Every finding on record at Villages of Lake Highlands

Based on observation, interview, and record review, the facility failed to develop and implement a baseline care plan within 48 hours for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 3 of 9 residents (Residents #20, #26, and #46) reviewed for baseline care plan. 1.The facility failed to ensure Resident #20 had a baseline care plan for her CPAP after admission to the facility on [DATE]. 2.The facility failed to ensure Resident #26 had a baseline care plan for her CPAP after admission to the facility on [DATE]. 3.The facility failed to ensure Resident #46 had a baseline care plan for risk for fall after admission to the facility on [DATE]. These failures could place the resident at risk of not receiving necessary care, treatment, and services upon admission that could result in worsening conditions.Findings included: 1.Record review of Resident #20's Face Sheet, dated 07/21/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. Upon admission, the resident had a diagnosis of sleep apnea. Record review of Resident #20's Comprehensive MDS Assessment, dated 07/17/2026, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated that the resident was using a BiPAP (bilevel positive airway pressure - normalizes breathing by delivering pressurized air into the upper airway leading into the lungs). Record review of Resident #20's Baseline Care Plan, dated 07/11/2026, reflected that the resident did not have a care plan for her BiPAP. Record review of Resident #20's Physician Order, dated 07/12/2026, reflected BiPAP: APPLY QHS at bedtime. During an observation and interview on 07/21/2026 at 9:32 a.m., revealed Resident #20 was in her bed, awake. A BiPAP machine was observed on top of her side table. She said she would use the BiPAP every night. 2.Record review of Resident #26's Face Sheet, dated 07/21/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. Upon admission, the resident had a diagnosis of sleep apnea. Record review of Resident #26's Comprehensive MDS Assessment, dated 07/19/2026, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident was not coded for her CPAP. Record review of Resident #26's Baseline Care Plan, dated 07/13/2026, reflected that the resident did not have a care plan for her CPAP. Record review of Resident #20's Physician Order, dated 07/14/2026, reflected CPAP 5 CM AT BEDTIME WITH SETTINGS (TDV-305 ML)-EXHAL MIN VOL-6.4 L, LEAK-14.3, PIP 5.7 CM)2-IVAB. During an observation and interview on 07/21/2026 at 9:18 a.m., revealed Resident #26 was in her bed, awake. A CPAP machine was observed on top of her side table. She said she had been using her CPAP for months every night. She said she had the CPAP when she was re-admitted to the facility. During an interview on 07/21/2026 at 9:26 a.m., LVN D said Resident #26 would wear her CPAP every night and was taken off every morning. 3.Record review of Resident #46's Face Sheet, dated 07/23/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. Upon admission, the resident had a diagnosis of a foot ulcer (wound on the foot) and difficulty in walking. Record review of Resident #46's Comprehensive MDS Assessment, dated 06/23/2026, reflected the resident was cognitively intact with a BIMS score of 13. The Comprehensive MDS Assessment indicated that the resident had foot ulcer and difficulty in walking. Record review of Resident #46's Baseline Care Plan, dated 07/11/2026, reflected that the resident was not care planned for being at risk for fall. Record review of Resident #46's Progress Note, dated 06/17/2026, reflected The resident has a cast on his left foot and is non weight bearing. Record review of Resident #46's Progress Note, dated 06/18/2026, reflected Hospitalization History . 06/09/2026 - admitted for left heel abscess and fall while weightbearing on external fixation device . NURSING / SAFETY . Fall precautions: yellow armband, non-skid socks, bed in lowest position, call light within reach. Record review of Resident #46's Progress Note, dated 06/18/2026, reflected History of Present Illness . On 06/09/2026, the patient was admitted after a fall that occurred while weightbearing on the external fixation device, presenting with a twisted leg . The patient has been maintained on strict non-weightbearing status of the left lower extremity throughout. During an observation and interview on 07/22/2026 at 9:23 a.m., Resident #46 was in the hall ambulating using a scooter. His left leg was on the scooter and was not touching the floor. He said he had wounds in his left foot that was why it had bandages on it. He said he was hospitalized because of the wounds and because he fell. During an observation and interview on 07/23/2026 at 7:05 a.m., MDS Coordinator I said if a resident was admitted to the facility with a CPAP or a BiPAP, then the baseline care plan should reflect it so the staff would know what immediate interventions should be done. She opened Resident #20 and Resident #26's baseline care plans and saw both residents did not have a baseline care plan for their non-invasive mechanical ventilator. She said if a resident had a fall before admission to the facility, the resident's base line care plan should reflect the resident was at risk for fall so proper monitoring could be done. She said the above treatment and incidents should have been captured to provide appropriate care. She said she would make sure the residents had a comprehensive care plan. During an interview on 07/23/2026 at 7:32 a.m., ADON A said the baseline care plan was a form of an initial evaluation to provide immediate care. She said if a resident was admitted to the facility with a CPAP or a BiPAP, they should have been included in the baseline care plan to provide the immediate treatment needed regarding the non-invasive mechanical ventilator. She said if a resident had a fall outside the facility, then there should be baseline care plan that he was at risk for fall and just revise it if the resident had an actual fall while in the facility. During an interview on 07/23/2026 at 8:13 a.m., the DON said the baseline care plans were important because it would give the providers the minimum healthcare information about the resident that needed to be addressed immediately or upon admission. She said without the baseline care plan, the immediate needs of the resident would not be met. She said the CPAP and the BiPAP should have been captured during admission. She said Resident #46 was admitted to the facility due to infected wounds and not because of fall. She said, but if the resident had a fall prior to admission to the facility, it would be proper that a risk for fall was included in the baseline care plan. She said she would review Resident #46's progress notes to see if he had a fall. She said she would coordinate with the MDS Coordinator about the issue. During an interview on 07/23/2026 at 8:46 a.m., the Administrator said all the residents must have a baseline care so that the staff would know how to take care of the residents as soon as they were admitted to the facility. He said the expectation was for the staff to initiate the baseline care plan immediately after admission. He said he would collaborate with the DON and the MDS Coordinator. Record review of the facility's policy Care Plans - Baseline 2001 MED-PASS, Inc. revised March 2022 reflected Policy Statement: A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission.

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights 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 5 of 12 residents (Resident #20, #12, #29, #40, and #61) reviewed for care plans. 1.The facility failed to ensure Resident #20 had a care plan for her indwelling catheter on 07/21/2026. 2.The facility failed to ensure Resident #29 had a care plan for his mode of transfer on 07/21/2026. 3.The facility failed to ensure Resident #61 had a care plan for his mode of transfer on 07/21/2026. 4.The facility failed to ensure Resident #40 had a care plan for his feeding tube on 07/22/2026. 5.The facility failed to develop Resident # 12's care plan related to his use of antipsychotic medication. These failures could place the residents at risk of not receiving the necessary care and services.Findings included: 1.Record review of Resident #20's Face Sheet, dated 07/21/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with ESBL (Extended-Spectrum Beta-Lactamase: bacteria that resist most antibiotics). Record review of Resident #20's Comprehensive MDS Assessment, dated 07/17/2026, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated that the resident had an indwelling catheter (a thin, flexible tube inserted in the bladder to allow the urine to flow in the catheter bag). Record review of Resident #20's Comprehensive Care Plan, dated 07/14/2026, reflected that the resident did not have a care plan for her indwelling catheter. Record review of Resident #20's Physician Order, dated 07/11/2026, reflected Indwelling Catheter Care Q shift every shift. Record review of Resident #20's Progress Note, dated 04/02/2026, reflected UA culture via catheter. During an observation and interview on 07/21/2026 at 9:18 a.m., Resident #20 was in her bed, awake. A catheter bag, with a privacy bag, was observed hanging at the side of the bed. The resident said she had the catheter for months. 2.Record review of Resident #29's Face Sheet, dated 07/23/2026, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with included muscle weakness. Record review of Resident #29's Comprehensive MDS Assessment, dated 07/15/2026, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment did not indicate the resident was using a mechanical lift. Record review of Resident #29's Comprehensive Care Plan, dated 05/11/2026, reflected the resident did not have a care plan for transfer via mechanical lift. Record review on 07/21/2026 of the Lift Transfer List, provided by the DON, reflected Resident #29 was transferred via mechanical lift. 3.Record review of Resident #61's Face Sheet, dated 07/23/2026, reflected a [AGE] year-old male, admitted to the facility on [DATE]. The resident was diagnosed with paraplegia. Record review of Resident #61's Comprehensive MDS Assessment, dated 05/13/2026, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment did not indicate the resident was using a mechanical lift. Record review of Resident #61's Comprehensive Care Plan, dated 06/03/2026, reflected the resident was not care planned for transfer via mechanical lift. Record review on 07/21/2026 of the Lift Transfer List, provided by the DON, reflected Resident #61 was transferred via mechanical lift. 4.Record review of Resident #40's Face Sheet, dated 07/22/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with dysphagia (difficulty in swallowing). Record review of Resident #40's Comprehensive MDS Assessment, dated 06/24/2026, reflected the resident had severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident had a feeding tube. Record review on 07/22/2026 of Resident #40's Comprehensive Care Plan reflected the resident did not have a care plan for his feeding tube. Record review of Resident #40's Physician Order, dated 07/23/2026, reflected every shift Administer 75 cc tap water via G-tube (gastrostomy feeding tube: a tube that is surgically inserted through the skin of the belly and into the stomach) prior to formula or medication administration. During an observation on 07/22/2026 at 8:30 a.m. revealed Resident #40 was in his bed awake. The resident had a g-tube connected to a feeding formula. The resident was unable to reply when interviewed due to aphasia (an impairment that affects an individual's comprehension or formulation of language). During an observation and interview on 07/22/2026 at 8:35 a.m., LVN C was about to administer Resident #40's medication via g-tube. He said the resident had the g-tube since he was admitted to the facility. During an interview on 07/23/2026 at 7:05 a.m., MDS Coordinator I said if a resident had a g-tube or indwelling catheter, then there should be a care plan for them. She said the comprehensive care plan could be done annually, quarterly, and if there was a change in condition. She said the care plans should be in place so that everybody taking care of the resident would be aware of how to manage the resident. She said the care plan should reflect the potential issues of the residents and provide interventions for such issues. During an interview on 07/23/2026 at 7:15 a.m., MDS Coordinator K said the mode of transfer should be included in the residents' care plan so the staff would know the kind of transfer to prevent untoward incidents like fall during transfer. During an interview on 07/23/2026 at 7:32 a.m., ADON A said care plans should reflect the needs of the residents that needed to be addressed. She said the care plan served as the facility's agreement with the resident in terms of the care and services that the facility would be providing. She said another purpose of the care plan was that the individuals taking care of the residents would be on the same page. During an interview on 07/23/2026 at 8:13 a.m., the DON said the MDS Coordinators were responsible for making the care plans of the residents. She said care plans should be in place to reflect the realistic goals and the needed interventions for a certain condition. She said the care plans could be used as well to gauge if the expectations were met. She said the expectation was for all the issues of the residents were care planned appropriately. She said she would coordinate with the MDS Coordinators with regard to the care plan of the residents. During an interview on 07/23/2026 at 8:46 a.m., the Administrator said the expectation was that all the residents were care planned specific to their needs so the staff taking care of the residents could provide the care and services needed. He said care plans should be in place so that the individuals providing care for the residents would be on the same page. He said she would coordinate with the MDS Coordinators and the DON regarding the care plans of the residents. 5.Record review of face sheet dated 07/23/2026 reflected Resident #12 was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included stroke (blood flow to part of the brain stops or gets blocked), aphasia (a disorder that affects the ability to speak or understand speech), hemiplegia ( a medical condition that causes total or partial paralysis on one side of the body) and seizure disorder (a medical condition marked by sudden, unprovoked, and repeating electrical surges to the brain). Record review of Resident #12's admission MDS assessment dated [DATE] indicated his BIMS was not completed due to his inability to rarely or never understood. Record review of Resident #12's care plan on 07/22/2026 revealed he did not have a care plan to address the use of Seroquel; an antipsychotic medication related to restlessness. In an interview on 07/22/2026 at 2:42 p.m., the MDS Coordinator stated that residents who take anti-psychotic medications should have a care plan to address that. She stated that behavior monitoring was occurring, and it was she must have just missed it. She stated there was no risk to the resident for not having a care plan for the medication. In an interview on 07/23/2026 at 3:54 p.m., the DON revealed that she expected there to be a care plan to address the use of an anti-psychotic medication and that the MDS nurse was responsible for having that in the care plan. She stated it was an oversight, and there was no risk to the resident for not having a care plan to address the use of an anti-psychotic medication. Record review of the facility's policy Care Plans, Comprehensive Person-Centered 2001 MED-PASS, Inc. revised March 2022 reflected Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on observation, interview, and record review, the facility failed to ensure that the resident's environment remains as free from accidents and hazards as possible and that each resident receives adequate supervision and assistance devices to prevent accidents for 3 of 5 residents (Residents #17, #34, and #46) reviewed for quality of care. The facility failed to ensure CNA G did not leave Resident #17, in her bed, after she removed the fall mat and raised her bed on 07/22/2026. 2. The facility failed to ensure the DOA did not take Resident #34's tray from the food cart without the nurse checking it first on 07/21/2026. 3. The facility failed to ensure Resident #46 did not have a packet of single edge razors and screw drivers in his room on 07/21/26. These failures placed the residents at risk for misuse of sharp objects, injuries, accidents, choking and could result in a decline in health.Findings included: Record review of Resident #17's Face Sheet, dated 07/22/2026, reflected an [AGE] year-old female admitted [DATE]. The resident was diagnosed with Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills), anxiety (intense or excessive fear or worry), and mood disorder (condition characterized with abnormal emotional state such as irritability and intense sadness). Record review of Resident #17's Comprehensive MDS Assessment, dated 05/15/2026, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident was dependent on staff for transfer. Record review of Resident #17's Comprehensive Care Plan, dated 05/16/2026, reflected the resident required a mechanical lift x 2 staff assist. The plan indicated the resident had an impaired self-mobility and was at risk for falls. The goal for both was the resident would be free from falls and intervention for both was to provide a safe environment. During an observation on 07/22/2026 at 8:06 a.m. revealed CNA G and CNA J were about to transfer Resident #17 via mechanical lift. CNA G and CNA J entered the resident's room. CNA G went to the restroom and washed her hands. CNA G removed the fall mat and then went to the restroom to wash her hands. Both CNAs were inside the restroom and left the resident unattended without her fall mat. CNA G told CNA J that she needed to get the mechanical lift from outside the room. While CNA J was getting the mechanical lift, CNA G raised the resident's bed and stepped out again, leaving the bed raised with the resident still in it. During an interview on 07/22/2026 at 8:27 a.m., CNA G said she should have not left Resident #17 unattended when she removed the fall mat and when she raised her bed because the resident might move and fall from the bed. She said the fall mat and the keeping the bed in its lowest position were fall precautions to prevent falls or any injuries if a resident fell. She said they should have washed their hands one at a time to keep somebody with the resident when the fall mat was removed and when the bed was raised. 2. Record review of Resident #34's Face Sheet, dated 07/22/2026, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with gastrointestinal hemorrhage (loss of blood in the digestive tract), cognitive communication deficit (unable to convey or understand messages), and protein-calorie malnutrition inadequate intake of protein). Record review of Resident #34's Comprehensive MDS Assessment, dated 05/19/2026, reflected the resident had moderate impairment (resident may need additional support and monitoring) in cognition with a BIMS score of 10. The Comprehensive MDS Assessment indicated the resident required set-up assistance for eating. Record review of Resident #34's Comprehensive Care Plan, dated 05/28/2026, reflected the resident was resistive to ADL care assistance and one of the interventions was to give clear explanation of all care prior to each contact. During an observation on 07/21/2026 at 11:42 a.m., revealed the food cart was delivered to hall 100. As soon as the food cart was left in the hallway, the DOA opened the food cart, took a tray, and entered Resident #34's room. The DOA did not wait for the nurse to check the food tray. During an interview on 07/21/2026 at 11:45 a.m., the DOA said she was just helping out to deliver the food trays of the residents. She said she checked the name on the tray before getting the food tray and giving it to the resident. She said the nurse could check it again. She said she was not aware the food trays should be checked first by the nurses before leaving the food cart. She said she should have waited for the nurse. She said she was also a CNA but was not working on the floor anymore. During an observation and interview on 07/21/2026 at 11:48 a.m., CNA H was in the hallway beside the food cart. She said she was waiting for LVN E to check the food tray before they could take them to the residents. She said a nurse should check if the food in the tray was the residents' diet. During an interview on 07/21/2026 at 11:55 a.m., LVN E said the DOA should have waited for a nurse to check Resident #34's food tray before taking it from the food cart. She said a staff member could not bring the food tray until a nurse checked it to check if the tray had the right diet for a particular resident. She said the staff might give the wrong food tray that could lead to chocking because a wrong diet was given or allergic reactions because the resident was allergic to the wrong food. She said she did not know the DOA was also a CNA, and she did not usually give the residents their food trays. During an interview on 07/23/2026 at 7:32 a.m., ADON A said nurses should always check the food trays before they leave the food carts for safety reasons because they need to check if it was the right resident and right diet. Even though kitchen would prepare them per meal ticket, nurses still needed to re-check them as another layer of safety measures specially if a staff member that was helping was not working on the floor, not from the nursing department, and had no knowledge of the residents' diet. She said the risk could be allergic reactions, and wrong food consistency was given. She said one example was that the resident had a mechanical diet and was given a regular diet. The resident could choke because the resident was given bigger chunks of food that he could not swallow. She said helping was good, but the staff should follow the right protocol. She said the fall precautions, such as fall mats and beds in its lowest position, should have been left in place until they were ready to transfer to the resident. She said leaving the resident unattended after fall precautions were removed could result in falls with major injuries. She said the residents' safety had always been their biggest concern. She said they would educate the staff, assess where they were lacking, what their weak spots were, so they would know what areas to focus on their education. During an interview on 07/23/2026 at 8:13 a.m., the DON said the staff should have taken turns in leaving the resident if they needed to wash their hands or do something else but not leave the resident without the fall mat and the bed already raised. She said the resident might move, fall from the bed, and sustain injuries because there was no mat and falling from a raised bed. She said the expectation was for the nurses to check out the food trays first before giving them to the residents. She said she would start an in-service to re-educate the staff to prevent anything that could be harmful for the residents. She said the CNAs knew to wait for the nurses to check the food trays but would educate the non-clinical staff on what to do if they wanted to help pass the trays. During an interview on 07/23/2026 at 8:46 a.m., the Administrator said the fall mat should have not been removed, and the bed was not raised until the staff were ready to transfer the residents. He said the fall precautions were in place to protect the residents and leaving the residents without them could lead to major injuries. He said food trays should be checked by the nurses. He said the expectation was for the staff to be mindful not to inflict any harm to the residents. He said they would do an in-service about the concern identified, talk to the individuals involved to do a one-on-one re-education, and monitor closely that they understood the in-service. 3. Record review of Resident #46's Face Sheet, dated 07/21/26, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with Type 2 Diabetes with foot Ulcer (High blood sugar with foot ulcer), Muscle weakness (generalized) and Difficulty in walking. Record review of Resident #46's Quarterly MDS Assessment, dated 06/23/26, revealed that the resident had a BIMS of 13 (intact cognition), it revealed the resident a fall in in the last month prior to admission. Record review of Resident #46's Comprehensive Care Plan dated 07/01/26, revealed the resident likes to keep his room messy and places towels and clothes on the floor. Resident #46 will not allow staff to pick up the towels and clothes. Staff has educated that this could be a fall risk and is an infection control issue. He verbalizes understanding but still request that staff not touch or clean his room with intervention for Staff will continue to educate and remind Resident #46 to allow staff to pick up and clean his room for safety and infection purposes. During an observation on 07/21/26 at 11:48 a.m., Resident #46 was not in his room during rounding in the 300 hall. It was observed that a pack or single edge razor and 2 screw drivers were on his nightstand. RN Q was notified and she promptly removed the items from the nightstand. During an interview on 07/21/26 at 12:05 p.m., RN Q stated no residents are allowed to have sharp objects in the razor. She stated that Resident #46 likely got the razors and screw drivers when he went out on pass. She stated that they have educated Resident #46 on not having such items in his room. She stated when hazards are found they are removed and reported to the administrator. She stated that the resident is here for antibiotics and will be discharged after 7/24/26 after his antibiotic therapy is completed. She stated that they always check the rooms in the mornings and not sure where he got them from. She states that all staff are responsible for checking and removing any hazards from resident rooms and letting them know why they should not have them. She stated it is a safety issue. She stated Resident #46 can cut himself with the razor. She stated that the resident shaves himself with an electric razor under staff supervision. She stated she is not sure why the resident has them. During an interview on 07/21/26 at 12:15 p.m., CNA L stated that she does not know how Resident #46 got the razor and tools in his room. She stated that the resident is not allowed to have any open razors or tools in the room. She stated it is for safety and he can use it when they are not supposed to. She stated that it might harm him, it can cause injury if he cuts himself. She stated that he is supervised during shaving using a shaving stick or electric razor. She stated that she does rounds every 15 minutes, she stated that she has never noticed the razors in Resident #46's room. She stated that if she finds any items the resident should not have in the facility, she removes it and gives them to the nurse. She stated that every staff member does rounds and is responsible for removing and reporting any prohibited items to the nurse or administrator. During an interview on 07/22/26 at 9:55 a.m., Resident #46 stated that he had been here since 06/17/26. He stated that the charge nurse RN Q did not inform him that she removed his razors from his room for safety and that is upsetting to him. He stated that he had been educated about not having razors in the open but must have forgotten to store them securely after he used them. During an interview on 07/22/26 at 10:30 a.m., RN Q stated that she had not informed Resident #46 about the razors that were removed from his room, she just handed them over to the ADON who took them to the Administrator. During an interview on 07/22/26 at 12:17 p.m., the Administrator stated that the policy is that no residents should have blades in their rooms. He stated that the policy is to ensure safety of all residents in the building. He stated that the residents can injure themselves with blades, especially those who are confused. He stated that they had provided education to Resident #46 on not keeping blades in his room, however, he keeps possession of them. He stated that they have removed the blades from Resident #46 room and will provide him with safety blades for shaving. He stated they will make rounds to ensure that hazardous items are not in any of the residents' rooms. During an interview on 07/23/26 at 11:20 a.m., the Administrator stated that he found out 07/23/26 that Resident #46 had a fall on 06/26/26 during Physical therapy. He stated that the therapy department informed him about it, and they have investigated why it was not documented properly. He stated that all falls have to be reported to the charge nurse, assess the resident before he is moved off the floor and follow the fall protocol. He stated that the protocol was not followed because Physical therapist W did not follow the fall protocol, he stated that the therapist is trained on what to do with falls and how to report any changes to the charge nurse. He stated that the therapist is on suspension pending the outcome of an investigation of the incident. He stated that an incident report had been initiated after he found out about the fall. He stated that training was initiated with physical therapy team and the rest of the staff on what to do in case of a fall. Record review of the facility's policy Lifting Machine, Using a Mechanical 2001 MED-PASS, Inc. revised July 2017 reflected Purpose: The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. Record review of the facility's policy Timely Meal Service Dining/Meal Service revised February 2026 reflected Policy: Food will be delivered promptly to ensure safe . food served . Procedure 4. Food will be distributed promptly . with supervision by nursing staff.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services. The facility failed to ensure all food items in the kitchen were dated and discarded prior to their use-by date and were properly sealed. This failure could place residents at risk for food contamination and food-borne illness.Findings Included: An observation on 07/21/2026 between 9:19 AM and 9:55 AM in the facility's kitchen revealed. One 11lb. plastic tub of chocolate fudge icing expired 07/12/26. One gallon bag containing pasta elbow noodles dated 07/20/26 with no visible expiration date. One gallon jug Apple cider Vinegar dated 06/30 with a used by date of 04/25/25. One gallon bag containing sausage dated 07/12/26 with no visible expiration date. One gallon bag containing diced turkey date 07/02/26 with no visible expiration date.One 10.15 lbs. bag Frozen Salsbury steak with no visible dates, not properly sealed and exposed to air contaminants. One plastic bag containing frozen cookie dough with no visible dates. One bag of breadstick dough with no visible dates, not properly sealed and exposed to air contaminants. One gallon bag of sweet potatoes dated 06/19 with no visible expiration date. During an interview on 07/22/26, at 10:14 AM, DSM stated he was the person overall responsible for ensuring the kitchen was meeting guidelines for food storage and kitchen sanitization. DSM confirmed the observations and stated these items would be corrected. DSM stated once items are opened, they should be properly sealed and dated. DSM stated he was responsible for ensuring policy was followed. DSM stated he and the kitchen aides were responsible for labeling and making sure that the items were labeled properly. DSM stated the risk to residents if policy was not followed was a health risk to the residents. DSM stated the items should be labeled, and the risk of the concerns not being addressed could result in food-borne illnesses. DSM stated if food items were not dated when opened, then they would not know how long the item would last. DSM stated that a full in-service, will be completed in reference to food rotation and storage pertaining to what the proper procedures were dealing with food rotation and storage. DSM stated the risk of serving foods that were past the use-by date, or serving food that was not labeled or dated, could cause food borne illness to residents. During an interview on 07/23/26, at 1:55 PM, ADMIN stated oversaw all departments, and ensured residents were taken care of. ADMIN stated the DSM made him aware of the concerns observed in the kitchen. ADMIN stated the issues could cause food contamination. If items were expired, they should not serve them to residents. ADMIN stated the risk of those concerns observed in the kitchen could result in residents getting sick. ADMIN stated his expectation is for the DSM and kitchen staff to ensure that the kitchen staff followed all guidelines, including ensuring the food items were labeled properly in the kitchen. He said the risk to residents if policy was not followed, was they could get sick from food borne illnesses. Record review of Facility's Policy & Procedure Manual Food Storage, dated 2023. Policy: Sufficient storage facilities will be provide to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. 7. All stock must be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of all foods. a. Old stock is always used first (first in -first out method or FIFO). b. Food should be dated as it is placed on the shelves if required by state regulation. c. Date marking should be visible on all high risk food to indicate the date by which a ready-to-eat TCS food should be consumed, sold, or discarded.

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 three of fifteen residents (Residents #3, #34, and #40) and five of eight facility staff (CNA G, LVN E, LVN C, LVN F, and the DOA) reviewed for infection control. 1.The facility failed to ensure CNA G performed hand hygiene and changed her gloves during Resident #3's incontinent care on 07/22/2026. 2.The facility failed to ensure LVN E and the DOA wore gowns when Resident #34, who was on enhanced barrier precautions due to wound to left heel, was repositioned on 07/21/2026. 3.The facility failed to ensure LVN C performed hand hygiene during medication administration for Resident #40 on 07/22/2026. 4.The facility failed to ensure LVN F did not put her chocolate bar on top of her cart on 07/22/2026. These failures could place residents at risk of cross-contamination and development of infections.Findings include: 1.Record review of Resident #3's Face Sheet, dated 07/22/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness. Record review of Resident #3's Comprehensive MDS Assessment, dated 05/10/2026, reflected the resident had severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment did not indicate the resident was incontinent (unable to control) for bladder and bowel. Record review of Resident #3's Comprehensive Care Plan, dated 05/27/2026, reflected the resident had bladder and bowel incontinence and one of the interventions was to clean peri-area (area between the legs) each incontinent episode. During an observation on 07/22/2026 at 6:50 a.m., CNA G and CNA H were about to perform Resident #3's incontinent care. Both CNAs washed their hands and put on gloves and gowns. CNA G positioned herself on the left side of the resident and CNA H on the right side. CNA G unfastened the resident's brief and tucked it between the resident's legs. She did not change her gloves after touching the soiled brief. CNA H did the process of incontinent care while CNA G was on standby. When CNA H was done with perineal (area between the legs) care, she placed the new brief underneath the resident and rolled back the resident. CNA G assisted by fixing the brief with the same gloves she used to unfasten the soiled brief. When incontinent care was done, CNA G fixed the resident's blanket and fixed the resident's eye mask. During an interview on 07/22/26 at 7:15 a.m., CNA G said gloves should be changed after touching the soiled brief and before touching the new brief to prevent infections. She said if gloves were not changed during perineal care, it could result in the resident developing a UTI. She said she was so focused on checking that CNA H was doing the right procedure that she forgot to change her gloves. She said in-services were conducted for hand hygiene and infection control periodically for all care staff. 2.Record review of Resident #34's Face Sheet, dated 07/22/2026, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with orthopedic aftercare (care provided after orthopedic [relating to the bones or muscles] surgery). Record review of Resident #34's Comprehensive MDS Assessment, dated 05/19/2026, reflected the resident had moderate impairment in cognition with a BIMS score of 10. The Comprehensive MDS Assessment indicated the resident had a deep tissue injury (injury to underlying tissues). Record review of Resident #34's Comprehensive Care Plan, dated 05/28/2026, reflected the resident had a deep tissue injury to left heel and one of the interventions was to provide treatment. Record review of Resident #34's Physician Order, dated 07/08/2026, reflected Enhanced Barrier Precautions: Providers and Staff must wear gloves and a gown when performing High - Contact resident care activities-WOUNDS every shift for Prophylaxis (action taken to prevent disease). During an observation on 07/21/2026 at 11:47 a.m., LVN E and the DOA were about to reposition Resident #34. They did not wear gowns while repositioning the resident, and both of them were leaning on the bed during the process. A sign was outside the resident's door indicating the resident was on enhanced barrier precautions. During an interview on 07/21/2026 at 11:55 a.m., LVN E said gowns were required when they repositioned Resident #34 because it was a high contact activity. She said she forgot to wear one and even forgot to instruct the DOA to wear a gown as well. She said the resident had a wound to his left heel that needed dressing change. She said the gown was required to prevent the spread of microorganisms. 3.Record review of Resident #40's Face Sheet, dated 07/22/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with dysphagia. Record review of Resident #40's Comprehensive MDS Assessment, dated 06/24/2026, reflected the resident had severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment did not indicate the resident had a feeding tube. Record review on 07/22/2026 of Resident #40's Comprehensive Care Plan reflected the resident did not have a care plan for his feeding tube. During an observation on 07/22/2026 at 8:35 a.m., LVN C was about to administer Resident #40's medication via g-tube. While he was dissolving the resident's medication that was on top of the resident's overbed table, the resident's left leg hung down from the bed and the resident's pillows fell on the floor. LVN C, with his gloves on, picked up the pillow and the wedge from the floor and lifted the resident's left leg and placed it back to the bed. He fixed the pillow and the wedge at the side of the bed. He changed his gloves but did not do hand hygiene before putting on a new pair of gloves. He continued to prepare the resident's medication. The resident's left leg hung again from the bed, and the pillows fell again to the floor. He fixed again the resident's leg and fixed the pillow and wedge at the side of the bed. He changed his gloves but did not perform hand hygiene. During an interview on 07/22/2026 at 9:32 a.m., LVN C said he got distracted because Resident #40's left leg and the pillows kept on falling from the bed and at the same time preparing his medications that he forgot to do hand hygiene when he changed his gloves. He said hand hygiene should be done before putting on new gloves because he used the gloves to touch the pillow and wedge from the floor and the resident's bare skin. He said he needed to make sure that his hands were clean before touching the new gloves to use in preparing the medications and touching the resident's g-tube. He said the purpose of hand hygiene was to prevent cross contamination. 4.During an observation on 07/22/2026 at 10:23 a.m., a bar of chocolate was observed on top of a nurse's cart. During an interview on 07/22/2026 at 10:42 a.m., LVN F said the chocolate bar was given to her by a resident. She said she was doing something, that was why she placed the chocolate on her cart. She said after she was done with what she was doing, she took the chocolate bar from the top of her cart and placed it on her pocket. She said she should have placed the chocolate bar in her pocket directly instead of putting it on top of her cart. She said she did not know the last place it was set down and if the individual who handed it to her had clean hands or did not have any skin condition. She said putting the chocolate bar on her cart could be an infection control issue. During an interview on 07/23/2026 at 7:32 a.m., ADON A said the expectation was for staff to not cause any spread of infection in the facility. She said the staff should change their gloves after touching the soiled brief and before touching the new brief, perform hand hygiene between changing gloves, and wear PPE when residents were on EBP. She said not following the said procedures could result in probable infection. She said the procedure should always be from clean to dirty and not the other way around. She said staff should not put any personal items, like food or drinks, on top of their cart where they prepare their medications because they would not know if they were clean or not. She said it could eventually contaminate the cart and the medications being prepared. She said the residents' well-being had always been their biggest concern. She said they would educate the staff, assess where they were lacking, what their weak spots were, so they would know what areas to focus on their education. During an interview on 07/23/2026 at 8:13 a.m., the DON said hand hygiene was the most effective way to prevent cross contamination and spread of infection. She said staff should do hand hygiene when they were changing their gloves, said gloves should be changed after touching the soiled brief, and said staff should wear gowns when required. She said soiled gloves should not be used in fixing the new brief. She said if there was an EBP sign outside the residents' rooms, then staff were required to wear a gown for high contact activities, in addition to gloves, to protect the residents from cross contamination and probable infection. She said the chocolate bar could also be a source of cross contamination and should not be placed on top of the cart. She said the expectation was for the staff to adhere to the policy of hand washing and infection control. She said she would start an in-service about hand hygiene and infection control to re-educate the staff. During an interview on 07/23/2026 at 8:46 a.m., the Administrator said the expectation was for the staff to change their gloves after touching something soiled, to do hand hygiene when changing their gloves, and to put on a gown when required. He said there should be no personal food on top of the cart because it could also be an infection control issue. He said the concerns discussed could result in development and spread of infection. He said they would do an in-service about the concern identified, talk to the individuals involved to do a one-on-one re-education, and monitor closely that they understood the in-service. Record review of the facility's policy Enhanced Barrier Protection undated, reflected Summary of PPE Use and Room Restrictions When Caring for Residents . wounds . high contact resident care activities . transferring . gloves and gown. Record review of the facility's policy Infection Control Guidelines for All Nursing Procedures Nursing Services Policy and Procedures Manual for Long-Term Care revised August 2012 reflected Purpose: To provide guidelines for general infection control while caring for the residents . 4. Hand hygiene . d. before preparing or handling medications . f. Before moving from a contaminated body site to a clean body site during resident care . g. after contact with resident's intact skin . j. After removing gloves. Record review of the facility's policy FOOD FROM OUTSIDE SOURCES Policy & Procedure Manual, undated, reflected Policy: Food from outside sources is discouraged due to problems with food safety and infection control.

Based on observation, interviews, and record review, the facility failed to ensure assessments accurately reflected the resident's status for 9 of 29 residents (Residents #3, #17, #26, #29, #40, #61, , #77, #100, and #113) reviewed for accuracy of assessments.1.The facility failed to ensure Resident #26's Comprehensive MDS Assessment accurately reflected the resident was using a CPAP. 2.The facility failed to ensure Residents #3, #17, #29, #40, #61, #77, #100, and #113's Comprehensive MDS Assessments accurately reflected the residents were using mechanical lifts. These failures could place residents at risk for not receiving care and services needed to meet their needs, diminished function of health, and regression in their overall health.Findings included: 1.Record review of Resident #26's Face Sheet, dated 07/21/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. Upon admission, the resident had a diagnosis of sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep). Record review of Resident #26's Comprehensive MDS (assessment used to determine functional capabilities and health needs) Assessment, dated 07/19/2026, reflected the resident had a severe impairment (resident required significant assistance and support in daily life) in cognition with a BIMS (screening tool used to assess cognitive status) score of 00. The Comprehensive MDS Assessment indicated the resident was not coded for her CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open). Record review of Resident #26's Baseline Care Plan, dated 07/13/2026, reflected that the resident did not have a care plan for her CPAP. Record review of Resident #26's Physician Order, dated 07/14/2026, reflected CPAP 5 CM AT BEDTIME WITH SETTINGS (TDV [Therapy Delivery pressure: amount of pressure delivered by a CPAP]-305 ML)-EXHAL MIN VOL-6.4 L, LEAK (escape of air from the mask) -14.3, PIP (Peak Inspiratory Pressure: the highest pressure in a single breath) 5.7 CM 2-IVAP (Intelligent Volume-Assured Pressure Support: is an advanced non-invasive ventilation mode that automatically adjusts the level of pressure support to breathing). During an observation and interview on 07/21/2026 at 9:18 a.m., revealed Resident #26 was in her bed, awake. She said she had been using her CPAP for months every night. She staff would put in on at night and would take it off in the morning. During an interview on 07/21/2026 at 9:26 a.m., LVN D said Resident #26 would wear her CPAP every night and was taken off every morning. 2.Resident #3 Record review of Resident #3's Face Sheet, dated 07/22/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with fracture (broken bone) and weakness. Record review of Resident #3's Comprehensive MDS Assessment, dated 05/10/2026, reflected the resident had severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment did not indicate the resident was using a mechanical lift (a device used to lift, transfer, or position an individual with limited mobility). Record review of Resident #3's Comprehensive Care Plan, dated 05/27/2025, reflected the resident was at risk for falls and one of the interventions was mechanical lift transfer 2 person assist. During an observation and interview on 07/21/2026 at 11:41 a.m., Resident #3 was sitting in her wheelchair. She said the staff just transferred her to her wheelchair using a mechanical lift because she needed to go to therapy. During an interview on 07/21/2026 at 11:43 a.m., LVN E said the staff had already transferred Resident #3 because she was scheduled for therapy. She said the resident was transferred via mechanical lift. Resident #17 Record review of Resident #17's Face Sheet, dated 07/22/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with contracture (tightening or shortening of the muscles) and presence of artificial hip. Record review of Resident #17's Comprehensive MDS Assessment, dated 05/15/2026, reflected the resident had severe impairment with a BIMS score of 00. The Comprehensive MDS Assessment did not indicate the resident was using a mechanical lift. Record review of Resident #17's Comprehensive Care Plan, dated 05/17/2026, reflected the resident required mechanical lift times 2 staff assist and one of the interventions was to transfer via mechanical lift times two staff assistance. During an observation on 07/22/2026 at 8:33 a.m., revealed CNA G and CNA J transferred Resident #17 via mechanical lift. Resident #29 Record review of Resident #29's Face Sheet, dated 07/23/2026, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with included muscle weakness. Record review of Resident #29's Comprehensive MDS Assessment, dated 07/15/2026, reflected the resident was cognitively intact (resident capable of normal cognition and needs little support) with a BIMS score of 15. The Comprehensive MDS Assessment did not indicate the resident was using a mechanical lift. Record review of Resident #29's Comprehensive Care Plan, dated 05/11/2026, reflected the resident did not have a care plan for transfer via mechanical lift. Resident #40 Record review of Resident #40's Face Sheet, dated 07/22/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with cerebral infarction (insufficient oxygen in the brain causing stroke) and dystonia (uncontrollable muscle contractions leading to abnormal twisting movements). Record review of Resident #40's Comprehensive MDS Assessment, dated 06/24/2026, reflected the resident had severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment did not indicate the resident was using a mechanical lift. Record review of Resident #40's Comprehensive Care Plan, dated 07/13/2026, reflected the resident had ADL self-care and mobility deficits and one of the interventions was to transfer via mechanical lift. During an interview on 07/22/2026 at 8:45 a.m., LVN C said Resident #40 would be transferred to his wheelchair via mechanical shift after medication administration because he needed to go to his therapy. Resident #61 Record review of Resident #61's Face Sheet, dated 07/23/2026, reflected a [AGE] year-old male, admitted to the facility on [DATE]. The resident was diagnosed with paraplegia (paralysis of the legs and lower part of the body). Record review of Resident #61's Comprehensive MDS Assessment, dated 05/13/2026, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment did not indicate the resident was using a mechanical lift. Record review of Resident #61's Comprehensive Care Plan, dated 06/03/2026, reflected the resident was not care planned for transfer via mechanical lift. Record review on 07/21/2026 of the Lift Transfer List, provided by the DON, reflected Resident #61 was transferred via mechanical lift. Resident #77 Record review of Resident #77's Face Sheet, dated 07/23/2026, reflected an [AGE] year-old female admitted to the facility 02/20/2026. The resident was diagnosed with amyotrophic lateral sclerosis (a disorder that affects the brain and the spinal cord that results to loss of movement to both upper and lower extremities). Record review of Resident #77's Comprehensive MDS Assessment, dated 07/17/2026, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment did not indicate the resident was using a mechanical lift. Record review of Resident #77's Comprehensive Care Plan, dated 06/18/2026, reflected the resident had physical mobility limitations and one of the interventions was to use mechanical lift for transfer. Record review on 07/21/2026 of the Lift Transfer List, provided by the DON, reflected Resident #77 was transferred via mechanical lift. Resident #100 Record review of Resident #100's Face Sheet, dated 07/23/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and obesity (excessive accumulation of body fats). Record review of Resident #100's Comprehensive MDS Assessment, dated 06/16/2026, reflected the resident was cognitively intact with a BIMS score of 13. The Comprehensive MDS Assessment did not indicate the resident was using a mechanical lift. Record review of Resident #100's Comprehensive Care Plan, dated 06/19/2026, reflected the resident had limited physical mobility and one of the interventions was to transfer via mechanical lift. Record review on 07/21/2026 of the Lift Transfer List, provided by the DON, reflected Resident #100 was transferred via mechanical lift. Resident #113 Record review of Resident #113's Face Sheet, dated 07/23/2026, reflected an [AGE] year-old male, admitted to the facility on [DATE]. The resident was diagnosed with a history of falling and muscle weakness. Record review of Resident #113's Comprehensive MDS Assessment, dated 07/02/2026, reflected the resident was cognitively intact with a BIMS score of 14. The Comprehensive MDS Assessment did not indicate the resident was using a mechanical lift. Record review of Resident #113's Comprehensive Care Plan, dated 07/23/2026, reflected the resident had an ADL self-care performance deficit and one of the interventions was to transfer via mechanical lift. Record review on 07/21/2026 of the Lift Transfer List, provided by the DON, reflected Resident #113 was transferred via mechanical lift. During an interview on 07/23/2026 at 7:05 a.m., MDS Coordinator I said she was the one doing the residents' MDSs. She said if the residents were being transferred via mechanical lifts, then their MDS Assessments should reflect they were being transferred via mechanical lifts. She opened Resident #17's profile and saw the resident was not coded for mechanical lift. She said she would edit Resident #17's MDS, and she would also check the MDS of the other residents being transferred via mechanical lifts if their MDS reflected their mode of transfer. She then went to Resident #26's profile, checked her MDS, and saw she was not coded for her CPAP. She said, just like the mechanical lift, her MDS should reflect she was using a CPAP. She said the MDS was not only for reimbursement but a tool to identify the needs of the residents regarding their care. She said, in order to provide the appropriate care, the residents should be assessed thoroughly to provide the needs of residents so they would be care planned accordingly. She said the MDS gave the overall picture of the residents, and it was like puzzle pieces that needed to be put together. residents' needs. She said she would also audit the other residents using a non-invasive mechanical ventilator. During an interview on 07/23/2026 at 8:13 a.m., the DON said the resident's MDS should reflect their mode of transfer and if the residents were using a CPAP because the MDS was the basis of what should be included in the care plans of the residents. She said she would coordinate with the MDS Coordinators to fix the issue. During an interview on 07/23/2026 at 8:46 a.m., the Administrator said if there was a provision in the MDS Assessment to code the mode of transfer and the CPAP, then the MDS should reflect the residents were using a mechanical lift and were on CPAP. He said he would coordinate with the DON and the MDS Coordinator to audit the MDS of the residents and edit them appropriately. Record review of the facility policy, Resident Assessments 2001 MED-PASS, Inc. revised March 2022 reflected Policy Statement: A comprehensive assessment of every resident's needs is made . Policy Interpretation and Implementation . 3. A comprehensive assessment includes . a. completion of the Minimum Data Set (MDS); b. completion of the care area assessment (CAA) process; and c. development of the comprehensive care plan.

Based on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for two of three residents (Resident #3 and Resident #40) reviewed for feeding tube management. 1.The facility failed to ensure LVN E cleaned Resident #3's syringe used for bolus feeding and medication administration after use on 07/21/2026. 2.The facility failed to ensure LVN C flushed Resident #40's g-tube before medication administration on 07/22/2026. These failures could place residents with g-tubes at risk for clogging and infection.Findings included: 1.Record review of Resident #3's Face Sheet, dated 07/22/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with gastrostomy status (having done a surgical procedure that creates artificial opening into the stomach to provide nutritional support). Record review of Resident #3's Comprehensive MDS Assessment, dated 05/10/2026, reflected the resident had severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident had a feeding tube. Record review of Resident #3's Comprehensive Care Plan, dated 05/27/2026, reflected the resident required a feeding tube and one for the interventions was to provide g-tube care and monitor for signs and symptoms of infection. Record review of Resident #3's Physician Order, dated 07/01/2026, reflected Enteral Feed Order four times a day PEPTAMEN 1.5 . kcal/mL-250 mL G-TUBE 4 times a day for BOLUS (large dose of medication or food given at once) feeding via G-TUBE. Record review of Resident #3's Physician Order, dated 05/04/2026, reflected Gabapentin Oral Tablet 400 MG (Gabapentin) Give 1 tablet via Gtube every 8 hours for NERVE PAIN. During an observation on 07/21/2026 at 11:27 a.m., LVN E administered Resident #3's bolus feeding using a 60 ml piston syringe. After giving the bolus feeding, she placed the syringe back to its plastic packaging. She did not clean the syringe after use. During an observation on 07/21/2026 at 1:34 p.m., LVN E was about to administer Resident #3's medication via g-tube. After preparing the medication, she took the syringe from its plastic packaging and used it to dissolve the medication. The syringe was observed to have dried white particles. After medication administration, she placed the syringe back to its plastic container. She did not clean the syringe after use. During an interview on 07/21/2026 at 1:45 p.m., LVN E said the re-usable syringes should be cleaned after every use to make sure it would be clean for the next use and to prevent bacterial growth. She said the same with after medication administration so that the residual of the medication would be washed away. 2.Record review of Resident #40's Face Sheet, dated 07/22/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with dysphagia. Record review of Resident #40's Comprehensive MDS Assessment, dated 06/24/2026, reflected the resident had severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment did not indicate the resident had a feeding tube. Record review on 07/22/2026 of Resident #40's Comprehensive Care Plan reflected the resident did not have a care plan for his feeding tube. Record review of Resident #40's Physician Order, dated 07/23/2026, reflected every shift Administer 75 cc tap water via G-tube prior to formula or medication administration. Record review of Resident #40's Physician Order, dated 07/14/2026, reflected Juven Oral Packet (Nutritional Supplements) Give 1 packet via Gtube two times a day for WOUND HEALING MIX WITH 8 OUNCES OF WATER, During an observation on 07/22/2026 at 8:35 a.m., LVN C was about to administer Resident #40's medication via g-tube. He sanitized his hands, put the medications in small plastic cups, crushed them, and returned the crushed medications to the small plastic cups. One of the medications being prepared was in a packet. He teared one side of the packet, placed its content in a cup, and dissolved it with eight ounces of water giving a yellow solution. He put the medications on top of the resident's overbed table, along with a cup of half-filled water, and dissolved them one-by-one. He took a 60 ml piston syringe from the IV pole at bedside. He put on a gown and a pair of gloves, raised the bed, elevated the head of the bed, turned off the g-tube pump, and disconnected the g-tube (gastrostomy tube: a tube inserted through the abdomen that delivers nutrition directly to the stomach) from the formula. After disconnecting the g-tube, he pulled the plunger of the syringe halfway, attached the syringe to the g-tube, checked for the placement, and for the residual (food, liquid, and secretions remaining in the stomach). He disconnected the syringe, pulled the plunger of the syringe, and connected the barrel of the syringe to the g-tube. After connecting the barrel of the syringe, he started by pouring medication. He started with the yellow solution. He did not flush the g-tube before pouring the yellow solution. After pouring the yellow solution, LVN E realized the g-tube was clogged; he returned the yellow solution to its respective cup. He disconnected the feeding port of the g-tube and washed it. He connected the feeding port, connected the barrel of the syringe, and poured the yellow solution. He did not flush again before pouring the yellow solution. During an interview on 07/22/2026 at 9:32 a.m., LVN C said he was not aware he did not flush the g-tube before giving the first medication. He said if he did flush the g-tube before the yellow solution, he would be returning water to the cup instead of the yellow solution when he realized the g-tube was clogged. He said the g-tube should be flushed to make sure the tube was patent and to prevent any complications. During an interview on 07/23/2026 at 7:32 a.m., ADON A said the syringes used for bolus feeding and medication administration should be cleaned after every use to make sure the residue from the feeding formula and the medications were washed away to prevent any bacterial growth. She said contaminated equipment could introduce harmful microorganisms into the feeding system, causing gastrointestinal infections. She said the g-tube should be flushed before medication administration to prevent the residues from hardening, thus making future feeding and medication administration challenging. She said the residents' safety had always been their biggest concern. She said they would educate the staff, assess where they were lacking, what their weak spots were, so they would know what areas to focus on their education. During an interview on 07/23/2026 at 8:13 a.m., the DON said not cleaning the syringes after every use could be an infection control issue because feeding formula di support bacterial growth if not handled properly. She said feeding formulas, once opened and mixed, could be a breeding ground for bacteria within hours. She said not cleaning the syringe after medication administration could result in medication interaction if the medication that was still in the syringe had contact with another medication that could affect the effectiveness of the treatment. She said the expectation was for the staff to do the right procedure for g-tube. She said she would start an in-service to re-educate the staff about care of the g-tube. During an interview on 07/23/2026 at 8:46 a.m., the Administrator said he was not a clinician and would let the DON take a lead on the issue of g-tube. He said they would do an in-service about the concern identified, talk to the individuals involved to do a one-on-one re-education, and monitor closely that they understood the in-service. Record review of the facility's policy Administering Medications through an Enteral Tube Nursing Services Policy and Procedure Manual for Long-Term Care reviewed November 12, 2018, reflected Purpose: The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube . 7 . flush the tube.

Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of ten residents (Resident #3) reviewed for respiratory care. The facility failed to ensure Resident #3's nasal cannula was properly stored when not in use on 07/21/2026. This failure could place residents at risk of respiratory infection and not having their respiratory needs met.Findings included: Record review of Resident #3's Face Sheet, dated 07/22/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with chronic respiratory failure (condition where there is not enough oxygen in the body or too much carbon dioxide in the body). Record review of Resident #3's Comprehensive MDS Assessment, dated 05/10/2026, reflected the resident had severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment did not indicate the resident was on oxygen therapy. Record review of Resident #3's Comprehensive Care Plan, dated 06/12/2026, reflected the resident required oxygen therapy as needed and one of the interventions was O2: Oxygen @ (2-3L) via (NC) as needed for SOB To maintain O2 sats above 92%. Record review of Resident #3's Physician Order, dated 05/05/2026, reflected O2: Oxygen @ (2-3L) via (NC) as needed for SOB To maintain O2 sats above 92%. Record review of Resident #3's eMAR for the month of July 2026 reflected the last time the resident used oxygen was on July 09, 2026.During an observation and interview on 07/21/2026 at 1:32 p.m., Resident #3 was in her bed, awake. An oxygen concentrator was at bedside with a nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) connected to it. A plastic bag was also attached to the oxygen concentrator, but what was inside the bag was the tube of the nasal cannula. The prongs of the nasal cannula were outside the plastic bag and were touching the side of the plastic bag. The resident said she did not remember the last time she used oxygen.During an observation and interview on 07/21/2026 at 1:45 p.m., LVN E said she did not notice Resident #3's nasal cannula was not properly stored. She said, maybe, the aides that transferred her did not store the nasal cannula properly. She said the prongs of the nasal cannula should be inside the bag to keep it clean and prevent any respiratory infection. She disconnected the nasal cannula and said she would replace it. During an interview on 07/23/2026 at 7:32 a.m., ADON A said the tube and the prongs of the nasal cannula should be inside a plastic bag and not just the tube when not in use to maintain its cleanliness as well as its patency (opened, unobstructed, or unblocked). She said bagging the nasal cannula was important to prevent cross contamination and development of any respiratory infections. She said the staff was responsible for bagging the nasal cannula once the treatment was done. She said they would educate the staff about bagging the nasal cannula. During an interview on 07/23/2026 at 8:13 a.m., the DON said the expectation was for the staff to bag the nasal cannula properly and to change it if seen not properly stored to prevent any respiratory infection. She said she would start an in-service about respiratory care to re-educate the staff. During an interview on 07/23/2026 at 8:46 a.m., the Administrator said the expectation was that all the nasal cannulas be bagged properly when the residents were not using them to keep them clean. He said they would do an in-service about the concern identified and monitor closely that they understood the in-service. Record review of the facility's policy, Policy and Procedure: Bagging Oxygen Tubing undated, reflected Purpose: To establish a standardized process for safely storing oxygen tubing when oxygen therapy is temporarily discontinued or not in use . Policy: The facility shall ensure oxygen tubing is handled, stored, and maintained in a clean manner that minimizes the risk of contamination and promotes resident safety. Oxygen tubing shall be bagged when not in active use but expected to be reused.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one of eight residents (Resident #40) reviewed for pharmaceutical services. The facility failed to ensure LVN C disposed Resident #40's excess medication properly on 07/22/2026. This failure placed residents at risk of receiving contaminated medication. Findings included: Record review of Resident #40's Face Sheet, dated 07/22/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with polyneuropathy (nerve disease caused by damage to the nerves that could cause pain). Record review of Resident #40's Comprehensive MDS Assessment, dated 06/24/2026, reflected the resident had severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident was receiving a scheduled pain medication. Record review on 07/22/2026 of Resident #40's Comprehensive Care Plan reflected the resident did not have a care plan for his neuropathy (nerve pain). Record review of Resident #40's Physician Order, dated 07/13/2026, reflected Gabapentin Oral Solution 250 MG/5ML (Gabapentin) Give 2 ml via PEG Tube (Percutaneous Endoscopic Gastrostomy PEG-Tube: procedure to place a feeding tube in the stomach) two times a day for NEUROPATHY. During an observation on 07/22/2026 at 8:35 a.m., LVN C was about to administer Resident #40's medication via g-tube. One of the medications he prepared was a liquid medication. He poured the liquid medication into a small cup and then checked if he had poured the required dose. He then realized that he poured more than required. He took the original container and poured the excess medication back to the original container. During an interview on 07/22/2026 at 9:32 a.m., LVN C said he did not think returning the excess medication to the original container was wrong because the small cup was clean. During an interview on 07/23/2026 at 7:32 a.m., ADON A said the excess medication, whether liquid or tablets, should not be returned to its original container; it could contaminate the rest of the medications. She said the excess medication should have been discarded properly. She said they would educate the staff, assess where they were lacking, what their weak spots were, so they would know what areas to focus on their education. During an interview on 07/23/2026 at 8:13 a.m., the DON said staff should not return any excess medications to their original container because of the risk of contamination. She said the cup might have been exposed to other substances that could compromise the medication's safety and effectiveness. She said she would start an in-service about medication administration and proper disposal of medications. During an interview on 07/23/2026 at 8:46 a.m., the Administrator said he was not a clinician and would let the DON take a lead on the issue about excess medication. He said they would do an in-service about the concern identified, talk to the individuals involved to do a one-on-one re-education, and monitor closely that they understood the in-service. Record review of the facility's policy Administering Medications Nursing Services Policy and Procedure Manual for Long-Term Care revised April 2019 reflected Policy Statement: Medications are administered in a safe and timely manner, and as prescribed . Policy Interpretation and Implementation . 4. Medications are administered in accordance with prescriber orders . 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable and failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for one of eighteen residents (Resident #40) reviewed for labelling of drugs and biologicals. The facility failed to ensure LVN C placed a change of instruction sticker on Resident #40's amantadine after a change to the order on 07/21/2026. This failure could place residents at risk of wrong medication administration, not getting the full benefit of the medication, accidental overdose, and possible adverse reactions.Findings included: Record review of Resident #40's Face Sheet, dated 07/22/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with dystonia (uncontrollable muscle contractions leading to abnormal twisting movements). Record review of Resident #40's Comprehensive MDS Assessment, dated 06/24/2026, reflected the resident had severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident was receiving an anticonvulsant (medication to prevent convulsion [sudden irregular movement of the body], sudden muscle contractions [tightening of the muscles], or spasms [sudden contraction of a muscle]). Record review of Resident #40's Comprehensive Care Plan, dated 07/15/2026, reflected the resident had a significant neurological impairment resulting to uncontrolled flinging of the extremities and one of the interventions was administer medication as ordered. Record review of Resident #40's Physician Order, dated 07/21/2026, reflected Amantadine HCl Oral Capsule 100 MG (Amantadine HCl) Give 2 capsule via PEG-Tube one time a day for TREMORS (involuntary movement of the body). Record review of Resident #40's eMAR for the month of July 2026 reflected the order for amantadine 100 mg two capsules twice a day was discontinued on 07/20/2026. During an observation on 07/22/2026 at 8:35 a.m., LVN C was about to administer Resident #40's medication via g-tube. One of the medications that he was preparing was amantadine 100 mg. He picked up the blister pack for the said medication and placed 2 capsules in a cup. On the PCC (point click care: a software that provides real-time access to patient data), the order said to give the medication once a day. On the blister pack, the order specified to give the medications twice daily. During an interview on 07/22/2026 at 9:32 a.m., LVN C said the order for Resident #40's amantadine was changed from twice a day to once a day. He said since the order did not change the dose of the medication and only the frequency, he still used the same blister pack. He said he was the one who received the order and he changed the order in the resident's eMAR. He said, aside from changing the order in the PCC, he also needed to put a change in order sticker on the blister pack to let the other staff administering the medication know that there was a change in order. He said the staff might still give it twice a day. During an interview on 07/23/2026 at 7:32 a.m., ADON A said the staff should put a sticker saying there was a change in the order on the resident's blister pack for any medication. She said if there was a change in order and the staff would still use the old blister pack because it was the same milligrams, then a sticker which indicated a change in order should be placed on the blister pack to avoid confusion in administering the medication. She said it was the proper thing to do. She said the medication might be given more than ordered. During an interview on 07/23/2026 at 8:13 a.m., the DON said if there was a change in order and the staff would be using the same blister pack, a sticker denoting that there was a change in physician order must be placed on the blister pack to prevent confusion when giving the medications resulting to medication errors. She said the expectation was that the staff would do what was supposed to be done. She said she would start an in-service about labeling the medication. During an interview on 07/23/2026 at 8:46 a.m., the Administrator said he was not a clinician and would let the DON take a lead about the issue. He said they would do an in-service about the concern identified, talk to the individuals involved to do a one-on-one re-education, and monitor closely that they understood the in-service. Record review of the facility's policy Physician Order Changes undated, reflected Policy: All physician, nurse practitioner (NP), physician assistant (PA), and other authorized prescriber orders shall be reviewed, implemented, and communicated promptly. Order changes shall be entered accurately into the electronic health record (EHR), communicated to appropriate staff, and documented to ensure continuity of care . 4. Communication of Order Changes . The nurse implementing the order shall communicate changes to all affected departments before the next scheduled service whenever possible.Policy for putting a sticker on the blister pack after a change in order requested verbally on 07/23/2026 but was not provided prior to exit.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary comfortable environment for residents, staff, and the public for 2 of 5 rooms (Resident #104 and #12) reviewed for environment. The facility failed to ensure that the trash can in Resident #104's room had trash liners 07/21/26. The facility failed to ensure that the trash can in Resident #12's room had trash liners 07/21/26. This failure could place residents at risk for diminished quality of life due to unsanitary environment.Findings Included: Record review of Resident #104's Face Sheet, dated 07/22/26, revealed an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with Dementia (A progressive loss of memory, reasoning, and communication skills). Record review of Resident #104's Quarterly MDS Assessment, dated 06/05/26, revealed a BIMS score of 07 (severe cognitive impairment). It revealed she was dependent to needing substantial / maximal assistance with Toileting hygiene, shower/bathe self, lower/upper body dressing, personal hygiene and putting on/taking off footwear. Record review of Resident #104's care plan dated 09/16/25 revealed Resident #104 likes to wander with intervention to Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book Resident prefers. During an observation on 07/21/26 at 9:55 a.m. it was observed that the trash can in Resident #104's room had no liner in it. Record review of Resident #12's Face Sheet, dated 07/22/26, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with Dementia (A progressive loss of memory, reasoning, and communication skills). Record review of Resident #12's Quarterly MDS Assessment, dated 06/27/26, revealed no BIMS assessment, staff assessment for mental status, cognitive skills for daily decision making on the MDS assessment revealed Resident #12 is severely impaired. The MDS assessment revealed he was dependent with Toileting hygiene, shower/bathe self, lower/upper body dressing, personal hygiene, oral hygiene and putting on footwear. During an observation on 07/21/26 at 10:12 a.m., Resident #12 was in bed, awake and nonverbal, it was observed that the trash can in Resident #12's room had no liner in it. During an interview on 07/22/26 at 7:20 a.m. with housekeeping supervisor, she stated that trash cans should always have liners in them. She stated that if trash cans do not have liners, they can become contaminated from use over time if not cleaned and that placing liners in the trash cans at all times will help avoid contamination. She stated that she is there to protect the residents and that if the trash cans are not lined the residents could get sick. She stated that housekeeping does rounds and check all the trash cans to make sure they had liners in place. During an interview on 07/22/26 at 7:28 a.m. with Housekeeper M, she stated that all trash cans should always have liners in them. She stated that she makes rounds to make sure all the trash cans have liners at least twice a day. She stated that the CNAs, nurses, DON, and Administrator also make rounds to check for that too and make sure the residents received the care they are supposed to. She stated that not having the trash can liners will contaminate the trash can. She stated that if the trash can was not lined and becomes dirty, it will not be the clean homelike environment that the facility is expected to provide for the residents. She stated that the residents can get sick and the confused residents can dig in the trash and could get sick or hurt depending on what is in the trash can. During an interview on 07/23/26 at 2:35 p.m. with the DON, she stated that the nurses and CNAs change the liners and make sure the trash cans are lined, they check for spills and get housekeeping involved. She stated that they verbally inform housekeeping of any concerns with environmental cleanliness. She stated that all the nursing staff are trained on how to keep the facility clean and tidy and when to call for housekeeping if needed. She stated that an in-service was started on trash liners and cans and to replace trash cans with new liners whenever they are emptied. Record review of the facility's Resident Rights Policy statement dated 2001 and revised February 2021 did not reveal any information on safe, functional, sanitary and comfortable environment.

Based observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 of 8 residents (Residents #20 and Resident #40) reviewed for catheter care. 1.The facility failed to ensure Resident #20's catheter bag was off the floor on 07/21/2026. 2.The facility failed to ensure Resident #40's catheter bag was off the floor on 07/22/2026. These failures could place the residents at risk of urinary tract infection.Findings included: 1.Record review of Resident #20's Face Sheet, dated 07/21/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with ESBL. Record review of Resident #20's Comprehensive MDS Assessment, dated 07/17/2026, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated that the resident had an indwelling catheter. Record review of Resident #20's Comprehensive Care Plan, dated 07/14/2026, reflected that the resident did not have a care plan for her indwelling catheter. Record review of Resident #20's Physician Order, dated 07/11/2026, reflected Indwelling Catheter Care Q shift every shift. During an observation and interview on 07/21/2026 at 9:18 a.m., Resident #20 was in her bed, awake. A catheter bag, with a privacy bag, was observed hanging at the side of the bed. It was observed that the catheter bag was touching the floor. It was also observed that the straps to the privacy bag were long. The resident said she had the catheter flexible tube inserted into the bladder to remove the urine) for months. During an observation on 07/21/2026 at 9:52 a.m., revealed Resident #20's catheter bag (collects urine from the urinary bladder) was still touching the floor. During an interview on 07/21/2026 at 10:01 a.m., LVN D said catheter bags, even if they were inside a privacy bag, should not be touching the floor to prevent cross contamination. He said he did not notice that the catheter bag was touching the floor when he checked on Resident #20. He said he would go and see if the catheter bag was still touching the floor. During an interview on 07/21/2026 at 10:21 a.m., LVN D said he had already changed Resident #20's catheter bag because it touched the floor and made the straps of the privacy bag shorter so that even though the bed was lowered, it would not touch the floor. 2.Record review of Resident #40's Face Sheet, dated 07/22/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with cerebral infarction (stroke) and chronic kidney disease (damaged kidney that cannot filter blood). Record review of Resident #40's Comprehensive MDS Assessment, dated 06/24/2026, reflected the resident had severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment did not indicate the resident was using an external catheter (non-invasive device used for urine collection that fits outside the body). Record review of Resident #40's Comprehensive Care Plan, dated 06/22/2026, reflected the resident had a condom catheter and one of the interventions was to position the catheter bag below the bladder. Record review of Resident #40's Physician Order, dated 06/26/2026, reflected Condom Catheter drain bag to be changed every 30 days and as needed at bedtime every 30 day(s) for catheter care. During an observation on 07/22/2026 at 8:48 a.m., Resident #40 was in his bed awake. The resident had a catheter bag hanging at the side of his bed and the catheter bag was touching the floor. During an observation on 07/22/2026 at 8:50 a.m., LVN C entered Resident #40's room to give the resident's medications. He did not notice that the catheter bag was touching the fall mat. He raised the resident's bed during the process of medication administration but did not address that the catheter touched the floor. During an interview on 07/22/2026 at 9:27 a.m., the family member said Resident #40 had the catheter since he was admitted to the facility. She said staff were with the resident earlier to change him. She said, maybe, they were the ones who lowered the bed. She said she did not notice the catheter bag was touching the fall mat. She said nobody talked to her about the resident's catheter. During an interview on 07/22/2026 at 9:32 a.m., LVN C said he did not notice Resident #40's catheter was touching the fall mat before he administered his medications. He said catheter bags should not be touching the fall mat because the fall mat was dirty. He said even though he raised the resident's bed, the mere fact that it touched the floor, then the catheter bag was already considered dirty. He said he would go ahead and change the catheter bag. During an interview on 07/23/2026 at 7:32 a.m., ADON A said catheter bags should always be off the floor because it could cause UTI. She said the expectation was that catheter bags would always be off the floor to prevent cross contamination and probable infection. She said she would coordinate with the DON on what to do about the issue regarding the catheter. She said they would educate the staff, assess where they were lacking, what their weak spots were, so they would know what areas to focus on their education. During an interview on 07/23/2026 at 8:13 a.m., the DON said the expectation was catheter bags should not be touching the floor and for the catheter bags be changed when seen touching the floor. She said catheter bags touching the floor could lead to UTI. She said she would start an in-service to re-educate the staff about catheter care. During an interview on 07/23/2026 at 8:46 a.m., the Administrator said the expectation was that the catheter bag would be off the floor to prevent infection. He said they would try to find a way to keep the catheter bag off the floor even with the beds of the residents were on the lowest position. He said they would do an in-service about the concern identified, talk to the individuals involved to do a one-on-one re-education, and monitor closely that they understood the in-service. Record review of the facility's policy, Catheter Care, Urinary Nursing Policy and Procedure Manual revised August 2022 reflected Purpose: The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infection . Infection Control . 2. Be sure catheter tubing and drainage bag (collects urine from the urinary bladder) are kept off the floor.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames that met the residents clinical and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #14) out of 5 residents reviewed for comprehensive person-centered care plans. The facility failed to ensure that Resident #14's Comprehensive Care Plan included the following:1. The facility failed to ensure that Resident #14's Comprehensive Care Plan included physician orders for hip precautions.2. The facility failed to ensure that Resident #14's Comprehensive Care Plan included physician orders for her toe-touch weight bearing status.3. The facility failed to ensure that Resident 14's Comprehensive Care Plan included physician orders for Full Code Advanced Status. These failures could place residents at risk of having received inadequate interventions not individualized to their care needs and diagnoses. Findings Included:Record review of Resident #14's admission face sheet dated 10/06/25 reflected she was an [AGE] year-old female was originally admitted to the facility on [DATE] and readmitted on [DATE] with active diagnoses that included: aftercare following joint replacement surgery, pain in right hip, aftercare following explanation of hip joint prothesis, and inflammatory reaction due to internal right hip prosthesis with subsequent encounters effusion of the right hip, generalized muscle weakness, chronic pain syndrome, and abnormalities of gait and mobility, lack of coordination, and COPD (a group of lung diseases that cause ongoing airflow obstruction and breathing difficulties). Record review of Resident #14's readmission MDS assessment dated [DATE], reflected a BIMS score of 15 indicating that her memory was cognitively intact. Resident #14's MDS Assessment reflected that she had an impairment on one side of her lower extremity (hip, knee, ankle, foot). Resident #14 required assistance with her ADL's for eating (Setup or clean-up assistance), Oral Hygiene (Supervision or touching assistance), Shower/bath (Substantial/maximal assistance), Upper body dressing (Supervision or touching assistance), Lower body dressing (Substantial/maximal assistance), Putting on/taking off footwear (Substantial/maximal assistance), Roll left and right (Substantial/maximal assistance), Sit to lying (Substantial/maximal assistance), Lying to sitting on side of bed (Substantial/maximal assistance). Resident #14 Urinary and Bowel Continence was always incontinent. Resident #14 had active diagnoses of Other Orthopedic Conditions. Resident #14's Pain Assessment Interview revealed that she had frequent pain or hurting with occasional pain during sleep. Record review of Resident #14's Care Plan dated 09/16/2025 reflected, Special Instructions: Max assist x 2 with transfers Problem: The resident is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t Physical Limitationsdaily routine needs.Date Initiated: 09/18/2025Revision on: 09/18/2025 Goals: The resident will maintain involvement in cognitive stimulation, social activities as desired through review date.Date Initiated: 09/18/2025Target Date: 09/24/2025 Interventions: Encourage ongoing family involvement. Invite the resident's family to attend special events, activities, meals.Date Initiated: 09/18/2025 Invite the resident to scheduled activities.Date Initiated: 09/18/2025 Provide with activities calendar. Notify resident of any changes to the calendar of activities.Date Initiated: 09/18/2025 Thank resident for attendance at activity function.Date Initiated: 09/18/2025. Record review of Resident #14's Care Plan reflected no information regarding Advanced Directives. Record review of Resident #14's Discharge from the hospital dated 09/16/2025 reflected, TTWB, Partial Weight Bearing, Physical Therapy and Occupational Therapy. Record review of Resident #14's Physician Orders reflected an Active Phone Order on 09/16/2025 of Full Code. Record review of the facility's Admission/Discharge Report for 4/6/2025 to 10/6/2025, revealed that Resident #14 was originally admitted to the facility from an acute care hospital on [DATE]. Resident #14 was discharged from the facility to an acute care hospital on [DATE]. Resident #14 was readmitted to the facility from an acute care hospital on [DATE]. In an interview and Observation of Resident #14 on 10/06/25 at 11:14 AM, revealed that she was alert and oriented and lying in bed. Resident #14 stated that she had been a resident at the facility for 3 weeks. Resident #14 stated that she was originally admitted to the facility after having surgery on her left hip. Resident #14 stated that she was originally admitted to the facility sometime during the first week of September 2025. She stated that during her 1st stay at the facility, she had been at the facility about 1 week and was in pain and told the staff that she needed to go to the hospital because she was in a lot of pain. Resident #14 stated that she informed staff that she was in pain and they notified her physician who told the staff to have her sent to the ER because of her pain. Resident #14 stated that she had to have a second surgery on her hip and was at the hospital for a week and returned to the facility. Resident #14 stated that her pain had been managed since returning to the facility. Resident #14 stated that she is her own RP, but stated that her FM is involved with her care management. Resident #14 stated that she did not recall being involved in a Care Plan Meeting with the staff at the facility. On 10/06/25 at 12:02 PM, an attempted telephone call to Resident #14's Physician was unsuccessful. In an interview with Part-Time MDS Coordinator B on 10/06/2025 at 1:00 PM revealed, she had been employed at the facility for 11 years. She stated that MDS Coordinator E and MDS Coordinator F are the Full-Time MDS Coordinators at the facility. She stated that both MDS Coordinator E and MDS Coordinator F were currently unavailable due to both being on Leave. She stated that the MDS Assessment for Resident #14 was completed and both MDS Coordinators were to make sure that the Care Plan for Resident #14 included all the information that was pertinent to the care of the resident. MDS Coordinator B stated that she was unfamiliar with Resident #14. She stated that both MDS Coordinator E and MDS Coordinator F dropped the ball with this resident's Care Plan and were responsible for ensuring that Resident #14's Care Plan was completed in a timely manner. She stated that she is currently retired and had worked over 30 years as a MDS Coordinator. She stated that she assists the facility as the MDS Coordinator when both MDS Coordinators are on Leave. She stated that [Resident #14] was originally admitted to the facility on [DATE] and was discharged from the facility on 09/09/25. She stated that [Resident #14] was readmitted to the facility on [DATE] and her Care Plan should have been completed 13 days after [Resident #14's] readmission to the facility. MDS Coordinator B stated that there should have been more information, such as her hip precautions from her hospital discharge paperwork, infection of the right hip and COPD should have been addressed. She stated that there was a risk to Resident #14's Care Plan not being completed is that staff would not have available to them the care information needed that was pertinent to the care of the resident. She stated that harm could be caused to Resident #14 if her Care Plan was not completed. She stated that [Resident #14] recently had hip surgery and she was a complex resident and there could have been cause for her to have some injuries if staff were not aware of the care she needed that was not on her current Care Plan. On 10/06/25 at 2:05 PM, an attempted telephone call to Resident #14's Pain Management doctor was unsuccessful. On 10/06/25 at 2:15 PM, an attempted telephone call to Resident #14's FM was unsuccessful. In an interview with ADON C on 10/07/25 at 9:33 AM, she stated that she had been employed at the facility for 6 years. ADON C stated that she was unaware that Resident #14's current Care Plan was not updated. ADON C stated that Resident #14 recently had 2 hip surgeries which included hip precautions. ADON C stated that Resident #14's Advanced Directives, Pain Management and Hip Precautions should have been added to her Care Plan. ADON C stated that the MDS Coordinators were responsible for completing the residents Care Plans. ADON C stated that the CNO was responsible for ensuring that each residents Care Plan met their needs. She stated that Care Plans are utilized by staff to minimize the risk of any further injuries to the resident. She stated that she did not feel that there was any harm caused to Resident #14 with the current Care Plan in her EHR. In an interview on 10/07/25 at 11:07 AM with CNO A, CNO A stated that Resident #14's Care Plan should have been completed within 13 days after she was readmitted to the facility. CNO A stated that [Resident #14] was admitted to the facility on [DATE] and went to the hospital on [DATE] and was discharged from the facility. CNO A stated that [Resident #14] returned to the facility on [DATE] and was readmitted to the facility. CNO A stated that [Resident #14's] current Care Plan was incomplete and did not include the information that is needed for her Care Plan to be completed, such as her Advanced Directives and information regarding her recent hip surgeries. She stated that it the MDS Coordinators responsibility to ensure that the residents Care Plans are completed in a timely manner. She stated that she thinks that when [Resident #14] returned to the facility, her Care Plan completion fell through the cracks because of the timeframes from when she was admitted , discharged and readmitted to the facility were misconstrued and her Care Plan fell through the cracks. CNO A stated that she performed monthly Audit Checks on resident Care Plans, but Resident #14's Care Plan was overlooked. CNO A stated that she will implement a plan to ensure that resident Care Plan are audited every morning. CNO A stated that she did not feel that there was any risks, or harm caused to Resident #14 with the current Care Plan in her EHR. In a telephone interview on 10/07/2025 at 11:30 AM with Director of Social Services, revealed that he had been employed at the facility for a year. The Director of Social Services revealed that he met with Resident #14 upon her admission to the facility. He stated that the facility's Nurse Case Manager and Director of Rehabilitation also were present to establish a plan of care and review safe discharge planning. The Director of Social Services revealed that he did not recall any collaboration with the residents plan of care, but does recall having a Collaborative Care Plan meeting. The Director of Social Services stated that the importance of Care Plans is to direct staff on how to properly care for each residents need of care. The Director of Social Services stated that not having a personalized plan of care can potentially lead to the risk of crucial resident care being missed. Record review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated 2001 and revised, December 2016 reflected, Policy Statement:A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation:1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.3. The IDT includes:a. The Attending Physician;b. A registered nurse who has responsibility for the resident;c. A nurse aide who has responsibility for the resident;d. A member of the food and nutrition services staff;e. The resident and the resident's legal representative (to the extent practicable); andf. Other appropriate staff or professionals as determined by the resident's needs or as requested by the resident.4. Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to:a. Participate in the planning process;b. Identify individuals or roles to be included;c. Request meetings;d. Request revisions to the plan of care;e. Participate in establishing the expected goals and outcomes of care;f. Participate in determining the type, amount, frequency and duration of care;g. Receive the services and/or items included in the plan of care; andh. See the care plan and sign it after significant changes are made.5. The resident will be informed of his or her right to participate in his or her treatment.6. An explanation will be included in a resident's medical record if the participation of the resident and his/her resident representative for developing the resident's care plan is determined to not be practicable.7. The care planning process will:a. Facilitate resident and/or representative involvement;b. Include an assessment of the resident's strengths and needs; andc. Incorporate the resident's personal and cultural preferences in developing the goals of care.8. The comprehensive, person-centered care plan will:a. Include measurable objectives and timeframes;b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment;d. Describe any specialized services to be provided as a result of PASARR recommendations;e. Include the resident's stated goals upon admission and desired outcomes;f. Include the resident's stated preference and potential for future discharge, including his or her desire to return to the community and any referrals made to local agencies or other entities to support such a desire;g. Incorporate identified problem areas;h. Incorporate risk factors associated with identified problems;i. Build on the resident's strengths;j. Reflect the resident's expressed wishes regarding care and treatment goals;k. Reflect treatment goals, timetables and objectives in measurable outcomes;l. Identify the professional services that are responsible for each element of care;m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels;n. Enhance the optimal functioning of the resident by focusing on the rehabilitative program; [NAME]. Reflect currently recognized standards of practice for problem areas and conditions.9. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan.10. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process.a. No single discipline can manage an approach in isolation.b. The resident's physician (or primary healthcare provider) is integral to this process.11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.a. When possible, interventions address the underlying source(s) of the problem area(s), not just addressing only symptoms or triggers.b. Care planning individual symptoms in isolation may have little, if any, benefit for the resident.12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS).13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.14. The Interdisciplinary Team must review and update the care plan:a. When there has been a significant change in the resident's condition;b. When the desired outcome is not met;c. When the resident has been readmitted to the facility from a hospital stay; andd. At least quarterly, in conjunction with the required quarterly MDS assessment.15. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals will be documented in the resident's clinical record in accordance with established policies.

Based on observation, record review and interview, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 20 residents reviewed for quality of care. The facility failed to provide Resident #1 with diabetic treatments on 09/10/25 which included checking blood sugars and administering insulin. The non-compliance was identified as past non-compliance (PNC). The IJ began on 09/10/25 and ended on 09/12/25 and the facility had corrected the non-compliance before the state's investigation began. This failure could place residents' health and safety at risk.Findings included: Record review of Resident #1's face sheet, dated 09/12/25 reflected, she was a [AGE] year-old female who was admitted [DATE] and diagnosed with but not limited to: Type 2 Diabetes Mellitus (chronic disease characterized by high blood sugar) with diabetic chronic kidney disease(Diabetic nephropathy affects the kidneys' usual work of removing waste products and extra fluid from the body), end stage renal disease(chronic kidney disease progresses to a point where the kidneys lose nearly all their filtering ability. atherosclerotic heart disease of native coronary artery without angina pectoris( A condition where the arteries supplying blood to the heart become narrowed due to the accumulation of plaquette and altered mental status unspecified. Record review of Resident #1's MDS assessment, dated 09/10/25 reflected his BIMS score was 06 which indicated severe cognitive impairment. Record review of Resident #1's orders, dated 09/10/25 reflected: Humalog Kwik Pen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 70 - 240 = 0 UNITS <70 INSTITUTE HYPOLYCEMIA PROTOCOL AND CALL MD;241 - 300 = 2 UNITS; 301 - 350 = 3 UNITS; 351 - 400 = 4 UNITS >400 GIVE 5 UNITS AND CALL MD, subcutaneously at bedtime for DM start date on 09/05/25 at 6:00pm. Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine)Inject 23 unit subcutaneously one time a day for DM start date of 09/10/25 at 8am INSULIN LISPRO 100 UNIT/ML VL Inject as per sliding scale: if 70 - 130 = 0 UNIT <70 INSTITUTE HYPOGLYCEMIA PROTOCOL AND CALL MD; 131 - 180 = 1 UNIT; 181 - 240 = 2 UNITS; 241 - 300 = 3 UNITS; 301 - 350 = 4 UNITS; 351 - 400 = 5 UNITS >400 GIVE 6 UNITS AND CALL MD, subcutaneously before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITH DIABETIC CHRONIC KIDNEYDISEASE (E11.22) start date of 09/08/25 at 7:30 am Record review of Resident #1's TAR for the month of September 2025 reflected on 09/10/25: At 7:30am Resident #1 blood sugar was 522 and injected 9 units of Insulin Lispro 100unit/ML signed by LVN B [SH1] [SH1] At 8:00 am Resident #1's blood sugar was 522 and injected 23 units of Insulin Glargine 100 unit/ml, signed by LVN A At 11:30 am Resident#1 blood sugar was 522 and injected 9 units of Insulin Lispro 100unit/ML, signed by LVN A At 4:30 pm Resident#1 blood sugar was 522 and injected 4 units of Insulin Lispro 100unit/ML, signed by LVN A At 8:00 pm Resident#1 blood sugar was 522 and injected 1 units of Insulin Lispro 100unit/ML, signed by LVN A At 6:00 pm Resident#1 sugar was 522 and injected with 4 units of Humalog kwik pen, signed by LVN A Record review of Resident#1 progress note dated 09/10/25 at 6:59 am reflected: .After 6AM, resident requested BS check and it was 522mg/dl, [MD] notified and said to give sliding scale, order carried out and 6 units of insulin lispro given by LVN B Record review of Resident#1 progress note dated 09/10/25 at 1:39 pm reflected: Resident#1 vital signs were noted to be B/p 158/74, pulse 93, temp 98.0, resp 17 and o2 sat 97% . at 7:30 AM. [Resident#1] was noted to be laying in bed with no concerns noted at that time. Prior to medication administration. Prior to administration of routine Lantus order resident request an addition 6 units of insulin. [LVN A] educated resident that [LVN A] could not administer an addition dose of insulin as that would be double dosing and there isn't an order. [LVN A] administered resident's routine Lantus order at 825 AM.[LVN B] instructed the [resident#1] that [LVN A] would recheck her blood sugar but her husband transported resident from facility. Resident#1 [family member#1] arrived at facility with wheelchair stated, I'm taking [Resident#1] for an evaluation as she was in DKA and we will return later.[ Family member#1] also stated, [Resident#1] knows her body. When asked how did [family member#1] determine she was in DKA. [Resident#1] was seated in wheelchair and smiled at [LVN A] when exciting facility with no distress noted. [LVN A] then received a phone call from [Resident#1 family member#2] aggressively state that [Resident#1] blood sugar was taken at 5:30am and that no one has done anything or even check on [Resident#1].[LVN A] attempt to tell [family member#2] what was done while she continue to call [LVN A] a liar, a neglectful nurse until she hung up. by LVN A Record review of Resident#1 progress notes dated 09/10/25 at 4:54 pm[LVN M ] and [Admin] spoke with [resident#1 family member#1] regarding the status of [Resident#1]and to follow up with any concerns he may have. [Family Member#1] was very appreciative of the care [Resident#1] has received since she admitted to [facility], stating the care has been great and he has no questions or concerns at this time. [Family Member#1] also apologized for [Family Member#2] behavior towards the charge nurse this morning, stating, [Family Member#2] is an alarmist, asking us to disregard anything [Family Member#2] stated as [Family member#1] was the POA. [LVN M ] did reiterate that charge nurse did follow all policies and procedures, following Physician's orders during the care of [Resident#1] this morning. [Family Member#1] agreed and stated that [Resident#1] was just a brittle diabetic, knows her body and wanted to ensure she wasn't in DKA, so [Family Member#1] chose to [Resident#1] to the ER to be evaluated. He also stated that he will be bringing her back to [Facility]. by LVN M Record review of Resident#1 hospital record dated 09/12/25 reflected, Resident#1 was admitted to the hospital at 10:44 am on 09/10/25. Record review reflected Resident#1 was diagnosed with DKA (serious complication of diabetes that occurs when the body lacks sufficient insulin This condition leads to high blood sugar levels and the accumulation of acidic substances called ketones in the body.) Record review revealed Resident#1 insulin level was 364 at 1:55 pm. Record review revealed Resident#1 received intravenous fluids and insulin. An interview on 09/12/25 at 12:30 pm with Resident #1 at the hospital revealed she had been feeling weak and tried to do anything. Resident#1 stated that she did not want to participate in PT which was her main reason for being in the facility to get stronger. Resident#1 stated she knew she was in DKA and wanted to go to the hospital. Resident#1 stated she called her husband because he would get her to the hospital faster than the facility. Resident#1 stated LVN A did not check her blood sugar or give her insulin on 09/10/25 before she left the facility. An interview on 09/12/25 at 12:45pm, the hospital Nurse stated Resident#1 last blood sugar results were 84. Attempted to call LVN A on 09/12/25 at 4:15pm and on 09/13/25 at 12:30 PM, surveyor was not able to leave voicemail. During an interview over the phone at 5:10 am LVN B stated she checked Resident#1 blood sugar around 6:30 am and it was 522. LVN B stated she called the MD and he said to check her blood sugar again at 8am when she received her 8am scheduled insulin and call the MD back. LVN B stated she informed LVN A about Resident#1 current condition. Resident#1 orders were updated in the system. During an interview on 09/13/25 at 2:30 pm, the Medical Director stated he was called about Resident #1's blood sugar reading being in the 500's on 09/10/25 about 6:45 am. The Medical Director stated he sent new orders and additional monitoring steps for Resident#1. The Medical Director stated staff had to check Resident#1 blood sugars before giving insulin to make sure the right number of units are given. The Medical Director stated staff cannot falsify documentation because that will put residents in the facility health at risk. The non-compliance was identified as past non-compliance (PNC). The IJ began on 09/10/25 and ended on 09/12/25. The facility had corrected the non-compliance before the state's investigation began. During an interview on 09/12/25 at 3:30 pm, with the Admin and the CN/DON, the CN/DON stated the facility implemented the following interventions and procedures to ensure residents received necessary care/treatment to prevent serious injury or harm: revised Diabetic protocol with the Medical Director, QAPI meeting with Medical Director, diabetic resident audited daily for a week then weekly for a month and then monthly after, in-service on ANE, recognizing the signs and symptoms of hypoglycemia/hyperglycemia, record review of Emergency QAPI plan dated 09/11/25, signed by MD, Admin, the CN/DON. The CN/DON stated staff have had competency testing blood sugars, given insulin, abuse/neglect and documentation. The CN/DON stated LVN A was suspended after Resident#1 family stated he did not do her blood sugar check on 09/10/25. The CN/DON stated after investigating the incident, LVN A stated he did not check Resident#1 blood sugar and used LVN B readings the morning of 09/10/25. The CN/DON and Admin reported LVN A license to the BON on 09/11/25. The Admin and DON terminated LVN A on 09/12/25. The CN/DON except staff to follow the orders, check blood sugars, use proper hygiene and document their own observation. Observation and interview on 09/12/25 between 3:30 pm to 4:00 pm revealed LVN C completed a mock trial and went over the process of taking blood sugars, giving insulin, and completing documentation. During an interview and observation round on 09/12/25 at 4:30 pm, the surveyor observed LVN C take Resident#2's Blood sugar, sanitize machine and area, complete and document findings in the TAR. LVN C stated documenting false information will result in termination, and your license being reported to the board. During an interview on 09/12/25 4:30 pm to 5:30 pm LVN C, LVN H, LVN I, LVN B, LVN N, RN O and ADON P were knowledge about updated policy and procedures for the diabetic residents, abuse/neglect and documentation. During interviews over the phone on 09/13/25 between 4:00 am to 5:00 am, LVN E, LVN F, LVN G stated documenting false information would result in termination, and their license being reported to the board. LVN E, LVN F, LVN G stated nurses could only document the readings that he or she observed. LVN E, LVN F, LVN G stated documenting incorrect information could result in possible harm or death. LVN E, LVN F, LVN G were knowledge about updated policy and procedures for the diabetic residents, signs/symptoms of hypo/hyperglycemia, abuse/neglect and documentation. During interviews on 09/13/25 between 10:30 am and 11:25 am, LVN D LVN J, LVN K and LVN L were able to describe and give examples of abuse/neglect, updated policy for diabetics, documentation, and sign/symptoms for hypo/hyperglycemia. LVN D LVN J, LVN K and LVN L stated if a resident blood sugar tested too high or too low the nurse had to monitor the resident and recheck blood sugar in 30 minutes. During an interview and observation round on 09/13/25 at 11:30 am, surveyor observed LVN D take Resident#3, Resident#4, Resident#5's Blood sugar, sanitize machine and area, complete and document findings in the TAR. LVN D stated that nurses could not document the previous nurse readings, nurses could only document their own observed readings. LVN D stated that documenting false information would result in termination, and their license would be reported to the board. LVN D stated residents could be in danger of not getting enough medication or too much that could be harmful. During interviews on 09/13/25 between 11:45 am to 12:15 pm, Resident #2, Resident#3, Resident#4 and Residents#5 did not have any concerns about blood sugars or receiving diabetic medications. Attempted to call LVN A on 09/13/25 at 12:30pm, the surveyor was not able to leave voicemail. During an interview on 09/13/25 at 2:00 pm, the PCP stated Resident#1 was a Type one diabetic, and her blood sugar usually was 400 and could change quickly. The PCP stated blood sugars had to be checked before given insulin. The PCP stated Resident#1 had a history of being non-compliant with her diet and DKA in the past. Record review of facility Emergency QAPI meeting and sign sheet, dated 09/11/25 reflected: Identification of concern: On 09/11/25, the facility identified a serious concern regarding a nurse failing to check residents' blood sugars as ordered and falsifying documentation of a blood sugar reading. The a facility immediately Conducted a review of diabetic residents' charts and practices. It was determined that staff competency, documentation, integrity and monitoring system were Compliant with facility protocols, nursing practice and regulatory requirements. This emergency QAPI plan is developed in response to the isolated and the purpose of this plans to.Ensure resident safety by preventing neglect, reinforce accurate timely and honest documentation. Verify staff competency in performing blood glucose check and administering insulin. Maintain monitoring and auditing practices for accountability and compliance. Root cause analysis and corrective actions:1. resident safety review: The Don/designee immediately reviewed our residents with diabetes to ensure to ensure blood sugars were properly checked and treatment provided as needed on 9/11/2025.2. Chart Audit: The facility initiated daily audits of 100% of diabetic charts beginning on 9/11/2025 to ensure blood sugar checks and insulin administration were completed and documented accurately. This will continue daily for two weeks, then weekly for six weeks, then monthly until compliance is sustained for three consecutive months.3. Competency checks- blood sugar monitoring. All licensed nurses begin. Return demonstration on 9/11/2025 to verify competency in performing blood glucose checks completely, including infection control, accurate use of the glucometer. Notification of the physician when warranted. correct documentation.4. Competency, check insulin administration: All licensed nurses begin return to demonstrations on insulin administration on 9/11/2025. Competency includes dosage verification, injection techniques, resident monitoring, and documentation.5. Education on neglect and documentation. The Executive Director/Designee provided mandatory and services beginning 9/11/2025 for all nursing staff on: resident neglect related to miss blood sugars. Legal and ethical consequences of falsifying documentation.6. Random spot checks. Supervisors will conduct unannounced direct observation of staff performing blood sugar checks and insulin administration to ensure compliance and procedures.7. Accountability: Staff who failed to check blood sugars as ordered or falsely documentation or face disciplinary actions up to and including termination. #8. Oversight The DON/ designee will continue to oversee diabetic care and staff compliance audits. Results will be reported to the Administrator, Medical Director and QAPI Committee for ongoing review.9. Emergency QAPI Meeting: The facility held an emergency QAPI meeting on 9/11/2025 to discuss their concerns and implement corrective actions and engage the Medical Director in oversight.10. Facility Actions: The investigation determined the nurse did not check the resident blood sugar and falsified his actions by documenting a blood sugar of 522. The nurse was reported to the Texas Board of Nursing on 9/11/25, was immediately suspended from work, and the facility has terminated the nurse employment on 9/12./2025.11. QAPI Statement Any staff members found to have engaged in false documentation or neglect will face immediate disciplinary action, up to and including termination and reporting to the State Board of Nursing according to facility policy and state law. The facility reported the incident to HHSC on 9/11/25 after Resident#1 family reported the incident. Record review of chart audit of diabetic residents started on 09/11/25. Record review of the BON complaint form dated 09/11/25 completed by the CN/DON reflected: on 09/10/25 at 6:40 am LVN B check resident#1 one blood sugar and received a reading of 522. The physician was notified and gave order to administer sliding scale insulin and monitor resident around 8:00 AM LVN B administered Resident#1 Scheduled Lantus 23 unit via route subcutaneous. Documentation shows LVN A noted blood sugar of 522 at 8:00am administration. Resident#1 family member reported LVN A did not take Resident#1 blood sugar. When questioning LVN A did not collect glucose reading before administering the Lantus, he replied, I did not When further questioned where this 522 reading he enters came from, he stated, It was the one collected by other nurse at 6:40 am. Resident is currently in the hospital for DKA. Record review of in-service training dated 09/11/25 titled care of patients with diabetes reflected, monitoring patient, checking blood sugars, measuring and administering insulin, follow up, notifying MD and documentation. Record review of LVN A's termination documentation reflected:LVN A was terminated on 09/12/25 with LVN A signature. Record review of chart audit of diabetic residents started on 09/12/25. Record review of the facility's in-Service Training: Zero Tolerance for Falsifying Documentation, undated, and reflected:19 staff participated in the in-serviceLearning Objectives1. Understand the facility's zero-tolerance policy for falsifying documentation.2. Recognizing how failing to provide care but documenting care was provided constitutes both neglect and fraudulent documentation.3. Demonstrate knowledge of correct procedures for documentation.4. Identify the disciplinary consequences of falsifying documentation.________________________________________Content1. What is Falsification of Documentation? Recording information in the medical record that is not true, not performed, or intentionally altered. Examples include:o Documenting a blood sugar reading that was not actually taken.o Signing off medications or treatments that were not provided.o Changing a resident's vital signs to appear within normal limits.o Backdating entries or forging signatures. o Changing test results or omitting critical details. o Ghost entries for care that never occurred.________________________________________2. Why is This Serious? Resident Safety: Missing or falsified provision of care can lead to residents not receiving what they need to ensure they are safe and could include hospitalization or death. Inaccurate records can lead to misdiagnoses, improper treatment, and dangerous medical errors. Neglect: Failing to provide care as ordered is considered neglect and violates residents' rights to proper care. Legal & Regulatory Consequences: Falsification can result in serious legal action, including criminal charges, fines, and civil lawsuits, especially in cases of fraud or medical malpractice. This can result in loss of licensure, fines, or termination. Healthcare professionals, such as nurses, can face licensing suspension, revocation, or probation from their state board for fraudulent documentation.________________________________________3. Facility Zero Tolerance Policy Falsifying documentation in any form is strictly prohibited. No Tolerance Standard:o Any employee found falsifying documentation will face disciplinary action, up to and including termination of employment.o Repeated or intentional violations may be reported to the state licensing board and law enforcement if fraud or resident harm is involved.________________________________________4. Staff Responsibility Provide care exactly as ordered. Document only what you did, when you did it, and the actual results. Ask for clarification if you are unsure of an order or what documentation is required. Report errors and mistakes in a timely manner. Record review of facility Post-Test: Zero Tolerance for Falsifying Documentation, undated reflected: 19 staff had participated in the post test for zero tolerance for Falsifying Documentation Staff results reflected a score of 100%Record review of facility post- test: Abuse, Neglect and Misappropriation dated 09/11/25 reflected,45 staff participated in the post with a score of 100%.1. Abuse id defined as : The intentional infliction of physical harm, pain, or mental anguish2. Neglect occurs when staff: Intentionally fail to provide needed care or services3. Misappropriation of resident property means: Intentionally using or taking a resident's money, belonging, or property without consent.4. All staff considered mandatory reporters of abuse, neglect and misappropriation5. If you witness or suspect abuse, neglect, or misappropriation, your first responsibility is to:-I have attended training on abuse, neglect, and misappropriation-I understand the definitions, signs, and reporting requirements-I understand that I am a mandatory reporter and must immediately report any suspected or witnessed abuse, neglect, or misappropriation.-I understand that failure to follow reporting procedures may result in disciplinary action, up tp and including termination, and potential legal consequences.

Based on observation, record review, and interview, the facility failed to maintain medical records on each resident that are accurately documented for 1 (Resident #1) of 5 residents reviewed for administration. The facility failed to ensure Resident #1 had accurate TAR documentation in the EHR on 09/10/25 for Resident #1's blood sugar checks, Humalog Kwik pen injection, and insulin lispro 100 unit/ml injection by LVN A . The non-compliance was identified as past non-compliance (PNC). The PNC began on 09/10/25 and ended on 09/12/25 and the facility had corrected the non-compliance before the state's investigation began. This failure could place residents at risk of not receiving the proper care or treatment and services.Findings included:Record review of Resident #1's face sheet, dated 09/12/25 reflected, she was a [AGE] year-old female who was admitted [DATE] and diagnosed with but not limited to: Type 2 Diabetes Mellitus (chronic disease characterized by high blood sugar) with diabetic chronic kidney disease(Diabetic nephropathy affects the kidneys' usual work of removing waste products and extra fluid from the body), end stage renal disease (chronic kidney disease progresses to a point where the kidneys lose nearly all their filtering ability. atherosclerotic heart disease of native coronary artery without angina pectoris (A condition where the arteries supplying blood to the heart become narrowed due to the accumulation of plaquette and altered mental status unspecified. Record review of Resident #1's MDS assessment, dated 09/10/25 reflected his BIMS score was 06 which indicated severe cognitive impairment. Record review of Resident#1 orders reflected: HumaLOG KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro)Inject as per sliding scale: if 70 - 240 = 0 UNITS <70 INSTITUTE HYPOLYCEMIA PROTOCOL AND CALL MD;241 - 300 = 2 UNITS; 301 - 350 = 3 UNITS; 351 - 400 = 4 UNITS >400 GIVE 5 UNITS AND CALL MD,subcutaneously at bedtime for DM start date on 09/05/25 at 6:00pm. Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine)Inject 23 unit subcutaneously one time a day for DM start date of 09/10/25 at 8am INSULIN LISPRO 100 UNIT/ML VL Inject as per sliding scale: if 70 - 130 = 0 UNIT <70 INSTITUTE HYPOGLYCEMIA PROTOCOL AND CALL MD; 131 - 180 = 1 UNIT; 181 - 240 = 2 UNITS; 241 - 300 = 3 UNITS; 301 - 350 = 4 UNITS; 351 - 400 = 5 UNITS >400 GIVE 6 UNITS AND CALL MD, subcutaneously before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITH DIABETIC CHRONIC KIDNEYDISEASE (E11.22) start date of 09/08/25 at 7:30 am Record review of Resident#1 TAR for the month of September 2015 reflected on 09/10/25:At 7:30am Resident#1 blood sugar was 522 and injected 9 units of Insulin Lispro 100unit/ML signed by LVN B At 8:00 am Resident#1 blood sugar was 522 and injected 23 units of Insulin Glargine 100 unit/ml, signed by LVN A At 11:30 am Resident#1 blood sugar was 522 and injected 9 units of Insulin Lispro 100unit/ML, signed by LVN A At 4:30 pm Resident#1 blood sugar was 522 and injected 4 units of Insulin Lispro 100unit/ML, signed by LVN A At 8:00 pm Resident#1 blood sugar was 522 and injected 1 units of Insulin Lispro 100unit/ML, signed by LVN A At 6:00 pm Resident#1 sugar was 522 and injected with 4 units of Humalog kwik pen, signed by LVN A Record review of Resident #1's hospital records dated 09/12/25 reflected, Resident#1 was admitted to the hospital 10:44 am on 09/10/25. Record review reflected Resident#1 was diagnosed with DKA (serious complication of diabetes that occurs when the body lacks sufficient insulin This condition leads to high blood sugar levels and the accumulation of acidic substances called ketones in the body.) Record review revealed Resident#1 insulin level was 364 at 1:55 pm. Record review revealed Resident#1 received intravenous fluids and insulin). During an interview on 09/13/25 at 2:30 pm, the Medical Director stated he was called about Resident #1's blood sugar reading being in the 500's on 09/10/25 about 6:45 am. The Medical Director stated he sent new orders and additional monitoring steps for Resident#1. The Medical Director stated staff had to check Resident#1 blood sugars before giving insulin to make sure the right number of units are given. The Medical Director stated staff cannot falsify documentation because that will put residents in the facility health at risk. The non-compliance was identified as past non-compliance (PNC). The PNC began on 09/10/25 and ended on 09/12/25. The facility had corrected the non-compliance before the state's investigation began. During an interview on 09/12/25 at 3:30 pm, The CN/DON stated staff have had competency testing blood sugars, given insulin, abuse/neglect and documentation. The CN/DON stated LVN A was suspended after Resident#1 family stated he did not do her blood sugar check on 09/10/25. The CN/DON stated after investigating the incident, LVN A stated he did not check Resident#1 blood sugar and used LVN B readings the morning of 09/10/25. The CN/DON and Admin reported LVN A license to the BON on 09/11/25. The Admin and DON terminated LVN A on 09/12/25. The CN/DON except staff to follow the orders, check blood sugars, use proper hygiene and document their own observation. During an interview on 09/12/25 at 4:30 pm LVN C stated documenting false information will result in termination, and your license being reported to the board. During an interview over the phone on 09/13/25 between 4:00am to 5:00am, LVN E, LVN F, LVN G stated documenting false information will result in termination, and your license being reported to the board. LVN E, LVN F, LVN G stated nurses can only document the readings that he or she observed. LVN E, LVN F, LVN G stated documenting incorrect information could result in possible harm or death. During an interview with the CN/DON on 09/13/25 3:30 pm she stated purposely documenting wrongful information will result in suspension until investigation was completed, termination and license reported to the appropriate state board. The CN/DON stated residents can have a decline in health from falsifying documentation. Record review of falsifying documentation in-service, dated 09/11/25 reflected:Learning Objectives1. Understand the facility's zero-tolerance policy for falsifying documentation.2. Recognizing how failing to provide care but documenting care was provided constitutes both neglect and fraudulent documentation.3. Demonstrate knowledge of correct procedures for documentation.4. Identify the disciplinary consequences of falsifying documentation.Content1. What is Falsification of Documentation? Recording information in the medical record that is not true, not performed, or intentionally altered. Examples include:o Documenting a blood sugar reading that was not actually taken.o Signing off medications or treatments that were not provided.o Changing a resident's vital signs to appear within normal limits.o Backdating entries or forging signatures. o Changing test results or omitting critical details. o Ghost entries for care that never occurred.2. Why is This Serious? Resident Safety: Missing or falsified provision of care can lead to residents not receiving what they need to ensure they are safe and could include hospitalization or death. Inaccurate records can lead to misdiagnoses, improper treatment, and dangerous medical errors. Neglect: Failing to provide care as ordered is considered neglect and violates residents' rights to proper care. Legal & Regulatory Consequences: Falsification can result in serious legal action, including criminal charges, fines, and civil lawsuits, especially in cases of fraud or medical malpractice. This can result in loss of licensure, fines, or termination. Healthcare professionals, such as nurses, can face licensing suspension, revocation, or probation from their state board for fraudulent documentation.3. Facility Zero Tolerance Policy Falsifying documentation in any form is strictly prohibited. No Tolerance Standard:o Any employee found falsifying documentation will face disciplinary action, up to and including termination of employment.o Repeated or intentional violations may be reported to the state licensing board and law enforcement if fraud or resident harm is involved.4. Staff Responsibility Provide care exactly as ordered. Document only what you did, when you did it, and the actual results. Ask for clarification if you are unsure of an order or what documentation is required. Report errors and mistakes in a timely manner.

Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices when they failed to ensure physician orders were communicated and carried out in a timely manner for 1 of 4 residents reviewed (Resident #1).The facility failed to check Resident #1's blood sugar twice a day per physician orders from 08/06/25 to 08/13/25. On 08/13/25 Resident #1 had a FSBS of 34 resulting in her being sent to the hospital for emergency interventionAn IJ was identified on 08/27/25. While the IJ was removed on 08/28/25, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm because the facility was continuing to monitor the implementation and effectiveness of their Plan of Removal.This failure could place residents at risk of experiencing a medical emergency and transfer to the hospital for treatment.Findings included:Record review of Resident #1's quarterly MDS, dated [DATE], revealed a [AGE] year-old female who admitted on [DATE]. Her cognitive skills for decision making were that she sometimes understood and sometimes was able to make her needs understood, she had no BIMS score documented. Her diagnoses included mechanical complication of surgically created arteriovenous fistula(complications that can cause issues such as poor fistula function, limb swelling(edema) or heart failure due to increased workload of the heart), methicillin-susceptible Staphylococcus aureus (a bacterial infection caused by Staphylococcus aureus bacteria), dependency on renal dialysis (a life-sustaining treatment that filters waste and excess fluid from the blood when the kidneys can no longer do), heart failure (a condition where the heart cannot pump blood effectively enough to meet the body's needs), renal insufficiency (a condition where the kidneys do not function properly, leading to a decreased ability to filter waste products from the blood and maintain fluid balance), diabetes mellitus (a chronic metabolic disease characterized by persistently high blood sugar (glucose) levels), and cerebrovascular accident (a medical condition that occurs when blood flow to the brain is interrupted, causing brain tissue damage). Record review of Resident #1's care plan, initiated 08/13/2025, reflected the following: Focus: Risk for Infection. Intervention: Administer antibiotic therapy as prescribed, Educate Resident/Representative on infection control practices. Record review of Resident #1's physician orders for August 2025 reflected the following: Please check fingerstick BID. Verbal . Active .Order date of 08/06/25 and no start date.Record review of Resident #1's physician orders for August 2025 reflected the following: ceFAZolin Sodium(antibiotic primarily used to treat bacterial infection used before, during or after surgery) Injection Solution Reconstituted 1GM (Cefazolin Sodium) Use 1 gram intravenously in the morning every Mon, Tue, Wed, Thu for bacteremia until 09/12/2025 23:59 Administered via HDVerbal Active 08/08/2025 08/11/2025 with stop date 09/12/2025. ceFAZolin Sodium Injection Solution Reconstituted 1GM (Cefazolin Sodium) Use 2 gram intravenously one time a day every Fri for Infection Administered via HD Verbal Active 08/08/2025 08/15/2025. Record review of Resident# 1's MAR dated 08/26/2025 reflected Insulin Degludec FlexTouch Subcutaneous Solution Pen injector 200 UNIT/ML (Insulin Degludec) Inject 20 unit subcutaneously (under the skin) one time a day for DM -Start Date- 08/06/2025 0800.The only FSBS documented was with insulin administration. The was no order noted on the MAR for FSBS BID. Record review of Resident #1's Progress Notes, written by LVN A, reflected the following:08/13/25 at 7:10AM - The Resident was noted to be unresponsive to verbal stimuli. Resident opened her eyes to physical stimuli but was unable to respond to verbal questions. Resident could normally interact fully with staff at baseline. B/P 138/64, pulse 82, O2 at 95 on 2L via nasal cannula with crackles noted on exhalation FSBS noted to be 34 (considered dangerously low) administered fast acting carbohydrate orally, blood sugar remained low. Resident was noted to have redness to bilateral feet and hands. 911 emergency call and resident was transported to [Name] hospital for a further evaluation. I spoke with [NAME](daughter) via phone to inform her regarding this situation. During a telephone interview on 08/26/2025 at 10:10 AM, Resident #1's FM revealed that Resident#1 was admitted [DATE] to the facility because she needed to be on antibiotics for an infection in her dialysis shunt. The FM stated that the facility called her the morning of 08/13/2025 and told her Resident #1 was found unresponsive, her blood sugar was low and was transferred to [Name] a hospital in Dallas. She stated after the hospital stay, Resdient#1 did not return to the facility but was transferred home on hospice. She stated Resident #1 had a diagnosis of Diabetes Mellitus with end renal stage disease, yet the facility did not check Resident #1's blood sugar for more than twelve hours. She stated she was told the doctor had orders for Resident#1 to be check every 12 hours. During a telephone interview on 08/26/25 at 12:31 PM, the MD C revealed an order was given on 08/06/25 to check blood sugar twice a day. She stated that on 8/13/2025 the DON notified her the order to check blood sugar twice a day was not followed because the order was entered under other category; therefore, it did not flag in the system to alert the nurses there was a new order. MD C stated the DON had corrected the issue in the EMR system. MD C stated she had given orders to the facility that any resident admitted with diagnosis of diabetes must have FSBS BID for the first week. MD C stated that risk to the resident if the EMR failed to communicate physician orders to the nurses to follow orders to check FSBS BID was the resident could suffer from hyperglycemia (high blood sugar) and/or hypoglycemia(low blood sugar), which could be serious, and lead to hospitalization of the resident. During a telephone interview on 08/27/2025 at 12:26 PM, with RN B, revealed he worked a double shift on 08/12/2025. He stated that he checked the resident's blood sugar at bedtime as a precaution because he had given Resident#1 insulin in the morning. RN B stated that he did not know there was an order for blood sugar checks twice a day. RN B stated he did a late entry remotely to document that he had checked the Resident #1's blood sugar, but it did not reflect on EMR. 8/26/25 at 12:38 PM Phone interview with LVN A revealed that on 08/13/2025 he observed Resident #1 was not responding to verbal stimuli. He checked Resident #1's blood sugar and vital signs. Resident #1's blood sugar was 34. He followed the hypoglycemic oral protocol (oral glucose paste rubbed onto the buccal mucosa (inner lining of the cheek) called the doctor and sent the resident to the emergency room. 08/26/2025 at 1:18PM Interview with DON revealed that Resident#1 admitted with complex medical issues. The DON stated Resident#1 was on hemodialysis for follow up care and an antibiotic for infection in her dialysis shunt. She stated Resident#1 started having redness to her lower extremities and her hands, MD C talked to the FM, and we were to send Resident #1 to the ER. The DON stated the ER said it was vascular, not an allergic reaction to the antibiotic. The DON stated that on 08/13/2025 Resident#1 had a change in condition, a drop in blood sugar, and was sent to the hospital. She stated Resident #1's FM was upset that Resident #1's blood sugar was low. The DON stated that Resident#1's blood sugar was checked the night before on 08/12/2025 by RN B. 08/26/2025 at 2:50PM Phone interview with RN M revealed he worked at night and Resident#1 did not have an order to check FSBS at night. RN M stated all residents with diagnosis of diabetes got a bedtime snack. He stated the nurses' entered orders on the EMR. RN M stated the risk to the patient when the EMR fails to communicate with the nurse to check blood sugar on a resident that was diabetic could have serious complications, including hospitalization. 08/26/25 at 4:43 PM Interview with DON revealed that on 08/13/2025 she noted there was an order entered on 08/06/2025 by the physician to check Resident #1's blood sugar twice a day but the system did not alert the nurses to confirm the order and that was the reason the order was not added to the MAR and not followed by the nurses. 08/26/25 at 4:43 PM interview with CNO revealed that the physician, MD D, entered the order, incorrectly, so the EMR did not alert for the nurse to confirm so it could go on the MAR. She stated the DON had educated the physicians and changed the physicians EMR access so physicians cannot enter the orders. She stated the risk to the patient was a missed high or low blood sugar. An interview on 08/27/2025 at 1:56 PM, MD D revealed Resident #1 had a lot of comorbidities. She stated that blood glucose levels were based on resident's oral intake so even if the nurses checked Resident #1's blood sugar and her oral intake was poor it would not have made a difference. She stated that with aging and with Resident #1 having had a serious infection that could alter blood sugar levels. Review of facility policy titled Medication and Treatment Orders dated 07/2016, and reviewed on 8/27/25 with no identified changes required, reflected, Verbal Orders must be recorded immediately in the residents' chart by the person receiving the order . Record review of the facility's policy titled Diabetes - Clinical Protocol revised November 2022, reflected:As indicated the Physician will order appropriate lab test (for example periodic finger sticks or A1C) and adjust treatments based on these results and other parameter, such as glycosuria, weight gain, or loss hypoglycemia episode, etc.The Physician will order desired parameters for monitoring and reporting information related to blood sugar management.a. The staff will incorporate such parameters into the Medication Administration Record and care plan .5. The staff will identify and report issues that may affect, or be affected by, a patient's diabetes and diabetes management such as foot infections, skin ulceration, increased thirst, or hypoglycemia.a. For example, urgent notification may be indicated if the individual has not eaten well or consumed sufficient fluids for 2 or more days and has fever, hypotension, lethargy, or confusion.b. The Physician will help the staff clarify and respond to these episodes.6. The staff and Physician will manage hypoglycemia appropriately.a. It is important to avoid excessive diabetes management that leads to recurrent episodes of hypoglycemia. For example, a realistic target for AIC in frail older individuals is between approximately 7 and 8, while A1C consistently under 7 is unlikely to provide significant additional benefits but may expose the individual to recurrent hypoglycemia.b. It is important to avoid over-treatment of hypoglycemia, which can result in rebound hyperglycemia and hamper subsequent glucose control.(1) For example, a borderline low blood sugar in the absence of signs and symptoms may not need any acute intervention and may or may not suggest the need to modify oral hypoglycemia medications or insulin.(2) An example of appropriate treatment of hypoglycemia for a responsive individual would be 15 g to20 g of carbohydrate in the form of glucose, sucrose tablets, or juice, combined with a sandwich, crackers, or other light snack containing protein.(3) For someone who is lethargic but not comatose, treatment might include oral glucose paste rubbed onto the buccal mucosa, intramuscular glucagon, or intravenous 50% dextrose. This was determined to be an Immediate Jeopardy (IJ) on 08/27/2025 at 4:43PM. The Administrator, CNO and DON were notified on 08/27/2025 at 5:00PM. The Administrator was provided with the IJ template on 08/27/2025 at 5:13PM. The following Plan of Removal submitted by the facility was accepted on 08/28/25 at 10:13AM. The facility POR for Immediate Jeopardy reflected the following: 1.All current physician orders for all residents were immediately reviewed by DON and Unit Managers on 8/27/25 to ensure accuracy and that orders populate correctly to the MAR/TAR. Any orders entered in the Other category were corrected and properly linked to the MAR/TAR.2.CNO educated DON on proper procedure for receiving, documenting, and verifying physician orders, including recording verbal/telephone orders immediately; ensuring orders are entered under the correct category; verifying that orders populate to the MAR/TAR; and immediate notification to DON/charge nurse if an order does not appear on the MAR. Completed 08/27/25.3.DON/Designee began education to all licensed nurses on 8/27/25 and were immediately in-serviced on the proper procedure for receiving, documenting, and verifying physician orders, including: recording verbal/telephone orders immediately; ensuring orders are entered under the correct category; verifying that orders populate to the MAR/TAR; and immediate notification to DON/charge nurse if an order does not appear on the MAR. Nursing staff unavailable for education will not be allowed to work until in servicing is completed. Education is in progress for all nursing staff and will be required to be completed prior to working their next scheduled shift.4.The EHR system order entry process was corrected to ensure all physician orders trigger a flag for nurse confirmation and MAR placement. The Director of Nursing /designee verified on 8/27/25 that all pending and new orders populate correctly.5.Facility policy Medication and Treatment Orders was reviewed on 8/27/25 and no identified changes required.6.All licensed nurses and providers will be re-educated by DON/Designee on revised order-entry procedures, verification steps, and accountability for ensuring orders are implemented. Physicians and NP/PA staff were notified of updated procedures to ensure clarity of documentation.7.DON/Unit Managers will perform 100% audits of all new physician orders daily for 14 days, then 5x weekly for 30 days, and then weekly for 60 days to verify correct entry and MAR/TAR population. Any discrepancies will be corrected immediately, and staff responsible will receive re-education.8.DON/designee will review all new orders during daily clinical meetings to ensure timely communication and implementation. A monthly QA review will include order-entry accuracy, with findings reported to QAPI committee for ongoing oversight.9.DON/Designee educated Providers their security role in PCC was changed so Providers are no longer able to activate orders within the EMR system. Any order entered by an MD would trigger the nurse to activate. Education for Providers reviewing that they no longer have permissions to enter any orders into PCC was completed by 08/27/25. Monitoring of the facility's Plan of Removal included the following:Interviews with the following staff from 08/28/25 at 10:33 AM to 3:04 PM who worked all shifts and all days of the week revealed they had been in-serviced on the proper procedure for receiving, documenting, and verifying physician orders, including: recording verbal/telephone orders immediately; ensuring orders are entered under the correct category; verifying that orders populate to the MAR/TAR; and immediate notification to DON if an order does not appear on the MAR. LVN A, RN B, LVN F, LVN H, RN I, RN J, RN K.Record review of Emergency QAPI Agenda titled order entry and documentation, dated 08/27/25, reflected Medical Director, Administrator, CNO and DON were in attendance.Record review of in-service sign in sheets, dated 08/27/25, and titled Order Entry Education reflected the DON had signed.Record review of in-service sign in sheets, dated 08/27/25, and titled Order Entry Monitoring Process reflected 26 staff including nurse managers had been in-serviced.Record review of Physician order Confirmation in-service dated 08/14/25 revised on 08/28/2025, reflected 20 staff had been in-serviced.Record review of Chart/New order audit report dated 8/27/2025. 08/28/2025 Interview with CNO and DON reflected that all practitioners have been educated that they no longer have the privilege to confirm orders on PCC. Interview 8/28/2025 11:10am with MD E revealed that he was notified of the Immediate Jeopardy, and he approved of the plan of removal. He stated that now the physicians had been in serviced that doctors cannot confirm orders and only the nurses will confirm all new orders, and he agreed with the POR. An IJ was identified on 08/27/25 at 4:43PM. The IJ template was provided to the facility on [DATE] at 5:13 PM. While the IJ was removed on 08/28/25, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm, because the facility was continuing to monitor the implementation and effectiveness of their Plan of Removal.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 3 Residents (Residents #99) reviewed for respiratory care. The facility failed to promptly notify emergency services when Resident #99 developed respiratory distress following incontinence care on [DATE] at 2:00 PM. The resident's oxygen saturation was 66% and he was on 5 liters of oxygen via nasal cannula. The resident remained in respiratory distress until emergency medical services arrived at 2:45 PM on [DATE] and transferred him to the hospital. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 11:00 AM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on [DATE]. This failure could place residents requiring respiratory care at risk for exacerbation of condition up to and including death. The findings included: Record review of Resident 99's admission MDS assessment, dated [DATE], revealed the resident was a [AGE] year-old male admitted on [DATE]. His diagnoses included heart failure, renal failure requiring dialysis, chronic obstructive pulmonary disease (lung disease), and respiratory failure. The resident's BIMs score was 14 indicating the resident was cognitively intact. The resident received oxygen. Record review of Resident #99's physician orders, dated [DATE], reflected: 1. Code Status: Full Code. 2. Oxygen @ 5 Liters per minute via nasal cannula as needed to maintain oxygen saturation at 92%. 3. Albuterol-Ipratropium Inhalation Solution 2XXX,d+[DATE].5 milligrams/3 milliliters (medication to treat respiratory conditions) 1 vial, inhale four times a day for wheezing/shortness of breath. 4. Albuterol-Ipratropium Inhalation Solution 0XXX,d+[DATE].5 milligrams/3 milliliters 1 vial, inhale every 4 hours as needed for shortness of breath. 5. Budesonide Inhalation Suspension 0.5 milligrams/2 milliliters (medication to treat respiratory conditions) 1 vial, inhale two times a day for wheezing. There were no orders for bi-pap therapy. (a machine that provides noninvasive ventilation that helps a person breathe.) Record review of Resident #99's Care Plan, dated [DATE], reflected: 1. Resident has oxygen therapy related to congested heart failure and respiratory illness. Facility interventions included: Monitor for signs and symptoms of respiratory distress and report to physician as needed for respirations, pulse, oximetry, increased heart rate, restlessness, sweating, headaches, lethargy, confusion, atelectasis (the airways or air sacs in the lungs collapse or do not fully expand), Hemoptysis (coughing up blood or blood-stained mucus), cough, Pleuritic pain (sharp, stabbing chest pain caused by inflammation of the tissue layers surrounding the lungs), accessory muscle usage (the engagement of additional muscles during breathing, particularly when the primary muscles diaphragm and intercostals are insufficient to meet respiratory demands), and skin color. Record review of Resident #99's nurse note: [DATE] 6:07 PM Note Text. Late entry: 2:03 PM, notified by wound care nurse that resident complaining of shortness of breath. On arrival resident presents with labored breathing, oxygen saturation at 66%, blood pressure ,d+[DATE], heart rate 113, respirations 22, temperature 97.2 degrees Fahrenheit. On call provider notified, order received for duo nebulizer treatments every 4 hours as needed, and STAT (as soon as possible) chest x-ray. Duo nebulizer treatment administered; oxygen saturation improved to ,d+[DATE]% on 5 liters of oxygen per nasal cannula. After completing the nebulizer treatment resident oxygen saturation dropped to 79%. Nurse Practitioner notified and order received to send resident to the hospital. Resident placed on non-rebreather mask; oxygen saturation increased to 97%. Resident picked up by paramedics at 2:57 PM. Resident family notified, DON and ADON aware of the transfer to emergency room . Written by LVN A. An observation of Resident #99 in his room on [DATE] revealed: 2:00 PM The resident was almost finished with incontinence care that WCN B and CNA C had been providing. Resident #99 said he was having trouble breathing. The resident had oxygen at 5 liters per nasal cannula. WCN B repositioned the resident and left the room to notify LVN A. CNA C went to the resident's room door. Resident #99 was in respiratory distress. The resident was using his accessory muscles to breathe, he closed his eyelids halfway, he would rouse when spoken to and say he was ok,, but his respirations were rapid in the 30's. There was no nurse with the resident. The resident had a bi-pap machine in his room. 2:06 PM LVN A entered Resident #99's room. The resident remained in respiratory distress. LVN A donned PPE. LVN A then started taking vital signs. 2:11 PM LVN A was able to get a temperature of 97.1 degrees Fahrenheit, a pulse rate of 112, and an oxygen saturation of 66%. LVN A and CNA C repositioned Resident #99 to sit straight up. The oxygen saturation improved to 70%. The resident continued to be in respiratory distress. The resident continued to say he was ok even though he was not. LVN A left and said he was going to call the doctor. 2:12 PM Resident #99 continued to be in respiratory distress. His oxygen saturation was 70%. He had a congested cough and his respiratory rate remained in the 30's. 2:17 PM LVN A returned to Resident #99's room and started a breathing treatment for the resident. LVN A removed the pulse oximeter and left the room saying he was going to call the doctor again. The resident was struggling to breathe, respirations 30, heaving to breathe, nebulizer treatment continued. There was no nurse in the room, the resident had his eyes closed. 2:29 PM LVN A re-entered the room. LVN A checked, and the resident's oxygen saturation reached 85% at the highest point and the pulse rate was 113. LVN A said the doctor ordered a chest x-ray and labs. The resident continued to be in respiratory distress. The resident's oxygen saturation began dropping rapidly to 82%, 79%, and 77%. LVN A left the room and said he was calling the doctor. 2:37 Resident #99's oxygen saturation was at 76%, and his pulse rate was 114. The resident continued to be in respiratory distress. 2:40 PM ADON D entered the resident's room and had an oxygen tank and non-rebreather mask with her. Resident #99's oxygen saturation was at 75%. The resident's oxygen saturation rapidly rose to 95% after applying the non-rebreather mask. ADON D asked the resident if he felt tightness in his chest and he said no. ADON D stayed in the room with the resident. 2:45 PM Resident #99's oxygen saturation was 97% and emergency medical services entered the resident's room and began assessing him. An interview on [DATE] at 03:01 PM with LVN A revealed his shift started at 2:00 PM and that he did not enter Resident #99's room until 2:06 PM because his shift had just started. LVN A said he did not know how long the resident had to wait to get increased oxygen, but that he gave the resident a nebulizer treatment. LVN said if a resident had a low oxygen saturation, then he was supposed to give the resident oxygen, sit them up, and notify the doctor. He said the process should take no more than 15 minutes. LVN A said it took longer than that this time, because he thought the resident was ok, because the resident said he was, ok. He said he did not know why the oxygen saturation showed something different. LVN A said he thought the resident's respiratory rate was about 22 breaths/minute and the resident was using his accessory muscles to breathe, but the resident said he was, ok. LVN A said he thought the resident's oxygen saturation increased to 88 or 89%, not 85%. LVN A said he had been trained to call 911 but did not because the resident did not have respiratory distress until staff laid him down to provide care. LVN A said the nurse was supposed to wait with the resident, but he was not able to because he had to call the doctor. LVN A said he could have called ADON D, but she was in another resident's room. LVN A said a resident who remained in prolonged respiratory distress could develop respiration failure and death. An interview on [DATE] at 2:50 PM with ADON D revealed she did not know how long Resident #99 was in respiratory distress before she arrived and gave him increased oxygen. She said if a resident reported shortness of breath, then the nurse was to check the resident's vital signs, evaluate breath sounds with a stethoscope, assess to see if resident was using accessory (muscles to breathe) and check the resident's diagnosis. She said if she had known Resident #99 had an oxygen saturation of 66% she would have given him a breathing treatment, notified the physician, and called 911. An interview on [DATE] at 4:12 PM with WCN B revealed she knew Resident #99 was in respiratory distress during incontinence care because he said he needed to catch his breath, started having trouble breathing, and said he was, ok, but he was not. WCN B said she immediately sat him up and raised his head of bed and notified LVN A. She said she did not know how long he remained in respiratory distress and did not know what his oxygen saturation was. WCN B said if a resident had respiratory distress, the nurse was to check the airway and the oxygen level. She said if the oxygen saturation was less than 90% or if the resident had chronic obstructive pulmonary disease, then it might get as low as 88%. WCN B said the nurse needed to know the resident's orders, call rapid response and the physician. WCN B said she did not know it took 40 minutes for Resident #99 to get relief and if she had known it was going to take that long, then she would have stayed with the resident and taken care of him herself. WCN B said if a resident was in respiratory distress, then you could call for help from the ADON and DON and 911 if needed, but the nurse had to stay with the resident. She said a resident would be at risk of death if they continued to have respiratory distress. An interview on [DATE] at 3:16 PM with the DON revealed she was familiar with Resident #99. She said she saw the resident in the morning on [DATE] before the resident went to dialysis. She said she was told Resident #99 was in respiratory distress at around 2:00 PM and was at the nurse station (directly next to Resident #99's room). She said she did not see LVN A and that he must have been in Resident #99's room. The DON said if a resident was in respiratory distress, the nurse was supposed to elevate the head of the bed, notify the physician, and make sure the resident had oxygen. The DON said she never went into the resident's room to assess because she was at the nurse station working on paperwork to send the resident to the hospital. The DON said LVN A did what he was supposed to do and she did not see anything wrong with the actions of LVN A. She said he had to call the doctor to get an order for a breathing treatment. The DON said LVN A gave the treatment, reassessed the resident, but the resident's oxygen saturation was dropping. The DON said she did not know the resident already had orders for breathing treatments as needed. The DON said Resident #99 had shortness of breath, the nurse intervened, the nurse notified the physician, performed the interventions, but the interventions were ineffective. The DON said LVN A followed the physician orders. The DON said the nurse could call 911 only after notifying the physician unless the resident was unresponsive. The DON said the situation did not require LVN A to contact 911 until after he performed the ordered interventions. The DON said a resident with prolonged respiratory distress could develop hypoxia (life threatening condition when there are low oxygen levels), and further respiratory distress. An interview on [DATE] at 4:39 PM with the FNP revealed she was the provider for Resident #99 and that LVN A had contacted her when the resident was in respiratory distress. The FNP said she was contacted by LVN A at 2:14 PM and was told that during care the resident claimed he had shortness of breath. She said LVN A did the appropriate nursing interventions and was told his oxygen saturation had recovered, and he had a little tachycardia (rapid heart rate). The FNP said she gave an order for a chest x-ray as long as the resident was not in distress. The FNP said LVN A called her back at 2:37 PM and said Resident #99's oxygen saturation had dropped. She said she did not know it took 40 minutes to get the resident relief. She said she was not told that the resident was using his accessory muscles to breathe, and he was heaving his chest to breathe. She said if she had known that, then she would have told LVN A to call 911. She said a resident with continued respiratory distress could lead to cardiac arrest and death. The FNP said she did not know the status of the resident in the hospital because she did not have hospital privileges. An interview on [DATE] at 10:01 AM with the family of Resident #99 revealed he was in the ICU at the hospital and they were monitoring his breathing. Interviews on [DATE] at 10:05 AM and 10:35 AM with the DON revealed she did not know the status of Resident #99. She said the family called on the night of [DATE] and thought the resident had overexerted himself. Additionally, the DON said the facility did not have a rapid response policy, because each resident situation was different. An interview on [DATE] at 6:15 PM at the hospital with Resident #99 revealed he was breathing without distress. He was wearing oxygen and said he was doing very well. His Hospital RN said he was on IV antibiotics but did not know if he had pneumonia or another type of infection. The Hospital FNP was in his room and said he admitted to the hospital with acute hypoxic respiratory failure and said that when the resident went into respiratory distress at the facility, he should have been placed on bi-pap. The FNP said due to the resident's diagnoses he had a hypoxic drive to breathe (hypoxic drive to breathe is a physiological mechanism that stimulates breathing in response to low oxygen levels in the blood, particularly significant in patients with chronic lung diseases like COPD.) The FNP said the resident was supposed to be placed on bi-pap immediately after finishing his dialysis treatments. The FNP said the resident needed a respiratory therapist to monitor him at the facility and she said she made it clear to the facility before he was admitted to the facility that he had to have respiratory therapy as well as a bi-pap machine. Review of the facility policy, Acute Condition Changes - Clinical Protocol, revised [DATE], reflected: Assessment and Recognition 1. The physician will help identify individuals with a significant risk for having acute changes of condition during their stay; for example, an individual with an indwelling urinary catheter who has had recurrent symptomatic urinary tract infections, or someone with unstable vital signs or recurrent pneumonia. 2. In addition, the nurse shall assess and document/report the following baseline information: a. Vital signs; b. Neurological status; c. Current level of pain, and any recent changes in pain level; d. Level of consciousness; e. Cognitive and emotional status; f. Resident's age and sex; g. Onset, duration, severity; h. Recent labs; i. History of psychiatric disturbances, mental illness, depression, etc.; j. All active diagnoses; and k. All current medications . 8. The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less) . 10. The nurse and physician will discuss and evaluate the situation. a. The physician should request information to clarify the situation; for example, vital signs, physical findings, a detailed sequence of events and description of symptoms. Cause Identification I. The staff and physician will discuss possible causes of the condition change based on factors including resident/patient history, current symptoms, medication regimen, and diagnostic test results. a. If necessary, the physician will order diagnostic tests and evaluate the patient directly. 2. As needed, the physician will discuss with the staff and resident/patient and/or family the pros and cons of diagnosing and managing the situation in the facility or the need for hospitalization . a. Many acute changes of condition can be managed effectively in nursing facilities with outcomes that are comparable to those of hospitalization . b. This discussion should consider the patient's overall condition, prognosis, and wishes (either direct or as conveyed by a substitute decision-maker). Treatment/Management 1. The physician will help identify and authorize appropriate treatment. 2. The physician and staff will identify relevant resident/patient wishes, including advance directives and POLST orders related to life-sustaining treatments. 3. If it is decided, after sufficient review, that care or observation cannot reasonably be provided in the facility, the physician will authorize transfer to an acute hospital, emergency room , or another appropriate setting . This was determined to be an IJ on [DATE] and 11:00 AM. The Administrator and the DON were notified. The Administrator was provided with the IJ template on [DATE] at 11:15 AM. The Plan of Removal was accepted on 4:02 PM on [DATE] and reflected the following: Immediate action: Medical Director was notified on [DATE] at 12:26 PM. Emergent QAPI meeting was conducted on [DATE]. Root-cause identified that re-education of the Professional Standards of Respiratory Care process was needed. Systematic Approach: 1. LVN A was educated on [DATE] and received one on one education on [DATE], prior to working his next shift, regarding acceptable standards of practice for residents in respiratory distress. Education was completed by the Chief Nursing Officer. Weekly education will continue for LVN A for four weeks completed by the Director of Nursing/Designee and will be monitored for understanding and implementation of knowledge. 2. The facility began education to all licensed nursing staff and certified nurse aides on [DATE] regarding acute change in condition including residents experiencing respiratory distress. Education being completed with all licensed nurses and nurse aides by the Director of Nursing/Designee, RN. 3. The facility completed an audit on [DATE] of all patients that require respiratory treatment to ensure care plans and standards of practice were updated and followed. There were no identified patients in the facility that required changes. 4. The Director of Nurses/Designee will continue to educate new staff upon hire and monthly for 3 months on providing respiratory care according to professional standards of practice. 5. The facility contracted Respiratory Therapist will conduct ongoing monthly training and education for all licensed nurses beginning [DATE] to ensure professional standards of practice are followed for respiratory care needs. 6. An emergency QAPI meeting was completed on [DATE] by the Executive Director regarding respiratory care. The QAPI team determined that best practices would include notifying 911 to transfer a resident to the hospital for respiratory distress that resulted in oxygen saturation below 70% regardless of overall status. Any resident showing signs of respiratory distress would prompt the nurse to begin immediate interventions while remaining at the bedside of the resident and calling the Medical Doctor. 7. The Director of Nursing/Designee will monitor all current patients and newly admitted patients that require respiratory care for appropriate treatment and services. Monitoring of the facility's Plan of Removal included the following: Record reviews of the facility Plan of Removal In-services reflected: 11 staff were in-serviced on: Emergency Intervention for Residents in Distress During Respiratory Distress, dated [DATE], reflected: Purpose To ensure rapid, appropriate, and safe intervention for residents experiencing respiratory distress while alert, in order to stabilize the resident and prevent deterioration or death. Procedures A. Immediate Assessment o Stay with the resident. Do not leave the resident alone. o Call for assistance. Notify the nurse in charge immediately. o Assess and document: Respiratory rate and pattern (labored, shallow, fast, etc.) Oxygen saturation (SpO,) [oxygen saturation] via pulse oximeter Skin color (cyanosis, pallor) Use of accessory muscles or nasal flaring Resident's ability to speak full sentences Presence of audible wheezing, gurgling, or stridor 2. Positioning o Sit the resident upright in High Fowler's position (90 degrees) to facilitate breathing. 3. Oxygen Administration o Apply supplemental oxygen per facility standing orders or physician's order (e.g., nasal cannula at ,d+[DATE] U min [liters per minute] or non-rebreather mask if needed). o Monitor SpO continuously. 4. Notification o Notify the following: Attending physician or on-call provider immediately. Responsible party/family as appropriate per resident's preference or facility policy. Facility Administrator and Director of Nursing (DON) if condition escalates or 911 is activated. 5.Initiate Emergency Response (if needed) o If resident becomes nonresponsive, deteriorates, or SpO, drops critically: Activate Emergency Medical Services (911). Initiate CPR if resident is pulseless and DNR is not in place. Follow facility's Code Blue protocol. 6. Medication Administration o Administer prescribed PRN [as needed] respiratory medications (e.g., bronchodilators, inhalers, nebulizer) as ordered. o Ensure respiratory treatments (e.g., albuterol) are started immediately per standing or emergency orders. 7. Documentation o Record all observations, interventions, time of events, vitals, oxygen use, medication administered, and communication with physician/family. o Document resident's response to interventions. o Complete incident report if EMS is called or acute change occurs. 8. Staff Training and Competency o All staff must be trained in: Recognition of respiratory distress Use of pulse oximetry Emergency oxygen delivery Facility's emergency protocols 15 staff were in-serviced on: Change of Condition, dated [DATE], reflected: Utilizing SBAR [document used to communicate with physician - situation, background, assessment, and recommendation.] Situation - What is happening with the resident? Background - What is the clinical background of resident? Assessment - What does it appear the problem is? Recommendation - How can condition be resolved? When change of condition is reported or noted, nurses should respond with a sense of urgency and quick response to minimize risk of negative outcomes. Anyone with O2 sats 70% or less, call 911 stat. Observations on [DATE] from 1:17 PM to 1:26 PM revealed Residents #1, #2, and #260 were doing well. They were on ordered oxygen therapy and were not in respiratory distress. Interviews with staff from [DATE] at 4:48 PM to [DATE] at 1:35 PM were completed. 13 staff were interviewed in person/on the phone who worked all shifts at the facility. The interviewed staff were LVN A, ADON E, LVN F, LVN G, LVN H, LVN I, LVN J, RN K, LVN L, LVN M, LVN N, RN O, and LVN P. The staff were able to verbalize they were in-serviced on the new Respiratory distress protocol, the SBAR tool, and acute condition changes. The nurses said in order to call 911, the resident needed to be in respiratory distress and not responding to treatment. The nurses said they had to call 911 anytime a resident's oxygen saturation was below 70% but did not have to wait until it was below 70%. The nurses said they had to stay with a resident who was in respiratory distress and did not have to call the doctor before calling 911. An interview with the DON on [DATE] at 12:52 PM revealed LVN A was educated on [DATE] and received one on one education on [DATE], prior to working his next shift, regarding acceptable standards of practice for residents in respiratory distress. The DON said he would receive weekly education that would include response to emergency situations, actions to take, elevate head of bed, and respiratory distress. She said LVN A would be understood that if a resident was in extreme distress, he was to send them out, stay with the resident in room, and alert people to help him. The DON said the majority of the nurses had been in-serviced and everyone would be inserviced prior to their next shift. The DON said the facility completed an audit on [DATE] of all residents that require respiratory treatment to ensure care plans and standards of practice were updated and followed. The DON said there were no issues identified and she would ensure all new admits had the right orders and treatments. The DON said going forward, if she was notified that a resident was in respiratory distress she would go to the hall and help assist with the resident. An interview on [DATE] at 12:33 PM with the Administrator revealed he would monitor to ensure that all staff were trained on providing respiratory care according to professional standards of practice. The Administrator said he had an emergency QAPI meeting focusing on respiratory issues. He said his expectation for nursing leadership was for them to intervene if a resident was in respiratory distress, but that all staff were trained to respond to a resident in respiratory distress. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 11:00 AM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on [DATE].

Based on observation, interview, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for the facility's two (400 and 500 halls) of four medication cart reviewed for storage. The facility failed to ensure Residents #23, #13, #68's insulin lispro vials, Resident #95's insulin lispro pen, Resident #103's glargibe-yfgn insulin vial and Resident #68 Tresiba flex touch insulin were dated when opened. This failure could affect residents and staff resulting in diminished effectiveness, and not receiving the therapeutic benefits of the medications. The findings included: Observation on [DATE] at 12:21 PM with LVN Q in the 400-hallway's medication cart revealed vials of insulin and insulin pen without an open date. The insulin lispro 100unit/ml vials were for Residents #23, #13, and #95. The insulin lispro 100units/ml pen was for Resident #95 In an interview on [DATE] at 12:24 PM with LVN Q, he stated he was not aware why the insulins were not dated. He stated he had used some on the undated insulin and did not realize they did not have open date. LVN Q stated the insulins were supposed to be dated when they were opened because they were good for 28 days before they expire. LVN Q stated insulin was to be dated to make sure expired medication was not administered to the residents because the medication could not be effective to the residents and could cause negative drug effects. Observations on [DATE] at 12:26 PM with RN K in the 500-hallway's medications cart revealed vials of insulin without the open date. The insulin lispro 100unit/ml vial and Tresiba Flex touch 100 units/ml vial for Resident #68. In an interview on [DATE] at 12:30 PM with RN K, she stated she was not aware why the insulins were not dated. She stated it was the responsibility of every nurse to check the open date for the insulin being administered but she failed to. RN K stated insulin was supposed to be dated because it was good for 28 days after open date, so without the open date, the staff might administer expired insulin which could not be effective or cause negative side effects. RN K stated normally the pharmacist will check for expired medication in the cart. In an interview on [DATE] at 10:51 AM with the DON, she stated she had been informed of the medication's carts containing undated insulin. She stated after the report the facility had audited all the medications carts to make sure there was no undated insulin. The DON stated she expected the charge nurse to check and make sure the insulin being administered had an open date and discarded after 28 days. The DON stated the pharmacists checked the carts to make sure the insulins were dated but it was the responsibility of the nurse to make sure the insulins had an open date when administrating. The DON stated she completed random checks of the cart, and she did not have a schedule when she checked. The DON stated undated insulin could be expired which could decrease effectiveness of the insulin when used by the resident. Review of the facility policy revised February 2023 and dated Medication Labelling and Storage reflected, Medication Labelling. 1. Labelling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. 2. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #209) reviewed for infection control. LVN R failed to wear the appropriate PPE while assessing Resident #209's wound. This failure could place residents at risk of being infected by staff in contact with other residents with infections. Findings included: Review of Resident #209's face sheet dated 05/16/25 revealed she was a [AGE] year-old female, she was admitted on [DATE]. Admitting diagnoses included, endocarditis, type 2 diabetes, end stage renal failure and hypertension. Review of Resident #209's care plan dated 05/13/25 reflected, the resident had a diabetic ulcer to left heel related to diabetes. Goal, the resident will have no complications related to ulcer. Review of the Resident #209's orders summary dated 05/16/25 for the month of May reflected, an order of enhanced barrier precautions: providers and staff must wear gloves and a gown when preforming high - contact resident care activities every shift. Observation on 05/13/25 at 09:47 AM revealed LVN R enter Resident #209's room without a gown. On the door of the resident's room there was a posting indicating the resident was on enhanced barrier precaution. Upon entering the room, LVN R was observed bent over attending to Resident #209's right leg. LVN R stated she was doing the resident's wound care to the leg, and then she proceeded to get the trash that was on the side. The resident was noted having a dressing on the left ankle area. LVN R placed the trash in the trash can and procced to the bathroom and she stated she was going to complete hand hygiene. In interview on 05/15/25 at 02:34 with LVN R, at first, she stated she had gone to check if the resident had a wound, and later she stated it was documented the resident had two wounds and wanted to assess the wounds and provide wound care. When asked if she was supposed to put on PPE, she stated she was supposed to have a gown and gloves on because she was in contact with the resident. LVN R stated she did not have a reason why she did not put on a gown while being in contact with the resident. LVN R stated per facility policy she was supposed to put on PPE for infection control. LVN R stated she had had access to PPE and there were some on the hallway in the cart. In an interview on 05/16/25 at 10:58 AM with the DON, she stated she expected the staff to use PPE while assessing the wound or providing care to the wounds. The DON stated the PPE were available on the hallways. She stated the staff had been in-serviced monthly on PPE use, enhanced barrier precautions, infection control. The DON stated the staff were supposed to have PPE while taking care of residents on enhanced barrier precautions to prevent multi -drug resistant. Review of the facility policy revised August, 2022 and titled Enhanced Barrier Precautions reflected, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. 1.Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). b. Personal protective equipment (PPE) is changed before caring for another resident. c. Face protection may be used if there is also a risk of splash or spray.

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 of four residents (Resident #1) reviewed for accidents and supervision. 1. The facility failed to ensure Resident #1 was transferred from her bed to her wheelchair utilizing a Hoyer lift (mechanical lift) with two staff members present as indicated on her care plan. 2. The facility failed to ensure CNA A transferred Resident #1 using a hoyer lift, bruising Resident #1's right arm and left wrist and a skin tear to her left knee. The noncompliance was identified as PNC. The noncompliance began on 07/02/24 and ended on 07/02/224. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk for neglect, harm, pain, and injuries . Findings include: Record review of Resident #1's Admission record, dated 10/24/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #1's Quarterly MDS Assessment, dated 9/25/24, reflected she had moderately impaired cognition. Her diagnoses included congestive heart failure (chronic condition in which the heart does not pump blood as it should); anemia (lack of blood cells needed to carry adequate oxygen to the body); Hypertension (high blood pressure); depression; muscle wasting and atrophy (loss of muscle tissue and strength); back and joint pain. She required the use of a wheelchair and maximum assistance for bed mobility, transfers, dressing and bathing. Record review of Resident #1's Care Plan reflected the following entries: Problem: The resident has limited physical mobility r/t Weakness, Muscle Wasting and Atrophy Date initiated 11/10/22. Interventions . Transfers: The resident is totally dependent on 2 staff for locomotion using Hoyer Lift. Record review of Resident #1's Order Summary Report, dated 10/24/24, reflected the following entries: May Use Mechanical Lift. Order date 11/9/22. May Use Mechanical Lift with 2 Person Assist. Order date 3/23/23. Monitor: Left knee with steri strips for s/s of infection, warmth, or drainage. Notify MD, if there are increased changes/worsening every shift for skin tear monitoring. Order date 7/2/24. Record review of Resident #1's Progress Notes reflected the following entries: Entry dated 7/2/24 at 11:30 AM: reflected Th8is [sic] nurse along with DON notified by [LVN B] that resident has new bruising to her BUE, BLE, and skin tear to Left knee. Skin assessment completed at this time by DON/CNO at this time with above findings noted. Resident reported CNA transferred her without a Hoyer lift during morning care. CNA removed from the floor immediately, POA, Administrator, MD, HHSC, and DPS all notified. The entry was signed by the CNO. Entry dated 7/2/24 at 2:33 PM titled, Skin Only Evaluation: Skin Issue: Bruising. Skin Issue Location: MULTIPLE BRUISING ON LEFT OUTTA [sic] KNEE Skin Issue: Bruising. Skin Issue Location: MULTIPLE BRUISING ON RIGHT ARM Skin Issue: Bruising. Skin Issue Location: LEFT WRIST Skin Issue: Skin Tear. Skin Issue Location: LEFT KNEE Clinical Suggestions: Evaluated for pain, discomfort. PRN medication administered, and effectiveness evaluated. Area evaluated for signs of infection: redness, warmth, swelling, increased temperature, drainage, etc. Area evaluated for signs of healing: approximation, pink tissue, scabbing, etc . The entry was signed by LVN B. During an observation and interview on 10/24/24 at 9:38 AM, Resident #1 was observed lying in her bed. A sign above her bed reflected Hoyer Lift. Resident #1 stated she just finished breakfast and staff would be there soon to get her up. When asked about the incident with CNA A, Resident #1 stated it only happened once and never since. She stated, they took care of it, I don't want to talk about it. She denied any concerns about her care. A nickel-sized bruise was observed on her L hand between her thumb and first finger. When asked about the bruise, Resident #1 stated, I'm 101, my skin is so frail, just touch me and I bruise, I bruise very easily. She denied any staff being rough with her since that last one. CNA C and CNA D entered the room, provided incontinent care and changed Resident #1's clothing. A small scab was observed on her left knee. No other bruises or skin tears were observed. LVN A entered the room with a Hoyer lift. All three staff assisted Resident #1 to her wheelchair utilizing the Hoyer lift. Resident #1 tolerated the transfer well. Resident #1 could not recall how she sustained the injury to her left knee. She declined any further interview. In an interview on 10/24/24 at 1:59 PM, LVN B stated she was working the day of the incident involving Resident #1. She stated Resident #1 had always been transferred using a mechanical lift. LVN B stated, on 7/2/24, she was making her normal rounds when she checked on Resident #1 and noticed the bruising on her arm and skin tear on her knee. She described the injuries as looking fresh. She stated Resident #1 pointed at her arms and said, look what that aide did to me. LVN B stated Resident #1 had bruises on both arms, her left forearm near her wrist and her right forearm. She stated she had a fresh skin tear on her left knee. She stated Resident #1 told her the CNA transferred her to her chair without using the lift . LVN B stated she assessed Resident #1's skin, and she and another nurse cleaned and dressed her skin tear. She stated she reported the incident to the Administrator, DON and CNO right away. She stated she also called Resident #1's physician and responsible party. LVN D stated CNA A was not present when she assessed Resident #1, but she knew it was her because CNA A was working her hall that morning. LVN B stated she was sitting at the nurse's station while CNA A was rounding and never asked her for any assistance or reported any issues with Resident #1's skin. She stated she had only worked with CNA A a couple of times prior to the incident. She stated she never heard of anything like that happening before because everybody knows [Resident #1] is a 2 person assist. She stated the sign above her bed indicated Hoyer Lift was definitely there the day the incident occurred. She stated CNA A was the only aide working that unit that day. LVN B stated the CNAs typically assisted each other with transfers or requested the charge nurse to assist. She stated there had been no further issues with Resident #1 since the incident. LVB B stated she received in-service training related to safe transfers again after the incident which included ensuring proper transfer technique was used and there should always be 2 staff present for mechanical lift transfers. She stated the risk of improperly transferring a resident was injury. During an interview with the CNO and the DON on 10/24/24 at 2:53 PM, the CNO stated CNA A admitted to them she transferred Resident #1 alone that day. She stated CNA A told her there was no one around to help. The CNO stated LVN B told her, I was sitting right there, why didn't you call me? She stated CNA A stopped answering their questions and was sent home. The DON stated she was informed by LVN B of the incident and interviewed Resident #1 who told her the CNA had been rough with her during care. She stated she immediately reported it to the Administrator and CNO. The DON stated both she and the CNO observed Resident #1's wounds and her skin tear looked fresh. She stated they pulled CNA A immediately from the floor. She stated LVN B notified the physician and received treatment orders and obtained an order for a psychological consult. She stated the Administrative staff initiated safe surveys for all residents and skin assessments. The CNO stated they terminated CNA A's employment and initiated in-service training related to transfers for all nursing staff as well as initiating a checklist used to conduct weekly Hoyer spot checks. She stated the spot checks included observing staff during transfers to ensure they were done correctly. The DON stated the Hoyer Lift signage in the room was there prior to the incident and she believed there was sufficient staff to ensure resident safety. During an interview with the Administrator on 10/24/24 at 3:00 PM, he stated he knew Resident #1 very well and went to see her right after hearing about the incident. She was upset but doing okay. He stated, when he spoke to CNA A about the incident, she acted like she didn't do anything wrong and tried to say there was no one available to assist her. If no one was available, you wait a few minutes until someone was. The Administrator stated the risk of not using the lift was injuries. He stated LVN B told them she was sitting nearby and he saw the Hoyer lift in the hallway near Resident #1's room when he went to see her. During a telephone interview on 10/24/24 at 3:28 PM, CNA A stated she did not know what happened to Resident #1, and the resident had very fragile skin and her bruises and skin tear were already there before she provided her care. She stated she knew she was supposed to report any skin issues to the charge nurse but did not that day because the nurse was not at the desk, so she moved on. She stated she had a different assignment than usual that day and was not aware Resident #1 required a mechanical lift for transfers and denied seeing the sign posted above her bed. CNA A stated she felt like the facility staff was looking for somebody to blame for her bruises and had approached her because they saw the skin tear. CNA A stated she transferred Resident #1 to her chair on 7/2/24 by herself by placing her arms under Resident #1's arms and moving her to her chair. She stated Resident #1 was unable to stand but could bear some weight. CNA A stated Resident #1 did not complain or say anything to her about the transfer. She stated she received previous training on safe transfers at the facility and had worked there since March 2024. She stated she had been a CNA since 2005. She stated she did not know Resident #1 well and did not ask the Charge Nurse or the resident how she was to be transferred. She stated she could have asked the Charge Nurse or checked the computer to determine how Resident #1 was to be transferred out of bed, but she did not. She stated, From looking at her, I felt she wasn't too heavy. She stated she did not use a gait belt and transferred her using her arms under the resident's arms. CNA A stated she knew if a mechanical lift was used, there should always be 2 people present. She stated she did not know what the risk was for Resident #1 or even that she needed a mechanical lift. In an interview on 10/24/24 at 5:44 PM, the DON stated all nursing staff completed in-service trainings related to Abuse and Neglect as well as safe transfers. The DON stated CNA A had received her initial skills check off training upon hire, which included transfers of all types. Interviews with the facility nursing staff which included 5 CNAs, 3 LVNs, and 2 RNs, covering all three shifts and weekends, were conducted on 10/24/24 between 9:51 AM and 4:50 PM. The staff revealed they received the in-service training and were able to describe how to determine the type of transfer needed for each resident by checking with nursing staff, rehabilitation staff, and/or the resident's care plan. Staff reported 2 staff must be present at all times for residents requiring mechanical lifts or maximum assistance as there was a risk for injuries. Record review of CNA A's personnel file reflected she completed a Certified nursing Assistant Orientation Skills Checklist on 3/11/24. The checklist included transferring residents from bed to chair and back ambulatory and non-ambulatory; and using a mechanical lift. Her personnel file included a letter, dated 7/2/24 and signed by the DON and HR Coordinator. The letter reflected, .Upon interview of concern [CNA A] stated she assisted resident with care and verbalized she was unaware of anything that was done wrong. admitted to transferring resident via self alone without assistance which is a violation of company policy. [CNA A] failed to carry out the proper transfer policy which she was previously educated on. Employee terminated breach of facility policy. Record review of the facility's Provider Investigation Report, dated 7/8/24, reflected the facility self-reported and investigated the matter to HHSC in a timely manner. The report reflected the following: The Investigation Summary section reflected, Resident #1 reported to her nurse that an aide was rough during provided care. The DON/Abuse coordinator were immediately notified. Resident #1 stated CNA A transferred her to a chair without the use of a Hoyer lift. When asked by staff how her bruising and skin tear had occurred, Resident #1 stated the aide grasped her arms and put her in her chair, but she did not know how the skin tear had occurred. The report reflected CNA A was immediately removed from the floor and suspended. An emergency QAPI was conducted, Abuse, Neglect, and Transfer in-service trainings were initiated. Resident interviews were conducted on all interviewable residents and assessments were conducted on all non-interviewable residents. Facility wide skin assessments were completed. The investigation concluded it was an isolated incident. Record review of an included statement signed by the Administrator reflected the following: 2 July 2024 Met with [Resident #1] this am after transfer by aid and upon report from nursing team. [Resident #1] was upset by the transfer and told me the aid [CNA A] identified as the aid on the hall by staff just came in and picked her up and put her in the chair. I asked her how her knee was hurt and she didn't know how that happened but said she held her by the arms and said 'she was so strong and just put me in the chair.' I asked [Resident #1] if this had ever happened before and she said 'no, I don't know why she didn't use the machine Like they always do' She commented she knew that was wrong and tried to hit the aid. I asked her if the aid hit her and she said 'no, but seemed so mean and she always talks so nicely to me, then she went and got me a sprite.' I reassured [Resident #1] she was safe; I was handling all of this with our team and the aid would never be back to care for her or anyone else and we were investigating why this happened. I know [Resident #1] well and sat with her to explain how this can be very upsetting and if she was ok with it, I would like to have a professional come speak with her for extra support and she agreed. I told her we needed to call her family and she agreed to that. I met with the aid [CNA A] who was removed from the floor in the DON office with nursing leadership. I asked her, according to her training, why she didn't use the Lift with a helper for a routine transfer to get her up like we do every morning and she said she couldn't find anyone, they were with other residents. I did confirm the lift was outside the door of [Resident #1's] room the aid had brought down and the nurse, was sitting a few feet away at the station. I further asked why she would do that when she knew better has been an aid here since March and she shrugged her shoulders and said 'those bruises on her arm look old to me. 1 followed up with [Resident #1] to check on her later that afternoon. She of course remembers the event and told me she was doing better and felt safe with the nurses but still doesn't understand why this happened. 3 July 2024 Met with [Resident #1] this morning and afternoon to check-in on her. She said a Lady from the Army came to see her (Police officer we called yesterday came by to interview her) No issues reported and she feels safe. 4 July 2024 Checked in with [Resident #1] this morning after breakfast to check on how she was doing. No new issues or concerns. She asked me what happened to the aid and told she has been terminated and hasn't been back in the building since her report. Complete investigation and QAPI information conducted by team attached. Record review of an in-service, dated 7/2/24, reflected all staff received training on Resident Abuse, Neglect, and Resident Rights. Record review of an in-service, dated 7/2/24, reflected all nursing staff received training related to transfers, Hoyer lifts and gait belts. The Inservice training report reflected: All Hoyer transfers must be with 2 staff members. No Exceptions. If you are unsure of how a resident transfers, ask the nurse. If a resident cane bare [sic] weight, transfer is with a gait belt and additional staff if needed. If resident is no longer able to transfer safely, inform management and therapy. Record review of the facility's policy titled, Lifting Machine, Using a Mechanical, dated revised July 2017, reflected the following: Purpose: The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions. General Guidelines: 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift .Steps in Procedure: 1. Before using a lifting device, assess the resident's current condition, including: a. Physical: (1) Can the resident assist with transfer? (2) Is the resident's weight and medical condition appropriate for the use of a lift? b. Cognitive/Emotional: (1) Can the resident understand and follow instructions? (2) Does the resident express fear or appear anxious about the use of a lift? (3) Is the resident agitated, resistant, or combative

Based on observations, interviews, and record review the facility failed to ensure residents were free of any significant medication errors for 1 (Resident #389) of 8 residents reviewed for pharmacy services. The facility failed to prevent LVN A from injecting an unknown amount of Kenalog (a steroid for pain relief) and lidocaine (numbing medicine) medication into Resident #389's arm despite an order to hold the medications on the medication cart for the physician to administer into the resident's knees. The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 02/01/24 and ended on 02/02/24. The facility corrected the non-compliance before the survey began. This failure placed residents at risk for harm and/or serious injury. Findings included: Record review of Resident #389's Admission Record revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including influenza due to identified influenza A virus with pneumonia, acute respiratory failure with hypoxia (low levels of oxygen in the tissues), Type 2 diabetes, pain in the right knee, pain in the left knee, and difficulty walking. Record review of Resident #389's Admission MDS assessment dated [DATE] revealed she had a BIMS score of 14 indicating she was cognitively intact. Her preferred language was Spanish. She had functional limitations to her range of motion in both lower extremities (legs). Record review of Resident #389's Order Summary Report dated 04/17/24 revealed the following orders: Kenalog [steroid used to treat inflammatory conditions] injection suspension 40 mg/ml .2 milliliter intra-articularly [into a joint space] one time only for BL [bilateral] knee pain for 14 days hold in cart for [MD B]. Order dated 01/31/24. Xylocaine Injection Solution 1% (Lidocaine HCL (local Anesth.)) [numbing medication] 10 milliliter intra-articularly one time only for BL knee pain for 14 Days hold in cart for [MD B]. Order dated 01/31/24. Monitor: left shoulder for s/s of infection, warmth, or drainage. Notify MD of any changes. Every shift for prophylactic. Order dated 02/01/24. Record review of Resident #389's Medication Administration Record dated 02/01/24 through 02/29/24 revealed the following entries: Kenalog [steroid used to treat inflammatory conditions] injection suspension 40 mg/ml .2 milliliter intra-articularly [into a joint space] one time only for BL [bilateral] knee pain for 14 days hold in cart for [MD B] The order was signed as administered on 2/1/24 at 9:50 AM by LVN B. Xylocaine Injection Solution 1% (Lidocaine HCL (local Anesth.)) [numbing medication] 10 milliliter intra-articularly one time only for BL knee pain for 14 Days hold in cart for [MD B]. The order was signed as administered on 2/1/24 at 9:50 AM by LVN A. Record review of Resident #389's Treatment Administration Record dated 02/01/24 through 02/29/24 revealed the following entry: Monitor: Monitor: left shoulder for s/s of infection, warmth, or drainage. Notify MD of any changes. Every shift for prophylactic Start date 02/02/24. The order was signed as completed every shift from 02/02/24 through 02/08/24. Record review of the facility's Provider Investigation Report dated 02/07/24 reflected the following: Description of the Allegation: 2/1/24 at [3:30 PM] [LVN A] reported administration of Kenalog/lidocaine injection to [Resident #389]. [LVN A] administered injection in right knee and left shoulder. Order placed by [MD B] to be administered by [MD B] with direction to hold in cart for [MD B]. [MD B] notified. Description of Assessment: Assessment to include skin/residual effects/ mobility completed upon notification of injection and revealed no adverse effects to resident. [MD B/MD C] notified. 2/2/24 Follow up assessment conducted at approximately 10am pain/skin/range of motion assessed, resident stated range of motion improved. [MD B] assessed resident in facility. Provider Response: Immediately upon notification nurse sent home on suspension pending investigation. MD notified, new order received to monitor for signs and symptoms of infection, resident assessed and interviewed with Spanish speaking translator, resident son notified. Nurse [LVN A] interviewed and resulted in termination of employment on 2/2/24 as well as reported to the Texas Board of Nursing due to practicing outside scope of practice. Investigation Summary: 2/1/2024 at [3:30 PM] [LVN A] reported administration of Kenalog/lidocaine injection to [Resident #389], [LVN A], administered injection in right knee and left shoulder. Order placed by [MD B] to be administered by [MD B] with direction hold in cart for [MD B]. Assessment to include skin/residual effects/mobility completed upon notification of injection and revealed no adverse effects to resident. 2/2/24 Follow up assessment conducted at approximately 10 am pain/signs symptoms of infection/skin/range of motion assessed, resident stated range of motion improved no adverse event noyed [sic ] at this time. [MD B] assessed resident in facility. Provider Action Taken Post-Investigation: Out of an abundance of caution incident reported to HHCS [sic] and board of nursing for nurse practicing outside the scope of practice. Medication Administration, following physician orders/direction, and reporting in service/training conducted with all nursing staff. Additional direction/instruction to be placed on future Kenalog medication orders via MD. The following written statements were included with the Provider Investigation Report and reflected: Statement dated 02/05/24 and signed by the ADON: On [DATE]st 2024 Pain injection that was to be administered by pain MD was administered by floor nurse, Medication was administered in her left shoulder according to the patient but it was meant for her bilateral knee. Res made aware of the error by nurse and will be monitored closely. Res stated that her shoulder feels a lot better since she was also experiencing shoulder pain. Son made aware and he is ok. Res is continued to be monitored, head to toe assessment done and some bruising is noted to her left deltoid area [muscle on the upper, outer arm at the shoulder]. [Admissions staff] present for Spanish translation, no s/s of distress noted, wctm [will continue to monitor]. Statement dated 02/01/24 and signed by Admissions Staff: On 2/1/2024 I was called for translation services to assist [ADON]. I was told to translate to patient, [Resident #389], that she was given a pain shot administered by the nurse instead of [MD B] on the knees. While I was talking to [Resident #389], she stated that she received the shot on her shoulder, and feels relief, but was confused about the site of the shot as she was expecting to get it on her knees instead. The patient continued to show the site where the shot was given on her left shoulder and explained to me that she did see the nurse had more than one shot on her hands to give her, but she only gave her one, on her shoulder but nothing on her knees. She again stated that she felt the sharp pain come in her shoulder before she started to feel the relief and still feels the sore area of the shot. The patient told me she was feeling concerned that the nurse's statement would keep her from receiving the correct order of her pain medication on her knees. I informed [ADON] and he asked me to inform her that [MD B] and [MD C] will be in to see her on Friday [2/2/24] and they would discuss her medication and will see if they would be able to give her the shots on her knees. Statement dated 02/02/24 and signed by the DON and CNO. Nurse Interview: [LVN A] Incident-[Resident #389]. Order populated to [DATE]am; proceeded to mix solution for administration. The nurse admitted to being unaware how to mix solution and proceeded to google for instruction. Questioned if any supervisor was notified or attempt made to notify for assistance stated no. The nurse questioned if the order was completely read and replied with, she did not completely read the order. Informed of written instructions to hold for MD stated she was unaware, further stated no report seen and administered just as other medication retacrit [a medication given for anemia and injected subcutaneously beneath the skin]. Asked nurse if order instruction was seen as order stated to 'hold in cart for [MD B]' verbalized she did not see it. Inquired of administration nurse initially stated the injection was given in right knee. Inquired nurse to physically identify injection site exact location not admitted . Nurse next verbalized she would be 'completely honest' she divided injection into two 5 ml syringes with small approximately 22' gauge [needle] and physical identified location injection site via pointing to anterior/lateral [outer and toward the front] right knee and L deltoid, two cleaned with alcohol, no bleeding pain noted at injection site. 3:30p-3:45p Nurse reported to [ADON] she gave an injection she did not think she was able to give. [MD C/MD B] immediately notified via [ADON/CNO]. Skin assessment performed. Record review of Resident #389's SNF Rounding Note dated 01/31/24, completed by MD B reflected: Chief Complaint: Resting in bed. Pt with 8/10 achy L shoulder and BL knee pain, worse with activity, would like BL knee injections. Pt denied any CP. Pt denied any Shortness of Breath. Pt with no bowel incontinence. Pt with bladder incontinence. Gait [walking]: 70 ft RW CGA [rolling walker with care giver assist] . Physical Exam .[Extremities] No LE edema appreciated, no atrophy [wasting of muscle mass] appreciated in all 4 extremities. MSK: At least 3/5 in all 4 extremities except 2/5 in L shoulder .BL LE movement slow . Assessment .Has 7/10 achy L-sided pain from fall, worse with activity, Tylenol helps. Incontinent of bowel and bladder. Plan: Physical Therapy .Needs to work on gait distance. Will try knee injections . Pain: L shoulder pain c/w DJD vs labral tear [injury to tissue that holds joint together]. BL knee pain, XRs with DJD. Therapy for pain modalities. Gabapentin, Tylenol, Lidoderm. Will order injection meds. Monitor for side effects Record review of Resident #389's SNF Rounding Note dated 02/02/24, completed by MD B reflected: Chief Complaint: BL knee pain. Yesterday I received a call that the injection meds that I ordered for her BL knees were injected by the nurse without authorization or my approval. After several discussions with DON and ADON, it seems that the nurse administered Kenalog and Lidocaine to the pt's L shoulder and R lateral knee sometime between 1/31/24 and 2/1/24. Since receiving the injections, pt is able to use her LUE more and states that the shaking in her L hand had greatly improved. Pt stated that she only remembered getting a L shoulder injection, not any knee injection. Pt with up to 8/10 achy BL knee pain with gait, better with rest. Denies any L shoulder pain but reports occasional L upper arm pain with ROM, which has been ongoing since she fell . Pt denied any CP. Pt denied any shortness of breath . Physical Exam .[extremities] No LE edema [swelling caused by fluid] appreciated. No atrophy appreciated in all 4 extremities. No L shoulder joint tenderness or warmth. No needle sit [sic] appreciated. No deformity or erythema [redness] BL knees with no tenderness or erythema. No increased warmth compared to rest of LEs-Res spot that looks like a needle mark at R lateral/superior lower leg, just below knee. No surrounding erythema or tenderness. MSK: At least 3/5 strength in all 4 extremities. No abnormal tone in all 4 extremities. BL LE movement slow. Full active ROM in L shoulder, even with R shoulder . Plan . Pain: L shoulder pain c/w DJD vs labral tear. BL knee pain, XRs with DJD. Therapy for pain modalities. Gabapentin, Tylenol, Lidoderm [oral and topical pain medications]. L shoulder Kenalog/Lidocaine injection performed by nurse (without my authorization) and possible a R knee /proximal gastroc [muscle near the knee] injection. I am unaware of how much was injected and what techniques were uses [sic] to minimize the possibility of infection. I instructed the DON and ADON to inform the family, which they said they have. They also said that the incident has been reported to the state and board of nursing. There does not seem to be any infection at this time or any MSK damage. Function is not only intact but improved in the L shoulder. Gait distance is improved as well. I have no plans to administer any further injections at this time. If needing any injections, I recommend she consult her PCP for possible referral to Pain or Ortho. Will continue to monitor function and for any possible infection. Discussed with nursing about monitoring for redness, increased pain or fevers. Monitor for side effects Record review of Resident #389's Progress notes revealed the following entries: 01/31/24 3:17 PM: New order CBC, CMP, Magnesium STAT Signed by LVN A 01/31/24 4:18 PM: Order called in Signed by LVN A There were no other entries were made by LVN A after 01/31/24. 02/01/24 10:50 PM: Resident is alert and awake, no acute distress noted. No present concern at this time. Respiration even and unlabored. Resident expresses no other needs at this time. Call light within reach. Plan of care ongoing. Signed by LVN H. 02/02/24 5:10 PM Physician Progress Note: Chief Complaint: Follow-up Medical evaluation. HP [history/physical]: [Resident #389] is a 75 y.o. female with PMHx significant for chronic back pain, diabetes who was admitted to [hospital name] on 12/27/23 after being found down by family. Patient had possible sepsis and was started on empiric antibiotics. Chest x-ray revealed right upper and lower lobe pneumonia and was found to have elevated LFT [liver function tests] as well. She was given IV fluid with some subsequest improvement but remained very weak so she was discharged to [nursing facility name] for continues care and therapy. Today's Visit: Incident note with nursing staff. Order blood work to monitor for infection .stated that her overall pain is about the same and is a chronic pain Signed by MD C. 02/09/24 11:05 AM: Resident discharged home in stable condition During an interview on 04/16/24 at 8:25 AM, the DON stated she did not believe there were any current residents in the facility who had orders for intra-articular injections but would confirm with the pharmacist and MD B. During an interview on 04/17/24 at 6:40 AM, the CNO was asked to provide any additional training material or information related to the incident involving Resident #389 as well as contact information for the staff and physicians involved. She stated the resident was seen the next day by her physicians and no adverse reactions were found. She stated they were never able to determine the volume of the injections administered and she would gather any additional information she could locate. The CNO stated there were no current orders for intra-articular injections and no medications being held for such in the facility. She stated, the normal procedure for intra-articular injections was, MD B ordered the medications he intended to use from the pharmacy and the medications would be locked in the medication cart. She stated MD B would retrieve the medications from the cart when he arrived to perform the procedure. Observations during medication pass on 04/17/24 from 7:00 AM through 8:25 AM revealed medications were administered by RN F, RN G, and LVN D. Medication route observed included subcutaneous injection, enteral feeding tube, nasal spray, transdermal patch, and oral administrations. No medication errors were observed. During a follow-up interview and record review with the DON on 04/17/24 at 8:54 AM, she stated she had confirmed there were no medications for intra-articular injections in the facility. She stated she spoke with MD B and he confirmed he had no recent or pending orders for the injections. She provided MD B's progress notes retrieved from Resident #389's clinical record. The Facility Investigation Report and MD B's progress note were reviewed with the DON. She reviewed MD B's progress note dated 02/02/24 and stated he had been called immediately after learning of the incident on 02/01/24. She stated she had left the facility for the day. LVN A had reported the incident to the ADON who immediately notified the CNO. She stated LVN A was immediately removed from the floor and brought in for questioning. She stated the ADON had assessed the resident and brought the Admissions Staff member with him for translation. She identified the Admissions staff member and stated she no longer worked for the facility. The DON stated she assessed Resident #389 the next morning and did not recall seeing a puncture mark on her knee. She thought she recalled seeing a small puncture mark on her shoulder but could not recall the exact location. She did not see any swelling, puffiness, or bruising. She stated Resident #389 had denied getting an injection in her knee. The DON stated she and the CNO had interviewed LVN A again the next day and asked about the injection to the shoulder. The DON said she remembered LVN A saying she gave it like Retacrit [a medication for anemia administered subcutaneously]. When asked if they had attempted to get a written statement from LVN A, the DON stated they could never get a straight story from her, when they asked her why she injected Resident #389's arm she just sat silent. The MAR was reviewed, and the DON was asked if they had ever determined the time of administration. The DON stated she had noted the medication was signed out around 10:00 AM. She stated LVN A worked the 6:00 AM-2:00 PM shift and had reported the incident around 3:30 PM-4:00 PM. She stated staff were supposed to sign out a medication at the time of administration, but they could never get an exact time of administration from her. The DON stated she immediately initiated in-service training for all nursing staff which included a review of medication administration policy/procedures and scope of practice for RNs and LVNs. She stated MD B had previously administered the injections in the facility and nothing like this had ever happened before. She stated he told her he would continue to make it very clear on his orders to hold the medications for him. She stated, we are always telling the nurses, any questions at all about medications, stop what you are doing and ask us, the doctor, the pharmacist, just ask. She stated the risks included she could have hit a nerve, caused an infection or other injury. The DON stated Resident #389's discharge home was unrelated to the incident and had already been in the planning process. During a telephone interview on 04/17/24 at 9:33 AM, LVN A declined to answer any questions related to the incident. During an interview on 04/17/24 at 9:30 AM, MD B confirmed he had been notified of the incident involving Resident #389 receiving injections from a nurse which he had intended to administer by intra-articular injection. MD B stated he assessed Resident #389 the next morning. He stated he did not have his notes in front of him and referred this state surveyor to his progress note for 02/02/24. He stated he did not recall seeing any damage or injury and stated, she actually seemed to have improved functionality, no sign of infection. He stated he did not recall seeing anything abnormal and he was not overly concerned with injury. MD B stated he typically administered the intra-articular injections and was the only person who did them. He stated he had been conducting rounds in the facility since the summer of 2016 and had been doing the injections since that time. He stated he had never encountered anything like this incident before. MD B stated the medications had always been kept in the medication cart for him and he personally ordered the medications and added the note to hold the medications for him. He stated, This was a shock. They called me immediately when they found out, and I came in the next day to assess her. He stated he had instructed them to monitor her and call him with any concerns. MD B confirmed he had no current orders for any other resident and could not recall when he had performed his last injections. He stated the injections were infrequent. He stated he probably performed 3-4 injections per month over three different facilities he covered so maybe 1 injection every 3 months or so at this facility. MD B stated whenever he performed the intra-articular injections, he had the residents sign a consent form and discussed the risks with the resident. He stated the main risk for Resident #389 was infection as he was unable to tell what process she used to prepare the area. He stated injection risks included muscle damage, tendon, and nerve damage. He stated, with the shoulder, there is a brachial plexus nerve or lung that could be damaged depending on where she inserted the needle. He stated he could not recall if he saw a puncture mark. He stated he had no clear picture of how much of each medication was injected at each site. MD B stated he thought the resident told him only her shoulder was injected. During a telephone interview on 04/17/24 at 10:30 AM, Resident #389 stated she had had a fall at home in December 2023, was hospitalized , and ended up in the nursing facility for therapy. She stated she was having arm pain in the past due to arthritis but, after her fall, she had increased pain in her arm and knees. She stated, around 4:00 PM that day, a nurse arrived and told her she was going to give her a shot. She was not certain of the exact time but stated it was after lunch and her therapy. She told her ok because she thought it was her insulin, but then saw she had various injections and could not recall how many. She stated the nurse told her she was going to give her a shot in the shoulder and knee. Resident #389 stated the doctor had already told her he was going to give her shots and she thought maybe he sent the nurse instead. Resident #389 stated the nurse injected her shoulder and it hurt very bad and never gave her a shot in her knee. She stated the nurse stayed to monitor her for a bit then took the rest of the injections and put them in the red box disposal. Resident #389 stated she asked the nurse if she was going to give her a shot in her knee and she did not answer. She stated she asked her three times in English with no response. Resident #389 stated on the third time, when she did not answer, she thought maybe it was not her day for her shot. Resident #389 stated later, around 6:00 PM, staff approached her and asked if she was doing ok. She stated her arm was feeling better, she was moving it better, and it was not shaky anymore. Resident #389 stated they asked her about her knee, and she told them it was still hurting, that the doctor told her she would get a shot in her shoulder and knee, and she only got one in her shoulder. She stated she told them she did not understand why the nurse only used one injection and she did not know why she had so many injections with her. She stated she did not know why the nurse told her she was getting a shot in her shoulder and knee, then only injected her shoulder. Resident #389 stated they got the nurse and brought her to her room. She stated the nurse was crying and yelling Tell them I gave you a shot in the knee! and was being dramatic. She stated she told the nurse No, you didn't give me a shot in the knee. She stated she did not understand why the nurse said she did, she stated she was not demented, and remembered the incident. Resident #389 stated she believed the nurse was being dramatic because she was told only the doctor should have given her the injection. She stated that was the first time a mistake had been made. She stated she felt like the staff thought she was lying but she knew what she got. Resident #389 stated her doctor came to see her the next day and was upset about the situation. During an interview on 04/17/24 at 12:00 PM, the Administrator stated LVN A was pulled immediately from duty when she reported the incident and was terminated shortly after. He did not recall whether anyone took her back to Resident #389's room after the incident. During an interview on 04/17/24 at 12:08 PM, the CNO stated she was working in the facility on the day of the incident. She stated the ADON brought the nurse in to her and said, We have a problem, she administered [MD B's] injection. The CNO stated she started asking her what?, where?, why? She said it obviously stated on the order to hold for MD B. The CNO stated the ADON left to check on Resident #389 while she interviewed the nurse. He returned and told her the resident stated she had only been injected in her shoulder. She stated LVN A originally told them she had injected her knee. She stated LVN A kept going back and forth on her story and it did not match the resident's statement. She stated she finally told LVN A, come and show me, at which time LVN A began to cry, got on her knees, and said, I'm sorry, I don't know why I did that. She stated she was not sure if the ADON took LVN A to the resident's room for clarification and the two of them were quickly trying to investigate and contact her physicians. She stated when she asked LVN A why she injected her shoulder when that was not even part of the order, she replied, 'because her shoulder hurt'. The CNO stated she told her, So, basically you played doctor. She stated she told her at that time she was going to be terminated and her license would be referred. The CNO stated the Human Resources (HR) staff was not there at that time so the next day she had them terminate her employment. She stated she had never encountered anything like this before. She stated she did part of the HR portion, initiated a State report and the BON referral. The CNO stated they were never able to clarify the time the incident occurred because she did not have the MAR in front of her at the time of her interview. She stated, there was so much back and forth, she did not know what was true and what was not. She stated Resident #389's attending physician and MD B were contacted as well as her family. The ADON completed a physical assessment and initiated ongoing assessments to monitor for any adverse reactions. She stated she believed both physicians saw her the next day. The CNO stated LVN A had received the normal training and skills check-off that all nurses receive. She stated reading a physician's order was a basic nursing skill, and the instructions were added to the order and MAR specifically for that purpose. She stated there was no specific training for this particular situation because the physician brought all his own equipment, retrieved the medications, and took care of everything himself. She stated the risks included adverse effects from the medication, infection, and nerve injury. The CNO stated the DON immediately prepared and initiated in-services and went specifically in-depth regarding MD B's orders. She stated she also included handouts from the BON related to nurse's scope of practice. On 04/17/24 at 12:40 PM, an attempt to reach the ADON for a telephone interview was unsuccessful. During an interview and record review on 04/18/24 at 10:55 AM, the OT reviewed her notes and stated she had cared for Resident #389 during the first week of April 2024. She stated she had heard about the incident involving her injection and the resident had told her she had received an injection in her shoulder but not her knee. The OT stated they always checked for swelling in the joints and she did not recall seeing any swelling or bruising on her. She stated Resident #389 did well during her therapy on 02/02/24 and was ambulating with her walker. She stated she had already been progressing well toward her discharge goal when the incident occurred. An interview with LVN H on 04/18/24 at 8:50 AM revealed she had cared for Resident #389 on 2/1/24 during the evening shift. LVN H stated she was aware of the incident that had occurred but had not witnessed anything. She stated she recalled the resident telling her as well as receiving orders to monitor her closely for any reactions like swelling, redness, or increased pain. She reviewed her notes and stated she did not recall Resident #389 having any complaints that evening. LVN H stated she had attended the in-service training the next day related to medication administration and scope of practice. She stated, as an LVN, she was only allowed to administer intramuscular and subcutaneous injections. She stated she had additional training to administer intravenous medications. LVN H stated it would never be appropriate to administer intra-articular injections as only physicians could administer those. She stated she knew to call her manager if she had any questions related to her medication orders The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 02/01/24 and ended on 02/02/24. The facility corrected the non-compliance before the survey began. The facility took the following actions to correct the non-compliance prior to the investigation: Record review of LVN A's personnel file revealed a Termination of Employment Statement dated 02/02/24, which shows LVN A's employment had been terminated on 02/02/24. The document was signed by the DON and the Administrator. Record review of a Complaint Form dated 02/02/24 revealed the CNO submitted a referral to the Texas Board of Nursing related to the actions taken by LVN A. Record review of the following in-services dated 02/02/24 reflected: Topic: Medication Administration. Contents or summary of training session: Medication Administration, Following physician orders and direction, reporting. See attached Conducted by the DON. A Signature sheet was attached and included named of the nursing staff. The attached training materials included: Bulletproof Medication Administration 1. Right Patient check two unique identifiers such as name and birthdate, or name and medical record number. Ask the patient whenever possible. 2. Right Mediation-Never assume .always look at your medication to make sure it's the right one. Many medications look and sound alike. 3. Right Time-verify your institution's policy for the timeframe to give scheduled meds; double-check PRN intervals to ensure patient safety. 4. Right Dose-If you're unsure of your dosage, ask another nurse to verify. If you're ever opening multiple packages or vials .check again! 5. Right Route-Some meds can be given via multiple routes, and oral liquid meds should never be given IV. 6. Right Indication-Understand why your patient is receiving each medication. It will help you understand their condition and alert you to what you need to monitor. 7. Right Formulation-Some medications come in different formulations such as tablets, elixirs, or suppositories. Tylenol is a great example of this! 8. Right Documentation-Document immediately when giving medication and be sure to include any pertinent data such as vital signs or pain scores. 9. Right Response-You must understand what response you are expecting from each of the medications, so you know if they are effective or not. 10. Right Compatibility-Ensure any IV medications running together are compatible. Also, give enteral medications one at a time. 11. Right Contraindications-Know what situations would cause you to hold the dose. This may be vital signs, physiologic conditions, or even an allergy. Administering Medication Checklist 'TRAMP' T- Time: Check the order for when it would be given and when was the last time it was given. R-Route: Check the order if it's through oral, IV, SQ, IM, or etc. A-Amount (Dose): Check the Medication Sheet and the doctor's order before Medicating. Be aware of the difference of an adult and a pediatric dose. M-Medication: Check and verify if it's the right name and form. Beware of look-alike and sound-alike medication names. P-Patient: Ask the name of the client and check his ID band before administering. Even if you know the patient's name, you still need to ask

Based on interview and record review, it was determined the facility failed to ensure one (Resident #1) of three sampled residents identified as fall risks, received adequate supervision and assistance devices to prevent accidents. Resident #1 was care planned to have a personal safety alarm at all times while in bed and in his wheelchair, due to his risk for falls. Resident #1 fell from his wheelchair sustaining a laceration to his forehead. The resident's personal safety alarm did not activate and sound to alert staff to his movement on that date. Due to the severity of the resident's injury, he was transported to the hospital where he subsequently expired. This failure could result in falls, injury, and potentially death. This failure could affect all eight residents in the facility identified with a history of falls. Findings included: 1) Resident #1's admission MDS assessment signed as complete by the RN Assessment Coordinator on [DATE] reflected Resident #1 entered the facility on [DATE] from an acute hospital setting. The resident's active [DIAGNOSES REDACTED]. Resident #1's MDS assessment reflected he scored an 8 out of 15 on the BIMS indicative of moderate cognitive impairment. The assessment further reflected Resident #1 required the extensive assistance of one person for transfers from surface-to-surface and with locomotion on/off the unit. In the area of balance during transitions and walking, Resident #1 was assessed to be unsteady and only able to stabilize with staff assistance when moving from a seated to standing position, moving on and off the toilet, and when doing surface-to-surface transfers. The MDS assessment reflected the activities of walking and turning around did not occur. The resident was assessed to have functional limitation in range of motion to his bilateral upper and lower extremities. The resident's primary means of mobility was identified as a wheelchair. In the area of falls, the MDS assessment reflected Resident #1 had a fall within the last month, prior to his admission to the facility. The assessment further reflected the resident had a fracture related to a fall he experienced within the six-month period preceding his entry to the facility. There were no falls indicated since his admission to the facility at the time the MDS assessment had been completed. 2) Resident #1's Comprehensive Plans of Care, dated [DATE] and [DATE], reflected the following care planned approaches to address Resident #1's falls on [DATE] and [DATE]: "Approach 1) Encourage resident to ask for assistance of staff. 2) Ensure call light is in reach, answer promptly 3) Therapy to eval and treat per orders 4) Anticipate needs, provide prompt assistance 5) Assure lighting is adequate and areas are free of clutter 6) Encourage socialization and activity attendance - as tolerated 7) Low bed 8) Personal alarm at all times 9) Floor mat (Added to the care plan on [DATE])." 3) Resident #1's Fall Risk Evaluations reflected he scored at risk for falls on [DATE], [DATE], and [DATE]. 4) Resident #1's Geriatric Psychiatry Initial Consultation dated [DATE] reflected Resident #1 was assessed to have moderate to severe dementia with sundowning and anxiety. 5) Resident #1's [DATE] physician's orders [REDACTED]. 6) Electronic Health Records for Resident #1 reflected the following entry made by LVN C: "Narrative Notes [DATE] 07:51 PM Nursing: pt found by (Resident #2's family member) on the floor calling for help, bleeding from the right side of the forehead. resident asked what happened she (sic, he) said "I dont (sic) know". this nurse applied pressure on the opening on forehead to stop the bleeding with the help of the med aide and the cna (sic, CNA) - (CNA A). head to toe assessment done, pt able to move all extremities, clear speech, pupils reactive to accomodation (sic), vital signs assessed. pt assisted to chair and then to bed. 7:52 on call nurse notified, 7:55 Dr. (Physician B) nofied (sic, notified) and gave an order to send pt to ER, 9:58 call placed with 911 and 9pm family notified - pt (family member), 8:10 ambulance arrived and took res to ER." 7) Resident #1's hospital records were obtained and reviewed on [DATE]. The hospital Facesheet Admission/Registration Record printed on [DATE] reflected Resident #1 was admitted to the hospital on [DATE] at 8:40 PM due to a fall resulting in a laceration to his head. The Patient Care Report, dated [DATE], completed by the DF-RD EMS reflected: "Comments Narrative: Bystanders state that pt was sitting in wheel chair, watching TV when he began slipping in chair and hit head on floor. Nursing staff proceeded to take pt to his bedroom, and called 911. Upon arrival, engine company found pt laying in bed with 1 ,[DATE]" lac to forehead that had not been dressed. Dressing applied to head by engine crew. Upon (EMS Crew) arrival, pt was bandaged and presented with a lethargic/sleepy presentation. Pt would respond to voice. On scene staff could not provide clear baseline LOC. Their only comment was that pt would normally ramble on. While enroute to hospital, pt would respond to voice and speak incoherently. Proceeded to transport pt to (local) hospital, condition remained unchanged during transport." The hospital ED Physician Record, print date and time [DATE] 09:33:44, reflected Resident #1 was diagnosed with [REDACTED]. ",[DATE] 00:53 (12:53 AM) ED course: Called to see patient for sudden hypotension with SBP in 70's. Chart reviewed and discussed with family. Fall at Nursing Home PTA with scalp lac./head injury. Had been given his sleeping meds and therefore unable to arouse and get further HX and limited exam. BP reproducible in 70's. CT head negative and age indeterminate transverse process C7 seen. Possible L hip FX with 2 view pending. Ordered CXR and CT abd/pelvis in light of low BP post-trauma, and discussed case with Dr. ____/Trauma to inform him of the circumstances and he concurred with TART which was done. 01:01 (1:00 AM) ED course: 2nd line started and IVF pushed. EKG showed AFIB as before, controlled. Discussed with TRAUMA and with Dr. (Physician B) for Med Provider... 02:38 (2:38 AM) ED course: Called to see patient who had been made DNR by family. My exam: Pulseless/Apneic. No heart beat auscultated. Pronounced by me at 0237 (2:37 AM) hrs...." The ED Nursing Record, print date and time [DATE] 09:33:40, reflected Resident #1 expired in the hospital on [DATE] at 2:37 AM. The record reflected the Medical Examiner's Office was not going to examine the resident's body upon his death, and the resident's body was sent to the morgue. 8) The facility's Provider Investigation Report completed by the facility's Executive Director/Administrator on [DATE] reflected the following Investigation Summary regarding Resident #1's fall: "Resident was last observed at 7:35pm watching TV close to nursing station in a common room. Resident unable to state how he came to rest on the floor. It is the facility's belief that the resident fell forward from his chair and struck his head on the floor. Resident had a w/c alarm ordered and alarm was sounding at the time of the incident. The resident had also been receiving physical therapy at the facility as part of a fall prevention program." An Accident/Incident Report, completed by LVN C on [DATE], attached to the Provider Investigation Report reflected: "Witness Account of Event (Facts Only) When this nurse arrive at Station 500 found Resident (Resident #1) on floor being assisted by the Med Aide (MA D) and CNA (CNA A), at this time Pt was bleeding from a laceration on (R) side of forehead. This nurse took a clean towel and applied pressure on bleeding site asking Res what happened - He said "I do not know". Res assisted back to chair after head to toe assessment done - Pt was able to move all ext and talking." LVN C's Witness Statement, dated [DATE], reflected: "7:20 PM This nurse went for break and left Resident (Resident #1) sitting on his w/c by the nurse's station watching TV. When I arrived at nurse's station at 7:45 Resident was on the floor being assisted by (MA D) and (CNA A)." MA D's Witness Statement, dated [DATE], reflected: "On [DATE] at 7:45 PM, I was with (Resident #3) at room ___ giving her her night medications when one of the family member came and called me that Mr. (Resident #1) was on the floor." CNA A's Witness Statement, dated [DATE], reflected: "On ,[DATE]/ at 7.40 PM i was with ,(Resident #4) at (Room) ___ giving him care so when i was finshes (sic, finished) i come out of the room that (is) when the Med Aid call me and say a rest (sic, resident) is on the floor." CNA E's Witness Statement, dated [DATE], reflected: "I was in a pt room (___) giving care came out after care and the nurse told me that he fell . Before that time the last time I saw him was 7.35 pm pt was sitting up in his wheelchair and his footrest was there with his foot on it. Pt was awake in his wheelchair, he spoke to me "Hi" and I responded. He was well awake at that time. I was going to give care. After care I came out to discard linens. I saw the nurse, med aide and his caregiver with him." 9) CNA A was interviewed via telephone on [DATE] at 3:51 PM regarding Resident #1's fall on [DATE]. CNA A stated she was in another resident's room providing care when she heard MA D tell her to come because a resident was on the floor. She stated when she got to Resident #1 there was blood "everywhere." When asked when she had last seen Resident #1, she stated she had observed him approximately ,[DATE] minutes before. She stated the room she was in providing care to another resident was a far distance from where Resident #1 was when he fell . When asked if she heard Resident #1's personal safety alarm sounding when he fell , she stated she did not hear an alarm. 10) LVN C was interviewed via telephone on [DATE] at 3:56 PM regarding Resident #1's fall on [DATE]. LVN C confirmed he was the charge nurse on duty the night Resident #1 had a fall. He explained he left the station for break. When he returned from his break, Resident #1 was on the floor. He stated he heard the resident saying repeatedly, "Help. Help. Hurry. Hurry." He stated MA D and another person were trying to help the resident. He stated the resident was bleeding from a laceration to the forehead, and he applied pressure to the wound. LVN C stated Resident #1 was alert and verbalizing that he wanted to go to bed. After he assessed Resident #1, the resident was assisted back to his room and allowed to go to bed. While he was being assisted back to bed, the nurse stated he called 911. LVN C was asked if Resident #1's personal safety alarm was sounding when he observed the resident on the floor. He stated the alarm was sounding. 11) MA D was interviewed via telephone on [DATE] at 9:17 AM regarding Resident #1's fall on [DATE]. MA D stated it was around 7:45 PM, and she was passing medications to residents on the hall. She stated a family member informed her at that time that a resident was on the floor. The family member asked her to come down to the TV room to help the resident. When she got to the TV room, she stated Resident #1 was on the floor. He was bleeding from the head. She informed his aide, CNA A, that the resident had fallen. The resident's nurse, LVN C, came back to the station, and he helped with the resident as well. During the interview, MA D was asked if she heard Resident #1's personal safety alarm sounding around the time he had fallen or when she got to the resident. She stated she did not hear anything. For confirmation purposes, she was asked if she was positive she did not hear the personal safety alarm. MA D stated she did not hear anything. MA D was asked if the resident had gotten his evening medications prior to falling. She stated she had given Resident #1 his evening medications around 7:30 PM or 7:40 PM. 12) Resident #2's family member, the first person to find Resident #1 after he had fallen on [DATE], was interviewed via telephone on [DATE] at 3:11 PM. Resident #2's family member explained he/she usually came to the facility almost every evening to visit Resident #2. He/she stated he/she had noticed Resident #1 on previous visits, and he/she knew the resident had not been at the facility very long. He/She stated the resident usually made noises, and he often repeatedly called out, "Help me, help me." Resident #2's family member stated on the evening of [DATE] he/she was pushing Resident #2 down the hallway when he/she heard, "Hurry, hurry, hurry." He/She stated when he/she got to the TV room on Station 500, he/she saw Resident #1 lying on the floor. He/She stated there was "just a pool of blood" on the floor, and he/she described the scene as "ghastly." He/She explained the flooring was not carpet, but a hard-type of flooring material which the resident fell forward on. Resident #2's family member stated there was a woman sitting at the nurses' station directly across from the TV room. He/She stated he/she did not think she saw the resident on the floor because she was behind a large cabinet. He/She stated the woman informed him she did not work at the facility. Resident #2's family member stated he/she summoned the assistance of MA D. About that time, he/she stated LVN C arrived back on the unit. The family member stated LVN C was very concerned that nobody was there when the resident fell . Resident #2's family member was asked if he/she heard any alarms sounding when he/she found Resident #1 on the floor in the TV room. The family member stated he/she did not hear anything sounding. He/She was alerted to the resident because of the resident repeatedly calling out, "Hurry, hurry, hurry." 13) Review of Resident #1's personal safety alarm check-off sheet for [DATE] revealed the safety alarm was supposed to be checked on each shift as indicated by the initials of the staff person checking the alarm. The entry for the second shift, 2:00 PM - 10:00 PM, reflected the alarm was supposed to be checked by 3:30 PM each day. Review of the entry for the second shift on [DATE] revealed the entry was blank. Further review revealed the sheet continued to be initialed by nursing staff as being applied to Resident #1 and working through [DATE]. Resident #1 expired in the hospital on [DATE]. This information was shown to the DON on [DATE] at approximately 4:45 PM. She acknowledged there was not an entry for [DATE] as well as the continued entries after the resident had already expired. 14) During a discussion with the Administrator, DON, and ADONs on [DATE] at 4:15 PM, they were not aware Resident #1's personal safety alarm did not sound on [DATE] when he fell that evening according to the first three people to assist the resident (CNA A, MA D, and Resident #2's family member). They also were not aware that there was a woman sitting at the desk directly across from the TV room where Resident #1 fell . In addition, they were unaware Resident #1 was found by Resident #2's family member. 15) The facility's Roster/Sample Matrix printed on [DATE] reflected there were eight residents identified with a history of falls, including falls with major injury.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for one (Resident #1) of five residents reviewed for quality of care. LVN C failed to assess Resident #1's groin area and obtain treatment orders after she was informed by CNA B the area was red on 06/08/12, until surveyor intervention on 06/25/12. These failures resulted in Resident #1 experiencing "terrible" itching for over two weeks weeks. These failures could affect the other 19 residents, who lived on the 300 hall, by placing them at risk for not being properly assessed or receiving the care and services needed to maintain their well-being and comfort. Findings included: 1) The readmission MDS assessment, dated 04/24/12, reflected Resident #1 was an [AGE] year-old female re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. per the readmission Minimum Data Set ((MDS) dated [DATE]. The assessment reflected Resident #1 was independent for cognition, required extensive assistance for transfers, dressing, toilet use and hygiene, had impaired range of motion to both lower extremities and was occasionally incontinent of urine. The MDS further revealed Resident #1 was at risk for developing pressure ulcers. Resident #1's Comprehensive Care Plan, dated 04/17/12, reflected: "Resident has current skin concerns: stasis ulcers BLE @ bilateral achilles." The approaches included: "...6) Assess skin weekly and record findings in clinical record - will refuse at times." Resident #1's Comprehensive Care Plan, dated 04/22/12 through 07/21/12, reflected: "Resident has inadequate food and beverage intake R/T multiple wounds as evidence by BMI 19.3, weight loss and increased needs for wound care." The interventions included: "...Monitor skin per nursing policy...." On 06/25/12 at 1:32 PM, Resident #1 was observed receiving wound care from the Wound Treatment Nurse to her lower legs. She had ulcers to her Achilles tendon area (back of her ankles) on both legs and stated standing was difficult and walking was very painful. After the treatment, Resident #1 was asked by the surveyor if she had any skin discomfort anywhere else. Resident #1 stated she had a rash around her groin area and it "itched terribly." Resident #1 went on to explain she had been "itching for weeks" and sometimes the CNAs put powder on the area when they remembered. Resident #1 pointed to a bottle of [MEDICATION NAME] powder on her nightstand and stated that was the powder the CNAs used. The bottle of [MEDICATION NAME] had a label attached that reflected the name of Resident #2. During the interview, the Wound Treatment Nurse left the room and RN A (Charge Nurse 6:00 AM to 2:00 PM) entered and stated the treatment nurse had mentioned she was complaining about a rash. RN A looked at the bottle of [MEDICATION NAME] and stated, "That's not her's." She stated the Nurse Practitioner was in the facility and she would send her in to examine the rash. On 06/25/12 at 2:37 PM, CNA B was queried about Resident #1's skin condition. CNA B stated she had seen redness on Resident #1's groin area. When asked what she did about it, CNA B stated she went right out and reported it to LVN C (Charge Nurse 2:00 PM to 10:00 PM) and LVN C had given her a powder to use. When asked if it was called [MEDICATION NAME], CNA B confirmed it was. When asked when she had informed LVN C about the redness, CNA B replied, "Maybe a month or so ago." On 06/25/12 at 2:38 PM, LVN C and NP examined Resident #1's groin area with this surveyor. Both sides of Resident #1's groin as well as her abdominal fold were dark red and the left side of her groin was excoriated. The NP told Resident #1 she had a yeast infection and was going to prescribe a medication for her. On 06/25/12 at 2:44 PM, when LVN C was asked whether she had been documenting Resident #1's skin condition she replied, "No ma'am, I didn't know anything about it until now." On 06/25/12 at 2:46 PM, RN A was queried who was responsible for the resident's weekly skin assessments. RN A stated it was the responsibility of the Wound Treatment Nurse to complete the weekly head to toe skin assessments. When asked whether the CNAs documented any issues they found, RN A produced a binder with Skin Assessment Sheets and stated the CNAs completed these "shower sheets" if they found any issues. When asked about Resident #1, RN A searched the book and found one sheet dated 06/08/12. Review of the Skin Assessment Sheet for Resident #1 dated 06/08/12 revealed a diagram of the human body was circled around the left and right groin areas and "Redness" was written with a line indicating the areas. "Report to (LVN C)" was written next to the areas and the sheet was signed by CNA B and LVN C. On 06/25/12 at 2:49 PM, LVN C was observed in the hallway speaking with CNA B. LVN C then approached this surveyor and stated she did not recall the skin issues on Resident #1. She stated, "(CNA B) said she told me but I don't remember." When LVN C was shown the Skin Assessment sheet dated 06/08/12 and asked if it was her signature on the sheet, LVN C looked at the document and replied, "Yes, but I don't recall that." When asked whether she gave CNA B the [MEDICATION NAME] powder to use, LVN C replied, "No ma'am." Interview with the Wound Treatment Nurse on 06/25/12 at 3:08 PM revealed he did skin assessments on Resident #1's hall on Wednesdays. When whether he had performed a head to toe skin assessment on Resident #1 last Wednesday, he replied, "Yes." When asked if he had looked at her groin, he replied, "Sometimes I do, sometimes I don't." When asked if he looked at her groin last Wednesday, the Wound Treatment Nurse looked at his documentation and stated, "All I have are the bilateral lower extremities." He explained that sometimes the residents did not want him to check their more private areas and, when that was the case, he would tell the CNAs to check them during their showers and report any concerns to the charge nurse. The DON was present during the interview and was asked what the usual chain of events should be if a skin issue was found. The DON pointed to the skin assessment sheet and stated, "If they (CNAs) see anything they fill out a skin ID sheet and tell the nurse. As you can see the nurse signs it, should go assess it and go from there." During another interview on 06/25/12 at 3:26 PM, LVN C was shown the bottle of [MEDICATION NAME]. The bottle reflected "[MEDICATION NAME] 100,000 USP [MEDICATION NAME]" and a label that reflected Resident #2's name. When asked about the identity of Resident #2, LVN C stated he was a former resident and she thought he discharged sometime within the past two weeks from the 300 Hall. She maintained she did not know how his medication had gotten into Resident #1's room. Interview with CNA D on 06/25/12 at 3:40 PM revealed she had taken care of Resident #1 for a long time. She stated Resident #1 had redness to her groin area for a long time, "...ever since she's been admitted ." When asked if she had told anyone, CNA D replied, "I think the nurse knows." When asked if she was aware of any treatments for it, CNA D stated she used a barrier cream on it and added "...she (Resident #1) has a prescription powder, sometimes I use that too." Review of Resident #1's Weekly Body assessment dated from 04/17/12 through 06/20/12 and provided by the Wound Treatment Nurse revealed there were no entries related to Resident #1's groin area. Review of Resident #1's daily Skilled Nursing Observations + ADL notes for the month of June 2012 revealed there were no entries related to the redness on her groin. All skin entries reflected her skin was "Warm/Dry" or "WNL (within normal limits)." Resident #1's Skilled Nursing Observations +ADL notes dated 06/08/12 and entered by LVN C at 7:28 PM reflected "Skin Warm/Dry." Resident #1's Skilled Nursing Observations +ADL notes dated 06/08/12 and entered by RN A at 10:30 AM reflected: "Skin Warm/Dry." Resident #1's Physician's Telephone Order dated 06/25/12 reflected the following: "[MEDICATION NAME] Powder - Apply to affected area three times daily X (times) 14 days Keep area dry, clean with warm water with each change of briefs" Indication-Dx (diagnosis) reflected: "Yeast." There were no prior physician's orders for [MEDICATION NAME]. 2) Review of Resident #2's closed clinical record revealed a Record of Admission, dated 05/29/12. The Record reflected he was admitted to the facility on [DATE] Review of resident #2's Discharge Instructions, dated 06/19/12, revealed the resident was discharged on the same date, 06/19/12. Resident #2's admission orders [REDACTED]." The order [DIAGNOSES REDACTED]." 3) The facility's current policy entitled, "Pressure Ulcer Risk Assessment" dated 2005 and revised April 2007, reflected the following: Assessment: "...2. Skin Assessment. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. 3. Monitoring: a. Staff will maintain a 'skin alert,' performing routine skin inspections daily or every other day as needed. b. Nurses are to be notified to inspect the skin if skin changes are identified. c. Nurses will conduct skin assessments at least weekly to identify changes. " The facility's current policy on Wound Care dated 2005 (Revised April 2007) reflected the following: "Purpose The purpose of this procedure is to provide guidelines for the care of wounds to promote healing...Preparation 1. Verify that there is a physician's order for this procedure...." 4) The facility's Resident Census and Conditions of Residents, Form CMS-672, dated 06/25/12, reflected there were no residents "With rashes." Review of the Resident Roster dated 06/24/12 provided by the Administrator revealed 20 residents lived on the 300 Hall.