Every finding on record at The Bradford at Brookside

Based on observation, interview, and record review, the facility failed to ensure each resident's drug regimen was free from significant medication error, in excessive dose (including duplicate drug therapy) for 1of 6 residents (Residents #2) reviewed for unnecessary medications. The facility failed to ensure Resident #2's routine pain medication, Hydrocodone-Acetaminophen Tablet (prescribe for acute pain, opioid agonist and a Schedule II controlled substance) 10-325 mg one tablet by mouth four times a day was not duplicated on 04/06/2026 at 9:00 p.m. by LVN C. The failure could place residents at risk for being administered unnecessary pain medication and could have adverse reactions including over sedation and decline in health condition.Record review of Resident #2's face sheet, dated 04/22/2026 indicated a [AGE] year-old male originally admitted on [DATE] and readmitted on [DATE] with diagnoses of ulcerative colitis (chronic inflammatory bowel disease (IBD) that causes inflammation in the colon lining), Crohn's disease (type of inflammatory bowel disease (IBD) that causes swelling and irritation of the tissues, called inflammation, in the digestive tract), tracheostomy (surgically created opening in the front of the neck into the trachea (windpipe) to provide an airway for breathing), chronic pain, and acute respiratory infection (infection of the upper or lower respiratory tract causing common cold to pneumonia). Record review of Resident #2's significant change in status MDS assessment, dated 03/07/2026, indicated a BIMS score of 15 indicating Resident #2 was cognitively intact. Pain management assessment indicated Resident #2 received scheduled pain medications. He was independent with self-care and mobility tasks. Record review of Resident #2's care plan, dated 12/02/2025, indicated pain management. Interventions included, Assess for change in bowel habits, appetite, and ability to rest/sleep. Assess for presence of pain at frequent routine intervals and before/after specific activities. When assessing for pain, speak slowly and clearly, and loud enough for residents to hear. If using hearing aid, make certain that it is in place and functional. Assess for ability to read the pain scale. Record review of Resident #2's care plan, dated 04/07/2026, indicated Resident #2 had a history of being involved in alleged misappropriation (intentional, unauthorized, and improper use property) related to pain medications. Interventions included, 1. Pain assessment completed. 2. Lipid panel ordered. 3. Police notified. 4. Reported to HHSC. 5. Drug screens initiated. 6. Ad Hoc QAPI. 7. In-services initiated on pharmacy services, misappropriation, drug and alcohol policy, steps to counting narcotics. Record review of Resident #2's physician orders, dated 04/22/2026, indicated the following: Hydrocodone-Acetaminophen Tablet 10-325 mg give one tablet by mouth four times a day for pain related to chronic pain and Atorvastatin Calcium (helps lower cholesterol) Oral Tablet 80 mg give one tablet by mouth at bedtime. During an observation and interview on 04/22/2026 at 1:10 p.m., Resident #2 was ambulating independently within the facility. Resident #2 said he recalled the incident with a duplication of pain medication error. He said he knew his medications, but his Hydrocodone-Acetaminophen (acute/chronic pain med) and Atorvastatin Calcium (used to treat high cholesterol and to reduce the risk of heart attack, stroke, angina, and to decrease the chance that heart surgery will be needed in people who have heart disease or who are at risk of developing heart disease) looked similar in color, shape and size, so when he took the meds, he did not realize he had taken two Hydrocodone instead of one Hydrocodone and one Atorvastatin pill on the evening of 04/06/2026. He said he had no negative effects from the medication duplication error. He said the facility ordered labs, but he refused the labs he really did not like needles and did not feel the labs were necessary. During an interview on 04/22/2026 at 4:30 p.m., LVN C said she initially was hired as a medication aide to administer medications. She said on 04/06/2026 she was working as a medication aide and at 9:00 p.m. she was preparing Resident #2's routine bedtime medications and realized she accidently popped two Hydrocodone pain pills when logging the medication out of the narcotic control count. She said she identified the mistake and removed a white oblong rounded pill (thinking it was the duplicated Hydrocodone pill) from the medication cup and then administered the prepared medications to Resident #2. She said it was later identified she had removed Resident #2's Atorvastatin Calcium, which looked similar, from the prepared bedtime medications instead of the duplicated Hydrocodone. She said she accidentally prepared and administered Resident #2 two Hydrocodone on 04/06/2026 during his bedtime medication administration. She said she received training and staff shadowing during her first three days of medication administration orientation She said she received training and in-services during orientation (prior to incident) and after the incident from the facility especially regarding medication administration, unnecessary medications, and medication errors. She said a negative effect if a resident received a duplication of pain medication could cause over sedation, increase drowsiness, and respiratory status change. She said she was suspended related to the medication error or misappropriation incident and later resigned. During an interview on 04/22/2026 at 4:50 p.m., MA D said she provided LVN C training during her orientation process. She said she explained to her during the orientation to follow the 5 R's rule (Right Patient, Right Drug, Right Dose, Right Route, and Right Time) when administering medication. She said during the orientation process with LVN C she trained her to slow down when reconciling medications, to stay alert, and free from distraction while preparing medications. She said she told LVN C if medication errors occurred, and/or if medications needed to be wasted, she should have the charge nurse or supervisor verify the wasted medication and both sign the narcotic control count book for verification and routine medications required verification if wasting as well. She said that if any issues with wasting medications or possible duplications of medication occurred, the charge nurse should be notified prior to administering the medications to verify the correct medications were administered to the resident. During an interview on 04/23/2026 at 2:50 p.m., the DON said she expected facility staff to administer medications as prescribed by the physician, and if a medication error or unnecessary medications occurred, the charge nurse was to complete an assessment, notify the DON, MD, and resident or RP. She said the management team would initiate investigation, in-services, competency checks on medication administration, and narcotic counts and emergency QAPI with medical director involvement. She said she as the DON would notify the administrator for authority notification, if applicable. She said the facility initially reported the incident as a missing Hydrocodone-Acetaminophen but during investigation discovered LVN C had administered a duplicate dose on 04/06/2026 during the bedtime medication regimen. She said a negative outcome for Resident #2 receiving duplicate dose of Hydrocodone-Acetaminophen10-325 mg, it could cause increase drowsiness, change in respiratory status, and interactions with other medications. She said after the medication error was identified, and MD notified, new orders for labs ordered but Resident #2 refused the labs to be obtained. She said Resident #2 was closely monitored after the incident identified with no negative outcomes identified. During an interview on 04/23/2026 at 3:10 p.m., the RDCS said she expected facility staff to administer medications as ordered by the physician. She said all unnecessary medications should be reported to the charge nurse and DON immediately. She said involved residents should be monitored for adverse effects and appropriate training provided to staff regarding incidents. She said the incident should be QAPI (a data-driven framework to maintain and enhance care quality in healthcare facilities) and performance improvement initiated. She said the risk of unnecessary or duplicate pain medications could be dizziness, drowsiness, and lightheadedness. During an interview on 04/23/2026 at 3:20 p.m., the Administrator said his expectations were that all staff adhere to administering medications as prescribed. He said receiving unnecessary or duplicate medications could cause adverse effects. Record review of a facility policy titled, Unnecessary Drugs, dated 12/30/2025, indicated the following, Policy: It is the facility's policy that each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical and psychosocial well-being free from unnecessary drugs Policy Explanation and Compliance Guidelines: 1. The indications for initiating, maintaining, or discontinuing medication(s) are determined by evaluating the resident's physical, behavioral, mental, and psychosocial signs and symptoms in order to identify and rule out any underlying medical conditions, including the assessment of relative benefits and risks, and the preferences and goals for treatment. The resident's medical record should include documentation of this evaluation and the rationale for chosen treatment options. 2. The facility will ensure that the initiation or change in a medication is not: a. Due to a medical condition or problem (e.g., pain, fluid or electrolyte imbalance, infection, obstipation, medication side effect or polypharmacy) that can be expected to improve or resolve as the underlying condition is treated or the offending medication(s) are discontinued; b. Due to environmental stressors alone, that can be addressed to improve the symptoms; and c. Due to psychological stressors alone, that can be expected to improve or resolve as the situation is addressed. 3. The attending physician will assume leadership in medication management by developing, monitoring, and modifying the medication regimen in collaboration with residents and/or representatives, other professionals, and the interdisciplinary team. Each resident's drug regimen will be reviewed on an ongoing basis, taking into consideration the following elements: a. Dose (including duplicate therapy); b. Duration of use; c. Indications and clinical need for medication; d. Adequate monitoring for efficacy and adverse consequences; e. Preventing, identifying and responding to adverse consequences; f. Any combination of the reasons stated above. 4. Documentation will be provided in the resident's medical record to show adequate indications for the medication's use and the diagnosed condition for which it was prescribed.

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 1 of 4 residents (Residents #1) observed for infection control. The facility failed to implement EBP for Resident #1 during a wound care and dressing change on 04/23/2026. This failure could place residents at risk of communicable diseases.Record review of admission Record, dated 04/23/2026, indicated Resident #1 was a [AGE] year old female, admitted on [DATE], with diagnoses including Alzheimer's Disease (progressive disease that destroys memory and other important mental functions), cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), major depression (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), dysphagia (difficulty swallowing), schizophrenia (is a serious mental health condition that affects how people think, feel and behave), and pressure ulcer (bedsore are wound that occur from prolonged pressure on skin) of buttocks. Record review of Resident #1's quarterly MDS assessment, dated 03/25/2026, indicated she was severely impaired cognitively. She rarely/never made herself understood and sometimes understood others. She was dependent on facility staff and/or maximum assistance for self-care and mobility tasks. Record review of Resident #1's care plan, dated 10/07/2025, indicated Resident #1 had a pressure ulcer with interventions for infection control precautions. Record review of physician's orders for Resident #1, dated 04/22/2026, indicated EBP related to chronic wound every shift following facility policy to use for patients with any of the following (when contact precautions do not otherwise apply): wounds or indwelling medical devices, regardless of MDRO colonization(state where a microorganism, such as a bacterium or fungus, has successfully established a presence and is multiplying on or within a host body) statusinfection or colonization with an MDRO. During an observation on 04/23/2026 at 8:40 a.m., outside of Resident #1's room was an EBP signage. There was a 3-drawer PPE cart located at the entrance to Resident #1's room. Resident #1 was lying in bed; she did not respond appropriately to interview questions. During an observation on 04/23/2026 at 8:45 a.m., NP A (consulting wound care NP) and LVN B provided care to Resident #1's right buttock stage 3 (serious skin injury characterized by full-thickness skin loss, exposing the fatty tissue beneath) pressure injury. NP A and LVN B, during direct contact with Resident #1, did not wear a gown during the wound assessment, procedure, and dressing change. During an interview on 04/23/2026 at 9:15 a.m., LVN B said she failed to follow the EBP because she forgot to wear a gown during Resident #1's wound assessment and care, and dressing change. She said she was trained on EBP and should have applied a gown prior to entering the room to perform care. She said that not wearing a gown during the wound assessment and care could spread infection or cross contamination. During an interview on 04/23/2026 at 9:20 a.m., NP A said she was the interim consulting wound care NP to assess and oversee Resident #1's wound care. She said she failed to follow the EBP because she forgot to wear a gown during Resident #1's wound assessment and procedure. She said she should have followed facility policy on EBP and should have applied a gown prior to entering the room to perform care. She said that not wearing a gown during the wound assessment and care could spread infection or cross contamination. During an interview on 04/23/2026 at 1:40 p.m., the ICP said she expected the facility staff and consultants, including the wound care NP, to follow the EBP policy when providing direct care to residents identified as requiring EBP which included residents with chronic wounds, indwelling devices, and MDROs. She said Resident #1 was on EBP because she had a Stage 3 pressure ulcer requiring precautions and staff and vendors should be wearing PPE when providing wound assessment and care. The ICP said she provided facility staff training on infection control measures and EBP annually and as needed. The ICP said not following the EBP as ordered could lead to spread of infection, transfer of bacteria, putting both staff and residents at risk. During an interview on 04/23/2026 at 2:45 p.m., the DON said she expected facility staff and consultants, including the wound care NP, to apply PPE when providing direct resident care for residents with EBP ordered. She said Resident #1 was on EBP because she had a pressure ulcer requiring precautions and staff should be wearing the proper PPE while providing direct care to her wound. She said EBP should be followed by staff and vendors with direct care provided to residents with MDROs, wounds, and indwelling devices. The DON said the risk of failing to perform EBP could lead to spread of MDROs, infections to other residents or even staff. During an interview on 04/23/2026 at 3:00 p.m., the RDCS said she expected that facility staff and consultants to follow the EBP policy, orders, and signage when providing direct care to residents requiring EBP which includes wounds (chronic wounds such as pressure ulcers, diabetic and stasis ulcers), indwelling medical devices (tracheostomy, feeding tubes, urinary catheters, central lines, etc.) and infection or colonization with a targeted MDRO when contact precautions do not otherwise apply. She said the risk of failing to perform EBP could lead to spread of MDROs, and other infections to the other residents or even staff. During an interview on 04/23/2026 at 3:15 p.m., the Administrator said his expectations were that all staff adhere to the EBP policy, orders and signage when providing high- contact care for residents requiring EBP (residents with MDROs, chronic and pressure wounds, and indwelling devices). He said not following EBP as required could cause spread of infection or cross contamination. Record review of facility policy titled, Enhanced Barrier Precautions, dated 12/30/2025, indicated the following: .Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.2. Initiation of enhanced barrier precautions: . b. An order for enhanced barrier precautions will be obtained for residents with any of the following i. Wounds (e.g., chronic wounds such as pressure ulcers diabetic foot ulcers unhealed surgical wounds and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters) even if the resident is not known to be infected or colonized with a MDRO . 3. Implementation of enhanced barrier precautions: a. Make gowns and gloves available immediately here or outside of the residence room. Note: face protection may also be needed if performing activities with risk of splash or spray (i.e., wound irrigation, tracheostomy care). b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the residence room. 4. High contact resident care activities include:.h. Wound care: any skin opening requiring a dressing.

Based on interview and record review, the facility failed to ensure the social worker had the required qualifications for 1 of 1 facility reviewed for social worker qualifications. The Social Worker hired on 12/09/2024, as a full-time social worker was not licensed by the Texas State Board of Social Worker Examiners. This failure could place all residents at risk for unmet social services and psychosocial needs.Record review of an employee file on 08/27/2025 indicated the SW was not a licensed social worker and held a bachelor's degree in social work. The facility hired her as a social worker on 12/09/2024. Review of the facility's January 2017 job description for the Social Worker position indicated Qualifications: Minimum of a bachelor's degree in social work or in human services fields. Licensed per state requirements or eligible for licensure. Record review of the ASWB licensure examinations website dated 08/28/2025, indicated the following process: To become a licensed social worker in Texas, you must earn a CSWE-accredited degree in social work, complete a Texas specific jurisprudence exam, pass the relevant Association of Social work boards (ASWB) exam, undergo a fingerprint background check, and fulfill supervised practice hours for clinical licenses, all while applying through the Texas Board of Social Worker Examiners (part of the Texas Behavioral Health Executive Council) to maintain your license. During an interview on 08/27/2025 at 12:00 p.m., the Administrator said the SW had been employed at the facility since December 2024. The Administrator said the SW had a bachelor's degree in social work and had been preparing to take the licensure exam. He said currently, the SW was not licensed. The administrator said the facility employed a licensed social worker on a PRN basis, and so she was not assigned to oversee the current social worker. During an interview on 08/27/2025 at 1:00 p.m., the SW said she had passed the ASWB examination and had taken the required fingerprint background check. The SW said she had not taken the SW Jurisprudence Exam. The SW said some of her duties included participating in care plan meetings with residents and family, promotes resident rights, provides individual and group help for residents and/or family at times of adjustment, crisis or particular needs. Record review of a Certificate of Completion - Texas State Board of SW Examiners Jurisprudence Exam awarded to [SW] in recognition of having successfully completed online examination dated 08/27/2025 (after surveyor intervention).

Based on interview and record review, the facility failed to provide pharmaceutical services to ensure the accurate administration of medications for 1 of 18 residents reviewed for medication administration. (Resident #3)The facility failed to follow the physician's orders related to blood pressure medication and did not administer a PRN medication for Resident #3. This failure could place the residents at risk of not receiving necessary medications and a decline in health. Record review of the face sheet for Resident #3, indicated a [AGE] year-old male, with a readmission date of 07/27/2025 with diagnoses including hypertension (high blood pressure) and anxiety disorder. Record review of Resident #3's Quarterly MDS dated [DATE] indicated a BIMS of 14 indicating cognition intact. Diagnoses included high blood pressure and anxiety disorder. Record review of Resident #3's comprehensive care plan dated 03/03/2025 indicated diagnosis of hypertension. Interventions included to administer medication as ordered; monitor for serious side effects related to the medication such as a higher or lower blood pressure than usual. Record review of the physician's orders dated August 2025 indicated Resident #3 was prescribed clonidine HCl 0.2 mg. Instructions included to give 1 tablet by mouth every 8 hours PRN for BP if the SBP (top number) was over 160. (SBP refers to the pressure in the arteries when the heart beats and pumps blood throughout the body - diastolic blood pressure refers to the pressure your blood is pushing against your artery walls while the heart muscle rests between beats).Record review of Resident #3's MAR dated August 2025 indicated on the following dates and times, Resident #3's BP was elevated above the prescribed parameters and clonidine had not been administered as prescribed:*08/05/2025 at 09:00 a.m., BP was 184/78; *08/07/2025, at 09:00 a.m., BP was 166/98;*08/07/2025, at 09:00 p.m., BP was 167/90;*08/08/2025, at 09:00 p.m., BP was 168/88;*08/09/2025, at 09:00 a.m., BP was 161/82;*08/15/2025, at 09:00 a.m., BP was 164/78;*08/19/2025, at 09:00 a.m., the BP was 166/89;*08/23/2025, at 09:00 a.m., the BP was 182/79; and *08/24/2025, at 09:00 a.m., the BP was 165/89. During an interview on 08/26/2025 at 3:00 p.m., the DON said her expectations were for the LVNs to administer all medications as prescribed by the physician. The DON said Resident #3 should have received the clonidine at the time when the BP was over the parameters set by the physician. The DON said possible adverse effects of not receiving medications as prescribed included risk of a stroke or BP could go higher. During an interview on 08/27/2025 at 02:12 p.m., MA G said the MAs do not give PRN medications. She said the nurses gave all the PRN medications. MA G said she was unaware of the clonidine order because it would be on the nurse MAR and not the MA MAR.During an interview on 08/27/2025 at 2:30 p.m., LVN B said she had been unaware of Resident #3's SBP being elevated above 160. She said the MAs normally reported abnormal BPs to the nurses and the nurses would assess and/or medicate as needed. She added she would start asking the MAs about any BPs out of range. Review of the facility policy dated December 2012 titled Administering Medications indicated. Medications shall be administered in a safe and timely manner, and as prescribed. 3. Medications must be administered in accordance with the orders, including any required time frame.

Based on interview 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, recognizing each resident's individuality for 1 of 18 Residents (Resident #7) who were reviewed for dignity. The facility failed to ensure LVN J spoke to Resident #7 in a way that promoted his dignity and self-worth. The failure could place residents at risk of decline in their sense of dignity level of satisfaction with life and feeling of self-worth. The findings included: Record review of Resident #7's face sheet dated 08/26/25 indicated he was admitted on [DATE] and readmitted [DATE]. He was [AGE] years old with diagnoses of dementia, and cancer of the esophagus. Record review of Resident #7's Annual MDS assessment dated [DATE] indicated he had a BIMS of 14 which indicated that his cognition was intact. He was not getting his antianxiety medication. Record review of the investigation worksheet for Resident #7's dated 07/30/25 indicated the allegation was made on 7/30/25 at 2:30 p.m. and was reported to state on 07/30/25 at 4:30 p.m. Record review of Resident #7's Provider Investigation Report dated 07/30/25 indicated Resident #7 said LVN J was arguing with him about his medication, then she called him stupid. The DON at that time (ex-employee) assessed the resident with no injuries. Resident #7 said he had no more concerns. The nurse was sent home pending the investigation. The facility called the physician and family member. The physician reordered the resident's lorazepam 0.5 mg. The facility interviewed the other residents on the hall with safe interviews, and no other residents had issue with this nurse. The findings indicated inconclusive for the allegation of abuse. The nurse was terminated for being unprofessional and her conduct was not the facility's policy. Record review of the witness statement dated 07/31/25 indicated CNA H said LVN J asked her to come to Resident #7's room with her. The statement indicated LVN J told the resident his medication had been discontinued. The resident told LVN J he felt like he was having withdrawals and when could he get his medication. LVN J said that was a stupid thing to say telling the resident he could not have withdrawals from that medication. CNA H said Resident #7 became upset and LVN J just walked out. The witness indicated she apologized to Resident #7 for the nurse actions and immediately reported the incident to the interim DON and the new Administrator. During a phone interview on 08/27/25 at 11:15 a.m., LVN J said Resident #7 was yelling and cursing at her. She said, You know he was drug seeking. She denied calling the resident stupid. LVN J said the medication had been discontinued. She said she did not call the resident's physician about the resident saying he thought he was having withdrawals. During a phone interview on 08/27/25 at 12:30 p.m., CNA H said she remembered the incident between LVN J and Resident #7. She said she answered Resident #7's call light, and he wanted medication, so she reported that to LVN J. She said LVN J asked her to come to the room to be a witness. She said Resident #7 was not rude to LVN J and he was trying to explain to the nurse that he thought he was having withdrawals from the medication being discontinued. She said LVN J told Resident #7 that was a stupid thing to say. CNA H said the resident was not rude and did not curse at LVN J; however, she was unprofessional and rude to the resident. CNA H said it was verbal abuse, and she had been trained to report, so she went to Administrator and reported. During a phone interview 08/27/25 at 1:00 p.m., the Resident #7's family said he was in the hospital for his GI and esophagus. His family said the resident said the nurse was rude on 07/30/25. She said she had talked to her with an attitude before, but she did not report it. She said she was proud of the CNA that reported the incident. She said the facility should be homelike and no one should be rude and unprofessional. She said that was not severe verbal abuse; however, it was verbal abuse. Record review of Resident #7's physician orders date August 2025 indicated lorazepam 0.5 mg was restarted on 07/30/25. Record review of the alleged perpetrator's LVN J employee file indicated a hire date of 03/04/25, all the pre-hire checks were done, and her nurse license was current. The file contained her completed orientation for abuse on hire. During an interview on 08/27/25 at 10:10 a.m., the Administrator said LVN J was terminated on 07/31/25 due to her behavior of being rude to a resident which went against their policies. During an interview on 08/27/25 at 10:45 a.m., the DON said her expectation was for all the residents to be free of verbal and physical abuse. She said she was not the DON on 07/30/25; however, she would not stand for the residents to be verbally abused and said she had zero tolerance for the resident to be spoke to like that. Record review of the Abuse Protocol dated June 2013 indicated 1. Our facility will not condone Patient abuse, neglect, mistreatment or misappropriation of patient property (collectively Patient Abuse by anyone, including staff member, other patients, consultants, volunteers, guardians, sponsors, friends or other individuals. 6. C. Verbal abuse is defined as any use of oral, written or gestured language that includes disparaging [to criticize or belittle someone] and derogatory [critical or disrespectful] terms to patients or their families, or within their hearing distance to describe patients, regardless of their age, ability to comprehend, or disability.

Based on interview and record review, the facility failed to ensure the physician was consulted regarding a need to alter treatment for 1 of 18 residents reviewed for notification of changes. (Resident #4) The facility did not consult with Resident #4's physician about the pattern of low blood pressure over multiple days and of the blood pressure medication being held for 5 of 50 opportunities in August 2025. This failure could place residents at risk for complications due to delayed or failed physician intervention. Record review of the face sheet for Resident #4, an [AGE] year-old female, indicated admission to facility on 05/16/2025 with diagnosis including hypertension (high blood pressure). Record review of Resident #4's admission MDS dated [DATE] included diagnoses of coronary artery disease and high blood pressure. Resident #4's BIMS score was 09, indicating moderately impaired cognition. Record review of Resident #4's care plan dated 05/17/2025 indicated altered cardiovascular status related to hypertension. Interventions included monitor for serious side effects related to the medication such as a higher or lower blood pressure than usual, rapid heartbeat, and falling. Record review of Resident #4's physician orders dated 05/19/2025 included metoprolol tartrate 100 mg tablet - Give one tablet twice daily related to hypertension (high blood pressure). Parameters set by the physician were to hold for SBP (top number) less than 110 and/or DBP (bottom number) less than 50 and/or HR less than 50. (SBP refers to the pressure in the arteries when the heart beats and pumps blood throughout the body - diastolic blood pressure refers to the pressure your blood is pushing against your artery walls while the heart muscle rests between beats). Record review of Resident #4's August 2025 MAR included prescribed metoprolol tartrate 100 mg - one tablet by mouth twice daily related to hypertension - hold for SBP less than 110 and/or DBP less than 50 and/or HR less than 50. On the following dates, Resident #4's metoprolol tartrate 100 mg was held and coded as being held due to being outside the prescribed parameters: 08/10/2025 - AM BP 109/55;08/11/2025 - PM BP not documented;08/12/2025 - AM BP not documented;08/13/2025 - AM BP 104/52; and08/21/2025 - AM BP 118/58.Record review of the Nurse Notes dated 08/01/2025 through 08/27/2025 for Resident #4 gave no indication or documentation of physician notification of Resident #4's metoprolol tartrate 100 mg being held on 5 occasions from 08/10/2025 through 08/21/2025. During an interview 08/26/2025 at 3:00 p.m., the DON reviewed Resident #4's August 2025 MAR with the surveyor. The DON acknowledged the metoprolol tartrate 100 mg was documented as held due to the prescribed parameters. She said best practice would be for the nursing staff to notify the physician when medications with parameters were held 3 times, or even immediately. The DON said the potential adverse effects for residents could be dizziness or weakness. The DON said the best practice would be for nursing staff to document in the resident's electronic record when notifying physician of medications being held. During an interview on 08/27/2025 at 9:15 a.m., the RDCS said her expectation was for the physician to be notified each time a resident's medications were held. She said notification must have been overlooked. She said possible negative effects to a resident could be their BP going lower, possibly leading to falls, injuries, or dizziness. During an interview on 08/27/2025 at 2:12 p.m., MA G said they verbally informed the nurses when any medication was held or refused. When BP medications were withheld, they rechecked the BP prior to informing the nurse. MA G said the nurses then would assess the residents. During an interview on 08/27/2025 at 2:30 p.m., LVN B said the MAs were to report to them when medications were held or refused by residents. She said she was unaware Resident #4's metoprolol had been held when outside prescribed parameters. LVN B said when reported to the nurses, they would assess the resident and notify physician when warranted. Record review of policy dated January 2024 titled Physician Notification indicated the following: . It is the responsibility of the nursing staff to observe change, make an assessment, and notify the physician as indicated based on the assessment. The nurse will notify the physician of any change in condition.

Based on observation, interview, and record review, the facility failed to maintain personal privacy during delivery of personal care and services to 1 of 18 residents (Resident #47) reviewed for privacy. The facility failed to provide Resident #47 with a privacy curtain that would close completely. This failure could place residents at risk of loss of dignity due to lack of privacy. Findings included: Record review of the face sheet dated 08/27/25 indicated Resident #47 was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, and fear that are strong enough to interfere with daily living). Record review of the care plan dated 04/03/25 indicated Resident #47 required assistance with ADLs and to turn and reposition every 2 hours related to her terminal illness. Record review of the quarterly MDS dated [DATE] indicated Resident #47 had a BIMS score of 9 indicating she had moderate cognitive impairment, was dependent for personal hygiene and toileting, and was always incontinent of bladder and bowel. During an observation and interview on 08/25/25 at 10:10 a.m., Resident #47 was in bed in her room with Hospice CNA E at her bedside. Hospice CNA E said Resident #47 had no privacy. She said she had told the nurses and CNAs at the facility that her privacy curtain would not close, and nothing had been done to fix the curtain. She then pulled the privacy curtain and when extended completely it left an approximate 3-foot open gap. The curtain was too short to close completely. Resident #47 said she would be more comfortable during her bed baths if her privacy curtain shut all the way. She said she got embarrassed when people came in the room when she was receiving a bed bath or personal care because the curtain didn't close, and she was afraid someone would see her. She said it had been too short for a long time, but she was not sure if she ever told anyone. She said facility staff had seen that it was too short, so she thought they knew. During an interview on 08/26/25 at 2:25 p.m., CNA F said she usually provided care for Resident #47. She said she knew that the privacy curtain was not long enough to close all the way. She said when she provided personal care to Resident #47 that she just tried to position the curtain for the least exposure of the resident. CNA F said she had never reported to anyone that Resident #47's privacy curtain did not close. During an observation and interview on 08/26/25 at 3:30 p.m., the DON viewed Resident #47's privacy curtain and said it was too short to close. She said no one had ever reported the issue to her or the facility and she would have the curtain replaced immediately. She said she expected all residents to have privacy during personal care and for staff to report any issues that prevented providing residents with privacy. During an interview on 08/26/25 at 3:34 p.m., the Administrator said he would make sure that Resident #47's privacy curtain was replaced. He said protecting every resident's privacy was important to the resident and the facility. During an interview on 08/26/25 at 4:25 p.m., Resident #47 said the facility had hung a new privacy curtain and it closed all the way around. She said she was happy to have her new curtain. During an interview on 08/27/25 at 1:27 p.m., the DON said no staff or outside vendor had ever reported that Resident #47's privacy curtain was too short to close. She said all staff should pull the privacy curtain closed and shut the door to the room when providing personal care to a resident. She said she expected all staff to protect the privacy and safety of all residents. She said all staff had been trained on resident rights and privacy. She said staff or the outside vender should have reported that Resident #47's privacy curtain would not close. Record review of a facility policy titled Confidentiality of Information and Personal privacy, last revised October 2017, indicated . Our facility will protect and safeguard resident confidentiality and personal privacy. 2. The facility will strive to protect the resident's privacy regarding his or her: d. personal care.

Based on observation, interview and record review the facility failed to ensure resident assessments accurately reflected the resident's status for 1 of 18 resident (Resident #2) reviewed for accuracy of assessments. The facility failed to accurately complete the MDS assessment to indicate Resident #2's tobacco use. This failure could place residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings include: Record review of Resident #2's face sheet, dated 08/25/25, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #2 had diagnoses which included chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe). Record review of a Smoking safety screen, dated 07/25/25, indicated Resident #2 was safe to smoke without supervision but would be supervised per facility policy. Record review of Resident #2's care plan, initiated 07/24/25, indicated Resident #2 was a smoker at risk of injury with interventions that included staff would store and distribute the resident's smoking materials and monitor. Record review of Resident #2's admission MDS assessment, dated 07/31/25, indicated Resident #2 was not marked for current tobacco use during the assessment period. The assessment indicated Resident #2 had a BIMS score of 13 of 15, which indicated intact cognition with a diagnosis of chronic obstructive pulmonary disease. During an interview on 08/25/25 at 8:00 a.m., Resident #2 said she smoked cigarettes, multiple times a day. She said staff kept her smoking supplies and monitored her while she smoked. During an interview and observation on 08/26/25 at 3:10 p.m., Resident #2 was sitting in her wheelchair smoking a cigarette during smoking break that was observed lit by staff, and she was monitored during the smoking episode. Resident #2 said she smoked daily since admission and the staff kept her smoking supplies, lit her cigarette and monitored during her smoking time. During an interview on 08/26/25 at 3:25 p.m., LVN B said she was providing care for Resident #2 today (08/26/25) and Resident #2 smoked daily. She said the staff kept her smoking supplies and monitored her during smoking times. LVN B said MDS Nurse A was responsible for all MDSs in the facility and smoking should be documented on the MDS assessment. During an interview on 08/26/25 at 3:25 p.m., MDS nurse A said she was responsible for all MDSs in the facility. She said MDS Nurse D came twice a week and helped with some MDSs. She said the backup was the Regional Case Manager that did some random checks on random MDSs. MDS Nurse A said she was educated on completion of MDS and received frequent update trainings. MDS Nurse A said Resident #2 smoked daily and should have been marked as tobacco use on the MDS. She said she overlooked it. MDS Nurse A said the resident risk of a resident that used tobacco not marked on the MDS was the MDS did not provide an accurate picture of the resident, no resident risk. She said the facility follows the RAI (Resident Assessment Instrument, a process for evaluating residents in nursing home) for a facility policy. During an interview on 08/26/25 at 3:30 p.m., the DON said MDS A was responsible for all MDSs in the facility and the Regional Case Manager was the backup which did random checks on MDS. She said the MDS nurses were educated on completion of MDSs. The DON said Resident #2's MDS was overlooked and not marked for tobacco use. She said there was no resident risk of tobacco use not marked on an MDS for a resident that used tobacco. She said the MDS was just not accurate. The DON said her expectation was all MDS completed accurately. During an interview on 08/26/25 at 3:40 p.m., the Administrator said MDS Nurse A was responsible for all MDSs in the facility and educated on completion of MDSs. He and the Regional Case Manager was the backup that completed random checks on MDS. The Administrator said Resident #2's MDS was overlooked and not marked for tobacco use. He said there was no resident risk of tobacco use not marked on an MDS for a resident that used tobacco He said the MDS was not accurate. The Administrator said his expectation was all MDS completed accurately. Attempted interview on 08/26/25 at 4:00 p.m., with Regional Case Manager with no return call. Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2024, indicated . J1300: Current Tobacco Use . Steps for Assessment 1. Ask the resident if they used tobacco in any form during the 7-day look-back period. 2. If the resident states that they used tobacco in some form during the 7-day look-back period, code 1. Yes. Coding Instructions, Code, no: if there are no indications that the resident used any form of tobacco. Code 1, yes: if the resident or any other source indicates that the resident used tobacco in some form during the look-back period.

Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 2 (Resident #67) residents reviewed for respiratory care with tracheostomy. The facility failed to ensure Resident #67's oxygen was administered at the correct setting of 4-6 liters per minute on 08/25/25 as ordered by the physician. This failure could place residents who receive oxygen at an increased risk for receiving oxygen at the wrong rate which could lead to hypercapnia (too much carbon dioxide in the blood), pulmonary oxygen toxicity (damage to the lung lining tissues and air sacs), hypoxemia (low levels of oxygen in the blood, decreasing the oxygen supply to vital organs), and shortness of breath.Record review of Resident #67's face sheet indicated she was readmitted [DATE] was [AGE] years old with diagnoses which included acute respiratory failure with hypoxia, chronic obstructive pulmonary disease and heart failure. Record Review of Resident #67's admission Minimum Data Set assessment dated [DATE] indicated she received continuous oxygen therapy and received tracheostomy care. Resident #67's was rarely/never understood. Record review of Resident #67's comprehensive care plan dated 08/12/25 indicated Resident #67 had oxygen therapy related to acute respiratory failure with hypoxia. The interventions included provide oxygen as ordered. Record review of Resident #67 's physician's orders dated August 2025 indicated her orders included oxygen at 4-6 LPM per oxygen concentrator via trach with start date of 08/12/25. Trach - Air Compressor every day and night shift with Setting = 60 PSI start date of 08/06/25. During an observation on 08/25/25 at 8:30 a.m., revealed Resident #67 was in her bed and was receiving O2 at 8 LPM via oxygen concentrator per her tracheostomy. The air compressor was set on 40 PSI. During an interview and observation on 08/25/25 at 2:38 p.m., LVN B and LVN C checked Resident #67's orders in the computer, after surveyor intervention. LVN B and LVN C said the O2-concentrator setting should have been between 4-6 LPM per the concentrator not 8 LPM. LVN B changed the setting on the air compressor to 60 PSI. LVN C turned the concentrator to 6LPM. LVN B and LVN C said they had been trained on administering oxygen. They said they knew to follow the physician's orders to ensure the residents received the right amount of oxygen to prevent complications like low oxygen saturation. LVN C checked Resident #67's O2 saturation and said Resident #67 was at 94%. LVN B said they were both responsible however she said LVN C was in training. During an interview on 08/26/25 at 2:10 p.m., the DON said she wanted the nurses to follow the physician's orders. She said the resident could not receive enough oxygen, if the concentrator settings were not followed as per doctor's orders. Record review of the policy on Oxygen Administration dated October 2010 indicated Purpose The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation 1. Verify that there is a physician's order for this procedure.

Based on interviews and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 18 residents reviewed for medication administration. (Resident #3).The facility failed to ensure clonidine 0.2 mg (used to lower blood pressure) was administered to Resident #3 as ordered from 08/01/2025 - 08/27/2025. (there were 9 opportunities) This failure could place residents at risk for not receiving medications as ordered by their physician. Record review of the face sheet for Resident #3, indicated a [AGE] year-old male, with a readmission date of 07/27/2025 with diagnoses including hypertension (high blood pressure) and anxiety disorder. Record review of Resident #3's Quarterly MDS dated [DATE] indicated a BIMS of 14 indicating cognition intact. Diagnoses included high blood pressure and anxiety disorder. Record review of Resident #3's comprehensive care plan dated 03/03/2025 indicated diagnosis of hypertension. Interventions included to administer medication as ordered; monitor for serious side effects related to the medication such as a higher or lower blood pressure than usual. Record review of the physician's orders dated August 2025 indicated Resident #3 was prescribed clonidine HCl 0.2 mg. Instructions included to give 1 tablet by mouth every 8 hours PRN for BP if the SBP (top number) was over 160. (SBP refers to the pressure in the arteries when the heart beats and pumps blood throughout the body - diastolic blood pressure refers to the pressure your blood is pushing against your artery walls while the heart muscle rests between beats).Record review of Resident #3's MAR dated August 2025 indicated on the following dates and times, Resident #3's BP was elevated above the prescribed parameters and clonidine had not been administered as prescribed:*08/05/2025 at 09:00 a.m., BP was 184/78; *08/07/2025, at 09:00 a.m., BP was 166/98;*08/07/2025, at 09:00 p.m., BP was 167/90;*08/08/2025, at 09:00 p.m., BP was 168/88;*08/09/2025, at 09:00 a.m., BP was 161/82;*08/15/2025, at 09:00 a.m., BP was 164/78;*08/19/2025, at 09:00 a.m., the BP was 166/89;*08/23/2025, at 09:00 a.m., the BP was 182/79; and *08/24/2025, at 09:00 a.m., the BP was 165/89. During an interview on 08/26/2025 at 1:00 p.m., Resident #3 said he had prescriptions for blood pressure medications. He said he had experienced no ill effects such as dizziness, headaches, or light-headedness. He said he does not know when blood pressure was elevated. During an interview on 08/26/2025 at 3:00 p.m., the DON said her expectations were for the LVNs to administer all medications as prescribed by the physician. The DON said Resident #3 should have received the clonidine at the time when the BP was over the parameters set by the physician. The DON said possible adverse effects of not receiving medications as prescribed included risk of a stroke or BP could go higher.During an interview on 08/27/2025 at 02:12 p.m., MA G said the MAs do not give PRN medications. She said the nurses gave all the PRN medications. MA G said she was unaware of the clonidine order because it would be on the nurse MAR and not the MA MAR. During an interview on 08/27/2025 at 2:30 p.m., LVN B said she had been unaware of Resident #3's SBP being elevated above 160. She said the MAs normally reported abnormal BPs to the nurses and the nurses would assess and/or medicate as needed. She added she would start asking the MAs about any BPs out of range. LVN B said Resident #3 had not exhibited any adverse effects of not receiving the clonidine, nor voiced any concerns that she was aware of. Review of the facility policy dated December 2012 titled Administering Medications indicated. Medications shall be administered in a safe and timely manner, and as prescribed. 3. Medications must be administered in accordance with the orders, including any required time frame.

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 1 of residents (Resident #1) reviewed for resident abuse. The facility failed to ensure Resident #1 was free from abuse when CNA C put her fingers in Resident #1's face. This failure could cause the residents at risk of disrespect, mental anguish, and/or emotional distress. Findings included: Record review of Resident #1 face sheet dated 05/19/25 indicated a [AGE] year-old female initially admitted to the facility on [DATE]. Resident #1 had diagnoses including alzheimer's disease (a progressive disease that destroys memory and other important mental functions), cerebral infarction (occurs when blood flow to the brain is blocked, causing brain tissue to die), anxiety disorder, dysphagia following cerebral infarction (difficulty swallowing), dysphagia oral phase (difficulty with the initial stages of swallowing) and schizophrenia (a disorder that affects a person's ability to think feel, and behave clearly). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 was rarely understood and usually understood others. No BIMS assessment was performed on Resident #1. Resident #1 required moderate assistance for oral hygiene and eating. Resident #1was dependent with toileting hygiene, personal hygiene, and shower/bathe self. Resident #1 was always incontinent to bowel and bladder. Record review of Resident #1's care plan dated 04/17/25 indicated: Resident #1 had impaired cognitive function/dementia or impaired thought process. Interventions: administer medications as ordered. Monitor/document for side effects and effectiveness. Ask yes/no questions in order to determine the resident's needs. Communicate with the resident, family and caregiver regarding resident's capabilities and needs. During an interview on 5/19/25 at 9:47 A.M., Family Member #1 said she had a video of aides putting their fingers in her family member mouth. She said the aides that was putting their fingers in her family member's mouth was CNA C and CNA E. She said after watching the video she did not know what the reasoning was for the aides putting their fingers in her family member's face. She said when she watched the video 3 days later after the incident happened it was disturbing to see them doing this to her family member. She said later she had a conversation with CNA C. Family Member #1 said she liked to laugh and joke with her family member. Family Member #1 said she told CNA C she thought they were laughing at her family member. She said she did not speak to CNA C until a month ago about the incident, because management removed her and CNA E from her family member's hall. She said one day she spoke to CNA C and CNA C told her she had thought about what she did to her family member a couple months ago and that was not right, so she apologized for her behavior. During an observation and interview on 5/19/25 at 12:47 P.M., Resident #1 was lying in bed watching T.V. Resident #1 said she was comfortable. During an observation on 5/20/25 at 8:25 A.M., the surveyor received a video from Family Member #1 via text message. Surveyor observed CNA E and CNA C preparing to perform incontinent care for Resident #1 as she laid in bed. As Resident #1 was laid in bed CNA C kept putting her fingers in Resident #1's face continuously. After several attempts of putting her fingers in Resident #1's face, Resident #1 tried to bite CNA C fingers. The footage clearly showed Resident #1 was agitated and CNA C stopped putting her fingers in her face afterwards. During an interview on 5/20/25 at 8:46 A.M., the Interim DON said he did not believe Resident #1's behaviors were due to how staff were treating her. He said he had observed the CNA's take care of her on a daily basis. The Surveyor showed the Interim DON video footage from Resident #1's camera. After watching the video of CNA C providing care to Resident #1, he said, it was not appropriate for CNA C to place her hands in the resident's face. During an interview on 5/20/25 at 9:07 A.M., the Regional Director of Clinical Services asked to see the video footage from Resident #1's camera. She said it was not appropriate for CNA C to put her hands in a Resident #1's face. During an interview on 5/20/25 at 9:45 A.M., CNA C said she was playing with Resident #1 when she put her fingers in Resident #1's face. She said everyday was different with her Resident #1. She said she did not play with her anymore since she found out she had dementia (a group of thinking and social symptoms that interferes with daily functioning). CNA C said she did not feel like it was appropriate behavior for her to put her fingers close to Resident #1's mouth. She said once the family member got involved, she apologized to her for her actions with her Resident #1. She said she was a new CNA when she did that. During an interview on 5/21/25 at 9:38 A.M., LVN A said she felt like staff putting their fingers in a resident's face was inappropriate. She said she would not do that to a resident. She said a staff member putting their fingers in a resident's face could affect their dignity. She said she would not want anyone to put their hands in her face. During an interview on 5/21/25 at 10:01 A.M., the Interim DON said the video could have been interpreted in a different way that might lead someone to think that CNA C was trying to distract Resident #1 from not fighting. He said he had not spoken to CNA C. He said he saw CNA C's fingers in Resident #1's face, but he could not hear anything from the video. He said CNA C putting her fingers in Resident #1 face could affect her dignity and her trying to bite the CNA's finger was a way to express she did not like her putting her fingers in her face. He said the facility was going to do in servicing on resident rights with all staff. During an interview on 5/21/25 at 10:30 A.M., the Regional Director of Clinical Services said she did not speak to CNA C to know the intention of the video, but what she saw she thought was CNA C was being playful with the resident, until the resident tried to bite the staff. She said that was clearly an indication that the resident did not like the staff members fingers in her face. She said that behavior could affect the residents' dignity. She said the facility would do trainings over dignity to ensure that type of behavior was not happening in the facility. She said she would not feel comfortable with staff putting their fingers in her face. Record review of the facility's policy on Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021 indicated: 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 . 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including but not necessarily limited to . a. facility staff . Record review of the facility's policy on Resident Rights revised December 2016 indicated: Employees shall treat all residents with kindness, respect, and dignity. 1.Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: .a. a dignified existence; .b.be treated with respect, kindness, and dignity.

Based on observation, interview and record review the facility failed to ensure residents had the right to be treated with respect and dignity for 1 of 6 residents reviewed for resident rights. (Resident #1) The facility failed to ensure CNA C did not put her fingers in Resident #1's face. This failure could cause the resident to be distressed and could cause residents to feel disrespected. Findings included: Record review of Resident #1 face sheet dated 05/19/25 indicated a [AGE] year-old female initially admitted to the facility on [DATE]. Resident #1 had diagnoses including alzheimer's disease (a progressive disease that destroys memory and other important mental functions), cerebral infarction (occurs when blood flow to the brain is blocked, causing brain tissue to die), anxiety disorder, dysphagia following cerebral infarction (difficulty swallowing), dysphagia oral phase (difficulty with the initial stages of swallowing) and schizophrenia (a disorder that affects a person's ability to think feel, and behave clearly). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 was rarely understood and usually understood others. No BIMS assessment was performed on Resident #1. Resident #1 required moderate assistance for oral hygiene and eating. Resident #1was dependent with toileting hygiene, personal hygiene, and shower/bathe self. Resident #1 was always incontinent to bowel and bladder. Record review of Resident #1's care plan dated 04/17/25 indicated: Resident #1 had impaired cognitive function/dementia or impaired thought process. Interventions: administer medications as ordered. Monitor/document for side effects and effectiveness. Ask yes/no questions in order to determine the resident's needs. Communicate with the resident, family and caregiver regarding resident's capabilities and needs. During an interview on 5/19/25 at 9:47 A.M., Family Member #1 said she had a video of aides putting their fingers in her family member mouth. She said the aides that was putting their fingers in her family member's mouth was CNA C and CNA E. She said after watching the video she did not know what the reasoning was for the aides putting their fingers in her family member's face. She said when she watched the video 3 days later after the incident happened it was disturbing to see them doing this to her family member. She said later she had a conversation with CNA C. Family Member #1 said she liked to laugh and joke with her family member. Family Member #1 said she told CNA C she thought they were laughing at her family member. She said she did not speak to CNA C until a month ago about the incident, because management removed her and CNA E from her family member's hall. She said one day she spoke to CNA C and CNA C told her she had thought about what she did to her family member a couple months ago and that was not right, so she apologized for her behavior. During an observation and interview on 5/19/25 at 12:47 P.M., Resident #1 was lying in bed watching T.V. Resident #1 said she was comfortable. During an observation on 5/20/25 at 8:25 A.M., the surveyor received a video from Family Member #1 via text message. Surveyor observed CNA E and CNA C preparing to perform incontinent care for Resident #1 as she laid in bed. As Resident #1 was laid in bed CNA C kept putting her fingers in Resident #1's face continuously. After several attempts of putting her fingers in Resident #1's face, Resident #1 tried to bite CNA C fingers. The footage clearly showed Resident #1 was agitated and CNA C stopped putting her fingers in her face afterwards. During an interview on 5/20/25 at 8:46 A.M., the Interim DON said he did not believe Resident #1's behaviors were due to how staff were treating her. He said he had observed the CNA's take care of her on a daily basis. The Surveyor showed the Interim DON video footage from Resident #1's camera. After watching the video of CNA C providing care to Resident #1, he said, it was not appropriate for CNA C to place her hands in the resident's face. During an interview on 5/20/25 at 9:07 A.M., the Regional Director of Clinical Services asked to see the video footage from Resident #1's camera. She said it was not appropriate for CNA C to put her hands in a Resident #1's face. During an interview on 5/20/25 at 9:45 A.M., CNA C said she was playing with Resident #1 when she put her fingers in Resident #1's face. She said everyday was different with her Resident #1. She said she did not play with her anymore since she found out she had dementia (a group of thinking and social symptoms that interferes with daily functioning). CNA C said she did not feel like it was appropriate behavior for her to put her fingers close to Resident #1's mouth. She said once the family member got involved, she apologized to her for her actions with her Resident #1. She said she was a new CNA when she did that. During an interview on 5/21/25 at 9:38 A.M., LVN A said she felt like staff putting their fingers in a resident's face was inappropriate. She said she would not do that to a resident. She said a staff member putting their fingers in a resident's face could affect their dignity. She said she would not want anyone to put their hands in her face. During an interview on 5/21/25 at 10:01 A.M., the Interim DON said the video could have been interpreted in a different way that might lead someone to think that CNA C was trying to distract Resident #1 from not fighting. He said he had not spoken to CNA C. He said he saw CNA C's fingers in Resident #1's face, but he could not hear anything from the video. He said CNA C putting her fingers in Resident #1 face could affect her dignity and her trying to bite the CNA's finger was a way to express she did not like her putting her fingers in her face. He said the facility was going to do in servicing on resident rights with all staff. During an interview on 5/21/25 at 10:30 A.M., the Regional Director of Clinical Services said she did not speak to CNA C to know the intention of the video, but what she saw she thought was CNA C was being playful with the resident, until the resident tried to bite the staff. She said that was clearly an indication that the resident did not like the staff members fingers in her face. She said that behavior could affect the residents' dignity. She said the facility would do trainings over dignity to ensure that type of behavior was not happening in the facility. She said she would not feel comfortable with staff putting their fingers in her face. Record review of the facility's policy on Resident Rights revised December 2016 indicated: Employees shall treat all residents with kindness, respect, and dignity. 1.Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: .a. a dignified existence; .b.be treated with respect, kindness, and dignity.

Based on observation, interview and record review the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 3 residents (Resident #2) reviewed for pressure injury. The facility failed to ensure the Treatment Nurse measured and adequately documented Resident #2's wound in the EMR when it was initially found on 05/15/2025. These failures could place residents at risk for deterioration of wounds. Findings included: Record review of Resident #2's face sheet dated 05/19/25 indicated a [AGE] year-old female initially admitted to the facility on [DATE]. Resident #2 had diagnoses including major depressive disorder (a serious mental illness characterized by persistently low mood, loss of interest or pleasure in activities, and other symptoms like changes in sleep, appetite and energy), down syndrome (a genetic chromosome 21 disorder causing developmental and intellectual delays) and urinary tract infections (an illness in any part of the urinary tract, the system of organs that makes urine). Record review of Resident #2's quarterly MDS assessment dated [DATE] indicated Resident #2 was rarely understood and usually understood others. No BIMS assessment was conducted for Resident #2 due to severe cognitive impairment. Resident #2 required moderate assistance for oral hygiene, toileting hygiene, shower/bathe self, personal hygiene, roll left and right and sit to lying. Resident #2 was always incontinent of bowel and bladder. Record review of Resident #2's care plan dated 04/24/25 indicated pressure ulcer prevention: assess for appropriate footwear. Encourage out of bed. Therapy disciplines to screen, evaluate, and treat as indicated. Record review of a facility's wound report dated 05/14/25 indicated Resident #2 was not listed on the report. Record review of Resident #2's order summary report dated 05/15/25 indicated wound treatment: collagen every shift, cleanse wound to right gluteal fold with normal saline or skin cleanser. Pat dry. Apply collagen to wound bed. Cover with dry dressing. Record review of Resident #2's progress note dated 05/21/25 by the Treatment Nurse indicated: Skin Issue: #001: Skin issue has been evaluated. Location: Rear right thigh. Additional location information: right gluteal fold. Issue type: Abrasion. Wound acquired in-house. Exact date: 05/15/2025 Signs and symptoms of infection: None. Painful: No. Staged by: In-house nursing. Length (cm): 2.6 Width (cm): 0.4 Depth (cm): 0.1 Undermining: No. Tunneling: No. Epithelial: 100%. Exudate amount: Light. Exudate type: Serous: clear watery fluid, which is separated from solid elements. Odor after cleansing: None. Periwound: Attached. Surrounding tissue: Fragile. Surrounding tissue: Blanching. Dressing appearance: Intact. Dressing saturation: Minimal less than 25%. Cleansing solution: Generic wound cleanser. Other primary dressing: Collagen sheet Secondary dressing: Dry. Additional care: Incontinence management. Additional care: Moisture barrier. During an interview on 5/19/25 at 10:53 A.M., Resident #2's family member said Resident #2 was not getting wound care until CNA F contacted someone. She said Resident #2 received the sore to the back of her legs from the facility a couple of weeks ago. She said all she wanted was for Resident #2 to be taken care of. During an interview on 5/20/25 at 1:42 P.M., Resident #2 said she did not hurt her leg and it does not hurt. During an interview and observation on 5/20/25 at 1:52 P.M., CNA B said Resident #2 had an open area on the back of her right leg and she thought it was from her pulling up her brief. She said she knew the sore had been on the Resident #2 for at least 2 weeks. She knew or didn't know how long the area had been opened. CNA B showed the surveyor the shallow opening, pink/red, moist area to the back of Resident #2's right thigh below her buttocks which appeared to be a stage 2 pressure injury with no signs and symptoms of infections. The area was opened to air with no dressing during time of observation. During an interview on 5/20/25 at 2:20 P.M., CNA D said the open area had been on Resident #2 for about 2 or 2 1/2 weeks. She said it was a reoccurring thing that comes and goes. She said she reported it to LVN G and the Treatment Nurse. She said she does not remember the exact date she reported the wound. During an interview on 5/20/25 at 2:52 P.M., the Treatment Nurse said she had not put the wound assessment for Resident #2 in the EMR yet, because staff told her about the wound last week. She said she put the orders in for Resident #2's wound treatment on 5/15/25 and she went on vacation for the next 4 days. She said she just returned back to work today. She said she put a wound treatment in the system for Resident #2's wound 5/15/25 and had a nurse to cover her tasks while she was off and on the weekends. She said the nurse covering her treatments for her when she was off just did not do the wound assessment form for Resident #2 for her when she was off. She said she had been the treatment nurse at the facility for 2 years. She said she was notified of the new skin issue with Resident #2 on 5/15/25. During an interview on 5/20/25 at 3:03 P.M., the Treatment Nurse said she did not complete the wound assessment for the new skin issue for Resident #2. She said she looked at Resident #2's wound, but she never filled out the wound form for that area. She said the treatments pop up on the wound tab in the EMR to let the nurse know the treatment needs to be done. She said the aides had notified her that Resident #2 had a spot on the back of her leg right leg where she pulled up the brief. She said the CNA notified her of the skin issue on 5/15/25. She said she did not remember who the CNA was that notified her of the new skin issue. She said she had the measurements in her bag that she took on 5/15/25, but she had not filled out the wound form in the EMR. During an interview on 5/20/25 at 3:36 P.M., the Regional Director of Clinical Services said whenever a new wound was found in the facility, it should be measured and documented. She said the Treatment Nurse told her she found the new wound on Resident #2 and started a new treatment, but she just didn't document the measurements. She said the nurses should be doing measurements and documenting the wounds they find in the EMR. She said there was an initial skin assessment that should be done in EMR for new skin issues and she could not find it at this time. During an interview on 5/21/25 at 9:25 A.M., the Interim DON provided the surveyor with a skin assessment for Resident #2 dated 5/13/25. Surveyor informed him that the Treatment Nurse said that she assessed the wound on 5/15/25, but did not document the measurements in EMR, he said he agreed. During an interview on 5/21/25 at 9:38 A.M., LVN A said the nurse was responsible for documenting a new wound. She said if it happened while the Treatment Nurse was there, she would go ahead and assess the wound and take care of the resident and notify the Treatment Nurse about the skin issue. She said an initial assessment should be performed to understand the severity of the skin issue. She said if there was no documentation on a wound no one would know it was there and it would not be monitored. During an interview on 5/20/25 at 9:50 A.M., the Treatment Nurse said if she was not at the facility the charge nurse was responsible for documenting new skin issues. She said she was busy the day of 5/15/25 and she did not have a good excuse as to why she did not document Resident #2's wound and measurements. She said not being able to tell if the wound had worsened could cause infection. During an interview on 5/21/25 at 10:01 A.M., the Interim DON said the charge nurse or the treatment nurse was responsible for documenting a new wound. He said sometimes things happens and it just slipped her mind, but the treatment was there. He said sometimes staff just get distracted. He said an initial wound assessment should be documented so the wound could be monitored. He said without wound documentation how would we know how the wound was progressing? He said he ran the wound care report every week to follow up to make sure the documentation was completed. During an interview on 5/21/25 at 10:30 A.M., the Regional Director of Clinical Services said the responsibility of documenting new wounds fell on the charge nurse or the wound care nurse. She said the Treatment Nurse told her she got in a hurry and forgot to put Resident #2's wound measurements in the system. She said the initial wound assessment was important to monitor for improvement or decline. She said the DON monitored the documentation of the wounds. She said she did go over everything in the EMR with the Treatment Nurse and in-serviced her on documentation of wounds . Record review of the facility's policy on Patient Care Management System 1 Skin dated July 2022 indicated 4. Any newly identified wounds will be addressed by the Treatment Nurse or charge nurse to include assessment and documentation of the skin site and initiate appropriate clinical interventions. Notify patient's representative and medical provider of any new or change in existing wound(s) and document in EMR . 5. A wound assessment will be completed by the treatment nurse or charge nurse and a narrative of each site will be documented weekly for any pressure injury and non-pressure skin condition, including but not limited to arterial ulcers, diabetic neuropathy ulcers, venous insufficiency ulcers, bruises, skin tears, and surgical wounds. Wound measurements will be in centimeters . 7. A pressure injury plan of care or a non-pressure injury plan of care will be completed by the treatment nurse or charge nurse upon identification of pressure ulcers and updated with any changes to interventions and upon resolution . 9. The certified nurse aide will notify the treatment nurse or charge nurse of any newly identified skin issues .

Based on observation, interview, and record review, the facility failed to ensure the right to formulate an advance directive was provided for 1 of 4 residents (Resident #1) reviewed for resident rights. The facility did not have a DNR order when Resident #1 provided a copy of his Advanced Directive upon admission. The facility did not provide emergency medical technician and hospital personnel with any information relating to Resident #1's known existing advance directive. This failure could place residents at risk of lifesaving procedures being performed against their wishes resulting in bruising, broken ribs, electrical shocking of the heart, having a tube placed in the throat and provided artificial breathing methods, and possibly being brought back to life in an unaware and unresponsive state. Findings included: Record review of a face sheet dated [DATE] indicated Resident #1 was an [AGE] year-old male who admitted to the facility on [DATE]. Record review of Physician Orders dated [DATE] indicated Resident #1 had diagnoses including hypertension (condition in which the force of the blood against the artery walls is too high), cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), hemiplegia (severe or complete loss of strength leading to paralysis on one side of the body and is usually the result of brain damage) affecting right dominant side, vascular dementia (a type of loss of cognitive functioning caused by conditions that damage blood vessels and block blood flow to your brain), and respiratory failure (a serious condition that makes it difficult to breathe on your own). The orders indicated he had an order dated [DATE] for Full Code Status. Record review of A Directive to Physicians and Family or Surrogates Advanced Directive signed by Resident #1 on [DATE] indicated: In addition to this advance directive, Texas law provides for two other types of directives that can be important during a serious illness. These are the Medical Power of Attorney and the Out-of- Hospital Do-Not-Resuscitate Order. You may wish to discuss these with your physician, family, hospital representative, or other advisers Directive: I [Resident #1] recognize that the best health care is based upon a partnership of trust and communication with my physician. My physician and I will make health care decisions together as long as I am of sound mind and able to make my wishes known. If there comes a time that I am unable to medical decisions about myself because of illness or injury, I direct that the following treatment preferences be honored: If, in the judgment of my physician, I am suffering with a terminal condition from which I am expected to die within six months, even with available life-sustaining treatment provided in accordance with prevailing standards of medical care: I request that all treatments other than those needed to keep me comfortable be discontinued or withheld and my physician allow me to die as gently as possible; . was initialed by Resident #1. It further indicated: If, in the judgment of my physician, I am suffering with an irreversible condition so that I cannot care for myself or make decisions for myself and am expected to die without life-sustaining treatment provided in accordance with prevailing standards of medical care: I request that all treatments other than those needed to keep me comfortable be discontinued or withheld and my physician allow me to die as gently as possible . was initialed by Resident #1. Record review of the admission MDS dated [DATE] indicated Resident #1 was not in a persistent vegetative state and had no discernible consciousness; had minimal difficulty hearing; had clear speech; he was usually understood; he could usually understand others; had adequate vision with corrective lenses; and had moderately impaired cognition with a BIMS of 12 out of 15 score. Record review of the undated Care Plan in the previous EMR program indicated Resident #1 was a Full Code status with interventions of inform staff of code status and to make sure that code status was signed by Resident #1 or the responsible party and in the active medical record. Record review of the hospital History and Physical dated [DATE] indicated He was DNR at an outside facility but this was not transmitted to the emergency room . The patient presented after he taken his oxygen off at night he was found to be very altered. He was in some respiratory distress. Upon arrival to the emergency room he was placed on oxygen SpO2 initially increased but had an EKG demonstrated he was having a STEMI The patient was also noted to be in respiratory distress and intubated. The patient was transferred to our facility. The patient was placed on propofol (a medication that slows the activity of your brain and nervous system used to sedate a patient requiring mechanical ventilation (breathing machine)) and a small amount of Levophed (medication used to treat life-threatening low blood pressure). Patient's family at bedside are not certain that he would have want to have been intubated agree with continuing current level of care right now During an observation and interview on [DATE] at 04:32 p.m. Resident #1 was in bed. He had oxygen going with an oxygen concentrator via nasal canula at 2L/minute. He did not appear to be in any respiratory distress. When asked about what happened to him he said he died and they had to bring him back. He said he was supposed to be a DNR status. During an interview on [DATE] at 05:15 p.m., LVN B said most residents had an OOH DNR. She said if a resident had an Advanced Directive, then they were terminal, and it was a DNR for them. She said she had taken care of Resident #1, and he was a Full Code. She said he had not been and was not on hospice or deemed having a terminal illness. During a phone interview on [DATE] at 01:02 p.m., LVN A said she worked at the facility PRN. She said she went to Resident #1 room about 07:30 a.m. to administer his breathing treatment and found him with some disorientation. She said she noticed his fingers were ashen colored and he was having trouble breathing. She said she checked his oxygen level and it was 56% so she increased his oxygen to 4L/minute and his level started coming up. She said his EMR showed he was a Full Code with a DNR pending. So, she sent him to the hospital for further treatment. She said she was not aware of him having an Advanced Directive uploaded in the EMR. During an interview on [DATE] at 03:40 p.m. the Corporate Nurse said Resident #1's Advanced Directed was not a DNR. She said she had reviewed the form when a family member made a grievance about Resident #1 being sent to the hospital. She said the form indicated it was if he had a terminal illness which he did not have a terminal illness. She said so he was correctly deemed a Full Code status. Record review of the Advanced Directive policy revised [DATE] indicated Policy Statement: The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. Policy Interpretation and Implementation: If the Resident Has an Advance Directive 1. If the resident or the residents representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the residents medical record and are readily retrievable by any facility staff. 2. The director of nursing services (DNS) or designee notifies the attending physician of advance directives (or changes in advance directives) so that appropriate orders can be documented in the residents medical record and plan of care 3. The residents wishes are communicated to the residents direct care staff and physician by placing the advance directive documents in a prominent, accessible location in the medical record and discussing the residents wishes in care planning meetings. 4. The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive. a. Facility staff are not required to provide care that conflicts with an advance directive 9. The nurse supervisor is required to inform emergency medical personnel of a residents advance directive regarding treatment options and provide such personnel with a copy of the advance directive or POLST when transfer from the facility via ambulance or other means is made

Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs to each resident for 1 of 7 residents reviewed for medications. (Resident #175) The facility failed to ensure Resident #175 was not administered a saline IV flush before administration of an IV antibiotic and an IV saline and an IV heparin flush after medication administration (SASH-saline administer, saline heparin) without a physician's order. This deficient practice could place residents at risk of consuming unprescribed medications, harm, and hospitalization . Findings included: Record review of Resident #175's face sheet indicated she was a [AGE] year-old-female admitted [DATE] with a diagnosis of UTI. She was to receive Piperacillin/Tazobactam (a penicillin antibiotic used to treat bacterial infections) 3.375 gm/NS 200 ml at 200 ml per hour via midline IV catheter. Record review of Resident #175's baseline care plan dated 07/16/24 indicated she was to receive IV antibiotics. Record review of Resident #175's Admission MDS dated [DATE] was incomplete at this time due to required time frame of completion. During record review of Resident #175's physician orders and reconciliation indicated Resident #175 was ordered Piperacillin/Tazobactam 3.375 gm/NS 200 ml at 200 ml per hour every 8 hours for 7 days with a start date of 7/16/24. The electronic medical record gave no indication of physician orders for NS 0.9% before antibiotic administration and NS 0.9% and 10 ml or Heparin 500 units/5 ml (100 USP units/ml) after administration of the antibiotic. Record review of Resident #175's MAR indicated she received Piperacillin-Tazobactam 3.375 gm IV every 8 hours for 7 days with a start date of 07/16/24 with no indication of the SASH IV flush. During an observation during the medication pass on 07/22/24 at 12:36 p.m., LVN A prepared and administered Piperacillin/Tazobactam 3.375 gm/NS 200 ml at 200 ml per hour to Resident #175. Prior to administration, LVN A flushed Resident #175's midline catheter with NS 0.9% 10 ml. After completion of the infusion, LVN A flushed Resident #175's midline catheter with NS 0.9% 10 ml followed by Heparin 500 units/5 ml (100 USP units/ml). During an interview and record review on 07/23/24 at 1:51 p.m., LVN D said Resident #175 did not have the SASH documentation on the MAR for Resident #175's antibiotic. She said the MAR should have included the SASH documentation. LVN D said she was educated on IV administration and documentation with the yearly check offs in March or April. She said the potential negative outcome of the SASH documentation not in the MAR was a nurse may not flush the antibiotic in the correct order and the PICC line could clog and not be usable. She said she would add the SASH documentation cue into the computer system now, after surveyor intervention. During an interview on 07/23/24 at 2:12 p.m., the Corporate Nurse and Interim DON said the Unit Manager was responsible for ensuring the SASH documentation was in the computer system for all IV antibiotics and the DON was ultimately responsible. They said Resident #175's MAR should have included SASH documentation for her IV antibiotic. They said it was overlooked. The Interim DON said any resident with an IV or PICC line had a standing order to administer SASH per facility protocol and document in the MAR. He said the nursing staff were educated on the IV process and documentation at the annual skills fair 2 months ago. The Corporate Nurse said the potential negative outcome of the SASH documentation not in the MAR was a resident could potentially have a drug allergy. They said the expectation was for nurses to follow physician orders and IVs administered according to facility policy including documentation in the computer system. During an interview on 07/23/24 at 2:13 p.m., UM said Resident #175's MAR IV documentation should have included the SASH documentation. She said it was overlooked. She said the charge nurse was responsible for completing orders and it was her responsibility to double check orders for completion and accuracy. The UM said she was educated on order documentation including all correct orders put in place. The UM said the potential negative outcome of the SASH documentation not in the MAR was not following the plan of care. During an interview on 07/24/24 at 8:22 a.m., LVN A, said she was responsible for making sure the SASH order was in the computer system before she gave Resident #175 the IV antibiotic and she did not. She said she assumed the SASH order was in the computer system. She said the facility policy was to follow the SASH method when administering IV antibiotics and she gave the antibiotic according to policy. She said the IV SASH documentation was probably missed being entered in the computer system. LVN A said the process starts with the admission nurse, the other nurses should double check the orders and then the unit manager audits the orders for accuracy. She said then the DON audits orders for accuracy. LVN A said the potential negative outcome of the SASH documentation not in the MAR was a potential reaction to medication. Record Review of the facility's Physician's Orders policy dated January 2020 indicated, It is the policy of this facility that physician orders are maintained per state and federal regulations. 1. All physicians orders shall be recorded on the Patients Medical Record and must be signed electronically by the attending/ prescribing physician. 6. Medications, diets, therapy, or any treatment may not be administered to the patient without a written order from the attending physician.

Based on observation, interview and record review, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 20 residents reviewed for respiratory care and services. (Resident #66) *The facility failed to administer the correct dose of oxygen to Resident #66. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: Record review of physician orders dated July 2024 indicated Resident #66, admitted [DATE], was a [AGE] year old female with diagnoses of chronic respiratory failure with hypoxia (a condition where you do not have enough oxygen in the tissues of your blood or when there is too much carbon dioxide in the blood) and a tracheostomy (a surgical opening into the windpipe to allow air to fill the lungs). The resident was to receive oxygen at 2-4 L/min via nasal cannula. Record review of the admission MDS assessment dated [DATE] indicated Resident #66 had severe cognitive impairment, received tracheostomy care, and received oxygen therapy. Record review of a care plan dated 06/20/24 indicated Resident #66 was unable to maintain oxygen saturation and received oxygen at 2-4 L/min via nasal cannula. During the following observations Resident #66 had oxygen in progress at 4.5 L/min via nasal cannula: *on 07/22/24 at 9:32 a.m., *on 0722/24 at 2:25 p.m., *on 07/23/24 at 8:50 a.m., and *on 07/23/24 at 8:57 a.m. During observation and interview on 07/23/24 at 8:57 a.m., LVN C said Resident #66's oxygen was set at 4.5 L/min and should be set between 2 to 4 L/min nasal cannula. She said she had to suction the resident that morning and checked the resident's oxygen saturation levels (measurement of how much oxygen is bound to the hemoglobin in the red blood cells) and it was 98% (WNL) at that time but she did not check the setting of the oxygen dosage. She said it was her responsibility to assess each resident at the beginning of the shift and make sure their oxygen was set correctly. She said she would reset Resident #66's oxygen to 4L/min as ordered. She said the possible negative outcome of having the oxygen set too high would be the resident could become dependent on the higher dose of oxygen. During an interview on 07/23/24 at 2:33 p.m., the interim DON said his expectations were for the staff to follow the orders for oxygen administration. He said the plan of care was not followed. He said Resident #66 could have received too much oxygen and she could become more dependent on the higher dose. Record review of the Oxygen Administration policy revised October 2010 indicated: Purpose- The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.

Based on observation, interview, and record review, the facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 20 residents reviewed for range of motion. (Resident #66) The facility did not ensure Resident #66's palm guard (device used as a barrier between fingers and palmar skin to prevent injury to the palm from severe finger flexion contracture) was placed in her hands bilaterally, after therapy assessed the resident's needs and referred the resident to restorative care. This failure could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being. Findings included: Record review of physician orders dated July 2024 indicated Resident #66, admitted [DATE], was a [AGE] year-old female with diagnoses of diabetes and benign neoplasm of the cranial nerve (a rare type of cancer that grows on the cranial nerves in the head or neck region causing weakness or loss of function in the affected area). Record review of the admission MDS assessment dated [DATE] indicated Resident #66 had severe cognitive impairment, had functional limitation in range of motion to both sides of the upper and lower extremities and was totally dependent for upper and lower body dressing and personal hygiene. Record review of a care plan dated 05/28/24 indicated Resident #66 received restorative care for passive ROM and splint/brace assistance. The goal was for the resident to achieve the highest level of optimal functioning. The intervention was to evaluate progress every month and PRN. During the following observations Resident #66's fingers on her bilateral hands were contracted inward towards the palm of each hand. The resident did not have a palm guard to her right hand and/or her left hand: *on 07/22/24 at 9:32 a.m., *on 0722/24 at 01:29 p.m., and *on 07/23/24 at 9:09 a.m. During observation and interview on 07/23/24 at 9:09 a.m., Resident #66 had a palm guard around the left wrist; not in the contracted left hand, and there was no palm guard to hand. LVN C said the resident was supposed to have the palm guard in her left hand. She said the resident had never had a palm guard for the right contracted hand since admission. The LVN reapplied the palm guard in the left hand. The right hand remained without a palm guard. She said she tried to put the palm guard back on the left hand when she noticed that it was off. She said Resident #66 did have contractures in both hands and did need the palm guards in both hands to prevent further contractures, but she had never seen a palm guard for the right hand. She said the Restorative Aide was the person responsible for placing the palm guards in the resident's hands. She said the possible negative outcome would be the resident's hands would become more contracted. During an interview on 07/23/24 at 1:23 p.m., Family Member D said Resident #66 was their family member and they did not remember ever seeing the palm guards in Resident #66's bilateral hands. During an interview on 07/23/24 at 03:16 p.m., the Director of Rehabilitation said Resident #66 was assessed for hand rolls, positioning and a wheelchair. He said the resident was seen by OT from 05/24/24 to 06/13/24 and was then referred to restorative. He said both of the resident's hands were contracted but the resident's right hand was tightly contracted, and they attempted to perform exercises on it, but the resident could not tolerate it. He said Resident #66 was referred to restorative for bilateral palm guards and range of motion exercise. He said the Restorative Aide was supposed to be placing palm guards in the resident's hands bilaterally daily. During observation, interview and record review on 07/24/24 at 8:01 a.m., Resident #66 was lying in bed with a palm guard to the left hand; there was no palm guard to the right hand. The Restorative Aide said she was seeing Resident #66 three times a week for ROM exercises. She said she was responsible for ensuring the resident had the palm guard in her left hand. She said she had too many residents to see and got pulled to the floor at times to work as a CNA and did not see the resident daily to ensure the palm guard was in her left hand. She said she only placed the palm guard in the resident's left hand, and she did not have a palm guard for the resident's right hand and had not been placing one in the right hand. She said the resident needed the palm guards in both hands. The Restorative Aide provided the surveyor with the Nursing Restorative Care Program document for Resident #66. The document indicated the restorative Plan of Care for Resident #66 was: . Patient will tolerate PROM exercises to BUE, as tolerated, within ROM tolerance, no s/sx of pain, 3 to 4 times a week. Patient will tolerate palmar guards on bilateral hands times 8 hours with no s/sx of redness, irritation, discomfort or pain, daily. The Restorative Aide said she was supposed to follow the plan of care but had not. She said she did not receive a palm guard for the resident's right hand and had not placed one in the right hand. She said she had not followed the restorative plan of care by not placing the palm guard in the resident's hands bilaterally and by not ensuring the palm guards were placed in the resident's left hand consistently every day. The Restorative Aide opened Resident #66's left and right hands for observation without open areas or odor noted. She said the possible negative outcome of not placing the palm guards in the resident's hands could be the resident's hands could become more contracted or she could get cuts in her hands from her fingernails. During an interview on 07/24/24 at 08:10 a.m. CNA E said the Restorative Aide was responsible for ensuring Resident #66 had the palm guards in her hands bilaterally. She said no one had told her she was responsible for ensuring the palm guards were in the resident's hands daily. She said she had only seen the palm guard in the resident's left hand and had not seen one in the right hand. During an interview on 07/24/24 at 8:15 a.m., the interim DON said his expectations were for Resident #66 to have the palm guards in place as specified in the restorative plan of care. He said not placing the palm guards in the resident's hand could lead to worsening of the resident's contractures. During observations on 07/24/24 at 10:23 a.m., after surveyor intervention, Resident #66 had palm guards in her hands bilaterally. The resident did not exhibit s/sx of pain. Record review of a Resident Mobility and Range of Motion policy revised July 2017 indicated: Policy Statement: 1. Residents will not experience an unavoidable reduction in range of motion. 2. Resident with limited range of motion will receive treatment and services to increase and/or prevent decrease in ROM.

Based on observation, interview, and record review, the facility failed to ensure residents who entered the facility with an indwelling catheter were assessed for removal of the catheter as soon as possible and restore continence to the extent possible for 1 of 2 residents reviewed for urinary catheters. (Resident #275) The facility failed to attempt bladder retraining and discontinuation of an indwelling urinary catheter (a tube which is inserted into the bladder, through the urethra and remains in place to drain urine) for Resident #275 whose clinical condition did not necessitate catheterization. This failure could place residents with a urinary catheter at increased risk of dependence on a urinary catheter and urinary tract infections. Findings included: Record review of physician orders dated July 2024 indicated Resident #275, admitted [DATE], was a [AGE] year-old female with diagnoses of respiratory failure (a serious condition that makes it hard to breathe on your own) and anoxic brain damage (a potentially fatal brain injury that occurs when the brain is completely deprived of oxygen) The resident had an indwelling urinary catheter (a catheter which is inserted into the bladder to drain urine). Record review of a care plan dated 07/10/24 indicated Resident #275 had an indwelling urinary catheter and was at risk for urinary tract infection (UTI). Record review of the admission MDS assessment dated [DATE] indicated Resident #275 was unable to respond, had severe cognitive impairment, was dependent for all ADLs, had an indwelling urinary catheter, and had no active genitourinary (refers to the urinary and genital organs) diagnosis. During an observation and interview on 07/22/24 at 10:12 a.m., Resident #275 was lying in bed and was unable to respond to questions. The resident had a urinary catheter bag hung at bedside to gravity drainage (below the level of the bladder). Her family was at bedside and said she got the catheter during her hospitalization , but she was not sure why the resident needed a catheter. During an interview on 07/24/24 at 09:50 a.m., the Unit Manager said Resident #275 had no genitourinary diagnosis that necessitated the use of a catheter. She said she had called Resident #275's physician (after surveyor intervention) and obtained an order to begin bladder retraining (clamping the catheter tubing for two hours to stop the flow of urine and then unclamping the tubing to empty the bladder repeatedly to mimic urination) so her catheter could be discontinued. She said the facility had not attempted bladder retraining until the order was obtained today. She said residents who have catheters had an increased risk for UTIs. During an interview on 07/24/24 at 10:05 a.m., the interim DON said an order had been obtained from Resident #275's physician to start bladder retraining so her catheter could be discontinued. He said Resident #275 did not have a related diagnosis necessitating a catheter and the physician should have been contacted earlier. He said his expectation was that all residents who were admitted to the facility with a catheter would have a diagnosis necessitating catheterization. He said possible negative outcome of providing catheters to residents who did not need them was the resident becoming reliant on a catheter to urinate. During an interview on 07/24/24 at 10:15 a.m., the Administrator said the facility should try bladder retraining and discontinuation of the catheter for all residents who were admitted with a catheter unless they had a medical diagnosis that indicated the use of a catheter. During an interview on 07/24/24 at 10:25 a.m., the Corporate Nurse said the facility did not have a policy to address diagnosis that indicated the use of a urinary catheter. She said facility policies only addressed skills and procedures such as catheter insertion and care.

Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 1 of 9 dietary staff (Dietary Staff B) reviewed for competencies. The facility failed to ensure Dietary Staff B had a current Food Handlers Certificate while working in the facility's kitchen. This failure could place residents who consume food prepared in the facility kitchen at risk of foodborne illness due to being served by improperly trained staff. Findings included: Record review of 9 dietary staff food handlers certificates indicated Dietary Staff B's certificate was expired on [DATE]. During an interview on [DATE] at 11:00 a.m., the DM said Dietary Staff B had worked a day or two with an expired food handler certificate. During an interview on [DATE] at 11:30 a.m., the HR staff said the food handler certificate was important for the dietary staff to renew their food handler certificate to obtain the latest training to prevent food born borne illnesses and handle food correctly. During an interview on [DATE] at 2:00 p.m., the Administrator said all dietary staff must keep their dietary food handler certificates current. She said continued education was important to keep the dietary staff up to date with changes. During an interview on [DATE] at 9:00 a.m., Dietary Staff B said her food handler certificate had expired. She said she was not aware that she had to take the course every 2 years. Record review of the undated dietary staff list indicated 1 (Dietary Staff B) of 8 dietary staff had an expired food handler certificate. Record review of the punch detail for Dietary Staff B indicated she worked on [DATE], [DATE], [DATE], and [DATE]. Record review of the food handler certificate for Dietary Staff B indicated her food handler was expired on [DATE]. Record review of the new food handler's certificate for Dietary Staff B indicated it was obtained on [DATE] after survey began on [DATE]. Record review of the policy dated [DATE] titled Licensure, Certification, and Registration of Personnel indicated Employees who require a license, certification or registration to perform their duties must present such verification with their application. 3. A copy of recertifications (annual, bi-annual, etc.,) as applicable must be presented to the human resource director/designee upon receipt of such recertifications and prior to the expiration of current licensure, certification, or registration. A copy of the recertification must be filed in the employee personnel record.

Based on interview and record review, the facility failed to ensure that the residents and/or representatives had the right to participate in the development and implementation of his or her person-centered plan of care, and to ensure that the planning process facilitated the inclusion of the residents and/or representatives for 5 (Resident #23, #28, #38, #42 and #51) of 16 residents reviewed for care planning. The facility failed to ensure the IDT, Resident #23, Resident #28, and Resident #38 and RP of Resident #38, Resident #42 and the RP of Resident #42, Resident #51 and RP of Resident #51 were involved in the review of the comprehensive assessment and were able to discuss their individualized care needs for services to include their need for medical and nursing care, medications, therapy, psychological and dietary needs. The failure could affect residents by placing them at risk for not receiving adequate or individualized care. Findings included: 1. Record review of Resident 23's undated face sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), dementia (group of thinking and social symptoms that interferes with daily functioning), and osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wears down). Record review of Resident #23's quarterly MDS assessment, dated 03/17/2023, reflected she had a BIMS score of 08, which indicated a moderate impaired cognitive status. Her functional status reflected she required extensive assistance with bed mobility, toilet use and personal hygiene. She required set up only for eating. Record review of Resident #23's comprehensive care plan showed the last review was done on 02/23/2023. Record review of Resident #23's EHR showed the last care conference was held on 10/03/2022. An interview with Resident #23 on 06/14/2023 at 11:15 a.m., revealed she had not been to her own care plan meeting in six months or greater. Resident #23 stated it was important to her to be a part of her plan of care and she did not want strangers to decide her care. Resident #23 stated that she used to get a letter from the social worker that said when the care plan meetings would be held but she had not gotten one in more than 6 months. 2 Record review of Resident 28's undated face sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: anemia (condition in which the blood doesn't have enough healthy red blood cells), bipolar disorder (a serious mental illness that causes unusual shifts in mood, ranging from extreme highs (mania) to lows (depression), and schizophrenia (a serious mental disorder in which people interpret reality abnormally). Record review of Resident # 28's quarterly MDS, dated [DATE], reflected she had a BIMS score of 09, which indicated a moderate impaired cognitive status. Her functional status reflected he required limited assistance with bed mobility, toilet use and personal hygiene. He required set up only for eating. Record review of the care plan reflected the last update to the comprehensive care plan for Resident #28 was on 02/23/2023. Record review of last recorded care plan meeting was dated 10/12/2022. The care plan meeting was recorded as a quarterly care plan meeting. An interview with Resident #28 on 06/13/2023 at 2:12 p.m., revealed Resident #28 had not had a care plan meeting in over six months. Resident #28 stated she had a family member that would attend if they were invited. Resident #28 wanted to have a care plan meeting to discuss her need for mental health services related to her bipolar and schizophrenia diagnoses. 3. Record review of Resident 38's face sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: hypothyroidism (when the thyroid gland doesn't make enough thyroid hormones to meet your body's needs), dementia (group of thinking and social symptoms that interferes with daily functioning), and depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act). Record review of Resident # 38's annual MDS, dated [DATE], reflected she had a BIMS score of 04, which indicated severe impaired cognitive status. Her functional status reflected she required supervision assistance with bed mobility, toilet use and personal hygiene. She required set up only for eating. Review of Resident #38's face sheet reflected she had a responsible party who was also listed as her primary contact. An interview with Resident #38's responsible party on 06/14/2023 at 11:30 a.m., revealed the RP had not been invited to a care plan meeting since 2022 and was not aware that of any care plan meetings since that time. 4. Record review of Resident 42's face sheet reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: dysphagia (swallowing difficulties), dementia (group of thinking and social symptoms that interferes with daily functioning), and Raynaud's syndrome (causes some areas of the body - such as fingers and toes - to feel numb and cold in response to cold temperatures or stress). Record review of Resident # 42's quarterly MDS, dated [DATE], reflected she had a BIMS score of 03, which indicated severe impaired cognitive status. Her functional status reflected she required extensive assistance with bed mobility, toilet use and personal hygiene. She required set up only for eating. Review of Resident #42's face sheet reflected she had a responsible party who was also listed as her primary contact. An interview with Resident #42's responsible party on 06/14/2023 at 12:30 p.m., revealed the RP had not attended a care plan meeting since October 2022 for Resident #42 because she had not received notice one was occurring. Record review of Resident #42's EHR revealed no care plan letter invitations and no documentation of a care plan being held since October 2022. 5. Record review of Resident 51's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: Unspecified Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), adjustment disorder with anxiety (nervousness, worry, difficulty concentrating or remembering things, and feeling overwhelmed), muscle weakness (commonly due to lack of exercise, ageing, muscle injury or pregnancy.), unspecified psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), lack of coordination (uncoordinated movement is due to a muscle control problem that causes an inability to coordinate movements), rheumatoid arthritis (a chronic inflammatory disorder affecting many joints, including those in the hands and feet), hyperlipidemia (too many lipids (fats) in your blood), depression (is a common and serious medical illness that negatively affects how you feel, the way you think and how you act.) Record review of Resident #51's quarterly undated MDS, reflected he had a BIMS score of 7, which indicated a severe impairment of cognitive status. His functional status reflected he required supervision and limited assistance. Review of Resident #51's face sheet reflected she had a resident representative who was also listed as his primary contact. During an interview on 06/14/2023 at 9:20 a.m. with Resident #51's Representative. she stated that she has not been to a care plan meeting since October of 2022. She stated she did not know the exact date. She stated that she has not been to a care plan meeting or has been invited to a care plan meeting for at least 8 months She stated that she would prefer to be a part of Resident #51's care planning. She said that it was important to her to be a part of the planning for Resident #51 so his voice could be heard. An interview was attempted with Resident #51 on 06/14/2023 at 09:40 am. Surveyor attempted to ask Resident #51 whether he had been a part of his care plan meeting. Resident #51 was unable to answer any questions regarding care plan meetings. An interview with the Social worker on 06/14/2023 at 1:15 p.m., revealed she was the one in charge of coordinating the care plan meetings. She stated care plan meetings were supposed to occur each quarter following the completion of the MDS. The social worker stated generally she sent out a care plan letter to inform the primary contacts of the care plan meetings and gave a copy to the residents to invite them. Then she scanned the letter into the EHR. The social worker stated that she recorded each meeting in the care plan section of the EHR. The social worker stated that each care plan meeting the social worker, dietary manager, activities, rehab coordinator, resident and resident representative were invited. The social worker stated the team had gotten behind on doing care plan meetings over the past several months. The social worker did not know specifically why Resident #23, Resident #28, #39, #42 and Resident #51 did not have recorded care plan meetings . The social worker stated not having a care plan meeting with the family and resident present could make the resident feel like they are not part of important decisions about their care and life. An interview with the DON on 06/14/2023 at 3:30 pm revealed the care plan meetings were important to be held quarterly and as needed so they family and resident could be a part of their plan of care. The DON stated it was the MDS nurse that gave the schedule of who was due for a care plan meeting and the social worker was to schedule and hold the care plan meetings. The DON stated she was aware several months had passed and the change of staff affected the completion of care plan meetings. The DON stated it was the responsibility of the Social Worker and MDS nurse to ensure the care plan meetings were happening and everyone attended. An interview with the Administrator on 06/14/2023 at 4:30 pm revealed the care plan meetings were to be attended by all members of the IDT team and were to be done quarterly and as needed. The Administrator stated the social worker was responsible for coordinating the care plan meetings and it had not been brought to her attention that care plan meetings were being missed. The Administrator stated it was important for the residents and family to have a say it the resident's care. The Administrator stated if the residents and family did not get as say in the care of the resident, they could feel their autonomy was not being honored. Review of an undated policy titled Care Planning/Interdisciplinary Team on 06/14/2023 at 4:45 p.m., revealed The care planning team shall be composed of but not necessarily limited to the following personnel: a. RN assessment coordinator, b. Director of nursing, c. Medical director, d. attending physician, e. Therapist, f. Activity director, g. Social service director, h. Dietician/food service manager, i. Pharmacist, j. other individuals as the resident's need dictates and meet quarterly.the secretary to the team shall be responsible for notifying team members when a meeting is scheduled, providing reports, ect., to be reviewed, and maintaining written reports of all meetings. 45643 Resident #51 FTag Initiation