Every finding on record at The Parks at Garland Healthcare and Rehab

Based on observation, interview, and record review the facility failed to provide a private meeting space for residents' monthly Resident Council Meeting for 7 of 14 confidential residents reviewed for Resident Council for 1 of 1 facility.1. The facility failed to provide a private space area for residents who attended monthly Resident Council Meetings.This failure could place residents who attend the monthly Resident Council Meetings at risk of not being able to voice their concerns amongst each other due to a lack of privacy.Findings included:In an interview with the Activities Director on 04/09/26 at 10:30 AM, she stated that the confidential group meeting on 04/09/26 with the residents of Resident Council and the State Surveyor would not be held in the Private Dining Room where the monthly Resident Council Meetings were normally held. The Activities Director stated that the confidential group meeting on 04/09/26 with the residents of Resident Council and the State Surveyor would be held in an empty resident room for privacy.A confidential group meeting was held on 04/09/26 at 10:35 AM in an empty resident room on the 100 Hall. In the confidential group meeting, 7 residents that regularly attended the facility's monthly Resident Council Meetings stated that their monthly Resident Meetings were held in the Private Dining Room, which was adjacent to the Dining Room. The residents described the Private Dining Room area as being a room connected to the Dining Room. The residents stated that the Private Dining Room had 1 door, which opened to the 300 Hall. The residents stated that the Private Dining Room had a large area that was open to the public and did not have any interior or exterior doors. The residents stated that the large opening that led to the Dining Room did not provide any privacy for the residents to discuss what they needed to discuss about the facility operations, including their concerns regarding the staff and the care that they were receiving by the staff and there was no privacy. The residents stated that they had never had any Resident Council Meetings in the area where the Resident Council Meeting was being held on 04/09/26. The residents stated during some of their previous monthly Resident Council Meetings, they were disrupted by staff during their meetings and would prefer that staff did not enter the Private Dining Room during their meetings, which occurred on several occasions. The residents stated that they would like the option to have their monthly Resident Council Meetings in a location that had doors to ensure privacy and would not cause staff or residents to overhear what was being discussed in their meetings to prevent retaliation from staff and other residents.An observation on 04/09/26 at 11:43 AM, revealed that the Private Dining Room area had 1 exterior/interior door that led to the 300 Hall. The Private Dining Room area shared common walls with the Dining Room and did not include any doors that separated the Private Dining Room area from the Dining Room.In an interview on 04/10/26 at 10:46 AM with the SW she revealed she had been employed at the facility for 2 months. The SW stated that she was unaware that the facility needed to have a private area for residents to have their monthly Resident Council Meetings. The SW stated that she was the facility's Grievance Officer and had not received any concerns/complaints from residents who attended the monthly Resident Council Meetings regarding their lack of privacy in the Private Dining Room during their meetings. The SW stated that she did not feel that there was any risk or harm to residents due to the facility not providing a private area/space for the residents to have their monthly Residential Council Meetings.In an interview on 04/10/26 at 11:05 AM, the Administrator revealed he had been employed at the facility for almost 2 years. The Administrator stated that the monthly Resident Council Meeting location was set up by the Activities Director. He stated that the Activities Director held the monthly Resident Council Meetings in the Private Dining Room, which was adjacent to the facility's Dining Room. The Administrator stated that he was unaware that the facility needed to have a private area that allowed residents who attended the monthly Resident Council Meetings for privacy, which included doors to ensure privacy for the residents during their meetings. The Administrator stated that the residents had not brought to his attention that they needed a private area for their monthly meetings to ensure privacy. The Administrator stated that he understood the need for residents to feel safe and secure about what they were discussing in their meetings during their monthly Resident Council Meetings and not have to worry about the potential of retaliation from staff and residents. The Administrator stated that there was a potential of someone in the Resident Council Meeting being harmed if someone overheard what was being discussed during the monthly Resident Council Meetings. The Administrator stated that the facility was in the process of getting some bids from some vendors for the pricing of enclosing the Private Dining Room area. The Administrator stated that he was going to provide some reeducation and training via In-Service Trainings to all staff members to advise them not to disrupt the monthly Resident Council Meetings as well as ensure that the monthly Resident Council Meetings are held in a private and secured area with doors.In an interview on 04/10/26 at 11:56 AM with CNA B revealed she had been employed at the facility for 1 month. CNA B stated that she was unaware that the facility needed to have a private area that allowed residents who attended the monthly Resident Council Meetings with privacy, which included doors to ensure privacy for the residents during their meetings. CNA B stated that residents had not told her anything about wanting to have more privacy during the monthly Resident Council Meetings. CNA B stated that the risk of not having a secure area for the residents during their monthly Resident Council is that they do not have any privacy due to there not being any doors in between the Private Dining Room and Dining Room areas. CNA B stated that if a resident(s) mentioned their concerns during one of their monthly Resident Council Meetings and it involves another resident or staff member, there was a potential for harm to the residents in the meeting to be bullied, harassed or physically hurt.In an interview on 04/10/26 at 1:50 PM, the Activities Director stated she had been employed at the facility since February 2026. She stated the residents in Resident Council met once a month and reported that up to 15 residents attended the monthly meetings. She stated prior to the beginning of the monthly Resident Council meetings, she will close the door to the 300 Hall and post a sign on the door advising Do Not Disturb due to Meeting in Progress. She stated that during previous Resident Council Meetings, she had been unable to close off the opening attached to the Dining Hall because there were not any doors. The Activities Director stated that the residents that had attended previous Resident Councils meeting had not voiced to her anything about there not being enough privacy during the monthly Resident Council Meetings. The Activities Director stated she understood that the residents that attend the monthly Resident Council Meetings should feel free to express their opinions about what they need to discuss amongst each other. The Activities Director stated that there was a risk to residents that attended the monthly Resident Council Meetings to have everything they mentioned in the meeting being overheard by someone who did not attend the meeting. The Activities Director stated that harm could be caused to a resident, if their discussions were overheard, which could cause retaliation and an unsafe environment for the staff and residents.Record review of the facility's policy, Resident Council, revised April 2017, reflected:Policy StatementThe facility supports residents' rights to organize and participate in the Resident Council.Policy Interpretation and Implementation1. The purpose of the Resident Council is to provide a forum for:a. Residents, families and resident representatives to have input in the operation of the facility;b. Discussion of concerns and suggestions for improvement;c. Consensus building and communication between residents and facility staff; andd. Disseminating information and gathering feedback from interested residents .

Based on observation, interview, and record review, the facility failed to ensure the right to file grievances anonymously for 12 of 12 residents (Resident #75 and confidential group members) reviewed for grievances.1. The facility failed to ensure that the 93 residents at the facility had access to file a grievance anonymously.The facility's failure could place the residents at risk for concerns not being reported and addressed.Findings included:Record review of Resident #75's Face Sheet, dated 04/10/26, reflected she was a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident # 75's active diagnoses included: Stage 3A chronic kidney disease (mild to moderate loss of kidney function), Alzheimer's disease (a progressive, neurodegenerative disorder and the most common cause of dementia, characterized by memory loss, cognitive decline, and behavioral changes), dementia (cognitive decline-including memory loss, language issues, and poor reasoning-severe enough to disrupt daily life), and muscle wasting and atrophy (the loss of muscle mass caused by inactivity (disuse), aging, or underlying medical conditions like nerve damage (neurogenic) or chronic diseases). Record review of Resident #75's MDS Quarterly Assessment, dated 02/19/25, reflected that she had a BIMS score of 12, indicating her cognition was moderately impaired.Record review of the facility's Grievance Logs for October 2025 and March 2026 reflected there were no grievances completed for Resident #75.An interview on 04/09/26 at 11:15 AM with Resident #75 revealed she had a personal notebook that she wrote her complaints in. Resident #75 stated that she would normally not complete a Grievance for her concerns due to verbally telling the staff about her concerns. Resident #75 stated that the Grievance Forms were located at the Nurses Station and she did not like that they were located at the Nurses Station. Resident #75 stated that she would like to have the option to file a grievance anonymously but did not know how.In a confidential group meeting on at an undisclosed date and time, the residents stated that the facility's Grievance Forms were located at the Nurses Station in a black wire basket. The residents stated that they have completed grievances at the facility on several occasions. The residents stated that their concerns that were on their Grievance Forms had been addressed. The residents stated that after completing and filing a grievance, they would give it to staff and were uncertain if any staff were able to view their grievances and share with other staff their grievance concerns after they have been filed. The residents stated that the staff at the facility were not only coworkers, but also friends outside of work and they have not filed any grievances regarding their concerns because they feared being retaliated against by their caregivers and staff at the facility. The residents stated that they would like the option to file a grievance anonymously in a location that was in a discrete location.An observation on 04/09/26 at 11:40 AM revealed there were blank Grievance Forms in a black wire basket located at the Nurses' Station desk.In an interview on 04/10/26 at 10:13 AM with LVN D revealed she had been employed at the facility for 10 years. LVN D stated that she was unaware that the facility needed to have an area for Grievance Forms that could be completed and submitted anonymously. LVN D stated that the facility's Grievance Forms were in one area, which was at the Nurses' Station. LVN D stated that the Grievance Forms were in a black wire basket at the front of the Nurses' Station. LVN D stated that after a Grievance Form was completed, it should be placed in the same black wire basket as the blank Grievance Forms. LVN D stated that if the residents, their family members, friends and/or visitors wanted or needed to voice their concerns about something at the facility there should be an area designated for them to voice their concerns anonymously. LVN D stated that harm could be caused to a resident if a Grievance Form was completed about a staff member. LVN D stated that the potential harm could be resident abuse (ie: mental, verbal, emotional, and physical), resident neglect, retaliation against the resident and psychosociological harm to their well-being.In an interview on 04/10/26 at 10:46 AM with the SW she revealed she had been employed at the facility for 2 months. The SW stated that she was the facility's Grievance Officer. She stated there was not a way for a resident to file a grievance anonymously, but that a resident could report concerns to her. The SW stated that she was unaware that the facility needed to have an area for Grievance Forms that could be completed and submitted anonymously. The SW also stated that any staff member could take a grievance and fill it out for the residents. The SW stated if a Grievance is completed and filed after her business hours, staff can place the Grievance Form underneath her door. The SW stated a resident could file a grievance by getting a form from the Nurses' Station and stated that there were not any other places for anyone to obtain a Grievance Form. The SW stated that she was not aware if residents, family or visitors had access to the Grievance Forms if there was not a staff at the Nurses Station. The SW stated that after a Grievance Form was completed, it was given to her and she would assign the Grievance Form to the department that the concern was about. The SW stated that she was unaware that staff stated that the completed Grievance Forms were placed in the same black wire basket as the blank Grievance Forms. The SW stated that she had only been at the facility for 2 months and maybe prior to her being the SW at the facility, the staff may have been doing so because the SW position at the facility was vacant for a while prior to her being the SW. The SW stated that she did not know that there needed to be a designated area in the facility that allowed residents to complete a Grievance Form anonymously. The SW stated that she did not feel that there was any risk or harm to residents due to not having the opportunity to file a grievance anonymously.In an interview on 04/10/26 at 11:05 AM with the Administrator, he revealed he had been employed at the facility for almost 2 years. The Administrator stated that the SW was the Grievance Officer at the facility. The Administrator stated that he was unaware that the facility needed to have an area for Grievance Forms that could be completed and submitted anonymously. The Administrator stated that the facility's Grievance Forms were located in a wire basket at the Nurses' Station. The Administrator stated residents who were bed bound would have to get a Grievance Form from a staff member. The Administrator stated that the facility was in the process of posting grievance forms on the wall so that the Grievance Forms could be obtained and filed anonymously. The Administrator stated that the facility purchased a lock box for the Grievance Forms to be submitted anonymously. The Administrator stated that there will be a designated area for Grievance Forms to be obtained, completed and filed anonymously. The Administrator stated that the staff will be In-Serviced on the location of the newly purchased lock box. He stated that he would be the only person in the facility to have a key to the lock box to retrieve the Grievance Forms. The Administrator stated that residents, family members, or visitors who could not file anonymous grievances were at risk for not being able to safely express their concerns. The Administrator stated that the potential harm to residents, family members, or visitors who could not file anonymous grievances was that there could be some retaliation against the person filing the Grievance Form by staff, and/or other residents.In an interview on 04/10/26 at 11:56 AM with CNA B revealed she had been employed at the facility for 1 month. CNA B stated that she was unaware that the facility needed to have an area for Grievance Forms that could be completed and submitted anonymously. CNA B stated that the only area she was aware that the facility's Grievance Forms were located was at the Nurses' Station. CNA B stated that a resident had never requested a Grievance Form during any of her shifts. She stated that she was advised during here Orientation that if a Grievance Form was given to her, to give it to the SW. She stated if a resident reported any concerns about the care they were receiving at the facility, she would immediately notify the DON and Administrator. CNA B stated that the Administrator was the facility's Abuse Coordinator. CNA B stated that the risk of there not being a designated location for anyone to complete and submit a Grievance Form is that there was no privacy and the Grievance Form may not be submitted. CNA B stated if someone had an issue with a staff member or the care they were receiving, the staff member that received the Grievance Form may throw it away. CNA B stated that harm could be caused if the staff member, who received the Grievance Form knows the person who the Grievance was about and could retaliate against the person that filed the Grievance.Record review of the facility policy, Residence Grievances/Complaints, Filing, revised December 1, 2023, reflected:Policy StatementThe facility shall establish a grievance policy in order to ensure prompt resolution of all grievances regarding the residents' rights. All residents, family and resident representatives are to be encouraged and assisted (if necessary) in filing grievances, in the event they have a need to make a concern known. Policy Interpretation and Implementation1. Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished.2. Residents, family and resident representatives have the right to voice or file grievances without discrimination or reprisal in any form, and without fear of discrimination or reprisal.4. Grievances and/or complaints may be submitted orally or in writing, and may be filed anonymously.5. All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. The facility maintains and supports a Resident Council consisting of members who are residents of the facility. The council represents the resident body and meets on a regular basis to discuss facility policies and issues or concerns that affect them.10. If the grievance was filed anonymously, the Grievance Officer will inform the resident that a grievance has been anonymously filed on his or her behalf and the steps that will be taken to investigate the grievance(s) and report the findings.

Based on interview and record review, the facility failed to complete a discharge summary for 1 of 3 residents (Resident #2) reviewed for closed records. The facility failed to ensure Resident #2 discharged the facility with a discharge summary that included an accurate and current description of the clinical status of the resident and sufficiently detailed, individualized care instructions to ensure that care is coordinated and the resident transitions safely from one setting to another. This failure could place residents at risk for not receiving appropriate and timely care due to confusion among various facilities, agencies, practitioners, and caregivers involved with the resident's care. Findings Included: Record review of Resident #2's discharge MDS, dated [DATE], revealed the [AGE] year-old female admitted to the facility on [DATE] with a primary diagnosis of Alzheimer's disease (a fatal neurological disorder) and discharged the facility on 03/21/2026. A record review of Resident #2's progress notes, dated 03/16/2026 revealed Resident #2 was admitted to the facility for respite care arranged through her hospice provider and discharged home on 3/21/2026. Record review of Resident #2's assessments in PCC (the electronic health record) revealed a discharge summary had not been completed. During an interview with the Social Worker on 04/10/2026 at 10:51am, the Social Worker stated she was responsible for opening and closing the discharge summary. The Social Worker stated it was her responsibility to open the discharge summary and inform the rest of the IDT it was open. The Social Worker further stated that if she did not open the discharge summary, the IDT will not get a notification they need to complete their part of it. The Social Worker was asked to verify in PCC if Resident #2 had a discharge summary, and she confirmed it was not completed. The Social Worker stated the discharge summary should have been completed for Resident #2, and it was on her for not being done. The Social Worker stated she completed a trauma assessment and social history; she did not know why she did not complete the discharge summary. The Social Worker was asked if there was a risk for the resident if a discharge summary was not completed, and she stated she did not think so because the discharge summary was for the facility, and discharge instructions go with the resident. A review of the facility's Transfer or Discharge, Emergency policy dated August 2018 did not address the requirement to complete a discharge summary for a resident discharge. A request was made on 04/10/2026 at 1:36pm via email requesting a policy related to transfer or discharge that was scheduled or routine and addressed the requirement to complete a discharge summary, and the facility could not provide one.

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 5 residents (Resident #1) reviewed for infection control. CNA A failed to wear the appropriate PPE while providing incontinent care to Resident #1.CNA B failed to wear the appropriate PPE while transferring Resident #1 from bed to wheelchair. LVN C failed to wear the appropriate PPE while transferring Resident #1 from bed to wheelchair. This failure could place residents at risk of being infected by staff in contact with other residents with infections. Review of Resident 1's Quarterly MDS assessment dated [DATE] revealed that she was a [AGE] year-old female. Resident #1 was re-admitted to the facility on [DATE]. Admitting diagnoses included muscle wasting and atrophy, muscle weakness (generalized), morbid (severe) obesity (you have a body mass index (BMI) of 40 or higher) due to excess calories, depression (mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety disorder (intense, excessive and persistent worry and fear about everyday situations). Resident #1 was always incontinent with bowels and bladder and required maximum assistance with toileting. Resident #1 had more than one wound. Review of Resident #1's care plan revised on 11/15/24 reflected, Resident #1 was on enhanced barrier precaution implements due to wounds. Goal, EBP care should be maintained for the residents' entire stay or until wounds have healed or indwelling medical devices are no longer needed. Intervention, provide patient standard precautions using gowns and gloves during dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use and wound care. Observation on 04/10/26 at 12:06 pm revealed CNA A providing incontinent care after LVN C had completed proving wound care to Resident #1. During the care CNA A did not have appropriate PPE (gown) because the resident was on enhanced barrier precaution. After providing care, CNA A, CAN B and LVN C assisted the resident from bed to chair using a hoyer lift and none of the staff had the gown on. Observation on 04/10/26 at 12:30 pm revealed a posting on Resident #1 door that indicated the use of gloves and gown and there was a container at the door that contained gown, masks, and gloves. In an interview on 04/10/2026 at 1:32 pm with CAN A stated she did provide care to the resident, and she forgot to put on the gown. She stated she was expected to put on the gown when providing care because the resident was on EBP. CNA A stated she did not think she was required to wear a gown while transferring Resident #1. She stated that EBP (gown and gloves) was required when caring for the resident to prevent the spread of infection. In an interview on 01/10/26 at 1:38 pm with CNA B, she stated she had gone to assist with the transfer. She stated she was not aware she needed to have a gown while transferring Resident #1. CNA B stated she was required to wear a gown and gloves when caring for the residents who were on EBP. Then she stated that if Resident #1 was on EBP then she was expected to wear gloves and gown. CNA B using the appropriate PPE prevented the spread of infection. In an interview on 04/10/2026 at 1:42 pm with LVN C, she stated the gown was not required during transfer with Resident #1 who was on EBP. She stated she only put on the gown when she provided wound care to the resident. LVN C stated she was required to wear appropriate PPE to prevent the spread of infection. In an interview on 04/10/2026 at 1:50 pm with the DON, she stated the staff were expected to wear gown and gloves while taking care of Resident #1. The DON stated even with transferring the staff were expected to wear a gown. The DON stated she had in-serviced the staff on infection control and the use of the appropriate PPE. The staff were to wear the right PPE to prevent the spread of infection. Review of the facility policy dated 03/24 and titled Implementation of Standard and Transmission-Based Precautions, reflected, . Enhanced Barrier Precautions (EBP) - Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Enhanced-Based Precautions are indicated during: Dressing Bathing/showering in a shared/common shower room Transferring Providing hygiene Changing linens Changing briefs or assisting with toileting Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator Wound care; any skin opening requiring dressing. When working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility.

Based on observation, interview, and record review, the facility failed to ensure that each resident received food that is palatable, attractive, and at a safe and appetizing temperature for 1 of 1 lunch meals tested for nutritive value, flavor, and appearance: The facility failed to provide palatable food served at an appetizing temperature to residents, during lunch on 12/09/2025. This failure could affect the residents who ate food from the facility kitchen by placing them at risk of poor food intake and/or dissatisfaction of the meals served.The findings included: During an interview on 12/09/2025 at 9:58 a.m., CNA A stated she had received complaints from residents that the food was cold, but not often and only for residents who ate in their room. The CNA stated that trays were passed when the cart was on the hall. The CNA stated that it could take 10 minutes to pass all trays. During an interview on 12/09/2025 at 10:10 a.m., CNA G stated she had received complaints from residents stating that the food was cold. The CNA G stated that they asked the residents if they would like their tray to be reheated and residents were usually fine once the tray was reheated. The CNA stated that it could take a while to pass trays, just dependent on what was going on, staff could have assisted another resident with care and it was only one person on the hall to pass tray. During an observation on 12/09/2025 at 11:18 a.m., the DM who conducted temperature check of the barbeque, revealed the thermometer read 208 degrees Fahrenheit. For the okra the thermometer read 188 degrees Fahrenheit. For the potato salad the thermometer read 40 degrees Fahrenheit. The state surveyor requested a test tray. Observation of test tray provided to the state surveyor on 12/09/25 at 12:38 p.m., the state surveyor revealed barbeque meat was placed between two buns, the outside edges of the meat was cool to taste but the center was lukewarm; the okra was cold and the potato salad was no longer cold. No facility staff member was present. During an interview on 12/09/2025 12:57 p.m., Resident #2 revealed that the food is often cold. Resident #2 stated the trays often sit on the halls for approximately five minutes before staff pass then out. Resident #2 stated she had received her tray in her room today and the food was not cold, but not it was not hot. During an interview on 12/09/2025 at 3:59 p.m., the DM revealed that residents on halls 100 and 200 had expressed concerns about food being cold. The DM stated that they tried to ensure that the food was cooked and was hot as it could safely be. He stated they covered the plates, utilized plate warmers and had enclosed carts. The DM stated that the dietary staff delivered the cart on time to the hall and announced that the cart was on the hall, but the assigned hall staff did not start passing trays right away. The test tray provided on the last cart was delivered to the hall at 12:22 p.m. but was still on cart at 12:35p.m., that was 13 minutes after that cart had been delivered to the hall and that is unacceptable. The DM stated that he informed the clinical staff when trays would be delivered so they would be ready, but 13 minutes would cause food to be cold. During an interview on 12/09/2025 at 4:15 p.m., the DON revealed that her expectation was for the staff to disperse the trays as soon as they hit the hallway to ensure residents who ate in their room received warm meals. The DON stated that staff were notified by dietary that carts were on the hall and that there were enough staff to pass trays, they just had to find a way to have the carts delivered timely to the residents. The DON stated that she had spoken with the ADM on having staff member sign for cart and put what time cart was accepted and pass completed to be able to hold their staff accountable for getting food out on time. During an interview on 12/09/2025 at 436 p.m., the ADM stated his expectation was that food be served to residents at a safe and appetizing temperature. The ADM stated that the nursing staff was responsible for ensuring food trays were delivered as soon as the dietary staff brought the trays to the hall so that the residents who ate in their rooms received meals at appetizing temperatures. The ADM stated if food was not served at an appetizing temperature, it could have caused residents to not want to eat their food which could have led to weight loss. The ADM stated what led to failure was the staff not following facility policies. Record review of facility policy titled Meal Service dated October 2021 revealed: The facility believes that all residents should be treated with dignity and respect at all times. A respectful, positive dining experience is essential to residents' quality of life and helps to identify residents' needs attended to during meal service.Procedure:12. Room service trays will be delivered promptly upon reaching the floor.

Based on interview and record review, the facility failed to ensure the right to be free from misappropriation of property for 1 of2 residents reviewed for misappropriation (Resident #2). Based on interview and record review, the facility was unable to account for 11 Soma pills missing from Resident #2's blister pack of physician prescribed Soma (muscle relaxant). This failure could place residents at risk of misappropriation of physician ordered medications. Findings included: Record review of the Quarterly MDS dated [DATE] reflected indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: Congestive Heart Failure (heart pumps slow), Schizoaffective (mental disorder), panic disorder (mental disorder), dementia (confusion), diabetes, (increased sugar), other chronic pain (pain). Resident #2 was severely cognitively impaired and unable to make decisions. Resident #2 requires two staff for activities of daily living. Record review of a Physician's Order dated 12/10/2025 Resident #2 was ordered Soma 325mg three times a day and before bedtime. Record review of the Care Plan dated 12/10/2025 indicated Resident #2 had goals: to assist in control of the chronic pain, by use of the repositioning interventions and the muscle relaxant Soma. Record review of the Medications Administration Record for Resident #2 dated 09/1/2025, indicated Resident #2 missed no doses of Soma 325mg through the month of September. Record review of a pharmacy shipping manifest dated 9/13/2025 indicated 60 Soma 325 mg tablets were delivered for Resident #2 and signed in by LVN C. Record review of a provider investigation report dated 10/01/20235 indicated MA B and RN D noted while performing the count at the end of the shift, there was a count sheet that had the incorrect amount of medication on it and it appeared the count sheet had been written over. The police, the family, the pharmaceutical consultants, and the medical director were all notified. The agency for as needed employee replacement was contacted. An in-service for all staff that had anything to do with distribution of medication concerning the by the two-step system. Continuing, with monitoring by the nursing administration for two weeks after the in-service had occurred on all shifts, to assure compliance. The pharmacy consultant found no other medications discrepancies. The police detective came, and the facility provided the information for the drug diversion, a case number was given. The facility in their investigations could not confirm that the staff or LVN F (agency nurse) had misappropriated the medication. In an interview on 12/09/2025 with the DON revealed she had received a phone call from Medication Aide B and RN D on 09/23/2025 around 10:00 p.m. informing her that around 10:00 pm that 11 Soma tablets were missing for Resident #2. The staff stated to the DON the counting sheets were scribbled over on the original numbers. The DON stated she reported that to the Administrator, who called the agency for as needed employees. The DON stated they checked all the carts the next day and the medication rooms and the shredder box, and the medication was not found. The DON stated the counting sheet for the Soma had numbers that had been written over on the original number from 09/20/2025 all the way until 09/22/2025. All the staff were interviewed that worked with the cart, except for the nurse from the agency LVN E, who had worked on 09/22/2025 at 10:00p.m. to 6:00 a.m. The DON stated she was called multiple times, but no answer and no return call. The DON stated the Medical Director, police and pharmacy consultant were called. The DON stated the police came and the detectives filed a case. The DON stated she initiated an in-service on the two-step counting system in place. The DON stated that was the first time she had ever had something like that happen and she had no problems after. The Agency Supervisor stated the agency had also tried as well as the police to get ahold of LVN E, but LVN E would not return anyone's calls. The police report was requested by the surveyor on 12/09/2025 at 1:00 pm by email. In an interview on 12/09/2025 at 1:00 p.m. with LVN F revealed the count of the medication was conducted on 09/23/2025 at 6:00 a.m., with the off-going nurse, LVN E. LVN E called out the count sheet and LVN F checked the medication, it was the same number of pills, so LVN F did not look at the count sheet. In an interview on 12/09/2025 at 2:15 p.m. with RN D revealed that on 09/23/2025 at 10:15 p.m. the count with MA B, MA B noticed the counting sheet was written over. RN D stated both her and the MA B checked the count sheet and there were some numbers skipped, according to what medications that had been dosed. RN D noticed the count sheet was also signed at 4:00 am, but Resident #2 was not assigned to the nurse who had signed for the medication on the count sheet. Resident #2 did not have a PRN order for Soma. In an interview on 12/09/2025 at 2:30 p.m. with MA B it was revealed he had counted with LVN F on Monday 09/22/2025 at 10:00 p.m. The medication count was right. MA B came back to work on Tuesday 09/23/2205 at 2:00 pm and counted the medicine with LVN F. LVN F called out the number from the count sheet and the medication matched that number and was correct based on the count. MA B stated when he counted at 10:00 p.m. on 09/23/2025 with RN D, before MA B left, that was when it was noticed by RN D and MA B the count numbers had been scribbled over and new numbers written. RN D and MA B tried to count again, and the number of pills did not match the sheet, it showed the Soma count was not correct. The DON was then notified. In an interview on 12/09/2025 at 3:00 p.m. with the ADON revealed she had worked a shift to fill in 09/21/2025 and she counted with RN D. The Soma pills were counted at 42 pills, and the count was correct at that time. In an interview on 12/09/2025 at 11:10 a.m., Resident #2 revealed she was unable to answer the questions due to her confusion and forgetfulness. Resident #2 kept repeating she was fine. During an interview on 12/09/2025 at 10:00 a.m., the Administrator stated they reported the concerns to the local police department and to the state. The Administrator stated he reported to the Agency Supervisor concerning the missing medication and the inability to contact the nurse. The Administrator stated that the agency had tried to contact LVN F, but she had not returned any of his calls. The Supervisor stated he had removed her from the service. The Administrator stated the staff were in-serviced on the two-step counting process and reporting. In an interview on 12/09/2025 at 10:58 a.m., the Medical Director revealed he had been contacted by the facility concerning the missing Soma but had been assured that the resident had missed no dosing of the medications. The Medical Director stated he was informed by the Administrator he had reported it also to the police and the investigation had begun. The Medical Director stated he had no worries about the other staff that worked there, he had never had any problems related to misappropriation of any other medications. Record Review of Abuse Prevention Policy revised dated October 2022 reflected: Our residents have the fifth to be free freedom abuse, neglect, misappropriation of resident property and exploitation.

Based on interviews, and record review, the facility failed to incorporate recommendations from a PASRR evaluation report into a resident assessment, care planning, and transition of care for 1 (Resident #1) of 2 residents reviewed for PASRR services. The facility failed to submit a complete and accurate request for NFSS in the LTC online portal within 20 days after the IDT meeting. This failure could place residents who were PASRR positive at risk of not getting the PASARR services for a better quality of life and could lead to a decline in health. Findings included: Record review of Resident #1's quarterly MDS dated [DATE] revealed a [AGE] year-old male, admitted to the facility on [DATE]. He had the following diagnoses: muscle weakness (decreased strength), drug induced movement disorder (involuntary movements), unspecified lack of coordination (unable to control movement), diabetes (increased sugar), genetic related intellectual disabilities (abnormalities in genes or chromosomes), seizure (nerve disorder), schizophrenia (mental illness), Parkinson (muscle weakness). Resident #1 was severely cognitive impaired and unable to make decisions for himself. Resident #1 required the assistance of two staff for activities of daily living. Record review of Resident #1's care plan dated revision date 10/21/2025 revealed Resident #1 is PASRR positive, will participate in quarterly care plan meetings with PASRR representative/social worker, Coordination of PASRR services and Individual Service Plan developed by PASRR representative/social worker. Resident #1's goals will maintain highest level of practice wellbeing. interventions/task Resident has a customized Wheelchair and rehabilitation services of occupation, speech, and physical therapies. Record review of the Resident #1's PCSP dated 01/28/2025 revealed the IDT meeting was held on 01/28/2025. Attendees included the resident, PASRR habilitation coordinator, the MDS nurse, PASSR Evaluator, and Therapy Representative. The following NFSS were identified and confirmed: Customized Manual Wheelchair, speech, occupational, and physical therapy selected as new. Record review of Resident #1's PCSP dated 04/18/2025 revealed the IDT meeting was held on 04/18/2025. Attendees included the resident, the PASRR habilitation coordinator, the Social Worker, MDS RN, and Resident #1. The following NFSS were identified and confirmed: Customized Manual Wheelchair - 3 indicated on-going. Record review of the Resident #1's PCSP dated 01/28/2025 revealed the IDT meeting was held on 01/28/2025. During an interview on 12/09/2025 at 11:00 a.m. with the DOR revealed they had been treating Resident #1 for habilitation services since 2017. The DOR stated she had worked at the facility for the past 3 years and the resident had been on services since that time. The DOR stated she completed the NFSS forms for the past three years. She stated that the services for habilitation services had never stopped, except when the resident was in the hospital. Resident #1 was receiving habitation services for speech, occupation, and physical therapy services since 01/30/2025 seven times a week three times a day for the next 6 months. Record review of the NFSS with the DOR reflected. speech therapy with portal entries dated: 12/05/2025. change requested completed successfully.TMHP; Approved alert sent. speech therapy with portal entries dated: 02/11/2025:. Change requested completed successfully. TMHP: Approval alert sent. Speech therapy with portal dated: 04/09/2025 . change requested completed successfully. TMHP: Approved alert sent. Record review of the NFSS with the DOR reflected. occupational therapy with portal entries dated: 02/15/2025 change requested for therapy services completed successfully.TMHP: Approved alert sent. speech therapy with portal entries dated 10/08/2025 change requested completed successfully. TMHP: Approval sent. Speech therapy with portal entries dated 03/21/2025 change requested completed successfully. TMHP: Approval sent. Record review of the NFSS with the DOR reflected. physical therapy with portal entries dated: 02/15/2025 change requested for therapy services completed successfully.TMHP: Approved alert sent. physical therapy with portal entries dated 10/08/2025 change requested completed successfully. TMHP: Approval sent. physical therapy with portal entries dated 03/21/2025 change requested completed successfully. TMHP: Approval sent. During an interview on 12/09/2025 at 11:30 a.m., the MDS nurse stated it would have been in January of 2025 that she attended a PASRR meeting for Resident #1. During the meeting it was mentioned that therapy would need to continue the process for Resident #1 and coordinate with MDS on that process. She stated the DOR was working on a forms for the process to continue services for habitational therapy. Resident #1 had never missed any of the habilitation services, unless he was in the hospital. The MDS nurse verified during the change of ownership she could not access the portal in order to place the needed information, but she had sent all of her paperwork to the case managers for LIDDA/NF and they were aware of the habilitation services that had continued. The MDS nurse stated she had not spoken to anyone concerning her inability to access the portal system during the change of ownership, and that must have been when all that looked like there was a drop in services, but there was not. Record review with the MDS nurse reflected the LIDDA/NF Form was dated 01/31/2025. The IDT meeting occurred on 01/28/2025 with the Habilitation Service Plan. Further review LIDDA dated 01/28/2025 reflected, . changes made to the Habilitation Service Plan . description of change : IDT Meeting Habilitation Coordination. Speech, physical, and occupational Therapy selected as new. Outcome of the Action Plan:. occupational therapy will improve his ability to participate in activities.Physical therapy will improve ability to transfer and prevent falls,. and speech therapy will allow to increase his cognition and communication skills. During an interview on 12/09/2025 at 12:40 p.m., The Administrator said the MDS nurse took care of all the PASSR needs, he was aware that he had received a specialized wheelchair, but he was unaware of any lapse in service. The Administrator stated he did not have any phone calls or emails related to Resident #1 and a lapse in habilitation services. The Administrator did state that during the change of ownership that the portal would not work for them and he knew that the services from their side could not be placed in the portal. He got his information from the MDS nurse, she filled out all the paperwork, placed the information in the portal, the change of ownership was sometime in March 2025 he thought but he could not recall. The Administrator stated if there were changes following the IDT meeting and with the habilitation coordinator involved then the changes would be placed in the portal then, but he did not submit the form. He stated the facility did not complete the NFSS form in the LTC portal within the 20 days of the changes due to the change of ownership, then that would be a problem. The Administrator stated to his knowledge that no person had been contacted during the change of ownership, for the problems with the portal to see how to correct the problem until the new company had taken over. An observation and attempted interview on 12/09/2025 at 1:00 p.m. with Resident #1 revealed he was in habilitation therapy. He was sitting up in his wheelchair during speech therapy concerning speaking. The resident confirmed he had always been in therapy with no lapse and did not want to answer any further questions and closed his eyes. Record review of the paperwork provided by the Administrator and the MDS nurse dated 12/09/2025 through 01/30/2025 reflected emails: . from the MDS nurse to the IDT coordinator for PASRR meeting concerning habilitation therapies following [Resident #1's] readmit from the hospital. the meeting was scheduled for 01/28/2025. The recommendations at the meeting were followed by the MDS nurse and the DOR to continue the habilitation services. Record review of the NFSS Form Completion dated 01/28/2025 with the MDS nurse revealed The nursing facility provider must complete the NFSS form, including all required information, such as the resident's demographics, the therapist's assessment findings, and the physician's order. For habilitation services for Speech, Occupational, and Physical Therapies, the NFSS form was completed by a licensed therapist. The Worksheet is to be completed by Therapy and that information is to be imputed into SimpleLTC by MDS will upload the following forms into SimpleLTC -Once this is completed, we submit forms and wait for response from THHS. Once we have approval the completed NFSS form is submitted through the Texas Medicaid and Healthcare Partnership's LTC Online Portal. If any rejection error messages occur during the workflow process, the provider must take action to correct the request and resubmit it. Record review of the facility policy undated Resident Assessment - Coordination with PASRR Program reflected: Policy: The facility coordinates assessments with the preadmission screening and resident review PASRR program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidance: 1. to ensure forms are submitted timely and accurately. The facility only has 20 business days form the date of meeting to submit a completed and accurate form. 7. Recommendations, such as any specialized services, from a PASRR level II determination and/or PASRR evaluation report will be incorporated into the resident's assessment, care planning, and transactions of care.

Based on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. The facility failed to ensure staff were wearing the appropriate hair and beard coverings. This failure could place residents at risk for food contamination and foodborne illness. Findings included: Observation on 01/29/25 at 11:36 AM of the kitchen revealed Dietary Manager (DM) had facial hair on his chin, and he was not wearing a beard covering. The DM was observed checking temperatures of the food they prepared for the lunch meal service. In an interview on 01/30/25 at 03:35 PM, the DM stated that he had been the DM for over a year. He was made aware that during food temperatures he did not have a beard covering and that the Environmental. Director was observed taking food off the tray stand and delivered food to residents and he was not wearing a beard covering. The DM revealed he had beard coverings in the kitchen. The DM said the purpose of wearing a beard covering was to catch hair so it would not fall into the residents' food. The DM said if that were to happen it could contaminate the food. Review of the Employee Sanitation policy dated October 1, 2018, reflected: 3b. Hairnets, headbands, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food-contact surfaces. Record review of the Federal Food Code 2022 reflected: 2-402.11 Effectiveness. (Hair Restraints) 1. Code of Federal Regulations, Title 21, Sections 110.10 Personnel. (b) (1) Wearing outer garments suitable to the operation (4) Removing all unsecured jewelry (6) Wearing, where appropriate, in an effective manner, hair nets, head bands, caps, beard covers, or other effective hair restraints (8) Confining .eating food, chewing gum, drinking beverages or using tobacco and (9) Taking other necessary cautions

Based on interview and record review, the facility failed to ensure a comprehensive plan was reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, that includes but is not limited the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, and a member of food and nutrition services staff, for one of three residents (Resident #1) reviewed for comprehensive resident centered care plans. The facility failed to ensure all members of the interdisciplinary team were present for the care plan. The failure placed the residents at risk for unmet care needs and a decreased quality of life. Findings included: Record review of Resident #1's electronic face sheet, printed 3/26/2024, revealed a [AGE] year-old male was admitted to the facility on [DATE] and re admitted on [DATE] and 03/20/24 with diagnoses that included but not limited to pressure ulcer (areas of skin damage caused by a lack of blood flow), anxiety ( feeling of fear, dread, and uneasiness), heart failure(condition that develops when your heart doesn't pump enough blood for your body's needs). Record review of the quarterly MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 15 which indicated the resident was cognitively intact. In an interview on 03/26/24 at 12:00 PM, Resident #1 revealed she had a care plan meeting upon returning from the hospital on 3/21/24 and stated she had concerns about her care she wanted to address during the care plan meeting however no members of the interdisciplinary team showed up except the Social Worker. Resident #1 stated she felt the care plan should have been rescheduled to allow time for the other members of the interdisciplinary team to be present. The resident stated no other members from the interdisciplinary team had come to speak with her about her care following the meeting. Resident #1 stated she had not addressed her concerns because she was hoping the department heads would come to her room however no one had done so. Record review of the care conference report for Resident #1 revealed a post admission care plan dated 3/20/2024 with the Social Worker, and Director of Nursing which indicated they were the only staff who attended the meeting. Interview on 3/26/24 at 1:36PM with the Director of Nursing revealed the Social Worker was responsible for scheduling the care plan meetings and would let the members of the interdisciplinary team know about the meeting. The Director of Nursing stated all members of the interdisciplinary team should be present during the care plan meetings to ensure the resident was able to ask questions and be a part of their care. The Director of Nursing stated all department head were aware that they were expected to attend the care plan meetings and let the social worker if they were not able to attend. The Director of Nursing stated the risk of the interdisciplinary team not being at the care plan meeting would be the resident would not be fully informed about their care. Interview on 03/26/24 at 1:49 with the Social Worker revealed Resident #1 had a care plan meeting after returning from the hospital. The Social Worker stated she notified all members of the interdisciplinary team which included all department heads. The Social Worker stated she had 48 hours to complete the post admission care plan once a resident returned from the hospital. The Social Worker stated the interdisciplinary team should have let her know if they would not be able to attend the meeting however that did not happen. The Social Worker stated if the members of the interdisciplinary team were not able to attend the care plan meeting her expectation was that they would see the resident later and complete their portion of the care plan however she was not sure if the resident was seen. The Social Worker stated the risk of not having the interdisciplinary team at the meeting would be the resident wound not be able to ask them questions about their care. Review of the facility policy Care plan revised 02/2024 revealed The resident/representative's right to participate in the development and implementation of his or her plan of care includes the right to, participate in the planning process, identify individuals to be included in the planning process, request meetings, request revisions to the plan of care, participate in establishing his or her goals and expected outcomes of care, participate in the type, amount, frequency and duration of care, receive the services and/or items included in the care plan, be informed, in advance, of changes to the plan of care.

Based on observation, interview, and record review, the facility failed to ensure the resident was free from abuse for 1 (Resident #16) of 3 residents reviewed for abuse. The facility failed to protect Resident #16 from physical abuse. Resident #16 was pushed off of his bed, onto the floor by CNA J during incontinence care on 11/29/23. The non compliance was identified as PNC. The Immediate Jeopardy (IJ) began on 11/29/23 and ended on 11/29/23. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk for abuse and could lead to serious injury, serious harm, serious impairment, pain, and/or mental anguish. Findings included: Review of the facility Abuse, Neglect, molestation, and Misappropriation Policy dated 11/1/2022 stated that: A. The use of verbal, sexual, physical and mental abuse .of the resident is strictly prohibited. Review of Resident #16's face sheet, dated 12/7/23, revealed he was a [AGE] year-old male, initially admitted to the facility on [DATE] with diagnoses that included: Cerebrovascular Disease, Muscle Weakness, Dementia without Behavioral Disturbance, Primary Insomnia, and Benign Neoplasm of the Colon (A mass of tissue growing inside of the colon). Review of Resident #16's quarterly MDS assessment dated [DATE], revealed he had a BIMS score of 03: severe cognitive impact on decision making. The resident had the ability to usually understand, with clear speech, with no documented behaviors and required extensive assistance of one staff member to complete ADL's. Review of Resident # 16's Plan of Care dated 12/4/23 reflected 1. [Resident #16] had been assessed for actual Trauma symptoms as manifested by substantiated abuse from staff CNA. Interventions included: Provide and ensure a safe environment by providing consistent caregivers and provide Psych Eval as ordered/when needed. 2. [Resident #16] is physically aggressive to staff during cares (hit, fights). Interventions included: Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. 3. [Resident #16] has potential psychosocial well-being problem related to traumatic event (substantiated abuse from staff member 11/29/23. Interventions included: Consult with pastoral care, social services, increase communication between resident/family/caregivers about care and living environment. Explain all procedures and Treatments, Medications, results of labs/tests, Condition, All changes, rules, Options. Review of CNA J's time sheet revealed that CNA J worked on 11/28/23 to 11/29/23 during the 10:00 PM to 6:00 AM shift on the secure unit (300 wing). Further review of CNA J's time sheets showed that CNA J did not work at the facility after 11/29/23. Review of CNA K's time sheet revealed that CNA K worked on 11/28/23 to 11/29/23 during the 10:00 PM to 6:00 AM shift on the secure unit (300 wing). Review of RN M's time sheet revealed that RN M worked on 11/28/23 to 11/29/23 during the 10:00 PM to 6:00 AM on the secure unit (300 wing). Interview and observation on 12/5/23 at 12:05 PM with Resident #16 revealed that the resident did not have any visible bruising on any areas of observable skin. The resident stated he did remember his fall, he stated he was just fine, he felt safe at he the facility and that the staff all treated him nicely. Interview on 12/5/23 at 12:23 PM with CNA L revealed she had worked with Resident # 16 for several months now and that he was generally very happy. She had never had any problems with Resident #16 being combative while administering cares but that she could see him possibly being that way if he was disorientated late at night. Interview on 12/06/23 at 12:42 PM with ADM revealed it had been reported to him that Resident #16 had a fall around 5:00 AM on 11/29/23. The ADM reviewed video of the incident at 12:50 PM on 11/29/23 as was his normal course of investigating falls on the secure unit. He stated after reviewing the video and discerning that CNA J had pushed Resident #16 out of his bed intentionally, he immediately called CNA J to his office. CNA J reported continues to report that Resident #16 rolled out of bed.The ADM and CNA J watched the video together and CNA J then confessed to pushing Resident #16 out of his bed to the floor, CNA J was immediately terminated. He stated that he immediately called the police, then conducted 5 Safe Surveys on the secure unit and ordered the nursing staff to conduct immediate skin assessments of all residents on the secure unit. No negative findings were discovered for either the Safe Surveys or the skin assessments. He stated that he started in-service trainings for all secure unit staff that afternoon and completed in-service training for all staff within 24 hours of discovering the incident. He stated that the facility had had an extra nurse on the secure wing since discovery of the incident. Interview on 12/6/23 at 10:00 AM with SW revealed that she had spoken to Resident #16 right after the incident on 11/29/23 and that Resident #16 had expressed he did not feel it had been a big deal, that he still likes all of the staff and the other residents at the facility. Interview and review of video on 12/06/23 at 12:51 PM with DON revealed that DON identified CNA J on the video (no audio available) at timestamp 11/29/23 4:47 AM starting to administer cares for Resident #16. 5:01 AM rolled Resident #16 onto his left side, while Resident #16 was holding on to the side rail. At timestamp 11/29/23 at 5:02 AM CNA J turned resident to right side to move pad under resident. At time stamp 11/29/23 at 5:03 AM Resident #16 appeared to try to help initially, then the resident turned reaching out towards with an open hand and fist and while kicking towards CNA J. CNA J switched to the other side of bed, Resident #16 then moved himself onto his back, with knees up and perpendicular to his shoulders. Resident #16 was then observed to weakly kick CNA J on her right shoulder with his right foot. CNA J roughly pushed Resident #16's extended right leg away from her with enough force to move the resident from laying on his back to laying on his left side. At timestamp 11/29/23 at 5:04:03 CNA J was observed placing both hands on the residents back and pushed/shoved Resident#16 off the left side of the bed to the floor, where Resident #16 landed on his right side. At timestamp 11/29/23 at 5:04:09 AM, Resident #16 observed laying on his right side on the floor, CNA J was then observed immediately going to the resident room door. At timestamp 11/29/23 at 5:04:43 AM Resident #16 was observed still on the floor of his room, Resident #16 then pulls his bed towards him. DON identified CNA K at timestamp 11/29/23 at 5:05:04 AM. CNA K is observed in the video entering the room by himself. CNA K moved the bed away from the resident. At timestamp 11/29/23 at 5:05:36 AM CNA J re-enters room. DON identified RN M at timestamp 11/29/23 at 5:06:36 AM, RN M was observed entering Resident #16's room. RN M is then observed in the video doing an initial assessment of Resident #16 on the floor and is then observed with CNA K lifting Resident #16 from the floor back to his bed. CNA J was observed at the end of Resident #16's bed. RN M is then observed completing Resident #16's assessment. DON then stated that it was very fortunate Resident #16 sustained no immediate injuries. Interview on 12/6/23 at 1:22 PM with CNA K revealed he had been working the night of the incident with Resident #16. He stated he had never observed any actions by CNA J that caused him concern. He stated that Resident #16 could sometimes be combative during administering of care, but he was able to redirect Resident #16's behavior. He stated that he had received immediate in-services the next day for Abuse and neglect and Resident Behaviors. Interview on 12/7/23 at 3:38 PM with RN M revealed that CNA J had reported to her that Resident #16 had had a fall while she had been administering cares to Resident #16. RN M reported that after she had gone to resident #16's room and assessed Resident #16 that CNA J described that Resident #16 had been aggressive during administration of cares and that he had fell out of the bed. RN M stated that she had worked with CNA J for several months. She stated that she had never received any complaints about CNA J from residents or other staff and that none of CNA J's actions had ever given her any pause for concern. She stated that she had cared for Resident #16 the next night shift and he had never complained of or exhibited any signs of pain. She stated that the previous shifts nurse had reported that Resident #16 had not complained of or exhibited any signs of pain. Review of the facility's Provider Investigation Report, incident date 11/29/23 and reported to HHSC on 11/29/23, reflected an incident category of abuse. The reports description of the allegation revealed, CNA J reported to the nurse that Resident #16 rolled out of bed during care. As part normal fall investigation routine when DON and ADM review the fall video, it showed memory care unit Resident #16 becoming combative punching and kicking the CNA during care .CNA deliberately pushed hard on residents back and rolled him out the bed. The reports Investigations findings revealed Confirmed. The reports description of injury revealed no injuries. The reports description of assessment revealed Head to toe assessment. The reports Provider Action Taken Post-Investigation revealed X-ray results were all negative. Resident does not show signs of distress. Abuse in-service and Resident Behavior during Care in-service completed. Employee interviews and statements were completed on 11/29/23. The ADM was informed of the PNC IJ and completed the IJ Template on 12/07/23 at 12:42 PM. Monitoring of the facility's implemented actions that corrected the non-compliance prior to entry included: Review of CNA J's employee file revealed that she had no prior criminal history, and her license was unobstructed. Three references were positive in nature and the CNA had completed all orientation training . Record review of skin assessment sheets dated 11/29/23 for all residents on the secure wing (300 Hall) revealed that there were no unexplained bruising, abrasions or scratches for all residents assessed. Review of the in-service training dated 11/29/23 reflected Abuse and Neglect and Combative Residents/Abuse. Both identified types of abuse, procedures for reporting abuse and interventions for combative residents. Interviews were conducted on 12/07/23 from 1:53 PM to 12/07/23 at 3:38 PM with licensed nursing staff and CNA staff, CNA B, CNA D, CNA N, LVN F, LVN P, and RN M. The nursing staff and CNA's were able to accurately summarize the facility's reporting policy and procedure related to abuse/neglect to include unknown bruising, injuries of unknown origin reporting and documenting and interventions with combative residents. Observations on the secure unit from 12/05/23 at 9:00AM to 12/07/23 at 2:00 PM revealed that the facility had scheduled two nurses on the secure unit at all times/shifts. Review of CNA J's Separation Report dated 11/29/23 revealed CNA J was terminated immediately for Gross Misconduct, and terminated due to resident abuse. The document was signed by both the ADM and DON on 11/29/23. Review of the facility's incident/accident reports and grievance files for the last three months revealed no relevant findings to the incident. The non compliance was identified as PNC. The Immediate Jeopardy (IJ) began on 11/29/23 and ended on 11/29/23. The facility had corrected the noncompliance before the survey began.

Based on observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. 1. The facility failed to date food stored in the freezer that should no longer be consumed. 2. The facility failed to discard food stored in the refrigerator that was past use by date and should no longer be consumed. These failures could affect Residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed, and food contamination. Findings included: Observation in facility's kitchen on 12/05/23 at 09:25 AM revealed Whipped topping in freezer was not dated. Observation in facility's kitchen on 12/05/23 at 09:28 AM revealed whole frozen turkey found in the kitchen walk-in freezer in original packaging was not dated. Observation in facility's kitchen on 12/05/23 at 09:31 AM revealed spoiled Lettuce stored in walk-in refrigerator with use-by date of 11/26/2023. In an interview with FSD on 12/05/2023 at 9:47 AM revealed that whipped topping was to be used for tonight's dinner and his aide may have forgotten to date it. He also revealed that the frozen turkey was bought during Thanksgiving week of November 20th and had a dated label on it but may have fallen off. He reported that he has been working with the facility kitchen for the last three years and was aware that all foods should be covered and dated. He revealed that he had not conducted his daily rounds in the kitchen yet and the lettuce that was in the refrigerator beyond use-by date will be thrown out immediately. He revealed that risk of not dating the food was the food can be spoiled. If such spoiled food was served to the resident, it could lead to food borne illness. He also stated he conducted in-service regarding food storage, dating and labeling on a regular basis with the kitchen employees. In an interview with AM Cook/Aide on 12/07/23 at 08:25 AM revealed that she was also responsible for storing food in the refrigerator and freezer. She stated she has been in-serviced that all foods should be covered, dated, and labeled. She also stated that the risk of not dating any food was that food can be spoiled, and it was unknown how long it was stored. She also stated that she would let FSD know about any undated food and throw out the food when in doubt. In a phone interview with Facility Dietitian on 12/07/2023 at 01:47 pm revealed her expectation was all food items in the kitchen should be covered, dated, and labeled appropriately, and all the kitchen staff adhere to facility policy. She stated that the risk of not dating the food items was not being sure how long the food items have been stored and could be spoiled. Such spoiled foods cannot be served to residents and should be discarded immediately. She revealed she along with FSD provide in-services to the staff when she rounds the facility. Some of the in-services include food storage, labelling and dating, Time and temperature-controlled food safety, and hand hygiene. Record Review of Facility's Food safety and Sanitation undated revealed that .4. b. All time and temperature control for safety (TCS) leftovers are labeled, covered, and dated when stored. They are used within 72 hours (or discarded). Foods with expiration dates are used prior to the use by date on the package. Review of the Food and Drug Administration Food Code, dated 2022, reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each Resident, consistent with Resident rights, that include measurable objectives and time frames to meet Residents' mental and psychosocial needs for 2 of 4 (Residents #6 and Resident#235) Residents reviewed for care plans. 1) The facility did not develop and implement a comprehensive person-centered care plan to address Resident # 6 noncompliance with Physician orders of using O2 via Nasal cannula. 2) The facility did not develop and implement a comprehensive person-centered care plan to address Resident #235 Significant weight loss of 8.64% in 1 month.) This failure could place resident at risk of not having a plan developed to address care needs. Findings include: Resident #6 Record Review of Resident # 6 MDS dated [DATE] revealed that Resident #6 was a [AGE] year-old female admitted to facility on 06/3/2023 with BIMS Score of 13 which means that resident was cognitively intact. Resident # 6 had diagnoses of Cardiovascular condition (conditions affecting the heart or blood vessels) with Heart failure (condition that develops when your heart doesn't pump enough blood for your body's needs), respiratory failure ( a serious condition that makes it difficult to breathe on your own) , hypertension (when the pressure in your blood vessels is too high) , Diabetes mellitus ( metabolic disease, involving inappropriately elevated blood glucose levels). MDS review indicated Resident #6 is on Oxygen therapy. MDS did not indicate rejection of care for oxygen therapy. MDS also indicated that resident #6 required total dependence on staff for all transfers and extensive assistance for dressing, bed mobility and toileting. Record Review of Resident #6 physician order dated 9/15/2023 revealed O2 at 2 L/min via NC to maintain O2 stats > 92% every shift. Record Review of Resident # 6's care plan dated 10/2/2023 revealed: Problem: Resident#6 has oxygen therapy related to respiratory failure and COPD (Chronic obstructive pulmonary disease, or COPD, refers to a group of diseases that cause airflow blockage and breathing-related problems). Goals: Resident will have no signs and symptoms of poor oxygen absorption through the review date Intervention: Monitor for Signs and symptoms of respiratory distress and report to MD. Oxygen settings: O2 via NC per MD orders. Observation and interview on 12/06/23 at 8:30 AM revealed that Resident # 6 had just finished with her breakfast, she was slow to respond to question. Also observed that resident # 6 was not on NC and resident # 6 stated that she had taken off her NC tubing. Resident # 6 revealed that she had taken off NC tubing a while back, she was not able to provide a time frame. She also stated that she took the NC tubing off frequently multiple times a day. Observation and interview on 12/6/023 at 08:48 AM revealed resident #6 stated that she wanted to be back on oxygen and appeared to be little uncomfortable and gasping for breath. Observed O2 NC tubing was fallen on the side of the bed touching the floor. Observation on 12/06/23 at 08:50 AM revealed that Agency LVN H was called for helping resident #6 with Oxygen delivery. Agency LVN H changed the Oxygen tubing, refilled the humidifier bottle with water and reinserted the nasal cannula prongs at Resident #6 face. Interview with CNA E on 12/6/2023 at 09:10 AM revealed that resident #6 often takes off her nasal cannula from the face multiple times a day. She revealed whenever she sees the resident #6 has taken off her nasal cannula, she will try to put it back on her. She revealed this behavior should be care planned and reported that the Floor nurses are aware of resident #6's behavior. She was not sure if ADON and DON were aware of resident # 6's behavior of taking off Nasal cannula by herself. Interview with Agency LVN H on 12/06/23 at 09:20 AM revealed that he was an Agency LVN (he did not work at the facility full time; was hired through a nursing agency to work that shift ) but was familiar with care of Resident #6. He had worked the Hall Resident # 6 was placed couple of times in the past. He revealed that resident # 6 took off her oxygen tubing by herself many times in the past and if any staff saw that she had taken it off, they would help put the NC prongs back on resident#6 face. He also stated that the staff redirected her if she took off her NC tubing. He also noted that Resident's removal of Nasal cannula by herself should be care planned. If care planning was not done, it can lead to decrease in resident's quality of care. He was not sure if the Administration or Nursing was aware about resident's behavior but will report it to ADON on the day of the interview. In an interview with CNA D on 12/06/23 at 09:45 AM revealed that she has worked in the facility for more than a month. She stated that she was familiar with Resident # 6's care. She revealed that resident # 6 takes off her NC tubing and it was usually found on the side of the bed. She also stated that the staff will put on the nasal cannula back if she has taken it off and there were no specific rounding times, but she rounds when they are providing ADL care. She does not look at the Care plans but thinks resident's behavior should be care planned. Observation on 12/7/2023 at 07:55 AM revealed resident #6 was sleeping without Nasal cannula attached to her nose. The tubing was observed at the side of the bed. In an interview with LVN G on 12/07/23 at 03:21 PM revealed that if there was significant changes or behaviors that are not consistent with physician orders, it needs to be care planned. The risk for not care planning was not knowing what the interventions were and can lead to deficient care in resident's care. Care planning helps with understanding what was involved in resident's care and interventions associated with it. Interview with MDS RN on 12/06/23 at 01:18 PM revealed all change in conditions that include significant weight loss or respiratory care including external Oxygen delivery should be care planned for resident so that the staff was aware about interventions. She stated that the Nursing administrative staff was not aware of resident#6 being non-compliant of O2 orders until today. The risk of not documenting care plans appropriately or not being resident specific may result in decreased quality of care for the resident. Interview with ADON on 12/6/2023 at 01:30 PM revealed she was not aware that resident #6 took off her nasal cannula by herself and hence it was not documented in the care plan. In an interview with Agency LVN I on 12/06/23 at 2:40 PM said he was not familiar with resident's #6 care. He did not get anything in the report about resident#6 takes off her Nasal cannula tubing by herself. He said he saw an order from 12/6 about checking O2 levels every shift. He was not sure if Respiratory care/ resident behavior was care planned. He reported care planning was important because if it was not care planned, staff will not know what to do and can affect quality of care for resident. Resident #235 Record Review of Resident #235 MDS dated [DATE] revealed that Resident #235 was a [AGE] year-old Male admitted to the facility on [DATE] with diagnoses of Medically complex condition including aphasia (loss of ability to understand or express speech, caused by brain damage), gastrostomy status (a surgical procedure used to insert a tube, often referred to as a G-tube, through the abdomen and into the stomach) , Cerebrovascular Accident (an interruption in the flow of blood to cells in the brain) , late onset Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment) , Esophagitis without bleeding (inflammation in esophagus) and Respiratory failure (a serious condition that makes it difficult to breathe on your own). Resident #235 had BIMS score of unknown which indicated that resident # 235 was cognitively impaired. Resident # 235 admission weight was 111.6 lbs., Height unknown. MDS indicated that resident# 235 required substantial assistance for eating. Record review of resident's weight history included the following: 11/27/2023 103.6 Lbs 11/17/2023 107.0 Lbs 11/10/2023 106.8 Lbs 10/23/2023 113.4 Lbs 10/12/2023 112.2 Lbs 9/18/2023 111.6 Lbs On 10/23/2023, the resident weighed 113.4 lbs. On 11/27/2023, the resident weighed 103.6 pounds which was -8.64 % Loss. Record review of Resident # 235 care plan dated 10/9/2023 included the following: Problem: Resident # 235 was NPO/enteral feeds (Enteral nutrition, also known as tube feeding, is a way of delivering nutrition directly to your stomach) and has potential nutritional problem r/t BMI too low 17.03. Goal: (1) The resident will maintain adequate nutritional status as evidenced by maintaining weight within (5) % of current weight, no s/sx of malnutrition through review date. Intervention: (1) Monitor/record/report to MD PRN s/sx of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. (2) Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow-up as indicated. (3) RD to evaluate and make diet change recommendations PRN. (4) Speech Therapy to evaluate for potential diet (5) Weigh at same time of day and record monthly Record review of Dietitian's progress note dated 10/27/2023 revealed that Dietitian spoke with speech therapist regarding Resident #235 receiving po diet. Currently. Resident #235 was eating with speech therapist and doing well. Expect to initiate routine meals x3 over the next week: Puree w/nectar thick liquids. Will monitor intake to adjust /reduce bolus tube feeding. Record review of Dietitian's progress note dated 11/17/2023 reflected Resident #235 was noted with Feeding tube replacement. Resident #235 was now eating regular diet now with bolus (small volume of feeding given multiple times a day) tube feeding during the day twice a day was discontinued. Current weight was noted weight loss. Will increase night feeding till weight level was stable. Continue to monitor weight weekly. Monitor feeding rate increases for tolerance. Record Review of Dietitian's progress note dated 12/4/2023 revealed Resident # 235 with unstable weight. Weight = 103.6 lbs.; loss of 3.4 lbs. without noted change of appetite. Skin with wound to Right toe and 2nd toe. Will increase tube feeding time from 12 hour to 15 hour and add house shakes with meals. Monitor feeding tolerance and weight trend. Record Review of Resident #235 physician orders dated 11/8/2023 revealed resident #235 was started on Regular diet, Pureed texture. Record review of resident #235 Physician orders dated 11/17/2023 increase rate of tube feed Jevity 1.5 to 80 ml/hr. feeding from 6PM to 6 AM. Record review of resident #235 Physician orders dated 10/24/2023 increase rate of tube feed Jevity 1.5 feeding to 75 ml/ hr. for 12 hours from 6PM to 6 AM. Record review of resident #235 Physician orders dated 10/20/2023 revealed that resident was on weekly weights. Interview with CNA B on 12/5/2023 at 1:38 PM revealed that Resident #235 did not eat lunch yet since he was too sleepy. She also revealed that resident #235 did not sleep all night. She revealed resident#235 had lost some weight but was not sure if there were any interventions put in place for it. She said that Nursing staff would be more aware. She also revealed she does not take part in care planning process. She revealed that if resident # 235 had lost weight, it needs to care planned so the interventions were known to all staff members. Interview with LVN F on 12/5/2023 at 01:40 PM revealed that ADON does all the care planning. LVN F was aware of resident's weight loss since it was discussed in their meeting yesterday. She also revealed that Dietitian had recently increase the timing of resident's tube feed. She also stated that if it was not documented in care plan then the staff does not know how to do care for the resident. It can also affect the quality of care for the resident. In an interview with Charge RN O on 12/5/2023 at 2:35 PM revealed that resident #235 eats three meals a day, about 80-100% on most meals. He also stated that Dietitian had increased tube feeding hours to 15 hours per day today. RN O reported he was aware that resident was losing weight. He reported that weight loss interventions should be care planned, if not care planned appropriately it can lead to not following the interventions and hence resident's quality of care can be compromised. Interview with Staffing Coordinator/ CNA C on 12/06/2023 at 01:00 PM revealed that he does all the weights in the facility including daily, weekly, and monthly weights. He revealed that resident #235 was on weekly weights since the end of October. He has a list of residents in the facility on weekly weights given to him by ADON. He revealed resident #235 lost weight on 11/27/2023 and he notified ADON about it. He was not sure if any weight loss interventions were added. Interview with MDS RN on 12/06/23 at 01:18 PM revealed that the nursing team was responsible for initial and interim care plans. ADON was responsible for weight loss care plans usually, but they try to do Inter Disciplinary team approach for comprehensive care plans. She also stated that all change in conditions that include significant weight loss should be care planned for resident so that the staff was aware about interventions. She stated that care plans should be resident centered. Interview with ADON on 12/6/2023 at 01:30 PM revealed that She and other ADON along with DON are responsible for care planning acute issues/ Change in conditions etc. She noted that Nursing staff on the floor are expected to inform Charge RN if resident chooses to not follow physician orders or exhibits different behaviors. She stated that she was responsible for monitoring weights in the facility and notify the Dietitian, Physician, and family if resident had a 3 pounds gain or loss. She also reported that Resident # 235 was on weekly weight since October related to weight loss history as a part of weight loss intervention. The risk for not care planning resident's behavior or significant weight changes may lead to not following interventions as stated and can result in quality-of-care issues. She also revealed that care plans should be resident specific since it was resident's planning of care. In a phone interview with Dietitian on 12/06/23 at 01:47 pm revealed that she was aware of resident's weight loss and was present in the facility on 12/4/23. She had increased Resident # 235 tube feedings to 15 hours and added House Shakes daily to provide additional kilocalories after reported weight loss. She also revealed that resident #235 started eating orally sometime in November and weight become a little unstable. She reported that per records, resident # 235 was eating 100% of most meals and increased tube feeding; she anticipated weights to be stable. She reported some of the interventions to mitigate weight loss were: (1) increase tube feeding volume and time (2) Conduct weekly weights (3) Addition of house shakes (4) Initiation of Oral diet. She does not participate in any care panning activities but notes that interventions should be care planned appropriately so that all staff know what the interventions were put in place and followed appropriately. In an interview with DON on 12/07/23 at 08:53 AM revealed that Nursing Administration team that includes herself, ADON's, MDS RN were responsible for Comprehensive/ acute care plans and all care plans should be resident specific. She reported that not documenting care plans appropriately can lead to resident's care being compromised and can affect quality of care. In an interview with Administrator 12/07/23 at 09:08 AM revealed that MDS RN and DON/ ADON were responsible for Comprehensive and Acute care Planning. He stated that he was aware that there were care plan issues in the facility and they have conducted in-services with the team in the past. He stated that the risk for not documenting care plan appropriately that are resident specific can lead to missing out on proper care of residents. His expectation was that Nursing follows Inter Disciplinary team approach to adequately document care plans that were person specific for all the residents. Record Review of Facility's Care Plans, Comprehensive Person-Centered date March 2022 revealed 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to conduct activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 (Resident #1, Resident #2, Resident #3) of 5 residents reviewed for ADL care. The facility failed to ensure Resident #1's facial hair was removed and nails were trimmed and cleaned. The facility failed to ensure Resident #2's facial hair was removed. The facility failed to ensure Resident #3's nails were trimmed and cleaned. These failures could place residents at risk of infections and skin tears resulting in pain, discomfort and decreased psycho-social well-being and self-worth. Findings included: Record review of Resident #1s Quarterly MDS assessment dated [DATE] revealed he was a [AGE] year-old male admitted on [DATE]. He had a BIMs of 15 (cognitively intact) and required extensive assistance with ADLs. He had diagnoses of blindness, stroke, hemiplegia (one sided weakness), and neurogenic bladder (dysfunctional bladder). Record review of Resident #1's care plans dated 06/14/23 revealed Resident #1 has an ADL self-care performance deficit r/t hemiplegia, vision deficit (legally blind), with a goal of resident will improve current level of function in ADLs through the review date. Interventions included bathing showering: check nail length and trim and clean on bath days and as needed, and monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in functions. Interview and observation on 09/19/23 at 11:50am with Resident #1 revealed he had long facial hair that was about 3/4 of an inch long and nails that were overgrown his fingertips about 1/2 an inch and appeared to have a dark colored substance underneath them. The resident stated he preferred to have a clean-shaven face and he had been waiting to be shaved. He stated he felt like a hippy due to the long facial hair, and the long nails. He did not like to keep his nails, or facial hair long. He stated he knows his hair grows fast but would like it shaved more often. He has asked for assistance since he is blind and sometimes gets help but it has been a while since his last shave. He stated on his last shower day he asked for assistance shaving his facial hair and trimming his nails and he was told they will come back to help him, and they never returned. Record review of Resident #2's Annual MDS assessment dated [DATE] revealed he was a [AGE] year-old male admitted on [DATE]. He had a BIMs of 03 (cognitive impairment) and requires extensive assistance with ADLs. He had diagnoses of Alzheimer's disease (dementia), generalized muscle weakness, and hypertension (high blood pressure). Record review of Resident #2's care plans dated 02/21/23 revealed Resident #2 has an ADL self-care performance deficit r/t dementia, with a goal of resident will improve current level of function in ADLs through the review date. Interventions included bathing showering: check nail length and trim and clean on bath days and as needed, and monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in functions. No indication of religious preference of keeping hair bald was reflected within the care plan. Interview and observation on 09/19/23 at 01:05pm with Resident #2 revealed he had facial hair that was about 1/2 of an inch long. He stated that he needed help to keep it shaved and cannot recall the last time he was helped. He stated that because of his religion he prefers to not have any hair. He usually likes to keep all his hair shaved bald which included his beard and mustache. He stated he had asked his daughter to help him shave during her next visit because he was unable to get assistance shaving. He could not recall the last time he asked facility staff for assistance. Record review of Resident #3's Annual MDS assessment dated [DATE] revealed he was an [AGE] year-old male admitted on [DATE]. He had a BIMs of 15 (cognitively intact) and required limited assistance with ADLs. He had diagnoses of unspecified dementia, spinal stenosis (abnormal narrowing of the spinal canal), and hypertension (high blood pressure). Record review of Resident #3's care plans dated 02/02/23 revealed Resident #3 has an ADL self-care performance deficit r/t spinal stenosis and dementia, with a goal of resident will improve current level of function in ADLs through the review date. Interventions included bathing showering: check nail length and trim and clean on bath days and as needed, and monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in functions. Interview and observation on 09/19/23 at 01:50pm with Resident #3 revealed he had long fingernails that were overgrown his fingertips about 1/2 an inch and appears to have a dark colored substance underneath them. He stated he liked to keep his nails trimmed and could not recall the last time he had them trimmed. He stated it made it difficult to do small tasks with long nails. He stated he gets his showers on time but did not get his nails trimmed on his shower days. He stated he asked for them to be trimmed sometime last week, and he was told the Activities Director can cut them. When he asked her, she stated she only does the nail care as an activity if he requests them to be painted. He stated he did not want them painted and declined due to the nailcare activity. Interview on 09/19/23 at 2:58pm with RN A revealed the CNAs are the ones who check and trim the residents' nails and facial hair. It should be done on shower days and as needed. The nurses were responsible to ensure it was done and assist if needed. He stated Residents #1, #2, and #3 are not resistant to care and he was not sure why they have not received the proper ADL care and maintenance. He listed the residents who prefer to have long facial hair which did not include Residents #1, #2, and #3. He was not aware of Resident #2's religious preference to keep his hair bald. The potential harm to the residents could be risk for infections from long nails or they might not feel good about themselves by having overgrown facial hair. He cannot recall if any of the residents ADLs had been skipped. Interview on 09/19/23 at 5:10pm with CNA B revealed the CNAs were responsible to help the residents with ADL care such as trimming their nails and shaving them if they prefer to have no facial hair. She stated she could not recall any residents on her hall that had unkept nails or facial hair. She stated they checked them on shower days and as needed if the resident requests a trimming. She stated she was unsure why Residents #1, #2, and #3 did not get their facial hair trimmed or their nails. She was also unaware of Resident #2's preference for being bald. Some negative outcomes of not trimming their nails or facial hair could be getting germs under the nails or in the beard if food gets in it and it looks bad for the family to see them like that and could impact their dignity. Interview on 09/19/23 at 05:55pm with CNA C revealed that the CNAs are responsible to keep up with the residents ADLs which includes trimming their nails and facial hair. If they felt uncomfortable with either of them then the CNAs can ask the nurse for help. He stated he could not recall Resident #1, #2, or #3 asked for assistance with trimming their facial hair or nails. He could not recall if they had preferences on how to keep their facial hair and nails. He stated their facial hair trim and nail trim may have been missed during their shower days. He stated if their hair grows fast then they should shave them as needed and on shower days. If that gets missed it could pose a risk of infection for the residents. The last in-service on ADL care he received was within the last week. Interview on 09/19/23 at 6:11pm with LVN D revealed that the CNAs do the ADL care on shower days and as needed. The ADL care included nail trimming and facial hair. Their ADLs were provided according to their preferences, if they liked a clean-shaved face then that was what the staff would provide. The nurses were responsible to ensure that the ADL care was provided properly. He stated Residents #1 and #2 were not resistant to care but Resident #3 at times refused his shower days. He stated Residents #1, #2, and #3 were not resistant to having their nails trimmed or facial hair trimmed. He was not aware of Resident #2s preference to be bald but stated he had only seen him with hair recently within the last month, and in the past, he had maintained having no hair. The harm that could come from them not trimming their nails or facial hair could be accidentally injuring themselves by scratching and facial hair could be uncomfortable to the resident if they were not used to it or like it long. He stated his last ADL training was last week. Interview on 09/19/23 at 6:32pm with the Activities Director revealed she does an activity called pretty nails. It was for residents who want their nails painted. She does not provide ADL care to the residents with this activity, she stated she would shape the nails if needed and clean them to prepare for the polish. She could not recall Resident #3 asking to participate in the pretty nails activity. Interview on 09/19/23 at 6:38pm with the DON revealed her expectation was to provide ADL care to residents per their needs and wants. She stated the nurses should check to ensure the ADLs were completed by the CNAs, along with herself and other administrative nursing staff. She stated today and the previous day she had noticed a few residents whose ADL care was not completed and requested it be done. She was not sure why the ADL care was not being completed, and stated it was an area that could be improved. She stated that she did notice the need for more education on ADL care specific to facial hair and nail care. The harm to residents could be not feeling good about themselves. Interview on 09/19/23 at 7:13pm with the Administrator revealed his expectation with ADL care was that it was done and done with the care of the resident's comfort in mind, this included nail trimming and facial hair trimming. ADL care was overseen by the DON and during daily rounds of the administrative nursing staff. He could not recall why the ADLs were missed and stated it would improve with more education for the staff. If the residents did not receive the proper grooming it could cause many issues including residents' rights. Record review of the facility's Activities of Daily Living (ADL), Supporting Policy dated 2001 revealed, residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on interview, and record review, the facility failed to ensure that each resident received adequate supervision/assistance to prevent accidents for one (Resident #1) of four residents reviewed for accidents in that: Agency CNA A failed to utilize the appropriate safety precautions and amount of assistance Resident #1 required while providing incontinence care for the resident, as a result, Resident #1 rolled out of the bed and sustained a black eye. This failure could place residents at risk for accidents and injury. Findings included: Review of Resident #1's facility electronic face sheet, undated, reflected the resident was a [AGE] year-old male who admitted on [DATE] with diagnoses of dementia and muscle weakness. Review of the Minimum Data Set (MDS ) assessment dated [DATE] revealed Resident #1 required total assistance of two staff members for activities of daily living (ADL), including incontinence care and bed mobility. Further review of the MDS revealed a Brief interview of mental status (BIMS) score that had not been completed. Review of the Care Plan dated 02/17/2023 revealed Resident #1 had goals to be checked every two hours and assist with toileting as needed. The Care Plan did not specify how much assistances was required for activities of daily living (ADL's) Review of the Nurse D's notes dated 09/10/2023 revealed Nurse notified by CNA about resident fall, on getting to his room he was on the floor by the wall, the aide stated that he went to get supplies, on getting back resident on was the floor. Head to toe assessment was performed, he had a cut on his upper eyebrow and swollen head. Vitals (blood pressure) /B/P 133/78/81(temperature) temp 98.1(respiratory) resp 18 02 96%. Icepack was applied tohis forehead eyebrow was cleansed and dry dressing was applied NP, hospice nurse, daughter and DON notified. Hospice nurse on the way. Review of the nursing notes 09/11/23 revealed a follow up after fall with neuro checks. Review of the video captured by facility monitoring agency revealed CNA A began incontinent care and rolled Resident #1 on his side. Observation revealed CNA A leaving the room and Resident #1 being left alone. Resident #1 became shaky and rolled out of the bed toward the wall. CNA A was arriving back to the room as the resident was rolling out of the bed. The date and time staff of the video were not observed due to the video being shown via video call with the monitoring agency sharing their screen. Observation and Interview on 09/12/2023 at 10:50 AM of Resident #1 sleeping in his room with family members in the room. Resident #1 was observed having a black ety The family members stated Resident#1 was not verbal and was not able to move his body other than his arms which caused them to be confused regarding how Resident# fell from the bed. Interview on 09/12/2023 at 11:00AM with CNA B revealed he had worked in the facility for 8 years. He stated he was aware that residents were two people assist if they needed a Hoyer lift to be lifted. CNA B stated Resident #1 was a two person assist and both staff should be present before initiating care. CNA B stated staff should never leave a resident in the middle of care. Interview on 09/12/2023 at 11:26AM with Nurse A revealed she was the nurse on duty when Resident #1 fell . She stated CNA A was calling for her and when she entered the room, she saw Resident #1 on the floor. She stated CNA A was changing the resident alone and went to get more supplies. She stated when CNA A returned Resident #1 was on the floor. She stated she assessed Resident #1, and he had a swollen eye. She stated Resident#1's family member was contacted and did not want him sent out however the hospice nurse did see the resident that day. Interview on 09/12/2023 at 3:00PM with CNA C revealed she had worked in the facility for 1 year. She stated she was aware of residents being two people assist if the resident was heavy or aggressive during care. CNA C stated Resident #1 was a two person assist and staff should not began care until both staff were present. CNA C stated staff should never leave residents while providing care and if the resident was a one person assist and additional supplies were needed then the staff should call for help instead of leaving the resident during care. Interview on 09/12/2023 at 3:26 PM with CNA A via phone revealed he had worked in the facility for 1 month. CNA A stated he had worked in the facility in December 2022 and during that time Resident #1 was not a two person assist. CNA A stated he did not look at Resident #1's care plan to determine that Resident #1 was no longer a one person assist. CNA stated he was providing incontinent care to Resident #1 and realized he needed additional supplies. CNA A stated he left the room briefly to obtain additional supplies and by the time he returned Resident #1 was actively falling out of the bed. CNA A stated other staff or management would have communicated to him that CNA A had a change in condition and was no longer one person assist however that did not occur. CNA a stated he could have checked Kardex however he assumed the resident was still one person assist. CNA A stated had not returned to work however he was contacted by the DON regarding Resident#1 being a two person assist. Interview on 09/12/2023 at 3:35PM with the DON revealed she had been acting as Interim DON for about 1 month. She stated staff were informed weekly regarding resident change of conditions. She stated staff should have looked at the facility Kardex (brand name for an informational filing system that is used as a quick reference for nurses) to determine if the resident was one person or two people assist before providing care. The DON stated staff should never begin care and leave a resident during care. The DON stated all staff were informed of resident changes weeks and daily upon beginning their shift. The DON stated if a resident was documented as 2 people assist then caregiver should be present before care is provided. The DON stated she was not sure what the risk would be if staff were not adhering to the resident care plan and providing care as directed. The DON stated all staff were in- serviced 09/12/23 regarding not leaving residents during care, having all supplies prior to beginning care and never leaving a resident unattended on their side. Interview on 09/12/2023at 4:00PM with the Administrator and Regional Director of Operations revealed the expectation was for staff to review resident care on the Kardex before providing care. The Regional [NAME] President stated after reviewing the video it was determined that the staff member did not provide appropriate care by not providing 2 people during care for Resident #1. The Regional [NAME] President stated CNA A has been suspended pending further investigation and the investigation was still on going. and all staff had been reeducated. Review of the In-services completed on 09/12/23 with all staff regarding not leaving residents during care, having all supplies prior to beginning care and never leaving a resident unattended on their side. Review of the facility AD Hoc QAPI meeting/ four-point plan of correction dated 09/12/2023 revealed opportunity for improvement: education for CAN ton bed mobility and where to find resident transfer or function status needs in Kardex Review of the facility Action plan revealed systematic changes- will reeducate nurses and CNA on proper review of Kardex/ MDS for function status and required number of staff for assistance prior to providing care for residents. Changes will be communicated to staff via paper in-service 1:1 for staff member involved with return demonstration for care for resident involved. Review of the facility policy Fall: Clinical protocol, dated March 2018, revealed based on the preceding assessment, the staff an physician will identify pertinent interventions to try to prevent subsequent falls and to address the risk of clinically significant consequences of falling.

Based on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility was free of pests for 1(bathroom room [ROOM NUMBER]) of 6 bathrooms reviewed for pest control The facility failed to ensure Resident bathrooms did not contain live roaches. This failure could place residents at risk of a diminished quality of life due to an unsafe environment. The findings were: Observation on 09/12/2023 10:45 a.m. revealed a live roach on Resident #2 and Resident #3's bathroom ceiling. The bathroom had a dead roach on the floor of the shower. Interview on 09/12/2023 at 10:35 AM with Resident #2 revealed she had lived in the facility off an on for 4 years. She stated she had complained of roaches being in the room and maintenance did spray bug spray however the issue had not been resolved. Resident #2 stated she did file a grievance regarding the roaches however did not remember the exact date. Resident #2 was not sure how long there has been issues with roaches in the room and was not sure when was the last time the room was treated Interview on 09/12/2023 at 10:40AM with Resident #3 revealed she and Resident#2 had complained about roaches in their room. She stated saw roaches near her bed and in the bathroom. Observation of the room revealed no roaches near Resident #3's bed. Resident #3 was not sure how long there had been issues with roaches Interview on 09/12/2023 at 1:30 PM with the Maintenance Director stated he had worked in the facility since November. He stated if a resident had an issue with pest he would be alerted and would contact his pest control company and they would come out the same day. He stated if he was not alerted of any issues, pest control came out every two weeks. He stated he was not alerted of any residents having any issues with pest that had not been resolved. Review of the facility grievance log from August 2023 to September 12,2023 revealed no grievance regarding roaches from Resident #2 Review of the facility's pest control log from 09/01/23- 09/013/23 revealed no pest citing for room [ROOM NUMBER]. Review of the facility pest control activity revealed the facility was in the facility on 09/12/2023 Review of the facility policy Pest control undated revealed, An effective pest control program is maintained so the facility is free of pest and rodents. The facility has a vendor contract with pest control services that agrees to treat the facility at regular and routine intervals for control of pest.

Based on interview and record review, the facility failed to consult the resident's physician when there was a significant change in the resident's physical, mental or psychosocial status for one (Resident #1) of five residents reviewed for resident rights. 1. The facility failed to ensure Resident #1's physician was notified of a critical CMP (comprehensive metabolic panel) lab with a glucose with a reading of 480. 2. The facility failed to notify Resident #1's physician, when her blood sugar reading was 453 on 07/01/23 and out of parameters. On 07/21/23 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 07/22/23, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their corrective systems. This failure could place residents at risk of not having their physician consulted of changes in condition timely, resulting in a delay in medical intervention and decline in health or possible worsening of symptoms, including death Findings included: Review of Resident #1's significant change MDS assessment dated [DATE] reflected she was an [AGE] year old female who admitted to the facility on [DATE]. Resident #1's active diagnoses included diabetes, non-Alzheimer's dementia (the loss of cognitive functioning -thinking, remembering, and reasoning), aphasia (loss of ability to understand or express speech, caused by brain damage), stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts), hemiplegia (paralysis of one side of the body), malnutrition (lack of proper nutrition), hyperlipidemia (an elevated level of lipids like cholesterol and triglycerides in the blood), GERD (a condition in which the stomach contents move up into the esophagus), hypertension (when the pressure in your blood vessels is too high (140/90 mmHg or higher) and dysphagia (swallowing difficulty). Resident #1 had no speech and was rarely/never understood and had adequate vision and hearing. Resident #1 had long and short term memory problems and severely impaired cognitive decision making skills. Resident #1 has signs/symptoms of delusions, including inattention and altered level of consciousness with vigilance (startled easily with sound or touch), but had no indicators of psychosis, wandering or rejection of care. Resident #1 was totally dependent on staff for all ADLs and had upper and lower range of motion impairment on both sides of her body and was incontinent of bowel and bladder. Resident #1 did not have a condition or chronic disease that would result in a life expectancy of less than 6 months. Resident #1 did experience significant unplanned weight loss in the past six months and used a feeding tube, was given insulin injections and anticoagulant medication. Review of Resident #1's care plan dated 02/05/23 reflected she had Diabetes Mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels) and was at risk for signs and symptoms and complications. Interventions were to monitor/document for side effects and effectiveness, dietary consult for nutritional regimen, fasting serum blood sugar as ordered by doctor, if infections was present than consult doctor regarding any changes in diabetic medications, inspect feet daily, and monitor/document/report signs and symptoms of hypoglycemia and infection to any open areas. Review of Resident #1's physician orders for June 20223 and July 2023 reflected a one-time order, CBC, CMP, A1C (start date 06/28/23 and ordered by PHY B), Insulin Lispro Injection Solution 100 UNIT/ML-Inject as per sliding scale: if 151-200 = 3 Units; 201-250 = 6 Units; 251-300 = 9 Units; 301-350 = 12 Units; 351-400 = 15 units Give insulin and call MD if BS >400, subcutaneously before meals (start date 04/25/23), Levemir Subcutaneous Solution-Inject 30 unit subcutaneously one time a day (06/22/2023). Review of Resident #1's CMP lab result on 06/29/23 reflected it was a critical result with her blood glucose at 480 (Reference range is 81 to115). The lab result electronically documented on the form that RN J was notified on 06/29/23 at 11:38 PM. Review of Resident #1's July 2023 MAR/TAR reflected on 07/01/23 at 8:54 AM, agency LVN D took Resident #1s blood sugar and it was 453. There was no indication any insulin was given at that time as the nurse did not reflect that sliding scale was administered and did not document any administration of insulin in a nursing note or an assessment of the resident. The MAR/TAR reflected, Inject as per sliding scale: .351-400=15 units; Give insulin and call MD if BS>400. There was no evidence through nursing documentation that the physician was notified, or the resident was assessed for any decline in condition. Resident #1's MAR/TAR reflected her last 24 hours of blood sugar readings prior on 06/30/23 were 252 at 7:00 AM, 218 at 11:30 AM and 385 at 4:30 PM. Review of nursing progress notes for Resident #1 on 06/29/23 through 07/02/23 revealed neither the physician or nurse practitioner were notified of the resident's critical lab result on 06/29/23 and of the elevated blood glucose reading on 07/01/23. Review of NP E's progress note on 07/03/23 reflected she had a face to face visit with Resident #1 and a facility nurse reported that the resident was not acting her normal self. NP E noted no moaning or facial grimaces during care/turning per the facility nurse. Resident #1 was seen lying in bed with eyes closed. She did not have any response to verbal, tactile stimuli and sternal rubs. Her respirations were even and unlabored and she did not appear to be in acute distress and her vital signs were stable. The NP ordered Resident #1 to be sent to the ER for altered mental status. NP E documented she reviewed a CMP lab dated 06/21/23 that she had previously ordered where Resident #1's glucose was 355. There was no evidence she reviewed the critical lab from 06/29/23 ordered by PHY B when her blood sugar was 480. Requested EMS Run Report and hospital records on 08/07/23, but investigator was unable to obtain the records. An interview with the overnight nurse RN J on 07/20/23 at 4:39 PM revealed she remembered Resident #1, but she did not remember receiving a critical lab result for the resident on 06/20/23 on the overnight shift. RN J stated, When a lab is critical, the lab company, you know I haven't received any, but they would call the facility, I haven't received any in, god, a long time, and they do call, ask who you are. Then the nurse would immediately call the doctor. Even overnight, you still attempt to call them and see. You would notify the family and you need to hear from the doctor. RN J stated the harm of not following up would be the resident could go into a coma if she began to have symptoms of hyperglycemia and it was not treated. RN J stated the facility nurse who the lab company contacted was responsible for documenting it in a progress note and complete a change in condition form, call the doctor and document results and complete vitals. RN J stated, I don't remember getting any such call, .As a nurse, communication is how I know if labs need to be followed up on the 24-hour form .I haven't gotten a call for a critical lab in a long time. I am talking way long time, three to six months. An interview with the DON on 07/20/23 at 2:15 PM revealed Resident #1 passed away in the hospital and she did not know what her was the cause of Resident #1's death. The DON confirmed as she observed Resident #1's nursing progress notes, an order for a CMP on 06/29/23 but she did not see where the critical lab was reported in the system by the nurse. The DON stated if a lab company could not reach a nurse at the facility for a critical lab, they can contact her and the treatment nurses 24/7. The DON stated the receiving nurse for the critical lab was supposed to call the nurse practitioner if it was Monday through Friday and the Physician if it was Saturday and Sunday and notify them and the nurse then would write a progress note and notate any new orders. Regarding Resident #1's high blood sugars on the MAR, the DON stated if a blood sugar was over 400, what should have happened was the doctor should have been notified, the resident given insulin and then her blood sugar re-checked and if it was still high, then notify the doctor and he would have decided to send her to the ER or not. The DON stated even if Resident #1's blood sugar readings the rest of that day were not under 400, it meant the insulin was not working properly. She stated the issue with using agency nurses was they did not know where a resident's baseline was at for vitals and condition. The DON stated the nurse who made the error (LVN D) with the lack of notification and documentation when Resident #1's blood sugar was over 400 was an agency nurse. She said when a resident's blood sugar was over 400, the nurse would also need to complete a significant event form for high blood sugar reading in e-charting software and that information would be reflected the next morning for management to review. An interview with the DON on 07/20/23 at 4:26 PM revealed, We dropped the ball with [Resident #1]'s lab. The DON confirmed the critical lab notification was made by the lab at 11:38 PM and the lab documented RN J was the person notified. The DON stated RN J was a facility nurse and knew the protocols, but the DON could not find a progress note or anything on the 24-hour report. She said the morning nurse (LVN A) did not remember being notified of a critical lab during change of shift report the next day. The DON stated again, I hate to admit it, but the ball was dropped. She said RN J was a seasoned nurse and had been at the facility for six years and knew better. The DON stated ADON H was going to start in-services on critical lab readings, who to notify and what steps to take. A follow up interview with the DON on 07/20/23 at 4:58 PM revealed she had pulled the hard copy of the 24-hour report that the nurses wrote on versus the one in the e-charting system and pointed to where RN J had hand-written on the 24-hour report for the shift on 06/29/23, that Resident #1's lab results were in, and the NP was notified. The DON stated, But she did not indicate it was a critical lab and she did not do the proper follow up notifications and receive orders as to how to proceed. The DON stated she was unaware of this error prior to investigator intervention. Review of the facility's 24-hour report for the overnight shift on 06/30/23 reflected revealed a hand written note that the nurse practitioner was notified of labs, next to Resident #1's name. The DON had verified in an earlier interview that it was the handwriting of RN J. An interview with NP E on 07/20/23 at 6:47 PM revealed she was unaware of the critical lab result for Resident #1 on 06/29/23 and she did not see any documentation where PHY B was notified either. NP E stated she rounded every Monday at the facility and last time she saw Resident #1 was on 07/03/23 and saw the critical lab and the resident did not look good to her, She stated Resident #1 was not responding and usually would moan when moved, but this time she did not. She did a sternal rub and Resident #1 still would not open her eyes, so she sent her to the ER. NP E stated her visit was three days after the critical lab result came in. NP E stated, They should notify us of critical lab results, but not all of them are doing it. We cannot check everyone's labs all the time, that is why we have the nurses let us know, so we can adjust the insulin. She said if she had seen Resident #1's critical lab and she was not in the condition she had been in, she would have just adjusted her insulin. Regarding the high blood sugar reading on 07/01/23, NP E stated even though Resident #1's blood sugar was high, she was on sliding scale to cover it, but she did not see any documentation where the resident's blood sugar was re-checked, and the nurse did not document that she gave insulin. NP E stated she wanted the nurses to contact her if a resident's blood sugar was over 400 and there was a sliding scale protocol. She stated, If it is way higher, we give insulin to lower it. I want them to call me if over 400, we have a sliding scale protocol. If it is way higher, we give extra insulin to lower it. NP E stated high blood sugar could cause a resident to go into diabetic ketoacidosis (develops when your body doesn't have enough insulin to allow blood sugar into your cells for use as energy.) and then a coma but she felt that the issue was not Resident #1's high blood sugar that caused the change in condition but could not be sure. An interview with PHY B on 07/21/23 at 10:30 AM revealed he did not receive a call from the facility to notify him of Resident #1's critical lab result. He said he knew Resident #1 well and she was in a very debilitated condition and had a recent stroke. PHY B stated Resident #1 had short and long acting insulin, so even though the facility did not notify him of the critical lab or blood sugars over 400, she was still covered for any sugar abnormalities. However, PHY B stated with critical labs, the nurse needed to be looking at signs and symptoms and if the blood sugar was more than 400/450 or something like that, they are supposed to call him, or the NP and they could make changes. PHY B stated, Like if 500, they call me and I know I am covering the insulin and sometimes I know someone is a brittle diabetic, like in her case, then what we do, if persistently going up and we add another 5 or 6 units of insulin short acting on top of sliding scale, then they would check again in four hours to make sure the glucose is covered. PHY B stated hyperglycemia above 800 could cause altered mental status, but not around 400. He said Resident #1's body was used to the high blood sugar. PHY B stated Resident #1 was sent to the hospital because she was unresponsive, it was not the blood sugar. In our mind, she had a stroke. Attempted interview with LVN D on 07/21/23 at 2:21 was unsuccessful. A voicemail was left with a request to return investigator's call. An interview with the DON on 07/22/23 at 2:19 PM revealed she talked to RN J about not reporting the critical lab for Resident #1 the night prior and RN J admitted that she forgot that she had received the lab notification, which was in contradiction to what she stated during the investigator's interview. RN J told the DON that she told another nurse working at that time that Resident #1 had a critical lab because it was that resident's nurse. However, RN J did not document that she notified that nurse of the critical lab and when the DON asked the other nurse about it, she said she was never notified of the critical lab. The nurse was only notified by a screen shot that a lab was completed for Resident #1, but the whole lab could not be seen. The DON stated, The critical values were not communicated at that point. So I have taken the necessary steps with her as well. The DON felt the IJ occurred because of documentation. She said the critical lab was not reported and the hand-written note on the 24-hour report was not accurate. She said it was human error. The DON stated that going forward, the facility nursing management would add spot checks to monthly nursing audits and the ADON would oversee that critical lab notifications were done and documented in the resident records. Review of the facility's policy titled, Lab and Diagnostic Test Results, revised November 2018, reflected, .Identifying Situations that Warrant Immediate notification: 1. Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: -Whether the physician has requested to be notified as soon as result is received, -Whether the result should be converted to a physician regardless of other circumstances, -Whether the resident/patient's clinical status is unclear or he/she has signs and symptoms of acute illness or condition change and is not stable of improving, or there are no previous results for comparison; .Options for Physician Notification: 1. A physician can be notified by phone, fax, voicemail, e-mail, mail, pager, or a telephone message to another person acting as the physician's agent, a. Facility staff should document information about when, how, and to whom the information was provided and the response. This should be done in the Progress Notes section of the medical record and not on the lab results report, because test results should be correlated with other relevant information such as the individual's overall situation, current symptoms, advance directives, prognosis, b. Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the resident's clinical status is unstable or current treatment records needs review or clarification. The facility Administrator received the IJ template on 07/21/23 at 12:58 PM. The Plan of Removal (POR) was accepted on 07/21/23 at 5:23 PM and reflected: Plan for Removal-[Facility Name] / July 21, 2023 The Texas Department of Health and Human Services entered [Facility Name] on July 21, 2023. During their investigation, an IJ (Immediate Jeopardy) was cited on 7/21/23 at approx. 12:50pm regarding Resident Rights r/t Physician Notification of Change in Condition. The Facility failed to ensure that a physician was notified of a critical lab value for one resident on 6/29/23. F580- Plan of Removal All nurses, to include agency staff, will be in-serviced on the following: o Inservice to include SBAR for critical labs. o Inservice for critical lab reporting and documentation. On 7/20/23, the Director of Nursing began in-services with 2-10 shift nurses. The nursing leadership team also began calling nurses who were not on-shift at that time for verbal education and to provide immediate action and compliance. Any non-agency nurses who have not completed in-services will do so prior to the beginning of their next shift. All currently staffed nurses will not be allowed to work until completing competency. Agency nurses will be required to review in-services, located in a binder at nurse's station, prior to start of their shift. Compliance will be monitored by the DON daily with notification provided to any new agency nurse prior to start of their shift. The DON will provide all staffed nurses with a competency quiz to confirm understanding of in-services listed above. Quizzes will be completed prior to any staffed nurse working another shift, until all nurses have completed the competency. No nurse will work a shift until competency is completed. The nurse involved, [RN J], to be terminated effectively immediately by Administrator on 7/21/23. A daily audit tool will be utilized to monitor for critical labs and documentation of such including timely reporting to provider. This audit tool will include monitoring on the weekends. DON and ADON will complete an immediate audit of critical labs will be completed on 7/21/22, going back to 6/21/23, in order to confirm proper notification and documentation were completed and to ensure there are no active resident health or safety concerns related to lab services. On 7/20/23, an Ad Hoc QAPI meeting was held with the leadership team for root cause discussion. It was determined that the notification to physician was not completed per policy. PIPs will be initiated for physician notification with all in-services and audit tools attached for review in monthly QAPI. Administrator will host weekly Ad Hoc QAPI meetings to assist in monitoring audit tools and in-service tracking. The audits will be completed daily x 2 weeks, weekly x 4 weeks and monthly x2 or until substantial compliance is met. Findings will be corrected in real time and discussed monthly at QAPI by the interdisciplinary team. Monitoring interviews for the Immediate Jeopardy were started on 07/22/23 at 1:00PM with nursing staff across all three shifts , including weekdays and weekends, from the nursing, administration. The following staff's in-service logs and competency tests were reviewed and they were interviewed during the monitoring time frame and were able to articulate what they had been taught, protocols and procedures related to physician notification of critical labs, documentation protocol, and expectations for elevated blood sugar over 401: ADON H, LVN I, LVN K, RN P, LVN Q, LVN M, RN N, RN O, DON and ADM. Monitoring and review of all new lab results from 07/21/23 through 07/24/23 for all facility residents reflected two results came in for two different residents and were both abnormal, not critical. Proper notifications were made to the MD/NP and documentation was completed per facility protocol. The facility's ADM was notified the IJ was removed on 07/22/23 at 3:31 PM. While the Immediate Jeopardy was removed on 07/22/23, the facility remained out of compliance due to the facility's need to evaluate the effectiveness of the Plan of Removal.

Based on interview and record, the facility failed to promptly notify the ordering physician, physician assistant or nurse practitioner of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for one (Resident #1) of three residents reviewed for quality of care. The facility failed accurately document and follow up with the Resident #1's physician when Resident #1's had a critical CMP (comprehensive metabolic panel) lab with a glucose with a reading of 480. Due to the delay, the physician did not order necessary interventions. Resident #1 was admitted to the hospital three days later, where she died from unknown reasons. On [DATE] an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their corrective systems. The facility Administrator received the IJ template on [DATE] at 12:58 PM. This failure placed residents at risk for potential delay in medical intervention and decline in health or possible worsening of symptoms, including death. Findings included: Review of Resident #1's significant change MDS assessment dated [DATE] reflected she was an [AGE] year old female who admitted to the facility on [DATE]. Resident #1's active diagnoses included diabetes, non-Alzheimer's dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), aphasia (loss of ability to understand or express speech, caused by brain damage), stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts), hemiplegia (paralysis of one side of the body), malnutrition (lack of proper nutrition), hyperlipidemia (an elevated level of lipids like cholesterol and triglycerides in the blood), GERD (a condition in which the stomach contents move up into the esophagus), hypertension (when the pressure in your blood vessels is too high (,d+[DATE] mmHg or higher) and dysphagia (swallowing difficulty). Resident #1 had no speech and was rarely/never understood and had adequate vision and hearing. Resident #1 had long and short term memory problems and severely impaired cognitive decision making skills. Resident #1 has signs/symptoms of delusions, including inattention and altered level of consciousness with vigilance (startled easily with sound or touch), but had no indicators of psychosis, wandering or rejection of care. Resident #1 was totally dependent on staff for all ADLs and had upper and lower range of motion impairment on both sides of her body and was incontinent of bowel and bladder. Resident #1 did not have a condition or chronic disease that would result in a life expectancy of less than 6 months. Resident #1 did experience significant unplanned weight loss in the past six months and used a feeding tube, was given insulin injections and anticoagulant medication. Review of Resident #1's care plan dated [DATE] reflected she had Diabetes Mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels) and was at risk for signs and symptoms and complications. Interventions were to monitor/document for side effects and effectiveness, dietary consult for nutritional regimen, fasting serum blood sugar as ordered by doctor, if infections is present than consult doctor regarding any changes in diabetic medications, inspect feet daily, and monitor/document/report signs and symptoms of hypoglycemia and infection to any open areas. Review of Resident #1's physician orders for [DATE] and [DATE] reflected, CBC, CMP, A1C (start date [DATE] and ordered by PHY B), Insulin Lispro Injection Solution 100 UNIT/ML-Inject as per sliding scale: if ,d+[DATE] = 3 Units; ,d+[DATE] = 6 Units; ,d+[DATE] = 9 Units; ,d+[DATE] = 12 Units; ,d+[DATE] = 15 units Give insulin and call MD if BS >400, subcutaneously before meals (start date [DATE]), Levemir Subcutaneous Solution-Inject 30 unit subcutaneously one time a day ([DATE]). Review of Resident #1's CMP lab result on [DATE] reflected it was a critical result with her blood glucose at 480 (Reference range is 81 to115). The lab result electronically documented on the form that RN J was notified on [DATE] at 11:38 PM. Review of Resident #1's [DATE] MAR/TAR reflected on [DATE] at 8:54 AM, agency LVN D took her blood sugar, and it was 453. There was no indication that any insulin was given at that time as the nurse did not reflect that sliding scale was administered and did not document any administration of insulin in a nursing note or an assessment of the resident. The MAR/TAR reflected, Inject as per sliding scale: XXX,d+[DATE]=15 units; Give insulin and call MD if BS>400. There was no evidence through nursing documentation that the physician was notified, or the resident was assessed for any decline in condition. Resident #1's MAR/TAR reflected her last 24 hours of blood sugar readings prior on [DATE] were 252 at 7:00 AM, 218 at 11:30 AM and 385 at 4:30 PM. Review of nursing progress notes for Resident #1 on [DATE] through [DATE] revealed neither the physician or nurse practitioner were notified of the resident's critical lab result on [DATE] and of the elevated blood glucose reading on [DATE]. Review of NP E's progress note on [DATE] reflected she had a face to face visit with Resident #1 and a facility nurse reported that the resident was not acting her normal self. NP E noted no moaning or facial grimaces during care/turning per the facility nurse. Resident #1 was seen lying in bed with eyes closed. She did have any response to verbal, tactile stimuli and sternal rubs. Her respirations were even and unlabored and she did not appear to be in acute distress and her vital signs were stable. The NP ordered Resident #1 to be sent to the ER for altered mental status. NP E documented she reviewed a CMP lab dated [DATE] that she had previously ordered where Resident #1's glucose was 355. There was no evidence she reviewed the critical lab from [DATE] ordered by PHY B when her blood sugar was 480. Requested EMS Run Report and hospital records on [DATE], but investigator was unable to obtain the records. An interview with the overnight nurse RN J on [DATE] at 4:39 PM revealed she remembered Resident #1 but she did not remember receiving a critical lab result for the resident on [DATE] on the overnight shift. RN J stated, When a lab is critical, the lab company, you know I haven't received any but they would call the facility, I haven't received any in, god, a long time, and they do call, ask who you are. Then the nurse would immediately call the doctor. Even overnight, you still attempt to call them and see. You would notify the family and you need to hear from the doctor. RN J stated the harm of not following up would be the resident could go into a coma if she began to have symptoms of hyperglycemia and it was not treated. RN J stated the facility nurse who the lab company contacted was responsible for documenting it in a progress note and complete a change in condition form, call the doctor and document results and complete vitals. RN J stated, I don't remember getting any such call, .As a nurse, communication is how I know if labs need to be follow up on the 24-hour form .I haven't gotten a call for a critical lab in a long time. I am talking way long time, three to six months. An interview with the DON on [DATE] at 2:15 PM revealed Resident #1 passed away in the hospital and she did not know what her cause of death was. The DON verified she observed in Resident #1's nursing progress notes, an order for a CMP on [DATE] but she did not see where the critical lab was reported in the system by the nurse. The DON stated of a lab company could not reach a nurse at the facility for a critical lab, they can contact her and the treatment nurses ,d+[DATE]. The DON stated the receiving nurse for the critical lab was supposed to call the nurse practitioner if it was Monday through Friday and the Physician if it was Saturday and Sunday and notify them and the nurse then would write a progress note and notate any new orders. Regarding Resident #1's high blood sugars on the MAR, the DON stated if a blood sugar was over 400, what should have happened was the doctor should have been notified, the resident given insulin and then her blood sugar re-checked and if it was still high, then notify the doctor and he will decided to send her to the ER or not. The DON stated even if Resident #1's blood sugar readings the rest of that day were under 400, it still meant that the insulin was not working properly. She stated the issue with using agency nurses was they did not know where a resident's baseline was at for vitals and condition. The DON stated the nurse who made the error (LVN D) with the lack of notification and documentation when Resident #1's blood sugar was over 400 was an agency nurse. She said when a resident's blood sugar was over 400, the nurse would also need to complete a significant event form for high blood sugar reading in e-charting software and that information would be reflected the next morning for management to review. An interview with the DON on [DATE] at 4:26 PM revealed, We dropped the ball with [Resident #1]'s lab. The DON confirmed the critical lab notification was made by the lab at 11:38 PM and the lab documented RN J was the person notified. The DON stated RN J was a facility nurse and knew the protocols but the DON could not find a progress note or anything on the 24-hour report. She said the morning nurse (LVN A) did not remember being notified of a critical lab during change of shift report the next day. The DON stated again, I hate to admit it, but the ball was dropped. She said RN J was a seasoned nurse and had been at the facility for six years and knew better. The DON stated ADON H was going to start in-services on critical lab readings, who to notify and what steps to take. Review of the facility's 24-hour report for the overnight shift on [DATE] reflected revealed a hand written note that the nurse practitioner was notified of labs, next to Resident #1's name. The DON had verified in an earlier interview that it was the handwriting of RN J. A follow up interview with the DON on [DATE] at 4:58 PM revealed she had pulled the hard copy of the 24-hour report that the nurses wrote on versus the one in the e-charting system and pointed to where RN J had hand-written on the 24-hour report for the shift on [DATE], that Resident #1's lab results were in and the NP was notified. The DON stated, But she did not indicate it was a critical lab and she did not do the proper follow up notifications and receive orders as to how to proceed. The DON stated she was unaware of this error prior to investigator intervention and was just discovering it. An interview with NP E on [DATE] at 6:47 PM revealed she was unaware of the critical lab result for Resident #1 on [DATE] and she did not see any documentation where PHY B was notified either. NP E stated she rounded every Monday at the facility and last time she saw Resident #1 was on [DATE] and saw the critical lab and the resident did not look good to her, She stated Resident #1 was not responding and usually would moan when moved, but this time she did not. She did a sternal rub and Resident #1 still would not open her eyes, so she sent her to the ER. NP E stated her visit was three days after the critical lab result came in. NP E stated, They should notify us of critical lab results, but not all of them are doing it. We cannot check everyone's labs all the time, that is why we have the nurses let us know, so we can adjust the insulin. She said if she had seen Resident #1's critical lab and she was not in the condition she had been in, she would have just adjusted her insulin. Regarding the high blood sugar reading on [DATE], NP E stated even though Resident #1's blood sugar was high, she was on sliding scale to cover it, but she did not see any documentation where the resident's blood sugar was re-checked and the nurse did not document that she gave insulin. NP E stated she wanted the nurses to contact her if a resident's blood sugar was over 400 and there was a sliding scale protocol. She stated, If it is way higher, we give insulin to lower it. I want them to call me if over 400, we have a sliding scale protocol. If it is way higher, we give extra insulin to lower it. NP E stated high blood sugar could cause a resident to go into diabetic ketoacidosis (develops when your body doesn't have enough insulin to allow blood sugar into your cells for use as energy) and then a coma but she felt that the issue was not Resident #1's high blood sugar that caused the change in condition but could not be sure. An interview with PHY B on [DATE] at 10:30 AM revealed he did not receive a call from the facility to notify him of Resident #1's critical lab result. He said he knew Resident #1 well and she was in a very debilitated condition and had a recent stroke. PHY B stated that Resident #1 had short and long acting insulin, so even though the facility did not notify him of the critical lab or blood sugars over 400, she was still covered for any sugar abnormalities. However, PHY B stated with critical labs, the nurse needed to be looking at signs and symptoms and if the blood sugar was more than ,d+[DATE] or something like that, they are supposed to call him or the NP and they could make changes. PHY B stated, Like if 500, they call me and I know I am covering the insulin and sometimes I know someone is a brittle diabetic, like in her case, then what we do, if persistently going up and we add another 5 or 6 units of insulin short acting on top of sliding scale, then they would check again in four hours to make sure the glucose is covered. PHY B stated hyperglycemia above 800 could cause altered mental status, but not around 400. He said Resident #1's body was used to the high blood sugar. PHY B stated Resident #1 was sent to the hospital because she was unresponsive, it was not the blood sugar. In our mind, she had a stroke. Attempted interview with LVN D on [DATE] at 2:21 was unsuccessful. A voicemail was left with a request to return investigator's call. An interview with the DON on [DATE] at 2:19 PM revealed she talked to RN J about not reporting the critical lab for Resident #1 the night prior and RN J admitted that she forgot that she had received the lab notification, which was in contradiction to what she stated during the investigator's interview. RN J told the DON that she told another nurse working at that time that Resident #1 had a critical lab because it was that resident's nurse. However, RN J did not document that she notified that nurse of the critical lab and when the DON asked the other nurse about it, she said she was never notified of the critical lab. The nurse was only notified by a screen shot that a lab was completed for Resident #1, but the whole lab could not be seen. The DON stated, The critical values were not communicated at that point. So I have taken the necessary steps with her as well. The DON felt the IJ occurred because of documentation. She said the critical lab was not reported and the hand-written note on the 24-hour report was not accurate. She said it was human error. The DON stated that going forward, the facility nursing management would add spot checks to monthly nursing audits and the ADON would oversee that critical lab notifications were done and documented in the resident records. Review of the facility's policy titled, Lab and Diagnostic Test Results, revised [DATE], reflected, .Identifying Situations that Warrant Immediate notification: 1. Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: -Whether the physician has requested to be notified as soon as result is received, -Whether the result should be converted to a physician regardless of other circumstances, -Whether the resident/patient's clinical status is unclear or he/she has signs and symptoms of acute illness or condition change and is not stable of improving, or there are no previous results for comparison; .Options for Physician Notification: 1. A physician can be notified by phone, fax, voicemail, e-mail, mail, pager, or a telephone message to another person acting as the physician's agent, a. Facility staff should document information about when, how, and to whom the information was provided and the response. This should be done in the Progress Notes section of the medical record and not on the lab results report, because test results should be correlated with other relevant information such as the individual's overall situation, current symptoms, advance directives, prognosis, b. Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification, especially when the resident's clinical status is unstable or current treatment records needs review or clarification. On [DATE] an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. The facility Administrator received the IJ template on [DATE] at 12:58 PM. The Plan of Removal (POR) was accepted on [DATE] at 5:23 PM and reflected: Plan for Removal- [Facility Name]/ [DATE]-The Texas Department of Health and Human Services entered [Facility] on [DATE]. During their investigation, an IJ (Immediate Jeopardy) was cited on [DATE] at approx. 12:50pm regarding Laboratory Services. The Facility failed to ensure that a physician was notified of a critical lab value for one resident on [DATE]. F773- Plan of Removal All nurses, to include agency staff, will be in-serviced on the following: o Inservice to include SBAR for critical labs. o Inservice for critical lab reporting and documentation. On [DATE], the Director of Nursing began in-services with ,d+[DATE] shift nurses. The nursing leadership team also began calling nurses who were not on-shift at that time for verbal education and to provide immediate action and compliance. Any non-agency nurses who have not completed in-services will do so prior to the beginning of their next shift. All currently staffed nurses will not be allowed to work until completing competency. Agency nurses will be required to review in-services, located in a binder at nurse's station, prior to start of their shift. Compliance will be monitored by the DON daily with notification provided to any new agency nurse prior to start of their shift. The DON will provide all staffed nurses with a competency quiz to confirm understanding of in-services listed above. Quizzes will be completed prior to any staffed nurse working another shift, until all nurses have completed the competency. No nurse will work a shift until competency is completed. The nurse involved, [RN J], to be terminated effectively immediately by Administrator on [DATE]. A daily audit tool will be utilized to monitor for critical labs and documentation of such including timely reporting to provider. This audit tool will include monitoring on the weekends. DON and ADON will complete an immediate audit of critical labs will be completed on [DATE], going back to [DATE], in order to confirm proper notification and documentation were completed and to ensure there are no active resident health or safety concerns related to lab services. On [DATE], an Ad Hoc QAPI meeting was held with the leadership team for root cause discussion. It was determined that the notification to physician was not completed per policy. PIPs will be initiated for physician notification with all in-services and audit tools attached for review in monthly QAPI. Administrator will host weekly Ad Hoc QAPI meetings to assist in monitoring audit tools and in-service tracking. The audits will be completed daily x 2 weeks, weekly x 4 weeks and monthly x2 or until substantial compliance is met. Findings will be corrected in real time and discussed monthly at QAPI by the interdisciplinary team. Monitoring interviews for the Immediate Jeopardy were started on [DATE] at 1:00PM with nursing staff across all three shifts , including weekdays and weekends, from the nursing, administration. The following staff's in-service logs and competency tests were reviewed and they were interviewed during the monitoring time frame and were able to articulate what they had been taught, protocols and procedures related to physician notification of critical labs, documentation protocol, and expectations for elevated blood sugar over 401: ADON H, LVN I, LVN K, RN P, LVN Q, LVN M, RN N, RN O, DON and ADM. Monitoring and review of all new lab results from [DATE] through [DATE] for all facility residents reflected two results came in for two different residents and were both abnormal, not critical. Proper notifications were made to the MD/NP and documentation was completed per facility protocol. The facility's ADM was notified the IJ was removed on [DATE] at 3:31 PM. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance due to the facility's need to evaluate the effectiveness of the Plan of Removal.

Based on interview and record, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive resident-centered care plan for one (Resident #1) of three residents reviewed for quality of care. 1. The facility failed to assess and intervene for a potential change in condition or decline when Resident #1's had a critical CMP (comprehensive metabolic panel) lab with a glucose with a reading of 480. 2. The facility failed to ensure that when Resident #1's blood sugar was 453, that the physician was notified and it wss unclear if the resident received insulin. On 07/21/23 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 07/22/23, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure placed residents at risk for potential delay in medical intervention and decline in health or possible worsening of symptoms, including death. Findings included: Review of Resident #1's significant change MDS assessment dated [DATE] reflected she was an [AGE] year old female who admitted to the facility on [DATE]. Resident #1's active diagnoses included diabetes, non-Alzheimer's dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), aphasia (loss of ability to understand or express speech, caused by brain damage), stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts), hemiplegia (paralysis of one side of the body), malnutrition (lack of proper nutrition), hyperlipidemia (an elevated level of lipids like cholesterol and triglycerides in the blood), GERD (a condition in which the stomach contents move up into the esophagus), hypertension (when the pressure in your blood vessels is too high (140/90 mmHg or higher) and dysphagia (swallowing difficulty). Resident #1 had no speech and was rarely/never understood and had adequate vision and hearing. Resident #1 had long and short term memory problems and severely impaired cognitive decision making skills. Resident #1 has signs/symptoms of delusions, including inattention and altered level of consciousness with vigilance (startled easily with sound or touch), but had no indicators of psychosis, wandering or rejection of care. Resident #1 was totally dependent on staff for all ADLs and had upper and lower range of motion impairment on both sides of her body and was incontinent of bowel and bladder. Resident #1 did not have a condition or chronic disease that would result in a life expectancy of less than 6 months. Resident #1 did experience significant unplanned weight loss in the past six months and used a feeding tube, was given insulin injections and anticoagulant medication. Review of Resident #1's care plan dated 02/05/23 reflected she had Diabetes Mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels) and was at risk for signs and symptoms and complications. Interventions were to monitor/document for side effects and effectiveness, dietary consult for nutritional regimen, fasting serum blood sugar as ordered by doctor, if infections is present than consult doctor regarding any changes in diabetic medications, inspect feet daily, and monitor/document/report signs and symptoms of hypoglycemia and infection to any open areas. Review of Resident #1's physician orders for June 20223 and July 2023 reflected, CBC, CMP, A1C (start date 06/28/23 and ordered by PHY B), Insulin Lispro Injection Solution 100 UNIT/ML-Inject as per sliding scale: if 151-200 = 3 Units; 201-250 = 6 Units; 251-300 = 9 Units; 301-350 = 12 Units; 351-400 = 15 units Give insulin and call MD if BS >400, subcutaneously before meals (start date 04/25/23), Levemir Subcutaneous Solution-Inject 30 unit subcutaneously one time a day (06/22/2023). Review of Resident #1's CMP lab result on 06/29/23 reflected it was a critical result with her blood glucose at 480 (Reference range is 81 to115). The lab result electronically documented on the form that RN J was notified on 06/29/23 at 11:38 PM. Review of Resident #1's July 2023 MAR/TAR reflected on 07/01/23 at 8:54 AM, agency LVN D took her blood sugar, and it was 453. There was no indication that any insulin was given at that time as the nurse did not reflect that sliding scale was administered and did not document any administration of insulin in a nursing note or an assessment of the resident. The MAR/TAR reflected, Inject as per sliding scale: .351-400=15 units; Give insulin and call MD if BS>400. There was no evidence through nursing documentation that the physician was notified, or the resident was assessed for any decline in condition. Resident #1's MAR/TAR reflected her last 24 hours of blood sugar readings prior on 06/30/23 were 252 at 7:00 AM, 218 at 11:30 AM and 385 at 4:30 PM. Review of nursing progress notes for Resident #1 on 06/29/23 through 07/02/23 revealed neither the physician or nurse practitioner were notified of the resident's critical lab result on 06/29/23 and of the elevated blood glucose reading on 07/01/23. Review of NP E's progress note on 07/03/23 reflected she had a face to face visit with Resident #1 and a facility nurse reported that the resident was not acting her normal self. NP E noted no moaning or facial grimaces during care/turning per the facility nurse. Resident #1 was seen lying in bed with eyes closed. She did have any response to verbal, tactile stimuli and sternal rubs. Her respirations were even and unlabored and she did not appear to be in acute distress and her vital signs were stable. The NP ordered Resident #1 to be sent to the ER for altered mental status. NP E documented she reviewed a CMP lab dated 06/21/23 that she had previously ordered where Resident #1's glucose was 355. There was no evidence she reviewed the critical lab from 06/29/23 ordered by PHY B when her blood sugar was 480. Requested EMS Run Report and hospital records on 08/07/23, but investigator was unable to obtain the records. An interview with the overnight nurse RN J on 07/20/23 at 4:39 PM revealed she remembered Resident #1, but she did not remember receiving a critical lab result for the resident on 06/20/23 on the overnight shift. RN J stated, When a lab is critical, the lab company, you know I haven't received any but they would call the facility, I haven't received any in, god, a long time, and they do call, ask who you are. Then the nurse would immediately call the doctor. Even overnight, you still attempt to call them and see. You would notify the family and you need to hear from the doctor. RN J stated the harm of not following up would be the resident could go into a coma if she began to have symptoms of hyperglycemia and it was not treated. RN J stated the facility nurse who the lab company contacted was responsible for documenting it in a progress note and complete a change in condition form, call the doctor and document results and complete vitals. RN J stated, I don't remember getting any such call, .As a nurse, communication is how I know if labs need to be follow up on the 24-hour form .I haven't gotten a call for a critical lab in a long time. I am talking way long time, three to six months. An interview with the DON on 07/20/23 at 2:15 PM revealed Resident #1 passed away in the hospital and she did not know what her cause of death was. The DON verified she observed in Resident #1's nursing progress notes, an order for a CMP on 06/29/23 but she did not see where the critical lab was reported in the system by the nurse. The DON stated of a lab company could not reach a nurse at the facility for a critical lab, they can contact her and the treatment nurses 24/7. The DON stated the receiving nurse for the critical lab was supposed to call the nurse practitioner if it was Monday through Friday and the Physician if it was Saturday and Sunday and notify them and the nurse then would write a progress note and notate any new orders. Regarding Resident #1's high blood sugars on the MAR, the DON stated if a blood sugar was over 400, what should have happened was the doctor should have been notified, the resident given insulin and then her blood sugar re-checked and if it was still high, then notify the doctor and he would have decided to send her to the ER or not. The DON stated even if Resident #1's blood sugar readings the rest of that day were under 400, it still meant that the insulin was not working properly. She stated the issue with using agency nurses was they did not know where a resident's baseline was at for vitals and condition. The DON stated the nurse who made the error (LVN D) with the lack of notification and documentation when Resident #1's blood sugar was over 400 was an agency nurse. She said when a resident's blood sugar was over 400, the nurse would also need to complete a significant event form for high blood sugar reading in e-charting software and that information would be reflected the next morning for management to review. An interview with the DON on 07/20/23 at 4:26 PM revealed, We dropped the ball with [Resident #1]'s lab. The DON confirmed the critical lab notification was made by the lab at 11:38 PM and the lab documented RN J was the person notified. The DON stated RN J was a facility nurse and knew the protocols, but the DON could not find a progress note or anything on the 24-hour report. She said the morning nurse (LVN A) did not remember being notified of a critical lab during change of shift report the next day. The DON stated again, I hate to admit it, but the ball was dropped. She said RN J was a seasoned nurse and had been at the facility for six years and knew better. The DON stated ADON H was going to start in-services on critical lab readings, who to notify and what steps to take. Review of the facility's 24-hour report for the overnight shift on 06/30/23 reflected revealed a hand written note that the nurse practitioner was notified of labs, next to Resident #1's name. The DON had verified in an earlier interview that it was the handwriting of RN J. A follow up interview with the DON on 07/20/23 at 4:58 PM revealed she had pulled the hard copy of the 24-hour report that the nurses wrote on versus the one in the e-charting system and pointed to where RN J had hand-written on the 24-hour report for the shift on 06/29/23, that Resident #1's lab results were in and the NP was notified. The DON stated, But she did not indicate it was a critical lab and she did not do the proper follow up notifications and receive orders as to how to proceed. The DON stated she was unaware of this error prior to investigator intervention and was just discovering it. An interview with NP E on 07/20/23 at 6:47 PM revealed she was unaware of the critical lab result for Resident #1 on 06/29/23 and she did not see any documentation where PHY B was notified either. NP E stated she rounded every Monday at the facility and last time she saw Resident #1 was on 07/03/23 and saw the critical lab and the resident did not look good to her, She stated Resident #1 was not responding and usually would moan when moved, but this time she did not. She did a sternal rub and Resident #1 still would not open her eyes, so she sent her to the ER. NP E stated her visit was three days after the critical lab result came in. NP E stated, They should notify us of critical lab results, but not all of them are doing it. We cannot check everyone's labs all the time, that is why we have the nurses let us know, so we can adjust the insulin. She said if she had seen Resident #1's critical lab and she was not in the condition she had been in, she would have just adjusted her insulin. Regarding the high blood sugar reading on 07/01/23, NP E stated even though Resident #1's blood sugar was high, she was on sliding scale to cover it, but she did not see any documentation where the resident's blood sugar was re-checked, and the nurse did not document that she gave insulin. NP E stated she wanted the nurses to contact her if a resident's blood sugar was over 400 and there was a sliding scale protocol. She stated, If it is way higher, we give insulin to lower it. I want them to call me if over 400, we have a sliding scale protocol. If it is way higher, we give extra insulin to lower it. NP E stated high blood sugar could cause a resident to go into diabetic ketoacidosis (develops when your body doesn't have enough insulin to allow blood sugar into your cells for use as energy) and then a coma, but she felt that the issue was not Resident #1's high blood sugar that caused the change in condition but could not be sure. An interview with PHY B on 07/21/23 at 10:30 AM revealed he did not receive a call from the facility to notify him of Resident #1's critical lab result. He said he knew Resident #1 well and she was in a very debilitated condition and had a recent stroke. PHY B stated that Resident #1 had short and long acting insulin, so even though the facility did not notify him of the critical lab or blood sugars over 400, she was still covered for any sugar abnormalities. However, PHY B stated with critical labs, the nurse needed to be looking at signs and symptoms and if the blood sugar was more than 400/450 or something like that, they are supposed to call him, or the NP and they could make changes. PHY B stated, Like if 500, they call me and I know I am covering the insulin and sometimes I know someone is a brittle diabetic, like in her case, then what we do, if persistently going up and we add another 5 or 6 units of insulin short acting on top of sliding scale, then they would check again in four hours to make sure the glucose is covered. PHY B stated hyperglycemia above 800 could cause altered mental status, but not around 400. He said Resident #1's body was used to the high blood sugar. PHY B stated Resident #1 was sent to the hospital because she was unresponsive, it was not the blood sugar. In our mind, she had a stroke. Attempted interview with LVN D on 07/21/23 at 2:21 was unsuccessful. A voicemail was left with a request to return investigator's call. An interview with the DON on 07/22/23 at 2:19 PM revealed she talked to RN J about not reporting the critical lab for Resident #1 the night prior and RN J admitted that she forgot that she had received the lab notification, which was in contradiction to what she stated during the investigator's interview. RN J told the DON that she told another nurse working at that time that Resident #1 had a critical lab because it was that resident's nurse. However, RN J did not document that she notified that nurse of the critical lab and when the DON asked the other nurse about it, she said she was never notified of the critical lab. The nurse was only notified by a screen shot that a lab was completed for Resident #1, but the whole lab could not be seen. The DON stated, The critical values were not communicated at that point. So I have taken the necessary steps with her as well. The DON felt the IJ occurred because of documentation. She said the critical lab was not reported and the hand-written note on the 24-hour report was not accurate. She said it was human error. The DON stated that going forward, the facility nursing management would add spot checks to monthly nursing audits and the ADON would oversee that critical lab notifications were done and documented in the resident records. Review of the facility's policy titled, Nursing Care of the Older Adult with Diabetes Mellitus, revised November 2020, reflected, .Symptoms Associated with Diabetes: 1. Hyperglycemia. Uncontrolled diabetes from lack of insulin or inadequate insulin results in hyperglycemia (blood sugars above target levels). Signs and symptoms of hyperglycemia may include the following: a. Increased thirst, b. Frequent urination, c. Sugar in the urine, d. Fatigue, e. Headache; and f. Blurred vision; 2. Diabetic ketoacidosis (DKA)(diabetic coma). Ketoacidosis occurs when hyperglycemia is untreated, and the cells begin to metabolize fat for energy. The byproduct of fat metabolism is ketones, which build up quickly in the blood. Diabetic ketoacidosis is a life-threatening emergency that needs immediate medical attention; .Complications associated with Diabetes .1. Hyperglycemia and vascular damage can lead to: a. Cardiovascular and cerebrovascular disease, including heart disease and stroke .; Glycemic Targets .6. Establish provider notification protocols. Review of the facility's policy titled, Change in Resident's Condition or Staus, revised May 2017, reflected, Our facility shall promptly notify the resident, his or her Attending Physicians, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, resident rights, etc.). 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): .d. Significant change to the resident's physical/emotional/mental condition; e. Need to alter the resident's medication significantly; .i. Specific instruction to notify the Physician of changes in the resident's condition . On 07/21/23 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 07/22/23, the facility remained out of compliance at a severity level of severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy with a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. The facility Administrator received the IJ template on 07/21/23 at 12:58 PM. The Plan of Removal (POR) was accepted on 07/21/23 at 5:23 PM and reflected: Plan for Removal-[Facility Name] / July 21, 2023 The Texas Department of Health and Human Services entered [Facility Name] on July 21, 2023. During their investigation, an IJ (Immediate Jeopardy) was cited on 7/21/23 at approx. 12:50pm regarding Resident Rights r/t Physician Notification of Change in Condition. The Facility failed to ensure that a physician was notified of a critical lab value for one resident on 6/29/23. F684- Plan of Removal All nurses, to include agency staff, will be in-serviced on the following: o Inservice on policy and procedure + documentation for blood glucose monitoring o Inservice on SBAR for change in condition o Inservice on physician notification for blood glucose monitoring On 7/20/23, the Director of Nursing began in-services with 2-10 shift nurses. The nursing leadership team also began calling nurses who were not on-shift at that time for verbal education and to provide immediate action and compliance. Any non-agency nurses who have not completed in-services will do so prior to the beginning of their next shift. All currently staffed nurses will not be allowed to work until completing competency. Agency nurses will be required to review in-services, located in a binder at nurse's station, prior to start of their shift. Compliance will be monitored by the DON daily with notification provided to any new agency nurse prior to start of their shift. The DON will provide all staffed nurses with a competency quiz to confirm understanding of in-services listed above. Quizzes will be completed prior to any staffed nurse working another shift, until all nurses have completed the competency. No nurse will work a shift until competency is completed. The nurse involved, [RN J], to be terminated effectively immediately by Administrator on 7/21/23. A daily audit tool will be utilized to monitor for critical labs and documentation of such including timely reporting to provider. This audit tool will include monitoring on the weekends. DON and ADON will complete an immediate audit of critical labs will be completed on 7/21/22, going back to 6/21/23, in order to confirm proper notification and documentation were completed and to ensure there are no active resident health or safety concerns related to lab services. On 7/20/23, an Ad Hoc QAPI meeting was held with the leadership team for root cause discussion. It was determined that the notification to physician was not completed per policy. PIPs will be initiated for physician notification with all in-services and audit tools attached for review in monthly QAPI. Administrator will host weekly Ad Hoc QAPI meetings to assist in monitoring audit tools and in-service tracking. The audits will be completed daily x 2 weeks, weekly x 4 weeks and monthly x2 or until substantial compliance is met. Findings will be corrected in real time and discussed monthly at QAPI by the interdisciplinary team. Monitoring interviews for the Immediate Jeopardy were started on 07/22/23 at 1:00PM with nursing staff across all three shifts , including weekdays and weekends, from the nursing, administration. The following staff's in-service logs and competency tests were reviewed and they were interviewed during the monitoring time frame and were able to articulate what they had been taught, protocols and procedures related to physician notification of critical labs, documentation protocol, and expectations for elevated blood sugar over 401: ADON H, LVN I, LVN K, RN P, LVN Q, LVN M, RN N, RN O, DON and ADM. Monitoring and review of all new lab results from 07/21/23 through 07/24/23 for all facility residents reflected two results came in for two different residents and were both abnormal, not critical. Proper notifications were made to the MD/NP and documentation was completed per facility protocol. The facility's ADM was notified the IJ was removed on 07/22/23 at 3:31 PM. While the Immediate Jeopardy was removed on 07/22/23, the facility remained out of compliance due to the facility's need to evaluate the effectiveness of the Plan of Removal.

Based on interview, and record review, the facility failed to maintain medical records on each resident that are accurately documented for one (Resident #1) of three residents reviewed for clinical records. The facility failed to maintain a copy of Resident #2's urine analysis and culture and sensitivity test results when ordered by his physician. This failure can place residents at risk of inaccurate needs or services based on comprehensive assessment. Findings included: Review of Resident #2's quarterly MDS assessment dated [DATE] reflected he was an [AGE] year old male admitted to the facility on [DATE]. Resident #2's active diagnoses included gastronomy status, Parkinson's disease, Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), aphasia (loss of ability to understand or express speech, caused by brain damage), cerebrovascular accident (A stroke, also referred to as a cerebral vascular accident (CVA) or a brain attack, is an interruption in the flow of blood to cells in the brain), diabetes (a chronic condition that affects the way the body processes sugar/glucose), neurogenic bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems), hypertension (high blood pressure), hyperlipidemia (an elevated level of lipids - like cholesterol and triglycerides in the blood) and thyroid disease (a general term for a medical condition that keeps your thyroid from making the right amount of hormones). Resident #2 had no speech and was rarely/never understood, had severely impaired vision, severely impaired cognitive skills for decision making, and long/short memory impairments. Resident #2 had delirium as evidenced by continuous inattention and altered levels of consciousness, but no indicators of psychosis of rejection of care. Resident #2 was total physically dependent on one to two staff for all ADLs, had range of motion impairment on both sides of his upper and lower extremities, was always incontinent of bowel and used a catheter and a feeding tube. Review of Resident #2's care plan dated 04/20/23 reflected he used a foley catheter and interventions were, Assess need for continued use, Change catheter per facility policy. Review of Resident #2's physician orders reflected, UA C&S and Urine Culture one time only (Start Date 05/08/2023 by PHY B. Review of a nursing note for Resident #2 dated 05/08/23 reflected, Received N/O from [NP E] for UA and C&S and urine culture. Review of Resident #2's clinical chart revealed no evidence of a UA with C&S during his stay at the facility. Review of a progress note from the Infectious Disease NP Q on 5/12/2023 reflected, Reason for Consultation: ID consult requested for management of antibiotics and work up of any and all infectious causes that could complicate the patient's recovery process .5/9/23 UA cloudy yellow, negative nitrite, 2+ LE, 25-49 WBC, moderate bacteria. Start empiric Macrobid 100mg PO BID via G tube x7 days. Pt admitted at [facility name] on 4/18/23, has the same SPC Foley since then, unknown last Foley exchange date. Need Foley exchange. Review of a follow up nursing note for Resident #2 dated 05/12/23 reflected, UA/C&S results in new order. Give Nitrofurantoin (also known as Macrobid) 100 mg BID for 7 days. An interview with NP E on 07/20/23 at 6:47 PM revealed she was Resident #2's nurse practitioner and he had a chronic suprapubic catheter and a history of recurrent UTI's. NP E was not sure why she ordered a UA with C&S on 05/08/23; she stated she had not seen Resident #2 on that date for a face to face visit, so the facility must have called her about it. NP E stated on 05/13/23, she stated Resident #2 was noticed to have shortness of breath, phlegm, mucus and his oxygen saturation was 82 on room air. She stated that he was sent to the hospital as a result of his change in condition. An interview with the DON on 07/21/23 at 12:01 PM revealed she tried to contact the previous lab company the facility contracted with during May 2023 and they would not provide a copy of Resident #1's UA with culture results. The DON stated the facility terminated their contract with the lab company because of some issues and now the lab company would not cooperate with providing the lab. The DON acknowledged that the lab should have been uploaded in the e-charting system and confirmed that ID NP Q documented it was reviewed. A follow up interview on 07/22/23 at 2:19 PM with the DON revealed the previous lab company could not interface with the facility's e-charting system which was also another reason they terminated their contract with the lab company. The DON stated the previous ADON used to log into the online portal for the lab company every day and compare it with the labs uploaded into the facility's e-charting system to see what was done and what was not done. The DON stated the previous ADON, herself and the nurses could print out the lab reports from their portal and upload it into the facility's system for record keeping during that time frame. The DON stated it was important to keep a copy of a resident's lab and results in their clinical record because, We can use it as a baseline if a resident has a recurrent UTI or we are watching values over time to see if they are dropping or elevated or have returned to baseline. Review of the facility's policy titled, Lab and Diagnostic Test Results revised November 2018, and a policy titled, Charting and Documentation revised July 2017; however, neither of the policies addressed facility retention of labs in the resident's clinical record. The DON also provided a policy titled, Laboratory Services (not dated) which reflected, .Laboratory reports are filed in each resident's clinical record. Laboratory reports are dated and contain the name and address of the testing laboratory

Based on observation, interview, and record review the facility failed to respect the residents right to personal privacy, including the right to privacy in written, and electronic communications, including the right to receive unopened mail for 2 (Residents #1 and #2) of 6 residents reviewed for resident rights. The facility failed to ensure that Residents #1 and #2 received their mail unopened. This failure could place residents at risk of not having privacy when receiving personal documents in the mail. Findings included: During an interview with Resident#1 on 06/22/2023 at 9:45 am. revealed the facility regularly opened her mail. The resident stated the last time it occurred was in October and November 2022. The resident complained to the administrator around that same time and has not noticed any mail opened since. The resident felt like her mail should not have been opened. An interview on 06/22/2023 at 2:40 pm with Admissions Director revealed Resident Rights policy was provided to the Resident or Authorized Representative at the time of admission. During an interview with the Business Office Manager on 06/22/2023 at 2:50 pm revealed the facility regularly opened mail addressed to residents. She stated she opened mail when she expected payments or information intended for the facility. She explained the following :updated insurance information, checks for the facility, or changes in Medicaid was what the facility was looking to obtain. She stated not all mail was opened, only mail that looked like it could have facility information in it was opened. She stated if a check goes directly to the resident and they do not provide the payment to the facility, the resident may have to be given notice to leave the facility for non-payment. The BOM did not indicate how this practice could affect the residents. During an interview with the Administrator, on 06/22/2023 at 4:10 pm it was confirmed the facility did open mail that appeared to be intended for the facility. He confirmed that this was done by the Business office Manager. During an interview and observation on 06/22/2023 at 4:35 pm The Business Office Manager provided two open letters from insurance companies addressed to Resident #2. The Business Office Manager stated she opened the letters herself. She stated when she opened the resident's mail, she wrote opened by the Business Office on the envelope and the mail was returned to the resident. She stated when checks were found they were applied to the resident's account. The mail for Resident #2 was provided as an example of a letter opened by the Business Office Manager. The opened mail addressed to Resident #2 was observed with a note that the mail was opened directly on the envelope. The name of the Insurance company was noted above the return address. The Business Office Manager indicated that she was going to give Resident #2 the opened mail. Record review of the Resident Rights Policy revised December 2016 reflected the following: . communicate in person and by mail, email and telephone with privacy .

Based on observation, interview and record review, the facility failed to implement written policies and procedures that prohibited the mistreatment, neglect and abuse for one (Resident #1) of six sampled residents reviewed for neglect. 1) On 05/06/12, the CNA reported Resident #1 did not fall, but was near falling when she was rescued by the CNA who placed her in her wheelchair. The resident was not assessed by the nurse and the incident was not reported and investigated; 2) On 05/07/12, a knot and bruise was found on Resident #1's forehead. The bruise of unknown origin was not immediately reported or investigated; 3) On 05/10/12, an unwitnessed resident-to-resident altercation occurred, but Resident #1 reportedly did not fall. Resident #1 was assisted to bed but was not assessed; 4) On 05/11/12, Resident #1 was found with bruising to her lower right leg and hip. An x-ray confirmed a refracture of her right hip and a [MEDICAL CONDITION] and fibula (both bones in the lower leg); and 5) The resident's responsible party was not notified of any incidents or injuries until 05/11/12. These failures could affect the 60 residents in the facility with Dementia by placing them at risk for abuse, neglect, emotional distress, and lack of family member and physician involvement following an injury. Findings included: 1) The MDS assessment, dated 04/30/12, reflected Resident #1 had the following active Diagnoses: [REDACTED]. The assessment reflected Resident #1 required extensive assistance with transfers and staff needed to provide weight-bearing support. The assessment reflected Resident #1 had problems with both her short-term and long-term memory, had severe cognitive impairment, and exhibited inattention and disorganized thinking. The Face Sheet, dated 03/30/12, reflected Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE]. The Face Sheet reflected a [DIAGNOSES REDACTED]. 2) During an interview with Resident #1's RP on 05/16/12 at 9:45 AM, she revealed she visited Resident #1 at the nursing facility on Sunday, 05/06/12. The RP stated she did not observe any bruises or swelling to Resident #1's face at that time. The RP stated no one at the facility mentioned a fall or any other injury to Resident #1 during her visit. The RP stated on Tuesday, 05/08/12, her spouse met Resident #1 at the orthopedic physician's office for a follow-up visit and at that time her spouse noticed a "knot" above the resident's right eye. She stated the "knot" had blue-green bruising that extended from the resident's right eye to her ear and neck. The RP stated the facility did not notify her of the injury. She stated when she called the facility on 05/08/12, the Administrator told her Resident #1 fell trying to get out of bed by herself. The RP stated she carried her cell phone with her at all times and there was no call or voice message left on her cell phone or home phone notifying her that Resident #1 had sustained a fall or injury to her forehead or neck. The RP stated on 05/11/12 at approximately 4:30 PM the facility called and informed her the resident had three fractures, including the femur, and it had happened when she was trying to get out of bed without assistance. The RP stated she met the ambulance at the hospital and was informed by the transport paramedics, "There is no way her injuries are consistent with a fall with a wheelchair." She stated the paramedic also revealed the facility found her at 6:00 AM and it should not have taken them 12 hours (6:00 PM) to get her to the hospital. She stated Resident #1 was taken to surgery for [REDACTED]. During the same interview, the RP stated she spoke with the Administrator regarding the incident. The Administrator initially revealed the facility did not know how it happened but later revealed Resident #1 was in another resident's room, putting on clothes from another resident's closet. She stated the Administrator said Resident #1 fell from the wheelchair, but the Administrator did not provide any other explanation. An interview with the RP's spouse on 05/17/12 at 12:45 PM revealed he was shocked to see Resident #1 on 05/08/12, because "she looked like she had been in a wreck." He stated he was extremely upset the facility had not notified the family or RP. He described Resident #1's injuries as blue-green bruises that extended across her forehead, and "blackened" both her eyes and the left side of her face and neck. The RP's spouse stated there was a raised knot on the right front side of Resident #1's forehead about the size of a 50-cent piece. He stated Resident #1 was not able to tell him what happened. He stated he was concerned the physician was not notified, so x-rays or other studies could be done. He stated he did not know if Resident #1 received first aid while at the facility. The RP's spouse stated he and the RP visited Resident #1 two days before (on 05/06/12) and she was "fine." He stated when the RP called the facility, she was told Resident #1 fell getting out of bed. The RP's spouse stated the Administrator apologized when he went to the facility later that day. The Administrator blamed "new weekend staff" for not calling the family about the injury. 3) The Nurses' Notes for Resident #1 reflected the following: 05/06/2012 at 7:00 AM - " It was brought to this nurse's attention that the resident was trying to get herself out of bed. CNA discovered resident sliding out of bed. Resident assisted to W/C (wheelchair). Bed alarm on and will continue to monitor." The CNA was not identified in the note. The nurse's signature was illegible. 05/07/12 at 6:20 AM - "noted resident has a small bump on the rt. (right) side of her forehead with yellow discoloration around. (symbol for no) pain to touch...7pm sitting up in the W/C. (symbol for no) pain or discomfort noted from the bump on the rt side of the forehead." Further review of Resident #1's clinical records and Nurses' Notes revealed no assessment was completed by the nurse and the injury was not recorded anywhere else. There was also no documentation the family or physician had been notified. The last Nurses' Note was dated 05/08/12 and reflected the nurse practitioner was notified of a previously scheduled x-ray report. There was no documentation of any fall or incident. Review of the Physician order [REDACTED]. There was a Physician order [REDACTED]. The Initial Care Plan, dated 03/30/12 and provided by facility as current, reflected Resident #1 was a Fall/Safety Risk. The facility was to "Assess for contributors: BP, standing/sitting, pain, need to void, meds, gait; Encourage to use call light; PT (physical therapy) ref (referral); Instruct on safety measures; Adaptive device (non-specific)." The care plan did not specify preventive measures, such as a Low Bed (a bed at or near floor level) or chair and bed alarms. The care plan indicated the resident was receiving anticoagulation therapy (Aspirin 81 mg once a day). Review of the facility's Nursing Service Schedule revealed the 24-hour schedule stated at 6:00 AM and when through the next morning at 6:00 AM. 4) Review of the facility's Incident Report logs for March 2012 through May 2012 revealed no documentation of a fall or incident report completed for Resident #1 on 05/06/12. The facility's Fall Log reflected on 05/10/12 at 2:05 AM, Resident #1 pushed Resident #2 from her wheelchair. The following Incident/Accident Report was provided that involved Resident #1: Review of an Incident/Accident Report, dated 05/10/12 at 2:05 AM, revealed Resident #1's roommate (Resident #2) was found on the floor by her wheelchair. Resident #2 accused Resident #1 of pushing her, which caused her to loose her balance and fall. LVN D signed as the nurse completing the report. The report was signed by the DON on 05/14/12 and by the Administrator on 05/15/12. An attached witness statement from LVN D dated 05/10/12 reflected she was called to Residents #1 and #2's room by CNA E on 05/10/12. Resident #2 was on the floor. The statement did not reflect where Resident #1 was or any assessment of Resident #1. Resident #2's explanation for the incident was that Resident #1 had pushed her wheelchair, causing her to fall. It was also reported that Resident #1 was wearing Resident #2's clothes. A second witness statement was signed by LVN D and dated 05/15/12. The information in the statement was similar to the witness statement dated 05/10/12. Both statements implied they were for Residents #1 and #2. An attached witness statement from CNA E reflected he found Resident #2 sitting on the floor in front of her wheelchair. Resident #1 was in a wheelchair. Resident #2 revealed Resident #1 had pushed her down. Resident #2 also reported that Resident #1 was wearing her clothes. The statement was signed by CNA E and dated 05/10/12. Another written statement similar in information was signed by CNA E and dated 05/15/12. (Note: The 05/15/12 date had been altered.) The Investigation Follow-up, dated 05/10/12, reflected, "Resident (Resident #1) proceeded to push roommate (Resident #2) with her w/c (wheelchair) and her body out of the w/c." The recommendation from the investigation was to "Encourage resident to stay on her side. D/T (due to) dementia resident needs redirection by staff." The follow-up was signed by the DON and Administrator. A second Investigation Follow-up, dated 05/11/12, regarding an incident dated 05/11/12 reflected Resident #1 complained of pain in her right leg and was treated with Tylenol. An x-ray was ordered. The Summary of the Investigation reflected, "... (after) further investigation, conversation (with) staff and roommate, (Resident #1) stood to get clothes of roommate on 5/10/12 @ (at) 2:05 am and also used legs and w/c to push roommate (Resident #2) from w/c...Resident used enough force to push roommate from a sitting position in her w/c from behind as this leg of resident has [MEDICAL CONDITION] and past fracture of femur leg is compromised. Res. (resident) did not c/o (complain of) pain in this area @ time of incident, injury was noted within 28 hours of incident." The follow-up was signed by LVN A, the DON and Administrator. An attached statement from LVN A that was attached to the 05/11/12 incident reflected CNA C found a "skin discoloration" on Resident #1's right leg and informed LVN A. LVN A's assessment reflected Resident #1's right lower leg had an area 3 cm X 3 cm that was swollen, blue, and hot to the touch. In addition LVN A found two bruises on the resident's left hip. An attached statement from CNA C revealed she found a bruise on Resident #1's right leg and informed the nurse. No Incident/Accident Report was located regarding a bruise on Resident #1's forehead found on 05/07/12. 5) During an interview on 05/18/12 at 11:45 AM, CNA C revealed on 05/11/12 at approximately 6:30 AM while preparing to shower Resident #1, she found a bruise, "the size of a grapefruit" on Resident #1's lower right leg that was black-purple in color. She stated she was present when the x-ray was done later that day. She also stated it was later in the day when she noticed a quarter-sized purple bruise on the resident's hip. CNA C stated the x-ray technician revealed to her that Resident #1 was "messed up." She stated she had not been aware that Resident #1 and Resident #2 were "fighting over clothes." She revealed that on 05/10/11 from 6:00 AM - 2:00 PM, she took care of Resident #1. She stated Resident #1 had been fine and had no complaints of pain on 05/10/11. When asked about fall prevention for Resident #1, CNA C revealed Resident #1 had a bed and chair alarm, but the resident knew how to disarm it. CNA C was queried about the bruise on Resident #1's forehead. She revealed she saw a yellowish knot on Resident #1's forehead earlier that week and reported it to LVN A. She stated you "couldn't miss it" but no one knew how or when it happened. CNA C revealed Resident #1 sometimes resisted care and would hit the caregiver. LVN A was interviewed on 05/18/12 at 1:30 PM. She stated she remembered documenting the Nurses' Note dated 05/07/12 pertaining to Resident#1's forehead injury. The Nurses' Note was reviewed with LVN A at that time, and LVN A acknowledged the initials and entry on the note were hers. LVN A stated she noticed the forehead bruise while on rounds that Monday morning. She stated the bruise was not reported to her by the night shift staff. She stated no falls or other incidents that occurred during the weekend involving Resident #1 were reported to her. As LVN A reviewed the Nurses' Notes, she stated she believed Resident #1's injury must have occurred on the weekend when Resident #1 slipped out of bed. LVN A stated Resident #1 denied having pain or tenderness to the area when she assessed her on rounds on 05/07/12 and her vital signs were normal. LVN A stated she did not record the vital signs or her assessment, because the facility only documented abnormal or unusual findings. She stated if the assessment was normal, it was not recorded. LVN A stated she recorded the "bump" in the Nurses' Notes and on the 24-hour status report on 05/07/12. LVN A stated the "bump" was very small, about the size of a "dime." She stated she did not initiate an incident report, because the injury was "old, not something new." LVN A stated she reported the bruise during the facility's "stand up" meeting with nursing staff on 05/07/12. The facility's 24-hour status report for 05/07/12 regarding Resident #1 reflected: "Stable, fall risk bump & yellow discoloration on forehead [MEDICATION NAME] 0.25 (mg) i (one) p.o. (by mouth) given at 4 pm (symbol for increased) anxiety." Review of the facility's 24-hour report for 05/06/12, and 05/08/12 through 05/10/12 revealed no notation regarding a fall or injury for Resident #1. On 05/18/12 at 2:45 PM, Resident #2 revealed Resident #1 had fallen to the floor one day, but she could not recall the date. She did recall that it was during the daytime, probably the morning, and not at night. She stated someone came and put Resident #1 back to bed. Resident #2 was able to recall the events during a night (05/06/12) that Resident #1 was putting on her clothes and she (Resident #1) bumped into her (Resident #2) knocking her to the floor. She stated Resident #1 was not trying to hurt her and she was not hurt. She revealed Resident #1 did "like to fight." 6) The facility's current policy entitled Accident/Incident, dated January 2009, reflected the following: "POLICY To provide a safe and healthful work environment. Therefore, all accidents or incidents occurring on facility premises must be reported to the administrator. DISCIPLINES RESPONSIBLE All facility staff are responsible for reporting to their immediate supervisor an accident/incident. PROCEDURE ...a. Regardless of how minor an accident or incident may be, it must be reported to the department supervisor, and an Accident/Incident Report form should be completed on the shift that the accident or incident occurred. b. An employee or contract employee...witnessing an accident or incident involving a resident...should be report such occurrence to his/her immediate supervisor as soon as practical. ...c. The charge nurse should be informed of all accidents or incidents so that medical attention can be provided, so they can follow their reporting to their supervisor. d. If the Incident includes an allegation of abuse or neglect, see the abuse & neglect P&P also in regards to reporting requirements. ...4. Investigative Action: a. The charge nurse and/or department director or supervisor should conduct an immediate investigation of the accident or incident. ...13) The Investigative Report form must be submitted to the director of nursing services no later than the following day...after the occurrence of the accident/incident. 5. Accident/Incident Report The charge nurse and/or the department director or supervisor should: a. Complete an Accident/Incident Report form and submit it to the director of nursing services along with the Accident Investigation Report form." 7) An interview with the DON on 05/18/12 at 4:30 PM revealed an incident report was probably not initiated for Resident #1 by the weekend staff on 05/06/12, because the injury was not evident at the time. The DON stated she believed it was a small bruise and the resident was not complaining of pain. The DON stated she understood a CNA walked in when Resident #1 was sliding out of bed and helped the resident to the wheelchair. She stated she did not recall which CNA reported the information to the nurse working that shift. She stated there were usually three or four CNAs working the 300 hall. She stated since the injury was believed to have been due to the episode witnessed on 05/06/12, an incident report was not needed. The DON stated she did not personally assess Resident #1, but depended on her staff report for that day. The DON stated Resident #1 was weight-bearing on both legs and was assessed as a one or two person transfer. She stated Resident #1 had both a chair and bed "clip" alarm. The DON stated she was out the week of the incident and did not recall talking to the responsible party or any other details. 8) The facility's current policy entitled "Reporting Abuse and Neglect Policy," dated 02/2010, reflected the following: "POLICY Any facility staff member who has cause to believe that the physical or mental health or welfare of a resident has been, or may be adversely affected by abuse, neglect or exploitation caused by another person, is to report the abuse, neglect or exploitation immediately. ...The following incidents of abuse and/or neglect must be reported to the DADS...immediately upon learning of the incident. A written investigation report must be sent no later than the fifth working day after the oral report. ...NEGLECT 1. The facility must determine if an injury, harm or death of a resident was due to facility failure to provide services, treatment of [REDACTED]. ...Conduct an Investigation Investigate the facility actions when conducting an investigation and initiate...Incident/Accident Report form. The following is documentation to include: ? Observations of the situation (resident(s), the surroundings...), interviews and record reviews of all residents involved; ? Interviews of all witnesses, including residents, staff, and family members & obtain written statements; ? Notifying the physicians and, where appropriate, the families or responsible parties, of the involved residents; and ? Recording all relevant physical findings." 9) The EMS report, dated 05/11/12, reflected the resident had an unwitnessed fall. The EMS assessment noted the resident, in addition to shortening of the right hip, ...had a "bump and bruise over R (right) eye." The ED Nurse Assessment, dated 05/11/12 at 6:15 PM, reflected: "...Pt (patient) has hematoma to R (right) head from fall on Saturday (05/05/12)." The Admission History and Physical, dated 05/12/12, reflected, "hematoma to head" and Fractured Right Femur, Right Tibia and Right Fibula. 10) On 05/17/12 at approximately 10:00 AM, the surveyor observed Resident #1 in the hospital. Resident #1 was a frail, elderly female with yellow bruising over and under her right eye, entire forehead, left cheek and left ear. The surveyor observed swelling above her right eye. Resident #1's lower left neck area was observed with bluish-colored areas. 11) The Resident Census and Conditions of Residents Form, CMS 672, dated and completed the DON on 05/16/12, reflected 60 residents in the facility had a [DIAGNOSES REDACTED].

Based on observation, interview and record review, the facility failed to ensure injuries of unknown origin were thoroughly investigated, and reported to the State survey and certification agency within five working days of the incident for one (Resident #1) of six sampled residents reviewed for neglect. 1) On 05/06/12, the CNA reported Resident #1 did not fall, but was near falling when she was rescued by the CNA who placed her in her wheelchair. The resident was not assessed by the nurse and the incident was not reported and investigated; 2) On 05/07/12, a knot and bruise was found on Resident #1's forehead. The bruise of unknown origin was not immediately reported or investigated; 3) On 05/10/12, an unwitnessed resident-to-resident altercation occurred, but Resident #1 reportedly did not fall. Resident #1 was assisted to bed but was not assessed and the incident was not thoroughly investigated; 4) On 05/11/12, Resident #1 was found with bruising to her lower right leg and hip. An x-ray confirmed a refracture of her right hip and a [MEDICAL CONDITION] and fibula (both bones in the lower leg). The injury of unknown origin was not reported and thoroughly investigated; and 5) The resident's responsible party was not notified of any incidents or injuries until 05/11/12. These failures could affect the 60 residents in the facility with Dementia by placing them at risk for abuse, neglect, emotional distress, and lack of family member and physician involvement following an injury. Findings included: 1) The MDS assessment, dated 04/30/12, reflected Resident #1 had the following active Diagnoses: [REDACTED]. The assessment reflected Resident #1 required extensive assistance with transfers and staff needed to provide weight-bearing support. The assessment reflected Resident #1 had problems with both her short-term and long-term memory, had severe cognitive impairment, and exhibited inattention and disorganized thinking. The Face Sheet, dated 03/30/12, reflected Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE]. The Face Sheet reflected a [DIAGNOSES REDACTED]. 2) During an interview with Resident #1's RP on 05/16/12 at 9:45 AM, she revealed she visited Resident #1 at the nursing facility on Sunday, 05/06/12. The RP stated she did not observe any bruises or swelling to Resident #1's face at that time. The RP stated no one at the facility mentioned a fall or any other injury to Resident #1 during her visit. The RP stated on Tuesday, 05/08/12, her spouse met Resident #1 at the orthopedic physician's office for a follow-up visit and at that time her spouse noticed a "knot" above the resident's right eye. She stated the "knot" had blue-green bruising that extended from the resident's right eye to her ear and neck. The RP stated the facility did not notify her of the injury. She stated when she called the facility on 05/08/12, the Administrator told her Resident #1 fell trying to get out of bed by herself. The RP stated she carried her cell phone with her at all times and there was no call or voice message left on her cell phone or home phone notifying her that Resident #1 had sustained a fall or injury to her forehead or neck. The RP stated on 05/11/12 at approximately 4:30 PM the facility called and informed her the resident had three fractures, including the femur, and it had happened when she was trying to get out of bed without assistance. The RP stated she met the ambulance at the hospital and was informed by the transport paramedics, "There is no way her injuries are consistent with a fall with a wheelchair." She stated the paramedic also revealed the facility found her at 6:00 AM and it should not have taken them 12 hours (6:00 PM) to get her to the hospital. She stated Resident #1 was taken to surgery for [REDACTED]. During the same interview, the RP stated she spoke with the Administrator regarding the incident. The Administrator initially revealed the facility did not know how it happened but later revealed Resident #1 was in another resident's room, putting on clothes from another resident's closet. She stated the Administrator said Resident #1 fell from the wheelchair, but the Administrator did not provide any other explanation. An interview with the RP's spouse on 05/17/12 at 12:45 PM revealed he was shocked to see Resident #1 on 05/08/12, because "she looked like she had been in a wreck." He stated he was extremely upset the facility had not notified the family or RP. He described Resident #1's injuries as blue-green bruises that extended across her forehead, and "blackened" both her eyes and the left side of her face and neck. The RP's spouse stated there was a raised knot on the right front side of Resident #1's forehead about the size of a 50-cent piece. He stated Resident #1 was not able to tell him what happened. He stated he was concerned the physician was not notified, so x-rays or other studies could be done. He stated he did not know if Resident #1 received first aid while at the facility. The RP's spouse stated he and the RP visited Resident #1 two days before (on 05/06/12) and she was "fine." He stated when the RP called the facility, she was told Resident #1 fell getting out of bed. The RP's spouse stated the Administrator apologized when he went to the facility later that day. The Administrator blamed "new weekend staff" for not calling the family about the injury. 3) The Nurses' Notes for Resident #1 reflected the following: 05/06/2012 at 7:00 AM - " It was brought to this nurse's attention that the resident was trying to get herself out of bed. CNA discovered resident sliding out of bed. Resident assisted to W/C (wheelchair). Bed alarm on and will continue to monitor." The CNA was not identified in the note. The nurse's signature was illegible. 05/07/12 at 6:20 AM - "noted resident has a small bump on the rt. (right) side of her forehead with yellow discoloration around. (symbol for no) pain to touch...7pm sitting up in the W/C. (symbol for no) pain or discomfort noted from the bump on the rt side of the forehead." Further review of Resident #1's clinical records and Nurses' Notes revealed no assessment was completed by the nurse and the injury was not recorded anywhere else. There was also no documentation the family or physician had been notified. The last Nurses' Note was dated 05/08/12 and reflected the nurse practitioner was notified of a previously scheduled x-ray report. There was no documentation of any fall or incident. Review of the Physician order [REDACTED]. There was a Physician order [REDACTED]. The Initial Care Plan, dated 03/30/12 and provided by facility as current, reflected Resident #1 was a Fall/Safety Risk. The facility was to "Assess for contributors; BP, standing/sitting, pain, need to void, meds, gait; Encourage to use call light; PT (physical therapy) ref (referral); Instruct on safety measures; Adaptive device (non-specific)." The care plan did not specify preventive measures, such as a Low Bed (a bed at or near floor level) or chair and bed alarms. The care plan indicated the resident was receiving anticoagulation therapy (Aspirin 81 mg once a day). Review of the facility's Nursing Service Schedule revealed the 24-hour schedule stated at 6:00 AM and when through the next morning at 6:00 AM. 4) Review of the facility's Incident Report logs for March 2012 through May 2012 revealed no documentation of a fall or incident report completed for Resident #1 on 05/06/12. The facility's Fall Log reflected on 05/10/12 at 2:05 AM, Resident #1 pushed Resident #2 from her wheelchair. The following Incident/Accident Report was provided that involved Resident #1: Review of an Incident/Accident Report, dated 05/10/12 at 2:05 AM, revealed Resident #1's roommate (Resident #2) was found on the floor by her wheelchair. Resident #2 accused Resident #1 of pushing her, which caused her to loose her balance and fall. LVN D signed as the nurse completing the report. The report was signed by the DON on 05/14/12 and by the Administrator on 05/15/12. An attached witness statement from LVN D dated 05/10/12 reflected she was called to Residents #1 and #2's room by CNA E on 05/10/12. Resident #2 was on the floor. The statement did not reflect where Resident #1 was or any assessment of Resident #1. Resident #2's explanation for the incident was that Resident #1 had pushed her wheelchair, causing her to fall. It was also reported that Resident #1 was wearing Resident #2's clothes. A second witness statement was signed by LVN D and dated 05/15/12. The information in the statement was similar to the witness statement dated 05/10/12. Both statements implied they were for Residents #1 and #2. An attached witness statement from CNA E reflected he found Resident #2 sitting on the floor in front of her wheelchair. Resident #1 was in a wheelchair. Resident #2 revealed Resident #1 had pushed her down. Resident #2 also reported that Resident #1 was wearing her clothes. The statement was signed by CNA E and dated 05/10/12. Another written statement similar in information was signed by CNA E and dated 05/15/12. (Note: The 05/15/12 date had been altered.) The Investigation Follow-up, dated 05/10/12, reflected, "Resident (Resident #1) proceeded to push roommate (Resident #2) with her w/c (wheelchair) and her body out of the w/c." The recommendation from the investigation was to "Encourage resident to stay on her side. D/T (due to) dementia resident needs redirection by staff." The follow-up was signed by the DON and Administrator. A second Investigation Follow-up, dated 05/11/12, regarding an incident dated 05/11/12 reflected Resident #1 complained of pain in her right leg and was treated with Tylenol. An x-ray was ordered. The Summary of the Investigation reflected, "... (after) further investigation, conversation (with) staff and roommate, (Resident #1) stood to get clothes of roommate on 5/10/12 @ (at) 2:05 am and also used legs and w/c to push roommate (Resident #2) from w/c...Resident used enough force to push roommate from a sitting position in her w/c from behind as this leg of resident has [MEDICAL CONDITION] and past fracture of femur leg is compromised. Res. (resident) did not c/o (complain of) pain in this area @ time of incident, injury was noted within 28 hours of incident." The follow-up was signed by LVN A, the DON and Administrator. An attached statement from LVN A that was attached to the 05/11/12 incident reflected CNA C found a "skin discoloration" on Resident #1's right leg and informed LVN A. LVN A's assessment reflected Resident #1's right lower leg had an area 3 cm X 3 cm that was swollen, blue, and hot to the touch. In addition LVN A found two bruises on the resident's left hip. An attached statement from CNA C revealed she found a bruise on Resident #1's right leg and informed the nurse. No Incident/Accident Report was located regarding a bruise on Resident #1's forehead found on 05/07/12. 5) During an interview on 05/18/12 at 11:45 AM, CNA C revealed on 05/11/12 at approximately 6:30 AM while preparing to shower Resident #1, she found a bruise, "the size of a grapefruit" on Resident #1's lower right leg that was black-purple in color. She stated she was present when the x-ray was done later that day. She also stated it was later in the day when she noticed a quarter-sized purple bruise on the resident's hip. CNA C stated the x-ray technician revealed to her that Resident #1 was "messed up." She stated she had not been aware that Resident #1 and Resident #2 were "fighting over clothes." She revealed that on 05/10/11 from 6:00 AM - 2:00 PM, she took care of Resident #1. She stated Resident #1 had been fine and had no complaints of pain on 05/10/11. When asked about fall prevention for Resident #1, CNA C revealed Resident #1 had a bed and chair alarm, but the resident knew how to disarm it. CNA C was queried about the bruise on Resident #1's forehead. She revealed she saw a yellowish knot on Resident #1's forehead earlier that week and reported it to LVN A. She stated you "couldn't miss it" but no one knew how or when it happened. CNA C revealed Resident #1 sometimes resisted care and would hit the caregiver. LVN A was interviewed on 05/18/12 at 1:30 PM. She stated she remembered documenting the Nurses' Note dated 05/07/12 pertaining to Resident#1's forehead injury. The Nurses' Note was reviewed with LVN A at that time, and LVN A acknowledged the initials and entry on the note were hers. LVN A stated she noticed the forehead bruise while on rounds that Monday morning. She stated the bruise was not reported to her by the night shift staff. She stated no falls or other incidents that occurred during the weekend involving Resident #1 were reported to her. As LVN A reviewed the Nurses' Notes, she stated she believed Resident #1's injury must have occurred on the weekend when Resident #1 slipped out of bed. LVN A stated Resident #1 denied having pain or tenderness to the area when she assessed her on rounds on 05/07/12 and her vital signs were normal. LVN A stated she did not record the vital signs or her assessment, because the facility only documented abnormal or unusual findings. She stated if the assessment was normal, it was not recorded. LVN A stated she recorded the "bump" in the Nurses' Notes and on the 24-hour status report on 05/07/12. LVN A stated the "bump" was very small, about the size of a "dime." She stated she did not initiate an incident report, because the injury was "old, not something new." LVN A stated she reported the bruise during the facility's "stand up" meeting with nursing staff on 05/07/12. The facility's 24-hour status report for 05/07/12 regarding Resident #1 reflected: "Stable, fall risk bump & yellow discoloration on forehead [MEDICATION NAME] 0.25 (mg) i (one) p.o. (by mouth) given at 4 pm (symbol for increased) anxiety." Review of the facility's 24-hour report for 05/06/12, and 05/08/12 through 05/10/12 revealed no notation regarding a fall or injury for Resident #1. On 05/18/12 at 2:45 PM, Resident #2 revealed Resident #1 had fallen to the floor one day, but she could not recall the date. She did recall that it was during the daytime, probably the morning, and not at night. She stated someone came and put Resident #1 back to bed. Resident #2 was able to recall the events during a night (05/06/12) that Resident #1 was putting on her clothes and she (Resident #1) bumped into her (Resident #2) knocking her to the floor. She stated Resident #1 was not trying to hurt her and she was not hurt. She revealed Resident #1 did "like to fight." 6) The facility's current policy entitled Accident/Incident, dated 01/2009, reflected the following: "POLICY To provide a safe and healthful work environment. Therefore, all accidents or incidents occurring on facility premises must be reported to the administrator. DISCIPLINES RESPONSIBLE All facility staff are responsible for reporting to their immediate supervisor an accident/incident. PROCEDURE ...a. Regardless of how minor an accident or incident may be, it must be reported to the department supervisor, and an Accident/Incident Report form should be completed on the shift that the accident or incident occurred. b. An employee or contract employee...witnessing an accident or incident involving a resident...should be report such occurrence to his/her immediate supervisor as soon as practical. ...c. The charge nurse should be informed of all accidents or incidents so that medical attention can be provided, so they can follow their reporting to their supervisor. d. If the Incident includes an allegation of abuse or neglect, see the abuse & neglect P&P also in regards to reporting requirements. ...4. Investigative Action: a. The charge nurse and/or department director or supervisor should conduct an immediate investigation of the accident or incident. ...13) The Investigative Report form must be submitted to the director of nursing services no later than the following day...after the occurrence of the accident/incident. 5. Accident/Incident Report The charge nurse and/or the department director or supervisor should: a. Complete an Accident/Incident Report form and submit it to the director of nursing services along with the Accident Investigation Report form." 7) An interview with the DON on 05/18/12 at 4:30 PM revealed an incident report was probably not initiated for Resident #1 by the weekend staff on 05/06/12, because the injury was not evident at the time. The DON stated she believed it was a small bruise and the resident was not complaining of pain. The DON stated she understood a CNA walked in when Resident #1 was sliding out of bed and helped the resident to the wheelchair. She stated she did not recall which CNA reported the information to the nurse working that shift. She stated there were usually three or four CNAs working the 300 hall. She stated since the injury was believed to have been due to the episode witnessed on 05/06/12, an incident report was not needed. The DON stated she did not personally assess Resident #1, but depended on her staff report for that day. The DON stated Resident #1 was weight-bearing on both legs and was assessed as a one or two person transfer. She stated Resident #1 had both a chair and bed "clip" alarm. The DON stated she was out the week of the incident and did not recall talking to the responsible party or any other details. 8) The facility's current policy entitled "Reporting Abuse and Neglect Policy," dated 02/2010, reflected the following: "POLICY Any facility staff member who has cause to believe that the physical or mental health or welfare of a resident has been, or may be adversely affected by abuse, neglect or exploitation caused by another person, is to report the abuse, neglect or exploitation immediately. ...The following incidents of abuse and/or neglect must be reported to the DADS...immediately upon learning of the incident. A written investigation report must be sent no later than the fifth working day after the oral report. ...NEGLECT 1. The facility must determine if an injury, harm or death of a resident was due to facility failure to provide services, treatment of [REDACTED]. ...Conduct an Investigation Investigate the facility actions when conducting an investigation and initiate...Incident/Accident Report form. The following is documentation to include: ? Observations of the situation (resident(s), the surroundings...), interviews and record reviews of all residents involved; ? Interviews of all witnesses, including residents, staff, and family members & obtain written statements; ? Notifying the physicians and, where appropriate, the families or responsible parties, of the involved residents; and ? Recording all relevant physical findings." 9) The EMS report, dated 05/11/12, reflected the resident had an unwitnessed fall. The EMS assessment noted the resident, in addition to shortening of the right hip, ...had a "bump and bruise over R (right) eye." The ED Nurse Assessment, dated 05/11/12 at 6:15 PM, reflected: "...Pt (patient) has hematoma to R (right) head from fall on Saturday (05/05/12)." The Admission History and Physical, dated 05/12/12, reflected, "hematoma to head" and Fractured Right Femur, Right Tibia and Right Fibula. 10) On 05/17/12 at approximately 10:00 AM, the surveyor observed Resident #1 in the hospital. Resident #1 was a frail, elderly female with yellow bruising over and under her right eye, entire forehead, left cheek and left ear. The surveyor observed swelling above her right eye. Resident #1's lower left neck area was observed with bluish-colored areas. 11) The Resident Census and Conditions of Residents Form, CMS 672, dated and completed the DON on 05/16/12, reflected 60 residents in the facility had a [DIAGNOSES REDACTED].

Based on observation, interview and record review, the facility failed to implement policies and procedures that prohibit mistreatment, neglect, and abuse of residents for one (Resident #1) of six sampled residents reviewed for neglect. 1) On 05/06/12, the CNA reported Resident #1 did not fall, but was near falling when she was rescued by the CNA who placed her in her wheelchair. The resident was not assessed by the nurse and the incident was not reported and investigated; 2) On 05/07/12, a knot and bruise was found on Resident #1's forehead. The bruise of unknown origin was not immediately reported or investigated; 3) On 05/10/12, an unwitnessed resident-to-resident altercation occurred, but Resident #1 reportedly did not fall. Resident #1 was assisted to bed but was not assessed. The incident was not thoroughly investigated; 4) On 05/11/12, Resident #1 was found with bruising to her lower right leg and hip. An x-ray confirmed a refracture of her right hip and a [MEDICAL CONDITION] and fibula (both bones in the lower leg). The injuries were not thoroughly investigated; and 5) The resident's responsible party was not notified of any incidents or injuries until 05/11/12. These failures could affect the 60 residents in the facility with Dementia by placing them at risk for abuse, neglect, emotional distress, and lack of family member and physician involvement following an injury. Findings included: 1) The facility's current policy entitled "Reporting Abuse and Neglect Policy," dated 02/2010, reflected the following: "POLICY Any facility staff member who has cause to believe that the physical or mental health or welfare of a resident has been, or may be adversely affected by abuse, neglect or exploitation caused by another person, is to report the abuse, neglect or exploitation immediately. ...The following incidents of abuse and/or neglect must be reported to the DADS...immediately upon learning of the incident. A written investigation report must be sent no later than the fifth working day after the oral report. ...NEGLECT 1. The facility must determine if an injury, harm or death of a resident was due to facility failure to provide services, treatment of [REDACTED]. ...Conduct an Investigation Investigate the facility actions when conducting an investigation and initiate...Incident/Accident Report form. The following is documentation to include: ? Observations of the situation (resident(s), the surroundings...), interviews and record reviews of all residents involved; ? Interviews of all witnesses, including residents, staff, and family members & obtain written statements; ? Notifying the physicians and, where appropriate, the families or responsible parties, of the involved residents; and ? Recording all relevant physical findings." 2) The MDS assessment, dated 04/30/12, reflected Resident #1 had the following active Diagnoses: [REDACTED]. The assessment reflected Resident #1 required extensive assistance with transfers and staff needed to provide weight-bearing support. The assessment reflected Resident #1 had problems with both her short-term and long-term memory, had severe cognitive impairment, and exhibited inattention and disorganized thinking. The Face Sheet, dated 03/30/12, reflected Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE]. The Face Sheet reflected a [DIAGNOSES REDACTED]. 3) During an interview with Resident #1's RP on 05/16/12 at 9:45 AM, she revealed she visited Resident #1 at the nursing facility on Sunday, 05/06/12. The RP stated she did not observe any bruises or swelling to Resident #1's face at that time. The RP stated no one at the facility mentioned a fall or any other injury to Resident #1 during her visit. The RP stated on Tuesday, 05/08/12, her spouse met Resident #1 at the orthopedic physician's office for a follow-up visit and at that time her spouse noticed a "knot" above the resident's right eye. She stated the "knot" had blue-green bruising that extended from the resident's right eye to her ear and neck. The RP stated the facility did not notify her of the injury. She stated when she called the facility on 05/08/12, the Administrator told her Resident #1 fell trying to get out of bed by herself. The RP stated she carried her cell phone with her at all times and there was no call or voice message left on her cell phone or home phone notifying her that Resident #1 had sustained a fall or injury to her forehead or neck. The RP stated on 05/11/12 at approximately 4:30 PM the facility called and informed her the resident had three fractures, including the femur, and it had happened when she was trying to get out of bed without assistance. The RP stated she met the ambulance at the hospital and was informed by the transport paramedics, "There is no way her injuries are consistent with a fall with a wheelchair." She stated the paramedic also revealed the facility found her at 6:00 AM and it should not have taken them 12 hours (6:00 PM) to get her to the hospital. She stated Resident #1 was taken to surgery for [REDACTED]. During the same interview, the RP stated she spoke with the Administrator regarding the incident. The Administrator initially revealed the facility did not know how it happened but later revealed Resident #1 was in another resident's room, putting on clothes from another resident's closet. She stated the Administrator said Resident #1 fell from the wheelchair, but the Administrator did not provide any other explanation. An interview with the RP's spouse on 05/17/12 at 12:45 PM revealed he was shocked to see Resident #1 on 05/08/12, because "she looked like she had been in a wreck." He stated he was extremely upset the facility had not notified the family or RP. He described Resident #1's injuries as blue-green bruises that extended across her forehead, and "blackened" both her eyes and the left side of her face and neck. The RP's spouse stated there was a raised knot on the right front side of Resident #1's forehead about the size of a 50-cent piece. He stated Resident #1 was not able to tell him what happened. He stated he was concerned the physician was not notified, so x-rays or other studies could be done. He stated he did not know if Resident #1 received first aid while at the facility. The RP's spouse stated he and the RP visited Resident #1 two days before (on 05/06/12) and she was "fine." He stated when the RP called the facility, she was told Resident #1 fell getting out of bed. The RP's spouse stated the Administrator apologized when he went to the facility later that day. The Administrator blamed "new weekend staff" for not calling the family about the injury. 4) The Nurses' Notes for Resident #1 reflected the following: 05/06/2012 at 7:00 AM - " It was brought to this nurse's attention that the resident was trying to get herself out of bed. CNA discovered resident sliding out of bed. Resident assisted to W/C (wheelchair). Bed alarm on and will continue to monitor." The CNA was not identified in the note. The nurse's signature was illegible. 05/07/12 at 6:20 AM - "noted resident has a small bump on the rt. (right) side of her forehead with yellow discoloration around. (symbol for no) pain to touch...7pm sitting up in the W/C. (symbol for no) pain or discomfort noted from the bump on the rt side of the forehead." Further review of Resident #1's clinical records and Nurses' Notes revealed no assessment was completed by the nurse and the injury was not recorded anywhere else. There was also no documentation the family or physician had been notified. The last Nurses' Note was dated 05/08/12 and reflected the nurse practitioner was notified of a previously scheduled x-ray report. There was no documentation of any fall or incident. Review of the Physician order [REDACTED]. There was a Physician order [REDACTED]. The Initial Care Plan, dated 03/30/12 and provided by facility as current, reflected Resident #1 was a Fall/Safety Risk. The facility was to "Assess for contributors; BP, standing/sitting, pain, need to void, meds, gait; Encourage to use call light; PT (physical therapy) ref (referral); Instruct on safety measures; Adaptive device (non-specific)." The care plan did not specify preventive measures, such as a Low Bed (a bed at or near floor level) or chair and bed alarms. The care plan indicated the resident was receiving anticoagulation therapy (Aspirin 81 mg once a day). Review of the facility's Nursing Service Schedule revealed the 24-hour schedule stated at 6:00 AM and when through the next morning at 6:00 AM. 5) Review of the facility's Incident Report logs for March 2012 through May 2012 revealed no documentation of a fall or incident report completed for Resident #1 on 05/06/12. The facility's Fall Log reflected on 05/10/12 at 2:05 AM, Resident #1 pushed Resident #2 from her wheelchair. The following Incident/Accident Report was provided that involved Resident #1: Review of an Incident/Accident Report, dated 05/10/12 at 2:05 AM, revealed Resident #1's roommate (Resident #2) was found on the floor by her wheelchair. Resident #2 accused Resident #1 of pushing her, which caused her to loose her balance and fall. LVN D signed as the nurse completing the report. The report was signed by the DON on 05/14/12 and by the Administrator on 05/15/12. An attached witness statement from LVN D dated 05/10/12 reflected she was called to Residents #1 and #2's room by CNA E on 05/10/12. Resident #2 was on the floor. The statement did not reflect where Resident #1 was or any assessment of Resident #1. Resident #2's explanation for the incident was that Resident #1 had pushed her wheelchair, causing her to fall. It was also reported that Resident #1 was wearing Resident #2's clothes. A second witness statement was signed by LVN D and dated 05/15/12. The information in the statement was similar to the witness statement dated 05/10/12. Both statements implied they were for Residents #1 and #2. An attached witness statement from CNA E reflected he found Resident #2 sitting on the floor in front of her wheelchair. Resident #1 was in a wheelchair. Resident #2 revealed Resident #1 had pushed her down. Resident #2 also reported that Resident #1 was wearing her clothes. The statement was signed by CNA E and dated 05/10/12. Another written statement similar in information was signed by CNA E and dated 05/15/12. (Note: The 05/15/12 date had been altered.) The Investigation Follow-up, dated 05/10/12, reflected, "Resident (Resident #1) proceeded to push roommate (Resident #2) with her w/c (wheelchair) and her body out of the w/c." The recommendation from the investigation was to "Encourage resident to stay on her side. D/T (due to) dementia resident needs redirection by staff." The follow-up was signed by the DON and Administrator. A second Investigation Follow-up, dated 05/11/12, regarding an incident dated 05/11/12 reflected Resident #1 complained of pain in her right leg and was treated with Tylenol. An x-ray was ordered. The Summary of the Investigation reflected, "... (after) further investigation, conversation (with) staff and roommate, (Resident #1) stood to get clothes of roommate on 5/10/12 @ (at) 2:05 am and also used legs and w/c to push roommate (Resident #2) from w/c...Resident used enough force to push roommate from a sitting position in her w/c from behind as this leg of resident has [MEDICAL CONDITION] and past fracture of femur leg is compromised. Res. (resident) did not c/o (complain of) pain in this area @ time of incident, injury was noted within 28 hours of incident." The follow-up was signed by LVN A, the DON and Administrator. An attached statement from LVN A that was attached to the 05/11/12 incident reflected CNA C found a "skin discoloration" on Resident #1's right leg and informed LVN A. LVN A's assessment reflected Resident #1's right lower leg had an area 3 cm X 3 cm that was swollen, blue, and hot to the touch. In addition LVN A found two bruises on the resident's left hip. An attached statement from CNA C revealed she found a bruise on Resident #1's right leg and informed the nurse. No Incident/Accident Report was located regarding a bruise on Resident #1's forehead found on 05/07/12. 6) During an interview on 05/18/12 at 11:45 AM, CNA C revealed on 05/11/12 at approximately 6:30 AM while preparing to shower Resident #1, she found a bruise, "the size of a grapefruit" on Resident #1's lower right leg that was black-purple in color. She stated she was present when the x-ray was done later that day. She also stated it was later in the day when she noticed a quarter-sized purple bruise on the resident's hip. CNA C stated the x-ray technician revealed to her that Resident #1 was "messed up." She stated she had not been aware that Resident #1 and Resident #2 were "fighting over clothes." She revealed that on 05/10/11 from 6:00 AM - 2:00 PM, she took care of Resident #1. She stated Resident #1 had been fine and had no complaints of pain on 05/10/11. When asked about fall prevention for Resident #1, CNA C revealed Resident #1 had a bed and chair alarm, but the resident knew how to disarm it. CNA C was queried about the bruise on Resident #1's forehead. She revealed she saw a yellowish knot on Resident #1's forehead earlier that week and reported it to LVN A. She stated you "couldn't miss it" but no one knew how or when it happened. CNA C revealed Resident #1 sometimes resisted care and would hit the caregiver. LVN A was interviewed on 05/18/12 at 1:30 PM. She stated she remembered documenting the Nurses' Note dated 05/07/12 pertaining to Resident#1's forehead injury. The Nurses' Note was reviewed with LVN A at that time, and LVN A acknowledged the initials and entry on the note were hers. LVN A stated she noticed the forehead bruise while on rounds that Monday morning. She stated the bruise was not reported to her by the night shift staff. She stated no falls or other incidents that occurred during the weekend involving Resident #1 were reported to her. As LVN A reviewed the Nurses' Notes, she stated she believed Resident #1's injury must have occurred on the weekend when Resident #1 slipped out of bed. LVN A stated Resident #1 denied having pain or tenderness to the area when she assessed her on rounds on 05/07/12 and her vital signs were normal. LVN A stated she did not record the vital signs or her assessment, because the facility only documented abnormal or unusual findings. She stated if the assessment was normal, it was not recorded. LVN A stated she recorded the "bump" in the Nurses' Notes and on the 24-hour status report on 05/07/12. LVN A stated the "bump" was very small, about the size of a "dime." She stated she did not initiate an incident report, because the injury was "old, not something new." LVN A stated she reported the bruise during the facility's "stand up" meeting with nursing staff on 05/07/12. The facility's 24-hour status report for 05/07/12 regarding Resident #1 reflected: "Stable, fall risk bump & yellow discoloration on forehead [MEDICATION NAME] 0.25 (mg) i (one) p.o. (by mouth) given at 4 pm (symbol for increased) anxiety." Review of the facility's 24-hour report for 05/06/12, and 05/08/12 through 05/10/12 revealed no notation regarding a fall or injury for Resident #1. On 05/18/12 at 2:45 PM, Resident #2 revealed Resident #1 had fallen to the floor one day, but she could not recall the date. She did recall that it was during the daytime, probably the morning, and not at night. She stated someone came and put Resident #1 back to bed. Resident #2 was able to recall the events during a night (05/06/12) that Resident #1 was putting on her clothes and she (Resident #1) bumped into her (Resident #2) knocking her to the floor. She stated Resident #1 was not trying to hurt her and she was not hurt. She revealed Resident #1 did "like to fight." 7) The facility's current policy entitled Accident/Incident, dated 01/2009, reflected the following: "POLICY To provide a safe and healthful work environment. Therefore, all accidents or incidents occurring on facility premises must be reported to the administrator. DISCIPLINES RESPONSIBLE All facility staff are responsible for reporting to their immediate supervisor an accident/incident. PROCEDURE ...a. Regardless of how minor an accident or incident may be, it must be reported to the department supervisor, and an Accident/Incident Report form should be completed on the shift that the accident or incident occurred. b. An employee or contract employee...witnessing an accident or incident involving a resident...should be report such occurrence to his/her immediate supervisor as soon as practical. ...c. The charge nurse should be informed of all accidents or incidents so that medical attention can be provided, so they can follow their reporting to their supervisor. d. If the Incident includes an allegation of abuse or neglect, see the abuse & neglect P&P also in regards to reporting requirements. ...4. Investigative Action: a. The charge nurse and/or department director or supervisor should conduct an immediate investigation of the accident or incident. ...13) The Investigative Report form must be submitted to the director of nursing services no later than the following day...after the occurrence of the accident/incident. 5. Accident/Incident Report The charge nurse and/or the department director or supervisor should: a. Complete an Accident/Incident Report form and submit it to the director of nursing services along with the Accident Investigation Report form." 8) An interview with the DON on 05/18/12 at 4:30 PM revealed an incident report was probably not initiated for Resident #1 by the weekend staff on 05/06/12, because the injury was not evident at the time. The DON stated she believed it was a small bruise and the resident was not complaining of pain. The DON stated she understood a CNA walked in when Resident #1 was sliding out of bed and helped the resident to the wheelchair. She stated she did not recall which CNA reported the information to the nurse working that shift. She stated there were usually three or four CNAs working the 300 hall. She stated since the injury was believed to have been due to the episode witnessed on 05/06/12, an incident report was not needed. The DON stated she did not personally assess Resident #1, but depended on her staff report for that day. The DON stated Resident #1 was weight-bearing on both legs and was assessed as a one or two person transfer. She stated Resident #1 had both a chair and bed "clip" alarm. The DON stated she was out the week of the incident and did not recall talking to the responsible party or any other details. 9) The facility's current policy entitled "Reporting Abuse and Neglect Policy," dated 02/2010, reflected the following: "...NEGLECT ? Notifying the physicians and, where appropriate, the families or responsible parties, of the involved residents...." 10) The EMS report, dated 05/11/12, reflected the resident had an unwitnessed fall. The EMS assessment noted the resident, in addition to shortening of the right hip, ...had a "bump and bruise over R (right) eye." The ED Nurse Assessment, dated 05/11/12 at 6:15 PM, reflected: "...Pt (patient) has hematoma to R (right) head from fall on Saturday (05/05/12)." The Admission History and Physical, dated 05/12/12, reflected, "hematoma to head" and Fractured Right Femur, Right Tibia and Right Fibula. 11) On 05/17/12 at approximately 10:00 AM, the surveyor observed Resident #1 in the hospital. Resident #1 was a frail, elderly female with yellow bruising over and under her right eye, entire forehead, left cheek and left ear. The surveyor observed swelling above her right eye. Resident #1's lower left neck area was observed with bluish-colored areas. . 12) The Resident Census and Conditions of Residents Form, CMS 672, dated and completed the DON on 05/16/12, reflected 60 residents in the facility had a [DIAGNOSES REDACTED].

Based on observation, interview and record review, it was determined the Administrator and the DON failed to effectively and efficiently manage facility resources. The DON and Administrator failed to supervise and apprise staff to ensure: 1) Three (Residents #4 #8, and #10) of nine residents observed during meal service maintained acceptable parameters of nutrition and received a therapeutic diet as ordered. 2) Five (Residents #6, #7, #8, #9, and #10) of six residents, one (Resident #6) of one who entered the facility without pressure ulcers did not develop pressure ulcers and Residents #6, #7, #8, #9, and #10 were provided the necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing. These failures could affect the facility's 89 residents and did affect Residents #4, #6, #7, #8, #9, #10 and placed the residents at risk for the development of pressure ulcers and problems with nutritional status, resulting in a decreased quality of life, the potential for depression, decreased participation in activities and having a negative impact on their health and well-being. Findings included: 1a) During the initial tour on 10/05/10 at 5:24 AM, Resident #4 was observed in bed sleeping. The head of the bed was elevated to approximately 80 degrees, and Resident #4 appeared thin. Resident #4 was admitted to the facility on [DATE], according to the Face Sheet dated 07/27/10. This same record reflected a [DIAGNOSES REDACTED]. A History and Physical dated 03/10/10 reflected Resident #4 was status [REDACTED]." In addition, a History and Physical dated 07/10/10 reflected Resident #4 had severe Failure to Thrive, Cachexia (general physical wasting and [MEDICAL CONDITION] usually associated with chronic disease), Kyphoscoliosis, [MEDICAL CONDITIONS], and Dysphagia. Resident #4's most current consolidated physician orders [REDACTED]. During the breakfast meal on 10/05/10, Resident #4 received her meal in her room at 7:28 AM. Resident #4 received a bowl of grits, a glass of cranberry juice, and a glass of water. Review of Resident #4's meal tray slip revealed the resident received a Regular Pureed diet. At this time, CNA N, who served the resident's tray, was asked why the resident only received a bowl of grits. CNA N stated, "She only wants grits or oatmeal." Resident #4 was observed to eat 100% of her grits and drank all of her cranberry juice. Following the meal at 8:03 AM, Resident #4 was asked if she would eat more than just a bowl of grits. Resident #4 stated that was all she usually received, but she would eat more, including pureed fruit and pureed bacon. She stated she would be open to try more options. Further review of Resident #4's physician orders [REDACTED]. In addition, a physician's telephone order dated 09/14/10 reflected the [DIAGNOSES REDACTED]. Review of the facility Diet Roster dated 10/05/10 revealed Resident #4 was to receive a Regular Pureed diet. There was no mention of the fortified food plan or ice cream. Review of the facility's breakfast extended menu for a fortified food plan pureed diet on 10/05/10 revealed: Fruit Juice, one cup of Fortified cereal, two eggs, one sausage or bacon strip, one muffin, two pats of margarine, whole milk, coffee or hot tea, and water. Review of the lunch extended menu for a fortified food plan pureed diet for 10/05/10 revealed: Smothered Pork Chop with Gravy, macaroni and cheese, mixed vegetables, bread, 2 pats of margarine, cinnamon applesauce, beverage of choice, water, and 4 ounces of fortified pudding. During the lunch meal on 10/05/10, Resident #4 received her meal tray in her room at 11:45 AM. Her meal tray slip reflected Resident #4 was on a Regular Pureed diet and was to receive ice cream. No mention of the fortified meal plan was listed on the tray slip. The resident only received one pat of margarine and did not receive the planned applesauce or the fortified pudding. Resident #4 ate 100% of her meal. Review of the lunch extended menu for a fortified food plan pureed diet on 10/06/10 revealed: Lasagna with meat sauce, Italian Green Beans, pureed vegetables, garlic bread, 2 pats of margarine, ice cream, beverage of choice, water and 4 ounces of fortified pudding. During the lunch meal on 10/06/10, Resident #4 received her meal tray in her room at 11:46 AM. Her meal tray slip reflected Resident #4 was on a Regular Pureed diet and was to receive ice cream. No mention of the fortified meal plan was listed on the tray slip. Resident #4 did not receive the 4 ounces of fortified pudding. Resident #4 ate 90% of her meal. On 10/06/10 at 12:19 PM, the FSM provided a list entitled Fortified Food Plan Updated Weekly July 25, 2010. The FSM revealed the list was complete and current. Review of the list revealed the names of six current residents. Resident #4 was not on the list. At this time the surveyor requested a list of all residents who received snacks. The FSM provided the list and stated it contained all the residents who currently received snacks. Resident #4's name was not on the list. On 10/06/10 at 1:20 PM, LVN M, Resident #4's charge nurse, was queried regarding Resident #4's breakfast plan. LVN M was asked why Resident #4 only received oatmeal or grits for breakfast. LVN M replied, "That's all she'll eat." A review of Resident #4's nutritional assessment dated [DATE] revealed Resident #4 was 53 inches in height and weighed 93.5 pounds. The RD also documented Resident #4 had moderate to severe depletion of her [MEDICATION NAME] which was 2.1 grams per deciliter of blood. (Normal 3.4-4.8 g/dl). In addition, the RD documented Resident #4's pre-[MEDICATION NAME] level was low at 10.2 mg/dl. (Normal 18-45 mg/dl). On 06/14/10, the RD documented a significant weight loss and recommended a fortified food plan. The physician's orders [REDACTED]. A review of the weight manual revealed the following weights for Resident #4: 11/21/09 (date of admission): 93.5 12/01/09: 94.6 12/07/09: 97.4 12/14/09: 97.8 12/21/09: 96.4 01/01/10: 94.6 02/01/10: 90.8 03/01/10: 89.6 04/01/10: 88.0 05/01/10: 83.8 06/01/10: 81.4 07/01/10: 85.8 08/01/10: 79.5 09/01/10: 82.0 10/01/10: 79.0 According to these weights, Resident #4 suffered severe weight loss of 10.1 pounds, which equaled a loss of 22.3% of her body weight, in six months, from 03/01/10 to 08/01/10. In addition, Resident #4 suffered severe weight loss of 6.3 pounds which equaled 7.4% of her body weight in one month, from 07/01/10 to 08/01/10. Resident #4's care plan dated 08/03/10, reflected weight loss related to acute illness, many food preferences, and poor food/fluid intake. The goal listed was for Resident #4's weight to be stabilized with weight range for ideal body weight within the next 90 days. One of the planned approaches to address this problem was that Resident #4 be provided with the diet as ordered by the physician and offered enhanced or fortified foods and snacks. On 10/06/10 at 1:25 PM, Resident #4 stated she did not receive snacks and did not get pudding with her lunch tray. Again, Resident #4 stated she would eat more for breakfast if the kitchen staff could puree fruit, ham, and bacon. On 10/06/10 at 3:21 PM, the RD was informed Resident #4 had not received the ordered fortified diets during the surveyor's meal observations on 10/05/10 and 10/06/10. In response, the RD stated there was a "communication problem." When informed Resident #4 only received a bowl of grits for breakfast on 10/05/10, the RD stated she had told the kitchen staff "three items" needed to be on Resident #4's tray because she needed the protein and calories. 1b) During the initial tour on 10/05/10 at 5:30 AM, Resident #8 was observed in bed sleeping. The head of the bed was elevated to approximately 30 degrees. Resident #8 appeared thin. Resident #8's Physician order [REDACTED]. Observation during the breakfast meal on 10/05/10 revealed Resident #8 received his meal tray in his room at 7:30 AM. The resident received: a plate with pureed eggs, sausage, and bread; a glass of cranberry juice, milk, and a glass of water. Review of Resident #8's meal tray slip revealed he was on a regular pureed diet, NAS (no added salt), with Nectar thickened liquids. Resident #8 ate 100% of his eggs, sausage, bread and juice. Resident #8's October 2010 Physician order [REDACTED]. A telephone order for Resident #8 reflected the fortified food plan was initially ordered on [DATE] to address the resident's weight loss. In addition a Physician's Telephone Order dated 09/23/10 reflected the resident was to receive four ounces of Ready Care 2.0 for 60 days for his poor appetite. In addition to the telephone orders, a communication form from nursing to dietary dated 09/23/10 reflected the need for Resident #8 to receive a "Fortified food plan with meals." Review of the Diet Roster dated 10/05/10, revealed Resident #8 was to receive a pureed diet no added salt nectar thickened liquids. There was no mention of a fortified food plan. Review of the facility's breakfast extended menu for a fortified food plan pureed diet on 10/05/10 revealed: Fruit Juice, one cup of Fortified cereal, two eggs, one sausage or bacon strip, one muffin, two pats of margarine, whole milk, coffee or hot tea, and water. Review of the lunch extended menu for a fortified food plan pureed diet on 10/05/10 revealed: Smothered Pork Chop with Gravy, macaroni and cheese, mixed vegetables, bread, 2 pats of margarine, cinnamon applesauce, beverage of choice, water, and 4 ounces of fortified pudding. During the lunch meal on 10/05/10, Resident #8 received his meal tray in his room at 11:35 AM. His meal tray slip reflected Resident #8 was on a Pureed, NAS, Nectar thickened liquid diet. No mention of the fortified meal plan was listed on the tray slip. He only received one pat of margarine and did not receive the fortified pudding. Resident #8 ate 75% of his meal. The lunch extended menu for a fortified food plan pureed diet on 10/06/10 was: Lasagna with meat sauce, Italian Green Beans, pureed vegetables, garlic bread, 2 pats of margarine, ice cream, beverage of choice, water and 4 ounces of fortified pudding. During the lunch meal on 10/06/10, Resident #8 received his meal tray in his room at 11:46 AM. His meal tray slip reflected Resident #8 was on a Pureed No Added Salt Nectar thickened liquids diet. No mention of the fortified meal plan was listed on the tray slip. Resident #8 did not receive the 4 ounces of fortified pudding or any type of dessert. Resident #8 ate 75% of his meal. On 10/06/10 at 12:19 PM, the FSM provided a list entitled Fortified Food Plan Updated Weekly July 25, 2010. The FSM revealed the list was complete and current. Review of this list revealed six names of residents who currently resided in the facility. Resident #8 was not on the list. A review of the nutritional assessment dated [DATE], revealed Resident #8 was 67 inches and height and weighed 164 pounds. The RD further documented Resident #8 was to begin the Fortified Food Plan. Review of the weight record for 2010 dated 09/14/10 revealed Resident #8's admission height as 5 feet 7 inches and weight as 164 pounds. The weekly weights were as follows: On 9/20/10: 164.4 pounds, On 9/27/10: 156.4 pounds, On 10/01/10: 156.2 pounds, On 10/04/10: 153.6 pounds. Review of these weights revealed Resident #8 lost approximately 11 pounds in 20 days which was a 6.34% weight loss which was significant. Resident #8's initial care plan dated 9/14/10 reflected weight issues were not identified or addressed. The facility Care Plan dated 9/23/10 did not reveal any nutritional issues or weight losses regarding Resident #8. Review of the facility Diet roster dated 10/05/10 revealed Resident #8's fortified meal plan was not included. On 10/06/10 at 3:25 PM, the RD was informed Resident #8 had not received the ordered fortified food plan during the surveyor's meal observations. The RD stated there was a "communication problem." The RD was informed the yellow copy of the communication forms between nursing and dietary were located in Resident #8's clinical record. 1c) Resident #10's facility Face Sheet dated 08/23/10 reflected she was admitted to the facility on [DATE] with a re-admission on 07/22/10. Resident #10's October 2010 Physician order [REDACTED]. Resident #10's October 2010 Physician order [REDACTED]. A Physician's Telephone Order dated 08/26/10 reflected, "Change to diet low in phosphorus." Further review of the clinical record revealed the resident's [MEDICAL TREATMENT] RD sent a formal letter to the facility dated 08/26/10 which reflected, "Following you will receive a copy of her latest labs. These have been reviewed by her physician, Dr. ____ ([MEDICAL TREATMENT] Physician). Of note is her phosphorus which is 5.5 mg/dl. Tight control over phosphorus levels helps prevent metabolic bone and [MEDICAL CONDITION]. According to her medical record here at ____ ([MEDICAL TREATMENT] Center telephone number), her phosphorus binder is [MEDICATION NAME], 800 mg, 3 with each meal. It would also be helpful if she would continue to avoid foods high in phosphorus. Also, her [MEDICATION NAME] is low - 3.3g/dL. While most labs report 3.5 as "normal, " it is recommended that chronic [MEDICAL TREATMENT] patients do better with [MEDICATION NAME] of 4.0 or greater. When Mrs. ______ (Resident #10) (is) here she receives Nepro supplement. It would also be helpful if she could receive some Nepro on the days that she does not come to [MEDICAL TREATMENT]...." Further review of Resident #10's clinical record revealed a Communication Form dated 08/26/10 to the facility's dietary department notifying the kitchen of the resident's change in diet to include foods low in phosphorus. Review of the dietary section of Resident #10's clinical record revealed the last evaluation done by the RD was 08/04/10. There was no documentation in the clinical record reflecting the facility's Consulting RD was consulted regarding the provisions of this low phosphorus diet for Resident #10. In addition, there was not a care plan developed to address how the facility was going to ensure a low phosphorus food diet was going to be provided to the resident. Review of the facility's planned therapeutic diets revealed no formalized planned meals for the low phosphorus diet. The facility's Diet Manual was the Texas Department of Agriculture Manual for Medical Nutrition Therapy. The manual reflected the following under the title, "NUTRITION CARE IN [MEDICAL CONDITION]:" "...What should I do if my Phosphorus levels gets too high? Instead of: Try: 1 cup of milk 230 1 c. nondairy milk substitute, or 80 1/2 cup milk 115... 1/2 cup ice cream 80 1 popsicle or 1/2 cup sherbet 0... 1 ounce chocolate 40 1 ounce hard candy 2." During the lunch meal observation on 10/06/10 at 12:00 PM, Resident #10's tray card was observed. It did not reflect the low phosphorus food diet. At that meal, she was given chocolate ice cream for dessert which she ate. At 12:30 PM on 10/06/10, the FSM was asked about the low phosphorus foods diet for Resident #10. He stated he was aware she was on the diet, and he would update the tray card to reflect the low phosphorus food diet. He stated he was not familiar with the diet, so he looked up the diet in the Diet Manual when he received the Communication Form changing her diet to one low in phosphorus foods. On 10/06/10 at 3:21 PM when queried regarding Resident #10's low phosphorus diet requirements, the FSM revealed the resident's tray card did not reflect the low phosphorus food diet that was ordered. She stated the kitchen might not have received a Communication Form from nursing. The surveyor notified her there was a copy of the Communication Form in the resident's clinical record reflecting the kitchen was notified of the diet change. The FSM gave no other explanation and stated she would have to look at the resident's clinical record. Review of Resident #10's clinical record revealed a Nutrition Progress Noted documented by the RD dated 10/07/10 (after surveyor inquiry) which reflected: "Diet order now Reg, NCS, NAS, Low in Phos. - per rec of [MEDICAL TREATMENT] RD - 1 phos level elevated (symbol used) @ 5.5, Alb 3.4 - discussed with (symbol used) [MEDICAL TREATMENT] RD - following recs for decreased (symbol used) dairy products, decreased (symbol used) beans, no (symbol used) peanut butter. [MEDICAL TREATMENT] RD stressed need to provide [MEDICATION NAME] @ mealtimes for better control. Recent labs to be faxed to facility by [MEDICAL TREATMENT] Center. Will follow through with (symbol used) recs, con't to monitor labs as available; St IV wound to right (symbol used) heel decrease (symbol used) in size - 5.5 x 2.5 x 0.5 > 3.5 x 2.0 x 0.3 - con't Nepro for increased (symbol used) protein & Renal MVI for healing - con't to monitor. Wt: 102.8# with (symbol used) sig wt loss (symbol used) x 3 mo, 19.2# (15%) > with (symbol used) several hospital admits, wt stable x 2 mo now - is currently 98% IBW range, goal 100-105# - con't to monitor....Nepro adequate to meet est needs." A Physician's Telephone Order, dated 09/23/10, reflected the Nepro was discontinued on that date due to the resident refusing it. 2a) During the initial tour at 5:30 AM on 10/05/10, Resident #8 was observed lying in bed with the head of the bed positioned at an angle of approximately 30 degrees. Resident #8's heels were lying directly on the mattress without any type of preventative measures, and the resident was lying flat on his back without any positioning devices noted. The resident was not on an air loss mattress. The surveyor along with CNA H observed the sacrum/coccyx area, which was slightly pink and on the left buttock was a dark purple area. Resident #8's Physician order [REDACTED]. The Admission/Readmission Data Summary dated 09/14/10 did not identify any red skin sites or pressure ulcers on Resident #8 on admission. Review of the MDS assessment dated [DATE] revealed Resident #8 had no pressure ulcers. The acute care plan dated 09/14/10 did not identify skin breakdown as an issue for Resident #8. On 10/06/10 at 10:45 AM during a conversation with Resident #8's family member, the surveyor was told by the family member he/she had observed an open area on Resident #8's buttocks that morning when taking Resident #8 to the bathroom. On 10/06/10 at approximately 11:00 AM, the surveyor observed Resident #8 in the therapy room ambulating with a walker. It was observed the resident was wearing diabetic shoes, and the resident's wheelchair did not have any extra padding on the seat cushion. On 10/06/10 at 1:50 PM, the surveyor, along with CNAs E and O, observed Resident #8's skin. At that time, it was observed Resident #8 had a Stage II pressure ulcer on the left buttock surrounded by a dark red circle, a purple area on the buttocks and the left heel, which was red and mushy. On 10/06/10 at 3:40 PM, the surveyor spoke with the charge nurse, LVN FF, and asked if he was aware of Resident #8 having any pressure ulcers or whether the off-going charge nurse reported anything to him. LVN FF revealed he was only told about constipation experienced by Resident #8. LVN FF was unaware of any new skin issues. On 10/06/10 at 3:45 PM, the surveyor and the Treatment Nurse observed and assessed the skin condition of Resident #8 with the following results: Progress Notes and the Weekly Pressure Ulcer Healing Report dated 10/06/10 reflected the following identified areas: "1) The left buttocks had a deep tissue injury dark purple in color and soft to touch. It measures 5.5 cm x 5 cm, surrounding deep tissue injury is red. 2) Left buttocks has an open area 1 x 1.2 cm open area Stage 2, with slight odor and granulation tissue. 3) Left buttocks 0.6 x 0.3 cm Stage 2 and has a slight odor and granulation tissue present. 4) Right Sacral area 1 x 1.7 cm open area Stage 2. 5) Right heel 5.5 cm x 5 cm Stage 1 red with no drainage or odor." On 10/07/10 at approximately 10:05 AM, the surveyor spoke with Resident #8 and a family member with the family member acting as an interpreter. Resident #8 was sitting in a wheelchair, and the surveyor noted a cushion in the seat of the chair. Both of Resident #8's feet were wrapped with kerlix. Resident #8 told the surveyor, through his family member, he did not know how he was supposed to lie in the bed, because the staff kept coming in and turning him from side to side and placing pillows behind him so he could not move. When asked if the staff had done this before "today," his reply was "No." The resident also voiced concerns about being able to do therapy with the wraps on his feet, and the surveyor assured him he could. On 10/07/10 at 3:00 PM, the surveyor observed Resident #8 lying in bed on has side propped with a pillow, and his feet off-loaded. Resident #8's mattress had also been changed to an alternating air mattress. 2b) During observation rounds with LVN K on 10/05/10 at 5:25 AM, Resident #10 was observed awake in bed. LVN K stated Resident #10 had a pressure ulcer on the right heel. She proceeded to show the surveyor the resident's feet, and the resident's right heel, which had a dressing on it, was positioned directly on the bed. A torn pillow with the stuffing exposed was underneath the resident's legs but was not positioned in a manner to promote off-loading of the resident's heels. The resident was not on an air-loss mattress. At that time, LVN K stated Resident #10 received [MEDICAL TREATMENT] services and had Diabetes. She stated the resident was able to make her needs known, and she required the assistance of one staff person for transfers. She added the resident was continent of bowel and bladder. Resident #10's Face Sheet, dated 08/23/10, reflected she was admitted to the facility on [DATE] with a re-admission on 07/22/10. Resident #10's October 2010 Physician order [REDACTED]. Resident #10's Weekly Pressure Ulcer Healing Report reflected she had a Stage IV pressure ulcer on the right heel. The assessment done on 10/06/10 reflected the pressure ulcer was assessed to be 3.0 cm x 2.5 cm with a large amount of purulent drainage. Resident #10's quarterly MDS assessment, dated 08/02/10, reflected she required the extensive assistance of two people with bed mobility to include positioning in bed. The MDS assessment further reflected she had short-term memory problems with moderately impaired cognitive skills for daily decision-making requiring cueing and supervision. Resident #10 was observed lying in bed at 7:05 AM on 10/05/10. Her heels were not off-loaded, while she was in bed, and were directly in contact with the bed. A pillow was under her calves, but it did not off-load her heels. At 8:22 AM on 10/05/10, the Treatment Nurse was observed treating Resident #10's pressure ulcer with CNA CC assisting by holding up the resident's right foot. After the treatment was completed at 8:36 AM, CNA CC placed Resident #10's foot on the bed. She then walked away from the bed. The Treatment Nurse asked CNA CC to off-load Resident #10's feet. CNA CC proceeded to place a flat pillow under Resident #10's calves, which did not provide off-loading of the resident's heels. The resident's heels were directly on the bed. The Treatment Nurse proceeded to demonstrate to CNA CC how to off-load Resident #10's heels by folding the pillow over, then placing it under the resident's calves resulting in the feet being completely off-loaded from the bed. The Treatment Nurse also assisted in placing the Multi-Podus boot on the resident's right foot to provide additional off-loading. On 10/06/10 at 9:57 AM, Resident #10 was observed lying in bed with both heels directly in contact with the bed. 2c) During observation rounds with LVN K on 10/05/10 at 6:00 AM, Resident #9 was observed asleep in bed in a fetal position lying on her right side. LVN K stated Resident #9 had a pressure ulcer on the left foot. She proceeded to show the surveyor the resident's feet. The resident's left foot had a dressing on it, and it was resting on top of the right foot. The resident's feet were not off-loaded, and no positioning devices or pillows were used for this purpose. Resident #9 had not been provided with an air-loss mattress. Resident #9's Record of Admission, dated 02/02/09, reflected she was admitted to the facility on [DATE] with a re-admission on 03/14/08. Resident #9's October 2010 Physician order [REDACTED]. The orders also reflected an order dated 07/28/10 to off-load the resident's heels and feet. Resident #9's Weekly Pressure Ulcer Healing Report reflected she had a Stage III pressure ulcer on her left heel, which was first observed on 05/28/10. The assessment, dated 10/06/10, reflected the pressure ulcer measured 2.5 cm x 1.3 cm. Review of Resident #9's care plan, updated on 09/29/10, reflected an approach identified for addressing the resident's pressure ulcer was to: "...5) Use padding between pressure areas and positioning devices for proper body alignment, 6) Provide pressure relieving device for bed and wheelchair...." Resident #9's quarterly MDS assessment, dated 08/15/10, reflected she had severe cognitive impairment. The assessment further reflected she required the extensive assistance of one person for bed mobility to include positioning in bed. Regarding transfers, the assessment reflected she required the extensive assistance of two people for transfers. Resident #9's Braden Scale-For Predicting Pressure Sore Risk completed on 08/18/10 reflected she scored an eleven, which placed her at high-risk for pressure ulcer development. On 10/05/10 at 7:10 AM, Resident #9 was observed seated in a wheelchair in the assisted dining room. She had shoes on both of her feet, and her feet were positioned on the wheelchair foot rests. Her heels were not off-loaded to prevent pressure. At 10:22 AM on 10/05/10, Resident #9 was observed lying in a fetal position on her right side in bed. Her left foot with the pressure ulcer was resting on top of her right foot, which was directly on the bed and not off-loaded. At 12:50 PM on 10/05/10, Resident #9 was observed lying in a fetal position in bed on her right side. Her left foot with the pressure ulcer was resting on top of her right foot, which was directly on the bed and not off-loaded. At 9:45 AM on 10/06/10, Resident #9 was observed lying in a fetal position in bed on her right side. Her left foot with the pressure ulcer was resting on top of her right foot, which was directly on the bed and not off-loaded. Review of Resident #9's October 2010 Treatment Sheet revealed the licensed nurses were supposed to ensure Resident #9's heels and feet were off-loaded each shift. On 10/06/10 at 10:00 AM, LVN V was notified of the observations of Residents #9 and #10. She stated the residents' feet were supposed to be off-loaded, especially Resident #9. When asked how the aides knew which resident needed their heels and feet off-loaded, LVN V was unsure how this was communicated to the aides. She did not know if it was on their assignment sheets. LVN V proceeded to Resident #9's room. Upon entering the room, she stated Resident #9's roommate, Resident #29, particularly needed her feet off-loaded due to her declining health and hospice status. She left the room to obtain pillows. Upon returning to the room, she proceeded to off-load Resident #29's feet. Next she went over to Resident #9, and she placed a pillow under Resident #9's right foot. The left foot with the pressure ulcer remained on top of the right foot, and the right foot was on top of the pillow. LVN V then washed her hands and left the room. At 10:30 AM on 10/06/10, CNA DD was interviewed regarding her knowledge of off-loading. She confirmed at that time she was an aide on the hall where Residents #9 and #10 resided. When asked how she knew which residents required their feet to be off-loaded, she stated if they had something on their foot like a wound, then they used a pillow. She was asked if she knew what the term off-loading meant, and she stated she did not. At 10:35 AM on 10/06/10, the facility's only ADON was asked how aides were informed which residents required their heels and feet to be off-loaded. She stated it should be in the ADL Flow Book. She proceeded to look in the book for Resident #9's ADL Flow Sheet. She acknowledged it was not documented in the book for any of the residents on Hall 200. LVN V approached the ADON, and she informed the ADON the off-loading was in the Nurse MAR. The ADON told LVN V the information needed to be in the ADL Flow Book for the CNAs. The ADON stated it should be written in the Special Notes section for the residents, who required off-loading. She showed LVN V where the nurses where signing off they were checking to ensure residents' heels and feet were off-loaded. She showed LVN V where she (LVN V) had already signed off on the 6:00 AM - 2:00 PM shift for 10/06/10 that Resident #9's feet were off-loaded for that shift. The ADON then proceeded to go through all of the ADL Flow Books for all four nursing halls, and wrote off-loading down in the Special Notes section for those she identified as requiring off-loading. At 10:38 AM on 10/06/10, CNA EE was interviewed regarding her knowledge of off-loading. She stated if a resident had redness, then they put a pillow underneath to off-load. She confirmed she was the 6:00 AM - 2:00 PM aide assigned to Resident #9 on this date. She stated she assisted Resident #9 to bed after breakfast, and she did not off-load the resident's heels and feet. She stated she did not off-load the resident's feet because the wound nurse and the wound doctor were doing rounds in the building that morning, and they would be looking at the resident's feet. At 11:00 AM on 10/06/10, the DON was notified of the observations of Residents #9 and #10's feet not being properly off-loaded. She was also notified of the inconsistencies regarding the CNAs and LVNs knowledge of how to properly off-load heels, and the lack of a system for aides to know which residents required off-loading to prevent pressure ulcers fr