Every finding on record at Sunflower Park Health Care

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 7 residents (Resident #1) reviewed for care plans. The facility failed to ensure that Resident #1's care plan included updated interventions for falls after a fall on 06/24/2026. This failure could place residents at an increased risk of decline in physical or functional well-being, of not receiving necessary care or services, and having personalized plans developed/implemented to address their needs. The findings included: A record review of a facesheet dated 07/28/2026 indicated Resident #1 was an [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had diagnoses which included age-related cognitive decline, unspecified lack of coordination, other abnormalities of gait and mobility, muscle weakness, and vascular dementia, mild, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (a reduction in blood flow to the brain, leading to problems with memory, thinking, and behavior). A record review of Resident #1's most recent Quarterly MDS assessment dated [DATE] indicated a BIMS of 5, which indicated severe cognitive impairment. The MDS indicated Resident #1 was dependent on staff for transferring to and from a bed to a chair or wheelchair. The MDS indicated Resident #1 used a manual wheelchair. A record review of Resident #1's care plan, last reviewed 07/25/2026, indicated Resident #1 was at risk for falls, initiated 01/08/2026. The care plan indicated the goal, initiated 01/08/2026, was for Resident #1 to be free of falls through the review date. Interventions initiated on 01/08/2026 included physical therapy evaluate and treat as ordered or PRN and activities that minimized the potential for falls while providing diversion and distraction. The care plan did not address Resident #1's fall on 06/24/2026. A record review of a progress note dated 06/24/2026 at 4:25 AM indicated the ADON heard Resident #1 screaming help and found Resident #1 on the ground. The progress note indicated the ADON completed a head to toe assessment and Resident #1 had a head bleed, a right wrist contusion (bruise), and a swollen right knee. The progress note indicated the ADON took vital signs which revealed a blood pressure of 87/49 and Resident #1 denied pain, shortness of breath, or dizziness. The progress note indicated Resident #1 stated she was attempting to transfer herself into her wheelchair and she lost her balance. The progress note indicated the ADON called emergency services. A record review of hospital records dated 07/02/2026 indicated Resident #1 had a forehead laceration. Hospital records indicated Resident #1 received a spine, head, and chest, abdomen, and pelvis CT scan and no acute fractures or trauma. During an observation interview on 07/28/2026 at 1:07 PM, Resident #1 was observed sitting in her wheelchair in her room. Resident #1's bed was in the lowest position, her call light was within reach, and a fall mat was placed next to the bed. Resident #1 did not have any bruising or scarring to her head. Resident #1 stated she fell in June as she was attempting to get into her wheelchair on her own. Resident #1 stated she was supposed to ask for help from staff but liked to transfer on her own. Resident #1 stated staff often came to check on her and were timely to answer her call light when she pushed it. During a telephone interview on 07/28/2026 at 2:07 PM, Resident #1's representative stated Resident #1 had no falls during her stay at the facility aside from the fall on 06/24/2026. Resident #1's representative stated Resident #1 had probably been trying to transfer herself and gotten confused due to her diagnosis of dementia. Resident #1's representative stated he had not been contacted regarding an update to Resident #1's care plan addressing fall interventions. During an interview on 07/29/2026 at 11:14 AM, CNA A stated she was working on Resident #1's hall. CNA A stated she was not sure Resident #1 had a fall recently, but that Resident #1 had mentioned it while she was providing care earlier that day. CNA A stated interventions for Resident #1 included keeping a fall mat beside the bed and nonskid socks. CNA A stated Resident #1 at times tried to get out of the bed by herself and staff attempt to provide education to press her call button. During an interview on 07/29/2026 at 11:22 AM, LVN B stated she was working on Resident #1's hall. LVN B stated she was aware of Resident #1 having a fall three or four weeks ago. LVN B stated interventions included educating Resident #1 to push her call light for assistance, keep the bed in the lowest position, and keep a fall mat next to the bed. LVN B stated she had not looked at Resident #1's care plan. LVN B stated care plans do help show staff specific interventions for each resident. During an interview on 07/29/2026 at 11:27 AM, the ADON stated he was Resident #1's nurse when she fell on [DATE]. The ADON stated Resident #1 told him she was trying to transfer herself to her wheelchair. The ADON stated Resident #1 had a cut on her head. The ADON stated when a resident has a fall, interventions include putting a fall mat beside the bed, providing education on utilizing the call light for assistance, and documenting this information in the care plan. The ADON stated he believed Resident #1's care plan to be updated. The ADON reviewed the care plan and recognized it was not updated to include specific interventions after Resident #1's fall. The ADON stated he was not the ADON at the time of the fall and that typically the ADON was responsible for making sure care plans got updated alongside the MDS Coordinator. The ADON stated as her nurse he could have updated the care plan and must have missed it due to the emergent situation. The ADON stated the risk to residents for not updating care plans included a lack of communication within staff to ensure everyone was aware of specific interventions to implement. During an interview on 07/29/2026 at 12:08 PM, the DON stated after a resident falls they should receive updates to their care plan. The DON stated she had only been employed at the facility about a week and a half and had not yet reviewed Resident #1's electronic medical record in depth. The DON stated administrative staff including the DON and the ADON were responsible for ensuring care plans were updated. The DON stated nursing staff were also able to update care plans when orders came in. The DON stated Resident #1 should have had an updated care plan to include interventions such as ensuring Resident #1 was provided education to utilize her call light for assistance. The DON stated the risk to residents included a lack of communication for staff regarding interventions. During an interview on 07/29/2026 at 12:20 PM, the ADM stated when a resident falls the care plan should be updated to include new interventions. The ADM stated she was not employed at the facility at the time of Resident #1's fall. The ADM stated typically it was the DON, the ADON, or the MDS Coordinator's responsibility to update the care plan. The ADM stated the risk to residents not being appropriately care planned included a risk for additional falls, not having interventions communicated, and not being able to follow up to ensure interventions are appropriate. During an interview on 07/29/2026 at 12:29 PM, the MDS Coordinator stated she was the MDS Coordinator when Resident #1 fell. The MDS Coordinator stated Resident #1's care plan should have been updated. The MDS Coordinator stated there was no excuse and the care plan just got missed. The MDS Coordinator stated the risk to residents included staff not having education on how to provide specific care to the residents. A record review of an undated facility policy, titled Fall Policy, indicated the following: Appropriate interventions will be addressed immediately on the interdisciplinary plan of care. Reassessment will occur after each fall. A record review of an undated facility policy, titled Comprehensive Care Planning, indicated the following: Through the care planning process, facility staff will work with the resident and his/her representative, if applicable, to understand and meet the resident's preferences, choices and goals during their stay at the facility. The facility will establish, document and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life. Care planning drives the type of care and services that a resident receives.

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 3 of 6 residents (Resident #1, Resident #6, and Resident #26) reviewed for infection control. 1. The facility failed to ensure CNA K performed proper glove changes while providing incontinent care to Resident #6 on 01/05/2026. 2.The facility failed to ensure the Treatment nurse and the DON used PPE while providing wound care for Resident #1 on 01/05/26. 3.The facility failed to ensure Resident #1 and Resident #26 had enhanced barrier precaution signage and PPE available in a cart for the staff to be aware of EBP (enhanced barrier precautions). 4. The facility failed to ensure Resident #1 had an order in place for enhanced barrier precautions. These failures could place residents at risk for cross contamination and the spread of infection.Findings included: 1. Record review of Resident #6's face sheet dated 01/06/2026 indicated she was an [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses which included cerebral palsy (a group of neurological disorders that appear in infancy or early childhood and permanently affect body movement and muscle coordination). Record review of Resident #6's Quarterly MDS assessment dated [DATE] indicated she was understood by others and understood others. The MDS assessment indicated Resident #6 had a BIMS score of 15, which indicated her cognition was intact. The MDS assessment indicated Resident #6 required substantial/maximal assistance with toileting hygiene. The MDS assessment indicated Resident #6 was frequently incontinent of urine and bowel. Record review of Resident #6's care plan reviewed 12/23/2025 indicated she had frequent bladder incontinence to provide incontinent care at least every 2 hours and apply moisture barrier after each episode. During an observation and interview on 01/05/2026 at 8:32 AM, CNA K provided incontinent care to Resident #6. CNA K put on gloves wiped Resident #6's front, then turned her on her side and cleaned her buttocks. CNA K grabbed the clean brief and put it on Resident #6. CNA K did not change her gloves prior to applying the clean brief. CNA K proceeded to dress Resident #6 still using the dirty gloves. After assisting Resident #6 with dressing herself CNA K grabbed Resident #6's wheelchair and walker with the dirty gloves. CNA K assisted Resident #6 into her wheelchair, and then CNA K looked in Resident #6's drawers for her comb. CNA K touched the drawers with the dirty gloves. CNA K found the comb and continued to brush Resident #6's hair, still using the same dirty gloves she used to provide the incontinent care. CNA K gathered the trash and dirty linen, placed Resident #6's overbed table in front of her. CNA K removed her gloves, disposed of the trash/linen outside of Resident #6's room, and then performed hand hygiene in the hallway. CNA K said when providing incontinent care gloves should be changed after wiping the resident and before the clean items were touched. CNA K said gloves should be changed and hand hygiene performed at the end of the incontinent care prior to dressing and assisting the resident with care. CNA K said she did not perform hand hygiene properly or change gloves appropriately because she was nervous. CNA K said not changing gloves during incontinent care could result in infections, and touching the residents' personal items with dirty gloves could result in germs traveling. During an interview on 01/07/2026 at 12:10 PM, the ADON said the DON and she completed proficiency checks when the CNAs started their first shift. The ADON said they completed the proficiency checks on the CNAs recently and there was no other oversight provided. The ADON said during incontinent care gloves should be changed and hand hygiene performed after cleaning the front area and when going to different areas of the body or if the gloves were visibly soiled. The ADON said gloves should be changed and hand hygiene performed prior to applying the clean brief. The ADON said gloves should be changed and hand hygiene performed before helping the residents with their personal care. The ADON said when she observed CNA K for her proficiency check there were no issues, and if there were, they were corrected at that moment. The ADON said not changing gloves properly, not performing hand hygiene during incontinent care could result in infections and cross contamination. The ADON said touching clean items with dirty gloves could result in the spread of infection. During an interview on 01/07/2025 at 12:41 PM, the Administrator said he expected all the staff to know what they had to do when providing incontinent care. The Administrator said he expected them to change gloves when required. The Administrator said nurse management should ensure they were making rounds and monitoring what the CNAs were doing by occasional pop ins. Nurse Management should make sure the CNAs were doing incontinent care the correct way, and if they noticed incontinent care was completed incorrectly, they should fix it right away. The Administrator said not changing gloves properly was an infection control issue, and the staff should make sure they were hand washing to prevent the spread of infection. During an interview on 01/07/2025 at 2:13 PM, the DON said gloves should be changed and hand hygiene performed after wiping the residents, when touching anything clean, and when they were finished putting on the clean brief. The DON said CNA K should have changed gloves prior to touching the residents' personal items. The DON said gloves were not required to comb the resident's hair, so CNA K should have removed her gloves. The DON said the ADON and she conducted random audits to ensure incontinent care was provided correctly. The DON said she had not noticed any issues with incontinent care. The DON said not changing gloves properly during incontinent care and touching the residents' personal items with dirty gloves could transfer bacteria. 2. Record review of Resident #1's face sheet dated 01/06/26 indicated he was an [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of dementia (condition characterized by progressive loss of intellectual functioning and memory impairment), major depression (a serious mood disorder causing persistent sadness, loss of interest, and life impairment), chronic heart failure(long term condition in which the heart does not pump blood effectively), chronic kidney disease(loss of kidney function where kidneys cannot filter waste from blood), and high blood pressure. Record review of Resident #1's admission MDS assessment dated [DATE] indicated he was understood by others and made himself understood. The MDS also indicated he had a BIMS score of 8 which meant he had moderate cognitive impairment. The MDS also indicated he required maximal assistance from staff for bathing, transfers, bed mobility, and toileting, and setup assistance with eating. Record review of Resident #1's undated care plan indicated he had actual impairment to skin integrity related to a non-pressure area to right great toe and stage 2 intact blister to the top of his right foot with interventions in place to provide treatment per orders, to follow facility policies/protocols for the prevention/treatment of skin breakdown, but the care plan did not include enhanced barrier precautions. Record review of Resident #1's order summary report as of 01/06/26 indicated he had an order for: 1)skin prep to blister on right foot. one time a day with a start date of 01/05/26 The order summary did not indicate an order for enhanced barrier precautions nor the non-pressure area of the right toe. During an observation and interview 01/05/2026 at 4:40 PM the Treatment Nurse and the DON entered Resident #1's room with no gown on but donned gloves. Resident # 1 did not have an enhanced barrier precaution sign on his door, nor did he have a PPE cart outside of her room. The Treatment Nurse and DON agreed Resident #1 had a wound to his right great toe that was open and abrasi0ons to the top of his second third and fourth toes. The DON assisted the Treatment Nurse in measuring the right great toe. 3. Record review of Resident #26's face sheet dated 01/06/26 indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with the diagnoses of chronic kidney disease (gradual loss of kidney function to where kidneys cannot filter waste effectively), high blood pressure, and bipolar disorder (disease that causes extreme mood swings from high manic to depressive lows). Record review of Resident #26's admission MDS assessment dated [DATE] indicated she understood others and usually made herself understood. The MDS also indicated she had a BIMS score of 11 which meant she had moderate cognitive impairment. The MDS also indicated she was dependent on staff for toileting, bathing, and transfers, and required setup assistance from staff for eating. Record review of Resident #26's care plan dated 09/16/25 indicated she had impaired vision and impaired cognitive function with interventions in place to provide medications as ordered. Record review of Resident #26's order summary report dated as of 01/06/26 indicated she had orders for: Clean wound with wound cleanser or normal saline and cover with abdominal pad or gauze. Change/clean daily and when soiled as needed for wound care with a start date of 12/31/25 and no end date. May apply barrier cream to Bilateral buttocks as needed every shift with a start date of 08/26/25 and no end date. During an observation on 01/04/26 at 9:45 AM Resident #26 did not have an enhanced barrier precaution sign on her door nor did she have a PPE cart outside of her room. During an observation on 01/05/26 at 8:35 AM Resident #26 did not have an enhanced barrier precaution sign on her door nor did she have a PPE cart outside of her room. During an interview on 01/07/26 at 12:40 PM the ADON said the Treatment Nurse and DON should have been wearing a gown and gloves for enhanced barrier precautions. The ADON said there should have been a sign on the door and the cart in the hallway fully stocked for Resident #1 and Resident #26. The ADON said the Nursing management (DON, ADON, and Treatment Nurse) were responsible for ensuring the enhanced barrier precaution signs and carts were on the halls. The ADON said the failure placed a risk for infection. During an interview on 01/07/26 at 1:32 PM The Administrator said he said he expected the EBP signage and carts on the hallway for Resident #1 and Resident #26. The Administrator said the failure of having no EBP placed a risk of infection. The Administrator said the DON and nursing department were responsible for ensuring the EBP signage and carts were in place. During an interview on 01/07/26 at 2:51 PM The DON said EBP should have been used with foley catheter care, intravenous line care, and when residents have wounds. The DON said Resident #1 and Resident #26 should have EBP signage and PPE carts outside of their rooms. The DON said the failure placed a risk for infection. The DON said the DON and ADON were responsible for ensuring the EBP signage and the carts were in place. The DON said she asked the Administrator for carts for PPE, but she thought it fell by the side, and she forgot about it. Record review of the facility policy Enhanced Barrier Precautions undated indicated: Multidrug-resistant organism (MDRO) transmission is common in long term care (LTC) facilities. Many residents in nursing homes are at increased risk of becoming colonized and developing infections with MDROs. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following: Colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply (see MDRO list on page 3); or Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Communication to Staff the facility will utilize postings outside the room and Point Click Care to communicate to staff if a resident requires EBP. Record review of the facility's policy titled, Perineal Care, effective 05/11/2022 indicated, 10) Perform hand hygiene 11) [NAME] gloves and all other PPE per standard precautions.17) Gently perform perineal care, wiping from clean, urethral area, to dirty, rectal area, to avoid contaminating the urethral area – CLEAN to DIRTY! Female resident: Working from front to back, wipe one side of the labia majora, the outside folds of perineal skin that protect the urinary meatus and the vaginal opening.20) Reposition the resident to their side 21) Gently perform care to the buttocks and anal area, working from front to back without contaminating the perineal area.24) Doff gloves and PPE 25) Perform hand hygiene 26) Provide resident comfort and safety by re-clothing (if applicable - incontinence pad(s) and briefs), straightening bedding, adjusting the bed and/or side rails, and placing call light within resident's reach 27) Clean and store reusable items 28) If visibly soiled or contaminated during the procedure, disinfect or discard the barrier towel on the table 29) Return resident items on the table 30) Tie off the disposable plastic bag of trash and/or linen 31) Perform hand hygiene 32) Thank you: thank the resident for assisting in self-care.

Based on observation, interview, and record review, the facility failed to enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 3 (Resident #11, Resident #29, Resident #52) of 8 residents reviewed, in that: The facility failed to ensure the thermometers inside Resident #11's, Resident #29's and Resident #52's personal refrigerators were present and functioning properly and the staff recorded the accurate temperatures of the refrigerator for two months. This failure could place residents at risk of foodborne illness due to consuming foods which might be spoiled. The findings included: Record review of Resident #11's face sheet, dated 01/05/2026, revealed an [AGE] year-old admitted [DATE] and readmitted [DATE] with diagnoses that included heart failure (a condition that occurs when the heart cannot pump enough blood for the body's needs), dementia (general term for severe cognitive decline), hypothyroidism (a condition that occurs when the thyroid gland doesn't make enough thyroid hormones to meet the body's needs), hypertension (high blood pressure), atrial fibrillation (an irregular heart rhythm that increases risk for stroke due to blood pooling and clotting) and major depressive disorder (a mood disorder causing persistent sadness, and loss of interest). Record review of Resident #11's comprehensive MDS, dated [DATE], revealed a BIMS score of 6 indicting Resident #11 had severe cognitive impairment. Resident #11 had lower extremity range of motion impairment, required a wheelchair for mobility, supervision in toileting, upper body dressing, moderate assistance in bathing, lower body dressing, bed mobility and transfers. During an observation and interview on 01/04/2026 at 10:15 a.m., Resident #11 allowed surveyor to observe personal refrigerator. Observation revealed refrigerator was packed full of undated food and drink items and no thermometer was visible. Resident #11 stated that the Activity Director does personal shopping for him and that to his knowledge, no one checks the refrigerator temperature, and he takes care of the refrigerator items himself. Resident #11 stated he thinks there used to be a thermometer in the refrigerator. Record review of Resident #29's face sheet, dated 01/07/2026, revealed a [AGE] year-old male admitted [DATE] and readmitted [DATE] with diagnoses that included peripheral vascular disease (a circulation disorder affecting blood vessels outside of the heart), chronic obstructive pulmonary disease (a progressive lung condition that makes breathing difficult), chronic kidney disease (a gradual loss of kidney function), chronic lymphocytic leukemia (a slow-growing blood cancer), diabetes mellitus type II (a chronic condition leading to high blood sugar levels), hypertension (high blood pressure), atrial fibrillation (an irregular heartbeat) Record review of Resident #29's comprehensive MDS dated [DATE] revealed a BIMS score 11 that indicated moderate cognitive impairment, had lower extremity impairment and required a wheelchair for mobility, maximum assistance in bathing, lower body dressing, moderate assistance in upper body dressing, and was totally dependent in toileting, bed mobility and transfers. During an observation and interview on 01/04/2026 at 10:25 a.m., Resident #29 allowed surveyor to observe personal refrigerator. Observation revealed refrigerator contained undated food items and no thermometer was visible. Resident #29 stated his family and the Activity Director assist with personal needs and shopping as needed. Resident #29 stated he did not know who checked the temperature of the refrigerator and could not recall the last time he saw a thermometer in the refrigerator. Record review of Resident #52's face sheet, dated 01/07/2026, revealed an [AGE] year-old male admitted [DATE] and readmitted [DATE] with diagnoses that included chronic kidney disease (a condition that occurs when the kidneys cannot filter blood well, leading to waste buildup), macular degeneration (an eye disease that damages central vision), hypertension (high blood pressure), chronic obstructive pulmonary disease (a progressive lung condition that blocks airflow causing breathing difficulties), osteoporosis (a condition that weakens bones, making them thin, brittle and prone to fracture), and dorsalgia (medical term for pain in the back and neck). Record review of Resident #52's quarterly MDS dated [DATE] revealed a BIMS score of 13 indicating resident #52 was cognitively intact, had lower extremity range of motion impairment, utilized no mobility devices, was dependent in toileting, bathing, lower body dressing, and bed mobility, required maximum assistance in upper body dressing and transfers. During an observation and interview on 01/04/2026 at 10:30 a.m., Resident #52 allowed surveyor to observe personal refrigerator. Observation revealed refrigerator contained undated food items and no thermometer was visible. Resident #52 stated the Activity Director assists with personal needs shopping. Resident #52 stated he does not know who checks the refrigerator temperature and could not recall the last time he saw a thermometer. Record review of temperature log for Resident #11's refrigerator from 01/01/26-01/06/26 revealed 45 degrees Fahrenheit each day. Record review of temperature log for Resident #29's refrigerator from 01/01/26-01/06/26 revealed 33 degrees Fahrenheit each day. Record review of temperature log for Resident #52's refrigerator from 01/01/26-01/06/26 revealed 32 degrees Fahrenheit each day. Surveyor notes no thermometer was visible in all three refrigerators from 01/04/2026-01/06/2026. During an interview on 01/05/2026 at 8:24 a.m., LVN B stated that she does not check the personal refrigerators, and she was not sure who checks them. During an interview on 01/07/2026 at 8:35 a.m., MA D stated that the maintenance department was responsible for checking the resident's' personal refrigerators and noted that she never opens them. During an interview on 01/07/2026 at 8:42 a.m., Housekeeper F stated that she does not check their refrigerators for the residents for cleanliness or temperature. Housekeeper F stated she believed her supervisor was responsible for the refrigerators. During an interview on 01/07/2026 at 9:15 a.m., CNA H stated she believed the housekeeping staff were responsible for checking the refrigerator temperatures and cleaning the refrigerators. During an interview on 01/07/26 at 9:50 a.m., the Housekeeping Supervisor stated that the families were responsible for maintaining the refrigerators, but she checked them when she cleans the rooms. The Housekeeping Supervisor stated she keeps a log of the temperatures and will try to clean them out but stated that a lot of times, the residents do not let me. The Housekeeping Supervisor stated that it was important to take out old food items because they could make the residents sick and that she would notify the Administrator of any residents who do not allow her to clean their refrigerator. During an interview on 01/07/2026 at 10:25 a.m., the Administrator stated that the facility does allow long term residents to have a personal refrigerator in their rooms. The Administrator stated that he expects the administrative staff who complete Champion Rounds (daily room checks) to monitor the refrigerator for proper functioning, temperature and ensure no spoiled food items are present. The Administrator stated he will assist with any residents who refuse to let staff check or clean their refrigerators. The Administrator stated adverse effects of not having refrigerator temperatures monitored could result in resident eating spoiled food items causing him/her to become ill. During an interview on 01/07/2026 at 2;30 p.m., the DON stated that she was aware the residents were allowed to have a personal refrigerator and that she believed housekeeping was responsible for monitoring temperatures and cleanliness. The DOM stated this was a concern she had when she was hired when she learned that not all of the refrigerators had a thermometer and accurate temperatures. The DON stated that failure to monitor the temperature could result in the residents consuming spoiled food items that would cause them to become sick. Record review of facility Food and Nutrition Services policy, revised 04/13/2022 revealed resident and/or family members are responsible for monitoring the interior temperature of personal refrigerators to ensure all foods are stored at a safe temperature of 40 degrees Fahrenheit or less. Additionally, perishable foods should be discarded within 7 days after preparation for food safety.

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 in 1 of 1 kitchen reviewed for dietary services. The facility failed to ensure regular texture corn, pureed corn, and pureed chicken strips were held at the proper temperature on 01/04/2025. This failure could place residents at risk for foodborne illness. Findings included: During an observation on 01/04/2026 at 11:53 AM, temperatures were taken of the food on the steam table by [NAME] A. The regular texture corn was 130 F, the pureed corn was 130 F, the pureed chicken strips were 132 F. During an interview on 01/05/2026 at 6:02 PM, [NAME] A said food should be held at least at 140 F. [NAME] A said if the food was not at 140 F, the food should be reheated. [NAME] A said she did not think about reheating the food before serving it because she was just trying to start serving the trays. [NAME] A said not holding food at the correct temperatures could cause the food to be bad. During an interview on 01/07/2026 at 11:35 AM, the Dietary Manager said food should be held at or above 140 F. The Dietary Manager said she liked for it to be at 165 F. The Dietary Manager said if the food temperature was not correct the food should be pulled off, and it should have been reheated to ensure it reached the appropriate temperature. The Dietary Manager said she had not observed the food temperatures to be incorrect. The Dietary Manager said the food not being held at the proper temperature could make the residents sick. During an interview on 01/07/2026 at 12:33 PM, the Administrator said he expected the food to be held above the recommended level. The Administrator said the Dietary Manager and the dietary staff should ensure they were holding the food at the proper temperatures. The Administrator said the food not held at the proper temperature could affect the quality of the food the residents received. Record review of the facility's policy titled, Daily Food Temperature Control, revised 04/09/2025 indicated, We will assure that food is served at a safe temperature. Temperatures of all hot and cold food shall be taken prior to every meal service and recorded on the Temperature Log. This is done to help ensure that food is safe and is served within acceptable ranges.4. All hot foods shall be cooked and held for service at temperatures of 140 degrees F or above. 5. Any hot or cold food which does not meet the minimum acceptable temperature shall be heated to a temperature of 165 degrees F and held at least 15 seconds.

Based on observations, interviews, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 1 of 1 meal (lunch meal) reviewed for food and nutrition services. The facility failed to ensure dietary staff provided food that had an appetizing temperature on 01/04/2026. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. Findings included: During an interview on 01/04/2026 at 10:24 AM, Resident #4 said the food was cold when she received it. During an interview on 01/04/2026 at 10:55 AM, Resident #30 said sometimes the food was cold when he received it. During an observation and interview on 01/04/2026 at 12:53 PM, the lunch tray was sampled by the Dietary Manager and three surveyors. The lunch tray sampled consisted of chicken fried chicken, corn, and mashed potatoes. The chicken fried chicken was lukewarm, and the mashed potatoes and corn were cold. The Dietary Manager said some people may have wanted the chicken fried chicken to be hotter. The Dietary Manager said the corn needed to be a little warmer because it was not hot. The Dietary Manager said the mashed potatoes needed to be warmer, as they had cooled down a little bit. During an interview on 01/04/2026 at 2:38 PM, Resident #23 said sometimes when she received her food it was cold. During an interview on 01/04/2026 at 3:46 PM, Resident #13 said the food was cold because it took so long to pass out the food to the halls from the time the food was in the kitchen. During an interview on 01/05/2026 at 6:02 PM, [NAME] A said she had not received any complaints from the residents about the food being cold. [NAME] A said the residents were supposed to be served a hot meal. [NAME] A said she was not sure how the residents receiving a cold meal could affect them. During an interview on 01/07/2025 at 11:30 AM, the Dietary Manager said she received cold food complaints from the residents. The Dietary Manager said the food was hot when it left the kitchen, but sometimes the food was not passed out in a timely manner by the staff. The Dietary Manager said she had reported the cold food complaints and the food not being passed out in a timely manner to the Administrator, DON, and previous Administrators. The Dietary Manager said she had suggested closed carts to keep the meals warmer but did not receive any resolution. The Dietary Manager said the food being cold could make the residents sick or the residents would not eat it. During an interview on 01/07/2025 at 12:30 PM, the Administrator said he expected the food to be served hot to the residents. The Administrator said the Dietary Manager was responsible for ensuring this happened. When asked if the Dietary Manager had told him about the cold food complaints and the trays not being passed out in a timely manner, the Administrator said when the food came out of the kitchen, the nursing department needed to be involved to make sure the food was taken to the residents in a timely manner, so the residents could receive their meals at the appropriate temperatures. The Administrator said if the food was cold, it was not going to taste good. Record review of the facility's policy titled, Preparation of Foods, from the Dietary Services Policy & Procedure Manual 2012, indicated, We will establish safe and nutritional preparation of food. Food is to be prepared in such a manner as to maximize flavor, appearance, and nutritional value.2. All food will be prepared by methods that preserve nutritive value, flavor, and appearance with a variety of color, and will be attractively served at the proper temperature and in a form to meet the individual needs of the resident.

Based on interview and record review, the facility failed to ensure residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 3 of 5 residents (Resident #3, Resident #8, and Resident #12) reviewed for unnecessary psychotropic drugs. 1. The facility failed to ensure Resident #12's GDR dated 10/08/25 for citalopram (antidepressant) was completed after being approved by the physician on 11/26/25. 2. The facility failed to ensure Resident #3's duloxetine (psychotropic medication used for depression) was decreased after the PMHNP-BC agreed to the pharmacy recommendation to reduce the duloxetine to 40 mg on 11/26/2025. 3. The facility failed to ensure documentation of attempted gradual dose reductions were made for Resident #8's Invega Sustenna and Olanzapine (antipsychotic medications used to treat schizophrenia and bipolar disorder). These failures could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications.Findings included: 1. Record review of Resident #12's face sheet dated 01/07/26 indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses dementia (condition characterized by progressive loss of intellectual functioning and memory impairment), high blood pressure, diabetes mellitus (disease where the body is unable to make insulin causing high blood sugars), and major depressive disorder (a serious mood disorder causing persistent sadness, loss of interest, and life impairment). Record review of Resident #12's admission MDS assessment dated [DATE] indicated he understood others and made himself understood. The MDS also indicated he had a BIMS score of 13 which meant he was cognitively intact. Record review of Resident #12's care plan undated indicated he required an antidepressant with interventions to give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness. (Antidepressant side effects: dry mouth, dry eyes, constipation, urinary retention, suicidal ideations). Record review of Resident #12's medication regimen review indicated a gradual dose reduction request for medication: Citalopram 30mg tab daily signed by the physician to decrease the Citalopram to 20mg daily on 11/26/25. Record review of Resident #12's order summary report dated as of 01/07/26 after surveyor intervention indicated he had an order for: Citalopram Hydrobromide Oral Tablet 20 MG (Citalopram Hydrobromide) Give 1 tablet by mouth one time a day related to major depressive disorder, recurrent, mild with a start date of 01/06/26 and no end date. Record review of Resident #12's medication administration record dated 12/01/25-12/31/25 indicated he received Citalopram Hydrobromide Oral Capsule 30 MG (Citalopram Hydrobromide) Give 1 capsule by mouth one time a day for Depression for the entire month of December 2025. (with some refusals documented) Record review of Resident #12's medication record dated 1/01/26-1/07/26 indicated he received Citalopram Hydrobromide Oral Capsule 30 MG (Citalopram Hydrobromide) Give 1 capsule by mouth one time a day for Depression on 1/01/26-1/06/26. (with some refusals documented) Record review of Resident #12's medication record dated 1/01/26-1/07/26 indicated he received Citalopram Hydrobromide Oral Capsule 20 MG (Citalopram Hydrobromide) Give 1 capsule by mouth one time a day for Depression on 01/07/26 after surveyor intervention. 2. Record review of a face sheet dated 01/07/2026 indicated Resident #3 was initially admitted on [DATE] and re-admitted [DATE] with diagnoses which included paranoid schizophrenia (mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior) and depression. Record review of Resident #3's Quarterly assessment dated [DATE] indicated she was understood by others and understood others. The MDS assessment indicated Resident #3's BIMS score was an 11, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #3 received an antidepressant medication. Record review of Resident #3's Medication Regimen Review dated 10/07/2025 indicated Gradual Dose Reduction Request, Medication: Duloxetine 60 mg QHS. The PMHNP-BC signed they agreed to reduce medication to 40 mg signed 11/26/2025. Record review of Resident #3's Order Summary Report dated 01/06/2026 indicated she had an order for duloxetine 60 mg give 1 capsule by mouth at bedtime with a start date of 04/11/2025. Record review of Resident #3's care plan reviewed 12/02/2025 indicated she required antidepressant medication to give antidepressant medications ordered by the physician. Record review of Resident #3's MAR for November 2025, December 2025, and January 2026 indicated duloxetine 60 mg give 1 capsule by mouth at bedtime was administered. There was no indication that the duloxetine was decreased to 40 mg. 3. Record review of Resident #8's face sheet dated 01/07/2026 indicated she was an [AGE] year-old-female initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included bipolar disorder (a disorder associated with episodes of mood swings ranging from depression lows to manic highs) and schizophrenia (mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior). Record review of Resident #8's Quarterly MDS assessment dated [DATE] indicated she understood others and was understood by others. The MDS assessment indicated Resident #8 had a BIMS score of 8, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #8 received antipsychotics, and the physician documented a GDR was clinically contraindicated on 09/05/2024. Record review of the pharmacy recommendations dated 12/04/2025 indicated for Resident #8 Invega Sustenna 78 mg/0.5 ml inject 1 application intramuscularly one time a day every 28th day, date ordered, 04/28/2025, last GDR requested 06/07/2025. Olanzapine 10 mg give 1 tablet by mouth at bedtime, date ordered 02/07/2024, last GDR requested 06/07/2025. Record review of the pharmacy recommendations for June 2025 did not indicate documentation a GDR was attempted for Invega Sustenna and Olanzapine. Record review of Resident #8's Order Summary Report dated 01/07/2025 indicated the following orders: Invega Sustenna Intramuscular Suspension prefilled syringe 78 mg/0.5 ml inject 1 application intramuscularly one time a day every 28th day with a start date of 04/28/2025. Olanzapine 10 mg give 1 tablet by mouth at bedtime with a start date of 02/07/2024. Record review of Resident #8's care plan reviewed 10/14/2025 indicated Resident #8 required antipsychotic medications to administer medications as ordered and consult with pharmacy and doctor to consider dosage reduction when clinically appropriate. Record review of Resident #8's TARs indicated she received Invega Sustenna 78 mg/0.5 ml November 2025 and January 2025. Resident #8 refused the Invega Sustenna in October 2025 and December 2025. Record review of Resident #8's MARs for October 2025, November 2025, December 2025, and January 2026 indicated she received olanzapine 10 mg (some refusals were documented each month). During an interview on 01/06/2026 at 5:45 PM, the ADON said the DON and she were completing the pharmacy recommendations. The ADON said she did not know why Resident #12's citalopram was not decreased to 20 mg. The ADON said she did not know why Resident #3's duloxetine was not decreased. The ADON said she did not know if Resident #8's had a GDR attempt for her olanzapine and Invega Sustenna. The ADON said if a medication was supposed to be decreased and it was not the resident could possibly overdose. During an interview on 01/07/2026 at 8:15 AM, the Regional Compliance Nurse said per the pharmacy recommendations Resident #8's GDRs for olanzapine and Invega Sustenna were attempted in June 2025, but she was not able to find documentation for it. During an interview on 01/07/2026 at 12:49 PM, the Administrator said he expected reductions of medications recommended by the pharmacy to be completed. The Administrator said the nursing department was responsible for providing oversight to ensure reductions to medications were in place. The Administrator said not implementing the pharmacy's recommendations could affect the condition of the resident and the care the resident received. The Administrator said not attempting GDRs affected the quality of care and the outcome of the care for the residents. During an interview on 01/07/2026 at 2:19 PM, the DON said the ADON and she were responsible for the pharmacy recommendations. The DON said she was not aware the pharmacy recommended Resident #12's citalopram be decreased to 20 mg. The DON said she was not aware the pharmacy recommended for Resident #3's duloxetine to be decreased to 40 mg. The DON said when they receive the pharmacy recommendations, they go through them and put them in the providers folder for them to sign, and once it is signed off, they put the order in. The DON said she did not know if GDRs were done for Resident #8's olanzapine and Invega Sustenna. The DON said the ADON and she kept track of the GDRs with the pharmacy recommendation binder. The DON said GDRs should be attempted because of the side effects associated with the medications. Record review of the facility's policy titled, Psychotropic Medication, revised 02/12/2025, indicated, The facility will ensure that the resident is free from chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. Residents should only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Also, residents will only remain on psychotropic medications when a gradual dose reduction and behavioral interventions have been attempted and/or deemed clinically contraindicated. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: Anti-psychotic; Anti-depressant; Anti-anxiety; and Hypnotic. b. Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, to discontinue these drugs. Residents who use psychotropic drugs will receive gradual dose reductions (GDRs), unless clinically contraindicated, to discontinue these drugs. For any resident who is receiving a psychotropic medication, the facility will show evidence that a GDR has been attempted unless clinically contraindicated. Medical record documentation should reflect the date of the GDR attempt, the outcome of the dose reduction attempt, and the plan regarding future GDR attempts. Physician documentation should contain the rationale for why GDR attempts are clinically contraindicated for the resident.

Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 4 residents (Resident #44) reviewed for hospice services. The facility failed to obtain Resident #44's most current Form 3071 Texas Medicaid Hospice Program Individual Election/Cancellation/Update, Form 3074, Physician Certification of Terminal Illness, Hospice Nurses' Notes, and Hospice Physician Orders. This deficient practice could place residents who receive hospice services at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. Findings included: Record review of a face sheet dated [DATE] indicated Resident #44 was a [AGE] year-old-male initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung condition that affects the respiratory system). Record review of Resident #44's Quarterly MDS assessment dated [DATE] indicated he was understood by others and understood others. The MDS assessment indicated Resident #44 had a BIMS score of 13, which indicated his cognition was intact. The MDS assessment indicated he required supervision or touching assistance for eating, toileting hygiene, partial/moderate assistance for personal hygiene, and substantial/maximal assistance for showering/bathing himself. The MDS assessment did not indicate he received hospice services. Record review of Resident #44's Order Summary dated [DATE] indicated he had an order to admit to hospice for diagnosis of chronic obstructive pulmonary disease with a start date of [DATE]. Record review of Resident #44's care plan reviewed [DATE] indicated he required hospice as evidenced by a terminal illness of chronic obstructive pulmonary disease and cancer. Record review of Resident #44's hospice binder did not indicate:Form 3071 Texas Medicaid Hospice Program Individual Election/Cancellation/UpdateForm 3074, Physician Certification of Terminal IllnessHospice Nurses' NotesHospice Physician Orders. During an interview on [DATE] at 5:02 PM, the Hospice Case Manager said Resident #44 was on hospice services. She said the Hospice Marketer or herself took required hospice documents to the facility. The Hospice Case Manager said she usually did not take the nurses' notes to the facility. She said Resident #44 went on hospice services in September of 2025 and then re-admitted to services on [DATE] or [DATE] due to a discharge because he went to the hospital. The Hospice Case Manager said she thought she had taken all the required hospice documents for Resident #44 to the facility. She said it was important for the facility to have the required hospice documents to ensure they were all in line with the plan of care. During an interview on [DATE] at 5:39 PM, the ADON said the DON was the one making sure the hospice brought the required documents to the facility. The ADON said it was important to have hospice documents in the facility to be prepared for what the residents might need when they expired. During an interview on [DATE] at 12:38 PM, the Administrator said he expected all hospice documents to be in the facility to be able to provide appropriate care to the residents. The Administrator said the DON and the nursing department was responsible for ensuring the hospice documents were in the facility and hospice collaboration occurred. The Administrator said it was important so they knew what they had to do and what they should do for the residents' care plans. During an interview on [DATE] at 2:11 PM, the DON said the ADON and she were responsible for ensuring the required hospice documents were in the facility. The DON said she had not checked the hospice binders to see if the required hospice documents were in the hospice binders. The DON said it was important to have the required hospice documents, so they knew what was going on with the residents. Record review of the facility's undated policy titled, Hospice Service, indicated: .The DON or designee will be responsible for ensuring that documentation is a part of the current clinical record. At a minimum, the documentation will include:The current and past Texas Medicaid Hospice Recipient Election/Cancellation Form (#3071)Texas Medicaid Hospice-Nursing Facility Assessment Form (#3073)Physician Certification of Terminal Illness (#3074)Medicare Election Statement (if dual eligible)Verification that the recipient does not have Medicare Part AHospice Plan of CareCurrent interdisciplinary notes to include nurses notes/summaries, physician orders and progress notes, and medications and treatment sheets during the hospice certification period.

Based on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 3 (Resident #1) residents reviewed for quality of care. 1. The facility failed to ensure the Treatment Nurse documented accurate skin assessments for Resident #1.2. The facility failed to ensure Resident #1 had was provided treatment for his wound to his great right toe. This failure could place residents at risk for not receiving appropriate care and treatment, a decreased quality of life, and pressure ulcers.Findings included: Record review of Resident #1's face sheet dated 01/06/26 indicated he was an [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of dementia (condition characterized by progressive loss of intellectual functioning and memory impairment), major depression (a serious mood disorder causing persistent sadness, loss of interest, and life impairment), chronic heart failure(long term condition in which the heart does not pump blood effectively), chronic kidney disease(loss of kidney function where kidneys cannot filter waste from blood), and high blood pressure. Record review of Resident #1's admission MDS assessment dated [DATE] indicated he was understood by others and made himself understood. The MDS also indicated he had a BIMS score of 8 which meant he had moderate cognitive impairment. The MDS also indicated he required maximal assistance from staff for bathing, transfers, bed mobility, and toileting, and setup assistance with eating. The MDS also indicated Resident #1 had no pressure ulcers or other skin conditions. Record review of Resident #1's undated care plan indicated he had actual impairment to skin integrity related to a non-pressure area to right great toe and stage 2 intact blister to the top of his right foot with interventions in place to provide treatment per orders, to follow facility policies/protocols for the prevention/treatment of skin breakdown. Record review of Resident #1's order summary report as of 01/05/26, with discontinued orders included, indicated he had an order for:1) skin prep to blister on right foot. one time a day with a start date of 01/05/262) Cleanse with Normal saline, apply anasept gel, and apply boarded dressing every day shift for eruption of [NAME] with a start date of 12/07/2025 and discontinued on an unknown date.The order summary did not indicate an order for the non-pressure area of the right toe. Record review of Resident #1's skin assessment 1/05/26 at 10:48 AM completed by the Treatment Nurse indicated his skin was intact. Record review of Resident #1's skin assessment 1/05/26 at 6:25 PM completed by the MDS Nurse indicated his skin had a blister to top of his right foot, right big toe scabbed area right 2nd and 3rd toes scabbed areas. Record review of Resident #1's wound evaluation dated 1/01/26 indicated he had a wound of the lower back, full thickness that measured 0.3 centimeters X 0.3 centimeters X 0.6 depth with a treatment of anasept daily. The wound evaluation also indicated Resident #1 had a non-pressure wound to his right great toe that measured 2.3 centimeters X 2.8 centimeters and no depth with a treatment of mupirocin 2% daily and as needed if saturated, soiled, or dislodged for 30 days and xeroform gauze apply once daily and cover with gauze island and as needed if saturated, soiled, or dislodged for 30 days. During an observation and interview 01/05/26 at 4:40 PM the Treatment Nurse and the DON entered Resident #1's room with no gown on but donned gloves. The Treatment Nurse and DON agreed Resident #1 had a wound to his right great toe that was open and abrasions to the top of his second, third, and fourth toes. The area noted to his mid back was not open. The DON assisted the Treatment Nurse in measuring the right great toe. The Treatment Nurse said she completed a skin assessment on 01/05/26 after being told on 01/04/26 that Resident #1 had a blister on his right foot. The Treatment Nurse said when she completed the skin assessment on 01/05/26, she completed the skin assessment as no areas because the blister was already found, and she did not look at or notice Resident #1's right great toe re-opening. The Treatment Nurse said she should have completed the assessment of the entire body, input orders for all areas noted, and updated Resident #1's care plan as well. The Treatment Nurse said the failure could have caused worsening of wounds. During an interview 01/05/226 at 4:53 PM The the DON said in the past an unknown department head had been instructing the staff to only input new skin areas in the weekly skin assessment, and she had been trying to instruct the nurses on completing a full assessment and adding all skin issues. The DON said a wound doctor came in on a weekly basis and completed rounds. The DON said she and the Treatment Nurse reviewed the notes on Fridays and then input any orders or changes. The DON said the wound doctor saw Resident #1 on 1/01/26 and the facility decided he did not need the wound care doctor since Resident #1 had no pressure wounds. The DON said when the Treatment Nurse re-assessed Resident #1, the Treatment Nurse should have placed in the orders for wound care to Resident #1's foot. During an interview on 01/07/26 at 12:42 PM the ADON said when a nurse completed a skin assessment anything new should be in the skin assessment, including what it looks like, drainage, and treatment. The ADON said the previous DON taught them that. The ADON said she understood a skin assessment to be an assessment of the entire body, and it should have been documented according to what was seen. The ADON said the failure of not completing an accurate skin assessment could have placed a risk for skin areas being missed and worsened skin problems. During an interview on 01/07/26 at 1:33 PM The the Administrator said he expected the skin assessments to include all skin issues correctly and the size each week. The Administrator said the failure placed a risk for the skin assessments not being accurate and could have caused skin issues to worsen. During an interview on 01/07/26 at 2:54 PM The the DON said she and the ADON had discussed the issues with the skin assessments, and she expected the nurses to assess and document all findings. The [NAME] said the failure placed a risk for skin assessments not being completed accurately and could cause worsening of wounds. Record review of thee facility policy Skin Assessment revised 12/24 indicated:It is the policy of this facility to establish a method whereby nursing can assess a resident's skin integrity to allow of appropriate intervention be initiated in a timely manner. Procedure:1. All new admits and residents returning from a hospital stay will have a head-to-toe skin assessment completed If the facility Treatment Nurse/designee is available he/she should complete the assessment within four (4) hours of the resident's arrival at the facility. If the Treatment Nurse/designee isn't available then the charge nurse should complete the assessment within four (4) hours of the resident's arrival at the facility. The charge nurse will then notify the Treatment Nurse/designee of any skin problems noted. Complete the appropriate attachments/assessments. The DON or designee, along with the Treatment Nurse/designee and other team members will review for the follow-up assessment and recommendations. Any pressure ulcer should also be care planned. Any alterations in skin integrity will be treated according to physician orders. Notify DON and responsible family member. Documentation will then be entered into the resident's chart with the following information. 2. All residents should have a skin assessment on a weekly basis completed in PCC3. If the resident has any type of ulcer (pressure injury, arterial, venous, diabetic) an ulcer assessment should be completed at least weekly.

Based on observation, interview, and record review the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel, and labeled and dated correctly for 1 of 27 residents (Resident #26) observed for medication storage. 1. The facility failed to ensure Resident #26 did not have a bottle of normal saline, a bottle of wound cleanser spray, a tube of zinc oxide protectant, and 2 tubes of zinc oxide silicone cream (medications used for wound care and barrier cream used for wound prevention) in a mauve basin on top of her personal refrigerator in her room. These failures could place residents at risk for obtaining injury or harm from misuse.Findings include: Record review of Resident #26's face sheet dated [DATE] indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with the diagnoses of chronic kidney disease (gradual loss of kidney function to where kidneys cannot filter waste effectively), high blood pressure, and bipolar disorder (disease that causes extreme mood swings from high manic to depressive lows). Record review of Resident #26's admission MDS assessment dated [DATE] indicated she understood others and usually made herself understood. The MDS also indicated she had a BIMS score of 11 which meant she had moderate cognitive impairment. The MDS also indicated she was dependent on staff for toileting, bathing, and transfers, and required setup assistance from staff for eating. Record review of Resident #26's care plan dated [DATE] indicated she had impaired vision and impaired cognitive function with interventions in place to provide medications as ordered. Record review of Resident #26's order summary report dated as of [DATE] indicated she had orders for:Clean wound with wound cleanser or normal saline and cover with abdominal pad or gauze. Change/clean daily and when soiled as needed for wound care with a start date of [DATE] and no end date.May apply barrier cream to Bilateral buttocks as needed every shift with a start date of [DATE] and no end date. During an observation on [DATE] at 9:45 AM Resident #26 had a bottle of normal saline, a bottle of wound cleanser spray, a tube of zinc oxide protectant, and 2 tubes of silicone cream in the mauve basin on top of Resident #26's personal refrigerator in her room. During an observation on [DATE] at 8:35 AM Resident #26 continued to have a bottle of normal saline, a bottle of wound cleanser spray, a tube of zinc oxide protectant, and 2 tubes of silicone cream in the mauve basin on top of fridge in her room. During an interview on [DATE] at 1:18 PM RN C said none of the medications should have been left in Resident #26's room. RN C said all staff were responsible for ensuring no medications were in residents' rooms. RN C said the failure placed a risk for Resident #26, family, or other residents getting the medication and misusing or harming themselves. During an interview on [DATE] at 1:33 PM the Administrator said all medications should be stored in medication carts. The Administrator said the failure of leaving the medications in the room placed a risk for Resident #26 using and not knowing how to use the medications correctly and the failure also placed a risk for wandering residents getting the medications and misusing them. During an interview on [DATE] at 2:50 PM the DON said none of the medications should have been left in Resident #26's room. The DON said the wound care medications should have been kept in the medication cart with Resident #26's name and date they were opened on them. The DON said the failure placed a risk for Resident #26 or any other residents getting the medications and using, or the medications could have expired, and no one would have known. Record review of the facility policy Medication storage in the facility dated 3-2025 indicated: Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications. An unnecessary medication is any medication used: In excessive doses; or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued for 1 of 8 residents (Resident #41) reviewed for unnecessary medication. The facility failed to ensure Resident #41's protein pump inhibitor (PPI) Omeprazole had been decreased according to pharmacy recommendations and physician's approval. This failure could place residents at risk for adverse drug reactions (unintended, harmful events attributed to the use of medication) and providing medication without physician's knowledge.The findings included: Record review of Resident #41's admission record, dated 01/06/2026, revealed an [AGE] year-old admitted on [DATE] and readmitted on [DATE] with diagnoses that included atherosclerotic heart disease (the buildup of fats and other substances in and on the artery walls), diabetes mellitus (a chronic condition where the body does not produce enough insulin leading to high blood sugar levels), dementia (severe cognitive decline beyond normal aging), osteoporosis (a bone disease where bones become thin, weak, and brittle due to decreased bone mass and density), dysphagia (difficulty swallowing), major depressive disorder (a mood disorder causing persistent sadness and loss if interest), hypertension (high blood pressure), and gout (a painful inflammatory arthritis from uric acid crystals in joints). Record review of Resident #41's comprehensive MDS dated [DATE] revealed BIMS Score 10 indicating resident had moderate cognitive impairment, required a wheelchair for mobility, moderate assistance in toileting, bathing, lower body dressing and transfers, supervision in bed mobility and upper body dressing. Record review of Resident #41's care plan, revised 11/11/2025, does not address use of PPI for acid indigestion. Record review of pharmacy recommendations dated 12/04/2025 revealed Resident #41 had been receiving Omeprazole PPI since 01/13/2024 and long-term use has been associated with increased risk of C.diff (stool infection), bone loss, and fractures. Pharmacy recommendation was to decrease Omeprazole to 20mg daily. Physician Response dated 12/10/2025 indicated he agreed with this recommendation.Record review of Resident #41's medication administration record dated 12/01/2025-01/06/2026 revealed resident received Omeprazole Capsule Delayed Release 40 mg by mouth one time a day with order start date 01/13/2024 indicating that the physician approved pharmacy recommendation was not followed.During an interview on 01/06/2026 at 3:29 p.m., RN C stated that the pharmacy recommendations were completed by the administrative nurses, and the floor nurses were advised once the updated order was in the electronic medical record. During an interview on 01/06/2026 at 5:40 p.m., the ADON stated that the pharmacy recommendations were the responsibility of the DON & ADON and that she was unable to say why the pharmacy recommendation agreed to by the physician on 12/10/2025 was not followed for Resident #41. ADON stated that failure to follow the recommendations once approved by the physician could result in the resident not receiving the appropriate / prescribed medication. ADON stated that she and the DON write the new orders once the physician signs the denial or agreement of the recommendation.During an interview on 01/07/2026 at 8:24 a.m., LVN B stated that the ADON or DON make changes based on the pharmacy recommendations once they are signed by the physicians and tell the nurse when completed to put on the 24-hour report. LVN B stated that the charge nurse does not see the actual recommendations or contact the physician for approval or denial. During an interview on 01/07/2026 at 10:25 a.m., the Administrator stated that the nursing staff and ultimately the DON were responsible for ensuring that the pharmacy recommendations once completed by the physician are put in place and that he expected the nursing administration to monitor and manage this system. The Administrator stated he was ultimately responsible to ensure the job tasks were being performed. Adverse effects to the residents could be harmful if the physician believes a medication change had occurred and it did not. During an interview on 01/07/2026 at 2:30 p.m., the DON stated that she and the ADON were responsible for reviewing and processing the pharmacy recommendations to include notifying the physician and adjusting orders as indicated. The DON was unable to state why this pharmacy recommendation was not completed. The DON stated it was important that the recommended changes were completed to ensure physicians' orders were followed. Adverse effect of not following physician's orders could cause harm or injury to the resident. Facility policy on Unnecessary Medications or Pharmacy Recommendations was requested on 01/06/2026 and 01/17/2026 but was not received prior to survey exit. During an interview with the Regional Nursing Director on 01/07/2026 at 1:45 p.m., the Regional Nursing Director stated the facility follows HHSC standards and protocol for medication administration. According to Guidance 483.45(d) Unnecessary Drugs and (c)(3) and (e) Psychotropic Drugs .Proper medication .without adequate monitoring-ma increase the risk of a broad range of adverse consequences such as medication interactions, depression, confusion, immobility, falls, hip fractures, and death.

Based on observation, interview, and record review, the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practice for 1 of 3 residents reviewed for respiratory care (Residents #26). The facility failed to ensure Resident #26's suction machine yankauer was bagged. The facility failed to ensure Resident #26 had a physician order for the use of the suction machine. The facility failed to ensure Resident #26 had the use of the suction machine included on her care plan. This failure could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory disease. Findings Included: Record review of Resident #26's face sheet dated 01/06/26 indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with the diagnoses of chronic kidney disease (gradual loss of kidney function to where kidneys cannot filter waste effectively), high blood pressure, and bipolar disorder (disease that causes extreme mood swings from high manic to depressive lows). Record review of Resident #26's admission MDS assessment dated [DATE] indicated she understood others and usually made herself understood. The MDS also indicated she had a BIMS score of 11 which meant she had moderate cognitive impairment. The MDS also indicated she was dependent on staff for toileting, bathing, and transfers, and required setup assistance from staff for eating. Record review of Resident #26's physician's order summary report as of 01/06/26 did not indicate an order for the suction machine in Resident #26's room. Record review of Resident #26's care plan dated 09/16/25 did not indicate resident required the use of the suction machine. During an observation and interview on 01/04/26 at 9:45 AM Resident #26 was lying in her bed and had a suction machine on the dresser that was bagged but had a used yankauer (tool used to suction a resident's mouth) connected to the suction machine lying outside of the bag hanging on the side of the suction machine. During an observation on 01/05/26 at 8:35 AM Resident #26 was lying in her bed and the unbagged yankauer continued to hang on the outside of the bagged suction machine on the dresser. Resident #26 said she used the suction machine on occasions. Resident #26 said she would not want to use the suction machine if the yankauer was hanging out and not clean. During an observation and interview on 01/07/26 at 10:45 AM RN L was shown the suction machine and yankauer outside of the bag hanging in Resident #26's room and she said the yankauer in Resident #26's room should have been bagged or removed after use. RN L said she had never had to use the suction machine for Resident #26 but there should have been an order in place, and the suction machine and use of it should have been included in Resident #26's care plan. RN L said the failure placed a risk for infection. During an interview on 01/07/26 at 12:37 PM the ADON said the yankauer should have been bagged while in the resident's room. The risk is was for infection from germs being in the room. The ADON said there should have been an order for the suction machine and the suction machine should have been care planned. the The ADON said it was important to have an order and care plan os for any care provided by staff. The ADON said the facility had to have a physician's order and the facility needed a care plan is to ensure the staff could provide the care and know how. During an interview on 01/07/26 at 1:28 PM the Administrator said Resident #26 should have had an order to use the suction machine and without the order in place the machine should not have been in her room. The Administrator said he expected the suction machine to be on Resident #26's care plan as well for care. The Administrator said the failure placed a risk for infection control with the yankauer not being stored properly. During an interview on 01/07/26 at 2:47 PM the DON said the suction machine should have had an order for use and a care plan. The yankauer should have been in a clean bag and not attached to the machine. The DON said providing care without and order paced a risk for practicing medicine; failure of the care plan is no one knows what is going on or why the suction machine was there. The DON said the risk of the yankauer being unbagged is was bacteria and unsanitary conditions and could cause infection or sickness. Record review of the undated facility policy Airway Suctioning indicated:Suctioning is performed to ensure a patent airway by removing secretions from the nose, pharynx, and trachea. Assemble the sectioning materials with clean container, tubing, and the kit or individually wrapped supplies for the procedure. Dispose of all supplies according to Universal Precautions. Perform hand washing. Document care.

Based on observation, interview, and record review, the facility failed to ensure the Resident environment remained as free of accident hazards as is possible for 2 of 16 residents (Resident #16, Resident #41) reviewed for accidents and hazards, in that: Resident #16 had an unsecured oxygen cylinder in his room. Resident #41 was utilizing a wheelchair with an unsecured seat backrest resulting in a fall. These deficient practices placed residents at risk for injuries.The findings included: 1. Record review of Resident #16's face sheet dated 01/06/26 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses of fracture of left femur, high blood pressure, diabetes mellitus (disease where the body is unable to make insulin causing high blood sugars), and atrial fibrillation (most common type of irregular heartbeats). Record review of Resident #16's admission MDS assessment dated [DATE] indicated she was able to understand others, and she was able to make herself understood. The MDS also indicated she had a BIMS score of 11 which meant she had moderate cognitive loss. Record review of Resident #16's care plan dated 11/09/25 did not indicate Resident #16 used oxygen. Record review of Resident #16's order summary report as of 01/06/26 did not indicate Resident #16 had an order for oxygen. During an observation on 01/04/26 at 9:55 AM Resident #16 had an oxygen cylinder laying in the corner of her room against the wall. Resident #16 said she did not use oxygen, but the oxygen cylinder had been laying there against her wall since she had been admitted in the facility on 11/09/25. During an observation on 01/05/26 at 8:46 AM the oxygen cylinder in Resident #16's room continued to be in the corner laying against the wall. During an observation and interview on 01/06/2025 at 10:48 AM RN L said the oxygen cylinder should not have been in the resident's room. She said oxygen cylinders was were supposed to be stored on the hall in the storage room in a rack. She said the failure placed a risk for the cylinder falling or getting knocked over and possibly exploding. During an interview on 01/07/26 at 12:36 PM the ADON said the closet for oxygen is was where the oxygen cylinder should have been stored. The ADON said the oxygen cylinder should not be left in the residents' rooms propped against the wall. The ADON said the failure placed a risk for the oxygen cylinder being knocked over and could have exploded or the resident getting injured from the oxygen cylinder falling on her or it could have caused Resident #16 to trip over it. During an interview on 01/07/26 at 1:27 PM the Administrator said the oxygen cylinder should have been stored upright in the proper oxygen storage room. The Administrator said the failure placed a risk for the cylinder falling over in Resident #16's room and it was dangerous. The Administrator said the oxygen cylinder could have exploded. During an interview on 01/07/26 at 2:45 PM the DON said the oxygen cylinder should not have been lying against the wall in Resident #16's room. The DON said if Resident #16 was using the oxygen cylinder it should have been in a bag and on the back of her chair or the oxygen cylinder should have been stored in the oxygen room in the proper storage rack. The DON said the failure placed a risk to the oxygen cylinder exploding if it fell or was knocked over. Record review of the facility Compressed Gases, Safe Handling Of policy dated 12/10/25 indicated: 1. Only qualified and trained personnel may handle gas cylinders located within the facility.9. Never drop cylinders or permit them to strike against each other or against other surfaces violently.11. When tanks are stored, all tanks and cylinders should be stored in a cylinder cart or securely chained in a secure storage area. Never leave cylinders free-standing. All cylinders must be individually secured. 2. Record review of Resident #41's admission record, dated 01/06/2026, revealed an [AGE] year-old admitted on [DATE] and readmitted on [DATE] with diagnoses that included atherosclerotic heart disease (the buildup of fats and other substances in and on the artery walls), diabetes mellitus (a chronic condition where the body does not produce enough insulin leading to high blood sugar levels), dementia (severe cognitive decline beyond normal aging), osteoporosis (a bone disease where bones become thin, weak, and brittle due to decreased bone mass and density), dysphagia (difficulty swallowing), major depressive disorder (a mood disorder causing persistent sadness and loss if interest), hypertension (high blood pressure), and gout (a painful inflammatory arthritis from uric acid crystals in joints). Record review of Resident #41's comprehensive MDS dated [DATE] revealed a BIMS Score of 10 indicating resident had moderate cognitive impairment, required a wheelchair for mobility, moderate assistance in toileting, bathing, lower body dressing and transfers, supervision in bed mobility and upper body dressing. Record review of Resident #41's care plan, revised 11/11/2025, revealed resident had a history of falls and remained at risk for falls with interventions to replace wheelchair, review information on past falls and attempt to determine cause of falls. Record review of maintenance work order logs 06/01/2025-01/05/2026 revealed no work order request was completed identifying a loose bolt on Resident #41's wheelchair back rest prior to bolt loosening and falling out resulting in Resident #41 falling as per facility self-report #1045709. During an interview on 01/05/2026 at 2:01 P.M., Resident #41 stated that she never noticed that the bolt on the back of her wheelchair back rest was loose. Resident #41 stated she has received a refurbished wheelchair and was told a new wheelchair has been ordered. Resident #41 stated she has no residual effects related to the fall. During an interview on 01/05/2025 at 2:20 p.m., the Maintenance Director stated that he did not have a wheelchair safety check system in place prior to the time the back rest on Resident #41 came loose causing her to fall backwards. The Maintenance Director stated that all staff members notify him of maintenance concerns utilizing an on-line referral system that he receives immediately at time of submission. The Maintenance Director stated that after this incident with Resident $41's wheelchair back rest coming loose, he and the Director of Rehab completed a safety check on all facility wheelchairs. During an interview on 01/07/2026 at 8:24 a.m., LVN B stated that she vaguely remembered that Resident #41 had a fall related to her wheelchair breaking but could not remember the details. LVN B stated she notifies maintenance personally because she was not very knowledgeable with the computer and does not like to use the online maintenance workload referral system. LVN B stated that to her knowledge, there are no outstanding work orders for C Hall (hallway where Resident #41 resides). During an interview on 01/07/2025 at 8:35 a.m., MA D stated that she submits any maintenance concerns thru the online program whenever she sees something. MA D stated she did not notice the bolt was loose on Resident #41's wheelchair backrest. During an interview on 01/07/2025 at 9:15 a.m., CNA H stated that she does utilize the scan code for maintenance work order requests, and the last one she submitted what a while back. CNA H stated she was not aware that Resident #41 had a fall related to wheelchair malfunction. During an interview on 01/07/2025 at 8:52 a.m., the Director of Rehabilitation Services (DOR) stated that all wheelchairs were checked at the time of the incident with Resident #41 and that his team completes monthly wheelchair safety audit on all residents who go to the therapy gym. The DOR stated that approximately 80% of the residents are on therapy caseload so chairs are seen regularly. The DOR was unable to provide documentation that wheelchair safety checks were on-going and stated that he tends to repair as concerns arise and if it is outside of his capability, he will notify maintenance or the specialty wheelchair company. During an interview on 01/07/2026 at 10:25 a.m., the Administrator stated the facility had a system in place called Champion Rounds to help monitor the rooms and equipment for maintenance repairs. The Administrator stated he follows up with the maintenance director to ensure the work orders are completed timely. The Administrator stated he expected the Department Heads assigned to participate in Champion Rounds to complete a thorough review of the room and medical equipment to include wheelchairs and walkers to ensure proper functioning. The Administrator stated he was not employed at the facility at the time the self-report regarding Resident #41's wheelchair malfunction and that he would review with the DOR and the Maintenance Director to ensure monthly wheelchair safety rounds are completed and logged. The Administrator stated he received the weekday Champion Round logs and monitors daily to ensure repairs are completed. During an interview on 07/07/2026 at 2:30 p.m., the DON stated that all staff were responsible for reporting maintenance concerns for resident's' rooms and equipment. The DON stated that each room has a Department Head assigned to monitor equipment repair needs and she expected the person assigned to report concerns timely. The DON stated that failure to identify equipment repair needs could result in harm or injury to the resident as in this incident with Resident #41. Requested facility policy for wheelchair maintenance on 01/05/2026 at 2:20 p.m. The ADMIN and Maintenance Director stated they did not have a policy regarding equipment repair and maintenance.

Based on interviews and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 2 of 3 residents (Resident #44 and Resident #47) reviewed for resident rights. The facility failed to ensure Resident #44 and Resident #47 were treated respectfully by CNA E. This failure could place residents at risk of decreased self-worth, loss of dignity, and a diminished quality of life.Findings included: 1. Record review of a face sheet dated 01/06/2026 indicated Resident #47 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side (paralysis and weakness of the left side due to affected blood flow and vessels in the brain) and major depressive disorder recurrent severe without psychotic features (recurrent mood disorder characterized by intense depression or loss of interest or pleasure that lasts weeks). Record review of Resident #47's Quarterly MDS assessment dated [DATE] indicated he was understood by others and understood others. Resident #47's BIMS score was a 15, which indicated his cognition was intact. The MDS assessment indicated Resident # 47 required setup or clean-up assistance with eating, substantial/maximal assistance with personal hygiene, and dependent on staff for toileting and showering/bathing self. Record review of Resident #47's care plan reviewed 12/16/2025 indicated he had an ADL self-care performance deficit and required assistance from staff for his ADLs. During an interview on 01/04/2026 at 2:45 PM, Resident #47 said CNA E was the rudest aide, and he did not like the way she talked to him. Resident #47 said for example yesterday (01/03/2026), his roommate (Resident #44) spilled coffee, and today (01/04/2026) CNA E refused to give his roommate coffee because he spilled it yesterday. Resident #47 said he reported to RN C that CNA E was rude to him. 2. Record review of a face sheet dated 01/07/2026 indicated Resident #44 was a [AGE] year-old-male initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung condition that affects the respiratory system) and generalized anxiety disorder (mental illness defined by feelings of uneasiness, worry and fear). Record review of Resident #44's Comprehensive MDS assessment dated [DATE] indicated he understood and was understood by others. Resident #44 had a BIMS score of 13, which indicated his cognition was intact. The MDS assessment indicated Resident #44 required supervision or touching assistance with eating, partial to moderate assistance with personal hygiene and substantial/maximal assistance with showering/bathing self. Record review of Resident #44's care plan reviewed 12/23/2025 indicated he had an ADL self-care deficit related to activity intolerance and shortness of breath. Resident #44's care plan indicated he required supervision as needed for eating. During an interview on 01/04/2026 at 2:55 PM, Resident #44 said yesterday, he accidentally dropped his cup of coffee, and this morning CNA E told him she was not going to give him any coffee because he spilled it yesterday. Resident #44 said he told RN C, CNA E was rude and would not give him his coffee, and RN C gave him coffee. Resident #44 said CNA E was rude to him. Resident #44 said it was the way CNA E spoke to him. During an interview on 01/04/2026 at 3:23 PM, RN C said in the morning (01/04/2026), CNA E called her down to Resident #44's room because he was upset and had knocked over his tray and an old cup of coffee. When she went to Resident #44's room, Resident #44 was upset because he did not get his coffee. RN C said she did not ask CNA E why she would not give Resident #44 his coffee. RN C said she just went and got him coffee. Resident #44 and Resident #47 had previously reported to her that CNA E was rude to them. RN C said she reported it to the ADON and DON, and they said they would talk to her. RN C said they should do what the resident requests because they were there to provide customer service to them. RN C said not doing what the resident requested could make them angry or change their behaviors. During an interview on 01/04/2026 at 4:16 PM, CNA E said she had not been rude to Resident #44 or Resident #47. CNA E said Resident #44 was shaking as if he could not hold a cup of coffee, so she told him she was going to get him up in his chair and then give him coffee. CNA E said Resident #44 became upset and started cussing and threw the tray on the floor. CNA E said Resident #44 had never behaved in this manner. CNA E said she did not tell Resident #44 he could not have any coffee because he spilled it yesterday. CNA E said they should meet the requests of the residents because it was their right. During an interview on 01/05/2026 at 5:30 PM, CNA G said Resident #44 and Resident #47 reported to her that CNA E was rude to them. CNA G said management was aware of the residents reporting that CNA E was rude to them. CNA G said the residents were saying it's the way CNA E talks to them and the tone she uses. During an interview on 01/07/2026 at 12:53 PM, the Administrator said he was told Resident #44 dropped his coffee on the floor the morning of 01/04/2026, and Resident #44 requested CNA E give him another cup of coffee. CNA E refused to do so, and he was really upset because he said she should have given him another one. The Administrator said RN C gave him another cup of coffee. The Administrator said CNA E told him she did not give Resident #44 coffee because she was waiting until he was in his chair because he was shaking. The Administrator said none of the staff or residents reported to him CNA E was rude to them. The Administrator said he expected all the residents to be treated with dignity and respect. The Administrator said he and the DON were responsible for ensuring the staff was treating residents with dignity and respect. The Administrator said the residents not being treated with dignity and respect could affect the residents' outcome and could make them feel unhappy. During an interview on 01/07/2025 at 2:29 PM, the DON said CNA E reported to her that Resident #44 threw his coffee and spilled it everywhere. The DON said CNA E told her she was going to get Resident #44 up, and she told him to let her get him up in his chair and then she would get him the coffee. CNA E said he became upset and knocked the coffee over, and she left and got another nurse. The DON said Resident #44 told her he just wanted his coffee. The DON said Resident #44 did not report to her that CNA E was rude to him, but RN C told her Resident #44 reported CNA E was rude to him. The DON said prior to this incident she did not receive any complaints about CNA E being rude from the staff or the residents. The DON said she had received complaints from the residents and staff saying CNA E was too loud and talked too much. The DON said she expected the staff not to be rude to the residents, to have empathy and be caring towards them. The DON said treating the residents rudely could make them feel like the staff do not care about them and make them not feel safe. Record review of the facility's undated policy titled, Resident Rights, indicated, A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.Respect and dignity - The resident has a right to be treated with respect and dignity.

Based on interview and record review, the facility failed to ensure each resident had the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of treatment and treatment alternatives for 1 of 5 residents (Resident #3) reviewed for psychoactive medications. The facility failed to ensure written consent on HHSC Form 3713 was obtained from Resident #3 prior to the administration of Invega Sustenna, an antipsychotic medication, used to treat schizophrenia. This failure could place residents at risk for receiving medications they had not consented to, experiencing potential adverse reactions, and a potential decline in physical and mental health status.Findings included: Record review of a face sheet dated 01/07/2026 indicated Resident #3 was a [AGE] year-old female initially admitted on [DATE] and re-admitted [DATE] with diagnoses which included paranoid schizophrenia (mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior). Record review of Resident #3's Quarterly MDS assessment dated [DATE] indicated she was understood by others and understood others. The MDS assessment indicated Resident #3's BIMS score was an 11, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #3 received an antipsychotic medication. Record review of Resident #3's Order Summary Report dated 01/06/2026 indicated she had an order for Invega Sustenna prefilled syringe 234 mg/1.5 ml inject 1.5 ml intramuscularly (shot in the muscle) one time a day on the 17th every month with a start date of 10/17/2025. Record review of Resident #3's care plan reviewed 12/02/2025 indicated she required an antipsychotic medication to administer medications as ordered and educate the resident/family/caregivers about risks, benefits, and side effects. Record review of Resident #3's Treatment Administration Records for October 2025, November 2025, and December 2025 indicated she received the Invega Sustenna. Record review of Resident #3's electronic health record on 01/06/2026 did not indicate a consent for Invega Sustenna. Resident #3's electronic health record did not indicate a Form 3713 for Invega Sustenna. During an interview on 01/06/2026 at 4:22 PM, the Regional Compliance Nurse said they did not have a consent for Resident #3's Invega Sustenna. During an interview on 01/06/2025 at 5:39 PM, the ADON said the DON and she were ensuring consents were obtained for medications. The ADON said she was not aware Resident #3 did not have a consent for her Invega Sustenna. The ADON said she thought Resident #3 was not receiving the medication due to insurance issues. The ADON said it was important for the residents to have consents completed for their medications because they had to agree to the medication and the medication had to be explained to them. During an interview on 01/07/2026 at 9:29 AM, Resident #3 said she signed her consents, and she had not been asked to sign for the administration of Invega Sustenna. Resident #3 said she believed it was for schizophrenia. Resident #3 said she did not know what schizophrenia was, and the staff did not provide information regarding the risks and benefits of the medication. During an interview on 01/07/2026 at 12:45 PM, the Administrator said he expected consents for medications to be obtained. The Administrator said the nursing department was responsible for ensuring the proper consents were obtained. The Administrator said not obtaining consents for medications placed the resident at risk of receiving medications that were inappropriate. During an interview on 01/07/2026 at 1:19 PM, RN C said she administered Resident #3's Invega Sustenna last month (December 2025). RN C said she was not aware Resident #3 did not have a consent for the Invega Sustenna. RN C said when a nurse received an order for a new medication that required a consent the nurse should have the consent completed. RN C said consent should be obtained to explain to the residents the risks and benefits of the medication and the risks of not getting the medication and to get their permission. During an interview on 01/07/2026 at 2:17 PM, the DON said when there was a new order for a medication that required a consent the nurse should get the consent and the DON and ADON double checked to ensure it was obtained. The DON said the nurses were supposed to get Form 3713 signed and then give it to the DON or ADON for them to take it to medical records. The DON said she was not aware Resident #3 did not have a consent or a Form 3713 for Invega Sustenna. The DON said it was important to obtain consents for medications because of the type of medications they were and to ensure the patient was consenting. Record review of the facility's policy titled, Psychotropic Medication, revised 02/12/2025, indicated, Residents have the right to be informed of and participate in their treatment. Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative will be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase. The resident has the right to accept or decline the initiation or increase of a psychotropic medication. The resident's medical record will include documentation that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and was able to choose the option he or she preferred. A written consent form may serve as evidence of a resident's consent to psychotropic medication, but other types of documentation are also acceptable.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 2 of 8 resident rooms (Rooms 24a and 30B) whose environments were reviewed, in that: 1.The privacy curtain rod in room [ROOM NUMBER] was not secure to the ceiling.2. An electrical extension cord was in use in room [ROOM NUMBER]a. These deficient practices could place residents at-risk for injury and poor quality of life.The findings were: 1.Observation of room [ROOM NUMBER]B on 01/04/2026 at 9:33 a.m. revealed the privacy curtain and rod on the B side of the room was hanging from the ceiling with approximately 15 not secured to the ceiling. During an interview on 01/04/2026 at 9:33 a.m., Resident #7 stated that she had not reported the loose privacy curtain rod, but that her roommate had reported it, lots of times. During an interview on 01/04/2026 at 10:35 a.m., Resident #41 stated she had told many staff members about the curtain rod but was unable to recall the staff members' names or when she had reported the concern. During an interview on 01/05/2026 at 2:20 p.m., the Maintenance Director stated that he had not been informed of the hanging privacy curtain rod and stated that he would repair it right away. During an interview on 01/07/2026 at 8:24 a.m. LVN B stated she was not aware that the privacy curtain rod was loose in room [ROOM NUMBER]. LVN B stated she would notify maintenance of work order. LVN B stated that if the privacy curtain fell down, it could injure the resident. During an interview on 01/07/2026 at 8:35 a.m., MA D stated that she was not aware the privacy curtain rod in room [ROOM NUMBER] was not secured. MA D stated that if the curtain rod were to fall down it could cause injury to Resident #7 and possibly her roommate, Resident #41. During an interview on 01/07/2026 at 10:25 a.m., the Administrator stated he was not aware that the privacy curtain in room [ROOM NUMBER] was not secured to the ceiling and that the Champion Rounds log did not reflect this. The Administrator stated he would notify maintenance immediately to ensure the rod was secured. The Administrator stated that he expects all staff members to be diligent in their rounds and identify concerns that could affect residents' safety. The Administrator stated he was ultimately responsible for monitoring the upkeep of the facility. During an interview on 01/07/2026 at 2:30 p.m., the DON stated that she was not aware the privacy curtain rod in room [ROOM NUMBER] was not securely attached. The DON stated that the Administrator monitors the room rounds that are completed daily by administrative staff, and she believed the Maintenance Director completes separate rounds. The DON stated that failure to provide a safe environment could result in harm or injury to the residents. 2. Observation of room [ROOM NUMBER]A on 01/04/2025 at 10:35 a.m. revealed a brown extension cord attached to Resident #48's phone charger. During an interview on 01/04/2025 at 10:35 a.m., Resident #48 stated the extension cord was hers because she needed it to charge her phone. Resident #48 stated no one had told her she could not have the extension cord. During an interview on 01/07/2026 at 8:24 a.m. LVN B stated she was not aware that there was an extension cord in room [ROOM NUMBER]a. LVN B stated that to her knowledge, extension cords were not allowed, and she would notify the Administrator. During an interview on 01/07/2026 at 8:35 a.m., MA D stated she was not aware that resident #48 had an extension cord. MA D stated an extension cord could be a fire hazard. During an interview on 01/07/2026 at 10:25 a.m., the Administrator stated that residents were not allowed to have extension cords unless they were checked and URL approved. The Administrator stated he was not aware of any residents who have an extension cord and upon being made aware that Resident #48 had an extension cord for her cell phone charger, stated he would purchase a longer phone charger cord to get rid of the extension cord. The Administrator stated that inappropriate or unapproved electrical items could result in an electrical fire and pose a hazardous risk of harm and injury to the residents and the facility. During an interview on 01/07/2026 at 2:30 p.m., the DON stated that she was not aware Resident #48 in room [ROOM NUMBER]a had an extension cord. The DON stated this should have been identified during Champion Rounds and stated that the Administrator monitors the room rounds that were completed daily by administrative staff, and she believed the Maintenance Director completed separate rounds. The DON stated that failure to provide a safe environment could result in harm or injury to the residents and in this case an electrical fire. Record review of the facility admission Packet, p. 24 titled Items Not Allowed in Resident Room revealed, Extension Cords and multiple plugs - not allowed.

Based on interview and record review the facility failed to ensure assessments accurately reflected the resident status for 2 of 27 residents (Resident #6 and Resident #44) reviewed for MDS assessment accuracy. The facility did not ensure Resident #6's Comprehensive MDS assessment dated [DATE] was accurately coded to reflect her level II PASRR status. The facility did not ensure Resident #44's Quarterly MDS assessment dated [DATE] accurately reflected he received hospice services. These failures could place residents at risk of not receiving care and services to meet their needs.Findings included: 1. Record review of Resident #6's face sheet dated 01/06/2026 indicated she was an [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses which included cerebral palsy (a group of neurological disorders that appear in infancy or early childhood and permanently affect body movement and muscle coordination). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #6 was not considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Record review of Resident #6's care plan reviewed 12/23/2025, indicated she had an intellectual disability and was PASRR positive. Record review of Resident #6's PASRR Evaluation dated 01/05/2023 indicated she had a developmental disability other than an intellectual disability that manifested before the age of 22. 2. Record review of a face sheet dated 01/07/2026 indicated Resident #44 was a [AGE] year-old-male initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung condition that affects the respiratory system) and generalized anxiety disorder (mental illness defined by feelings of uneasiness, worry and fear). Record review of Resident #44's Quarterly MDS assessment dated [DATE] did not indicate he received hospice services. Record review of Resident #44's Order Summary dated 01/05/2026 indicated he had an order to admit to hospice for diagnosis of chronic obstructive pulmonary disease with a start date of 10/03/2025. Record review of Resident #44's care plan reviewed 12/23/2025 indicated he required hospice as evidenced by a terminal illness of chronic obstructive pulmonary disease and cancer. Record review of Resident #44's hospice documents indicated an admission date of 09/05/2025. During an interview on 01/07/2026 at 11:56 AM, the MDS Coordinator said she completed Resident #6's and Resident #44's MDS assessments. The MDS Coordinator said Resident #44 went on hospice in September 2025, so his MDS should have reflected he was on hospice. The MDS Coordinator said it was not coded accurately because it was a data entry error. The MDS Coordinator said Resident #6's MDS assessment should have reflected she was PASRR positive. The MDS Coordinator said she was aware Resident #6 was PASRR positive, and it was an oversight that she coded her MDS assessment incorrectly. The MDS Coordinator said regional provided oversight by doing spot checks, but not every MDS assessment was reviewed. The MDS Coordinator said it was important for PASRR status to be coded accurately to ensure the residents received the needed services. The MDS Coordinator said the hospice not coded accurately would affect the residents' care plan. During an interview on 01/07/2026 at 12:36 PM, the Administrator said he expected the MDS assessments to be completed accurately. The Administrator said the MDS Coordinator was responsible and the corporate MDS nurse completed audits to ensure she completed them accurately. The Administrator said not coding the MDS assessments correctly could affect the residents' function and diagnoses. During an interview on 01/07/2026 at 2:31 PM, the Regional Compliance Nurse said they did not have a policy for MDS accuracy that they followed the RAI. Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.18.11 dated October 2023 indicated, .Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions.Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services.

Based on observation, interview, and record review, the facility failed to refer all Level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for Level II resident review upon a significant change in status assessment for 1 of 8 residents (Resident #38) reviewed for PASRR services. Resident #38 had a diagnosis of bipolar disorder but did not have a Level II evaluation. This deficient practice could place residents at risk of not receiving appropriate services to meet their individual needs.The findings were: Record review of Resident #38's face sheet, dated 01/06/2026, revealed the resident was a [AGE] year old female and was admitted to the facility on [DATE] and re-admitted [DATE] from another skilled nursing facility with diagnoses that included chronic kidney disease, Parkinson's Disease (a progressive brain disorder that affects movement), Bipolar disorder (a serious mental illness causing mood swings), anxiety disorder (a serious mental illness causing persistent, excessive fear and worry that interferes with daily life)r, major depressive disorder (a mood disorder causing persistent sadness and loss of interest that impacts daily life), dysphagia (difficulty swallowing), dementia (a general term for significant cognitive decline), hypertension (high blood pressure), and heart failure (a chronic disease that occurs when the heart cannot pump enough blood to meet the body's needs). Record review of Resident #38's EHR diagnoses list revealed the resident's diagnoses of bipolar disorder and dementia were present at time of admission.Record review of Resident #38's comprehensive MDS assessment dated [DATE] revealed under section A1500 PASRR that Resident #38 did not have a serious mental illness and a level 2 evaluation was not completed. A1510 Level 2 PASRR conditions, serious mental illness was blank. Section I6000 indicated resident did have a bipolar disorder diagnosis. Further review of Resident #38's comprehensive assessment revealed a BIMS Score of 11 indicating moderate cognitive impairment. Record review of Resident #38's care plan revealed a focus initiated on 12/19/2025 that resident had a mood problem related to bipolar disorder and impaired cognitive function/dementia or impaired thought processes. Record review of Resident #38's PASRR (Preadmission Screening and Resident Review) Level 1 screening completed by the referring entity, a nursing facility, and dated 12/04/2025 did not reflect Resident #38 had a diagnosis of bipolar disorder or an indicator that Resident #38 had a mental illness. Record review of Resident #38's PASRR Level 1 screening completed on 5/22/23 did not reflect Resident #38 had a diagnosis of Psychosis or an indicator that Resident #38 had a mental illness.Record review of Resident #38's EHR on 01/05/2026 revealed a corrected Level 1 screening was not completed and no Level 2 PASRR evaluation was completed.Observation and interview of Resident #38 on 01/04/2025 at 10:51 a.m. revealed resident presented alert, oriented to person, general place. Presented clean, odor free, appropriately dressed. Responded appropriately to direct questions, limited responses to short phrase answers. Resident #38 did not feel she was missing any services but was unsure what was available to her under PASRR services.In an interview on 01/05/2026 at 5:22 p.m. with the MDS Nurse revealed that she was responsible for PASRR screenings and had been in this position since August 2025. The MDS Nurse stated that Level 1 on admission for Resident #38 did not indicate a positive PASRR, a PASRR Evaluation (PE2) was never completed. The MDS Nurse stated that once the qualifying diagnosis of bipolar disorder was identified, a PASRR Evaluation should have been completed and submitted to the Local Intellectual and Developmental Disability Authority (LIDDA) to determine if the resident was eligible for specialized services. The MDS Nurse stated that she was not aware the PASRR Level 1 Evaluation was incorrect, and because of this finding, and based on this finding, she would initiate a sweep of all PASRR's to ensure accurate coding and complete a PASRR Evaluation (PE2) or Form 1012 indicating dementia as primary diagnosis as indicated. In an interview with the Administrator on 01/07/2026 at 10:25 a.m., the Administrator stated that he expects nursing staff to properly identify and code resident status to ensure they receive the appropriate services under the PASRR program. Failure to provide these services could cause the resident to decline. The Administrator stated the nursing team was responsible for ensuring accurate coding for PASRR residents and he, as the Administrator, was ultimately responsible for ensuring the staff are competent in their job duties. During an interview on 01/07/2026 at 2:30 p.m., the DON stated she has a general understanding of PASRR services, but the MDS Nurse is responsible for reviewing the PASRR Level 1's on admission and submitting the PASRR Evaluations to determine eligibility. The DON stated that failure to ensure PASRR Evaluations were submitted could cause the eligible resident not to receive the care they may need and the care services they are eligible for. The DON stated that she was responsible for the accuracy of the PASRR program in the facility. Review of a facility policy, titled, PASRR Level 1 Screen Policy and Procedure, dated 03/06/19, indicated, Policy: It is the policy of Creative Solutions in Healthcare facilities to obtain a PASRR Level 1 screening form from the RE (referring entity) prior to admission to the NF. The PASRR Level1 will be submitted via Simple Long-Term Care timely per PASRR Regulatory timeframes. PASRR is a federally mandated program requiring all states to pre-screen all individuals seeking admission to a Medicaid-certified nursing facility, regardless of payor source or age. The PASRR Program is important because it provides options for individuals to choose where they live, who they live with, and the training and therapy they need to live as independently as possible.PASRR Program has 3 Goals:1. To identify individuals with MI, ID, or DD/RC (this includes adults and children).2. To ensure appropriate placement, whether in a community or in a Nursing Facility.3. To ensure individuals receive the required services for their MI, ID, or DD.Procedure:1. The Facility Admissions process will ensure a PL1 Screening Form is obtained from the RE on day of admission or prior to admission. A PL1 is obtained for every individual, regardless of payment type. 2. The PL1 Screening Form is completed by the RE (referring entity) using the paper copy of the PL1 Screening Form. 3. The Facility will review the PL1 Screening Form for completion and correctness prior to admission and submit the PL1 form per regulations. Procedures: 1. The facility's designated staff will review all potential admissions for possible positive PASARR conditions and ensure that Centers for Medicare Services Preadmission guidelines are followed Review the PL1 Form for completion and correctness before admission.

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 1 of 8 residents (Resident #48) reviewed for PASRR Level I screenings and services.The facility failed to ensure the residents who were identified as PASRR positive on admission were assessed for appropriate services and care coordination in that Resident #48 was never evaluated for PASRR services that she was eligible for.This failure could place residents who had a mental illness at risk of not receiving individualized care, or specialized services to meet their needs. Findings included:Record review of Resident #48's face sheet dated 01/07/2026 revealed a [AGE] year-old female admitted [DATE] with diagnoses to included schizophrenia (a brain disorder causing distorted perceptions, thoughts, and emotions), pulmonary fibrosis (a lung disease where lung tissue becomes scarred, making it hard for oxygen to get into the blood stream) , hypertension (high blood pressure), mood affective disorder (a mental health condition characterized by significant disruptions in emotional stated), rheumatoid arthritis (a chronic autoimmune disease where the immune system causing painful inflammation, swelling, warmth and stiffness), depression (a mood disorder causing persistent sadness and loss of interest), and osteoporosis (a bone disease causing bones to become thin, brittle, and weak from loss of bone mass and density). Record review of Resident #48's comprehensive MDS dated [DATE] revealed a BIMS Score of 12 indicating moderate cognitive impairment. Further review of the comprehensive MDS revealed Resident #48 had upper and lower extremity range of motion impairment, utilized a wheelchair or walker for mobility, required set-up assistance in eating, supervision with bathing, upper/lower body dressing, bed mobility and moderate assistance in transfers. Record review of consolidated physician's orders dated 01/07/2026 revealed Resident #48 received Seroquel 50mg one time a day & Risperdal 1mg two times a day for schizophrenia. Record review of Resident #48's care plan identified focus initiated 10/22/2024 revealed resident required anti-psychotic medications related to schizophrenia. Record review of a PASRR Level 1 Screening dated 06/28/2024 Section C0100 indicated Yes for Mental Illness. Record review of EMR revealed no PASRR Level 2 was completed. During an interview on 01/06/2025 at 12;21 p.m., the MDS Nurse confirmed that Resident #48 did not have a PASRR Level 2 completed. The MDS Nurse stated that she has worked at this facility since August 2025 and she was responsible for reviewing the new admissions PASRR Level 1 for accuracy and completing a correction if necessary. The MDS Nurse stated that she would complete a corrected PASRR Level 1 and submit it to the Local Intellectual & Developmental Disability Authority (LIDDA) for determination of PASRR eligibility and complete an audit of all PASRR Level 1's.During an interview on 01/07/2026 at 10:25 a.m., the Administrator stated he expected the nursing department to properly identify and code resident status to ensure they receive the appropriate services under the PASRR program. The Administrator stated failure to provide these services could cause a resident to miss out on services he/she may be eligible for. The Administrator stated the MDS Nurse was responsible for reviewing the PASRR Level 1's on admission and submitting for PASRR Evaluation. The Administrator stated that he is ultimately responsible for ensuring the staff are competent in their work. During an interview on 01/07/2026 at 2:30 p.m., the DON stated she has a general understanding of PASRR services, but the MDS Nurse was responsible for reviewing the PASRR Level 1's on admission and submitting the PASRR Evaluation to determine eligibility. The DON stated that failure to ensure PASRR Evaluation was submitted could cause the eligible resident not to receive the care they may need and the care services they are eligible for. The DON stated that she was responsible for the accuracy of the PASRR program in the facility. Record review of PASRR Person Centered Service Plan / Interdisciplinary Team Policy and Procedure revealed 2. Contact the LA (Local Authority) within 2 calendar days after the individual's admission.to discuss specialized services. Record review of PASRR Policy & Procedures dated 03/16/2019 revealed 3. The Facility will review the PASRR Level 1 Screening form for completion and correctness prior to admission and submit the PASRR level 1 form per regulations.

Based on interviews and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care within 48 hours of a resident's admission, including initial goals based on admission orders, physician orders, dietary orders, and social services for 2 of 16 (Resident #5, Resident #59) reviewed for baseline care plans.The facility failed to ensure a baseline care plan was completed within 48 hours from admission for Resident #5 and Resident #59.These failures could place residents at risk of not receiving care and services to meet their needs.The findings were: 1.Record review of Resident #5's face sheet, dated 01/06/2026, revealed Resident #5 was admitted on [DATE], with diagnoses which included: cerebral infarction (a stroke that occurs when blood flow to part of the brain is blocked, causing brain cells to die), anxiety disorder (mental illnesses causing persistent worry or fear about everyday situations), polyneuropathy (damage to multiple peripheral nerves causing numbness, tingling, weakness and pain), peripheral vascular disease (a circulation disorder leading to narrowed, blocked or weakened arteries and veins) and chronic obstructive pulmonary disease (a progressive lung condition that makes breathing difficult). Record review of Resident #5's admission MDS assessment, dated 10/13/2025, revealed a BIMS score of 15 indicating Resident #5 was cognitively intact. Further review revealed Resident #5 had lower extremity range of motion impairment, required use of a wheelchair for mobility, moderate assistance in toileting, transfers, bathing and lower body dressing and supervision in upper body dressing, and bed mobility. Record review of Resident #5's electronic medical record revealed Resident #5 did not have a baseline care plan. During an interview on 01/06/2026 at 2:45 p.m., the MDS Nurse stated the Admitting Nurse initiates the baseline care plan and completes the Baseline Care Plan acknowledgement form. The MDS Nurse stated the baseline care plan should be completed at the time of admission. The MDS Nurse stated that if the admitting nurse was not an RN, the DON usually opens the care plan for new admissions or another RN in the facility if needed. The MDS Nurse stated this facility utilized the comprehensive care plans as the Baseline Care Plan and could not say why the comprehensive care plan for Resident #5 was not initiated until 10/07/2025, 4 days after admission. During an interview on 01/06/2026 at 3:29 p.m., RN C stated that the baseline care plan was initially opened by the DON or another facility registered nurse as needed and the admitting nurse had access to add focus areas on admission. RN C stated that the MDS Nurse was responsible for the comprehensive care plan. During an interview on 01/07/2026 at 8:24 a.m., LVN B stated that she does not usually do anything about a baseline care plan and thought it was completed by the administrative nurses. LVN B stated she knew the care plan was important to understand the needs of the residents. During an interview on 01/07/2026 at 10:25 a.m., the Administrator stated that the nursing department was ultimately responsible for ensuring baseline care plans and all care plans were implemented according to state guidelines. The ADMIN stated he was ultimately responsible for ensuring the appropriate staff were competent in their job duties to ensure the care was provided appropriately. The Administrator stated he has not been at the facility very long and was still getting to know the staff and review their capabilities. During an interview on 01/07/2026 at 2:30 p.m., the DON stated that the MDS Nurse was responsible for initiating the baseline care plan and that she was responsible for monitoring that the baseline care plan was completed. The DON stated adverse effects of not completing the baseline care plan would be that no one would know how to care for the resident. 2.Record review of Resident #59's face sheet dated 01/06/26 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses diabetes mellitus (disease in which the body is unable to produce insulin to control the blood sugars), high blood pressure, heart failure (disease in which the body cannot pump blood as needed), and depression (serious mood disorder that causes persistent sadness). Record review of Resident #59's admission MDS assessment dated [DATE] indicated she made herself understood and she understood others. The MDS also indicated she had a BIMS score of 15 which meant she was cognitively intact. The MDS also indicated she required maximal assistance from staff for toileting, transfers, bathing, and bed mobility, and set up assistance for eating. Record review of Resident #59's electronic medical record on 01/06/26 indicated she did not have a base line care plan completed. During an interview on 01/07/26 at 12:33 PM the ADON said the MDS Nurse was responsible for completing the baseline care plan when residents were admitted to the facility. The ADON said the DON was responsible for providing the baseline care plan to the family of residents. The ADON said the failure of the baseline care plan not being completed placed Resident #59 at risk for staff not knowing Resident #59's limitations or any other care Resident #59 needed. During an interview on 01/07/26 at 1:24 PM the Administrator said the baseline care plan should have been completed within 72 hours of Resident #59's admission date. The Administrator said the nursing department was responsible. The Administrator said the failure of the baseline care plan not being completed placed a risk of staff not providing the care that Resident #59 needed. During an interview on 01/07/26 at 2:35 PM the DON said the charge nurse was responsible for the baseline care plan when the resident admits to the facility. The DON said she was not aware that the baseline care plan for Resident #59 was not completed. The DON said she thought she completed her comprehensive care plan, but it was only started. The DON said all of Resident #59's information should have been included in the care plan and not just the surgical wound and medication monitoring. The DON said the failure of the baseline care plan not being completed placed a risk for no staff knowing how to care for the Resident #59. Record review of facility's policy titled Baseline Care Plan, undated, read This facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. and The baseline care plan will be developed within 48 hours of a resident's admission.

Based on observation, interview, and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 2 of 8 residents (Residents #7 and #59) reviewed for activities, in that:1. Resident #7 was not taken to activities after she expressed an interest in them or provided in-room activities.2. Resident #38 was not provided with 1-on-1 activities.This deficient practice could affect residents who received in-room and out-of-room activities, and place them at-risk for lack of stimulation, boredom, and depression.The findings were:1. Record review of Resident #7's face sheet revealed an [AGE] year-old female admitted [DATE] and readmitted [DATE] with diagnoses that included: chronic kidney disease (a long term condition where the kidneys lose their function over time), osteoarthritis ( a degenerative joint disease leading to pain and stiffness in the affected joints), diabetes mellitus type II (a chronic condition characterized by high blood sugar levels due to lack of insulin), chronic obstructive pulmonary disease (a group of lung disease that make it hard to breathe), hypertension (high blood pressure), major depressive disorder (a mental health condition characterized by persistent sadness and loss of interest) and reduced mobility and hand contractures. Record review of Resident #7's comprehensive MDS dated [DATE] revealed a BIMS score of 14 indicating Resident #7 was cognitively intact, had upper and lower extremity range of motion limitations, required use of a wheelchair for mobility, was dependent with toileting, bathing, lower body dressing, transfers and bed mobility, required maximum assistance in transfers and upper body dressing.Record review of Resident #7's care plan, revised 11/11/2025, revealed the care plan did not address an activity focus area. Record review of the Activity Director's 1:1 room visit log revealed no documentation available for this resident. Record review of all activity progress notes in the electronic medical record revealed two entries for Resident #7 on 06/12/2023 and 06/07/2023 reflecting that Resident #7 came to the dining room to play bingo. Record review of the Activity assessment dated [DATE] revealed that it was very important to Resident #7 to do her favorite activities and that she needed assistance to and from activities and that it was important to her to have books or magazines. Record review of all activity assessments since admission [DATE], 02/06/2023, 05/11/2023, 08/14/2023, 08/16/2023, 11/11/2023, 04/12/2024, 07/05/2024, 10/05/2024 revealed no assessment identified resident's preference of activities or indicated attendance in group events or indicated individual activities provided to include in room visits. Record review of nurse aid assignments 01/06/2025 revealed tasks to include 1. Assist the resident in developing / Provide the resident with a program of activities that is meaningful and of interest to the resident. Encourage and provide opportunities for exercise, physical activity. 2. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. 3. Invite the resident to activities that promote additional fluid intake. Offer drinks during one-to-one visits. 4. The resident needs activities that minimize the potential for falls while providing diversion and distraction. Observation and interview on 01/04/2026 at 9:33 a.m. revealed Resident #7 lying in bed, awake. Resident #7 stated that the Activity Director does personal shopping for her on Tuesdays. Resident #7 stated that she does not go to activities very often anymore, noting that she was sad about that because she really loved Bingo but cannot work the markers anymore. During an interview on 01/05/2026 at 5:44 p.m., the Activity Director stated that she has only worked at the facility for a few weeks and so far, had not identified a resident who required in -room visits. The Activity Director stated that she would identify residents who could not come out of the room for medical reasons or personal reasons as eligible for in-room visits.During an interview on 01/05/2026 at 5:50 p.m., the Human Resources Director (former Activity Director at this facility) stated that she did not have any documentation for in-room visits or activity attendance for Resident #7. She stated she last worked as Activity Director on 11/30/2025.During an interview on 01/07/2026 at 8;35 a.m. MA D stated that Resident #7 only came out of the room for dialysis and does not go to other activities that she was aware of. MA D stated that she visits with Resident #7 when she passes her medications but does not stay with her long. MA D stated that not going to activities could increase depression. During an interview on 01/07/2026 at 9:15 a.m., CNA H stated that Resident #7 misses a lot of activities because of dialysis three times per week. CNA H stated that Resident #7 has told her that she misses playing Bingo.2. Record review of Resident #38's face sheet, dated 01/06/2026, revealed a [AGE] year old female who was admitted to the facility on [DATE] and re-admitted [DATE] with diagnoses that included chronic kidney disease, Parkinson's Disease (a progressive brain disorder that affects movement), Bipolar disorder (a serious mental illness causing mood swings), anxiety disorder (a serious mental illness causing persistent, excessive fear and worry that interferes with daily life)r, major depressive disorder (a mood disorder causing persistent sadness and loss of interest that impacts daily life), dysphagia (difficulty swallowing), dementia (a general term for significant cognitive decline), hypertension (high blood pressure), and heart failure (a chronic disease that occurs when the heart cannot pump enough blood to meet the body's needs). Record review of Resident #38's comprehensive MDS assessment dated [DATE] revealed a BIMS score of 1 indicating Resident #38 had severe cognitive impairment, had upper and lower range of motion limitations, required use of a wheelchair for mobility, maximum assistance in toileting, bathing, dressing and bed mobility, and moderate assistance in transfers. Record review of Resident #38's care plan, revised 12/19/2025, revealed the care plan did not address an activity focus area.Record review of Resident #38's Activity assessment dated [DATE] revealed Resident #38 required assistance to and from activity events, and preferred books, newspapers, magazines and music. Observations of Resident #38 from 01/04/2025-01/07/2025 revealed no books, newspapers, magazines or music in room. Resident observations from 01/04/2025-01/07/5025 revealed resident remained in her room during the entire survey with only a television for activity interventions.During an interview on 01/05/2026 at 5:44 p.m., the Activity Director stated that she has only worked at the facility for a few weeks and so far, had not identified a resident who required in-room visits. The Activity Director stated she believes Resident #38 did come to the Christmas Party event. The Activity Director stated that she would classify residents who were unable to come out of their room for medical reasons or personal reasons as eligible for in-room activities. During an interview on 01/05/2026 at 5:50 p.m., the Human Resources Director (former Activity Director at this facility) stated that she did not have any documentation for in-room visits or activity attendance for Resident #38 because she was a new admission. The Humans Resources Director stated she last worked as the Activity Director 11/30/2025.During an interview on 01/07/2026 at 8:35 a.m. MA D stated that Resident #38 attended scheduled activity events once in a while but most of the time just watched television in her room. During an interview on 01/07/2026 at 9:15 a.m., CNA H stated that Resident #38 does not come out of her room very often and that her family does visit in the evenings. During an interview on 01/07/2026 at 10:25 a.m., the Administrator stated that the current Activity Director has only been here a few weeks and was still learning the residents. The Administrator stated he expected the Activity Director to provide high and low functioning events to address the activity needs of all residents and meet their needs accordingly. During an interview on 01/07/2026 at 2:30 p.m., the DON stated that there are some residents who are considered bedfast and would benefit from in-room activities. The DON sated the Activity Director was responsible for ensuring activity services were provided for each resident. The DON stated she expected that activities be provided appropriately for each resident and failure to provide activity interventions could cause them to feel isolated, exacerbate depression and cause an overall decline. Record review of facility Activity Policy & Procedure manual, dated 2011, policy titled, Activity Programing, revealed Practice Guidelines, 1. Recreation programs are based on the interest and needs of the residents expressed through the Activity assessment, 3. Activity programs are designed based on resident's leisure interests and implemented to meet the needs (physical, cognitive, creative, social, spiritual, independent, and sensory ) of the residents., and 5. Those who cannot participate in group settings are provided individual programming. Inability to participate could include those who refuse to participate in activities, those who are in isolation, or physician ordered bed rest.

Based on observation, interview and record review, the facility failed to ensure the rights of the residents to be free from abuse and neglect for 1 of 4 residents (Resident #30) reviewed for abuse. The facility failed to keep Resident #30 free from abuse and neglect, when CNA K, CNA EE, Student NA FF, and Student NA O held her down and provided incontinent care while she was screaming and yelling stop, leave me alone on 10/05/2024. An Immediate Jeopardy (IJ) was identified on 10/29/2024 11:10 AM. The IJ template was provided to the facility on [DATE] at 11:13 AM. While the IJ was removed on 10/30/2024 the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on abuse policies, behavior management policies, and restraint policies. This failure could place residents at risk for serious psychosocial harm from abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. The findings included: Record review of the face sheet dated 10/29/24, reflected Resident #30 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included cerebral infarction (necrotic tissue in the brain), dementia (memory loss) with behavioral disturbances, essential hypertension (high blood pressure), and need for assistance with personal care. Record review of the quarterly MDS assessment dated [DATE], reflected Resident #30 was understood by others and was able to understand others. The MDS reflected Resident #30 had a BIMS score of 10, indicating her cognition was moderately impaired. The MDS reflected Resident #30 had verbal behaviors and refused care daily. The MDS reflected Resident #30 was dependent on staff with toileting, showers, and personal hygiene. The MDS reflected Resident #30 was always incontinent of bowel and bladder. Record review of the comprehensive care plan revised on 10/15/24, reflected Resident #30 was resistive to care, refused nursing/CNA care frequently such as weights, incontinent care, medications, showers, vital signs, labs, and other care. The care plan interventions included: allow the resident to make decisions about treatment regimen, to provide sense of control; if resident resists with ADLs, reassure resident, ensure safety, leave, and return 5-10 minutes later and try again; and it was her choice to be changed or not when asked/offered by CNAs/nurses. Record review of Resident #30's comprehensive monthly note dated 10/15/24 and created by the NP indicated . When seen last week, she reported an episode of abuse to me and other staff members. DON and Administrator notified. She was seen today while lying in bed. Pt initially started off calm and pleasant, then started yelling and cursing. In the midst of her yelling, she reported physical abuse again by staff and how she has pain in her [left] arm. Offered pain meds [medications] and scans, she refused and started yelling more . Record review of the social history assessment dated [DATE], reflected Resident #30 had a history of trauma. The assessment reflected Resident #30 had experienced a life-threatening illness, physical assault, physically threatened, sexually assaulted, and sexually threatened. The assessment reflected Resident #30 had been in and witnessed an extremely frightening situation. The assessment reflected Resident #30 reported at the age of 29 she was kidnapped from a store where she was working at. She states that two black men kidnapped, raped, and attempted to murder her. The FBI was involved, and she was found. Record review of the Abuse/Neglect policy, revised 09/09/24, reflected the resident has the right to be free from abuse . During an observation and interview on 10/28/24 at 11:19 AM, Resident #30 stated she remembered an incident where she was held down and changed against her will. Resident #30 was unable to remember the date of the incident. Resident #30 said she did not yell unless there was a reason. Resident #30 said she did not know the names of the staff members that held her down, but it was abuse. Resident #30 stated if anyone held another person down, that was abuse. Resident #30 said she had bruising on her arm and her left shoulder was hurting from the incident. Resident #30 showed surveyor her arm, which was free of bruising. Resident #30 had large, blue, veins that were visible. Resident #30 said during the incident the woman walked in and took her stuff, moved it to the side, grabbed her arm and twisted from the elbow to her wrist. Resident #30 stated she reported it to the staff but did not know their names. Resident #30 said the Administrator came in and told Resident #30 the girls were not fired; they just were not allowed to come back into her room. During an interview on 10/29/24 at 4:29 AM, CNA K stated she remembered an incident with Resident #30. CNA K stated she had only assisted with Resident #30's care on two occasions. CNA K stated on 10/05/24 she had just clocked into work when Student NA O requested assistance cleaning up Resident #30. CNA K stated herself, CNA EE, Student NA O, and Student NA FF were in Resident #30's room. CNA K stated they explained to Resident #30 she needed to be cleaned because she had bowel movement all over her. CNA K stated as soon as CNA EE moved Resident #30's fridge all hell broke loose. CNA K stated Resident #30 started screaming, cussing, hitting, and kicking staff. CNA K stated they had to clean her, so they held her down and continued cleaning her. CNA K stated Resident #30 kept yelling No, stop! CNA K stated Resident #30 told her she was hurting her when she was wiping. CNA K stated she apologized but explained she had to get her cleaned and a new brief placed on her. CNA K stated Resident #30 said she understood but kept yelling No, stop, leave me alone! CNA K stated normally when residents refused care or said no, she would stop performing care and go back at a later time. CNA K said she was told by the charge nurses that Resident #30 had to be changed twice a shift no matter what. CNA K stated she wanted to stop but felt like if she did not get Resident #30 changed, she would have gotten into trouble for disobeying. CNA K said it was important to respect Resident #30's wishes because it was her right to refuse care. CNA K stated holding someone down against their will could have been considered abuse. CNA K stated she would have done the same thing if she was changed against her will. During an interview on 10/29/24 at 4:37 AM, CNA EE stated on 10/05/24 she was asked by Student NA O to assist with changing Resident #30. CNA EE stated she had only worked at the facility for one week at the time of the incident. CNA EE said from what she remembered, there was a lot of screaming and yelling from Resident #30 when she was changed. CNA EE stated the other staff members stated it was normal for Resident #30 to yell, scream, and become combative during care so they continued. CNA EE said she held her over from the left shoulder area and on her back. CNA EE stated Resident #30 was mostly yelling and screaming and not hitting much. CNA EE said Resident #30 was pushing against the railing to try and push herself away. CNA EE said if a resident refused care, started yelling no, or became combative they should have backed away and reported it to the charge nurse. CNA EE said they did not do that in Resident #30's case. CNA EE said 4 people were in the room and it was chaos. CNA EE stated it was important to respect the resident's rights. CNA EE said continuing care for someone against their will, could have been considered abuse. During an interview on 10/29/24 at 4:38 AM, LVN LL stated Resident #30 refused to be changed most of the time. LVN LL said when Resident #30 refused care, the CNAs reported it to her, and she would have tried to talk Resident #30 into letting them help her. LVN LL said bargaining with Resident #30 worked at times, but if she adamantly refused, then she would have documented it. LVN LL stated she was recently hired, and she was working her third shift. LVN LL said if Resident #30 refused care, she expected the CNAs to stop providing care and report it to her. LVN LL said CNAs should not have continued care if the resident refused, started yelling, or became combative. LVN LL said it was important to respect the residents' rights and it could have been considered abuse to force care on someone. During an interview on 10/29/24 at 5:00 AM, the DON stated Resident #30 had reported on 10/14/24 that she was held down and changed against her will. The DON stated 4 people were identified during the investigation, which included CNA K, CNA EE, Student NA O, and Student NA FF. The DON stated the CNAs reported they went into change Resident #30, and she became combative. The DON said the CNAs reported Resident #30 was not held down but when she became combative the CNAs blocked and protected themselves from her hitting and kicking. The DON stated the facility policy was to stop providing care if a resident was refusing or becoming combative. The DON said Resident #37 reported her arm was hurting and she had bruising to her left arm. The DON stated an assessment was completed and no bruising was observed. The DON stated an x-ray was ordered but the resident refused. The DON stated staff should have left the room and came back at a later time to provide care. The DON stated Resident #30 had a right to refuse care. The DON stated no fault was identified during the investigation because the CNAs and NAs were doing their jobs. The DON stated Resident #30 had a history of refusing incontinent care for days to the point urine was running off her bed onto the floor. The DON stated they had tried different things to convince Resident #30 to allow staff to change her, but she continued to refuse care. The DON stated she told staff Resident #30 should have been changed at least once a shift. The DON stated it was important to respect the residents right to refuse care for multiple reasons, that included resident rights, injury, and traumatization. During an attempted interview on 10/31/24 at 8:53 AM to obtain additional information, Student NA FF did not answer the phone. A brief message was left with call back number. No return call upon exit of the facility. During an interview on 10/31/24 at 8:54 AM, Student NA O stated on 10/05/24 Resident #30 had asked for assistance with incontinent care. Student NA O stated it was only her second day on the job and she was not certified yet. Student NA O stated she was unable to find other staff members to assist her with changing Resident #30 during her shift. Student NA O stated the charge nurse told her she needed assistance. Student NA O did not remember the name of the charge nurse. Student NA O stated at the end of her shift when the night shift arrived, she asked CNA K, CNA EE, and Student NA FF for assistance with changing Resident #30. Student NA O stated Resident #30 was upset it had taken so long to find assistance. Student NA O said as they started changing Resident #30, and she became really upset. Student NA O said they just kept trying to encourage her. Student NA O said Resident #30 hit CNA K in the face a couple of times. Student NA O stated they rolled Resident #30 so they could change her brief and Resident #30 kicked her in the chest. Student NA O said she grabbed Resident #30's legs and loosely put them beside her body to block her hitting and kicking. Student NA O stated she used her body to keep Resident #30 from hitting and kicking. Student NA O said CNA EE was shielding Resident #30's hands from hitting other staff by holding her hands. Student NA O stated they were holding her hands for protection. Student NA O said Resident #30 was yelling and cussing at them. Student NA O stated Resident #30 said they did not know what the fuck they were doing, and it only took one person to change her. Student NA O said Resident #30 was mad because of all the staff members in the room. Student NA O said she talked to Resident #30 after the incident and Resident #30 explained she only liked one person in the room with her. Student NA O said changing Resident #30 against her will could have been considered abuse or a restraint. This was determined to be an Immediate Jeopardy (IJ) on 10/29/24 at 11:10 AM. The ADO was notified. The ADO was provided the IJ template on 10/29/24 at 11:13 AM. The following plan of removal submitted by the facility was accepted on 10/29/24 at 5:11 PM and included the following: Interventions 1. Resident #30 was assessed for emotional distress by the DON on 10/29/24. A trauma informed care assessment was completed on 10/29/24 by the DON. No additional emotional distress was noted. On 10/29/2024, DON completed a skin assessment and pain assessment with no negative findings. 2. The DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on following topics below. The administrator is on paid time off. The administrator will be in-serviced prior to returning to work by the Area Director of Operations. Completed with DON and ADON on 10/29/24. a. Abuse and Neglect to include not to hold a resident down while providing care at any time. If a resident is yelling stop, the staff members will stop and notify the charge nurse, DON, or Administrator for assistance and further direction. b. Behavioral management policy- Explain care to be provided prior to providing the care. If the resident refuses care or becomes combative with care, stop attempting to perform the care being resisted, ensure the resident's safety allow the resident to calm down. Attempt the care at a later time or with different staff. Continued combativeness with care should be reported to the Charge nurse, Administrator and/or DON immediately. c. Restraint Policy- holding a resident against their will to provide care is considered a restraint. 3. The 4 staff members were in-serviced 1:1 by the DON and ADON on 10/29/24 on the following topics below. i. Addendum - On 10/29/2204 ADO, DON, and ADON attempted to communicate with the 4 staff members via text and phone call. 2 of the 4 staff members verbally self-termed, 1 staff member was a no call no show for their shift on 10/29/2024 and is being termed and the 4th staff member is PRN and has not responded to text messages or phone calls. Images of the in-services have been texted to her and if she is to return to work she will be in serviced by DON or ADON prior to the start of her shift. a. Abuse and Neglect to include not to hold a resident down while providing care at any time. If a resident is yelling stop, the staff members will stop and notify the charge nurse, DON, or Administrator for assistance and further direction. b. Behavioral management policy- Explain care to be provided prior to providing the care. If the resident refuses care or becomes combative with care, stop attempting to perform the care being resisted, ensure the resident's safety allow the resident to calm down. Attempt the care at a later time or with different staff. Continued combativeness with care should be reported to the Charge nurse, Administrator and/or DON immediately. c. Restraint Policy- holding a resident against their will to provide care is considered a restraint. 4. The medical director was informed of the immediate jeopardy citation on 10/29/24 by DON. 5. An ADHOC QAPI meeting was held on 10/29/24 to include the interdisciplinary team and medical director to discuss the immediate jeopardy citation and plan of removal. In-services: All staff will be in-serviced on 10/29/2024 for the following topics below by the ADO and Regional Compliance Nurse, DON, and ADON. All staff not present will not be allowed to assume their duties until in-serviced. All PRN staff will be in-serviced prior to their next assignments. All new hires will be in-service on their date of hire, during facility orientation. All agency staff will be in-serviced prior to the start of their assignment. a. Abuse and Neglect to include not to hold a resident down while providing care at any time. If a resident is yelling stop, the staff members will stop and notify the charge nurse, DON, or Administrator for assistance and further direction. b. Behavioral management policy- Explain care to be provided prior to providing the care. If the resident refuses care or becomes combative with care, stop attempting to perform the care being resisted, ensure the resident's safety allow the resident to calm down. Attempt the care at a later time or with different staff. Continued combativeness with care should be reported to the Charge nurse, Administrator and/or DON immediately. c. Restraint Policy- holding a resident against their will to provide care is considered a restraint. On 10/30/24 the survey team confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: 1. Record review of Resident #30's electronic medical record, reflected a new trauma informed care assessment dated [DATE] was completed. The assessment reflected Resident #30 had a history of trauma, was sexually assaulted, had been in a situation that was extremely frightening, had witnessed an extremely frightening situation, and did not feel comfortable explaining any of the situations. 2. Record review of Resident #30's skin assessment dated [DATE], reflected no injuries or skin concerns. 3. Record review of Resident #30's pain assessment dated [DATE], reflected no pain concerns. 4. Record review of the ADHOC QA meeting document dated 10/29/24, reflected the immediate jeopardy concerns were discussed with the plan of removal and monitoring. The Medical Director attended verbally and a copy of the plan was provided. 5. Record review of the in-service training attendance roster dated 10/29/24, reflected education was provided on behavior management to the DON and the ADON. 6. Record review of the in-service training attendance roster dated 10/29/24, reflected education was provided on restraints policy to the DON and the ADON. 7. Record review of the in-service training attendance roster dated 10/29/24, reflected education was provided on abuse and neglect polices to the DON and the ADON. 8. Record review of the in-service attendance roster dated 10/29/24, reflected education was provided to all staff across all shifts and disciplines on the restraint policy. There were 47 staff signatures. 9. Record review of the in-service attendance roster dated 10/29/24, reflected education was provided on the restraint policy via telephone to twelve staff members across all shifts and disciplines. 10. Record review of the in-service attendance roster dated 10/29/24, reflected education was provided on abuse and neglect policies. There were 47 staff signatures from across all shifts and disciplines. 11. Record review of the in-service attendance roster dated 10/29/24, reflected education was provided on abuse and neglect policies via telephone to 11 staff members from across all shifts and disciplines. 12. Record review of the in-service attendance roster dated 10/29/24, reflected education was provided on the behavior management policy. There were 47 staff signatures from across all shifts and disciplines. 13. Record review of the in-service attendance roster dated 10/29/24, reflected education was provided on the behavior management policy via telephone to 12 staff members from across all shifts and disciplines. 14. During a telephone interview on 10/30/24 at 9:48 AM, the Medical Director stated he was notified of the immediate jeopardy situation and attended a QAPI meeting via phone over the immediate jeopardy and subsequent plan of removal on 10/29/24. 15. During interviews on 10/30/24 between 9:16 AM and 11: 23 AM, Housekeeper M, Housekeeper CC, LA Y, the Housekeeping Supervisor, DA R, [NAME] DD, DM SS, Student NA O, Student NA Z, CNA N, CNA S, CNA V, MA BB, LVN A, LVN D, LVN L, LVN T, RN AA, PTA Q, COTA W, COTA X, OT P, OT U, the MDS Coordinator, the Human Resource Coordinator, Medical Records, the AD, the Maintenance Supervisor, the ADON, and the DON were able to verbalize they were provided in-service education on behavior management policy, restraint policy, and abuse neglect policies. The staff members were able to explain if residents were refusing care or became combative during care, they should stop providing care, ensure the resident was safe, and notify the charge nurse. The staff stated they could attempt care at a later time with a different staff member. The staff members stated holding a resident down against their will to provide care was considered a restraint. The staff members stated it could have also been considered abuse. The staff members were able to verbalize the different types of abuse, when to report abuse, and who the abuse coordinator was. 16. Record review of the personnel action form reflected CNA K was self-terminated effective 10/30/24. 17. Record review of the personnel action form reflected CNA EE was self-terminated effective 10/20/24. The ADO was informed the IJ was removed on 10/20/24 at 11:54 AM. The facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observations, interviews, and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 3 of 4 residents' (Resident's #2, #4, and #30) reviewed for trauma-informed care. 1. The facility failed to ensure Resident #30 was not held down and provided incontinent care while she was screaming and yelling stop, leave me alone on [DATE] by CNA K, CNA EE, Student NA FF, and Student NA O. 2. The facility failed to ensure Resident #30's history of being kidnapped, raped, and almost murdered was included on the care plan. 3. The facility failed to ensure Resident #30's potential triggers for re-traumatization were assessed and documented in the care plan. 4. The facility failed to ensure Resident #4's history of trauma and diagnosis of PTSD was reflected on her trauma screening. 5. The facility failed to ensure Resident #4's history of trauma and diagnosis of PTSD was included on the care plan, with her potential triggers for re-traumatization identified. 6. The facility failed to ensure Resident #2's trauma screening reflected her diagnosis of PTSD. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 11:13 AM. While the IJ was removed on [DATE] the facility remained out of compliance at a scope of patterned and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on abuse policies, behavior management policies, and restraint policies. These failures could put residents at an increased risk for severe psychological distress due to re-traumatization. The findings included: 1. Record review of the face sheet dated [DATE], reflected Resident #30 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included cerebral infarction (necrotic tissue in the brain), dementia (memory loss) with behavioral disturbances, essential hypertension (high blood pressure), and need for assistance with personal care. Record review of the quarterly MDS assessment dated [DATE], reflected Resident #30 was understood by others and was able to understand others. The MDS reflected Resident #30 had a BIMS score of 10, indicating her cognition was moderately impaired. The MDS reflected Resident #30 had verbal behaviors and refused care daily. The MDS reflected Resident #30 was dependent on staff with toileting, showers, and personal hygiene. The MDS reflected Resident #30 was always incontinent of bowel and bladder. Record review of the comprehensive care plan revised on [DATE], reflected Resident #30 was resistive to care, refused nursing/CNA care frequently such as weights, incontinent care, medications, showers, vital signs, labs, and other care. The care plan interventions included: allow the resident to make decisions about treatment regimen, to provide sense of control; if resident resists with ADLs, reassure resident, ensure safety, leave, and return ,d+[DATE] minutes later and try again; and it was her choice to be changed or not when asked/offered by CNAs/nurses. The comprehensive care plan did not address Resident #30's history of trauma to include potential triggers for re-traumatization. Record review of the social history assessment dated [DATE], reflected Resident #30 had a history of trauma. The assessment reflected Resident #30 had experienced a life-threatening illness, physical assault, physically threatened, sexually assaulted, and sexually threatened. The assessment reflected Resident #30 had been in and witnessed an extremely frightening situation. The assessment reflected Resident #30 reported at the age of 29 she was kidnapped from a store where she was working at. She states that two black men kidnapped, raped, and attempted to murder her. The FBI was involved, and she was found. Record review of Resident #30's comprehensive monthly note dated [DATE] and created by the NP indicated . When seen last week, she reported an episode of abuse to me and other staff members. DON and Administrator notified. She was seen today while lying in bed. Pt initially started off calm and pleasant, then started yelling and cursing. In the midst of her yelling, she reported physical abuse again by staff and how she has pain in her [left] arm. Offered pain meds [medications] and scans, she refused and started yelling more . Record review of Resident #30's progress note dated [DATE], reflected . Pt [patient] gets anxious and combative with nursing care. She has a history of being sexually assaulted by several males. She denies symptoms of PTSD (a mental and behavioral disorder that develops from experiencing a traumatic event). I cannot rule out post-traumatic stress disorder at this time . During an interview on [DATE] at 11:19 AM, Resident #30 stated she remembered an incident where she was held down and changed against her will. Resident #30 said she did not yell unless there was a reason. Resident #30 said she did not know the names of the staff members that held her down, but it was abuse. Resident #30 stated if anyone held you down, that was abuse. Resident #30 said she had bruising on her arm and her left shoulder was hurting. Resident #30 said the woman walked in and took her stuff, moved it to the side, grabbed her arm and twisted from the elbow to her wrist. Resident #30 stated the girls were not fired; they just were not allowed to come back into her room. Resident #30 stated she was kidnapped by two men, sexually assaulted, and almost murdered. Resident #30 said the two men came into the store and asked for some liquor. Resident #30 stated they followed her into the back and grabbed her. Resident #30 stated they placed a gun to her head and made her take off her clothing. Resident #30 stated she was raped for hours. Resident #30 said her brain shut off, but she remembered being by some water. Resident #30 said after they were done, they tried to make her get out of the car. Resident #30 said a short time later the FBI rescued her. Resident #30 said she knew if she got out of the car she would have been killed. Resident #30 said for the longest time she was unable to talk about the incident because her brain was trying to protect itself. During an interview on [DATE] at 4:29 AM, CNA K stated she remembered an incident with Resident #30. CNA K stated she had only assisted with Resident #30's care on two occasions. CNA K stated on [DATE] she had just clocked into work when Student NA O requested assistance cleaning up Resident #30. CNA K stated herself, CNA EE, Student NA O, and Student NA FF were in Resident #30's room. CNA K stated they explained to Resident #30 she needed to be cleaned because she had bowel movement all over her. CNA K stated as soon as CNA EE moved Resident #30's fridge all hell broke loose. CNA K stated Resident #30 started screaming, cussing, hitting, and kicking staff. CNA K stated they had to clean her, so they held her down and continued cleaning her. CNA K stated Resident #30 kept yelling no, stop. CNA K stated Resident #30 told her she was hurting her when she was wiping. CNA K stated she apologized but explained she had to get her cleaned and a new brief placed on her. CNA K stated Resident #30 said she understood but kept yelling no, stop, leave me alone. CNA K stated normally when residents refused care or said no, she would stop performing care and come back at a later time. CNA K said she was told by the charge nurses that Resident #30 had to be changed twice a shift no matter what. CNA K stated she wanted to stop but felt like if she did not get Resident #30 changed, she would have gotten into trouble for disobeying. CNA K stated she was aware of Resident #30's history of trauma. CNA K stated Resident #30 told her the story of being kidnapped, raped, and almost murdered. CNA K stated changing someone against their will could have triggered re-traumatization, but she was told by the DON Resident #30 had to be changed. CNA K stated she would have done the same thing if she was changed against her will. During an interview on [DATE] at 4:37 AM, CNA EE stated on [DATE] she was asked by Student NA O to assist with changing Resident #30. CNA EE stated she had only worked at the facility for one week at the time of the incident. CNA EE said from what she remembered, there was a lot of screaming and yelling from Resident #30 when she was changed. CNA EE stated the other staff members stated it was normal for Resident #30 to yell, scream, and become combative during care so they continued. CNA EE said she held her over from the left shoulder area and on her back. CNA EE stated Resident #30 was mostly yelling and screaming and not hitting much. CNA EE said Resident #30 was pushing against the railing to try and push herself away. CNA EE said if a resident refused care, started yelling no, or became combative they should have backed away and reported it to the charge nurse. CNA EE said they did not do that in Resident #30's case. CNA EE said 4 people were in the room and it was chaos. CNA EE stated she was unsure if Resident #30 had a history of trauma. Resident #30 said it was important to know if a resident had a history of trauma, but she was unsure where to find out if a resident had a history of trauma. CNA EE said she usually asked the nurse. CNA EE said continuing care for someone against their will, could have traumatized the resident. During an interview on [DATE] at 4:38 AM, LVN LL stated Resident #30 refused to be changed most of the time. LVN LL said when Resident #30 refused care, the CNAs reported it to her, and she would have tried to talk Resident #30 into letting them help her. LVN LL said bargaining with Resident #30 works at times, but if she adamantly refused, then she would have documented it. LVN LL stated she was recently hired, and she was working her third shift. LVN LL said if Resident #30 refused care, she expected the CNAs to stop providing care and report it to her. LVN LL said CNAs should not have continued care if the resident refused, started yelling, or became combative. LVN LL said she was not aware if Resident #30 had a history of trauma. LVN LL said she found out if residents had a history of trauma by looking in the chart or asking staff. LVN LL said if Resident #30 had a history of trauma and was changed against her will, it could have caused re-traumatization. During an interview on [DATE] at 5:00 AM, the DON stated Resident #30 had reported that she was held down and changed against her will. The DON stated 4 people were identified during the investigation, CNA K, CNA EE, Student NA O, and Student NA FF. The DON stated the CNAs reported they went into change Resident #30, and she became combative. The DON said the CNAs reported Resident #30 was not held down but when she became combative the CNAs blocked and protected themselves from her hitting and kicking. The DON said Resident #30 reported the Administrator she was assaulted in her 30's. The DON stated she was unaware of Resident #30's history of trauma until the incident occurred. The DON said Resident #30 being held down and changed against her will could have triggered her and caused re-traumatization. The DON stated the facility policy was to stop providing care if a resident was refusing or becoming combative. The DON stated staff should have left the room and came back at a later time to provide care. The DON stated no fault was identified during the investigation because the CNAs and NAs were doing their jobs. The DON stated Resident #30 went days refusing incontinent care to the point urine was running off her bed onto the floor. The DON stated they had tried different things to convince Resident #30 to allow staff to change her, but she continued to refuse care. The DON stated she told staff Resident #30 should have been changed at least once a shift. The DON stated it was important to respect the residents right to refuse care for multiple reasons, that included resident rights, injury, and traumatization. During an interview on [DATE] at 8:10 AM, the psychiatric NP stated he was familiar with Resident #30. The psychiatric NP stated Resident #30 was on his services. The psychiatric NP said the staff reported Resident #30 was irritable and refused care. The psychiatric NP said when he visited with Resident #30, she was pleasant and in a good mood. The psychiatric NP stated Resident #30 reported no issues. The psychiatric NP stated Resident #30 did not want help or medications. The psychiatric NP stated Resident #30 reported a history of trauma, that included sexual assault on her initial evaluation but denied any PTSD symptoms. The psychiatric NP stated Resident #30 had depressive symptoms that included irritable mood and lack of motivation to care for herself. The psychiatric NP stated he had tried several antidepressant medications in the past and Resident #30 recently started sertraline (antidepressant). The psychiatric NP said Resident #30 recently reported an incident were staff held her down to change her. The psychiatric NP said that incident had the potential to cause PTSD symptoms related to her history of trauma. The psychiatric NP said that she was assessed for trauma and trauma triggers on initial evaluation but since Resident #30 denied symptoms of PTSD, they did not assess further. The psychiatric NP stated counseling and medications were the only interventions attempted at this time. 2. Record review of the face sheet dated [DATE], reflected Resident #4 was a [AGE] year-old female who originally admitted to the facility on [DATE] with diagnoses that included cerebral palsy (group of neurological disorders that affect a person's ability to move, balance, and maintain posture), intellectual disabilities (below average intelligence and set of life skills present before age 18), essential hypertension (high blood pressure), and post-traumatic stress disorder (disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). Record review of the quarterly MDS assessment dated [DATE], reflected Resident #4 was able to make herself understood and usually understood others. The MDS reflected Resident #4's had a BIMS score of 13, indicating her cognition was intact. The MDS reflected Resident #4 had no behaviors or refusal of care. The MDS reflected Resident #4 had an active diagnosis of PTSD. Record review of Resident #4's comprehensive care plan, last reviewed on [DATE], reflected no care plan in place for her diagnosis of PTSD or history of trauma. The care plan did not address potential triggers for re-traumatization. Record review of the social history dated [DATE], reflected Resident #4 had no diagnosis of PTSD or history of trauma. Record review of the most recent psychiatric note dated [DATE], reflected Resident #4's diagnosis of PTSD was not addressed. During an interview on [DATE] at 10:15 AM, Resident #4 said she had trauma related to being born with drugs in her system. Resident #4 said her family member molested her and poured drugs and alcohol down her. Resident #4 stated she was made to take care of her younger family members at the age of 10. Resident #4 said the facility staff were aware of her history of trauma. 3. Record review of Resident #2's face sheet dated [DATE], indicated a [AGE] year old female who admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Cerebral palsy (also known as CP, a group of neurological disorders that affect a person's ability to move, balance, and maintain posture), diabetes mellitus type 2 (also known as diabetes, a chronic disease that occurs when the body has high blood sugar levels), Post-traumatic stress disorder (also known as PTSD, a mental health condition that can develop after someone experiences or witnesses a traumatic event),Depression (a mental health condition that can affect anyone, causing a persistent low mood and loss of interest in activities), and Anxiety( a feeling of fear, dread, and uneasiness that can be a normal reaction to stress). Record review of Resident #2's annual MDS assessment dated [DATE], indicated Resident #2 was usually able to make herself understood and understood others. The MDS assessment indicated Resident #2 had a BIMS score of 06, indicating her cognition was severely impaired. The MDS assessment indicated Resident #2 had received insulin 7 days out of the 7-day look back period. The MDS assessment indicated Resident #2 had received a hypoglycemic medication within the last 7 days of the look back period. Record review of Resident #2's comprehensive care plan dated [DATE] indicated Resident #2 had PTSD or other similar diagnoses related to memories from her childhood. The interventions were for staff to identify situation/event/images that trigger recollections of the traumatic event and limit the resident's exposure to these as much as possible, If the resident has escalated, if possible do not touch the resident unless absolutely necessary for resident's or others safety. Monitor for escalating anxiety, depression or suicidal thought and report immediately to the nurse. Record review of Resident #2's physician order dated [DATE] revealed an order for [name] Psychiatric Services. Record review of Resident #2's social history dated [DATE] completed by the social worker did not indicate any history of PTSD. During an interview on [DATE] at 9:14 AM, Resident #2 said she had PTSD related to being verbally and mentally abused by her family member from the age of nine months old until she was [AGE] years old when her family member died . Resident #2 said she told one of the social workers at the facility when she was admitted , and she had also told some of the other staff about having PTSD. During an interview on [DATE] at 4:45 PM, the Social Worker said he screened residents for a history of trauma on admission when he completed the social history. The Social Worker said if a resident had trauma or PTSD the DON asked him to complete a trauma assessment as needed. The Social Worker said he was responsible for checking the residents for trauma. The Social Worker said he also assessed for the triggers, and sometimes he put them in the notes because there was no column on the social history to add the triggers. The Social Worker said PTSD/trauma and the triggers were placed in the care plan by the MDS Coordinator. The Social Worker said it was important to assess for trauma and the triggers to understand the residents' behaviors. The Social Worker said Resident #2 had not reported her mother abusing her to him. The Social Worker was aware Resident #4 and Resident #30 had a history of trauma. During an attempted interview on [DATE] at 8:53 AM to obtain additional information, Student NA FF did not answer the phone. A brief message was left with call back number. No return call upon exit of the facility. During an interview on [DATE] at 8:54 AM, Student NA O stated on [DATE] Resident #30 had asked for assistance with incontinent care. Student NA O stated it was only her second day on the job and she was not certified yet. Student NA O stated she was unable to find other staff members to assist her with changing Resident #30 during her shift. Student NA O stated the charge nurse told her she needed assistance. Student NA O stated at the end of her shift when the night shift arrived, she asked CNA K, CNA EE, and Student NA FF for assistance with changing Resident #30. Student NA O stated Resident #30 was upset it had taken so long to find assistance. Student NA O said as they started changing Resident #30, she became really upset. Student NA O said they just kept trying to encourage her. Student NA O said Resident #30 hit CNA K in the face a couple of times. Student NA O stated the rolled Resident #30 so they could change her brief and Resident #30 kicked her in the chest. Student NA O said she grabbed Resident #30's legs and loosely put them beside her body to block her hitting and kicking. Student NA O stated she used her body to keep Resident #30 from hitting and kicking. Student NA O said CNA EE was shielding Resident #30's hands from hitting other staff. Student NA O stated they were holding her hands for protection. Student NA O said Resident #30 was yelling and cussing at them. Student NA O stated Resident #30 said they did not know what the fuck they were doing, and it only took one person to change her. Student NA O said Resident #30 was mad because of all the staff members in the room. Student NA O said she talked to Resident #30 after the incident and Resident #30 explained she only liked one person in the room with her. Student NA O said Resident #30 had a history of trauma. Student NA O said changing Resident #30 against her will could have caused her to re-live her traumatic event. During an interview on [DATE] at 4:37 PM, the MDS nurse said she did the comprehensive care plans. She said the social worker usually does the trauma care plans and they reviewed them during the care plan meetings. She said she did not realize Resident #2 and Resident #4's care plan was not specific to their trauma. During an interview on [DATE] at 11:45 AM, the ADON said she was aware Resident#2 had trauma but did not know in full detail what the trauma was until this week ([DATE] until [DATE]) when she asked her what happened. She said she was not aware of who was supposed to do the care plan for trauma but said it needed to be on the care plan. She said it was important for the staff to know how to meet her needs. Record review of the Trauma Informed Care policy, dated ,d+[DATE], reflected the intent of this requirement is to ensure that facilities deliver care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally- competent and account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization .facilities should use a multi-pronged approach to identifying a resident's history of trauma as well as his or her cultural preferences .include asking resident about triggers that may be stressors or may prompt recall of a previous traumatic event .facilities must identify triggers which may re-traumatize residents with a history of trauma The facility should collaborate with resident trauma survivors to develop and implement individualized interventions .trigger specific interventions should be identified . This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 11:10 AM. The ADO was notified. The ADO was provided the IJ template on [DATE] at 11:13 AM. The following plan of removal submitted by the facility was accepted on [DATE] at 5:11 PM and included the following: Interventions 1.Resident numbers #2, #4, and #30 were assessed for emotional distress by the DON on [DATE]. A trauma informed care assessment was completed for each resident on [DATE] by the DON. No additional emotional distress was noted for each resident. DON updated care plans for resident #2, #4 and #30 on [DATE]. DON documented trauma informed care interventions with identified triggers and assistance with avoidance on Care Plan and Kardex as of [DATE]. Residents #2, #4, and #30 are all receiving psych services. Residents #2, #4, and #30 were involved in setting interventions to reduce re-traumatization. 2. The DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on following topics below. The administrator is on paid time off. The administrator will be in-serviced prior to returning to work by the Area Director of Operations. Completed with the DON and ADON [DATE]. a. Trauma Informed Care Policy- all residents with a history of trauma or a diagnosis of PTSD will be assessed for potential triggers and have their plan of care modified accordingly. b. Abuse and Neglect to include not to hold a resident down while providing care at any time. If a resident is yelling stop, the staff members will stop and notify the charge nurse, DON, or Administrator for assistance and further direction. c. Behavioral management policy- Explain care to be provided prior to providing the care. If the resident refuses care or becomes combative with care, stop attempting to perform the care being resisted, ensure the resident's safety allow the resident to calm down. Attempt the care at a later time or with different staff. Continued combativeness with care should be reported to the Charge nurse, Administrator and/or DON immediately. d. Restraint Policy- holding a resident against their will to provide care is considered a restraint. 3. The 4 staff members were in-serviced 1:1 by the DON and ADON on [DATE] on the following topics below. i. Addendum - On [DATE] ADO, DON, and ADON attempted to communicate with the 4 staff members via text and phone call. 2 of the 4 staff members verbally self-termed, 1 staff member was a no call no show for their shift on [DATE] and is being termed and the 4th staff member is PRN and has not responded to text messages or phone calls. Images of the in-services have been texted to her and if she is to return to work, she will be in-serviced by DON or ADON prior to the start of her shift. a. Abuse and Neglect to include not to hold a resident down while providing care at any time. If a resident is yelling stop, the staff members will stop and notify the charge nurse, DON, or Administrator for assistance and further direction. b. Behavioral management policy- Explain care to be provided prior to providing the care. If the resident refuses care or becomes combative with care, stop attempting to perform the care being resisted, ensure the resident's safety allow the resident to calm down. Attempt the care later or with different staff. Continued combativeness with care should be reported to the Charge nurse, Administrator and/or DON immediately. c. Restraint Policy- holding a resident against their will to provide care is considered a restraint. 4. The medical director was informed of the immediate jeopardy citation on [DATE] by DON. 5. An ADHOC QAPI meeting was held on [DATE] to include the interdisciplinary team and medical director to discuss the immediate jeopardy citation and plan of removal. In-services: All staff will be in-serviced on [DATE] regarding the following topics below by the ADO and Regional Compliance Nurse, DON, and ADON. All staff not present will not be allowed to assume their duties until in-serviced. All PRN staff will be in-serviced prior to their next assignments. All new hires will be in-service on their date of hire, during facility orientation. All agency staff will be in-serviced prior to the start of their assignment. a. Abuse and Neglect to include not to hold a resident down while providing care at any time. If a resident is yelling stop, the staff members will stop and notify the charge nurse, DON, or Administrator for assistance and further direction. b. Behavioral management policy- Explain care to be provided prior to providing the care. If the resident refuses care or becomes combative with care, stop attempting to perform the care being resisted, ensure the resident's safety allow the resident to calm down. Attempt the care at a later time or with different staff. Continued combativeness with care should be reported to the Charge nurse, Administrator and/or DON immediately. c. Restraint Policy- holding a resident against their will to provide care is considered a restraint. All clinical staff will be in-serviced on [DATE] regarding the following topic below by the ADO and Regional Compliance Nurse, DON, and ADON. All staff not present will not be allowed to assume their duties until in-serviced. All PRN staff will be in-serviced prior to their next assignments. All new hires will be in-service on their date of hire, during facility orientation. All agency staff will be in-serviced prior to the start of their assignment. a. Trauma Informed Care - Definition of and locating triggers/interventions on Care Plan or Kardex. On [DATE] the survey team confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: 1. Record review of Resident #2, Resident #4, and Resident #30's electronic medial record, reflected a new trauma informed care assessment dated [DATE] was completed. 2. Record review of Resident #2, Resident #4, and Resident #30's comprehensive care plan, reflected an updated plan of care to include potential triggers for re-traumatization was dated [DATE]. 3. Record review of Resident #2, Resident #4, and Resident #30's Kardex, reflected the history of trauma and interventions in place to prevent re-traumatization. 4. Record review of Resident #2, Resident #4, and Resident #30's progress notes, reflected they were being seen by psychiatric services. 5. Record review of the ADHOC QA meeting document dated [DATE], reflected the immediate jeopardy concerns were discussed with the plan of removal and monitoring. The Medical Director attended verbally and copy of the plan was provided. 6. Record review of the in-service training attendance roster dated [DATE], reflected education was provided on trauma informed care to the DON, the ADON, and the Social Worker. 7. Record review of the in-service training attendance roster dated [DATE], reflected education was provided on behavior management to the DON and the ADON. 8. Record review of the in-service training attendance roster dated [DATE], reflected education was provided on restraints policy to the DON and the ADON. 9. Record review of the in-service training attendance roster dated [DATE], reflected education was provided on abuse and neglect polices to the DON and the ADON. 10. Record review of the in-service attendance roster dated [DATE], reflected education was provided to all staff on the restraint policy. There were 47 staff signatures. 11. Record review of the in-service attendance roster dated [DATE], reflected education was provided on the restraint policy via telephone to twelve staff members. 12. Record review of the in-service attendance roster dated [DATE], reflected education was provided to clinical staff on trauma informed care. There were 27 staff signatures. 13. Record review of the in-service attendance roster dated [DATE], reflected education was provided to clinical staff on trauma informed care via telephone to 5 staff members. 14. Record review of the in-service attendance roster dated [DATE], reflected education was provided on abuse and neglect policies. There were 47 staff signatures. 15. Record review of the in-service attendance roster dated [DATE], reflected education was provided on abuse and neglect policies via telephone to 11 staff members. 16. Record review of the in-service attendance roster dated [DATE], reflected education was provided on the behavior management policy. There were 47 staff signatures. 17. Record review of the in-service attendance roster dated [DATE], reflected education was provided on the behavior management policy via telephone to 12 staff members. 18. During a telephone interview on [DATE] at 9:48 AM, the Medical Director stated he was notified of the immediate jeopardy situation and attended a QAPI meeting via phone over the immediate jeopardy and subsequent plan of removal on [DATE]. 19. During interviews on [DATE] between 9:16 AM and 11: 23 AM, Housekeeper M, Housekeeper CC, LA Y, the Housekeeping Supervisor, DA R, [NAME] DD, DM SS, Student NA O, Student NA Z, CNA N, CNA S, CNA V, MA BB, LVN A, LVN D, LVN L, LVN T, RN AA, PTA Q, COTA W, COTA X, OT P, OT U, the MDS Coordinator, the Human Res[TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure that the resident environment remained as free of accident hazards as was possible to prevent accidents for 1 of 20 residents (Resident #5) reviewed for accidents and hazards related to coffee burns. The facility failed to follow the policy and procedure for preparing and temping coffee. On 10/02/24, Resident #5 spilt coffee on herself, which caused a second-degree burn (tissue damage to the outer layer of your skin and the second layer of your skin) to Resident #5's right upper thigh and lower abdomen. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 10/02/2024 and ended on 10/02/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at an increased risk for serious burn injuries while drinking hot liquids. The findings included: Record review of the face sheet dated 10/29/24, reflected Resident #5 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (a chronic, progressive brain disorder that affects movement and other systems of the body), dementia (memory loss), muscle weakness, and lack of coordination. Record review of the quarterly MDS assessment dated [DATE], reflected Resident #5 was able to make herself understood and usually understood by others. The MDS reflected Resident #5 had a BIMS score of 1, indicating her cognition was severely impaired. The MDS reflected Resident #5 had bilateral (both) upper and lower extremity limited range of motion. The MDS reflected Resident #5 required partial/moderate assistance with eating, oral hygiene, and upper body dressing. The MDS reflected Resident #5 was dependent on staff with toileting, showering and personal hygiene. Record review of the comprehensive care plan dated 10/02/24, completed post incident, reflected Resident #5 was at risk for burns due to impaired cognition and Parkinson's. The care plan interventions included: coffee and other hot liquids should not be served if over 140 degrees, resident to use a cup with lid, resident to wear clothing/lap protector when drinking hot liquids and should be seated in upright position with table or overbed table when hot liquids are being consumed. Record review of the event nurses note dated 10/02/24 signed by the DON, reflected Resident #5 had a burn/blister, caused by coffee, tea, or other hot liquid, to her right upper thigh that occurred in the dining room. The note reflected under details of injury; Resident #5 had a superficial layer of skin peeled measuring 2.5cm x 1.3cm. The note reflected Resident #5 had cognitive impairment. The note reflected the nursing description of the event, which indicated . Resident was drinking coffee in the dining room and dropped coffee on herself. The note reflected the resident statement of event was I spilt my coffee. The note reflected new orders to cleanse are with normal saline, Silvadene cream twice a day. Record review of the hot liquid assessment dated [DATE], completed post incident, reflected Resident #5 had moderate to severe cognitive impairment and Parkinson's. The assessment reflected Resident #5 could not consume hot liquids/food without special interventions. The assessment reflected the interventions needed to decrease potential burns included: lids on cups, clothing/lap barrier, and should be seated in upright position with table or overbed table. Record review of the self-reporting protocol/ad hoc QAPI dated 10/2/24, reflected the physician was notified and treatment was initiated, hot liquids assessment and care plans were updated for residents determined at risk, in-servicing was provided to dietary and nursing staff. The ad hoc QAPI reflected monitoring was initiated by the dietary manager at least 5 days per week. Record review of the witness statement dated 10/02/24, signed by the DON, reflected I was notified by [Student NA Z] that [Resident #5] had spilt coffee on herself in the dining room. [Student NA Z] and I took her to the bathroom to get her changed and assessed her. I noticed a 2.5 cm x 1.3 cm red area. Notified NP and hospice immediately. Received new orders for Silvadene cream twice daily. I immediately went to the dining room to confiscate any coffee that had been poured for a resident. I took the coffee pot into the kitchen to allow it to cool down. At this time only residents in the dining room had been served coffee. No other residents had any spilt coffee on them at this time. Record review of a list of residents identified at risk for hot liquid spills dated 10/02/24, reflected 21 residents (Resident's #3, #5, #6, #8, #17, #21, #23, #24, #25, #26, #36, #39, #41, #44, #45, #46, #48, #49, #109, #259, and #260) were at risk. Record review of Resident's #3, #5, #6, #8, #17, #21, #23, #24, #25, #26, #36, #39, #41, #44, #45, #46, #48, #49, #109, #259, and #260 comprehensive care plan, dated 10/02/24 after the incident, reflected they were at risk for hot liquid spills and interventions were put in place. Record review of Resident's #3, #5, #6, #8, #17, #21, #23, #24, #25, #26, #36, #39, #41, #44, #45, #46, #48, #49, #109, #259, and #260 hot liquids assessments, dated 10/02/24 after the incident, were completed. Record review of the in-service training attendance roster dated 10/02/24, reflected education was provided on residents at risk for spills. There were 47 staff signatures from across all shifts and disciplines. Record review of the in-service training attendance roster dated 10/02/24, reflected 1:1 education was provided to Cook, DD, [NAME] UU, [NAME] VV, [NAME] WW, DA H, DA XX, and DM SS regarding the coffee preparation steps, which included cooling the coffee down prior to serving. Record review of the in-service training attendance roster dated 10/02/24, reflected all staff were provided education on reporting burns immediately to the abuse coordinator, DON, and charge nurse. There were 76 staff signatures from across all shifts and disciplines. Record review of the in-service training attendance roster dated 10/02/24, reflected education was provided on if residents are demanding coffee, it cannot be served if not under 140 degrees. Notify administrator and DON of resident's demand. There were 26 staff signatures from across all shifts and disciplines. Record review of the in-service training attendance roster dated 10/02/24, reflected education was provided on hot liquids and food spills. There were 76 staff signatures from across all shifts and disciplines. Record review of the in-service training attendance roster dated 10/02/24, reflected education was provided on abuse and neglect. There was 76 staff signatures from across all shifts and disciplines. During an observation and interview on 10/28/24 beginning at 11:33 AM, DA H performed a temperature check on the coffee. The coffee temperature was 136.6 degrees Fahrenheit. DA H stated she was unable to serve coffee above the temperature of 140 degrees Fahrenheit. DA H stated the kitchen had a process for preparing the coffee that had to be followed. DA H stated she was provided 1:1 in-service training on preparing the coffee and making sure the coffee was at or below 140 degrees F prior to serving. During an observation and attempted interview on 10/28/24 beginning at 4:13 PM, Resident #5 was lying in her bed. Resident #5 was unable to answer questions appropriately as evidenced by confused conversations. During an interview on 10/28/24 beginning at 5:02 PM, the DON stated the incident on 10/02/24 with Resident #5 happened early in the morning during breakfast time. The DON stated staff were still getting residents into the dining room. The DON said a student nurse was looking for Resident #5 and found her in the dining room fanning her pants, which were wet. The DON stated she was immediately notified by the student nurse and immediately took Resident #5 for an assessment. The DON stated she observed a burn on her leg which appeared to have the top layer of skin missing. The DON stated she notified Resident #5's family member and physician. The DON stated she thought the coffee had to have been too hot, so she into the dining room and removed all the coffee. The DON stated she temped the coffee at 158 degrees F, so she had the dietary staff remake the coffee and follow the coffee preparation process until the temperature was at or below 140 degrees F. The DON said the coffee preparation process was in place prior to the incident and should have been followed. The DON stated she identified all other residents at risk for burns from hot liquids. The DON said she performed new hot liquid assessments and updated the plan of care for each resident identified at risk. The DON stated residents were identified as being at risk for burns from hot liquids by observations such as increased shaking, ROM difficulties, or contractures. The DON stated in-servicing was provided to the staff on residents who were at risk, which included the interventions in place to prevent burns. The DON said 1:1 in-serving was provided to dietary staff on coffee preparation process, coffee temperatures, and temperature logs. During an observation and interview on 10/29/24 beginning at 5:32 AM, DM SS prepared the coffee. DM SS brewed the coffee and then added ice until the temperature in the coffee cup was below 140 degrees F. The final temperature was at 124 degrees F. DM SS stated he did not normally prepare the coffee but was helping out this morning. During an interview on 10/29/24 beginning at 8:05 AM, CNA E stated Resident #5 did not drink coffee routinely. CNA E stated when Resident #5 requested coffee she had to have a lid on her cup, a cover on her lap, and she must be sitting upright. CNA E stated there was a list of residents at risk for spills from hot coffee and interventions in place. CNA E stated she could also find the information in the plan of care. During interviews on 10/30/24 between 9:16 AM and 11: 23 AM, Housekeeper M, Housekeeper CC, LA Y, the Housekeeping Supervisor, DA R, [NAME] DD, DM SS, Student NA O, Student NA Z, CNA N, CNA S, CNA V, MA BB, LVN A, LVN D, LVN L, LVN T, RN AA, PTA Q, COTA W, COTA X, OT P, OT U, the MDS Coordinator, the Human Resource Coordinator, Medical Records, the AD, the Maintenance Supervisor, the ADON, and the DON were able to verbalize they were provided in-service education on how to identified residents at risk for coffee burns. The staff members were able to verbalize who was at risk for burns from hot liquids and where to find out interventions needed. The staff said there were to report coffee burns immediately to the abuse coordinator, DON, and charge nurse. The staff verbalized coffee should not have been served over 140 degrees F. The staff said if Residents demanded hotter coffee, it should have been reported to the Administrator and DON. The staff verbalized coffee burns could have been considered neglect. DA R, [NAME] DD, DM SS were able to verbalize to correct steps for preparing the coffee. During an interview on 11/01/2024 beginning at 8:50 AM, DM SS stated he was not in the facility for the coffee incident with Resident #5. DM SS stated the nursing department handled the situation. DM SS stated he was provided education on the coffee preparation process. DM SS stated he expected his staff to follow the coffee preparation process. DM SS stated coffee should not have been served until the temperature was at 140 degrees F or below. DM SS said coffee temperatures were documented in the coffee temperature log. DM SS stated it was important to ensure coffee was served at the correct temperature to prevent coffee burns. During an interview on 11/01/24 beginning at 11:42 AM, the ADO stated Resident #5 had a burn from a coffee spill on 10/02/24. The ADO stated immediate action was taken to correct the noncompliance and monitoring was put into place to prevent further incidents. The ADO stated education was provided on the coffee preparation process and coffee temperatures. The ADO stated a process was in place prior to the incident and it was not followed. The ADO stated he expected the facility staff to follow the coffee preparation process and coffee should not have been served unless it was at or below 140 degrees F. The ADO stated it was important to ensure coffee was served at the appropriate temperatures to prevent burn injuries related to hot liquid spills. Record review of the hot liquid / food spills policy, undated, reflected residents are at risk of having any hot liquid/food spilled on their person causing burns .if any staff member observes a resident spill hot liquid or food on themselves or another resident, the staff member will attempt to dissipate the heat of the item spilled with at least a liquid that is at a temperature of room temperature or below, by pouring the room temperature of cooler liquid directly on the area affected . the charge nurse is to be immediately notified so that an assessment of the resident can be completed .the charge nurse will report any injury to the attending physician and responsible party and follow any further physician orders .staff will assist with changing of clothes as needed . an incident report and investigation will then be completed and determine if the resident needs further intervention and prevent future occurrences . Record review of the coffee preparation steps, undated, reflected coffee temperature will be obtained during the coffee preparation process, ice will be added until the temperature is at or below 140 degrees F. When the temperature is at or below 140 degrees F it may be served and recorded on the temperature log.

Based on observation, interview and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 10 Residents (Resident #2) reviewed for treatment and services. The facility failed to perform the [MEDICATION(S)] maneuver on Resident #2 in a timely manner when he was choking while eating his lunch on. The resident expired at the facility. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and severity of actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of abuse, neglect, decline in health, being displaced or hospitalized , and death. Findings included: 1. Record review of an undated face sheet indicated Resident #2 was [AGE] year old and admitted on [DATE]. Record review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of MDS dated [DATE] indicated Resident #2 had a BIMS of 12 which indicated his cognition was mildly impaired. MDS indicated Resident #2 Supervision to extensive assistance with ADL's. Extensive assistance with eating. MDS indicated resident was understood and understood others. During an interview on [DATE] at 12:09 p.m. CNA A said Resident #2 was a feeder and he ate peanut butter sandwiches. CNA A said he would take 3 bites and then would want a drink. She said they could not give him a second bite until he swallowed the first bite. She stated she was there the day he passed away. She said she was going to the kitchen to get something for him (she saw NCNA A in the hall). She said NCNA A was feeding him, he said I can't do it anymore and he was purplish color, she said go get a nurse real quick. CNA A said NCNA A was allowed to feed residents because he was going to NA school. He had exited the room and was coming down the hall when she saw him. She never heard a call light, help, or anything like that. She said when she entered Resident #2's room he was not the color he was supposed to be. She said she tried [MEDICATION(S)] first and then did back thrusts. She said Nurse A then came into the room and he did the [MEDICATION(S)] and back thrusts. He tried to suction it out. He was then laid on the floor and they checked, and he had passed. She said NCNA A did not say anything about doing anything to prevent, such as doing the [MEDICATION(S)]. She did not do a witness statement, and no one came to her and asked her about this incident. She said they had no training or in-service following this incident that she was aware of. During an interview on [DATE] at 2:06 p.m. CNA B said they told her NCNA A was feeding Resident #2 when he choked. She said NCNA's were not encouraged to feed someone that was having trouble swallowing. She said it was shocking to her that he died while eating. She said she was trained following this incident. During an interview on [DATE] at 3:44 p.m. the Assistant Director of Nursing, said she was not on site when Resident #2 died . She said she was told that NCNA A was feeding him and he got choked up. The Assistant Director of Nursing said NCNA A called Nurse A and Nurse A went in to assess Resident #2 and did the [MEDICATION(S)] and CPR to no avail. She said she would have thought that it was appropriate for NCNA A to feed him due to having his proficiency for feeding on check offs. She said NCNA's were allowed to feed residents with swallowing issues as they were checked off for those duties. She stated she did in-services on the [MEDICATION(S)] and the DON did 5 or 6 others for eating, choking, etc. She said all staff should be in-serviced, even housekeeping, and that allstaff should have signed the in-services. During an interview on [DATE] at 4:00 p.m. the Speech Therapist said she never heard of Resident #2 not feeding himself. She did not say he needed assistance. Her assessments noted he had zero signs of aspiration or choking. He did not need a food waiver. She said peanut butter was considered mechanical soft. She was told that somebody was feeding him, and they didn't know if he had choked or what had happened to him and that was basically it. She gave in-services on choking and coughing textures. She said everyone who came to her in-services should have been there and signed. There was nothing noted that he had any issues with swallowing or choking even with her assessments. He had been on mechanical soft since she came there. During an interview on [DATE] at 4:33 p.m. the DON said she vaguely remembered the day Resident #2 expired. She didn't know who came and got her, she was in the building, but didn't know where. She said they told her after he expired the other RN was here. She said Nurse A told her he expired. Nurse A said he did the Heimlic, CPR and suctioned and something like that. I think that is all I can remember. Maybe he didn't do CPR if he was a DNR, I don't remember. I know NCNA was feeding Resident #2 and NCNA came and got Nurse A. NCNA A left Resident #2 to go get Nurse A. NCNA A said he knew something wasn't right but that was it. She didn't know where Nurse A was when NCNA A went to get him. She said only Nurse A and NCNA A were involved in the incident. She didn't remember being told NCNA A or any other CNA did the [MEDICATION(S)] on Resident #2. She said NCNA's were allowed to assist residents with swallowing issues as they were checked off on those duties. During an interview on [DATE] at 5:07 p.m. Nurse A said Resident # 2 was fed by staff ever since he started in 2019. Nurse A said Resident #2's dysphagia was controlled based on what he ate, although he did still cough when he ate. He said coughing was not always indicative of choking, it could be but, not always. Nurse A said he did the [MEDICATION(S)] on him. He said a female staff, unknown, told Nurse A they were calling for help down the hall and thought he was needed. When he got to the room there was NCNA A and CNA A in the room. He assessed Resident #2, he was leaned forward with his head down and cyanotic. Nurse A said he knew Resident #2 was a DNR, he had a good strong pulse, but not breathing. He did a back blow on him and he coughed; mucous came out of him. He did the [MEDICATION(S)] due to his choking. He finger swept his mouth. Resident #2 did take a deep breath. Nurse A didn't know if it was stuck in his throat or the oregeneal breath. He applied oxygen and suctioned to him. After this, he didn't breathe anymore. I put him back in his bed. I went and got the DON, did a stethoscope and checked him for one minute and pronounced him. He said the staff were standing around him talking when I entered the room to assess him. He said he did an assessment of him. The staff in the room said he was feeding him, and he started choking and that was what happened. No staff in the room told him they had done the [MEDICATION(S)] maneuver on the resident prior to his arrival. It looked to him that the resident was in a dangerous situation and something was seriously wrong; he was cyanotic, blue. It would appear that he had gone without oxygen. His arms were distal and cyanotic. If someone choked all staff were trained to do the [MEDICATION(S)]. Since he was not alert, I couldn't ask if he needed help. He was slumped over in his chair when I entered. To be honest he had severe dysphagia so him to choke was possible. I did not do CPR at all. During an interview on [DATE] at 5:44 p.m. LVN A said she knew nothing of the incident with Resident #2 other than she came to the room following him being deceased and she contacted hospice. She said NCNA's were allowed to assist with feeding residents with swallowing issues. During an interview on [DATE] at 6:00 p.m. LVN B said they had to assist with eating. LVN B said NCNA A may have come and got her. Nurse A and CNA A were in the room when she got there. She said NCNA said to her when he came to get her Resident #2 is choking and she responded, Ok here I come. Nurse A beat her in there; he was in there with the suction machine. She knew he was gone when she got in the room. Nurse A checked for a pulse and said he was not getting anything, and she checked for a pulse and didn't get one either. She did not hear that any of the CNA's did the [MEDICATION(S)] on him or not. She did not give a written statement over this incident. She said the [MEDICATION(S)] couldn't be done in a wheelchair that she was aware of and he was in a wheelchair when he was being fed. During an interview on [DATE] at 10:24 a.m. NCNA A said on the day Resident #2 died he was feeding him. NCNA A said Resident #2 was eating a sandwich as usual. He wanted a drink, so he gave him a drink, he ate some more then drank, then he started choking. When he realized Resident #2 was choking he went and got the head nurse, Nurse A. Nurse A was on B hall and then he went and got LVN B who was on C Hall. He went and got LVN B and they both went back into the room. Nurse A started the [MEDICATION(S)] maneuver, so he guessed Resident #2 choked to death. He said the [MEDICATION(S)] maneuver was hard to do for someone who was in the wheelchair. NCNA A said Resident # 2 was limp and he couldn't do anything. When they got back to the room Nurse A told him to go and get the crash cart. The [MEDICATION(S)] was started after he got back with the crash cart. NCNA A said at the time Resident #2 was choking, he was not speaking to him, he turned blue and that was when he went to go and get a nurse. He was never not sitting up. From the time he left the room to go and get the nurse and they got back to the room it was 4 or 5 minutes. He was leaned over to the side of his chair when they entered the room and he was cold. He knew this because he felt his hands. His color was blue still. He was breathing and had a pulse if he was not mistaken, he didn't check those the nurse did. We did not do back thrusts we did do the [MEDICATION(S)]; no CPR he was a DNR. He said he did not receive any training following this incident for the following: proper procedure for assisting resident with swallowing difficulty to eat, reporting changes in a resident condition to a nurse immediately using stop and watch, [MEDICATION(S)] maneuver, implementing interventions to prevent aspiration in residents with swallowing difficulties, promptly and correctly assessing a resident with a change in condition. During an interview on [DATE] at 1:20 the Hospice Nurse said she was told Resident #2 had expired and that he had been eating at the time; had no food in his mouth. She said she was told Nurse A had performed a finger sweep, the [MEDICATION(S)] maneuver and had suctioned Resident #2 during this incident. She said he was a DNR, he did not want CPR. She said it would be expected if they thought he was choking they would do the [MEDICATION(S)]. The Hospice Nurse said, I don't recall saying that he had a [CONDITION(S)], [CONDITION(S)], or anything like that. did not talk to the facility. I talked to what was going on and he said that it was related to his disease process and it was to be expected at some time. and the DON were who I talked to about this. I was not on site. When I got there, he was deceased . They had put him back into the bed for dignity purposes. There is a way to do the [MEDICATION(S)] maneuver sitting, in a chair, I have not done it in a wheelchair. During an interview on [DATE] at 1:33 p.m. the Hospice Physician said it was his understanding Resident #2 was eating when he collapsed and expired shortly after. He said it was not clear if he choked or aspirated. He was not provided with what was done at the time. He said he would expect them to try to make him comfortable and attempt something to get the food removed. He didn't document any notes for hospice. Record review of the on-site visit form completed by the Executive Director on [DATE] indicated the census was 51 residents. Record review of an undated policy Choking/Aspiration indicated: Choking and aspiration are common problems in the older adult . The resident will be free from aspiration or airway obstruction associated with chewing or swallowing activities . Record review of an undated policy Feeding, Assistive/Complete indicated: Assistive or complete feeding of meals is provided to residents who have decreased appetites .weakness, or neuromuscular disorders. The resident will be free from aspiration . Record review of the Competencies for Aides training for NCNA's indicated: Feeding the dependent resident . feed residents you are instructed to. You should only feed residents who do not have a known swallowing problem.Choking: If you think a resident is choking yell out for assistance and attempt the [MEDICATION(S)] maneuver . The Administrator was notified on [DATE] at 4:59 p.m. that an IJ was identified due to the above failures. The facility's plan of removal was accepted on [DATE] at 8:33 a.m. and included: Interventions: Residents requiring a mechanically altered diet will only be assisted to eat by a CNA or Nurse Regional Nurse in-serviced DON and ADON on Choking and Aspiration procedures on [DATE]. The following in-services were initiated by the DON, ADON and Regional Nurse on [DATE]: Any staff member not present or in-serviced on [DATE], will not be allowed to assume their duties until in-serviced. o Licensed Nurses: Promptly assessing a resident when a change of condition related to swallowing has been identified / reported. Performing the [MEDICATION(S)] maneuver Implementing interventions to prevent aspiration in residents with swallowing difficulties as outlined below. Choking/Aspiration Choking and aspiration are common problems in the older adult. Choking is usually the result of chewing and swallowing (dysphagia) dysfunctions and can lead to aspiration. Chewing can be affected by poorly fitting dentures. Dysphagia can be related to unconscious states, disorders that cause a loss of or diminished swallowing reflex, or a decrease in muscle strength. Chewing and swallowing dysfunctions increase the possibility of aspiration of foods, fluids, saliva, [MEDICATION(S)] and other secretions. Inability to chew and swallow effectively allows for accumulation of foods and fluid and thus, aspiration into the trachea since the separation between the airway and the esophagus is rendered inadequate when swallowing is inadequate. Complications of aspiration and associated difficulties include aspiration pneumonia and malnutrition. Goals 1. The resident will control coughing, chewing, and swallowing activities to prevent possible aspiration. 2. The resident will be free from aspiration or airway obstruction associated with chewing or swallowing activities. Procedure 1. Wash hands. 2. Explain the purpose of assessments and procedure and expected results. 3. Place in semi-Fowler's position for feedings and with head turned to the side depending on level of consciousness. 4. Become familiar with the ability to swallow and the possibility of coughing or choking while eating or drinking. 5. Facilitate eating by offering soft-textured foods and note ability to chew and swallow and motor control of the lips and tongue. 6. Maintain the head in an elevated position without hyperextension of the neck. 7. Note any accumulation of food or secretions and suction as needed. 8. Allow time for chewing and swallowing small amounts of food or fluids during meals. o Non-licensed nursing staff Reporting changes in a resident's condition to a nurse immediately Staff were in serviced on [DATE] by the Director of Nursing and Regional Compliance nurse on proper procedure for assisting residents with swallowing difficulties. Therapy will assist with ongoing education of staff on proper procedures to prevent choking/aspiration. Performing the [MEDICATION(S)] maneuver The medical director was notified of the immediate jeopardy situation on [DATE] at 6:19pm Monitoring The DON / designee will make daily rounds on all residents. The DON / designee will ask 8 nursing staff per week what they would do if a resident had a change of condition, or it was reported to them that a resident had a change in condition X 4 weeks. The DON / designee will monitor ,d+[DATE] meals per week to ensure the proper procedure is being used when feeding residents with swallowing difficulties x 4 weeks. A department head will be present during each meal to monitor meal service The QA committee will review findings and makes changes as needed. On [DATE] the surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: During an interview on [DATE] at 8:15 a.m., Administrator, stated they had started in-servicing staff on [DATE] and all staff were being in-serviced [DATE] prior to coming on shift. Per their plan of correction submitted to the state. During an interview on [DATE] at 8:22 a.m., NCNA C said she had received trainings prior to coming on shift for Hoyer lift, choking, and the [MEDICATION(S)] maneuver, and what to do in the event of an emergency. During an interview on [DATE] at 9:03 a.m. NCNA B said she had received trainings prior to coming on shift for Hoyer lift, choking, and the [MEDICATION(S)] maneuver, and what to do in the event of an emergency. During an interview on [DATE] at 9:50 a.m. LVN C said she had received training on [DATE] (she is a ,d+[DATE] staff) prior to coming on shift for Hoyer lift, choking, and the [MEDICATION(S)] maneuver, and what to do in the event of an emergency. During an interview on [DATE] at 10:22 a.m. CNA C said she had received trainings prior to coming on shift for Hoyer lift, choking, and the [MEDICATION(S)] maneuver, and what to do in the event of an emergency. During an interview on [DATE] at 10:32 a.m. Medication aide A said she had received trainings prior to coming on shift for Hoyer lift, choking, and the [MEDICATION(S)] maneuver, and what to do in the event of an emergency. During an interview on [DATE] at 12:02 p.m. NCNA D she had received trainings prior to coming on shift for Hoyer lift, choking, and the [MEDICATION(S)] maneuver, and what to do in the event of an emergency. During an interview on [DATE] at 1:25 CNA E said she had received trainings prior to coming on shift for Hoyer lift, choking, and the [MEDICATION(S)] maneuver, and what to do in the event of an emergency. During an interview on [DATE] at 1:39 p.m. CNA F said she had received trainings prior to coming on shift for Hoyer lift, choking, and the [MEDICATION(S)] maneuver, and what to do in the event of an emergency. During an interview on [DATE] at 1:45 p.m. LVN D said she had received trainings prior to coming on shift for Hoyer lift, choking, and the [MEDICATION(S)] maneuver, and what to do in the event of an emergency. During an interview on [DATE] at 2:08 p.m. LVN B said she had received trainings prior to coming on shift for hoyer lift, choking, and the [MEDICATION(S)] maneuver, and what to do in the event of an emergency. During an interview on [DATE] at 3:15 p.m. CNA G said he had received trainings prior to coming on shift for Hoyer lift, choking, and the [MEDICATION(S)] maneuver, and what to do in the event of an emergency. During an interview on [DATE] at 3:30 p.m. CNA H she had received trainings prior to coming on shift for Hoyer lift, choking, and the [MEDICATION(S)] maneuver, and what to do in the event of an emergency. During an interview on [DATE] at 3:38 p.m. LVN E she had received trainings prior to coming on shift for Hoyer lift, choking, and the [MEDICATION(S)] maneuver, and what to do in the event of an emergency. Administrator was notified the IJ was removed on [DATE]. The facility remained out of at compliance at a scope of isolated and severity of actual harm due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview, and record review, the facility failed to ensure adequate supervision to prevent accidents was provided for 1 of 1 resident reviewed for supervision. (Resident #1) The facility did not implement interventions to prevent Resident #1 from sustaining a [CONDITION(S)] which required staples and a skin tear. Resident #1 fell from a shower chair after CNA A left the resident unattended. This failure could place residents who require assistance with transfers at risk for falls and injuries. Findings included: The Physician orders dated 02/25/2020 indicated Resident #1 was an [AGE] years old male and admitted on [DATE] with diagnoses including unspecified dementia, cerebral infraction unspecified, unsteadiness on feet, history of falling and need for assistance with personal hygiene. A Facility Reported Incident dated 02/27/2020 indicated Resident #1 had an actual fall with injuries, requiring transport to the emergency room for additional medical care. A Closed Care Plan dated 03/09/2020 indicated Resident #1indicated Resident #1 had an actual fall on 02/27/2020 with injuries and Resident #1 had an actual fall on 02/26/2020 with no injury, due to poor balance and an unsteady gait. The initial MDS dated [DATE] indicated Resident was severely cognitively impaired, non-ambulatory and totally dependent for care. Record review of the Baseline Care Plan, dated 02/26/20, indicated Resident #1 was at risk for falls. Record review of the Fall assessment dated , 02/26/2020 indicated Resident #1 was a high risk for falls,required use of assistive devices and has a balance problem while walking and standing. During an interview on 03/04/2021 at 11:50 a.m., the administrator said CNA (A) stuck her head out the door to get help from a nurse and when she turned around, resident #1 had tipped over the shower chair, striking his head on the tile and was positioned with his back against the wall of shower. He said resident had a cut to the back of his head. He said resident was treated on site, but later transported to the ER. During a record review of the Facility Reported Incident dated 02/27/2020, the administrator's written statement states resident returned to the facility from the hospital with staples to the back of his head. During an interview on 03/04/2021 at 11:50a.m., the administrator said, as a corrective action, CNA A was in-serviced, that day, on not leaving residents unaccompanied in the shower. He said CNA (A) is no longer employed with the facility. During an interview and record review on 03/04/2021 at 12:05p.m., the Human Resource Director said CNA A was no longer employed with the facility. She said CNA A was not employed at the time she started working at facility. The HR Director was not able to print the document of separation from employment but did allow surveyor to view document on computer screen. HR Director provided a signed confirmation statement that CNA A was in-serviced on 02/27/2020 and quit her employment on 2/28/2020. Record review of a progress note written by Charge Nurse, B, dated 02/27/2020 at 2:00p.m., indicated that he was called to the shower on hall 100 by the shower aide. Upon entering, resident was lying in the floor with his back against the wall with head near the ledge of tile where you sit. Upon closer assessment he had a 0.5 x 3 x 0.3 cm laceration to occiput that is bleeding which was cleansed, and pressure held for several minutes. Alert and talking but speech is difficult to understand. He is moving all extremities. Assisted him back to shower chair to rinse off blood and ask him if he was hurting. He initially laughed and nodded a little, this happens all the time. Assessed for further injury and noted bleeding from a skin tear on right forearm 3 x 3x < 0.1 CM. Cleansed and pressure applied. Notified NP of fall at 1:42p.m. with laceration and he gave order to send to ER for evaluation. EMS called, and paperwork printed for transport. Called resident's family to update and voicemail left to return call at 1:52p.m EMS arrived, and resident was transported on stretcher at 1400 to Presbyterian Dallas. E-signed Charge Nurse B. During an interview on 03/04/2021 at 1:15p.m., the HR Director said with Charge Nurse at time of incident, is no longer with the facility. Review of hospital visit summary indicated: Resident #1 complained of head injury, a fall in shower initial encounter, resident received x-rays to right knee and right wrist, suffered a bad bruise that causes blood to collect and pool under the skin on his head, an x-ray of his head which compared the right and left of his brain.

Based on interview, and record review, the facility failed to ensure adequate supervision to prevent accidents was provided for 1 of 1 resident reviewed for supervision. (Resident #1) The facility did not implement interventions to prevent Resident #1 from sustaining a head laceration which required staples and a skin tear. Resident #1 fell from a shower chair after CNA A left the resident unattended. This failure could place residents who require assistance with transfers at risk for falls and injuries. Findings included: The Physician orders dated 02/25/2020 indicated Resident #1 was an [AGE] years old male and admitted on [DATE] with diagnoses including unspecified dementia, cerebral infraction unspecified, unsteadiness on feet, history of falling and need for assistance with personal hygiene. A Facility Reported Incident dated 02/27/2020 indicated Resident #1 had an actual fall with injuries, requiring transport to the emergency room for additional medical care. A Closed Care Plan dated 03/09/2020 indicated Resident #1indicated Resident #1 had an actual fall on 02/27/2020 with injuries and Resident #1 had an actual fall on 02/26/2020 with no injury, due to poor balance and an unsteady gait. The initial MDS dated [DATE] indicated Resident was severely cognitively impaired, non-ambulatory and totally dependent for care. Record review of the Baseline Care Plan, dated 02/26/20, indicated Resident #1 was at risk for falls. Record review of the Fall assessment dated , 02/26/2020 indicated Resident #1 was a high risk for falls,required use of assistive devices and has a balance problem while walking and standing. During an interview on 03/04/2021 at 11:50 a.m., the administrator said CNA (A) stuck her head out the door to get help from a nurse and when she turned around, resident #1 had tipped over the shower chair, striking his head on the tile and was positioned with his back against the wall of shower. He said resident had a cut to the back of his head. He said resident was treated on site, but later transported to the ER. During a record review of the Facility Reported Incident dated 02/27/2020, the administrator's written statement states resident returned to the facility from the hospital with staples to the back of his head. During an interview on 03/04/2021 at 11:50a.m., the administrator said, as a corrective action, CNA A was in-serviced, that day, on not leaving residents unaccompanied in the shower. He said CNA (A) is no longer employed with the facility. During an interview and record review on 03/04/2021 at 12:05p.m., the Human Resource Director said CNA A was no longer employed with the facility. She said CNA A was not employed at the time she started working at facility. The HR Director was not able to print the document of separation from employment but did allow surveyor to view document on computer screen. HR Director provided a signed confirmation statement that CNA A was in-serviced on 02/27/2020 and quit her employment on 2/28/2020. Record review of a progress note written by Charge Nurse, B, dated 02/27/2020 at 2:00p.m., indicated that he was called to the shower on hall 100 by the shower aide. Upon entering, resident was lying in the floor with his back against the wall with head near the ledge of tile where you sit. Upon closer assessment he had a 0.5 x 3 x 0.3 cm laceration to occiput that is bleeding which was cleansed, and pressure held for several minutes. Alert and talking but speech is difficult to understand. He is moving all extremities. Assisted him back to shower chair to rinse off blood and ask him if he was hurting. He initially laughed and nodded a little, this happens all the time. Assessed for further injury and noted bleeding from a skin tear on right forearm 3 x 3x < 0.1 CM. Cleansed and pressure applied. Notified NP of fall at 1:42p.m. with laceration and he gave order to send to ER for evaluation. EMS called, and paperwork printed for transport. Called resident's family to update and voicemail left to return call at 1:52p.m EMS arrived, and resident was transported on stretcher at 1400 to Presbyterian Dallas. E-signed Charge Nurse B. During an interview on 03/04/2021 at 1:15p.m., the HR Director said with Charge Nurse at time of incident, is no longer with the facility. Review of hospital visit summary indicated: Resident #1 complained of head injury, a fall in shower initial encounter, resident received x-rays to right knee and right wrist, suffered a bad bruise that causes blood to collect and pool under the skin on his head, an x-ray of his head which compared the right and left of his brain.

Based on interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for 1 of 11 residents reviewed for quality of care. (Resident #1) The facility did not thoroughly assess Resident #1 when she expressed pain to her right shoulder after she was found after a fall on 11/19/18. The facility did not notify the physician or request an x-ray until 11/21/18. Resident #1 was sent to the hospital on [DATE] and an x-ray revealed Resident #1 sustained a fracture of her right clavicle. This failure could place residents at risk for not receiving care and services to meet their needs, and/or death. Findings included: A face sheet dated 6/6/19 indicated Resident #1 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #1's cognition was severely impaired. Resident #1 required extensive assistance of 1 person with bed mobility, toilet use, and personal hygiene. Resident #1 was frequently incontinent of bladder and always incontinent of bowel. A care plan revised on 12/18/18 indicated Resident #1 had unrealistic thoughts, impaired decision making, and memory/recall problems due to her dementia. Resident #1 had difficulty making herself understood, and difficulty putting sentences together. Resident #1 required staff assistance for ADLs due to an amputation below her right elbow. The care plan with a start date of 9/1/15 noted Resident #1 had a history of [REDACTED]. The care plan noted Resident #1 had a fall with no injury on 10/30/17, a fall with minor injury on 4/14/18, and a fall with no injury on 11/8/18. A nursing note dated 11/19/18 at 10:06 p.m., indicated Resident #1 was found lying on her right side on the floor. The resident voiced slight right shoulder discomfort when assisted. She was given PRN (as needed) Tylenol per orders. An incident report dated 11/19/18 at 9:45 p.m. indicated Resident #1 was assisted into bed and given Tylenol per orders for complaint of right shoulder discomfort. A nursing note dated 11/20/18 at 9:35a.m., indicated Resident #1 had pain to her right shoulder. A nursing note dated 11/21/18 at 8:04 a.m., indicated Resident #1 was given pain medication due to pain in her right shoulder. The note indicated an x-ray was ordered. A nursing note dated 11/21/18 at 10:00 p.m., indicated the facility received Resident #1's x-ray results at 7:30 p.m., indicating the resident sustained [REDACTED]. The note indicated orders were received to place Resident #1's arm in a sling and to have the orthopedic specialist follow up on 11/23/18. The resident was to receive pain medication as needed for her complaint of right shoulder pain. The note indicated Resident #1's right shoulder had dark purple blue discoloring, and she complained of pain when she was touched or moved. A care plan dated 11/21/18 indicated Resident #1 had a discoloration to her right shoulder/upper arm due to fracture in the right upper extremity after a fall, as confirmed by the x-ray. A consolidated physician order [REDACTED].#1 received [MEDICATION NAME] ([MEDICATION NAME] - for pain) 50 mg, three times a day at 8 a.m., 2 p.m., and 8 p.m. The order indicated Resident #1 also had medications for pain on an as-needed basis, including [MEDICATION NAME] 10-325 1 tab every 8 hours, Tylenol, 325 mg 1 tab every 6 hours, and [MEDICATION NAME] 0.25 ml which was discontinued 12/12/18. A MAR indicated [REDACTED] During a telephone interview on 6/5/19 at 4:57 p.m., CNA A said when Resident #1 fell on [DATE], he was on Hall C when he heard the emergency light around 9:50 p.m. He said he went to the room and found Resident #1 on the floor, and he notified the nurse. CNA A said he did not chart anything regarding the incident because they changed things at the facility to where you have to just notify the nurse. During an interview on 6/6/19 at 3:07 p.m. DON said she if she had been working at the facility at the time of the incident, she would have reported the fracture to the state, and she would have done things different. During an interview on 6/6/19 at 4:30 p.m. the ADON said she would have sent Resident #1 out for an x-ray the day of the fall, but she was not working at the facility at that time. An Abuse/Neglect policy dated, 11/07/2016 indicated, Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on observation, interview, and record review, it was determined the facility failed to ensure injuries and bruises of unknown origin and allegations of mistreatment and/or abuse were reported to the State agency, were thoroughly investigated, and prevented further potential neglect while the investigation was in progress for seven (Resident #2, #8, #9, #14, #15, #16, #19) of ten residents reviewed for abuse and neglect. 1) On 07/15/10, Resident #8's lower legs were "mangled" during a transfer by CNA K and CNA T. The facility did not conduct an investigation of the incident, because it was "witnessed," did not interview the resident and/or the CNAs to determine a causative factor and whether abuse/neglect was involved; and no interventions, such as transfer training or monitoring of transfers were implemented to prevent another recurrence. Resident #8's wounds on her legs were still being treated as of 09/30/10 due to "slow" healing and caused the resident continual pain. On 09/28/10, the resident had multiple bruises on her left forearm, which were not investigated or reported. 2) On 09/27/10, Resident #9 alleged a nurse aide had "grabbed/pulled" her arm too hard during a transfer from the bed to a chair three or four days earlier, which caused a 7.0 cm x 11.0 cm bruise on her left forearm. The incident was not investigated and a Provider Investigation Report was not filed until 09/30/10 following surveyor inquiry. 3) On 09/21/10, Resident #2 was assessed with [REDACTED]. A Provider Investigation Report was not filed until 09/23/10 at 10:00 PM (more than two days later). 4) Resident #19's family member alleged had back pain "the first week of September." The family member told the Administrator, "Somebody must've thrown him (the resident) in the bed." The allegation was not reported to DADS, and no investigation was done. 5) On 08/30/10 Resident #14 had a 5.0 cm x 7.0 cm area of yellow/purple bruising on her upper left arm. There was no investigation to find out the etiology of the bruise in order to determine if the bruise was the result of abuse, neglect or mistreatment and who might have been the perpetrator. It was not reported to DADS. 6) On 9/10/10, Resident #15 had a bruise on her right arm. There was no investigation and the bruise was not reported to DADS. 7) On 09/07/10, a 4.5 cm by 2.0 cm purplish bruise was found on the back of Resident #16's thigh and a 1.0 cm x 1.0 cm purplish bruise was on the resident's calf. No investigation was done for the bruising of unknown origin, and it was not reported to DADS. On 09/28/10 at 4:40 PM, these findings resulted in an Immediate Jeopardy (IJ) situation with Substandard Quality of Care (SQC) affecting Residents #2, #9, #8, #14, #15, #16 and #19 in the area of Resident Behavior/Facility Practice. While the IJ was removed on 09/30/10, after the facility began reviewing incident reports, assessing residents and inservicing staff, the facility remained out of compliance at a severity level of "Actual harm that is not immediate jeopardy" and a scope of "pattern," based on the facility continuing to inservice staff and monitor for compliance. These failures could affect the facility's 83 residents, including Residents #2, #9, #8, #14, #15, #16 and #19, and placed them at risk for abuse/neglect to occur resulting in the potential for falls and injury causing residents to be afraid of being transferred and handled by staff, loss of self-esteem and self-worth, decreased socialization and having a negative impact on their quality of life. Findings included: 1) Based on the Record of admitted d 08/31/10, Resident #8 was admitted on [DATE] with [DIAGNOSES REDACTED]. A Patient Visit Note from the physician dated 08/20/10 reflected she also had [DIAGNOSES REDACTED]. Review of the resident's MDS assessment of 07/02/10 revealed the facility assessed Resident #8 as requiring weight-bearing support from two persons to transfer. Resident #8 was assessed as not being able to balance while standing. The resident's MDS assessment also reflected she was able to understand others and to make herself understood, as well as locate her room and identify staff by names or faces. The MDS reflected Resident #8 had moderate cognitive impairment. Resident #8 was observed on initial rounds with LVN B in her room on 09/27/10 at 10:00 AM. Resident #8 had gauze bandages wrapped around both lower legs. The LVN reported the resident was injured when her legs hit the bed during a transfer in July 2010. The LVN described the injuries to the resident's legs as "severe," but stated the wounds were "healing now." A review of the nurses' note for 07/15/10 at 9:00 PM revealed Resident #8 received two "V" shaped skin tears on her left, lower leg and one, 3.0 cm x 3.0 cm skin tear on her right lower leg while CNAs were transferring her. Review of the facility incident report dated 07/15/10 revealed Resident #8 sustained skin tears to both legs during a transfer by CNA F and CNA G. The incident report reflected, "CNAs were transferring resident to the bed when resident feet slid forward into bed frame causing 2 s/t (skin tears) on L (left) leg and 1 s/t on R (right) leg." Her feet reportedly slid forward into the bed rail. An investigation report was not attached to the incident report, and the incident report was not signed or dated. During an interview on 09/28/10 at 5:30 PM, the DON reported no investigation was initiated concerning Resident #8's leg injuries, because the injuries were witnessed by the aides. She stated no additional transfer training was provided to the two aides, and no nurses were assigned to monitor the aides when they transferred any of the residents. A physician's orders [REDACTED]. Resident #8's Skin Condition Report sheets for July 2010 through September 2010 were reviewed with LVN E on 09/28/10 at 4:00 PM. LVN E reported she completed the initial skin assessment of the resident's skin tears on 07/15/10. Resident #8's Skin Condition Reports for 07/15/10 reflected the following: a) The site was identified as being located on the front towards the right side of the left (sic) lower leg. The diagram reflected the wound was on the left lower leg and was measured as 1.0 cm x 4.0 cm. b) Two other sites were identified as being on the right (sic) lower leg. Both were on the front of the right lower leg with one directly below the knee and the second one being further down on the leg. The wound below the knee was measured as 3.0 cm x 2.0 cm and the second wound was 5.0 cm x 3.0 cm. The interview continued at 4:05 PM on 09/28/10 and LVN E described the resident's legs as "mangled" from the collision with the bed frame. She stated she did the treatments daily, and the resident's injuries were slow to heal. Resident #8 was interviewed in her room on 09/28/10 at 5:00 PM. She reported her legs were hurt when the aides were transferring her to her bed. She pointed to the bed frame and said her legs hit the frame. She stated her legs still hurt, and the nurses have to "doctor" her legs every day. She said she could hardly stand anything touching them. Resident #8 told the surveyors she was not able to do as much since she injured her legs. She stated, "They hurt all the time." Resident #8 then stated, "The aides do hurt you when moving people around. They get in a hurry and are rough with you, because they are in a hurry." At that time, the surveyors observed multiple, reddish-blue bruises in a circular pattern. When Resident #8 was asked about them, she stated she got the bruises from being transferred. The resident stated a "couple of days ago," an aide grabbed her arm when she was transferring her. The bruises were reported to the Treatment Nurse by an unidentified CNA, who stated she would report and measure the bruises after she completed treatments. Review of Resident #8's Nurse's Notes revealed nothing was documented on 09/28/10 or 09/29/10 regarding the bruises on her arm. On 09/30/10 at 5:10 a.m., documentation reflected the nurse was informed by staff Resident #8 had bruises on her arm. At 5:50 a.m., staff reported to the nurse Resident #8 had told them a CNA from the previous shift caused the bruising when she was transferred. The LVN assessed the bruising: 0.5 cm x 0.5 cm bruise on the right arm and three bruises measuring 2.0 cm x 1.0 cm and one bruise 0.5 cm x 0.5 cm on the left arm. The same measurements were documented on a Skin Condition Report for Resident #8. On 09/30/10 at 10:40 AM, during a skin observation, LVN I determined the bruises on Resident #8's left forearm (which the resident had pointed out to surveyors in the interview on 09/28/10) had not been reported, despite having been documented on 09/29/10 by facility staff. LVN I stated she would measure and report the forearm bruises. At that time, Resident #8's leg wounds were observed with LVN I in the resident's room. Each lower leg had two open areas, approximately 2.0 cm x 3.0 cm, which were denuded of skin. There were patchy clumps of skin with yellow exudate on both shins, which extended to both calf areas. The skin on the left shin was bright red. At that time, LVN I described Resident #8's legs as "mangled" when she slid into the bed frame in July 2010. She said the skin on both legs was turned up on itself, so the nurses used "q-tips" to pull the skin out and piece the skin together to cover the exposed tissue underneath. She stated the nurses used "steri-strips"to push the edges of the torn skin together. She further stated the resident was diabetic and added it was "really hard" to get the skin to start healing. She described the wounds as "magnificent," compared to what they originally looked like in July 2010. While the nurse was showing the resident's wounds to the surveyor, Resident #8 grimaced and told the surveyor her legs hurt all the time. She stated, "They hurt me." Interview with CNA F on 09/30/10 at 11:30 AM established she was one of the aides, who transferred Resident #8 from the chair to her bed on 07/15/10, when the resident sustained [REDACTED].#8's roommate while CNA G was caring for Resident #8. CNA F reported CNA G was transferring Resident #8 by herself from the chair to the bed, and she called out for CNA F to assist her in the transfer. CNA F stated when she got Resident #8's bedside, the resident was in a standing position between the chair and the bed. CNA G told her (CNA F) she (CNA G) could not get the resident to pivot to the bed, so she (CNA G) needed assistance. CNA F stated she held onto the the back of the resident's pants to turn her. She stated Resident #8's knees "buckled," and the resident slid under the bed, with her legs scraping the bed frame. CNA F said the skin was peeled off the resident's legs beneath her knees, and she was bleeding on both legs. The CNA stated she and the other aide did not use a gait belt during the transfer. She stated, "If we had used a gait belt, we could have stopped her from sliding down." Physical Therapist (PT) H was interviewed on 09/30/10 at 12:30 PM concerning Resident #8. He reported he knew the resident, and she had received physical therapy, most recently in March 2010. He reported the resident had "bad knees," and said, "She can stand and pivot sometimes, and sometimes she can't." He stated if a resident cannot pivot during a transfer, the aide should place the resident back into the chair and consider an alternative way to transfer the resident, such as a mechanical device. PT H reported the therapy department instructed aides to always use a gait belt during transfers and to never lift a resident by pulling them up by their pants. 2) Resident #9's Record of admitted d 09/07/10 indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Patient Visit note signed by the physician on 07/02/10, reflected [DIAGNOSES REDACTED]. Resident #9's Physician order [REDACTED]. Review of the MDS assessment, dated 08/27/10 revealed the facility assessed Resident # 9 as requiring staff assistance from one person to transfer. Resident #9 was not able to balance while standing without assistance. The MDS reflected Resident #9 was moderately cognitively impaired. Resident #9 was identified as interviewable by facility staff on the Detail Census Report provided to the survey team and dated 09/27/10. A facility incident report, dated 07/27/10, reflected Resident #9 was found to have a 7.0 cm x 11.0 cm bruise on her left inner arm. The nurse, who completed the report, documented Resident #9 reported the daytime CNA pulled on her arm too hard during a transfer. There was no evidence an investigation had been completed. Review of Resident #9's nurses' note, dated 07/27/10, revealed LVN J documented the resident told her the "daytime CNA grabbed/pulled her too hard." When the 07/27/10 nurses' note was reviewed with the DON on 09/28/10 at 4:00 PM, the DON was asked why the incident was not investigated, since Resident #9 alleged an aide hurt her. The DON acknowledged the incident should have been investigated. Resident #9 was interviewed in her room on 09/30/10 at 10:30 AM. She said the bruise on her arm was gone, but said she remembered being hurt by an aide a couple of months ago. The resident demonstrated how she was injured by grabbing her left forearm with her right hand. Resident #9 stated, " I think she broke a blood vessel." The resident did not remember the aide's name. She stated the bruise happened a long time ago. An interview with Resident# 9's family member on 09/30/10 at 6:30 PM revealed Resident #9 was legally blind due to [MEDICAL CONDITION] and had a moderately severe hearing loss in both ears, which required hearing aids. The family member stated a facility nurse called about the bruise on the resident's arm, but no one from the facility provided any information about how the bruise occurred. 3) Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An Incident Report dated 09/23/10 reflected an incident involving Resident #2 on 09/23/10 at 10:00 PM. A review of Resident #2's clincal record revealed an entry in the Nurses' Notes dated 09/21/10 at 6:00 PM and signed by RN C. The note reflected Resident #2 was resistant to care during a transfer and was kicking, scratching and cursing at the staff, who were attempting to transfer her. There was no mention of injury to either the resident or the staff involved. An entry in Nurses' Notes dated 09/21/10 and signed by LVN A revealed Resident #2 had "purple discoloration" on her right forearm, but the resident was unable to say what had happened. LVN A also completed an Incident/Accident Report dated 09/21/10 at 12:30 PM. In an interview with RN C on 09/28/10 at 2:15 PM, she reported on evening rounds on 09/20/10 at approximately 6:00 PM, Resident #2 was resistant to being transferred. She stated she and CNA A were transferring the resident from her recliner to the bed, and Resident #2 was hitting, scratching, kicking and yelling at them. RN C stated once the resident was in the bed, she held Resident #2's arms down, so CNA A could remove the resident's brief and pants and put some pajamas or a gown on the resident. RN C stated they were not supposed to put a resident to bed in street clothes. RN C also stated CNA A got a small scratch on her forearm during the transfer, but at the time of the incident, they did not fill out an incident report or report the incident to anyone. In an interview with CNA A on 09/30/10 at 5:25 PM, she confirmed she had assisted RN C with the transfer of Resident #2 on 09/20/10, when the resident became resistant. CNA A stated RN C held Resident #2's arms down while CNA A took the resident's brief and pants off and put pajamas on. CNA A stated they were not supposed to put residents to bed wearing their clothing. She stated she got a small scratch during the transfer, but they did not fill out an incident report. The Provider Investigation Report reflected the report was made to DADS on 09/23/10 at 10:00 PM, which was three days after the incident between Resident #2 and CNA A and RN C occurred. 4) Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #19's MDS assessment dated [DATE] reflected the resident was severely impaired cognitively for daily decision-making. In an interview with Resident #19's family member on 09/30/10 at 12:01 PM, she stated in the first week of September 2010, she visited Resident #19, and he complained of his back hurting. She stated at that time, she communicated the information to the facility Administrator. She stated because of Resident #19's memory problems, he would be unable to report whether anyone harmed him, but she felt he must have been injured by someone at the facility, as he had never complained of back pain before. The facility did an x-ray, which showed a compression fracture in his spine. She stated she told the Administrator at that time, "Someone must've thrown him in the bed, because there's no other way that this could happen." The Administrator was asked about Resident #19 on 10/01/10 at 9:35 AM. The Administrator stated no Incident/Accident Report had been done in regard to the incident involving Resident #19. He stated he had kept some informal notes about his communication with Resident #19's family member, but no report had been made to DADS, because he did not believe this was an allegation of abuse. He stated he had gone to the resident's room and asked him if anyone had hurt him and Resident #19 stated, "No." Because the resident had said no one had ever hurt him, the Administrator did not consider it an allegation of abuse. The Administrator was also asked what type of procedure there was to make sure the nursing needs of the residents were being met. He replied, "I don't know what you want me to say." 5) Resident #14 was first observed on 09/27/10 at 10:43 AM during initial rounds by the surveyor while accompanied by RN U. At the time of the observation, RN U stated Resident #14 was not interviewable, was bedfast, utilized a geri chair, was total care for ADLs, fed by staff, incontinent of bowel and bladder, and was on Hospice care. During the interview conducted with the RN at that time, there was no mention the resident had sustained any bruising. At the time of the observation, Resident #14 was sleeping under covers, and no observation of bruising was made. On 09/29/10 at 12:00 Noon, Resident #14 was observed and there was no bruising at that time. An attempt was made to interview the resident, but due to confusion, she was not interviewable. According to the Record of admitted d 12/07/09 Resident #14 was admitted to the facility on [DATE] with a readmitted [DATE]. Review of Resident #14's consolidated physician's orders [REDACTED]. Review of Resident #14's Quarterly MDS assessment dated [DATE] revealed she had memory problems, was severely impaired cognitively, was total care for all ADLs, unable to sit or stand without assistance, had partial loss of voluntary movement of both upper and lower extremities, required two + people to transfer, dress, toilet, and was incontinent of bowel and bladder. Review of Resident #14's Comprehensive Care Plan, which was updated 07/16/10, revealed a "Problem" the resident was at risk for falls as evidenced by Cognitive Impairment, being Non-Weight Bearing, had Physical Impairment and [MEDICAL CONDITION]. Review of a facility Incident/Accident Report dated 08/30/10 at 7:00 PM revealed Resident #14 was observed with a 5.0 cm x 7.0 cm discolored area on the left upper arm during a shower. The report was prepared by LVN W. There was a one page, "Administrative Inquiry" attached, which had the following notation: "To be completed on all unwitnessed bruises, skin tears and questionable incidents." The Administrative Inquiry Report reflected it was also completed by LVN W, regarding Resident #14, and involved a Hospice CNA. The "Description of Incident or Noted Injury" reflected the following notation: "while having shower noted discolored area to (symbol (arrow) for upper) L arm 5 x 7 cm Very light in color," and the Hospice CNA reported the injury. The form included the resident was to be questioned about the injury and reflected the resident was to be asked the question even if very confused. This question was notated with "N/A." The form reflected another question: "What did the roommate say about the injury?" Again, it was answered with "N/A." The form reflected which staff were on duty the past eight hours and who were presently on duty, but there were no witness statements attached to the form. LVN W documented there were no trends on the hall and the aides had not noticed any trends. LVN W also wrote, "No" for any additional comments, concerns, and facts, which might have explained how the injury happened. There was no investigation of the bruise of unknown origin. Review of Resident #14's Skin Condition Report on 08/30/10 reflected a new 5.0 cm x 7.0 cm bruise on the upper left arm, which was yellow and purple in color. Review of Resident #14's Nurses' Notes dated 08/30/10 at 7:00 PM revealed the following notation by LVN W: "during shower Hospice CNA noted discolored area to (symbol (arrow) for upper) L arm - 5 x 7 cm light in color purple & (and) yellow resident unable to state what happened show no s/s (signs and symptoms) of pain during movement ..." An interview was conducted with LVN W on 09/28/10 at 4:00 PM. She stated on 08/30/10, a Hospice aide had given Resident #14 a shower and reported the bruise to her, but she could not remember who the aide was. The LVN said she went to go look at the bruise and it was a light, pale, faded purple with a "weird" shape. The LVN stated she saw it and "incidented" it (wrote an incident report). The LVN stated that was the first day she had seen the bruise. The LVN stated the procedure for bruises of unknown origin was to prepare an Incident Report, which went to the DON, who was to do an investigation and then place it in "follow-up." LVN W stated when preparing Incident Reports, statements were usually obtained when a bruise was found. LVN W stated she did not know why they did not get statements. She stated she should have obtained a statement from the Hospice CNA. LVN W further stated she asked for a statement from the Hospice Aide at that time, and the Hospice Aide just left. The LVN stated she did not think to ask her again. LVN W also stated she did not get statements from the CNAs on the hall. LVN W stated the procedure was to put the report in the DON's box. Incident Reports were to go straight to the DON. The LVN stated the resident did not exhibit pain at that time. She also stated Resident #14 was a Hoyer lift with two people, a one-person bath, and two people put her back to bed with the Hoyer lift. LVN W further stated the bruise should have been investigated and asked, "Isn't that why we do Incident Reports?" LVN W also stated bruises of unknown origin were also brought up in morning meetings to decide whether to investigate it or not. During the interview on 09/28/10 at 4:00 PM, LVN W was asked why she placed N/A in the question, "What did the roommate say about the injury?" LVN W stated Resident #20, the roommate, "gets upset when you go into the room." Review of Resident #20's Record of admitted d 05/24/10 revealed she was admitted to the facility on [DATE]. Resident #20 had been designated as "interviewable" on the list of residents presented to the survey team on 09/27/10 by facility staff. Resident #20's quarterly MDS assessment dated [DATE] reflected she had no memory problems, was understood and understands, and was independent for all ADLs. An interview was conducted with Resident #20, Resident #14's roommate, on 09/28/10 at 5:00 PM. Resident #20 stated she did not need any help and could do everything for herself. She stated she had heard talk about a bruise from the CNAs but did not remember anything specific about her roommate. She said she had not observed Resident #14 being transferred by facility staff. Resident #20 also stated no one had talked to her at the facility about her roommate or any knowledge she would have about someone receiving a bruise. The Hospice "Visit Note Reports" were reviewed and revealed no documentation of the bruise found by a Hospice Aide on 08/30/10. An interview was conducted with LVN X, the Hospice Nurse, on 09/29/09 at 12:20 PM, who had been taking care of Resident #14. She was unaware of the bruise, but stated CNA Y had been the Hospice aide taking care of the resident at that time. An interview was conducted with CNA Y, the Hospice Aide on 09/29/10 at 12:38 PM and 10/01/10 at 12:30 PM. She stated she was the aide Monday through Friday at the time Resident #14 had been found with the bruise, and provided showers to Resident #14 on Mondays, Wednesdays and Fridays. CNA Y stated on 08/30/10, Monday, around 7:00 PM, she got Resident #14 up for her shower, saw the bruise, and showed the bruise to another facility aide, CNA Z. She stated CNA Z went to LVN W and reported it to her. CNA Y, the Hospice Aide, stated she had worked the previous Friday and had not seen the bruise but could have overlooked it. The Hospice Aide stated two facility staff used the Hoyer lift to transfer the resident to and from the shower, but she showered the resident by herself. The Hospice Aide stated no one asked her for any type of statement at the time she found the bruise. CNA Y stated she was asked for a statement on 10/01/10 about the bruise she found on Resident #14 on 08/30/10. CNA Y described the bruise as having a yellow inside with purple on the outside of the bruise. The CNA further stated it was mostly on the outside of the upper left arm and did not entirely circle the arm. CNA Y further stated she heard CNA Z state he had not seen the bruise before either. An interview was conducted with CNA Z on 09/29/10 at 2:05 PM. He stated when CNA Y told him about he bruise, he informed LVN W who stated she already knew about the bruise. He stated he had seen the bruise during the week prior to that day, maybe one or two days prior, and assumed it had already been reported. Review of the staffing sheet dated 08/30/10 revealed he had worked on Resident #14's hall on the 2 PM to 10 PM shifts on 08/23/10, 08/24/10, 08/25/10, 08/26/10, 08/29/10 and 08/30/10, the day CNA Y saw Resident #14's bruise. An interview was also conducted with CNA AA on 09/29/10 at 2:15 PM. She had also worked on Resident #14's hall at the time the Hospice Aide found the bruise. She stated the Hospice Aide showed both of them the bruise. She stated it looked yellowish, and she had not seen it before that day. Review of the staffing sheets revealed CNA AA had worked on the 2 PM to 10 PM shifts on 08/23/10, 08/24/10, 08/25/10, 08/28/10, 08/29/10, and 08/30/10, the day it was reported by the Hospice Aide. An interview was conducted with CNA DD on 10/01/10 at 10:20 AM. The CNA stated she could not remember for sure if there was bruising on Resident #14's arm and did not remember discussing it with anyone. Review of staffing sheets revealed CNA DD worked on Resident #14's hall on the 6 AM to 2 PM shifts on 08/23/10, 08/24/10, 08/25/10, 08/26/10, and 08/29/10, the day before the bruise was reported by the Hospice Aide. An interview was conducted with CNA BB on 10/01/10 at 10:38 AM. CNA BB stated she did not see the bruise Friday, because she did not give Resident #14 a shower. CNA BB also stated she came in on Sunday, 08/29/10 for a short time and was told about Resident #14's bruise from an aide. She was unable to recall which aide told her. She stated LVN CC asked her to write a statement, because she had worked on Friday, 08/27/10, when the Hospice Aide showered Resident #14. CNA BB stated she wrote a statement and slid it under the DON's door Monday morning (08/30/10). CNA BB stated no one talked to her any further or asked any questions about the bruising. Review of the staffing sheets revealed CNA BB worked on Resident #14's hall on 08/24/10, 08/25/10, 08/26/10 and Friday, 08/27/10, prior to the bruise being reported by the Hospice Aide on 08/30/10. An interview was conducted with LVN CC, the Weekend Double LVN on 10/01/10 at 11:20 AM. She denied she told CNA BB to write a statement. LVN CC stated if she (LVN CC) had seen the bruise, she would have written an Incident Report and told the CNA to write a statement. The LVN stated she looked at her own personal notes she kept, and she had not written anything about a bruise on Resident #14. An interview was conducted with the DON on 10/01/10 at 10:50 AM. The DON stated she did not receive any report under her door, and no one called her during the weekend to tell her about a bruise on Resident #14. 6) Resident #15 was admitted to the facility in October 2005 with [DIAGNOSES REDACTED]. A review of the incident report dated 09/10/10 at 1:00 PM and signed by LVN V, revealed Resident #15 had discolored areas present on her right upper extremity. There were no measurements of the discolored area, and no indication as to the exact location of the discolored area. The Incident/Accident report reflected the resident's family member was notified, and the FNP was notified at 2:10 PM Review of Administrative Inquiry dated 09/10/10 at 1:00 PM and signed by LVN V reflected Resident #15's injury was reported by "aides." There was no documentation of any aides being interviewed regarding the incident. The Administrative Inquiry also reflected when Resident #15 was asked about the discolored area, the resident said, "Nothing," and the resident's roommate was "not present." During an interview with the DON on 09/28/10 at 3:30 PM, she stated no report had been made to DADS with regard to this incident, and no further investigation into the matter had been done. 7) The Record of admitted d 09/08/10 for Resident #16 reflected she was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 09/07/10, an Incident/Accident Report reflected Resident #16 had bruising on the back of the resident's right thigh, which measured 4.5 cm x 2.0 cm and on the lower right calf measuring 1.0 cm x 1.0 cm. There was no evidence interviews were conducted to determine how the resident might have gotten the bruising. Resident #16 had been identified as interviewable on the Detail Census Report provided by facility staff and dated 09/27/10. During an interview with Resident #16 on 10/01/10 at 9:47 AM, she stated she did not know how the bruising occurred to the back o

Based on observation, interview and record review, it was determined the facility failed to implement its written policies and procedures to prohibit neglect for seven (Residents #2, #8, #9, #14, #15, #16 and #19) of ten residents reviewed/observed for abuse/neglect. 1) On 07/15/10, Resident #8's lower legs were "mangled" during a transfer by CNA K and CNA T. The facility did not conduct an investigation of the incident, because it was "witnessed," did not interview the resident and/or the CNAs to determine a causative factor and whether abuse/neglect was involved; and no interventions, such as transfer training or monitoring of transfers were implemented to prevent another recurrence. Resident #8's wounds on her legs were still being treated as of 09/30/10 due to "slow" healing and caused the resident continual pain. On 09/28/10, the resident had multiple bruises on her left forearm, which were not investigated or reported. 2) On 09/27/10, Resident #9 alleged a nurse aide had "grabbed/pulled" her arm too hard during a transfer from the bed to a chair three or four days earlier, which caused a 7.0 cm x 11.0 cm bruise on her left forearm. The incident was not investigated and a Provider Investigation Report was not filed until 09/30/10 following surveyor inquiry. 3) On 09/21/10, Resident #2 was assessed with [REDACTED]. A Provider Investigation Report was not filed until 09/23/10 at 10:00 PM (more than two days later). 4) Resident #19's family member alleged had back pain "the first week of September." The family member told the Administrator, "Somebody must've thrown him (the resident) in the bed." The allegation was not reported to DADS, and no investigation was done. 5) On 08/30/10 Resident #14 had a 5.0 cm x 7.0 cm area of yellow/purple bruising on her upper left arm. There was no investigation to find out the etiology of the bruise in order to determine if the bruise was the result of abuse, neglect or mistreatment and who might have been the perpetrator. It was not reported to DADS. 6) On 9/10/10, Resident #15 had a bruise on her right arm. There was no investigation and the bruise was not reported to DADS. 7) On 09/07/10, a 4.5 cm by 2.0 cm purplish bruise was found on the back of Resident #16's thigh and a 1.0 cm x 1.0 cm purplish bruise was on the resident's calf. No investigation was done for the bruising of unknown origin, and it was not reported to DADS. On 09/28/10 at 4:40 PM, these findings resulted in an Immediate Jeopardy (IJ) situation with Substandard Quality of Care (SQC) affecting Residents #2, #9, #8, #14, #15, #16 and #19 in the area of Resident Behavior/Facility Practice. While the IJ was removed on 09/30/10, after the facility began reviewing incident reports, assessing residents and inservicing staff, the facility remained out of compliance at a severity level of "Actual harm that is not immediate jeopardy" and a scope of "pattern," based on the facility continuing to inservice staff and monitor for compliance. These failures could affect the facility's 83 residents, including Residents #2, #9, #8, #14, #15, #16 and #19, and placed them at risk for abuse/neglect to occur resulting in the potential for falls and injury causing residents to be afraid of being transferred and handled by staff, loss of self-esteem and self-worth, decreased socialization and having a negative impact on their quality of life. Findings included: On 10/01/10, the facility's current undated abuse/neglect policy and procedure was provided to the survey team by the Corporate RN and included the following: "...Therefore the facility has developed operational policies and procedures for protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect... The facility's purpose is to assure that the facility is doing all that is within their control to prevent occurrences. These... will give facility guidance to assure the protection of all of their residents while they reside in the facility...." "...All direct care staff have been trained to identify the three signs that might indicate abuse of residents. Staff are knowledgeable in recognizing suspicious bruising, swelling, pain or other injuries;...." "...All allegations, no matter what types of incidents reported will be investigated fully. All employees who suspect abuse at any time it is identified are to report it to their immediate supervisor. If the supervisor is not the charge nurse, then the supervisor will report it to the charge nurse who is responsible for the resident suspected of being abused. The charge nurse receiving the allegation shall immediately contact either one of the following: the nurse on call, who will then report the allegation to the director of nursing, or the assistant director of nursing, the director of nursing and/or the administrator. The administrator or his/her designee will report the allegation of abuse immediately to the state agency (DADS) and to the proper local authorities. An immediate investigation will be instigated and the person responsible for this coordination of the investigation will be the director of nursing. The director of nursing will ensure that facility completes the appropriate investigated forms and forwards a copy of the investigation to DADS within 5 calendar days. Facility forms used in the investigative process include: Investigation go-by, investigation, staff interview form, staff member's statement, resident interview, and the resident to resident confrontation report...." "The facility policy and procedure on reporting is to follow state guidelines as outlined in the TDHS Provider Letter # 00-22-Guidelines for Reporting Incidents and to answer all questions as outlined in the TDHS letter dated January 2007. Upon completion of investigation the "Facility Investigation Report," will be faxed or mailed to DADS within 5 days. The facility will report to the State nurse aide registry or licensing authorities any knowledge it has of any actions by a court of law which would indicate that one of its employees is unfit for service. Upon completion of an investigation, the director of nurses and administrator will analyze the occurrences and determine what changes, if any, are needed to prevent any further occurrences. This response will be dictated as to the findings indicating trends and patterns that would warrant a policy and/or procedure change for the betterment of the residents and the prevention of any further abuse. An interview with the Administrator on 09/28/10 at 10:30 AM established the facility's policy concerning injuries of unknown origin. The Administrator reported injuries of unknown origin were discussed in a routine morning meeting, which included all department heads. He stated if the injury could not be explained, it would be reported (to DADS) as possible neglect. 1) Based on the Record of admitted d 08/31/10, Resident #8 was admitted on [DATE] with [DIAGNOSES REDACTED]. A Patient Visit Note from the physician dated 08/20/10 reflected she also had [DIAGNOSES REDACTED]. Review of the resident's MDS assessment of 07/02/10 revealed the facility assessed Resident #8 as requiring weight-bearing support from two persons to transfer. Resident #8 was assessed as not being able to balance while standing. The resident's MDS assessment also reflected she was able to understand others and to make herself understood, as well as locate her room and identify staff by names or faces. The MDS reflected Resident #8 had moderate cognitive impairment. Resident #8 was observed on initial rounds with LVN B in her room on 09/27/10 at 10:00 AM. Resident #8 had gauze bandages wrapped around both lower legs. The LVN reported the resident was injured when her legs hit the bed during a transfer in July 2010. The LVN described the injuries to the resident's legs as "severe," but stated the wounds were "healing now." A review of the nurses' note for 07/15/10 at 9:00 PM revealed Resident #8 received two "V" shaped skin tears on her left, lower leg and one, 3.0 cm x 3.0 cm skin tear on her right lower leg while CNAs were transferring her. Review of the facility incident report dated 07/15/10 revealed Resident #8 sustained skin tears to both legs during a transfer by CNA F and CNA G. The incident report reflected, "CNAs were transferring resident to the bed when resident feet slid forward into bed frame causing 2 s/t (skin tears) on L (left) leg and 1 s/t on R (right) leg." Her feet reportedly slid forward into the bed rail. An investigation report was not attached to the incident report, and the incident report was not signed or dated. During an interview on 09/28/10 at 5:30 PM, the DON reported no investigation was initiated concerning Resident #8's leg injuries, because the injuries were witnessed by the aides. She stated no additional transfer training was provided to the two aides, and no nurses were assigned to monitor the aides when they transferred any of the residents. A physician's orders [REDACTED]. Resident #8's Skin Condition Report sheets for July 2010 through September 2010 were reviewed with LVN E on 09/28/10 at 4:00 PM. LVN E reported she completed the initial skin assessment of the resident's skin tears on 07/15/10. Resident #8's Skin Condition Reports for 07/15/10 reflected the following: a) The site was identified as being located on the front towards the right side of the left (sic) lower leg. The diagram reflected the wound was on the left lower leg and was measured as 1.0 cm x 4.0 cm. b) Two other sites were identified as being on the right (sic) lower leg. Both were on the front of the right lower leg with one directly below the knee and the second one being further down on the leg. The wound below the knee was measured as 3.0 cm x 2.0 cm and the second wound was 5.0 cm x 3.0 cm. The interview continued at 4:05 PM on 09/28/10 and LVN E described the resident's legs as "mangled" from the collision with the bed frame. She stated she did the treatments daily, and the resident's injuries were slow to heal. Resident #8 was interviewed in her room on 09/28/10 at 5:00 PM. She reported her legs were hurt when the aides were transferring her to her bed. She pointed to the bed frame and said her legs hit the frame. She stated her legs still hurt, and the nurses have to "doctor" her legs every day. She said she could hardly stand anything touching them. Resident #8 told the surveyors she was not able to do as much since she injured her legs. She stated, "They hurt all the time." Resident #8 then stated, "The aides do hurt you when moving people around. They get in a hurry and are rough with you, because they are in a hurry." At that time, the surveyors observed multiple, reddish-blue bruises in a circular pattern. When Resident #8 was asked about them, she stated she got the bruises from being transferred. The resident stated a "couple of days ago," an aide grabbed her arm when she was transferring her. The bruises were reported to the Treatment Nurse by an unidentified CNA, who stated she would report and measure the bruises after she completed treatments. Review of Resident #8's Nurse's Notes revealed nothing was documented on 09/28/10 or 09/29/10 regarding the bruises on her arm. On 09/30/10 at 5:10 a.m., documentation reflected the nurse was informed by staff Resident #8 had bruises on her arm. At 5:50 a.m., staff reported to the nurse Resident #8 had told them a CNA from the previous shift caused the bruising when she was transferred. The LVN assessed the bruising: 0.5 cm x 0.5 cm bruise on the right arm and three bruises measuring 2.0 cm x 1.0 cm and one bruise 0.5 cm x 0.5 cm on the left arm. The same measurements were documented on a Skin Condition Report for Resident #8. On 09/30/10 at 10:40 AM, during a skin observation, LVN I determined the bruises on Resident #8's left forearm (which the resident had pointed out to surveyors in the interview on 09/28/10) had not been reported, despite having been documented on 09/29/10 by facility staff. LVN I stated she would measure and report the forearm bruises. At that time, Resident #8's leg wounds were observed with LVN I in the resident's room. Each lower leg had two open areas, approximately 2.0 cm x 3.0 cm, which were denuded of skin. There were patchy clumps of skin with yellow exudate on both shins, which extended to both calf areas. The skin on the left shin was bright red. At that time, LVN I described Resident #8's legs as "mangled" when she slid into the bed frame in July 2010. She said the skin on both legs was turned up on itself, so the nurses used "q-tips" to pull the skin out and piece the skin together to cover the exposed tissue underneath. She stated the nurses used "steri-strips"to push the edges of the torn skin together. She further stated the resident was diabetic and added it was "really hard" to get the skin to start healing. She described the wounds as "magnificent," compared to what they originally looked like in July 2010. While the nurse was showing the resident's wounds to the surveyor, Resident #8 grimaced and told the surveyor her legs hurt all the time. She stated, "They hurt me." Interview with CNA F on 09/30/10 at 11:30 AM established she was one of the aides, who transferred Resident #8 from the chair to her bed on 07/15/10, when the resident sustained [REDACTED].#8's roommate while CNA G was caring for Resident #8. CNA F reported CNA G was transferring Resident #8 by herself from the chair to the bed, and she called out for CNA F to assist her in the transfer. CNA F stated when she got Resident #8's bedside, the resident was in a standing position between the chair and the bed. CNA G told her (CNA F) she (CNA G) could not get the resident to pivot to the bed, so she (CNA G) needed assistance. CNA F stated she held onto the the back of the resident's pants to turn her. She stated Resident #8's knees "buckled," and the resident slid under the bed, with her legs scraping the bed frame. CNA F said the skin was peeled off the resident's legs beneath her knees, and she was bleeding on both legs. The CNA stated she and the other aide did not use a gait belt during the transfer. She stated, "If we had used a gait belt, we could have stopped her from sliding down." Physical Therapist (PT) H was interviewed on 09/30/10 at 12:30 PM concerning Resident #8. He reported he knew the resident, and she had received physical therapy, most recently in March 2010. He reported the resident had "bad knees," and said, "She can stand and pivot sometimes, and sometimes she can't." He stated if a resident cannot pivot during a transfer, the aide should place the resident back into the chair and consider an alternative way to transfer the resident, such as a mechanical device. PT H reported the therapy department instructed aides to always use a gait belt during transfers and to never lift a resident by pulling them up by their pants. 2) Resident #9's Record of admitted d 09/07/10 indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Patient Visit note signed by the physician on 07/02/10, reflected [DIAGNOSES REDACTED]. Resident #9's Physician order [REDACTED]. Review of the MDS assessment, dated 08/27/10 revealed the facility assessed Resident # 9 as requiring staff assistance from one person to transfer. Resident #9 was not able to balance while standing without assistance. The MDS reflected Resident #9 was moderately cognitively impaired. Resident #9 was identified as interviewable by facility staff on the Detail Census Report provided to the survey team and dated 09/27/10. A facility incident report, dated 07/27/10, reflected Resident #9 was found to have a 7.0 cm x 11.0 cm bruise on her left inner arm. The nurse, who completed the report, documented Resident #9 reported the daytime CNA pulled on her arm too hard during a transfer. There was no evidence an investigation had been completed. Review of Resident #9's nurses' note, dated 07/27/10, revealed LVN J documented the resident told her the "daytime CNA grabbed/pulled her too hard." When the 07/27/10 nurses' note was reviewed with the DON on 09/28/10 at 4:00 PM, the DON was asked why the incident was not investigated, since Resident #9 alleged an aide hurt her. The DON acknowledged the incident should have been investigated. Resident #9 was interviewed in her room on 09/30/10 at 10:30 AM. She said the bruise on her arm was gone, but said she remembered being hurt by an aide a couple of months ago. The resident demonstrated how she was injured by grabbing her left forearm with her right hand. Resident #9 stated, " I think she broke a blood vessel." The resident did not remember the aide's name. She stated the bruise happened a long time ago. An interview with Resident# 9's family member on 09/30/10 at 6:30 PM revealed Resident #9 was legally blind due to [MEDICAL CONDITION] and had a moderately severe hearing loss in both ears, which required hearing aids. The family member stated a facility nurse called about the bruise on the resident's arm, but no one from the facility provided any information about how the bruise occurred. 3) Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An Incident Report dated 09/23/10 reflected an incident involving Resident #2 on 09/23/10 at 10:00 PM. A review of Resident #2's clincal record revealed an entry in the Nurses' Notes dated 09/21/10 at 6:00 PM and signed by RN C. The note reflected Resident #2 was resistant to care during a transfer and was kicking, scratching and cursing at the staff, who were attempting to transfer her. There was no mention of injury to either the resident or the staff involved. An entry in Nurses' Notes dated 09/21/10 and signed by LVN A revealed Resident #2 had "purple discoloration" on her right forearm, but the resident was unable to say what had happened. LVN A also completed an Incident/Accident Report dated 09/21/10 at 12:30 PM. In an interview with RN C on 09/28/10 at 2:15 PM, she reported on evening rounds on 09/20/10 at approximately 6:00 PM, Resident #2 was resistant to being transferred. She stated she and CNA A were transferring the resident from her recliner to the bed, and Resident #2 was hitting, scratching, kicking and yelling at them. RN C stated once the resident was in the bed, she held Resident #2's arms down, so CNA A could remove the resident's brief and pants and put some pajamas or a gown on the resident. RN C stated they were not supposed to put a resident to bed in street clothes. RN C also stated CNA A got a small scratch on her forearm during the transfer, but at the time of the incident, they did not fill out an incident report or report the incident to anyone. In an interview with CNA A on 09/30/10 at 5:25 PM, she confirmed she had assisted RN C with the transfer of Resident #2 on 09/20/10, when the resident became resistant. CNA A stated RN C held Resident #2's arms down while CNA A took the resident's brief and pants off and put pajamas on. CNA A stated they were not supposed to put residents to bed wearing their clothing. She stated she got a small scratch during the transfer, but they did not fill out an incident report. The Provider Investigation Report reflected the report was made to DADS on 09/23/10 at 10:00 PM, which was three days after the incident between Resident #2 and CNA A and RN C occurred. 4) Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #19's MDS assessment dated [DATE] reflected the resident was severely impaired cognitively for daily decision-making. In an interview with Resident #19's family member on 09/30/10 at 12:01 PM, she stated in the first week of September 2010, she visited Resident #19, and he complained of his back hurting. She stated at that time, she communicated the information to the facility Administrator. She stated because of Resident #19's memory problems, he would be unable to report whether anyone harmed him, but she felt he must have been injured by someone at the facility, as he had never complained of back pain before. The facility did an x-ray, which showed a compression fracture in his spine. She stated she told the Administrator at that time, "Someone must've thrown him in the bed, because there's no other way that this could happen." The Administrator was asked about Resident #19 on 10/01/10 at 9:35 AM. The Administrator stated no Incident/Accident Report had been done in regard to the incident involving Resident #19. He stated he had kept some informal notes about his communication with Resident #19's family member, but no report had been made to DADS, because he did not believe this was an allegation of abuse. He stated he had gone to the resident's room and asked him if anyone had hurt him and Resident #19 stated, "No." Because the resident had said no one had ever hurt him, the Administrator did not consider it an allegation of abuse. The Administrator was also asked what type of procedure there was to make sure the nursing needs of the residents were being met. He replied, "I don't know what you want me to say." 5) Resident #14 was first observed on 09/27/10 at 10:43 AM during initial rounds by the surveyor while accompanied by RN U. At the time of the observation, RN U stated Resident #14 was not interviewable, was bedfast, utilized a geri chair, was total care for ADLs, fed by staff, incontinent of bowel and bladder, and was on Hospice care. During the interview conducted with the RN at that time, there was no mention the resident had sustained any bruising. At the time of the observation, Resident #14 was sleeping under covers, and no observation of bruising was made. On 09/29/10 at 12:00 Noon, Resident #14 was observed and there was no bruising at that time. An attempt was made to interview the resident, but due to confusion, she was not interviewable. According to the Record of admitted d 12/07/09 Resident #14 was admitted to the facility on [DATE] with a readmitted [DATE]. Review of Resident #14's consolidated physician's orders [REDACTED]. Review of Resident #14's Quarterly MDS assessment dated [DATE] revealed she had memory problems, was severely impaired cognitively, was total care for all ADLs, unable to sit or stand without assistance, had partial loss of voluntary movement of both upper and lower extremities, required two + people to transfer, dress, toilet, and was incontinent of bowel and bladder. Review of Resident #14's Comprehensive Care Plan, which was updated 07/16/10, revealed a "Problem" the resident was at risk for falls as evidenced by Cognitive Impairment, being Non-Weight Bearing, had Physical Impairment and [MEDICAL CONDITION]. Review of a facility Incident/Accident Report dated 08/30/10 at 7:00 PM revealed Resident #14 was observed with a 5.0 cm x 7.0 cm discolored area on the left upper arm during a shower. The report was prepared by LVN W. There was a one page, "Administrative Inquiry" attached, which had the following notation: "To be completed on all unwitnessed bruises, skin tears and questionable incidents." The Administrative Inquiry Report reflected it was also completed by LVN W, regarding Resident #14, and involved a Hospice CNA. The "Description of Incident or Noted Injury" reflected the following notation: "while having shower noted discolored area to (symbol (arrow) for upper) L arm 5 x 7 cm Very light in color," and the Hospice CNA reported the injury. The form included the resident was to be questioned about the injury and reflected the resident was to be asked the question even if very confused. This question was notated with "N/A." The form reflected another question: "What did the roommate say about the injury?" Again, it was answered with "N/A." The form reflected which staff were on duty the past eight hours and who were presently on duty, but there were no witness statements attached to the form. LVN W documented there were no trends on the hall and the aides had not noticed any trends. LVN W also wrote, "No" for any additional comments, concerns, and facts, which might have explained how the injury happened. There was no investigation of the bruise of unknown origin. Review of Resident #14's Skin Condition Report on 08/30/10 reflected a new 5.0 cm x 7.0 cm bruise on the upper left arm, which was yellow and purple in color. Review of Resident #14's Nurses' Notes dated 08/30/10 at 7:00 PM revealed the following notation by LVN W: "during shower Hospice CNA noted discolored area to (symbol (arrow) for upper) L arm - 5 x 7 cm light in color purple & (and) yellow resident unable to state what happened show no s/s (signs and symptoms) of pain during movement ..." An interview was conducted with LVN W on 09/28/10 at 4:00 PM. She stated on 08/30/10, a Hospice aide had given Resident #14 a shower and reported the bruise to her, but she could not remember who the aide was. The LVN said she went to go look at the bruise and it was a light, pale, faded purple with a "weird" shape. The LVN stated she saw it and "incidented" it (wrote an incident report). The LVN stated that was the first day she had seen the bruise. The LVN stated the procedure for bruises of unknown origin was to prepare an Incident Report, which went to the DON, who was to do an investigation and then place it in "follow-up." LVN W stated when preparing Incident Reports, statements were usually obtained when a bruise was found. LVN W stated she did not know why they did not get statements. She stated she should have obtained a statement from the Hospice CNA. LVN W further stated she asked for a statement from the Hospice Aide at that time, and the Hospice Aide just left. The LVN stated she did not think to ask her again. LVN W also stated she did not get statements from the CNAs on the hall. LVN W stated the procedure was to put the report in the DON's box. Incident Reports were to go straight to the DON. The LVN stated the resident did not exhibit pain at that time. She also stated Resident #14 was a Hoyer lift with two people, a one-person bath, and two people put her back to bed with the Hoyer lift. LVN W further stated the bruise should have been investigated and asked, "Isn't that why we do Incident Reports?" LVN W also stated bruises of unknown origin were also brought up in morning meetings to decide whether to investigate it or not. During the interview on 09/28/10 at 4:00 PM, LVN W was asked why she placed N/A in the question, "What did the roommate say about the injury?" LVN W stated Resident #20, the roommate, "gets upset when you go into the room." Review of Resident #20's Record of admitted d 05/24/10 revealed she was admitted to the facility on [DATE]. Resident #20 had been designated as "interviewable" on the list of residents presented to the survey team on 09/27/10 by facility staff. Resident #20's quarterly MDS assessment dated [DATE] reflected she had no memory problems, was understood and understands, and was independent for all ADLs. An interview was conducted with Resident #20, Resident #14's roommate, on 09/28/10 at 5:00 PM. Resident #20 stated she did not need any help and could do everything for herself. She stated she had heard talk about a bruise from the CNAs but did not remember anything specific about her roommate. She said she had not observed Resident #14 being transferred by facility staff. Resident #20 also stated no one had talked to her at the facility about her roommate or any knowledge she would have about someone receiving a bruise. The Hospice "Visit Note Reports" were reviewed and revealed no documentation of the bruise found by a Hospice Aide on 08/30/10. An interview was conducted with LVN X, the Hospice Nurse, on 09/29/09 at 12:20 PM, who had been taking care of Resident #14. She was unaware of the bruise, but stated CNA Y had been the Hospice aide taking care of the resident at that time. An interview was conducted with CNA Y, the Hospice Aide on 09/29/10 at 12:38 PM and 10/01/10 at 12:30 PM. She stated she was the aide Monday through Friday at the time Resident #14 had been found with the bruise, and provided showers to Resident #14 on Mondays, Wednesdays and Fridays. CNA Y stated on 08/30/10, Monday, around 7:00 PM, she got Resident #14 up for her shower, saw the bruise, and showed the bruise to another facility aide, CNA Z. She stated CNA Z went to LVN W and reported it to her. CNA Y, the Hospice Aide, stated she had worked the previous Friday and had not seen the bruise but could have overlooked it. The Hospice Aide stated two facility staff used the Hoyer lift to transfer the resident to and from the shower, but she showered the resident by herself. The Hospice Aide stated no one asked her for any type of statement at the time she found the bruise. CNA Y stated she was asked for a statement on 10/01/10 about the bruise she found on Resident #14 on 08/30/10. CNA Y described the bruise as having a yellow inside with purple on the outside of the bruise. The CNA further stated it was mostly on the outside of the upper left arm and did not entirely circle the arm. CNA Y further stated she heard CNA Z state he had not seen the bruise before either. An interview was conducted with CNA Z on 09/29/10 at 2:05 PM. He stated when CNA Y told him about he bruise, he informed LVN W who stated she already knew about the bruise. He stated he had seen the bruise during the week prior to that day, maybe one or two days prior, and assumed it had already been reported. Review of the staffing sheet dated 08/30/10 revealed he had worked on Resident #14's hall on the 2 PM to 10 PM shifts on 08/23/10, 08/24/10, 08/25/10, 08/26/10, 08/29/10 and 08/30/10, the day CNA Y saw Resident #14's bruise. An interview was also conducted with CNA AA on 09/29/10 at 2:15 PM. She had also worked on Resident #14's hall at the time the Hospice Aide found the bruise. She stated the Hospice Aide showed both of them the bruise. She stated it looked yellowish, and she had not seen it before that day. Review of the staffing sheets revealed CNA AA had worked on the 2 PM to 10 PM shifts on 08/23/10, 08/24/10, 08/25/10, 08/28/10, 08/29/10, and 08/30/10, the day it was reported by the Hospice Aide. An interview was conducted with CNA DD on 10/01/10 at 10:20 AM. The CNA stated she could not remember for sure if there was bruising on Resident #14's arm and did not remember discussing it with anyone. Review of staffing sheets revealed CNA DD worked on Resident #14's hall on the 6 AM to 2 PM shifts on 08/23/10, 08/24/10, 08/25/10, 08/26/10, and 08/29/10, the day before the bruise was reported by the Hospice Aide. An interview was conducted with CNA BB on 10/01/10 at 10:38 AM. CNA BB stated she did not see the bruise Friday, because she did not give Resident #14 a shower. CNA BB also stated she came in on Sunday, 08/29/10 for a short time and was told about Resident #14's bruise from an aide.