Every finding on record at Trucare Living Centers - Selma

Based on interview and record review the facility failed to ensure the physician reviewed the resident's total program of care, including medications and treatments, and write, sign, and dated progress notes at each visit for 4 of 5 residents (Resident #1, #2, #4, and #5) reviewed for physician visits for 1 of 2 physicians (Physician A), in that:1. Resident #1's physician (Physician A) did not provide physician visit notes between 06/08/2025 and 04/22/2026 when Physician A reported he had seen Resident #1 every other month.2. Resident #2's physician (Physician A) did not provide any physician visit notes since the resident's readmission on [DATE] when Physician A reported he had seen Resident #2 every other month.3. Resident #4's physician (Physician A) did not provide any physician visit notes since the resident was admitted to the facility on [DATE] when Physician A reported he had seen Resident #4 every other month and had last seen her in February 2026.4. Resident #5's physician (Physician A) did not provide any physician visit notes since the resident was admitted to the facility on [DATE] when Physician A reported he had had seen Resident #5 every other month and had last seen the resident in February 2026.This deficient practice could place residents at-risk for any physician identified concerns, inadequate monitoring of medical conditions and miscommunication with other health care providers.Findings Include:1. Record review of Resident #1's admission Record (Face Sheet) dated 04/26/2026, revealed she was admitted on [DATE] with diagnoses which included Hypertension Encephalopathy (severe increase in blood pressure that leads to brain swelling), rotator cuff (shoulder muscles) tear of right shoulder, anxiety disorder (excessive persistent fear or worry that interferes with daily life), low blood pressure, stroke, and high blood pressure; and Physician A was her primary medical doctor.Record review of Resident #1's MDS, a Quarterly assessment dated [DATE], revealed a BIMS score of 15 out of 15, and was independent in her cognitive skills for daily decision making.Record review of Resident #1's electronic clinical record progress notes from 06/03/2025 to 04/26/2026 revealed she had a visit note from Physician A on 06/08/2025 and on 04/22/2026, with no visit notes from Physician A between 06/08/2025 to 04/22/2026.Record review of Resident #1's electronic clinical record progress notes from 06/03/2025 to 04/26/2026 revealed there were visit progress notes from the following providers:NP C06/03/2025,06/05/2025,06/12/2025,06/19/2025,07/01/2025,07/03/2025,07/08/2025,07/15/2025,07/17/2025,07/21/2025;08/04/2025,08/06/2025,08/11/2025,08/18/2025,09/03/2025,10/22/2025,11/05/2025, and12/08/2025. NP B06/22/2025,06/25/2025, and06/27/2025.PA D 01/07/2026,01/12/2026,01/21/2026,02/13/2026,03/04/2026,04/01/2026,04/13/2026, 04/15/2026, and04/20/2026.2. Record review of Resident #2's admission Record, dated 04/26/2026, revealed she was admitted on [DATE] and readmitted on [DATE] with diagnoses which included pneumonia (lung infection), swallowing difficulties, anemia (low iron stores in the blood), cognitive communication deficit (difficulty speaking due to memory dysfunction), atrial fibrillation (chronic heart rhythm disorder causing the heart to beat irregularly), high blood pressure and diabetes (chronic elevated blood sugars due to insufficient insulin production); and her primary physician was Physician A.Record review of Resident #2's MDS, an Annual assessment dated [DATE], revealed her BIMS score was 0 out of 15, which indicated her cognitive skills for daily decision making were severely impaired.Record review of Resident #2's electronic clinical record progress notes from 01/13/2026 to 04/26/2026 revealed there were no physician visit progress notes from Physician A.Record review of Resident #2's electronic clinical record progress notes from 01/13/2026 to 04/26/2026 revealed there were visit progress notes from PA D on 01/14/2026, 01/16/2026, 01/19/2026, 01/21/2026, 01/23/2026, 01/26/2026, 01/28/2026, 01/30/2026, 02/02/2026, 02/04/2026, 02/06/2026, 02/09/2026, 02/11/2026, 02/13/2026, 02/13/2026, 03/11/2026, 03/13/2026, 04/15/2026, and 04/24/2026.3. Record review of Resident #4's admission Record dated 04/26/2026, revealed she was admitted on [DATE] with diagnoses which included lymphedema (chronic condition that causes swelling in extremities due to lymphatic fluid buildup), high blood pressure, hyperlipidemia (elevated blood level of fats, cholesterol and triglycerides), chronic obstructive pulmonary disease (chronic lung disease that restricts airflow, making breathing difficult), and cellulitis (bacterial skin infection) of a limb (leg or arm); and her primary physician was Physician A.Record review of Resident #4's MDS, a Quarterly assessment dated [DATE], revealed a BIMS score of 12 out of 15, which indicated her cognitive skills for daily decision making were moderately impaired.Record review of Resident #4's electronic clinical record progress notes from 10/17/2025 to 04/26/2026 revealed there were no physician visit progress notes from Physician A.Record review of Resident #4's electronic clinical record progress notes from 10/17/2025 to 04/26/26 revealed there were visit progress notes from the following providers:NP C10/20/2025 and 12/04/2025.PA D12/31/2025,01/12/2026,02/17/2026,02/19/2026,03/11/2026, and 04/15/2026.4. Record review of Resident #5's admission Record dated 04/26/2026, revealed she was admitted on [DATE] with diagnosis of anxiety disorder (excessive persistent fear or worry that interferes with daily life), hyperlipidemia (elevated blood level of fats, cholesterol and triglycerides), bipolar disorder (chronic mental health condition characterized by intense mood swings with emotional highs and lows), neuromuscular dysfunction of the bladder (nerve damage that causes loss of bladder control), and fibromyalgia (chronic disorder characterized by widespread musculoskeletal pain and fatigue); and her primary physician was Physician A.Record review of Resident #5's MDS, an Annual assessment dated [DATE], revealed a BIMS score of 15 out of 15, and she was independent in her cognitive skills for daily decision making.Record review of Resident #5's electronic clinical record progress notes from 02/05/2025 to 04/26/2026 revealed there were no physician visit progress notes from Physician A.Record review of Resident #5's electronic clinical record progress notes from 02/05/2025 to 04/26/2026 revealed there were visit progress notes from the following providers:NP B02/22/2025,02/27/2025,03/16/2025 and05/29/2025. NP C 08/11/2025,09/23/2025,10/15/2025,10/22/2025,11/14/2025, and12/22/2025. PA D01/14/2026,01/17/2026,02/09/2026,03/02/2026,03/04/2026,03/16/2026,03/18/2026,03/20/2026,03/23/2026,03/27/2026,04/08/2026,04/17/2026,04/22/2026, and04/24/2026.In an interview on 04/26/2026 at 3:36 p.m., the DON said Physician A was in the facility weekly to see his residents and did not know why the physician did not have any progress notes for Resident #2, #4, and #5; or any further notes for Resident #1.In a telephone interview on 04/26/2026 from 3:40 p.m. to 3:53 p.m., Physician A said he was in the facility weekly to see residents along with his PA (PA D) who was in the facility three times a week. Physician A said he would write a visit note in the residents' electronic clinical record after each visit. Physician A said that he looked at Resident #2's, Resident #4's, and Resident #5's clinical record, he did not see his physician notes in their electronic clinical record, and he must not have put a note in their electronic clinical record. Physician A stated he was sure he visited Resident #1, Resident #2, Resident #4 and Resident #5 in February 2026 because he saw all his residents that month. Physician A said that he had seen Resident #1, Resident #2, Resident #4, and Resident #5 numerous times during their stay at the facility. Physician A said that he would visit all his skilled nursing facility residents once a month for the first three months, then the long-term care residents he would visit them every two to four months, depending on their acuity level, and his visits are alternated by the NP or PA who would see the residents at least monthly.In a telephone interview on 04/26/2026 at 3:55 p.m., the Administrator said she would check the residents' electronic clinical record after a physician has visited the facility to ensure they have a note in the residents clinical record but a lot of times they [the physicians, NPs, PAs] do not write the note right away and will write the notes a couple of days later. The Administrator stated they did not have a policy on accuracy of clinical records or ensuring the physician wrote a note after each visit. The Administrator stated she did not see any harm that could happen to a resident by not having a physician visit in the electronic clinical record because Physician A was in the facility weekly and he was in communication with the nurses, Administrator, and the DON.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety. The facility failed to keep a crate of milk off the floor. The facility failed to date items in the nourishment refrigerator. The facility failed to label items in the nourishment refrigerator/freezer. This deficient practice could place residents at risk for food borne illness.The findings include: Observation on 02/10/2026 at 9:30 a.m., of the kitchen refrigerator revealed the following: -1 crate of individual milk boxes on the floor under shelving During an interview on 02/10/2026 at 9:55 a.m., the DM stated that items in the fridge should be 8 inches from the floor and 16 inches from the ceiling. The DM stated the risk to the residents for leaving items on the floor in the refrigerator could be mold, a dirty floor or critters getting into the items. The DM stated items are labeled with a date, so they know when the item was opened and when they are getting ready to expire. The DM stated if there were no dates on opened items they would not know when they were opened. During an interview on 2/12/2026 at 11:46 a.m., the DM stated they were not sure who was responsible for the nourishment refrigerator. Observation on 02/12/2026 at 11:54 a.m., of the nourishment refrigerator/freezer revealed the following: -1 cottage cheese, with no seal and a lid, with no open date or resident name -1 sealed cottage cheese with no resident name -3 [NAME] homestyle chicken noodle soups with no resident names -1 [NAME] chicken soup with no resident name -1 Amy's frozen cheese enchiladas meal with no resident name During an interview on 02/12/2026 at 11:54 a.m., the DON stated they were unsure of who was responsible for the nourishment refrigerator. The DON stated items in the nourishment refrigerator/freezer should have the resident's names on them and if opened the date when the item was opened. The DON stated the risk could be someone else being able to take the item and if the item had no date, it would be thrown away. During an interview on 02/12/2026 at 1:51 p.m., the DDM stated there is no specific policy regarding the nourishment refrigerator/freezer, During an interview on 02/12/2026 at 2:22 p.m., the Administrator stated the dietary department is responsible for the nourishment refrigerator. Record review of the facilities policy, Food Storage: Cold Foods, revised date 2/2023, reflected: Procedures All food items will be stored 6 inches above the floor and 18 inches below the sprinkler unit.

Based on interviews, and record review, the facility failed to ensure preadmissions screening for individuals with a mental disorder and individuals with intellectual disability for 1 of 6 residents (Resident #39) reviewed for PASARR accuracy. The MDS Case Manager failed to accurately screen Resident #39 for mental illness upon admission to the facility. This deficient practice could place the residents at risk of not receiving the necessary care and services. The findings included:Record review of Resident #39's face sheet, dated 02/11/2026, revealed a [AGE] year-old female admitted to the facility on [DATE] with a primary diagnosis of spinal stenosis, lumbar region with neurogenic claudication (narrowing of spinal canal which can lead to nerve compression). Record review of Resident #39's MDS, dated [DATE], revealed the resident's BIMS score was a 15 out of 15 which suggested the resident's cognition was intact for daily decisions. Record review of Resident #39's diagnosis information on the face sheet dated 02/11/2026 revealed a diagnosis of bipolar disorder, unspecified, (a mental condition characterized by significant mood swings, including manic episodes and depressive episodes) with an onset date of 02/05/2025. Record review of Resident #39's PASARR Level 1 screening, dated 02/05/2025 and completed at the hospital, revealed section C0100. Mental Illness: Is there evidence or an indicator this is an individual that has a mental illness recorded as a no. Record review of Resident #39's PASARR Level 1 screening, dated 02/05/2025 and completed at the nursing facility, revealed section C0100. Mental Illness: Is there evidence or an indicator this is an individual that has a mental illness recorded as a no. During an interview on 02/13/2026 at 8:45 a.m., the MDS Case Manager stated they were responsible for looking over PASSAR documents when a resident is admitted and reviews the clinical record for accuracy for the PASSAR assessment. The MDS case manager confirmed Resident #39 were marked as no for mental illness on their PASSAR. The MDS case manager confirmed Resident #39 having a mental illness. The MDS case manager stated the importance of an accurate PASSAR would be residents being able to receive the specialized serves or counseling they require. During an interview on 02/13/2026 at 9:26 a.m., the MDS case manager stated they did not have a policy for PASSAR assessments.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for 1 of 2 medication carts (the 300/400 hall medication aide cart) assessed for medication storage and labeling. The facility failed to ensure all medications located inside the 300/400 hall medication aide cart were stored in properly labeled containers. This failure could place residents at risk of receiving inadequate treatments or ingesting medications for which they were not prescribed.The findings included: During an observation of the 300/400 hall medication aide cart on 02/12/2026 at 8:10 AM, a clear dosing cup with loose pills was observed sitting in the drawer of the medication cart. During an interview with MA A on 02/12/2026 at 8:10 AM, MA A stated that dosing cups with pills should not be left in the cart. MA A further stated that the pills in the cup should have been disposed of if they were not going to be administered immediately. MA A stated if pills were left in dosing cups to be administered at a later time, the person administering the medications could be confused and give the pills to the wrong resident. During an interview with the DON on 02/12/2026 at 10:09 AM, the DON stated pills that are not dispensed should not be left in the cart. The DON stated his expectation for staff was they should dispose of any medications that could not be administered, and that staff should not have put pills into a dosing cup if a resident was not present to take them, or if they had not checked with the resident first to ensure they were ready to take them. The DON stated if medications were left in the carts in dosing cups it could cause a medication error, because if there was no label, the medication could be given to the wrong resident. Record review of the facility policy titled Labeling of Medication Containers with a revision date of April 2007 noted All medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations.

Based on record review and interview the facility failed to send a copy of the residents' discharge notice, prior to discharge, to the representative of the Office of the State Long-Term Care (LTC) Ombudsman of the residents' transfer or discharge and the reasons for the move, for 1 of 3 residents (Resident #18) reviewed for notifying the LTC Ombudsman of the residents' discharge.Resident #18 was discharged on 1/19/26 without any notice to the State LTC Ombudsman.This failure could place residents at risk of not knowing their rights or receiving the services of the State LTC Ombudsman.The findings included:Record review of Resident #18's face sheet dated 2/10/26 reflected an [AGE] year-old female admitted to the facility on [DATE] and discharged on 1/19/26 with diagnoses that included diabetes, depression, and hypercholesterolemia (high cholesterol levels in the blood).Record review of Resident #18's most recent quarterly MDS assessment dated [DATE] reflected the resident was cognitively intact for daily decision-making skills.Record review of Resident #18's comprehensive care plan with revision date 5/9/23 reflected discharge planning expectation, based on care plan meetings and talking with family was for long term care with interventions that included discharge planning for medication management and the resident's family or friend support network to be included in discharge planning if discharge was optional.Record review of Resident #18's Hospital Transfer Form dated 1/19/26 reflected the reason for transfer to the hospital was related to behavioral symptoms (e.g. agitation, psychosis). Record review of Resident #18's medical record revealed no evidence of a discharge notice to the State Ombudsman.During a telephone interview on 2/11/26 at 8:20 a.m., Resident #18's family member stated the resident was in the hospital beginning 1/19/26 and even before the resident was medically cleared from the hospital, the facility SW reached out to her to inform her the facility did not want to take back Resident #18 due to safety concerns for their employees, but if the facility could not find placement, then the resident would be allowed back to the facility temporarily until they found alternate placement. Resident #18's family member stated, they dumped her (Resident #18). Resident #18's family member stated there was no care plan meeting, no discussion about discharge, only that she was notified about placement to a facility where the resident could be accepted but, the facility they sent her (Resident #18) to was of less caliber. Resident #18's family member stated the hospital case manager arranged for the resident's transfer to the new facility. During a telephone interview on 2/11/25 at 1:42 p.m., the State LTC Ombudsman stated she did not receive notification regarding Resident #18's discharge to the hospital or discharge to another facility. The State LTC Ombudsman stated she searched through her files and e-mails regarding facility notification for Resident #18's discharge and although was able to locate discharge notification for 3 other residents from the same facility, she could not locate a discharge notification for Resident #18. The State LTC Ombudsman stated, typically, discharge information was provided to her from the facility by the Administrator. The State LTC Ombudsman stated in part, what facilities should be doing is, every month, first of every month.provide me with full discharges, with full name, date, and where they (the resident) went. That is a federal regulation. During a follow up telephone interview on 2/11/26 at 2:24 p.m., Resident #18's family member stated she contacted the State LTC Ombudsman and was instructed to call the HHSC state hotline and report that the facility failed to give a 30-day discharge notice. During an interview on 2/12/26 at 4:15 p.m., the Administrator stated she did not notify the State LTC Ombudsman regarding Resident #18's discharge because it was not considered a 30-day discharge because the resident was sent to the hospital on an emergency basis related to aggressive behavior. The Administrator stated, for a 30-day I would have (notified the Ombudsman), but I did not in this case.Record review of the facility document titled Transfer or Discharge, Emergency with revision date 3/14/19 reflected in part, .Emergency transfers or discharges may be necessary to protect the health and/or well-being of the resident(s).Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures.Notify the State Ombudsman when practicable.

Based on record review and interview, the facility failed to permit a resident to return to the facility after being hospitalized and failed to document sufficient preparation and orientation to residents to ensure a safe and orderly transfer or discharge from the facility for 1 of 3 residents (Resident #18) reviewed for transfer and discharge rights:The facility failed to ensure Resident #18 was readmitted to the facility, after being sent to the hospital on 1/19/26 for evaluation and treatment related to behavioral symptoms. The facility did not document Resident 18's medical record the reason for not accepting Resident #18 to return to the facility.This failure could place discharged residents and residents residing in the facility at risk of being discharged and not allowed to return to the facility causing a disruption in their care and/or services.The findings included:Record review of Resident #18's face sheet dated 2/10/26 reflected an [AGE] year-old female admitted to the facility on [DATE] and discharged on 1/19/26 with diagnoses that included diabetes, depression, and hypercholesterolemia (high cholesterol levels in the blood).Record review of Resident #18's most recent quarterly MDS assessment dated [DATE] reflected the resident was cognitively intact for daily decision-making skills.Record review of Resident #18's comprehensive care plan with revision date of 5/13/25 reflected the resident had dementia and was at risk for cognitive decline in decision-making skills with interventions that included frequent interactions with the resident to ensure all needs were being met. Resident #18's comprehensive care plan reflected the resident had the potential to demonstrate behaviors related to dementia including being accusatory, alleging personal items were being stolen, refusing medications, and assistance with personal care. Resident #18's comprehensive care plan reflected discharge planning expectation, based on care plan meetings and talking with family was for long term care with interventions that included discharge planning to include medication management.Record review of Resident #18's Psychiatric Initial Evaluation dated 12/15/25 and completed by the Psych NP reflected Resident #18's treatment recommendations that included psychotherapy evaluation and treatment, behavior management techniques, and recommendation for major depressive disorder management the resident declined medications but was agreeable to psychotherapy. Record review of Resident #18's Hospital Transfer Form dated 1/19/26 reflected the reason for transfer to the hospital was related to behavioral symptoms (e.g. agitation, psychosis). Record review of Resident #18's progress notes dated 1/19/26 and time stamped 10:27 a.m. and authored by the SW reflected the resident was having increased behaviors, going in and out of resident rooms, raising her voice, and threatened to fire the SW. The SW documented, after meeting with the IDT, SW will be looking for alternate placement, as this may no longer be the best fit for the resident.Record review of Resident #18's progress notes dated 1/19/26 time stamped 10:40 a.m. (late entry) and authored by the SW reflected, Psych NP, who inquired about a UTI and testing resident for a UTI. (Psych) NP spoke with nursing before meeting with resident.Record review of Resident #18's progress notes dated 1/19/26 time stamped 12:30 p.m. and authored by LVN B reflected in part, Resident #18 accused CNA C of stealing her phone and the resident grabbed CNA C's scrub top causing her to fall on the floor. Record review of Resident #18's progress notes dated 1/19/26 time stamped 12:40 p.m. and authored by the Psych NP reflected in part, Resident #18 was approached by the Psych NP and observed agitated, yelling, and verbally hostile. The Psych NP documented Resident #18 accused the Psych NP of stealing her watch and the resident attempted to strike at me by swinging her arm toward my face. The Psych NP documented Resident #18 did not respond to de-escalation attempts and remained verbally aggressive and noncompliant at the time of the incident. Per chart history, patient has a baseline of delusional thinking, including beliefs that medications are poison. Patient routinely refuses prescribed medications and does not comply with laboratory testing or urine analysis (UA) due to these beliefs. Provider advised for patient to be sent out to hospital for further medical evaluation.Record review of Resident #18's progress notes dated 1/19/26 time stamped 1:15 p.m. and authored by LVN B reflected the Psych NP recommended Resident #18 be sent out because she was a danger to other residents and the residents family member was made aware of clinical situation and the resident would be sent out to the hospital. During a telephone interview on 2/11/26 at 8:20 a.m., Resident #18's family member stated the resident was in the hospital beginning 1/19/26 and even before the resident was medically cleared from the hospital, the facility SW reached out to her to inform her the facility didn't want to take back Resident #18 due to safety concerns for their employees, but if the facility could not find placement, then the resident would be allowed back to the facility temporarily until they found alternate placement. Resident #18's family member stated, they dumped her (Resident #18). Resident #18's family member stated there was no care plan meeting, no discussion about discharge, only that she was notified about placement to a facility where the resident could be accepted but, the facility they sent her (Resident #18) to was of less caliber. Resident #18's family member stated the hospital case manager arranged for the resident's transfer to the new facility. During a telephone interview on 2/11/25 at 3:28 p.m., the Psych NP stated she had visited Resident #18 for a follow up on 1/19/26 and was walking into the facility when she received a text message from the SW about Resident #18 beating up a CNA. The Psych NP stated she met Resident #18 in the activity room and the resident accused her of stealing her watch. The Psych NP stated Resident #18 raised her arm to strike her, but the Psych NP blocked the resident. The Psych NP stated, Resident #18 had a history of verbal aggression, and delusions, but the physical aggression was a new onset, it was something they had not seen before. The Psych NP stated, I let the nurses know about the suspicion of a UTI. The Psych NP stated, my line of thinking was, yes, she (Resident #18) has had delusions, but this level of aggression was new onset for her, so I suspected UTI. The Psych NP stated she wanted Resident #18 to be sent to the hospital to rule out a UTI and then proceed further based on the results to determine if her behavior was medically or psychiatrically related. The Psych NP stated as of the time of the telephone interview she was not sure where Resident #18 was, believed the resident was not back in the facility, did not know if the resident remained in the hospital, and believed the facility would have been notified if Resident #18 required a higher level of care based on a psychiatric issue, but I was not notified of that.During an interview on 2/11/26 at 3:48 p.m., LVN B stated Resident #18 had a history of verbal aggression, had hallucinations, but did not recall the resident displaying physical aggression. LVN B stated she was ordered by the Psych NP on 1/19/26 to transfer Resident #18 to the hospital because she was a danger to other residents in the facility. LVN B stated the Psych NP said the resident was being combative and needed psychiatric evaluation and the resident might have a UTI because the resident did not normally act that way. LVN B stated she was unsure if Resident #18 was still in the hospital at the time of the interview and assumed the resident was sent to another facility that had a locked down unit. LVN B stated that discharges from the facility included a medication reconciliation, a final discharge review, and a written progress note in the resident's record that indicated the resident was discharged and the resident condition at the time of the discharge. LVN B stated she was not aware of the facility declining Resident #18 from returning to the facility from the hospital and stated, they (residents) should come back (to the facility) once stable, it it's a suitable environment.During an interview on 2/11/26 at 4:48 p.m., the SW stated the IDT had a meeting on 1/19/26, without Resident #18's family member, related to the resident attacking a CNA C and almost striking the Psych NP. The SW stated, the Psych NP believed the resident had a UTI, but also wanted the resident sent to the hospital because the Psych NP believed Resident #18 was a threat to everybody around her. The SW stated she made contact with Resident #18's family member about referral to other facilities. The SW stated Resident #18's family member had questions about the resident being admitted back to the facility, but was told it was hard to accept her (Resident #18) back with her aggression, and she (family member) said 'but you don't know if she will do it again', but we could not take that chance. The SW stated the hospital determined Resident #18 had a UTI and because the resident refused to take medications, and she developed another UTI, the resident would not comply with treatment. The SW stated, no 30-day notice was given, no discharge summary was done. The SW stated, with a proper discharge, there would have to be a Discharge Planning Review, a Comprehensive Discharge Instruction Form, and the Final Discharge Summary completed. The SW stated, those forms were done collaboratively with herself and Nursing. The SW stated the aforementioned documents were not completed and should have been completed. The SW stated, we did not follow the policy, and that was not good, but thought that it was still proper (discharge) for the safety of the other residents.During an interview on 2/12/26 at 8:13 a.m., the DON stated, a proper discharge for a resident transferred to another facility or to their home consisted of a 30-day notice, arrangement for durable medical equipment, information regarding follow-up doctor appointments, and a supply of at least 7 days of medication provided to the resident at the time of discharge. The DON stated, in the case of an emergency situation in which a resident went to the hospital, the 30-day notice did not apply. The DON stated the discharge process consisted of three different assessments, which included a comprehensive assessment, a final discharge summary, and a discharge planning review. The DON stated that for a resident transferred to the hospital, a change of condition form was required. The DON stated Resident #18 was sent to the hospital related to physical aggression, and because of the aggression the resident was not allowed back to the facility for the safety of other residents and the staff. The DON stated he believed Resident #18 was accepted at another nursing facility but did not know where the resident was at the time of the interview. The DON stated, it was not a proper discharge, but we are obligated to keep everybody safe. The DON would not or could not elaborate on what a safe, proper discharge was.During an interview on 2/12/26 at 4:15 p.m., the Administrator stated, Resident #18 was diagnosed with a UTI while she was at the hospital beginning 1/19/26. The Administrator stated, the hospital would keep Resident #18 until she was ready to be discharged . The Administrator stated the SW reached out to the family about alternate placement while the resident was still in the hospital. The Administrator stated that the SW secured placement at another nursing facility and notified the resident's family member, but the family did not like the nursing facility Resident #18 had been referred to. The Administrator stated, we would not accept her (Resident #18) back because she was literally going after people, and it was an emergency, and if she comes back and hurts somebody, I felt like I did not have another choice, she (Resident #18) was that dangerous and in this care it was an emergency and a proper discharge. The Administrator stated she did not know where Resident #18 was at the time of the interview.Record review of the facility document titled Discharge Planning and Assessments with revision date 4/5/13 reflected in part, .Facility will develop and implement an effective discharge planning process that focuses on the resident's goals, the preparation of residents to be active partners and effectively transition them to post-discharge care.Social Services or Designee will complete a Discharge Planning Review in [computer system] prior to the first comprehensive assessment.This form must be updated, as needed, to reflect any changes that may have occurred until discharge status is confirmed.When the facility anticipates a resident's discharge to a private residence or another nursing care facility.the following actions must be completed, which will assist the resident to adjust to his or her new living environment.Medical Records or Designee to obtain a discharge order from the physician.Complete the following assessments in [computer system].Comprehensive Discharge Instruction Form [Post Discharge Plan]; and Final Discharge Summary.Final Discharge Summary.These summaries will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident.

Based on interview and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for 2 of 6 residents (Resident #3 and Resident #6) who were reviewed for resident assessments. 1. The facility failed to correctly document Resident #3's use of insulin injections on the quarterly MDS assessment. 2. The facility failed to correctly document Resident #6's use of antidepressant medications on the quarterly MDS assessment. These failures could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. The findings included: 1. Record review of Resident #3's admission sheet dated 01/13/2026 with an original admission date of 4/26/2022 documented a [AGE] year-old female resident with diagnoses including depression, cerebral infarction (stroke), type 2 diabetes mellitus, hyperlipidemia (high cholesterol), and hypertension (high blood pressure). Record review or Resident #3's MDS assessment dated [DATE] documented a BIMS score of 0 indicating severe cognitive impairment and recorded the use of antidepressant, anticoagulant, antibiotic, and hypoglycemic medications. Further review of the MDS noted an answer of 5 in Section N - Medications N0350 Insulin A. Insulin injections Record the number of days that insulin injections were received during the last 7 days or since admission if less than 7 days. Record review of Resident #3's order summary included an order for the insulin Humalog with an order date of 8/04/2025 and an order for the insulin Lantus with an order date of 01/13/2026. Humalog was ordered as Humalog 100 unit/mL, Inject as per sliding scale: if 100-149=0; 150-199=2; 200-249=4; 250-299=6; 300-349=8; 350-399=10 if>400 contact MD/NP. Lantus was ordered as Lantus 100 unit/mL, Inject 5 unit subcutaneously at bedtime. Record review of Resident #3's January 2026 MAR documented the resident received injections of Lantus on 7 days during the 7 day look back period from 01/14/2026 through 01/20/2026. Further review of the January MAR documented the resident received injections of Humalog on 7 days during the 7 day look back period from 01/14/2026 through 01/20/2026. Record review of Resident #3's care plan with an initiation date of 5/11/2022 documented the resident has Diabetes Mellitus with interventions including Monitor/document/report to MD PRN s/sx of hypoglycemia: Sweating, Tremor, Increased heart rate (Tachycardia), Pallor, Nervousness, Confusion, slurred speech, lack of coordination, Staggering gait and Monitor/document/report to MD PRN for s/sx of hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abd pain, Kussmaul breathing, acetone breath (smells fruity), stupor, coma. 2. Record review of Resident #6's admission sheet dated 5/03/2025 documented a [AGE] year-old male resident with diagnoses including dementia, depression, anxiety, hypertension, and chronic pain. Record review of Resident #6's MDS assessment dated [DATE] documented a BIMS score of 5 indicated severe cognitive impairment and recorded the use of antianxiety and opioid medications. Further review of the MDS revealed the assessment did not include the use of antidepressant medication in section N0415 High-Risk Drug Classes: Use and Indication. Record review of Resident #6's order summary included an order for the antidepressant medication Effexor XR with an order date of 6/29/2025. Effexor XR was ordered as Effexor XR 150 mg, Give 1 capsule by mouth one time a day. Record review of Resident #6's November 2025 MAR documented the resident had been receiving Effexor XR as prescribed during the 7 day look back period from 11/19/2025 through 11/25/2025. Record review of Resident #6's care plan with an initiation date of 5/05/2025 documented the resident uses antidepressant medication with interventions including Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness. ANTIDEPRESSANT SIDE EFFECTS: dry mouth, dry eyes, constipation, urinary retention, suicidal ideations. During an interview with the MDS Coordinator on 2/12/2026 at 9:45 AM, the MDS Coordinator stated they follow the RAI manual regarding formulation of the MDS assessment. The MDS Coordinator stated after they have gathered the information for the MDS assessment, she sends it to corporate for a scrub down and to make corrections if needed, then the assessment is given to the DON for signature before transmission. The MDS Coordinator stated the assessment should be accurate, and she was responsible for making sure it was accurate before it was transmitted. The MDS Coordinator stated it was important for the MDS to be accurate because it is a reflection of the care a resident is receiving at the facility. During an interview with the DON on 2/12/2026 at 10:09 AM the DON stated the MDS should be accurate in order to provide the best care for residents. The DON further stated his expectation for staff is to get the best, most accurate data for the MDS and care plan. During a second interview with the DON on 2/12/2026 at 11:12 AM, the DON stated they follow the RAI regarding MDS assessments. Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1, dated October 2025 noted in Section N: Medications The intent of the items in this section is to record the number of days, during the last 7 days (or since admission/entry or reentry if less than 7 days) that any type of injection, insulin, and/or select medications were received by the resident. Section N0415: High-Risk Drug Classes: Use and Indication noted Code all high-risk drug class medications according to their pharmacological classification, not how they are being used. Column 1: Check if the resident is taking any medications by pharmacological classification during the 7-day observation period (or since admission/entry or reentry if less than 7 days).

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 of 18 residents (Resident #5) reviewed for accidents and hazards:The facility failed to ensure Resident #5 did not have a pair of scissors in his room.This failure could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health. The findings included:Record review of Resident #5's face sheet dated 2/13/26 reflected a [AGE] year old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included reduced mobility, dementia, anxiety disorder, restless leg syndrome, and hemiplegia (complete paralysis of one side of the body) and hemiparesis (weakness of one side of the body) affecting right dominant side.Record review of Resident #5's most recent quarterly MDS assessment dated [DATE] reflected the resident was moderately cognitively impaired for daily decision-making skills and required substantial to maximal assistance with ADLs.Record review of Resident #5's comprehensive care plan with revision date 6/16/25 reflected the resident had an ADL self-care performance deficit related to impaired balance. Record review of Resident #5's Functional Abilities and Goals document dated 6/16/25 reflected the resident required substantial/maximal assistance with upper body dressing including the ability to dress and undress above the waist, including fasteners.During an observation on 2/12/26 at 9:34 a.m., Resident #5 was observed with a blue handle pair of scissors on the top of a chest of drawers located at the foot of the bed. During an observation on 2/13/26 at 8:06 a.m., Resident #5 was observed with a blue handle pair of scissors on the top of a dresser next to the resident's television. During an observation and interview on 2/13/26 at 8:09 a.m., CNA D observed a pair of blue handle scissors on Resident #5's dresser and stated, he probably should not have them (scissors) because it was a potential for an accident. CNA D stated items such as scissors, or disposable razors were sharp and could cause injury to the resident if it not used properly and it was also a hazard because there were other residents in the unit who wandered into resident rooms, and they could have access and get hurt. CNA D stated he tried to make rounds at least every two hours and sometimes more often and one of the things he looked for were items such as scissors. CNA D stated the scissors in Resident #5's room would have to be reported to the charge nurse or the administrative staff.During an interview on 2/13/26 at 8:15 a.m., Resident #5 stated he did not know there was a pair of blue handle scissors in his room and denied ever seeing them or using them.During a joint interview on 2/13/26 at 8:43 a.m., the DON and Administrator stated there was an ongoing issue with Resident #5's family taking scissors from the activity room and using them in the resident's room. The DON stated the facility had a system in process where a staff was assigned to a unit to monitor for items such as scissors and rounding occurred before their morning meetings or in the afternoons. The DON stated the facility had residents who wandered and for Resident #5 to be allowed to have access to the scissors, he would have to be assessed for safety, and it would have to be care planned. The Administrator stated, if a resident gained access to the scissors, they could cut themselves or hurt themselves. Record review of the facility document titled Safety and Supervision of Residents with revision date 12/13/17 reflected in part, .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes.Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 2 residents (Residents #5) reviewed for infection control:The facility failed to ensure CNA E utilized proper hand hygiene between glove changes and did not place a clean brief on the resident's bed during incontinent/peri-care on Resident #5. This failure could place residents at-risk for infection due to lack of hand hygiene and could result in infection or illness.The findings included:Record review of Resident #5's face sheet dated 2/13/26 reflected a [AGE] year old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included reduced mobility, dementia, anxiety disorder, restless leg syndrome, and hemiplegia (complete paralysis of one side of the body) and hemiparesis (weakness of one side of the body) affecting right dominant side.Record review of Resident #5's most recent quarterly MDS assessment dated [DATE] reflected the resident was moderately cognitively impaired for daily decision-making, required substantial to maximal assistance with ADLs, and was frequently incontinent of bladder and bowel. Record review of Resident #5's comprehensive care plan with revision date 6/16/25 reflected the resident had bladder incontinence with interventions that included for staff check for incontinence and wash, rinse, and dry perineum. Resident #5's comprehensive care plan reflected the resident was incontinent of bowel with interventions that included to check the resident every two hours, assist with toileting, and provide peri care after each incontinent episode.Observation on 2/12/26 at 9:34 a.m., during incontinent/peri care revealed Resident #5 was instructed by CNA E to roll over to his right and was observed with copious amounts of stool. CNA C handed CNA E disposable wipes and CNA E used several wipes to clean the stool off the resident. CNA E then removed the soiled brief from the bed and tossed it in the trash. CNA E then removed her soiled gloves, did not wash her hands with soap and water, sanitized her hands and put on a new pair of gloves. CNA E then took a clean brief and placed it on the resident's bed. CNA E then retrieved more disposable wipes from CNA C and continued to clean stool from Resident #5's anal area. CNA E then removed her gloves, did not wash her hands with soap and water, sanitized her hands, and put on a new pair of gloves. CNA E then took the brief resting on the bed and placed it on the resident. CNA E, after completing incontinent/peri care to Resident #5, fastened the resident's brief, took the resident's pajama pants and put them on Resident #5. CNA E then removed her gloves and sanitized her hands. During an interview on 2/12/26 at 9:50 a.m., CNA E stated she realized Resident #5 had stool and instead of sanitizing her hands, she should have washed her hands with soap and water because you never know if the glove is torn and it is a break in infection control and was considered cross contamination. CNA E stated she realized she should have washed her hands with soap and water after coming in contact with stool, but it was too late, I just messed up. CNA E stated, even though she continued to clean Resident #5's anal area to ensure there was no more stool, placing the clean brief on the bed she considered the area to be clean because the brief did not touch the resident's skin during that time. CNA E stated, if cross contamination had occurred, the resident could get an infection. CNA E stated competencies were done at least monthly, including incontinent/peri care and believed the last competency was done within the past two weeks. During an interview on 2/12/26 at 10:41 a.m., the DON stated he expected staff to use hand sanitizer between glove changes, unless there was stool, then the expectation would be for the staff to wash their hands with soap and water because there was a chance of coming in contact with stool. The DON stated it was considered an infection control issue and cross contamination which could result in passing an infection to the resident. The DON stated that the environment should be clean before the brief was placed on the bed, and when the aide placed the clean brief on the resident's bed, and continued to provide incontinent/peri care, at that point the brief should have been discarded as it was also considered cross contamination.Record review of the facility document titled Handwashing/Hand Hygiene with revision date 3/1/22 reflected in part, .This facility considers hand hygiene the primary means to prevent the spread of infections.All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations.When hands are visibly soiled.Use alcohol-based hand rub.or alternatively, soap.and water for the following situations.Before and after direct contact with residents.Before handling clean or soiled dressings.Before moving from a contaminated body site to a clean body site during resident care.After contact with a resident's intact skin.The use of gloves does not replace hand washing/hand hygiene.

Based on observation, interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation were reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse, to the State Survey Agency for 1 of 4 residents (Resident #1) reviewed for abuse. The facility did not report to the State Survey Agency (HHSC) an incident of Resident #1 being physically abused by the RP in the facility. This failure could place residents at risk for harm to include physical abuse, a diminished quality of life, and psychosocial harm. The findings included: Record review of Resident #1 's face sheet, dated 4/11/25 reflected resident was a female aged 81 admitted on [DATE] with diagnoses that included: UTI and sepsis (infection) at admissions, and dementia (disease leading to decline in memory, cognition, and activity of daily living). The RP was listed as: a family member. Record review of Resident#1's quarterly MDS, dated [DATE], revealed: the resident's BIMS score was zero (severely impaired in cognition). The resident was incontinent of both bowel and bladder and required maximum assistance with incontinent care. As for transfer and mobility, the resident required maximum assistance with two staff in transferring and bed mobility. Record review of Resident# 1's Care Plan, undated, revealed, the goals and interventions included: monitoring of combative and aggressive behaviors due to dementia. Interventions included: providing verbal cues, engage in calmed conversations, and re-direction. Record review of facility's incident log for the month of March 2025 reflected it did not document an incident of a family member or RP physically abusing Resident #1 in the presence of CNA A on 3/29/25. Record review of Resident#1's Skin Assessments completed by LVN B reflected: 3/29/25: Resident's skin was thoroughly inspected during routine assessment. No skin abnormalities, redness, bruising, or open areas were observed. Skin is intact and within normal limits. Record review of Resident #1's vitals on 3/19/25 reflected vitals within normal limits. Observation and interview on 4/10/25 at 11:00 AM, revealed Resident#1 was in bed, alert and oriented to person. There were no injuries, skin tears or bruises present. Her disposition was one of anxiety. The Resident had difficulties answering direct questions. Resident #1 said she did not remember how staff placed the brief when they change her. Resident #1 said she sometimes felt bad when staff turn her. No response was given by the resident regarding any complaints involving staff. [Resident became exhausted, and interview was ended by the surveyor] Observation and interview on 4/10/25 at 2:40 PM, revealed Resident #1 and RP were present for a joint interview. Resident #1 was sitting in a W/C and disengaged from the conversation. The RP stated he was restricted in his movements in the facility. The RP stated, the facility alleged that, the RP slapped her (Resident #1). The RP denied physically abusing Resident #1 on 3/29/25. During a brief interview on 4/10/25 at 3:15 PM, in a private setting without the presence of the RP, Resident #1 said she did not know if she was afraid of the RP or whether she had ever been abused by the RP in the facility. During an interview on 4/11/25 at 11:47 AM, the SW stated: there was an allegation by a CNA [A]) . the RP slapping the resident in the face in the resident's room. The SW stated, the facility decided to restrict the RP's' movement to common areas. The restriction was verbal and the RP agreed to visit the resident in the common area. The SW stated, the RP was informed that the facility needed to complete an investigation before allowing RP liberal visits in the resident's room. The SW stated that the allegation the RP slapped the resident was a reportable event to HHSC. The SW stated that she did not know why the event was not reported. The SW stated she fully knew the regulations on reporting abuse either by a staff member, resident, visitor, or a family member. During an interview on 4/11/25 at 1:04 PM, LVN B, stated: on 3/29/25, they were alerted by CNA A and LVN C that while Resident #1 was repositioned and agitated, the RP slapped the resident in the face and jaw to control the resident's agitation. LVN B stated that CNA A witnessed the physical abuse of Resident #1 by the RP. LVN B said it was absolutely a reportable event if a family member slapped a resident; and could be reportable to police as an assault. LVN B stated, the said incident was reported to the DON and the Administrator at the time of the incident. During an interview on 4/11/25 at 1:42 pm, CNA D stated: she assisted CNA A in transferring Resident #1 after lunch to her room to check on peri-care. CNA D stated, we explained the transfer procedures to the Resident and the RP who was present. CNA D stated, the resident attempted to strike the CNAs and the RP held the resident's hand. CNA D stated, the RP informed her that he was going to assist CNA A and no need existed for CNA D to stay in the room. CNA D stated, shortly after leaving Resident #1's room, she heard CNA A tell the RP that he could not slap the resident on the face. CNA D stated that she was trained on ANE and one of the highlights of the training was to report abuse. During an interview on 4/11/25 at 2:37 PM, the DON stated that there was an allegation made by CNA A that the RP slapped Resident #1 in the face during a transfer on 3/29/25 around 5:00 PM. The DON stated, CNA A informed LVN C of the alleged physical abuse of the resident by the RP. The DON was notified, and he notified the Abuse Coordinator. The DON stated law enforcement was not called. The DON stated the abuse incident by the RP was still under investigation by the facility. The DON stated that he was not sure whether the incident on 3/29/25 was reported to HHSC. The DON stated that all incidents of abuse whether from a staff member, visitor, or family member were reportable to HHSC; and could be reported to law enforcement. During a telephone interview on 4/11/25 at 2:45 PM, CNA A, stated: she witnessed Resident #1's RP slap her in the face on 3/29/25 in the late afternoon during a transfer from W/C to bed. CNA A stated, she and CNA D transferred Resident #1 back to her room and the RP was present. CNA A stated Resident #1 was agitated and combative. CNA A stated that the RP excused CNA D from the room and that he was going to assist CNA A with the transfer. CNA A stated that Resident #1 was resistant to the transfer and the RP slapped her on the face. CNA A stated, I told him it was abuse and he (the RP) should not have engaged in the abusive behavior. CNA A stated, she then informed LVN C about the abuse. CNA A stated that she was trained on ANE and learned to immediately report any incidents of abuse. During a telephone interview on 4/11/25 at 3:00 PM, LVN C stated: CNA A reported to her on 3/29/25 that she witnessed the RP slap Resident #1 in the face and chin during a transfer. LVN C stated she reported the alleged abuse to the DON. LVN C stated, she assessed the resident, and the resident's vitals were within limits, there was no psychosocial harm, and the skin was intact. The resident also did not exhibit any pain. LVN C stated she confronted the RP about the alleged abuse and he said nothing and left the facility. LVN C stated that she reminded the RP that he could not cause injury to a resident. LVN C stated she attended ANE in-service, and the highlight of the training was to report abuse to the Abuse Coordinator (the Administrator). During a telephone interview on 4/11/25 at 3:15 PM, the Administrator stated: she was informed of the incident on 3/29/25 where the RP slapped R#1 in the face witnessed by CNA A. The Administrator stated, on 4/1/25 she interviewed the RP, and he denied the abuse of Resident #1. The Administrator stated, that pending a facility investigation [not completed as of 4/11/25], out of safety for Resident#1, the RP needed to visit the resident in common areas. The Administrator stated the incident was not reported to law enforcement or HHSC. The Administrator stated that all allegations of abuse were reportable to HHSC. The Administrator did not provide a reason for not reporting the incident of physical abuse by the RP on 3/29/25 to HHSC within the 2 hours after an allegation of physical abuse of a resident was made by a staff member. Record review of Facility's policy titled. Abuse Neglect, dated revised 8/10/2022, read . Abuse is defined as the willful inflection of injury .resulting in physical harm, pain or mental anguish .Any employee or individual in the facility engages with that witness, suspect, or receive alleged statements of abuse .must report to the Administrator or Designated Representative according to the following: a. Immediately after the allegation is made, .The Administrator, DON, or Designated Representative will be responsible to report according to regulations including: a. DADS no later than 2 hours following discover[y] .

Based on observations, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and environment that promoted personal privacy for each resident's individuality for 1 (Resident #6) of 12 residents reviewed for dignity in that: Resident #6's Foley catheter bag was observed without a privacy cover on it to provide dignity and privacy. This failure could affect the privacy and dignity of residents with Foley catheters. Findings included: Record review of Resident #6's face sheet revealed Resident #6 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included pneumonia (an infection that inflames one or both lungs), acute respiratory failure with hypoxia (caused when a person does not have enough oxygen in the blood) and reflux uropathy (a urinary tract obstruction). Record review of Resident #6's care plan, date initiated 02/24/2025 revealed Resident #6 had an indwelling Foley catheter and the potential to display physical and verbally abusive behaviors related to Dementia (a general term for impaired ability to remember, think or make decisions). Record review of Resident #6's February MAR revealed an order that stated, verify privacy bag in place every shift, order date was 02/23/2025. The MAR is initialed as completed on every shift for 02/24/2025, 02/25/2025, 02/26/2025 and 02/27/2025. Observation of Resident #6 on 02/27/2025 at 10:35 a.m., revealed the resident was in bed, asleep, with his door open. Resident #6 had a Foley catheter bag hanging on the side of the bed facing the door making it visible to anyone who walked by the room. The bag contained a yellow fluid and did not have a cover to provide privacy. During an interview with CNA A, 02/27/2025 at 11:05 a.m., CNA A stated she was the CNA assigned to provide care to Resident #6 that day. CNA A stated Resident #6 did not have a privacy cover over his Foley bag. CNA A stated the nurses were responsible for placing the privacy covers over the bags and CNA A stated she did not have access to the privacy covers. CNA A stated the privacy bags were important because no one needs to see their business and what output they had and stated the privacy covers should be on at all times. During an interview with LVN B, 02/27/2025 at 11:51 a.m., LVN B stated she was the charge nurse assigned to provide care to Resident #6 that day and stated that Resident #6 did not have a privacy cover over his Foley catheter bag. LVN B stated the nurses and CNAs were responsible for ensuring the privacy covers were on the bags. LVN B stated the covers were important to provide privacy to the resident. LVN B stated she had been trained on the importance of privacy covers in orientation. During an interview with the DON, 03/04/2025 at 8:58 a.m., the DON stated that all staff were responsible for making sure catheter bags had privacy covers when rounding in the facility and stated the CNAs and nurses were responsible for providing the providing the Foley catheter bags with privacy covers. The DON stated all residents should have privacy covers on the Foley catheter bags at all times. The DON stated he was not sure when facility staff received training on providing privacy to residents by using privacy covers on the catheter bags but stated it was important for the resident's dignity and their right to privacy. Record review of a facility document titled, Resident's Rights in Nursing Homes (dated April 2019), stated in part that a resident has the right to privacy and confidentiality, including the right to privacy in treatment, and the care of their personal needs and confidentiality regarding their medical, personal or financial affairs. It also stated residents had the right to dignity, respect and freedom including the right to be treated with the fullest measure of consideration, respect and dignity.

Based on observation, interview and record review, the facility failed to notify the residents representative when the resident experienced a change in physical condition for 1 (Resident #1) of 12 residents reviewed for change in condition. The facility failed to notify Resident #1's resident representative when Resident #1 had episodes of diarrhea, a temperature and exhibited increased lethargy. This failure could result in the family or guardian not being aware of conditions that may require them to make medical decisions. The findings included: Record review of Resident #1's undated face sheet revealed Resident #1 was a [AGE] year old female who admitted to the facility in 06/15/2023 and had diagnoses that included Kidney Failure (a condition in which the kidneys can no longer filter waste products from the blood sufficiently), Dementia (a general term for impaired ability to remember, think, or make decisions), Edema (swelling caused by excess fluid trapped in the body's tissues), Type II Diabetes (a disease that occurs when a person's blood sugar is too high), Peripheral Vascular Disease (narrowing of the blood vessels), Hypertension (high blood pressure) surgical amputation (surgical removal of a limb) and morbid obesity (defined as having a body mass index of 40 or higher). Record review of Resident #1's undated face sheet revealed Resident #1 family member was listed as responsible party, POA -Financial, POA -Care, Substitute Decision Maker, Care Conference Person and Emergency Contact #1. Record review of Resident #1's quarterly MDS assessment, dated 02/08/2025, revealed a BIMS score of 9, indicating moderate cognitive impairment. Record review of Resident #1's care plan, date initiated 06/16/2023, revealed Resident #1 had care plan that reflected the resident had a history of osteomyelitis (an infection in the bone) and was at risk for future infections. The care plan was updated 02/07/2025 to reflect Resident #1 readmitted from the hospital with antibiotics for colitis (inflammation of the lining of the colon) x 7 days and 2/13/2025 Resident #1 was on antibiotics for the flu x 7 days. Resident #1 also had a care plan for Dementia, Diabetes, Hypertension, Peripheral Vascular Disease and full code status. Record review of Resident #1's progress note written by LVN H, dated 2/24/2025 at 1:00 p.m., revealed, LVN H notified NP N that Resident #1 has a slight temperature of 101.2 [degrees Fahrenheit], B/P 125/69, pulse 89, Res. 18, 02 is 95RA. Informed resident has no appetite, had three episodes of diarrhea and that resident was previously hospitalized with Dx of ileus (temporary and often painful lack of movement in the bowels that can lead to a bowel obstruction) and proctocolitis (a general term for inflammation of the rectum and colon). New order received for a STAT KUB, CBC, CMP. Record review of Resident #1's progress note written by the DON, dated 02/24/2025 at 8:50 p.m., revealed, during morning clinical, it was reported that the resident was not feeling well and had experienced a loose bowel movement the previous afternoon. The resident's vital signs obtained that morning were blood pressure 116/70 mmHg, temperature 99.1F (temporal), heart rate 85bpm, and respiratory rate 19 breaths per minute. The Nurse Practitioner was notified promptly, and stat orders were obtained for a KUB, CBC and CMP at approximately 11:30 a.m. At 4:30 p.m., the [resident's family member] stated that the resident was not feeling well; upon immediate reassessment, the resident exhibited an altered mental status, being non-verbal and responding only to gentle stimuli. At that time, the resident's vital signs had declined to blood pressure 88/52 mmHg, temperature 97.9F, heart rate 86 bpm, and respiratory rate 17 breaths per minute. Due to this rapid deterioration in her condition, a 911 emergency call was placed, and the resident was transferred to the hospital, with the resident's [family member] escorting her to the hospital. During an interview with Resident #1's family member, 02/26/2025 at 3:30 p.m., Resident #1's family member stated she arrived at the facility on 2/24/2025 around 4:30 p.m. to visit Resident #1. The family member stated no one had called her during the day to tell her that Resident #1 was having a change in condition. The family member said when she entered Resident #1's room she immediately knew something was wrong and said she looked like a corpse and her face looked swollen. I went to the charge nurse and told her that I wanted [Resident #1] sent out to the hospital and she said she had to call the Nurse Practitioner and get an order to send her out. The DON came in the room to check on her and her blood pressure was 85/52 when EMS got there. She was sent to the hospital, and she was being treated for a change in her dementia, low potassium and an infection of sort. I don't think they know yet. During an interview with the Hospital RN, 02/27/2025 at 3:45 p.m., the hospital RN stated Resident #1's admitting diagnosis was altered mental status, hypotension (low blood pressure), acute kidney injury (reduce in kidney function), and C-Diff (a highly contagious bacterium that causes diarrhea and colitis often infects people who've recently taken antibiotics).The Hospital RN stated the acute kidney injury was likely contributed to the diarrhea with the CDIFF and the CDIFF was a side effect of the recent usage of antibiotics to treat previous infections. During an interview with LVN H, 02/28/2025 at 3:11 p.m., LVN H stated she was notified on Monday, 02/24/2025, by the CNA that Resident #1 was having diarrhea and the CNA had asked for a medication to be administered. LVN H stated she obtained Resident #1's vitals and then notified NP N around 12:00 p.m. of the temperature and diarrhea. LVN H stated she provided NP N a background of Resident #1's recent hospitalization for an ileus so NP N ordered a STAT KUB, CBC and CMP. LVN H said she entered the orders for the stat labs and stated Resident #1's family member came in later in the day and I told her I had not had a chance to call her yet, but we were doing STAT labs for [Resident #1] because of the diarrhea and temperature. LVN H stated Resident #1's family member became upset and was yelling and stating Resident #1 looked bad and she wanted her sent out 911. LVN H stated she told the family member that she had to call and get an order from NP N to send her out and Resident #1's family member stated she did not want to wait for the labs to come back and wanted Resident #1 assessed in the hospital. LVN H stated she spoke to NP N and she gave orders to send Resident #1 to the hospital for an evaluation. During an interview with LVN H, 03/02/2025 at 11:35 a.m. LVN H stated she did not notify Resident #1's responsible party at the time of the change in condition and she should have notified the responsible party around the same time she notified NP N of the changes in condition Resident #1 was experiencing. LVN H stated she last observed Resident #1 around 4 p.m. when she completed an accu check for Resident #1 and stated Resident #1's blood sugar was 98. LVN H stated she provided Resident #1 some orange juice. LVN H stated Resident #1 was talking and alert at that time. LVN H stated Resident #1's responsible party arrived at the facility around 4:30 p.m. and that was when she notified her of the change in condition. LVN H stated it was important to notify the responsible at the time of the change of condition so they are aware. During an interview with the DON, 03/04/2025 at 8:58 a.m., the DON stated that staff had received training on notifying the physician and responsible party when a resident has a change in condition. The DON stated some examples of changes in condition included fever, abnormal labs, not eating, and skin tears or breakdown. The DON stated that LVN H failed to notify Resident #1's responsible party at the time of the change in condition and stated it was extremely important to notify the responsible party. The DON stated LVN H got busy with an admission or it was lunch time but yes, she should have called. The DON stated staff had received training on changes in condition and notifications as recently as 01/30/2025. During an interview with NP N, 03/04/2025 at 11:50 a.m., NP N stated she started providing clinical services to the facility on [DATE]. NP N stated she was notified by LVN H on 02/24/2025 around noon that Resident #1 was having diarrhea, was not feeling well and had a slight temperature and all other vitals were ok. NP N stated LVN H informed NP N of Resident #1 history of a recent ileus and NP N ordered a STAT KUB, CMP and CBC. NP N stated she was notified later in the day by a nurse that the [family member] was at the facility and the resident was continuing to decline and wanted her to go to the hospital and NP N stated she gave the orders to send Resident #1 to the hospital for evaluation. Record review of a facility document titled, [Facility Name] Inservice Education, revealed an in-service topic, Importance of Reporting Changes of Condition, dated 01/22/2025 and listed the Instructor as the DON. The in-service revealed, Monitoring and reporting changes in a resident's condition is a critical part of ensuring their safety and well-being. Early detection of subtle changes, such as unusual behavior, altered mental status, changes in appetite, or new physical symptoms, can be a sign of an underlying health issue. By promptly recognizing and reporting these changes, nurses can initiate early interventions that may prevent condition from worsening. Failure to report these changes can delay treatment, leading to complications or even life-threatening situations. Nurses are responsible for completing the Change of Condition (COC) assessment in (PCC) to ensure proper documentation of any changes. They must also promptly notify the resident's physician, family and the Director of Nursing to ensure a coordinated response. Timely reporting saves lives by notifying providers to identify potential problems before they escalate, enabling early treatment and improved outcomes. The document was signed by 25 direct care employees. Record review of a facility document titled, [Facility Name] Inservice Education, revealed an in-service topic, Change of Condition and Notification, dated 02/25/2025 and listed the Instructor as the DON. The in-service revealed, All nursing staff are required to complete a change in condition report immediately for any resident showing signs of illness or when it is reported that a resident is not feeling well, with immediate notification to the attending physician and family members; failure to follow these protocols will be considered a serious breach of policy and may result in disciplinary action, up to and including termination. The document was signed by 20 direct care staff including LVN H.

Based on observation, interview, and record review, the facility failed to provide care and services to prevent complications for 1 (Resident# 6) of 3 residents reviewed for enteral nutrition, in that; Resident #6's enteral feeding order did not include a frequency for changing the formula bottle or tubing. This failure could affect residents receiving enteral feedings by placing them at risk of complications related to expired formula, clogged tubing, delay in care and decline in health. The findings included: Record review of Resident #6's face sheet revealed Resident #6 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included pneumonia (an infection that inflames one or both lungs), acute respiratory failure with hypoxia (caused when a person does not have enough oxygen in the blood) and reflux uropathy (a urinary tract obstruction). Record review of Resident #6's care plan, date initiated [DATE], revealed Resident #6 required a tube feeding related to Dysphagia (difficulty swallowing) and stated Resident #6 was dependent for tube feedings and water flushes. Record review, [DATE] at 12:14 p.m., of Resident #6 February 2025 MAR revealed, Enteral Feed Order. Every shift formula: Jevity 1.2 at 20ml/hr for 24 hours. The order date was [DATE] at 10:57 p.m. The MAR was initialed as completed on [DATE], [DATE] and [DATE] on shifts 6 a.m. -2 p.m., 2 p.m. -10 p.m., 10 pm. - 6 a.m., and on [DATE] on 6 a.m. -2 p.m. Record review, [DATE] at 12:41 p.m., of Resident #6's February 2025 MAR revealed,, change all tubing and hang new formula of Jevity 1.2 to run at 20ml/hr one time a day for enteral feed, order date [DATE] at 12:34 p.m. The MAR reflected a scheduled time of 1:00 a.m. daily. During an observation, [DATE] at 10:35 a.m., Resident #6 was observed lying in bed in his room. Resident #6's tube feeding formula was on a feeding pump and the pump was running at a rate of 20ml/hr. The tube feeding formula was a 1500ml bottle of Jevity 1.2 and it was dated [DATE] at 1030hrs. During an observation, [DATE] at 3:05p.m., Resident #6 was observed lying in bed in his room. Resident #6's feeding pump was running at a rate of 20ml/hr. The Jevity 1.2 bottle was dated [DATE] at 12:45 p.m. During an observation, [DATE] at 1:44 p.m., Resident #6 was observed lying in bed in his room. Resident #6's feeding pump was running at a rate of 20ml/hr. The Jevity 1.2 bottle was dated [DATE] at 12:45 p.m. During an interview with LVN B, [DATE] at 11:51a.m., LVN B stated Resident #6's Jevity formula was dated [DATE] and stated 1030hrs meant the bottle was hung at 10:30 a.m. LVN B stated she knew when to change a resident's formula and tubing because it was reflected in a resident's administration record. LVN B stated Resident #6's orders did not specify when to change the tubing and formula and stated the order should have had included how often the tubing and formula should be changed. LVN B stated her initials on the MAR on [DATE] for the 6 a.m.- 2p.m. shift meant that Resident #6's formula was running but she had not changed the formula or the tubing. During an interview with the LVN B, [DATE] at 3:04 p.m., LVN B stated she hung a new formula bag and changed out the tubing for Resident #6. LVN B said she clarified the administration order for Resident #6 to include changing the tubing and formula once a day. During an interview with the facility Dietician, [DATE] at 12:50 p.m., the Dietician stated she was notified of Resident #6's admission on [DATE] and was planning to assess Resident #6 and increase his tube feeding rate on [DATE]. The Dietician stated the tube feeding orders should include a frequency on changing the tubing and the formula and stated that should be completed every 24 hours. The Dietician stated she did not give the original order and stated the facility must have received it from the hospital and had not clarified it. The Dietician stated the order was corrected to include a frequency for changing the formula and tubing on [DATE]. The Dietician stated Resident #6's feedings were running at a rate of 20ml/hr because Resident #6 had been an aspiration risk. The Dietician stated the tube feeding formula would expire after being hung for 48 hours. The Dietician stated the original order, without clarification of when to change the tubing and formula, could cause the formula to expire leading to the resident receiving expired nutritional formula. During an interview with the DON, [DATE] at 8:58 a.m., the DON stated that tube feeding orders from the hospital for a new admission are entered in the administration record by the admitting nurse and then the nurse managers, including himself, review the orders in the clinical meeting to validate accuracy. The DON stated that the facility policy was that tube feeding tubing had to be changed every 24 hours and a new bottle of formula would be hung with the new tubing because the bottle cannot be re-spiked (reinserted). The DON said staff had been educated that tubing should be changed every 24 hours and the staff have to sign off on it in the MAR as being completed. The DON stated if a resident's formula expired, or the tubing was not changed it could cause the resident to become sick or contract an infection. Record review of [Product Manufacturer] Product Information Sheet for Jevity 1.2 Cal, updated [DATE], revealed in part for ready to hang containers hang product up to 48 hours when clean technique and only one screw cap set is used. Record review of facility policy titled, Administration Set Changes with revision date of [DATE], revealed the purpose of the policy was to provide guidelines for aseptic administration set changes in order to prevent infections associated with contaminated IV therapy equipment and stated, if parenteral nutrition is administered continuously or intermittently, change administration set every 24 hours.

Based on interview and record review, the facility failed to have complete and accurate documented medical records for 1 (Resident #1) of 12 residents whose clinical record was reviewed for accuracy. The facility failed to identify and discontinue an order for a fluid restriction for Resident #1 that was listed on Resident #1's MAR twice and listed as an intervention in Resident #1's care plan. This deficient practice could place residents at risk for not receiving necessary care and services due to the staff not having an accurate record upon which to make care decisions. The findings included: Record review of Resident #1's undated face sheet revealed Resident #1 was an [AGE] year old female who admitted to the facility in 06/15/2023 and had diagnoses that included Kidney Failure (a condition in which the kidneys can no longer filter waste products from the blood sufficiently), Dementia (a general term for impaired ability to remember, think, or make decisions), Edema (swelling caused by excess fluid trapped in the body's tissues), Type II Diabetes (a disease that occurs when a person's blood sugar is too high), Peripheral Vascular Disease (narrowing of the blood vessels), Hypertension (high blood pressure) surgical Amputation (surgical removal of a limb) and Morbid Obesity (defined as having a body mass index of 40 or higher). Record review of Resident #1's quarterly MDS assessment, dated 02/08/2025, revealed a BIMS score of 9, indicating moderate cognitive impairment. Section J - Health Conditions revealed Resident #1 had not been dehydrated at the time of the MDS assessment. Section K -Swallowing/Nutritional Status revealed Resident #1 had not had weight loss or weight gain at the time of the assessment and was on a therapeutic diet (e.g., low salt, diabetic, low cholesterol). Section M -Skin Conditions revealed Resident #1 did not have any ulcers or wounds at the time of the assessment. Record review of Resident #1's care plan revealed Resident #1 had a care plan, date initiated 06/16/2023, that reflected, Nutrition: at risk for changes and was updated 12/28/2023 to reflect Resident #1 was on a CCD/NAS (no added salt) diet, regular texture, thin consistency. An intervention listed on the nutrition care plan was, 07/28/23 Fluid restriction 300cc 6-2pm-125mls, 2-10pm -125mls and 10-6am 50mls 3 x a day for fluid monitoring, dated initiated 07/31/2023. Resident #1 had a care plan that reflected she was on diuretic therapy related to edema, date initiated 07/27/2023. Record review of Resident #1's February 2025 MAR, dated 08/19/2023 revealed, Fluid restriction Nursing-300cc - 6-2p, - 125mls, 2-10pm 125mls and 10-6am 50mls every shift for fluid monitoring. The order was initialed as completed on the MAR on all 3 shifts. Resident #1's MAR revealed a duplicate order for the same fluid restriction and was also initialed as completed. Record review of Resident #1's Nutritional Comprehensive Assessment, effective date 02/11/2025, by the Dietician revealed Resident #1's current food and fluid intake at the time of the assessment was 75% and listed a nutrition goal of 2470cc of fluid per day. Record review of Resident #1's assessment titled, Dietary Profile Admission/Change of Status/Quarterly, and completed by the Dietary Manager or the Dietician on 06/16/2023, 03/18/2024, 06/17/2024, 09/23/2024, 12/24/2024 and 02/10/2025 revealed Resident #1 was not on a fluid restriction. A Dietary Profile assessment completed by the Dietitian on 09/19/2023 and 12/18/2023 revealed Resident #1 was on a 1500cc fluid restriction. Record review of a facility document titled, Diet Order & Communication, listed Resident #1 name, indicated with a check mark the communication form was for a diet change. Under a section titled, Restrictions/Modifications, the Fluid Restriction option was circled and 900 was written in the space for the amount of mls/24hrs. Beside the number 900 reflected (Dietary) and beneath it reflected, Nursing = 300mls. The document was signed by an LVN and dated 07/27/2023. Record review of Resident #1's meal tray ticket, dated 02/23/2025, revealed Resident #1 was on a 300cc fluid restriction per day. Fluids listed on Resident #1's breakfast tray card was Milk 8 oz, Coffee or hot tea 6 oz, and orange juice 4 oz., Lunch and Dinner fluid listed was Tea of choice 6 oz. During an interview with CNA A, 02/27/2025 at 11:05 a.m., CNA A stated she was not aware of Resident #1 being on a fluid restriction. CNA A stated she did not usually provide direct care to Resident #1 but would see Resident #1 at meals in the dining room and stated she always had juice, tea, and water on her tray and she knew other staff would get her cokes and other drinks. During an interview with LVN D, 02/28/2025 at 8:45 a.m., LVN D stated she no longer worked at the facility but stated she had worked with Resident #1 and that Resident #1 had always been on a fluid restriction. LVN D stated she could not remember the exact amount of the fluid restriction but thought it was 1200cc or 1500cc a day. LVN D stated she did not know why Resident #1 was on a fluid restriction. During an interview with LVN E, 02/28/2025 at 9:53 a.m., LVN E stated Resident #1 was on a fluid restriction, but LVN E did not know how much. LVN E stated the fluid restriction was listed on the MAR and care plan and she believed Resident #1 was on the fluid restriction due to edema. LVN E stated nursing was responsible for communicating fluid restrictions to dietary so the fluid restriction dietary was provided would have been the same as the order in Resident #1's MAR. During an interview with CNA G, 02/28/2025 at 10:44 a.m., CNA G stated she was not sure if Resident #1 was on a fluid restriction and stated Resident #1 always had at least 2 drinks on her meal trays and CNA G stated she would fill up Resident #1 water pitcher in her room each day. CNA G stated she had not seen a fluid restriction listed with Resident #1's diet on the resident's profile in the computer where a fluid restriction would be listed. During an interview with the Dietician, 02/28/2025 at 12:50 p.m., the Dietician stated the physician was responsible for prescribing a fluid restriction and it should have been reevaluated by the physician probably monthly I would say. The Dietician stated Resident #1's order in the administration record said Resident #1 had a fluid restriction with nursing for 300cc but stated the order did not look right and stated that was not how the fluid restriction orders were written. The Dietician stated there was a duplicate order in the MAR and it did not make any sense to her that the order was for nursing only. The Dietician stated she completed dietary profiles on Resident #1 monthly and did not recall her being on a fluid restriction. During an interview with CNA C, 02/28/2025 at 3:03 p.m., CNA C stated she did not think Resident #1 had a fluid restriction and she would give Resident #1 the Dr. Pepper's Resident #1 kept in her refrigerator. CNA C stated she passed fresh ice water to Resident #1 at the start of each shift and Resident #1 always drank the water. CNA C also stated she observed fluids on Resident #1's meal trays and Resident #1 would ask for additional coffee and would be served. CNA C stated she would know if a resident was on a fluid restriction because it would be reflected at the top of a resident's profile in the computer and it was not listed there. During an interview with LVN H, 02/28/2025 at 3:11 p.m., LVN H stated Resident #1 was on a 1500cc fluid restriction and stated the fluid restriction was on Resident #1's MAR that the nurses had to sign off on and stated dietary gave Resident #1 300cc at each meal. LVN H looked at Resident #1's MAR and stated it did not say 1500cc and she thought it used to say 1500cc. LVN H stated Resident #1 carried around a large cup that was always full of fluid and Resident #1 was noncompliant with the fluid restriction. LVN H stated Resident #1's family member would bring her drinks for her refrigerator and flavor packets to mix in her water and Resident #1 would always get water and fluids from the drink stations provided in the facility. LVN H stated Resident #1 was put on a fluid restriction a long time ago after going to a doctor appointment for edema and fluid retention. During an interview with Resident #1's Responsible Party, 02/28/2025 at 4:45 p.m., the Responsible Party stated Resident #1 was on a fluid restriction a long time ago when Resident #1 went to a kidney doctor and that doctor told her she was retaining fluids and had edema. The Responsible Party stated Resident #1 had been seeing a nephrologist for years prior to admitting to the facility and had kidney issues for a long time but stated she did not think Resident #1 was currently on a fluid restriction. The responsible party stated if Resident #1 was on a fluid restriction she would not have been compliant and stated Resident #1 did what she wanted and she loved her drinks and she drank what she wanted and when she wanted. The Responsible Party stated Resident #1 was always carrying around a large cup and the she (Responsible Party) never had concerns about Resident #1 not getting enough fluids. During an interview with the Dietary Manager, 03/03/2025 at 9:41 a.m., the Dietary Manager stated she received a diet communication form from nursing on new admissions and readmission residents that included the type of diet the resident was on and if the resident was on a fluid restriction. The Dietary Manager stated she entered the diet information into her tray card system and the diet would appear on each resident's tray card along with their food preferences. The Dietary Manager stated she was provided a dietary communication form by a nurse a long time ago and said Resident #1 was on a 300cc a day diet. The Dietary Manager stated she felt that number was very odd but did not question the fluid restriction. The Dietary Manager stated she provided Resident #1 10 oz of fluid at each meal. The Dietary Manager stated she tried to audit her diet tickets about once a month and stated if Resident #1 returned from a hospital stay and The Dietary Manager did not receive a new diet communication form, the Dietary Manager would just continue what was already on the tray ticket. During an interview with LVN H, 03/03/2025 at 11:35 a.m., LVN H stated she believed Resident #1's fluid restriction originated from a vascular surgeon appointment Resident #1 went to a few months after her admission because her amputation stump was swollen. LVN H stated she remembered there being an order that the DON put in the system and nursing was providing 300cc of fluid a day and dietary would provide 300cc each meal. LVN H stated she did not know why the order was entered like it was and believed the order had been entered wrong. During an interview with NP M, 03/03/2025 at 1:16 p.m., NP M stated she reviewed a resident's prescribed orders every time she would assess a resident and stated fluid restrictions were usually determined by the resident physician or outside specialist and was monitored by the facility. NP M stated she did not know when Resident #1 was placed on a 300cc fluid restriction and stated That is not a normal order,. I do not know if she came back from the hospital with that order or where that came from. I cannot imagine the facility was following that order. The group I work for was not even seeing patients in the building at that time when it was ordered. NP M stated she never saw that fluid restriction in her orders and stated, It had to have been buried way back in her orders because I would have questioned that. NP M stated, That is not a common fluid restriction, and she is not even a dialysis patient. A nephrologist would not even order that. During an interview with Resident #1's facility Physician,03/03/2025 at 3:02 p.m., the Physician stated he was not aware that Resident #1 was on a fluid restriction and stated, I know she had the flu and diarrhea and I know she was in and out of the hospital. I am not sure what fluid restriction you are talking about. The Physician stated, If we do a fluid restriction it would not be 300cc.; 3000cc maybe or 1500cc, but that is not correct. We would not have been following that. I think someone missed a zero The Physician stated, This is the first time I am hearing about this whatsoever. She would be dehydrated in a week if she had that for 2 years. There is no way. The Physician stated he reviewed residents' orders monthly and did not recall seeing Resident #1's fluid restriction. During an interview with the MDS Nurse, 03/04/2025 a 11:34 a.m., the MDS Nurse stated she was responsible for completing and updating resident care plans. The MDS Nurse stated she was not aware that Resident #1 was on a fluid restriction and MDS Nurse stated she reviewed the care plans quarterly and updated the care plan as needed when a change occurred. The MDS Nurse stated reviewing a residents' orders and care plan was part of the MDS assessment process when an MDS and care plan was updated quarterly or annually. During an interview with the DON, 03/04/2025 at 8:58 a.m., the DON stated a physician would have given a fluid restriction order and some of the reasons a resident was placed on a fluid restriction included dialysis, heart problems, edema or kidney problems. The DON stated when a fluid restriction order was received by a nurse for a resident, that nurse would have entered the order in the resident's MAR provided a dietary communication form to dietary to inform dietary of the fluid restriction. The DON stated staff were able to identify residents on a fluid restriction because the fluid restriction was listed in the resident Kardex (summary of resident plan of care) that contained profile information. The DON stated the facility had a subcommittee meeting that meets monthly to discuss resident weights, fluid restriction, skin changes, etc. and stated he did not think they had discussed Resident #1. The DON stated he thought Resident #1 was on a 1200cc diet and then looked in Resident #1's chart and stated he could not find the 1200cc anywhere mentioned in the orders or notes. The DON said Resident #1 was discussed in the clinical meeting around 02/06/2025 or 02/13/2025 and the DON thought Resident #1 was on a 1200cc fluid restriction. The DON stated no one had looked at the orders and stated the Dietary Manager was not at the meeting that day and stated, We should have looked at it. There is no excuse but the order for the 300 cc probably should have been discontinued a long time ago and it was not. The DON said Resident #1 was very noncompliant with her fluid restriction and would drink whatever she wanted to drink, including coffee in the morning and multiple hot cocoas at lunch or dinner meals in addition to other fluids and her family brought her snacks and drinks. The DON said, since becoming DON of the facility in December 2024, when a resident admitted to the facility or returned from the hospital, the nursing managers reviewed the hospital orders and orders added to the resident's MAR to validate accuracy of the transcribed orders. During an interview with the DON, 03/04/2025 at 1:38 p.m., the DON stated that when a resident returned from the hospital, the nursing staff reviewed the hospital orders and got clarification orders as needed. The DON stated when Resident #1 would return from hospital stays, the DON thought the fluid restriction orders were entered as part of the standard house orders for Resident #1 and that was why the order was reinstated each time she returned from the hospital. The DON stated the fluid restriction should have been discontinued and that NP M and the physician were not aware of Resident #1 being on a fluid restriction. The DON stated the facility did not have a policy for fluid restriction.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 of 7 residents (Residents #121 and #55) reviewed for infection control in that: 1. The facility failed to ensure CNA-A followed proper infection control practices while providing peri -care to Resident #121 by not wiping in the proper direction (front to back) and by not changing her gloves after going from dirty to clean. 2. The facility failed to ensure LVN-C followed Enhanced Barrier Precautions (EBP) when she did not wear a gown while administering medications via g-tube for Resident #55. These failures could place residents at risk for cross contamination and the spread of infection. Finding include: 1. Record review of Resident #121's face sheet dated 11/22/2024 revealed he was a [AGE] year-old male admitted to the facility initially on 07/11/2023 with re-admission on 11/13/2024, with diagnoses that included: Encounter for surgical aftercare following surgery on the skin and subcutaneous tissue; Epididymitis (Inflammation of coiled tube that stores and carries sperm in scrotum); and obstructive and reflux uropathy (condition where flow of urine is blocked). Record review of Resident #121's Quarterly MDS assessment dated ,d+[DATE] revealed a BIMS score of 15, indicating normal cognition. Review of Section GG - Functional Abilities and Goals, revealed he was assessed at 01 - Dependent for toileting hygiene, indicating helper does ALL the effort. Record review of Resident #121's Care plan initiated 07/23/2023 revealed a focus area of incontinent of bowel and bladder with risk for complications, with goal to remain free from skin breakdown due to incontinence and indwelling catheter dx [diagnosis] obstructive uropathy and urethral stricture' with goal to show no s/sx [signs or symptoms] of urinary infection. Record review of Resident #121's Order Summary dated 11/22/2024 includes orders for: Foley cath [catheter] care q [each] shift and prn [as needed], and staff to clean penis (urethra) daily to prevent infection. Observation of peri-care for Resident #121 on 11/20/2024 at 01:54 p.m., revealed CNA-A wiped from back to front while cleansing his buttocks/anal area, pushing material cleaned from anal area towards a surgical wound dressing on his scrotum, changing direction of wipe only after verbal intervention from assisting CNA-B, and then after cleansing the buttocks area, did not wash her hands or change gloves before placing a clean brief under the resident and assisting in re-dressing and repositioning him. Interview with CNA-A on 11/20/2024 at 2:10 p.m. revealed CNA-A had worked at the facility for 3 years and did not know why she had wiped in the wrong direction and was not aware that she had forgotten to wash her hands/change gloves after cleaning the resident's buttocks area and before placing a clean brief and repositioning the resident. She stated she had received training in peri-care and passed the performance checks. Interview with CNA-B on 11/20/2024 at 2:13 p.m. revealed she had worked at the facility about 8 months, but had many years experience as a CNA in other facilities prior to working at this facility. She stated she did observe CNA-A wipe in the wrong direction when cleansing the buttocks area and had told her she was wiping in wrong direction. CNA-B also stated that she observed CNA-A did not wash her hands or change gloves after completing cleansing of buttocks area, and verbally asked CNA-A to change her gloves before moving on, but stated CNA-A may not have heard her, as she did not change her gloves. CNA-B stated it was important to wipe from front to back, and to change gloves when going from dirty to clean to prevent infection. During an interview with the DON on 11/21/2024 at 09:00 a.m., the DON stated when performing peri-care, cleansing wipes should always be done front to back, and hands should be washed and gloves changed when moving from dirty to clean. The DON stated that CNA-A received training and passed performance checklists in peri-care and had always done a good job, so the DON was surprised with the observation. Record review of Personnel Competency Review for CNA-A in area of Perineal Care, dated 8/14/2024 revealed CNA-A had passed all areas of competency for perineal care, including: cleanse skin folds from front to back, and to wash hands and change gloves after step of cleansing rectal area/buttocks and wiping downward on thighs Review of facility policy titled Perineal Care revised 10-3-2016 revealed directions for step 12. Remove gloves and discard into designated container. Wash and dry your hands thoroughly. Then step 13. Reposition the bed covers, make resident comfortable. 2. Record review of Resident #55's face sheet dated 11/22/2024 revealed he was a [AGE] year-old male who was admitted on [DATE], with diagnoses that included: Acute Cerebrovascular Insufficiency (obstruction of one or more arteries supply blood to brain); Dysphagia (difficulty swallowing food/liquids), and Gastrostomy Status (has surgical opening into stomach for nutritional support). Record review of Resident #55's Quarterly MDS assessment dated [DATE] revealed Resident #55 had a BIMS score of 01, indicating severe cognitive impairment, and was assessed under Section K - Swallowing/Nutritional Status as coughing or choking during meals or when swallowing medications with subsequent placement of feeding tube. Record review of Resident #55's Care Plan initiated 12/02/2022 revealed a focus area of enhanced barrier precautions D/T use g-tube, with interventions that included: proper use of PPE to be observed, use of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDRO Record review of Resident #55's Order Summary dated 11/22/2024 revealed an order for Enteral Feed Order every 8 hours three times a day. Observation on 11/22/2024 at 10:40a.m. revealed there was an Enhanced Barrier Protection sign posted on the wall to the right of the Resident #55's door, and a PPE supply drawer next to the door underneath the EBP sign. Further observation inside the room revealed LVN-C was at the side of Resident #55's bed, administering a bolus feeding through Resident #55's g-tube. LVN-C was wearing gloves, but not a gown. During an interview on 11/22/2024 at 10:45 a.m., LVN-C stated she was administering a bolus feeding to Resident #55 via his g-tube and was aware that EBP precautions should be used when administering feedings through a g-tube, but stated she just forgot, and normally does wear gown and gloves to administer g-tube feedings. LVN-C stated she had received training on infection control and stated Enhanced Barrier Precautions were used to prevent spread of infection. Interview with the DON on 11/22/2024 at 10:53 a.m. revealed that the DON confirmed that both gown and gloves should be worn by Nurse when administering g-tube feedings to a resident, and stated that LVN-C had received training in infection control and Enhanced Barrier Precautions. Record review of LVN-C's Personnel Competency Review for area of Personal Protection Equipment dated 5/30/2024 showed that LVN-C did pass her competency in use of PPE. Record review of facility policy titled Enhance Barrier Precautions dated 6/17/2024 revealed EBP are indicated for residents with any of the following: Infection of colonization with a CDC targeted MDRO when contact precautions do not otherwise apply or wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.

Based on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 1 medication rooms reviewed for drugs and biologicals. 1. The facility failed to ensure one over-the-counter medication Feosol was removed from the medication room when it had expired on 06/2024. 2. The facility failed to ensure medications for 2 of 2 discharged residents (DR's #1 and #2) were removed from current medication supply for proper disposition. These failures could place residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications, medication misuse, and drug diversion. Findings included: 1. Observation of the facility medication storage room with the DON present on 11/20/2024 starting at 1:18 p.m., revealed one over-the-counter medication Feosol with an expiration date of 06/2024 found stored with other current OTC medications in the medication room. 2. Further observation of the facility medication room on 11/20/2024 starting at 1:18 p.m. revealed 2 baskets filled with medications labeled with the names of 2 discharged residents (DR's #1 and #2), stored on a storage rack at back of medication room. The basket labeled with DR #1's name contained medications that included: Diclofenac Topical 1% cream and Probiotic Culturelle and the basket labeled with DR #2's name contained medications which included Lidocaine 4% ointment, along with bottles containing Simvastatin and Midodrin. During an interview on 11/20/24 at 1:30 p.m., the DON stated that all expired medications should be removed from stock, as expired medications were at risk of being ineffective. The DON also stated that medications for discharged residents should be stored in the locked disposal box with the expired/discontinued medications for proper disposal by the pharmacist. The DON stated that the supply clerk, MA-D was responsible for stocking and maintaining the medication room, which included rotating stock and removing expired medications and medications for discharged residents. Interview on 11/22/24 at 10:00 a.m., with MA-D revealed that she had worked at facility for about a year and in addition to working as a medication aide, was responsible for stocking the supply room and ensuring all expired medications, and medications for discharged residents were removed from the medication room. She stated when she received new medication stock once a week, she would rotate and check all medications for expiration dates, circling the dates on the bottles as she stocked the new medication. She did not know how she missed the expired Feosol. Further interview with MA-D revealed she did not know how the medications for the discharged patients ended up in the medication room, noting all the nurses and medication aides had access to the room, and postulated that one of the nurses or medication aides removed the medications from a medication cart and placed them in the medication storage room without her knowledge. MA-D stated that DR #1 was discharged home, and DR #2 was in the hospital, and it was unknown if he would be returning to the facility. Further interview revealed that MA-D stated non-controlled expired and medications for discharged residents should be placed in the locked medication disposal box in the medication room to be stored until disposal with pharmacist. Record review of facility policy titled Storage of Medications revised April 2007, revealed under #4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.

Based on interviews and record reviews, the facility failed to ensure before a resident was transferred or discharged the facility must notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood and the facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 5 residents (Resident #1) reviewed for transfer or discharge. in that: The facility failed to give the representative of Resident #1 written documentation which informed them of the facility- initiated decision to discharge the resident. This deficient practice could affect residents who are discharged from the facility and could place them at risk of having their discharge rights violated. The findings were: Record review of Resident #1's face sheet dated 10/23/24 reflected Resident # 1 was an [AGE] year old male admitted on [DATE]. Resident #1 had diagnoses which included unspecified dementia (a condition in which a persons cognitive abilities decline which affects their daily life and activities), major depressive disorder (a condition in which there is persistent low or depressed mood), and unspecified pulmonary fibrosis (a condition in which scarring of the lungs creates breathing difficulty). Resident #1 was discharged on [DATE]. Record review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS's score of 10 which indicated moderate cognitive impairment. Record review of Resident # 1's current care plan initiated on 6/7/23 reflected that in staff discussions with the resident and family there was an expectation of remaining in the facility on a long-term basis During an interview on 10/23/24 at 10:05am with family members (FM#2 and FM#3) revealed they were the family representatives for Resident #1. They stated they met with the facility social worker and Administrator during the week of 10/8/24 to 10/11/24 and were informed Resident #1, had to be discharged from the facility because of his wandering behaviors. FM#2 and FM#3 stated they agreed to Resident #1's discharge to another facility because they felt they had no other choice or option. FM#2 and FM#3 stated the family provided transportation for Resident #1 to attend an adult day care while at the facility and the resident was taking medication for his wandering behavior. FM #2 and FM #3 stated they had not received any written notice of the facility's discharge decision for Resident #1. During an interview on 10/24/24 at 2:15pm with the facility social worker she stated she was not aware of the family representatives having received written notification of the facility's decision to discharge Resident #1. During an interview on 10/24/24 at 2:40pm with the Administrator she stated the family representatives for Resident #1 had not received a written notice of the Resident's discharge. The Administrator stated she did not feel a written notice was necessary since the family agreed to the facility's discharge request. The Administrator stated the facility did not have a policy requiring written notification to the responsible party for the discharge decision for Resident #1.

Based on observation, interview and record review the facility failed to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being for 2 of 4 residents (Residents #1 and #4) reviewed for care plans, in that: 1. The facility failed to ensure Resident #1's care plan was revised on (2) occasion, to reflect the use of bedrails, diagnosis of OSA, and the use of CPAP. 2. The facility failed to ensure Resident #4's care plan was revised on (2) occasions, to reflect the discontinuation of hospice services and diuretic medications. These failures could place residents at risk of current needs not being met. Findings included: 1. Record review of Resident #1's Admission Record, dated 9/24/24, revealed the resident was admitted to the facility on [DATE] with diagnoses which included: Cellulitis (common bacterial skin infection), Hypothyroidism (condition in which the thyroid gland doesn't produce enough thyroid hormone), Type 2 Diabetes (condition in which the body has trouble controlling blood sugar and using it for energy) , Major Depressive Disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities), Obstructive Sleep Apnea (disorder that occurs when the upper airway partially /completely collapses leading to reduced/absent breathing during sleep), Hypertension (high blood pressure) and Atrial Fibrillation (An irregular, often rapid heart rate that commonly causes poor blood flow). Record review of Resident #1's Physical Device Consent and Acknowledgement, dated 9/5/24, revealed the resident signed consent for 1/4 bilateral side rails for generalized weakness and to improve mobility during transfers and repositioning. Record review of Resident #1's Progress Note, dated 9/5/24 and authored by LVN B, revealed: .Resident is bedbound at this time and is able help turn. 1/4 rails on bed to assist resident in repositioning . Record review of Resident #1's Side Rail/Mobility/Positioning Bar Assessment, dated 9/6/24 and authored by RN A, revealed the resident requested the use of 1/4 rails for general weakness or impaired mobility. Further review of this document revealed the resident was observed using the device on 9/5/24. The physician and DON were notified, and the intervention was care planned. Record review of Resident #1's comprehensive MDS assessment, dated 9/9/24, revealed the Resident #1 had a BIMS score of 15, suggesting intact cognition. Record review of Resident #1's Care Plan, dated 9/6/24, revealed the document did not include the use of a bedrails , CPAP, or diagnosis of OSA. Record review of Resident #1's Order Summary, dated 9/24/24, revealed the resident did not have an order for bedrails or CPAP. During an observation and interview on 9/24/24 at 12:58 PM, Resident #1 was lying in bed, cleaned/groomed, with no visible injuries. 1/4 rails were observed on the bed as well as a CPAP on the side table. Resident #1 said he had a CPAP. Resident #1 said he used the bed rails to help the staff with repositioning. During an interview on 9/25/24 at 1:54 PM, Resident #1 said he brought the CPAP from home, used it every night and applied it himself because the nurses refused to assist him due to not having an order. Resident #1's family member said she brought the CPAP to the facility when he was admitted but did not remember when that was. Resident #1's family member further stated he had been using the CPAP for at least [AGE] years. During an interview on 9/25/24 at 12:50 PM, LVN E said Resident #1 had a diagnosis of OSA, but this diagnosis/CPAP were not included in the care plan. During an interview on 9/25/24 at 2:04 PM, LVN A said she did not work overnight, but knew Resident #1 did have a CPAP which he used every night. During an interview on 9/25/24 at 2:58 PM, LVN B said Resident #1 was admitted to the facility on [DATE] and she had the resident sign the consent for the bedrails to assist with repositioning. During an interview on 9/25/24 at 3:45 PM, the DON said Resident #1 had bedrails, but they were not included in the care plan. The DON further stated the facility included bedrails in the care plans. The DON said she did not know why bedrails were not included in Resident #1's care plan. The DON said she did not know if Resident #1 had a CPAP and had not seen it in his room. The DON said CPAPs were usually included in the resident care plan. The DON stated Resident #1 had a diagnosis of OSA and she guessed this was why the family member brought in the CPAP. The DON said she was told by LVN B that Resident #1's family member brought his CPAP, but she didn't know he had it. The DON further stated she was responsible for ensuring the resident's care plan was accurate. The DON said accuracy of care plans was important for continuity of care and so staff were aware what the needs of the residents were. 2. Record review of Resident #4's Admission Record, dated 9/24/24, revealed the was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included: Congestive Heart Failure (condition in which the heart can't pump blood well enough to meet the body's needs) , Morbid Obesity (disorder that involves having too much body fat), Major Depressive Disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities), Anxiety (feeling of dread, fear, or uneasiness), Insomnia (sleep disorder that makes it difficult to fall asleep or stay asleep), OSA (disorder that occurs when the upper airway partially/completely collapses leading to reduced/absent breathing during sleep), and Lymphedema (swelling in the extremities caused by a lymphatic blockage). Record review of Resident #4's Care Plan, dated 3/14/24 and revised 7/17/24, revealed: [Resident #4] has a terminal prognosis r/t Chronic Systolic (Congestive) Heart Failure Hospice Record review of Resident #4's quarterly MDS assessment, dated 7/29/24, revealed Resident #4 had a BIMS score of 15, suggesting intact cognition. Record review of Resident #4's Medicaid Hospice Program Individual Election/Cancellation/Update, signed by Resident #4 on 9/5/24, revealed: Terminal diagnoses of Chronic Systolic Heart Failure, Lymphedema, and Depression, Pt wishes to seek aggressive treatment. Record review of Resident #4's Baseline Care Plan, dated 9/19/24, revealed Resident #2 did not require terminal care. Attempted interview on 9/25/24 at 11:58 AM to the Hospice A nurse was unsuccessful. During an interview on 9/25/24 at 12:50 PM, LVN E said Resident #4's diuretics were discontinued prior to the hospitalization on [DATE] and should have been resolved on her care plan. LVN E said Resident #4 was not receiving hospice services anymore because the resident revoked the services before going to the hospital on 9/6/24 in order to receive extensive therapy at the hospital. LVN E further stated Resident #4 was not readmitted to hospice upon her return from the hospital. LVN E said she did not know how she missed that Resident #4's care plan still had hospice services included and was not sure what happened. During an interview on 9/25/24 at 3:45 pm, the DON said Resident #4 was not receiving hospice services, adding Resident #4 completed a hospice revocation form on 9/5/24. The DON further stated LVN E must have updated Resident #4's care plan when she saw the discharge order. Record review of Resident #4's Care Plan, dated 3/14/24 and revised 7/15/24, revealed: [Resident #4] is on diuretic therapy r/t edema, fluid retention . Record review of Resident #4's Order Summary revealed: .Bumex Oral Tablet 2 MG .for edema .Discontinued .Order Date 04/15/2024 .Bumex Oral Tablet 2 MG .for edema .Discontinued .Order Date 07/14/2024 .Furosemide Oral Tablet 40 MG .for DIURETICS .Discontinued .Order Date 03/13/24 During an observation and interview on 9/24/24 at 1:15 PM, Resident #4 was sitting in her wheelchair, she said she was on hospice but terminated the services because she wanted to go to the hospital for rehabilitation. Resident #4 said she was not receiving a diuretic at the facility. During an interview on 9/25/24 at 12:50 PM, LVN E said when Resident #4 was readmitted to the facility she reinstated the care plan that she previously had. LVN E further stated she ran daily reports for medications and changes in condition, so the discontinued medication should have been caught, adding an audit should be done with each MDS assessment. LVN E said the expectation was care plans be updated as necessary after each daily audit (or 72-hour audit following the weekends). LVN E said it was her responsibly, as the MDS nurse, to ensure the accuracy of care plans. During an interview on 9/25/24 at 1:49 PM, MA B said she had not administered a diuretic to Resident #4 during her shift since her return from the hospital. MA B further stated Resident #4 refused the diuretic because it made her urinate too much and she did not like that. During an interview on 9/25/24 at 3:45 PM, the DON said Resident #4 was currently not on a diuretic. The DON further stated Resident #4's care plan did reflect she received diuretic therapy. The DON said the expectation was for the diuretic therapy to be removed from the care plan within I'm guessing 72 hours after it was discontinued. The DON said she did not have a timeline for care plans to be updated. The DON further stated she did not know why Resident #4's care plan was not updated. The DON said LVN E was responsible for auditing the care plans for accuracy. The DON further stated she audited resident records on a weekly basis but focused on different areas, such as weights and falls. the DON said LVN E was responsible for ensuring care plans were accurate, but she took responsibility. The DON further stated it was important that care plans were correct because other staff could see the information and so ensuring they were kept accurate was important. During an interview on 9/25/24 at 5:17 PM, the Administrator said bedrails were supposed to be included in resident care plans and nursing management was responsible for ensuring this. The Administrator further stated CPAPs should be included in resident care plans and her expectation was care plans were updated within 7 days of a change. The Administrator said LVN E was responsible for ensuring the accuracy of resident care plans. Record review of the facility's policy, titled Care Plans, Comprehensive, revised 3/1/2022, revealed: .An individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident . 5. Care plans are revised as changes in the resident's condition dictate. Care plans are reviewed at least quarterly and any significant change in status

Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 2 of 4 (Resident #1 and Resident #2) reviewed for respiratory care. 1. The facility failed to ensure Resident #1 was assessed for the use of a CPAP to obtain orders. 2. The facility failed to ensure Resident #2 received CPAP treatments at bedtime or while sleeping per physician orders. These failures could place residents who receive CPAP treatments at risk of no receiving the full therapeutic treatments. Findings included: 1. Record review of Resident #1's Admission Record, dated 9/24/24, revealed the resident was admitted to the facility on [DATE] with diagnoses which included: Cellulitis (common bacterial skin infection), Hypothyroidism (condition in which the thyroid gland doesn't produce enough thyroid hormone), Type 2 Diabetes (condition in which the body has trouble controlling blood sugar and using it for energy) , Major Depressive Disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities), Obstructive Sleep Apnea (disorder that occurs when the upper airway partially /completely collapses leading to reduced/absent breathing during sleep), Hypertension (high blood pressure) and Atrial Fibrillation (An irregular, often rapid heart rate that commonly causes poor blood flow). Record review of Resident #1's comprehensive MDS assessment, dated 9/9/24, revealed the Resident #1 had a BIMS score of 15, suggesting intact cognition. The MDS did not include the diagnosis of OSA or need for CPAP. Record review of Resident #1's Care Plan, dated 9/6/24, revealed the document did not include the diagnosis of OSA or need for a CPAP. Record review of Resident #1's Order Summary, dated 9/24/24, revealed the resident did not have an order for a CPAP. During an observation and interview on 9/24/24 at 12:58 PM, Resident #1 was lying in bed and a CPAP was observed on the side table. Resident #1 said he had a CPAP. During an interview on 9/25/24 at 12:50 PM, LVN E said Resident #1 had a diagnosis of OSA, but this diagnosis/CPAP were not included in the care plan. During an interview on 9/25/24 at 1:54 PM, Resident #1 said he brought the CPAP from home, used it every night and applied it himself because the nurses refused to assist him due to not having an order. Resident #1's family member said she brought the CPAP to the facility when he was admitted but did not remember when that was. Resident #1's family member further stated he had been using the CPAP for at least [AGE] years. During an interview on 9/25/24 at 2:04 PM, LVN A said she did not work overnight, but knew Resident #1 did have a CPAP which he used every night. During an interview on 9/25/24 at 2:58 PM, LVN B said Resident #1 did not have a CPAP when he was admitted but his family member brought it to the facility the next day. During an interview on 9/25/24 at 3:45 PM, the DON said she did not know if Resident #1 had a CPAP and had not seen it in his room. The DON said CPAPs were usually included in the resident care plan. The DON stated Resident #1 had a diagnosis of OSA and she guessed this was why the family member brought in the CPAP. The DON said she was told by LVN B that Resident #1's family member brought his CPAP, but she didn't know he had it. 2. Record review of Resident #2's Admission Record, dated 9/24/24, revealed the resident was admitted to the facility on [DATE] with diagnoses which included: Pulmonary Fibrosis (scarring in the lungs making it difficult to breathe), Type 2 Diabetes (condition in which the body has trouble controlling blood sugar and using it for energy), Hyperlipidemia (high levels of fat in the blood), Dementia (group of thinking and social symptoms that interferes with daily functioning) , Major Depressive Disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities), Hemiplegia (paralysis of one side of the body), Pulmonary Hypertension (high blood pressure affecting the arteries of the lungs and heart), Atrial Fibrillation (An irregular, often rapid heart rate that commonly causes poor blood flow), Peripheral Vascular Disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and Emphysema (lung disease causing shortness of breath, coughing, and fatigue). Record review of Resident #2's Care Plan revealed the following: [Resident] has altered respiratory status/Difficulty Breathing .has a terminal prognosis r/t pulmonary fibrosis . Resident #2's Care Plan revealed the document did not include the use of a CPAP. Record review of Resident #2's comprehensive MDS assessment, dated 6/14/24, revealed Resident #2's had a BIMS score of 14, suggesting intact cognition. Further review of the MDS revealed Resident #2 had a diagnosis of chronic lung disease and listed Pulmonary Fibrosis as an active diagnosis. Record review of Resident #2's Order Summary revealed: .C-pap, apply at bedtime or when sleeping .order date 9/10/24 During an observation and interview on 9/24/24 at 1:04 PM, Resident #2 was lying in bed, cleaned/groomed, with no visible injuries, the CPAP was on the side table. Resident #2 said she had a CPAP, but it was missing pieces and was not using it. During an interview on 9/25/24 at 12:50 PM, LVN E said Resident #2 had an order for a CPAP but did not see it in her care plan. LVN E further stated she did not know why the CPAP was not included in Resident #2's care plan. During an interview on 9/25/24 at 3:45 PM, the DON said Resident #2 had a CPAP but was not sure how it got out because it was missing pieces and she had put it away. The DON further stated Resident #2 had never used the CPAP and she did not have an order for it. The DON said Resident #2's care plan did not include a CPAP because the resident did not have an order for CPAP. Facility policy regarding physician orders for medications/treatments was requested on 9/25/24 at 3:45 pm. The facility provided a policy titled Physician Medication Orders, which did not address physician orders for treatments/devices.

Based on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices for 1 of 4 residents (Resident #1) reviewed for quality of care/treatment, in that: The facility failed to obtain device orders for Resident #1 on (2) occasions. These failures could place residents at risk for improper care due to inaccurate records. Findings included: Record review of Resident #1's Admission Record, dated 9/24/24, revealed the resident was admitted to the facility on [DATE] with diagnoses which included: Cellulitis (common bacterial skin infection), Hypothyroidism (condition in which the thyroid gland doesn't produce enough thyroid hormone), Type 2 Diabetes (condition in which the body has trouble controlling blood sugar and using it for energy) , Major Depressive Disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities), Obstructive Sleep Apnea (disorder that occurs when the upper airway partially /completely collapses leading to reduced/absent breathing during sleep), Hypertension (high blood pressure) and Atrial Fibrillation (An irregular, often rapid heart rate that commonly causes poor blood flow). Record review of Resident #1's Physical Device Consent and Acknowledgement, dated 9/5/24, revealed the resident signed consent for 1/4 bilateral side rails for generalized weakness and to improve mobility during transfers and repositioning. Record review of Resident #1's Side Rail/Mobility/Positioning Bar Assessment, dated 9/6/24 and authored by RN A, revealed the resident requested the use of 1/4 rails for general weakness or impaired mobility. Further review of this document revealed the resident was observed using the device on 9/5/24. The physician and DON were notified, and the intervention was care planned. Record review of Resident #1's comprehensive MDS assessment, dated 9/9/24, revealed the Resident #1 had a BIMS score of 15, suggesting intact cognition. Record review of Resident #1's Care Plan, dated 9/6/24, revealed the document did not include the use of a bedrails or CPAP. Record review of Resident #1's Order Summary revealed the resident did not have orders for bedrails or CPAP. Record review of Resident #1's Progress Note, dated 9/5/24 and authored by LVN B, revealed: .Resident is bedbound at this time and is able help turn. 1/4 rails on bed to assist resident in repositioning Record review of Resident #1's Order Summary, dated 9/24/24, revealed the resident did not have an order for bedrails or CPAP. During an observation and interview on 9/24/24 at 12:58 PM, Resident #1 was lying in bed, cleaned/groomed, with no visible injuries. 1/4 rails were observed on the bed as well as a CPAP on the side table. Resident #1 said he had a CPAP. Resident #1 said he used the bed rails to help the staff with repositioning. During an interview on 9/25/24 at 1:54 PM, Resident #1 said he brought the CPAP from home, used it every night and applied it himself because the nurses refused to assist him due to not having an order. Resident #1's family member said she brought the CPAP to the facility when he was admitted but did not remember when that was. Resident #1's family member further stated he had been using the CPAP for at least [AGE] years. During an interview on 9/25/24 at 12:50 PM, LVN E said Resident #1's assessment for bedrails was completed on 9/5/24. LVN E further stated Resident #1 did not have an order for bedrails. LVN E said it was important the physician was contacted for an order for bedrails to ensure bedrails were appropriate for the resident. LVN E said the bedrails were a device Resident #1 consented to and were utilized for bed mobility and increased independence. LVN further stated that due to Resident #1 no having an order for the bedrails, staff may think that this intervention was not correct and remove them, limiting his independence and bed mobility. LVN E said Resident #1 did have a diagnosis of OSA, but the resident did not have an order for a CPAP. LVN E further stated if a CPAP was brought from home for Resident #1 the facility was responsible for contacting the physician to see if this is a treatment he wanted to implement at the facility. LVN E said she believed the charge nurses were responsible for entering orders for the residents. LVN E further stated obtaining orders was important because resident could receive treatment that were not beneficial or could potentially harm them. During an interview on 9/25/24 at 2:04 pm, LVN A said she did not work overnight, but knew that Resident #1 did have a CPAP which he used every night. LVN A said she had not seen the order for a CPAP for Resident #1 but was knew he had orders to wear it overnight because an order was required for CPAP. LVN A said the nurse that admitted Resident #1 was responsible for ensuring the resident had an order for a CPAP or call the physician to obtain an order. LVN A further stated it was important to obtain orders to ensure it was approved by the physician, they had the proper settings, and the resident was wearing it correctly. During an interview on 9/25/24 at 2:58 pm, LVN B said Resident #1 was admitted to the facility on [DATE] and she had the resident sign the consent for the bedrails to assist with repositioning. LVN B further stated she did not remember if she added an order for the bedrails when Resident #1 was admitted . LVN B said an order was required if a resident used bed rails. LVN B further stated an order was needed to verify the bedrails were being used as an assistive device and not a restraint. LVN B said she was not aware that Resident #1 didn't not have an order for bedrails, and she did not have time to review the records for accuracy. LVN B said Resident #1 did not have a CPAP when he was admitted but his family member brought it to the facility the next day. LVN B further stated she refused to assist Resident #1 apply the CPAP when he asked for help because he didn't have an order. LVN B said she messaged the physician a couple days later in regard to the CPAP and had not received a response. LVN B further stated she did not remember if the physician responded to her message or not, adding she deleted all messages to the physician. LVN B said she did not actually call the physician for follow-up. LVN B said she was responsible for orders, as well as other nurses that provide care to Resident #1. LVN B further stated the nurses that audit the charts, sometimes the DON or the ADON were also responsible for ensuring residents had the required orders B said it was important that Resident #1 had an order for the CPAP because it was considered a treatment and they had to make sure he could breathe adequately, are getting the oxygen that they need, are not having difficulties, and the pressure settings were correct. LVN B further stated the facility did not have a way of verifying if Resident #1's CPAP settings were correct because he did not have an order. LVN B said not having an order for the CPAP may affect Resident #1 negatively because he may be dependent on the CPAP to help him rest. LVN B further stated she was not sure what the indications were because there were no orders, he may have apnea, which means he stops breathing at night and may wake up gasping for air which affected his sleep/rest and possible also affected activities due to lack of rest. LVN B said she did miss stuff because she was overworked at times. Attempted telephone interview on 9/25/24 at 3:40 pm with the ADON was unsuccessful. During an interview on 9/25/24 at 3:45 pm, the DON said Resident #1 did have bedrails and a diagnosis of OSA but did not have an order for bedrails or CPAP. The DON further stated she did not know why Resident #1 did not have an order for bedrails. The DON said she did not believe not having orders for the bedrails could result in a negative outcome because the facility obtained a consent from Resident #1 and just did not document for medical record purposes. The DON said she did not know if Resident #1 had a CPAP and had not seen it in his room. The DON further stated Resident #1 did have a diagnosis of OSA and she guessed this was why the family member brought in the CPAP. The DON said she was told by LVN B that Resident #1's family member had brought his CPAP, but she didn't know he had it. The DON further stated Resident #1 did not have an order for a CPAP and that if it were in his room, Resident #1 would have orders. The DON further stated she had never seen Resident #1 with a CPAP or seen it in his room. The DON said the admitting nurse was responsible for ensuring residents had the proper equipment orders. The DON said she was responsible for ensuring resident orders were accurate to ensure the admission process was completed and the ADON was responsible for auditing orders. The DON further stated this was important for continuity of care and so that staff were aware what the resident needs were.