Every finding on record at Val Verde Nursing and Rehabilitation Center

Based on interview and record review the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who was licensed or registered by the State for 1 of 1 facility reviewed for qualifications of activity professionals. The facility failed to have a qualified Activities Professional direct their activities program. This deficient practice could place residents at risk of not receiving approaches that were individualized to match the skills, abilities, and interests/preferences of each resident for activities. The findings included: During an interview on 08/11/2026 at 5:50 p.m., the Activity Director revealed that she has not obtained her certification as an activity director, but she started her online training as of February 2026. She stated that she has completed 8 of 12 modules of online training and the Administrator oversees her coursework and provides guidance in activities for the NF. She stated that she is unable to obtain an online transcript of her activity director's course she is enrolled in at this time. She stated that prior to accepting the full-time activity director position at the NF she was employed as the NF's receptionist and assisted with medical records and did not have a former training or background in activity director. During an interview on 08/12/2026 at 3:01 p.m., the Administrator revealed that the Activity Director was not licensed, and she was not sure where in the process of certification she was currently at. She stated that she was aware that the Activity Director did find a school, but she was not sure she had started classes. She stated that she would need to make sure she was enrolled online. She stated that currently she works with a regional corporate consultant who oversees the Activity Director's work. The Administrator stated that a certified Activity Director would have more knowledge of the process of State requirements. She stated that the facility had been without a certified Activity Director since 11/2025. Requested a policy for Activity Director from the Administrator on 08/12/2026. The administrator stated on 08/12/2026 at 2:40 p.m. that if she did not provide us with a policy, then she did not have one.

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 diseases and infections for 2 (Resident #20, Resident #23) of 3 residents reviewed for infection control in that:1.The facility failed to ensure CNA C performed hand hygiene before applying clean gloves while providing incontinence care to Resident #20.2. LVN E did not change gloves from clean to dirty during ostomy care for Resident #23.This failure could lead to infection or illness. Findings included: 1.Record review of Resident #20's admission Record dated 08/12/2026 reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Relevant diagnoses included: hemiplegia and hemiparesis following cerebral infarction (when a blocked artery or blood clot stops blood and oxygen from reaching part of the brain, resulting in muscle weakness or paralysis on one side of the body), and unspecified urinary incontinence. Record review of Resident #20's Medicare 5-day MDS dated [DATE] reflected in section C0100: 0. No (resident is rarely/never understood), section GG0130: C. Toileting hygiene: 01. Dependent, section H0300. Urinary Continence: 3. Always incontinent, and H0400. Bowel Continence: 3. Always incontinent. Record review of Resident #20's Care Plan Report revealed: Problem: The resident has bladder incontinence r/t decreased mobility, CVA with left side hemiplegia. Date Initiated: 05/14/2024 Revision on: 07/22/2024, Intervention: Clean peri-area with each incontinence episode and Problem: The resident has bowel incontinence r/t CVA and Decreased mobility. Date Initiated: 08/01/2026 Revision on: 08/01/2026, Intervention: Provide peri-care after each incontinent episode. In an observation and interview on 08/10/2026 at 9:55 a.m., CNA C was observed performing incontinence care for Resident #20. CNA C cleaned the residents' buttocks, rolled soiled draw sheet under resident's hip, removed gloves, did not perform hand hygiene, applied new gloves and applied clean brief under resident. During an interview with CNA C on 08/11/2026 at 10:00 a.m., she stated she should have performed hand hygiene when changing gloves before applying the clean brief and that she was nervous. CNA C stated failing to do so may result in the resident getting an infection. In an interview with the DON on 08/12/2026 at 10:30 a.m., she said staff were expected to perform hand hygiene between glove changes and failing to do so may result in infection. The DON stated staff have received training on infection control and incontinent care. 2. Record review of Resident #23's admission Record dated 8/10/2026 reflected she was admitted on [DATE] with diagnoses of Dementia, and colostomy status. Record review of Resident #23's consolidated physician orders for August 2026 revealed she had an order for ostomy, to check skin, around the stoma for redness and irritation, colostomy care every shift and as needed, empty colostomy pouch contents every shift, and as needed, Report changes in color, consistency, type and amount of colostomy drainage to medical provider and document in progress notes, every shift and as needed. Record review of Resident #23's Quarterly MDS dated [DATE] reflected that she had had a BIMS score of 4/15 (severe cognitive impairment), and ostomy. Record review of Resident #23's care plan dated 7/10/2026, reflected the resident has an altercation in gastro-intestinal status related to colostomy bag. Intervention was give medication as ordered. Monitor/document side effects and effectiveness. Observation on 8/10/2026 at 11:18 AM in Resident #23's room, during ostomy care. LVN E was observed removing the soiled dressing and emptying the pouch. Observed Resident #23's stoma had brown substance, that LVN E wiped off and placed in garbage bag. LVN E then affixed the pouch and cleaned the dressing without removing the soiled gloves, sanitizing his hands, and applying new, clean gloves. Interview on 8/10/2026 at 12:18 PM with DON stated the nurse policy and procedures they follow are from the [NAME], regarding ostomy procedure, had no mention of changing gloves between dirty and clean. Interview on 8/10/2026 at 12:19 PM with LVN E stated the stoma was soiled with feces, he wiped with a wipe and placed new ostomy bag on Resident #23. LVN E stated he was busy talking and he did not get gloves soiled or take the old (dirty) gloves off his hands. LVN E stated best practice was to change gloves between dirty and clean. Record review of policy titled, Hand Hygiene dated 10/24/22 read: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors.

Based on observation, interviews and record reviews, the facility failed to ensure a resident who was incontinent with bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #58) of 1 resident reviewed for catheter care. The facility failed to ensure Resident #58 had a leg strap to secure her indwelling urinary catheter tubing. This deficient practice could place residents at risk of complications and infection from movement at the insertion site. The findings included: Record review of Resident #58's admission Record dated 08/11/2026 reflected an [AGE] year-old female newly admitted on [DATE] with diagnoses of secondary malignant neoplasm (cancer that has spread from its original site to another area of the body), fracture of superior rim of left pubis (a break in the upper bone at the front of the pelvis), and dementia (loss of memory, language, problem-solving and other thinking abilities). Record review for Resident #58 indicated an Entry MDS dated [DATE], Admission/Medicare 5-day MDS in progress. Record review of Resident #58's Care Plan Report reflected: Problem: The resident has Indwelling Foley Catheter, Date Initiated: 08/06/2026, Revision on: 08/10/2026, and Goal: The resident will be/remain free from catheter-related trauma through review date, Date Initiated: 08/06/2026. The care plan did not reflect the need for a leg strap to secure the tubing. Record review of Resident #58's Order Summary Report indicated orders for: Indwelling Catheter: Size 16Fr with balloon 10cc (Dx: Peritoneal CA (affects the peritoneum, the thin tissue lining the belly and organs) every shift. Active 08/06/2026, and Check Indwelling Urinary catheter use securement device every shift for urinary retention, Use leg strap to secure Foley in place. Active 08/06/2026. Observation of catheter care on 08/11/2026 at 9:24 a.m. for Resident #58 revealed she had an indwelling urinary catheter and did not have a leg strap/securement device in place. During an interview with CNA B on 08/11/2026 at 9:40 a.m., CNA B stated the resident did not have her catheter tubing secured to her leg, but it should have been. CNA B stated the purpose of securing the catheter is to prevent pulling on the tubing which could cause it to come out and cause an infection if the catheter must be reinserted. CNA B stated that if the leg securement device is not in place, the charge nurse is notified to replace it. During an interview with LVN D on 08/11/2026 at 10:45 a.m., LVN D stated there is an order to check placement of urinary tubing securement device every shift. LVN D stated she does not know why Resident #58's securement device was not in place because she checks it at the beginning of the shift, so it must have come off for some reason. LVN D stated the possible consequences of not having the tubbing secured could be bleeding, pain, or irritation to the residents if the catheter is pulled. During an interview on 08/11/2026 4:15 PM with ADM stated she did not have policy for catheter care. During an interview with DON on 08/12/2026 at 10:30 a.m., the DON stated it was her expectation that urinary catheter tubing be secured to prevent the catheter from being pulled or causing pain to the resident. DON stated Resident #58 had been having incontinent episodes, and the securement device probably came off, and the CNAs should be notifying the nurse if a securement device needs to be replaced. The DON stated there is no facility policy related to catheter care.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #35) of 7 residents reviewed for medication administration in that:The facility failed to accurately transcribe a physician-ordered medication onto Resident #35's Medication Administration Record. As a result, the medication was reflected on the MAR with an incorrect route of administration. This failure could place residents at risk of injury due to incorrect medication administration and inaccurate orders.Findings included: Record review of Resident #35's admission Record dated 08/11/2026, revealed the resident was an [AGE] year-old male, admitted to the facility on [DATE], with diagnoses of cerebral infarction (when a blocked artery or blood clot stops blood and oxygen from reaching part of the brain), dysphagia oropharyngeal phase (swallowing problems occurring in the mouth and throat), and gastrostomy status (a tube placed directly into the stomach through the abdomen). Record review of Resident #35's quarterly MDS submitted 08/04/2026 reflected in section C0100: 0. No (resident is rarely/never understood), section K Swallowing/Nutritional Status, K0520: B Feeding tube. Record review of Resident #35's Care Plan Report revealed: Problem: The resident requires tube feeding r/t stroke. Date Initiated: 02/26/2026, Revision on: 03/24/2026 with Goal: The resident will be free of aspiration through the review date. Date Initiated: 02/26/2026, Revision on: 03/16/2026. Record review of Resident #35's Order Summary Report indicated an order for Acetaminophen Oral Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 6 hours as needed for pain give 2 tablets to = 650 mg, active 07/29/2026, and NPO diet NPO texture, NPO (Nothing by Mouth) consistency, related to dysphagia following cerebral infarction, active 02/27/2026. During an observation of g-tube medication administration on 08/11/2026 at 6:55 a.m., Resident #35 did not receive acetaminophen, and all scheduled medications were administered through gastrostomy tube. Record review of Administration Record Report MAR dated 07/01/2026-07/31/2026 indicated that on 07/29/2026, Resident #35 received 650mg of acetaminophen at 7:02 a.m., with no other administered doses documented. During an interview LVN A on 08/11/2026 at 10:10 a.m., LVN A reviewed the order for Acetaminophen Oral Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 6 hours as needed for pain give 2 tablets to = 650 mg and stated the order instructions indicated to give the medication by mouth. LVN A stated Resident #35 is NPO and does not take anything by mouth. LVN A stated that she was the nurse who received the original order from the physician. LVN A stated she must have accidentally marked the wrong route of administration when transcribing the order into PCC. LVN A stated she gave one dose of the medication on the day it was ordered, but she administered the medication through the gastrostomy tube because she is aware the resident has an order for NPO. If he were given a medication by mouth, he could choke and aspirate. LVN A stated that she would clarify the order with the physician and update the order with the correct administration route. During an interview with the DON on 08/12/2026 at 10:30 a.m., the DON stated the charge nurse receiving a physician order is responsible for transcribing the order into electronic medical record (PCC-point click care) right away. New orders are reviewed every morning by the nurse managers. DON stated the order was likely reviewed, but the incorrect route of administration was missed by the team. DON stated the possible consequences of administering medication orally when a resident is NPO status included choking or aspiration. Record review of policy Medication Reconciliation dated 04/10/23 read: 5. Daily Processes: b. Verify medication labels match physician orders and consider rights of medication administration each time a medication is given, and c. Obtain and transcribe any new orders in accordance with facility procedures. Obtain clarifications as needed.

Based on observation, interview 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 (Resident #3) residents reviewed for PASARR accuracy. The MDS Nurse failed to accurately screen Resident #3 for mental illness upon admission to the facility. This failure could place the residents at risk of not receiving the necessary care and services.The findings included: Record review of Resident #3's admission Record, dated 08/11/2026 revealed a [AGE] year-old male admitted [DATE] and re-admitted [DATE]. Resident #3 was not listed as his own responsible party. Record review of Resident #3's Medical Diagnoses, undated and accessed 08/11/2026 at 5:15 p.m., revealed diagnoses including other specified fracture of unspecified pubis, subsequent encounter for fracture with routine healing (pelvic injury) being listed as principal diagnosis, major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest, Alzheimer's disease (most common cause of dementia), dementia (syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities), and anxiety disorder (mental health condition characterized by excessive, uncontrollable worry about everyday issues, affecting daily functioning and quality of life). Record review of Resident #3's quarterly MDS, dated [DATE] and signed 06/09/2026 as completed, reflected a BIMS score of 00, indicating severe cognitive impairment. Resident #3 was documented with active diagnoses of Alzheimer's Disease, Non-Alzheimer's Dementia, Anxiety Disorder, Depression, and Psychotic Disorder. Record review of Resident #3's care plan, undated and accessed 08/11/2026 at 5:10 p.m., revealed . [Resident #3] has potential to be physically aggressive [related to] Dementia/confusion, Alzheimer's. yelling, kicking, hitting/pinching staff. and . uses antidepressant medication [related to] Depression. initiated 11/21/2025 and revised 08/10/2026 and . [Resident #3] has an alteration in musculoskeletal status r/t fracture of the Pubis [related to] fall. initiated 11/21/2025. Record review of Resident #3's PASRR Level 1 Screening, dated 01/20/2024 and completed at the incoming nursing facility, revealed section C0090. Primary Diagnosis of Dementia: Is there evidence that dementia is the primary diagnosis for this individual (This must be listed in the medical record as the primary diagnosis by the physician) recorded as a Yes and 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 #3's electronic medical record on 08/11/2026 at 5:10 p.m., did not reveal a Mental Illness/Dementia Resident Review form 1012. Observation and interview on 08/10/2026 at 10:52 a.m. with Resident #3 revealed he was lying bed. Resident #3 was oriented to only his identity, but disoriented to place, time, and situation. Resident #3's cognition was severely impaired, and he was unable to respond to interview questions. During an observation and interview on 08/12/2026 at 1:43 p.m., the MDS Nurse revealed that she was responsible for PASARR Screening for MD & I. She stated that residents who have been found to be PASARR positive could be eligible for extra services. She stated that it was important for PASRR Level 1 Screenings to be accurate when she receives them from the incoming facility. She stated that she checks the PL1 Screening against the hospital paperwork received for residents to confirm accuracy. She stated that if PL 1 Screenings were not accurately completed upon admission, it could leave the resident without extra services they need or qualify for. The MDS Nurse was observed to review Resident #40's electronic medical record and stated that PASRR PL 1 was inaccurate at admission. She stated that dementia was not documented as the resident's primary diagnosis, thus rendering the PL 1 screening as positive. She stated that she believed that PASRR PL 1 was coded as ineligible as dementia was the primary diagnosis and stated that she does not see dementia or Alzheimer's listed as Resident #40's primary diagnoses, and this would be an error. She stated that she would be responsible for ensuring the medical diagnoses record reflects dementia as primary diagnoses and to secure physician documentation supporting PL1 ineligible screening. The MDS Nurse stated now that she was aware that PASARR PL1 Screening was inaccurate she will then move forward with redoing the PL1 Screening with accurate diagnoses and move forward with a positive PL1 Screening and notify the local authority for evaluation. During an interview on 08/12/2026 at 2:28 p.m., the DON revealed that if PASRR Screenings were inaccurate, the residents would not be getting all the services available that PASRR has to offer. She stated that if something in the community that was needed or wanted, like wheelchair, outings to the community; the eligible PASRR residents would fail to receive. She stated that Resident #3 does not have specialized services. She stated that Resident #3 does have behaviors, but they were manageable by the staff. During an interview on 08/12/2026 at 3:01 p.m., the Administrator revealed that the MDS Nurse should have reviewed diagnoses when reviewing PASARR Screenings provided by the hospitals. She stated that if a resident was PASRR positive MDS Nurse would continue the steps after. She stated that inaccurate PASARR Screenings could impact the services provided to the residents. She stated that nursing staff should make corrections. The Administrator stated that the plan of correction will be to ensure nursing staff reviews the PASARR Screenings for accuracy and not trust information from the hospital. Requested a policy for PASRR Screenings from the Administrator on 08/11/2026 and 08/12/2026. The administrator stated on 08/12/2026 at 2:40 p.m. that if she did not provide us with a policy, then she did not have one.

Based on observation, interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 3 of 8 (Resident #3, Resident #40 and Resident #56) residents whose records were reviewed for assessments. Nursing staff failed to code Resident #3 had musculoskeletal Other Fracture, exhibited behavioral symptoms, including physical behavioral symptoms toward others, and inaccurately documented active diagnoses on his MDS assessment.Nursing staff failed to code Resident #40 had falls, frequency of falls, and falls with no injury and with injury on her MDS assessment. Nursing staff failed to code Resident #56 had falls and musculoskeletal other fracture on her MDS assessment. These failures could place residents at risk of not identifying care areas and result in residents not receiving needed care and services.The findings included: 1. Record review of Resident #3's admission Record, dated 08/11/2026 revealed a [AGE] year-old male admitted on [DATE] and re-admitted on [DATE]. Resident #3 was not listed as his own responsible party. Record review of Resident #3's Medical Diagnoses, undated and accessed 08/11/2026 at 5:15 p.m., revealed diagnoses including other specified fracture of unspecified pubis, subsequent encounter for fracture with routine healing (pelvic injury) being listed as principal diagnosis, major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest, Alzheimer's disease (most common cause of dementia), dementia (syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities), and anxiety disorder (mental health condition characterized by excessive, uncontrollable worry about everyday issues, affecting daily functioning and quality of life). Record review of Resident #3's quarterly MDS, dated [DATE] and signed 06/09/2026 as completed, reflected a BIMS score of 00, indicating severe cognitive impairment. Resident #3 was documented as having no musculoskeletal Other Fracture and was documented as having not exhibited any behavioral symptoms, including physical behavioral symptoms toward others. Resident #3 was documented with active diagnoses of Alzheimer's Disease, Non-Alzheimer's Dementia, Anxiety Disorder, Depression, and Psychotic Disorder. Record review of Resident #3's care plan, undated and accessed 08/11/2026 at 5:10 p.m., revealed . [Resident #3] has potential to be physically aggressive [related to] Dementia/confusion, Alzheimer's. yelling, kicking, hitting/pinching staff. and . uses antidepressant medication [related to] Depression. initiated 11/21/2025 and revised 08/10/2026 and . [Resident #3] has an alteration in musculoskeletal status r/t fracture of the Pubis [related to] fall. initiated 11/21/2025 2. Record review of Resident #40's admission Record, dated 08/12/2026, revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Resident #40 was not listed as her own responsible party. Record review Resident #40's Medical Diagnoses, undated and accessed 08/12/2026 at 3:34 p.m., revealed diagnoses including major depressive disorder, muscle wasting and atrophy, Parkinson's disease (a movement disorder of the nervous system that worsens over time.), and dementia. Record review of Resident #40's quarterly MDS Assessment, dated 07/06/2026 and signed 07/08/2026 as completed, reflected a BIMS score of 00, indicating severe cognitive impairment. Resident #40's functional limitations in range of motion were documented with impairment on both sides of upper and lower extremities, and functional abilities were documented as dependent on staff. Record review of Resident #40's care plan, undated and accessed 08/12/2026 at 3:36 p.m., revealed . [Resident #40] has impaired cognitive function/dementia or impaired thought process [related to] Dementia.has little or no activity involvement [related to] Physical Limitations and cognitive impairment initiated 04/22/2021. Interventions included 1 on 1 activities in room initiated 03/08/2024 and Encourage the resident's participation daily. 3. Record review of Resident #56's admission Record, dated 08/09/2026 revealed an [AGE] year-old female admitted on [DATE] and re-admitted on [DATE]. Resident #56 was not listed as her own responsible party. Record review of Resident #56's Medical Diagnoses, undated and accessed 08/09/2026 4:20 p.m., revealed diagnoses including laceration of spleen, wedge compression fracture of T7-T8 vertebra (thoracic spine injury where the front of the vertebral body collapses into a wedge shape), subsequent, encounter for fracture with routine healing, age-related osteoporosis with current pathological fracture, fracture of upper end of right humerus, with routine healing, fracture of unspecified part of neck of right femur (refers to a break in the region connecting the femoral head to the femoral shaft. ), depression (mental state of low mood), altered mental status (describing any change from a person's normal level of awareness, cognition, or behavior), type 2 diabetes (insulin resistance and high blood sugar levels), vitamin D deficiency (body does not have enough vitamin D, which is essential for healthy bones and muscles), unspecified cirrhosis of liver (liver is scarred and damaged), chronic kidney disease, stage 3 (kidneys have a moderate loss of function), cognitive communication deficit (condition where a person's ability to communicate effectively is impaired). Record review of Resident #56's quarterly MDS, dated [DATE] and signed 07/24/2026 as completed, reflected a BIMS score of 05, indicating severe cognitive impairment. Resident #56's functional abilities were documented as requiring dependent to substantial/maximal assistance. The falls with and without injury Resident #56 sustained during the current MDS look-back period, 07/15/2026 and the noted end date of the observation for the assessment, 07/22/2026 were not coded. Resident #56 was documented as having no falls with or without injury since prior assessment. Record review of Resident #56's quarterly MDS, dated [DATE] and signed 05/01/2026 as completed, reflected a BIMS score of 11, indicating moderate cognitive impairment. Resident #56 was documented as having no musculoskeletal Other Fracture. Resident #56's functional abilities were documented as requiring dependent to substantial/maximal assistance. Record review of Resident #56's care plan, undated and accessed 08/09/2026 at 5:44 p.m., revealed . [Resident #56] is dependent on staff etc., for meeting emotional, intellectual, physical, and social needs [related to] Physical Limitations. at risk for falls [related to] [history] of falls. unwitnessed fall in room [ROOM NUMBER]/16/026. unwitnessed fall in restroom [ROOM NUMBER]/12/2026. initiated 02/10/2026 and revised 07/27/2026. Record review of Resident #56's Hospital Discharge Report dated 07/25/2026, revealed Imaging Data CT abdomen pelvis and chest: Radiologist's impression: IMPRESSION: 1.Acute minimally displaced fractures of the left lateral eighth, ninth and 10th ribs. 2. Heterogeneity of the spleen with surrounding hyperdense fluid, concerning for splenic laceration with perisplenic hematoma. Discharge Plan Discharge. Patient Disposition: DC [discharge] to Another Hosp. Clinical Impression: Splenic laceration, Multiple rib fractures, Fall, Anemia, Chronic idiopathic thrombocytopenia, Chronic . Record review of Resident #56's #2434 Un-witnessed Fall incident report dated 07/16/2026 at 9:58 p.m., revealed Nursing Description: resident found on bathroom floor, sitting up against toilet. Resident Description: resident states, I don't not know how or why I fell. Description: head to toe assessment done, resident remains with same skin tears to left arm x 2, bandage changed and reapplied. neuros [neurological assessment] check reinitiated. Record review of Resident #56's #2433 Un-witnessed Fall incident report dated 07/1/2026 at 7:17 p.m., revealed Nursing Description: resident was on the floor in her room. Upon entering room noted resident laying supine on floor in between both beds. Also noted bleeding to Lt [left] arm. Resident Description: Resident stated she slipped after using the commode while she was on her way to lay down onto bed. Resident could not state how she slipped . Description: Head to toe and neuros [neurological assessment] assessed. Resident placed on bed x2 [2 person] assist. Noted 2 skin tears and 2 abrasions noted to Lt [left] arm. WC [wound care] provided to Lt [left] arm. Record review of Resident #56's #2432 Un-witnessed Fall incident report dated 07/16/2026 at 6:15 a.m., revealed Nursing Description: Heard a loud noise and went to Resident's room and found Resident sitting on the floor by her bedside table and bed, one shoe on and one shoe off with pull up at her thighs twisted and upside down. Resident Description: I was trying to go to the bathroom. Description: Resident assessed and noted skin tear to Lt. [left] elbow 2x0.5 [size]. Resident states did not hit head. Alert and oriented x 2 [oriented to person and place] . During an observation and interview on 08/12/2026 at 1:43 p.m., the MDS Nurse revealed that she was responsible for the accuracy of assessments. She stated that assessments were completed following new admission, significant change, quarterly, and discharge. She stated that assessments were for care provided to residents. She stated that assessments capture residents' care provided, medications, changes in conditions, behaviors, falls, ADL declines, psychosis, falls, etc. She stated that if assessments were inaccurate, it could impact a resident's care, and the nursing staff would not have a bassline of their care. The MDS Nurse was observed to review Resident #3's electronic medical record and stated that his quarterly MDS had several areas not coded accurately and should have been coded as having musculoskeletal Other Fracture, exhibited behavioral symptoms, including physical behavioral symptoms toward others and accurately coding active diagnoses listing either Alzheimer's Disease or Non-Alzheimer's Dementia. The MDS Nurse was observed to review Resident #40's electronic medical record and stated that her quarterly MDS inaccurately coded falls history, frequency, and number of falls with no injury and with injury. The MDS Nurse was observed to review Resident #56's electronic medical record and stated that her quarterly MDS was coded inaccurately for falls and musculoskeletal other fracture following her recent hospitalization. She stated that she would review Resident #3's, Resident #40's, and Resident #56's assessments and make corrections accordingly During an interview on 08/12/2026 at 2:28 p.m., the DON revealed that she reviews and signs resident assessments. She stated the assessments were a story of the resident; it would paint a picture of the resident and their care. She stated the impact of inaccurate assessments could give staff members an inaccurate picture of the residents. She stated that assessment of information transfers over to care plans. She stated that the staff know the residents well and does not believe inaccurate assessments would have an impact on residents or their care. During an interview on 08/12/2026 at 3:01 p.m., the Administrator revealed that assessments report everything that occurs with the residents' care and the impact if not accurate or coded correctly would result in information being inaccurately reported to the State. She stated that inaccurate assessments would only affect the facility. Requested a policy for Assessment Accuracy from the Administrator on 08/11/2026 and 08/12/2026. The administrator stated on 08/12/2026 at 2:40 p.m. that if she did not provide us with a policy, then she did not have one.

Based on observation, interview, and record review, the facility failed to provide activities based on the comprehensive assessment and care plan, designed to meet the interests of and support the physical, mental and psychosocial well-being of 2 of 8 (Resident #40 and Resident #56) residents who were reviewed for activities. The facility failed to consistently provide individualized activities and did not meet the needs of Resident #40 and Resident #56 on a weekly basis. This failure placed the residents at risk of becoming apathetic (marked indifference to the environment), isolated from others, having a depressed mood, boredom, loneliness, and a decreased quality of life. The findings included: 1. Record review of Resident #40's admission Record, dated 08/12/2026, revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Resident #40 was not listed as her own responsible party. Record review Resident #40's Medical Diagnoses, undated and accessed 08/12/2026 at 3:34 p.m., revealed diagnoses including major depressive disorder (serious mental disorder that negatively affects how you feel, think, act, and perceive the world.), muscle wasting and atrophy(Muscle atrophy is the wasting or thinning of muscle mass.), Parkinson's disease (a disorder of the nervous system that affects movement and gets worse over time.), and dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life.). Record review of Resident #40's quarterly MDS Assessment, dated 07/06/2026 and signed 07/08/2026 as completed, reflected a BIMS score of 00, indicating severe cognitive impairment. Resident #40's functional limitations in range of motion were documented with impairment on both sides of upper and lower extremities, and functional abilities were documented as dependent on staff. Record review of Resident #40's care plan, undated and accessed 08/12/2026 at 3:36 p.m., revealed . [Resident #40] has impaired cognitive function/dementia or impaired thought process [related to] Dementia.has little or no activity involvement [related to] Physical Limitations and cognitive impairment initiated 04/22/2021. Interventions included 1 on 1 activities in room initiated 03/08/2024 and Encourage the resident's participation daily. Record Review of Resident #40's Activity Progress Notes dated 08/11/2026 and handwritten entries undated and accessed 08/11/2026 at 5:50 p.m., revealed 9 in-room activity entries were documented for the last 12 months: 11/10/2025, 11/26/2025, 12/29/2025, 01/29/2026, 03/02/2026, 04/27/2026, 06/20/2026, 07/20/2026, and 08/10/2026. Observation and interview on 08/09/2026 at 1:14 p.m. with Resident #40 revealed she was lying in bed. Resident #40's cognition was severely impaired and was non-interviewable. 2. Record review of Resident #56's admission Record, dated 08/09/2026 revealed an [AGE] year-old female admitted [DATE] and re-admitted [DATE]. Resident #56 was not listed as her own responsible party. Record review of Resident #56's Medical Diagnoses, undated and accessed 08/09/2026 4:20 p.m., revealed diagnoses including laceration of spleen, wedge compression fracture of T7-T8 vertebra (thoracic spine injury where the front of the vertebral body collapses into a wedge shape), subsequent, encounter for fracture with routine healing, age-related osteoporosis with current pathological fracture, fracture of upper end of right humerus, with routine healing, fracture of unspecified part of neck of right femur (refers to a break in the region connecting the femoral head to the femoral shaft. ), depression (mental state of low mood), altered mental status (describing any change from a person's normal level of awareness, cognition, or behavior), type 2 diabetes (insulin resistance and high blood sugar levels), vitamin D deficiency (body does not have enough vitamin D, which is essential for healthy bones and muscles), unspecified cirrhosis of liver (liver is scarred and damaged), chronic kidney disease, stage 3 (kidneys have a moderate loss of function), cognitive communication deficit (condition where a person's ability to communicate effectively is impaired). Record review of Resident #56's quarterly MDS, dated [DATE] and signed 07/24/2026 as completed, reflected a BIMS score of 05, indicating severe cognitive impairment. Resident #56's functional abilities were documented as requiring dependent to substantial/maximal assistance. Record review of Resident #56's care plan, undated and accessed 08/09/2026 at 5:44 p.m., revealed . [Resident #56] is dependent on staff etc., for meeting emotional, intellectual, physical, and social needs [related to] Physical Limitations. with Interventions to Ensure that the activities the resident is attending are: Compatible with physical and mental capabilities; Compatible with known interests and preferences. Invite the resident to scheduled activities. Provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression and responsibility. The resident needs 1: 1 bedside/in-room visits and activities if unable to attend out of room events. initiated 02/25/2026 and The resident has little or no activity involvement initiated and resolved date 06/12/2026. Record Review of Resident #56's Activities - Quarterly Participation Review dated 07/22/2026, revealed [Resident #56] participates in one on one and group activities. Progress Toward Residents Activity goals were documented as goals were met. Record Review of Resident #56's Activity Note dated 08/11/2026 and handwritten entries undated and accessed 08/11/2026 at 5:50 p.m., revealed 4 in-room activity entries were documented for the last 12 months: 01/26/2026, 05/14/2026, 07/02/2026, and 08/09/2026. Observation and interview on 08/09/2026 at 1:14 p.m. with Resident #56 revealed she was lying in bed. Resident #56's cognition was severely impaired and was non-interviewable. During an observation and interview on 08/11/2026 at 5:50 p.m., the Activity Director revealed that non-verbal and non-ambulatory residents who were unable to join in the group activities will be provided with in-room activities. She stated she documents activities in the resident's electronic medical record and will keep a handwritten log for each group and individual in-room activity provided to residents. She stated that the impact of not receiving activity services on a regular basis would cause a resident to become sad. She stated that all residents deserve attention and some sort of engagement in activities. The Activity Director stated that Resident #56 was provided with strictly in-room activities. The Activity Director reviewed Resident #40's and Resident #56's electronic medical record and handwritten activity logs and stated only nine entries had been documented for Resident #40 and only four entries had been documented for Resident #56 in a year period. She stated that she was unsure as to why few entries were documented for each resident and she was unable to locate additional entries. During an interview on 08/12/2026 at 10:37 a.m., CNA C stated that she believed that Resident #40 received daily activities in her room, but could not recall frequency, or which staff provided this service. She stated that Resident #56 was total care and believed that staff provided in-room activities for her, but she could not recall frequency. During an interview on 08/12/2026 at 10:56 a.m., MA N revealed that she was unsure if total care residents received in-room activities. During an interview on 08/12/2026 at 11:16 a.m., LVN A revealed that the Activity Director provides residents with bingo in the morning in the dining room and offers activities in-room. She stated that she had seen the Activity Director provide in-room activities to Resident #40, but she was not sure what activities were provided and could not recall how often or frequency of these activities. During an interview on 08/12/2026 at 11:50 a.m., LVN D revealed that the in-room activities were necessary for non-verbal and non-ambulatory residents. She stated that the impact of not receiving activities often could cause a resident depression and they would not feel safe. She stated that the Activity Director does visit the hall daily and sees how residents are doing but stated that she was not sure of the frequency of activities provided for Resident #40 and Resident #56. During an interview on 08/12/2026 at 1:12 p.m., Social Services revealed that the Activity Director provided in-room activities to non-ambulatory residents. She stated that if residents did not receive in-room activities on a regular basis, it could cause them to be emotional and to withdraw. She stated she could not recall if Resident #40 and Resident #56 received in-room activities and could not provide information into the frequency. During an interview on 08/12/2026 at 1:43 p.m., the MDS Nurse revealed that she and the Activity Director were responsible for ensuring 1:1 in-room activities were appropriate for residents who are non-ambulatory, non-verbal, or refuse to engage in group activities. She stated she was not sure of the frequency of activities and stated that one in-room activity per month would not be appropriate to meet the residents' needs. She stated that three times per week would be an appropriate amount of time to provide in-room activities. She stated that if residents were offered only one in-room activity a month would be seen as isolation. She stated she could not recall the last time she had worked with the Activity Director to ensure activities were appropriate for residents and if activities were being provided. She stated that she was aware that Resident #40 was documented as 1:1 in-room activities on her care plan but could not recall the frequency of activities and stated she was unsure if activities were being provided for her. The MDS Nurse stated that prior to her recent hospital visit Resident #56 would come out of her room every now and then engage in group activities. She stated that Resident #56 now requires 1:1 in-room activities and believed they were provided by the Activity Director but stated she could not provide frequency of activities being provided but would begin working with the Activity Director to ensure activities and frequency of activities were being documented. During an interview on 08/12/2026 at 2:28 p.m., the DON revealed that 1:1 in-room activities should be provided to bedbound residents, but she was not sure of the regulations for activities and frequency. She stated that she was not familiar with what activities the Activity Director was providing for bedbound residents. During an interview on 08/12/2026 at 3:01 p.m., the Administrator revealed that in-room activities should be provided for residents if they were not participating in group activities. She stated that in-room activities should be provided often but stated that she was not familiar with the regulations on frequency and would need to look further into this. She stated that 9 in-room activities in a 12-month period were not sufficient as residents need the connection, and this could have an impact on the residents' mental health and cause them to get depressed and feel lonely. The Administrator stated that regional staff visited and checked in on activities, but in general she, as the Administrator, should have known and should have checked in with the Activity Director and the activities she provided for the residents and ensure it meets the needs of each resident. Requested a policy for Activities from the Administrator on 08/11/2026 and 08/12/2026. The administrator stated on 08/12/2026 at 2:40 p.m. that if she did not provide us with a policy, then she did not have one.

Based on interview and record review, the facility failed to incorporate the recommendations from PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care. for 1 of 3 (Resident #57) PASRR resident in that:Resident #57's PASRR II recommendations for a customized manual wheelchair (10/10/2025) and Occupational Therapy (8/4/2025)/Physical Therapy (7/28/2025) NFSS was submitted after 20 days. This could affect all residents on PASRR services and could result in residents on PASRR services not provided with DME or specialized services. The Findings:1.Record review of Resident 57's admission Record dated 8/9/2026 documented she was admitted on [DATE] and was discharged to the community on 3/3/2026. Resident #57 had a diagnosis is of Spina Bifida (a neural tube birth defect where the spinal column fails to close completely during the first month of pregnancy) with Hydrocephalus) (the abnormal buildup of cerebrospinal fluid in the brain's ventricles) and Cerebral Palsy (a group of permanent movement disorders that appear in early childhood). Resident #57's health insurance was Medicaid.Record review of Resident 57's discharge MDS dated [DATE] revealed she had a BIMS score of 15/15 (cognitively intact) and resident used a [NAME] wheelchair. Record review of Resident 57's care plan dated 3/3/2026 revealed she had been identified as having PASRR positive related to Spina Bifida. Interventions were customized manual wheelchair. Record review of Resident 57's PASRR II meeting dated 8/4/2025 revealed a customized manual wheelchair and OT and PT recommended. Record review of Resident #57's NFSS for customized wheelchair dated 10/2/2025 was denied on 10/10/2025 due to missing the required customized wheelchair signature page. Please have all required parties sign the signature page before 10/24/2025 The NFSS for customized wheelchair was denied on 10/24/2025 due to facility did not respond to request. Record review of Resident #57's NFSS for customized wheelchair dated 10/2/2025 was denied on 11/14/2025 due to the customized wheelchair assessment was over 30 days old and no longer valid. A new customized wheelchair request may be submitted. Record review of Resident #57's customized wheelchair receipt was dated 1/19/2026 and was signed by Resident #57 on 2/10/2026. 2.Record review of Resident #57's NFSS for Occupational Therapy dated 8/4/2025, revealed this was denied on 12/9/2025 due to date of assessment being over 30 days old and had passed the time period allotted for authorization. Record review of Resident #57's NFSS for Physical Therapy dated 8/4/2025 revealed due to assessment being over 30 days old and had passed the time period allotted for authorization. Interview on 08/12/2026 at 8:00 AM with the ADM stated they had no policy for PASSAR services and had no other comments. Interview on 8/12/2026 at 11:12 AM with the MDS nurse stated she was new and was not sure how to figure out [NAME] the PASARR specialized services worked and submission timelines. MDS nurse (responsible for PASRR residents and submitting NFSS) stated if residents did not receive the PASRR service recommendations, this would affect residents by not getting the services recommended. MDS was responsible for all the PASARR services for the residents at the facility. MDS nurse stated Resident #57 did receive her DME before she was discharged .Interview on 8/12/2026 at 4:15 PM with the DON stated residents with PASRR DME could be affected by residents not receiving their recommended services from PASSAR. Record review of policy Comprehensive care plan dated 10/24/2022 read, It is the policy of the facility to develop and implement a comprehensive person centered care plan for each resident, consistent with rights resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy explanation and compliance guidelines; 1. The care planning process will include an assessment of the road's strengths and needs and will incorporate the residents' personal and cultural purposes in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma informed. 2. A comprehensive care plan will be developed within seven days after the condition of the comprehensive MDS assessment 3. A comprehensive care plan will be described, at a minimum the following the services that are furnished to tanning and or maintaining delivers high flexibility physical, mental, and psychosis well-being. Any specialized services or specialized rehabilitation services their nursing facility will provide as a result of PASARR recommendations.

Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 8 (Resident, #3 and Resident #25) residents in that:Resident #25 was not care planned for his full code status. Nursing staff failed review and revise Resident # 3's comprehensive person-centered care plan following recent behaviors prompting psychiatric assessment on 7/23/2026 that documented Resident #3 as unstable and direction to Employ use of redirection at this time. This failure could affect all residents and could result in residents not having their wants and needs identified and met. The Findings: 1. Record review of Resident #25's admission Record dated 8/12/2026 documented he was admitted on [DATE] with diagnoses of complete traumatic amputation of right foot, diabetes II, ( a long-term health condition where your body does not make enough insulin or cannot use insulin the right way) and cognitive communications deficit. admission Record for #25's was documented he was a full code. Record review of Resident #25's consolidated physician orders for August 2026 documented he had an order for a full code (2/11/2026). Record review of Resident #25's admission MDS dated [DATE] documented his BIMs score was 13/15 (cognitively intact) and required a wheelchair.Record review of Resident #25's care plan dated 8/10/2026 revealed no care plan to address his code status. Interview on 08/12/2026 at 11:09 AM with the MDS nurse stated she was responsible for care plans. MDS nurse stated Resident #25's code status of Full Code should have been in his care plan. MDS nurse stated she missed the code status of Resident #25. She said the effect on residents was that they could get the wrong care.Interview on 8/12/2026 at 4:15 PM with the DON stated, residents not having a code status on their care plan, could affect residents by not having a code status. The DON stated the nurses can check the resident orders for code status. 2. Record review of Resident #3's admission Record, dated 08/11/2026 revealed a [AGE] year-old male admitted on [DATE] and re-admitted on [DATE]. Resident #3 was not listed as his own responsible party. Record review of Resident #3's Medical Diagnoses, undated and accessed 08/11/2026 at 5:15 p.m., revealed diagnoses including other specified fracture of unspecified pubis, subsequent encounter for fracture with routine healing (pelvic injury) being listed as principal diagnosis, major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest, Alzheimer's disease (most common cause of dementia), dementia (syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities), and anxiety disorder (mental health condition characterized by excessive, uncontrollable worry about everyday issues, affecting daily functioning and quality of life). Record review of Resident #3's quarterly MDS, dated [DATE] and signed 06/09/2026 as completed, reflected a BIMS score of 00, indicating severe cognitive impairment. Resident #3 was documented as having no musculoskeletal Other Fracture and was documented as having not exhibited any behavioral symptoms, including physical behavioral symptoms toward others. Resident #3 was documented with active diagnoses of Alzheimer's Disease, Non-Alzheimer's Dementia, Anxiety Disorder, Depression, and Psychotic Disorder. Record review of Resident #3's care plan, undated and accessed 08/11/2026 at 5:10 p.m., revealed . [Resident #3] has potential to be physically aggressive [related to] Dementia/confusion, Alzheimer's. yelling, kicking, hitting/pinching staff. and . uses antidepressant medication [related to] Depression. initiated 11/21/2025 and revised 08/10/2026 and . [Resident #3] has an alteration in musculoskeletal status r/t fracture of the Pubis [related to] fall. initiated 11/21/2025. Record review of Resident #3's Psychiatry Subsequent Note dated 07/23/2026, revealed that visit from psychiatrist that [Resident #3] is unstable requiring psychiatric Assessment. As per collected information and interview, it appears that the patient is unstable. I feel the symptoms are occurring due to confusion. Ongoing medical stabilization, emotional support, and closer monitoring from our side would be good enough. Continue monitoring and document frequency of behaviors. Employ use of redirection at this time. Observation and interview on 08/10/2026 at 10:52 a.m. with Resident 3 revealed he was lying in bed. Resident #3 was oriented to only his identity, but disoriented to place, time, and situation. Resident #3's cognition was severely impaired and was unable to respond to interview questions. During an interview on 08/12/2026 at 11:16 a.m., LVN A revealed that care plans contained information on dietary needs activities, refusal of care, behaviors, falls, and other important information for resident care. She stated that if care plans were not updated with resident changes of condition, behaviors, and interventions, it could harm a resident's care. During an interview on 08/12/2026 at 11:50 a.m., LVN D revealed that care plans document resident's ADLs, wounds, fractures, cognition, behaviors, etc. and includes interventions to provide residents with specific care. She stated that the impact of not updating care plans frequently and with new behaviors and interventions could impact residents' care as staff would not know how to provide specific care for residents and this could injure them. During an interview on 08/12/2026 at 1:12 p.m., Social Services revealed that care plans documented advance directives, discharge planning, behavior changes, in-room activities, etc. for residents. She stated that the impact of care plans not being updated could leave staff not knowing what was going on with residents and their specific care. During an observation and interview on 08/12/2026 at 1:43 p.m., the MDS Nurse revealed that she was responsible for regularly updating care plans. She stated that care plans should include resident behaviors, ADLs, code status, in-room activities, and specific falls and interventions. She stated the impact of care plans not being updated would leave the floor staff not knowing what to do and what interventions would help residents. She stated that Resident #3's behavior should be documented on his care plan. The MDS Nurse was observed to review Resident #3's progress notes and care plan and stated that his recent behaviors documented on his progress notes should have been reviewed and should have been updated on his care plan. She stated that a revision to Resident #3's care plan should have taken place. She stated that she was working towards updating his care plan. She stated that updating Resident #3's care plan with recent behaviors would provide the nursing staff with guidance on the type of care he requires. She stated that Resident #3's care plan does have a goal and interventions regarding behaviors initiated on 11/21/2025. She stated that this goal had not been reviewed and revised following his most recent behaviors and stated that an IDT meeting should have triggered following three behavior incidents. She stated that the behaviors had been addressed during the morning nursing staff meetings; however, the care plan should have been revised to include behaviors and interventions. During an interview on 08/12/2026 at 2:28 p.m., the DON revealed that falls, activities, behaviors, 1:1 in-room activities should all be documented on the care plan. She stated that care plans were tailored to the residents and will list their specific goals and interventions. She stated that the impact of not updating care plans regularly would be a challenge to new staff as they would not know what type of care or specifics were needed for the residents. She stated that Resident #3 had a few behaviors recently, but his aggression was not out of anger it was out of confusion. She stated that the care plan could be updated. She stated that the nursing team had discussed each of his behaviors, but they were not being revised in the care plan. During an interview on 08/12/2026 at 3:01 p.m., the Administrator revealed that care plans should be updated frequently, should be updated with the change as they happen, new orders, and quarterly updates. She stated that if care plans were not updated or accurate, it would have an impact on the residents' care. She stated that failing to revise care plans could cause the nursing staff to miss something. She stated that care plans should be personalized and should include falls, activities, and behaviors. Record review of policy Comprehensive care plan dated 10/24/2022 read, It is the policy of the facility to develop and implement a comprehensive person centered care plan for each resident, consistent with rights resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy explanation and compliance guidelines; 1. The care planning process will include an assessment of the road's strengths and needs and will incorporate the residents' personal and cultural purposes in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma informed. 2. A comprehensive care plan will be developed within seven days after the condition of the comprehensive MDS assessment 3. A comprehensive care plan will be described, at a minimum the following the services that are furnished to tanning and or maintaining delivers high flexibility physical, mental, and psychosis well-being.

Based on observations, interviews and record reviews, the facility failed to ensure the Nurse Staffing Information. Data requirements. The facility must post the following information on a daily basis. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift and Resident census. Posting requirements. The facility must post the nurse staffing data of this section on a daily basis at the beginning of each shift. Data must be posted as follows: Clear and readable format. In a prominent place readily accessible to residents, staff, and visitors. Public access to posted nurse staffing data. Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater for 1 of 1 nursing home in that:The Nurse Staffing posting was not posted on the correct date, and for some nursing staffing posting the data of census and actual hours were missing. The Facility failed to ensure the retained 10 months of Nurse Staffing posting.This could affect all residents and visitors and could result in not having who was working for the day, was not available to public to view. The Finding: Observations on 8/09/2026 at 11:50 AM revealed the Nurse Staffing posting dated 8/7/2026 was missing the actual hours (this was posted on the wall). The Nurse Staffing posting was kept in a clear 8 by11 folder posted on wall. There were 2 days of Nurse Staffing posting on the wall at a time. Observation on 8/09/2026 at 11:51 AM revealed the Nurse Staffing posting, dated 8/10/2026, had no actual hours and no census. The Nurse Staffing posting for 8/9/2026 was missing for the day.Interview on 8/11/2026 at 2:51 PM with ADON (person responsible for posting the Nurse Staffing posting), stated she posted the next day's Nurse Staffing posting before she left for the day. ADON stated the Nurse Staffing posting for 8/9/2026 was posted behind the 8/7/2026 Nurse Staffing posting. ADON stated she kept all the Nurse Staffing posting together, and some were behind each other. ADON stated no staff were responsible for ensuring the correct date for the Nurse Staffing posting. ADON stated they had retained 10 months of Nurse Staffing posting but will continue to look. No additional evidence was provided. Interview on 8/12/2026 at 8:00 AM with ADM stated there was no policy for Nurse staffing posting. Interview on 8/12/2026 at 4:15 PM with DON stated she did not believe having the correct information or missing Nurse Staffing posting could affect residents and visitors and residents could ask the charge nurse. Record review of Nurse Staffing posting from October to December 31, 2025, reflected they were missing the actual hours staff worked. Record Review of Nurse Staffing posting for January 2026, Nurse Staffing posting dated, 1/1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27,28/2026, and 1/30-31/2026 reflected they were missing the actual hours staff worked. Nurse staffing posting for 1/29/2026 Nurse staffing posting sheet was missing.Record Review of Nurse Staffing posted for February 2/, 2, 5, 6, 8/2026 reflected they were missing the actual hours. For 2/9,28/2026 the census was missing. Record Review of Nurse Staffing posted for March 3/1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20, 21,22,23,24,25,26,27,28,29,30/2026 and 3/28,29,30/2026 reflected they were missing the census. Record Review of Nurse Staffing posted for May 5/23, 24, 25, 26, 28, 30, 31/2026 reflected they were missing the census. Record Review of Nurse Staffing posted June 6/17, 20, 21, 22, 24, 27, 28,30/2026 reflected they were missing the census.

Based on observation, interview, and record review, the facility failed to ensure all alleged violations involving mistreatment, neglect, abuse or misappropriation of resident property were reported immediately, but not later than 2 hours if the alleged violation involved abuse or resulted in serious bodily injury, to other officials (including to the State Agency) for one (1) of five (5) residents (Resident #1) reviewed for abuse. The ADMIN, who is the Abuse Coordinator, failed to immediately report (within 2 hours) an allegation of abuse made by Resident #1's family member on 01/21/2026 to HHSC. The failure could affect 46 residents and could result in undetected abuse and/or decline in feelings of safety and well-being.The findings included: Record review of Resident #1's admission Record, dated 02/03/2026, revealed a [AGE] year-old female admitted on [DATE]. Under Contacts, Resident #1 was listed as Self and Resident #1's family member was noted as [NAME] to Responsible Party and Emergency Contact #1. Record review of Resident #1's Diagnosis Report, undated and accessed on 02/03/2026 at 10:25 a.m., revealed diagnoses including spastic hemiplegic cerebral palsy (a type of cerebral palsy, a neurological disorder that damages part of the brain, that affects muscle control and movement on one side of the body), generalized anxiety disorder (a mental health condition characterized by excessive, uncontrollable worry about every day issues), and unspecified spina bifida (a condition that affects the spine and spinal cord and can lead to incontinence, loss of feeling, and leg paralysis) with hydrocephalus (a condition that can result in increased pressure in the skull and cause headaches, nausea, vomiting, double vision, and seizures). Record review of Resident #1's Quarterly MDS, dated [DATE], reflected Resident #1 had a BIMS score of 15, indicating she was cognitively intact. Resident #1's mood interview revealed she felt down, depressed, or hopeless and felt bad about herself or that she was a failure or had let herself or her family down seven (7) to eleven (11) days or half or more of the days (over the last two weeks). Her behavior symptoms were documented as having not exhibited physical, verbal, or other behavioral symptoms directed toward others and had not exhibited potential indicators for hallucinations or delusions. She had rejected evaluations or care one (1) to three (3) days per week. Record review of Resident #1's Care Plan, undated and accessed on 02/03/2026 at 10:32 a.m., revealed the following problems and interventions:- Problem: Ineffective coping related unmet emotional needs, low self-esteem, and inadequate coping strategies R/T seeking validation and attention from multiple male figures, difficulty forming appropriate interpersonal boundaries. Going into male rooms saying, they asked for me to come in. making up stores., date initiated 01/21/2026 and revised on 01/27/2026. - Intervention: Assist the patient in identifying triggers for sexualized or attention-seeking behaviors., date initiated 01/21/2026. - Intervention: Collaborate with the interdisciplinary team., date initiated 01/21/2026. - Intervention: encourage verbal expression of feeling and unmet emotional needs., date initiated 01/21/2026. - Intervention: Establish a therapeutic nonjudgemental relationship., date initiated 01/21/2026. - Intervention: Identifying triggers for sexualized or attention seeking behavior., date initiated 01/21/2026. - Intervention: set clear consistent boundaries regarding appropriate behaviors., date initiated 01/21/2026. - Intervention: Teach and reinforce alternative coping strategies assertive communication., date initiated 01/21/2026.- Problem: The resident has a behavior problem. Crys [sic] out, yells at family and staff, refuses to wait for assistance for transfers or assist to toilet, will go into visitors RR alone. Pt has made comments of wanting to find a boyfriend in the facility., date initiated 08/01/2025 and revised on 01/27/2026. - Intervention: continue with behavioral support, date initiated 02/03/2026. - Intervention: Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed., date initiated 08/01/2025. - Intervention: Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes., date initiated 01/01/2026. - Intervention: Provide a program of activities that is of interest and accommodates residents status., date initiated 01/01/2026. Record review of Resident #2's admission Record, dated 02/03/2026, revealed a [AGE] year-old male admitted on [DATE]. Record review of Resident #2's Diagnosis Report, undated and accessed on 02/03/2026 at 10:25 a.m., revealed diagnoses including fusion of spine, cervical region (a surgical procedure that involves permanently connecting two or more vertebra in the neck region to eliminate movement between them), radiculopathy, cervical region (a condition characterized by the compression of a nerve root in the neck, leading to symptoms such as pain, numbness, and tingling), and acute respiratory failure with hypoxia (a medical condition where the lungs cannot provide adequate oxygen to the blood). Record review of Resident #2's Quarterly MDS, dated [DATE], reflected Resident #2 had a BIMS score of 15, indicating he was cognitively intact. Resident #2's mood interview revealed he had not experienced little interest or pleasure in doing things or felt down, depressed (a state of general unhappiness or in low spirits), or hopeless over the last two weeks. His behavior symptoms were documented as having not exhibited physical, verbal, or other behavioral symptoms directed toward others and had not exhibited potential indicators for hallucinations or delusions. He did not have documented rejection of care. Record review of facility file labeled with Resident #1 and Resident #2's names revealed the following documents:- Receipt of Complaint / Grievance, dated 01/21/2026 with ADMIN and DON noted as person receiving complaint/grievance and complaint/grievance made by Resident #1's family member for Resident #1. - The nature of the complaint/grievance was noted as Residents RP ([family member type]) brought her into my office stating resident was going to tell me & DON about a male resident being inappropriate with her. - The final resolutions were noted as Resident was moved to [room number] as [sic, resident family member]'s request. It was learned through investigation that male & female resident had a consensual relation with intimate encounters happened on occasion, according to what [Resident #1] stated, however., facility couldn't prove any type of relationship or innappropriatness [sic] happenning [sic] between residents. - A typed Interview with resident [Resident #1] with [family member] present, dated 01/21/2026 at 02:30 p.m. revealed Resident #1 reported Resident #2 had touched her five (5) times with three (3) occurrences on Saturday, 01/17/2026 and two (2) occurrences on Sunday, 01/18/2026. Resident #1's interview notes included that she, Resident #1 had invited Resident #2 into her room to view a woman with large breasts on her television, which led to Resident #2 having touched Resident #1's breasts. Resident #1 stated she later went to Resident #2's room by his invitation, where he told her not to enter his room but stay at the doorway and he kissed her mouth. She stated she would watch the hallway to ensure no one was coming. Resident #1 denied reporting the incidents to staff or telling Resident #2 no because she liked the way he made her body feel. She stated he also touched her private area over her clothes and that she lowered her pants while sitting in the wheelchair so he could touch her more intimately. She stated she moved his hand away when she felt uncomfortable. She stated there were times when she did not verbally consent but he, Resident #2 knew she consented and there were times when she told him no, I do not want to do this now. Resident #1 was noted to have been asked if she would like the facility to contact law enforcement because she was forced and she stated No. - A typed Interview with resident [Resident #2] (room [room location] bedside), dated 01/21/2026 at 03:30 p.m. with the interview noted to have been done at Resident #2's bedside revealed Resident #2 was aware that males were not to enter female resident's rooms and female residents were not to enter male resident's rooms. He confirmed Resident #1 invited him into her room on Saturday, 01/17/2026 around 03:00 p.m. to 04:00 p.m. He stated, she called me into her room to see something on television. He stated when he entered Resident #1's room there were ladies on the television and the other resident, Resident #1, said something about the size of the lady's breasts on the television. He stated that he did not usually watch that type of stuff on television and had exited the room. He denied having any type of relationship with Resident #1 other than waving hello when she passed in her wheelchair. He denied ever touching another resident other than a handshake. He confirmed that he had given Resident #1 a necklace that did not fit him and some food at one time. He denied ever having been touched by Resident #1.- Typed interview notes by OTR A included: - On 01/21/2026, Resident #1's family member approached OTR A at a local church event and notified her of a sexual assault on Resident #1. Resident #1's family member had reported the assault occurred at the facility on 01/19/2026 and stated the facility abuse coordinator was already notified and a report had been made to the state, HHSC earlier in the day, 01/21/2026. - On 01/22/2026, Resident #1 came to her normal therapy session but looked tearful. OTR A noted she asked Resident #1 if she was okay and Resident #1 replied that she was just confused and upset. OTR A told Resident #1 that she had spoken to Resident #1's family member the day prior and she was available if Resident #1 wanted to talk. Resident #1 reported she lied to her family member because she feared what her family member would think. She stated she had had a consensual relationship with an older man for some time now. She described the contact and stated she liked him touching her. OTR A documented Resident #1 stated she was lonely and wanted a relationship very badly. OTR A noted Resident #1 had a history of sexually inappropriate behaviors towards other patients and staff, lying and manipulating, and was concerned that if she told the truth this time no one would ever believe her again. She documented Resident #1 wanted to keep the truth from her family member for now, but she did not want to get the male resident in trouble. OTR A noted she encouraged Resident #1 to speak with her counselor on how to tell her family member the truth. - On 01/23/2026, Resident #1 was crying in the therapy gym and reported the other residents did not want to be her friend anymore because she lied and that she felt like the other residents knew and would not forgive her. Resident #1 reported that she keeps lying about somethings and cannot seem to keep her story straight. She did not want to take any personal responsibility but knew she needed to. - Three (3) Resident Investigation Interviews, dated 01/21/2026 with all three noted to have denied having experienced verbal or physical abuse by a staff person or having witnessed any residents doing inappropriate things. - Critical Behavior Monitoring Log, dated 01/21/2026 - 01/23/2026, on Resident #2 noted to have started monitoring at 03:00 p.m. on 01/21/2026 to 11:00 p.m. on 01/23/2026. Resident #2 was noted to be primarily in his bedroom, with one instance of him in the hallway and another of him in the bathroom. He was noted as lying down, asleep, walking, sitting, awake, watching television/movie, or eating. He was documented as calm during all notations. During an interview on 02/03/2026 at 09:41 a.m., LCSW B revealed she had been providing Resident #1 with private, not associated with the nursing facility, therapy services. She revealed Resident #1 reported to her that Resident #1 was engaged in a sexual relationship with another resident. LCSW B stated she was only aware of the one incident reported by Resident #1. During an observation on 02/03/2026 at 10:00 a.m., a posting on a facility hallway wall was noted to identify the ADMIN as the abuse coordinator. During an observation and interview on 02/03/2026 at 12:00 p.m., Resident #2 was observed sitting in a wheelchair in his room watching television. He revealed he had not experienced any issues with other residents except for a male resident in which the staff intervened quickly, and he was not harmed. He stated he tried to stick to himself and did not like to sit and interact with other residents very much. He stated he had not had a romantic relationship with any other residents at the facility and had never intentionally touched another resident. During an observation and interview on 02/03/2026 at 12:08 p.m., Resident #1 was observed sitting in a wheelchair in the back dining room with a staff member and other residents present in the room. She had pushed her lunch tray away from her, had an earbud in her ear, and appeared to be interacting with her phone. Following a request for interview, Resident #1 requested to discuss the incident in a private location. At 12:22 p.m., in a private office, Resident #1 revealed she and Resident #2's relationship had started as a friendship where she had received a few snacks and trinkets from Resident #2. She revealed the physical aspect of their relationship changed when on a cold day, date unknown, Resident #2 noted that Resident #1 was cold and had offered her a hug. Resident #1 stated she said sure, agreed to a second hug, and then kissed Resident #2 on the cheek. Resident #1 stated the next day she invited Resident #2 into her room to see something on the television, a person with large breasts. She stated this led to Resident #2 indicating he preferred women more closely sized to Resident #1 and he proceeded to slightly touch her breast and then kissed her. She stated she liked the physical contact and gave Resident #2 an invitation to do other things, including touching her intimately. Resident #1 stated after that day, Resident #2 would invite her to his room and while sitting in her wheelchair in Resident #2's doorway, she would watch the hall for staff members while Resident #2 would touch her sexually. Resident #1 stated she initiated some of the contact and stated Resident #2 was not forcing her. She stated she knew how to stand up for herself and say no. She stated when she told her counselor, LCSW B, about the relationship, the counselor stated the other resident, Resident #2, was being forceful and when she, LCSW B, stated Resident #1 had to tell her family member she, Resident #1 panicked. Resident #1 stated she told her counselor, LCSW B the same information and that it was not rape. She stated she lied because she did not want her family member to know. She stated she felt safe in the facility and felt that she should have gone to him, Resident #2, more maturely to end the romantic part of their relationship instead of saying that he, Resident #2, was being forceful. She stated she avoided Resident #2 now because the facility staff set boundaries between them, so they do not cross paths, but when she saw Resident #2 in the facility, she did not feel fear but did feel embarrassment and shame. She stated Resident #2 is an old man and not threatening to her. She stated following the report of the incident she was moved rooms per her family member's request and with her agreement due to previously living in a room across the hall from Resident #2. She stated she discussed the incident with facility staff, the ADMIN and DON and she felt they convinced her that the police did not need to be involved. She stated, to be honest, at that moment, I don't know if I wanted the police involved. Resident #1 stated she was capable and involved in making personal medical decisions. During an interview on 02/03/2026 at 01:22 p.m., Resident #1's family member revealed she found out about Resident #1's report of having had a physical relationship with another resident on 01/21/2026. She revealed Resident #1 was typically frequently moody, and she had not observed any changes in Resident #1's mood prior to the reported incident. She revealed she and Resident #1 had been going through a rough month prior to this reported incident which resulted in them not speaking frequently. She revealed Resident #1 had called her the day prior to the therapy session, on 01/20/2026, and had stated she wanted to speak to her therapist about something very serious and did not want her, Resident #1's family member, to hear. She stated she felt concerned following the phone call. Resident #1's family member stated she reported Resident #1's physical relationship with another resident to the facility staff at the time Resident #1 returned to the facility on [DATE]. She stated the facility staff reacted quickly in moving Resident #1's room, per her request and with Resident #1's agreement. She revealed the facility staff discussed a police report and stated that they were going to file a report and complete an internal investigation. She stated upon her return to the facility, on the same day, 01/21/2026 at unknown time, she had asked the ADMIN if they had called the police and was told that Resident #1 did not want the facility to file one. She revealed on the same night, Resident #1 told her that the facility staff had convinced her that she did not need to file a police report. Resident #1's family member revealed she would not say that she had observed Resident #1 to feel more fearful since the reported incident but more so uncomfortable as a resident in the facility. She stated she felt Resident #1 was safe where her current room was located and was aware the facility staff were discouraging Resident #1 from going down her prior hall, where Resident #2 resided. During an interview on 02/03/2026 at 02:14 p.m., LCSW B revealed she had been providing Resident #1 with private therapy services for three (3) to four (4) years. She revealed her therapy sessions with Resident #1 were weekly and the first and only mention of a sexual encounter or regarding relationships was on the reported day of the incident, 01/21/2026. LCSW B revealed Resident #1 appeared to have increased anxiety and emotional effect on the day she reported the relationship but had returned to her regular, nothing of increased note, during her following two sessions. LCSW B stated she was working with Resident #1 regarding her statement that she lied about the incident due to her family member knowing and feeling shame and embarrassment about the incident. She stated she reported the incident to Adult Protective Services, and she understood when she reported the incident and spoke with an Adult Protective Services officer that the police and HHSC would be contacted. During an interview on 02/03/2026 at 02:42 p.m., CNA C revealed she was familiar with Resident #1 and Resident #2. She revealed she believed Resident #1 had been more emotional recently and that Resident #1 was just uncomfortable with her recent room change and Resident #1 felt that she did not have any friends. CNA C stated she never observed any interactions between Resident #1 and Resident #2 other than them being friendly and talking in the hallway. She denied having observed any suspicious or unusual interactions between the two residents. CNA C revealed the DON explained that Resident #1 had reported having had a relationship with Resident #2, Resident #1's room was changed, and that staff were to ensure Resident #1 was comfortable and to try to prevent the two residents from interacting. CNA C stated she had observed Resident #1 initially try to go down Resident #2's hallway, but when the intervention was explained, Resident #1 was initially upset but did understand. CNA C stated she had not observed any changes in Resident #2's behaviors but that he did not typically leave his room. During an interview on 02/03/2026 at 02:22 p.m., the ADMIN revealed the facility did not submit a self-report regarding the reported incident between Resident #1 and Resident # 2 because the facility investigation found what Resident #1 was claiming was not true. During an interview on 02/03/2026 at 02:53 p.m., LPN D revealed she was familiar with Resident #1 and Resident #2. She revealed she had not observed any changes in either resident's behaviors or mood. She revealed she had not received any complaints from Resident #1 regarding safety or emotional distress. She stated she was aware of the reported incident involving both residents because the DON notified her individually because she was working in the hall where Resident #1 was relocated to and the DON wanted to ensure she was knowledgeable to monitor Resident #1 for any type of stress or crying. During an interview on 02/03/2026 at 03:05 p.m., Therapy Provider E stated he had seen Resident #1 on 01/20/2026. He stated he completed a BIMS assessment for her on the same day, 01/20/2026. He revealed that if a resident was assessed with a BIMS over 12 and was considered alert and oriented, then the resident would have been considered competent. He revealed he would need to review his documentation for Resident #1 to verify that she was determined to be competent. During an interview on 02/03/2026 at 04:09 p.m., Therapy Provider E stated he assessed Resident #1 to have a BIMS of 13 and she was alert and oriented times four (4; refers to a person's level of awareness regarding knowing who they are, where they are, what time it is, and what is happening around them). He stated that anyone assessed with a BIMS more than 12, they (the contracted psychiatry services company) would consider the resident capable of making personal decisions. He stated Resident #1 was able to tell him why she was a resident at the nursing facility, list her medications, and explain if she was doing better with the medication she was prescribed for her depression. During an interview on 02/03/2026 at 04:33 p.m., the DON revealed when she and the ADMIN first tried to interview Resident #1 on 01/21/2026 Resident #1 was starting to explain how she was interested in Resident #2 and when she and the ADMIN tried to explain that the feelings were normal, Resident #1's family ended that part of the discussion. The DON revealed that later on in the day, time not specified, Resident #1's family member left the facility and Resident #1 came back to the ADMIN's office and stated she did not want to get anyone in trouble, she liked how the contact felt, and she wanted to go on birth control. The DON revealed she and the ADMIN explained to Resident #1 that she was saying one thing to them and another to her family member and Resident #1 was adamant about not telling anyone including calling the police because she did not want rumors. The DON stated she was unsure if a state report was completed but knew the police were not called because Resident #1 said she did not want them notified. The DON stated the facility moved Resident #1's room per her request and started an investigation into the incident. The DON stated Resident #1's interview revealed Resident #1 initiated the invitation to her room. The DON stated Resident #1 stated she had a right to have a boyfriend when consent was discussed and stated Resident #1 knew what she was doing and knew what she wanted. The DON stated Resident #2 was adamant he never touched Resident #1. The DON revealed for state reports, the procedure was to normally call their corporate team to discuss and she knew they did discuss the incident. She revealed the Administrator was responsible for making the report to state. The DON stated determinations of a resident's capacity to consent was based on the resident's BIMS score and Resident #1 would sometimes state if she did not want her family member to know something regarding her care and/or status. The DON revealed she believed they did an abuse and neglect training following this reported incident. During an interview on 02/03/2026 at 05:02 p.m. the ADMIN revealed the reported incident between Resident #1 and Resident #2 was initially reported by Resident #1's family member and that the family member felt Resident #1 having a relationship with a man was inappropriate. The ADMIN revealed that when she asked Resident #1 what occurred, Resident #1 said that Resident #2 had made a move on her and she did not like it and started to cry and did not ask for it. The ADMIN stated Resident #1 went into details regarding the incident. The ADMIN stated after Resident #1's report, she asked Resident #1 to step out of the office and asked Resident #1's family member what she would like to be done and Resident #1's family member requested for Resident #1's room to be changed. The ADMIN stated they moved Resident #1 and started an investigation. The ADMIN stated following Resident #1's family member leaving, Resident #1 came back and told her and the DON that she had invited him, Resident #2, into her room, made an inappropriate comment, that she then went to his room where they kissed. She stated she liked it and kept coming back multiple times a day. The ADMIN revealed Resident #1 stated she did not want to say that in front of her family member. The ADMIN revealed that she and the DON went to interview Resident #2, who denied the allegations. The ADMIN revealed Resident #1 had a good relationship with OTR A and Resident #1 had told OTR A that she had lied and just liked the attention. The ADMIN revealed the facility would review a resident's BIMS score and a resident's behavior in general to determine capacity to consent and Resident #1 was alert and oriented and made her own decisions. The ADMIN revealed as part of their investigation they interviewed the three (3) residents that occupied the rooms closest to Resident #1's prior room and Resident #2's current room and no witnesses to the alleged relationship were found. The ADMIN revealed the staff were in-serviced on abuse and neglect following the alleged incident and psych services were notified. The ADMIN revealed the alleged incident was initially treated as abuse but during the two (2) hours that the facility had to report, Resident #1 had changed her story and stated she was lying. Record review of In-Service Training Report, dated 01/21/2026 with topic Abuse/Neglect/Exploitation, reflected 17 staff signatures indicating receipt of the training. Record review of facility policy titled Abuse, Neglect and Exploitation, dated as implemented 07/11/2025, reflected Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: . 'Alleged Violation' is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property.Policy Explanation and Compliance Guidelines: .IV. Identification of Abuse, Neglect and Exploitation .B. Possible indicators of abuse include, but are not limited to:1. Resident, staff or family report of abuse.VII. Reporting/ResponseA. The facility will have written procedures that include:1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, . Record review of facility policy titled Incidents and Accidents, dated as implemented 08/15/2022, reflected Policy: It is the policy of this facility for staff to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. Compliance Guidelines: .4. The following incidents/accidents require an incident/accident report but are not limited to: alleged abuse.

Based on observation and interview, the facility failed to post on a daily basis information that included the facility name, current date, total number and actual hours worked by registered nurses, licensed practical or licensed vocational nurses, certified nurse aides directly responsible for resident care per shift and the resident census for 4 of 4 days (01/31/2026 - 02/03/2026) reviewed for posting of required information. The facility failed to post the required current nurse staffing and census information from 01/31/2026 to 02/03/2026. This failure could place all residents, their families, and facility visitors at risk of not having access to information regarding staffing data and the facility census. The findings included: During an observation on 02/03/2026 at 10:14 a.m. and at 04:15 p.m., a document labeled [facility name] Direct Care Daily Staffing 8-Hour, dated 01/30/2026, was posted on a wall of the front lobby/ front dining space. The document included the following information: current census and the number and hours worked of registered nurses, licensed vocational nurses, medication aides, and certified nurse aides for the 06:00 a.m. - 02:00 p.m. shift, 02:00 p.m. - 10:00 p.m. shift, and the 10:00 p.m. - 6:00 a.m. shift. During a telephone interview on 02/03/2026 at 04:33 p.m., the DON revealed she used to be responsible for posting the daily census and nurse staffing posting; however, the ADON took over the responsibility in February (of 2026). She stated the posting is expected to be posted in the dining room and in addition the staff have a sign-in sheet. She stated there was also a staff schedule posted in the employee breakroom. She stated she did not believe the daily census and nurse staffing posting having not been posted for several days would have impacted the residents or facility guests because they could ask staff who was on schedule and when they could expect a certain staff member back. She stated facility guests and residents were not supposed to have access to the employee breakroom but would sometimes peak into the room and would therefore also be able to view the staff schedule. During an interview on 02/03/2026 at 04:56 p.m., the ADON revealed she was not too familiar with the daily census and staff posting because she had just started being responsible for doing the staffing schedules. She revealed she was aware that the facility had a sheet that was posted daily regarding this information, and it was the responsibility of the person that managed the staffing. She stated she believed the DON was posting the form and was unsure why the posting on 02/03/2026 was dated 01/30/2026. She stated she had not taken over this responsibility, but she was the DON's back-up. She stated on the weekends, 01/31/2026 was a Saturday and 02/01/2026 was a Sunday, she was unsure if the daily census and nurse staffing posting was posted or not and did not know the procedures for those days. She revealed she did not believe the residents or facility guests would have been impacted by the posting not having been current because they could ask the staff directly. The ADON stated she was unsure if there was a facility policy regarding the posting of the daily census and nurse staffing. During an interview on 02/03/2026 at 05:02 p.m., the ADMIN revealed the DON was responsible for posting the daily census and nurse staffing posting. She stated for the weekends, the DON would prepare the postings and leave them for the weekend staff. She stated the weekend staff, specifically the weekend nurse supervisor, was responsible for moving the pre-prepared sheets. She stated she believed the lack of posting the document daily could impact the residents and facility guests because they might want to know who was working or how many staff were working the floor, but they might also ask staff directly. During an interview on 02/03/2026 at 05:32 p.m., the ADON revealed she had just created and posted the current day's (02/03/2026) daily census and nurse staffing posting. She revealed she found the prior day's postings behind the 01/30/2026 posting and believed the staff just did not flip the sheets around. During an interview on 02/03/2026 at 06:18 p.m., the ADMIN revealed she could not find a facility policy regarding the daily census and nurse staffing posting. She stated the facility procedures were to follow the state and federal regulations.

Based on interviews and record review, the facility failed to have evidence all allegations of abuse, neglect, or mistreatment were thoroughly investigated and documented for 2 of 10 residents (Resident #1 and Resident #2) reviewed for a fall injury. The facility failed to have evidence that a thorough investigation was conducted following the allegation Resident #1 had an unwitnessed fall with injury on 10/07/2025 and Resident #2 had an unwitnessed fall with injury on 11/12/2025. These failures could place residents at risk for abuse and neglect by not investigating injuries of unknown origin. The findings included: Review of Resident #1's admission record dated 12/03/2025 reflected he was admitted to the facility on [DATE], readmitted on [DATE], and discharged on 11/18/2025. His diagnoses included acute respiratory failure with hypoxia (a condition when the respiratory system fails to maintain adequate oxygen levels in the blood), dementia (a condition characterized by a decline in cognitive function), muscle wasting and atrophy (is the loss of muscle mass and strength), sepsis, unspecified organism (condition when the body's immune system reacts severely to an infection, leading to widespread inflammation), and other lack of coordination (condition characterized by difficulty controlling voluntary muscle movements, leading to symptoms such as clumsiness, unsteady gait). Review of Resident #1's discharge MDS dated [DATE] reflected a BIMS score of 11, indicating moderately impaired cognition. It reflected that he required substantial/maximal assistance with sit to stand, chair/bed-to-chair transfer, toilet transfer and required the use of a manual wheelchair. Review of Resident #1's care plan dated 10/10/2025 reflected the following: [Resident #1] The resident is at risk for falls r/t decreased mobility d/t respiratory failure, CHF, Dementia, muscle wasting. The goals were for Resident #1 to be free of falls through the next review date. And interventions included ensuring Resident #1's call light is within reach, encourage the resident to use it for assistance as needed, and needs prompt response to all requests for assistance. Review of Resident #1's nursing progress note dated 10/08/2025 reflected the following: LVN A At 2250 [10:50 PM] 10/7/2025 found Resident [Resident #1] on the floor next to his low bed laying on his Rt. side. Noted blood on the floor, noted laceration to Rt. eyebrow with swelling and bleeding, pressure applied. Resident [Resident #1] is alert, unable to say what happened, kept saying thank you God in Spanish. Resident [Resident #1] is confused as he has been since admit [admission] 10/4/25. Aggressive and combative with assessment and Neuros, PEARLA, moves all extremities. No other visible injury noted. Called 911, Resident sent to ER. MD and DON notified. Review of Resident #1's electronic medical record on 12/02/2025 and 12/03/2025 reflected that an incident report was not documented for the un-witnessed fall on 10/07/2025. Review of Resident #1's electronic medical record on 12/02/2025 and 12/03/2025 reflected there was no facility incident report to HHSC for the alleged violation of injury of unknown source on 10/07/2025. Review of Resident #2's admission record dated 12/03/2025 reflected he was admitted to the facility on [DATE]. His diagnoses included heart failure, unspecified (a condition where the heart cannot pump enough blood to meet the body's needs), shortness of breath, repeated falls, other lack of coordination (condition characterized by difficulty controlling voluntary muscle movements, leading to symptoms such as clumsiness and unsteady gait), and muscle wasting and atrophy (is the loss of muscle mass and strength). Review of Resident #2's admission MDS dated [DATE] reflected a BIMS score of 06, indicating severely impaired cognition. It reflected an active diagnosis of repeated falls and that he required partial/moderate assistance with toileting hygiene, sit to stand, chair/bed-to chair transfer, and toilet transfer. Review of Resident #2's care plan dated 10/10/2025 reflected the following: [Resident #2] The resident is at risk for falls r/t SOB, decreased mobility, s/p NSTEMI. The goals were for Resident #2 to be free of falls through the next review date. And interventions included ensuring Resident #1's call light is within reach, encourage the resident to use it for assistance as needed, and needs prompt response to all requests for assistance.Review of Resident #2's un-witnessed fall report dated 11/12/2025 at 2:00 AM reflected: RN A Heard resident [Resident #2] call for help, upon entering room resident [Resident #2] was on the floor on his right side next to his bed. Resident [Resident #2] stated he fell when getting out of bed. Resident [Resident #2] has small hematoma (an abnormal collection of blood outside of a blood vessel) to left cheekbone and has small laceration to left side of eyebrow. RN [RN A] cleansed laceration, applied pressure, bleeding stopped and TAO was applied. RN [RN A] also applied ice pack to left cheekbone hematoma. Resident [Resident #2] is able to move all extremities without difficulty. Denies pain but has discomfort to BLE due to swelling.MD and DON notified. Review of Resident #2's electronic medical record on 12/02/2025 and 12/03/2025 reflected there was no facility incident report to HHSC for the alleged violation of injury of unknown source on 11/12/2025. During an interview on 12/03/2025 at 1:15 PM, the DON stated she in-serviced her staff on ANE following a recent fall report to the State in November. She stated she educates herself by constantly reviewing the ANE policy. She stated the abuse coordinator is the ADM. She stated the facility ANE policy is to think of the resident's safety first, remove anyone suspected of ANE, notify the ADM and then notify upper management, and submit a self-report. She stated the nursing staff are expected to report ANE immediately - day or night. She stated all falls witnessed and unwitnessed requires a call to her and ADM. She stated she would have spoken to Resident #2 after the un-witnessed fall on 11/12/2025. She stated he's alert, he needs assistance and reminders with walking. She stated Resident #1 would have been receiving PT services, he has short term memory, requires minimal assistance and no behaviors. She stated she was not sure why there are no ANE reports to the state regarding the unwitnessed falls for Resident #1 on 10/7/2025 and Resident #2 on 11/12/2025. DON stated she believes ANE report was not submitted to the state because Resident #1 and Resident #2 have high BIMS, and she interviewed them after the falls, and they explained why they fell. She stated she does not keep documentation on post-fall interviews, and she does not chart it in their electronic medical record. After she was informed of Resident #2's BIMS score of 06 signifies severe cognitive impairment she stated she would have to review his electronic medical record and get back to me. No additional information was received prior to exit. During an interview on 12/03/2025 at 1:58 PM, the ADM stated the last ANE training conducted was in November following a fall incident that was reported to HHSC. She stated the nursing staff are required to report any allegations of ANE to her immediately. She stated the fall protocol is to ensure when a resident is found to have fallen to make sure there are no injuries, the charge nurse conducts an assessment of the resident and notifies the DON, ADM, RP, and MD. She stated if there is no injury the management team will talk about it in the morning meeting the following day, give screening referral to therapy staff and talk about interventions. ADM stated if there is an injury with the fall there is a whole investigation process, this entails completing an incident report, conducting all the interviews with staff present, resident interview, and documenting timeframes of what occurred to report it to the state. She stated if the fall protocol is not followed it could impact the resident and serious injuries would go unreported. She stated that she has 2 hours after she is notified of the allegation to report to the state. She stated that if allegation with serious injury, unknown injury, resident cannot tell her what happened, no witnesses, or unexplainable injury she is to report to the state within 2 hours. She stated she does not recall the 11/12/2025 un-witnessed fall incident involving Resident #2 and stated the management team usually discusses incidents in the morning meeting. She stated she may have been notified the following morning of Resident #2's un-witnessed fall incident, but she is not sure. She stated because the resident can tell them what occurred even if unwitnessed, this is not suspicious or unknown and this would not rise to the level of a reportable incident to the state. ADM reviewed Resident #1's nurse's progress notes for 10/07/2025 un-witnessed fall and stated she would need to review the documentation further for this one. She stated there was no severe bodily injury, no suspicion, would have to look at documentation, but believed he was alert and may have had a history of being combative, but she doesn't recall and would need to coordinate with management team to provide the un-witnessed fall report that would provide additional details to the progress note. No additional information was provided prior to exit.Review of the facility document dated 11/03/2025, titled In-Service Training Report reflected the following: Topic: Fall Precautions and contents include call bell in reach, answer promptly, assist post fall care, toilet as often as needed, equipment, and documentation. Review of the facility policy dated 8/15/2022, titled Incidents and Accidents reflected the following: Policy: It is the policy of this facility for staff to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. Definitions: Accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident.Policy Explanation: The purpose of incident reporting can include: Alert administration of occurrences that could result in reporting requirements. Meeting regulatory requirements for analysis and reporting of incidents and accidents. Compliance Guidelines: Incidents that rise to the level of abuse, misappropriation, or neglect, will be managed and reported according to the facility's abuse prevention policy. Review of the facility policy undated, titled Fall Prevention Program reflected the following: Falls can cause people to restrict their activities, lead to depression, helplessness, social isolation, loss of confidence in independent mobility, injuries and even death. Most falls occur as a result of multiple intrinsic and extrinsic factors. Review of the facility policy dated 8/15/2025, titled Abuse, Neglect and Exploitation reflected the following: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; b. Establish policies and procedures to investigate any such allegations; and c. Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of resident property, reporting procedures, and dementia management and resident abuse prevention; and IV. Identification of Abuse, Neglect and Exploitation A. The facility will have written procedures to assist staff in identifying the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations. 3. Physical injury of a resident, of unknown source. V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation; 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence); 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation. VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.

Based on interviews and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedure. In response to allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source for 2 of 10 residents (Resident #1 and Resident #2) reviewed for reporting allegations of abuse and neglect. The DON failed to identify an un-witnessed fall as an alleged violation of injury of unknown source for Resident #1 on 10/07/2025 resulting in the resident having a laceration to the right eyebrow with swelling and bleeding and being sent to the hospital The DON failed to identify an un-witnessed fall as an alleged violation of injury of unknown source for Resident ##2 on 11/12/2025 resulting in the resident having a small hematoma to the left cheekbone and laceration to the left side of eyebrow. The DON failed to report an alleged violation of injury of unknown source for Resident #1 on 10/07/2025 and Resident #2 on 11/12/2025 to the Administrator of the facility and the Administrator failed to report the violations of injury of unknown source not later than 24 hours to other officials (including to the State Survey Agency) in accordance with State law through established procedure.This deficient practice of not following ANE reporting protocol could place residents at risk of harm by not having their injuries investigated.The findings included: Review of Resident #1's admission record dated 12/03/2025 reflected he was admitted to the facility on [DATE], readmitted on [DATE], and discharged on 11/18/2025. His diagnoses included acute respiratory failure with hypoxia (a condition when the respiratory system fails to maintain adequate oxygen levels in the blood), dementia (a condition characterized by a decline in cognitive function), muscle wasting and atrophy (is the loss of muscle mass and strength), sepsis, unspecified organism (condition when the body's immune system reacts severely to an infection, leading to widespread inflammation), and other lack of coordination (condition characterized by difficulty controlling voluntary muscle movements, leading to symptoms such as clumsiness, unsteady gait). Review of Resident #1's discharge MDS dated [DATE] reflected a BIMS score of 11, indicating moderately impaired cognition. It reflected that he required substantial/maximal assistance with sit to stand, chair/bed-to-chair transfer, toilet transfer and required the use of a manual wheelchair. Review of Resident #1's care plan dated 10/10/2025 reflected the following: [Resident #1] The resident is at risk for falls r/t decreased mobility d/t respiratory failure, CHF, Dementia, muscle wasting. The goals were for Resident #1 to be free of falls through the next review date. And interventions included ensuring Resident #1's call light is within reach, encourage the resident to use it for assistance as needed, and needs prompt response to all requests for assistance. Review of Resident #1's nursing progress note dated 10/08/2025 reflected the following: LVN A At 2250 [10:50 PM] 10/7/2025 found Resident [Resident #1] on the floor next to his low bed laying on his Rt. side. Noted blood on the floor, noted laceration to Rt. eyebrow with swelling and bleeding, pressure applied. Resident [Resident #1] is alert, unable to say what happened, kept saying thank you God in Spanish. Resident [Resident #1] is confused as he has been since admit [admission] 10/4/25. Aggressive and combative with assessment and Neuros, PERRLA, moves all extremities. No other visible injury noted. Called 911, Resident sent to ER. MD and DON notified. Review of Resident #1's electronic medical record on 12/02/2025 and 12/03/2025 reflected that an incident report was not documented for the un-witnessed fall on 10/07/2025. Review of Resident #1's electronic medical record on 12/02/2025 and 12/03/2025 reflected there was no facility incident report to HHSC for the alleged violation of injury of unknown source on 10/07/2025. Review of Resident #2's admission record dated 12/03/2025 reflected he was admitted to the facility on [DATE]. His diagnoses included heart failure, unspecified (a condition where the heart cannot pump enough blood to meet the body's needs), shortness of breath, repeated falls, other lack of coordination (condition characterized by difficulty controlling voluntary muscle movements, leading to symptoms such as clumsiness and unsteady gait), and muscle wasting and atrophy (is the loss of muscle mass and strength). Review of Resident #2's admission MDS dated [DATE] reflected a BIMS score of 06, indicating severely impaired cognition. It reflected an active diagnosis of repeated falls and that he required partial/moderate assistance with toileting hygiene, sit to stand, chair/bed-to chair transfer, and toilet transfer. Review of Resident #2's care plan dated 10/10/2025 reflected the following: [Resident #2] The resident is at risk for falls r/t SOB, decreased mobility, s/p NSTEMI. The goals were for Resident #2 to be free of falls through the next review date. And interventions included ensuring Resident #1's call light is within reach, encourage the resident to use it for assistance as needed, and needs prompt response to all requests for assistance.Review of Resident #2's un-witnessed fall report dated 11/12/2025 at 2:00 AM reflected: RN A Heard resident [Resident #2] call for help, upon entering room resident [Resident #2] was on the floor on his right side next to his bed. Resident [Resident #2] stated he fell when getting out of bed. Resident [Resident #2] has small hematoma (an abnormal collection of blood outside of a blood vessel) to left cheekbone and has small laceration to left side of eyebrow. RN [RN A] cleansed laceration, applied pressure, bleeding stopped and TAO was applied. RN [RN A] also applied ice pack to left cheekbone hematoma. Resident [Resident #2] is able to move all extremities without difficulty. Denies pain but has discomfort to BLE due to swelling.MD and DON notified. Review of Resident #2's electronic medical record on 12/02/2025 and 12/03/2025 reflected there was no facility incident report to HHSC for the alleged violation of injury of unknown source on 11/12/2025. During an interview on 12/03/2025 at 9:34 AM, CNA C stated she received ANE training in the last month, she was knowledgeable of ANE and Resident Rights and provided examples. She stated the abuse coordinator is the ADM, she has not witnessed ANE, but if she did, she would report it immediately. She stated the impact abuse and neglect would have on a resident would be seclusion, would not eat, not want to be around others, depression, feel like quitting, and crying. She stated she was familiar with Resident #2's care. She stated Resident #1 required extensive care and he is extremely forgetful, and he does ambulate with a walker, or wheelchair. She stated she was not present for his fall, but fall precautions are in place for him. During an interview on 12/03/2025 at 10:40 AM, CNA B stated ANE in-service is every Thursday during nursing meetings and online every 3 months. She was knowledgeable of ANE, provided examples, and stated the abuse coordinator is the ADM. She stated if suspects or witnesses ANE she would report immediately to the charge nurse, ADON, DON, and ADM. She stated she would report ANE right away. She stated if a resident were abused or neglected it could impact their mental state. During an interview on 12/03/2025 at 11:16 AM, CNA A stated she received ANE training online, she was knowledgeable of ANE, provided examples and stated the abuse coordinator is the ADM. She stated she has not witnessed or suspected ANE. She stated residents who are abused or neglected can have a negative impact and they may refuse care, cause depression, or may not want to do anything, not want to shower, and would feel like a burden. During an interview on 12/03/2025 at 11:45 AM, RN B stated she has received ANE training online, she was knowledgeable and provided examples of ANE. She stated the abuse coordinator is the ADM and any ANE suspected or witnessed is expected or to be reported immediately. She stated the impact ANE would have on residents includes secluding self, weight loss, and decline in health. She stated the post-fall procedures are to notify the DON and ADM regardless of if witnessed or un-witnessed fall. She stated witnessed and un-witnessed falls follow the same process for notification. She stated she was not familiar with Resident #1's care, but she was familiar with Resident #2's care. RN B stated Resident #2 needs partial standby assistance, but lately he has been declining, sometimes he uses a walker and wheelchair, he requires reminders for the restroom, and he is very forgetful. During an interview on 12/03/2025 at 1:15 PM, the DON stated she in-serviced her staff on ANE following a recent fall report to the State in November. She stated she educates herself by constantly reviewing the ANE policy. She stated the abuse coordinator is the ADM. She stated the facility ANE policy is to think of the resident's safety first, remove anyone suspected of ANE, notify the ADM and then notify upper management, and submit a self-report. She stated the nursing staff are expected to report ANE immediately - day or night. She stated all falls witnessed and unwitnessed requires a call to her and ADM. She stated she would have spoken to Resident #2 after the un-witnessed fall on 11/12/2025. She stated he's alert, he needs assistance and reminders with walking. She stated Resident #1 would have been receiving PT services, he has short term memory, requires minimal assistance and no behaviors. She stated she was not sure why there are no ANE reports to the state regarding the unwitnessed falls for Resident #1 on 10/7/2025 and Resident #2 on 11/12/2025. DON stated she believes ANE report was not submitted to the state because Resident #1 and Resident #2 have high BIMS, and she interviewed them after the falls, and they explained why they fell. She stated she does not keep documentation on post-fall interviews, and she does not chart it in their electronic medical record. After she was informed of Resident #2's BIMS score of 06 signifies severe cognitive impairment she stated she would have to review his electronic medical record and get back to me. No additional information was received prior to exit. During an interview on 12/03/2025 at 1:58 PM, the ADM stated the last ANE training conducted was in November following a fall incident that was reported to HHSC. She stated the nursing staff are required to report any allegations of ANE to her immediately. She stated the fall protocol is to ensure when a resident is found to have fallen to make sure there are no injuries, the charge nurse conducts an assessment of the resident and notifies the DON, ADM, RP, and MD. She stated if there is no injury the management team will talk about it in the morning meeting the following day, give screening referral to therapy staff and talk about interventions. ADM stated if there is an injury with the fall there is a whole investigation process, this entails completing an incident report, conducting all the interviews with staff present, resident interview, and documenting timeframes of what occurred to report it to the state. She stated if the fall protocol is not followed it could impact the resident and serious injuries would go unreported. She stated that she has 2 hours after she is notified of the allegation to report to the state. She stated that if allegation with serious injury, unknown injury, resident cannot tell her what happened, no witnesses, or unexplainable injury she is to report to the state within 2 hours. She stated she does not recall the 11/12/2025 un-witnessed fall incident involving Resident #2 and stated the management team usually discusses incidents in the morning meeting. She stated she may have been notified the following morning of Resident #2's un-witnessed fall incident, but she is not sure. She stated because the resident can tell them what occurred even if unwitnessed, this is not suspicious or unknown and this would not rise to the level of a reportable incident to the state. ADM reviewed Resident #1's nurse's progress notes for 10/07/2025 un-witnessed fall and stated she would need to review the documentation further for this one. She stated there was no severe bodily injury, no suspicion, would have to look at documentation, but believed he was alert and may have had a history of being combative, but she doesn't recall and would need to coordinate with management team to provide the un-witnessed fall report that would provide additional details to the progress note. No additional information was provided prior to exit.Review of the facility document dated 11/03/2025, titled In-Service Training Report reflected the following: Topic: Fall Precautions and contents include call bell in reach, answer promptly, assist post fall care, toilet as often as needed, equipment, and documentation. Review of the facility policy dated 8/15/2022, titled Incidents and Accidents reflected the following: Policy: It is the policy of this facility for staff to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. Definitions: Accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident.Policy Explanation: The purpose of incident reporting can include: Alert administration of occurrences that could result in reporting requirements. Meeting regulatory requirements for analysis and reporting of incidents and accidents. Compliance Guidelines: Incidents that rise to the level of abuse, misappropriation, or neglect, will be managed and reported according to the facility's abuse prevention policy. Review of the facility policy undated, titled Fall Prevention Program reflected the following: Falls can cause people to restrict their activities, lead to depression, helplessness, social isolation, loss of confidence in independent mobility, injuries and even death. Most falls occur as a result of multiple intrinsic and extrinsic factors. Review of the facility policy dated 8/15/2025, titled Abuse, Neglect and Exploitation reflected the following: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; b. Establish policies and procedures to investigate any such allegations; and c. Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of resident property, reporting procedures, and dementia management and resident abuse prevention; and IV. Identification of Abuse, Neglect and Exploitation A. The facility will have written procedures to assist staff in identifying the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations. 3. Physical injury of a resident, of unknown source. V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation; 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence); 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation. VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.

Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 facility reviewed for dietary requirements. The Food Service Director did not have the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services. This deficient practice could place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition. Findings included: During an interview on 6/5/25 at 9:50am, the Food Service Director was hired 03/10/25. She stated she was not a certified dietary manager or certified food service manager, and she did not have an associate's or higher degree in food service management or in hospitality. The Food Service Director stated she previously worked in positions in the medical records and central supply departments. The Food Service Director stated she had no other dietary management experience. She stated she registered with a national dietary certification course on 6/1/25 called My Food Service License. The Food Service Director stated having the national dietary certification would increase her knowledge base on serving the resident's dietary needs. During an interview with the Administrator on 6/5/25 at 10:25am she stated if the Food Service Director obtained her dietary certification, it would increase her knowledge base of kitchen operations. She stated she understood the regulation requirement for the Food Service Director to be certified and she was now enrolled in a dietary manager certification course. During an interview with the Human Resource Director on 6/5/25 at 11:57am she stated the Food Service Director obtaining her national certification would provide her with an increased knowledge base of food quality and presentation for the residents. Record review of the facility's job description for Certified Dietary Manager that was undated revealed the education/training requirements for the position was being a graduate of a 2 or 4 year Dietary Manager's program or a Registered Dietician. It stated the licensing requirements for the position was a successful completion of a Certified Dietary Manager exam. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 1-201.10.10(B) Accredited Program. (1) Accredited program means a food protection manager certification program that has been evaluated and listed by an accrediting agency as conforming to national standards for organizations that certify individuals. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 2-102.12 Certified Food Protection Manager. (A) The PERSON IN CHARGE shall be a certified FOOD protection manager who has shown proficiency of required information through passing a test that is part of an ACCREDITED PROGRAM. 2-102.20 Food Protection Manager Certification. (B) A FOOD ESTABLISHMENT that has a PERSON IN CHARGE that is certified by a FOOD protection manager certification program that is evaluated and listed by a Conference for FOOD Protection-recognized accrediting agency as conforming to the Conference for FOOD Protection Standard for Accreditation of FOOD Protection Manager Certification Programs is deemed to comply with §2-102.12.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 facility in that: 1. The facility failed to clean an overhead ceiling vent in the main kitchen area. 2. The facility failed to close an attic trap door on the outside kitchen patio area. 3. The facility failed to paint over a peeling ceiling area located over the dish machine conveyor line. These failures could place residents at risk for food borne illness. The findings included: Observation on 06/03/2025 from 9:05am until 9:40am with the Food Service Director revealed the following: a. There was a 4x1.5 foot overhead ceiling vent in the main kitchen area that was covered with dirt and dust particles. b. There was an attic ceiling trap door that was not fully closed above the outside kitchen patio area where two food storage freezers used by kitchen staff were located c. In the dish room above the dish machine conveyor belt that was an area on the ceiling that measured approximately 1 foot by 6 inches that had exposed and peeling paint particles. During an interview on 06/03/25 at 9:45am, the Food Service Director stated that she had placed a work order for the dirty ceiling vent to be cleaned and that the dirt/dust particles could potentially fall onto the kitchen floor. The Food Service Director stated that the ceiling attic trap door should be fully closed at all times and that a rodent could potentially access the kitchen patio area. The Food Service Director stated that the ceiling above the dish machine conveyor belt needed to be re-painted and that paint particles could potentially fall onto the clean dishware. She stated that the Maintenance Director was responsible for the work in the dish room and a work order had not been requested. During an interview with the Administrator on 6/3/25 at 9:50am she stated that the Maintenance Director was responsible for repairs in the kitchen including the ceiling vent cleaning, the patio attic door closure, and the dish room ceiling painting to maintain a clean kitchen environment. During an interview with the Maintenance Director on 6/6/25 at 10:35am he stated he had received a work order for the kitchen ceiling vent to be cleaned, to maintain a clean kitchen environment, in May of 2025. The Maintenance Director stated that the ceiling in the dish room that needed re-painted to prevent the paint chips from falling onto the dish conveyor belt was last noted on a TELS work order in 2024. Record review of facility policy entitled General Kitchen Sanitation Policy Number 04.003 stated All Nutrition and Foodservice employees will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness. Clean non-food-contact surfaces of equipment at intervals as necessary to keep them free of dust, dirt, insects and other contaminants. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles for, 1 of 4 medication carts observed, in that: The Nurse Medication Cart in the 300 hall contained five loose medication pills. This failure could place residents who receive medications at risk for not receiving the intended therapeutic effects of medications. The findings were: Observation on 06/05/2025 at 10:18 a.m. of the 300 Hall Nurse Medication Cart revealed there were five loose medication pills inside one of the drawers. During an interview with LVN (B) on 06/05/2025 at 10:25 a.m., LVN(B) confirmed there were five loose medication pills inside a drawer of the Nurse Medication Cart. She stated the pills must have dropped at some point during her medication pass this morning, or perhaps another nurse at an undetermined time. During an interview with the DON on 06/05/2025 at 10:30 a.m., she stated medication carts should not have loose medications. They were the responsibility of the nurse who accepted responsibility for the cart. Record review of the facility policy, Labeling of medications, 10/1/2019, revealed Prescription medication will be labeled with the following information: medication name, name of resident, strength of medication.

Based on interview and record review, the facility failed to maintain clinical records that were complete and accurate, in accordance with accepted professional standards and practices, for 1 of 6 residents (Resident #159) reviewed for complete and accurate medical records in that: Resident #159's diagnoses list was incomplete. This deficient practice could result in errors in care and treatment. The findings were: Record review of Resident #159's face sheet, dated 06/06/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Heart Failure, Pneumonia, and Muscle Wasting and Atrophy. Further review revealed Hypertension and Hypothyroidism were not included. Record review of Resident #159's clinical record as of 06/06/2025 revealed an admission MDS assessment was not yet due to be completed and therefore, the resident's BIMS score was unavailable. Further review of Resident #159's clinical record as of 06/06/2025 revealed the resident's comprehensive care plan was in process but not yet due to be completed and therefore, did not include all of the resident's diagnoses. Further review of Resident #159's clinical record as of 06/06/2025 revealed an order dated 05/29/2025, Levothyroxine Sodium Oral Tablet 50 MCG (Levothyroxine Sodium) Give 1 tablet by mouth one time a day for hypothyroidism, and an order dated 05/31/2025, Lisinopril-hydroCHLOROthiazide Oral Tablet 10-12.5 MG (Lisinopril & Hydrochlorothiazide) Give 1 tablet by mouth one time a day for Hypertension. Record review of Resident #159's clinical record as of 06/06/2025 revealed the resident's list of diagnoses did not include Hypertension or Hypothyroidism. During an interview with the DON on 06/05/2025 at 12:26 p.m., the DON confirmed Resident #159's diagnoses of Hypertension and Hypothyroidism were not included in her list of diagnoses in her clinical record or on her face sheet. The DON confirmed the resident's face sheet was utilized by outside health providers and should accurately reflect the resident's health status. Record review of the Documentation in Medical Record policy, dated 10/24/22, revealed Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.

Based on interview and record review, the facility failed to accurately complete assessments for 1 of 6 residents reviewed (Resident #20) for accuracy of assessments, in that: Resident #20's MDS assessment was inaccurate. This deficient practice could result in diminished quality of care due to inaccurate resident assessment. The findings were: Record review of Resident #20's face sheet, dated 06/06/2025, revealed the resident was admitted to the facility on [DATE] with diagnoses including: Unspecified Dementia, Cognitive Communication Deficit, and Chronic Obstructive Pulmonary Disease. Record review of Resident #20's Quarterly MDS, dated [DATE], revealed the resident was rarely or never understood, and Staff Assessment for Mental Status revealed the resident had both short-term and long-term memory problems. Further review revealed the MDS noted the resident was not receiving hospice services. Record review of Resident #20's Care Plan, revised 10/22/2024, revealed The resident has a terminal prognosis and is on hospice [company name]. Record review of Resident #20's clinical record as of 06/06/2025, revealed an order dated, 10/9/2024, Admit to hospice . During an interview with the MDS Coordinator on 06/05/2025 at 2:42 p.m., the MDS Coordinator confirmed Resident #20's Quarterly MDS, dated [DATE], was incorrectly coded no for hospice services and stated the deficient practice was an oversight. During an interview with the DON on 06/05/2024 at 3:54 p.m., the DON stated she expected all MDS assessments to be correctly coded. The DON stated the facility followed the RAI manual for MDS assessments and did not have an additional policy regarding MDS assessments.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to personal privacy and confidentiality of his or her personal and medical records for 1 of 5 residents (Resident #37) reviewed for privacy, in that: MA (A) did not lock the computer after she walked away and left it unattended, which exposed Resident #37's morning medication list. This failure could place residents at risk of having their medical information exposed to others and cause residents to feel uncomfortable and disrespected. The findings include: Record review of Resident #37's face sheet dated 6/04/25 reflected an [AGE] year-old female resident who was admitted to the facility on [DATE] with diagnoses which included: Heart Failure (condition in which the heart isn't pumping as well as it should), kidney disease ( means your kidneys are damaged and can't filter blood the way they should) and Peripheral vascular disease(disorder of the blood vessels that affects the legs and feet). Record review of Resident #37's Quarterly MDS assessment, dated 3/27/25, reflected a BIMS score of 11, which indicated moderate cognitive impairment. During an Observation on 6/04/25 at 8:40 AM revealed MA (A) prepared Resident #37's morning medication and walked away from the computer, leaving the computer screen unlocked ; she was away from the computer for 4 minutes. During an interview on 6/04/25 at 8:50 AM, MA (A) stated she was not aware of the option to lock the computer screen and believed minimizing the screen was sufficient. MA (A)noted Resident #37's private medical information might have been exposed when she stepped away from the computer. During an interview on 06/05/25 at 2:34 PM, the DON stated her expectation was for the facility nursing staff to uphold HIPAA regulations and lock computer screens when they were away from them. The DON emphasized that all staff members should protect residents' information. The DON expressed concern that leaving residents' charts open and unattended could lead to unauthorized access. The DON also stated she would be responsible for overseeing compliance with this task, and she would monitor it by conducting random computer screen checks. Record review of the facility's policy dated 10/1/2019, titled medication administration, reflected: Privacy is maintained at all times for all resident information.

Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 6 residents who required wound prevention, treatment, and monitoring for 1 of 6 residents (Resident #1) in that: The facility failed to ensure Resident #1 received wound care and treatment as ordered by a physician. -Resident #1's right great toe was not monitored daily for changes once per day as ordered by a physician. -Resident #1's right heel was not monitored daily for changes once per day as ordered by a physician. -Resident #1's skin tear to the left upper leg was not monitored every shift for signs of infection as ordered by a physician. -Resident #1's pressure ulcer to her left buttock was not cleansed with wound cleaner, patted dry and did not have medseptic QA applied every shift as ordered by a physician. -Resident #1's pressure ulcer to her right buttock was not cleansed with wound cleaner, patted dry and did not have medseptic QA applied every shift as ordered by a physician. -Resident #1's pressure ulcer to her right gluteal fold was not cleansed with wound cleaner, patted dry and did not have medseptic QA applied every shift as ordered by a physician. Resident #1 was admitted to the hospital with sepsis which was presumed to be caused by an infected sacral decubitus ulcer. An IJ was identified on 09/27/2023 at 6:00 p.m., and a template was provided to the facility at this time. While the IJ was removed on 10/1/2023, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place additional residents at risk for a delay in treatment, hospitalization , loss of limb and/or a significant decline in health. The findings included: Record review of Resident #1's face sheet dated 9/28/2023 revealed she was [AGE] years of age with an admitted [DATE] and a readmitted [DATE] with diagnoses which included: Type 2 diabetes mellitus with diabetic neuropathy, end stage renal disease, major depressive disorder, mild cognitive impairment, dysphagia, cognitive communication deficit, urinary tract infection, degenerative disease of nervous system, lack of coordination, morbid obesity, muscle wasting, anemia in chronic kidney disease, fluid overload, anxiety disorder, cerebral infarction, nausea with vomiting, diarrhea. Record review of Resident #1's comprehensive MDS dated [DATE] revealed a BIMS score of 10 indicating moderate impairment. Further review under category, Skin Conditions, revealed Resident #1 was indicated as having zero venous and arterial ulcers, and no other ulcers, wounds and skin problems. Record review of Resident #1's Care Plan, start date 6/1/2023, stated, (Resident #1) has potential impairment to skin integrity r/t incontinence and decreased mobility. (Resident #1) will be free from skin break down through the review date Interventions included, Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heel, s/sx of infection, maceration etc. to MD. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Record review of Resident #1's Care Plan, start date, 8/18/2023, stated, (Resident #1) has DTI to left toe. (Resident #1's) Pressure ulcer will show signs of healing and remain free from infection by/through review date. (Resident #1) will have intact skin, free of redness, blisters or discoloration by/through review date. Interventions included, Administer treatments as ordered and monitor for effectiveness. Record review of Resident #1's Care Plan, start date, 8/18/2023, stated, (Resident #1) has DTI to right great toe. The (Resident #1s) will Pressure ulcer will show signs of healing and remain free from infection by/through review date. Interventions included, Administer treatments as ordered and monitor for effectiveness. Record review of Resident #1's Care Plan, start date, 8/18/2023, stated,(Resident #1) has DTI to right heel. (Resident #1's) pressure ulcer will show signs of healing and remain free from infection by/through review date. PHYSICIAN ORDERS Record review of Resident #1's physician's orders, start date, 7/26/2023, stated, DTI to Right heel-monitor daily for changes. Record review of Resident #1's physician's orders, start date, 7/26/2023, stated, DTI - right great toe monitor daily for changes. Record review of Resident #1's physician's orders, start date, 8/30/2023 stated, DTI-right great toe monitor daily for changes. Frequency, one time a day. Record review of Resident #1's physician's orders, start date, 8/30/2023 stated: DTI to Right heel-monitor for changes. Frequency, one time a day. Record review of Resident #1's physician's orders, start date, 8/30/2023 stated: stage 2 to R buttock: cleanse with wound cleanser pat dry apply mediseptic QS. Frequency, every shift. Record review of Resident #1's physician's orders, start date, 8/30/2023 stated: Stage 2 to L buttock: cleanse with wound cleanser, pat dry apply mediseptic QS. Frequency, every shift. Record review of Resident #1's physician's orders, start date, 9/9/2023 stated: Monitor skin tear left upper leg Monitor every shift for signs of infection until heeled. Frequency, every shift. Record review of Resident #1's physician's orders, start date, 9/11/2023 stated: Stage 2 to R gluteal fold cleanse with wound cleanser pat dry apply mediseptic QS. Frequency, every shift. TREATMENT ADMINISTRATION: Record review of Resident #1's TAR September 2023 stated, DTI - right great toe monitor daily for changes one time a day -Start Date 08/01/2023. Further review revealed holes in the TAR the following: 9/5, 9/6, 9/8, 9/13, 9/14, 9/15. Record review of Resident #1's September 2023 TAR stated, TI to Right heel-monitor daily for changes one time a day -Start Date 08/01/2023. Further review revealed holes in the TAR on the following: 9/5, 9/6, 9/8, 9/13, 9/14, 9/15. Record review of Resident #1's September 2023 TAR stated, Monitor skin tear left upper leg Monitor every shift for signs of infection until heeled every shift -Start Date 09/09/2023 Further review revealed holes in the TAR for the following: Shift 6:00 AM - 2:00 PM - 9/13 thru 9/15, 9/18 Shift 2:00 PM - 10:00 PM - 9/9, 9/11 thru 9/15 Shift 10:00 PM - 6:00 AM - 9/9 Record review of Resident #1's September 2023 TAR stated, stage 2 to L buttock: cleanse with wound cleanser, pat dry apply mediseptic QS every shift -Start Date 08/30/2023. Further review revealed holes in the TAR for the following: Shift 6:00 AM - 2:00 PM - 9/4 thru 9/6, 9/8, 9/13 thru 9/15, 9/18 Shift 2:00 PM - 10:00 PM - 9/5-9/9, 9/11 thru 9/18 Shift 10:00 PM - 6:00 AM - 9/9 Record review of Resident #1's September 2023 TAR stated, stage 2 to R buttock: cleanse with wound cleanser pat dry apply mediseptic QS every shift -Start Date 08/30/2023. Further review revealed holes in the TAR for the following: Shift 6:00 AM - 2:00 PM - 9/4 thru 9/6, 9/8, 9/13 thru 9/15, 9/18 Shift 2:00 PM - 10:00 PM - 9/5-9/9, 9/11 thru 9/18 Shift 10:00 PM - 6:00 AM - 9/9 Record review of Resident #1's September 2023 TAR stated, Stage 2 to R gluteal fold cleanse with wound cleanser, pat dry apply mediseptic QS every shift -Start Date 09/11/2023. Further review revealed holes in the TAR for the following: Shift 6:00 AM - 2:00 PM - 9/13, 9/14, 9/15, 9/18 Shift 2:00 PM - 10:00 PM - 9/11 thru 9/18 Shift 10:00 PM - 6:00 AM - 0 missed SKIN ASSESSMENTS Record review of Resident #1's Weekly Skin Evaluation, effective date, 9/14/2023, revealed: What type of wound(s) does patient have? - A. Pressure Ulcer(s). Further review revealed there these were new since last skin assessment. Type of wound was, Right gluteal fold - Stage 2 to R gluteal fold measuring 2cmx4cm. This document was signed by Treatment Nurse, LVN B. Record review of Resident #1's Weekly Pressure Ulcer Evaluation, effective date, 9/14/2023, revealed: date of assessment was 9/11/2023 -Right Great Toe, length 1.5 cm, width 1.5 cm, depth N/A, stage suspected deep tissue injury. Further review revealed the wound developed 8/13/2023 and was, admitted with. This document was signed by Treatment Nurse, LVN B. Record review of Resident #1's Weekly Pressure Ulcer Evaluation, effective date, 9/14/2023, revealed: date of assessment was 9/11/2023 - Right Heel, length 4cm, width 4.5cm, depth N/A, stage suspected deep tissue injury. Further review revealed the wound developed 8/13/2023 and was, admitted with. This document was signed by Treatment Nurse, LVN B. Record review of Resident #1's Weekly Pressure Ulcer Evaluation, effective date, 9/14/2023, revealed: date of assessment was 9/11/2023 - Right Buttock pressure ulcer, length 5cm, width 6cm, depth .1cm, stage N/A. Further review revealed the wound developed 8/30/2023 and was, in house developed. This document was signed by Treatment Nurse, LVN B. Record review of Resident #1's Weekly Pressure Ulcer Evaluation, effective date, 9/14/2023, revealed: date of assessment was 9/11/2023 - Left Buttock pressure ulcer, length 3.5cm, width 4cm, depth .1cm, stage II. Further review revealed the wound developed 8/30/2023 and was, in house developed. This document was signed by Treatment Nurse, LVN B. PROGRESS NOTES Record review of Resident #1's progress note, dated 6/1/2023 - 6:18 PM, stated, Note Text: Received resident via stretcher by Amistad ambulance. (Resident #1) is a [AGE] year-old female with PMH of HTN, DM, CAD, neuropathy, anxiety, depression, seizure, CVAx2, ESRD on HD M, W, F, with Fresenius, morbid obesity. (Resident #1) is A/Ox4, skin intact, respirations even and unlabored, lung sounds clear to all lobes, active BS to all 4 quadrants, abdomen non distend, non-tender. Left upper extremity shunt functioning properly. (Resident #1) unable to ambulate due to extreme weakness. (Resident #1) is able to help with transfer with assistance, incontinent X2. (Resident #1) with no belongings. RP and MD made aware. (Resident #1) voices no concerns at this time. (Resident #1)) orientated to room, call bell and bed remote control. Record review of a typed summary drafted by Resident #1's Hospital Physician, received by email on 9/27/2023, stated: Regarding patient (Resident #1) from (Nursing Facility) (Resident #1) arrived to (Hospital B) as a transfer from (Hospital A) on 9/19/2023 for the evaluation and management of altered mental status in the setting of sepsis which was presumed to be caused by an infected sacral decubitus ulcer. Upon my initial evaluation the patient was very lethargic and disoriented and there was a very strong odor. After turning her to the side there was a large unstageable sacral decubital ulcer and other surrounding decubital ulcers of varying stage with some noted purulence. The wounds were also noted in the perineal and groin areas near the skin folds. Photos of the wounds are available in the medical record if needed. Due to low blood pressure/shock (Resident #1) was transferred to the ICU to be placed on pressors to maintain blood pressure. She underwent a CT of the abdomen and pelvis with IV contrast to further assess the wound for surgical planning. Incidentally found on the CT scan was the presence of blood clots in both lungs (bilateral pulmonary embolism). Since clots in the lungs typically originate in the legs we next obtained US dopplers of both legs to assess for any further clots and was found to have blood clots in both legs. An echocardiogram was performed to assess for any strain on the heart caused by the blood clots in the lungs, the study did not indicate any strain to the heart.Since her cardiac function was stable the surgeon and anesthesiologist agreed to proceed with debridement of the sacral wound. The wound was extensively debrided to removed any nonviable tissues which required resecting tissue down to the sacral bones (stage 4 pressure ulcer). I have not seen the wound personally since the surgery was performed but per discussion with (Resident #1's) nurse, the wound is approximately the diameter of a basketball. [sic]Due to the location of the wound, near the anus, there is high risk of stool entering and subsequently causing infection within the wound. For this reason (Resident #1) had to be taken back to the operating room for placement of a colostomy to divert stool away from the wound. Once the wound heels it will be possible to reverse the colostomy. A wound vac is to be placed to assist in wound healing. Due to the extent of the injury, this wound will take significant time and optimal conditions in order to heel. I am unable to provide more specific details on prognosis/outcome. A specialist in wound care may be able to provide more information.(Resident #1) is to remain on blood thinners for at least 3 months for the management of blood clots in the legs and lungs.The wound on (Resident #1's) back/buttock/perineal area is caused by prolonged pressure to the skin and underlying tissue which results in poor blood flow to the affected tissue. These injuries can be made worse or more likely to get infected when patients are incontinent of urine or stool and are not promptly cleaned. In patients who are bed bound or with limited mobility, these injuries can be avoided or made less likely to occur by frequent repositioning to offload pressure on a particular area for prolonged periods of time. Other measures include making sure the skin is regularly cleaned and dried. For patients at risk for developing pressure injuries, the skin should be regularly monitored for signs of injury so that it can be addressed early in the course of the injury. I am unaware of the care that was being provided at the nursing home to address the decubital ulcers or what measures were being implemented to heel or prevent these injuries. (Resident #1) presented to our facility/care at a late stage in the course of this injury process. If this was the first presentation for evaluation of these injuries then it would be an unusually late recognition on the part of the party responsible for her care and would suggest that she was not being adequately monitored or that the injuries were possibly noted but not being adequately tended to. The presence of clots in the legs and lungs also would indicate that she has been very immobile given that immobility is the greatest risk factor for development of these types of blood clots. Interview and attempted observation on 9/22/2023 at 10:51 AM at a hospital ICU (Intensive Care Unit) with Resident #1: Resident #1's Family Member A, revealed Resident #1 had just left for dialysis treatment and would return in approximately 4 hours. During this interview, Family Member A stated the resident had been residing at a nursing facility for the last 3 months. Family Member A said she used to work at a nursing facility and was familiar with protocol specific to resident care. Family Member A indicated staff at the Nursing Facility were not turning, repositioning, or transferring Resident #1 to her wheelchair on the occasions she would visit the resident. Family Member A further stated the Resident #1 was obese and confused and that facility staff had skipped several of the resident's dialysis appointments and also said staff were not adequately feeding the resident and that she had had a significant weight loss. Additionally, Family Member A said Resident #1 had a severe infection in her brain and large pressure wound to sacral area which required surgical intervention at the hospital. Family Member A said Resident #1's wound, .smelled like a dead animal, and that hospital staff had to make special interventions in Resident #1's ICU room in an attempt to mask the odor. Finally, Family Member A said she had signed a DNR for Resident #1 and indicated Resident #1's medical team informed her there was a good chance Resident #1 would not survive much longer. Additionally, Family Member A said medical imaging revealed blood clots in Resident #1's lungs and lower extremities as well as an infection to her brain. Finally, Family Member A mentioned a representative from the facility had just left and was attempting to determine if Resident #1's family was under the impression the facility was responsible for the Resident #1's deteriorating condition. Family Member A showed this investigator a business card whom she purported was a representative of the facility at which time this investigator took a photograph of the business card. A review of this business card revealed an RN D. Telephone interview 9/22/2023 at 1:11 PM with Resident #1's Hospital Physician revealed, Resident #1 appeared , .extremely unkempt . upon her admission to the hospital and was discovered to have .blood clots in both her legs and lungs . The doctor explained that he would typically see these symptoms in patients that, .had not been moved enough . or, .kept in one place for extended periods of time. The doctor further stated it was obvious Resident #1, .had not been turned enough . and that, . her wounds were pretty extensive, specific to Resident #1's peri area. The doctor further stated Resident #1 was, .septic upon arrival. Interview and record review on 9/26/2023 at 9:55 AM, LVN A was asked to describe Resident #1, and replied that Resident #1 came to the facility for physical therapy, was a dialysis patient, was a diabetic, and was alert and oriented times 4 upon admission. LVN A said the Resident #1 had to go to San [NAME] one time because staff thought she had a stroke. LVN A said when Resident #1 returned to the facility, she became totally dependent on staff for assistance. LVN A said Resident #1 seemed to fail to thrive. LVN A said Resident #1 had a referral for psych services and started to take Zoloft. LVN A also said Resident #1 had to downgrade her diet from regular to puree. When asked if Resident #1 had any wounds, LVN A said that Resident #1 had a stage II to her bottom. When asked why Resident #1 was recently discharged , LVN A said she was not sure. When asked how Resident #1 acquired her wound, LVN A said she was unsure. During a record review at this time, LVN A agreed that multiple wound treatments were missed for Resident #1 during the month of September 2023. When asked why, LVN A indicated she did not know because Resident #1 was not combative and was bedbound so she couldn't run away. LVN A agreed this was a concern and that missed wound treatments could lead to serious infection. When asked again what the breakdown was as to why residents were missing so many treatments, LVN A said there really was no good reason as the treatment nurse would typically administer treatments for wounds and then nursing staff would also divide treatments up if and when the treatment nurse was out of the facility. When asked who the treatment nurse was, the LVN said it was LVN B. Interview and record review on 9/26/2023 at 10:31 AM, Treatment Nurse, LVN B was asked to describe Resident #1, LVN B responded that Resident #1 came to the facility with a DTI to her right heel and tip of her right great toe. LVN B said (Resident #1's) bottom started breaking down, and that the, .area between her brief and her leg started breaking down as well. LVN B said Resident #1 started getting another area on her left gluteal fold, and then she went to dialysis on 9/18/2023 and from there was sent to the hospital for low blood pressure, and said (Hospital A) sent Resident #1 to a hospital Hospital B with a diagnosis of encephalopathy. When asked what encephalopathy was, LVN B responded that, it was something in the brain where you get confused, and, get an altered mental status. LVN B said Resident #1's wounds to her peri area were acquired at the facility and that the resident was refusing to be turned. When asked why the resident was refusing to be turned, LVN B said it was because, (Resident #1) wasn't comfortable. When asked why the Hosptial A sent Resident #1 to Hospital B, LVN B responded that she was unsure. When asked if Resident #1's wound was getting infected, the LVN responded that, it wasn't looking great but it didn't have a smell or anything. During this interview, LVN B was shown Resident #1's September 2023 TAR, at which time LVN B confirmed that multiple entries for Resident #1's skin treatments were blank and responded that she may have been working the floor those days. LVN B said that she would have to work the floor if someone called in and would have to also attend to wounds simultaneously. When asked if that posed a problem because she was having to do 2 jobs during a shift, LVN B said she would delegate to other nurses to handle the lower category wounds. When asked what could be done to ensure treatments could never be missed, LVN B said a lot of the 2pm-10pm nurses moved to the hospital which had caused a bit of a strain on staffing. When asked if the facility utilized agency staff, LVN B responded that the facility did not. Interview and record review on 9/26/2023 at 11:03 AM, RN C stated she was filling in for the DON as the DON was out of the facility. During this interview, the RN C said she was not that familiar with the residents as she currently only worked PRN. RN C said staffing had been short and she was frequently asked to work. RN C was shown September 2023 TARs for Resident #1 and agreed they had missing entries. When asked what that meant, the RN C said it meant the treatments, didn't occur. When asked what the concern was specific to wound treatments, RN C said it was a concern because the missed treatments could cause the wounds to evolve into serious infections which could lead to sepsis and or death. RN C said this facility had difficulty retaining staff because other facilities in the area were paying more and believed staffing was the reason some of these treatments were being missed. RN C said that if the treatment nurse is required to work the floor, other nurses on the shift will be delegated to do wound care. Interview and record review on 9/26/2023 at 2:00 PM, the DON said the facility had the staff they need but had been overlapping their shifts. The DON agreed that if there was a missed entry in the TAR it didn't happen. The DON said Resident #1 was very sick and she said the staff tried to get her family to sign a DNR. The DON said facility staff would fear that when (Resident #1) would go to dialysis, they would send her to the hospital and said that is exactly what happened. The DON said Resident #1 was previously discharged from dialysis because she didn't look right. The DON said Resident #1 was, very young and they were having to spoon feed her. The DON said Resident #1 was much more motivated when she was admitted but started to decline. At this time, the DON was shown Resident #1's September TAR, the DON agreed it was a concern that there were missed wound treatments and that missed wound treatments had the potential to evolve into more serious issues like infections. Interview on 9/26/2023 at 3:09 PM, the Medical Director, said he found out recently that there had been missed treatments relative to wound care and that he was very surprised. When asked who was supposed to be doing wound treatments between his visits, the Medical Director responded, LVN B. When asked if he was noticing the decline in Resident #1 and if he would have given different orders, the Medical Director responded that he was not aware of a decline specific to Resident #1's wounds. The Medical Director said he had only heard that another resident had been sent to the ER and insisted on not coming back to the facility and that the resident alleged she was not being provided care for her wounds. The Medical Director further stated this resident had a wound vac. The Medical Director said Resident #1's name came up a couple of times but he could not recall the reason. The Medical Director said Resident #1 was not eating well and had to have IV fluids once or twice and said DON or charge nurse would typically be the one who contacted him when there was a decline. When asked if the Medical Director would come in more than just monthly if a resident experienced a decline, the Medical Director said that he would. The Medical Director said he expected residents would receive nursing care and that he knew skin care was important because a lot of the residents have a lot of vulnerabilities. The Medical Director also stated that staff should be documenting and not missing treatments because the ultimate concern would be that the wounds would get worse. The Medical Director said, A soft tissue wound can lead to infection and lead to hospitalization . The whole idea of being in a nursing home is to avoid hospitalization s. The Medical Director said he was not responsible for training the facility staff. The Medical Director said he was notified and aware of concerns with resident wound care but could not remember the names of the residents for which he had been notified. The Medical Director stated, I probably would have called the DON and asked what was going on with the care the resident was not receiving, when asked what he would have done if he had been notified that a resident did not receive wound care as ordered. The doctor said he, wouldn't like to think there was willful neglect. Finally, the Medical Director stated, there has got to be someone who has to be responsible if the treatment nurse is away so staff have to be more pro-active than reactive. Interview on 9/26/2023 at 4:40 PM, LVN B, when asked about training, said she would get relias training quarterly or if and when an incident of abuse and neglect occurred, and said those trainings, occur frequently. When asked if there were any training the last several weeks, LVN B said there was training for covid, hand washing, abuse and neglect and said that was all. LVN B said that staff were told daily that they need to clear their MARs and TARs, meaning to complete all prompted tasks for their shift. When asked if there had been any trainings specific to Resident #1 since she had been discharged to the hospital, the LVN B said training occurred only when the resident started to decline. When asked when this was, the LVN B said it was after the resident came back from one of her admissions from the hospital. When asked if any trainings occurred in response to the Resident #1's most recent discharge, the LVN B indicated there had been no trainings specific to this incident since Resident #1 discharged on [DATE]. When asked if any other nurses were qualified to do wound treatment, LVN B said that LVN A and several other LVNs had become qualified. LVN B said those LVN staff do a rotation with me when they get hired. LVN B said staff typically get evaluated annually. LVN B was asked if she had her wound treatment skills evaluated, she responded, yes, by the DON. LVN B was asked when this evaluation took place and said it was in in March or April 2023 and said the evaluations would occur annually. Interview on 9/26/2023 at 5:07 PM, DON, stated Resident #1 was sent from dialysis to the hospital. When asked what diagnosis Resident #1 was sent out for the DON responded that she was not sure. The DON said she guessed it was encephalopathy and found out Resident #1 was going to the ER when dialysis called to inform her. When asked if staff had any training since Resident #1 was sent to the hospital relative to encephalopathy or other issues related to the Resident #1's incident the DON responded, no. The DON said Resident #1 was unpredictable and her alert and oriented status would frequently change. The DON said Resident #1 was continent when she arrived to the facility but once she became incontinent, staff noticed Resident #1 had genital warts upon changing her. Interview on 9/27/2023 at 5:02 PM, the DON stated the facility's Medical Director came to the facility monthly and talked to residents, reviewed charts/meds, would look at wounds if staff requested. The DON said she was informed of residents' wound status by reviewing a weekly skin report and would check to see who was progressing or declining and who needs what type of interventions.The DON said staff communications began with the CNAs who would inform their charge nurse of concerns and the charge nurse would put those concerns on the 24-hour report and contact physician to get orders. The DON was made aware by staff Resident #1's wounds were getting worse. The last time she had seen the resident had been a little while, and she was under the impression the resident's sacral pressure ulcer had evolved into a stage II pressure ulcer. When asked what facility staff could have done differently for this resident, the DON said facility staff should have sent the resident to the hospital more frequently but said the hospital would just send her back and we had to have a van on standby to pick her up, implying the resident was frequently sent to the hospital. (note: Resident #1 was only sent out 3 times in 3 months including most recent visit). Interview on 9/27/2023 at 5:14 PM, the Administrator revealed information obtained during the previous interview with the DON. Additionally, when asked what could have been done differently for Resident #1, the Administrator said, We should have added the resident to patients at risk, and could have sent her to the hospital for slightest decline. Interview on 9/28/2023 at 10:42 AM, the Administrator revealed LVN B did not have Wound Care Certification. Telephone interview on 9/29/2023 at 12:30 PM, the Medical Director said that had he been made aware that Resident #1's wound status had changed, he would have wanted to have found out the last time Resident #1 saw the vascular surgeon, would have wanted to talk to the treatment nurse, and would have looked for any signs of infection. Record review of facility policy, Job Description for Treatment Nurse, revised 3/2015, stated, The Treatment Nurse will provide quality of care to prevent and promote healing of alterations in skin integrity of each resident as determined by resident assessments and individual plans of care . 12. Initiate and continue treatments on residents in the facility with skin breakdown and other conditions requiring treatment. 13. Modify and/or change treatments as necessary and notifying physician for approval. 14. Inform the DON and the assessment nurse of resident change of condition. Record review of facility policy, Pressure Injury Prevention and Management, dated 8/15/2022, stated, This facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries . The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabal;ize, reduce or remove underlying risk factors; monitoring the impact of interventions; and modifying the interventions when appropriate. Record review of facility policy, Abuse, Neglect, and Exploitation, dated 8/15/2022, stated, It is the policy of this faciity to provide protections for the health, welfare and rights of each resident by deeloping and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . Neglect - means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. On 9/27/2023 at 6:00 PM, the Administrator and DON were notified of an Immediate Jeopardy (IJ) situation for the above failure, a completed IJ template was provided, and a Plan of Removal was requested. The facility' [TRUNCATED]

Based on the comprehensive assessment of a resident, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 6 residents (Resident #1) reviewed for pressure sores, in that: The facility failed to ensure Resident #1 received wound care and treatment as ordered by a physician. -Resident #1's right great toe was not monitored daily for changes once per day as ordered by a physician. -Resident #1's right heel was not monitored daily for changes once per day as ordered by a physician. -Resident #1's skin tear to the left upper leg was not monitored every shift for signs of infection as ordered by a physician. -Resident #1's pressure ulcer to her left buttock was not cleansed with wound cleaner, patted dry and did not have medseptic QA applied every shift as ordered by a physician. -Resident #1's pressure ulcer to her right buttock was not cleansed with wound cleaner, patted dry and did not have medseptic QA applied every shift as ordered by a physician. -Resident #1's pressure ulcer to her right gluteal fold was not cleansed with wound cleaner, patted dry and did not have medseptic QA applied every shift as ordered by a physician. -Resident #1 had a significant weight from August 2023 to September 2023. Resident #1 was admitted to the hospital with sepsis presumed to be from an infected sacral decubitus ulcer. An IJ was identified on 9/27/2023 at 6:00 p.m., and a template was provided to the facility at this time. While the IJ was removed on 10/1/2023, the facility remained out of compliance at a scope of pattern and a scope of actual harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place additional residents at risk for a delay in treatment, hospitalization , loss of limb and/or a significant decline in heelth. The findings included: Record review of Resident #1's face sheet dated 9/28/2023 revealed she was [AGE] years of age with an admitted [DATE] and a readmitted [DATE] with diagnoses which included: Type 2 diabetes mellitus with diabetic neuropathy, end stage renal disease, major depressive disorder, mild cognitive impairment, dysphagia, cognitive communication deficit, urinary tract infection, degenerative disease of nervous system, lack of coordination, morbid obesity, muscle wasting, anemia in chronic kidney disease, fluid overload, anxiety disorder, cerebral infarction, nausea with vomiting, diarrhea. Record review of Resident #1's comprehensive MDS dated [DATE] revealed a BIMS score of 10 indicating moderate impairment. Further review under category, Skin Conditions, revealed Resident #1 was indicated as having zero venous and arterial ulcers, and no other ulcers, wounds and skin problems. Record review of Resident #1's Care Plan, start date 6/1/2023, stated, (Resident #1) has potential impairment to skin integrity r/t incontinence and decreased mobility. (Resident #1) will be free from skin break down through the review date Interventions included, Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heel, s/sx of infection, maceration etc. to MD. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Record review of Resident #1's Care Plan, start date, 8/18/2023, stated, (Resident #1) has DTI to left toe. (Resident #1's) Pressure ulcer will show signs of healing and remain free from infection by/through review date. (Resident #1) will have intact skin, free of redness, blisters or discoloration by/through review date. Interventions included, Administer treatments as ordered and monitor for effectiveness. Record review of Resident #1's Care Plan, start date, 8/18/2023, stated, (Resident #1) has DTI to right great toe. The (Resident #1s) will Pressure ulcer will show signs of healing and remain free from infection by/through review date. Interventions included, Administer treatments as ordered and monitor for effectiveness. Record review of Resident #1's Care Plan, start date, 8/18/2023, stated,(Resident #1) has DTI to right heel. (Resident #1's) pressure ulcer will show signs of healing and remain free from infection by/through review date. PHYSICIAN ORDERS Record review of Resident #1's physician's orders, start date, 7/26/2023, stated, DTI to Right heel-monitor daily for changes. Record review of Resident #1's physician's orders, start date, 7/26/2023, stated, DTI - right great toe monitor daily for changes. Record review of Resident #1's physician's orders, start date, 8/30/2023 stated, DTI-right great toe monitor daily for changes. Frequency, one time a day. Record review of Resident #1's physician's orders, start date, 8/30/2023 stated: DTI to Right heel-monitor for changes. Frequency, one time a day. Record review of Resident #1's physician's orders, start date, 8/30/2023 stated: stage 2 to R buttock: cleanse with wound cleanser pat dry apply mediseptic QS. Frequency, every shift. Record review of Resident #1's physician's orders, start date, 8/30/2023 stated: Stage 2 to L buttock: cleanse with wound cleanser, pat dry apply mediseptic QS. Frequency, every shift. Record review of Resident #1's physician's orders, start date, 9/9/2023 stated: Monitor skin tear left upper leg Monitor every shift for signs of infection until heeled. Frequency, every shift. Record review of Resident #1's physician's orders, start date, 9/11/2023 stated: Stage 2 to R gluteal fold cleanse with wound cleanser pat dry apply mediseptic QS. Frequency, every shift. TREATMENT ADMINISTRATION: Record review of Resident #1's TAR September 2023 stated, DTI - right great toe monitor daily for changes one time a day -Start Date 08/01/2023. Further review revealed holes in the TAR the following: 9/5, 9/6, 9/8, 9/13, 9/14, 9/15. Record review of Resident #1's September 2023 TAR stated, TI to Right heel-monitor daily for changes one time a day -Start Date 08/01/2023. Further review revealed holes in the TAR on the following: 9/5, 9/6, 9/8, 9/13, 9/14, 9/15. Record review of Resident #1's September 2023 TAR stated, Monitor skin tear left upper leg Monitor every shift for signs of infection until heeled every shift -Start Date 09/09/2023 Further review revealed holes in the TAR for the following: Shift 6:00 AM - 2:00 PM - 9/13 thru 9/15, 9/18 Shift 2:00 PM - 10:00 PM - 9/9, 9/11 thru 9/15 Shift 10:00 PM - 6:00 AM - 9/9 Record review of Resident #1's September 2023 TAR stated, stage 2 to L buttock: cleanse with wound cleanser, pat dry apply mediseptic QS every shift -Start Date 08/30/2023. Further review revealed holes in the TAR for the following: Shift 6:00 AM - 2:00 PM - 9/4 thru 9/6, 9/8, 9/13 thru 9/15, 9/18 Shift 2:00 PM - 10:00 PM - 9/5-9/9, 9/11 thru 9/18 Shift 10:00 PM - 6:00 AM - 9/9 Record review of Resident #1's September 2023 TAR stated, stage 2 to R buttock: cleanse with wound cleanser pat dry apply mediseptic QS every shift -Start Date 08/30/2023. Further review revealed holes in the TAR for the following: Shift 6:00 AM - 2:00 PM - 9/4 thru 9/6, 9/8, 9/13 thru 9/15, 9/18 Shift 2:00 PM - 10:00 PM - 9/5-9/9, 9/11 thru 9/18 Shift 10:00 PM - 6:00 AM - 9/9 Record review of Resident #1's September 2023 TAR stated, Stage 2 to R gluteal fold cleanse with wound cleanser, pat dry apply mediseptic QS every shift -Start Date 09/11/2023. Further review revealed holes in the TAR for the following: Shift 6:00 AM - 2:00 PM - 9/13, 9/14, 9/15, 9/18 Shift 2:00 PM - 10:00 PM - 9/11 thru 9/18 Shift 10:00 PM - 6:00 AM - 0 missed SKIN ASSESSMENTS Record review of Resident #1's Weekly Skin Evaluation, effective date, 9/14/2023, revealed: What type of wound(s) does patient have? - A. Pressure Ulcer(s). Further review revealed there these were new since last skin assessment. Type of wound was, Right gluteal fold - Stage 2 to R gluteal fold measuring 2cmx4cm. This document was signed by Treatment Nurse, LVN B. Record review of Resident #1's Weekly Pressure Ulcer Evaluation, effective date, 9/14/2023, revealed: date of assessment was 9/11/2023 -Right Great Toe, length 1.5 cm, width 1.5 cm, depth N/A, stage suspected deep tissue injury. Further review revealed the wound developed 8/13/2023 and was, admitted with. This document was signed by Treatment Nurse, LVN B. Record review of Resident #1's Weekly Pressure Ulcer Evaluation, effective date, 9/14/2023, revealed: date of assessment was 9/11/2023 - Right Heel, length 4cm, width 4.5cm, depth N/A, stage suspected deep tissue injury. Further review revealed the wound developed 8/13/2023 and was, admitted with. This document was signed by Treatment Nurse, LVN B. Record review of Resident #1's Weekly Pressure Ulcer Evaluation, effective date, 9/14/2023, revealed: date of assessment was 9/11/2023 - Right Buttock pressure ulcer, length 5cm, width 6cm, depth .1cm, stage N/A. Further review revealed the wound developed 8/30/2023 and was, in house developed. This document was signed by Treatment Nurse, LVN B. Record review of Resident #1's Weekly Pressure Ulcer Evaluation, effective date, 9/14/2023, revealed: date of assessment was 9/11/2023 - Left Buttock pressure ulcer, length 3.5cm, width 4cm, depth .1cm, stage II. Further review revealed the wound developed 8/30/2023 and was, in house developed. This document was signed by Treatment Nurse, LVN B. PROGRESS NOTES Record review of Resident #1's progress note, dated 6/1/2023 - 6:18 PM, stated, Note Text: Received resident via stretcher by Amistad ambulance. (Resident #1) is a [AGE] year-old female with PMH of HTN, DM, CAD, neuropathy, anxiety, depression, seizure, CVAx2, ESRD on HD M, W, F, with Fresenius, morbid obesity. (Resident #1) is A/Ox4, skin intact, respirations even and unlabored, lung sounds clear to all lobes, active BS to all 4 quadrants, abdomen non distend, non-tender. Left upper extremity shunt functioning properly. (Resident #1) unable to ambulate due to extreme weakness. (Resident #1) is able to help with transfer with assistance, incontinent X2. (Resident #1) with no belongings. RP and MD made aware. (Resident #1) voices no concerns at this time. (Resident #1)) orientated to room, call bell and bed remote control. Record review of a typed summary drafted by Resident #1's Hospital Physician, received by email on 9/27/2023, stated: Regarding patient (Resident #1) from (Nursing Facility) (Resident #1) arrived to (Hospital B) as a transfer from (Hospital A) on 9/19/2023 for the evaluation and management of altered mental status in the setting of sepsis which was presumed to be caused by an infected sacral decubitus ulcer. Upon my initial evaluation the patient was very lethargic and disoriented and there was a very strong odor. After turning her to the side there was a large unstageable sacral decubital ulcer and other surrounding decubital ulcers of varying stage with some noted purulence. The wounds were also noted in the perineal and groin areas near the skin folds. Photos of the wounds are available in the medical record if needed. Due to low blood pressure/shock (Resident #1) was transferred to the ICU to be placed on pressors to maintain blood pressure. She underwent a CT of the abdomen and pelvis with IV contrast to further assess the wound for surgical planning. Incidentally found on the CT scan was the presence of blood clots in both lungs (bilateral pulmonary embolism). Since clots in the lungs typically originate in the legs we next obtained US dopplers of both legs to assess for any further clots and was found to have blood clots in both legs. An echocardiogram was performed to assess for any strain on the heart caused by the blood clots in the lungs, the study did not indicate any strain to the heart.Since her cardiac function was stable the surgeon and anesthesiologist agreed to proceed with debridement of the sacral wound. The wound was extensively debrided to removed any nonviable tissues which required resecting tissue down to the sacral bones (stage 4 pressure ulcer). I have not seen the wound personally since the surgery was performed but per discussion with (Resident #1's) nurse, the wound is approximately the diameter of a basketball. [sic]Due to the location of the wound, near the anus, there is high risk of stool entering and subsequently causing infection within the wound. For this reason (Resident #1) had to be taken back to the operating room for placement of a colostomy to divert stool away from the wound. Once the wound heels it will be possible to reverse the colostomy. A wound vac is to be placed to assist in wound healing. Due to the extent of the injury, this wound will take significant time and optimal conditions in order to heel. I am unable to provide more specific details on prognosis/outcome. A specialist in wound care may be able to provide more information.(Resident #1) is to remain on blood thinners for at least 3 months for the management of blood clots in the legs and lungs.The wound on (Resident #1's) back/buttock/perineal area is caused by prolonged pressure to the skin and underlying tissue which results in poor blood flow to the affected tissue. These injuries can be made worse or more likely to get infected when patients are incontinent of urine or stool and are not promptly cleaned. In patients who are bed bound or with limited mobility, these injuries can be avoided or made less likely to occur by frequent repositioning to offload pressure on a particular area for prolonged periods of time. Other measures include making sure the skin is regularly cleaned and dried. For patients at risk for developing pressure injuries, the skin should be regularly monitored for signs of injury so that it can be addressed early in the course of the injury. I am unaware of the care that was being provided at the nursing home to address the decubital ulcers or what measures were being implemented to heel or prevent these injuries. (Resident #1) presented to our facility/care at a late stage in the course of this injury process. If this was the first presentation for evaluation of these injuries then it would be an unusually late recognition on the part of the party responsible for her care and would suggest that she was not being adequately monitored or that the injuries were possibly noted but not being adequately tended to. The presence of clots in the legs and lungs also would indicate that she has been very immobile given that immobility is the greatest risk factor for development of these types of blood clots. Interview and attempted observation on 9/22/2023 at 10:51 AM at a hospital ICU (Intensive Care Unit) with Resident #1: Resident #1's Family Member A, revealed Resident #1 had just left for dialysis treatment and would return in approximately 4 hours. During this interview, Family Member A stated the resident had been residing at a nursing facility for the last 3 months. Family Member A said she used to work at a nursing facility and was familiar with protocol specific to resident care. Family Member A indicated staff at the Nursing Facility were not turning, repositioning, or transferring Resident #1 to her wheelchair on the occasions she would visit the resident. Family Member A further stated the Resident #1 was obese and confused and that facility staff had skipped several of the resident's dialysis appointments and also said staff were not adequately feeding the resident and that she had had a significant weight loss. Additionally, Family Member A said Resident #1 had a severe infection in her brain and large pressure wound to sacral area which required surgical intervention at the hospital. Family Member A said Resident #1's wound, .smelled like a dead animal, and that hospital staff had to make special interventions in Resident #1's ICU room in an attempt to mask the odor. Finally, Family Member A said she had signed a DNR for Resident #1 and indicated Resident #1's medical team informed her there was a good chance Resident #1 would not survive much longer. Additionally, Family Member A said medical imaging revealed blood clots in Resident #1's lungs and lower extremities as well as an infection to her brain. Finally, Family Member A mentioned a representative from the facility had just left and was attempting to determine if Resident #1's family was under the impression the facility was responsible for the Resident #1's deteriorating condition. Family Member A showed this investigator a business card whom she purported was a representative of the facility at which time this investigator took a photograph of the business card. A review of this business card revealed an RN D. Telephone interview 9/22/2023 at 1:11 PM with Resident #1's Hospital Physician revealed, Resident #1 appeared , .extremely unkempt . upon her admission to the hospital and was discovered to have .blood clots in both her legs and lungs . The doctor explained that he would typically see these symptoms in patients that, .had not been moved enough . or, .kept in one place for extended periods of time. The doctor further stated it was obvious Resident #1, .had not been turned enough . and that, . her wounds were pretty extensive, specific to Resident #1's peri area. The doctor further stated Resident #1 was, .septic upon arrival. Interview and record review on 9/26/2023 at 9:55 AM, LVN A was asked to describe Resident #1, and replied that Resident #1 came to the facility for physical therapy, was a dialysis patient, was a diabetic, and was alert and oriented times 4 upon admission. LVN A said the Resident #1 had to go to San [NAME] one time because staff thought she had a stroke. LVN A said when Resident #1 returned to the facility, she became totally dependent on staff for assistance. LVN A said Resident #1 seemed to fail to thrive. LVN A said Resident #1 had a referral for psych services and started to take Zoloft. LVN A also said Resident #1 had to downgrade her diet from regular to puree. When asked if Resident #1 had any wounds, LVN A said that Resident #1 had a stage II to her bottom. When asked why Resident #1 was recently discharged , LVN A said she was not sure. When asked how Resident #1 acquired her wound, LVN A said she was unsure. During a record review at this time, LVN A agreed that multiple wound treatments were missed for Resident #1 during the month of September 2023. When asked why, LVN A indicated she did not know because Resident #1 was not combative and was bedbound so she couldn't run away. LVN A agreed this was a concern and that missed wound treatments could lead to serious infection. When asked again what the breakdown was as to why residents were missing so many treatments, LVN A said there really was no good reason as the treatment nurse would typically administer treatments for wounds and then nursing staff would also divide treatments up if and when the treatment nurse was out of the facility. When asked who the treatment nurse was, the LVN said it was LVN B. Interview and record review on 9/26/2023 at 10:31 AM, Treatment Nurse, LVN B was asked to describe Resident #1, LVN B responded that Resident #1 came to the facility with a DTI to her right heel and tip of her right great toe. LVN B said (Resident #1's) bottom started breaking down, and that the, .area between her brief and her leg started breaking down as well. LVN B said Resident #1 started getting another area on her left gluteal fold, and then she went to dialysis on 9/18/2023 and from there was sent to the hospital for low blood pressure, and said (Hospital A) sent Resident #1 to a hospital Hospital B with a diagnosis of encephalopathy. When asked what encephalopathy was, LVN B responded that, it was something in the brain where you get confused, and, get an altered mental status. LVN B said Resident #1's wounds to her peri area were acquired at the facility and that the resident was refusing to be turned. When asked why the resident was refusing to be turned, LVN B said it was because, (Resident #1) wasn't comfortable. When asked why the Hosptial A sent Resident #1 to Hospital B, LVN B responded that she was unsure. When asked if Resident #1's wound was getting infected, the LVN responded that, it wasn't looking great but it didn't have a smell or anything. During this interview, LVN B was shown Resident #1's September 2023 TAR, at which time LVN B confirmed that multiple entries for Resident #1's skin treatments were blank and responded that she may have been working the floor those days. LVN B said that she would have to work the floor if someone called in and would have to also attend to wounds simultaneously. When asked if that posed a problem because she was having to do 2 jobs during a shift, LVN B said she would delegate to other nurses to handle the lower category wounds. When asked what could be done to ensure treatments could never be missed, LVN B said a lot of the 2pm-10pm nurses moved to the hospital which had caused a bit of a strain on staffing. When asked if the facility utilized agency staff, LVN B responded that the facility did not. Interview and record review on 9/26/2023 at 11:03 AM, RN C stated she was filling in for the DON as the DON was out of the facility. During this interview, the RN C said she was not that familiar with the residents as she currently only worked PRN. RN C said staffing had been short and she was frequently asked to work. RN C was shown September 2023 TARs for Resident #1 and agreed they had missing entries. When asked what that meant, the RN C said it meant the treatments, didn't occur. When asked what the concern was specific to wound treatments, RN C said it was a concern because the missed treatments could cause the wounds to evolve into serious infections which could lead to sepsis and or death. RN C said this facility had difficulty retaining staff because other facilities in the area were paying more and believed staffing was the reason some of these treatments were being missed. RN C said that if the treatment nurse is required to work the floor, other nurses on the shift will be delegated to do wound care. Interview and record review on 9/26/2023 at 2:00 PM, the DON said the facility had the staff they need but had been overlapping their shifts. The DON agreed that if there was a missed entry in the TAR it didn't happen. The DON said Resident #1 was very sick and she said the staff tried to get her family to sign a DNR. The DON said facility staff would fear that when (Resident #1) would go to dialysis, they would send her to the hospital and said that is exactly what happened. The DON said Resident #1 was previously discharged from dialysis because she didn't look right. The DON said Resident #1 was, very young and they were having to spoon feed her. The DON said Resident #1 was much more motivated when she was admitted but started to decline. At this time, the DON was shown Resident #1's September TAR, the DON agreed it was a concern that there were missed wound treatments and that missed wound treatments had the potential to evolve into more serious issues like infections. Interview on 9/26/2023 at 3:09 PM, the Medical Director, said he found out recently that there had been missed treatments relative to wound care and that he was very surprised. When asked who was supposed to be doing wound treatments between his visits, the Medical Director responded, LVN B. When asked if he was noticing the decline in Resident #1 and if he would have given different orders, the Medical Director responded that he was not aware of a decline specific to Resident #1's wounds. The Medical Director said he had only heard that another resident had been sent to the ER and insisted on not coming back to the facility and that the resident alleged she was not being provided care for her wounds. The Medical Director further stated this resident had a wound vac. The Medical Director said Resident #1's name came up a couple of times but he could not recall the reason. The Medical Director said Resident #1 was not eating well and had to have IV fluids once or twice and said DON or charge nurse would typically be the one who contacted him when there was a decline. When asked if the Medical Director would come in more than just monthly if a resident experienced a decline, the Medical Director said that he would. The Medical Director said he expected residents would receive nursing care and that he knew skin care was important because a lot of the residents have a lot of vulnerabilities. The Medical Director also stated that staff should be documenting and not missing treatments because the ultimate concern would be that the wounds would get worse. The Medical Director said, A soft tissue wound can lead to infection and lead to hospitalization . The whole idea of being in a nursing home is to avoid hospitalization s. The Medical Director said he was not responsible for training the facility staff. The Medical Director said he was notified and aware of concerns with resident wound care but could not remember the names of the residents for which he had been notified. The Medical Director stated, I probably would have called the DON and asked what was going on with the care the resident was not receiving, when asked what he would have done if he had been notified that a resident did not receive wound care as ordered. The doctor said he, wouldn't like to think there was willful neglect. Finally, the Medical Director stated, there has got to be someone who has to be responsible if the treatment nurse is away so staff have to be more pro-active than reactive. Interview on 9/26/2023 at 4:40 PM, LVN B, when asked about training, said she would get relias training quarterly or if and when an incident of abuse and neglect occurred, and said those trainings, occur frequently. When asked if there were any training the last several weeks, LVN B said there was training for covid, hand washing, abuse and neglect and said that was all. LVN B said that staff were told daily that they need to clear their MARs and TARs, meaning to complete all prompted tasks for their shift. When asked if there had been any trainings specific to Resident #1 since she had been discharged to the hospital, the LVN B said training occurred only when the resident started to decline. When asked when this was, the LVN B said it was after the resident came back from one of her admissions from the hospital. When asked if any trainings occurred in response to the Resident #1's most recent discharge, the LVN B indicated there had been no trainings specific to this incident since Resident #1 discharged on [DATE]. When asked if any other nurses were qualified to do wound treatment, LVN B said that LVN A and several other LVNs had become qualified. LVN B said those LVN staff do a rotation with me when they get hired. LVN B said staff typically get evaluated annually. LVN B was asked if she had her wound treatment skills evaluated, she responded, yes, by the DON. LVN B was asked when this evaluation took place and said it was in in March or April 2023 and said the evaluations would occur annually. Interview on 9/26/2023 at 5:07 PM, DON, stated Resident #1 was sent from dialysis to the hospital. When asked what diagnosis Resident #1 was sent out for the DON responded that she was not sure. The DON said she guessed it was encephalopathy and found out Resident #1 was going to the ER when dialysis called to inform her. When asked if staff had any training since Resident #1 was sent to the hospital relative to encephalopathy or other issues related to the Resident #1's incident the DON responded, no. The DON said Resident #1 was unpredictable and her alert and oriented status would frequently change. The DON said Resident #1 was continent when she arrived to the facility but once she became incontinent, staff noticed Resident #1 had genital warts upon changing her. Interview on 9/27/2023 at 5:02 PM, the DON stated the facility's Medical Director came to the facility monthly and talked to residents, reviewed charts/meds, would look at wounds if staff requested. The DON said she was informed of residents' wound status by reviewing a weekly skin report and would check to see who was progressing or declining and who needs what type of interventions.The DON said staff communications began with the CNAs who would inform their charge nurse of concerns and the charge nurse would put those concerns on the 24-hour report and contact physician to get orders. The DON was made aware by staff Resident #1's wounds were getting worse. The last time she had seen the resident had been a little while, and she was under the impression the resident's sacral pressure ulcer had evolved into a stage II pressure ulcer. When asked what facility staff could have done differently for this resident, the DON said facility staff should have sent the resident to the hospital more frequently but said the hospital would just send her back and we had to have a van on standby to pick her up, implying the resident was frequently sent to the hospital. (note: Resident #1 was only sent out 3 times in 3 months including most recent visit). Interview on 9/27/2023 at 5:14 PM, the Administrator revealed information obtained during the previous interview with the DON. Additionally, when asked what could have been done differently for Resident #1, the Administrator said, We should have added the resident to patients at risk, and could have sent her to the hospital for slightest decline. Interview on 9/28/2023 at 10:42 AM, the Administrator revealed LVN B did not have Wound Care Certification. Telephone interview on 9/29/2023 at 12:30 PM, the Medical Director said that had he been made aware that Resident #1's wound status had changed, he would have wanted to have found out the last time Resident #1 saw the vascular surgeon, would have wanted to talk to the treatment nurse, and would have looked for any signs of infection. Record review of facility policy, Job Description for Treatment Nurse, revised 3/2015, stated, The Treatment Nurse will provide quality of care to prevent and promote healing of alterations in skin integrity of each resident as determined by resident assessments and individual plans of care . 12. Initiate and continue treatments on residents in the facility with skin breakdown and other conditions requiring treatment. 13. Modify and/or change treatments as necessary and notifying physician for approval. 14. Inform the DON and the assessment nurse of resident change of condition. Record review of facility policy, Pressure Injury Prevention and Management, dated 8/15/2022, stated, This facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries . The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabal;ize, reduce or remove underlying risk factors; monitoring the impact of interventions; and modifying the interventions when appropriate. Record review of facility policy, Abuse, Neglect, and Exploitation, dated 8/15/2022, stated, It is the policy of this faciity to provide protections for the health, welfare and rights of each resident by deeloping and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . Neglect - means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. On 9/27/2023 at 6:00 PM, the Administrator and DON were notified of an Immediate Jeopardy (IJ) situation for the above failure, a completed IJ template was provided, and a Plan

Based on interviews and record reviews the facility failed to have nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population for 2 of 32 residents (Resident #14 and #140) reviewed for infections / infestations, in that: 1. Resident #140 was diagnosed with a urinary tract infection with 2 different microbial pathogens for which Resident #140 was not treated for over 25 days 04/08/2023 to 05/07/2022 and resulted in Resident #140's hospitalization with a diagnosis of urinary tract infection sepsis [the body's extreme response to an infection] and passed away. 2. Resident #14 was assessed with a lice infestation, received treatment without a physician's communication documented and orders documented. An Immediate Jeopardy (IJ) situation was identified on 04/07/2023. While the IJ was removed on 04/08/2023, the facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy and a scope of isolated. This failure placed residents at risk for not receiving necessary care and services resulting in worsening of condition, hospitalization and/or death. The findings included: 1. Record review of Resident #140's admission record revealed an admitted [DATE], and a hospital emergency discharge date of [DATE], and diagnoses which included neuromuscular dysfunction of bladder and bladder neck obstruction [when a person lacks bladder control due to brain, spinal cord or nerve problems]. A record review of Resident #140's quarterly MDS, dated [DATE], revealed Resident #140 was a [AGE] year-old male without cognitive mental impairment evidenced by a 15 out of 15 score on a BIMS. Resident #140 had a suprapubic catheter [a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow] and a history of urinary tract infections. Resident #140 was frequently incontinent of bowels. Resident #140 was not weight bearing and used a wheelchair to ambulate. A record review of Resident #140's care plan, dated 04/06/2023, revealed, The resident had an activities of daily life self-care performance deficit related to contractures to the left leg and above knee amputation; toilet use; the resident is totally dependent on staff for toilet use. Resident is incontinent of bowel and required staff to check every two hours. staff to help provide catheter care and empty out the urine collection bag. The resident has suprapubic catheter at risk for UTI sepsis. The resident has suprapubic catheter; position catheter bag and tubing below the level of the bladder . monitor record report to medical doctor for signs and symptoms of urinary tract infection pain burning blood thinning hearing cottages fever chills altered mental status. A record review of Resident #140's nursing progress notes, dated 04/01/2022 , at 03:12 AM, revealed RN A documented, Resident c/o pain to bladder area. c/o burning to stoma area. noted with leakage from stoma area around foley catheter. Catheter irrigated with NS but noted to drain poorly and leak more around stoma area. Unable to aspirate urine residual from catheter with 60cc syringe. Area around stoma cleaned and TAO applied generously around catheter. Belly bag repositioned below resident's scrotum to provide better drainage to gravity. plan to collect urine for ua /c & s this am. A record review of Resident #140's nursing progress notes revealed LVN B documented on 04/06/2022 , at 09:35 PM resident back from urology appt. NP E requested for resident to have SP drain to gravity and no belly bag. facility to collect UA and send to [local hospital] for C/S. and to continue with current medications. Follow up in four months [DATE], at 01:50 PM. This SN advised resident that I needed to change foley bag [urine collection] to either a leg bag or normal foley bag, resident refused and stated he wants AM shift to change it. A record review of Resident #140's laboratory report, dated 04/08/2022, revealed Resident #140, collected 04/03/2022 .reported 04/08/2022 .detected urinary tract assay results organism's enterococcus faecalis .proteus mirabilis. A record review of Resident #140's nurse progress notes revealed LVN C documented on 04/12/2022 , at 10:25 AM, UA with CS results dated 04/07 faxed to Dr. F [urologist] office for review. Culture revealed 2 organisms. Proteus mirabilia and enterococcus faecalis. Pending MD response. A record review of Resident #140's laboratory report, dated 04/12/2022, revealed Resident #140, collected 04/07/2022, urine culture final organism 1 proteus mirabilis .organism 2 enterococcus faecalis. [Proteus mirabilis a bacterium known to cause serious infections in humans. Enterococcus faecalis a bacterium can cause life-threatening infections]. A record review of Resident #140's nurse progress notes, dated 04/13/2022 , at 12:08 PM, revealed LVN C documented, called and left voicemail on Dr. F's office line to follow up with urinalysis results. Pending call back. A record review of Resident #140's nurse progress notes, dated 04/19/2022 , at 11:31 AM, revealed LVN C documented, spoke with [medical office person] regarding residents UA with CS results. states she will look into it and relay message to the nurses. A record review of Resident #140's nurse progress notes revealed LVN C documented on 05/07/2022, at 08:15 AM, resident noted with severe AMS and complaining of pain. RP has been notified and EMS has been dispatched .resident admitted to [local hospital] med surge room [xxx], DX: UTI, Sepsis as per RN G. During an interview on 04/05/2023 at 10:20 AM, LVN C stated nurses enter lab orders into the facility's lab contractor's portal website, then document on the nurses' 24-hr. report and from there the nurse checks the lab's website for the results, print out the results, and then the DON recovers the lab reports and gives them to LVN J the MDS nurse. LVN C was given a report of the survey finding for Resident #140 where on 04/12/2023, 04/13/2023, and 04/19/2023 LVN C attempted to contact Dr. F.; once faxed abnormal lab results to Dr. F's office, then called and left a message for Dr. F, and then called and left a message for Dr. F with office personnel. LVN C was asked if she escalated the inability to provide Dr. F an SBAR to her supervisors, Resident #140's attending physician Dr. H, and ultimately to the facility's medical director; LVN C stated she could not recall the details of a year ago, however LVN C stated, if it was not documented it was not done. LVN C stated the review of her documentation on the dates 04/12/2022, 04/13/2022, and 04/19/2022 appeared as if she was attempting, unsuccessfully, to SBAR Dr. F for Resident #140's UTI infections evidenced by the UA C&S abnormal lab results. During an interview on 04/05/2023 at 2:25 PM, LVN B received a report of her documentation for Resident #140 on 04/06/2022 where she documented Resident #140 had returned from their urology appointment and had a new order for a UA with a CS. LVN B stated she could not recall the details but stood on the accuracy of her note. LVN B was asked to demonstrate her documentation for the physicians' order for the UA with C&S. LVN B stated she reviewed Resident #140's record and could not find any order for Resident #140 to have a UA with a C&S on 04/07/2022. In response to the lack of a documented order for the UA with C&S LVN B stated, I am human and I can make mistakes. During an interview on 04/07/2023 at 03:48 PM, with the DON and the ADON, the DON stated Resident #140 had a need for a suprapubic catheter related to a neurogenic bladder, which was to drain via gravity to a dependent urine collection bag positioned below the bladder. Resident #140 was non-compliant with the position of the dependent urine collection bag positioned below the bladder and would often reposition the collection bag in between his legs where the bag could be exposed to bacteria related to incontinence of bowels. Resident #140 was assessed by LVN C, on 03/30/2022, with s/s of a UTI and received an order for a UA and CS from NP E which was executed, and the facility received results on 04/05/2022. Resident #140 was seen on 04/06/2022 by Dr. F and returned to the facility with new orders from Dr. F's NP E, for a UA w/ CS to be collected and sent to the local hospital, no order for the UA was evidenced in the record, however the UA sample was collected and sent to the local hospital on 04/07/2022. The facility received the UA results on 04/12/2022 to reveal 2 urinary bacterium and the report was faxed to Dr. F office at 10:30 AM, on 04/12/2022. The DON stated Resident #140 received a 1-time dose of amoxicillin 2000mg on 04/12/2022 for dental extraction, and the ADON stated amoxicillin is a broad-spectrum antibiotic which the 04/12/2022 UA CS revealed Amoxicillin could treat the infection. The DON stated LVN C attempted three separate times to reach Dr. F and Dr. F's office could not be reached, once by fax, and once with a voice message, and once with an actual call to Dr. F's office with Dr. F's office person who stated she would relay the message to the nurses. The ADON stated Resident #140 was alert and oriented x3, without a fever, no nausea, no vomiting, no diarrhea. The DON stated and read from the hospital admission record dated 05/07/2022, on arrival patient communicated well states he feels fine, he follows commands appropriately, denies any nausea and vomit, abdominal pain, patient is non tachycardic [a heart rate over 100 beats a minute], no distress noted and afebrile [no fever]. He was sent for confusion and facility stated he was talking in word salad [a confused or unintelligible mixture of seemingly random words and phrases]. when the DON was asked what should have happened the DON stated she refused to answer. During an interview on 04/07/2023 at 10:50 AM, the Medical Director stated he was familiar with Resident #140 and recalled Resident #140 had a history of recurrent UTI's related to his suprapubic catheter. The Medical Director was given a report of survey findings to include Resident #140 was recognized with a urinary tract infection on 04/06/2022 and again on 04/12/2022, specifically the pathogens enterococcus faecalis and proteus mirabilis, without any documentation for communication with a physician, without any documented order for a urinalysis lab, and no report to a physician for the 2 pathogens identified. The Medical Director was given a report of survey findings to include Resident #140 was assessed with altered mental status on 05/07/2022 and was transferred to the local hospital where Resident #140 was admitted with the diagnosis urinary tract infection sepsis and passed away during his hospital stay. The Medical Director stated Resident #140 should have been supported with an opportunity for a physician to intervene and possibly provide various supports to address the infections prior to Resident #140's hospital transfer. The Medical Director was given survey evidenced data to include the facility unsuccessfully attempted to report to Dr. F, the urologist, on 04/12/2022, 04/13/2022, and again on 04/19/2023. The Medical Director stated the expectation was for the facility staff to have given a report of the double pathogen infection to the next escalated physician to include a report to Resident #140's attending physician, Dr. H, and ultimately himself, the medical Director. The Medical Director stated he could not recall if he had been given a report but if he had been given a report, he would have intervened. The Medical Director stated sepsis is a serious infection where the infection has spread from its origin to the systemic body to possibly include the blood and could have serious injury potentials to include death. The Medical Director stated the report of a double pathogen urinary infection was a serious result and would not have been ignored and required a physician's intervention. The Medical Director stated he has intervened in similar infections and could have treated the infection at the resident's home to include many possible interventions to include, pushing fluids, monitoring for signs and symptoms of infection, oral and intravenous antibiotics, and to ultimately transfer a patient to the hospital. The Medical Director stated there could have been an advantage to treat residents in their home and in theory reduce the possibility for cross contamination of pathogens which could happen at the hospital. The Medical Director was given a report of survey findings to include Resident #140 was assessed during his time at the facility with the infection to be free from signs and symptoms of infection to include Resident #140 was without a fever, and had vital signs within normal limits; the Medical Director stated the fact was Resident #140's urinalysis lab revealed a serious double pathogen infection and was enough to warrant treatment. The Medical Director stated in his medical practice he has encountered a patient without any signs and symptoms of infection other than a positive infection lab result and he would not ignore the lab result and would intervene with some type or types of treatment to eliminate the infection. 2. A record review of Resident #14's admission record, dated 04/04/2023, revealed an admitted [DATE], with diagnoses which included personal history of transient ischemic attack, TIA, and cerebral infarction [Infarction refers to death of tissue. A cerebral infarction, or stroke, is a brain lesion in which a cluster of brain cells die when they don't get enough blood]. A record review of Resident #14's admission MDS, dated [DATE], revealed Resident #14 was a [AGE] year-old female admitted from her home. Resident #14 was assessed with no impaired mental cognition evidenced by a 15 out of 15 BIMS score. Resident #14 was assessed with urinary and bowel incontinence and needed extensive assistance with all activities of daily life. Resident #14 was assessed with a status of medically complex to include a diagnosis of hemiplegia [Hemiplegia is a condition caused by brain damage that leads to paralysis on one side of the body]. A record review of Resident #14's care plan, dated 04/04/2023, revealed, The resident has an activities of daily life self-care performance deficit related to decreased mobility, hemiplegia to the right side, intervention: bathing / shower; the resident requires assistance by staff with bathing showering as necessary. A record review of Resident #14's nursing progress notes revealed LVN B documented on 03/24/2023 , at 08:30 PM, CNA notified this SN that upon showering resident she noticed bugs on hair. Upon assessment it was verified resident has an infestation of head lice. DON was notified and contact isolation in place until Treatment is completed. A record review of Resident #14's nursing progress notes revealed LVN T documented on 03/25/2023 , at 03;29 PM, Lice treatment was applied as indicated this am. Continues on contact isolation. Denies pain or discomfort. During an interview on 04/05/2023 at 2:25 PM, LVN B stated on 03/24/2023 she assessed Resident #14 with head lice, text messaged the medical director and the DON. LVN B stated she received an order from the medical director to treat the head lice. LVN B stated the DON gave her the medication and Resident #14 was treated for head lice. LVN B was asked to demonstrate the documented communication with Resident #14's physician, the order for the medicated shampoo for lice, and the documentation for communication with the DON. LVN B stated she could not demonstrate the documentation because she did not document the events in Resident #14's medical record. LVN B stated she believed the DON would have done the documentation since she gave the DON a report. LVN B stated in retrospect she should have documented the SBAR, the order, and the follow up. LVN B stated, I am human and I can make mistakes. During an interview on 04/07/2023 at 03:48 PM, the DON stated on 03/08/2023 LVN B alerted her that Resident #14 had head lice. The DON stated she retrieved the head lice medicated shampoo from the medication storeroom and provided the medication to LVN B. the DON stated the expectation is for nurses to document all communications with physicians, new orders, and follow ups in the residents' medical records. During an interview on 04/07/2023 at 10:50 AM, the Medical Director stated he could not recall if he had been given a report for Resident #14's head lice. The medical director stated the expectation was for all physician communications, orders, and nursing follow ups to be documented accurately in the resident's medical record. A record review of the National Institute of Aging's website, an official website of the United States government, https://www.nia.nih.gov/health/taking-medicines-safely-you-age , accessed, 04/24/2023, Taking Medicines Safely as You Age revealed, It can be dangerous to combine certain prescription drugs, OTC medicines, dietary supplements, or other remedies .To avoid potentially serious health issues, talk to your doctor about all medicines you take, including those prescribed by other doctors, and any OTC drugs, vitamins, supplements, and herbal remedies. Mention everything, even ones you use infrequently. Starting a new medicine: Talk with your health care provider before starting any new prescription, OTC medicine, or supplement, and ensure that your provider knows everything else you are taking. Discuss any allergies or problems you have experienced with other medicines. These might include rashes, trouble breathing, indigestion, dizziness, or mood changes. Make sure your doctor and pharmacist have an up-to-date list of your allergies so they don't give you a medicine that contains something that could cause an allergic reaction. You will also want to find out whether you'll need to change or stop taking any of your other prescriptions, OTC medicines, or supplements while using this new medicine. Mixing a new drug with medicines or supplements you are already taking might cause unpleasant and sometimes serious problems. For example, mixing a drug you take to help you sleep (a sedative) and a drug you take for allergies (an antihistamine) can slow your reactions and make driving a car or operating machinery dangerous. A record review of the manufactures lice shampoo treatment's website, https://ridlice.com/wp-content/uploads/2022/04/RID_Complete_Kit_Insert_English.pdf , accessed 04/24/2023, revealed, WARNINGS: For External use only Do not use near the eyes, inside nose, mouth, vagina, or on lice in eyebrows or eyelashes. See a doctor if lice are present in these areas. Ask a doctor before use if you are allergic to ragweed. May cause breathing difficulty or an asthmatic attack. When using this product keep eyes tightly closed and protect eyes with a washcloth or towel. If product gets in eyes, flush with water right away. Scalp itching or redness may occur. Stop use and consult a doctor if breathing difficulty occurs, eye irritation occurs, skin or scalp irritation continues, or infection occurs. Keep out of reach of children. If swallowed, get medical help or contact a Poison Control Center right away .Use towels to protect eyes and clothes from treatment. Apply RID(R) Lice Killing Shampoo to DRY HAIR or affected area. Apply enough product to saturate. Thoroughly massage product into scalp, behind ears and onto back of neck. Allow product to remain on hair for 10 minutes, but no longer. Add warm water and massage to form lather. Rinse thoroughly, e.g., in a sink. Repeat this step in 7-10 days to kill any newly hatched lice. A record review of the facilities Laboratory Services and Reporting policy dated, 04/08/2023, Revealed, the facility must provide or obtain laboratory services in ordered by a physician, positions assistant, nurse practitioner, or clinical nurse specialist in accordance with state law. policy and explanation and compliance guidelines: the facility must provide or obtain laboratory services to meet the needs of its residents. the facility is responsible for the timeliness of the services. should the facility provide its own laboratory services the services must meet the applicable requirement for laboratories. if the laboratory chooses to refer specimens for testing to another laboratory, the referral laboratory must be certified in the appropriate specialties and subspecialties of service in accordance with requirements. assist the resident in making transportation arrangements to and from the laboratory if necessary. all laboratory reports will be dated and contain the name and address of the testing laboratory and will be filed in the residence clinical record. promptly notified the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range. if unable to reach the ordering prescriber with abnormal lab results the medical director will be notified. This was determined to be an Immediate Jeopardy (IJ) on 04/07/2023 at 08:00 PM. The administrator was notified. The Administrator was provided with the IJ template on 04/07/2023. The following Plan of Removal was accepted on 04/08/2023 at 3:30 PM. Plan of Removal Verification, April 8, 2023 LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY Issue: F-Tag: 684 The facility failed to notify MD/Medical director of change in condition and abnormal lab values. Resident #140 no longer resides in the building. A record review of Resident #140's admission record dated, 04/07/2023, revealed an admitted and discharge hospital date of 05/07/2022. During an interview on 04/07/2023 at 03:40 PM the DON stated Resident #140 was discharged to the hospital on 05/07/2022 for altered mental status. Director of Nursing and/ or designee completed a Lab audit, consisting of 39 residents with 5 lab orders from March 1, 2023- April 7, 2023, on 4/8/2023 looking for abnormal values, transcription, and MD/Medical Director notification. Medical Director will be notified if Primary MD does not respond. During an interview on 04/08/2023 at 3:53 PM the ADON stated the facility assessed all 39 residents for changes of condition, PCP SBARs, new orders, and lab results for the last month up to 04/07/2023. And discovered 5 residents (#1, #4, #8, #26, and #29), with new orders for labs, SBARS, and progress notes to detail the changes of conditions. AON stated, During an audit we did a lab audit on every single Resident, reviewed for accuracy, specific to include, Progress notes, PCP, communications, orders, lab results, follow with next nurse. A record review of Resident #1's medical record revealed orders for labs, dated 03/01/2023. A record review of the resulted labs revealed abnormal results. Continued review of the medical record revealed a progress note by the DON which read, phoned doctor T to discuss resident lab values CBC, Keppra, mag, CMP, phenobarbital, A1C. no new orders received resident to keep appointment to reestablish care next week. A record review of Resident #4's medical record revealed lab orders for PT/INR dated 03/18/2023 revealed the Medical Director ordered, recheck in 2 weeks. A record review revealed a progress note dated 03/18/2023 by LVN C, PT/INR results reviewed with medical director. new order to continue same strength and recheck PT INR in two weeks. A record review of the lab result dated 03/31/2023 revealed abnormal results for PT/INR. A record review revealed a progress note, dated 04/05/2023, LVN C documented, PT/INR results from 03/30/2023 reviewed with the medical director. PT - 32.9, INR, 3.3. recheck PT/INR in three weeks. PT INR updated on the log. A record review revealed a new order, dated 04/05/2023, from the medical director, PT/INR in three weeks 04/25/2023. A record review of Resident #8's medical record revealed an order, dated 03/27/2023, CBC, CMP, iron, TIBC, ferritin, magnesium. a record review of the lab results revealed an abnormal lab, dated 03/31/2023. A record review of the progress notes revealed the DON documented on 04/08/2023, reviewed lab results CBC, CMP, ferritin, magnesium, iron, with doctor H. no new orders. A record review of resident #26's medical record revealed an order dated 03/14/2023 revealed CBC, CMP, lipid, TSH, microalbumin, UA with C&S to be drawn today 03/14/2023 and take into the local hospital laboratory. A record review revealed a progress note dated 03/30/2023, by LVN I, over the phone appointment with doctor W, medical director will refer resident to kidney specialist both referral and lab orders will be faxed to the facility tomorrow morning once the medical director closes the note the medical director verbalized no new orders for 03/14/2023 urinalysis results resident asymptomatic. resident aware and representative stated understood. Director of Nursing was reeducated by the Regional Clinical Specialist on 4/8/23 regarding the below education. After receiving the training the Director of Nursing Service or designee will re-educate the current Licensed Nursing (24 Licensed Nurses) staff and any new Licensed Nurses hires prior to working their next assigned shift regarding notification of MD/Medical director of abnormal lab values, change of condition and correct transcription of lab orders. The Medical Director will be notified if Primary MD does not respond in a timely manner. Notification efforts will be documented in progress notes. Current Licensed Nurse staff (24 Licensed Nurses) and any new Licensed Nurse hires will also be re-educated on Abuse, Neglect and Exploitation prior to working their next assignment shift. No staff will be allowed to work until the re-education is completed. Re-education will be completed as of 4/8/23. A policy was developed in regard to the above education on Laboratory Services and Reporting which includes notifying the Medical Director if unable to contact the ordering Physician, Physician extenders, including NP and PA with abnormal lab results. A record review of the facility's in-service dated 04/07/2023, revealed the DON received a 1 hr. education to cover orders for UA and CNS should be transcribed to PC in order form. medical director nurse practitioners' physicians' assistants and medical doctors must be informed of abnormal lab results. If no response escalates to the medical director. all efforts to be documented in PCC. all abnormal labs must be called to a physician. changes in condition are called to physician and documented and followed up. Further review revealed the DON's signature and printed name. During an interview on 04/08/2023 at 08:18 PM the DON stated she received the 1 hr. in-service and returned the education to all 24 of her nurses. The DON stated any new Licensed Nurses hires prior to working their next assigned shift regarding notification of MD/Medical director of abnormal lab values, change of condition and correct transcription of lab orders. The Medical Director will be notified if Primary MD does not respond in a timely manner. Notification efforts will be documented in progress notes. Current Licensed Nurse staff (24 Licensed Nurses) and any new Licensed Nurse hires will also be re-educated on Abuse, Neglect and Exploitation prior to working their next assignment shift. No staff will be allowed to work until the re-education is completed. Re-education will be completed as of 4/8/23. During an interview on 04/08/2023, at 04:04 PM, LVN B stated she was a charge nurse at the facility and usually worked the 02:00 PM to 10:00 PM shift on either the 100-200 hall or the 300-400 hall. LVN B stated she worked 04/08/2023 and received an in-service prior her LVN duties on the floor. LVN B stated the in-services included abuse, neglect, and exploitation prevention, documenting in residents' medical records, to include physicians' communications, SBAR's, orders, lab results, and continuity of care documentation. During an interview on 04/08/2023, at 03:54 PM, LVN D stated she was the treatment nurse for the facility from 08:00 AM to 05:00 PM and last worked 04/08/2023. LVN D stated she received in-service training prior to working her shift and included documenting in a residents record any changes of condition, communication with physicians, new orders, lab results, and if a physician cannot be contacted the medical director should be included in a report to include new orders documented in the residents' permanent record. Monitoring of the plan of removal included: During an interview on 04/08/2023, at 03:54 PM, LVN K stated she is the MDS nurse, works Monday through Friday, 8-5 PM and occasionally works the floor. LVN K stated she was in-serviced 04/08/2023 to include a communication w/ document in the resident's permanent record any change of condition, SBAR to the PCP, and if the PCP is unavailable to escalate the communication to the next PCP to ultimately include the Medical Director. LVN K stated the in-services also included documenting in the Resident's permanent record all orders documenting the communication with the doctor. LVN K stated all lab results are to be reported to the PCP and critical labs are to be immediately reported to a physician up and including the Medical Director. LVN K stated she was also in-serviced on ANE allegations and ANE preventions. During an interview on 04/08/2023 at 04:34 PM LVN X stated she worked as an LVN charge nurse and her usual shift was 02:00 PM to 10:00 PM. LVN X stated she received and in-service for ANE allegation reporting, and ANE prevention, as well as, documenting in the residents permanent record any and all PCP communications, changes of conditions, lab results, new orders, and documents PCP communications without new orders in the progress notes, LVN X stated if she could not report to any PCP's she would escalate the order to the Medical Director. During an interview on 04/08/2023 at 04:40 PM LVN W, stated she worked the 10:00 PM to 06:00 Am shift as a charge nurse in the facility and received in-service training on 04/08/2023 which included 2 in-services for ANE allegations, ANE prevention, to which a report would be given to the ANE prevention coordinator the Administrator, LVN W stated she received an in-service which included education to document in the residents permanent record any and all communications with the PCP and if the PCP was not available to escalate the SBAR to the Medical Director. During an interview on 04/08/2023 at 05:00 pm RN N stated she works as a RN supervisor on the weekends from 06:00 to 02:00 PM. RN N stated she was in-serviced on 04/08/2023 to include education for ANE prevention to include reporting to the Administrator. RN N stated she received an in-service which included education to document in the resident's permanent record any and all communications with the PCP and if the PCP was not available to escalate the SBAR to the Medical Director. During an interview on 04/08/2023 at 05::33 PM LVN O stated she worked as an LVN charge nurse and her usual shift was 02:00 PM to 10:00 PM. LVN O stated she received and in-service for ANE allegation reporting, and ANE prevention, as well as, documenting in the residents permanent record any and all PCP communications, changes of conditions, lab results, new orders, and documents PCP communications without new orders in the progress notes, LVN O stated if she could not report to any PCP's she would escalate the order to the Medical Director. During an interview on 04/08/2025 at 04:57 PM LVN I stated she last worked 04/07/2023 and was responsible for Resident #4, on 03/18/2023 she received PT [TRUNCATED]

Based on interviews and record review, the facility failed to ensure resident's received adequate supervision to prevent accidents for 2 of 5 residents (Residents #4 and #5) reviewed for accidents, in that: The facility failed to properly supervise Resident #5 who wandered into Resident #4's personal room, which resulted in Resident #4 striking Resident #5 resulting in injury and transfer to hospital of Resident #5. This deficient practice could place residents at risk for physical or psychological harm, hospitalization , and serious injury. The findings were: Record review of Resident #5's undated face sheet, revealed an [AGE] year-old female with an admitted [DATE] with diagnosis to include unspecified dementia, type 2 diabetes mellitus, muscle wasting and atrophy, hypertension (hypertension is another name for high blood pressure. It can lead to severe health complications and increase the risk of [CONDITION(S)], stroke, and sometimes death), and lack of coordination. Record review of Resident #5 Initial MDS, dated [DATE] revealed Resident #5 had a BIMS Score of 3 which indicated severe cognitive disability. Section E for behaviors indicated verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others), occurred 1 to 3 days. Wandering occurred 1 to 3 days. ADLs required assistance of 1 staff. Record review of Resident #5's initial care plan, initiated 2/22/2022, revealed, Problem: o The resident is an elopement risk/wanderer related to history of attempts to leave facility unattended, Impaired safety awareness, Resident wanders aimlessly. Date Initiated: 02/22/2022, Interventions: o Assess for fall risk. Date Initiated: 02/22/2022, o Complete wandering evaluation tool Date Initiated: 02/22/2022 o Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Date Initiated: 02/22/2022o Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. Date Initiated: 02/22/2022. Problem: The resident has potential to have verbally behaviors r/t Dementia and Anxiety Date Initiated: 03/03/2022. Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Date Initiated: 03/03/2022o Psychiatric/Psychogeriatric consult as indicated. Date Initiated: 03/03/2022o When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Date Initiated: 03/03/2022.Problem: The resident has impaired cognitive and thought processes r/t Dementia Date Initiated: 02/24/2022.interventions: Cue, reorient and supervise as needed. Date Initiated: 02/24/2022. Monitor/document/report PRN any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Date Initiated: 02/24/2022 Record review of Resident #5's Fall risk assessment done on 2/17/2022 revealed a risk of 12 which indicated high risk. Record review of Resident #5's Wander evaluation done on 2/21/2022 revealed a score of 11, indicating moderate risk. Record review of Resident #5's electronic medical record progress note dated 3/23/2022 at 4:30 p.m., written by LVN 10pm-6am shift indicated the resident was wandering at the beginning of this shift, going into different rooms, and laying in beds that are not assigned to her. Redirected multiple times while resident was cursing at staff. Went to bed at midnight, no further behaviors noted. Will continue to monitor. Record review of Resident #5's electronic medical record progress note dated 3/23/ 1:09 p.m., indicated the staff reported to LVN (A) that another resident had hit resident on her head and was found lying down on the floor in other residents' room. LVN A assessment performed hematoma/raised area was noted to resident left side of back of head. Resident continues with confusion. Resident sent to local hospital for evaluation. Record review of Resident #5's hospital records of emergency room provider note dated 3/23/2022 revealed, '[AGE] year-old here for altercation that she had today at the nursing home with another nursing home patient, where she was punched in the face and head, and unknown witness fall. Patient is at her baseline as per EMS and nursing home personnel. Has a history of hypertension and dementia. Narrative, upon re-evaluation per CT, dated 3/23/2022 patient discovered to have subarachnoid hemorrhage, hemorrhagic contusion, subdural hematoma Resident #5 was transferred to another hospital out of town for a higher level of care. Record review of Resident #4 face sheet undated, revealed a [AGE] year-old male with an admitted [DATE], original admitted [DATE] with diagnosis to include [CONDITION(S)] Disease, hypertension, anxiety disorder, major depressive order, lack of coordination, and muscle wasting. Record review of Resident #4 MDS initial dated 2/14/2022 section C: revealed a BIMS score of 15, indicating cognitively intact. Record review of Resident #4 care plan revealed: Problem: The resident is/has potential to be physically aggressive r/t Hx of altercation with another resident Date Initiated: 02/08/2022. Goal: The resident will not harm self or others through the review date. Date Initiated: 02/08/2022. The resident will seek out staff/caregiver when agitation occurs through the review date. Date Initiated: 02/08/2022. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 02/08/2022. Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. Date Initiated: 02/08/2022. Monitor and Document observed behavior and attempted interventions in behavior log. Date Initiated: 02/08/2022. Psychiatric/Psychogeriatric consult as indicated. Date Initiated: 02/08/2022.Problem: The resident has a mood problem related to diagnosis of [CONDITION(S)], constant changes in disease process. Date Initiated: 02/08/2022. Monitor/record/report to MD prn risk for harming others: increased anger, mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons Date Initiated: 02/08/2022. Record review of Resident #4 progress note dated 3/23/2022 21:45(9:45PM) indicated the resident reported to LVN(A) that resident had punched another resident in the face and was found lying down on the floor in other residents' room. LVN(A) assessment performed hematoma/raised area was noted to resident left side of back of head. Resident continues with confusion. Resident sent to local hospital for evaluation RP and MD aware. Record review of Resident #4 progress note dated 3/23/2022 10:30 PM indicated the resident in room awake light on. The resident was calm and remained on behavior monitoring. 1:1monitoring outside of residents' room. CNA remains outside of resident room at all times, Will continue to monitor closely. Record review of Resident #4 progress note dated 3/24/2022 13:35 indicated the CNA asked resident in the am if he would like to shower resident did not answer staff member, CNA also notified nurse resident did not eat breakfast. Resident continues on behavior monitoring at this time no behaviors noted. Record review of Resident #4's, Critical Behavior Monitoring Log, dated 3/23/2022- 3/25/2022 revealed staff were monitoring Resident #4 for behaviors, location, and activity. Documentation indicated Resident #4 was calm after altercation with Resident #5. Documentation on 3/23/2022 beginning at 8:45 am Resident #4 had a behavior of 5, indicating aggression while in his room. During an interview upon entrance to facility on 3/24/2022 at 2:00 p.m. the facility DON stated, I believe I know why you may be here. The DON stated the Administrator had done a self-report to HHSC regarding a fall after a resident hit another resident. The DON further revealed Resident #5 had gone into Resident #4's room on 3/23/2022 at around 8:30 p.m. and when Resident #4 asked Resident #5 to leave, she refused, Resident #4 then hit Resident #5 in the face, she fell to the floor hit her head. The DON stated Resident #5 was transported to the local hospital due to the nurse finding her to have swelling to the back of her head. The DON further revealed Resident #5 was transferred to a higher-level of care facility for further treatment. The DON stated Resident #4 who hit Resident #5, was alert and oriented had a BIMS score of 15, which indicated cognitively intact. The DON also stated Resident #5 had a BIMS score of 3 indicating cognitively impaired. The DON stated there was a resident witness (Resident #1) to the fall, in the hall across from Resident #4's room and Resident #4's roommate (Resident #2) was a witness to the altercation also. When asked what the facility did for Resident #5 prior to altercation to try and prevent Resident #5 from wandering into another resident's room or have confrontations with other residents, the DON stated Resident #5 had dementia and wandered about facility frequently, including an elopement that she had prior to the altercation with Resident #4. The DON stated we (all staff) would redirect Resident #5 frequently as she wandered about facility. The DON stated Resident #5 was confused and did require redirection for all activities of daily living . The DON further revealed Resident #5 had never become physically aggressive with another resident but would be verbally aggressive with staff, in that she would tell the staff to wash the dishes or clean up the mess. The DON stated Resident #5 had been at facility about a month and they were trying to do everything they could to help Resident #5 to acclimate to the facility. The DON stated, everyone here knows that she was confused and has the potential to exit the building if not watched and redirected. We basically anticipated all her needs and tried to keep her comfortable and occupied by having her do activities and walk with the staff. When asked if she had considered another more appropriate placement such as a memory care unit for Resident #5, the DON stated, we wanted her (Resident#5) to get used to being at our facility and felt a move would confuse her more. When asked what the facility did for Resident #4 prior to altercation to try and prevent the altercation with Resident #5, the DON stated, we had not had any issues with him before this. We were aware in the past that he aggressive behavior but none after being admitted during this stay. The DON stated the staff monitored him like they did all the residents. When asked what the facility did after the resident/resident altercation, the DON stated, we placed the resident (Resident #4) on a 1:1 watch, which meant a CNA was assigned to monitor Resident #4 for his behaviors throughout the night of the 3/23/2022 incident, by staying at his bedside. Then on 3/24/2022 he was placed on behavior monitor with visual check every 15 min. I then started in-servicing all staff immediately after the incident to monitor Resident #4 for any behaviors for the safety of himself and other residents. The DON further revealed that the staff would redirect Resident #5 often by talking to her when she would go into other Resident rooms. The DON stated we really wanted her to get used to being here at the facility and felt a change to another facility would just distress her more. When asked if there were any complaints or grievances from other Residents or responsible parties regarding Resident #5 wandering into other resident rooms and The DON stated, no. The DON identified the abuse coordinator as the Administrator. The Administrator stated she had educated staff on wandering behaviors, but not residents in the facility. During an interview on 3/24/2022 at 3:00 p.m., Resident #1 revealed she was sitting outside her room (which was directly across the hall of Resident #4's room) when she saw a female resident (Resident #5) enter another resident's room (Resident #4). Resident #1 stated the female resident (Resident#5) started ordering the male resident to drink his water then started cursing at him (drink your water). She stated she did not yell at him, just told him sternly. She stated the male resident (Resident #4) then got angry and punched the female resident (Resident #5) in the face. She stated she did not hear him yell at the resident or yell for help. She said she saw the female resident (Resident #5) fall to the floor hitting her head twice. The female resident (Resident #5) wasn't moving. Resident #1 stated she immediately yelled out, Come help, this lady has fallen to the floor. She states the nurse came running to help the resident (Resident #5). She stated the nurse came running very quickly. When asked if Resident #5 had ever come into her room, Resident #1 stated no. When asked if Resident #4 had ever been aggressive to her or yell at her, she stated no. She stated, I have never seen either one of them (Resident #4 or Resident #5) do anything bad. I have seen the lady (Resident #5) walking around in the halls but never yell or hurt anyone. The people who work here are always telling her (Resident #5) to go different places if she goes the wrong way. When asked if she feels safe at the facility, Resident #1 stated yes. Resident #1 further revealed that multiple staff had been checking on her to make sure she was ok. During an interview on 3/24/2022 at 3:30 p.m. Resident #4 was alert and oriented. He was sitting in his room. When asked if we could walk across the hall to the conference room for privacy, he stated yes When asked what happened Resident #4 stated, She (Resident #5) came into my room while I was sitting in my chair watching tv. She asked me if I wanted a drink of water, using my cup off my table. I told her politely at first yes ok. When I did not drink it all she told me to drink all the fu .water. I told her, no I didn't want any more and told her to leave my room. When she did not leave, I hit her in the face, and she fell to the floor. Then the nurses came after someone called them. When asked why he hit her, he said she made me mad and wouldn't leave. When asked if he felt it was ok to hit someone when they came into his room or if he got mad, he stated, yes it's my room and my stuff. When asked if he felt bad about what had happened, he stated, no. Surveyor asked Resident #4 if Resident #5 had ever been in his room before and he stated no. During an interview on 3/24/2022 at 4:00 p.m. LVN B stated she was the charge nurse on the 6-2pm shift. She stated she was not on shift the evening of 3/23/2022 when Resident #4 and Resident #5 had an altercation. The altercation was reported to her by the night shift nurse on 3/24/2022 during shift change report on 3/23/2022 around 8:00 p.m. that Resident #5 went into Resident #4's room and wanted him to drink water, when Resident #4 did not want to drink water , Resident #4 told Resident #5 to leave and when Resident #5 would not leave Resident #4's room he hit Resident #5 and she fell to the floor and hit her head resulting in a transfer to the hospital. LVN(B )stated Resident #4 had a 1:1 sitter during the night shift of 3/23/2022 through 3/24/2022 a.m. to observe him for any behavior changes of aggression or outbursts. She stated his roommate (Resident #2) was also asked by staff if he had any concerns of safety regarding Resident #4's behaviors. LVN (B) stated Resident #2 stated he felt safe with Resident #4 in his room. She further revealed documentation continued on a Behavior Log for Resident #4, every 15-minute visual checks were being done starting 3/24/2022 at 6:00 a.m. When asked what the facility did for Resident #5 prior to altercation, LVN B stated we would redirect her when she would go in other resident's rooms or if she was confused about where she was. She stated occasionally Resident #5 would argue with staff when they would redirect her, but she never did hit anyone as far as she was aware. When asked what the facility did for Resident #4 prior to altercation she stated we have not any issues with Resident #4 hitting or yelling at anyone. When asked if there had been any in servicing done after Resident #5 had an elopement and Resident #4 and #5 had an altercation, LVN (B) stated, yes we have had in-servicing on residents who wander and how to redirect them and also if residents have behaviors towards other residents or staff how to control the situation by redirecting the residents and too keep the residents safe. During an interview on 3/24/2022 at 4:10 p.m. CNA (C) She stated she worked on 3/23/2022 during the 2p-10pm shift. She stated she had just come back in from taking the smoking residents out and she heard LVNA call for help from the 100 hall. She stated she entered room 5 and saw Resident #5 on the floor and LVNA was checking her. CNA C stated she saw Resident #4 standing in his room near his bed pacing and agitated. CNAC asked Resident #4 what happened, and said I hit her She also said Resident #4's roommate (Resident #2) stated Resident #4 hit Resident #5 and she fell . CNAC stated she asked Resident #4 why he hit Resident #5, and he said because she would not leave my room. She said she asked Resident #4 why he did not call for help to have her leave and he did not answer. When asked what time CNAC had last seen Resident #5 she stated I saw her last in the main dining area about 5 minutes before I took the smoking residents outside , so about 15 minutes ago. She was sitting watching tv. She further revealed that we as staff know to keep an eye on her (Resident #5) because she wanders. We have been in serviced by our DON and told by our charge nurse to watch and redirect Resident #5 if she becomes confused. When asked what the facility did for Resident #4 prior to altercation CNA C stated we treat him like the other resident's and she hadn't had any behavior issues with him. During an interview on 3/24/2022 at 4:20 p.m. LVN A stated she was at facility working the evening shift 2pm-10pm of 3/23/2022 as the charge nurse covering the 100 hall. She stated she was at the nurse's station (which was approximately 50 feet from Resident #4's room), when she heard a loud bang and at the same time she heard a resident yell the lady fell , help. LVNA stated she ran to room #4 where Resident #1 had pointed to and she saw Resident #5 lying on the floor crying and moaning. She stated immediately to Resident #4, who was standing in his room, what happened? LVN A stated Resident #4 told her that he had hit Resident #5 and she fell to the floor. LVNA stated she told Resident #4 that was not a reason to hit her you should have called us for help. LVNA stated she had immediately started checking resident #5 for injuries and determined she had hit the back of her head. She called for help and CNA C immediately came to assist. She stated she told the CNA C to go get the other LVN(E) to help. LVN A stated an assessment was performed, hematoma raised area was noted to Resident#5's left side of back of head. LVN A stated she sent her to the local ER for evaluation and notified her RP and MD. When asked what the facility did for Resident #5's wandering behavior prior to altercation, LVN A stated Resident #5 would frequently wander about facility because she was confused. She required frequent redirection and was bossy at times. She would tell us to clean up things or to pay our bills. She never hit anyone. We would anticipate her needs and try to know where she was at all times because she had an elopement in February this year (2022). LVN A said she last saw Resident #5 about 5 minutes before the altercation. She was walking in hall 100 like she always walked around. Previously to that she was sitting in the main dining area watching tv. When asked what the facility did for Resident #4 prior to altercation LVN A stated she was aware that in the past he had aggressive behaviors at home , but if he became agitated he could be talked to and redirected. He had an agitated event on 3/23/2022 when he did not want to bath during the time his family was visiting. She stated he was told ok he could shower at another time. She stated Resident #4 refused this shiftX2 due to family visiting. Once family left, resident told the CNA to shower him now, but the CNA was unable to shower due to shift change, LVNA asked Resident #4 if he would like for oncoming shift to shower him and he state no because he only showers in the morning. She stated he then said he wasn't going to take a shower today. He then went to his room. She stated we started a behavior log on him after that . He did not have any outbursts or agitation after that until the altercation with Resident #5 coming into his room. During an interview on 3/24/2022 at 4:50 p.m. Resident #2 was lying in bed watching tv. He stated he saw Resident #5 get hit by his roommate (Resident #4), and then she fell to the floor. When asked if Resident's #4 and #5 were yelling at each other he said no, Resident #5 told his roommate to drink your water , and when he didn't want to, he hit her, and then she fell . Resident #2 stated he felt safe in the same room with Resident #4. He said he had never seen his roommate hit or yell at anyone before. He said Resident #5 had never came into his room before this altercation. Resident #2 stated the staff in the facility had told him if he needed assistance when another resident would come into his room or if he felt unsafe to use his call light so staff could come in and help him. During an interview on 3/24/2022 at 5:03 p.m. CNA D stated she was in the break room about 8:20 pm on 3/23/2022 and was approached by CNA C that said, they needed help in (Resident #4's room). She stated she went immediately to Resident #4's room and saw the 2 LVN's (A,E) on the floor taking care of Resident #5. She said she saw Resident #4 and he looked upset. There was water on the floor. CNAD further revealed that 4 of us picked Resident #5 up and placed her in a wheelchair and took her to her room. She was awake and crying. She further revealed Resident #4 told her it's your fault you are supposed to keep her out of my room. I don't care that I hit her. She stated then the nurse LVN A placed him (Resident #4) on 1:1 monitoring to watch him for outbursts or angry behaviors. She said he calmed down and went to bed a little after we left the room with Resident #5. When asked when the last time she had seen Resident #5 CNA C stated about 15 minutes prior to the altercation she was in the dining room area watching tv. She further revealed the DON had done an in-service a few months ago on elopement and behaviors and watching residents. She stated we watched Resident #5 and redirected her frequently. When asked what the facility did for Resident #4's behaviors prior to the altercation she said we just watch him, and he has not had any problems. During an interview on 3/24/2022 at 3:10 p.m. the facility Administrator stated there had been an altercation between 2 residents (Resident #4 and #5) on the evening of 3/23/2022. She stated Resident #5 went into Resident #4's room and when he (Resident #4) asked her (Resident #5) to leave she didn't, so he hit her, and she fell and was sent to the hospital. She stated she reported the incident to HHSC that night and also the police were notified that night. When asked what the facility did for Resident #5 prior to altercation, the Administrator stated, we all were frequently redirecting her from going in other resident rooms and trying to keep her busy because she was confused. After she had eloped when she first got here an in-service was done on watching and listening for residents to potentially leave the building. When asked if she had considered another more appropriate placement such as a memory care unit for Resident #5, she stated we wanted her (Resident#5) to get used to being at our facility and felt a move would confuse her more. Record review of Inservice conducted by DON for all staff on 1/4/2022 revealed, Topic: Abuse; summary types of abuse, unwanted touch, explain to resident's procedure, signs of abuse, change in behaviors in residents. Record review of Inservice conducted by DON for all departments on 3/23/2022 revealed, Topic: Wandering residents; Summary Incidents, reporting, resident safety ,redirect residents to room and accompany resident. When asked what the facility did for Resident #4 prior to altercation the Administrator stated he (Resident #4) had not had any behavior issues or altercations during current admission. She further revealed Resident #4 had a past history of becoming angry. She stated he was at home when this had occurred. When asked how the staff were informed of how to be aware of resident behaviors or elopement attempts, she stated we have done in-services several times this year. She further revealed she had no grievances from residents or responsible parties regarding either resident (Resident #4 or Resident #5). During an interview on 3/25/2022 at 10:05 a.m. with facility Activity Director she stated Resident #5 would wander about facility most of the day. She stated staff would redirect her because she was confused. She could not remember where her room was. Activity Director stated that she would have Resident #5 help her with activities by sorting supplies. She stated that Resident #5 would become easily distracted and would go walking in facility. The Activity Director further revealed the DON had done an in service in January of 2022 and then one 3/23/2022 on abuse and neglect and wandering. She stated we( the department heads) discuss in our stand up meetings daily when we are here any behaviors or concerns about residents. Resident #5 was frequently a topic of conversation in that she wandered and was redirected by staff. She stated Resident #4 had not had any behaviors of aggression or wandering that she was aware of . During an interview on 3/25/2022 at 2:30 p.m. the facility DON stated there was no behavior policy. She stated we do fall assessments on the residents and behavior monitoring if needed. DON stated there is behavior monitoring for the residents who are on [CONDITION(S)] medications or if they have behaviors such as aggression or wandering. DON stated the care plans are updated also with changes in residents. The nurses participate in care plan meetings every 90 days and as needed. The DON further revealed a psychiatric evaluation had been ordered by Resident #4's physician and the contracted psychologist was scheduled to come to facility for Resident #4 on 3/25/2022. Resident #4 had not been seen by a psychologist before the altercation with Resident #5. The facility social worker asked resident #4 if he would agree to see a psychologist and he said yes. During an interview on 3/25/2022 at 10:50 a.m. the facility Social Worker revealed she had a discussion with Resident#4 about an incident that occurred during the evening of 3/23/2022 with another resident (Resident #5). She stated Resident #4 had told her a Resident #5 had entered his room and told him to drink his water. Resident #4 told her he became angered because he spilled his water. He claimed he asked her to leave but she didn't, and this is when he hit her. The Social worker stated she told the resident (Resident #4) that hitting another person was not acceptable and instead should have told a nurse to remove her from his room. She further revealed that Resident #4 told her it was the nurse's fault that the situation had occurred because she should have been watching Resident #5 so she wouldn't have wandered into his room. The Social Worker stated she asked Resident #4 if he would see a psychologist to help him with his behaviors, and she said he told her yes. She asked him to sign a consent form for psychological services to evaluate and treat him and he did. Resident #4's RP was also notified of Resident #4 agreeing to see a psychologist .She further stated she asked Resident #4 if he wanted to transfer to another facility. She stated he said ok if needed. She said she followed up with notifying the RP) of the incident and the consent for psychiatric treatment. The Social worker revealed that the RP told her it wasn't an option for Resident #4 to come live with her. When asked what the facility did for Resident #5's behaviors prior to altercation she stated we all had been in-serviced by the DON about the resident potentially trying to leave the facility and that she was confused. She said we all redirect her if she goes into other residents' rooms. Our staff walk with her and try to give her things to do to keep her busy. She will sit and watch TV in the day room but not for very long. She stated she had not had a physical altercation with any other residents before the altercation with Resident #4. When asked what the facility did for Resident #4's behaviors prior to altercation she stated there had not been any altercations prior to the one that occurred with Resident #5, so we just watched him like we do all our residents. She stated after the altercation between Resident #4 and Resident #5, the DON did in-servicing about behaviors of residents with all the staff included. When asked who the abuse coordinator was, she stated the administrator. The Social Worker stated the stand up meetings are held each working day in the morning to discuss any issues with residents. She stated if there are any behavior changes or concerns then we discuss and plan for a resolution. The social worker stated Resident #5 ,seemed to be getting more comfortable being in the facility, with less wandering since her admission. The Social Worker further revealed she was not aware of any grievances by any residents or responsible parties about Resident #5 going into their rooms. Record review of facility grievances from 1/1/2022- 3/25/2022 , revealed no grievances by any residents or responsible parties about Resident #5 going into their rooms. Record review of In-services provided by DON revealed Inservice titled All dept in-service Wandering Residents: Incident reporting, resident safety, redirect to room accompany residents. Dated 3/23/2022. The DON stated the in-service was on going , 25 staff members signed for attendance. Record review of Inservice dated 1/4/2022, titled: For all dept in-service abuse: types unwanted touch explains to resident's procedure signs of abuse change in behavior investigations. The DON stated 31 staff members signed for attendance. Record review of the facility's policy, Nursing Administration, Section: Resident Rights, Subject: Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment, no date. Policy: It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Resident must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, resident representatives, families, friends, or other individuals. Record review of the facility's policy, Section: Resident Assessment, Subject: Fall Management System ,undated. Policy: It is the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. Fall Risk Evaluation will have individualized care plan development .