Every finding on record at The Bartlett Skilled Nursing and Assisted Living

Based on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 5 (Resident #1) residents reviewed for quality of care, in that:The facility failed to maintain communication, coordination, and collaboration with the dialysis provider for Resident #1. This failure could place residents who received dialysis treatments at risk for complications and not receiving proper care and treatment to meet their needs.Findings included: Record review of Resident #1's face sheet dated 06/17/26 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Record review of Resident #1's history and physical dated 05/16/26 revealed Resident #1 was admitted to the hospital on [DATE] with diagnoses which included acute on chronic renal failure (sudden worsening of already existing kidney disease), end stage renal disease (permanent kidney failure requiring dialysis or kidney transplant), acute metabolic acidosis (dangerous buildup of acid in the body due to the kidneys not removing waste properly), and metabolic encephalopathy (brain dysfunction caused by a medical condition affecting the body's normal balance). The history and physical revealed Resident #1 underwent placement of a hemodialysis catheter (a tube placed into a large vein that allows dialysis treatments to remove waste and excess fluid from the blood) and started hemodialysis (a treatment that filters waste and excess fluid from the blood when the kidneys can no longer do so adequately) during his hospitalization.Record review of Resident #1's initial MDS assessment dated [DATE] revealed a BIMS score of 15, indicating Resident #1 was cognitively intact. The assessment revealed Resident #1 was admitted to the facility on [DATE] following hospitalization. Record review from the MDS under section I, active diagnoses, revealed Resident #1 had diagnoses of renal insufficiency (decreased kidney function causing difficulty filtering waste and excess fluid from the blood), renal failure (the kidneys are no longer able to adequately remove waste and excess fluid from the body), or End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or kidney transplant). Section I revealed the resident was dependent on renal dialysis (requires routine dialysis treatments because the kidneys can no longer adequately filter waste and excess fluid from the blood).Record review of Resident #1's care plan dated 05/12/26 revealed Resident #1 received dialysis three times per week and was at risk for increased SOB (shortness of breath or difficulty breathing), chest pains, blood pressure changes, itchy skin, nausea and vomiting, impaired cognition (difficulty thinking, remembering, or making decisions), and infection to shunt site (infection at the dialysis access site used to access the bloodstream for dialysis treatments) and called for staff interventions on administering medications per order, monitoring labs and reporting abnormalities to MD, assessing shunt site before and after dialysis, and notifying MD of any abnormalities. The care plan revealed staff needed to monitor Resident #1's condition pre/post dialysis and report abnormalities to MD.Record review of the facility's PCC on 06/17/2026 at 10:43 a.m., for Resident #1 revealed there were no records of scanned hemodialysis communication forms into the system other than those for the appointments from 05/19/2026 and 06/11/2026. Review of the progress notes in PCC revealed there were no nursing notes entered into the system indicating the facility's staff communicated with the dialysis center to get any missing information for Resident #1's visit. Record review of Resident #1's dialysis communication forms for month of May and June 2026 revealed:-Resident #1's hemodialysis communication form dated 05/19/26 revealed pre-treatment vital signs of temperature 97.7 degrees Fahrenheit, pulse 80, respirations 16, and blood pressure 173/84. The post-treatment temperature, pulse, respirations, blood pressure, and weight sections were left blank. Dialysis center documentation indicated excessive fluid weight gain, mild restriction of one liter (32 ounces) of fluid intake, review of blood test results, and a request to review the medication list and phosphate binder orders with meals. The communication form did not contain documentation indicating facility follow-up regarding the dialysis center's recommendations.-Resident #1's hemodialysis communication form dated 06/11/26 revealed pre-treatment vital signs of temperature 98.6 degrees Fahrenheit, pulse 78, respirations 17, and blood pressure 127/91. The post-treatment temperature, pulse, respirations, blood pressure, and weight sections were left blank. Dialysis center documentation indicated fluid overload (excess fluid retained in the body), fluid restrictions of 1.5 liters per day, and dialysis treatment information. The communication form did not contain documentation indicating facility follow-up regarding the dialysis center's recommendations.During an interview on 06/17/2026 at 1:25 p.m., LVN A stated that upon a resident's return from dialysis, nursing staff were expected to obtain and document vital signs on the dialysis communication form and send the documentation to medical records. LVN A stated the dialysis communication form should be reviewed for changes in condition, medication changes, and new orders. LVN A stated that if dialysis documentation was incomplete or missing, staff were expected to contact the dialysis center and notify the DON. LVN A stated it was not acceptable for dialysis communication forms to be incomplete because a lack of communication between the dialysis center and the nursing facility could result in a failure to identify and follow up on a change in condition, placing the resident at risk.During an interview on 06/17/2026 at 1:50 p.m., LVN B stated that nursing staff were expected to complete the section of the dialysis communication form identified as 'Care Center Completes This Information' before the resident left for dialysis and again upon the resident's return. LVN B stated the dialysis communication form should include vital signs, dialysis access site information, and any changes in condition. LVN B stated that if information from the dialysis center was incomplete or missing, staff were expected to contact the dialysis center, request the missing information, and notify the DON. LVN B stated it was not acceptable for dialysis communication forms to be incomplete because important information regarding the resident's condition, including blood pressure changes and post-dialysis concerns, could be missed and not communicated to the facility.During an interview on 06/17/2026 at 2:18 p.m., the DON stated it was not acceptable that the dialysis communication forms did not contain post-dialysis vital signs after the resident returned from the dialysis center. The DON stated it was not acceptable that only two hemodialysis communication forms were available for review despite the resident residing at the facility for more than one month. The DON stated it was not acceptable to receive an incomplete dialysis communication form from the dialysis center and that the nurse receiving the resident back from dialysis was expected to contact the dialysis center and obtain the missing information. The DON confirmed there were no post-dialysis assessment progress notes documented in PCC and stated the facility should have documented vital signs and assessments in PCC following each dialysis appointment. The DON stated incomplete dialysis documentation could result in missing information, miscommunication between the dialysis center and the nursing facility, and the inability to identify and address a change in condition.During an interview on 06/17/2026 at 3:14 p.m., the RN Admin from the dialysis center stated that other nursing facilities routinely contacted the dialysis center when information was missing or clarification was needed regarding dialysis documentation. The RN Admin stated the current facility had not contacted the dialysis center regarding missing dialysis communication information. The RN Admin stated the dialysis communication forms were expected to be completed by both the dialysis center staff and the nursing facility staff to ensure continuity of care and communication regarding the resident's dialysis treatment. The RN Admin stated the forms should accurately document treatment information, vital signs, fluid removal, medication changes, physician recommendations, changes in condition, and follow-up needs. The RN Admin stated incomplete or inaccurate documentation could result in missed physician recommendations, unaddressed changes in condition, delays in treatment, medication discrepancies, fluid management issues, miscommunication between the dialysis center and the nursing facility, and the inability of facility staff to make informed clinical decisions regarding the resident's care following dialysis treatment.Record review of the facility's in-service record dated 04/10/2026 revealed that RNs (Registered Nurses) and LVNs (Licensed Vocational Nurses) were trained on the hemodialysis communication form. The in-service stated that for each resident scheduled for dialysis, staff needed to complete the communication form, send the form with the resident for the procedure, and once the resident returned, staff were to complete information and add nursing notes into PCC including vital signs, dressing at shunt site, location of shunt, and any comments from the dialysis center.Record review of the facility's Hemodialysis Access Care policy revised on September 2019 revealed in part:The general medical nurse should document in the resident's medical record every shift as follows:1. Location of catheter.2. Condition of dressing (interventions if needed).3. If dialysis was done during shift.4. Any part of report from dialysis nurse post-dialysis being given.5. Observations post-dialysis.

Based on interviews and record review, the facility failed to follow written policy on permitting residents to return to the facility after they are hospitalized for one of (Resident #1) six residents reviewed for transfer and discharge.The facility failed to readmit Resident #1 to the facility after she was sent to the hospital on [DATE].This failure could place residents at risk of being discharged and not allowed to return to the facility causing a disruption in their care and services and potential for decline.Findings included:Closed record review of the Face Sheet dated 04/10/26 for Resident #1 revealed an original admission date of 5/20/19 and re-admission date 12/08/2023. Diagnoses: Unspecified Dementia (a general term for a group of brain disorders that cause a gradual decline in cognitive abilities such as memory, thinking, language, problem-solving, judgement, and orientation), Mild Intellectual Disabilities (a neurodevelopmental condition characterized by and IQ between 50-70 and limitations in adaptive functioning), Major Depression (is a serious mood disorder causing persistent sadness, hopelessness and loss of interest in activities, significantly affecting daily life, sleep, appetite and concentration), End Stage Renal Disease (permanent kidney failure where the kidneys function at less than 15% of normal capacity). Date of discharge: [DATE] at 8:45 p.m.Review of History & Physical dated 6/20/19 provided by the DON revealed Resident #1 had a Past Medical History: Chronic mental deficiencies, end stage renal disease on dialysis.Review of the Annual MDS for Resident #1 dated 12/07/25 revealed: Level; II PASRR Conditions: Intellectual Disability. Reentry Date: 12/08/2023. admission Date: 05/20/19. Makes self usually understood. Usually understand others. Impaired vision. BIMS Summary Score: 4 (cognition severely impaired). Interview for Daily Preferences: Very Important to choose clothes to wear, bedtime, shower and have family or close friends involved in discussions about her care. Moderate assistance with toileting, oral hygiene, dressing, personal hygiene; substantial/maximum assistance with shower. Partial/moderate assistance sit to stand and chair/bed transfer. Mobility Device: Wheelchair. Active Diagnoses: ESRD, Non-Alzheimer's Dementia, Anxiety, Depression, Mild intellectual disabilities. High-Risk Drug Classes: Antipsychotic; dialysis. Discharge Plan: No. Return to Community: NoReview of the Care Plan for Resident #1 dated 12/30/25 revealed:-Resident uses psychotropic medication: Risperdal as ordered-Communication problem r/t cognitive deficits and intellectual disabilities-Behavior problem hitting herself on the head, yelling, slamming doors, hitting/slapping another patient, if someone is sitting where she likes to sit. Middle finger to staff, residents and visitors as she is wheeled down the hall.-Uses anti-anxiety mediation r/t anxiety disorder.-Major depressive disorder at risk of fluctuations in moods and decreased socialization. On antidepressant medication.-Resident has intellectual disabilities.Review of Psychiatric Follow-Up Evaluation dated 12/07/25 for Resident #1 revealed, Alert and oriented to person, cooperative, slow speech. Mood: Euthymic (tranquil, and normal mood), poor insight. Psychiatric Diagnosis: Unspecified Dementia without behavioral disturbances, Major depressive disorder, recurrent, moderate. Anxiety unspecified. Continue Risperidone 0.5 mg BID for dementia and aggressive behavior.Review of an Initial Psychiatry Note dated 1/08/26 written by the DNP for Resident #1 revealed a [AGE] year-old female and a long-term resident at this facility. She was seen per family's request. She was calm and cooperative. She smiles and answers yes and no to questions. She responded no to sadness and society and anger. Collateral information received from the nursing staff. The patient has a history of harming others, Combativeness and gets angry if she doesn't get what she wants immediately. She becomes combative, threatens staff, becomes verbally aggressive, and curses him. The patient tends to be possessive and wants the same staff to provide care. She has refused to go to dialysis and the driver she prefers is not available to take her. Assessment data: Mild recurrent. Major depressive disorder, Unspecified incident disorder. Unspecified dementia. With other behavioral disturbances. Plan: The patient has had more frequent episodes of aggressive behavior towards staff. Behavioral interventions have been unsuccessful. Recommended to increase Risperdal to 0.5 mg by mouth three times a day to help with behaviors and help stabilize mood. Continue with re-direction and re-orientation. Behavioral interventions recommended. When communicating with the patient, use a gentle approach, offer reassurance, keep communication simple and direct and be empathetic to the patient's needs and concerns. Avoid an over stimulating environment and use distraction and/or redirection to alter focus.Review of Nursing Note dated 2/02/26 at 8:00 p.m. for Resident #1 written by LVN L revealed, Patient sent to hospital for SOB and decreased oxygen level.Review of SNF/NF to Hospital Transfer Form dated 02/02/26 for Resident #1 written by LVN L revealed, Reason for Transfer: SOB. Vital Signs taken at 3:00 p.m. BP 106/56, HR 94, RR 18, Temp. 07.0, O2 Sat 91. Guardian notified of transfer.Review of EMS Care Report dated 02/02/26 at 8:19 p.m. for Resident #1 revealed, Symptom Onset: 02/02/26 at 8:00 p.m. Primary Complaint Shortness of Breath. Medical History: Hypertension, Dementia, Diabetes, Anxiety, Chronic kidney disease. Vitals at 8:39 p.m. BP 121/77, HR 98, SpO2 100. Procedures: O2 Therapy at 9:10 p.m. Response: Improved. Lung Assessment: Breath Sounds-Normal and equal. Increased respiratory effort. Narrative: Upon making patient contact the patient was found in her bed accompanied by nursing home staff. The patient was on 2 L of oxygen via nasal cannula. The staff stated the patient's saturation was dropping and was at 84. The patient was placed on non-rebreather oxygen mask at 10 L/min. The patient's oxygen saturation improved to 99% with the non-rebreather oxygen mask at 10 L/min.Review of Daily Census Report dated Saturday 2/14/26 provided by Executive Director documented there was an empty bed in room [ROOM NUMBER]-A for a female resident.Review of Census Report dated 2/16/26 provided by Executive Director documented there was an empty bed in room [ROOM NUMBER]-A for a female resident.Review of Daily Census Report dated Sunday 2/15/26 provided by Executive Director documented there was an empty bed in room [ROOM NUMBER]-A for a female resident.During a telephone interview 4/10/26 at 9:05 a.m., the Administrator said he had no direct involvement with discharge plans and the Executive Director kept tabs on discharges. He said he was not aware of any concerns related to specifically wrongful discharges and/or any concerns related to discharges that had been reported to him by the Executive Director. He said the facility was different than other buildings because most of the residents were admitted for short-term admissions and were discharged home with Home Health Services and only a few were referred to LTC facilities after the residents were issued a NOMNC. He said that they planned discharges with the HHA and assisted in getting the DME for the residents prior to exit. He said the insurance companies decided how long the resident qualified for services at the nursing home. He said that they had 2-3 LTC residents at the facility because most of the residents were admitted for short term placement. He said 60% of the resident census were residents on Medicare Advantage Plans and only qualified for 10 days of skilled services. He said that he had not received any concerns from family members or other pertinent individuals that the Executive Director was very rude and intimidating when concerns were brought to his attention. He said that the Executive Director had not reported to him any concerns related to Resident #1's discharge from the facility.During an interview on 4/10/26 at 9:20 a.m., the Executive Director said he was a good friend of Resident #1's attending physician and when he talked to him about Resident #1, the physician was aware of her behaviors. He said Resident #1 had been at another facility and they immediately discharged her because of her behavior. He said Resident #1 had been in long term placement at a facility for many years. He said the resident had been discharged to the hospital, could not remember the dates and the resident had been in ICU for 10-16 days and was not re-admitted on [DATE] because the facility was full and there were no beds available when she was ready to be discharged from the hospital. He said that he had made the decision that Resident #1 could not be placed in a semi-private room with another resident, after an incident in July 2025 when Resident #1 hit her roommate. He said that there was only one bed available in a semi-private room and there was a resident in one of the beds, so that was why Resident #1 could not be re-admitted back to the facility at the time that she was discharged from the hospital on 2/14/26. The executive Director stated she could not have a roommate to prevent recurrence of her hitting other residents, which was why the facility had been cited by another surveyor. He said that he had not offered a bed hold to the resident's guardian when the resident was admitted to the hospital on [DATE]. He said he believed the facility's policy was to offer a bed hold at time of transfer. He said, I did not offer a bed hold for the last hospitalization because we did not have any beds available to bring her back. I called the Resident #1's ardian to inform her that Resident #1 could not be re-admitted because they did not have any beds available at the facility at the time of discharge from the hospital on 2/14/26. He denied receiving any call from the resident's guardian to report that Resident #1 had pneumonia on the last hospital admission. He said he had not offered a 30-day notice. He said the case manager called regarding Resident #1's pending discharge, could not remember the date and he had informed them that he had no beds available. He said, I had a full house on February 14, 2026. The state surveyor requested copies of the census reports for February 2026 when the case worker called him, and he had informed them that he did not have any beds available at the time that Resident #1 was ready to be discharged from the hospital on 2/14/26.During an interview on 04/10/26 at 10:46 a.m., LVN E on the 6-2 shift revealed Resident #1 had unclear speech, could make needs known, required total assistance with showers, toileting, dressing, and was able to ambulate, but preferred to use a wheelchair. She went to dialysis on Monday-Wednesday-Fridays. She had some behaviors such as cussing at staff if they did not give her immediate assistance or attention, would throw things on the floor, had temper tantrums, and would hit herself on her legs. She said there was one incident where Resident #1 hit another resident and could not remember if the other resident was injured. She said Resident #1 had been sent to the hospital due to an upper respiratory infection and shortness of breath.During an interview on 4/10/26 at 11:08 a.m., LVN G on the day shift revealed Resident #1 had intellectual disabilities, was oriented to person and place, required minimum to moderate assistance with ADLS. She said the resident went to dialysis 3 x a week on Monday-Wednesday-Fridays. She said the resident had behaviors and would yell and scream at staff when she was having a temper tantrum. She said Resident #1 became very upset if the staff did not follow her daily routine and would resist care until she calmed down. She said that they had been informed that Resident #1 had an altercation with another resident and did not know if the other resident was injured. She said that she could not remember who had told her that the resident was not allowed to have a roommate and was not told why. She said the resident was sent to the hospital after she had returned from dialysis on a Friday 02/02/26. She said the resident was in respiratory distress and was transported to the hospital by EMS. She said the resident had been admitted to the hospital and did not know why she had not returned to the facility.During a telephone interview on 4/10/26 at 3:39 p.m., the PASRR Unit Supervisor said the facility did not want Resident #1 to return to the facility after she had been sent to the hospital on 2/02/26 and had been there for several days. She said the Executive Director said he did not want Resident #1 to return to the nursing facility because he got a citation because Resident #1 had hit another resident in July 2025 and was still at the facility. She said Resident #1 was sent to the hospital on 2/02/26 and was admitted for pneumonia. She said she and the resident's Guardian had placed multiple telephone calls to the facility's Executive Director and had also sent him an email and he did not answer any of the calls or respond to her email regarding Resident #1's discharge from the hospital and had been discharged from the hospital on 2/14/26 and needed to return to the nursing facility. She said that the Executive Director made it very clear that he did not want Resident #1 back at the facility. She said they had a Family Conference on 10/09/25 with the Executive Director, MDS Nurse, Care Coordinator, DON, Local Ombudsman, Resident's Guardian and a Nurse Practitioner. The Executive Director said that the facility had been converted to short-term stay facility and residents did not stay at the facility for more than 30 days. He said that Resident #1 needed to be placed in a stable LTC placement and not be at a facility that had a high turnover of short-term residents. She said the Ombudsman had asked the Executive Director if he was going to issue a 30-day notice that documented why they could not meet Resident #1's needs. She said the facility had not given the resident a 30-day discharge notice when the resident was transferred to the hospital with a diagnosis of pneumonia.During a telephone interview on 4/10/26 at 4:17 p.m., Resident #1's Guardian revealed Executive Director at the facility had not allowed her to enter the facility on Tuesday 2/17/26 when she went to the facility to pack Resident #1's belongings. She said, I was asked to stay at the front entrance of the facility, and they would bring me Resident #1's belonging. She said the facility had already packed Resident #1's belongings in cardboard boxes and they just handed her the cardboard boxes, and no one talked to her on that day. She said some of the nurses, therapy staff, and office staff were in a hurry to give her the boxes that contained Resident #1's belongings on that day, to get her out of the facility as soon as possible and no one assisted her in putting the boxes in her car. She said she noted a few missing items, and they told me that they did not know what happened to them. She said the Executive Director had been trying to discharge Resident #1 from the facility for a long time and that was why he had not allowed Resident #1 to return to the facility when the hospital called the facility on 2/14/26 to let them know that Resident #1 was ready to be discharged from the hospital. She said that the Executive Director called her to let her know that they did not have rooms available for Resident #1 to return to facility. She said the Executive Director had never offered a bed hold when Resident #1 was admitted to the hospital on [DATE]. She said Resident #1 had been at the facility for seven years and it was like her home. She said the Executive Director had arranged for a family meeting to meet with her, the Executive Director, ombudsman, the supervisor from the PASRR unit, and a Nurse Practitioner. She said the meeting was about discharging Resident #1 from the facility because they could not meet her needs and needed 1:1 supervision. She said, All they kept saying was that Resident #1 was very demanding. No one at the facility could give me a reason why Resident #1 could not return to the facility and they had never given Resident #1 a 30-day notice. She said Resident #1 had been admitted to the hospital with pneumonia on 2/02/26. She said resident's primary physician had called her on Sunday 2/15/26 to ask her why Resident #1 as still at the hospital because he had given a discharge order last night on Saturday 2/14/26. She said, I started looking for another facility on that day right after the physician had called me to let me know that he had given a discharge order on Saturday 2/14/26. She said she had informed the physician that the Social Worker at the hospital had informed her on 2/14/26 that the nursing facility did not have any beds available and needed to go to another facility. She said the physician said that he was going to call the Executive Directo to ask him why the facility had refused to allow Resident #1 to return to nursing facility. She said she started looking for another facility on Sunday 2/14/26 and Resident #1 had to stay in the hospital until she found a facility that was willing to take her on 2/17/26. She said Resident #1 was very depressed for a month, was not eating and did not want to go to dialysis because she wanted to go back to facility that had been her home for seven years and kept saying she wanted to go back home. She said that Resident #1 was slowly adjusting to being at the new facility. She said that after an incident when Resident #1 had hit an old lady at the facility, the Executive Director had started to tell her that Resident #1 could no longer be at the facility.During an interview on 4/10/26 at 4:31 p.m., the Executive Director in the presence of the DON and the Care Coordinator who is now HR Manager, revealed that the Executive Director had scheduled a Family Meeting with the Local Ombudsman, NP, MDS Nurse, PASRR Supervisor and resident's Guardian. The Executive Director said that he had made the decision to schedule this meeting to discuss and get everyone on the same page about why Resident #1 needed to be discharged from another facility. The Executive Director said Resident #1 had erratic behaviors such as throwing the middle finger at the staff when she became upset when she did not get her way, cursing and hitting the staff when care was provided, hitting herself on the legs when she became upset. He said that the facility had also been cited because Resident #1 had hit her roommate and he had made the decision that Resident #1 could not be in a room with a roommate to prevent her from hitting other residents. He said, We wanted to explain to the resident's Guardian, the Ombudsman and the PASRR Supervisor why Resident #1 was not appropriate to be at nursing facility because of the constant flow of residents that were admitted for short term rehab was not appropriate for Resident #1 and would do better in a LTC facility. He said that he had not offered a 30-day notice to the resident during the Family Meeting and the facility did not have any documentation in the resident's clinical record about what had been discussed during the Family Meeting on 10/09/25. He said they had packed the resident's belongings in cardboard boxes for the Guardian to come and pick them up since they did not have any beds available on 2/14/26 and 2/15/26 to readmit Resident #1 when she was ready to be discharged from the hospital. He said that the Guardian had voice that several personal items such as clothing and tennis shoes were missing at the time the personal belongings had been picked up by the Guardian and could not remember the date. He said We did not issue a 30-day discharge notice. He said that the facility had the right to discharge a resident if they thought the resident was a threat to themselves or others. He said, we did not give her a 30-day notice or offered a bed-hold when she was admitted to the hospital. During an interview and record review on 4/10/26 at 4:41 p.m., the Executive Director in the presence of the DON revealed they did not have any written documentation in Resident #1's electronic record regarding the room change from a private room to a semi-private room that was done in July 2025. They said that the facility did not have any documentation in the resident's clinical record that they had offered a bed-hold when Resident #1 was admitted to the hospital on [DATE]. He said the facility did not have any documentation when the resident's Guardian had come to pick up her personal belongings and/or signed the personal inventory form when the resident was discharged from the hospital and could not be re-admitted because the facility did not have any beds available. He said they had not completed a Grievance/Concern form when the resident's Guardian reported the resident was missing tennis shoes and clothing. He said he could not remember when this had been reported and to whom it was reported.During an interview on 4/10/26 at 4:53 p.m., former Care Coordinator J revealed that now he was Human Resources. He said that he assisted with admissions and discharges and would make referrals to the Social Worker. He said, I remember that we had a family meeting on 10/9/25 with Executive Director, DON, MDS Nurse, Ombudsman, PASRR Unit supervisor and the resident's Guardian. I do not remember what was discussed at the meeting. All we wanted was a good place for Resident #1 because the level of care provided at this facility was not appropriate for Resident #1 and would do better in a facility that did not have a high number of discharges and could become familiar of other residents in a LTC facility. She said Resident #1 would become easily frustrated if she did not get her way or if other residents were assisted before her, then she would start cussing, and calling the staff whores and would start throwing things on the floor. He said that he never saw Resident #1 verbally or physically abuse any of the residents. He said, I only witnessed when she mistreated the staff, by cussing, swearing, and calling them whores when she was having a temper tantrum.During an interview and record review on 4/10/26 at 5:00 p.m., LVN MDS Nurse O revealed she had attended the family meeting on 10/09/26 to inform Resident #1's guardian why Resident #1 needed to be discharged to another facility that provided LTC services. She said, That is all that I can remember. We did not document in the resident's electronic record any notes about the meeting that was held on 10/09/25.During an interview on 4/11/26 at 9:42 a.m., LVN L revealed he was assigned to Resident #1. He said Resident #1 had intellectual disabilities, had temper tantrums, would herself on her legs when she became upset, was able to ambulate, but preferred to use a wheelchair, throw things on the floor when she became upset, and yelled at the staff at times when care was provided. He said he never saw Resident #1 hit other residents or the staff. He said he had heard about an incident where she had hit one of the residents. He said Resident #1 had been sent to the hospital on 2/02/26 for shortness of breath, low oxygen saturation and labored breathing. He said that Resident #1 did not like to go to the hospital. He said Resident #1 had not returned after she was sent to the hospital and her belongings had been picked up by her Guardian during the weekend. He said that the resident's Guardian always complained that Resident #1 was missing clothes and shoes.During an interview on 4/11/26 at 10:17 a.m., CNA M revealed Resident #1 had been at the facility since 2020, was stubborn and only wanted things done her way. She said, She always wanted to be first, and if not, she would have a temper tantrum. She said that when she had a tantrum, she would cuss at the staff and hit herself on the legs, pulled her hair, and yelled. She said the resident was always in a private room, was moved to a semi-private room and had gotten a roommate prior to discharge. She said the roommate was a very quiet lady, and calm. She said that the DON had interviewed her regarding an injury that the roommate had on her face. The incident happened on a Sunday, and the resident did not have any apparent injuries. She said Resident #1 would walk but preferred to use a wheelchair. She said the resident waited for the morning staff by the door so they could give her a shower as soon they reported to work, and if not, she would get mad and would not shower.Review of the facility's Bed-Holds and Returns policy revised on October 2022 provided by the Executive Director revealed: Policy Statement: Residents and/or representatives are informed in writing of the facility and state bed-hold policies. Policy Interpretation and Implementation: All residents/Representatives are provided with written information regarding the facility and state bed-hold policies, which address holding or reserving a residence bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payment source, are provided with written notice about these policies at least twice: Notice 1: well in advance of any transfer; and notice 2: at the time of transfer (or if the transfer was an emergency, within 24 hours). Reissuance of notice 1: must occur if either the bed hold policy under the state plan or facility policy changes after the notice is issued. Multiple attempts to provide the resident representative with notice 2: should be documented in cases where staff were unable to reach and notify the representative timely. The written bed-hold, notices provided to the resident/representative explain in detail: The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the facility; the reserve bed payment policy is indicated by the state plan (for Medicaid residents); the policy regarding bed hold periods; the facility per diem required to hold the bed (for non-Medicaid residents), or to hold a bed beyond the state bed-hold policy (for Medicaid residents), or to hold a bed beyond the state bed-hold period (for Medicaid resident); and the facility return policy. The requirement that residents be permitted to return to the facility following hospitalization or therapeutic leave applies to all residents regardless of Payer source. Residents who seek to return to the facility within the bed-hold period defined in the state plan or allowed to return to their previous room, if available. If the facility determines that a resident cannot return, the facility must comply with the requirements for facility-initiated discharges. Residents are not discharged unless: The discharge or transfer is necessary for the resident's welfare and the facility cannot meet the resident's needs.; The residents have has improved sufficiently, so that the resident no longer needs the services of the facility; The resident's clinical or behavioral status endangers the safety of individuals in the facility; The resident's clinical or behavioral status endangers the health of individuals in the facility; and/or; the resident has failed, after reasonable and appropriate notice, to pay for his or her stay at the facility. Following a hospitalization, residents whom staff are concerned about permitting to return due to their clinical/behavioral condition at the time of transfer are evaluated based on their current condition, not their condition when originally transferred. Medicaid residents who have outstanding Medicaid balances are still permitted to return to the first available Bed.

Based on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were accurately documented for 2 (Resident #1 and Resident #2) of 6 residents reviewed for medical records. -The facility failed to document in Resident #1's electronic clinical record when the Executive Director had the staff moved to another room.-The facility failed to document in Resident #1's electronic clinical record when the Executive Director held a family meeting on 10/09/25 to discuss the need to transfer resident to another facility.-The facility failed to document in Resident #1's electronic clinical record when the hospital staff was informed by the Executive Director on 2/14/26 that Resident #1 would not be re-admitted to the facility, when she was ready to be discharged from the hospital.The facility failed to document in Resident#1's electronic clinical record when the Guardian for Resident #1 went to the facility on 2/17/26 to pick up the resident's belongings.-The facility failed to document in Resident #2's electronic clinical record when they received a telephone from the dialysis center to report that the resident had reported that his cell phone was lost at the nursing facility.This failure could place residents at risk of resident's records not reflecting accurate and complete information. Findings include:Closed record review of the Face Sheet dated 04/10/26 for Resident #1 revealed an original admission date of 5/20/19 and re-admission date 12/08/2023. Diagnoses: Unspecified Dementia, Mild Intellectual Disabilities, Major Depression, End Stage Renal Disease. Resident #1 had a change in condition and was discharged to the hospital on 2/02/26.Review of History & Physical dated 6/20/19 provided by DON revealed Resident #1 had a Past Medical History: Chronic mental deficiencies, end stage renal disease on dialysis.Review of the Annual MDS for Resident #1 dated 12/07/25 revealed: Level; II PASRR Conditions: Intellectual Disability. Reentry Date: 12/08/2023. admission Date: 05/20/19. Makes self usually understood. Usually understand others. Impaired vision. BIMS Summary Score: 4 (cognition severely impaired). Interview for Daily Preferences: Very Important to choose clothes to wear, bedtime, shower and have family or close friends involved in discussions about her care. Moderate assistance with toileting, oral hygiene, dressing, personal hygiene; substantial/maximum assistance with shower. Partial/moderate assistance sit to stand and chair/bed transfer. Mobility Device: Wheelchair. Active Diagnoses: ESRD, Non-Alzheimer's Dementia, Anxiety, Depression, Mild intellectual disabilities. High-Risk Drug Classes: Antipsychotic; dialysis. Discharge Plan: No. Return to Community: No.Review of Psychiatric Follow-Up Evaluation dated 12/07/25 for Resident #1 revealed, Alert and oriented to person, cooperative, slow speech. Mood: Euthymic (tranquil, and normal mood), poor insight. Psychiatric Diagnosis: Unspecified Dementia without behavioral disturbances, Major depressive disorder, recurrent, moderate. Anxiety unspecified. Continue Risperidone 0.5 mg BID for dementia and aggressive behavior.Review of Nursing Note dated 2/02/26 at 8:00 p.m., for Resident #1 written by LVN L revealed, Patient sent to hospital for SOB and decreased oxygen level.Record review of Resident #1's electronic record revealed there was no documentation of written notification to the resident's RP or the LTC Ombudsman of the resident's discharge from the facility. The facility did not have any documentation in the resident's clinical record when resident was moved from the private room to a semi-private room.During an interview on 4/10/26 at 9:20 a.m., the Executive Director revealed, Resident #1 had been long term placement at facility for many years. He said the resident had been discharged to the hospital, could not remember the dates and the resident had been in ICU for 10-16 days and was not re-admitted on [DATE] because the facility was full and there were no beds available when she was ready to be discharged from the hospital. He said that he had made the decision that Resident #1 could not be placed in a semi-private room with another resident, after an incident in July 2025 when Resident #1 had hit her roommate. He said that there was only one bed available in a semi-private room and there was a resident in one of the beds, so that was why Resident #1 could not be re-admitted back to the facility at the time that she was discharged from the hospital on 2/14/26 because she could not have a roommate to prevent recurrence of her hitting other residents and that was why the facility had been cited by another surveyor. He said that he had not documented in the resident's electronic record when he had informed the hospital that Resident #1 could not return to the facility due to not having a bed available at the time of the discharge from the hospital.During an interview on 4/10/26 at 11:08 a.m., LVN G on the day shift revealed Resident #1 had intellectual disabilities, was oriented to person and place, required minimum to moderate assistance with ADLS. She said the resident went to dialysis 3 x a week on Monday-Wednesday-Fridays. She said the resident had behaviors and would yell and scream at staff when she was having a temper tantrum. She said Resident #1 became very upset if the staff did not follow her daily routine and would resist care until she calmed down. She said that they had been informed that Resident #1 had an altercation with another resident and did not know if the other resident was injured. She said that she could not remember who had told her that the resident was not allowed to have a roommate and was not told why. She said the resident was sent to the hospital after she had returned from dialysis on a Friday 02/02/26. She said the resident was in respiratory distress and was transported to the hospital by EMS. She said the resident had been admitted to the hospital and did not know why she had not returned to the facility.During a telephone interview on 4/10/26 at 3:39 p.m., the PASRR Unit Supervisor said the facility did not want Resident #1 to return to the facility after she had been sent to the hospital on 2/02/26 and had been there for several days. She said the Executive Director had said that he did not want Resident #1 to return to the nursing facility because he got a citation because Resident #1 had hit another resident in July 2025 and was still at the facility. She said Resident #1 was sent to the hospital on 2/02/26 and was admitted for pneumonia. She said she and the resident's Guardian had placed multiple telephone calls to facility's Executive Director and had also sent him an email and he did not answer any of the calls or respond to her email regarding Resident #1's discharge from the hospital and had been discharged from the hospital on 2/14/26 and needed to return to the nursing facility. She said that the Executive Director had made it very clear that he did not want Resident #1 back at the facility. She said they had a Family Conference on 10/09/25 with the Executive Director, MDS Nurse, Care Coordinator, DON, Local Ombudsman, Resident's Guardian and a Nurse Practitioner. The Executive Director said that the facility had been converted to short-term stay facility and residents did not stay at the facility for more than 30 days. He said that Resident #1 needed to be placed in a stable LTC placement and not be at a facility that had a high turnover of short-term residents. She said the Ombudsman had asked the Executive Director if he was going to issue a 30-day notice that documented why they could not meet Resident #1's needs. She said the facility had not given the resident a 30-day discharge notice when the resident was transferred to the hospital with a diagnosis of pneumonia.During a telephone interview on 4/10/26 at 4:17 p.m., Resident #1's Guardian revealed the Executive Director at the facility had not allowed her to enter the facility on Tuesday 2/17/26 when she went to the facility to pack Resident #1's belongings. She said, I was asked to stay at the front entrance of the facility, and they would bring me Resident #1's belonging. She said the facility had already packed Resident #1's belongings in cardboard boxes and they just handed her the cardboard boxes, and no one talked to her on that day. She said some of the nurses, therapy staff, and office staff were in a hurry to give her the boxes that contained Resident #1's belongings on that day, to get her out of the facility as soon as possible and no one had assisted her in putting the boxes in her car. She said she had noted a few missing items, and they told me that they did not know what had happened to them. She said the Executive Director had been trying to discharge Resident #1 from the facility for a long time and that was why he had not allowed Resident #1 to return to the facility when the hospital called the facility on 2/14/26 to let them know that Resident #1 was ready to be discharged from the hospital. She said that the Executive Director had called her to let me know that they did not have rooms available for Resident #1 to return to facility. She said the Executive Director had never offered a bed hold when Resident #1 was admitted to the hospital on [DATE]. She said Resident #1 had been at the facility for seven years and it was like her home. She said the Executive Director had arranged for a family meeting to meet with her, the Executive Director, ombudsman, the supervisor from the PASRR, and a Nurse Practitioner. She said the meeting was about discharging Resident #1 from the facility because they could not meet her needs and needed 1:1 supervision. She said, All they kept saying was that Resident #1 was very demanding. No one at the facility could give me a reason why Resident #1 could not return to the facility and they had never given Resident #1 a 30-day notice. She said Resident #1 had been admitted to the hospital with pneumonia on 2/02/26. She said resident's primary physician had called her on Sunday 2/15/26 to ask her why Resident #1 was still at the hospital because he had given a discharge order last night on Saturday 2/14/26. She said, I started looking for another facility on that day right after the physician had called me to let me know that he had given a discharge order on Saturday 2/14/26. She said she had informed the physician that the Social Worker at the hospital had informed her on 2/14/26 that the nursing facility did not have any beds available and needed to go to another facility. She said the physician said that he was going to call the Executive Director to ask him why the facility had refused to allow Resident #1 to return to nursing facility. She said she started looking for another facility on Sunday 2/14/26 and Resident #1 had to stay in the hospital until she found a facility that was willing to take her on 2/17/26. She said Resident #1 was very depressed for a month, was not eating and did not want to go to dialysis because she wanted to go back to facility that had been her home for seven years and kept saying she wanted to go back home. She said that Resident #1 was slowly adjusting to being at the new facility. She said that after an incident when Resident #1 had hit an old lady at the facility, the Executive Director had started to tell her that Resident #1 could no longer be at the facility.During an interview on 4/10/26 at 4:31 p.m., the Executive Director in the presence of the DON and the Care Coordinator who is now HR Manager, revealed that the Executive Director had scheduled a Family Meeting with the Local Ombudsman, NP, MDS Nurse, PASRR Supervisor and resident's Guardian. The Executive Director said that he had made the decision to schedule this meeting to discuss and get everyone on the same page about why Resident #1 needed to be discharged to another facility. The Executive Director said Resident #1 had erratic behaviors such as throwing the middle finger at the staff when she became upset when she did not get her way, cursing and hitting the staff when care was provided, hitting herself on the legs when she became upset. He said that the facility had also been cited because Resident #1 had hit her roommate and he had made the decision that Resident #1 could not be in a room with a roommate to prevent her from hitting other residents. He said, We wanted to explain the resident's Guardian who was the resident's sister, the Ombudsman and the PASRR Supervisor and the [NAME] why nurse was not appropriate to be at nursing facility because of the constant flow of residents that were admitted for short term rehab was not appropriate for Resident #1 and would do better in a LTC facility. He said that he had not offered a 30-day notice to the resident during the Family Meeting and the facility did not have any documentation in the resident's clinical record about what had been discussed during the Family Meeting on 10/09/25. He said they had packed the resident's belongings in cardboard boxes for the Guardian to come and pick them up since they did not have any beds available on 2/14/26 and 2/15/26 to readmit Resident #1 when she was ready to be discharged from the hospital. He said that the Guardian had voice that several personal items such as clothing and tennis shoes were missing at the time the personal belongings had been picked up by the Guardian and could not remember the date. He said We did not issue a 30-day discharge notice. He said that the facility had the right to discharge a resident if they thought the resident was a threat to themselves or others. He said, we did not give her a 30-day notice or offered a bed-hold when she was admitted to the hospital. During an interview and record review on 4/10/26 at 4:41 p.m. with Executive Director in the presence of the DON, revealed they did not have any written documentation in Resident #1's electronic regarding the room change from a private room to a semi-private room that was done in July 2025. They said that the facility did not have any documentation in the resident's clinical record that they had offered a bed-hold when Resident #1 was admitted to the hospital on [DATE]. He said the facility did not have any documentation when the resident's Guardian had come to pick up her personal belongings and/or signed the personal inventory form when the resident was discharged from the hospital and could not be re-admitted because the facility did not have any beds available. He said they had not completed a Grievance/Concern form when the resident's Guardian had reported the resident was missing tennis shoes and clothing. He said he could not remember when this had been reported and to whom it was reported.During an interview and record review on 4/10/26 at 5:00 p.m., LVN MDS Nurse O revealed she had attended the family meeting on 10/09/26 to inform the Resident #1s' guardian why Resident #1 needed to be discharged to another facility that provided LTC services. She said, That is all that I can remember. We did not document in the resident's electronic record any notes about the meeting that was held on 10/09/25.During an interview on 4/11/26 at 9:42 a.m. with LVN L revealed, he was assigned to Resident #1. He said Resident #1 had been sent to the hospital on 2/02/26 for shortness of breath, low oxygen saturation and labored breathing. He said Resident #1 had not returned after she was sent to the hospital and her belongings had been picked up by her sister who was her Guardian during the weekend.Resident #2Closed record review of the Face Sheet dated 04/10/26 for Resident #2 revealed an original admission date of 9/27/25. Resident discharged home on [DATE].Review of History & Physical dated 10/03/25 revealed Resident #2 was a [AGE] year-old-male with a past medical history of end stage renal disease on dialysis, diabetes Type 2, and Hypertension. Alert, oriented. admitted for rehabilitation and occupational therapy.Review of admission MDS dated [DATE] for Resident #2 revealed, Entry date 09/27/2025. BIMS Summary Score: 10 (moderately cognitive impaired).Review of Inventory dated 09/27/25 signed by Resident #2 documented Did not want inventory. Items not labeled.Review of IDT notes dated 09/06/25 through 10/07/25 did not document Resident #2 had lost his cell phone.During a telephone interview 4/10/26 at 9:05 a.m., the Administrator said that he was not aware of missing cell phones and could not remember if Executive Director had reported this to him. He said when families or residents report missing personal items CNA Manager C immediately followed up on these concerns and usually most of the missing items were found.During an interview on 04/10/26 at 9:17 a.m., CNA Manager C revealed she assisted with trying to locate missing resident clothing and personal items and that 95% of the time the missing items were found. She said that usually reports of missing clothing and personal items such as phones are made to Executive Director by the families and/or staff, of missing items. She said she was not aware of the missing cell phone.During an interview on 04/10/26 at 9:45 a.m., the DON and LVN ADON D revealed that they did not remember anything about Resident #2 missing a cell phone. During an interview on 04/10/26 at 9:49 a.m., Receptionist B in the presence of the DON revealed that she had received a telephone call from someone at the dialysis center to report that Resident #2 had reported to them that he was missing his cell phone. Receptionist B said, I wrote it down on a sticky note and gave it to the nurse and did not remember who the nurse was and asked the nurse to give the note to CNA Manager C. She said she was not aware of the facility's policy and procedure on Grievances and was not aware that she needed to fill out a concern form when she received complaints/concerns related to missing items. She said that she did not know if they had found the resident's cell phone. She said that the resident's family had come to pick up the resident's belongings.During second interview on 04/10/26 at 9:58 a.m., the DON revealed she remembered she had received a call from the dialysis center and did not remember who she had talked to about Resident #2's concern related to his missing cell phone. She said she had not documented this in the resident's electronic clinical record.During an interview on 4/10/26 at 11:50 a.m., LVN I revealed Resident #2 was confused, lived [Country] and had been discharged home to his family member A home who lived in {Country]. She said that Resident #2 used to live with a family member B in [city] and that family member A could not come and visit due to not having a passport to come to the United States. She said that she remembered that the resident had lost his old cell phone on the weekend and was never found. She said that the resident had poor vision and the staff would help him to dial the telephone numbers so he could call family member C and family member A. She said it was an old basic cell phone, and he was able to only use [App] to face time with his family member A all the time. She said resident was sad that he had lost his cell phone because he could no longer communicate with his family. She said she had not documented this in the resident's clinical record.Review of the facility's policy on Charting and Documentation revised in July 2017 provided by the Executive Director revealed, Policy Statement: All services provided to the resident, progress towards the care plan goals or any changes in resident's medical, physical function or psychological condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the residence condition and response to care. Policy Interpretation and Implementation: Documentation in the medical record may be electronic, manual, or a combination. The following information is to be documented in the resident medical records. Events, incidents or accidents involving the resident.

Based on observation, interviews and record review, the facility failed to ensure efforts were made to resolve resident grievances, for 1 (Resident #2) of 6 residents reviewed for grievance resolution. The facility failed to follow their policy and procedure on Grievance/Complaints when Resident #2 lost his cell phone.This failure could place residents at risk of feeling that their voices were not being heard or taken seriously and could cause feelings of worthlessness. Findings included:Closed record review of the Face Sheet dated 04/10/26 for Resident #2 revealed an original admission date of 9/27/25. Resident discharged home on [DATE].Review of History & Physical dated 10/03/25 revealed Resident #2 was a [AGE] year-old-male with a past medical history of end stage renal disease on dialysis, diabetes Type 2, and Hypertension. Alert, oriented. admitted for rehabilitation and occupational therapy.Review of admission MDS dated [DATE] for Resident #2 revealed, Entry date 09/27/2025. BIMS Summary Score: 10 (moderately cognitive impaired).Review of Inventory dated 09/27/25 signed by Resident #2 documented Did not want inventory. Items not labeled.Review of IDT notes dated 09/06/25 through 10/07/25 did not document Resident #2 had lost his cell phone.During a telephone interview on 4/10/26 at 9:05 a.m., the Administrator said he was not aware of missing cell phones and could not remember if the Executive Director had reported this to him. He said when families or residents report missing personal items CNA Manager C immediately followed up on these concerns and usually most of the missing items were found.During an interview on 04/10/26 at 9:17 a.m., CNA Manager C revealed she assisted with trying to locate missing resident clothing and personal items and that 95% of the time the missing items were found. She said that usually reports of missing clothing and personal items such as phones are made to Executive Director by the families and/or staff, of missing items. She said she was not aware of the missing cell phone.During an interview on 04/10/26 at 9:45 a.m., the DON and LVN ADON D revealed that they did not remember anything about Resident #2 missing a cell phone. During an interview on 04/10/26 at 9:49 a.m., Receptionist B in the presence of the DON revealed that she had received a telephone call from someone at the dialysis center to report that Resident #3 had reported to them that he was missing his cell phone. She stated I wrote it down on a sticky note and gave it to the nurse and did not remember who the nurse was and asked the nurse to give the note to CNA Manager C. She said she was not aware of the facility's policy and procedure on Grievances and was not aware that she needed to fill out a concern form when she received complaints/concerns related to missing items. She said that she did not know if they had found the resident's cell phone. She said that the resident's family had come to pick up the resident's belongings.During an interview on 04/10/26 at 9:58 a.m., the DON revealed she remembered she had received a call from the dialysis center and did not remember who she had talked to about Resident #2's concern related to his missing cell phone. She said she had not written a Grievance/Concern form. She said they should have completed a Grievance/Concern according to the facility's Grievance policy and procedure to have documentation that grievances/concerns were addressed and resolved.During an interview on 04/10/26 at 10:01 a.m., CNA Manager C revealed Receptionist B had notified her of Resident #2's missing his cell phone. She said she had alerted the laundry staff to see if it had been sent to the laundry with the linen. She said Receptionist C had not given her a Grievance/Concern form when she reported to her that the resident's cell phone was missing. She said that she did not know if the resident's cell phone was found. She said that she was not aware of the facility's Grievance policy.During an interview on 4/10/26 at 11:18 a.m., LVN H revealed he was assigned to Resident #2 on the day shift. He said Resident #2 was in the 200 Hall, was alert and oriented to person and place, required total assistance with ADLs and went to dialysis three times a week. He said that he remembered that the resident had a cell phone. He said that he could not remember if the resident had lost his cell phone. He said, I remember that Resident #2 called his daughter all of the time.During an interview on 4/10/26 at 11:50 a.m., LVN I revealed Resident #2 was confused, and had been discharged home with a family member. She said that she remembered that the resident had lost his old cell phone on the weekend and was never found. She said that the resident had poor vision and the staff would help him to dial the telephone numbers so he could call his daughter and wife. She said it was an old basic cell phone, and he was able to only use What's Up App to face time with his wife all the time. She said resident was sad that he had lost his cell phone because he could no longer communicate with his family.During an interview on 4/11/26 at 10:41 a.m., the Executive Director revealed the Social Worker was designated as the Grievance Officer and was responsible for following up on Grievances/Concerns. He said that he did not know that Resident #2 had lost his cell phone while he was at the facility.The state surveyor was unable to contact Resident #2 or his family during the investigation process due to family only having contact numbers in [another country].Review of facility's Grievances/Complaints, filing revised 2017 provided by Executive Director, revealed Policy Statement: Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or the agency designated to hear grievances (e.g. the state Ombudsman). The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the residents and/or representatives. Policy Interpretation and Implementation: Any resident, family member or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished. Residents, families and resident representatives have the right to voice or file grievances without discrimination or reprisal in any form and without fear of discrimination or reprisal. Grievances and or complaints may be submitted orally or in writing and may be filed anonymously. The Administrator has delegated the responsibility of grievance and or complete investigations to the grievance officer who is. (was left blank) and can be contacted by (was left blank). Upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within 5 working days of receiving the grievance and/or complaint. The Grievance Officer will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations. All alleged violations of neglect, abuse and/or misappropriation of property will be reported and investigated under guidelines for reporting abuse, neglect and misappropriation of property as per state law. The administrator will review the findings with grievance officer to determine what corrective actions if any need to be taken. The resident or person filing the grievance and or complaint on behalf of the resident will be informed verbally and in writing of the findings of the investigation and the actions that were taken to correct any identified problems. The administrator or his or her designee will make such reports orally within (was left blank) working days of the filing of the grievance or complaint with the facility. A written summary of the investigation will also be provided to the resident, and a copy will be filed in the business office. The results of all grievances files are investigated and reported will be maintained on file for a minimum of three years from the issuance of the grievance decision.

Based on interview and record review, the facility failed to provide the mandatory training on standards, policies, and procedures for an infection prevention and control program for 2 of 8 staff (the MDS Nurse and the Administrator) reviewed for training, in that:The facility failed to ensure infection prevention and control training was provided to the MDS Nurse and the Administrator.This failure could place residents at risk of illness due to lack of staff training. The findings were:Review of Facility Staff Roster, undated, revealed: Administrator - date of hire - 03/07/2016MDS Nurse - date of hire- 11/10/2021In an interview on 08/22/25 at 02:02 PM with Human Resources, she stated she did not have documentation for the Annual Infection Control training for the Administrator and the MDS Nurse. She stated she had only been working for a few months and did not have a reason why the facility did not have documentation for this course. She stated, in this case, she would issue the Administrator and the MDS Nurse retraining, meaning the staff would complete the required training. She stated Human Resources and the DON were responsible for ensuring staff were up to date with training. She stated she and the DON met monthly to discuss issues or concerns including training. She stated the staff not completing training for Infection Control could potentially place residents and others at risk for illness or infection.In an interview on 08/22/25 at 2:18 PM with the MDS Nurse, she stated all staff were responsible for keeping their training up to date. She stated she did not have a reason why there was no documentation of her Infection Control training. She stated the DON was responsible for monitoring staff for infection control training but was unsure how often it was being followed up. She stated risks of staff not completing their Infection Control training places residents at risk for exposure to bacteria or illness.In an interview on 08/22/25 at 02:30 PM with the Administrator, he stated he was sure to have completed his Infection Control training, but unable to state the most recent one he had completed. He stated the risks of staff not completing their annual required training would have included facility personnel not being in the most up to date with information, but all staff have their basic training including infection control. He was asked by this surveyor if CMS required annual documented trainings, he replied, yes. The Administrator added that staff had their basic training from school or when starting in the nursing facility. He stated the DON was responsible for Infection Control training, since she was also the Infection Preventionist. He stated the administration department, and Human Resources were also responsible for monitoring staff training. In an interview on 08/22/25 at 02:36 PM with the DON, she stated she was responsible for ensuring staff were up to date with their training. She stated she monitored her staff, including their training, on a daily basis. She stated all staff were to be updated on their training. She stated staff not having updated training included residents being at risk for infections.Record review of the facility's policy titled, In-Service Training, All Staff, read in part: Policy Statement- All Staff must participate in initial orientation and annual in-service training. Policy Interpretation and Implementation- 1. All staff are required to participate in regular in-service education. In-service education participation is considered working time for which staff are paid their regular wages. 2. For the purposes of this policy, staff means all new and existing personnel, individuals providing services under contractual agreement, and volunteers. 3. The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the resident's quality of life and quality of care and can demonstrate competency in the topic areas of the training . 6. Required training topics include the following: . e. The infection prevention and control program standards, policies and procedures.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for three residents, (Residents #6, #33, and #44), of six residents reviewed for care plans.The facility failed to have a comprehensive person-centered care plan for Resident #6, #33 and #44 to address residents prescribed insulin medication.These failures could affect residents prescribed insulin medication by placing them at risk for not receiving care and services to meet their needs.Findings Include:Resident# 6Record review of Resident #6's admission Record dated 08/19/2025 revealed an admission date of 07/21/2025.Record review of Resident #6's Health and Physical not dated, revealed to Continue insulin regimen and PO (oral) diabetic medication.Record review of Resident #6's 5-day MDS assessment revealed a BIMS score of 11 indicating moderate cognitive impairment.Record Review of Resident #6's care plan revealed no information regarding insulin medication.Record review of Resident #6's Administration Record revealed Insulin Glargine Subcutaneous solution 100 unit/ml inject 30 unit subcutaneously in the morning for diabetes mellitus. Insulin Lispro injection solution 100 unit/ml, inject as per sliding scale subcutaneously before meals and at bedtime for diabetes mellitus.Resident# 33Record review of Resident #33's admission Record dated 08/22/2025 revealed that Resident #33 was admitted on [DATE]Record review of Resident #33's health and physical dated 08/01/2025 revealed a diagnosis of Diabetes Mellitus Type II. Plan explained Resident would be placed on sliding scale for management of hyperglycemia.Record review of Resident #'s 5-day MDS revealed a BIMS score of 13 indicating an intact cognitive function.Record Review of Residents #33's care plan revealed no information regarding insulin medication. Record review of Resident #33's Order Summary Report revealed Lantus SoloStar Subcutaneous Solution Pen injector 100 unit/ml inject 15 unit subcutaneously two times a day for diabetes mellitus. Insulin Lispro Subcutaneous Solution Cartridge 100 unit/ml inject 8 unit subcutaneously before meals for diabetes mellitus. Novolog pen fill subcutaneous solution cartridge 100 unit/ml inject 8 unit subcutaneously before meals for diabetes mellitus before meals for diabetes mellitus.Resident# 44Record review of Resident #44's admission Record dated 08/20/2025 revealed Resident #44 was admitted on [DATE]Record review of Resident #44's health and physical dated on 07/30/2025 revealed a diagnosis of diabetes with hyperglycemia (high blood sugar).Record review of Resident #44's 5-day MDS revealed a BIMS score of 15 indicating an intact cognitive function.Record Review of Resident #44's care plan revealed no information regarding insulin medication. Record review of Resident #44's Medication Administration Record revealed insulin Glargine subcutaneous solution 100 unit/ml inject 15 unit subcutaneous in the morning for diabetes mellitus type II.In an interview on 08/22/25 at 11:33 AM with LVN C, she stated the purpose of a care plan was for all staff to be aware of the residents' care and treatment plan. She stated the MDS nursing staff were responsible for ensuring care plans were updated. She stated nurses notified the MDS nurses of any changes of residents so the care plan could be updated. LVN C stated she was not aware how often they monitored care plans for accuracy. She stated the risk of care plans not being completed correctly included incorrect treatment of the resident. In an interview on 08/22/2025 at 12:16 PM with DON, she stated that the purpose of a care plan was to make sure that the residents were receiving the correct individualized treatment. She stated that the MDS nurses were responsible for creating and updating the Care Plan's. She stated that the floor nurses, DON and ADON were all in communication with the MDS nurses to notify of any updates needed on the care plan. She stated that insulin and diabetes diagnosis needed to be included in the care plan. The DON stated that residents were at risk of not receiving the right treatment if treatment was not in care plan.In an interview on 08/22/2025 at 1:30 PM with MDS nurse, she stated that the purpose of a care plan was like a blueprint for resident care. She stated that the MDS nurses were responsible for keeping up with the changes that had to be made. She stated that insulin and diagnosis of diabetes had to be included in the care plan. She stated that floor nurses, DON and ADON communicate with MDS nurses to fill them in on any changes that residents have. She stated that when pertinent medications and diagnosis had not been care planned it could lead to an interruption in communication of care.Record Review of the facility's policy titled Care Plans, Comprehensive Person- Centered revised March 2022 read in part . The comprehensive, person-centered care plan includes measurable objectives and timeframes, Describes the services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental and psychosocial well-being .

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed in that:-The facility failed, on 8/19/25, to maintain the bottom of freezer # 1 clean and free of food crumbs and ice cream drippings. -The facility failed, on 8/19/25, to maintain the bottom of refrigerator # 2 clean and free of dry meat juices. -The facility failed, on 8/19/25, to seal a bag of lettuce and to close a box containing an open stick of butter in refrigerator # 3.These failures could place residents who eat foods prepared in the kitchen at risk of cross contamination and food-borne illnesses.Findings included: In an observation on 8/19/25 at 8:45 AM during the initial kitchen tour in the facility's kitchen, revealed the following: Freezer # 1 - at the bottom of the freezer, there were dried drippings of what appeared to be lemon ice cream and around it, there were crumbs of unknown food residues.Refrigerator #2 - at the bottom of the refrigerator, there were dried drippings of meat juices that were dark red and pink in color.Refrigerator #3 - there was a bag with two heads of lettuce that were not sealed. The lettuce looked yellow in color. An open box containing 11 bars of 1/4 lb. sticks of butter had an open stick of butter that was not sealed or covered.An interview on 8/19/25 at 8:54 AM with the Dietary Director revealed it was not acceptable for refrigerators to have food residues or dry drippings from food or meat juices. The Dietary Director stated that all food inside the refrigerators needed to be labeled, sealed, and closed. She explained that by having food drippings and open boxes and unsealed packages, there was a risk of cross contamination which could result in food borne illness which could make the resident sick to their stomach resulting in infection, vomiting or diarrhea. She stated that the expectation was that all equipment in the kitchen was cleaned and sanitized, all boxes and packaging were closed and sealed to prevent contamination, and that all staff from the kitchen were responsible for making sure these standards were met. An interview on 8/20/25 at 10:23 AM with the Head [NAME] revealed that all staff were responsible for making sure that all cooking utensils and kitchen equipment were clean and sanitized during and after meal preparation and at the end of each kitchen staff member's shift. He stated it was not acceptable that freezers of refrigerators were dirty with crumbs or food drippings and that all food inside the refrigerator and freezers needed to be labeled, sealed and closed. The Head [NAME] stated that by not covering or sealing the food and having food drippings, there was a risk for cross contamination which could make the residents sick to their stomach which could result in them getting sick from foodborne diseases. He stated there was a potential risk of residents getting sick with diarrhea or gastrointestinal (an adjective that refers to or involves the stomach and intestines) infections. In an interview on 8/21/25 at 11:05 AM with a Dietary Cook, she stated that all kitchen staff were responsible for ensuring the kitchen equipment and utensils were clean and free of food residues. She said that dry drippings of meat juice or crumbs left in the refrigerators could result in cross contamination for the residents' meals if they were not properly closed or sealed, which could make them sick to their stomach, and it could make their current health issues get worse. An interview on 8/21/25 at 11:13 AM with the DON revealed that she was the infection preventionist for the facility. She stated that it was not correct to leave things opened and unsealed food in the refrigerators or the freezers, she stated that the expectation was for the kitchen staff to clean kitchen freezers, fridges and utensils by the end of their shift. The DON stated that having crumbs, dry drippings, and opened bags could result in cross contamination for the food items. The DON said there was a risk of infections for gastrointestinal bacteria or intoxications which could result in residents getting sick from vomiting or diarrhea.In an interview on 8/22/25 at 10:21 AM with the Administrator, he stated the food inside the refrigerators should always be covered or sealed and there was a risk of cross contamination or foodborne illness which could potentially make the residents sick with stomach infections which could result in vomiting or diarrhea and possible dehydration. He said that all kitchen equipment and utensils should be free of food residues and drippings because it could potentially lead to cross contamination which could also make the residents sick. Review of the FDA Food Code 2022 reflected Chapter 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by: (4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the food in packages, covered containers, or wrappings;. Record Review of the facility's policies and procedures revised in November 2022, titled Dietary Services-Food and Nutrition Services, stated in part: Food Receiving and Storage, Food services, or other designated staff, maintain clean and temperature/humidity-appropriate food storage areas at all times. Refrigerated/Frozen Storage: All foods stored in the refrigerator or freezer are covered, labeled and dated ( use by date). Uncooked and raw animal products and fish are stored separately in drip-proof containers and below fruits, vegetables and other ready-to-eat foods to prevent meat juices from dripping onto these foods. Other opened containers are dated and sealed or covered during storage. Record Review of the facility's policies and procedures revised in July 2014, titled Preventing Foodborne Illness - Food Handling, stated in part: Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. This facility recognizes that the critical factors implicated in foodborne illness are: contaminated equipment. All food service equipment and utensils will be sanitized according to current guidelines and manufacturers' recommendations.

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 1 of 6 (Resident #9) residents reviewed for infection control. CNA A failed, on 8/19/25, to properly serve a meal tray to Resident #9 by touching her cheeseburger with her bare hands. This deficient practice could place residents at risk for infection due to improper care practices.Findings included:During observation on 8/19/25 at 12:10 PM in the dining room, CNA A approached Resident #9 who was sitting at the table and had her lunch in front of her. CNA A took a quarter cut of (his/her) cheeseburger with her bare hands and handed it to the resident. Resident # 9 took the piece of cheeseburger with her hands and proceeded to eat it. CNA A was not wearing gloves and failed to provide the resident with her meal utilizing utensils.In an interview on 8/19/25 at 12:20 PM with the Director of Dietary, she stated that it was not acceptable to touch a resident's meal at any time after their meal left the kitchen. The Director of Dietary stated that if a Resident needed assistance, staff needed to wear gloves and use utensils for assistance such a fork, spoon or tongs. She stated the risk of touching the Resident's meal with bare hands could result in cross contamination or infection which could make the resident ill. In an interview on 8/19/25 at 12:25 PM with CNA A, she stated she should not have touched Resident # 9's meal with her bare hands because it could result in cross contamination and the possible outcome could be that the resident got sick from their stomach. CNA A stated she did not realize she had touched the resident's food with her hands, and the proper procedure was to assist the resident by using her utensils such a fork or spoon if necessary.In an interview on 8/21/25 at 11:05 AM with the Dietary [NAME] she stated when meals were served, staff was expected to use cooking utensils such as spoons, ladles, and tongs, and it was not acceptable for them to ever touch a resident's food with their bare hands. The Dietary [NAME] stated touching a resident's meal without gloves could result in cross contamination which could make the resident's sick from their stomach. In an interview on 8/21/25 at 11:13 AM with the DON, she stated CNAs were not supposed to touch the resident's meals with their bare hands. The DON said that if a resident required assistance from the staff, they needed to use the proper utensils for their meals such as spoons, forks or tongs. The DON said that CNA A touching Resident # 9's meal with her bare hands posed a risk of cross contamination and it was a concern with infection control. The DON said the result of not properly assisting the residents during mealtime could be for the residents to get sick from cross contamination resulting in vomiting or diarrhea or them getting a gastrointestinal infection. [SH1] In an interview on 8/22/25 at 11:05 AM with the Administrator, he stated it was not acceptable for staff to touch Resident # 9's meal with their bare hands and that staff should never touch a resident's meal once it left the kitchen. The Administrator said the expectation was for staff to use utensils such as spoons, forks or tongs if the resident required assistance. He stated that the possible outcome of a CNA touching a resident's meal with their bare hands could result in them getting sick due to cross contaminations which could make the resident sick from their stomach that could cause infections, vomit or diarrhea. Review of the U.S. FDA Food Code 2022 revealed Chapter 3-301.11 paragraph B .FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment ., CNA A was not in compliance with the Food Code.U.S. FDA Food Code 2022 Chapter 3-301.11 paragraph B .FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment ., CNA A was not in compliance with the Food Code by touching the resident's meal with her bare hands.Record Review of the facility's policies and procedures revised in October 2017, titled Dietary Services-Meals, Snacks and Services, stated in part: Dining Room Audits: Our facility audits the food and nutrition services department regularly to ensure that resident needs are met and that dining is a safe and pleasant experience for residents. The dietitian, food and nutrition services manager and/or dietary supervisor will make scheduled daily meal rounds to every dining room at all meal times to audit the dining room and the food service to the residents. The auditor will assess: whether proper sanitation is maintained by staff;. Record Review of the facility's policies and procedures revised in July 2014, titled Preventing Foodborne Illness - Food Handling, stated in part: Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. This facility recognizes that the critical factors implicated in foodborne illness are: poor personal hygiene of food service employees; All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents.Record Review of the facility's policies and procedures revised in March 2022, titled Assistance with Meals, read in part: Residents shall receive assistance with meals in a manner that meet the individual needs of each resident. Dining Room Residents: All employees who provide resident assistance with meals will be trained and shall demonstrate competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling.

Based on an observation, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (Resident #28) of 15 residents reviewed for dignity.The facility failed to ensure Resident #28 was groomed and dressed appropriately on 08/21/25.This failure could place the residents at risk of loss of dignity and self-worth.The findings include:Record review of Resident #28's face-sheet dated 08/21/25 revealed a [AGE] year-old male with an original admission date 09/18/24 and re-admission date 08/11/25.Record review of Resident #28's admission MDS assessment dated [DATE] revealed resident was unable to complete the interview for the BIMS assessment. The MDS revealed Resident #28 was dependent for personal hygiene including brushing of hair, and upper and lower body dressing. That meant the helper does all of the effort and the resident does none of the effort to complete the activity.Record review of Resident #28's history and physical dated 08/16/25 revealed resident had a medical history of Acute Ischemic Stroke (when blood circulation is blocked or reduced in the brain causing brain cell death), Tracheostomy (a surgical incision on the front of the neck to maintain the person's airway), PEG tube (a flexible feeding tube used to provide nutrition, fluids, and medications directly into the stomach), BPH (Benign Prostatic Hyperplasia, noncancerous enlargement of the prostate that causes frequent urination, weaker urine stream, and increased urgency for urination), Diabetes Mellitus 2 (), hypertension (High blood pressure), CAD (Coronary Artery Disease, the narrowing or blockage of coronary arteries, which supplied oxygen to the heart), and PVD (Peripheral Vascular Disease, narrowing or blockage in blood vessels which can cause restriction of blood flow to limbs).Record review of Resident #28's care plan revealed resident had an ADL self-care performance deficit related to stroke, and the goal notated was for Resident #28 to have maintained . a sense of dignity by being clean, dry, odor-free, well groomed . The care plan notated the staff interventions were to assist Resident #28 with dressing.Observation on 08/21/25 at 12:00 PM of Resident #28 in the 500-hall across the nurse's station. Resident was observed in his wheelchair disheveled with hair uncombed and sticking up. Resident #28 was observed with a white shirt, grey shorts that were shorter than resident's mid-thigh. He had a white blanket on top covering his legs. Resident #28 was observed resting with his eyes closed.In an interview on 08/22/25 at 10:45 AM with CNA B, she stated CNAs were responsible for preparing the residents in the morning which included getting residents dressed and having the residents look presentable. CNA B stated Resident #28 was not observed presentable per their facility policy. She stated the resident should have pants and his hair combed. CNA B stated nurses were responsible for monitoring residents' needs and appearance. She stated nurses were responsible for monitoring CNA staff ensuring they met residents' needs or if they had any concerns about residents such as Resident #28. CNA B stated the risk of not having residents groomed and presentable included it negatively affecting the residents' self-esteem. In an interview on 08/22/25 at 11:10 AM with CNA A, she stated Resident #28 was wearing shorts because it was the request of the family. She stated she asked for staff to cover the resident's legs because she thought resident would be cold in the hallway with only shorts on. She stated Resident #28 did not communicate understandably, so he did not report being cold. CNA A stated nurses and CNAs were responsible for ensuring residents were dressed appropriately. She stated residents were to be dressed their best, and it could affect their dignity if their appearance was not maintained. In an interview on 08/22/25 at 11:27 AM with LVN C, she stated the CNAs were responsible for assisting residents with dressing and grooming. She stated the nurses, ADON, DON, and CNA A were responsible for monitoring residents' grooming and appearance daily in the shift. She stated she had a concern with Resident #28's appearance on 08/21/25, since Resident #28 was observed with unkempt hair. She stated this could affect the resident's self-esteem. In an interview on 08/22/25 at 12:02 PM with the DON, she stated Resident #28's family only provided the resident with clothing including shorts. She stated the family of Resident #28 tended to get hot, and that was the reason Resident #28 was wearing shorts. She stated she observed Resident #28 on 08/21/25 and agreed the resident appeared unkempt due to his hair not being groomed. She stated she notified CNA A of her concern that day. She stated CNA's were responsible for assisting residents with dressing and grooming. She stated CNA A monitored her CNA's daily, ensuring needs were met and residents look presentable. She stated the risks to residents not being groomed could negatively affect their dignity.Record Review of the facility's policy titled Resident Rights, with revised date 02/2021, read in part: Policy Statement- Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation- Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a dignified existence; be treated with respect, kindness, and dignity; be free from abuse, neglect, misappropriation of property, and exploitation.

Based on interview and record review the facility failed to ensure residents were free from abuse, neglect, misappropriation of resident property, and exploitation for 2 of 5 residents reviewed for abuse. The facility failed to ensure Resident #1 was free from abuse when Resident #2 physically struck Resident #1 resulting in a bruise/hematoma to her forehead.This deficient practice placed residents at risk for further abuse.Findings include:1. Record review of Resident #1's face sheet, dated 8/6/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #1's history and physical, dated 7/7/25, revealed diagnoses which included dementia (a group of symptoms associated with a decline in cognitive functioning, it can cause difficulty with simple tasks, confusion, memory loss and difficulty communicating), COPD (serious lung disease that over time makes it hard to breathe), chronic kidney disease stage 3 (type of long-term kidney disease, defined by the sustained presence of abnormal kidney function and/or abnormal kidney structure), and failure to thrive (state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments).Record review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 03, which indicted her cognition was severely impaired.Record review of Resident #1's physician order, dated 6/19/25, revealed Eliquis oral Tablet 2.5mg by mouth two times a day to prevent DVT.Record review of Resident #1's incident report, dated 7/7/25 written by LVN A, revealed nurse description nurse went in during round to assess resident and noted discoloration to forehead; resident was unable to give description; bruise on top of scalp; was oriented to person; no predisposing factors noted; she was confused; and no predisposing situation factors identified.Record review of Resident #1's SBAR communication note, dated 7/7/25, revealed the change of condition was bruised forehead and left temple that started on 7/7/25 and was on anticoagulant, her vital signs were within normal range, no changes to mental and functional status.Record review of Resident #1's progress note, written by LVN A, dated 7/7/25 at 2:00 AM, revealed Upon rounding nurse observed discoloration to forehead of resident, nurse assessed site and noted no previous falls or incidents reported. Vital signs within normal limits, no open areas, no complaints of pain during shift, nurse reported to Dr. and RP. No new orders were given at this time.Record review of Resident #1's progress note, written by LVN B, dated 7/7/25 at 9:12 AM, revealed Resident send out per NP to local ER for evaluation and treatment of bruised forehead /temple. Report given to Dr. ResidentAOX1 pleasant response to question. Assisted total X1 person total with all ADLs transfers and mobility. Incontinent B/B wears briefs. Uses w/c for mobility. Denies pain, On O2 @2 LPM via NC at HS only. On room air in morning and evening but kept it on this morning. v/s 97.6 66 20 113/65 94% Ra.Record review of Resident #1's progress note, dated 7/7/25, at 5:45 PM, revealed Resident return from [local hospital] report given by [hospital nurse]. CT came back negative, urine negative, CT of spine negative. Returned at this time v/s 97 85 20164/90 93% O2 2 2 LPM via NC continuous. NP aware no new orders.Record review of Resident #1's Internal Medicine Progress Note, dated 7/7/25, revealed Patient was found to have new bruises on her forehead and face, to the left. She does not recall what happened. Denies falling. No other signs of trauma found on examination. Patient was sent to ER at [local hospital] and has returned in stable condition. No bleeding or fractures found.2. Record review of Resident #2's face sheet, dated 8/6/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE].Record review of Resident #2's history and physical, dated 7/6/25, revealed a diagnosis which included mild intellectual disability.Record review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 4, which indicated her cognition was severely impaired.Record review of Resident #2's care plan, dated 4/5/25, revealed focus area which documented she has a behavior problem, resident was observed hitting herself in the head, yelling and slamming the door with interventions Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Minimize potential for the resident's disruptive behaviors hitting self or others, by offering tasks which divert attention such as arts/crafts, manicure with nail polish. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. notify guardian when behaviors occur.Record review of Resident #2's progress notes from May 2025- August 2025 revealed no documented incidents prior to this event on 7/7/25, her history was limited to verbal behaviors towards others that warranted redirection and staff avoiding triggers, which included maintaining her preferred routine.Record review of HHSC witness statement written by AIT, dated 7/7/25, revealed [Resident #1] was sent out to [local hospital] for evaluation. upon re-entering the facility [Resident #2] entered my office, still flushed face and fidgety. I started the conversation by noting she is not in trouble but want to know what happened in her room last night. She commenced to tell me via hand gestures that she hit [Resident #1]. Record review of TULIP for July 2025 revealed no self-report reflecting resident to resident altercation. During an observation and interview on 8/6/25 at 2:58 PM, revealed Resident #2 was AOx2, the resident stated Resident #1 was no longer in her room and stated she was moved but could not recall when. Resident #2 stated she denied hitting Resident #1 or being hit by her. Resident #2 stated Resident #1 got the bruises on her face on her own but could not say how. Resident #2 stated she felt safe at the facility and denied any issues with other residents. Resident #2 stated no one else was staying in her room, she stated she was in her room alone. Observation of Resident #2's room noted only her belongings, with no evidence that a roommate was occupying the second bed. During an interview on 8/6/25 at 2:20 PM, Resident #2's RP stated the incident occurred on a Sunday (7/6/25) and was contacted until Monday by a nurse, whose name she did not recall and again on Tuesday by AIT. The RP stated this was the first known incident of aggression.During an interview on 8/6/25 at 3:18 PM, Resident #1 was AOx1, she had a bruise on her forehead green and yellow in color. Resident #1 stated she did not know how she got it and denied pain. Resident #1 denied falling and denied being hit. Resident #1 stated she did not know who Resident #2 was. Resident #1 denied any physical altercations with other residents. Resident #1 stated she felt safe. Resident #1 appeared pleasant and in good spirits, smiling when asked about abuse questions, she did not recall the incident and did not show any signs of distress. Resident #1 stated she would not report any abuse, and when asked why, she just smiled and did not answer. Resident #1 stated she had 0 distress noted.During an interview on 8/6/25 at 6:40 PM, Resident #1's Emergency Contact stated the resident was taken to the hospital after they noticed both eyes bruised and her face showed signs of trauma, as if she had been struck. Emergency contact #1 stated the facility claimed the resident woke up with the injuries and they did not know how it happened. Emergency contact #1 stated she was later contacted by someone identifying themselves as being from APS or a related agency. Emergency contact #1 stated she was aware the resident was sent to the hospital for further evaluation and no injuries were identified. Emergency contact #1 stated when she returned, she was placed in a different room away from the AP.During an interview on 8/6/25 at 7:11 pm, LVN B stated she had received report from LVN A regarding bruising to Resident #1. She stated the physician's order was to monitor for any changes and, if changes occurred, to send the resident to the hospital. Resident #1 voiced no pain, and when the bruise progressed into a hematoma, the facility sent Resident #1 for further assessment.During an interview on 8/7/25 at 8:54 am, LVN A stated he saw discoloration to Resident #1's forehead that appeared like a bruise during rounds at 2:00 AM. Prior to the injury being discovered, both residents were noted to be in bed sleeping. LVN A stated he did not hear any commotion that would have alerted him to intervene or follow up. He stated there was nothing out of the ordinary reported, heard, or witnessed. LVN A stated a call was placed to both the physician and responsible party; the physician gave orders to continue monitoring and, if any changes occurred, to send the resident to the hospital for further evaluation. LVN A stated the responsible party did not answer and staff were unable to leave a voicemail.During an interview on 8/7/25 at 9:56 AM, the DON stated that after she received report of Resident #1's bruise, she initiated an investigation for an injury of unknown origin. She stated she believed staff already knew what had happened at the time. DON stated she did not recall if she was present when Resident #2 disclosed to the AIT that she had hit Resident #1. The DON stated she did not consider the incident to be abuse and could not answer why, although interventions were in place and Resident #1 was kept safe from the AP. During an interview on 8/7/25 at 10:32 AM, the AIT stated he arrived at the facility around 8:00 AM and was informed by LVN B between 8:00 and 8:30 AM that Resident #1 had a bump and bruise on her head. The AIT stated he wanted to ask Resident #2 if she had heard or seen anything the night prior. The AIT stated Resident #2 appeared flushed, fidgety, and not her usual self. The AIT stated after reassuring Resident #2 that she was not in trouble, she reportedly gestured with closed fists and mimicked a striking motion. The AIT stated when asked if she had hit Resident #1, Resident #2 responded affirmatively. The AIT stated that following this disclosure, the facility was able to determine the cause of Resident #1's injury and rule out an unknown origin. The AIT stated at the time of Resident #2's disclosure, Resident #1 was already at the hospital. The AIT upon Resident #1's return, he followed up and noted that Resident #1 had no recollection of the incident and no findings were noted at the hospital. Resident #1 was moved out of Resident #2's room and reassigned to a private room. The AIT stated he did not view the situation as a resident-to-resident altercation due to Resident #2's cognitive impairment and intellectual disability and did not believe Resident #2 was aware of her actions. The AIT stated he did not consider the incident to be abuse.Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, dated April 2021, read in part Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: #1Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff; b. other residents; c. consultants; d. volunteers; e. staff from other agencies; f. family members; g. legal representatives; h. friends; i. visitors; and/or j. any other individual. #8- Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property.

Based on interview and record review the facility failed ensure alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 of 4 residents (Resident #1 and Resident#2) reviewed for reporting. The facility failed to report abuse when Resident #2 hit Resident #1 to State Office Agency, Law Enforcement, and Ombudsman.This failure could place residents at risk for abuse. Findings include:1. Record review of Resident #1's face sheet, dated 8/6/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #1's history and physical, dated 7/7/25, revealed diagnoses which included dementia (a group of symptoms associated with a decline in cognitive functioning, it can cause difficulty with simple tasks, confusion, memory loss and difficulty communicating), COPD (serious lung disease that over time makes it hard to breathe), chronic kidney disease stage 3 (type of long-term kidney disease, defined by the sustained presence of abnormal kidney function and/or abnormal kidney structure), and failure to thrive (state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments). Record review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 03, which indicted her cognition was severely impaired. Record review of Resident #1's physician order, dated 6/19/25, revealed Eliquis oral Tablet 2.5mg by mouth two times a day to prevent DVT. Record review of Resident #1's incident report, dated 7/7/25 written by LVN A, revealed nurse description nurse went in during round to assess resident and noted discoloration to forehead; resident was unable to give description; bruise on top of scalp; was oriented to person; no predisposing factors noted; she was confused; and no predisposing situation factors identified.Record review of Resident #1's SBAR communication note, dated 7/7/25, revealed the change of condition was bruised forehead and left temple that started on 7/7/25 and was on anticoagulant, her vital signs were within normal range, no changes to mental and functional status.Record review of Resident #1's progress note, written by LVN A, dated 7/7/25 at 2:00 AM, revealed Upon rounding nurse observed discoloration to forehead of resident, nurse assessed site and noted no previous falls or incidents reported. Vital signs within normal limits, no open areas, no complaints of pain during shift, nurse reported to Dr. and RP. No new orders were given at this time.Record review of Resident #1's progress note, written by LVN B, dated 7/7/25 at 9:12 AM, revealed Resident send out per NP to local ER for evaluation and treatment of bruised forehead /temple. Report given to Dr. ResidentAOX1 pleasant response to question. Assisted total X1 person total with all ADLs transfers and mobility. Incontinent B/B wears briefs. Uses w/c for mobility. Denies pain, On O2 @2 LPM via NC at HS only. On room air in morning and evening but kept it on this morning. v/s 97.6 66 20 113/65 94% Ra. Record review of Resident #1's progress note, dated 7/7/25, at 5:45 PM, revealed Resident return from [local hospital] report given by [hospital nurse]. CT came back negative, urine negative, CT of spine negative. Returned at this time v/s 97 85 20164/90 93% O2 2 2 LPM via NC continuous. NP aware no new orders.Record review of Resident #1's Internal Medicine Progress Note, dated 7/7/25, revealed Patient was found to have new bruises on her forehead and face, to the left. She does not recall what happened. Denies falling. No other signs of trauma found on examination. Patient was sent to ER at [local hospital] and has returned in stable condition. No bleeding or fractures found.2. Record review of Resident #2's face sheet, dated 8/6/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #2's history and physical, dated 7/6/25, revealed a diagnosis which included mild intellectual disability.Record review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 4, which indicated her cognition was severely impaired. Record review of Resident #2's care plan, dated 4/5/25, revealed focus area which documented she has a behavior problem, resident was observed hitting herself in the head, yelling and slamming the door with interventions Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Minimize potential for the resident's disruptive behaviors hitting self or others, by offering tasks which divert attention such as arts/crafts, manicure with nail polish. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. notify guardian when behaviors occur. Record review of HHSC witness statement written by AIT, dated 7/7/25, revealed [Resident #1] was sent out to [local hospital] for evaluation. upon re-entering the facility [Resident #2] entered my office, still flushed face and fidgety. I started the conversation by noting she is not in trouble but want to know what happened in her room last night. She commenced to tell me via hand gestures that she hit [Resident #1]. Record review of TULIP for July 2025 revealed no self-report reflecting resident to resident altercation. During an interview on 8/6/25 at 2:58 PM, revealed Resident #2 was AOx2, the resident stated Resident #1 was no longer in her room and stated she was moved but could not recall when. Resident #2 stated she denied hitting Resident #1 or being hit by her. Resident #2 stated Resident #1 got the bruises on her face on her own but could not say how. Resident #2 stated she felt safe at the facility and denied any issues with other residents. During an interview on 8/6/25 at 2:20 PM, Resident #2's RP stated the incident occurred on a Sunday (7/6/25) and was contacted until Monday by a nurse, whose name she did not recall and again on Tuesday by AIT. The RP stated this was the first known incident of aggression.During an interview on 8/6/25 at 3:18 PM, Resident #1 was AOx1, she had a bruise on her forehead green and yellow in color. Resident #1 stated she did not know how she got it and denied pain. Resident #1 denied falling and denied being hit. Resident #1 stated she did not know who Resident #2 was. Resident #1 denied any physical altercations with other residents. Resident #1 stated she felt safe. Resident #1 appeared pleasant and in good spirits, smiling when asked about abuse questions, she did not recall the incident and did not show any signs of distress. Resident #1 stated she would not report any abuse, and when asked why, she just smiled and did not answer. Resident #1 stated she had 0 distress noted.During an interview on 8/6/25 at 6:40 PM, Resident #1's Emergency Contact stated the resident was taken to the hospital after they noticed both eyes bruised and her face showed signs of trauma, as if she had been struck. Emergency contact #1 stated the facility claimed the resident woke up with the injuries and they did not know how it happened. Emergency contact #1 stated she was later contacted by someone identifying themselves as being from APS or a related agency. Emergency contact #1 stated she was aware the resident was sent to the hospital for further evaluation and no injuries were identified. Emergency contact #1 stated when she returned, she was placed in a different room away from the AP.During an interview on 8/7/25 at 9:56 AM, the DON stated the incident was not reported to the SO, ombudsman, or law enforcement. The DON stated the reason for not notifying agencies was because they were investigating an injury of unknown origin and believed they already knew what had happened. The DON stated she did not consider the incident to be abuse, although interventions were in place and Resident #1 was kept safe from the AP. The DON stated after reviewing their internal abuse policy, it appeared they needed to notify the correct agencies. During an interview on 8/7/25 at 10:32 AM, the AIT stated the incident was not reported to the SO or law enforcement. The AIT stated he attempted to call the local Ombudsman to notify, but he had not returned his call. The AIT stated the reason for not notifying agencies was because he did not view the situation as a resident-to-resident altercation due to Resident #2's cognitive impairment and intellectual disability and did not believe Resident #2 was aware of her actions. The AIT stated he did not consider the incident to be abuse.During an interview on 8/7/25 at 10:51 AM, the Ombudsman stated he was unsure if notification of resident-to-resident altercations was required. The Ombudsman stated facility staff occasionally provided him with information as a courtesy; he stated he did not recall receiving any notification regarding an incident between Resident #2 and Resident #1. Record review of the facility's Abuse, Neglect, exploitation or Misappropriation- Reporting and Investigating policy, dated September 2022, read in part All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. #1: If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. #2- The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative: d. Adult protective services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's attending physician; and g. The facility medical director.

Based on interview and record review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 2 of 4 residents (Resident#1 and Resident #2) reviewed for abuse. The facility failed to implement their abuse policy when they failed to report abuse when Resident #2 hit Resident #1. This failure could place residents at risk for abuse by not immediately following the facility policy and procedure manual of recognizing and reporting abuse. Findings include:1. Record review of Resident #1's face sheet, dated 8/6/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #1's history and physical, dated 7/7/25, revealed diagnoses which included dementia (a group of symptoms associated with a decline in cognitive functioning, it can cause difficulty with simple tasks, confusion, memory loss and difficulty communicating), COPD (serious lung disease that over time makes it hard to breathe), chronic kidney disease stage 3 (type of long-term kidney disease, defined by the sustained presence of abnormal kidney function and/or abnormal kidney structure), and failure to thrive (state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments). Record review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 03, which indicted her cognition was severely impaired. Record review of Resident #1's physician order, dated 6/19/25, revealed Eliquis oral Tablet 2.5mg by mouth two times a day to prevent DVT. Record review of Resident #1's incident report, dated 7/7/25 written by LVN A, revealed nurse description nurse went in during round to assess resident and noted discoloration to forehead; resident was unable to give description; bruise on top of scalp; was oriented to person; no predisposing factors noted; she was confused; and no predisposing situation factors identified.Record review of Resident #1's SBAR communication note, dated 7/7/25, revealed the change of condition was bruised forehead and left temple that started on 7/7/25 and was on anticoagulant, her vital signs were within normal range, no changes to mental and functional status.Record review of Resident #1's progress note, written by LVN A, dated 7/7/25 at 2:00 AM, revealed Upon rounding nurse observed discoloration to forehead of resident, nurse assessed site and noted no previous falls or incidents reported. Vital signs within normal limits, no open areas, no complaints of pain during shift, nurse reported to Dr. and RP. No new orders were given at this time.Record review of Resident #1's progress note, written by LVN B, dated 7/7/25 at 9:12 AM, revealed Resident send out per NP to local ER for evaluation and treatment of bruised forehead /temple. Report given to Dr. ResidentAOX1 pleasant response to question. Assisted total X1 person total with all ADLs transfers and mobility. Incontinent B/B wears briefs. Uses w/c for mobility. Denies pain, On O2 @2 LPM via NC at HS only. On room air in morning and evening but kept it on this morning. v/s 97.6 66 20 113/65 94% Ra. Record review of Resident #1's progress note, dated 7/7/25, at 5:45 PM, revealed Resident return from [local hospital] report given by [hospital nurse]. CT came back negative, urine negative, CT of spine negative. Returned at this time v/s 97 85 20164/90 93% O2 2 2 LPM via NC continuous. NP aware no new orders.Record review of Resident #1's Internal Medicine Progress Note, dated 7/7/25, revealed Patient was found to have new bruises on her forehead and face, to the left. She does not recall what happened. Denies falling. No other signs of trauma found on examination. Patient was sent to ER at [local hospital] and has returned in stable condition. No bleeding or fractures found.2. Record review of Resident #2's face sheet, dated 8/6/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #2's history and physical, dated 7/6/25, revealed a diagnosis which included mild intellectual disability.Record review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 4, which indicated her cognition was severely impaired. Record review of Resident #2's care plan, dated 4/5/25, revealed focus area which documented she has a behavior problem, resident was observed hitting herself in the head, yelling and slamming the door with interventions Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Minimize potential for the resident's disruptive behaviors hitting self or others, by offering tasks which divert attention such as arts/crafts, manicure with nail polish. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. notify guardian when behaviors occur. Record review of HHSC witness statement written by AIT, dated 7/7/25, revealed [Resident #1] was sent out to [local hospital] for evaluation. upon re-entering the facility [Resident #2] entered my office, still flushed face and fidgety. I started the conversation by noting she is not in trouble but want to know what happened in her room last night. She commenced to tell me via hand gestures that she hit [Resident #1]. Record review of TULIP for July 2025 revealed no self-report reflecting resident to resident altercation. During an interview on 8/6/25 at 2:58 PM, revealed Resident #2 was AOx2, the resident stated Resident #1 was no longer in her room and stated she was moved but could not recall when. Resident #2 stated she denied hitting Resident #1 or being hit by her. Resident #2 stated Resident #1 got the bruises on her face on her own but could not say how. Resident #2 stated she felt safe at the facility and denied any issues with other residents. During an interview on 8/6/25 at 2:20 PM, Resident #2's RP stated the incident occurred on a Sunday (7/6/25) and was contacted until Monday by a nurse, whose name she did not recall and again on Tuesday by AIT. The RP stated this was the first known incident of aggression.During an interview on 8/6/25 at 3:18 PM, Resident #1 was AOx1, she had a bruise on her forehead green and yellow in color. Resident #1 stated she did not know how she got it and denied pain. Resident #1 denied falling and denied being hit. Resident #1 stated she did not know who Resident #2 was. Resident #1 denied any physical altercations with other residents. Resident #1 stated she felt safe. Resident #1 appeared pleasant and in good spirits, smiling when asked about abuse questions, she did not recall the incident and did not show any signs of distress. Resident #1 stated she would not report any abuse, and when asked why, she just smiled and did not answer. Resident #1 stated she had 0 distress noted.During an interview on 8/6/25 at 6:40 PM, Resident #1's Emergency Contact stated the resident was taken to the hospital after they noticed both eyes bruised and her face showed signs of trauma, as if she had been struck. Emergency contact #1 stated the facility claimed the resident woke up with the injuries and they did not know how it happened. Emergency contact #1 stated she was later contacted by someone identifying themselves as being from APS or a related agency. Emergency contact #1 stated she was aware the resident was sent to the hospital for further evaluation and no injuries were identified. Emergency contact #1 stated when she returned, she was placed in a different room away from the AP.During an interview on 8/7/25 at 9:56 AM, the DON stated the incident was not reported to the SO, ombudsman, or law enforcement. The DON stated the reason for not notifying agencies was because they were investigating an injury of unknown origin and believed they already knew what had happened. The DON stated she did not consider the incident to be abuse, although interventions were in place and Resident #1 was kept safe from the AP. The DON stated after reviewing their internal abuse policy, it appeared they needed to notify the correct agencies. During an interview on 8/7/25 at 10:32 AM, the AIT stated the incident was not reported to the SO or law enforcement. The AIT stated he attempted to call the local Ombudsman to notify, but he had not returned his call. The AIT stated the reason for not notifying agencies was because he did not view the situation as a resident-to-resident altercation due to Resident #2's cognitive impairment and intellectual disability and did not believe Resident #2 was aware of her actions. The AIT stated he did not consider the incident to be abuse.During an interview on 8/7/25 at 10:51 AM, the Ombudsman stated he was unsure if notification of resident-to-resident altercations was required. The Ombudsman stated facility staff occasionally provided him with information as a courtesy; he stated he did not recall receiving any notification regarding an incident between Resident #2 and Resident #1. Record review of the facility's Abuse, Neglect, exploitation or Misappropriation- Reporting and Investigating policy, dated September 2022, read in part All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. #1: If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. #2- The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative: d. Adult protective services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's attending physician; and g. The facility medical director.

Based on interview and record review, the facility failed to ensure medical records were maintained on each resident that were complete and accurately documented for 1 (Resident #2) of 5 residents reviewed for resident records. -The facility failed to ensure the accuracy of Resident #2's medical records. The physician said to hold Resident #2's medication Donepezil due to an interaction and this was not in the medical records. This failure could put residents at risk of improper medication administration based on inaccurate documentation. Findings included: Record review of Resident #2's Admission Record dated 03/10/2025, revealed an [AGE] year-old male who was admitted to the facility on [DATE]. Record review of Resident #2's History and Physical (H&P) dated 10/31/2024, revealed resident diagnoses to include Lewy body dementia (a decline in thinking ability, especially in areas of attention, visual perception, and planning and organization). Plan read in part: Continue donepezil and reorient patient frequently. Record review of Resident #2's MDS assessment dated [DATE], revealed a BIMS not conducted as the resident is rarely/never understood. Resident #2 with short-term memory problem and was severely impaired in daily decision making. Record review of Resident #2's hospital discharge summary dated 10/29/2024, reads in part under medication instructions the medication Donepezil daily, with no information regarding dosage, or any other instructions. Record review of Resident #2's Care Plan initiated 11/05/2024 revealed focus area which included: (Resident #2) had cognitive impairment AEB: memory problems: short/long term, and diagnosis of dementia. Part of the intervention plan includes administer medications as ordered. Record review of Resident #2's PCP Progress Notes for the dates of 11/05/24, 11/11/2024, 11/19/2024, 11/29/2024, 12/06/2024, and 12/12/2024 included the following information: Plan: Continue donepezil and reorient patient frequently. Record review of Resident #2's Order Summary from December 2024 did not reveal an order for Donepezil. Record review of Resident #2's October 2024, November 2024, and December 2024 Medication Administration Record (MAR) was reviewed. There was no information on any of the MARs for the medication Donepezil. Record review of Resident #2's Transfer/Discharge Report dated 03/10/2025, revealed Resident #2 was discharged from the facility on 12/17/2024 and transferred to board and care /assisted living/group home. During an interview on 03/12/2025 at 8:20 a.m., Resident #2's FM (Family Member) said Resident #2 was currently at home and stable and fully recovered from surgery he had back in October 2024 which led to Resident #2 being admitted to the facility. FM said Resident #2 was not given Donepezil that had been prescribed to him according to review of resident records discharge medication list. FM said she did not know why the medication was not given while Resident #2 was at the facility. FM said she spoke with someone at the facility and asked why he had not been given the medication and facility staff did not know that he was on that medication. During an interview on 03/12/2025 at 9:35 a.m., the PCP said Resident #2 was under his care while at the facility. The PCP said the Donepezil was used to prevent longer term memory loss. The PCP said Resident #2 was on two antibiotics that had a weird interaction with the medication Donepezil. The PCP said he gave the facility a verbal hold order on the medication since admission. The PCP said it was an error on his part to include the information to continue Donepezil on the progress notes. The PCP said the hold was to prevent side effects from the antibiotics that resident had been taking. The PCP said he visited the resident weekly and examined the resident and at no time did he find the resident in any acute distress. The PCP said the resident was alert and oriented times three (x3). The PCP said there was no negative outcome and there were no risks of any adverse effects from not taking the medication and keeping it on hold for over a month. During an interview on 03/13/2025 at 11:31 a.m., the DON said the facility follows hospital medication reconciliation when admitting a resident to the facility. The DON said for medication Donepezil, the hospital information did not list a dose for the medication. The DON said Resident #2's PCP verbalized there was a contraindication with the medication Donepezil and antibiotics that Resident #2 was supposed to follow-up with his primary physician when discharged from the facility . The DON said the verbalized information should have been documented by the nurse who received the information from the PCP on the progress notes. The DON said the information was not documented accordingly. The DON said she did not know why the physician notes continued to show Donepezil. The DON said there was no negative effects from Resident #2 not receiving the medication and he was discharged stable condition. The DON said Resident #2 was calm and alert during his stay and followed commands and was eating well. The DON said this was a documentation issue because she did not find any documented information about the verbalize instruction to hold the medication from the physician. Review of facility provided Charting and Documentation policy dated July 2017, reads in part All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. Documentation in the medical record will be objective, complete, and accurate.

Based on observations, interviews, and record reviews, the facility failed to ensure they followed professional standards of practice in accordance with physician orders and facility policy for care of PICC for 1 (Residents #1) of 2 residents reviewed for parenteral and intravenous care. The facility failed to change Resident #1's PICC line dressing as ordered. This failure placed the residents at risk of complications with their PICC needed for infusion therapy. Findings included: Record review of Resident #1's face sheet dated 2/3/25 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of repeated falls, metabolic encephalopathy (condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), and pneumonia. Record review of Resident #1's admission MDS assessment still in progress had a BIMS score of 12, indicting her cognition was moderately impaired. Record review of Resident #1's care plan dated 1/15/25 revealed a focus area for at risk for complications due to PICC line located in left upper arm with interventions of change dressing as ordered and as needed if soiled, wet, or lose. Record review of Resident #1's physician order dated 1/14/25 revealed Nurse to use Sterile Technique when changing PICC line dressing changes once a week per facility protocol. In an observation and interview on 2/4/25 at 8:50 am, Resident #1 was in bed, the PICC line dressing was dated 01/27/25 and remained intact. Resident #1 denied any discomfort or pain at the site. There were no signs of soiling or infection observed. In an observation and interview on 2/5/25 at 9:33 am, Resident #1 was in bed, the PICC line dressing was dated 01/27/25 and remained intact. Resident #1 denied any discomfort or pain at the site. There were no signs of soiling or infection observed. In an interview on 2/5/25 at 9:35 am, LVN C stated that Resident #1's PICC line dressing should have been changed on Monday or Tuesday, as the order required it to be changed every seven days. LVN C mentioned that anyone could have done it the previous day. LVN C stated the dressing was intact and there were no signs of infection, such as redness, swelling, or discomfort at the site. LVN C stated that the order specified Wednesday, and it appeared that someone may have changed it early, but it still should have been changed by the seventh day by a charge nurse. In an interview on 2/6/25 at 12:22 pm, the DON stated that nurses were responsible for managing PICC lines. The DON stated orders specified changes every Wednesday and as needed. The DON stated the as needed covered situations where the dressing was wet, peeling off, or required an early change before the seven-day mark and if exceeding the seven-day mark. The DON stated nurses were expected to check the dressing every shift and during every antibiotic administration. The DON stated the primary risk associated with PICC lines was infection. The DON stated nurses received training on PICC line care upon hire and as needed. In an interview on 2/6/25 at 2:43 pm, the Administrator stated that nursing staff were responsible for PICC line management and stated that a frequency was in place. The Administrator deferred further details to the DON. Record review of the facility's Peripheral and Midline IV Dressing Changes policy dated March 2022 read in part change dressing if it becomes damp, loosened, or visibly soiled and: a. at least every 7 days for TSM dressing.

Based on observations, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments for 1 of 2 medication carts reviewed for medication storage and security. The facility failed to ensure LVN A secured the medication cart when it was left unattended. This failure: could place residents at risk for drug diversion or accidental ingestion. Findings included: In an observation on 2/3/25 at 1:34 pm, the medication cart on the 400 hall was left unattended and unlocked. 2 staff were noted in the hallway. In an observation on 2/3/25 at 1:35 pm, CNA B walked over to the medication cart and locked it. In an interview on 2/3/25 at 1:36 pm, CNA B stated that she was aware the medication cart needed to be closed and noticed that it was left unlocked while she saw the State Surveyor standing nearby. CNA B stated she then proceeded to lock the cart. CNA B stated the risk was a patient potentially accessing the medications and stated that it was the nurses' responsibility to ensure the cart remained secured. In an interview on 2/3/25 at 1:39 pm, LVN A stated that the unlocked medication cart was hers and explained that she had walked away to administer medication to a resident who was leaving for dialysis. LVN A stated that she had received training on locking the medication cart upon hire and stated the risk of a resident accessing the medications. LVN A stated that it was the nurses' responsibility to keep the cart secured. In an interview on 2/6/25 at 12:22 pm, the DON stated that medication carts were expected to be locked at all times when the nurse was not present. The DON stated nurses were responsible for locking the cart before stepping away. The DON stated the primary risk identified was unauthorized access by residents or family members. The DON stated training on medication cart security was provided upon hire and through in-services as needed. In an interview on 2/6/25 at 2:43 pm, the Administrator stated that medication carts were required to be locked and that the assigned nurse was responsible for ensuring security. The Administrator stated nurses received training on this requirement upon hire, as needed, and during annual training. The Administrator stated the primary risk identified was unauthorized access to medications. Record review of the facility's Security of Medication Cart policy dated April 2007 read in part the cart must be locked before the nurse enters the resident's room.

Based on interviews and record review the facility failed to include as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of the facility's QAPI program for 16 ( the Administrator, the DON, the Infection Disease Preventionist, the Social Worker, the Activity Director, the Housekeeping Supervisor, the Maintenance Supervisor, the Director of Food Services, RN H, LVN I, LVN J, LVN K, CNA L, CNA M, CNA N, and CNA O) of 16 employees reviewed for training regarding QAPI. The facility failed to include training regarding the facility's QAPI program in its training for employees. This failure put residents at risk of receiving poor-quality services as a result of staff being unaware of quality control concerns the facility was working to address. Findings included: In interview and record review on 07/11/2024 at 10:40 AM the HR Manager provided a list of employees with the following dates of hire and verbally confirmed the hire dates of these employees: Administrator- 9/17/2002, Director of Nurses-11/30/2020, Infection Control Preventionist - 6/3/2024, Social Worker - 3/24/2024, Activity Director - 5/13/2022, Housekeeping Supervisor, 2/18/2019, Maintenance Supervisor- 7/10/2023, Director of Food Services - 6/10/2019, RN H - 1/13/22, LVN I-8/18/2023, LVN J - 5/30/23, LVN K-6/14/24, CNA L - 1/12/2023, CNA M - 6/25/2019, CNA N - 4/16/2019, and CNA O - 11/22/23. In interview and record review on 07/11/2024 at 10:40 AM review of the facility orientation and training documents revealed no training regarding the facility's QAPI program to the Administrator, the Director of Nurses, the Infection Control Preventionist, the Social Worker, the Activity Director, the Housekeeping Supervisor, the Maintenance Supervisor, the Director of Food Services, RN H, LVN I, LVN J, LVN K, CNA L, CNA M, CNA N, and CNA O. The HR Manager stated that training regarding the facility's QAPI program was not provided to facility employees. In an interview on 07/11/2024 at 2:15 PM the Administrator-in-training revealed the facility did not provide formal training to employees regarding the QAPI program. The Administrator stated that provision of training about the QAPI program to employees would be beneficial so they could be aware of the quality-related efforts the facility was making. Record review of the facility policy In-service Training, All Staff revised 08/2022 revealed required training topics included elements and goals of the facility QAPI program.

49854 Based on observations, interviews, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three residents (Resident #252, Resident #31, Resident #20) of eight residents observed for infection control in that: 1. Resident #252's catheter drainage collection bag was left on the floor. 2. CNA D and CNA E did not change their gloves after they became contaminated during incontinent care while assisting Resident #20 and did not practice adequate hand hygiene after. 3. CNA F did not change their gloves after they became contaminated during incontinent care while assisting Resident #31 This deficient practice could affect residents with catheters and could result in cross contamination of germs and could result in a urinary tract infection (a painful infection of the urinary system, which includes the kidneys, bladder, urethra, and ureters). This failure could place residents at risk for cross contamination and the spread of infection. The findings included: Review of Resident #252's face sheet dated 07/11/2024, revealed resident was admitted to the facility on [DATE]. Review of Resident #252's History and Physical dated 6/14/2024, revealed diagnoses to include benign prostatic hyperplasia (a condition in which the prostate gland is larger than normal), other retention of urine, chronic kidney disease. Review of Resident #252's quarterly MDS assessment dated [DATE] revealed Resident had a BIMS (Brief Interview for Mental Status) of 6 suggesting severe cognitive impairment. Review of Resident #252's care plan dated 06/17/2024 revealed a diagnosis of benign prostatic hyperplasia (a condition in which the prostate gland is larger than normal). It revealed staff was to assess for obstruction (a condition on which the bladder stretches to hold more fluid due to lack of urination), bladder distention, absence of voiding, bladder fullness, and discomfort. It revealed the following orders: change catheter/drainage bag/tubing per doctor ' s orders, Ensure staff aware of correct placement of catheter gravity drainage bag and tubing. Keep tubing/bag below the bladder, do not kink tubing, monitor urine for odor, color, sediments, amount of urine, etc. and report any abnormalities, provide catheter care. During an observation on 07/09/24 at 10:44 AM, it was observed that the resident ' s Foley bag was hanging from his bed and touching the floor. During an interview on 07/10/24 at 10:53 AM with LVN A He said that the bag should not be touching the floor said there's a risk of contamination of the area if urine was to spill, there would also be a risk of infection to the patient if the bag was touching the floor and there was the potential of germs infecting the resident. LVN A said the bag needed to be always raised from the floor. He said that staff, including him, made rounds throughout the day to ensure these things did not happen but that sometimes it is unavoidable. During an interview on 07/10/24 at 03:02 PM CNA B she stated that the foley bag should not touch the floor because there is a risk of contamination both to the floor and the foley bag if the floors dirty. CNA B said that the potential outcome was that the resident could catch an infection if the bag was contaminated with germs by touching the floor. CNA B said that she has been trained to check on all the residents that have a foley bag every 4 hours and if she observed a foley bag touching the floor, she needed to contact the nurse so that it was changed. During an interview on 07/10/24 at 03:09 PM with DON, it revealed that she had been 3 months in the position as the DON in the facility and that she had worked at the company for about 3 and a half years. DON looked at the picture taken by the state surveyor on 07/09/2024 and after observation of the foley bag being on the floor, DON said that the foley bag should not be touching the floor and that the potential risk was that the patient could get an infection because the foley bag was touching the floor and there was a potential of cross contamination and germs infecting the resident. The DON stated that staff were trained to correct and prevent these issues. The DON said that the residents were checked every 2 hours and as needed. The DON said that CNA's and LVN's were constantly making rounds trying to prevent this kind of situation. Resident #20 Record review of Resident #20's face sheet dated July 11th, 2024, revealed the resident was admitted to the facility on [DATE]. Resident #20 has medical diagnoses that included incomplete paraplegia (impairment in motor or sensory function of the lower extremities), type 2 diabetes, muscle wasting and atrophy (a progressive and degeneration or shrinkage of muscles or nerve tissues), and chronic pain. Review of Resident #20's admission MDS dated [DATE] revealed the resident to be frequently incontinent of urine and bowel. Review of Resident #20's Care Plan dated 06/25/2024 shows a focus of I am at risk for UTIs and skin breakdown R/T incontinent of: Bladder/Bowel D/T Poor cognition with goals of My dignity will be maintained and will not have s/sx of UTI or evidence of skin breakdown through next review date and interventions of Monitor Q 2 hours/PRN for episodes - changes promptly, Provide for appropriate peri-care after each episodes, Perform weekly skin assessment per facility schedule. Observations on 07/09/24 at 1005 am of incontinent care for Resident #20 with CNA D and CNA E. Resident had loose stool that had run out of the brief, on his legs and on his back. CNA E wiped the resident's inner thighs, and genital area. CNA E doffed gloves, did not hand sanitize or wash hands, grabbed a new shirt for the resident. CNA E left the room to get a clean brief. The State Surveyor did not witness the staff sanitize or wash hands. After wiping the bowel movement off Resident #20's genital area and bottom, CNA D used a wet wipe to clean the gloves that were visibly soiled with bowel movement. CNA D placed the clean brief with the same gloves. Without changing gloves, CNA D grabbed the residents barrier cream and placed barrier cream on the resident's bottom. The resident was rolled to his back and CNA D placed barrier cream on his genital area. CNA D used a wet wipe to clean the barrier cream off the same gloves. CNA E and CNA D removed the resident's shirt which had bowel movement on it. When the CNAs turned the resident towards CNA D to fix the brief, there was still bowel movement on his back. CNA E wiped resident's bottom. CNA E then removed the soiled draw sheet and latched the clean brief. Without doffing gloves, CNA E moved the wet wipes and covered the resident with a blanket. Both CNAs after doffing their gloves did not wash their hands for a full 30 seconds and did not use a clean paper towel to turn water off. CNA D and CNA E were unavailable for interviews. Resident #31 Record review of Resident #31's face sheet dated July 11th, 2024, revealed the resident was admitted to the facility 05/11/2024. Resident #31 has medical diagnoses that includes urinary tract infection, neuromuscular dysfunction of bladder (a condition where a person lacks bladder control due to brain, spinal cord, or nerve problems.), severe protein calorie malnutrition, muscle wasting and atrophy (a progressive and degeneration or shrinkage of muscles or nerve tissues). Review of Resident #31's 5-day Medicare MDS dated [DATE] revealed the resident to be always incontinent of bowel movements. Resident has a foley catheter. Review of Resident #31's Care Plan dated 06/14/2024 shows a focus of I have potential for impaired skin integrity related to decreased mobility, incontinence, current skin concerns a goal of I will show no evidence of skin breakdown through next review Date. And interventions of Apply barrier cream PRN, Braden Risk assessment per facility protocols, Skin assessment Q week. Observation on 07/09/24 at 11:33 AM of incontinent care for Resident #31 with CNA F and LVN P. Both staff members donned two pairs of gloves (double gloving). After providing foley care and cleaning residents genitals the resident was turned towards LVN P so CNA F could wipe the resident's bottom. The resident began having a bowel movement at this time. CNA F wiped residents bowel movement, removed soiled brief. CNA F removed the outer layer of gloves that were visibly soiled with bowel movement. With the gloves that were under the soiled gloves, CNA F placed a new brief, new draw sheet, and covered the resident with a blanket. CNA F then drained the urine from the resident's foley bag. CNA F, with the same gloves, wiped the residents face with a damp wash rag, brushed the resident's hair, lowered the bed, moved the bedside table to the resident. LVN P used hand sanitizer after leaving room. CNA F did not wash their hands in the room. Interview on 07/11/24 at 10:34 AM with DON and ADON regarding incontinent care. The DON stated that she expected the staff to perform hand hygiene before and after incontinent care and wash their hands if they were visibly soiled. The DON stated the staff were to change gloves and hand sanitize between dirty and clean. The ADON stated the staff were not supposed to double glove during incontinent care to replace changing gloves and sanitizing between dirty and clean. The DON and the ADON stated the staff not changing gloves between dirty and clean, not adequately washing hands, and double gloving can cause a potential cross contamination and goes against infection control. Interview on 07/11/24 at 11:18 AM with LVN P regarding incontinent care. LVN P stated that she always wears double gloves because it was easier and faster than washing hands during incontinent care. LVN P did not think there was anything during care that could have been done better. Interview on 07/11/24 at 11:18 AM with CNA F stated that she always wears multiple pairs of gloves because it [NAME] faster than taking gloves off and sanitizing between glove changes. CNA F did not think this was an issue of cross contamination. POLICY Record review of the facility's policy titled Catheter Care, Urinary dated August 2022 indicated in part: Infection Control; be sure the catheter tubing and drainage bag are kept off the floor. Record review of the facility's policy titled Handwashing/ Hand Hygiene. The policy statement reads This facility considers hand hygiene the primary means to prevent the spread of infections. The policy interpretation and implementation reads in part, 6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: when hands are visibly soiled; and after contact with a resident with infectious diarrhea ., and 7.use an alcohol based hand run containing at least 62% alcohol; or, alternatively, soap and water for the following situations: h. before moving from a contaminated body site to a clean body site during resident care; m. after removing gloves; . and 9. The use of gloves does not replace hand washing/ hand hygiene. Intergration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections . under the Procedure - washing hands - portion of the policy states in part 2. rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. and 4. Use towel to turn off the faucet.

Based on observations, record review, and interviews, 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 food procurement. 1. The facility failed to ensure foods were properly labeled (contents of containers, opened date, date prepared), covered, and sealed. 2. The facility failed to ensure meat was thawed properly on a tray in the refrigerator. These failures could place residents who ate food from the kitchen at risk of food borne illness and disease. Findings Included: Observation and interview on 7/9/24 at 8:18 am with [NAME] C, revealed an unsealed plastic bag labeled cilantro found in the refrigerator labeled Produce. [NAME] C stated the risk of having the bag open and not inside a sealed bag was that there was no way to know when it had been opened. [NAME] C stated that cilantro was perishable and if it was used to cook, there was a potential to make the residents sick. A clear plastic container with no lid and no label containing red fruit was found inside the same refrigerator. The fruit in the container appeared overripe and mushy. [NAME] C stated that the same risks were present for having the fruit uncovered and unlabeled. He stated there was no way to know when they were placed in the refrigerator and if they were given to the residents and were spoiled, the residents could get sick. Observation and interview on 7/9/24 at 8:27 am with [NAME] C revealed, two briskets (wrapped in original plastic with label) on the bottom (floor) of the refrigerator, thawing, with meat juices and blood pooling around them onto the bottom of refrigerator labeled Raw. [NAME] C stated that the meat was not supposed to be thawed like that. He stated that the process to thaw meat was to move it from the freezer to the refrigerator 3 days before they cook the meat. He statedthey place it on a metal tray in case there were juices or blood drippings, so they fell into the metal tray and not into the refrigerator. He stated that the risk of the drippings falling into the fridge was that they could contaminate the food and create bacteria that could make the residents sick. Observation and interview on 7/9/24 at 8:40 am with the Registered Dietician revealed, inside the refrigerator labeled Dairy, a bottle of ranch dressing was found with dry dressing dripping outside the lid. The Registered Dietitian stated that by having dried food particles there was a possibility of spoiling the food items near the bottle or that it could attract pests. A clear plastic container labeled tomato sauce was found in the same refrigerator with a plastic cling-wrap cover that was not secured or sealed. The Registered Dietician stated that there was a risk of the tomato sauce spoiling because it was not properly sealed or that if it was to fall, the contents of the container could spill inside the refrigerator, creating a contamination issue. In an interview on 7/10/24 at 11:45 am with the Dietary Director, she stated that the meat found thawing in the refrigerator should have had a tray under it. She stated that refrigerator was only used for raw foods to be thawed out before they were cooked but the liquid could have soaked into boxes or other foods surrounding it. She stated that she did not believe there was a resident outcome from not having a tray under the thawing meat. She stated that the fruit found uncovered in the refrigerator should have had a lid with a label and a date. She stated that when she looked at the fruit some of it was still edible, but some was mushy in appearance. She stated the resident outcome was a lack in flavor, and possible contamination of the fruit from being left uncovered. She stated that the tomato sauce and the ranch dressing were both at risk of contamination due to not being properly sealed which could put residents at risk of becoming sick. She stated that the fruit, tomato sauce, and ranch dressing had all been disposed of when they were discovered. Review of facility policy titled Food Receiving and Storage, revision date November 2022, revealed, in part: All foods stored in the refrigerator or freezer are covered, labeled, and dated (use by date). Uncooked and raw animal products and fish are stored separately in drip-proof containers and below fruits, vegetables and other ready-to-eat foods to prevent meat juices from dripping onto these foods.

Based on interviews and record review the facility failed to ensure that residents who have not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 2 (Residents #3 and #7) of 8 residents reviewed for unnecessary medications, and failed to ensure PRN orders for psychotropic drugs were limited to 14 days for 1 (Resident #98) of 8 residents reviewed for unnecessary medications. The facility failed to ensure that Resident #7 and Resident #3 had appropriate diagnoses for Risperidone (an antipsychotic used to treat schizophrenia and bipolar disorder). The facility failed to ensure that Resident #98 had a 14-day limit on her order for PRN Lorazepam. These failures put residents at increased risk for adverse consequences such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status from receiving unnecessary antipsychotic medications. The findings included: Resident #98 Record review of Resident #98's face sheet dated 07/10/2024 revealed she was [AGE] years old, initially admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident # 98's history and physical dated 07/01/2024 revealed she had diagnoses including Parkinson's disease history of deep vein thrombosis (blood clots in the leg), pulmonary embolism (blood clot in the lung), and was receiving hospice care. Record review of Resident #98's Admission MDS assessment dated [DATE] revealed she had a BIMS score of 12 (moderate cognitive impairment). She had no symptoms of delirium, psychosis, and no behavioral symptoms. She had diagnoses including non-Alzheimer's dementia, Parkinson's disease, seizure disorder or epilepsy, and depression. She was taking an antipsychotic, and an antidepressant. Record review of Resident # 98's care plan dated 6/30/2024 revealed she was at risk of adverse consequences from taking antipsychotic medication (quetiapine). Her care plan dated 6/30/2024 revealed she had a diagnosis of depression/bipolar disorder and was at risk for fluctuation in moods, little interest, or pleasure in doing things, decreased socialization, and was currently receiving Mirtazapine (an antidepressant). Her care plan dated 6/30/2024 revealed she had episodes of anxiety, was at risk for fluctuation in moods, and was taking lorazepam (an anti-seizure and anti-anxiety medication). Record review of Resident # 98's physician's order for Lorazepam Oral Concentrate 2 MG/ML (Lorazepam) revealed she was to receive an application by mouth every four hours as needed for anxiety/restlessness. No end date for the as-needed order was indicated. Record review of Resident #98's June and July MARs revealed that she had never been administered Lorazepam Oral Concentrate 2 MG/ML . In an interview on 07/11/24 at 02:04 PM the DON revealed that Lorazepam prescribed for Resident #98 and other anxiolytics (medicines to treat anxiety) were psychotropic medications and that regulations put a 14-day limit on PRN psychotropics. She stated that she audited resident charts on admission and as needed to confirm psychotropic medications were ordered appropriately. She said the 14-day limit on psychotropic medications were in place to ensure that the patient was tolerating the medication and to see if the medication was effective. She said the 14-day limit on PRN psychotropic medications also helped prevent overuse of the medications. She pointed out that the medication had been prescribed for the resident as a comfort measure because the resident was in hospice but acknowledged that the facility was responsible for what the hospice did when providing services to facility residents. Review of Resident #7's Admission Record, dated 7/10/24, revealed she was a [AGE] year-old female originally admitted to the facility 5/20/19 with a most recent admitted [DATE]. She had diagnoses which included dementia with behavior disturbances, end stage renal disorder with dependence on dialysis, major depressive disorder, generalized anxiety disorder, and type 2 diabetes mellitus. Review of Resident #7's Annual MDS Assessment, dated 5/24/24, revealed she was receiving PASARR services for intellectual disability, she had a BIMS score of 2 indicating severe cognitive impairment with inattention, she used a wheelchair for mobility, required maximum assistance, or was dependent on staff for all ADLs except for eating. She received antipsychotic medication and antiplatelet medication. An antipsychotic GDR was documented as clinically contraindicated on 7/1/22. She received hemodialysis, speech therapy, occupational therapy, and physical therapy. Review of Resident #7's Care Plan, most recent revision 6/25/24, revealed the following: Focus - Resident uses psychotropic medication Risperidone as ordered. Goal - The resident will be/remain free of psychotropic drug related complications including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction, or cognitive/behavioral impairment through the review date. Interventions - Antipsychotic Medication - Monitor for dry mouth, constipation, blurred vision, disorientation/confusion, difficulty urinating, hypotension, dark urine, yellow skin, N/V, lethargy, drooling, EPS symptoms (tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue). Document: Y if monitored and none of the above observed, N if monitored and any of the above was observed, select chart code Other/See Nurses Notes and progress note findings. Behaviors - Monitor for the following: itching, picking at skin, restlessness (agitation), hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusing care - Document N if monitored and none of the above observed, Y if monitored and any of the above observed, select chart code Other/See Nurses Notes and progress note findings. Administer Psychotropic medications as ordered by physician - monitor for side effects and effectiveness. Consult with pharmacy and MD to consider dosage reduction when clinically appropriate at least quarterly. Monitor/document/report PRN any adverse reactions of psychotropic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, vomiting, behavior symptoms not usual to the person. Review of Resident #7's most recent Psychiatric Follow Up Evaluation, dated 5/19/24, revealed Psychiatric Diagnosis: 1. Unspecified dementia without behavioral disturbances; 2. Major depressive disorder, recurrent, moderate; 3. Anxiety unspecified. Psychiatric Treatment Plan: Continue risperidone 0.5 mg BID for dementia and aggressive behaviors. Review of Resident #7's Order Summary Report, dated 7/10/24, revealed the following: Antipsychotic Medication - Monitor for dry mouth, constipation, blurred vision, disorientation/confusion, difficulty urinating, hypotension, dark urine, yellow skin, N/V, lethargy, drooling, EPS symptoms (tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue). Document: Y if monitored and none of the above observed, N if monitored and any of the above was observed, select chart code Other/See Nurses Notes and progress note findings - every shift (Order Date 12/11/23) Risperidone oral tablet 0.5 mg: give one tablet by mouth two times a day for impulsive disorder (Order Date 12/14/23). Review of Resident #7's MAR on 7/10/24 revealed that in the months of May 2024, June 2024, and July 2024, she received risperidone 0.5mg twice a day as ordered. Resident #3 Record review of Resident #3's face sheet revealed she was [AGE] years old, was initially admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #3's history and physical dated 11/19/2023 revealed she had diagnoses including dementia. She was sent to a geriatric behavioral unit for being erratic, combative, and having violent behaviors. She had diagnoses including exacerbation of major depressive disorder, and dementia with behavioral disturbances. She was to continue receiving Risperidone for her diagnosis of dementia with behavioral disturbance. Record review of Resident #3's annual MDS assessment dated [DATE] revealed she had a BIMS score of 2 (severe cognitive impairment). She had no symptoms of delirium or psychosis and had no behavioral symptoms over the seven days before the assessment. Her active diagnoses included non-Alzheimer's dementia, anxiety disorder, and depression. She had received antipsychotic and antidepressant medication during the seven days before the assessment. She was receiving antipsychotics on a routine basis and no GDRs had been attempted. The physician had not documented that GDR was clinically contraindicated. Record review of Resident #3's physician's order dated 01/23/2024 revealed she was to be administered 0.25 MG of Risperidone at bedtime for behavioral disturbance. Record review of Resident #3'a MAR for May 2024 revealed she was administered 0.25 MG of Risperidone at bedtime every day for behavioral disturbance. Record review of Resident #3'a MAR for June 2024 revealed she was administered 0.25 MG of Risperidone at bedtime every day for behavioral disturbance. Record review of Resident #3'a MAR for July 2024 dated 07/10/2024 revealed she was administered 0.25 MG of Risperidone daily at bedtime for behavioral disturbance from 07/01/2024 through 07/09/2024. Record review of Resident #3's pharmacy review Note to Attending Physician/Prescriber dated 1/19/2024 revealed a note to the physician indicating that the conditions indicated for use of Risperdal, an antipsychotic, including Unspecified Dementia with behavioral disturbances, insomnia unspecified, and Major Depressive Disorder, recurrent moderate, did not justify the use of an antipsychotic. Based on the physician's note, the resident's dosage of Risperdal was decreased, but diagnoses were not changed. Record review of Resident #3's pharmacy review Note to Attending Physician/Prescriber dated 03/29/2024 revealed a note to the physician regarding Resident #3 indicating that her Risperdal was due for DGR and recommended reducing Risperdal 0.25 to 0.125 MG. A facility follow-though comment stated that a note was written to the secondary physician. Record review of Resident #3's pharmacy review Note to Attending Physician/Prescriber dated 04/30/2024 revealed a note to the physician indicating that Risperdal was presented for GDR the month before along with another suggested medication change (reduce Trazodone 150mg half tablet) and neither were changed. The pharmacy review note recommended that the physician consider reducing Risperdal to 0.25 MG to PRN for 14 days and then discontinuing it. The pharmacy review also noted that Risperdal did not currently carry an appropriate indication for the setting [nursing facility]. No response to the pharmacy recommendation was noted. Record review of Resident #3's pharmacy review Note to Attending Physician/Prescriber dated 05/16/2024 revealed a note to the physician indicating that Risperdal 0.25 was not properly indicated to continue at this time and to please discontinue the medication to comply with current regulations. The pharmacy review recommendation was signed on 6/6/2024 indicating the signer disagreed with the recommendation. No justification for disagreeing with the recommendation was written on the physician's note. In an interview on 07/11/24 at 02:17 PM the DON revealed that Resident #3 should not be prescribed Risperidone for behavioral disturbance, because it was an inappropriate diagnosis. She stated that she had not had an opportunity to audit medications due to her recent arrival, that the medication was prescribed before she took the position as DON so she had not seen it. She said that when pharmacy recommendations were received the physician would be notified. In the case of Resident #3's pharmacy recommendation it had been reviewed by the nurse practitioner, but no change had been made to the prescription. The DON said recommendations regarding antipsychotics might be made to prevent their overuse, that there were concerns that antipsychotics might be used as chemical restraints, that they could have side effects such as dyskinesia (uncontrolled, involuntary muscle movements), and neurological defects. She stated she was aware of black box warning that antipsychotics should not be used for older adults with dementia. She stated that the prescriber should indicate on the Pharmacy Recommendation why recommended changes were denied. Record review of the facility policy Antipsychotic Medication Use revised 07/2022 revealed that residents would not receive medications that were not clinically indicated to treat a specific condition for which they were indicated and effective. Physicians would respond by clearly documentation based on assessment why the benefits of the medication outweighed the risks. 45411

Based on interviews and record review, the facility failed to ensure dialysis services were provided consistently with professional standards of practice for 2 (Resident #7 and Resident #40) of 2 residents reviewed for dialysis services. The facility failed to ensure post-dialysis (treatment that filters water and waste from the blood when the kidneys are no longer able to do so) assessments were documented in Resident #7 and Resident #40's charts. These failures could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs. Findings included: Resident #7 Review of Resident #7's Admission Record, dated 7/10/24, revealed she was a [AGE] year-old female originally admitted to the facility 5/20/19 with a most recent admitted [DATE]. She had diagnoses which included dementia with behavior disturbances, end stage renal disease (condition in which the kidneys permanently stop working and can no longer perform their essential functions) with dependence on hemodialysis (treatment that filters water and waste from the blood when the kidneys are no longer able to do so), major depressive disorder, generalized anxiety disorder, and type 2 diabetes mellitus. Review of Resident #7's Annual MDS Assessment, dated 5/24/24, revealed she was receiving PASARR (Preadmission Screening and Resident Review) services for intellectual disability, she had a BIMS (Brief Interview for Mental Status) score of 2 indicating severe cognitive impairment with inattention, she used a wheelchair for mobility, and required maximum assistance or was dependent on staff for all ADLs except for eating. She received antipsychotic medication and antiplatelet medication. She received hemodialysis, speech therapy, occupational therapy, and physical therapy. Review of Resident #7's Care Plan, most recent revision 6/25/24, revealed the following: Focus - Impaired renal function: I receive dialysis three times per week and at risk for increased SOB (shortness of breath), chest pains, blood pressure, itchy skin, nausea and vomiting, impaired cognition, infection to shunt (a surgically created connection between an artery and a vein that allows a dialysis machine to access the bloodstream for hemodialysis) site, and decreased urine output. Goal - Will have no complications or infected shunt site through next review date. Interventions - Administer medications per order - monitor labs and report abnormalities to MD. Assess shunt site before and after dialysis - notify MD of any abnormalities. Auscultate (listen with a stethoscope) bruit (sound heard over an artery reflecting the turbulence of blood flow) to shunt every shift. Do not take BP on extremity of shunt site. Ensure resident is aware of dietary recommendations/restrictions r/t disease process. If bleeding noted from shunt site apply pressure until bleeding subsides and notify MD. Monitor resident condition pre/post dialysis, report abnormalities to MD. Monitor/assess shunt site for s/sx of infection, bleeding, etc., every shift - notify MD. Provide assist with ADLs and comfort measures as needed. Serve diet per order - monitor intake. Provide sack lunch as needed. Focus - Resident is dependent on dialysis Monday, Wednesday, and Friday r/t ESRD (End Stage Renal Disease). Goal - The resident will have no s/sx of complications from dialysis through the review date. Interventions - Monitor shunt for bleeding every hour for the first 4 hours upon return from dialysis center, report changes to NP/MD, document findings in nurses' notes. Check dialysis shunt for bruit and thrill (a vibration that can be felt on the skin over a blood vessel) every shift and report changes to NP/MD (redness, swelling, irritation, uncontrolled bleeding and change in bruit and thrill). Do not take BP or lab draws in right arm r/t fistula (an abnormal connection between two parts of the body) in place. Encourage resident to go for the scheduled dialysis appointments - resident receives dialysis (Monday, Wednesday, and Friday). Monitor labs and report to doctor as needed. Monitor/document/report PRN any s/sx of infection to access site: redness, swelling, warmth, or drainage. Monitor/document/report PRN for s/sx of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa (soft tissue lining of the mouth), changes in heart, and lung sounds. Monitor/document/report PRN for s/sx of the following: bleeding, hemorrhage (bleeding from a ruptured blood vessel), bacteremia (bacteria in the blood), septic shock (bacterial infection causing dangerously low blood pressure, organ failure, and widened blood vessels). Send snack with her to dialysis. Review of Resident #7's Order Summary Report, dated 7/10/24, revealed the following: Check dialysis shunt for bruit and thrill every shift and report changes to NP/MD (redness, swelling, irritation, uncontrolled bleeding, and change in bruit and thrill) - every shift (Order Date 12/8/23) Monitor dressing to perm-a-cath (flexible tube that can be used for a variety of medical procedures including dialysis) site every shift, report changes to NP/MD - every shift (Order Date 12/8/23) Monitor shunt for bleeding every hour for the first 4 hours upon return from dialysis center, report changes to NP/MD, document findings in nurses' notes - in the afternoon every Monday, Wednesday, and Friday (Order Date 12/8/23) No venipuncture (blood draw) or blood pressure to right upper extremity (right arm) with dialysis access - every shift (Order Date 4/4/24) Resident to be dialyzed every Monday-Wednesday-Friday, provide resident with a packed meal, report changes to NP/MD (ex: resident misses dialysis on scheduled days) - Chair time is 9:00 (Order Date 12/8/23) Observation and record review on 7/10/24 at 4:05 pm of 100/200 Hall Dialysis Communication binder revealed 17 communication sheets dating back to May 2024. Two of the sheets had the name of a discharged resident. Of the remaining 15 sheets, 5 had no resident name or identifier to indicate which resident they belonged to and the other 10 had Resident #7's name on them. The forms that had no resident identifier (name, birthdate, identification number) where completed by both the facility nurse and the dialysis center nurse. Review of facility form Hemodialysis Communication revealed the form contained a section for date of service, vital signs, pain assessment, vascular access type and site, and any changes with the resident since the last treatment to be communicated to the dialysis center, as well as a section for nurse signature/date/time. The form also contained a section to be completed by the dialysis center nurse regarding medications given during treatment, order changes, follow-ups, and any occurrences during the treatment, as well as a section for nurse signature/date/time. Record review on 7/10/24 at 4:10 pm of Resident #7's electronic chart progress notes section revealed no post-dialysis documentation in nurses notes for the months of May 2024, June 2024, and July 2024. Observation and interview on 7/10/24 at 3:45 pm Resident #7 was observed sitting in her wheelchair by the nurses station on the 100/200 Hall. Two flesh-colored bandages were noted to the resident's right upper arm at her dialysis access site. When asked if she went to dialysis that morning, Resident #7 stated yes and smiled. When asked if her arm was still bleeding when she returned to the facility she stated yes and held her right arm out and pointed to the bandages. Resident #7 denied pain to the site. When asked if the bandages were placed on her arm at the dialysis center, she shook her head side to side and stated no, here. The State Surveyor clarified by asking if the nurse put the bandage on her arm when she got home and Resident #7 stated yes. Resident #40 Review of Resident #40's Admission Record, dated 7/11/24, revealed he was an [AGE] year-old male originally admitted to the facility on [DATE] with a most recent admitted [DATE]. He had diagnoses which included chronic kidney disease (longstanding disease of the kidneys leading to kidney failure) with dependence on renal dialysis (treatment that filters water and waste from the blood when the kidneys are no longer able to do so), type 2 diabetes mellitus, history of heart attack, and anemia. Review of Resident #40's Medicare 5-Day MDS Assessment, dated 6/30/24, revealed a BIMS (Brief Interview for Mental Status) score of 6 indicating severe cognitive impairment, he required moderate to maximum assistance for most ADLs, but was dependent on staff for toileting, bathing, and dressing. e required a wheelchair for mobility. He received hemodialysis. Review of Resident #40's Care Plan, most recent revision date 7/6/24, revealed no care plan in place for dialysis. Review of Resident #40's Order Summary Report, dated 7/11/224, revealed the following: Check dialysis catheter to right upper chest every shift and report changes to NP/MD (redness, swelling, irritation, uncontrolled bleeding and change in bruit (sound heard over an artery reflecting the turbulence of blood flow) and thrill (a vibration that can be felt on the skin over a blood vessel) - every shift (Order Date 6/24/24) Check dialysis catheter to right upper chest every shift for bleeding and report changes to NP/MD (redness, swelling, irritation, uncontrolled bleeding, etc.) - every shift (Order Date 6/24/24) No venipuncture (blood draw) or blood pressure to right upper extremity (right arm) with dialysis access - every shift (Order Date 6/24/24) Resident to be dialyzed every Monday-Wednesday-Friday. Provide resident with a packed meal. Report changes to NP/MD (ex: resident misses dialysis on scheduled days) every shift, every Monday, Wednesday, Friday (Order Date 6/24/24) Record review on 7/11/24 at 4:28 pm of 300/400/500 Hall Dialysis Communication Binder revealed no Hemodialysis Communication forms for Resident #40. The binder contained only blank forms. Record review on 7/11/24 at 4:40 pm of Resident #40's electronic chart progress notes section revealed no post-dialysis documentation in nurses notes since his readmission to the facility on [DATE]. Review of the facility form Hemodialysis Communication on 7/10/24 at 4:05 pm revealed the form contained a section for date of service, vital signs, pain assessment, vascular access type and site, and any changes with the resident since the last treatment to be communicated to the dialysis center, as well as a section for nurse signature/date/time. The form also contained a section to be completed by the dialysis center nurse regarding medications given during treatment, order changes, follow-ups, and any occurrences during the treatment, as well as a section for nurse signature/date/time. In an interview on 7/10/24 at 4:19 pm, the ADON stated he believed there were currently only two residents in the facility on dialysis, but he needed to check in the computer. The ADON verified in the computer that there were, in fact, only two residents receiving dialysis: Resident #7 on 100 hall and Resident #40 on 300 hall. He stated that the nurses were supposed to document on the MAR when doing shunt site checks and monitoring vitals before and after the resident goes to dialysis. The ADON stated he had completed the assessments himself and knew the other nurses were completing them because he had observed them when they (the assessments) were done. He stated Resident #7's order did say to document the site check in a nurses note but he was unsure if that meant for every site check or just if there were issues. The ADON stated that after rereading it, he believed the order was for any exception to her regular status not to document each time. He stated he was uncertain of Resident #40's orders and would review them. He stated that the facility used the communications sheets and the MAR as their pre- and post-dialysis monitoring for residents. In an interview on 7/10/24 at 4:30 pm, the DON stated the nurses should have been documenting something in a progress note when a resident returned to the facility from receiving dialysis, not just using the communication sheets and the MAR. She stated she knew the nurses were completing assessments on the residents when they returned from dialysis because she had witnessed them being performed. She stated she was new to the position of DON, and she did not know what the facility policy was for documenting when a resident returned from dialysis, but she stated that the current documentation did appear lacking. Review of facility policy titled Hemodialysis Catheters - Access and Care of, revision date February 2023, revealed, in part: Care Immediately Following Dialysis Treatment: 1. The dressing change is done in the dialysis center post-treatment. 2. If the dressing becomes wet, dirty, or not intact, the dressing shall be changed by a licensed nurse trained in this procedure. 3. Mild bleeding from site (post-dialysis) can be expected. Apply pressure to insertion site and contact the dialysis center for instructions. 4. If there is major bleeding from site (post-dialysis), apply pressure to the insertion site, and contact emergency services and the dialysis center. Verify that clamps are closed on lumens. This is a medical emergency. Do not leave resident alone until emergency services arrive. The policy did not address documentation of pre/post-dialysis assessments.

Based on interview and record review the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #198) of 1 resident reviewed for pain. The facility failed to provide pain relief during wound care for Resident #198. This failure could place residents at risk for unnecessary pain, stress, irritability, aggressive behavior fear of treatment, seeking other means of managing pain, and decreased quality of care. Findings included: Review of Resident #198's undated face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -1 [MEDICATION(S)] 50mg every 6 hours as needed for pain start date 5/09/2022. -Tylenol with [MEDICATION(S)] #3 300-30 mg give 1 tablet 1 day for pain start date 5/10/2022. -Apply [NAME] Ointment 250 unit/grams apply to sacral area topically 1 time a day for stage 3 clean with n/s (normal saline) pat dry skin prep surround area with border foam dressing every day and as needed. Start date 5/09/2022 Review of Resident #198's initial care plan dated 04/26/22 revealed the resident had an ADL performance deficit. The resident had limited mobility. Resident #198 was on pain medication therapy. Review of the Resident #198's MAR and pain assessment dated [DATE] releveled the resident received the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] - On 5/10/22 at 8:45 AM the resident received Tylenol #3 (300 mg acetaminophen-30mg [MEDICATION(S)]) (for pain at 0 on a 0 to 10 pain scale 10 being the worst pain possible). -5/10/2022 at 3:36 PM the resident received [MEDICATION(S)] 50 mg with pain scale at 5 -5/11/2022 at 8:32 AM the resident received [MEDICATION(S)] 50 mg with pain scale of 6, (0 no pain 10 being the worst pain possible) Review of Resident #198 nurse's notes dated 5/9/2022 at 7:30 PM, revealed Resident #198 was having pain on her buttocks, Resident #198 was asked if she asked the nurses for her prn (as needed) medication and she stated she did not. Resident #198was asked if she would like the medication scheduled. Resident #198 stated she wanted the [MEDICATION(S)] 50 mg QHS the NP was notified and gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #198 nurse's notes dated 5/9/2022 at 10:42 AM revealed, the residents wound care completed today in AM (morning) noted resident wound bed with slough tissue diminishing and noted some palpable bone exposure with some depth to wound site area continue with no signs and symptoms of infection. The MD (medical doctor) was in facility and made aware. The MD suggested continuing treatment, resident peri area with rash and excoriated tissue resolving resident complaining of less pain. During an interview with Resident #198 on 05/08/22 at 11:14 AM she said, it took a while to get pain medication. During an interview on 5/9/2022 at 2:33 PM, Resident #198's husband said, she had pain due to her pressure wound and the nurses were not addressing it. He said she got medication for her migraines but not for her wound, Resident #198 said she presently had a pain of 8 on the pain scale of 0 to 10. During an interview with Nurse LVN B on 5/9/2022 at 2:50 PM, said, we do not have the [MEDICATION(S)] 50 mg available but expected it soon. During wound care observation on 05/10/22 at 10:38 AM, Resident #198 was given Tylenol #3 pre-medicate at 745 AM start wound care at 9:50 AM Resident #198's pain was at 6 with 0-10 scale. During wound care on 05/10/2022 at 9:50 AM, Resident #198 was crying out she was hurting, the wound care nurse LVN A continued asking if she was alright and she would say yes but continue to cry out in pain. After wound care Resident #198 reported a pain scale of 6. During an interview with the wound care nurse on 5/10/2022 at 10:45 AM he said he would stop providing wound care when the resident could no longer tolerate the pain. During an interview on 05/10/22 at 11:29 AM, LVN B she said they got the NP (nurse practitioner) to order a 1-time order for Tylenol #3 primarily for therapy because she was refusing therapy, but we gave it to her prior to her wound care for today (5/10/22). She said the [MEDICATION(S)] should arrive today. When asked why [MEDICATION(S)] was not available, she said it was not available when she tried to take it out from the medicine dispenser. During an interview with DON on 5/10/2022 at 3:15 PM she said if we need pain medication all we have to do was call the physician and the pharmacy to be able to get pain medication from the medication dispensed immediately if it was a stat (immediately) order. When it was revealed Resident #198 was complaining her pain that was not being relieved; and on 05/09/22 was at a pain scale of 8 and a family member complained the nursing staff are not taking care of her pain, the DON said she would address the issue. Facility's Policy , Pain Assessment and Management, dated March 2015 revealed the following: Purpose: the purposes of this procedure are to help the staff identify pain in the residents and to develop interventions that are consistent with the resident's goal and needs and that address the underlying causes of pain. General Guidelines: .2. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. 3. Pain management is a multi-disciplinary care process that includes the following: a. Assessing the potential for pain b. Effectively recognizing the presence of pain. .e. Developing and implementing approaches to pain management f. Identifying and using specific strategies for different levels and sources of pain. g. Monitoring for the effectiveness of interventions and h. Modifying approaches as necessary. 6. Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain at least weekly in stable chronic pain.

Based on observation, interview and record review, the facility failed to establish and maintain an Infection Prevention and Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four (June 2021, July 2021, August 2021 and September, 2021) of four months of screening logs reviewed, and failed to insure that all persons entered the facility through the specific single entrance for four (Kitchen Aide C, Kitchen Aide D, Kitchen Aide E and Dietary Manager) of fifteen employees reviewed for compliance with entrance to the facility though a single specified monitored entrance. Failures leading to the Immediate Jeopardy include: - facility failed to screen staff and visitors for symptoms of COVID-19 and risk factors for exposure to COVID 19 - facility failed to actively monitor that staff/visitors were taking and recording their temperatures - Facility failed to ensure that staff did not enter the facility through an unmonitored door. An Immediate Jeopardy (IJ) was identified and announced to the AIT on 10/1/2021. While the IJ was removed on 10/04/2021, the facility remained out of compliance at a potential for more than minimal harm with a scope of widespread due to the facility's need to evaluate the effectiveness of their plan of correction. These failures put all residents and staff at risk of exposure to the COVID-19 virus and variants and resulting infection, illness, impairment, and possible death. Findings Included: Observation on 09/28/2021 at 8:03 -8:06 AM, 09/28/2021 at 1:25 - 1:26 PM, and 10/29/2021 8:00 AM - 8:09 AM by three surveyors of the front entrance to the facility revealed the following: A stand containing hand sanitizing gel labeled Step One; a stand with an automatic temperature detection device, labeled Step two; and a table labeled Step Three, which contained pens, visitor labels, and a clip board containing untitled sheets with columns titled: Date, Time, Name (Please Print), Temp and Room. Multiple staff and visitors were observed coming into the building and following Steps 1-3. Receptionist F was observed seated at a desk which looked out on the reception area, but the receptionist was observed to be engaged in other activities such as answering/talking on the phone or looking at a computer screen or a cell phone. No active monitoring of the sign-in process was observed unless there were difficulties with the temperature taking device, as which point the receptionist would provide instructions on how to position oneself for temperature-taking. The untitled sheets (sign-in sheets) on the table in the reception area had no instructions requesting, no spaces for writing down, and no other manner for documenting information regarding the signer's risk factors for COVID-19 such as travel outside the country or exposure to persons diagnosed with COVID-19, or the presence/absence of any symptoms of COVID-19 that the signer might be experiencing. No instructions indicating how the untitled sheets were to be completed were observed on or around the table in the reception area. Record review of an e-mail received on 09/28/2021 at from the AIT indicated that there were 75 facility employees. In an interview on 09/28/2021 at 5:33 PM Kitchen Aide C stated that she entered the facility through the delivery door at the back of the kitchen. She stated that the facility did not take her temperature or otherwise screen her before she entered the facility that morning, and that this was true for the kitchen employees. She stated that the kitchen staff had been coming in the delivery door at the back of the kitchen for about one to two months. She stated that it been a couple a months since kitchen staff had stopped coming through the front entrance, getting their temperatures taken and signing in. In an interview on 09/28/2021 at 5:39 PM Cook D stated that there was an entrance to the facility at the back of the kitchen and that she had come in that way today [09/28/2021]. She stated that she had not been screened that day. In an interview on 09/28/2021 at 5:46 PM Kitchen Aide E stated that there was an entrance to the building at the back of the kitchen and that she had been coming in that way for a while. She stated that the facility had not been taking their temperatures since about two months ago when they started coming in the kitchen delivery door. In interviews on 09/28/2021 at 3:44 PM and 6:01 PM the DON/IDP stated that employees are to use the front entrance where they were to be screened. She stated that she had not done any trainings for staff regarding entrance through the front door, and was not aware whether someone else might have done this training. She stated that she was not sure if kitchen staff were entering the building through the front door but that they should be screened. She could not explain why kitchen staff would be entering from the kitchen delivery door rather than the front door. Observation on 09/29/2021 at 7:59 AM of the front entrance to the facility revealed the that the sign-in sheets had been replaced with a screening sheet which asked that people coming into the facility indicate if they had symptoms of COVID-19. In interviews and observation on 09/29/2021 at 10:34 AM and 10/03/2021 at 10:04 Family Member #1 was observed walking into the facility. On 09/29/2021 at 10:34 AM when greeted by the surveyor, Family Member#1 apologized for not using hand sanitizing gel as she entered the facility. She stated that she did take her temperature and had written it down on the sign in sheet. On 10/03/2021 at 10:04 Family Member #1 confirmed that she had noticed a change in the screening procedure at the front door and that someone had guided her though the new procedure that involved a checklist of symptoms. She stated that she had been oriented to the process for signing in when she came to tour the facility prior to her family member being admitted . In an interview on 09/29/2021 at 11:28 AM LVN A stated she had started working at the facility about three month ago and that during that time she had not been asked and had not filled out a questionnaire with screening questions about COVID symptoms or risks. In an interview on 09/29/2021 at 4:22 PM the DON/IDP stated that no one was designated to monitor screening of people coming into the facility. She stated that she had never seen any entrance screening questionnaire with COVID-19 symptoms or risk factors. The DON/IDP stated she had not asked why there was no screening questionnaire although she had seen these in other facilities. She stated that screenings were used to make sure that people coming into the facility had not been exposed to COVID-19. In an interview/observation on 9/29/2021 at 6:56 PM the AIT stated that he had been informed that day that dietary kitchen staff were entering through the back of the building and not through the front. He stated the policy is that everyone is supposed to be coming through the front door and getting screened. He believed that the policy did say something about a questionnaire, that the questionnaire is not being filled out, but was on the table in the reception area. The AIT was observed to walk to the table in the reception area and look for the questionnaire. He found it on a clipboard behind several sheets of Visitor badges. He stated that he did not know how long the questionnaire had not been filled out. He stated that the front office person was supposed to be monitoring that information is filled out. He stated that no one was checking that she is following the policy. He was not aware that some persons were not putting in their temperatures. He stated that the infection preventionist and he (AIT) were ultimately responsible to ensure that these things are done. In an interview on 9/30/2021 at 8:45 AM the Dietary Manager said that she oversees 15 kitchen staff members, three of whom work only on the Assisted Living side of the facility. She said that since the beginning of the pandemic employees were instructed to go through the front entrance and get screened prior to reporting to their work area. She said that sometime in the summer this year, kitchen staff started to report to work by coming through the kitchen delivery door. She said that she herself was coming into work and entering through the kitchen delivery door without first being screened at the front door. She said that there is no temperature check or questionnaire at the kitchen delivery door. She said that the cooks have keys for the door and open the door early in the morning when they first come to work and then leave the door unlocked for other employees and delivery services to come in. In an interview on 09/30/2021 at 8:46 AM Receptionist B stated that she started in May and had received training about COVID-19 symptom. She stated that since there had been no outbreaks of COVID-19 for a while people were coming in and out of the front door of the facility. She stated she received training to make sure that each family member, guest and employee took their temperatures, signed in and had a new mask. She stated that when the facility had the recent outbreak around Thursday or Friday [09/23 - 09/24/2021] they implemented the new policies like getting new masks. She stated that gaps in the recording of temperatures on the sign in sheets might have happened while she was away from her desk. In an interview on 09/30/2021 at 9:25 AM the AIT stated that he had not been aware until it was pointed out by surveyors that kitchen staff had been entering the facility through the kitchen delivery door directly into the kitchen and were not screened. He stated that he did not know how this happened but it was possible that this was happening because staff members parked at the back of the facility and it was easier for them to enter the facility through the kitchen delivery door rather than walk around to the front entrance. He stated that department heads were responsible for monitoring where their employees enter the facility and that the Dietary Manager should have informed him that her employees were not coming in the front entrance. He stated he had just been made aware of the absence of temperatures on the sign-in sheets. He stated that he had three people to monitor the front entrance to whom he had given some informal training but that they had no formal training and he did not have any written documentation that they had been trained sign-ins. At night (7:00 PM - 8:00 AM) nurses from the 100 and 200 hall were to monitor the sign-in process. In an interview on 10/02/2021 at 12:10 PM the Dietary Manager stated that kitchen staff started entering the facility through the kitchen delivery door because they just got lax. She stated that staff had gotten training regarding entrance to the facility during COVID-19 early-on - a few DONs ago and had not received retraining on this since then. She stated that in those early trainings employees were told they had to be screened and needed to come in through the front door. In an interview on 10/04/2021 at 2:52 PM the LNFA stated that the sign-in sheets present in the reception area at the time of the surveyor's entrance to the facility were working and stated that signs and symptoms and risk factors were in fact on the sign-in sheets. The surveyor pointed out to the LNFA original sign-in sheets from September 2021 which did not include information regarding signs, symptoms, or exposure risks for COVID-19. He stated that the sign-in sheets included an attestation regarding the signs, symptoms, and exposure risks for COVID-19. He then stated that information for attestations regarding signs, symptoms, or exposure risks for COVID-19 were on the table in the facility reception area. In interview/record review on 10/04/2021 at 4:20 PM the LNFA presented three documents as follows: - Prevent COVID-19: Screening Checklist - Recommendations for SNF Visitors [undated]; - BY SIGNING BELOW, YOU ARE AKNOWLEDGING THAT YOU ARE FREE FROM COUGH, FEVER, BODY ACHES, LOSE [SIC] OF TASTE AND SMELL, GI ISSUES AND CONFUSION [UNDATED] [Emphasis in original]; - Symptoms of Coronavirus (COVID-19) [from the CDC dated 07/21/ ] The LNFA stated that these three documents had been present in the facility reception area and that by signing in staff and visitors were attesting that they did not have any symptoms or risk factors for COVID-19. A record review of completed sign-in sheets (untitled) for dates during from June 2021, July 2021, August 2021, and September 2021 revealed that they did not ask for information regarding signs, symptoms, or exposure risks for COVID-19. They did ask for temperatures, but contained multiple instances where people entering the facility had written in their names but did not write in temperatures as follows: June 2021 - four signatures without temperatures; July - 138 signatures without temperatures, August - 234 signatures without temperatures; September 2021 - 329 signatures without temperatures. None of the sheets reviewed had any indication that the intent of the sheet was to affirm that the signer was confirming or denying that they did nor did not have symptoms of COVID-19 or risk factors for COVID-19. Review on 09/28/2021 of the undated facility policy titled Screening Protocol: Entering the Facility documented that all person will ONLY [emphasis in original] enter through the front entrance. Procedures included filling out a questionnaire. The questionnaire and completeness of the screening protocol would be reviewed by facility staff at all times. Review on 09/28/2021 of the undated Prevent COVID-19: Screening Checklist documented inclusion of questions regarding the purpose of the visit, respiratory symptoms, international travel, work in other health care settings, participation in events with crowds in a confined common setting, and contact with persons with confirmed COVID-19. Review of the facility policy COVID-19 Updated Visitation Guidelines dated March 11, 2021 documented that a core infection prevention principle was screening of all who entered the facility for signs and symptoms of COVID-19 (e.g., temperature checks, questions about and observation for signs or symptoms), and denial of entry to those with symptoms of COVID-19 or who had contact with someone with COVID-19 infection in the prior 14 days. In an interview on 10/01/2021 at 11:42 AM the AIT was notified that an IJ had been identified and a copy of the IJ Template identifying the areas of noncompliance, elements of risk, and need for immediate action were provided to the AIT and a Plan of Removal was requested within the hour. The facility's Plan of Removal was received on 10/02/2021 at 2:24 PM and accepted on 10/02/2021 at 3:11 PM. The acceptance of the Plan of Removal was announced to the AIT on 10/02/2021 at 3:11 PM. The Plan of Removal stated the facility took or would take the following actions: - Facility COVID-19 screening procedures were updated to ensure all entering the building are entering through a single point of entry and screened for COVID-19 signs, symptoms and possible exposure prior to entering the facility. Front entrance is the ONLY entrance for ALL employees, visitors, vendors, essential workers After 6:00 pm M-F and 5:00 pm Sat/Sun and holidays employees, entering the facility for their start of shift will utilize phone at screening station to call nurses station to come to front entrance to review temperature and complete COVID screening and cleared for entrance into the facility After 6:00 pm M-F and 5:00 pm Sat/Sun and holidays visitors, vendors and essential workers will ring doorbell so that facility staff can complete the COVID-19 screening and temperature check to allow entrance into the facility. Once the temperature has been taken and the COVID-19 questionnaire has been completed and has been cleared to enter the facility the person will be directed to hand sanitizing station to sanitize hands prior to entering the facility. Quality assurance review of the COVID-19 screening questionnaire will be completed on a daily basis by the Director of Nursing, Assistant Director of Nursing and/or weekend supervisor by auditing screening forms for accuracy and completeness. Administrator and/or designee will conduct QA reviews bi-weekly to verify that D.O.N. and A.D.O.N. are reviewing the screening on a daily basis for accuracy. - All facility staff were in-serviced 10/02/2021 - 10/03/2021 at 10:00 PM on COVID-19 screening process by the facility administrator included taking temperature and completing COVID-19 questionnaire prior to allowing entrance into the facility and after hours employee screening to include using the phone on screening table to call nurses station to come to front entrance and conduct COVID screening. - All kitchen staff re-inserviced on the COVID-19 screening process on October 1, 2021 and to provide clarification that they are to enter through the front designated entrance ONLY. Dietary manager will be checking that the kitchen staff is not entering through the kitchen delivery door daily. - Dietary manager was trained on October 1, 2021 by [NAME], Administrator-in-training on her role to ensure NO kitchen staff, including dietary manager, will enter through kitchen door. Kitchen door is to be used ONLY for deliveries. - Kitchen door lock will be changed on 10/02/2021 to ensure the door cannot be opened from the exterior. In an interview/observation on 10/03/2021 at 10:29 AM Kitchen Aide E stated she was off Friday and Saturday (10/01/21 and 10/02/21) and had received a phone message while she was off with a training about screening procedures. She stated that when she received the message that she looked at it briefly and sent a message Confirmed that she had looked at it. She showed the surveyor the phone message (a one page document regarding screening procedures) with Confirmed in a reply field. She stated that she arrived early the morning of 10/03/2021 [Screening Log documents sign in at 5:56 AM] but that she was running late and there was no one was at the front door to monitor her screening. She stated that she filled out the screening form but then came in without someone reviewing her answers. Interviews/ observations/ record review to confirm implementation of the Plan of Removal were conducted as follows: - Interview/observation on 10/03/2021 at 11:47 AM with Plant Operations Director confirming that kitchen delivery door lock had been replaced with a lock that cannot be opened from the outside and observed the lock that had been removed from the door. - 10/04/2021 between 8:10 and 8:21 AM of interactions between receptionists and five staff/visitors educating them about the new screening process, supervising and guiding visitors who were unfamiliar with the new screening process. - 10/04/2021 4:52 PM - Documentation that facility staff had been in-serviced regarding use of a single entrance to the facility and requirement for completion of a witnessed screening for symptoms and exposure to COVID-19 prior to entering the facility. - 10/04/2021 3:59 PM - Interview with DON/IDP regarding system for addressing any yes answers on screening log - Receptionist reviews answers on an ongoing basis will notifying DON/IDP of any Yes answer. Visitors will have entrance denied, staff will be tested . for her to address - w - will test is there are yes responses on - On 10/04/2021 completed at interviews to confirm in-servicing and understanding that staff were to enter the facility through the front door and must be witnessed completing the COVID screening log with 9 CNAs from three shifts, 9 nurses from three shifts, three housekeepers, one laundry attendant, Dietary Manager, Cook, four Kitchen Aides, Activities Director, Medical Records, three Receptionists, the Social Worker and the Plant Operations Director. - Record Review on 10/04/2021 at 8:43 AM of screening log to confirm that it screened for symptoms and risk factors for COVID-19 - Record Review and interviews regarding response to any Yes answers to questions on the witnessed screening for symptoms and exposure to COVID-19 - Reviewed revised facility policy Screening Protocol: Entering the Facility dated 09/29/2021 stating that all persons will enter the building through the front entrance, will fill in the blanks on the sign in with a yes or no, that the questionnaire and screening protocol would be reviewed by facility employees, and that access to the facility could be denied based on the response to the questionnaire. The AIT was notified on 10/4/2021 at 5:04 PM that the IJ was removed. However the facility remained out of compliance at a severity of potential for more than minimal harm, and a scope of widespread due to the facility's need to evaluate the effectiveness of their plan.