Every finding on record at Veranda Rehabilitation and Healthcare

Based 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 4 of 10 residents (Resident #9, #12, #26, and #89) reviewed for infection control. The facility failed to ensure CNA F performed hand hygiene while assisting Residents #9 and #26, and CNA G performed hand hygiene while assisting Residents #12 and Resident #89 with their lunch on 08/17/26. This failure could place residents at risk for healthcare associated cross-contamination and the spread of infection.Findings included:1. Record review of Resident #9's face sheet, dated 08/18/26, reflected an [AGE] year-old female, admitted on [DATE], diagnoses included: Alzheimer's disease (neurodegenerative disorder that affects memory, thinking, and behavior), osteoarthritis (progressive, degenerative joint disease that can cause pain, stiffness, and loss of mobility), major depressive disorder (mental health condition with persistent feelings of sadness, loss of interest, various emotional/physical problems), and hypertension (high blood pressure).Record review of Resident #9's quarterly MDS assessment, dated 08/06/26, reflected a BIMS score of 2, which indicated severe cognitive impairment. The MDS reflected Resident #9 needed setup or clean up assistance with eating and had a mechanically altered diet.Record review of Resident #9's care plan, dated 08/18/26, reflected [Resident #9] had an ADL self-care performance deficit related to Alzheimer's disease, osteoarthritis, and advanced age. Date initiated: 09/05/24. Interventions included: The resident required setup assist of one person for eating.2. Record review of Resident #26's face sheet, dated 08/18/26, reflected an [AGE] year-old female, admitted on [DATE], diagnoses included: Alzheimer's disease (neurodegenerative disorder that affects memory, thinking, and behavior), major depressive disorder (mental health condition with persistent feelings of sadness, loss of interest, various emotional/physical problems), anxiety disorder (uncontrollable worry about everyday issues, affecting daily functioning and quality of life), and hyperlipidemia (high levels of lipids or fats in your blood). Record review of Resident #26's quarterly MDS assessment, dated 05/27/26, reflected a BIMS score of 2, which indicated severe cognitive impairment. The MDS reflected Resident #26 needed substantial/maximal assistance with eating and had a mechanically altered diet.Record review of Resident #26's care plan, dated 08/18/26, reflected [Resident #26] had an ADL self-care performance deficit related to Alzheimer's disease, depression, and anxiety. Date initiated: 03/04/14. Interventions included: The resident required substantial/max assist of one person for eating.3. Record review of Resident #12's face sheet, dated 08/18/26, reflected a [AGE] year-old female, admitted on [DATE], diagnoses included: hypothyroidism (thyroid gland does not produce enough thyroid hormone), dementia (decline in cognitive function severe enough to interfere with daily life affecting memory loss, language, problem solving, and other cognitive abilities), major depressive disorder (mental health condition with persistent feelings of sadness, loss of interest, various emotional/physical problems), chronic kidney disease (condition that affects the kidneys' ability to filter waste from the blood), and history of cerebral infarction (stroke). Record review of Resident #12's quarterly MDS assessment, dated 06/04/26, reflected a BIMS score of 2, which indicated severe cognitive impairment. The MDS reflected Resident #12 was dependent for eating and had a mechanically altered diet.Record review of Resident #12's care plan, dated 08/18/26, reflected [Resident #12] had an ADL self-care performance deficit related to dementia, depression, hypothyroidism, and history of stroke. Date initiated: 05/11/22. Interventions included: The resident was dependent assist of one person for eating.4. Record review of Resident #89's face sheet, dated 08/18/26, reflected a [AGE] year-old female, admitted on [DATE], diagnoses included: dementia (decline in cognitive function severe enough to interfere with daily life affecting memory loss, language, problem solving, and other cognitive abilities), osteoporosis (weak and fragile bones), anemia (deficiency of healthy red blood cells), anxiety disorder (uncontrollable worry about everyday issues, affecting daily functioning and quality of life), and hypothyroidism (thyroid gland does not produce enough thyroid hormone).Record review of Resident #89's quarterly MDS assessment, dated 07/17/26, reflected a BIMS score of 2, which indicated severe cognitive impairment. The MDS reflected Resident #12 was dependent for eating and had a mechanically altered diet.Record review of Resident #89's care plan, dated 08/18/26, reflected [Resident #89] had an ADL self-care performance deficit related to dementia and anxiety. Date initiated: 12/29/23. Interventions included: The resident was dependent assist of one person for eating.During an observation, on 08/17/26 12:10 PM, revealed CNA F and CNA G assisted two residents with their meals. CNA F used his right hand to assist in feeding Resident #9 and Resident #26 and did not perform hand hygiene in between feedings. CNA G used her right hand to assist in feeding Resident #12 and Resident #89 and did not perform hand hygiene in between feedings.During attempted interviews and observations, on 08/17/26 from 1:55 PM-2:30 PM, Residents #9, #26, #12, and #89 were asked basic questions, but they did not respond or were not interviewable. Residents #9, #26, #12, and #89 were observed with no visible injury or distress.During an interview, on 08/18/26 at 11:15 AM, CNA G stated she assisted in feeding Residents #12 and #89 on 08/17/26 during the lunch meal. CNA G stated she used hand sanitized before sitting down to feed them. CNA G stated she did not remember if she used the same hand to feed both residents, but normally she tried to use one hand to feed one resident and the other hand to feed the other resident. CNA G stated she was in-serviced on infection control and hand hygiene about every month. CNA G stated it was important to not feed the residents with the same hand, use one hand for each resident, or sanitize in between residents, to avoid germs and prevent infections.Durin an interview, on 08/18/26 at 11:30 AM, CNA F stated he assisted in feeding Residents #9 and #26 on 08/17/26 during the lunch meal. CNA F stated he sanitized his hands before feeding the residents to avoid contaminating their meal. CNA F stated it was not okay to feed two residents at the same time, so he fed one resident and then the other. CNA F stated he fed the resident on his left side, Resident #9, with his left hand and the resident on his right side, Resident #26, with his right hand. CNA F stated he was in-serviced on infection control and hand hygiene about every week. CNA F stated it was important to sanitize in between feeding residents to avoid cross contamination.During an interview, on 08/18/26 at 11:45 AM, the WCN stated she supervised the dining room on 08/17/26 during the lunch meal to ensure the residents received their meal as ordered and monitored for any incidents. The WCN stated she monitored the staff helping residents that needed assistance with their meals. The WCN stated there could be a problem with infection control when assisting two residents with eating at the same time without performing hand hygiene in between residents. The WCN stated the staff were in-serviced on infection control and hand hygiene monthly. The WCN stated the staff were aware to sanitize in between residents to avoid cross contamination. During an interview, on 08/19/26 at 11:15 AM, the ADON stated she was the infection preventionist for the facility. The ADON stated she in-serviced staff on infection control, which included hand hygiene at least monthly. The ADON stated staff were in-serviced on how to feed the residents that required assistance. The ADON stated she instructed staff if they fed two residents at the same time, it was okay, but they had to use one hand for each resident. The ADON stated if the staff used the same hand to feed two residents, the staff had to sanitize in between residents. The ADON stated the purpose of this was to prevent the spread of germs and avoid risk of cross contamination. During an interview, on 08/19/26 at 11:35 AM, the DON stated the staff were in-serviced on infection control, hand hygiene, and how to feed the residents about every month. The DON stated if staff were feeding more than one resident, they had to perform hand hygiene between feeding the residents. The DON stated if the staff fed two residents, they had to feed one resident with one hand and the other resident with the other hand, or they had to sanitize in between. The DON stated the purpose was to prevent infection or cross contamination. The DON stated Residents #9, #26, #12, and #89 were not oriented and required different levels of assistance for eating. The DON stated the staff assisted Residents #9, #26, #12, and #89 for meals and they had no incident in the dining or change of condition related to cross contamination. Record review of the facility's Hand Hygiene policy, dated May 2007, revised April 2025, reflected - Policy: It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene, which is one of the most effective measures to prevent the spread of infection, based on accepted standards. Procedure: 2. Use an alcohol-based hand rub containing at least 62% alcohol, or, alternatively, soap and water for the following situations: .p. Before and after assisting a resident with meals.

Based on observation, interview, and record review, the facility failed to have physician orders for the resident's immediate care at time of admission, for 1 of 6 residents (Resident #96) reviewed for physician admission orders.The facility failed to have physician orders in place for Resident #96's cholecystostomy (gallbladder drain) tube of monitoring for signs/symptoms of infection and to change the dressing, when Resident #96 admitted to the facility on [DATE].This failure could place residents at risk of not receiving appropriate care.Findings included:Record review of Resident #96's face sheet, dated 08/18/26, reflected a [AGE] year-old female, admitted on [DATE], diagnoses included: sepsis (life-threatening reaction to an infection), unspecified Escherichia coli (bacteria found in the intestines of people), thrombocytopenia (low blood platelet count), cirrhosis of liver (advanced scarring of the liver, liver damage), esophageal varices (enlarged veins in the esophagus) without bleeding, acute cholecystitis (inflammation of the gallbladder), acute pyelonephritis (kidney infection), acute kidney failure (kidneys lose their ability to filter waste products from your blood), other ascites (abnormal buildup of fluid in the abdomen, most commonly caused by liver cirrhosis), and urinary tract infection (infection in any part of the urinary system). Record review of Resident #96's admission MDS assessment, dated 08/17/26, reflected a BIMS score of 11, which indicated moderate cognitive impairment. The MDS reflected Resident #96 had a diagnosis of acute cholecystitis. Record review of Resident #96's care plan, dated 08/19/26, reflected [Resident #96] had an alteration in gastrointestinal status related to esophageal varices and cholecystostomy tube. Date initiated: 08/14/26. Interventions included: give medications as ordered, monitor vital signs as ordered, monitor cholecystostomy tube output every shift. Date initiated: 08/14/26. Record review of Resident #96's order summary report, dated 08/18/26, reflected physician's order of cholecystostomy tube output every shift with start date of: 08/13/26. There was no other order for the cholecystostomy for monitoring signs/symptoms of infection or maintenance/care/change of dressing for the tube/site. During an interview and observation, on 08/17/26 at 9:45 AM, Resident #96 was observed with a drain bag and cholecystostomy tube on her lower back, right side. Resident #96 stated she had a drain placed for her gallbladder since she could not have her gallbladder removed because she had cirrhosis of the liver. Resident #96 stated the facility staff emptied out the bag, checked the tubing, and made sure she was doing well. Resident #96 stated there were no issues with the drain or the tube. Resident #96 was observed with no visible injury. During an interview, on 08/19/26 at 8:45 AM, RN J stated Resident #96 had a cholecystostomy tube, and they drained the bag and monitored the output. RN J stated Resident #96 should have had orders of monitoring for signs/symptoms of infection such as redness, swelling, pain to the tubing site and how often to change the dressing. RN J stated she was not sure if there were orders. RN J stated she reviewed the orders and Resident #96 only had the order for the cholecystostomy tube output every shift. RN J stated the admitting nurse input the orders, and she was not sure who was the admitting nurse for Resident #96. RN J stated as a nurse, she knew to monitor for signs/symptoms of infection and change the dressing as needed, but there should have been orders in place. During an interview, on 08/19/26 at 9:05 AM, the WCN stated Resident #96 had the cholecystostomy bag. The WCN stated Resident #96 should have had orders to drain output, monitor for signs and symptoms of infection, and change the dressing if it was soiled, leaking, or as needed. The WCN stated the orders were inputted by the admitting nurse and clarified as needed. The WCN stated Resident #96 was alert/oriented and knew to report any pain, changes, or issues. The WCN stated she checked Resident #96's skin and there were no abnormalities or changes to the tubing site. During an attempted interview via phone, on 08/19/26 at 11:00 AM, RN K did not answer, and a voicemail was left requesting a callback. A text message was sent. During an interview, on 08/19/26 at 11:15 AM, the ADON stated for new admissions, the admitting nurse received the orders, called the doctor to verify the orders, and clarified orders with the doctor if something was missing. The ADON stated Resident #96 had the cholecystostomy tube since admission. The ADON stated Resident #96 only had the order of cholecystostomy tube output every shift which meant to drain the bag. The ADON stated the WCN did head to toe assessments and obtained orders as well if an order was not in place. The ADON stated Resident #96 should have had orders to monitor the tubing site for infection and to change the dressing. The ADON stated sometimes the doctor wanted the dressing changed, sometimes they did not, but if there was no specific order for the dressing, they should have clarified that with the doctor. The ADON stated the nurses used their nursing judgment, but they should still have had orders in place for monitoring for infection and to change the dressing. The ADON stated it was a team effort to ensure orders were in place. The ADON stated if there were no orders in place, Resident #96 was not at risk of injury because they still assessed her skin and checked her tube site. The ADON stated it was important to have orders in place to ensure they were doing what was best for the resident and to provide her with care as ordered. During an interview, on 08/19/26 at 11:35 AM, the DON stated the admitting nurse input orders upon admission for the residents. The DON stated if there was no order for the resident's needs then the nurse should have called the doctor to clarify. The DON stated RN K was the admitting nurse for Resident #96. The DON stated Resident #96 should have had orders to monitor for signs/symptoms of infection for the cholecystostomy tube and orders to change the dressing. The DON stated the nurses drained out the tube, and the nurses ensured the site looked well or identified any changes. The DON stated as far as she knew, there were no changes or signs of infection for Resident #96's tubing site. The DON stated Resident #96 had no negative outcome, and she had no risk of injury because the nurses knew how to care for the tube and site. The DON stated it was a team effort to ensure the orders were in place. The DON stated it was important to have orders in place to know the care Resident #96 needed and ensure Resident #96 received the care appropriately. The DON verified RN K was not working. During an attempted interview via phone, on 08/19/26 at 12:15 PM, RN K did not answer, and a voicemail was left requesting a callback. Record review of the facility's Physician's Orders policy, dated May 2021, reflected - Policy: It is the policy of this facility to accurately implement orders in addition to medication orders (treatment, procedures) only upon the written order of a person duly licensed and authorized to do so in accordance with the resident's plan of care.Procedures: 3. admission orders are reviewed with the physician upon admission based on the discharge instructions from the discharging facility and are transcribed accordingly.

Based on observation, interview, and record review, the facility failed to ensure that a dependent resident receives necessary activities of daily living (ADLs) oral care, for 1 of 6 residents (Resident #4) reviewed for dependent care protocols.The facility failed to provide regular oral care and remove the accumulation of oral debris and thick film for Resident #4.This failure could place residents at risk of not receiving oral care, including an increased clinical risk for bacterial overgrowth, localized oral infections, and aspiration pneumonia. Record review of Resident #4's face sheet, dated 08/17/26, reflected a resident admitted on [DATE], diagnoses included: metabolic encephalopathy (temporary or permanent brain dysfunction caused by metabolic disorders), adult failure to thrive (progressive decline in physical and cognitive function), gastrostomy status (presence of a feeding tube inserted through the abdomen), hemiplegia, unspecified affecting left nondominant side (paralysis affecting the left side of the body), muscle weakness (generalized), limitation of activities due to disability, other reduced mobility, other lack of coordination, need for assistance with personal care, cognitive communication deficit, dysphagia, oropharyngeal phase (difficulty swallowing.Record review of Resident #4's admission MDS assessment, completed date 07/23/26, reflected a BIMS score of 12, which indicated moderate cognitive impairment. The MDS reflected Resident #4 had diagnoses of other neurological conditions, hemiplegia or hemiparesis, need for assistance with personal care, and gastrostomy status. Section GG of the assessment for self-care reflected Resident #4 was dependent on oral hygiene, which indicated a helper does all the effort or the assistance of two or more helpers is required for the resident to complete the activity.Record review of Resident #4's care plan, dated 08/12/26, reflected activities of daily living (ADLs) self-care performance deficit related to left flaccid hemiplegia and PEG tube status. Interventions included: provide total, dependent assistance with a minimum of one staff member to complete all daily oral hygiene tasks using suitable oral items to clean the resident's teeth and maintain oral health. Date initiated: 07/24/2026.Record review of Resident #4's order summary report, dated 08/18/26, reflected physician's order of NPO (Nothing by mouth) diet, texture: NPO consistency, fluid: NOT APPLICABLE with a start date of 07/17/26.During an observation, on 08/17/26 at 9:02 AM, Resident #4 was observed in bed. Resident #4's oral cavity was observed with a thick, visible film coating her oral cavity and distinct patches of dark, dry debris heavily embedded within her teeth and across her tongue.During an interview, on 08/17/26 at 9:08 AM, Resident #4's family member stated that the resident had been admitted to the facility for one month. Resident #4's family member stated that basic oral care appeared to have been completely neglected by the floor staff since Thursday 8/13/2026, 5 days past. Resident #4's family member stated she had immediate, severe concerns regarding her Resident #4's care.During an observation and interview, on 08/17/26 at 9:18 AM, LVN A was called to Resident #4's room by the family member, and the oral care concerns were addressed with her. LVN A proceeded to clean the resident's oral cavity in the presence of the family member and the surveyor, and all heavy debris was removed from Resident #4's tongue and teeth. Interview with LVN A verified that the resident had a thick accumulation of oral film and debris prior to the cleaning, and the resident had no visible injury or bleeding following the procedure.During an interview, on 08/17/26 at 9:38AM, LVN A stated that certified nurse aides (CNAs) were responsible for performing oral hygiene every shift. LVN A stated that it was here responsibility to ensure that cna's preformed the care. LVN A stated that she personally cleaned the resident's mouth after the family member identified and pointed out the heavily accumulated oral debris. LVN A explicitly admitted that the mandatory oral care had not been completed prior to her shift, stating that it was not right to be left like that. LVN A stated that leaving a dependent resident without proper mouth hygiene promotes harmful bacterial growth and serves as a source of infection.During an interview, on 08/18/26 at 12:20 PM, CNA D who was working with resident #4, stated Resident #4 required assistance from staff for activities of daily living (ADLs), including personal hygiene and oral care. CNA C acknowledged that all required resident care parameters, including oral hygiene, are placed in the electronic Kardex system(.is a digital, centralized patient care summary). CNA C stated that oral care should be performed after meals to prevent infections and maintain oral health.During an interview, on 08/19/26 at 10:01 AM, CNA C stated that residents with a strict nothing by mouth (NPO) and a gastrostomy tube (G-tube) needed oral care. CNA C explicitly confirmed that providing oral hygiene was her direct responsibility as the assigned CNA to hall. CNA C stated that her regular routine consisted of brushing the resident's teeth, using a toothbrush immediately after breakfast and after lunch. CNA C explained that completing daily mouth care was vitally important to prevent dental cavities and localized mouth infections. CNA C identified negative outcomes of not providing oral care can cause bacteria and bad breath. During an attempted interview, on 08/19/26 at 2:44 PM, primary physician office was contacted for resident #4 and message left with receptionist requesting a call back. No call back received.During an interview, on 08/19/26 at 08:42 AM, the DON stated the direct responsibility for delivering this daily care lies with the certified nurse aides (CNAs) and the licensed nurses. The DON stated that the staff were provided with explicit care instructions located within the electronic Kardex system, direct physicians' orders, and the comprehensive care plan. The DON stated that if a resident did not receive proper oral hygiene, it can cause dental cavities and gingivitis. The DON stated that teeth infections may occur as a negative outcomeRecord review of the facility's policies revealed that administration did not possess written protocols for basic hygiene or dental care for dependent residents.

Based on observation, interview, and record review, the facility failed to ensure that respiratory care and specialized oxygen therapies were provided in accordance with professional standards of practice and delivered exactly as prescribed by the attending physician, for 1 of 4 residents (Resident #50) reviewed for respiratory treatments.The facility failed to maintain Resident #50's oxygen concentrator at the physician-ordered flow rate of 2 liters per minute (LPM), the observed flow rate was set at 1.5 LPM.This failure could place residents at risk of not receiving appropriate care, including an increased clinical risk for unresolved shortness of breath, acute hypoxia (medical condition where the body's tissues and cells do not receive enough oxygen to function properly) and secondary anxiousness.Record review of Resident #50's face sheet, dated 08/18/26, reflected an [AGE] year-old female, admitted on [DATE], diagnoses included: moderate persistent asthma (chronic, long-term disease of the respiratory system, uncomplicated, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (progressive decline in memory and cognitive function).Record review of Resident #50's annual MDS assessment, dated 06/05/26, reflected a BIMS score of 8, which indicated moderate cognitive impairment. The MDS reflected Resident #50 had a diagnosis of asthma, chronic obstructive pulmonary disease (COPD), or chronic lung disease.Record review of Resident #50's care plan, dated 06/29/26, reflected [Resident #50] was at high risk for an altered respiratory status and breathing difficulties related to asthma, allergies, and a chronic cough. Interventions included: provide oxygen therapy exactly as ordered by the physician, administer all respiratory medications as prescribed.Record review of Resident #50's order summary report, dated 08/17/26, reflected physician's order of oxygen via a nasal cannula (NC) maintained strictly at a flow rate of 2 liters per minute (2L/min) as-needed (PRN) for shortness of breath (SOB), acute respiratory distress, cyanosis, and labored breathing with a start date of 07/09/21.During an interview and observation, on 08/17/26 at 9:56 AM, Resident #50 was observed sleeping in her bed with oxygen running via nasal cannula. The oxygen concentrator revealed the flow rate was set at 1.5 liters per minute (LPM). Resident #50 woke up and stated she was ok, just very sleepy.During an interview and observation, on 08/17/26 at 10:01 AM, LVN A stated Resident #50 had an oxygen concentrator running via nasal cannula and was set at 2 LPM. LVN A stated the physician's order was PRN and the flow rate at 2 LPM. LVN A was observed adjusting the O2 the flow rate by increasing from 1.5 LPM to 2 LPM. LVN A stated Resident #50 should have had her oxygen flow rate dial maintained exactly at the ordered 2 liters per minute (LPM). LVN A stated she physically examined the device and verified the machine's flow rate dial was incorrectly set at 1.5 LPM. LVN A stated she reviewed the orders and Resident #50 had an order for 2 LPM. LVN A stated that as a nurse, she knew oxygen flow rates were required to be verified by licensed nursing staff during routine shift changes and rounding to ensure device accuracy. LVN A stated the negative clinical outcome would be the resident not getting the right amount of oxygen to relieve her potential shortness of breath.During an interview, on 08/19/26 at 10:09 LVN B stated that licensed nurses were directly responsible for monitoring respiratory equipment, which includes physically checking the oxygen devices during rounds every two hours and verifying the machine's flow rate against the physician's order in the system. When presented with the bedside finding of Resident #50's concentrator being left running at a sub-therapeutic flow rate of 1.5 LPM, LVN B acknowledged that the resident would not be getting the respiratory support she clinically needed for her PRN shortness of breath, and a negative outcome being anxious or continued shortness of breath.During an interview, on 08/19/26 at 08:55 AM, the DON stated that licensed nurses are directly responsible for ensuring that the correct prescribed dose of oxygen is administered to residents. The DON stated that Resident #50's physician's order was maintained on the Medication Administration Record (MAR) on an as-needed (PRN) basis. The DON stated that if a resident did not receive the PRN oxygen order as needed for shortness of breath, or if the flow rate was delivered below the prescribed parameter of 2 liters per minute (LPM), the resident would continue to experience shortness of breath and suffer from anxiety as a direct negative clinical outcome. The DON verified that as far as she knew, there were no active negative outcomes for Resident #50, but it was important to have the correct parameters maintained to ensure the resident received appropriate care.Record review of the facility's written policy and procedure manual, titled Oxygen Administration (Subject: Licensed Nurse Procedures; Section: Nursing Clinical, Revised 2/2023), revealed under its baseline policy mandate: It is the policy of this facility that oxygen therapy is administered, as ordered by the physician .

Based on interview and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 2 of 6 residents (Resident #1 and Resident #2) reviewed for medical records. 1. The facility failed to ensure RN B, LVN C, and LVN D documented Resident #1's vital signs accurately on her MAR on multiple occasions from 06/19/26 to 06/24/26.2. The facility failed to ensure RN B, LVN C, and LVN D documented Resident #2's Skilled Assessments accurately and timely on multiple occasions from 07/06/26 to 07/26/26. This failure could place residents at risk of errors in care and treatment. The findings included: Record review of Resident #1's face sheet on 07/29/26 reflected an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included anemia (low levels of healthy red blood cells to carry oxygen in the body), gastrointestinal hemorrhage (bleeding in the stomach or intestines), gastrostomy status (a tube surgically implanted through the abdomen into the stomach used to provide nutrition, hydration, and medication), unspecified protein calorie malnutrition (a state of inadequate nutrient intake), dehydration (a state of inadequate fluid intake), and dementia (loss of memory, language, problem solving and other thinking abilities which significantly impair a person's ability to perform daily activities).Record review of Resident #1's discharge/ return not anticipated MDS assessment dated [DATE] reflected a blank BIMS score. The resident was in the facility from 06/19/26 to 06/24/26. Record review of Resident #1's order summary report on 07/29/26 reflected the following orders: Document Temp, 02 sats and monitor for the following symptoms: Fever, Cough, New shortness of breath or difficulty breathing, Chills, Repeated shaking with chills, Muscle pain, Headache, Sore throat, New loss of taste or smell, Congestion, Runny Nose. GI Symptoms: Diarrhea/Nausea/ Vomiting every shift **Notify NP/MD if present. Ordered on 06/19/26. Before nebulizer treatment, obtain and record pulse, O2 sat, tx minutes, post med lung sounds (scale 0=clear, 1=rales, 2=rhonchi, 3=diminished, 4--wheezing, 5=crackles, and 6=other) every 6 hours for 7 Days. Order date: 06/21/26. End date: 06/28/26. After nebulizer treatment, obtain and record pulse, O2 sat, tx minutes, post med lung sounds (scale 0=clear, 1=rales, 2=rhonchi, 3=diminished, 4--wheezing, 5=crackles, and 6=other) every 6 hours for 7 Days. Order date: 06/21/26. End date: 06/28/26.Record review of Resident #1's June 2026 MAR reflected the following documentation:Vital signs every shift:On 06/19/26, night shift (6:00 pm to 6:00 am), RN B documented Resident #1's BP: 98/56, Temp: 98.9F, P: 82, RR: 20, O2 Sat: 95%.On 06/20/26, day shift (6:00 am to 6:00 pm), LVN C documented Resident #1's BP: 98/56, Temp: 98.9F, P: 82, RR: 20, O2 Sat: 95%. (The exact same as 06/19/26 night shift)On 06/20/26, night shift, LVN D documented Resident #1's BP: 103/60, Temp: 97.1F, P: 74, RR: 18, O2 Sat: 98%.On 06/21/26, day shift, LVN C documented Resident #1's BP: 103/60, Temp: 97.1F, P: 74, RR: 18, O2 Sat: 98%. (The exact same as 06/20/26 night shift)On 06/22/26, night shift, LVN D documented Resident #1's BP: 136/72, Temp: 97.9F, P: 77, RR: 20, O2 Sat: 97%.On 06/24/26, day shift, LVN C documented Resident #1's BP: 136/72, Temp: 97.9F, P: 77, RR: 20, O2 Sat: 97%. (The exact same as 06/22/26 night shift)Pre and Post breathing treatment vital signs (every 6 hours):On 06/21/26 at 12:00 pm and 6:00 pm (4 sets of vital signs- all exactly the same), LVN C documented Resident #1's pre (before) and post (after) breathing treatment LS: clear, P: 74, RR 18, O2 Sat: 98%.On 06/22/26 at 12:00 am (2 sets of vital signs- both exactly the same), LVN D documented Resident #1's pre and post breathing treatment LS: clear, P: 75, RR: 20, O2 sat: 99%.On 06/22/26 at 6:00 pm (2 sets of vital signs- both exactly the same), LVN D documented Resident #1's pre and post breathing treatment LS: clear, P: 75, RR: 16, O2 Sat: 97%.On 06/23/26 at 12:00 pm (2 sets of vital signs- both exactly the same), LVN D documented Resident #1's pre and post breathing treatment LS: clear, P: 69, RR: 20, O2 Sat: 96%.On 06/24.26 at 12:00 am (2 sets of vital signs- both exactly the same), RN B documented Resident #1's pre and post breathing treatment LS: clear, P: 70, RR: 17, O2 Sat: 98%.On 06/24/26 at 6:00 am (2 sets of vital signs both exactly the same), RN B documented Resident #1's pre and post breathing treatment LS: clear, P: 77, RR: 20, O2 Sat: 97%.On 06/24/26 at 12:00 pm and 6:00 pm (4 sets of vital signs- all exactly the same), LVN C documented Resident #1's pre and post breathing treatment LS: clear, P: 77, RR: 20, O2 Sat: 97%. On 06/24/26 between 6:00 am and 6:00 pm, 6 sets of vital signs were documented as exactly the same by RN B and LVN C.Record review of Resident #1's blood pressure, temperature, pulse, respiration, and O2 sat summaries on 07/29/26 reflected the following:On 06/19/26 at 11:59 pm, RN B documented Resident #1's BP: 98/56, temp: 98.9F, P: 82, RR:20, O2 sat: 95%On 06/20/26 at 10:13 am, LVN C documented Resident #1's BP: 101/62. (But documented the exact same vital signs on the MAR for 06/20/26 day shift as RN B documented on 06/19/26 night shift)On 06/20/26 between 12:08 am and 10:57 pm, there was no temperature, pulse, respiratory rate, or O2 sat documented in the vital sign summaries. On 06/20/26 at 11:48 pm, LVN D documented Resident #1's BP: 103/60, Temp: 97.1F, P: 74, RR: 18, O2 Sat: 98%.Between 06/20/26 at 11:48 pm and 06/21/26 at 6:28 pm there was no blood pressure, pulse, respiratory rate, or O2 sat documented in the vital sign summaries. On 06/22/26 at 11:58 pm, LVN D documented Resident #1's BP: 136/72, Temp: 97.9F, P: 77, RR: 20, O2 Sat: 97%.On 06/24/26 at 3:12 am, LVN D documented Resident #1's blood pressure as 136/72, P: 77, RR: 20, O2 Sat: 97%.On 06/24/26 after 3:12 am, there was no blood pressure, pulse, respiratory rate, or O2 sat documented in the vital sign summaries. Record review of Resident #2's face sheet on 07/29/26 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included fracture of lumbar vertebra (broken bone in the spine in the lower back area), chronic obstructive pulmonary disease (a progressive, incurable lung disease that causes inflammation and difficulty breathing), cognitive communication deficit (difficulty with communication), anemia (low levels of healthy red blood cells to carry oxygen in the body), hypertension (high blood pressure), and hyperlipidemia (high cholesterol).Record review of Resident #2's admission MDS assessment dated [DATE] reflected a BIMS score of 13 which indicated he was cognitively intact.Record review of Resident #2's Nursing Advanced Skilled Evaluations and progress notes on 07/29/26 reflected the following:Type: N Adv Skilled EvaluationEffective date: 07/08/26 at 11:41 pmCreated date: 07/10/26 at 2:28 am, by LVN DVitals: Temp: 97.3F, BP: 146/74, P: 74, RR: 20, O2 sat: 97%- all dated 07/10/26 at 2:21 am (26.78 hours after the evaluation was done) Type: N Adv Skilled EvaluationEffective date: 07/09/26 at 11:59 pmCreated date: 07/12/26 at 2:03 am, by LVN D (50.07 hours after the evaluation was done) Type: N Adv Skilled EvaluationEffective date: 07/13/26 at 11:30 pmCreated date: 07/14/26 at 2:16 am, by LVN DVitals: Temp: 96.9F, BP: 138/96, P: 96, RR: 20, O2 sat: 98%- all dated 07/14/26 at 2:10 am (2.77 hours after the evaluation was done) Type: N Adv Skilled EvaluationEffective date: 07/14/26 at 11:47 pmCreated date: 07/18/26 at 3:37 am, by LVN DVitals: Temp: 96.9F, BP: 138/96, P: 96, RR: 20, O2 sat: 98%- all dated 07/18/26 at 3:33 am (75.83 hours after the evaluation was done) Type: N Adv Skilled EvaluationEffective date: 07/15/26 at 11:43 pmCreated date: 07/18/26 at 3:45 am, by LVN DVitals: Temp: 97.1F, BP: 107/69, P: 86, RR: 20, O2 sat: 97%- all dated 07/18/26 at 3:40 am (52.03 hours after the evaluation was done) Type: N Adv Skilled EvaluationEffective date: 07/16/26 at 11:45 pmCreated date: 07/18/26 at 3:49 am, by LVN DVitals: Temp: 97.3F, BP: 138/71, P: 72, RR: 20, O2 sat: 97%- all dated 07/18/26 at 3:47 am (28.07 hours after the evaluation was done) Type: Change in Condition EvaluationEffective date: 07/17/26 at 1:23 pmCreated date: 07/19/26 at 6:36 am by LVN C (41.22 hours after the change in condition evaluation was done) Type: N Adv Skilled EvaluationEffective date: 07/18/26 at 10:11 pmCreated date: 07/19/26 at 3:13 am, by RN BVitals: Temp: 97.2F, BP: 117/62, P: 87, RR: 20, O2 sat: 98%- all dated 07/19/26 at 3:13 am (5.03 hours after the evaluation was done) Type: N Adv Skilled EvaluationEffective date: 07/19/26 at 10:53 pmCreated date: 07/20/26 at 12:58 am, by RN BVitals: Temp: 98.9F, BP: 119/59, P: 67, RR: 19, O2 sat: 96%- all dated 07/20/26 at 12:59 am (2.08 hours after the evaluation was done) Type: N Adv Skilled EvaluationEffective date: 07/20/26 at 10:53 pmCreated date: 07/23/26 at 10:12 pm, by LVN DVitals: Temp: 98.1F, BP: 152/82, P: 78, RR: 18, O2 sat: 96%- all dated 07/23/26 at 9:57 pm (71.07 hours after the evaluation was done) Type: N Adv Skilled EvaluationEffective date: 07/21/26 at 10:13 pmCreated date: 07/23/26 at 10:27 pm, by LVN DVitals: Temp: 97F, BP: 127/72, P: 73, RR: 20, O2 sat: 97%- all dated 07/23/26 at 10:22 pm (48.15 hours after the evaluation was done) Type: N Adv Skilled EvaluationEffective date: 07/22/26 at 10:39 pmCreated date: 07/23/26 at 10:35 pm, by LVN DVitals: Temp: 97F, BP: 129/70, P: 76, RR: 20, O2 sat: 96%- all dated 07/23/26 at 10:30 pm (23.85 hours after the evaluation was done) Type: N Adv Skilled EvaluationEffective date: 07/24/26 at 10:22 pmCreated date: 07/26/26 at 2:25 am, by RN BVitals: Temp: 97.4F, BP: 140/75, P: 79, RR: (none documented), O2 sat: 99%- all dated 07/26/26 at 2:25 am (28.05 hours after the evaluation was done) Type: N Adv Skilled EvaluationEffective date: 07/25/26 at 4:37 pmCreated date: 07/26/26 at 7:43 am, by LVN EVitals: Temp: 97.4F, BP: 140/74, P: 79, RR: 20, O2 sat: 99%- all dated 07/26/26 at 7:38 am (15.1 hours after the evaluation was done) There were no Nurse Advanced Skilled Evaluations done on 07/06/26, 07/07/26, 07/12/26, 07/27/26, or 07/28/26. In an interview on 07/29/26 at 12:35 pm the DON stated documentation should be done as soon as possible. She stated she did not have a specific timeframe as the policy did not specify one. The DON stated for any resident assessments, the vital signs were to be done and documented when the assessment was performed. She stated skills check offs for medication administration were done annually, monthly by the pharmacist, and randomly as needed. The DON stated the last check off for LVN C was last week and she was not sure when the last ones for LVN D and RN B were done, as she needed to get the check offs. She stated it was not acceptable to copy/paste or recall vital signs for medication administration or documentation of vital signs were ordered by the provider. She stated in-services on documentation were done yearly. She stated they discussed medication administration and documentation quarterly and as needed if an issue arose.In an interview on 07/29/26 at 2:20 pm, LVN D stated pre and post breathing treatment documentation included duration of the treatment, lung sounds, respiratory rate, pulse and oxygen saturation. She stated she always checked the vital signs before and after Resident #1's breathing treatments and sometimes the pulse and respiration stayed the same before and after. She stated sometimes the pulse could go up with a breathing treatment, but everyone was different and sometimes it did not go up. LVN D stated it was important to check vital signs as ordered to ensure there were no status changes. LVN D stated it was important to document timely to ensure there were no changes with the resident. She stated if things were not documented correctly, then everyone would not have the correct information on the resident. She stated in-services for medication administration were done monthly and as needed. The last one was within the last week. In-services on documentation were done at least once a month and as needed, and the last one was within the last month. In an interview on 07/29/26 at 3:45 pm, LVN C stated for Resident #1's breathing treatments, pulse, oxygen saturation, respirations, and duration of treatment were to be documented before and after. She stated she checked all of them and documented them. She stated she documented whatever came up as per her assessment, so it was not unusual for Resident #1 to have the same pulse, respiratory rate and oxygen saturations 3 times in a row 6 hours apart. She stated she always checked vitals and documented the results. LVN C stated it was not uncommon for Resident #1 to have the same vital signs hours apart. She stated it was important to document vital signs correctly in case something came up unusual. She stated documentation was to be done when the event happened and if something was not documented timely it could cause a delay in care or errors in care. She stated on the MAR she could click the Use Last Recorded Value button or the Record New Entry button for each of the vital signs. She stated in-services on medication administration were monthly and the last one was within the last 2-3 weeks. She stated in-services on documentation were also monthly and the last one was within the last 2-3 weeks. She stated skills check offs for medication administration were done annually and the last one was this month. In an interview on 07/29/26 at 4:24 pm, the RN B stated Resident #1 left AMA (against medical advice) on 06/24/26 around 9:30 pm. She stated it was important to document accurate vital signs so they would know if there was any change in condition. She stated the facility did not have a specific time frame for documentation, but best practice would be as soon as possible. RN B stated if things were not documented timely and accurately, a resident's change in condition could be missed which could lead to hospitalization. RN B stated she always checked Resident #1's pre and post breathing treatment vital signs and it was not necessarily unusual for her to have the same vital signs hours apart. She stated in-services on medication administration were monthly and the last one was within the last couple of weeks. She stated medication administration skills check offs were done yearly and as needed and her last one was 07/17/26. RN B stated in-services on documentation were done monthly and as needed and the last one was within the last month. In an interview on 07/29/26 at 5:30 pm the Adm stated best practice would be to document things when they happened or at least by the end of the shift. He stated he would like staff to document as soon as they could, but he would rather have late documentation than no documentation. He stated documenting timely and accurately was important to know what was going on with the resident.Record review of the facility's undated Medication Administration Policy reflected in part: POLICY:It is the policy of this facility that medications shall be administered as prescribed by the attending physician. PROCEDURES:2. Medications must be administered in accordance with the written orders of the attending physician.Record review of the facility's undated Charting and Documentation Policy reflected in part: DEFINITION OF RECORD The resident's clinical record is a concise account of treatment, care, response to care, signs, symptoms and progress of the resident's condition.IMPORTANCE AND USE OF THE RECORD2. To the institution it reflects the quality of care given to the resident.3. To the physician, it guides him in his treatment, use and effects of drugs and plan for care.6. To the nurse, it provides a multidisciplinary record of the physical and mental status of the resident.RULES FOR CHARTING1. Notes are to be written on all long-term residents by day, evening and night shifts; frequency is determined by the individual nursing service.2. Daily notes are required as the necessary arises.3. The Admitting Nurse must write a complete physical and mental nursing assessment.4. Continuous nurse's notes are required on all residents as the necessary arises.

Based on interviews and record reviews, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and misappropriation for 1 of 3 residents (Resident #1) reviewed for developing and implementing abuse and neglect policies and procedures. 1) RN D did not report Resident#1's injury of unknown source to the facility management. 2) The facility did not report an incident of possible neglect to the state agency within the given time frame. These failures could place all residents residing in the facility at risk of abuse/neglect. Based on interviews and record reviews, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and misappropriation for 1 of 3 residents (Resident #1) reviewed for developing and implementing abuse and neglect policies and procedures. 1) RN D did not report Resident#1's injury of unknown source to the facility management. 2) The facility did not report an incident of possible neglect to the state agency within the given time frame. These failures could place all residents residing in the facility at risk of abuse/neglect. Findings included: Record review of Resident #1's face sheet dated 04/08/2026 reflected an [AGE] year-old female with an admission date of 02/11/2026 with pertinent diagnoses that included Unspecified Dementia, Unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (when a dementia diagnosis is made (e.g., Alzheimer's, unspecified), but the subtype, severity, or associated behavioral/psychological symptoms are not defined), muscle weakness. Record review of Resident #1's comprehensive care plan with date initiated 02/12/2026 revealed she was dependent x2 for chair/bed to chair toilet transfers and was dependent x1 person to bathe self, including washing, rinsing, and drying self. Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS was 3 which indicated Resident #1 had severe impaired cognition. Resident #1 was dependent for showers/bathing self and chair/bed to chair transfers. Record review of Resident #1's administration record dated March 2026, reflected Tramadol Oral tablet 50 mg give 1 tablet by mouth every 8 hours as needed for moderate to severe pain was administered on 3/23/26 at 9:10 a.m., and 7:24 p.m., for pain to surgical site Record review of Resident #1's progress notes on her electronic medical record dated 03/24/2026 at 2:23 p.m., authored by LVN A reflected: NP rounding with resident. Patient c/o pain to bilateral ribs at this time, new order obtained for x-ray to bilateral ribs at this time. Patient refused pain medication for pain at this time, patient transferred to w/c for comfort. Family member at bedside visiting with resident. Will continue with plan of care. Record review of Resident #1's progress notes on her electronic medical record dated 03/24/2026 at 6:19 p.m., authored by DON reflected RN assessed resident, resident denies pain or discomfort. Resident is able to move all extremities full ROM. No discoloration noted at this time. Resident is in good spirits. Even and unlabored respirations. Resident is able to move in bed with assistance. Record review of Resident #1's progress notes on her electronic medical record dated 03/24/2026 at 9:21 p.m., authored by DON reflected Left ribs x-ray results sent to NP for review and new orders. Record review of Resident #1's progress notes on her electronic medical record dated 03/25/2026 at 12:14 a.m., authored by LVN A reflected NP gave order for CBC CMP labs to be drawn and Augmentin 875mg PO bid and Doxycycline 100mg PO BID for 5 days to be started after labs are drawn. Scheduled Tylenol 650mg q8hrs x5 days. Incentive spirometer q2hrs while awake. Duo Nebs q8hrs x6days. Record review of Resident #1's progress notes on her electronic medical record dated 03/25/2026 at 12:19 a.m., reflected authored by LVN A Pt declined Tylenol 650 mg states pain is 0 out of 10 and does not want them Record review of Resident #1's progress notes on her electronic medical record dated 03/25/2026 at 5:56 p.m., authored by DON reflected New order for MD to send the resident to ER for eval and treatment. Record review of Resident #1's hospital records revealed a CT of the chest dated 03/25/2026 at 10:29 p.m., reflected chest wall and bones: subacute and chronic bilateral rib fracture deformities. Correlate for point tenderness to exclude acute on subacute/chronic injury. Impression: bilateral pleural effusions with adjacent airspace disease and atelectasis. Subacute and chronic bilateral rib fracture deformities. Correlate for point tenderness to exclude acute on subacute/chronic injury. Record review of Resident #1's administration record dated March 2026, reflected Acetaminophen 325mg give 2 tablets by mouth every 8 hours for pain for 5 days was administered on 3/25/26 at 6:00 a.m., 2:00 p.m., and 10:00 p.m. Record review of Resident #1 administration record dated march 2026, reflected Tramadol Oral tablet 50 mg give 1 tablet by mouth every 8 hours as needed for moderate to severe pain was administered on 3/23/26 at 9:10 a.m., and 7:24 p.m., for pain to surgical site During a phone interview on 4/7/2026 at 11:09 a.m., CNA B stated that Resident #1 required 2 person assist for transfers and 1 person assist for shower and that she and CNA C transferred resident from bed to shower chair on 3/21/2026 because it was her shower day. CNA B said that she asked Resident #1 if she wanted to shower and she responded yes. CNA B stated that after she took Resident #1 to the shower room and CNA C stayed in the room fixing the bed. CNA B showered Resident #1 and she took her back to the room and she and CNA C transferred Resident #1 back to bed. CNA B said that Resident #1 did not complain of pain during the transfers. CNA B said that she showered resident on the shower chair and that she did not transfer or that resident was standing up in the shower room. During a telephone interview on 4/7/2026 at 11:37 a.m., CNA C stated that Resident #1 was not able to transfer by herself and that she required 2 person assistance for transfers and 1 person assist for shower. CNA C stated that she did help with the transfer on 3/21/26 to the shower chair. CNA C stated that after the transfer she stayed in the room to fix the bed. CNA C said that when CNA B came back with Resident #1 from the shower she did help transfer the resident back. CNA C stated that resident did not complain of pain during the transfers. During a telephone interview on 4/7/2026 at 1:00 p.m., RP stated that her Resident #1 told her that on Saturday 3/21/2026, after the shower, that the CNAs pulled her. RP stated that Resident #1 started complaining about pain to her right side that afternoon. RP stated that she notified the nurses but was not able to recall who she mentioned to. RP stated that she asked her mom what had happened and that her mom was not able to tell her what happened until next day on 3/22/26. RP stated that her mom received pain medication. RP said that on 3/25/26 the NP came to the room and she told her that her mom had been complaining of pain to the right side of her body and RP said that the NP ordered X-rays. RP said that the next day on 3/25/26 her mom was sent out to the hospital for clarification on the x rays results. During a phone interview on 4/7/2026 at 2:30 p.m., Resident #1 stated that the ladies picked her up from the bottom of her arm. Resident #1 stated that she was standing up in the shower and that she felt pain to her ribs at that time. Resident #1 said that she showered standing up and when she felt the pain she did not tell anyone. During an interview on 4/7/2026 at 4:05 p.m., LVN A stated that Resident #1 was 2 person assist for transfers and 1 person assist for shower. LVN A stated that Resident #1 had complained of pain before to her amputation site. LVN A stated that on 3/24/26 the NP was rounding in the facility and that she went with NP to Resident #1's room. The NP stated that the family member was in the room and she told the NP that Resident #1 was complaining of pain to her right side of her body. LVN A stated that NP assessed the resident and that NP gave her orders for chest x ray, CMP, and CBC. LVN A stated that she did assess Resident #1 and she did not see any discolorations or abnormalities to her skin on her right side. LVN A stated that she called the x rays to notify them about the new orders and gave report to the incoming nurse. During an interview on 4/7/26 at 4:20 p.m., RN D stated that she got report from LVN A. RN D said that she got informed that Resident #1 had complained of pain to her right side of body and that x rays were done. RN D stated that resident had complained of pain to her amputation site but not to her right side. RN D stated that she got the x rays report and she forward the results to the NP. RN D stated that she missed the results of the fracture to right ribs and that she saw the results of pneumonia (an infection that inflames the air sacs in one or both lungs, causing them to fill with fluid or pus). RN D stated that this could affect Resident #1 because there was a delay of treatment. During an interview on 4/8/26 at 10:35 a.m., the DON stated that Resident #1 was an alert resident with episodes of confusion and that she was aware of name and she was able to communicate and verbalized her needs. The DON stated that Resident #1 needed assistance with transfers and repositioning. The DON stated she was notified by the ADON on 3/25/25 that the report on the x rays done on 3/24/26 showed a fracture . The DON stated that she reviewed the report and noted that the results did not specify if the fracture was acute or chronic. The DON stated that she called mobile x rays for clarification and she requested a second reading on the x rays done on 3/24/26. The DON stated that when she received the second reading there were different ribs mentioned on the report and she called mobile x rays for a third reading. The DON stated that the report was still showing different ribs mentioned on the report and then she contacted the NP. The DON stated that she got orders to transfer Resident #1 to the hospital for further evaluation. The DON stated that she did not know how the results were missed and addressed until the next day. The DON stated that nurses were capable of reading the x ray reports. The DON stated that because of the confusion of the ribs mentioned on the reports that was why the treatment was delayed. The DON stated that nurses are expected to identify and read the x rays reports. She stated the incident was not reported to HHSC because the facility was verifying the x ray results that were not clear. The DON stated that this incident should have been reported to the Administrator and to herself as soon as RN D received the x rays report. During a telephone interview on 4/8/2026 at 11:06 a.m., the NP stated that she was rounding on 3/24/26 in the facility and went to visit Resident #1 and the family member requested x rays because Resident #1 had complained of pain to her right ribs. The NP stated that she assessed the resident and she did not see any bruises or deformation to resident's right side of body. The NP stated that she gave orders for the x rays. The NP stated that she reviewed the x ray results and after she saw the results she saw the possible pneumonia and gave orders to start the resident on antibiotics. The NP stated that the next day on 3/25/26 she received a call from the DON to let her know that on the x ray report there was a fracture and that the DON asked the mobile x rays for clarification because the report mentioned different ribs and that the facility received 2 more readings on the x ray done on 3/24/26. The NP stated that she contacted the MD and decided to send Resident #1 to the hospital for further evaluation. The NP stated that Resident #1 had osteoporosis. During an interview on 4/9/26 at 2:20 p.m., the Administrator said that he was notified on 3/25/26 by the DON. The Administrator said that as soon as the x rays were clarified he reported the incident to HHSC. The Administrator said that incidents like injury of unknown origin should be reported within 2 hours. Record review of facility's policy titled Abuse: Prevention of and Prohibition Against with a revision date 4/2025 reflected: .H. Reporting/Response. 1. All allegations of abuse, neglect, misappropriation of resident property, or exploitation should be reported immediately to the Administrator. 2. Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations.

Based on interview and record review, the facility failed to ensure allegations of abuse, neglect, exploitation, or mistreatment, including injury of unknown origin, were reported immediately, but not later than 2 hours in accordance with State law through established procedures for one (Resident #1) of 3 residents reviewed for abuse. The facility failed to ensure Resident #1's Injury of Unknown origin, discovered on 3/24/26, was immediately, but no later than two hours, reported to the State Survey Agency. These failures could place residents at risk of delays in the investigations of incidents of abuse and neglect. Findings included: Record review of Resident #1's face sheet dated 04/08/2026 reflected an [AGE] year-old female with an admission date of 02/11/2026 with pertinent diagnoses that included Unspecified Dementia, Unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (when a dementia diagnosis is made (e.g., Alzheimer's, unspecified), but the subtype, severity, or associated behavioral/psychological symptoms are not defined), muscle weakness. Record review of Resident #1's comprehensive care plan with date initiated 02/12/2026 revealed she was dependent x2 for chair/bed to chair toilet transfers and was dependent x1 person to bathe self, including washing, rinsing, and drying self. Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS was 3 which indicated Resident #1 had severe impaired cognition. Resident #1 was dependent for showers/bathing self and chair/bed to chair transfers. Record review of Resident #1's administration record dated March 2026, reflected Tramadol Oral tablet 50 mg give 1 tablet by mouth every 8 hours as needed for moderate to severe pain was administered on 3/23/26 at 9:10 a.m., and 7:24 p.m., for pain to surgical site Record review of Resident #1's progress notes on her electronic medical record dated 03/24/2026 at 2:23 p.m., authored by LVN A reflected: NP rounding with resident. Patient c/o pain to bilateral ribs at this time, new order obtained for x-ray to bilateral ribs at this time. Patient refused pain medication for pain at this time, patient transferred to w/c for comfort. Family member at bedside visiting with resident. Will continue with plan of care. Record review of Resident #1's progress notes on her electronic medical record dated 03/24/2026 at 6:19 p.m., authored by DON reflected RN assessed resident, resident denies pain or discomfort. Resident is able to move all extremities full ROM. No discoloration noted at this time. Resident is in good spirits. Even and unlabored respirations. Resident is able to move in bed with assistance. Record review of Resident #1's progress notes on her electronic medical record dated 03/24/2026 at 9:21 p.m., authored by DON reflected Left ribs x-ray results sent to NP for review and new orders. Record review of Resident #1's progress notes on her electronic medical record dated 03/25/2026 at 12:14 a.m., authored by LVN A reflected NP gave order for CBC CMP labs to be drawn and Augmentin 875mg PO bid and Doxycycline 100mg PO BID for 5 days to be started after labs are drawn. Scheduled Tylenol 650mg q8hrs x5 days. Incentive spirometer q2hrs while awake. Duo Nebs q8hrs x6days. Record review of Resident #1's progress notes on her electronic medical record dated 03/25/2026 at 12:19 a.m., reflected authored by LVN A Pt declined Tylenol 650 mg states pain is 0 out of 10 and does not want them Record review of Resident #1's progress notes on her electronic medical record dated 03/25/2026 at 5:56 p.m., authored by DON reflected New order for MD to send the resident to ER for eval and treatment. Record review of Resident #1's hospital records revealed a CT of the chest dated 03/25/2026 at 10:29 p.m., reflected chest wall and bones: subacute and chronic bilateral rib fracture deformities. Correlate for point tenderness to exclude acute on subacute/chronic injury. Impression: bilateral pleural effusions with adjacent airspace disease and atelectasis. Subacute and chronic bilateral rib fracture deformities. Correlate for point tenderness to exclude acute on subacute/chronic injury. Record review of Resident #1's administration record dated March 2026, reflected Acetaminophen 325mg give 2 tablets by mouth every 8 hours for pain for 5 days was administered on 3/25/26 at 6:00 a.m., 2:00 p.m., and 10:00 p.m. Record review of Resident #1 administration record dated march 2026, reflected Tramadol Oral tablet 50 mg give 1 tablet by mouth every 8 hours as needed for moderate to severe pain was administered on 3/23/26 at 9:10 a.m., and 7:24 p.m., for pain to surgical site During a phone interview on 4/7/2026 at 11:09 a.m., CNA B stated that Resident #1 required 2 person assist for transfers and 1 person assist for shower and that she and CNA C transferred resident from bed to shower chair on 3/21/2026 because it was her shower day. CNA B said that she asked Resident #1 if she wanted to shower and she responded yes. CNA B stated that after she took Resident #1 to the shower room and CNA C stayed in the room fixing the bed. CNA B showered Resident #1 and she took her back to the room and she and CNA C transferred Resident #1 back to bed. CNA B said that Resident #1 did not complain of pain during the transfers. CNA B said that she showered resident on the shower chair and that she did not transfer or that resident was standing up in the shower room. During a telephone interview on 4/7/2026 at 11:37 a.m., CNA C stated that Resident #1 was not able to transfer by herself and that she required 2 person assistance for transfers and 1 person assist for shower . CNA C stated that she did help with the transfer on 3/21/26 to the shower chair. CNA C stated that after the transfer she stayed in the room to fix the bed. CNA C said that when CNA B came back with Resident #1 from the shower she did help transfer the resident back. CNA C stated that resident did not complain of pain during the transfers. During a telephone interview on 4/7/2026 at 1:00 p.m., RP stated that her Resident #1 told her that on Saturday 3/21/2026, after the shower, that the CNAs pulled her. RP stated that Resident #1 started complaining about pain to her right side that afternoon. RP stated that she notified the nurses but was not able to recall who she mentioned to. RP stated that she asked her mom what had happened and that her mom was not able to tell her what happened until next day on 3/22/26. RP stated that her mom received pain medication. RP said that on 3/25/26 the NP came to the room and she told her that her mom had been complaining of pain to the right side of her body and RP said that the NP ordered X-rays. RP said that the next day on 3/25/26 her mom was sent out to the hospital for clarification on the x rays results. During a phone interview on 4/7/2026 at 2:30 p.m., Resident #1 stated that the ladies picked her up from the bottom of her arm. Resident #1 stated that she was standing up in the shower and that she felt pain to her ribs at that time. Resident #1 said that she showered standing up and when she felt the pain she did not tell anyone. During an interview on 4/7/2026 at 4:05 p.m., LVN A stated that Resident #1 was 2 person assist for transfers and 1 person assist for shower . LVN A stated that Resident #1 had complained of pain before to her amputation site. LVN A stated that on 3/24/26 the NP was rounding in the facility and that she went with NP to Resident #1's room. The NP stated that the family member was in the room and she told the NP that Resident #1 was complaining of pain to her right side of her body. LVN A stated that NP assessed the resident and that NP gave her orders for chest x ray, CMP, and CBC. LVN A stated that she did assess Resident #1 and she did not see any discolorations or abnormalities to her skin on her right side. LVN A stated that she called the x rays to notify them about the new orders and gave report to the incoming nurse. During an interview on 4/7/26 at 4:20 p.m., RN D stated that she got report from LVN A. RN D said that she got informed that Resident #1 had complained of pain to her right side of body and that x rays were done. RN D stated that resident had complained of pain to her amputation site but not to her right side. RN D stated that she got the x rays report and she forward the results to the NP. RN D stated that she missed the results of the fracture to right ribs and that she saw the results of pneumonia (an infection that inflames the air sacs in one or both lungs, causing them to fill with fluid or pus). RN D stated that this could affect Resident #1 because there was a delay of treatment. During an interview on 4/8/26 at 10:35 a.m., the DON stated that Resident #1 was an alert resident with episodes of confusion and that she was aware of name and she was able to communicate and verbalized her needs. The DON stated that Resident #1 needed assistance with transfers and repositioning. The DON stated she was notified by the ADON on 3/25/25 that the report on the x rays done on 3/24/26 showed a fracture . The DON stated that she reviewed the report and noted that the results did not specify if the fracture was acute or chronic. The DON stated that she called mobile x rays for clarification and she requested a second reading on the x rays done on 3/24/26. The DON stated that when she received the second reading there were different ribs mentioned on the report and she called mobile x rays for a third reading. The DON stated that the report was still showing different ribs mentioned on the report and then she contacted the NP. The DON stated that she got orders to transfer Resident #1 to the hospital for further evaluation. The DON stated that she did not know how the results were missed and addressed until the next day. The DON stated that nurses were capable of reading the x ray reports. The DON stated that because of the confusion of the ribs mentioned on the reports that was why the treatment was delayed. The DON stated that nurses are expected to identify and read the x rays reports. She stated the incident was not reported to HHSC because the facility was verifying the x ray results that were not clear. The DON stated that this incident should have been reported to the Administrator and to herself as soon as RN D received the x rays report. During a telephone interview on 4/8/2026 at 11:06 a.m., the NP stated that she was rounding on 3/24/26 in the facility and went to visit Resident #1 and the family member requested x rays because Resident #1 had complained of pain to her right ribs. The NP stated that she assessed the resident and she did not see any bruises or deformation to resident's right side of body. The NP stated that she gave orders for the x rays. The NP stated that she reviewed the x ray results and after she saw the results she saw the possible pneumonia and gave orders to start the resident on antibiotics. The NP stated that the next day on 3/25/26 she received a call from the DON to let her know that on the x ray report there was a fracture and that the DON asked the mobile x rays for clarification because the report mentioned different ribs and that the facility received 2 more readings on the x ray done on 3/24/26. The NP stated that she contacted the MD and decided to send Resident #1 to the hospital for further evaluation. The NP stated that Resident #1 had osteoporosis. During an interview on 4/9/26 at 2:20 p.m., the Administrator said that he was notified on 3/25/26 by the DON. The Administrator said that as soon as the x rays were clarified he reported the incident to HHSC. The Administrator said that incidents like injury of unknown origin should be reported within 2 hours. Record review of facility's policy titled Abuse: Prevention of and Prohibition Against with a revision date 4/2025 reflected: .H. Reporting/Response. 1. All allegations of abuse, neglect, misappropriation of resident property, or exploitation should be reported immediately to the Administrator. 2. Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations.

Based on 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 resident's choices for 1 (Resident #1) of 3 residents reviewed for quality of care. The facility failed to recognize x-ray results done on 3/24/2026 that reflected There are acute appearing mildly displaced fractures of the right 4th and 5th ribs anterolaterally. Correlate with timing of trauma and pain for age of fractures. This failure could place residents at risk of delay in care, worsening of health conditions, adverse reactions, and hospitalization. Findings included: Record review of Resident #1's face sheet dated 04/08/2026 reflected an [AGE] year-old female with an admission date of 02/11/2026 with pertinent diagnoses that included Unspecified Dementia, Unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (when a dementia diagnosis is made (e.g., Alzheimer's, unspecified), but the subtype, severity, or associated behavioral/psychological symptoms are not defined), muscle weakness. Record review of Resident #1's comprehensive care plan with date initiated 02/12/2026 revealed she was dependent x2 for chair/bed to chair toilet transfers and was dependent x1 person to bathe self, including washing, rinsing, and drying self. Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS was 3 which indicated Resident #1 had severe impaired cognition. Resident #1 was dependent for showers/bathing self and chair/bed to chair transfers. Record review of Resident #1's administration record dated March 2026, reflected Tramadol Oral tablet 50 mg give 1 tablet by mouth every 8 hours as needed for moderate to severe pain was administered on 3/23/26 at 9:10 a.m., and 7:24 p.m., for pain to surgical site Record review of Resident #1's progress notes on her electronic medical record dated 03/24/2026 at 2:23 p.m., authored by LVN A reflected: NP rounding with resident. Patient c/o pain to bilateral ribs at this time, new order obtained for x-ray to bilateral ribs at this time. Patient refused pain medication for pain at this time, patient transferred to w/c for comfort. Family member at bedside visiting with resident. Will continue with plan of care. Record review of Resident #1's progress notes on her electronic medical record dated 03/24/2026 at 6:19 p.m., authored by DON reflected RN assessed resident, resident denies pain or discomfort. Resident is able to move all extremities full ROM. No discoloration noted at this time. Resident is in good spirits. Even and unlabored respirations. Resident is able to move in bed with assistance. Record review of Resident #1's progress notes on her electronic medical record dated 03/24/2026 at 9:21 p.m., authored by DON reflected Left ribs x-ray results sent to NP for review and new orders. Record review of Resident #1's progress notes on her electronic medical record dated 03/25/2026 at 12:14 a.m., authored by LVN A reflected NP gave order for CBC CMP labs to be drawn and Augmentin 875mg PO bid and Doxycycline 100mg PO BID for 5 days to be started after labs are drawn. Scheduled Tylenol 650mg q8hrs x5 days. Incentive spirometer q2hrs while awake. Duo Nebs q8hrs x6days. Record review of Resident #1's progress notes on her electronic medical record dated 03/25/2026 at 12:19 a.m., reflected authored by LVN A Pt declined Tylenol 650 mg states pain is 0 out of 10 and does not want them Record review of Resident #1's progress notes on her electronic medical record dated 03/25/2026 at 5:56 p.m., authored by DON reflected New order for MD to send the resident to ER for eval and treatment. Record review of Resident #1's hospital records revealed a CT of the chest dated 03/25/2026 at 10:29 p.m., reflected chest wall and bones: subacute and chronic bilateral rib fracture deformities. Correlate for point tenderness to exclude acute on subacute/chronic injury. Impression: bilateral pleural effusions with adjacent airspace disease and atelectasis. Subacute and chronic bilateral rib fracture deformities. Correlate for point tenderness to exclude acute on subacute/chronic injury. Record review of Resident #1's administration record dated March 2026, reflected Acetaminophen 325mg give 2 tablets by mouth every 8 hours for pain for 5 days was administered on 3/25/26 at 6:00 a.m., 2:00 p.m., and 10:00 p.m. Record review of Resident #1 administration record dated march 2026, reflected Tramadol Oral tablet 50 mg give 1 tablet by mouth every 8 hours as needed for moderate to severe pain was administered on 3/23/26 at 9:10 a.m., and 7:24 p.m., for pain to surgical site During a phone interview on 4/7/2026 at 11:09 a.m., CNA B stated that Resident #1 required 2 person assist for transfers and 1 person assist for shower and that she and CNA C transferred resident from bed to shower chair on 3/21/2026 because it was her shower day. CNA B said that she asked Resident #1 if she wanted to shower and she responded yes. CNA B stated that after she took Resident #1 to the shower room and CNA C stayed in the room fixing the bed. CNA B showered Resident #1 and she took her back to the room and she and CNA C transferred Resident #1 back to bed. CNA B said that Resident #1 did not complain of pain during the transfers. CNA B said that she showered resident on the shower chair and that she did not transfer or that resident was standing up in the shower room. During a telephone interview on 4/7/2026 at 11:37 a.m., CNA C stated that Resident #1 was not able to transfer by herself and that she required 2 person assistance for transfers and 1 person assist for shower. CNA C stated that she did help with the transfer on 3/21/26 to the shower chair. CNA C stated that after the transfer she stayed in the room to fix the bed. CNA C said that when CNA B came back with Resident #1 from the shower she did help transfer the resident back. CNA C stated that resident did not complain of pain during the transfers. During a telephone interview on 4/7/2026 at 1:00 p.m., RP stated that her Resident #1 told her that on Saturday 3/21/2026, after the shower, that the CNAs pulled her. RP stated that Resident #1 started complaining about pain to her right side that afternoon. RP stated that she notified the nurses but was not able to recall who she mentioned to. RP stated that she asked her mom what had happened and that her mom was not able to tell her what happened until next day on 3/22/26. RP stated that her mom received pain medication. RP said that on 3/25/26 the NP came to the room and she told her that her mom had been complaining of pain to the right side of her body and RP said that the NP ordered X-rays. RP said that the next day on 3/25/26 her mom was sent out to the hospital for clarification on the x rays results. During a phone interview on 4/7/2026 at 2:30 p.m., Resident #1 stated that the ladies picked her up from the bottom of her arm. Resident #1 stated that she was standing up in the shower and that she felt pain to her ribs at that time. Resident #1 said that she showered standing up and when she felt the pain she did not tell anyone. During an interview on 4/7/2026 at 4:05 p.m., LVN A stated that Resident #1 was 2 person assist for transfers and 1 person assist for shower. LVN A stated that Resident #1 had complained of pain before to her amputation site. LVN A stated that on 3/24/26 the NP was rounding in the facility and that she went with NP to Resident #1's room. The NP stated that the family member was in the room and she told the NP that Resident #1 was complaining of pain to her right side of her body. LVN A stated that NP assessed the resident and that NP gave her orders for chest x ray, CMP, and CBC. LVN A stated that she did assess Resident #1 and she did not see any discolorations or abnormalities to her skin on her right side. LVN A stated that she called the x rays to notify them about the new orders and gave report to the incoming nurse. During an interview on 4/7/26 at 4:20 p.m., RN D stated that she got report from LVN A. RN D said that she got informed that Resident #1 had complained of pain to her right side of body and that x rays were done. RN D stated that resident had complained of pain to her amputation site but not to her right side. RN D stated that she got the x rays report and she forward the results to the NP. RN D stated that she missed the results of the fracture to right ribs and that she saw the results of pneumonia (an infection that inflames the air sacs in one or both lungs, causing them to fill with fluid or pus). RN D stated that this could affect Resident #1 because there was a delay of treatment. During an interview on 4/8/26 at 10:35 a.m., the DON stated that Resident #1 was an alert resident with episodes of confusion and that she was aware of name and she was able to communicate and verbalized her needs. The DON stated that Resident #1 needed assistance with transfers and repositioning for transfers and 1 person assist for shower. The DON stated she was notified by the ADON on 3/25/25 that the report on the x rays done on 3/24/26 showed a fracture . The DON stated that she reviewed the report and noted that the results did not specify if the fracture was acute or chronic. The DON stated that she called mobile x rays for clarification and she requested a second reading on the x rays done on 3/24/26. The DON stated that when she received the second reading there were different ribs mentioned on the report and she called mobile x rays for a third reading. The DON stated that the report was still showing different ribs mentioned on the report and then she contacted the NP. The DON stated that she got orders to transfer Resident #1 to the hospital for further evaluation. The DON stated that she did not know how the results were missed and addressed until the next day. The DON stated that nurses were capable of reading the x ray reports. The DON stated that because of the confusion of the ribs mentioned on the reports that was why the treatment was delayed. The DON stated that nurses are expected to identify and read the x rays reports. She stated the incident was not reported to HHSC because the facility was verifying the x ray results that were not clear. During a telephone interview on 4/8/2026 at 11:06 a.m., the NP stated that she was rounding on 3/24/26 in the facility and went to visit Resident #1 and the family member requested x rays because Resident #1 had complained of pain to her right ribs. The NP stated that she assessed the resident and she did not see any bruises or deformation to resident's right side of body. The NP stated that she gave orders for the x rays. The NP stated that she reviewed the x ray results and after she saw the results she saw the possible pneumonia and gave orders to start the resident on antibiotics. The NP stated that the next day on 3/25/26 she received a call from the DON to let her know that on the x ray report there was a fracture and that the DON asked the mobile x rays for clarification because the report mentioned different ribs and that the facility received 2 more readings on the x ray done on 3/24/26. The NP stated that she contacted the MD and decided to send Resident #1 to the hospital for further evaluation. The NP stated that Resident #1 had osteoporosis. Record review of facility's policy titled Diagnostic Test Results Notification with a revision date 4/2025 reflected it is the policy of this facility to obtain laboratory and radiology services when ordered by a physician, Physician Assistant (PA), Nurse Practitioner (NP) or Clinical Nurse Specialist (CNS) and to promptly notify the ordering provider of test results.

Based on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards for 1 of 2 residents (Resident #1) reviewed for intravenous fluids.The facility failed to ensure Resident #1's intravenous medication bag was labeled with Resident #1's name, dose, frequency, and route. This failure placed the residents at risk for infections, wrong dose, and clinical monitoring of doses. Findings included:Record review of Resident's #1's face sheet dated 02/16/26 revealed a [AGE] year-old male was admitted to the facility on [DATE]. Resident #1's diagnosis included: osteomyelitis (bone infection) of vertebra (small bones forming the back bone), sacral (base at the base of the spine) and sacrococcygeal region (area of the tailbone), cellulitis (skin infection) of left lower limb, pressure ulcer of sacral region-stage 4 (a severe, full-thickness wound extending to exposed muscle, tendon, or bone ), muscle weakness, paraplegia (paralysis) and the need for assistance with personal care.Record review of Resident #1's admission MDS assessment dated [DATE] revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. The BIMS was not completed due to Resident #1 being newly admitted .Record review of Resident #1's care plan dated 02/06/26 revealed the following: Focus: [Resident #1] has infection r/t s/p hospitalization for osteomyelitis to sacrococcygeal, cellulitis of left lower limb. Goal: Will be free from complications related to infection through the review date. Interventions: administer antibiotic as per MD orders.Record review of Resident #1's Order Summary Report revealed a physician order dated 02/09/2026 for Vancomycin HCl solution: use 1 gram intravenously every 8 hours for sacral wound infection and sacrococcygeal osteomyelitis until 02/26/2026, cellulitis to right knee.Observation on 02/16/26 at 3:15 PM revealed Resident #1 was lying in his bed. The IV medication bag was hanging on the IV pole while the medication was actively running through a PICC line (thin, flexible tube that delivers treatments through a vein for various medical conditions) inserted into Resident #1's right arm. The IV medication bag was not labeled with Resident #1's name, mediation dose, medication frequency nor medication route. The IV medication bag only had a date of 02/16/26 and initials written on the bag with a black marker.Observation and interview on 02/16/26 at 3:20 PM with RN A. RN A observed the IV bag had only what he had written with a black marker, which was the date of administration, 02/16/26 and his initials. RN A stated he was aware the medication bag was missing the medication label. RN A stated he had just hung the bag a few minutes prior and threw away the label. RN A stated he knew the medication bag was supposed to have the resident's name, dosage, frequency and route. RN A stated that the failure to label the medication properly could lead to administering the wrong mediation to the wrong resident or it could lead to an infection.Interview on 02/16/26 at 3:48 PM with the DON stated RN A knew he had to label the IV medication bag but failed to do so. The DON stated she expected all the nurses to label medications appropriately prior to the administration of the medication to prevent infection. The DON stated it was the responsibility of the nurse that administered the medication to verify that everything was labeled correctly. Record review of the facility's Policy: Administration of Medications and Fluids, Intravenous with revision date of 3/2023 revealed:8. Verify that the container's label coincides with the prescriber's order. Verify content, dose, prescribed rate, and expiration date of the solution.

Based on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, the facility maintained medical records on each resident that were complete and accurately documented for 1 of 6 residents (Resident #1) reviewed for medical records accuracy. The facility failed to ensure Resident #1's January 2026 MAR accurately documented when her physician ordered Alprazolam was not given. This failure could place residents at risk for errors in care and treatment. The findings include: Record review of Resident #1's face sheet, dated 02/04/26, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: Alzheimer's disease , (decline in thinking skills and causing issues with memory, planning, focus and mood) with late onset, Anxiety disorder (persistent, excessive fear or worry), unspecified, and mood disorder due to known physiological condition with manic (abnormally elevated mood, high energy, erratic behaviors) features. Record review of Resident #1's care plan, with an initiation date of 09/05/24, reflected a focus of Psychotropic medications use r/t.8/3/25 antianxiety - anxiety with intervention of, Administer medications as ordered with an initiation date of 09/06/24. Record review of Resident #1's physician's orders reflected an order for, alprazolam 1mg tablet to be given 1 time every day at bed time, with a start date of 10/29/25. Record review of Resident #1's significant change MDS assessment, dated 12/21/25, reflected Resident #1 had a BIMS score of 01, which indicated severe cognitive impairment. Record review of Resident #1's controlled drug record sheet reflected her order for alprazolam was not provided on 01/09/26. Record review of Resident #1's January 2026 medication administration record reflected her order for alprazolam 1mg tablet at bedtime was documented as administered by LVN A on 01/09/26 at 8:00 PM. During an interview with LVN A on 02/03/26 at 5:57 PM, she stated she worked with Resident #1 on 01/09/26 and was responsible for her medication administration and documentation. LVN A stated she signed off first on the MAR for Resident #1's order for Alprazolam and then went to check on Resident #1, but did not provide her with her medication due to her already being asleep. LVN A stated she never removed the alprazolam from the packaging and documented on the controlled drug record for Resident #'1 that none were given to her. LVN A stated the process she should follow was to check the resident, retrieve the medication from the packing and sign the controlled drug record, then administer the medication to the resident and sign off on the MAR as administered. LVN A stated she should have struck out her documentation on Resident #1's MAR and put in the correct documentation. LVN A stated she got mixed up did not do that and did not know why. LVN A stated she was previously trained over the process for medication administration and documentation by one of the pharmacists. LVN A stated accurate documentation was important to make sure residents received their medication and to inform the physician of any pattern they identified. LVN A stated residents could be negatively affected by inaccurate documentation because residents may not get their medication if staff think it was already given and could cause their behavior to be impacted. During an interview with the DON on 02/04/26 at 6:15 PM, she stated, on 01/09/26, LVN A was responsible for providing medication and documentation on the MAR and controlled drug record for Resident #1. The DON stated on 01/09/26 LVN A signed on Resident #1's MAR that she administered her Alprazolam and documented on the controlled drug record that she did not. The DON stated through her conversation with LVN A, she understood LVN A did not provide Resident #1 with her Alprazolam because she was asleep. The DON stated the narcotic count also reflected the medication had not been given. The DON stated correct documentation was important because it could demonstrate if a resident was refusing their medication. The DON stated LVN A was trained over documentation on both the controlled drug record and the MAR. The DON stated herself and the ADON were responsible for monitoring and ensuring documentation was correct and stated she did this at least weekly when reviewing the MAR and controlled drug record. The DON stated in this situation there was no negative impact due to inaccurate documentation on the MAR. Record review of the facility's, undated, policy titled, Documentation of Medication Administration reflected, Documentation pertaining to medication administration should include.G. Document on the Electronic Medication Administration Record (MAR) as the medications are administered, not before or sometimes afterwards.

Based on observation, interview, and record review the facility to ensure when not in use, medication carts were stored and secured in a designated area for 1 of 4 carts (1 and 2 hallways) medication carts reviewed for drug security. The facility failed to ensure that the nurses medication cart for 1 and 2 hallways was secured by a lock when it was left unattended by RN A. The failure could place residents at risk of injury to other residents if medication left unsecured were consumed.Findings include: During an observation on 11/5/2025 from 03:20 PM revealed surveyor walking next to the medication cart and the 1 and 2 hallways nurse's medication cart was left unlocked and unattended in front the nurse's station. During the observation RN A was at the nurses' station. RN A was informed of the unlocked medication. RN A secured the cart by locking it. During an interview on 11/5/2025 at 03:25 PM with RN A revealed he was responsible for the nurse's medication cart that was left unlocked. He stated he was expected to lock the nurse's medication cart when he walked away from it. He stated if it was left unlocked then a resident could open a drawer and take anything that was not for them, or medications could get stolen. He stated he unlocked the medication cart for an auditor and that person left it unlocked, and he was not aware. RN A said that he thought the auditor locked it. During an interview on 11/5/2025 at 04:30 PM with the DON revealed numerous staff, including her and the ADON, were responsible for ensuring medications carts were locked. The DON stated her expectation of staff when they walked away from the medication cart was to lock it. The DON stated that the negative outcome for leaving the cart unlocked was that a resident or visitor could grab the medication from the cart, and it could harm them. Record review of facility policy Medication Storage, with a revised date 8/2023 revealed, All medications shall be stored to insure potency, patient safety and security of the product. Only licensed nurses, the consultant/clinical pharmacist, and those lawfully authorized to administer medications are allowed access to medications. Medications rooms, carts, and medication supplies are locked or attended to by persons with authorized access.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests for 1 of 1 kitchen reviewed for environmental conditions. The facility failed to have pest control effectively treat the kitchen for roaches. This deficient practice could place residents at risk of exposure to pests, diseases, infections, and diminished quality of life. Findings included: An observation and follow-up tour of the kitchen with the DM on 06/22/25 at 2:00 p.m., revealed there were roaches coming out of the floor drain under the 2-compartment sink on the north side of the kitchen. The DM said the kitchen had been fumigated last week and stated the roaches started coming out when the new parking lot construction began several weeks ago. She said she had already reported the problem to the facility ' s Maintenance Director and the Administrator. She said the negative outcome for having roaches in the kitchen was an infection control issue. In an interview on 06/22/25 at 2:30 p.m., the Maintenance Director said the DM had told him she had seen roaches in the kitchen. He said the roaches started coming out when they started the construction of their new parking lot in the back of the building. He said the entire facility had been fumigated last week for roaches. He was not able to say what the negative outcome of having roaches in the kitchen would have been. In an interview on 06/23/25 at 2:00 p.m., [NAME] E said the roach problem began a couple of weeks ago, when the construction of the new parking lot started. She said she had seen roaches in the morning when she came in and immediately reported it to the DM. She said the kitchen had been fumigated last week. She said she would only saw couple of roaches a day and said it was not an infestation. In an interview on 06/22/25 at 2:10 p.m., DA F said she had first noticed the roaches in the kitchen when the construction of the new parking lot started. She said the kitchen had been fumigated last week and that it was not like a lot of roaches. She said whenever she saw a roach she would kill it and then report it to the DM. In an interview on 06/22/25 at 4:00 p.m., the Administrator said the entire facility was fumigated at least once a week or more often if needed. He said the hot weather and the construction of the new parking lot behind the kitchen could be the reason the roaches were coming into the kitchen. He said he had already called the exterminator, and they would be coming back to fumigate the kitchen by tomorrow. He was not able to say what the negative outcome of having roaches in the kitchen would be. Record review on 06/22/25 at 3:00 of the facility ' s pest control log reflected the entire facility had been fumigated monthly from 01-25 to 05-25 and twice in 06-30-25 for ants, spiders, roaches, and silverfish. Record review on 06/23/25 of the facility's Infection Control Policy/Procedures: Pest Control Visits revised on May 2007 reflected: Policy: It is the policy of this facility to provide an environment free of pests. Procedures: 3. It will allow for additional visits when a problem is detected. 4. Monitoring of the environment will be done by the facility ' s staff. 5. Pest control problems will be reported promptly to the administrator.

Based on interview and record review, the facility failed to ensure residents had the right to be free from misappropriation of property and exploitation for 1 of 3 (Resident #39) reviewed for misappropriation and exploitation, in that: The facility failed to ensure Resident #39 was free from exploitation. On 03/10/25, the facility learned that the former ABOM had accessed R Resident #39's bank account information and withdrew funds without his knowledge or consent on 18 different occasions. As a result, Resident #39 lost $4671.22 from his checking account. This failure could affect residents and their responsible party by preventing them from having access to their funds. The findings included: Record review of Resident #39's admission Record dated 06/25/25 reflected a [AGE] year-old male, original admission date 04/03/24, his relevant diagnoses included Chronic Obstructive Pulmonary Disease (lung disease with (Acute) Exacerbation Muscle Weakness (Generalized), Essential (Primary) Hypertension (high blood pressure), and Unspecified Atrial Fibrillation (irregular heartbeat). Record Review of Resident #39's quarterly MDS assessment reflected a BIMS score of 14 (intact cognitive function). Record review of Resident #39's bank statement, not dated, revealed 18 unauthorized transactions beginning in October 2024 through March 2025 that totaled $4671.22. Record review conducted on in-service for all staff for incident dated 03/11/25, titled In-Service Training Report; Subject Abuse Neglect, Exploitation. In an interview on 06/22/25 at 10:00 a.m., Resident #39 said he noticed money missing from his bank account and asked the BOM for help. He said she transported him to his bank where he found out that someone was withdrawing money through a peer-to-peer money transfer service known as Cash App, without his knowledge or permission. He said he had been able to close that account and open a new one. He also said the local police department was called in to investigate this situation. He said he didn't know how the former ABOM got access to withdraw money from his account. He said he never gave her permission to. Resident #39 also said the facility reimbursed him the full amount of $4,671.22. In an interview on 06/22/25 at 2:44 p.m., the Administrator said they did not know the former ABOM had been taking the money from Resident #39. He said she resigned in December 2024. The Administrator said they immediately called the police when they found out about the incident and gave law enforcement information that they requested. He said they also reimbursed Resident #39 the full amount of $4,671.22. He said they in-serviced all staff on Abuse, neglect and exploitation and conducted an audit of all residents' finances for the past year and found no concerns. He also said they now have a filling cabinet with lock and key to store all resident's financial information to which only the BOM has access to. In a telephone interview on 06/23/25 at 4:15 p.m. the BOM said Resident #39 asked her for help when he could not access his account via telephone. She said she took him to his bank so he could find out what was going on. She said at that point they found out that the former ABOM was taking money from his account without his permission. The BOM said she was not aware that the former ABOM was doing that. The BOM said that the ABOM had access to Medicaid applications because that was one of her duties to help with. She said she did not know how she was able to take money from Resident #39's account. BOM said that after the incident, she completed an audit of all resident's finances for the past year and found no concerns. She said she also has a cabinet with lock and key to keep all resident's financial information secured and she is the only one with access. 06/24/25 at 9:02 a.m. Attempted to contact former ABOM via telephone, there was no answer, only able to leave voice message. In a telephone interview on 06/24/25 at 10:12 a.m. the Police Investigator said he investigated the incident and found that the former ABOM gained access to Resident #39's bank account information and linked it to her personal Cash App and was transferring money to her account from October 2024 to March 2025. He said when he interviewed her, she admitted to taking Resident #39's money without his consent. He also said she was arrested for this incident. Record review of the facility's policy titled Abuse: Prevention of and Prohibition Against revised on 12/2023 . reflected; 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. The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be free from abuse, neglect, misappropriation of resident property, exploitation, or use of technology that would infringe on the resident's right to personal property.

Based on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 8 residents (Resident #'s 44, Resident #30) reviewed for comprehensive care plans in that: 1.The facility failed to ensure Resident #44 ' s care plan included his ADL self-performance deficit for eating when Resident #44 needed substantial/maximal assistance and needed to be fed. 2. The facility failed to develop and implement a comprehensive person-centered care plan to address Resident #30's smoking. These deficient practices could place residents at risk of not receiving appropriate treatment and services. The findings included: 1.Record review of Resident #44 admission record dated 06/24/25 reflected an [AGE] year-old male admitted on [DATE], an initial admit date of 06/06/23, and an original admit date of 01/14/22. His relevant diagnoses included dementia (the loss of cognitive functioning, thinking, remembering, and reasoning) muscle weakness, dysphagia, oropharyngeal phase (difficulty in swallowing that originates in the mouth and throat and extends to the upper esophagus), anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations), and bipolar disorder ( a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) . Record review of Resident #44 ' s quarterly MDS assessment dated [DATE] reflected that he had a BIMS score of 02, which indicated his cognition was severely impacted. Further review reflected Resident #44 had a code of 5 (setup and clean-up assistance-helper sets up or cleans up; resident completes activity Helper assist only prior to or following the activity) for eating. Record review of Resident #44 ' s quarterly care plan dated 04/08/25 reflected a focus of assistance with ADLs: setup/clean-up: Eating. His interventions in part included eating peg tube ( a feeding tube inserted through the abdominal wall into the stomach). In an observation on 06/23/25 at 8:45 am, Resident #44 was observed in a sitting position on his bed. His bedside table was positioned over his bed. The breakfast tray was sideways, and his left elbow was observed to be resting in his pureed oatmeal bowl. His spoon had fallen between his contracted legs and was not within reach. Resident #44 kept repeating se me [NAME] y no puedo agararlo (it fell, and I can ' t get it) pointing to the spoon. Shortly after, CNA A was observed as she approached Resident #44 and asked him if he needed assistance with his breakfast, and he answered si (yes). CNA A began feeding Resident #44, and he ate 100% of his meal. In an interview on 06/23/25 at 8:55 a.m., CNA A said Resident #44 ADL for feeding was to set-up/clean-up for eating. She said that meant his meal tray had to be set up (uncover the drinks, making sure the utensils were within reach, and his tray was within reach). She said Resident #44 required assistance with feeding, but there were times in which he refused to be assisted with feeding. She said all they could do when he refused was to monitor him. She said Resident #44 had behavioral issues and would spit on them when he did not want to be fed. CNA A said she had set up his breakfast tray earlier that morning but had not checked up on him after that. In an interview on 06/23/25 at 9:00 a.m., MDS H said Resident #44 ' s care plan reflected that he had a feeding tube; therefore, there were no interventions for feeding. In an interview on 06/23/25 at 9:05 am, LVN B said Resident #44 never had a feeding tube. In an interview on 06/23/25 at 10:00 am, the DON approached this surveyor and provided a copy of Resident #44 ' s care plan and said, it was just revised. This surveyor asked what was revised, and her response was, I don't know, I was just told to bring it to you. In an interview on 06/23/25 at 10:05 am, MDS G said she had modified Resident #44 ' s care plan to reflect that he did not have a feeding tube and added x1 for feeding. She said the update meant he needed assistance with feeding. In an interview on 06/24/25 at 9:00 a.m., LVN B said there were days in which Resident #44 was able to eat on his own and days in which he required assistance with feeding. She said Resident #44 had behavior issues and when he did not want help with feeding, he would spit on the CNAs. She said there was no negative outcome for not having his care plan include he was a 1x for eating because the CNA staff were already assisting him in eating but at times he refused. In an interview on 06/24/25 at 9:40 am, the DON said she did not know why Resident #44 ' s care plan reflected he had a feeding tube. She said from what she recalled, Resident #44's ADL for eating was set-up and monitor, which meant a CNA would set up his meal tray and monitor him to see if he needed assistance with anything. This Surveyor asked the DON if set-up/clean-up (as reflected on Resident #44 ' s care plan) was the same as set-up and monitor and she did not respond. She said Resident #44 had behavior problems like spitting and hitting CNAs when they tried to feed him. The DON said there were no negative outcomes to Resident #44 because his care plan did not indicate that he required assistance X1 for feeding, because CNAs would assist with that task whenever he would allow them. 2. Review of Resident #30's Face sheet dated 06/22/2025 revealed an admission date of 05/21/2025. The Resident's diagnoses included Nicotine Dependence, Chronic Obstructive Pulmonary Disease (a progressive lung disease that makes it difficult to breath). Review of Resident #30's most recent comprehensive MDS assessment dated [DATE], revealed the resident's diagnosis of Chronic Obstructive Pulmonary Disease. Resident#30 was cognitively intact with a score of 13. Review of the Resident #30's Care Plan, dated 05/22/2025, revealed the care plan did not identify the resident's smoking interventions. Record Review of facility's smoking list provided by the facility on 6/23/24 Resident #30 was on the list. In an observation and interview on 06/23/25 at 8:45 am, Resident #30 was on his bed, lying down, resident did not have any concerns on abuse and neglect. The room was clean, resident was well groomed. during an interview Resident #30 revealed he was a smoker and the facility was facilitating his smoking needs. During an interview on 06/23/25 at 4:30 p.m. The MDS H nurse stated the care plan should have been updated when and by whomever found out that Resident #30 was a smoker. MDS H nurse stated that Resident #30 was very dependent and was able to light up the cigarette by himself. The MDS H nurse stated that a negative outcome was the lack of communication between staff and resident. During an interview on 6/24/25 at 11:20 a.m. The ADON stated that she did not know how was Resident#30's missed as a smoker. ADON stated that was important to have the care plan updated because that way Resident #30 could get the best care. The ADON stated the negative outcome would be not giving the care needed by Resident #30. During an interview on 06/24/25 at 11:50 a.m., the DON stated the care plan had to be updated to give the resident the best care and to verify if the interventions were effective. The DON stated care plans were created upon admission within 48 hours, updated 14 days after admission, quarterly, and upon change of condition. The DON stated Resident #30 was at risk of not receiving a proper care that she required. Record review of the facility ' s Comprehensive Person-Centered Care Planning policy, dated September 2016 revisied April 2025 reflected: Policy: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident ' s medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident ad instructions needed to provide effective and person-centered care that meet professional standard of quality care. Procedure: 3. The facility IDT will develop and implement a comprehensive persons-centered, culturally competent, and trauma-informed care plan for each resident within 7 days of completion of the Resident Minimum Data Set and will include resident ' s needs identified in the comprehensive assessment, any specialized services as a result of PASRR recommendation, and resident ' s goals and desired outcomes, preferences for future discharge and discharge plan. Review of the facility Smoking Policy with a revised date 03/2008 - reflected it is the policy of this facility to provide to its ' residents a smoke free environment. It is also policy to provide those residents who choose to smoke a means in which to do so that does not jeopardize their safety or the safety of others residing in the facility. The results of the evaluation will be placed in the resident ' s chart and the Interdisciplinary Team recommendations will be care planned

Based on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards for 1 of 4 residents (Resident #20) reviewed for infection control. The facility failed to ensure the dressing on Resident #20's peripheral intravenous line (a short flexible tube inserted into a vein to administer fluids and medications) was dated and initialed. The failures could affect residents by placing them at risk for infections. Findings included: Record review of Resident #20's electronic face sheet, dated 06/22/2025, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with an original admission date of 02/11/2017. The resident had diagnoses which included: Cellulitis of Left Foot (skin infection), Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), Type 2 Diabetes Mellitus, Dementia, Muscle Weakness, and Age-Related Osteoporosis (causes bones to become weak and brittle). Record review of Resident #20's Quarterly MDS assessment dated [DATE] reflected that she had intravenous access. Resident #20 BIMS score was 0, indicating her cognition was severely impaired. Record review of Resident #20's person- centered care plan, initiated date 06/17/25 reflected resident was on IV Medications related to cellulitis to left foot and IV hydration-initiated date 06/21/2025. Interventions included IV medication as ordered. Check dressing at site daily, monitor PIV line for s/s of infection/infiltration every shift, notify provider if present change intravenous tubing with new IV bag reinsert peripheral IV line. Notify md if unable to reinsert after attempts. Change dressing prn if wet, soiled, saturated or loose peripheral intravenous care. IV fluids as ordered. Record review of Resident #20's physician orders reflected, 0.9% NS at 80mL/Hr x1 Liter one time only for hydration for 1 Day dated 06/21/2025. Linezolid Intravenous Solution 600 MG/300ML (Linezolid) Use 1 dose intravenously every 12 hours for cellulitis to left foot for 7 Days, dated 06/17/2025. An observation on 06/22/2025 at 10:58 a.m. revealed Resident #20 was in her room lying in bed. She had a peripheral intravenous line dressing properly labeled on her left wrist with 0.9% NS running at 80mL/hr. She also had a peripheral intravenous line dressing with no date and no initials on her right hand. There were no signs or symptoms of infection or infiltration noted at both peripheral line sites. In an interview on 06/22/2025 at 11:02 a.m. LVN I, the charge nurse for Resident #20, confirmed the resident had a peripheral IV lock in her right hand covered with a transparent dressing that was not labeled. LVN I stated that she was not the one that initiated it. LVN I stated that the nurse who initiated the IV was responsible for labeling the dressing with the date and initials. She stated that it was important to label the IV sites to know when they needed to be changed. LVN I stated she would remove the one on the right hand because she did not know how long she has had it. She stated she checked the sites that morning and flushed both IV sites but missed the labeling. She stated she knew she was supposed to check the date on the dressing, the site for infection, and the status of the dressing every shift. LVN I stated that it was important to label the dressings because it can cause infection not knowing how long they have had it for. She stated she had done training on IV administration upon hire and once a month. In an interview on 06/22/2025 at 11:15 a.m. the ADON confirmed that Resident #20 had a peripheral IV lock in her right hand with a dressing that was not labeled. She stated that the IV dressings needed to be changed every three days. The ADON stated that it was important to label the dressings because they did not know how long they have had it for, and it can cause infection and infiltration. She stated that the staff was to date and initial the dressings. The ADON stated she does rounds to check after the nurses and ensure IV bags and dressings were labeled with date and initials, but she did not have a chance to go down Resident #20's hall. She stated that the staff was trained in IV administration to meet all criteria. In an interview on 06/22/2025 at 11:25 a.m., the DON stated that the IV dressings were to be labeled with the date and initials and were to be changed every three days. She stated that it was important for the nurse to ensure that it was labeled so they knew when to change it. The DON stated that by not having the dressing labeled the site can develop an infection. She stated the ADON rounds to check after the nurses and ensures the dressings were being labeled. She stated that IV administration trainings were done annually and as needed. Record review of the facility's skill check off record provided revealed LVN I met requirements for Inserting a Peripheral IV on 05/01/2025. Record review of the facility's Competency Checklist Inserting a Peripheral IV blank form revealed: Title: Labeling Description: Place a label with the date of catheter insertion, clinicians' initials. Rationale: Allows for recognition of type of device and length of time that device has been in place. Record review of the facility's Administration of Medication and Fluids, Intravenous policy, dated revised 3/2023, revealed .15. Rotate sites every seventy-two hours. Record review of the facility's Infection Prevention and Control Program Policy date revised 10/2022 revealed: Policy: The infection prevention and control program is a facility wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. The elements of the infection prevention and control program consist of coordination/oversight, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. Goals: Recognize infection control practices while providing care. Ensure compliance with state and federal regulations related to infection control.

Based on interview and record review, the facility failed to provide behavioral health services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for two (Resident #1 and Resident #2) of six residents reviewed for behavioral health services. The facility failed to follow-up to ensure Resident #1 and Resident #2 received a psychiatric consultation after an order was received from the MD on 05/30/24. This failure could place residents at risk for not receiving behavioral health services and a decline in quality of life. Findings included: 1. Record review of Resident #1's face sheet, dated 05/22/25, reflected the resident was a [AGE] year-old male, with an original admission date of 8/30/23. Resident #1 had diagnoses of Dementia (a decline in cognitive functioning, affecting memory, thinking, and language to such an extent that it interferes with a person's daily life and activities), cognitive communication deficit (communication difficulty), and metabolic encephalopathy (neurological disorder caused by impaired brain function due to problems with bodily metabolism, such as infections, organ dysfunction, or electrolyte imbalances). Record review of Resident #1's quarterly MDS assessment dated [DATE], reflected Resident #1 mental status had short-term and long-term memory problem, able to recall staff names and faces, and had severely impaired cognitive skills for daily decision making, Record review of Resident #1's undated care plan reflected the following: Focus: Potential to demonstrate physical behaviors R/T agitation high ammonia level 5/26/24 combative/ aggressive behaviors towards another resident and skilled nurse 8/4/24 discord with another Date Initiated: 04/26/2024, Revision on: 08/05/2024. Goal: Will not harm self or others through the review date. Date Initiated: 04/26/2024, Revision on: 02/13/2025, Target Date: 08/04/2025. Interventions: o Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. Date Initiated: 04/26/2024. o (psychiatry) to evaluate and treat as ordered Date Initiated: 05/31/2024. o Give as many choices as possible about care and activities. Date Initiated: 04/26/2024. o When becomes agitated, guide away from source of distress; engage calmly in conversation. If response was aggressive, staff to walk calmly away, and approach later. Date Initiated: 04/26/2024. Record review of a physician order for Resident #1 dated 05/30/2024 at 3:14 PM, confirmed by DON, reflected the following: Order Summary: psychiatry services to evaluate and treat. 2. Record review of Resident #2's face sheet, dated 05/22/25, reflected the resident was an [AGE] year-old male, with an admission date of 7/11/23. Resident #2 had diagnoses of Alzheimer's Disease (a progressive neurodegenerative disorder that primarily affects the brain, leading to a decline in memory, thinking, and other cognitive functions) and Cognitive Communication Deficit (communication difficulty). Record review of Resident #2's quarterly MDS assessment dated [DATE], reflected Resident #2 had a BIMS score of 15 indicating cognitively intact, and had inattention and disorganized thinking. Record review of Resident #2's undated care plan reflected the following: Focus: Potential for a psychosocial well-being problem r/t being kicked to leg by another resident 5/26/24 Date Initiated: 05/31/2024. Goal: Will have no indications of psychosocial well-being problem by/through review date. Date Initiated: 05/31/2024 Revision on: 04/15/2025 Target Date: 07/14/2025. Interventions: o 5/26/24 head-to-toe assessment Date Initiated: 05/31/2024 o Allow time to answer questions and to verbalize feelings perceptions, and fears. Date Initiated: 05/31/2024. Record review of a physician order for Resident #2 dated 05/30/2024 at 3:14 PM, confirmed by DON, reflected the following: Order Summary: psychiatry services to evaluate and treat. Record review of the Provider Investigation Report # 507305 dated 05/31/25, reflected the following: Other Action Taken: . . Psychiatry services to evaluate and treat both residents. Record review of Resident #1's and Resident #2's electronic record did not reflect any psychiatric consultation, any scheduled consultation, or any follow-up regarding the psychiatry consult order. In an interview on 5/21/25 at 3:28 pm DON said she remembered she received a call from staff and was informed Resident #1 was observed swinging and kicking at Resident #2. She said the facility implemented moving Resident #1 to a different hallway prevented the incident from happening again. She said Resident #1 had not exhibited those behaviors before, but the facility felt Resident #1 being moved prevented the behavior from happening again. She said Resident #1 did not receive the evaluation/treatment for psychiatry. She said the social worker who was working at that time did not follow through with the orders for psychiatry to evaluate and treat. The DON said she provided the order to the social worker at the time, and she did not follow through. The DON said the social worker was the designee for psychiatry referrals. The DON said that social worker no longer worked for the facility. The DON said there was not a negative outcome with this incident. In an interview on 5/22/25 at 2:20 pm the Administrator said Resident #2 loved to talk about religion. The Administrator said Resident #2 could preach a lot and could be unrelenting. The Administrator said he thought Resident #2 was doing that with Resident #1 and Resident #1 did not like it. The Administrator said the facility separated the two residents and placed everything on the investigation summary. The Administrator said everything listed on the investigation summary should have been done. The Administrator said the social worker at the time was responsible for carrying out those orders. The Administrator said with that behavioral/psychiatric referrals, the social worker was the designated person who made sure the referral happened. Record review of the facility's Behavioral Health Services policy with a revision date of 12/2023, reflected the following: Policy It is the policy of this facility to provide residents with necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes the prevention and treatment of mental and substance use disorders, as well as psychosocial adjustment difficulty, or those with history of trauma and/or post-traumatic stress disorder. Procedure . 6. The physician, in collaboration with the IDT team, will determine the appropriate psychiatric or psychological treatment or rehabilitative services needed. Treatment will be provided as ordered by the physician. 7. Social services will make the appropriate professional services referral, if needed, following agreement from the resident and/or resident representative.

Based on interviews 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 one (Resident #3) of six residents. The facility failed to ensure that Resident #3 received his eye drops to his left eye as prescribed on the physician's prescription orders dated 2/26/25. Resident #3 received 1 drop twice a day instead of 1 drop three times a day to his left eye. This facility's failure placed residents receiving medications at risk for drug diversion, drug overdose, and decrease efficacy of medications. Findings included: Record review of Resident #3's face sheet, dated 05/22/25, reflected the resident was a [AGE] year-old male, with an original admission date of 1/17/24. Resident #3 had diagnoses of Dementia (a decline in cognitive functioning, affecting memory, thinking, and language to such an extent that it interferes with a person's daily life and activities), cystoid macular degeneration, right eye (a condition where the central part of the retina responsible for detailed vision, swells and forms cyst-like fluid collections) and presence of intraocular lens (an artificial lens implanted in the eye to replace the natural lens). Record review of Resident #3's quarterly MDS assessment dated [DATE], reflected Resident #3 had a BIMS score of 13 indicating cognitively intact. Record review of Resident #3's undated care plan reflected the following: Focus: impaired visual function r/t presence of intraocular lens, cystoid macular degeneration, right eye, combined forms of age-related cataract, bilateral, diabetes 2/11/25 s/p right eye cataract surgery. 2/24/25 s/p left eye cataract surgery. Date Initiated: 01/31/2024 Revision on: 03/19/2025. Goal: Will have no indications of acute eye problems through the review date. Date Initiated: 01/31/2024 Revision on: 02/12/2025 Target Date: 07/28/2025. Interventions: o 2/17/25 eye drops as ordered Date Initiated: 02/18/2025 o 2/26/25 eye drops as ordered Date Initiated: 02/27/2025 o 3/3/25 eye drops as ordered Date Initiated: 03/03/2025 Revision on: 03/04/2025 o appt. with ., OD 03/10/25 @ 8:00 am Date Initiated: 03/03/2025 o appt. with ., OD ***03/25/25 Date Initiated: 03/17/2025 o eye drops as ordered Date Initiated: 03/10/2025 Revision on: 03/19/2025 o f/u appt with . Surgical Center ***02/26/25 @ 8:15am*** [M .,Tx] Date Initiated: 02/25/2025 o f/u with ophthalmologist as needed Date Initiated: 06/04/2024 o Monitor/document/report to MD the following s/sx of acute eye problems: Change in ability to perform ADLs, decline in mobility, sudden visual loss, pupils dilated, gray or milky, c/o halos around lights, double vision, tunnel vision, blurred or hazy vision. Date Initiated: 01/31/2024. Record review of a prescription order for Resident #3 from eye doctor's office, signed by OD and dated 2/26/25 reflected the following: Drop orders: Right eye Prednisolone i gtt OD BID, Left Eye Prednisolone i gtt OS TID . Record review of a physician order on PCC for Resident #3 dated 2/25/25 reflected Prednisolone Acetate Ophthalmic Suspension 1% in both eyes 1 drop two times a day, everyday post cataract surgery, start date 2/26/25. In a phone interview on 5/20/25 at 6:10 pm LVN A said one of Resident #3's eye drops had been discontinued with the previous cataract surgery, so she could not resume those drops without clarified orders. LVN A said nurses are required to obtain detailed physician orders to administer any medications. LVN A said if they did not have detailed orders, they must call the physician to receive clarified orders. LVN A said she could not recall if she received a written prescription order or a verbal order for the eye drops. LVN A said she could not recall if the drops were prescribed two or three times a day. LVN A said if she did not clarify the order, she could have given the wrong medication or the wrong dose and that would have been an error. In a phone interview on 5/21/25 at 10:17 am RN B said nurses could not give eye drops or any medications without a physician's order. RN B said if the eye drops had been given without an order or clarification, they could have given the wrong medication or the wrong dose, which could have damaged the resident's eyes and could have affected her nursing license. RN B said nurses received orders and ensured orders were accurate which was protocol. She said as a nurse they clarified any order that needed clarification prior to administering a medication. In an interview on 5/22/25 at 10:20 am, the DON said nurses cannot administer medications without a complete prescription order. The DON said if there was missing information, such as the specific medication name, frequency, dosage, etc., the nurses were required to clarify those orders. The DON said they received a written prescription for the eye drops. The DON looked up the order on PCC and said the prednisolone for both eyes was prescribed two times a day. She looked up the prescription on the Provider Investigation Report and read the prednisolone for the left eye was prescribed three times a day. She said she really was not sure if there was another prescription or what happened. She said the thing with Resident #3 was he went to two different clinics, one in one town and one in another town, so she was not sure if they received a different order as well. The DON also said Resident #3 was resistant to providing the facility/nurses with post doctor visit orders. The DON said they could not administer medications without a complete prescription order. The DON said Resident #3 received his eye drops so she could not tell this surveyor if there would have been a negative outcome. The DON said if nurses did not give medications as prescribed, a resident could get worse for whatever reason they were receiving the medication. In an interview on 5/22/25 at 2:20 pm Administrator said any incident involving medications, he let his DON manage it. The Administrator said if the facility received a completed physician's order, they gave the resident exactly what was ordered on that written order. In a phone interview on 5/22/25 at 4:15 pm with the Ophthalmic Assistant at the eye doctor's office stated that patients usually have a follow up appointment the day after cataract surgery and were given their prescriptions at that time. She said patients were usually prescribed prednisolone 1 drop three times a day x 1 week, then it was decreased to 1 drop two times a day x 2 weeks, then 1 drop one time a day x 1 week. She said that was what was ordered Resident #3. She said from 2/26/25 to 3/3/25 Resident #3 should have received 1 drop 3 times a day to his left eye. She said if he received 1 drop two times a day instead, it would have minimal to no effect on the patient. She reviewed the Resident #3's record and said it showed no inflammation to the back of his left eye, so it had no effect to this patient. Record review of the Medication Administration - Eye Drops check-off dated 2/28/25 revealed the following: .Title: Check. Description: Verify the five rights of medication administration: (right person, medication, route, time, and dose) by checking the medication label to the MAR three times, upon removal from storage, before preparation, and before administration. Rational: Prevents medication errors with a check-off under Met. . Title: Administer. Description: Rest your dominant hand on the individual's forehead and instill the prescribed number of drops into the conjunctival sac. Rational: Ensures proper administration of the medication and prevents discomfort with a check-off under Met. . Title: Administer. Description: Repeat the procedure on the other eye as ordered. Rational: Prevents medication errors with a check-off under Met. Record review of the facility's Policy/Procedure - Nursing Clinical reviewed 8/2022 revealed: Policy: .It is the policy of this facility to accurately implement orders in addition to medication orders (treatment, procedures) only upon the written order of a person duly licensed and authorized to do so in accordance with the resident's plan of care.

Based on interview and record review, the facility failed to maintain medical records that were complete, accurate, readily accessible, and systematically organized for 1 (Resident #11) of 24 residents reviewed for Advance Directives. The facility failed to have complete, accurate and readily accessible records to identify Resident #11's code status. Resident #11's medical record indicated Resident #11 code status was DNR, but the OOH-DNR form was not in Resident #11's medical record. This failure could affect residents who have implemented Advance Directives and established their choice to not be resuscitated at risk of receiving CPR against their wishes. The findings were: Record review of Resident #11's Physician's Orders dated [DATE] indicated Resident #11 was a 90-year female admitted to the facility on [DATE] with diagnoses of Essential Hypertension, Non-ST elevation myocardial infarction (a type of heart attack that usually happens when your heart's need for oxygen can't be met), dementia, mild, without behavioral disturbance, psychotic disturbance, mood disturbance (an early stage of memory loss), and chronic kidney disease, stage 3A (mild to moderate loss of kidney function). Record review of Resident #11's annual MDS assessment dated [DATE] indicated Resident #11 was understood by others, understood others, had good memory recall and had the cognitive skills for making decisions daily. Record review of Resident #11's care plan dated [DATE] revealed Resident #11 had code status of DNR with interventions that included, if resident is unresponsive, check for pulse, b/p, and respirations, if resident is unresponsive notify licensed staff immediately, review wishes annually and/or appointed healthcare representative. Record review of Resident #11's Physician's Orders dated [DATE] revealed Resident #11 had an order for DNR-Do Not Resuscitate dated [DATE]. Record review of Resident #11's electronic record did not reveal an OOH-DNR form. In an interview on [DATE] at 12:43 PM, the FM of Resident #11 said Resident #11 is a DNR. The FM said Resident #11 has told me several times that she does not want to be revived or put on a machine. The FM said the SW called her today to ask her to come to the facility so she could sign the DNR form. The FM said she thought Resident #11 already had a DNR form when she came from the hospital. FM said maybe the form wasn't valid, so they asked her to come to the facility and sign another DNR form. The FM said she had come in and signed the form. In an interview on [DATE] at 3:17 PM, ADON/LVN E said she checked PCC for Resident #11's record for the code status and it said Resident #11 code status was DNR. ADON/LVN said she asked the Medical Records clerk why Resident #11 was a DNR if they could not find any form to indicate she was a DNR. ADON/LVN E called the family and the FM said she had signed the DNR form. THE ADON/LVN E asked where she had signed the form and the FM said at the hospital. ADON/LVN E told the FM that the form was valid only at the hospital and the facility needed an OOH-DNR. The FM came in to sign the DNR form on [DATE], and the doctor was at the facility, so the form was signed by both. In an interview on [DATE] at 2:21 PM RN D said if a resident comes from the hospital the resident would be asked on admission if they were full code or DNR. If the resident was a DNR and something happened to the Resident, but they do not have the DNR form, and they do not resuscitate, the family could come in and say the resident was full code. If the resident was being admitted and the resident said they wanted to be DNR status, then the facility would start working on the DNR form right away. In an interview on [DATE] at 2:40 PM The SW said she did not fill out the DNR forms. The BOM assistant was the one that filled out the forms. The SW said she would only fill out the form if a family member came in and asked for her assistance. The SW said she did not audit the DNR forms to check if they were filled out correctly because she did not fill them out. The Medical records clerk takes the forms to the doctor to sign and then he would upload the form to PCC. In an interview on [DATE] at 8:57 AM, BOM Assistant said she did not fill out the DNR forms, the SW would fill out the DNR forms. The BOM Assistant said she would let the SW know the new admitting resident's code status was a DNR, so the SW could start the process. The BOM Assistant said she conducted the admission process and would check on PCC for the code status and if the resident code status was DNR, she would then follow up with the family or the resident if they were a DNR. The BOM Assistant would then let the SW know so the SW could get the form signed by all the necessary parties. Then the Medical Records Clerk would put the Advance directive in PCC. In an interview on [DATE] at 9:03 AM, Medical Records Clerk said when a resident comes from the hospital, sometimes they would come in with a DNR code status and during the meeting the staff would ask if the resident still wanted the DNR code status. If the resident did want to continue with the DNR code status, the SW was informed, and she assisted the family or resident with completing the form. Once the form was signed by the resident or representative, the SW would give the form to the Medical Records clerk. The Medical Records Clerk said he would send the form by carrier for the doctor's signature or if the physician comes to the facility, he can sign it here. Once the form was signed, the Medical Records Clerk would scan the form and send a copy to each department. Then it was up to each department to do their part. In an interview on [DATE] at 9:14 AM, MDS/LVN F said if a resident's code status was DNR, the resident would have an order from the physician and an OOH_DNR form. The staff would verify with the family/resident that the resident's code status was a DNR. The SW would assist the family with completing the form. Once the form was signed by all necessary persons the form would be uploaded to PCC. Then MDS would look for the order and would look under the miscellaneous tab in PCC for the form and then the care plan would be developed. MDS/LVN said she did not know how the care plan was developed for Resident #11 if they did not have the form. In an interview on [DATE] at 9:21 AM, the DON said Resident #11 came in from another nursing home as DNR. The SW would meet with the family and will initiate the process for the DNR. The SW would get it filled out and then the form goes to medical records. Medical Records Clerk would make sure it had all signatures and would upload to the form onto PCC and let all nursing departments know that Resident was now DNR. The MDS department will develop the care plan and will also check for the DNR form. The DON said she did not know how the error occurred. If Resident #11 had coded, they would still call the resident's loved one. The DON said sometimes the family would change their minds. The DON said if they started performing CPR once they start, they cannot stop. The DON said the DNR form might have been deleted from PCC by mistake. The DON said she would call the IT department and ask if the form was in PCC and if it could be retrieved. In an interview on [DATE] at 9:39 AM The SW said she would look at the referrals from the hospital and checked if they were full code or DNR status, but she did not review the DNR forms to check if they were correctly filled out or check if they were in the chart. The SW said the Medical Records Clerk would take the forms to the doctor to be signed and then would make sure the form had all the signatures and would scan the form and upload it onto PCC. In an interview on [DATE] at 11:09 AM, The Administrator said the SW was responsible for making sure the DNR form was in place and during care plans would review the code status and would review the form at that time. The Administrator said Resident #11 came in as a DNR from the hospital so there should be a DNR form somewhere. The Administrator said they had a couple of boxes with old medical records so they would go through them to look for the DNR form. In an interview on [DATE] at 12:31 PM, the DON provided the hard copy of the DNR form dated [DATE]. The DON said they had looked through boxes of old medical records and found Resident 11s DNR form. Record review of facility's policy on Advance Directives and Associated Documentation dated ,d+[DATE] and revised on ,d+[DATE] revealed: Procedure: 5. When an Advance Directive is completed: a. Review the Advance Directive to validate the document reflects the resident's choices and that the document is signed and dated by the resident or responsible agent. 6. Obtain a copy of the Advance Directive ad conservatorship/guardianship documents and place in resident's health record. b. Once the advance directive or information regarding resident preferences regarding treatment options is received by the facility, it will be confirmed in the resident medical record and communicated to members of the care plan team. c. The facility will notify the attending physician of advance directives so that, if necessary, appropriate orders can be documented in the resident's medical record and plan of care. i. A No CPR or DNR telephone order may be used once the Advance Directivee documents are received and in the health record.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #78 and Resident #241) of five residents reviewed for infection control in that: 1. LVN A failed to properly disinfect equipment after providing wound care for Resident #78. 2. LVN A failed to wear appropriate PPE while providing device care for Resident #241. 3. LVN A failed to change all required items during device dressing care for Resident #241. These deficient practices could place residents at risk of infection, transmission of communicable diseases, and a decline in health. The findings included: 1. Record review of Resident #78's admission record revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included encounter for orthopedic aftercare following surgical amputation, other acute osteomyelitis (infection of the bone) of right ankle and foot, acquired absence of right toe(s), sepsis (life threatening complication of an infection), pneumonia (infection of the lungs), and need for assistance with personal care. Record review of Resident #78's admission MDS dated [DATE] revealed Resident #78 had a BIMS score of 15 which indicated that she was cognitively intact. Record review of Resident #78's physician order summary report on 05/07/24 revealed an order that read, Cleanse right foot with NS (normal saline), pat dry with gauze, apply Medi honey, cover with gauze and wrap with kerlix (woven gauze used to cushion and protect wounds) daily every day shift for surgical post of amputation and enhanced barrier precautions: wound, every shift. Observation of Resident #78's wound care on 05/07/24 at 08:51 am, done by LVN A and assisted by LCNA revealed that LVN A used a pair of bandage scissors to cut the dressing off of Resident #78's right foot. When wound care was completed, LVN A took the bandage scissors back out into the hallway to the wound cart. LVN A unlocked and opened the wound cart and got an alcohol prep (approximately 1 inch by 1 inch 2 ply non-woven pad that contained 70% isopropyl (rubbing) alcohol), out and wiped only the scissor blades with it. LVN A then placed the scissors back into the left side of the top drawer of the wound care cart. LVN A then wiped down the table and hand sanitizer bottle with disinfectant wipes. The disinfectant wipes contained isopropyl alcohol and quaternary ammonium (a type of chemical used to kill bacteria, viruses and mold). In an interview on 05/07/24 at 09:44 am, LVN A stated it was very important to wipe down equipment and that she used alcohol on the scissor blades because she thought it was a 100% clean. LVN A stated if equipment was not wiped down with disinfectant wipes, it could lead to cross contamination which could lead to infection for the next resident it was used on. That could lead to sepsis, hospitalization , or death for the resident. In an interview on 05/07/24 at 2:47 pm, the DON stated that equipment was wiped with disinfectant wipes to prevent the spread of infections and if equipment was not cleaned/disinfected, it could cause cross contamination which could lead to multiple organism growths and hospitalization for other residents. In an interview on 05/08/24 at 01:14 pm, the ADON stated, No, we should not use alcohol preps to clean any equipment. We were always supposed to use disinfectant wipes to clean equipment/ supplies/ surfaces. If not done correctly, it could cause cross contamination, infections, and could lead to an outbreak, facility acquired infections or hospitalization s. Record review of the facility's Infection Prevention and Control Program dated 06/2021 and revised/reviewed 10/2022 stated in part: Goals: -Decrease the risk of infection to residents and personnel. -Recognize infection control practices while providing care. -Identify and correct problems relating to infection control. -Ensure compliance with state and federal regulations related to infection control. -The facility will provide areas, equipment, and supplies to implement its Infection Control Program with the goal of: -Effective cleaning and disinfecting equipment as needed. -Chemicals and equipment used for cleaning and disinfecting will be used in accordance with manufacturer's directions and recommendations. 2. Record review of Resident #241's admission record revealed a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included sepsis (life threatening complication of an infection), unspecified staphylococcus (bacteria that cause skin infection) as the cause of diseases elsewhere classified, cutaneous abscess (localized collection of pus in the skin) of right foot, type 2 diabetes, and need for assistance with personal care. Resident #241 had no known allergies. Record review of Resident #241's admission MDS dated [DATE] revealed Resident #241 had a BIMS score of 11 which indicated she had some cognitive impairment but was able to make her needs known and was oriented to self, place, and situation. Record review of Resident #241's physician order summary on 05/08/2024 revealed an order that read, Enhanced Barrier Precautions: PICC line- every shift and PICC LINE CARE: CHANGE PICC LINE DRESSING Q 7 DAYS IF SITE IS VISIBLE FOR ASSESSMENT. CHANGE DRESSING PRN IF WET, SOILED, SATURATED OR LOOSE. every day shift every Sun. Record review of Resident #241's progress notes reveal an entry created by LVN A on 05/09/24 at 11:18 am with an effective date of 05/08/24 at 3:16 pm, that read, Note Text: picc line dressing changed to rua,dressing [sic] noted with tape dislodging. sterile technique applied, pt tolerated well. pt and spouse aware. (PICC line dressing changed to right upper arm .) Observation on 05/08/24 at 2:21 pm with LVN A of Resident #241's entry way revealed an enhanced barrier precautions sign posted next to the door. Observation of Resident #241's PICC (a thin, long, soft catheter that is inserted into a vein of the upper arm and ending in a large vein that carries blood into the heart; used for long term intravenous antibiotics) line dressing revealed she had a right upper arm PICC line that had a folded piece of gauze under the clear dressing and a stat lock (a stabilization device used to hold the catheter in place) underneath the transparent dressing. There was tape on the entire right side of the dressing, indicating that the right side of the original dressing had come loose and had been taped back down. The tape was not adhered to the skin. LVN A stated the dressing needed to be changed because it was coming up on one side. Observation on 05/08/24 of the PICC line dressing change for Resident #241 performed by LVN A revealed that LVN A failed to put on a gown prior to or during the dressing change, as per the Enhanced Barrier Precautions sign outside the resident's door. It was noted that the central line dressing kit did not have a bio patch (an absorptive foam disc that is impregnated with chlorhexidine placed on top of the PICC line insertion site to aid in preventing blood stream infections) in it. LVN A stated, The bio patches usually come from the hospital. That I know of, we don't have them. We just put the split gauze on it. LVN A did not take the stat lock off the catheter or replace the two saline/heparin locks (needleless connectors used to seal off the IV catheter at the end where the medication is injected). LVN A did not clean the skin around the insertion site with the three PVP (Povidone Iodine) swab sticks or the three alcohol swab sticks provided in the kit. LVN A used the alcohol swab sticks to wipe down only the exposed PICC line catheter. The skin area around the insertion site that would be covered by the dressing was not cleaned. LVN A also did not use the skin protectant swab (used to help reduce the possibility of irritation from the adhesive in the transparent dressing) that was provided in the kit to provide a barrier film under the dressing. The PICC line was sutured into place, so LVN A was unable to slide a split gauze under it at the insertion site. Instead, LVN A unfolded the split gauze completely and laid it over the top of the entire external part of the PICC line, then placed the transparent dressing over it. In an interview on 05/09/24 09:49 am, with the DON and the CRN, the DON stated if the dressing has gauze under it, it should be changed every 7 days. The CRN stated, that's what our policy states. In reference to the PICC line having a stat lock, the DON stated, it didn't say a time frame in the policy. The CRN added, I don't think it says a date or anything. it's just best judgement. The DON stated if dressings aren't changed frequently enough or if they become soiled or loose, it could get infected, which could lead to sepsis. The CRN added, it could lead to catheter associated infection. When asked whether the facility carried stat locks the CRN stated, we have to go check supplies to see if we have the IV stat locks and the saline/ heparin locks. The CRN stated that Enhanced Barrier Precautions has been ongoing training, they've been talking to staff about it ever since it came out. The CRN further stated, If we are not doing formal training, we are out there talking to them and reminding them. We started training on it in Feb and March and it has been ongoing ever since. The DON and CRN both stated that Enhanced Barrier Precautions applied to anyone with a medical appliance or wound and that staff were to wear a gown whenever they touched the device or provided care. Observation in the med storage room with the DON and CRN on 05/09/24 at 10:02 am revealed there were saline/ heparin locks present in a bag hanging on the peg board. The CRN stated, I'm not sure how often they're changed, I'll have to check the policy on that. In an interview on 05/09/24 at 10:07 am, the ADON stated, PICC line dressings are changed every week and as needed if it becomes loose, wet, soiled, or peeling on the edges. If there was gauze under it, it is every 3 days, but I'll have to check the policy. The ADON further stated, If there was a stat lock in use, it gets changed with the dressing change. I have never seen stat locks here. Our kits do not have them. If there is a stat lock on there, it needs to come off when the dressing is changed, even though we don't have them. The connectors (saline/heparin locks) are changed weekly and as needed. IV tubing is changed every 24hours. To keep the end clean, the nurses put an alcohol impregnated cap on it. There are alcohol caps for the connectors (saline/ heparin locks), also. If the dressing is being changed, everything gets changed. All the nurses are sent for their IV validation- it is a half day course and is done by an RN that works for the parent company. The ADON stated the facility always has monthly education with the parent company nurse and that the new nurses went to IV training a couple of weeks ago. The ADON stated the nurses should know to change the dressing on a PICC/central/midline if it is loose, soiled, etc. In reference to IV medication, the ADON stated, If someone is getting any IV medication every 12 hours, the empty bag and tubing stay in the room until the next use. Then after 24 hours, it is all thrown out and new tubing it used. The ADON explained Enhanced Barrier Precautions were required when staff was doing wound care, incontinent care, transferring, oral care- any direct contact with a resident. The ADON explained the purpose of EBP was to prevent spreading infections from one resident to another and it was used on any resident that has a device, MDROs (multiple drug resistant organisms), foleys, nephrostomy tubes (a small flexible tube that goes from an opening in the back into the kidney and is used to drain urine from the kidney to a urine collection bag), etc. and used for dressing changes on lines, foley care, and dressing changes on wounds. The ADON stated the facility had just implemented it in March. The facility did a formal in-service in March, and it has been ongoing and daily. The ADON stated, every day I round and check new admissions. If they have lines, foleys, wounds, etc., I let the staff know, place the sign at the door and make sure the gowns are accessible. The gowns are placed in the room in a drawer with a little gown picture on it. Once staff finished with the gowns, they are thrown in the trash. The trash bag was tied and taken to the big bin that goes to the outside trash. In an interview on 05/09/24 at 10:29 am, LVN A stated, PICC dressings are changed every 7 days or when needed and can be changed by any qualified nurse. If there was gauze used with the dressing, I would change it every 4 to 7 days. If there was a stat lock on it and it was not loose or soiled, I would leave it on. In 7 days, I would just take it off because we do not have them in this facility. The connectors are changed every 7 days. If I was changing the dressing before 7 days, I would change the connectors, also. IV tubing is changed every 24 hours. If a resident had every 8 or every 12-hour infusions, cover the bag and tubing, after the date is checked, and put an alcohol impregnated protector on the end of it in between uses. LVN A also stated, EBP was used to prevent infection. We used EBP whenever the resident had something that was open. If there was a sign on the door it meant the resident had a device, wound or infection. EBP meant staff was supposed to use gloves and gown for wound care, peg tube care or use, IVs and anything that required touching the resident. In an interview on 05/09/24 at 10:52 am, LVN B stated Resident #241 got IV antibiotics every 8 hours. The medication ran for four hours, and after the four hours, the tubing was capped with the alcohol green cap. If the PICC dressing had a bio patch under it, it was to be changed every 7 days. If there was no bio patch, it was to be changed every 3 days. EBP means staff was to wear a gown with any contact with resident and any time dressings were changed or wound care/device care was done. Record review of the facility's Dressing Change for Vascular Access Devices policy/procedure dated 08/2021 stated in part: -Central venous access device and midline dressing changes will be done at established intervals and immediately if the integrity of the dressing is compromised, if moisture, drainage or blood is present, or for further assessment if infection is suspected. -Transparent semi-permeable membrane dressings are changed every 7 days and PRN. -If a chlorhexidine impregnated gauze sponge (Bio patch) is applied under the transparent dressing, change every 7 days. -If a patient is allergic to the transparent dressing and a gauze and tape dressing is used over the site, the gauze dressing must be changed every 48 hours and PRN. Gauze underneath a transparent semi-permeable membrane dressing is considered a gauze dressing. -A dressing is changed immediately if: -The dressing is non-occlusive or soiled. -If using a catheter securement device (Stat lock) it must be changed with each dressing change. Record Review of the facility's Central Line Dressing Change check off (not dated) stated: -Gather the necessary equipment: Antiseptic (chlorhexidine preferred) Sterile transparent semipermeable dressing (may be chlorhexidine impregnated) Or sterile 4 x 4 gauze pad Sterile tape Sterile drape Alcohol free skin barrier solution Sterile gloves Gloves Masks x2 (1 for nurse and 1 for the client) Label Sterile needless connectors (saline/ heparin lock) Sterile disinfectant caps Sterile, preservative free, prefilled syringes with 10 mL 0.9% normal saline (Number of syringes required based on number of lumens of the CVAD) *Many facilities have sterile pre-packaged CVAD dressing kits that contain the necessary supplies for a CVAD dressing change. Use of pre-packaged kits is recommended when available. -Follow manufacturer's recommendations for cleansing, application, and dry times: Follow manufacturer's recommendations for appropriate cleansing products, application, and dry times. Always allow the product to dry naturally without wiping, fanning, or blowing on the skin. Cleansing products are typically applied using back and forth motion while moving vertically and horizontally for at least 30 seconds. -Open the needleless connector package: Open the needleless connector package using sterile technique and inspect the integrity of the device. Attach the prefilled 10mL normal saline syringe and prime the connector. -Ensure the clamp between the connector and the catheter is closed -Remove the existing needleless connector and scrub the catheter hub: Remove the existing needleless connector. Perform a vigorous scrub of the catheter hub per facility policy. Allow it to dry completely. -Attach the new primed needleless connector: Attach the new primed needleless connector to the catheter hub and rotate to tighten. -Unclamp the catheter and aspirate for a blood return: Unclamp the catheter and aspirate for a blood return. If blood is aspirated, slowly inject the normal saline flush into the catheter using a pulsatile flushing technique. -Clamp the catheter and remove the syringe -Place a new antiseptic-impregnated sterile port cap: Place a new antiseptic-impregnated sterile port cap on the needleless connector, if available. Record review of the facility's Enhanced Barrier Precautions signage that was outside the entry doors of residents that required Enhanced Barrier Precautions states in part: -Providers and staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Device care or use: Central line.

Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one resident of 3 residents (Resident#1) reviewed for supervision. 1. The facility failed to ensure Resident #1 received adequate supervision when Resident #1 eloped from the facility on 12/06/23. Resident #1 was found by Driver A on 12/06/23 approximately 0.2 miles from facility near a highway. 2. The facility failed to implement interventions to prevent Resident #1's elopement from the facility. The non-compliance was identified as PNC. The IJ began on 12/06/23 and ended on 12/07/23. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of injury or death. Findings include: Record review of Resident #1's Admission Record, dated 04/10/24, documented an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included unspecified Dementia (decline in cognitive abilities), Muscle weakness, Abnormalities of gait and mobility and Cognitive communication deficit (difficulty with communication). Record review of Resident #1's Quarterly MDS, dated [DATE], reflected Brief Interview for Mental Status score of 2, which indicated severely impaired cognition. Record review of Resident #1's Elopement/Wandering Evaluation record, dated 12/6/23, reflected Resident #1 had a score of 13 and Category noted as High Risk. Record review of the Provider Investigation Report, dated 12/06/23, reflected Resident #1 was found at a Dialysis center by a Driver A. Driver A brought Resident #1 back to the facility. At 4:18 p.m. DON was notified and at 4:36 p.m. the resident was returned to facility with no injuries noted. The resident was no longer residing at the facility at the time of this investigation. In an interview on 04/10/24 at 9:08 a.m., the DON said Resident #1 left the facility and was found by the facility driver at a local dialysis center. She said they conducted an investigation. They reviewed the facility cameras and found Resident #1 exited the building from hall 300 at around 3:54 p.m. The DON said she did not know exactly how she ended up at the dialysis center. She said the area outside Hall 300 was fenced in. The DON said the facility driver found the resident around 4:07 p.m. and brought her back to the facility. She said Resident #1 was assessed and had a wander guard in place and had no injuries. DON said the cameras record for a short period of time and automatically record over. She did not have video of Resident #1 exiting facility saved for viewing. In an interview on 04/10/24 at 9:39 a.m., the Environmental Manager said Resident #1 left the facility from the exit door on hall 300. They reviewed the camera and found she went 3 times towards the exit trying to leave. She was able to get the door opened after a several attempts. The Environmental Manger said the door alarm did sound but it was not very loud. He said after the incident they placed another alarm near the top of the door. He said he was unsure how she left the premises since the area was fenced in. The Environmental Manager said they had a landscape company who went in every Wednesday and came in through that fenced area. He said there was a possibility the landscapers did not lock the fence or did not notice she walked out but he did not know if that was what happened. He said at the time, there was no one who verified if the fence was closed properly once they left the facility. Environmental Manager said after the elopement incident, he spoke to the contracted landscaping company and both he and the contractors will be ensuring the gates are closed and secured when they leave the facility grounds. In an interview on 04/10/24 at 10:01 a.m., LVN D said the day Resident #1 eloped, she was exit seeking. She said she redirected her at least once to the nurses station and Resident #1 went to the dining area where residents were participating in activities. In an interview on 04/10/24 at 10:22 a.m., Driver A said he was dropping off a resident at the dialysis center when he saw Resident #1 talking to a lady on the street at the dialysis center. He approached her and asked her to come with him back to the facility. He said she recognized him and appeared happy to see him and he was able to transport her back to the facility. Driver A said he called the facility to notify them he had found the resident at the dialysis center and was returning her back to the facility. In an interview on 04/10/24 at 2:56 p.m., the Activity Director said the day Resident #1 eloped, she was having an activity with the residents. She said Resident #1 was going towards the exit doors and she kept having to distract her with activities. In an interview on 04/10/24 at 3:00 p.m., CNA L said she conducted daily testing of door alarms for proper functioning and documented in the testing log. CNA L stated she also tested residents' wander guard bracelets for proper function. In an observation on 04/11/24 at 1:45 p.m. of hall 300 exit door located on north side of facility revealed door was equipped with code lock. Also noted was two white magnetic boxes at the top of the door. Further observation revealed door was programmed with delayed egress of 15 seconds. When door handle was held down door lock would release. The alarm was slightly audible, however, when door was ajar the alarm was audible at several decibels higher. In an observation on 04/11/24 at 1:50 p.m. revealed hall 300 exited into fenced off area of back yard. Gates were equipped with pool side gate latches. In an interview and observation on 04/11/24 at 2:20 p.m. with Environmental Manager revealed that after the resident was retrieved by the facility, he assessed the door Resident #1 had exited. The door was observed to function as designed. The Maintenance supervisor said they did notice that the door alarm was not audible, so additional door alarms were added to the top of the door. In an observation on 04/11/24 at 2:25 p.m. Environmental Manager engage two white magnetic boxes at the top of the door which initiated a high-pitched audible sound when door was open. In an interview on 04/11/24 at 2:45 p.m. with CNA L revealed she is in charge of testing the wander guard bracelets. CNA L said she checks every resident on the log to verify that the bracelets are placed as per orders and they are functional. If resident does not have guard on or it is not functional, she will get one from kit at nurses station. (Kit is a plastic box which contains parts for bracelets, replacement batteries and testing tool. Kit is located next to the wander guard log). CNA L said in addition to checking bracelets she also check that the locking mechanism at exit door is function properly. CNA L said only the main entrance is equipped with a wander guard lock, the rest of the doors only have alarms. In an interview on 04/11/24 at 2:50 pm CNA L demonstrated the use of testing wander guard device by walking towards system at which time there was an auditory signal and door lock engaged. In an observation on 04/11/24 at 2:55 p.m. CNA L demonstrated how bracelet was tested with resident by waving wand across bracelet. Record Review of Wander Guard Checklist dated April 2024 revealed daily testing of resident personal wander guards, photos of residents that are being monitored and documented daily testing log of wander guard bracelets. Record review of Resident #1's care plan, updated on 12/06/23, reflected the following interventions were put in place: -check for wander guard placement. -structured activities -check door alarms are working properly -elopement assessment completed -door alarms tested daily & documented Other precautions placed after incident were: -Daily Checking of exit Doors -Secondary door alarm (hall 3) -Pull lever on outside fence door Record Review revealed the following In-services conducted with staff after each incident: Topics: Elopement; abuse and neglect, missing resident policy and procedure, ensuring proper door engagement, fall and fall prevention. Dates: 12/06-12/23 Staff Interviews / All shifts: DON, ADON, LVN (3), RN (2), CMA (2), Environmental Manager, DON, . CNA's (4), Activity Director, Driver (1). All staff interviewed were informed and knowledgeable on facility policy and procedure related to identifying and monitoring residents with exit seeking tendencies, redirecting and ensuring residents at risk remained engaged. Record review of the facility's policy titled; Elopement / Unsafe Wandering Revised date 01/2022 states, Purpose: The facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision and diversional programs to prevent unsafe wandering while maintaining the least restrictive environment for those at risk for elopement.