diagnosis of diabetes mellitus. Record review of Resident #13's comprehensive care plan revised on 08/31/21 reflected Resident #13 had diabetes mellitus. The care plan interventions included: administer insulin per PCP orders, and monitor/document for side effects and effectiveness. Record review of Resident #13's physician order summary report, dated 05/22/25, reflected an active physician order for Hgb A1C every 4 months with a start date 07/21/23. Record review of Resident #13's electronic medical record indicated Resident #13 last Hgb A1C was drawn on 11/05/24. Resident #13's Hgb A1C should have been drawn for 04/25 according to the physician order. 3. Record review of Resident #27's face sheet, dated 05/27/25, reflected Resident #27 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis which included alcoholic cirrhosis (scarring of the liver due to chronic alcohol consumption) without ascites (excess abdominal fluid). Record review of Resident #27's quarterly MDS assessment, dated 04/19/25, reflected Resident #27 made himself understood, and understood others. The assessment did not address Resident #27's BIMS score. Record review of Resident #27's comprehensive care plan revised on 09/14/21, reflected Resident #27 had liver disease related cirrhosis and alcoholic dependence. The care plan interventions included: give medications as ordered, and obtain and monitor lab /diagnostic work as ordered by MD. Record review of Resident #27's physician order summary report, dated 05/22/25, reflected an active physician order for CBC every 3 months with a start date 03/01/24. Record review of Resident #27's electronic medical record did not reveal any CBC had been drawn. During an interview on 05/22/25 at 10:22 a.m., the Medical Director stated he expected labs to be drawn as ordered. The Medical Director stated he was unaware that the labs had been missed until state surveyor intervention. The Medical Director stated it was important to ensure labs were drawn to ensure the resident is not being undertreating or overtreating. During an interview on 05/22/25 beginning at 12:01 p.m., the DON stated the nurses were responsible for ensuring the standing orders were put in PCC. The DON stated her and the ADON were responsible for monitoring and reviewing labs orders and completed results by going into the lab portal for results. The DON stated the vendor did not complete scheduled lab orders and the facility was not able to monitor if the lab was completed or not. The DON stated the system was currently being reviewed with the vendor to ensure scheduled lab orders were completed in a timely manner. The DON stated it was important to ensure labs were drawn per the physician order to ensure residents were getting the best care for their diagnoses and all labs were in therapeutic range. During an interview on 05/22/25 beginning at 1:02 p.m., The Administrator stated he expected labs to be drawn per physician order. The Administrator stated the nursing department heads were responsible for monitoring and overseeing. The Administrator stated it was important to ensure labs were drawn as scheduled for their overall health. Record review of the facility's policy titled Diagnostic Test Results Notification reviewed 12/2023 indicated . It is the policy of this facility to obtain laboratory . 1. Laboratory . will be arranged as ordered. 3. Notification of test results will be documented in the resident's clinical record .

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure dented canned goods were removed from the pantry on [DATE]. 2. The facility failed to ensure the outdated milk was removed from the refrigerator before it expired on [DATE]. These failures could place residents at risk for food contamination and foodborne illness. Findings included: During an initial tour observation on [DATE] beginning at 10:00 a.m., the following were made in the kitchen refrigerator (1 of 1): -(1) carton of milk with an unopened date but an expired date of [DATE]. During observations on [DATE] beginning at 10:00 a.m., the following were made in the kitchen pantry (1 of 1): -(2) dent cans (1) 6 pounds of Mandarin Oranges and (1) 6 pounds of Turnip Greens. During an interview on [DATE] at 7:43 a.m., the Dietary manager said the expired milk should have been removed on or before the expiration date. She said the dietary aide was supposed to check the refrigerator daily. She said the dietary aide on the evening shift usually put up the cans/supplies on Friday and would let her know if any cans were dented, and she would call the company to get credit. She said Mondays were her day to check the refrigerator and pantry for any outdated food or dented cans. She said she had not had the opportunity to check before the surveyor entered the kitchen. She said the outdated milk could potentially make a resident sick, and the dented cans could place residents at risk of contamination or foodborne illness. During an interview on [DATE] at 11:22 a.m., Dietary Aide G said she was supposed to check the fridge daily on her shift for expired items. She said she was not aware the milk was outdated. She said she checked and put up the cans, and if she saw one dented, she would usually notify the Dietary Manager. She said expired milk or dented cans could cause contamination. During an interview on [DATE] at 12:05 p.m., the DON said she expected anything expired not to be in the refrigerator. She said she knew they could not have dented cans but was not sure why. She said the Dietary Manager was responsible for ensuring the staff were removing expired items and not having dented cans. She said residents were at risk for foodborne illness. During an interview on [DATE] at 12:17 p.m., the Administrator said the dietary staff should be looking for expired items and dent cans. He said the Dietary Manager was responsible for the kitchen. He said expired food items and dented cans can cause illness. During an interview on [DATE] at 12:30 p.m., the Dietary Manager said she did not have a policy on dented cans or labeling. Record review of the U.S Food and Drug Administration 2022 Food Code, revealed: ,d+[DATE].17 Ready -to-Eat, Time/Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) - (G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety.

Based on interview and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum of the required committee members for 3 of 6 meetings (10/21/24, 11/18/24, and 12/16/24) reviewed for QAA committee. 1. The facility did not ensure the Administrator D, or a representative attended QAPI meetings on 10/21/24, and 12/16/24. 2. The facility did not ensure the DON attended QAPI meetings on 11/18/24, and 12/16/24. These failures could place residents at risk for quality deficiencies being unidentified, no appropriate plans of action developed and implemented, and no appropriate guidance developed. Findings include: Record review of the facility's QAPI Committee sign-in-sheets for 10/21/24 and 12/16/24 reflected the Administrator D or a representative did not sign in for the meetings. Record review of the facility's QAPI Committee sign in sheets for 11/18/24 and 12/16/24 reflected the DON did not sign in for the meetings. During an interview on 05/22/25 beginning at 12:01 p.m., the DON stated she had never missed a QAPI meeting. The DON stated this had to have been one of those meetings that did not start off with signing in but was told by the Administrator to sign before they left the meeting. The DON stated it was important to ensure she attended the meetings so she could be a part of addressing issues and systems improvement. During an attempted telephone interview on 05/22/25 at 1:56 p.m. with Administrator D, was unsuccessful. Record review of the facility's policy 2025-2026 Quality Assurance and performance Improvement Plan reviewed on 01/20/25 indicated . 2. Governance and Leadership . the department heads will meet monthly with the Administrator to discuss the QAPI . the QAPI Committee, which includes the medical director, is ultimately responsible for assuring compliance with federal and state requirements and continuous improvement in quality of care and customer satisfaction .

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 4 residents (Resident #24, Resident #36 and Resident #10) reviewed for infection control. 1.The facility failed to ensure CNA L performed hand hygiene while providing incontinent care for Resident #24 on 05/21/25. 2. The facility failed to ensure CNA B and CNA C cleaned Resident #36's front perineal area when they provided incontinent care and failed to ensure CNA B followed enhanced barrier precautions when providing care on 05/19/2025. 3. The facility did not ensure CNA F followed enhanced barrier precautions while assisting Resident #10 with catheter care on 05/20/25. These failures could place any resident at the facility at risk for cross-contamination and spread of infection. Finding included: 1.Record review of Resident #24's face sheet, dated 05/22/25, revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses to include stroke, dementia (progressive loss of intellectual functioning), atrial fibrillation (irregular or rapid heartbeat that causes poor blood flow), and Congestive heart failure, or heart failure, is a long-term condition in which your heart can't pump blood well enough to meet your body's needs Record review of Resident #24's quarterly MDS assessment, dated 04/30/25, indicated Resident #24 usually understood and was usually understood by others. Resident #24's BIMS score was 04, which indicated she was severely cognitively impaired. The MDS indicated Resident #24 required total assistance with toileting, bed mobility, dressing, personal hygiene, transfers, and eating. The MDS indicated she was always incontinent of bowel and bladder. Record review of Resident #24's comprehensive care plan revised on 01/29/25, indicated Resident #24 was incontinent of bowel/bladder. The care plan interventions were for staff to check frequently for wetness, soiling, and change as needed. During an observation on 05/20/25 10:48 a.m., CNA L was performing incontinent care on Resident #24. She cleaned Resident #24's peri area and then turned her to her side, touching her gown without hand hygiene or changing her gloves. During an interview on 05/20/25 11:13 a.m., CNA L said she did not realize she did not perform hand hygiene or change her gloves before turning Resident #24 from front to back or before touching her clean gown. She said she knew that without hand hygiene or removing dirty gloves, she could cause cross-contamination. During an interview on 05/22/25 at 11:44 a.m., LVN H said she was Resident #24's nurse. She said she expected the CNAs to perform incontinent care the correct way. She said she expected them to change their gloves between clean and dirty to prevent cross-contamination. During an interview on 05/22/25 at 12:05 p.m., the DON said she expected the CNAs to perform incontinent care correctly. She said she expected staff to change their gloves between clean and dirty and to use hand hygiene between glove changes. The DON said they went over incontinence care and hand washing upon hire, annually, and as needed. The DON said staff should change gloves and practice hand hygiene to prevent infection and cross-contamination. During an interview on 05/22/25 at 12:17 p.m., the Administrator said he expected all staff to use proper hand hygiene techniques between dirty and clean areas with all care. The Administrator said the clinical team was responsible for ensuring staff were trained on incontinent care and infection control. He said improper hand hygiene could place residents at risk for infection. Record review of CNA L's proficiency on incontinent care and handwashing was dated 01/25/25 and 05/04/25. 46892 2. Record review of a face sheet dated 05/22/2025 indicated Resident #36 was a [AGE] year-old-female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (paralysis and weakness of the left side of the body) and contractures of the left and right knee and left and right hip (shortening of the muscles, tendons, skin, and nearby soft tissues of the left and right knew and left and right hip which caused the joints to shorten and become very stiff, preventing normal movement). Record review of the Quarterly MDS assessment dated [DATE], indicated, Resident #36 was understood by others and understood others. The MDS assessment indicated Resident #36 had a BIMS score of 13, which indicated her cognition was intact. The MDS assessment indicated Resident #36 was dependent on staff for bathing/showering, personal and toileting hygiene. The MDS assessment indicated Resident #36 had a functional limitation in range of motion to her lower extremity (hip, knee, ankle, foot) on both sides. Record review of Resident #36's care plan indicated she had bowel/bladder incontinence related to impaired mobility to change her after each incontinent episode and as needed. Resident #36's care plan indicated she had a diabetic ulcer (wounds that arise due to poor circulation and nerve damage caused by diabetes) to use enhanced barrier precautions (infection control intervention used to reduce transmission of multidrug resistant organisms). During an observation and interview on 05/19/2025 starting at 4:25 PM, CNA B and CNA C provided incontinent care to Resident #36. CNA B and CNA C turned Resident #36 on her side and cleaned the stool off her buttocks and back perineal area. CNA B and CNA C removed gloves and performed hand hygiene and put on a clean brief. After applying the clean brief CNA B removed her gloves performed hand hygiene and only put one glove on. CNA B said she ran out of gloves. CNA B repositioned Resident #36 in the bed, covered her up, repositioned her head and pillows using only one gloved hand. CNA B said she did not clean Resident #36's front perineal area because she was contracted, and she had difficulty getting to it. CNA B said she usually was able to clean her front area. CNA B said since it was difficult to get to Resident #36's front area she should have wiped further down from behind to ensure she had cleaned Resident #36 well enough. CNA B said because she had not cleaned Resident #36's front area this placed Resident #36 at risk of getting a urinary tract infection. CNA B said she should have gotten more gloves and applied both of her gloves to reposition Resident #36 in the bed because she required enhanced barrier precautions. CNA B said it was important to follow the enhanced barrier precautions to not spread infection and to protect herself and the residents. CNA C said they did not clean Resident #36's front area because it was hard to get to it. CNA C said it was important to clean the resident's perineal area on the front and back to prevent bacteria from getting in the lady parts and to prevent urinary tract infections. During an interview on 05/22/2025 at 10:56 AM, the DON said when a resident required enhanced barrier precautions the staff should wear gloves anytime they were touching the resident. The DON said she conducted random daily check to ensure the staff were following the enhanced barrier precautions, and the staff had been wearing the appropriate PPE. The DON said it was important for the enhanced barrier precaution to be followed to prevent infections to the residents. During an interview on 05/22/2025 at 11:50 AM, the Operation Manager said he expected for the staff to provide the residents incontinent care fully and for the residents to be cleaned. The Operation Manager said he expected for the staff to follow the protocols for enhanced barrier precautions. The Operation Manager said nursing was responsible for ensuring the staff provided proper incontinent care and followed the enhanced barrier precautions. The Operation Manager said he was not clinical and was not aware of the risks associated with not providing proper incontinent care and not following the enhanced barrier precautions. 43047 3. The facility did not ensure CNA F followed enhanced barrier precautions while assisting Resident #10 with catheter care on 05/20/25. Record review of Resident #10's face sheet, dated 05/27/25, reflected Resident #10 was a [AGE] year-old female, readmitted to the facility on [DATE] with a diagnosis which included diabetes mellitus without hyperglycemia (chronic condition that affects the way the body processes blood sugar). Record review of Resident #10's annual MDS assessment, dated 04/25/25, reflected Resident #10 made herself understood, and understood others. Resident #10's BIMS score was 15, which indicated her cognition was intact. Resident #10 was independent with eating. Resident #10 required supervision or touching assistance with toileting hygiene. Resident #10 had an indwelling catheter (thin, flexible tube inserted into the bladder to drain urine continuously). Record review of Resident #10's comprehensive care plan revised on 03/24/25, reflected Resident #10 had an indwelling catheter related to neuromuscular dysfunction of bladder (bladder's muscles and nerves did not communicate properly with the brain, leading to a loss of bladder control). The care plan interventions included: change catheter bag and tubing as ordered and use enhanced barrier precautions. Record review of the order summary report dated 05/22/25 reflected an active order for catheter care every shift for urinary retention with a start date 03/02/25. During an interview and observation on 05/20/25 beginning at 4:50 p.m., Resident #10 stated she performed her own catheter care every morning and night. Resident #10 stated she could show the two state surveyors how she performed catheter care. The two state surveyors observed CNA F donn (on) gloves without putting on a gown. CNA F assisted Resident #10 with pulling down her brief, which was a high-contact resident care activity. Resident #10 continued showing the state surveyors how she performed catheter care. CNA F assisted Resident #10 with pulling up her briefs, which was a high-contact resident care activity. During an interview on 05/20/25 at 5:10 p.m., CNA F stated she failed to use EBP when providing care with Resident #10. CNA F stated, I should have put a gown on, but I was in a rush. CNA F stated it was important that she wear a gown to prevent the spread of infection. During an interview on 05/22/25 beginning at 12:01 p.m., the DON stated she only expected CNA F to wear gloves not a gown when assisting with pulling down Resident #10 briefs because there was no body contact, and the resident was independent. The DON stated she and the ICP were responsible for monitoring and overseeing EBP by random rounds, in services and check offs. The DON stated she had not noticed any issues with staff not wearing the correct PPE with residents on EBP. The DON stated it was important the correct PPE was worn to prevent the spread of infection. During an interview on 05/22/25 beginning at 1:02 p.m., the Administrator stated he agreed with the DON that CNA F only had to wear a gown when assisting Resident #10 with pulling down her briefs. The Administrator stated the nursing department was responsible for monitoring and versing. The Administrator stated it was important to ensure the correct PPE to prevent the spread of infection. Record review of the facility's Police/Procedure-Nursing Clinical, Section: Routine Procedures, Subject: Incontinent Care, revised 05/2007, indicated, Assist resident to turn on side with back toward you. Expose buttocks area. Wash, using front-to-back strokes, rinses, and dry exposed skin surfaces. Apply lotion. Remove soiled linen and replace clothing/linen as necessary .D. Cleanse perennial/rectal area and apply a new brief. Record review of the facility's policy titled, Hand Hygiene, revised 10/22, indicated, Policy: It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene based on accepted standards. Purpose: Hand hygiene is one of the most effective measures to prevent the spread of infection All personnel shall follow the handwashing/hand hygiene procedure to help prevent the spread of infections to other personnel, residents, and visitors. Record review of the facility's policy titled, Infection Control, revised 03/24, indicated, Policy: It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions. Procedure: Standard Precautions are infection prevention practices that apply to the care of all residents, regardless of suspected or confirmed infection or colonization status. They are based on the principle that all blood, body fluids, secretions, and excretions (except sweat) may contain transmissible infectious agents Enhanced Barrier Protection (EBP}: used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident-to-resident. (e.g., residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs). a. PPE: The use of gown and gloves for high-contact resident care activities is indicated when Contact Precautions do not otherwise apply, for nursing home residents with: i. Wounds and/or indwelling, but are not limited to . urinary catheters, or medical devices regardless of known MDRO infection or colonization.

Based on observation, interview and record review the facility failed to ensure residents the right to be free from abuse for 1 of 19 residents reviewed for abuse (Resident # 10) in that: On 8/11/23 CNA A slapped Resident #10 on the left forearm with a washcloth multiple times telling her to stop complaining while giving her a shower on 8/11/23. The non-compliance was identified as past non-compliance. The immediate jeopardy (IJ) began on 8/11/23 and ended on 8/16/23. The facility had corrected the noncompliance before the investigation began. This failure could place all residents in the facility at risk for physical harm, and pain which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being. Findings included: Resident #10: Record review of a facility face sheet dated 3/6/24 for Resident #10 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: chronic multifocal osteomyelitis (a disease that causes pain and damage in bones due to inflammation), other spondylosis, lumbar region (age-related degeneration of the vertebrae and discs of the lower back), type 2 diabetes mellitus with diabetic neuropathy, unspecified (high blood sugar with nerve damage caused by high blood sugar), low back pain unspecified. Record review of the Quarterly MDS assessment for Resident #10 dated 2/2/24 revealed Resident #10's BIMS=15, which indicated Resident #10 was cognitively intact. Question GG0130 E, indicated Resident #10 needed supervision or touching assistance for showering. Record review of the comprehensive care plan revised on 7/21/23 for Resident #10 indicated resident had an ADL self-care performance deficit related to muscle weakness, unsteady gait, self-care deficit, lumbar spondylosis, confusion, and sciatica (pain, weakness, numbness, or tingling in the leg). Interventions: Staff to provide required assistance for ADL's. During an interview on 3/5/24 at 11:38 AM Resident #10 said CNA A gave her a shower after just having back surgery on 8/11/23. She said CNA A was scrubbing her back really hard with the washcloth which made her cry and complain of pain. Resident #10 said CNA A then took the washcloth and twisted it up and began slapping her on the left forearm and said, stop complaining. Resident #10 said she told her family member what happened, and he talked to the Administrator. She said CNA A was terminated from the facility. She said that was the only incident that she had and everyone else had been nice to her. During an interview on 3/6/24 at 11:40 AM Resident #10's family member said Resident #10 told him on 8/14/23, while getting a shower on 8/11/23 that CNA A had twisted up the washcloth and began slapping her on the arm because she was complaining that CNA was scrubbing her back too hard. He said Resident #10 showed him a bruise on her left forearm that was very large and that he had 2 pictures of the bruise. He said he did not remember sending an email to the business office manager but could have. He said he talked with the Administrator and wanted the police called. He said the Administrator did call the police and filed a report. He said the facility did terminate CNA A. He said he was very angry and upset about what happened. He said he was satisfied with how the facility handled the incident. During an interview on 3/7/24 at 9:00 AM the ADON said that no resident had ever complained about CNA A being mean or hurting them in any kind of way. During an interview on 3/7/24 at 9:18 AM LVN B said Resident #10 used to be on her hall. She said Resident #10 had been very sick and confused when she admitted . She said she did remember Resident #10 having back problems and pain. She said she had never received any complaints that CNA A had been rough with care or had hurt anyone in any kind of way. During an interview on 3/7/24 at 9:59 AM CNA C said there is one shower room on each hall. She said one resident can be showered at a time. She said there is only one CNA in the shower room giving a shower at a time unless the resident required a 2 person assist with care. During an interview on 3/7/24 at 10:08 AM The DON said she had worked at the facility since October of 2019. The DON said Resident #10's family member sent an email to the business office manager stating he wanted to speak to the Administrator regarding an incident with Resident #10. She said she spoke with Resident #10, and she told her that CNA A hit her on her arm with a twisted-up washcloth while she was getting a shower causing a bruise to her left forearm on 8/11/23. She said Resident #10 was cognitively intact and was able to verbalize in detail the incident. She said CNA A was suspended immediately on 8/14/23 and later terminated on 8/16/23. The DON said her expectations from her staff is never to harm or abuse any resident and to never infringe upon their rights. She said the potential negative outcome for the residents that had been abused is depression, anxiety, PTSD, physical harm and or death. During an interview on 3/7/24 at 11:23 AM the Administrator said he had worked at the facility since May of 2023. He said the facility does everything possible to prevent resident abuse including screening potential employees before hire and following all regulations. He said he expects that abuse will not happen at the facility and that all alleged abuse is reported to him immediately. He said the potential negative outcome for resident abuse is physical harm and psychosocial stress. During a phone interview on 3/7/24 at 11:12 AM CNA A said she was giving Resident #10 a shower on 8/11/23 and Resident #10 had not had a recent back surgery because there was not any sutures or staples on Resident #10's back. She said Resident #10 already had a bruise to her left forearm before her shower. She said Resident #10 never complained that she was scrubbing her back too hard or of any pain during her shower. She said that she had never hit Resident #10 with a washcloth on the arm. She said after the shower the ADON came to her and told her Resident #10 had said that CNA A had told her to shut up. CNA A said the facility had suspended her pending investigation and then terminated her. Record review of facility incident report dated 8/14/23 at 3:00 PM revealed Resident #10 stated that a CNA slapped her left arm with a washcloth as she was told to stop complaining on 8/11/23. Police interviewed Resident #10 and stated, I do not think any harm was caused but I do feel like the person was not as nice as she could have been. Agencies/People notified were the DON, family member, ombudsman, police, and physician. Record review of 2 pictures sent to surveyor on 3/6/24 at 12:01pm by Resident #10's family member revealed a 6cmx4cm purple discoloration and a blue band aide next to the discoloration on the resident's left forearm. Record review of a personnel file for CNA A indicated that her hire date was 7/15/23. Criminal history check indicated that it had been performed on 7/12/23. Employee misconduct registry check indicated a date of 7/11/23. No unemployable actions on either were indicated. Record review of CNA A's education record revealed CNA A had been trained on abuse, neglect, and exploitation on 8/5/2023 prior to the date of the incident on 8/11/23. Record review of a witness statement undated signed by CNA A stated on Friday when Resident #10 was being moved I took her in the shower where I saw a bruise on her arm. I forgot to document. Resident #10 had the bruise before I got her up for the shower. I let Resident #10 wash what she could on her own. I washed her back and she dried herself and I dried her back. Record review of a witness statement undated signed by CNA D stated As I was giving Resident #10 a shower me and therapy noticed she had a blue band aide on her arm. When asked what happened she stated a short girl with glasses hit her while giving her a shower. When asked was it on purpose she stated she didn't know. But she was looking for me to tell me what happened. She also stated she was washing her back really hard and when she told her it was hurting the girl told her to stop crying. I notified the Administrator. Record review of police report dated 8/14/23 at 3:23 PM revealed police were notified of incident on 8/14/23 at 3:23 PM. Officer spoke with Resident #10 on 8/14/23 at 4:11 PM. The Officer closed the incident on 8/14/23 at 4:36 PM. Record review of QAPI notes dated 9/18/23 indicated that the meeting was attended by the following members: Administrator, DON, ADON, MDS nurse, Activity Director, Social Worker, Business Office Manager, Assistant Business Office Manager, Director of Admissions, Operations Manager, Human Resources Manager and Medical Director. The interventions and plan for correction included: 1. Policies reviewed this month: Abuse/Neglect. Record review of sign in sheets for in-service dated 8/14/23 indicated that 27 staff members had signed the sign in sheet for the in-service on Preventing/Reporting Abuse. Record review of sign in sheets for in-service dated 8/14/23 indicated that 27 staff members had signed the sign in sheet for the in-service on Abuse Q & A, Types, When to Report, S/S. Record review of sign in sheets for in-service dated 8/14/23 indicated that 27 staff members had signed the sign in sheet for the in-service on Abuse Coordinator. Record review of sign in sheets for in-service dated 8/14/23 indicated that 27 staff members had signed the sign in sheet for the in-service on Resident Rights. Record review of sign in sheets for in-service dated 8/15/23 indicated that 9 staff members had signed the sign in sheet for the in-service on Abuse. Record Review of course completion history dated 3/6/24 revealed all 115 employees had been educated on abuse, neglect, exploitation, obligation to report abuse, and understanding abuse and neglect. During an interview with approximately 30 employees on 3/6/24, all employees were able to appropriately describe the types of abuse and how to report abuse. Record review of a termination form dated 8/16/23 for CNA A indicated that she was terminated on 8/16/23. Reason for termination: Involuntary-Code of conduct violation-Gross Misconduct. Employee handbook page 29 allegations from resident. Record review of the facility policy titled Abuse: Prevention of and Prohibition Against dated 11/2017 with revision date of 10/2022 indicated .The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be free from abuse, neglect, misappropriation of resident property, and exploitation . On 3/6/24 at 1:03 pm the Administrator, and DON were informed of IJ. The non-compliance was identified as past non-compliance. The IJ began on 8/11/23 and ended on 8/16/23. The facility had corrected the noncompliance before the investigation began.

Based on observation, interview, and record review the facility failed to consult the physician when pressure sores worsened or did not improve for 3 of 8 residents reviewed for physician consultation. (Resident #s 3, 4 and 7) Resident #7's physician was not consulted regarding the need for pressure sore treatment orders for 19 days and dietary recommendations to promote wound healing for 43 days. Resident #4's physician was not consulted regarding worsening pressure sores, dietary recommendations to promote wound healing for 25 days and treatment recommendations for 5 days. Resident #3 had pressure sores. Her physician was not consulted regarding dietary recommendations to promote wound healing for 26 days. This failure created an Immediate Jeopardy situation identified 8/14/12. The Immediate Jeopardy was removed on 08/15/12. The facility remained out of compliance at a pattern of actual harm with the potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures contributed to the development of new pressure sores and the worsening of existing pressure sores for Residents #s 4 and 7. This failure could place the 8 residents who had pressure sores at risk for developing new or worsening pressure sores, osteomylitis (infection of the bone),[MEDICAL CONDITION] (infection of the blood), [MEDICAL CONDITION] (skin infection) and death. Findings included: 1. Physician orders [REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #7 re-entered the facility from the hospital on [DATE] with one Stage II pressure sore. The MDS indicated a Stage II pressure sore was a partial thickness loss of the top layer of skin presenting as a shallow open sore with a red or pink wound bed, without slough (a stringy yellow tissue firmly adhered to the wound bed that inhibits healing). Physician treatment orders dated 07/11/12 indicated the wound on Resident #7's left buttock was to be cleaned with normal saline and have Santyl (an enzymatic [MEDICATION NAME] agent) ointment applied every day for 14 days. The end date was 07/26/12. A pressure sore care plan updated 07/30/12 indicated Resident #7 had an unstageable pressure sore. Staff were to perform treatment per physician orders [REDACTED]. During an observation and interview on 08/14/12 at 11:35 a.m., Resident #7 was in bed on his back. LVN A said Resident #7 was on a regular scoop mattress (not pressure reducing). The pressure sore on Resident #7's coccyx was covered with a saturated dressing. The date on the dressing was unreadable. The sore was approximately 5 x 4 cm with tunneling. The wound bed was non-visible due to dried drainage. During an interview on 08/14/12 at 2:50 p.m., after surveyor intervention, LVN A said Resident #7 did not have an August 2012 treatment sheet or current physician orders [REDACTED]. The physician was consulted and orders dated 08/14/12 with an end date of 08/28/12 were obtained to clean wound to left buttock with normal saline, apply Santyl ointment and cover with dressing every day for Resident #7. During an observation and interview on 08/14/12 at 3:00 p.m. LVN A said there was no documentation of Resident #7 receiving treatments for the pressure sore on his coccyx from 08/01-13/12. LVN A measured the pressure sore on Resident #7's coccyx extending to the left upper buttocks as a 5 cm x 4 cm with 1.6 cm tunneling at 11 o'clock, 1.5 cm at 12 o'clock, and 1.7 cm at 1 o'clock. There was slough at the edge of the wound between 1 and 2 o'clock. There was exposed muscle in the wound bed. During an interview on 08/15/12 at 3:45 p.m. the DON said she could not located physician orders [REDACTED]. The RD assessment dated [DATE] indicated Resident #7 had an unstageable area to his buttock. The RD recommended Resident #7 receive [MEDICATION NAME] (a nutritional supplement used for patients with chronic wounds) and Vitamin C twice a day (aids in wound healing) and [MEDICATION NAME] at bedtime (increase appetite). There was no evidence the physician was consulted regarding the recommendations. The RD assessment dated [DATE] indicated the RD again recommended Resident #7 receive [MEDICATION NAME], Vitamin C and [MEDICATION NAME]. There was no evidence the physician was consulted regarding the recommendations. Resident #7's physician orders [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. During an interview on 08/14/12 at 5:30 p.m. the DON said she identified last week the physician had not been consulted regarding the RD June and July recommendations for Resident #7. She said she made corrections 08/11/12. This was 43 days after RD made recommendations to promote wound healing for Resident #7. 2. Physician orders [REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #4 required extensive assistance with bed mobility and was incontinent of bowel and bladder. The resident's cognitive skills were severely impaired. Resident #4 had 2 stage II pressure sores at the time of this assessment. A Braden scale assessment dated [DATE] indicated Resident #4 was at high risk for skin breakdown. A pressure sore care plan dated 7/6/12 indicated staff were to keep the physician informed of the resident's progress and report no improvement. During a treatment observation and interview with LVN A on 8/14/12 at 10:00 a.m., had the following pressure sores: *right hip - 1 x .8 cm pressure sore with a 0.3 cm black eschar area in the center; *coccyx - 3.8 x 3 cm pressure sore with yellow slough covering 100% of the wound bed; *left upper buttock - 1.5 x 1.3 cm pressure sore with black eschar to the center; *right lower buttock - 1.5 x 1.6 cm Stage II. *left lower buttock - 2.5 x 1.8 cm pressure sore, wound bed 50% with black eschar LVN A said Resident # 4's pressure sores had gotten worse because some were unstageable now. She said the physician had not been consulted regarding Resident #4's worsening pressure sores. Skin assessment sheets for Resident #4 indicated the following: *08/01/12 - 1 x 1cm Stage II to the coccyx, a 1 x 1 cm Stage II to her right hip and a 2 x 2 cm Stage II to her left buttock. The treatment was hydrogel dressing every day. *08/08/12 - 3 x 2 cm unstageable pressure sore to her coccyx, a 1 x 1.5 cm Stage II to her right hip, and a 1.5 x 1.5 cm Stage II to her left buttock. The treatment was hydrogel dressing every day. Skin assessment sheets for Resident #4 dated 8/9/12, completed by the wound care consultant, indicated the following: *coccyx - 3 x 2 cm unstageable pressure sore, 80% slough with recommendation for a new treatment of [REDACTED]. *right hip - 1 x 1.5 cm unstageable pressure sore, 100% brown/necrotic with recommendation to apply skin barrier to peri wound, hydrogel and santyl oinment to wound bed and cover with bordered foam dressing and change daily. *left buttock - 1.5 x 1.5 cm 100% red/white dermal tissue with recommendation for a new treatment to apply skin protective barrier to peri wound, hydrogel and collagen to wound bed only, cover with bordered foam dressing and change daily. During an interview on 8/14/12 at 10:30 a.m., the DON said the treatment nurse had not reported a change in Resident #4's pressure sores. She said the wound consultant had made new treatment recommendations on 8/9/12; however, the recommendations had not been followed up. She said the physician had not been consulted regarding the changes in Resident #4's wounds or the wound consultant recommendations until today after surveyor intervention. During an interview on 8/14/12 at 10:30 a.m., the DON said the treatment nurse had not reported a change in Resident #4's pressure sores. She said the wound consultant had made new treatment recommendations on 8/9/12 however the recommendations had not been followed up. She said the physician had not been consulted regarding the changes in Resident #4's wounds or the wound consultant recommendations until today after surveyor intervention. A dietary assessment dated [DATE] indicated Resident #4's pressure sores to her coccyx and buttocks were slowly healing. Recommendations were made made to increase her Prostat (protein supplement) to 30 cc twice a day to promote wound healing. The Pressure Ulcer Record policy dated May 2012, #3 the nurse will notify the family and physician and obtain treatment orders and if no progress in healing the physician must be notified and documented. A physician order [REDACTED].#4 was to receive Prostat 30 cc twice a day for wound healing: During an interview on 8/14/12 at 5:05 p.m., the DON said the 7/16/12 RD recommendations for Resident #4 were not followed up on until 8/10/12. She said the physician agreed with the RD recommendations and they were initiated 8/11/12. 3. Physician orders [REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #3 required extensive assistance with bed mobility and was incontinent of bowel and bladder. Her cognitive status indicated she had disorganized thinking. Resident #3 had 2 unstageable pressure sores according to this assessment. A Braden scale assessment dated [DATE] indicated Resident #3 was at high risk for skin breakdown. During a treatment observation with the treatment nurse on 8/14/12 at 4:00 p.m. with new assessment including measurements performed at that time , Resident #3 had the following pressure sores: *left buttock -.9 x .9 cm Stage 2 and a 1 x .7 cm Stage 2; *right hip - 3 x 1.6 Stage 2; and *right inner buttock -1 x 5 cm stage 2. A dietary assessment dated [DATE] indicated recommendations were made for [MEDICATION NAME] twice a day and Vitamin C 500 mg everyday to promote wound healing. Resident # 3's MAR indicated [REDACTED]. During an interview with the DON on 8/14/12 at 5:05 p.m., the DON said the physician had not been consulted regarding dietary recommendations to promote wound healing for Resident #3 until 8/11/12 (26 days after recommendation). The website, www.mayoclinic.com/health/bedsores/DS /DSECTION=complications, accessed 8/20/12, pressure sore complications include: "*sepsis - occurs when bacteria enters your bloodstream through the broken skin and spreads throughout your body - a rapidly progressing, life-threatening condition that can cause organ failure; *[MEDICAL CONDITION] - an acute infection of the skin's connective tissue causing pain, redness and swelling, all of which can be severe. [MEDICAL CONDITION] can also lead to life-threatening complications, [MEDICAL CONDITION] and meningitis - an infection of the membrane and fluid surrounding your brain and spinal cord; *Bone and joint infections - these develop when the infection from a pressure sore burrows deep into your joints and bones. Joint infections (septic or [DIAGNOSES REDACTED]) can damage cartilage and tissue, and bone infections (osteo[DIAGNOSES REDACTED]) may reduce the function of your joints and limbs...." The National Pressure Ulcer Advisory Panel 2009, Prevention and treatment of [REDACTED]. *regarding pressure sore staging: a Stage III pressure sore as "full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Some slough may be present."; a Stage IV as "full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present ... Stage IV sores can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] or osteitis likely to occur; and unstageable as "full thickness tissue loss in which actual depth of the sore is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further description: Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV." *regarding monitoring healing: 2. Re-evaluate the pressure sore, the plan of care, and the individual if the pressure sore does not show progress toward healing within 2 weeks. 2.2 Signs of deterioration should be addressed immediately *regarding nutrition: 1.1 Refer all individuals with a pressure sore to the dietitian for early assessment of and intervention for nutritional problems. 5. Provide adequate vitamins and minerals. The administrator and DON were notified on 8/14/12 at 12:30 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 8/14/12 at 5:00 p.m. and included: "*the three residents identified with pressure sores be provided with low air loss mattresses *all residents with current wounds be assessed for appropriate support surfaces *all wounds reassessed to ensure current treatment orders were appropriate and correct. *physicians notified to update treatment orders as needed. *head to toe assessments completed on all residents. *Braden risk assessment completed on every resident *care plans to be updated on residents with current wounds and based on risk assessment *facility will in-service nurses on wound system including proper use of support surfaces." The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: *The three residents were reassessed with [REDACTED]. The physician had been notified of pressure assessments. *Six other residents with pressure sores were observed with the assessments and treatment adequate and had appropriate support surfaces in place. The physician had been notified of pressure assessments. *Nine nurses were interviewed and said they had been in-serviced on skin assessments, notifying the physician of new or worsening pressure sores and initiating treatments. They said in-serviced on Braden scale and residents at high risk for skin breakdown how to decide what preventative measures to be taken including what type of bed or cushions. On 8/15/12 at 3:45 p.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at a pattern of actual harm with the potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated 8/14/12 indicated 8 residents had pressure sores.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent development and worsening of pressure sores for 3 of 8 residents reviewed for pressure sores. (Resident #s 3, 4 and 7) Resident #7 had a community acquired Stage II pressure sore (05/30/12) on his left buttock that worsened to a Stage IV (8/14/12). The facility did not consistently and accurately document assessments, did not consistently provide treatments, did not promptly notify physician for treatment orders, did not provide pressure relief per the plan of care and did not implement RD recommendations to promote healing. Resident #4 had a facility acquired Stage II pressure sore (3/28/12) on her left buttock, coccyx and right hip that worsened to unstageable (8/9/12). The facility did not consistently and accurately document assessments, did not consistently provide treatments, did not promptly notify physician for treatment orders, did not provide pressure relief per the plan of care and did not implement RD recommendations to promote healing. Resident #3 had four community acquired pressure sores to her buttocks. The facility did not provide repositioning or pressure relief per the plan of care and did not implement RD recommendations to promote healing. These failure created an Immediate Jeopardy situation identified on 8/14/12. The Immediate Jeopardy was removed on 08/15/12. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures contributed to the development of new pressure sores and the worsening of existing pressure sores for Residents #s 3, 4 and 7. These failure could place 8 residents who had pressure sores at risk for developing new or worsening pressure sores, osteomylitis (infection of the bone),[MEDICAL CONDITION] (infection of the blood), [MEDICAL CONDITION] (skin infection) and death. Findings included: 1. Physician orders [REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #7 re-entered the facility from the hospital 05/30/12 with one Stage II pressure ulcer. The MDS indicated a Stage II pressure ulcer was a partial thickness loss of the first layer of skin presenting as a shallow open ulcer with a red or pink wound bed, without slough (a stringy yellow layer of dead tissue that is firmly adhered to the wound bed and inhibits healing). The MDS indicated Resident #7 required extensive assistance with bed mobility, had a catheter and was incontinent of bowel. An admission nursing assessment dated [DATE] indicated Resident #7 had a Stage II pressure ulcer. The assessment did not include a location or measurements of the pressure ulcer. Nurses' notes dated 05/30/12 at 4:00 p.m. indicated Resident #7 was readmitted with a Stage II ulcer on his coccyx. There were no measurements of the pressure ulcer. A Braden scale pressure ulcer risk assessment dated [DATE] indicated Resident #7 was at high risk for skin breakdown. A pressure ulcer care plan dated 07/06/12 indicated Resident #7 had a Stage II pressure ulcer on left buttock. Approaches were to provide pressure relieving devices for the bed and wheelchair. Staff were to perform treatment per physician orders [REDACTED]. Physician orders [REDACTED]. The end date was 07/26/12. The pressure ulcer care plan dated 7/12/12 indicated "after debridement" (the process of removing nonliving tissue from pressure ulcers) Resident #7's pressure ulcer was a Stage III. The care plan interventions remained the same. The pressure ulcer care plan dated 7/30/12 indicated Resident #7's pressure ulcer was "unstageable". The care plan interventions remained unchanged. A Braden scale pressure ulcer risk assessment dated [DATE], after surveyor intervention, indicated Resident #7 was at very high risk for skin breakdown. During an interview on 08/14/12 at 11:30 a.m. CNA B said Resident #7 had a "pressure sore on his tailbone" and they repositioned him but he would reposition himself to his back. During an observation and interview on 08/14/12 at 11:35 a.m., Resident #7 was in bed on his back. LVN A said Resident #7 was on a regular scoop mattress (not pressure reducing). The pressure ulcer on Resident #7's coccyx was covered with a dressing saturated with red/brown drainage. The date on the dressing was unreadable. LVN A removed the dressing and the ulcer was approximately 5 x 4 cm with tunneling. The wound bed was non-visible due to dried drainage. During an interview on 08/14/12 at 2:50 p.m., LVN A said Resident #7 did not have an August 2012 treatment sheet or current physician orders [REDACTED]. She said she needed to call the physician for orders. During an observation and interview on 08/14/12 at 3:00 p.m. LVN A said there was no documentation of Resident #7 receiving treatments for the pressure ulcer on his coccyx from 08/01-13/12. She said she obtained physician orders [REDACTED].#7's coccyx extending to the left upper buttocks as a 5 cm x 4 cm with 1.6 cm tunneling at 11 o'clock, 1.5 cm at 12 o'clock, and 1.7 cm at 1 o'clock. There was slough at the edge of the wound between 1 and 2 o'clock. There was exposed muscle in the wound bed. During an observation and interview on 08/14/12 at 3:50 p.m., after surveyor intervention, Resident #7 was on a low air loss mattress with a control setting set at 250 pounds. There was no cushion in his wheelchair. Resident #7 said this mattress was harder than the one he was on this morning. He said his wheelchair cushion had been missing for 5 to 6 months. During an observation on 08/14/12 at 5:33 p.m. Resident #7's air mattress control was set at 250 pounds. The August 2012 weight log indicated Resident #7 weighed 133 pounds. During interview on 08/14/12 at 5:35 p.m. the DON said she was responsible for checking the settings. After surveyor intervention, the DON changed Resident #7's mattress to 130 pounds. The RD assessment dated [DATE] indicated Resident #7 had an unstageable area to his buttock. The RD recommended Resident #7 receive [MEDICATION NAME] (a nutritional supplement used for patients with chronic wounds) and Vitamin C twice a day (aids in wound healing) and [MEDICATION NAME] at bedtime (increase appetite). The RD assessment dated [DATE] indicated the RD again recommended Resident #7 receive [MEDICATION NAME], Vitamin C and [MEDICATION NAME]. Resident #7's physician orders [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. During an interview on 08/14/12 at 5:30 p.m. the DON said she identified last week the RD June and July recommendations for Resident #7 had not been addressed. She said she made corrections 08/11/12. This was 43 days after RD made recommendations to promote wound healing for Resident #7. Resident #7's weekly skin assessment sheets indicated the following: *06/13/12 and 06/15/12- 8 cm x 5.5 cm Stage II on coccyx (marked through) and changed to left buttocks. There was no description of the wound bed or drainage. *06/22/12 and 06/27/12 - Unstageable 5.5 cm x 5.5 cm on the coccyx. There was no description of the wound bed or drainage. *07/05/12 and 07/12/12 - Unstageable 5.0 cm x 5.0 cm left buttock. There was no description of the wound bed or drainage. *07/18/12 - Stage III 5.5 cm x 4.5 cm with 1.5 cm undermining at 12 o'clock. There was no description of the wound bed or drainage. *07/25/12 - Stage III 5 cm x 4 cm with 1.5 cm undermining (no location documented). There was no description of the wound bed or drainage. There were no documented skin assessments between 05/30/12 and 06/13/12 or between 07/18/12 and 08/14/12. The treatment sheet dated July 2012 for Resident #7 indicated the following: *Hydrogel to the left buttocks was provided on 7/1-3/12; *treatment was changed 07/04/12 (did not specify what treatment was changed to): *treatment documented for 07/4-12/12; *treatment using Santyl was provided 07/13-26; and *no documentation of a treatment provided 07/27/12 and 07/31/12. Resident #7 did not have a treatment record for 08/1- 8/13/12. A weekly skin assessment sheet dated 08/14/12 completed by LVN A indicated Resident #7 had a 4 cm x 5 cm Stage III with tunneling of 1.6 cm at 11 o'clock, 1.5 cm at 12 o'clock and 1.7 at 1 o'clock with slough area between 11 and 12. The diagram on the skin sheet indicated the tunneling was between 7 and 5 o'clock. Weekly skin assessment sheet dated 08/14/12 contained the following inaccuracies: *pressure sore was Stage III, observed Stage IV; *diagram of tunneling indicated 7 to 5 o'clock, observed between 11 and 1 o'clock; *measurements documented as 4 x 5 cm, observed as 5 x 4 cm; and *slough documented between 11 and 12, slough observed between 1 and 2 o'clock. During an interview on 08/15/12 at 3:45 p.m. the DON said she could not locate August 1-13 treatment sheet and the missing assessments for Resident #7. 2. Physician orders [REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #4 had severe cognitive impairment, required extensive assistance with bed mobility and was incontinent of bowel and bladder. Resident #4 had two stage II pressure ulcers at the time of this assessment. A Braden scale assessment dated [DATE] indicated Resident #4 was at high risk for skin breakdown. A pressure ulcer care plan dated 7/6/12 indicated staff were to provide Resident #4 pressure relieving devices for the bed and wheelchair. Staff were to assist the resident with turning/repositioning every two hours. The facility skin report dated 8/7/12 indicated Resident #4 had (3) facility acquired Stage II pressure sores. During an observation and interview with LVN A on 8/14/12 at 8:40 a.m., Resident #4 was in bed incontinent of urine and feces with a dressing covering her coccyx and buttocks. The dressing was soiled with urine and feces. She was on a foam mattress. LVN A said she would get someone to clean up Resident #4. She did not remove the soiled dressing. During a treatment observation with LVN A on 8/14/12 at 10:00 a.m., after surveyor intervention, Resident #4 was on a low air loss mattress and had the following pressure sores: *right hip - 1 x .8 cm pressure sore with a 0.3 cm black eschar area in the center; *coccyx - 3.8 x 3 cm pressure sore with yellow slough covering 100% of the wound bed; *left upper buttock - 1.5 x 1.3 cm pressure sore with black eschar to the center; *right lower buttock - 1.5 x 1.6 cm Stage II. *left lower buttock - 2.5 x 1.8 cm pressure sore, wound bed 50% with black eschar. During an interview on 8/14/12 at 10:00 a.m., LVN A said Resident #4's pressure sores had gotten worse because some were unstageable now. Skin assessment sheets for Resident #4 indicated the following: *08/01/12 - 1 x 1 cm Stage II to the coccyx, a 1 x 1 cm Stage II to her right hip and a 2 x 2 cm Stage II to her left buttock. The treatment was hydrogel dressing every day. *08/08/12 - 3 x 2 cm unstageable pressure sore to her coccyx, a 1 x 1.5 cm Stage II to her right hip, and a 1.5 x 1.5 cm Stage II to her left buttock. The treatment was hydrogel dressing every day. Skin assessment sheets for Resident #4 dated 8/9/12, completed by contract wound care consultant, indicated the following: *coccyx - 3 x 2 cm unstageable pressure sore, 80% slough with recommendation for a new treatment of [REDACTED]. *right hip - 1 x 1.5 cm unstageable pressure sore, 100% brown/necrotic with recommendation to apply skin barrier to peri wound, hydrogel and santyl oinment to wound bed and cover with bordered foam dressing and change daily. *left buttock - 1.5 x 1.5 cm 100% red/white dermal tissue with recommendation for a new treatment to apply skin protective barrier to peri wound, hydrogel and collagen to wound bed only, cover with bordered foam dressing and change daily. During an interview on 8/14/12 at 10:30 a.m., the DON said the treatment nurse had not reported a change in Resident #4's pressure sores. She said the wound consultant had made new treatment recommendations on 8/9/12; however, the recommendations had not been followed up. She said the physician had not been consulted regarding the changes in Resident #4's wounds or the wound consultant recommendations until today after surveyor intervention. A dietary assessment dated [DATE] indicated Resident #4's pressure sores to her coccyx and buttocks were slowly healing. Recommendations were made made to increase her Prostat (protein supplement) to 30 cc twice a day to promote wound healing. A physician order [REDACTED].#4 was to receive Prostat 30 cc twice a day for wound healing. During an interview on 8/14/12 at 5:05 p.m., the DON said the 7/16/12 RD recommendations for Resident #4 were not followed up on until 8/10/12. She said the physician agreed with the RD recommendations and they were initiated 8/11/12. During an interview on 8/15/12 at 2:55 p.m. the DON provided manufacturer information for the mattresses Resident #s 4 and 7 were on prior to being placed on the low air loss mattresses. The undated mattress information sheet indicated the mattress was appropriate through Stage II. 3. Physician orders [REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #3 required extensive assistance with bed mobility and was incontinent of bowel and bladder. Her cognitive status indicated she had disorganized thinking. Resident #3 had 2 unstageable pressure sores according to this assessment. A Braden scale assessment dated [DATE] indicated Resident #3 was at high risk for skin breakdown. A care plan dated 7/18/12 indicated staff were to provide Resident #3 with pressure relieving devices for the bed and wheelchair and assist the resident with turning/repositioning every two hours. The facility skin report dated 8/7/12 indicated Resident #3 had four community acquired pressure sores. During an observation and interview on 8/14/12 at 12:15 p.m., Resident #3 was in bed lying on her back on a foam mattress. She said there was a "hump" in her bed that kept "sticking" her. During an observation on 8/14/12 at 2:15 p.m., Resident #3 was in a wheelchair. There was no pressure relieving device in the seat of the wheelchair. During a treatment observation with the treatment nurse on 8/14/12 at 4:00 p.m. with new assessment including measurements performed at that time, Resident #3 had the following pressure sores: *left buttock -.9 x .9 cm Stage II and a 1 x .7 cm Stage II; *right hip - 3 x 1.6 Stage II; and *right inner buttock -1 x 5 cm Stage II. During an interview on 8/14/12 at 5:05 p.m., the DON said she was not aware Resident #3 did not have a cushion in her wheelchair. A dietary assessment dated [DATE] indicated recommendations were made for [MEDICATION NAME] twice a day and Vitamin C 500 mg everyday to promote wound healing. Resident #3's MAR indicated [REDACTED]. During an interview with the DON on 8/14/12 at 5:05 p.m. the DON said orders were obtained for [MEDICATION NAME] and the Vitamin C 8/11/12 but were not transcribed to the MAR indicated [REDACTED]. The pressure ulcer policy dated May 2007 indicated: "1. The nurse who discovers a Stage I, II, III, IV or unstageable pressure ulcer will initiate a pressure ulcer record and place in the treatment book. 2. The nurse will indicate the site on the figure and note the condition of the wound: A. site B. stage C. diameter D. depth E. drainage 3. Nurse will notify family and physician and obtain treatment orders..." The policy did not address support surfaces, nutritional or wound consultant recommendations. The website, www.mayoclinic.com/health/bedsores/DS /DSECTION=complications, accessed 8/20/12, pressure sore complications include: "*sepsis - occurs when bacteria enters your bloodstream through the broken skin and spreads throughout your body - a rapidly progressing, life-threatening condition that can cause organ failure; *[MEDICAL CONDITION] - an acute infection of the skin's connective tissue causing pain, redness and swelling, all of which can be severe. [MEDICAL CONDITION] can also lead to life-threatening complications, [MEDICAL CONDITION] and meningitis - an infection of the membrane and fluid surrounding your brain and spinal cord; *Bone and joint infections - these develop when the infection from a pressure sore burrows deep into your joints and bones. Joint infections (septic or [DIAGNOSES REDACTED]) can damage cartilage and tissue, and bone infections (osteo[DIAGNOSES REDACTED]) may reduce the function of your joints and limbs...." The National Pressure Ulcer Advisory Panel 2009, Prevention and treatment of [REDACTED]. *regarding pressure ulcer staging: a Stage III pressure ulcer as "full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Some slough may be present." ; a Stage IV as "full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present ... Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] or osteitis likely to occur; and unstageable as "full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further description: Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV." *regarding monitoring healing: 2. Re-evaluate the pressure ulcer, the plan of care, and the individual if the pressure ulcer does not show progress toward healing within 2 weeks. 2.2 Signs of deterioration should be addressed immediately *regarding nutrition: multiple studies indicate that [MEDICAL CONDITION] is a risk factor for pressure ulcer formation. The state of the wound is correlated with the severity of nutritional deficits, particularly low protein intake or a below-normal serum [MEDICATION NAME]. " 1.1 Refer all individuals with a pressure ulcer to the dietitian for early assessment of and intervention for nutritional problems. 5. Provide adequate vitamins and minerals *regarding support surfaces: When pressure ulcers deteriorate or fail to heal, the professional should consider replacing the existing support surface with one that will improve pressure redistribution. 2. Replace the existing mattress with a support surface that provides better pressure redistribution, shear reduction, and microclimate control for the individual if she or he: *Cannot be positioned off of the ulcer *Has pressure ulcers on two or more turning surfaces (e.g., the sacrum and trochanter), limiting turning options *Fails to heal or demonstrates ulcer deterioration despite appropriate comprehensive care *Is at high risk for additional ulcers 3. If pressure ulcers are not healing: 3.3. Consider changing the support surface to improve pressure redistribution, shear reduction, and microclimate control matched to the individual's needs. The administrator and DON were notified on 8/14/12 at 12:30 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 8/14/12 at 5:00 p.m. and included: "* The three residents identified with pressure ulcers be provided with low air loss mattresses * All residents with current wounds be assessed for appropriate support surfaces * All wounds reassessed to ensure current treatment orders were appropriate and correct. * Physicians notified to update treatment orders as needed. * Head to toe assessments completed on all residents. * Braden risk assessment completed on every resident * Care plans to be updated on residents with current wounds and based on risk assessment * Facility will in-service nurses on wound system including proper use of support surfaces." The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: *The three residents were reassessed with [REDACTED]. *Six other residents with pressure sores were observed with the assessments and treatment adequate and had appropriate support surfaces in place. *Nine nurses were interviewed and said they had been in-serviced on skin assessments, notifying the physician of new or worsening pressure sores and initiating treatments. They said they were in-serviced on Braden scale and residents at high risk for skin breakdown how to decide what preventative measures to be taken including what type of bed or cushions. On 8/15/12 at 3:45 p.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at a pattern of actual harm with the potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS Form 672 dated 8/14/12 indicated 8 residents had pressure sores.

Based on interview and record review, the facility failed to notify the physician with an accurate assessment for 1 of 3 residents reviewed for constipation/diarrhea. (Resident #1) Resident #1 began having diarrhea 11/22/11 and continued to receive a diuretic. The physician was informed of the diarrhea but was not informed the resident stopped eating, would not get out of bed, and complained of pain. Three days later, the resident was sent to the emergency room at the family's request. The resident was hospitalized with admission [DIAGNOSES REDACTED]. This failure contributed to Resident #1's dehydration and subsequent hospitalization for intravenous fluids and could place the census of 96 residents at risk for serious health complications. Findings included: Physician orders [REDACTED]. Resident #1 was to receive [MEDICATION NAME], a diuretic, twice a day. The Drug Information Handbook for Nursing, 12th edition, page 648-649, indicated [MEDICATION NAME] was a loop diuretic which could lead to profound diuresis resulting in fluid and electrolyte depletion. Resident #1's care plan for dehydration updated 6/27/11 indicated she was at risk for dehydration due to use of diuretics. The care plan required staff to encourage Resident #1 to drink fluids and monitor her for poor skin turgor and dry cracked lips. The care plan required staff to notify the physician of abnormal findings. Resident #1's nursing notes documented the following: -11/22/11 at 10:00 a.m. - CNA reported the resident had not had a bowel movement in three days. Upon digital assessment of the rectum, a large amount of formed stool was felt in the resident's rectum. An attempt to remove the stool was unsuccessful. Upon digital assessment, a large amount of brown water was expelled from around the stool. There was no documentation the physician was consulted. -11/22/11 at 11:00 a.m. - Two brown watery stools were noted. Fluids were encouraged and taken fairly well. There was no documentation the physician was consulted. During an interview on 11/29/11 at 12:14 p.m., CNA A said he was in the shower room with Resident #1 and CNA C last Monday,11/21/11, or Tuesday, 11/22/11. CNA A said the resident was complaining her stomach was hurting and thought she was constipated. CNA A said he informed LVN F about the resident's complaints. He said LVN F came in the shower room and removed some stool from the resident's rectum. He said when LVN F was removing the stool a large amount of watery substance was "pouring" out of the resident's rectum. He said a day or so after the incident, Resident #1 became very weak, stayed in bed, and stopped eating. He said Resident #1 continued to have watery stools and diarrhea. He said he could tell Resident #1 did not feel good because she was not her "normal" self. He said the resident kept telling the nursing staff her stomach was hurting. During an interview on 11/29/11 at 12:30 p.m., CNA B said CNAs A and C were with Resident #1 in the shower room Tuesday, 11/22/11. She said she went in to assist and LVN F came in to check the resident. CNA B said LVN F was "digging" in the resident's rectum and she observed a large amount of water "pouring" from the resident's rectum. She said LVN F said the stool must be "high up" and she was going to give Resident #1 a "bomb". CNA B said she thought a "bomb" was some type of laxative. CNA B said the next day Resident #1 kept saying she was hurting, but did not specify where. She said the resident was weaker and couldn't stand up as well as she used to, and she stopped eating. CNA B said she reported Resident #1's change to LVN F. During an interview on 11/29/11 at 1:06 p.m., CNA C said Resident #1 was sitting in her wheelchair in her room Tuesday, 11/22/11, and she noticed a "large amount of watery diarrhea running down the resident's leg. She said she took the resident to the shower room and CNA A went to report it to LVN F. CNA C said Resident #1 complained her stomach was hurting and she thought she was constipated. CNA C said she felt the resident's stomach and it was hard. CNA C said LVN F came in the shower room and "dug" stool out of Resident #1's rectum. She said LVN F told her she was going to ask the medication aide to administer the resident a "bomb". CNA C said she thought a bomb was a laxative. She said the resident stopped eating and complained her stomach was hurting. She said she no longer wanted to get out of bed and that was not normal for her. CNA C said every time she noticed a change in condition with Resident #1 she reported it to the nurse. Resident #1's nursing notes documented the following: -11/23/11 at 6:30 a.m. - Continued to have watery stool. Fluids encouraged and taken fairly well. -11/23/11 at 8:00 a.m. - Resident #1's primary physician was contacted with response pending. -11/23/11 at 11:00 a.m. - Digital rectal exam done. No formed stool noted. Resident continued to have brown watery stool. -11/23/11 at 2:30 p.m. - Physician response regarding loose stools was to obtain a BMP in the morning. Resident with generalized weakness. Resident #1's BMP laboratory results dated [DATE] at 8:15 a.m. indicated the following: -BUN at a panic level at 111, reference range 7 - 20. -Potassium level low at 2.3, reference range 3.5 - 5.1. -Creatinine level high at 2.03, reference range 0.57 - 1.11. -Osmolarity level high at 323, reference range 258 - 280. The web site, <http://www.nlm.nih.gov/medlineplus/medlineplus.html>, viewed 12/12/11, dehydration means your body does not have as much water and fluids as it should. When it is severe, dehydration is a life-threatening emergency. Dehydration can be caused by losing too much fluid, not drinking enough water or fluids, or both. Your body may lose too much fluids from excessive sweating (for example, from exercise), excessive urine output, fever, and vomiting or diarrhea. Osmolality would increase with dehydration and decrease with overhydration. Potassium is an electrolyte. Electrolytes affect the amount of water in your body, the acidity of your blood (pH), your muscle function, and other important processes. Higher than normal levels of creatinine may be due to dehydration. Resident #1's nursing notes documented the following: -11/24/11 at 1:30 p.m. - BMP results received and BUN elevated at 111. Telephone order received for fluids (to be administered SQ) at 100 cc/hour for 10 hours and then decrease to 60 cc/hour for total of 72 hours. 22 gauge needle inserted SQ to left lower abdomen and fluids started. -11/25/11 at 12:35 a.m. - Resident in bed with decrease in verbal responses. Eyes open with left eye half way closed. Unable to voice needs. There was no documentation the physician was consulted. -11/25/11 at 5:20 a.m. - "Eyes sunken in. Skin turgor poor." There was no documentation the physician was consulted or notified. -11/25/11 at 6:30 a.m. - Abdomen is firm and slightly distended. Still no bowel movement. Resident continues to have liquid watery stools. Resident is slightly lethargic and slow to respond. There was no documentation the physician was consulted. -11/25/11 at 10:30 a.m. - Notified resident's primary physician of her status. New order to check for fecal impaction, upper abdominal x-ray, CBC, UA with C&S, and intravenous fluids of D5 1/2 normal saline at 100 cc/hour for 10 hours and then decrease to 60 cc/hour. -11/25/11 at 10:55 a.m. - Family in facility and requested the resident be immediately transported to the emergency room . Resident #1's November 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident #1's hospital history and physical dated 11/25/11 indicated the resident was confused and fatigued when she was admitted to the hospital. Her urine was dark and she had dry oral mucosa. The resident was dehydrated and was admitted for intravenous fluids and antibiotics. Resident #1's hospital admission orders [REDACTED]. A hospital progress note dated 11/28/11 indicated Resident #1 was constipated at the time of admission. During an interview on 11/29/11 at 1:23 p.m., RN E said Resident #1 looked like a completely different resident Friday, 11/25/11. She said the resident was in bed, had a blank stare, and could not answer simple questions. She said the resident's stomach was hard. The resident said she was hurting, but could not specify where she was hurting. She said the resident was usually talkative, able to make her needs known, and would normally be out of bed sitting in her recliner. During an interview on 11/29/11 at 1:39 p.m., LVN F said CNA A told her Tuesday, 11/22/11, Resident #1's stomach was hard and he and CNA C thought the resident was impacted. LVN F said she went to the shower room and assessed Resident #1. The resident's stomach was hard and she performed a digital rectal exam. She said the resident had a large amount of "clay like" stool in her rectum and it was hard to remove. She said the more she moved her finger around in the resident's rectum, the more water "poured" out. She said Resident #1 continued to have watery stool Wednesday, 11/23/11, so she notified the physician about the diarrhea and loose stools. She said the physician ordered a BMP. She said the BMP results received Thursday, 11/24/11, indicated the resident's BUN was at a panic level. She notified the physician and he ordered fluids to be administered SQ. She said she told the physician the resident continued to have loose stool but at that time, "chunks" of formed stool was mixed in with it. During an interview on 11/29/11 at 2:55 p.m., Resident #1's primary physician said he was informed the resident was having diarrhea and was potentially dehydrated. He said the nurse did not tell him the resident was complaining of stomach pains, not eating, not talkative like she normally was, and no longer getting out of bed. He said he would have immediately ordered an extensive work up or sent her to the emergency room . He said he was in the facility Tuesday, 11/22/11, and was not informed of the resident's condition. He said he would have assessed the resident at that time if he had known of the changes. The Change in Resident Condition/Notification to the Physician policy dated 11/1/11 indicated the following: "..Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for a physician visit promptly and/or acute care evaluation. The licensed nurse in charge will notify the physician AT ONCE". - "All symptoms and unusual signs will be communicated to the physician promptly. Routine changes are a minor change in physical and mental behavior, abnormal laboratory and x-ray results that are not life threatening, and weight loss or weight gain. - Documentation- "All attempts to reach the physician and responsible party will be documented in the Nursing Progress Notes. Documentation will include time and response." The CMS 672 dated 11/29/11 indicated the census was 96.

Based on interview and record review, the facility failed to ensure 1 of 3 residents reviewed for hydration was provided with sufficient fluid intake to prevent dehydration. (Resident #1) Resident #1 began having diarrhea 11/22/11 and continued to receive a diuretic. The resident later stopped eating, would not get out of bed, and complained of pain. Three days later, the resident was sent to the emergency room at the family's request. The resident was hospitalized with admission [DIAGNOSES REDACTED]. This failure contributed to Resident #1's dehydration and subsequent hospitalization for intravenous fluids and could place the census of 96 residents at risk for serious health complications. Findings included: Physician orders [REDACTED]. Resident #1 was to receive [MEDICATION NAME], a diuretic, twice a day. The Drug Information Handbook for Nursing, 12th edition, page 648-649, indicated [MEDICATION NAME] was a loop diuretic which could lead to profound diuresis resulting in fluid and electrolyte depletion. Resident #1's care plan for dehydration updated 6/27/11 indicated she was at risk for dehydration due to use of diuretics. The care plan required staff to encourage Resident #1 to drink fluids and monitor her for poor skin turgor and dry cracked lips. The care plan required staff to notify the physician of abnormal findings. Resident #1's nursing notes documented the following: -11/22/11 at 10:00 a.m. - CNA reported the resident had not had a bowel movement in three days. Upon digital assessment of the rectum, a large amount of formed stool was felt in the resident's rectum. An attempt to remove the stool was unsuccessful. Upon digital assessment, a large amount of brown water was expelled from around the stool. There was no documentation the physician was consulted. -11/22/11 at 11:00 a.m. - Two brown watery stools were noted. Fluids were encouraged and taken fairly well. There was no documentation the physician was consulted. During an interview on 11/29/11 at 12:14 p.m., CNA A said he was in the shower room with Resident #1 and CNA C last Monday,11/21/11, or Tuesday, 11/22/11. CNA A said the resident was complaining her stomach was hurting and thought she was constipated. CNA A said he informed LVN F about the resident's complaints. He said LVN F came in the shower room and removed some stool from the resident's rectum. He said when LVN F was removing the stool a large amount of watery substance was "pouring" out of the resident's rectum. He said a day or so after the incident, Resident #1 became very weak, stayed in bed, and stopped eating. He said Resident #1 continued to have watery stools and diarrhea. He said he could tell Resident #1 did not feel good because she was not her "normal" self. He said the resident kept telling the nursing staff her stomach was hurting. During an interview on 11/29/11 at 12:30 p.m., CNA B said CNAs A and C were with Resident #1 in the shower room Tuesday, 11/22/11. She said she went in to assist and LVN F came in to check the resident. CNA B said LVN F was "digging" in the resident's rectum and she observed a large amount of water "pouring" from the resident's rectum. She said LVN F said the stool must be "high up" and she was going to give Resident #1 a "bomb". CNA B said she thought a "bomb" was some type of laxative. CNA B said the next day Resident #1 kept saying she was hurting, but did not specify where. She said the resident was weaker and couldn't stand up as well as she used to, and she stopped eating. CNA B said she reported Resident #1's change to LVN F. During an interview on 11/29/11 at 1:06 p.m., CNA C said Resident #1 was sitting in her wheelchair in her room Tuesday, 11/22/11, and she noticed a "large amount of watery diarrhea running down the resident's leg. She said she took the resident to the shower room and CNA A went to report it to LVN F. CNA C said Resident #1 complained her stomach was hurting and she thought she was constipated. CNA C said she felt the resident's stomach and it was hard. CNA C said LVN F came in the shower room and "dug" stool out of Resident #1's rectum. She said LVN F told her she was going to ask the medication aide to administer the resident a "bomb". CNA C said she thought a bomb was a laxative. She said the resident stopped eating and complained her stomach was hurting. She said she no longer wanted to get out of bed and that was not normal for her. CNA C said every time she noticed a change in condition with Resident #1 she reported it to the nurse. Resident #1's nursing notes documented the following: -11/23/11 at 6:30 a.m. - Continued to have watery stool. Fluids encouraged and taken fairly well. -11/23/11 at 8:00 a.m. - Resident #1's primary physician was contacted with response pending. -11/23/11 at 11:00 a.m. - Digital rectal exam done. No formed stool noted. Resident continued to have brown watery stool. -11/23/11 at 2:30 p.m. - Physician response regarding loose stools was to obtain a BMP in the morning. Resident with generalized weakness. Resident #1's BMP laboratory results dated [DATE] at 8:15 a.m. indicated the following: -BUN at a panic level at 111, reference range 7 - 20. -Potassium level low at 2.3, reference range 3.5 - 5.1. -Creatinine level high at 2.03, reference range 0.57 - 1.11. -Osmolarity level high at 323, reference range 258 - 280. The web site, <http://www.nlm.nih.gov/medlineplus/medlineplus.html>, viewed 12/12/11, dehydration means your body does not have as much water and fluids as it should. When it is severe, dehydration is a life-threatening emergency. Dehydration can be caused by losing too much fluid, not drinking enough water or fluids, or both. Your body may lose too much fluids from excessive sweating (for example, from exercise), excessive urine output, fever, and vomiting or diarrhea. Osmolality would increase with dehydration and decrease with overhydration. Potassium is an electrolyte. Electrolytes affect the amount of water in your body, the acidity of your blood (pH), your muscle function, and other important processes. Higher than normal levels of creatinine may be due to dehydration. Resident #1's nursing notes documented the following: -11/24/11 at 1:30 p.m. - BMP results received and BUN elevated at 111. Telephone order received for fluids (to be administered SQ) at 100 cc/hour for 10 hours and then decrease to 60 cc/hour for total of 72 hours. 22 gauge needle inserted SQ to left lower abdomen and fluids started. -11/25/11 at 12:35 a.m. - Resident in bed with decrease in verbal responses. Eyes open with left eye half way closed. Unable to voice needs. There was no documentation the physician was consulted. -11/25/11 at 5:20 a.m. - "Eyes sunken in. Skin turgor poor." There was no documentation the physician was consulted or notified. -11/25/11 at 6:30 a.m. - Abdomen is firm and slightly distended. Still no bowel movement. Resident continues to have liquid watery stools. Resident is slightly lethargic and slow to respond. There was no documentation the physician was consulted. -11/25/11 at 10:30 a.m. - Notified resident's primary physician of her status. New order to check for fecal impaction, upper abdominal x-ray, CBC, UA with C&S, and intravenous fluids of D5 1/2 normal saline at 100 cc/hour for 10 hours and then decrease to 60 cc/hour. -11/25/11 at 10:55 a.m. - Family in facility and requested the resident be immediately transported to the emergency room . Resident #1's November 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident #1's hospital history and physical dated 11/25/11 indicated the resident was confused and fatigued when she was admitted to the hospital. Her urine was dark and she had dry oral mucosa. The resident was dehydrated and was admitted for intravenous fluids and antibiotics. Resident #1's hospital admission orders [REDACTED]. A hospital progress note dated 11/28/11 indicated Resident #1 was constipated at the time of admission. During an interview on 11/29/11 at 1:23 p.m., RN E said Resident #1 looked like a completely different resident Friday, 11/25/11. She said the resident was in bed, had a blank stare, and could not answer simple questions. She said the resident's stomach was hard. The resident said she was hurting, but could not specify where she was hurting. She said the resident was usually talkative, able to make her needs known, and would normally be out of bed sitting in her recliner. During an interview on 11/29/11 at 1:39 p.m., LVN F said CNA A told her Tuesday, 11/22/11, Resident #1's stomach was hard and he and CNA C thought the resident was impacted. LVN F said she went to the shower room and assessed Resident #1. The resident's stomach was hard and she performed a digital rectal exam. She said the resident had a large amount of "clay like" stool in her rectum and it was hard to remove. She said the more she moved her finger around in the resident's rectum, the more water "poured" out. She said Resident #1 continued to have watery stool Wednesday, 11/23/11, so she notified the physician about the diarrhea and loose stools. She said the physician ordered a BMP. She said the BMP results received Thursday, 11/24/11, indicated the resident's BUN was at a panic level. She notified the physician and he ordered fluids to be administered SQ. She said she told the physician the resident continued to have loose stool but at that time, "chunks" of formed stool was mixed in with it. During an interview on 11/29/11 at 2:55 p.m., Resident #1's primary physician said he was informed the resident was having diarrhea and was potentially dehydrated. He said the nurse did not tell him the resident was complaining of stomach pains, not eating, not talkative like she normally was, and no longer getting out of bed. He said he would have immediately ordered an extensive work up or sent her to the emergency room . He said he was in the facility Tuesday, 11/22/11, and was not informed of the resident's condition. He said he would have assessed the resident at that time if he had known of the changes. The Change in Resident Condition/Notification to the Physician policy dated 11/1/11 indicated the following: "..Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for a physician visit promptly and/or acute care evaluation. The licensed nurse in charge will notify the physician AT ONCE". - "All symptoms and unusual signs will be communicated to the physician promptly. Routine changes are a minor change in physical and mental behavior, abnormal laboratory and x-ray results that are not life threatening, and weight loss or weight gain. - Documentation- "All attempts to reach the physician and responsible party will be documented in the Nursing Progress Notes. Documentation will include time and response. " The CMS 672 dated 11/29/11 indicated the census was 96.