Every finding on record at Windsor Arbor View

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident needs, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 of 5 residents (Resident #2) reviewed for care plans. The facility failed to ensure Resident #2's comprehensive care plan reflected his weight bearing status since admission on [DATE] and it was not initiated on his care plan until 07/09/26 (discharge date ).This failure could place the residents at risk of not receiving appropriate interventions and care to meet their needs.Findings included:Record review of Resident #2's face sheet, dated 07/30/26, reflected a [AGE] year-old male, admitted on [DATE], diagnoses included: encounter for orthopedic (bones or muscles) aftercare following surgical amputation, acquired absence of right toe, lack of coordination, type 2 diabetes mellitus (insulin resistance and high blood sugar levels), unspecified Escherichia coli (bacteria), peripheral vascular disease (narrowed arteries that reduce blood flow to the limbs, primarily the legs, leading to symptoms like leg pain and cramping), and atherosclerotic heart disease (hardening of arteries from plaque limiting blood flow to the heart muscle). Resident #2 was discharged home on 7/09/26. Record review of Resident #2's MDS assessment, dated 06/29/26, reflected a BIMS score of 14, which indicated intact cognition. The MDS reflected Resident #2 had impairment to both lower extremities and was dependent (helper does all of the effort) for toileting hygiene. Record review of Resident #2's care plan, dated 07/30/26, reflected [Resident #2] had an ADL self-care performance deficit related to surgical procedure for right 3rd toe amputation. Date initiated: 06/25/26. Interventions included: [Resident #2] was dependent for toileting hygiene. Date initiated: 06/29/26. WB as per MD orders. Date initiated: 07/09/26. Record review of Resident #2's order summary, dated 07/30/26, reflected physician's orders of non weight bearing to right lower extremity for right 3rd toe amputation with start date: 06/24/26, may bear weight on left foot with toe wedge shoe and ok for weight bearing to right foot with toe wedge shoe with start date: 07/06/26.During an interview, on 07/31/26 at 10:05 AM, LVN A stated Resident #2 was non weight bearing since admission due to the toe amputation. LVN A stated days before Resident #2 discharged , he had different weightbearing orders, but that was closer to discharge and she did not recall the dates. An interview was attempted, on 07/31/26 at 11:05 AM. The DON was unavailable as she was out of the country. A call was attempted but was unsuccessful. During an interview, on 07/3126 at 2:00 PM, the MDS Nurse stated she developed and updated care plans as needed. The MDS Nurse stated care plans were also updated by the ADON and the team. The MDS Nurse stated Resident #2 was non weight bearing when he was admitted because he had the right 3rd toe amputation. The MDS Nurse stated Resident #2 had the intervention under ADLs to follow MD orders for weight bearing status. The MDS Nurse stated the weight bearing status on the care plan was not specific, but it indicated to follow the MD orders so if the orders changed, staff followed the order. The MDS Nurse stated the intervention for weight bearing status was initiated on the care plan on 07/09/26 which was the date Resident #2 was discharged . The MDS Nurse stated the intervention of WB as per MD orders should have been added on the care plan since admission or when the MDS assessment was completed on 06/29/26. The MDS Nurse stated she was unsure if she initiated the intervention and since the care plan was closed, she was unable to check who edited the care plan. The MDS Nurse stated there was no negative outcome or risk of injury for Resident #2 as staff followed the orders for his weight bearing status. The MDS Nurse stated it was important for the care plan to be developed accurately to ensure all staff were aware of how to care for Resident #2 and for Resident #2 to not bear any weight on his extremities as ordered. During an interview, on 07/31/26 at 2:20 PM, the ADON stated she was not familiar with Resident #2. The ADON stated if a resident was admitted with non weight bearing status, that should have been in the resident's care plan since admission. The ADON stated the MDS Nurse developed and updated the care plans, but it was a team effort to ensure the care plan was accurate. The ADON stated if Resident #2 was admitted on [DATE] and discharged on 07/09/26, care plan of WB as per MD orders should have been care planned since 06/24/26, not on 07/09/26. The ADON stated there was no negative outcome or risk of injury for Resident #2 because staff followed the orders, as far as she was aware. The ADON stated it was important to include the weight bearing status in the care plan for staff to implement the intervention during Resident #2's admission to avoid injuries and help him recover. Record review of the facility's Comprehensive Care Plans policy, dated 10/24/22, reflected - Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychological needs that are identified in the resident's comprehensive assessment.6. Alternative interventions will be documented, as needed.

Based on observation, interview and record review, the facility failed to ensure in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete and accurately documented for 1 of 4 residents (Resident #1) reviewed for medical records. The facility failed to ensure MA A documented Resident #1's blood pressure on the MAR when the resident's blood pressure altering medication was not administered because it was outside the parameters for administration on 05/29/26. This failure could place residents at risk for errors in care and treatment. Findings included: Record review of Resident #1's admission record review, dated 06/04/26, reflected an [AGE] year-old-male with and admission date of 05/22/26. His relevant diagnoses included hypertension (a condition where the force of blood pushing against your artery walls is consistently high), atrial fibrillation (irregular heartbeat), cardiomyopathy (a progressive disease of the heart muscle), and chronic kidney disease (long term condition where your kidneys are damaged and lose their ability to filter waste and excess fluid from your blood). Record review of Resident #1's 5-day Medicare MDS assessment, dated 05/26/26, reflected a BIMS score of 13, which indicated his cognition was cognitively intact. Record review of Resident #1's care plan, dated 06/07/26, reflected:Problem: [Resident #1] has hypertension (HTN) r/t CHF, lifestyle choices. Date initiated and revised 05/25/26. His interventions included give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension (a sudden drop in blood pressure that occurs when you stand up after sitting or lying down) and increased heart rate (Tachycardia) and effectiveness. Date initiated 05/25/26. Record review of Resident #1's physician order summary, dated 06/04/26, reflected an order for Metoprolol Succinate ER Oral tablet extended-release 24 hour 50 MG (Metoprolol Succinate) give 1 tablet by mouth two times a day for hypertension, hold if SBP is under 110, or if DPB is under 60, or if pulse is under 60, start date 05/22/26. Record review of Resident #1's May 2026 MAR reflected on 05/29/26 at 9:00 a.m., Metoprolol Succinate ER Oral tablet extended-release 24 hour 50 MG (Metoprolol Succinate) give 1 tablet by mouth two times a day for hypertension, hold if SBP is under 110, or if DPB is under 60, or if pulse is under 60 was not administered due to vitals being outside the required parameters but no vital readings were entered by MA A. During an interview on 06/04/26 at 11:58 a.m., MA A said her responsibilities as a Med Aide were to administer oral medications to residents. She said some blood pressure medications had parameters that needed to be met before the medication could be administered. She was observed as she reviewed Resident #1's electronic medical record and said both had a diagnoses of high blood pressure which was being treated with medication. MA said the blood pressure medications Resident #1 were ordered had parameters that needed to be followed. MA said before she administered a blood pressure medication to Resident #1, she ensured she checked their vitals and entered them on their medication administration record before she administered their medication. She said she was not sure why Resident #1's electronic medication record did not show his vitals on 05/29/26 and pulse on 06/01/26. She said, I remembered entering their vitals. MA A said she was regularly in-serviced on the topic of medication administration by the facility's ADON and DON. MA A said a negative outcome for the resident could be staff would not know the blood pressure readings.During an interview and observation on 06/04/26 at 12:47 p.m., The ADON said Resident #1 had a diagnosis of hypertension and was being treated with medication. The ADON was observed as she reviewed Resident #1's electronic medical record and said Resident #1's high blood pressure medication was being treated with Metoprolol Succinate ER Oral tablet extended release 24-hour 50 MG (Metoprolol Succinate), give 1 tablet by mouth two times a day for hypertension, hold if SBP is under 110, or if DPB is under 60, or if pulse is under 60. The ADON said Resident #1's high blood pressure medication had parameters that needed to be followed to determine if the medication would be administered. The ADON said on 05/29/26 at 9:00 a.m., Resident #1 had not been administered his blood pressure medication. She said she knew because, MA A had documented a code 4 which she meant his vitals were not within the required parameters for that day/time. She said she was not sure why MA A had not documented his vitals. She said MA's and nursing staff must document vital signs prior to medication administration. She said a negative outcome to Resident #1 for having his blood pressure sign documented could be that nursing staff would miss a low or high reading. The ADON said each morning, she and the facility's DON reviewed the previous day's medication orders and medication administration records to ensure medications were administered correctly and all required vital signs had been documented. The ADON said she must have overlooked LVN C's medication error when she reviewed Resident #1's medication administration record for accuracy. She said a negative outcome to Resident #1 not having his medical record accurately documented would be staff would not know his vitals. During an interview on 06/04/26 at 4:00 a.m., the DON said Resident #1 had a diagnosis of hypertension which was being treated with medication. She was observed as she reviewed Resident #1's electronic medical record and said on 05/29/26, at 9:00 a.m., Resident #1 had not been administered his blood pressure medication, Metoprolol because a code 4 was documented on his medication administration record. She said code 4 indicated his vitals were not within the required parameters and was held. The DON said MA's and nursing staff were required to document a resident's vital signs before administering blood pressure medication. The DON said a negative outcome to Resident #1 could be that nursing staff could miss a resident's low or high vital signs if not documented. The DON said the facility did not have a medication administration policy. Record review of the facility's Documentation in Medical Record policy, dated 10/24/22 reflected: Policy:Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Policy Explanation and Compliance Guidelines: 1.Licensed staff and inter disciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2.Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.

Based on observation, interview and record review, the facility failed to ensure residents had the right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility was changed for for 1 of 3 residents (Resident #3) reviewed for resident rights. The facility failed to ensure Resident #1 received written notice prior to a room change on 03/04/26 and 04/07/26. This failure could place residents at risk for a decreased quality of life being in a new environment.The findings were:Record review of Resident #3's admission record, dated 06/05/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her relevant diagnoses included diabetes (a chronic condition where your body either cannot produce enough insulin or effectively se the insulin I t makes, causing blood sure (glucose) levels to rise), acute kidney failure (rapid loss of your kidney's ability to filter waster products from your blood), dementia (term for a decline in mental ability severe enough to interfere with daily life) and had an AR.Record review of Resident #3's quarterly MDS assessment, dated 05/28/26, reflected a BIMS score of 11, which indicated her cognition was moderately intact. Resident #3 was admitted as a short term resident.Record review of Resident #3's census record, dated 06/05/26, reflected the following room changes:01/21/26 Resident was admitted to room [ROOM NUMBER]-A03/04/26, Resident #3 was transferred to room [ROOM NUMBER]-B04/07/26, Resident #3 was transferred to room [ROOM NUMBER]-BDuring an interview on 06/05/26 at 8:30 a.m., Resident #3's FM said when Resident #3 was initially admitted to the facility, she was admitted to the short term unit but later became long term. The FM said Resident #3 was transferred multiple times without her consent or receiving a written notice. The FM said after the first transfer on 03/04/26, the facility informed her the room change was necessary because Resident #3 went from short term to long term. The FM said she thought the second time, Resident #3 was transferred was because she (FM) had complained to administration Resident #3 and her roommate were not compatible. The FM did not have dates of when she spoke to administration. The FM said she would have wanted to be informed of the room change to ensure Resident #3 was compatible with her roommate prior to being moved. The FM said Resident #3 was happy with her most recent room and roommate.During an observation and interview on 06/05/26 at 9:00 a.m., Resident #3 was observed lying in bed watching television. She said she was happy in her room and liked her roommate. Resident #3 said she had not received written notification of her room changes.During an interview and observation on 06/05/26 at 10:59 a.m., the SW said the DON was responsible for room changes. She said the DON would ensure both residents were compatible with each other and if approved, she would be responsible to notify the residents and their FMs of room changes. She said the manner in which she would notify the resident's FM of a room change was by phone and would then ensure the room change was documented in the resident's electronic medical record. The SW said she remembered on 03/04/26, Resident #3 transitioned from short term to long term and was transferred to room [ROOM NUMBER]-B. She said she remembered calling Resident #3's FM on that day and agreed to the room change. The SW said on 04/07/26, Resident #3 was moved to room [ROOM NUMBER]-B because her FM was not happy with the roommate. The SW was observed as she reviewed Resident #3's electronic medical record and said she had not found any documentation of the room change on 03/04/26 and 04/07/26.During an interview on 06/05/26 at 11:22 a.m., the DON said Resident #3 had an FM. She was observed as she reviewed Resident #3's medical electronic record and said she had not seen any documentation regarding room changes for Resident #3. She said she was responsible for all room changes. She said any room change was discussed with the IDT team to ensure both residents were compatible with each other. The DON said a resident's FM was notified by telephone or in person prior to the room change. The DON said the facility's protocol regarding room changes was the resident's FM needed to be notified by phone prior to the room change.During an interview on 06/05/26 at 2:45 p.m., the Administrator said the DON was responsible for all room changes. She said once the DON approved the room change, the facility's SW would ensure the resident and their FM were notified by telephone or in person. She said written notification was not necessary. The Administrator said she had reviewed Resident #3's electronic record and grievance logs and had not found any documentation regarding her room changes. The Administrator said there were no negative outcomes to Resident #3 being transferred to different rooms without notifying her FM. Record review of the facility's undated, Room Change, Transfer, and Discharge policy reflected: Room change.The resident and responsible party will be notified prior to a transfer and will have an opportunity to provide input on roommate selection and location.except in an emergency, the facility must notify the resident and either the responsible party, family member, or legal representative at leave 5 days before relocation of resident to another room within the facility. Facility must prepare a written notice that states the reason for the relocation, the effective date of the relocation, and the room to which the resident is being relocated.

Based on observation, interview and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 4 residents (Resident #1) reviewed for medication errors. The facility failed to ensure MA A did not administer Resident #1's blood pressure altering medication on 05/23/26 when his blood pressure was not within the required parameters per the physician's order.This failure could place residents at an increased risk for complications, exacerbation of symptoms and disease process, and potential hospitalization.Findings included: Record review of Resident #1's admission record review, dated 06/04/26, reflected an [AGE] year-old-male with and admission date of 05/22/26. His relevant diagnoses included hypertension (a condition where the force of blood pushing against your artery walls is consistently high), atrial fibrillation (irregular heartbeat), cardiomyopathy (a progressive disease of the heart muscle), and chronic kidney disease (long term condition where your kidneys are damaged and lose their ability to filter waste and excess fluid from your blood). Record review of Resident #1's 5-day Medicare MDS assessment, dated 05/26/26, reflected a BIMS score of 13, which indicated his cognition was cognitively intact. Record review on 06/04/26 of Resident #1's care plan, dated 05/27/26, reflected:Problem: [Resident #1] has hypertension (HTN) r/t CHF, lifestyle choices. Date initiated and revised 05/25/26. His interventions included to give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension (a sudden drop in blood pressure that occurs when you stand up after sitting or lying down) and increased heart rate (Tachycardia) and effectiveness. Date initiated 05/25/26. Record review on 06/04/26 of Resident #1's physician order summary, dated 06/04/26, reflected an order for Metoprolol Succinate ER Oral tablet extended-release 24-hour 50 MG (Metoprolol Succinate), give 1 tablet by mouth two times a day for hypertension, hold if SBP is under 110, or if DBP is under 60, or if pulse is under 60, start date of 05/22/26. Record review on 06/04/26 of Resident #1's May 2026 MAR reflected on 05/23/26 at 9:00 a.m., Metoprolol Succinate ER Oral tablet extended-release 24 hour 50 MG (Metoprolol Succinate) give 1 tablet by mouth two times a day for hypertension, hold if SBP is under 110, or if DBP is under 60, or if pulse is under 60 was administered when vital signs were 90/60, pulse 80, by LVN C. An attemped telephone interview on 06/04/26, LVN C did not answer.During an interview and observation on 06/04/26 at 12:47 p.m., The ADON said Resident #1 had a diagnosis of hypertension and was being treated with medication. The ADON was observed as she reviewed Resident #1's electronic medical record and said Resident #1's high blood pressure medication was being treated with Metoprolol Succinate ER Oral tablet extended-release 24-hour 50 MG (Metoprolol Succinate), give 1 tablet by mouth two times a day for hypertension, hold if SBP is under 110, or if DPB is under 60, or if pulse is under 60. The ADON said Resident #1's high blood pressure medication had parameters that needed to be followed to determine if the medication would be administered. The ADON said on 05/23/26 at 9:00 a.m., Resident #1 was administered his high blood pressure medication Metoprolol even though his blood pressure was not within the required parameters. The ADON said each morning, she and the facility's DON reviewed the previous day's medication orders and medication administration records to ensure medications were administered correctly and all required vital signs were documented. The ADON said she must have overlooked LVN C's medication error when she reviewed Resident #1's medication administration record for accuracy. The ADON said nursing staff were regularly in-serviced on the topic of medication administration. She said a negative outcome to Resident #1 being administered his blood pressure medication when his blood pressure was not within the required parameters could be his blood pressure could drop further. During an interview on 06/04/26 at 2:00 p.m., the MD said he treated Resident #1 since his admission to the facility. He said Resident #1 had a diagnosis of hypertension and was being treated with medication. He said he visited Resident #1 on 05/23/26 sometime before noon and had noticed his blood pressure had been low when he was administered his blood pressure medication. He said he immediately ordered a nurse to recheck Resident #1's blood pressure to ensure it was within the normal range. The MD said Resident #1's blood pressure was within normal range when it was rechecked, therefore; there were no negative outcomes to Resident #1 being administered blood pressure medication when his blood pressure was not within the required parameters. During an interview on 06/04/26 at 4:00 p.m., the DON said Resident #1 had a diagnosis of hypertension which was being treated with medication. She was observed as she reviewed Resident #1's electronic medical record and said on 05/23/26, at 9:00 a.m., Resident #1 was administered his high blood pressure medication, Metoprolol when his blood pressure reading was 90/60 by LVN C. The [NAME] said Resident #1's Metoprolol order had parameters to hold if SBP was under 110, or if SBP is under 60, or if pulse was under 60. The DON said, LVN C should not have administered Resident #1 Metoprolol medication on 05/23/26, at 9:00 a.m., because it was not within the ordered parameters. The DON said the facility's ADONs and herself reviewed all residents' orders and medication administration record to ensure medications were administered according to their orders and medications that required vitals to be checked were entered. The DON said nursing staff were regularly in-serviced on the topics of medication administration. The DON said a negative outcome to Resident #1 being administered Metoprolol when his blood pressure was not within the required parameter could be his blood pressure could drop further. The DON said the facility did not have a medication administration policy.

Based on observation, interview, and record review, the facility failed to establish 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 3 of 16 residents (Resident #29, Resident #117, and Resident #9) observed for infection control issues in that: 1. LVN H did not put on PPE when she entered Resident #29's room who was on contact precautions. 2. The facility failed to ensure Resident #117's breathing mask for his nebulizer (a medical device that turns liquid medicine into mist that could be inhaled through a face mask) was properly stored when not in use on 12/15/2025. 3. CNA A failed to hand sanitize before entering and after exiting Resident #9's room. Resident #9 was on Enhanced Barrier Precautions. These deficient practices could place residents at-risk for infection due to improper infection control practices and respiratory infection. The findings included: 1. Record review of Resident #29's face sheet dated 12/17/2025 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with an original admit date of 02/13/2024. Resident #29 had diagnoses which included the following: Metabolic Encephalopathy (a change in how the brain works due to an underlying condition), Type 2 Diabetes Mellitus (body either doesn't use insulin effectively or can't produce enough to manage blood sugar), Muscle Wasting and Atrophy (thinning or loss of muscle mass), Depression, Hemiplegia (paralysis or weakness of one side of the body), and Gastro-Esophageal Reflux Disease (a condition in which the stomach contents leak backwards from the stomach into the esophagus). Record review of Resident #29's Comprehensive MDS assessment, dated 12/01/2025, reflected that the resident had a BIMS score of 12 which indicates moderate cognitively impaired. Record review of the Physician Order Summary reflected Resident #29 had Contact Isolation every shift for ESBL to urine. Start Date: 12/15/25. Record review of the most recent Care Plan on 12/17/25 for Resident #29 reflected the resident had an infection of the (UTI/ESBL) Date Initiated: 12/15/2025. Interventions: Give antibiotic therapy as ordered (Meropenem until 12/22/2025) Date Initiated: 12/15/2025. Maintain Contact Isolation .Date intiated 12/15/2025. Observation on 12/15/2025 at 2:45 p.m. revealed LVN H entered Resident #29's room without donning a gown and gloves. A red contact precaution sign was observed above the room number with the following instructions: wear gown to enter the room, wear gloves when entering the room, and discard gowns in the room. In an interview on 12/15/25 at 2:50 p.m., LVN H stated she was aware that Resident #29 was on contact precautions due to ESBL to the urine. She stated that PPE was to be used when entering the room. She stated that contact precautions required staff to sanitize, wear a gown, and gloves prior to going into the room. LVN H stated that it slipped her mind and she forgot to put PPE on prior to going into the room. She stated that if they did not follow the instructions on the precaution signs located outside of resident rooms, they could spread infection. LVN H stated that the last infection control in-service she attended was a week ago. In an interview on 12/15/2025 at 2:55 p.m. with Resident #29 states she was aware that she was on isolation due to a urine infection. She stated that today was the first day. She stated that the staff had been going into her room wearing PPE, with the exception of LVN H. 2. Record review of Resident #117's face sheet dated 12/16/2025 reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. Resident #117 had diagnoses which included the following: Acute Respiratory Failure with Hypoxia (a condition where the lungs cant get enough oxygen into the blood), Acute Pulmonary Edema (excess fluid buildup in the lungs air sacs), Gastrostomy (a tube inserted through the wall of the abdomen directly into the stomach), Dementia (a decline in thinking, memory, and reasoning skills severe enough to interfere with daily life, caused by brain cell damage, not a normal part of aging), Alzheimer's, and Heart Failure (the heart cant's pump enough oxygen-rich blood for the body's needs, causing fluid backup and symptoms like shortness of breath, fatigue, and swelling). Record review of Resident #117's MDS assessment, dated 12/12/2025, reflected that the resident had a BIMS score of 0 which indicated he was severely cognitively impaired. Record review of the Physician Order reflected Resident #117 had Ipratropium-Albuterol Inhalation solution three times a day. Start Date: 12/12/2025. Record review of the most recent Care Plan on 12/17/25 for Resident #117 reflected the resident had altered respiratory status/difficulty breathing r/t Pulmonary Edema, acute respiratory failure Date Initiated: 12/14/2025. Interventions: Administer medication as ordered. Date Initiated: 12/14/2025. Observation on 12/15/2025 at 9:15 a.m. revealed Resident #117 was in his bed, with eyes closed. A nebulizer machine was noted on the resident's side table with a breathing mask connected to it. The breathing mask was not bagged. In an interview on 12/15/2025 at 9:25 a.m., LVN M confirmed that the breathing mask was not bagged. She stated that she used it earlier today, 12/15/25. LVN M stated she was going to come back and place it in a bag but forgot. She stated Resident #117 had breathing treatments that were scheduled. She stated that the mask should be bagged when not in use to ensure cleanliness. LVN M stated that it was important for infection control and hygiene as well. She stated she would get another mask and make sure it was inside the plastic bag to prevent any respiratory infection. She stated she had in service on respiratory care and infection control about 2 weeks ago. In an interview on 12/15/2025 at 9:43 a.m., ADON L stated the breathing mask was supposed to be in a bag when the resident was not using it to prevent cross contamination and worsening of any respiratory issues. She stated that this was the nurse's responsibility. She stated that she replaced the mask and placed it in a bag. She stated the bag should be labeled with the resident's name, room number, and date. ADON L stated that the negative outcome of not having the breathing mask in a bag would be respiratory infection. She stated that she conducted an in-service a couple months ago as well as a respiratory therapist. She stated that she goes and checks that masks are bagged but that she had not gotten to Resident #117's room. 3. Record review of Resident #9's admission Record dated 12/17/25 reflected an [AGE] year-old male with an admission date of 07/17/25. His diagnoses included Type 2 Diabetes Mellitus without complications (body either doesn't use insulin effectively or can't produce enough to manage blood sugar), Chronic Obstructive Pulmonary Disease, Unspecified (difficulty breathing due to airflow obstruction), and Acquired Absence of Left Upper Limb, Unspecified Level. Record review of Resident #9's admission MDS assessment dated [DATE] reflected a BIMS score of 15, which indicated his cognition was intact. Record review of Resident #9's most recent care plan assessment reflected Resident has the need for Enhanced Barrier Precautions due to wound. Resident is at risk of infection. Interventions reflected; Place on Enhanced Barrier Precautions, ensure a sign is placed on the door to notify staff and visitors of precautionary measures. Observation on 12/15/25 at 9:58 a.m. revealed CNA A entered Resident #9's room without hand sanitizing or washing hands. It was also observed she exited Resident #9's room without hand sanitizing or washing hands. Observation on 12/15/25 at 9:58 a.m. revealed a sign placed on the outside of Resident #9's room titled Enhanced Barrier Precautions; Everyone must: Clean their hands, including before entering and leaving the room. In an interview on 12/15/25 at 9:59 a.m. CNA A stated she knew she was supposed to hand sanitize before entering Resident #9's room as well as after leaving but forgot to do so. She stated she receives in-services on infection control frequently and stated she had received it about 2 weeks ago. CNA A stated if she did not practice hand sanitizing like they told her to do, she could contaminate one resident to another if they have an illness or bacteria. In an interview on 12/16/2025 at 10:55 a.m. CNA I, stated that when there was a contact precaution sign up, PPE was required before going into the room. The required PPE would be a gown and gloves. She stated the last infection control in-service she attended was last week, but they do have them frequently. She stated they went over hand hygiene before entering rooms and when exiting rooms. In an interview on 12/16/2025 at 11:14 a.m. with CNA J, she stated she was familiar with Resident #29. She stated that she was on contact precautions and staff had to sanitize and put on PPE before entering the room. She stated that the last infection control in-service she attended was last week. She said they went over the posted signs. She said if a resident had a yellow EBP sign, they must wear gowns and gloves while providing care. If a resident had a red sign posted for contact precautions, they must wear a gown and gloves whenever entering the room. She said they must sanitize their hands before and after entering and exiting all rooms. She stated they must remove PPE before coming out of the rooms and wash hands or sanitize. In an interview on 12/16/2025 at 4:53 p.m. with LVN K, she stated that infection control in-services were conducted at least three times a month; the most recent one was approximately a week ago. She stated they went over handwashing. She stated they also had in-service for respiratory care. LVN K stated that it was the nurse's responsibility for placing the breathing masks in a bag when not in use. She stated that the bag would be labeled with the resident's name, date, and room number before leaving the room. LVN K stated this was important for infection control, and so that the mask does not touch the floor. She stated that for residents who were on contact precautions, staff must wear a gown and gloves before going into the room. She was to remove PPE before leaving the room and wash hands before exiting the room. In an interview on 12/16/25 at 3:25 pm ADON L stated residents who have any opening in their body that was not normal, were at risk of infection and were placed on enhanced barrier precautions. She stated when a resident was on enhanced barrier precautions, staff should hand sanitize before entering room and after leaving the room and should don PPE if they were to provide patient care. ADON L stated it was standard precaution when entering any resident room, staff must sanitize or wash hands. She said they were trying to prevent infection of any kind towards the residents. She said she does spot checks on staff, using a mobile sink and she asks staff to perform the proper way to wash hands, dedicating 1 hall per day at a time. ADON L said not sanitizing hands could spread infection to other residents or staff. In an interview on 12/16/2025 at 5:04 p.m. with ADON L, she stated that she was the infection preventionist and was responsible for infection control training. She stated she had an in-service on infection control approximately three weeks ago. She stated they went over all protocols for contact precautions, EBP, hand hygiene and how to don and doff PPE. ADON L stated if a resident was in contact isolation, staff must go in with gown and gloves to render care to the resident any time they enter the resident's room because they cannot be sure what the resident had touched. She stated there were three bins in the room to discard trash, linens, and gowns. She stated they also provide education to families. In an interview on 12/17/2025 at 1:54 p.m., the DON stated that the breathing mask should be placed in a bag when the resident was not using it. She stated the bag should be labeled with the resident's name, room number, and date. She stated the date was also on the tubing. This was important for the mask not to touch other surfaces and to keep it clean. The DON stated that the nurse was responsible for bagging the mask. She stated the negative outcome would be that the residents would get an aggressive upper respiratory infection. She stated that the IP has in-services on infection control, weekly, and as needed. She stated she joined the in-services nighty percent of the time. She stated that in the training, they go over EBP and contact precautions. She stated if a resident was on contact precautions, staff must wear a gown and gloves prior to entering the resident's room. The DON stated this was to prevent the spread of infection. Record review of the Personal Protective Equipment Competency Assessment revealed: Transmission Based Precautions 1 Staff correctly identifies the appropriate PPE for the following scenarios: 1b Contact Precautions (gown & gloves) Record review of the facility's policy, titled Infection Prevention and Control Program, date implemented 5/13/2023, revealed: Policy: This facility has established and maintains 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 as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines: 2. All staff are responsible for following all policies and procedures related to the program. 5. Isolation Precautions: a. A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC guidelines.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 3 residents out of 8 (Resident #77, Resident #50, Resident #26) that were reviewed for safe environment. The facility failed to ensure bathroom sink water temperatures were between 100-110 degrees Fahrenheit in occupied rooms for Resident #77, Resident #50 and Resident #26. These failures could affect residents by placing them at risk for diminished quality of life due to the lack of a well-kept environment and water temperatures over 110 degrees Fahrenheit, placing residents at risk of being in an unsafe environment and at risk for burn injuries. The Findings Included: 1. Record review of Resident #77's face sheet dated 12/17/2025 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her pertinent diagnoses included: Orthopedic Care Aftercare following Surgical Amputation, Dementia (a decline in thinking, memory, and reasoning skills severe enough to interfere with daily life, caused by brain cell damage, not a normal part of aging), Depression, Muscle Wasting and Atrophy (thinning or loss of muscle mass), Type 2 Diabetes Mellitus (body either doesn't use insulin effectively or can't produce enough to manage blood sugar). Record review of Resident #77's Comprehensive MDS assessment, dated 11/03/2025 revealed a BIMS score of 15 indicated she was cognitively intact. She was independent of self-care. 2.Record review of Resident #50's face sheet dated 12/17/2025 reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her pertinent diagnoses included: Metabolic Encephalopathy (a change in how the brain works due to an underlying condition), Type 2 Diabetes Mellitus (body either doesn't use insulin effectively or can't produce enough to manage blood sugar), Anxiety, Dementia (a decline in thinking, memory, and reasoning skills severe enough to interfere with daily life, caused by brain cell damage, not a normal part of aging), Depression, Need for Assistance with Personal Care. Record review of Resident #50's Comprehensive MDS assessment, dated 11/12/2025 revealed a BIMS score of 05 indicated that Resident #50 was severely cognitively impaired. She required maximal assistance for toileting hygiene and was dependent on staff for mobility. 3. Record review of Resident #26's admission Record dated 12/17/25 reflected a [AGE] year-old female with an admission date of 07/17/25. Her diagnoses included Type 2 Diabetes Mellitus without complications (body either doesn't use insulin effectively or can't produce enough to manage blood sugar), Essential Primary Hypertension (high blood pressure) and Hypothyroidism (thyroid gland doesn't make enough thyroid hormones to meet your body's needs). Record review of Resident #26's admission Quarterly MDS assessment dated [DATE] reflected a BIMS score of 10, which indicated she had moderate cognition impairment. Section GG: Functional Abilities revealed her functional limitation in range of motion was coded as no impairment in upper extremity (shoulder, elbow, wrist, hand) and lower extremity (hip, knee, ankle, foot). Personal hygiene: Score: 04 (supervision or touching assistance) has the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excluding baths, showers and oral hygiene). During an observation on 12/15/25 at 10:49 a.m. the hot water faucet in Resident #26's bathroom was not warming up after a minute of running the water. During an observation on 12/16/2025 at 3:30 p.m. with the Maintenance Director and using the thermometer the bathrooms sink hot water temperatures were: Resident #77's and Resident #50's bathroom sinks hot water temperatures were 115 degrees Fahrenheit. During an observation on 12/16/2025 at 3:41 p.m. with the Maintenance Director and using the thermometer , Resident #26's bathroom hot water faucet sink temperature was at 81 degrees Fahrenheit. In an interview on 12/15/2025 at 9:59 a.m. with Resident #77, she stated that she does use the restroom sink and she has not been burned. She stated that she adjusted the water temperature before she used it. In an interview on 12/15/25 at 11:01 a.m. Resident #26 stated when she had opened the hot water faucet it was not warm or hot. She stated she would like to have the option to use warm water. Resident #26 stated she did not tell any of the staff about it because she thought they would not be able to fix it. In an interview on 12/15/2025 at 3:30 p.m. with the Maintenance Director, he stated that he checks the water temperatures at least two to three rooms in each hall every day and the last time he checked them was yesterday (12/14/2025). The Maintenance Director stated that he documented the temperature readings on a paper daily and then entered it in TELS at the end of the week. He stated if they were not within range, that he would notify the Administrator right away and adjust the temperature. The Maintenance Director stated the hot water temperature should not be over 110 degrees Fahrenheit. The Maintenance Director stated that the negative outcome of the water temperature being too hot in the resident's restroom was that the residents could get burned. In an interview on 12/17/25 at 3:15 p.m., the Administrator stated that the Maintenance Director randomly checked the water temperatures daily and enters the temperatures weekly in TELS. She stated that each hall shares the same boiler. She stated that the ambassadors, the management team, also check the water with their hands. If it felt too hot, they notify the Maintenance Director so he can check it with the thermometer. She stated the hot water should not be over 112 degrees Fahrenheit. She stated that if the water temperature was out of range either too hot or too cold, then the concern would be entered into TELS. She would also be notified by the Maintenance Director. They will then contact a plumber. She stated the negative outcome of the hot water being too hot was that the residents could get burned. Record Review of the Water Temperature TELS Logbook documentation for the week of 12/10/2025-12/17/2025 revealed minimal variation of temperature between 89 to 110 degrees Fahrenheit. Review of facility's incidents and accidents logs dated 10/2025, 11/2025, and 12/2025 did not reveal any injuries to residents due to hot water. Review of the facility's Grievance logs dated 10/2025, 11/2025, and 12/2025 did not reveal any complaints of water temperature being too hot. Review of the facility's Instructions Direct Supply TELS provided the following information: 1. Ensure patient room water temperatures are between 100 degrees and 110 degrees Fahrenheit or as specified by state requirement). Texas 100-110 degrees Fahrenheit 5. Common area bathrooms, public bathrooms and any other areas having sinks should be checked and recorded as well. Record results in the water temperature log 1. Note any discrepancies 2. Adjust water heater setting as required 3. Retest as necessary Review of the facility's Grievance logs dated 10/2025, 11/2025, and 12/2025 did not reveal any complaints of water temperature being too hot.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 2 of 26 residents (Resident #43 and Resident #54) reviewed for effective pest control. The facility failed to ensure Residents #43 and #54's room was free of pests.These failures could place residents at risk of exposure to bugs and bug bites. Findings included:Observation on 12/15/25 from 9:00 AM-9:30 AM revealed Resident #54's and Resident #43's room had one live cockroach next to floor mat. Record review of the facility's Pest Control log revealed 4 times cockroaches had been reported since October 2025. Pest control had treated for cockroaches every month. The last visit was on 11/15/25. In an interview on 12/16/25 at 5:30 PM the Maintenance Director stated their pest control company treated the whole facility and any rooms that were identified by staff or residents as having live bugs. The pest control company also sealed up any openings they discovered during their treatments. He stated the residents deserved to have a bug and rodent free facility for their overall health. He stated he did not know of a policy for pest control other than if they were required to have a pest control program. He stated that the pest control program comes every month.During an interview on 12/17/2025 at 3:20 p.m., ADM stated they have a pest control vendor entering the facility monthly and as needed. The staff do rounds every morning to check the environment and would report any concerns they found. If there were any concerns, we do a deep clean in that room. She stated staff documents it in the pest control sighting logbook. She stated that they do not have a pest control policy.Record review of Pest Control Invoice, dated 11/15/2025, revealed the following services, Regular Pest Service and Flying Insect Program. Under General Comments/Instructions: Talked to contact, look over sighting log and inspected and treated rooms 502, 618, 612, 604, 404, 406 and 603 for Roaches. Interior . Inspected and treated all common areas, kitchen, dining, laundry, employees' area and hallways checked and changed glue borders as needed. Exterior .Inspected and treated perimeter of building and replaced baits in rodent bait stations.

Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1of 8 residents (Resident #44) reviewed for dignity. The facility failed to ensure CNA A did not stand while assisting Resident #44 with lunch on 12/15/25. This failure could place the residents at risk of not having the right to a dignified existence maintained.Findings included: Record review of Resident #44's admission record dated 12/15/25 reflected an [AGE] year-old male with an admit date of 01/18/20. His relevant diagnoses included vascular dementia (a decline in thinking skills caused by conditions damaging blood vessels, reducing blood flow and oxygen to the brain, often after strokes or mini-stokes), heart failure (the heart can't pump enough oxygen-rich blood for the body's needs, causing fluid backup and symptoms like shortness of breath, fatigue, and swelling), lack of coordination, and dysphagia (difficulty swallowing). Record review of Resident #44's quarterly MDS assessment dated [DATE] reflected a BIMS score of 3, which indicated his cognition was severely impaired. His functional ability for eating (the ability to use utensils to bring food and/or liquid to mouth and swallow food and/or liquid once the meal is placed before the resident) was substantial/maximal (assist-helper does more than half the effort. Helper lifts or hold truck or limbs and provide more than half the effort).Record review of Resident #44's quarterly care plan dated 08/14/25 reflected a focus of [Resident #44 has an ADL self-care performance deficit (date initiated 01/18/20 and revised 05/04/20) His interventions in part included Eating: the resident requires supervision assistance by (1) staff to eat (date 08/10/21 and revised on 08/10/21).During an observation on 12/15/25 at 12:35 pm, CNA A was observed as she walked into Resident #44's room to assist him with his lunch meal. CNA A stood on his left side the entire time she fed him. After Resident #44 was done eating, she was observed as she removed his lunch plate from his bedside table.In an interview on 12/15/25 at 12:40 am, Resident #44 said he was glad CNA A had assisted him with his lunch tray. In an interview on 12/15/25 at 12:45 pm, CNA A said the facility's protocol when assisting a resident with their meals was for the CNA to be sitting next at their level while feeding them. CNA A said the reason she had forgotten to get a chair and sit while she fed Resident #44 was because she had rushed to get to his room. She said a negative outcome for her not sitting while she fed Resident #44 was that maybe Resident #44 felt rushed when eating. In an interview on 12/16/25 at 2:36 pm, ADON B said Resident #44 required assistance with all his meals. She said CNAs and/or nursing staff were required to sit at the resident's level when feeding them. She said a negative outcome for Resident #44 not fed by a CNA who was sitting at his level would be a dignity issue. She said CNAs were in-serviced to sit while feeding resident in their rooms or in the dining room. In an interview on 12/16/25 at 2:46 pm., the DON said residents that required assistance with their feeding were fed by CNAs. She said, should be sitting next to the resident's bed. The DON said a negative outcome for a resident who was fed by a CNA while standing was a dignity issue and they might feel the CNA was rushing them. Record review of the facility's Promoting/Maintaining Resident Dignity During Mealtimes, dated 01/13/23 reflected:Policy:It is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life, recognizing each resident's individuality and protecting the rights of each resident. Policy Explanation and Compliance Guidelines:5. All staff will be seated, if possible, while feeding a resident.

Based on observations, interviews, and record reviews, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for two of eight residents (Resident #44 and Resident #9) reviewed for accidents and hazards. 1. RN G failed to reposition Resident #9 using two employees as required by his care plan. 2. The facility left meal tray within reach for Resident #44 who required assistance with feeding allowing resident to reach drinks on tray. These failures place residents who require assistance with feeding and repositioning at risk of accidents and possible injuries. The findings included: The findings included: 1. Record review of Resident #9's Face Sheet dated 12/16/25 revealed an [AGE] year-old male was admitted to the facility on [DATE] with the following diagnoses: vascular dementia (a cognitive decline from brain damage due to reduced blood flow, often from strokes or tiny vessel issues, affecting thinking, memory, judgment, and walking), acquired absence of left upper limb (someone lost their left arm or part of it after birth). Record review of Resident #9's Care Plan, dated 6/5/25, documented Bed Mobility: Resident #9 required substantial/maximal assistance by two staff due to impaired mobility. Resident #9's quarterly MDS resident assessment, dated 12/2/25, documented Resident #9 needed partial/moderate assistance with roll left and right when lying on back. During a wound care observation on 12/16/2025 at 10:00am RN G failed to reposition Resident #9 using two employees as required by his care plan. WCN was washing his hands while RN G was repositioning Resident. During an interview on 12/16/25 at 10:30am, RN G said that he did not know Resident #9 was a two person assist. RN G said that he thought he was a one person assist, and he did not check the care plan. RN G said he was just assisting with the wound care. RN G said that the WCN should have checked the care plan. RN G said that if he did not follow the care plan, the resident or herself could be harmed. During an interview on 12/16/25 at 10:40am, WCN said that all staff could check the plan of care of each resident in the Point Click Care system (electronic health record). WCN said that he forgot to review the care plan before the wound care procedure. WCN said that he was worried about the wound care observation and that he forgot. WCN said that by not following the plan of care residents or staff could get injured. During an interview on 12/17/25 at 2:32pm, the DON said staff should follow the plan of care of each resident to do the proper repositioning. The DON said that both the resident and the staff could get injured if they failed to follow the plan of care. DON said that the facility did not have a policy for accidents and incidents. 2. Record review of Resident #44's admission record dated 12/15/25 reflected an [AGE] year-old male with an admit date of 01/18/20. His relevant diagnoses included vascular dementia (a decline in thinking skills caused by conditions damaging blood vessels, reducing blood flow and oxygen to the brain, often after strokes or mini-stokes), heart failure (the heart can't pump enough oxygen-rich blood for the body's needs, causing fluid backup and symptoms like shortness of breath, fatigue, and swelling), lack of coordination, and dysphagia (difficulty swallowing). Record review of Resident #44's quarterly MDS assessment dated [DATE] reflected a BIMS score of 3, which indicated his cognition was severely impaired. His functional ability for eating (the ability to use utensils to bring food and/or liquid to mouth and swallow food and/or liquid once the meal is placed before the resident) was substantial/maximal (assist-helper does more than half the effort. Helper lifts or hold truck or limbs and provide more than half the effort). Record review of Resident #44's quarterly care plan dated 08/14/25 reflected a focus of [Resident #44 has an ADL self-care performance deficit (date initiated 01/18/20 and revised 05/04/20) His interventions in part included Eating: the resident requires supervision assistance by (1) staff to eat (date 08/10/21 and revised on 08/10/21). In an observation and interview on 12/15/25 at 8:55 am, Resident #44 was observed sitting upright in his hospital bed with his breakfast tray positioned directly in front of him and within reach. Resident #44 had spilled coffee on his breakfast plate; and tray and some had spilled down to his bed sheet (left side) closer to the bed rail and away from him. Resident #44 said he attempted to reach for the coffee cup but dropped it. He said he had not gotten burned because the tray had been sitting at his bedside table for a while before he reached out for it (not able to say how long) and the coffee was already cold. Resident #44's clothing was dry. Resident #44 said he did not like to be fed because he felt he could feed himself. Surveyor was not able to take the temperature of the breakfast plate because it was soaked in coffee. In an observation and interview on 12/15/25 at 8:58 am, CNA A walked into Resident #44's room and said she was going in to assist in feeding him. She noticed Resident #44 had spilled coffee on his breakfast plate, tray, and bed sheet and quickly asked if he had burned himself. Resident #44 replied no, the coffee was cold and she immediately removed his breakfast tray. She was observed as she checked his arms and called out for the nurse. An observation on 12/15/25 at 9:03 am, revealed LVN C was observed as he walked into Resident #44's room and closed the door. In an interview on 12/15/25 at 9:20 am, LVN C said Resident #44 had been assessed and no injuries were noted. In an interview on 12/15/25 at 9:24 am, CNA A said Resident #44 required assistance with all his meals. She said Resident #44 at times refused to be fed because he thought he could still feed himself. She said the facility's protocol for residents who needed assistance with their meals was that only CNAs could deliver the meal tray, and they must stay with the resident to assist in feeding them. She said CNAs were not allowed to deliver meal trays and leave them in the resident's room unattended. CNA A said she had not delivered Resident #44's breakfast tray and had no idea who had delivered it. CNA A said she had been in-serviced in ADLs which included assisting residents with feeding. Record review of Resident #44's change in condition communication form dated 12/15/25 at 9:30 am, authored by LVN C, reflected a change in condition due to Resident spilled his coffee on himself during breakfast. Resident was assessed for possible burn on skin due to coffee spill. No redness, swelling or blistering noted on abdomen area or legs. Resident stated that coffee was not hot and that he did not have any pain. will continue to monitor. no injury sustained. Record review of Resident #44's progress note dated 12/1/25 at 2:43 pm, authored by LVN C, reflected Resident had an accident and spilled his coffee on himself. No burn marks, no redness, no swelling noted. Resident stated that he had no pain. Resident stated that coffee was not hot. Notified NP NNO given. In an interview on 12/16/25 at 2:27 pm, LVN D said after the meal cart had been delivered to the assigned hall, it was the responsibility of the charge nurse to check each meal tray to ensure it matched the resident's prescribed diet, including correct texture, liquid consistency, and any food allergies. She said once she confirmed the meal tray was correct, she would initial the meal ticket. She would then handover the tray to the staff that were helping in passing out trays. She said they first served those residents that were able to eat on their own. LVN D said the meal trays that were for residents that needed assistance could only be delivered by CNAs. She said whenever a CNA delivered a meal tray, that meant he/she was ready to assist the resident with their meal. LVN D said CNAs were not allowed to leave a meal tray in a resident's room unattended. She said the nursing staff and CNAs were regularly in-serviced on the topics of ADLs and assisting residents with their meals. In an interview on 12/16/25 at 2:36 pm, ADON E it was the responsibility of the dietary aides to deliver the meal carts to their assigned halls. She said once the meal carts were at their assigned hall, it was the responsibility of the charge nurse to check each tray to ensure the diet and liquid consistency matched the resident's order. ADON E said staff knew if the meal ticket had the charge nurse initials, it was ready for distribution. ADON E said aside from CNAs, the facility's management team also assisted in distributing meal trays. She said the management team were only allowed to distribute meal trays to residents that were able to eat on their own and were not allowed to assist in feeding. ADON E said residents that were able to eat on their own were first to receive their meal trays. She said resident's that required assistance to eat had their trays delivered by CNAs. She said that meal trays were only delivered when a CNA was available to assist, since trays were not to be left unattended in residents rooms. ADON E was not able to say if there were any negative outcomes to Resident #44 having his meal tray within reach/unattended. In an interview on 12/16/25 at 2:46 pm, the DON said aside from CNAs, management staff also assisted in distributing meal trays to residents who ate in their rooms. She said management staff were only allowed to distribute meal trays to residents that were able to eat on their own. The DON said residents who required assistance had their meal trays delivered only by CNAs. She said that meal trays were only delivered when a CNA was available to assist, since trays were not to be left unattended in residents rooms. The DON said Resident #44 had not sustained any injuries when he spilled his coffee. The DON said a negative outcome for leaving a meal tray unattended and within reach could be the resident might reach for it and spill the liquids. The DON said the facility did not have a supervision policy.

Based on observation, interview and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice for 1 of 6 residents reviewed for intravenous fluids. (Resident #96) The facility failed on 12/15/2025 to ensure the dressing on Resident #96's peripheral intravenous line (a short flexible tube inserted into the vein to administer fluids and medications) was dated and initialed.This failure could place residents at risk of not receiving the appropriate IV care and services. The findings included:Record review of Resident #96's admission record dated 12/15/25 revealed a [AGE] year-old female with diagnosis of Pneumonia (is a lung infection that inflames the air sacs, causing them to fill with fluid or pus, leading to cough, fever, chills, and difficulty breathing). Chronic Obstructive Pulmonary Disease (is a progressive lung disease that blocks airflow, making it hard to breathe, and includes conditions like emphysema and chronic bronchitis).Record review of Resident #96's care plan dated 8/29/25 revealed: Resident is on IV medications r/t pneumoniaRecord review of Resident #96's quarterly MDS assessment dated [DATE] revealed Resident #96's BIMS score was a 7 which indicated severe cognitively impairment. Section O - Special Treatments, Procedures, and Programs revealed Resident #96 was not marked for receiving IV medications. Record review of Resident #96's Order Summary Report dated 12/15/2025 revealed Resident #96 had an order for Sodium Chloride Intravenous Solution. 0.9% (sodium chloride). Use 2 liter intravenously every shift for hydration for 2 days infuse at 60 mL/hr x 2 liters. Start date 12/13/2025. During an observation on 12/15/25 at 9:25 a.m. Resident #96 was in her room sitting in her wheelchair. She had a peripheral intravenous lock covered with a transparent dressing with no date and no initials on her right hand. There were no signs or symptoms of infection or infiltration noted at the IV site. During an interview on 12/15/25 at 9:30 a.m., LVN F stated she was the nurse for Resident #96. She stated that the nurse who initiated the IV was responsible for labeling the dressing with the date of placement and initials. LVN F stated that it was important to label the IV site to know when the IV was placed or the last time it was changed. She stated that if the IV was not changed within the ordered time, then it could cause an infection. She stated that the last time she had checked the resident's IV site was this morning, at the beginning of her shift. LVN F stated that the IV site should be checked at every shift. The site was to be checked for any signs of infection, and the date and signature on the dressing. She stated she could not recall when the last training she had received on IV administration was. LVN F confirmed the resident had a peripheral IV lock on her right hand covered with a transparent dressing that was not labeled or dated.In an interview on 12/17/25 at 3:10 p.m., the DON stated she did not know why the dressing label had not been dated and initialed. The DON stated that the LVN F inserted the IV should have dated and initialed the dressing that was over the IV site. The DON stated that labeling the insertion site dressing was taught in nursing school and every nurse should have known to label it. She stated that the negative outcome of not labeling the dressing was that it could go over the recommended standard time of every 72 hours and could cause infection. During an interview on 12/17/25 at 4:00 p.m., the DON stated that she could not find a policy on IVs.

Based on interviews and record reviews, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 3 residents (Resident #1) reviewed for accuracy of records. The facility failed to ensure LVN B documented on Resident #1's electronic medical record that her foley catheter was re-inserted on 11/24/25. This failure could place residents at risk of not receiving appropriate care through inadequate documentation resulting in deterioration in condition, exacerbation of disease process, overmedication, and increased risk of harm or injury. The Findings included:Record review of Resident #1's admission sheet dated 12/02/25 reflected a [AGE] year-old female with an admit date of 10/26/25 and initial admission date of 09/28/25. Her relevant diagnoses included sepsis (a life-threatening medical emergency where the body's overwhelming response to an infection damages its own tissues and organs), vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect blood vessels in the brain). Record review of Resident #1's 5-Day MDS assessment dated [DATE] reflected a BIMS score of 4, which indicated her cognition was severely impaired. Record review of Resident #1's initial care plan dated 10/28/25 reflected a problem of [Resident #1] is at risk for falls r/t gait/balance problems (date initiated/revised 10/07/25). Interventions included to be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The Resident needs prompt response to all request for assistance, provide resident with mobility device: WC, walker, cane.(date initiated 10/04/25)Record review of Resident #1's progress notes dated 11/24/25 at 2:37 pm, authored by RN A reflected I heard a scream come from the patient's room when I walked into the patient's room patient was sitting down on the floor and foley had been pulled out, patient was unable to tell us what happened, assessed patient and took vitals, skin was intact, patient was able to move both upper and lower extremities without difficulty, patient was able to walk to bed had no complaint of pain, notified md patient just ordered for us to monitor patient, notified rp and don. In a telephone interview on 12/02/25 at 3:43 pm, RN A said that on 11/24/25, between 2:00 pm and 2:45 pm, while she was giving report to the incoming nurse (LVN B) they heard a scream coming from Resident #1's room. She said they both immediately made their way to Resident #1's room and found her in a sitting position on the floor. She said Resident #1 had both legs extended and her foley had been pulled out. She said a head-to-toe assessment was completed, and no injuries were noted. RN A said she asked Resident #1 how she fell but she was not able to say what happened. RN A said Resident #1 was transferred back to bed and where she was assessed for trauma or bleeding at the site where the foley catheter had been pulled out and no trauma or bleeding was observed. RN A said since it was towards the end of her shift, LVN B agreed to re-insert the foley catheter. She said she notified Resident #1's NP but no new orders were given. RN A said she initiated the neurological checks on Resident #1. RN A said Resident #1's foley had been re-inserted by the time she returned the next day. RN A said the facility's protocol for whenever a foley catheter was re-inserted was for the nurse who re-inserted the foley needed to create a progress note which indicated foley was re-inserted, if the resident felt discomfort or not, and flow. She was not able to say what the negative outcome was to Resident #1 was for not having her electronic medical record indicate her foley was re-inserted. An attempted telephone interview on 12/02/25 at 3:50 and 4:15 pm, LVN B did not answer, voice message was left. In an interview and observation on 12/2/25 at 4:13 pm, ADON D, she was observed as she reviewed Resident #1's electronic medical record and said that on 11/24/25, Resident #1 was found on the floor by RN A and LVN B and observed her foley catheter had been pulled out. She said Resident #1 had been assessed by RN A and no injuries were noted. ADON D said she could not find a note on Resident #1's electronic medical record that indicated who had re-inserted her foley catheter but was confident it had been re-inserted. She said because the insertion or re-insertion of a foley catheter was considered a sterile procedure the nurse who completed the procedure should make a note in the resident's electronic medical record that indicated the time, the size of the gauge size, and if the resident had tolerated the procedure. ADON D there was no negative outcome to Resident #1 for not having the re-insertion of her foley catheter documented on her electronic medical record. An interview on 12/02/25 at 4:46 pm, the DON said whenever a foley catheter was re-inserted the nurse who completed the procedure needed to document that it was re-inserted. She said note did not require anything else. The DON said there were no negative outcome to Resident #1 not having the re-insertion of her foley catheter documented in her electronic medical record. Record review of the facility's Documentation in Medical Record policy dated 10/24/22 reflected:Policy: Each residents medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate and timely documentation. Policy explanation and compliance guidelines: 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided int eh resident's medical record in accordance with state law and facility policy.

Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 3 residents (Resident 21) reviewed for accidents and supervision, in that:The facility failed to ensure Resident #2 received adequate supervision to prevent him from exiting the facility undetected on 06/06/25.The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 06/06/25 and ended on 06/07/2025. The facility corrected the non-compliance before the investigation began.Past Non-Compliance form sent to Administrator on 09/11/25 at 11:49 am.This failure could place the residents at risk for injury or death. The findings included: Record review of Resident #2's admission sheet dated 09/09/25 reflected a [AGE] year-old male with an admission date of 05/26/25 and a discharge date of 06/07/25. His relevant diagnoses included diabetes (too much sugar in the blood), hypertension (a condition in which the force of the blood against the artery walls is too high), abnormalities of gait and mobility (a change in walking pattern), and lack of coordination (impaired balance or coordination). Record review of Resident #2's 5-day Medicare MDS assessment dated [DATE], reflected a BIMS score of 6, which indicated his cognition was severely impaired. MDS further indicated, Resident #2 had not exhibited wandering behaviors. Record review of Resident #2's initial care plan dated 05/29/25, reflected:Problem: [Resident #2] is an elopement risk/wanderer r/t disorientated to place, impaired safety awareness resident wanders aimlessly (date initiated 06/06/25 and cancelled on 06/10/25).Interventions: in place included complete wandering evaluation tool, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books (date initiated 06/06/25 and cancelled on 06/10/25). Record review of Resident #2's wandering evaluation dated 05/25/25, reflected he was not a wandering risk. Record review of Resident #2's progress notes dated 06/06/25 at 9:20 pm, authored by LVN F, reflected Upon interviewing [Resident #2] he stated that he exited through the east exit door pushing the bar and door opening. Record review of Resident #2's progress notes dated 06/06/25 at 11:13 pm, authored by LVN F, reflected a change of condition Patient was found outside of facility across the street from facility in the sidewalk. Record review of Resident #2's progress notes dated 06/06/25 at 11:15 pm, authored by LVN F, reflected At 9 pm cna's moved resident to RM [ROOM NUMBER] from 407 due to plumbing issues. At 9:30 pm Med Aide F saw resident in his room. 9:40pm nurse went to check on patient and he was not in room nor in restroom. Activated code pink at 9:45pm. At 9:50pm resident was found across the street on sidewalk and was brought back to facility via wheelchair. At 9:55pm head to toe assessment was performed no noted injuries, patient denies falling while not at facility, denies pain or discomfort. Resident shows no signs of distress or discomfort, resident in good spirits. Notified family. Notified NP and ordered a cbc, cmp, and a ua to be collected . In an interview on 09/10/25 at 2:24 pm, CNA U said the last time she saw Resident #2 on 06/06/25 was around 8:00 pm. She said around 9:30 pm, she and CNA B went to his room to check on him and they discovered he was not in his room. She said she immediately notified LVN A (Charge Nurse), who activated code pink. She said at that time all staff started looking for him. She said by the time she checked her assigned hall/rooms; she was told Resident #2 had been found outside. She said she immediately went outside to see if staff needed help. She said by that time, Resident #2 was being escorted by LVN A and CNA B and were already in the facility's parking lot. She said she noticed Resident #2 was not wearing shoes, only socks. She said the weather was not too hot and not too cold. She said once Resident #2 was back in his room, she gave him water. CNA U said Resident #2 was confused and kept saying he was going home. She said at no point did she hear the door alarm go off. She said when the maintenance director was checking the door alarms after the incident (that same night), they were working. CNA U said the facility had provided in-services on the topics of elopement and responding to door alarms. CNA U said the facility also had monthly elopement drills. CNA U said Resident #2 was placed on a 1:1 for supervision immediately after he was found. CNA U said Resident #2 had not displayed any exit seeking behaviors since he was admitted . An interview on 09/10/2025 at 2:37 pm, CNA B said on 06/06/25, she last saw Resident #2 at about 8:00 pm. Resident #2 when she and CNA U had gone to his room to do their final round around 9:40 pm she noticed Resident #2 was not in his room. She said she checked down his hall and enclosed patio near his room, but he was not found. CNA B said she immediately notified LVN A (Charge Nurse) who activated code pink via the intercom. She said LVN A named the resident, what he was wearing and had his picture available for staff for that did not know who he was. She said she was assigned a certain hall and rooms to search for Resident #2. She said by the time she searched her assigned hall and rooms; she headed outdoor through the east side entrance. She said the east side entrance was the closest door to Resident #2's room. She said as soon as she went outside; she noticed other staff members were already out there searching for Resident #2. She said at some point she and LVN A saw Resident #2 directly across the street from the facility on the sidewalk. CNA B said when Resident #2 was identified, LVN A told her to go back to the facility to get a wheelchair. CNA B said by the time she went back outside with the wheelchair; Resident #2 was being escorted back to the facility by LVN A. She said she saw Resident #2 talking with two unidentified persons while he was standing on the sidewalk. She said once the resident was back in the room, she went in check on him. She said Resident #2 was thirsty and confused. She said she never heard any alarms go off. She said if she had heard the alarm, they are trained to stop what they are doing and go check on the door. She said they had received in-service on elopement and responding to door alarms days after the incident. CNA B said the facility also conducted practice elopement drills.In an interview on 09/10/25 at 2:45 pm, LVN A said on 06/06/25 at about 9:40 pm, CNA B and CNA U went to check on Resident #2 before their shift ended. LVN A said CNA B and CNA U told her that Resident #2 was not in his room. She said she and both CNAs checked his hallway and an enclosed patio but was not found. LVN A said she activated code pink via intercom at 9:45 pm and the search continued ensured both indoors and outdoors. LVN A said she and CNA B exited the facility through the east side entrance and combed the parking lot and that's when they saw Resident #2 on the sidewalk directly across the facility. She said the distance was about 50 yards from the facility. LVN A said Resident #2 was seen conversing with a couple that lived at a nearby apartment complex. LVN A said Resident #2 was wearing his own personal clothes and socks (no shoes). LVN A said Resident #2 had not sustained any injuries and Resident #2 kept saying he wanted to go home. LVN A said immediately after Resident #2 was [NAME] back to the facility, he was placed on a 1:1 for supervision until he was discharged on 06/07/2025. LVN A said the door alarm was not activated when Resident #2 exited the facility. LVN A said the maintenance Supervisor was called back to the facility that same night and checked all the door alarms and all were working.In an interview on 09/10/25 at 11:00 am, the Administrator said she had been notified the evening of 06/06/25 that Resident #2 had exited the facility sometime between 9:30 pm and 9:45 pm. She said Resident #2 was found at around 9:50 pm directly across the street from the facility on the sidewalk talking to two unidentified persons. She said she did not call the local police department because, he was found within 5 minutes. The Administrator said LVN A had conducted a head-to-toe assessment and no injuries were found. She said Resident #2 was immediately placed on a 1:1 for supervision. She said staff had told her that they did not hear any door alarms when Resident #2 had exited the facility. The Administrator said she was told by staff that the east side door entrance alarm had not been activated when R#2 exited the facility. She said when she interviewed R#2, he told her he had not heard any noise when he opened the door. The Administrator said she called Resident #2's RP the night of the incident and had given her the option to place Resident #2 in a secured unit at another facility. She said Resident #'2 RP had refused placing Resident #2 in a secured unit. The Administrator said Resident #2's RP opted to take him back home on [DATE]. The Administrator said on 06/06/25 sometime in the afternoon, the Maintenance Supervisor had called in a service request to a local electronic engineering company to service the same door Resident #2 used to exit the facility. She said before the technician left the facility, he ensured the door alarm and 15 second egress were functioning properly. The Administrator said the same night of the incident, the Maintenance Supervisor had gone to check all the door alarms, and all were working properly. She said she had called the same local electronic engineering company on 006/07/25 to inspect all the door alarms and install battery powered screamers to all doors. The Administrator said all staff had been in-serviced on the topic of elopements, responding to door alarms, and ANE. She said the facility's social worker had conducted a wander/elopement assessment on all residents. The Administrator said she was told by staff that the east side door entrance alarm had not been activated when Resident #2 exited the facility. In an interview on 09/09/25 at 4:49 pm, the Maintenance Supervisor said on 06/06/25 around 10:00 pm, he had received a call from the Administrator to report back to the facility due to an elopement. He said the DON and ADON were already in the facility. He said the first thing he did was change the codes to the alarm panels on all doors and check all door alarms and the 15 second egress. He said all were working. He said he went to the place where Resident #2 was found, and it was between 40 to 50 yards from the facility. He said the place where Resident #2 was found was directly across the facility and in front of an apartment complex. He said the following day (Saturday) he went back to the facility to recheck all the door alarms, and all were working. He said he also called a local electronic engineering company to come and check all doors alarms and all were working. He said earlier the day of 06/06/25 around 2:00-2:30 pm, a local electronic engineering company was called to service (as a priority call) for the same door it was believed Resident #2 had exited. He said the issue was that one of the bolts on the door was loose and making the maglock not have contact with the magnet. He said before the technician left both he and the technician had checked the door, and the alarm was working it was back to normal. The maintenance Supervisor said while the technician was in the building he had him check all doors alarms. He said he had no idea why the door alarm had not gone off when Resident #2 exited the facility. He said he would daily checks on all door/alarms to ensure they were working properly.Record review on 09/09/25, of the Maintenance Supervisor's daily door/alarm inspection log for the week of 06/02/25 to 06/06/25 and all doors passed the checks.Record review on 09/09/25 of a local electronic engineering company's invoice dated 06/06/25 reflected: That around 2:13 pm, technician call was made to investigate and correct maglock mounting problem to door frame. Screws are stripping out of door frame. The following was done: removed maglock and adjusted position slightly for new holes to be drilled and threaded in an unused portion of the door frame. Remounted maglock with bigger screws threading into the doorframe. Job completed. Record review on 09/10/25 of the facility's elopement drill logs for 2025 reflected they were done on:January 27, February 27, March 28, April 15, May 30, June 27, July 23, August 20, and September 5. Record review of the facility's Elopement and Wandering Residents policy dated 11/21/22 reflected:Policy:This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Definitions:Elopement occurs when a resident leaves the premises or a safe area without authorization (e.g., an order for discharge or leave of absence) and/or any necessary supervision to do so. Policy Explanation and Compliance Guidelines:2.Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner.4.Monitoring and managing residents at risk for elopement or unsafe wandering: d. adequate supervision will be provided to help prevent accidents or elopements.5. Procedure for locating missing residents:a. Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol (e.g., internal alert code.)b. The designated facility staff will look for the resident.c. If the resident is not located in the building or on the grounds, Administrator or designee will notify the policy department and serve as the designated liaison between the facility and the policy department. 6. Procedure Post-Elopement:a. A nurse will perform a physical assessment, document, and report finding to physician.b. Any new physician's orders will be implemented and communicated to the family/authorized representative.c. A social service designee will re-assess the resident and make any referrals for counseling or psychological/psychiatric consults.d. The resident and family/authorized representative will be included in the plan of care.g. Documentation in the medical record will include findings from nursing and social services assessments, physician/family notification, care plan discussions, and consultant note as applicable. Record review on 09/10/25 of the facility's in-services reflected the following in-services were conducted with staff after the incident on 06/06/25, 06/07/25, 06/08/25, 06/09/25, and 06/10/25:Topic: elopement prevention (code pink, acknowledge door alarms, do not only put the code on keypad but check outside/surroundings)Topic: abuse/neglect/exploitationTopic: resident supervision (monitor residents frequently) An interview on 09/10/25 and 09/11/25 with CNAs: B, C, D, F, G, H, I, J, L, U, V, X, Y, AA reflected all had been in-serviced on the topics of elopement prevention, resident supervision, and ANE. All knew the facility's elopement code and facility's protocols when a resident went missing. An interview on 09/10/25 and 09/11/25 with LVNs and RNs: A, E, M, N, O, P, Q, S, T, Z reflected all had been in-serviced on the topics of elopement prevention, resident supervision, and ANE. All knew the facility's elopement code and facility's protocols when a resident went missing. Record review on 09/10/25 of the facility's Social Worker's wander/elopement assessment conducted on 06/07/25 for 100% of residents. Record review on 09/11/25 of the facility's invoice on a service call done by a local electronic engineering company on 06/07/25 reflected checked all doors for functionality. All door maglocks were holding. Delayed egress was working as intended and annunciator was ringing. Maintenance added battery powered screamers to every door as additional alarms. System normal. Record review on 09/10/25 of the facility's elopement binder on the east and west side nurse's station reflected they were up to date. During an observation on 09/10/25, the Maintenance Supervisor was observed testing Door #6, #7, #10,#1, # 2, and #5. The alarms and the 15 second egress were working. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 06/06/25 and ended on 06/07/25. The facility corrected non-compliance before the investigation began.

Based on interviews and record reviews the facility failed to ensure all alleged violations including abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (which included to the State Survey Agency) in accordance with State law through established procedures for 1 of 4 residents (Resident #1) reviewed for reporting alleged allegation of abuse. The facility failed to report, within 2 hours, when Resident #1 was diagnosed with a nondisplaced proximal fibular fracture on 01/30/25. This failure could place residents at risk for undetected abuse, neglect and/or decline in feelings of safety and well-being. The finding included: Record review of Resident #1's admission sheet dated 09/11/25 reflected a [AGE] year-old female with an admit date of 04/06/21 and an original admission date of 06/12/18. Her relevant diagnoses included vascular dementia ( brain damage caused by multiple strokes), edema (swelling that occurs when fluid builds up in the body's tissue), muscle wasting and atrophy (decrease in size and wasting of muscle tissue), lack of coordination, osteoporosis (a condition in which bones become weak and brittle), and weakness. Record review of Resident #1's quarterly MDS assessment dated [DATE], reflected a BIMS score of 15, which indicated her cognition was intact. Record review of Resident #1's quarterly care plan dated 08/28/25, reflected:Problem:[Resident #1] has a nondisplaced proximal fibular fracture (dated initiated/revised 01/31/25).Goal: will not develop complications or permanent loss of mobility related to fracture (dated initiated/revised 01/31/25).Interventions/Tasks in part included: set up appointments with orthopedic, support injured area with pillows and immobilize part as appropriate, and weigh bearing as tolerated. Record review on 09/08/25 of Resident #1's change in condition completed by the DON dated (late entry) 01/26/2025 4:30 pm which reflected: SN informed by CNA that resident was assisted to restroom and when standing resident up, resident stated her knees gave out and resident was assisted to floor with CNA. Resident did not hit her head. SN performed head to toe assessment, no abnormalities noted. Resident states no pain upon assessment. Resident was transferred by mechanical lift on to chair then back to bed. Resident stated that she did not fall and stated that her knees gave out. Resident complains of no pain. Head to toe assessment performed, resident able to perform active range of motion to upper extremities. Resident able to perform active range of motion to lower extremities. Record review on 09/08/25 of Resident #1's late entry progress note dated 01/30/25 at 4:38 pm, reflected: NP came to round on patients. N.O. for an x-ray of the right leg and ankle due to pain. Record review on 09/08/25 of Resident #1's late entry progress note dated 01/30/25 at 5:54 pm, authored by NP reflected: complaining of some leg pain mainly to the lower part of her knee as per patient she states that she hit herself in the restroom few days ago. She states that she did not let any of the nursing staff know. Record review on 09/08/25 of Resident #1's x-ray results dated 01/30/25 at 9:50 pm, reflected Resident #1 had a nondisplaced proximal fibular fracture (still broken bones but the pieces didn't move far enough to be out of alignment during the break). Record review on 09/08/25 of Resident #1's progress note dated 01/31/25 at 5:16 am, reflected: Received report from 2-10 nurse regarding patients pending Xray of right leg and ankle due to pain. Results were reviewed and N/O from PA to do repeat of x-ray to the right leg and ankle were ordered and carried out. Record review on 09/08/25 of Resident #1's x-ray results dated 01/31/25 at 1:39 pm, reflected Resident #1 had an age-determinate fracture ( not sure how long ago the fracture occurred) of her right tibia/fibula . Record review on 09/08/25 of TULIP (HHSC online incident reporting application) reflected a self-report from the facility's Administrator on 01/31/25 at 4:20 am, more than 24 hours after Resident #1's diagnosis of a nondisplaced proximal fibular fracture. The allegation was injury of unknown origin. In an interview on 09/04/25 at 3:25 pm, Resident #1 said she did not remember the exact date but said she had an incident while she was being assisted from the toilet to her wheelchair. She said there were 2 CNAs assisting in the transfer, when of all of a sudden she felt her knees giving out. She said she advised the CNAs to sit on the floor because she was not going to make it to the wheelchair. She said one of the CNAs stayed with her and the other went to call the nurse. Resident #1 said between the nurse and both CNAs, she was transferred back to bed in a mechanical lift. Resident #1 said she did not have any pain at that time and refused medication. She said the following day, she started having pain and was given pain medication and it was alleviated. Resident #1 said days later her doctor visited her and she told him about the incident in the restroom and that she was still experiencing pain to her right lower leg. She said her pain started the day after the incident in the restroom. Resident #1 said at no time was she left with pain. Resident #1 said she had never been abused or neglected while in the facility. An interview on 09/04/25 at 4:08 pm, CNA C said she and CNA D took Resident #1 to the restroom and while assisting her from the toilet to the wheelchair (using a gait belt) she said they both felt Resident #1 was going limb, and her knees were giving out. She said at the same time Resident #1 told them her knees were giving out and to sit her on the floor. CNA C said at that point Resident #1 and both of them decided to assist the resident in sitting her on the floor. She said one of the CNAs stayed with her and the other one went to call LVN E. She said when LVN E arrived, she had done a head-to-toe assessment and Resident #1 was transferred back to bed in a mechanical lift. She said Resident #1 did not have any discolorations, bleeding, or injuries. CNA C said Resident #1 did not complain of pain when she was assessed by LVN E or when she was placed back in bed. CNA C said at no time did Resident #1 hit her legs or head while she was being assisted to the floor. An interview on 09/04/25 at 4:20 pm, CNA D said she and CNA C took Resident #1 to the restroom and while assisting her from the toilet to the wheelchair (using a gait belt) Resident #1 told them that her knees were giving out. She said Resident #1 told them to sit her on the floor. She said Resident #1 was sat on the floor and was assessed by LVN E. CNA D said between the three of them, Resident #1 was transferred back to bed in a mechanical lift. She said Resident #1 had not sustained any injuries while she was being assisted to the floor, and she denied having any pain. CNA D said at no time did Resident #1 hit her legs or head while she was being assisted to the floor. An interview on 09/4/25 at 4:35 pm., LVN E she had been called by either CNA D or CNA C when Resident #1 had requested to be sat in her restroom's floor on 01/26/25. She said when she got to the restroom, Resident #1 in a sitting position on the floor. LVN E said Resident #1 told her that while she was being assisted from the toilet to her wheelchair, her knees started to give out. She said Resident #1 said both CNA D and CNA C to sit her on the floor because she was not going to make it to her wheelchair. She said had immediately assessed her and did a ROM of upper and lower extremities and Resident #1 was able to move all limbs. She said Resident #1 told her she had no pain and had not hit her herself while being assisted to the floor. LVN E said after that, she and both CNAs transferred Resident #1 back to her bed in a mechanical lift. She said she re-assessed Resident #1 again while in bed and Resident #1 denied any pain. She said she did not see any discoloration, bleeding, or deformities on Resident #1. She said had not done a change of condition, or any assessment, or an incident report because to her it was not a fall. She said a negative outcome of not doing an incident report, a change in condition and informing her DON could be that Resident #1 would have been treated sooner.An interview on 09/04/25 at 4:44 pm, the DON said that on 01/30/25, Resident #1 had voiced to the NP that she had pain to her lower right extremity. She said the NP ordered x-rays that same day of her right tibia/fibula. She said the finding showed Resident #1 had a non-displace fibular fracture right leg on 01/30/25. She said the NP ordered a second x-ray on 01/31/25 and the findings showed an age-indeterminate fracture of the right tibia/fibula. The DON said LVN E had failed to do an incident report, change of condition, and/or notified herself of the incident. The DON said LVN E had received a counseling for failure to report an incident. The DON said Resident #1's first x-ray on 01/30/25 it showed a non-displaced proximal fibular fracture. The [NAME] said the facility received the first x-ray findings on 01/30/25 at 9:51 pm and was reported to state on 01/31/25 at 4:20 am. She said it had not been reported within the 2 hours window. An interview on 09/04/25 at 5:05 p.m., the Administrator said she had been notified by Resident #1's NP that she was having pain to her right lower extremity. She said on 01/30/25, Resident #1's NP ordered an x-ray of her right tibia/fibular. She said the results of the first x-ray (right tibia/fibula) were received on 01/30/25 and indicated a nondisplaced proximal fibular fracture. She said when Resident #1's NP was notified of the findings on 01/31/25, he ordered a second x-ray of right tibia/fibula. She said those results were received on 01/31/25 which indicated an age-indeterminate fracture. She said she waited for the results of the second x-ray to report it to state. The Administrator said the reason she had not reported Resident #1's nondisplaced proximal fibular fracture on 01/30/25 (within 2 hours of being received) was because her NP had ordered a second x-ray to confirm fracture. The Administrator said they had not done an investigation. During a telephone interview on 09/09/25 at 10:57 am, The NP said when he was doing his rounds on 01/30/25, Resident #1 had complained of having pain to her lower right extremity. He said he ordered an x-ray on 01/30/25 and was informed of the results that same day. He said Resident #1's first x-ray showed she had a nondisplaced proximal fibular fracture. The NP said at that point he accepted the findings of the first x-ray but ordered a second x-ray to confirm the injury. The NP said that was a normal practice for him when the findings showed a fracture to order a second x-ray to have a second set of eyes confirm the injury. Record review of the facility's Abuse, Neglect, and Exploitation policy dated 07/11/25 reflected:Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that exhibit and prevent abuse, neglect, exploitation and misappropriation of resident property. VII. Reporting/Response:A. The facility will have written procedures that include:1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:a. Immediately by no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or

Based on interviews and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1) of 3 residents by 1 of 1 nurse (LVN E) reviewed for accuracy and completeness of clinical records.The facility failed to ensure LVN E correctly completed Resident #1's assessment on 01/26/25 after her knees gave out and resident was assisted to the floor. This failure could place residents at risk for not receiving nursing services by adequately trained nurses and could result in a decline in health. The findings included:Record review of Resident #1's admission sheet dated 09/11/25 reflected a [AGE] year-old female with an admit date of 04/06/21 and an original admission date of 06/12/18. Her relevant diagnoses included vascular dementia (brain damage caused by multiple strokes), edema (swelling that occurs when fluid builds up in the body's tissue), muscle wasting and atrophy (decrease in size and wasting of muscle tissue), lack of coordination, osteoporosis (a condition in which bones become weak and brittle), and weakness.Record review of Resident #1's quarterly MDS assessment dated [DATE], reflected a BIMS score of 15, which indicated her cognition was intact.Record review of Resident #1's quarterly care plan dated 08/28/25, reflected:Problem:[Resident #1] has a nondisplaced proximal fibular fracture (dated initiated/revised 01/31/25).Goal: will not develop complications or permanent loss of mobility related to fracture (dated initiated/revised 01/31/25).Interventions/Tasks in part included: set up appointments with orthopedic, support injured area with pillows and immobilize part as appropriate, and weigh bearing as tolerated.Record review on 09/04/25 of Resident #1's change in condition completed by the DON dated (late entry) 01/26/2025 4:30 pm which reflected: SN informed by CNA that resident was assisted to restroom and when standing resident up, resident stated her knees gave out and resident was assisted to floor with CNA. Resident did not hit her head. SN performed head to toe assessment, no abnormalities noted. Resident states no pain upon assessment. Resident was transferred by Hoyer lift on to chair then back to bed. Resident stated that she did not fall and stated that her knees gave out. Resident complains of no pain. Head to toe assessment performed, resident able to perform active range of motion to upper extremities. Resident able to perform active range of motion to lower extremities.In an interview on 09/04/25 at 3:25 pm, Resident #1 said she did not remember the exact date but said she had an accident while she was being assisted from the toilet to her wheelchair. She said there were 2 CNAs assisting in the transfer, when of all of a sudden she felt her knees giving out. She said she told the CNAs to sit on the floor because she was not going to make it to the wheelchair. She said one of the CNAs stayed with her and the other went to call the nurse. Resident #1 said between the nurse and both CNAs, she was transferred back to bed in a Hoyer lift. Resident #1 said she did not have any pain at that time and refused medication. She said the following day, she started having pain and was given pain medication and it helped. Resident #1 said days later her doctor visited her and she told him about the incident in the restroom and that she was still experiencing pain to her right lower leg. She said her pain started the day after the incident in the restroom but was controlled with pain medication.An interview on 09/04/25 at 4:08 pm, CNA C said she and CNA D took Resident #1 to the restroom and while assisting her from the toilet to the wheelchair (using a gait belt) she said they both felt Resident #1 was going limb, and her knees were giving out. She said at the same time Resident #1 told them her knees were giving out and to sit her on the floor. CNA C said at that point Resident #1 and both of them decided to assist the resident in sitting her on the floor. She said one of the CNAs stayed with her and the other one went to call LVN E. She said when LVN E arrived, she had done a head-to-toe assessment and Resident #1 was transferred back to bed in a Hoyer lift. She said Resident #1 did not have any discolorations, bleeding, or injuries. CNA C said Resident #1 did not complain of pain when she was assessed by LVN E or when she was placed back in bed. CNA C said at no time dis Resident #1 hit her legs or head while she was being assisted to the floor.An interview on 09/04/25 at 4:20 pm, CNA D said she and CNA C took Resident #1 to the restroom and while assisting her from the toilet to the wheelchair (using a gait belt) Resident #1 told them that her knees were giving out. She said Resident #1 told them to sit her on the floor. She said Resident #1 was sat on the floor and was assessed by LVN E. CNA D said between the three of them, Resident #1 was transferred back to bed in a Hoyer lift. She said Resident #1 had not sustained any injuries while she was being assisted to the floor, and she denied having any pain. CNA D said at no time dis Resident #1 hit her legs or head while she was being assisted to the floor.An interview on 09/4/25 at 4:35 pm., LVN E she had been called by either CNA D or CNA C when Resident #1 had requested to be sat on the floor on 01/26/25. She said when she got to the restroom, Resident #1 in a sitting position on the floor. She said had immediately assessed her and did a ROM of upper and lower extremities. She said Resident #1 told her she did not have pain and had not hit her head. LVN E said after the head-to-toe assessment, she and both CNAs transferred Resident #1 back to her bed. She said she assessed Resident #1 again while in bed and Resident #1 denied any pain. She said she did not see any discoloration, bleeding, or deformities. LVN E said at that time, she had not done a change of condition or incident report, because to her it was not a fall. LVN E said on 01/31/25 she was counseled for failure to report the incident Resident #1 had on 01/26/25. She said she was told that even if a resident was guided to the floor, it was considered a fall. LVN E said she had completed a change in condition on 01/31/25 effective 01/26/25. She said a negative outcome of not doing an incident report, a change in condition, and notified her ADON, DON, and/or the Administrator would be that Resident #1 would not be tended to sooner. Record review on 09/04/25 of Resident #1's eMAR for the month of 01/2025 reflected on 01/27/25 the following was administered: at 12:14 am, she was administered 2 Acetaminophen tablet 325 mg due to having pain at level of 5 out of 10. A follow-up at 1:14 am, her pain level had dropped to a 1. At 7:56 am, Resident #1's pain level was at a 10 out of 10 and was administered 2 Acetaminophen tablet 325 mg. A follow-up at 8:58 am, her pain had dropped to a 3 out of 10. An interview on 09/04/25 at 4:44 pm, the DON said on 01/26/25, LVN E had been called to Resident #1's restroom in response to a guided fall. The DON said LVN E assessed Resident #1, and no injuries were reported. The DON said LVN E had failed to do an incident report, a change of condition, and notify her ADON/DON/Administrator when the incident occurred. She said LVN E had also failed to document Resident #2's head-to-toe assessment done after the guided fall. She said she and the Administrator found out about the incident on 01/30/25, by Resident #1's NP. The DON said she had done a change in condition for Resident #1 on 01/31/25 effective 01/26/25 at 4:30 pm. The DON said If LVN E had reported the incident when it occurred, we would have been able to assess the resident for pain and if the resident had voiced pain at that time, they would have notified the NP. The DON said it was her and the ADONs responsibility to ensure the nursing staff complete the required assessments for residents. She said she and the ADON review resident's electronic medical record on a daily basis to ensure nothing was missed. She said she and/or the ADON must have missed the documentation where nursing staff documented Resident #1 was having pain. An interview on 09/04/25 at 5:05 p.m., the Administrator said on 01/30/25, she had been notified by Resident #1's NP she had complained of having pain to her right lower extremity due to an incident she had on 01/26/25. She said on 01/30/25, Resident #1's NP ordered an x-ray of her right tibia/fibular. She said the results of the first x-ray (right tibia/fibula) indicated a nondisplaced proximal fibular fracture. She said when Resident #1's NP was notified of the findings that same day, he ordered a second x-ray, and those results were received on 01/31/25 which indicated an age-indeterminate fracture. The Administrator said LVN E had been counseled for failure to report an incident when Resident #1 was guided to the floor. She said LVN E had been re-education on falls and reporting incidents as soon as they occur. The Administrator said a negative outcome of LVN E not reporting Resident #1's incident was her not being treated sooner.Record review of the facility's Documentation in Medical Record policy dated 10/24/22 reflected:Policy: Each residence medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the residents progress through complete, accurate, and timely documentation.Policy Explanation and Compliance Guidelines:1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2. Documentation shall be complete at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.4. When documentation occurs after the fact, outside acceptable time limits, the entry shall be clearly indicated as late entry.

Based on observations, interviews, and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 1 of 3 residents (Resident #1) reviewed for nutritional status. The facility failed to initiate timely interventions to prevent weight loss when Resident #1 experienced significant weight loss of -6.95% (13 pounds) between the dates of 01/10/25 and 02/06/25. This failure could place residents who are dependent on staff for their nutrition and hydration at risk for nutritional deficit, weight loss, skin breakdown, and overall decline in quality of life. The findings included: Record review of Resident #1's face sheet dated 02/04/25 reflected a [AGE] year-old male with an original admitted [DATE] and last admitted [DATE]. His diagnoses included: Parkinsonism (tremors, slow movements, rigidity, postural instability), type 2 diabetes, hypertension, major depressive disorder, dementia, unspecified protein-calorie malnutrition, dysphagia (difficulty swallowing), and muscle wasting and atrophy. Record review of Resident #1's MDS assessment dated [DATE] reflected Resident #1 had a BIMS score of 8 (moderate cognitive impairment). Resident #1 required partial/moderate assistance (helper does less than half the effort) for eating. Record review of Resident #1's care plan dated 02/04/25 reflected Problem: Resident #1 had an ADL self-care performance deficit related to dementia. Date initiated: 04/27/24. Intervention: Resident #1 required partial/moderate assistance for eating. Date initiated: 10/31/24. Problem: Resident #1 had a nutritional problem or potential nutritional problem related to diet restrictions - regular diet, mechanical soft texture, regular liquids consistency. Date initiated: 05/13/24. Interventions: Monitor/document/report PRN any signs/symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals. Monitor/record/report to MD PRN signs/symptoms of malnutrition: emaciation, muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. Provide, serve diet as ordered. Monitor intake and record every meal. RD to evaluate and make diet change recommendations PRN. Date initiated: 04/27/24. Care plan did not reflect significant weight lost. Record review of Resident #1's updated care plan dated 02/06/25 reflected additional interventions for nutritional problem: Med pass three times a day for weight stability, give 120 ml. Date initiated: 02/05/25. New Problem: Resident #1 had unplanned/unexpected weight loss related to poor food intake. MDS: -5.0% change over 30 day(s) [comparison weight 01/10/25, 187 lbs., -10.2% , -19 lbs.] MDS: -10.0% change over 180 day(s) [comparison weight 08/3/24, 189 lbs., -11.1% , -21 lbs.] -5.0% change [comparison weight 01/10/25, 187.0 lbs., -10.2% , -19.0 lbs.] -7.5% change [comparison weight 12/06/24, 186.0 lbs., -9.7% , -18.0 lbs.] -10.0% change [comparison weight 11/01/24, 189.0 lbs., -11.1% , -21.0 lbs.] Date initiated: 02/05/25. Interventions: Alert dietician if consumption is poor for more than 48 hours. Give the resident supplements as ordered. Alert nurse/ dietitian if not consuming on a routine basis. If weight decline persists, contact physician and dietician immediately. Labs as ordered. Report results to physician and ensure dietician is aware. Monitor and evaluate any weight loss. Determine percentage lost and place interventions for weight loss per dietician/physician. Monitor and record food intake at each meal. Offer substitutes as requested or indicated. RP signed resident refusal of treatment/medication/diet. Weigh every month and PRN. Date initiated: 02/05/25. Record review of Resident #1's weight record reflected the following weights: 187 lbs. on 01/10/25 (readmission weight from hospitalization ), 187 lbs. on 01/17/25, 180 lbs. on 01/24/25, no weight entered on 01/31/25, 168 lbs. on 02/04/25, and 174 lbs. on 02/06/25. Record review of Resident #1's order dated 02/03/25 reflected Med Pass 2.0 three times a day for weight stability, give 120 ml. No new order for a house shake noted. Record review of Resident #1's change in condition communication form dated 02/04/25 reflected Resident #1 weighed for monthly weight. Resident #1 noted with 168.0 lbs. for February weight. Family present when Resident #1 was weighed. NP was notified of weight loss. New order for Med Pass 2.0 120ml TID for weight stability and dietician consult. Resident #1 continued on speech therapy services. Resident #1 was encouraged to go to dining room for meals. Completed by ADON P. Record review of Resident #1's RD assessment dated [DATE] reflected initial consult. Indicated [AGE] year old male presented with diagnosis of Parkinsonism and dementia. Present for assistance with ADLs due to tremors and therapy. Tolerated diet order well. Noted with good appetite and oral intakes to meals and snacks. Recommendation: Liberalize regular (mechanical soft) diet. Recommendation: large protein portions with lunch due to low protein labs. Goal: weight stability +/-5%, oral intakes remain >50% all meals and maintain skin integrity. Will monitor as needed. Completed by RD L. Record review of Resident #1's RD assessment dated [DATE] reflected consult related to new significant weight loss. Communication with ADON, verbal recommendation to continue new order for Med Pass 2.0 supplement to aid with weight stability. Food preferences continue to include milk with all meals, large protein portions with meals. Therapy following. Stable labs for hydration status. Improving albumin level. Recent poor oral intake. Likely unavoidable dietary/weight decline may be attributed to recent acute infection, pain, advanced age with dementia and chronic inflammatory diagnosis/condition. Goal: weight +-2%, oral intake>50%, and good skin integrity. Completed by RD L. Record review of Resident #1's progress notes: On 02/05/25 at 1:50 PM - Resident #1 ate poorly for lunch, offered second choice chicken nuggets, but refused. Asked if he is craving something else but he said no he is ok not hungry. Called daughter to notified of resident refusing lunch and offered other options but he continued to refuse, daughter asked if he is on a supplement resident is on Med pass TID. Documented by LVN E. On 02/05/25 at 6:36 PM - Resident #1 with dietary recommendation. Recommendation to promote weight stability. MD agrees. Continue Med Pass 2.0 120ml TID, weekly weights x 4 weeks, update food preferences. Will continue to observe. Documented by ADON P. On 02/06/25 at 8:27 AM - Resident #1's meal preferences and recommendations have been updated on dining details. Visited with him this morning. He stated he likes coffee, milk, and a variety of juices, oatmeal. He does not really like a lot of vegetables. He chooses to eat in room, if not eating 1st choice is offered 2nd choice, and always on hand menu items. He had no other specific meal preferences at this time. Will be monitoring meal intake, and weights to ensure proper nutrition. RD recommendations in place. Documented by DM I. On 02/06/25 at 9:24 AM - RD visit this morning during breakfast. Resident #1 consumed about 50% of meal, consumed 50% of large protein portion. Trial of fortified cereal provided this morning, accepted about 50%. Recently refused lunch and decreased intake for dinner. Resident #1 able to eat independently. Speech therapist at bedside providing assistance. Noted with snacks in room, per nursing, resident has family support to provide outside foods. DM updated food preferences this morning. Anticipated weight stability as infectious process resolves. Recommendations: continue plan of care at this. Will continue weekly weights for 4 weeks to monitor. Goal: weight +-2%, oral intake >50%, good skin integrity. RD to continue monitoring. Documented by RD L. On 02/06/25 at 10:13 AM - Resident #1 re-weighed in wheelchair. New weight 174.0 lbs. Patient continues on Med Pass 2.0 120ml TID. Resident with diagnosis of Unspecified Protein-Calorie Malnutrition. Documented by ADON P. Interview and Observation of Resident #1 on 02/05/25 at 11:00 AM revealed Resident #1 was eating candy and cookies in his room. Observation of snacks in Resident #1's room. Resident #1 said he liked his snacks. Interview and Observation of Resident #1 on 02/05/25 at 12:40 PM revealed Resident #1 was not eating. Resident #1 said he did not want to eat as he was not hungry. Interview with CNA B on 02/05/25 at 1:30 PM revealed CNA B said if a resident did not want to eat, she offered the second option. CNA B said if the resident still refused, she notified the nurse that the resident did not want to eat. CNA B said she worked with Resident #1 today, 02/05/25, and he did not want to eat lunch. CNA B said she told LVN E that Resident #1 did not eat and LVN E offered Resident #1 something else, but he still refused. CNA B said the nurses usually informed them when a resident was losing too much weight or asked about their eating habits. CNA B said she had not been informed that Resident #1 had lost a lot of weight. Interview with LVN E on 02/05/25 at 2:20 PM revealed LVN E said if a resident did not want to eat, she offered them second options, alternatives, and tried to convince them. LVN E said if it was a reoccurring issue, she would also inform the doctor to see if the doctor wanted to order maybe a supplement or an appetite stimulant. LVN E said the facility may have also implemented other interventions such as therapy or a swallow study. LVN E said today, 02/05/25, the staff informed her that Resident #1 did not eat lunch. LVN E said she offered Resident #1 the second option or if there was something else, he wanted, but he still refused. LVN E said some day last week, FM 1 asked about Resident #1's weight because he appeared thinner. LVN E said she was not sure if any interventions had been implemented for Resident #1 last week. LVN E said RA P was responsible for weighing the residents. Interview with FM 1 on 02/05/25 at 3:00 PM revealed FM 1 said the facility called her today, 02/05/25, and informed her that Resident #1 had lost 17 lbs. in the last 3 weeks. FM 1 said she had told the facility that Resident #1 had not been eating. FM 1 said she made the staff weigh Resident #1 yesterday, 02/04/25, and he weighed 168 lbs . FM 1 said Resident #1 was started on a supplement yesterday, 02/04/25. Interview with DM I on 02/0/25 at 3:40 PM revealed DM I said whenever there was a resident with weight loss, the nurses informed her or it flagged in the system. DM I said the dietitian came twice a month and the dietitian's technician was also here twice a month so they were here 4 times a month. DM I said if there was a resident with significant weight loss, the dietitian assessed and gave recommendations. DM I said she had not been informed recently that Resident #1 had significant weight loss. DM I said Resident #1 refused to eat at times, but they offered him second options or preferred foods. Interview with CNA C on 02/05/25 at 4:20 PM revealed CNA C said if a resident refused to eat, she informed the nurse. CNA C said she worked with Resident #1 yesterday, 02/04/25, and he threw the dinner plate as he refused to eat. CNA C said if a resident was losing weight, the nurse would inform them, so they ensured to report to the nurse if they were eating or not eating. CNA C said she had not been informed that Resident #1 lost a lot of weight nor had been asked about his eating habits. Interview with LVN F on 02/05/25 at 4:45 PM revealed LVN F said Resident #1 was ordered the Med Pass (protein supplement) to help with weight loss, but she was not sure when it was ordered or when the weight loss was noted. LVN F said RA P was responsible for weighing the residents and RA P reported the information to the ADON/DON. LVN F said ADON/DON would have implemented interventions for weight loss. Interview and Observation of Resident #1 on 02/05/25 at 5:30 PM revealed Resident #1 ate about half of the food. Resident #1 said the chicken was good. Interview with the DON on 02/05/25 at 5:40 PM revealed the DON said RA P weighed the residents then gave the DON the information to input in the system. The DON said she had not been informed that Resident #1 had lost a lot of weight. The DON said she was not sure when was the last time the dietitian saw him. Interview with ADON P on 02/05/25 at 6:00 PM revealed ADON P said the dietitian had not seen resident since he came back from the hospital on 01/09/25. Interview with the NP on 02/06/25 at 9:15 AM revealed who said the MD ordered the Med Pass (supplement) for weight loss, but he did not recall when. The NP said Resident #1 had been hospitalized in January 2025 and some weight loss would be normal. The NP said especially because of his age and diagnosis of Parkinson's. The NP said he could not remember when the dietitian reached out to him, but they did reach out to him. The NP said Resident #1's albumin level (protein in blood that regulates fluids/nutrients) was a little low but it had improved, and it was at a stable level for his age and condition. The NP said Resident #1 would likely continue to lose weight, but they tried to prolong it as much as they could. Interview with RD L on 02/06/25 at 9:40 AM revealed RD L said she had last assessed Resident #1 on 05/09/24 because he had not triggered for weight loss. RD L said she was notified yesterday, 02/05/25, at around 6:00 PM that Resident #1 needed a consult as there was significant weight loss identified. RD L said on 02/04/25, Resident #1 weighed 168 lbs. which was a big difference. RD L said 168 lbs. compared to 187 lbs. on 01/10/25 when Resident #1 was readmitted from the hospital was a difference of 19 lbs. RD L said as she followed the >5% trigger in 30 days, that was more than 5%, it was 10.2% which was severe weight loss. RD L said from 01/17/25 to 01/24/25, Resident #1 lost 7 lbs. RD L said she was not notified of that change. RD L said if Resident #1 lost 7 lbs. in one week, they did not necessarily need to report to her if the facility implemented interventions. RD L said when Resident #1 was readmitted from the hospital, he was supposed to be weighed weekly for 4 weeks. RD L said they usually monitored for 4 weeks to capture that window and reestablish their baseline when the resident returned from the hospital. RD L said Resident #1 was weighed on 01/10/25 after he was readmitted on [DATE]. RD L said Resident #1 weighed 187 lbs. on 01/10/25, 187 lbs. on 01/17/25, 180 lbs. on 1/24/25, and then on 01/31/25 there was no weight entered. RD L said they could have weighed Resident #1 within the week of 01/31/25 but there was nothing documented. RD L said Resident #1 weighed 168 lbs. on 02/04/25 and based on his overall clinical status or his anthropometrics (height/weight/BMI), Resident #1 had a healthy weight for his BMI and for his age. RD L said Resident #1 was overweight before when he was around 190 lbs. and now was at a healthy weight based on his BMI. Interview and Observation of Resident #1 on 02/06/25 at 10:13 AM revealed RA P weighed Resident #1 on his wheelchair. The scale read 213.6 lbs. with the wheelchair. RA P informed that the wheelchair weighed 40 lbs. Resident #1's weight was 173.6 lbs. and they rounded to the higher lb. if it is more than 0.5 so his weight was 174 lbs. Weight loss % from 01/10/25-02/06/25 from 187 lbs. to 174 lbs. was -6.95%. Interview with RA P on 02/06/25 at 10:20 AM revealed RA P said she was in charge of completing the weights for all the residents. RA P said the wheelchairs were all different so she weighed the wheelchair alone first for each resident. RA P said she weighed the residents at around the same time and tried to keep everything consistent. RA P said she weighed Resident #1's wheelchair on its own and it weighed 40 lbs. RA P said she weighed Resident #1 on 02/04/25 because FM 1 requested him to be weighed around lunch time. RA P said FM 1 thought Resident #1 was skinnier. RA P said she weighed Resident #1 on 02/04/25 and he weighed 168 lbs. standing on his own. RA P said when a resident returned from the hospital, the resident was weighed for 4 weeks, weekly. RA P said the 4 weekly weights were completed for Resident #1 after he was readmitted on [DATE] from the hospital. RA P said she gave the weights to the ADON or the DON. RA P said the ADON/DON inputted the information into the system. RA P said she weighed Resident #1 on 01/31/25 but she did not remember how much he weighed. RA P said she gave those numbers to the ADON/DON. RA P said if the resident lost a lot of weight, that would be determined by the ADON/DON. Interview with ADON P on 02/06/25 at 10:35 AM revealed ADON P was asked for the weight for Resident #1 on 01/31/25. ADON P said she only entered the monthly weights, and the DON would have entered weekly weights. Interview with the DON on 02/06/25 at 10:45 AM revealed the DON was asked for the weight for Resident #1 on 01/31/25. The DON said RA P wrote the weights on a paper, gave the DON the paper, the DON inputted the weights in the system, and shredded the paper. The DON said she would look for the weight for Resident #1 for the week of 01/31/25. Interview with ADON P on 02/06/25 at 11:10 AM revealed ADON P said when they identified weight loss for Resident #1, they notified the NP on 02/04/25 and the RD yesterday, 02/05/25. ADON P said RD L recommended to continue the Med Pass, update his food preferences, large protein portions, and weigh him weekly 4 more weeks to monitor his weight. ADON P said those interventions were implemented today, 02/06/25. ADON P said from 01/17/25-01/24/25, Resident #1 had lost 7 lbs. and normally that did not trigger for them to implement interventions such as reaching out to the MD, dietitian, and obtaining additional supplements, medications, orders, etc. ADON P said for the month it automatically triggered because it was more than 5%. ADON P said Resident #1's care plan indicated to monitor/notify MD for more than 3 lbs. in one week. ADON P said if it says that on the care plan, then they should have followed that, but they did not notify the MD for the 7 lbs. weight loss that week. ADON P said it was important to follow the care plan because that was what was structured for Resident #1. Observation of Resident #1 on 02/06/25 at 12:35 PM revealed Resident #1 eating lunch (ground beef with potatoes). Meal ticket indicated large protein portions. Resident #1 ate well on his own. Resident #1 was also observed by RD L. Interview with the DON on 02/06/25 at 1:10 PM revealed the DON said she did not find the weight for Resident #1 for 01/31/25 or that week. The DON said RA P gave her the paper with the weights and RA P did not keep records of the weights. Interview with the DON on 02/06/25 at 2:00 PM revealed when Resident #1 came back from the hospital, he was supposed to be weighed 4 times, weekly. The DON said Resident #1 was weighed on 01/10/25 at 187 lbs., on 01/17/25 at 187 lbs., on 01/24/25 at 180 lbs., and weighed on 01/31/25 but she was not aware of what his weight was. The DON said for 01/31/25, she just did not input the weight and did not know how that happened. The DON said when the resident returned from the hospital, they would take the 4 weekly weights to monitor the weight for any fluctuations or changes. The DON said from 01/17/25-01/24/25, Resident #1 lost 7 lbs. but the system did not flag for significant weight loss. The DON said Resident #1's care plan indicated to notify the MD for weight loss of 3 lbs. in 1 week. The DON said if the care plan says indicated that then they would still need to follow it even if it did not trigger in the system. The DON said if the staff did not follow the care plan, that could place the resident at risk of harm. The DON said when Resident #1 had 7 lbs. weight loss noted on 01/24/25, it did not flag for the >5% so there were no interventions implemented. The DON said the MD was not called, the NP was not called, and the dietitian did not see him until today, 02/06/25. The DON said if weight loss was not being monitored properly that could negatively affect the resident. The DON said the negative outcome could be weight loss. The DON said Resident #1 had diagnoses that could lead to weight loss eventually, but tried to prevent weight loss as much as they could. The DON said there was no negative outcome to Resident #1. Interview with ADM on 02/06/25 at 2:40 PM revealed the ADM said if an intervention was on the care plan, then it should be followed. The ADM said she did not know when the care plan was done for Resident #1 or that it indicated to notify the MD for weight loss of 3 lbs. in 1 week. The ADM said it was important to monitor for weight loss to prevent malnutrition and ensure the resident was medically stable. The ADM said although there were diagnosis or conditions that would cause the resident to continue to lose weight, they still had to monitor, address it, and try to prevent further weight loss. Record review of Weight Monitoring Policy (not dated) reflected the following: Policy: Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. 4. Interventions will be identified, implemented, monitored and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status. 5. A weight monitoring schedule will be developed upon admission for all residents: a. Weights should be recorded at the time obtained. Mathematical rounding should be utilized. b. Newly admitted residents - monitor weight weekly for 4 weeks. 7. Documentation: g. The interdisciplinary plan of care communicates care instructions to 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 the facility's only kitchen reviewed for storage, preparation and sanitation. The facility failed to ensure that food/ drink items in the reach- in freezer, refrigerator, and dry storage area were properly stored, labeled, and dated and were not expired. These failures could place residents at risk for food contamination. Findings included: During observation and interview on initial tour with Dietary Aide on [DATE] at 11:15 AM, Revealed two out of six milk jugs in the refrigerator were open and used and did not have an open date. The Dietary Aide stated they had probably just used it because they usually have an open date. One bags of low moisture mozzarella cheese was open to air in an unsealed bag. The Dietary Aide stated they would seal it properly. One bag of Mild Cheddar Cheese was open and not sealed. Mild cheddar cheese was wrapped with plastic wrap at the opening but not sealed from air. One of two boxes of mixed frozen vegetables were not sealed and open to air. One of two southern style biscuit and broccoli melody 1 out 1 were open to air in the freezer. The Dietary Aide stated the Dietary Manager had quit about 2 weeks ago. The facility Administrator was ordering what was needed for the kitchen. During interview with the Dietician on [DATE] at 10:40 AM, she stated that she was contract and visits the facility ,d+[DATE] times a month. The dietitian stated that Dietary Managers from other sister facilities have been helping in the last 2 weeks. During interview with the Administrator on [DATE] at 09:45 AM, she stated that she didn't know exactly when the previous dietary manager resigned, she wants to say about ,d+[DATE] weeks, but that thankfully there were 4 sister facilities in the area and the other three facility dietary managers have rotated into this facility to assist. The dietary managers will stay at the facility and sister facility will call if dietary manager is needed. She stated the dietary managers would do orders needed and she would approve. During an observation and interview with the Dietary Manager on [DATE] at 09:50 AM, who was from the sister facility that will start officially on [DATE] a follow-up walk through of refrigerator and freezer were completed. In the freezer there was 1 out 2 southern style biscuits still open to air, broccoli melody 1 out 1 no longer there and discussed of findings during initial walk through as she was not present. She stated that open foods need to be labeled with received date, open date and placed in bag or container. Surveyor discussed the finding of open milk jugs with no open date but no longer on shelf, cheese open and not sealed and she stated she was made aware of that and that was addressed. She did not know of biscuits but would address it immediately. During interview with the Dietary Manager from sister facility, on [DATE] at 10:54 AM, she stated that the food open to air in the freezer would get freezer burn, fresh produce could be open to air as it was fresh. She stated that if something was not dated like the cheese and milk it was to be discarded and would do in-services with staff. She stated that a negative outcome to residents would be if food in freezer or fridge was open to air more than a day and exposed to air it would affect the flavor and taste of the food. The food might absorb odors in fridge or freezer, and it should be discarded. The only negative outcome would be the flavor of food would be different. Record review of the Facility Policy for Food Storage Policy Number 03.003 revised [DATE] stated: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. 2. Refrigerators d. Date, label and tightly sealed all refrigerated foods using clean, nonabsorbent covered containers that are approved for food storage. 3. Freezer e. Store frozen foods in moisture-proof wrap or containers that are labeled and dated.

Based on observations, interview and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preference for one (Resident #11) of three residents reviewed for call lights. The facility failed to ensure Resident #11 had the call light within reach while in bed in his room. This failure could place residents at risk of being unable to obtain assistance or help when needed and in the event of an emergency. Findings were: Record review of Resident #11's Admission record dated 09/25/24 reflected an [AGE] year-old male with an initial admitted [DATE] and a diagnoses of Unspecified Dementia (decline in thinking, learning and reasoning), Unspecified Severity without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety, Heart failure unspecified, Essential (Primary)Hypertension, Muscle Wasting And Atrophy Unspecified Site, Anxiety (persistent and uncontrollable feelings of fear that disrupt daily living) Disorder Unspecified. Record Review of Resident #11's Annual MDS dated [DATE] reflected a BIMS score of 7 indicating severe cognitive impairment. Section GG - Functional Abilities and Goals indicated Resident uses a manual wheelchair, requires substantial /maximal assistance with upper and lower body dressing, sitting to lying on bed, rolling left and right side on bed, and toileting hygiene. Observation and interview on 09/22/24 at 11:33 a.m. revealed Resident #11's call light was hanging off the side of bed near the head rest touching the floor. Resident #11 said he did not know where his call light was. He said that he uses it when he needs help. During an interview on 09/22/24 at 11:36 a.m. CNA H observed Resident #11's call light hanging on the side of his bed near the floor. CNA H said Resident #11 was supposed to have his call light near him so he can call for help should he need to. She said he usually uses his call light. CNA H said she checks all residents to make sure their call lights are within reach and they are not in need of any other assistance. She said she does this at the beginning when she first begins working and throughout her shift. She said that she had not gone in to check Resident #11, she said it was another CNA who was responsible for him at that time. During an interview on 09/22/24 at 3:11 p.m. CNA K said that she and another CNA checked on Resident #11 and provided care in the morning around 9:00 a.m. She said at that time, they made sure Resident #11 had his call light within reach. She said he may have moved it away from himself. CNA K said Resident 11 does sometimes use his call light when he needs something. She said Administration and also the nurse in charge always remind them to always make sure the residents are able to reach their call lights to be able to ask for help or assistance. She said if a resident cannot reach it, he or she could fall and get hurt trying to get out of bed. During an interview on 09/25/24 at 10:55 a.m. LVN E said when she starts her shift she goes in to every residents room to introduce herself and to make sure residents are doing well and have everything within their reach including the call lights. She said Resident #11 uses his call light when he needs something. She said she always makes sure he has it within his reach and reminds him to use it. LVN E said that if a resident cannot reach the call light, then they cannot get help, they may have a fall and be at risk of getting hurt. Record review of facility's policy titled Call Lights: Accessibility and Timely Response date implemented: 10/13/22 states; Policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Policy Explanation and Compliance Guidelines: 1. All staff will be educated on proper use of the resident call system, including how the system works and ensuring resident access to the call light. 2. All residents will be educated on how to call for help by using the resident call system. 5. Staff will ensure the call light is within reachof resident and secured. As needed.

Based observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 (Resident #101, Resident #108, and Resident #1) of 4 residents observed for Infection Control. 1. CNA A failed to follow proper infection control while providing incontinent care to Resident #101. 2. CNA B failed to follow proper infection control while providing incontinent care to Resident #108. 3. The facility failed to prevent Resident#1's urinary catheter tubing (bag) from touching the floor. These failures could place the residents at risk of cross-contamination and development of infections. Findings included: 1. Review of Resident #101's Face Sheet, dated 09/25/2024, reflected that the resident was a [AGE] year-old male originally admitted on [DATE]. Resident #101 was diagnosed with benign prostatic hyperplasia without lower urinary tract symptoms. Review of Resident #101's Admission MDS Assessment, dated 07/21/2024, reflected that Resident #101's Cognitive Skills for Daily Decision Making - C1000 was severely impaired. Resident #101's Quarterly MDS Assessment indicated that the resident was incontinent for bowel and bladder. Review of Resident #101's Comprehensive Care Plan, dated 07/16/2024, reflected that Resident #101 was incontinent for bowel and bladder and required substantial/maximal assistance for toileting hygiene. Observation on 09/24/24 at 9:27 AM revealed during incontinent care of Resident # 101, CNA A retracted the foreskin of the penis, wiped half circle to tip of the penis, then crumpled and re-wiped opposite half circle to tip of the penis using same wipe. She did not use one wipe per swipe. She then replaced the foreskin and completed the rest of perineal care using proper technique and 1 wipe per swipe. CNA A proceeded to cleanse the buttock area. CNA did not doff soiled gloves, sanitize her hands, and don clean gloves when moving from perineal to buttock area. CNA proceeded to cleanse the buttocks area and wiped using 1 wipe per swipe but cleansed from back to scrotum (dirty to clean) one time out of 4 swipes. In an interview with CNA A on 09/24/2024 at 9:55 AM, she stated they must only use one wipe per swipe, they must change gloves after cleansing peri area and prior to cleansing buttocks area and sanitize hands between glove changes. CNA A said they must clean from clean to dirty not from the back to the scrotum. She said that she was just trying to make sure she removed all the BM. She said that she was nervous. She said that she thinks the last skills check-off she completed was about a month ago and they did an infection control training about a week ago. She said there is not a lack of training because the facility is constantly reminding them of proper techniques and asking if they feel they need more training. She said they even watch videos. She said that if she did not use 1 wipe per swipe, change gloves and hand sanitize between care of peri area and buttocks, or wipe from clean to dirty an infection can happen. 2. Review of Resident #108's Face Sheet, dated 09/25/2024, reflected that the resident was a [AGE] year-old female admitted on [DATE]. Resident #108 was diagnosed with muscle wasting and atrophy (waste away of body tissue or organ), and other abnormalities of gait (manner of walking) and mobility. Review of Resident #108's Admission MDS Assessment, dated 09/01/2024, reflected Resident #108 had a moderate impairment in cognition with a BIMS score of 10. The Quarterly MDS Assessment indicated that the resident was incontinent for bladder and bowel. Review of Resident #108's Comprehensive Care Plan, dated 08/30/2024, reflected Resident #108 required supervision/touching assistance for toileting hygiene. Observation on 09/24/2024 at 10:00 AM revealed during incontinent care of Resident # 108, CNA B cleansed top of external pubic area using one wipe per swipe, CNA B doffed soiled gloves and donned clean gloves. CNA did not sanitize between glove changes. CNA B continued cleansing the peri area starting with urethral area then right outer labia using one wipe per swipe. CNA B wiped the left outer labia, then wiped it again using the same wipe. CNA B did not use one wipe per swipe. CNA B continued to wipe the remaining of the peri area from front to back using appropriate technique and one wipe per swipe. She doffed her soiled gloves, washed hands with soap and water for more than 20 seconds, donned clean gloves and began cleansing the buttocks area. CNA B wiped the left side of the buttocks with a wipe, wiped again using the same wipe, then disposed of the wipe. She then grabbed another wipe and wiped the left side again, then wiped again using the same wipe. She repeated the same process to the right side of the buttocks. CNA B did not use one wipe per swipe. In an interview with CNA B on 09/24/2024 at 10:35 PM, CNA B stated she should use one wipe per swipe and always sanitize between glove changes. She said if they did not an infection can happen. She said that she completed a training on infection control about a week ago. She said she had also been checked off on her skills for incontinent care. In an interview with CNA C on 09/24/2024 at 10:40 AM, she stated she was the lead CNA and conducted training for the CNAs. She said wipes were used one time then must be thrown away. She said gloves must be changed between cleaning peri area and buttocks and must always sanitize between glove changes. She said if they don't do that the resident can get an infection. She said the CNAs do receive trainings and get checked off on their skills upon hire and around every 3 months. She said training is ongoing for perineal care and infection control. In an interview with the DON on 09/24/2024 at 10:50 AM, she said the facility trained and provided re-education for incontinent care and infection control monthly to include skills check offs. She said they are instructed to use a wipe once and throw it away because it cannot be used again. The DON said they are instructed to remove dirty gloves and apply clean gloves and sanitize in between. She said they must always change gloves after touching any soiled area. She said CNAs would have to change gloves when moving from care to vaginal area and care of the buttocks. She said that the CNAs must clean from clean to dirty. In an interview with the IP on 09/25/2024 at 10:58 am she said that training was constant and on-going every day because hand hygiene was the most effective way to prevent cross contamination and infection. She stated that she empowers other administration to observe and re-instruct on hand-hygiene and infection control. She stated they include information on infection control before morning meetings, they ask department heads if during their rounds anything was questionable or out of place so they can fix it right away. She stated they also try to make it fun. She said they have a sink that they take down all the halls and have staff go through the motions of hand washing and hand sanitizing. She said she made sure staff wait for sanitizer to evaporate. She said the facility also provided staff monthly trainings and checked-off in infection control. 3. Record review of Resident#1's face sheet revealed a [AGE] year-old male originally admitted on [DATE]. Resident#1 had primary/admitting diagnosis of alzheimer's disease (a progressive disease that destroys memory and other important mental functions), obstructive and reflux uropathy (when flow of urine is blocked in the bladder, ureter urethra), retention of urine (a disorder characterized by accumulation of urine within the bladder because of the inability to urinate). Record review of Resident #1's MDS dated [DATE], Section C-Cognitive patterns revealed Resident #1 had a BIMS score of 2 which indicated Resident #1 had severely impaired cognition. Section H-Bladder and bowel revealed resident #1 has an indwelling catheter. Record review of Resident #1's care plan revealed Resident #1 has a foley catheter Obstructive and reflux uropathy Date initiated 03/13/24 and revised on 03/20/24 and Resident #1 has (indwelling/foley) Catheter Obstructive and Reflux uropathy date initiated 03/13/24 and revised on 03/20/24 Intervention/tasks listed Provide catheter care every shift and Position catheter bag and tubing below the level of the bladder and away from entrance room door initiated and revised on 03/10/24. Record review of Order Summary has order printed 09/24/24 revealed order to Change Foley Catheter 16 # FR with 30mL/cc balloon q month and if plugged out or dislodged PRN. Order Foley catheter check q shift and PRN start dated 03/13/24. During an observation on 9/22/24 at 12:30 PM, Resident #1 foley catheter bag was noted laying on the floor under the Resident #1 wheelchair in the dining area. Resident #1 was non interviewable. During interview with LVN A on 09/22/24 at 1:00 PM, LVN A was informed and shown catheter bag laying on the floor. She stated it that she was taking Resident #1 to his room to have his midline check. She stated that she checked earlier around 11:00 AM and foley catheter bag was not touching the floor at that time when he was in his wheelchair. LVN A stated that she did not notice the foley bag dragging on the floor because she was preoccupied with getting Resident #1 to his room and back to the dining area. LVN A stated if Resident's #1 foley bag is dragging on the floor, it is an infection control issue. LVN A stated that foley bag should never be touching the floor because it could get pinched, or it could cause a leakage if the foley bag is dragging on the floor. During an interview with LVN B on 9/24/24 at 10:20 AM, LVN B stated that when a foley catheter bag is dragging the floor is a high risk for cross contamination, and Resident #1 was at risk to get an infection. LVN B stated that was a tripping hazard. During an interview with LVN C on 9/24/24 at 10:30 AM, LVN C stated that when foley catheter bag was on the floor bacteria could enter the bag and Resident #1 could be getting an infection. During interview with RN A on 09/24/24 at 10:45 AM, she stated that the foley catheter bag should not be on the floor because it could cause a urinary tract infection to Resident #1. RN A stated that residents were susceptible and by dragging the bag on the floor the risk of infection was higher. Record Review of Policy Titled Infection Prevention and Control Program with implemented date 5/13/2023, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections as per accepted national standards and guidelines. Review of the facility's Infection Control Policy implemented 5/13/23 revealed, Policy: This facility has established and maintains 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 as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines: . 4. Standard Precautions: a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE. Policy for Incontinent Care requested on 09/24/2024 at 10:50 AM and the DON provided a copy of pages from Lippincott Nursing Procedures, 7th Edition. The DON said they follow Lippincott Nursing Procedures. Review of documents revealed, Perineal Care: Perineal care, .includes care of the external genitalia and the anal area .promotes cleanliness and prevents infections. Standard precautions must be followed when providing perineal care . Implementation: Perform hand hygiene and put on gloves. Put on gloves to comply with standard precautions. For a female patient: Clean, rinse, and dry the anal area, .wiping from front to back. For a male patient: Clean the bottom of the scrotum and the anal area. Completing the procedure: Remove and discard your gloves. Perform hand hygiene. Reviewed Incontinent Care Proficiency Checklist provided by CNA C for CNA A and CNA B both dated 5/6/24. The checklists revealed the following: .Put on gloves. Turn resident to side away from you and cleaning from front to back clean the rectal area (for women clean from the vaginal area to the rectum). Use more than one washcloth, if needed (wipe) . Wash hands before performing peri care. Use hand gel between glove changes. If heavily soiled, wash hands with soap and water. Wash hands after cleaning the resident and before touching clean linens. Wash hands after peri care is completed and before leaving the room. Wash hands any time you are unsure if you touched something dirty. 50487

Based on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 2 (Resident #2 and Resident #3) of 10 residents reviewed for accuracy of assessments. 1. The facility failed to ensure Resident #2 was coded in the MDS for a fall on 10/18/23. 2. The facility failed to ensure Resident #3 was coded in the MDS for a fall on 4/4/24. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. The findings included: 1. Record review of Resident #2's face sheet dated 09/11/24 reflected Resident #2 was admitted on [DATE] and was [AGE] years old. Resident #2 had diagnoses of right sighted hemiplegia and hemiparesis following cerebral infarction, muscle wasting and atrophy, difficulty walking and lack of coordination. Resident #2 was discharged to private home/apt with home health services on 11/20/2023. Record review of Resident #2's comprehensive care plan reflected: The resident has had an actual fall 10/18/2023 cut on bottom lip, silver crown from tooth fell off. Initiated: 10/19/2023. Interventions included: left side floor pad, neuro checks, pain management q8 hours x 3 days. scheduled Tylenol, room change closer to nurses' station for increased visual checks, x-ray to facial and skull. Revision on: 12/08/2023 and Cancelled Date: 12/08/2023 due to resident discharge. Record review of Resident #2's Discharge MDS dated [DATE] revealed: A BIMS score of 7 (severe impaired) for Brief Interview of Mental status. Required substantial/maximal assistance for self-care except eating partial/moderate assistance. Required partial/moderate assistance for mobility. No falls since admission/Entry or Reentry or Prior MDS Assessment. Record review of Resident #2's progress notes dated: 10/18/2023 05:50 NURSING - Nurse Note Note Text: pt stated trying get up and went forward from wheelchair and hit bottom lip on floor causing a cut, also chip noted to top tooth with silver cap with assistance of other nurse and staff assessed and picked up pt to bed, notified husband and dr, neuro checks initiated. Record review of facility's incident log not dated revealed that on 10/18/2023 Resident #2 had an unwitnessed fall. No other falls noted. Interview on 07/11/24 at 9:48 AM MDS Nurse A, stated that the MDS department completes resident MDS assessments quarterly and as needed for significant changes, they assist with care plans, and talk to insurances. She said that other staff also assist with completing MDS assessments. She said that falls are typically completed by the MDS department, placed in PCC, and then added to the care plan. She said that they don't always update MDS as a Significant Change when there is a fall. She said that if it was not a significant injury, they do not complete a Significant Change MDS. She said that a significant injury would include injuries such as fracture, injury to head, or injury when a resident must be sent out for care because treatment cannot be completed at the facility. She said that they look at the RAI to see what should or should not be considered a major injury. She said that the RAI was located on PCC. She said that the RAI, section J was captured during the date the quarterly was completed and done within the last 180 days if already claimed in a significant change MDS. She said that for Resident #2 the quarterly MDS was completed on 10/16/23 before the fall. The MDS coordinator said that the discharge was done on 11/20/23 and that it was not coded correctly. She said that the fall should have been captured on the Discharge MDS. She said that she would not consider it a significant change MDS due to no major injury, so the fall would have been captured on Discharge MDS. She said that if the fall was not captured on the MDS, they can modify. She said that they have 2 years to fix. She said that they usually do quarterly audits which are completed by Regional corporate nurses. She said that they provide them with the information needed and they amend it. She said that there would not be any negative outcome. She said if it was care planned there should be no negative outcomes to the resident. She said that all the information gathered through care plan and MDS assessment would come from the resident assessments. Interview on 07/11/24 at 11:10 am DON stated that she has been working at the facility as a nurse for [AGE] years. She said that the MDS assessment was usually completed if there was a significant injury, such as a fracture or wound. She said that she would consider the injuries sustained during Resident #2's fall as a significant change that would warrant a significant change MDS or at least be coded on the Discharge MDS. She said an adverse effect of not completing an MDS assessment would be no updated care plans to communicate with other staff. She said that she was not sure if the care plans are completed first or the MDS. 2. Record review of Resident #3's Face Sheet revealed Resident #3 was admitted on [DATE] and was [AGE] years old. Resident #3 had diagnoses Type 2 Diabetes Mellitus, Legal Blindness, Epilepsy, Anemia, Emotional Lability, Muscle Wasting and Atrophy, other lack of coordination. Record review of Resident #3's comprehensive care plan reflected: The resident has had an actual fall on 04/04/2024- with raised area to left side of head and skin tear to left hand and skin tear to the left upper arm. Initiated: 04/05/2024. Revision on: 04/05/24. Record review of Resident #3's annual MDS dated [DATE] revealed: A score of 3 (severely impaired) for Brief Interview of [NAME] Status. Required substantial/maximal assistance from seat to stand. No falls since previous quarterly MDS assessment. Record review of facility's incident log not dated revealed that on 04/04/2024 at 2:15 PM Resident #3 had an unwitnessed fall. Record review of Resident #3's Change of Condition Communication Form dated 04/04/2024 revealed: Signs/Symptoms Details: Raised area to left side to the head, skin tear to left forearm, skin tear to right middle finger. SN was doing hall walking round and heard the resident yelling for help saying she hurt herself I closed my cart, and went into resident room and found resident face up on the left side of the bed. Upon assessment SN noticed raised skin to the left side of the head discoloration to right left eye and skin tear 3 inches in length to the left forearm, resident told family member she was reaching for her pillow that had fallen and didn't ask for assistance check started family was notified and NP was notified. An observation on 07/09/2024 at 1:17 PM, revealed Resident #3 was in her bed laying down, well dressed, and groomed. Resident #3 said did not remember any recent falls, that she cannot see and does not know. Interview on 07/11/2024 at 2:50 PM, with MDS Nurse A, who completed Resident #3 MDS assessment. MDS Nurse stated that if a fall with injury such as head injury or something that requires immediate intervention or being sent to ER , was sustained, a significant change MDS would be created but if fall without major injury it would be coded on the following MDS. She stated that the fall on 4/4/24 for Resident #3 should have been coded on MDS dated [DATE] but was not. She said not coding Resident#3's fall could reflect an inaccurate assessment but no negative outcome for Resident #3 as the fall was care planned and Resident #3 received proper care and services needed. In an interview on 05/29/24 at 3:54 PM, DON said the fall for Resident #3 needed to be coded in MDS and care planned to communicate to other staff the needs that Resident #3 required. Record review of CMS's RAI Version 3.0 Manual dated 10/2023, that Administrator provided, reflected section: J1800: Any falls since admission/entry or reentry or Prior to Assessment. Coding instructions: Code 1, yes if the resident has fallen since the last assessment. Continue to number of falls since admission/entry or reentry or prior to assessment. J1900: Any falls since admission/entry or reentry or Prior to Assessment. Coding instructions: Code 1, yes if the resident had one non-injurious fall since admission/entry or reentry or prior assessment. 50532

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 2 out of 2 residents receiving breathing treatments that included measurable objectives and time frames to meet residents' needs, for 2 of 2 residents reviewed for care plans belonging to Resident #68 and Resident #10. The facility failed to develop a comprehensive care plan for Resident #10 and Resident #68 to include their breathing treatments. These failures could place residents at risk for their medical, physical, and psychosocial needs not being met. The findings were: During an observation and interview with Resident #68 on 6/22/2023 at around 3:30 PM it was noted he had equipment for breathing treatments in his room. Record review of Resident #68 face sheet on 6/22/2023 indicates a [AGE] year-old male with a diagnosis of cerebral infarction, hemiplegia and vascular dementia. He has a BIMs score of 2, which is considered severe cognitive impairment. Resident was not interviewable. Record review of Resident #68's chart on 6/22/2023 showed a doctor's order start date 06/05/23 for a Nebulizer treatment every 6 hours. No stop date indicated. Record review of Resident #68's care plan on 6/22/2023 revealed no care plan for breathing treatments. During an observation and interview with Resident #10 it was noted she had equipment for breathing treatments in her room. Record review of Resident #10 face sheet on 6/22/2023 indicates a [AGE] year-old female with a diagnosis of congestive heart failure and cancer. She has a BIMs score of 12, which is considered moderate cognitive impairment. Record review of Resident #10's chart on 6/22/2023 showed a doctor's order for Oxygen as needed for shortness of breath and Nebulizer treatments. Record review of Resident #10's care plan on 6/22/2023 revealed no care plan for breathing treatments. During an interview and record review of Resident #68's care plan on 6/22/2023 at 4:40 PM with the Director of Nursing (DON) she said there should be a care plan for nebulizer treatments. The DON said the MDS department does the care plans, and the DON did not know why a care plan was not developed. During an interview and record review of Resident #68's care plan on 6/22/2023 at 4:50 PM the MDS coordinator (care plan specialist) #1 and #2 said it looked like the care plan for breathing treatments slipped through the cracks. They both said there should be a care plan for breathing treatments. MDS coordinator (care plan specialist) #1 and #2 said they reviewed orders in the morning meeting and communicate with the assistant director of nurses on a daily basis. Care plans are reviewed by nurses and CNAs and used as a guide for resident care. A resident with a doctor's order for as-needed breathing treatments or Oxygen should be assessed for that need on a regular basis. Failure to do so could result in acute respiratory failure and can be life-threatening. During an interview and record review of Resident #10's care plan on 6/22/2023 at 6:00 PM with the Director of Nursing (DON) she said there should be a care plan for nebulizer treatments. The DON said the MDS department does the care plans, and the DON did not know why a care plan was not developed The facility's Care Plans policy dated 10/24/2022 indicated the following: 1 The comprehensive care plan will describe, at a minimum, the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 2 The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs.

Based on observation, record review, and interview, the facility failed to provide Physician- ordered assistance devices (chair and bed alarms) to prevent falls, for two Residents (R#2 and R#3) of five residents reviewed for falls. 1) The facility failed to ensure R#3's physician-ordered bed alarm was in place. R#3 suffered an undetected fall which resulted in a fixated comminuted fracture of the left proximal femur with lateral displacement of a segment of the proximal femur (shattered upper thigh bone). 2) The facility failed to ensure R#2's physician ordered chair alarm was attached to his person. R#2 was observed standing unassisted in front of his wheel chair without the chair alarm clipped on. This failure could place 45 residents with bed alarms and 34 residents with chair alarms at risk for injuries. The findings were: 1) Face Sheet dated 01/22/14 revealed R#3 was an [AGE] year-old female, admitted on [DATE]. R#3's admitting [DIAGNOSES REDACTED]. R#3's January 2014 computerized physician's orders [REDACTED]. Same orders documented: -to clean left hip incision with wound cleanser and leave open to air BID (twice a day), order date of 01/17/14, and, -may apply bed alarm to alert staff when resident is attempting to self-transfer unassisted, due to high risk for falls, order date 01/17/14. R#3's clinical record did not contain a Minimum Data Set (MDS) assessment as R#3 had only been at the facility for one week at the time of R#3's fall in the facility. R#3's Care Plans dated 01/20/14 revealed: -R#3 was admitted for rehabilitation due to a left hip ORIF (open reduction and internal fixation - surgery to fix repair hip fracture). -R#3's intervention: "need to have a bed alarm and chair alarm and call light available at all times." "I am a two person assist for transfers and ADLs (activities of daily living); I need to have my bed at lowest position. Incident/Accident Report dated 01/25/14 at 7:00 a.m. documented the following: "Nurse called to Pt (patient) room. Observed Pt on floor, lying on her right side. Questioned pt what she was doing trying to get up. Passive/active ROM (range of motion) done on all extremities. Complaining of left hip pain. Pt then states she did fall on her left side. 2:1 assist with transfer to wheelchair. Call light was in place. Physician notified and ordered a stat (immediately) x-ray of left hip and left leg. Pt denies hitting head." Same report documented under, "Interventions implemented: Personal alarm", that a personal alarm was not present. The report indicated there was evidence of abuse, or neglect or exploitation and counseling was needed. R#3's Physician Communication and Progress Note for New Symptoms, Signs and other Changes in Condition form dated 01/25/14 documented the following:-R#3's x-ray dated 01/25/14 of left hip/knee, was positive for fracture, -R#3 in the nursing facility due to an ORIF of left hip, -R#3 fell on [DATE] at 7:00 a.m., and complaining of pain to left hip, and, -R#3 was transferred to the hospital. R#3's Left Hip X-ray dated 01/25/14 documented the following under findings: - There is a plate and screw device stabilizing a proximal femur fracture. The position of the plate and screws is normal. There is no loosening. There is a segmental proximal femur fracture. -Under impressions. Fixated comminuted fracture of the left proximal femur with lateral displacement of a segment of the proximal femur. In an interview on 01/30/14 at 9:14 a.m., Housekeeper "A" said on 01/25/14 after 7:00 a.m. she was walking down hall 600 when she heard someone yelling, "Llevante me (get me up)." Housekeeper "A" said she went to R#3's room and saw R#3 on the floor. Housekeeper "A" said R#3 said she was going to the bathroom and fell down. Housekeeper "A" went to get help for R#3. Housekeeper "A" said she saw Certified Nurse Aide (CNA) "B" coming down the hall and informed CNA "B" that R#3 was on the floor. CNA "B" went to R#3's room. Housekeeper "A" then informed Licensed Vocational Nurse (LVN) "C" that R#3 was on the floor. Housekeeper "A" she did not hear a bed alarm activated in the room, only R#3's voice. In an interview with 600 hall CNA "B" on 01/30/14 at 9:20 a.m., CNA "B" said she had taken R#3's vital signs in the morning. R#3 was in her bed. CNA "B" said that, sometime around 7:00 a.m., Housekeeper "A" told her that R#3 was on the floor. CNA "B" went into R#3's room. R#3 was yelling, "Ayudame (help me) me calli (I fell )." CNA "B" said R#3 was on the floor on her back, by the foot of her bed. CNA "B" said she asked R#3 why R#3 had not used the call light. R#3 said she did not want to bother staff. CNA "B" said R#3 did not have a bed alarm on her bed at the time. CNA "B" said she had never been informed that R#3 needed a bed alarm. CNA "B" said then LVN "C" came into R#3's room. LVN "C" assessed R#3, and then transferred R#3 to the wheelchair. CNA "C" said that the nurses and CNA team leader told CNAs which residents need a bed/chair alarm. In a telephone interview on 01/30/14 at 9:47 a.m., 600 hall CNA "E" said he could not remember if R#3 ever used a bed alarm while in bed. In a telephone interview on 01/30/14 at 10:25 a.m., LVN "C" said Housekeeper "A" informed her that R#3 was on the floor. LVN "C" went to R#3's room. R#3 was on her right side. LVN "C " said she assessed R#3. R#3 could move all extremities and did not complain of pain. LVN "C" said she and CNA "B" transferred R#3 to the wheelchair and took her to the toilet. R#3 grabbed the hand rails and sat on the toilet. LVN "C" said later R#3 complained of pain to her left hip. R#3's Physician was in the facility and ordered x-rays of R#3's left hip and leg. LVN "C" said a bed alarm was not in place on R#3's bed or wheelchair at the time of the fall. LVN "C " said R#3 was in the facility due to a left hip replacement. R#3's Treatment Administration Record (TAR) dated January 2014 documented: -may apply bed alarm to alert staff when resident is attempting to self-transfer unassisted, due to high risk for falls every shift, order date: 01/17/14. The TAR documented R#3 had the bed alarm on from: -01/21/14 to 01/25/14 on the day shift (6:00 a.m. to 2:00 p.m.), initialed by LVN "C." -01/21/14 to 01/24/14 on the evening shift (2:00 p.m. to 10:00 p.m.), and, -01/20/14 to 01/25/14 on the night shift (10:00 p.m. to 6:00 a.m. shift). In a telephone interview on 01/30/14 at 10:55 a.m., with LVN "C" surveyor noted R#3 ' s TAR had been initialed, indicating a bed alarm was being placed on R#3's bed daily. LVN "C" said those entries had been a, "mistake", and there were no bed alarms in use on 600 hall. In an interview on 01/30/14 at 10:33 a.m., CNA/Team Leader "D" said she was instructed to place a bed and chair alarm on R#3's bed and wheelchair only after R#3 was found on the floor on 01/25/14. In an interview on 01/30/14 at 1:25 p.m., the Director of Nurses (DON) said she found out during her investigation that the bed alarm was not on R#3's bed. The DON said that was why she immediately reported the incident to the state. The DON said R#3 was in another room, but was transferred to a room closer to the nurse's station. During the transfer to the other room, the bed alarm was not put on the bed R#3 was going to use. The DON said she did not remember the exact date R#3 changed rooms. Surveyor did not interview R#3 as she was in the hospital during the investigation. 2) Face Sheet dated 06/14/13 documented R#2 was [AGE] years-old, admitted to the facility on [DATE], and readmitted on [DATE]. R#2's original admitting [DIAGNOSES REDACTED]. R#2's January 2014 computerized physician's orders [REDACTED]. Same physician's orders [REDACTED]." The order date was 05/27/13. R#2's quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R#2: -had adequate hearing (no difficulty in normal conversation, social interaction, listening to TV -had clear speech (distinct intelligible words) -had moderately impaired vision (limited vision; not able to see newspaper headlines but can identify objects) - was able to complete an interview for mental status, - needed extensive assistance from one person for bed mobility, transfers, dressing, and personal hygiene, -needed extensive assistance from two persons for toilet use, -had no documented falls since admission/entry or prior to assessment, and, -used wheelchair for ambulation. R#2's care plan dated 04/25/13, with a target date of 02/10/14, indicated R#2 was at risk for falls related to being unaware of safety needs and vision/hearing problems. Interventions did not address a physician's orders [REDACTED]. Surveyor reviewed the Incident/Accident logs for November 2013, December 2013 and January 2014. There were no documented falls for R#2. On 01/28/14 at 10:22 a.m., surveyor observed R#2 in his room. R#2 was standing up in front of his wheelchair. Surveyor observed a chair alarm on the wheelchair. The chair alarm's cord was hanging behind the back of the wheelchair. The chair alarm cord was not clipped to R#2's clothing. At this time, surveyor called Licensed Vocational Nurse (LVN) "I" to R#2's room. R#2 had already sat down on the wheelchair when LVN "I" and surveyor returned to R#2's room at 10:24 a.m. LVN "I" and surveyor observed R#2's chair alarm cord was not attached to R#2's clothing, it was hanging behind the wheelchair. LVN "I" said R#2 could remove the chair alarm. In an interview with R#2 on 01/28/14 at 3:10 p.m., R#2 said he could transfer himself from the bed to wheelchair, but that an alarm would go off when he got out of bed. R#2 said he could transfer from wheelchair to bed, but did not recall an alarm going off when he transferred himself. In an interview with Certified Nurse Aide (CNA) "J" on 01/30/14 at 11:30 a.m., CNA "J " said R#2 could remove the wheelchair alarm. CNA "J" said the alarm was clipped to the shoulder of R#2's clothing. CNA "J" said R#2 could transfer himself, but only with supervision from staff. The Facility's undated policy entitled "Physical Restraints", documented that whenever possible, the facility would use alternatives to physical restraints, including the following: -bed/chair mobility detention devices, -protective safety devices, -positioning devices, -environmental modifications, resident cues, and -staff interventions to promote resident safety. On 01/30/14 at 3:50 p.m., the DON said the facility had 45 residents with bed alarms and 34 residents with chair alarms. During the exit conference on 01/30/14 at 4:10 p.m., the facility was given the opportunity to provide additional information related to the use of to bed/chair alarms. No other information was presented.

Based on interview and record review, the facility failed to implement their policy and procedures that prohibited neglect, for one Resident (R#3) of 13 residents reviewed for neglect. The facility failed to ensure R#3's bed alarm was in place. R#3 suffered an undetected fall which resulted in a fixated comminuted [MEDICAL CONDITION] proximal femur with lateral displacement of a segment of the proximal femur (shattered upper part of the femur). This failure could place 45 residents with bed alarms at risk for injuries. Findings were: Face Sheet dated 01/22/14 revealed R#3 was an [AGE] year-old female, admitted on [DATE]. R#3's admitting [DIAGNOSES REDACTED]. R#3's January 2014 computerized physician's orders [REDACTED]. Same orders documented: -to clean left hip incision with wound cleanser and leave open to air BID (twice a day), order date of 01/17/14, and, -may apply bed alarm to alert staff when resident is attempting to self-transfer unassisted, due to high risk for falls, order date 01/17/14. R#3's clinical record did not contain a Minimum Data Set (MDS) assessment as R#3 had only been at the facility for one week at the time of R#3's fall in the facility. R#3's Care Plans dated 01/20/14 revealed: -R#3 was admitted for rehabilitation due to a left hip ORIF (open reduction and internal fixation-surgery to fix repair [MEDICAL CONDITION]). -R#3's intervention: "need to have a bed alarm and chair alarm and call light available at all times." Incident/Accident Report dated 01/25/14 documented the following: "Nurse called to Pt (patient) room. Observed Pt on floor, lying on her right side. Questioned pt what she was doing trying to get up. Passive/active ROM (range of motion) done on all extremities. Complaining of left hip pain. Pt then states she did fall on her left side. 2:1 assist with transfer to wheelchair. Call light was in place. Physician notified and ordered a stat x-ray of left hip and left leg. Pt denies hitting head." Same report documented under, "Interventions implemented: Personal alarm", that a personal alarm was not present. The report indicted there was evidence of abuse, or neglect or exploitation and counseling was needed. R#3's Physician Communication and Progress Note for New Symptoms, Signs and other Changes in Condition form dated 01/25/14 documented the following:-R#3's x-ray dated 01/25/14 of left hip/knee, was positive for fracture, -R#3 in the nursing facility due to an ORIF of left hip, -R#3 fell on [DATE] at 7:00 a.m., and complaining of pain to left hip, and, -R#3 was transferred to the hospital. In an interview on 01/30/14 at 9:14 a.m., Housekeeper "A" said on 01/25/14 she was walking down hall 600 when she heard someone yelling, "Levantame (Translation: Get me up)." Housekeeper "A" said she went to R#3's room and saw R#3 on the floor. Housekeeper "A" said R#3 said she was going to the bathroom and fell down. Housekeeper "A" went to get help for R#3. Housekeeper "A" said she saw Certified Nurse Aide (CNA) "B" coming down the hall and informed CNA "B" that R#3 was on the floor. CNA "B" went to R#3's room. Housekeeper "A" then informed Licensed Vocational Nurse (LVN) "C" that R#3 was on the floor. Housekeeper "A" she did not hear a bed alarm activated in the room, only R#3's voice. In an interview with 600 hall CNA "B" on 01/30/14 at 9:20 a.m., CNA "B" said she had taken R#3's vital signs in the morning. R#3 was in her bed. CNA "B" said that, sometime around 7:00 a.m., Housekeeper "A" told her that R#3 was on the floor. CNA "B" went into R#3's room. R#3 was yelling, "Ayudame, me cai (Translation: Help me, I fell )." CNA "B" said R#3 was on the floor on her back, by the foot of her bed. CNA "B" said she asked R#3 why R#3 had not used the call light. R#3 said she did not want to bother staff. CNA "B" said R#3 did not have a bed alarm on her bed at the time. CNA "B" said she had never been informed that R#3 needed a bed alarm. CNA "B" said then LVN "C" came into R#3's room. LVN "C" assessed R#3, then transferred R#3 to the wheelchair. In a telephone interview on 01/30/14 at 9:47 a.m., 600 hall CNA "E" said he could not remember if R#3 ever used a bed alarm while in bed. In a telephone interview on 01/30/14 at 10:25 a.m., LVN "C" said Housekeeper "A" informed her that R#3 was on the floor. LVN "C" went to R#3's room. R#3 was on her right side. LVN "C" said she assessed R#3. R#3 could move all extremities and did not complain of pain. LVN "C" said she and CNA "B" transferred R#3 to the wheelchair and took her to the toilet. R#3 grabbed the hand rails and sat on the toilet. LVN "C" said later R#3 complained of pain to her left hip. R#3's Physician was in the facility and ordered x-rays of R#3's left hip and leg. LVN "C" said a bed alarm was not in place on R#3's bed or wheelchair at the time of the fall. LVN "C" said R#3 was in the facility due to a left hip replacement. R#3's Treatment Administration Record (TAR) dated January 2014 documented: -may apply bed alarm to alert staff when resident is attempting to self-transfer unassisted, due to high risk for falls every shift, order date: 01/17/14. The TAR documented R#3 had the bed alarm on from: -01/21/14 to 01/25/14 on the day shift (6:00 a.m. to 2:00 p.m.), initialed by LVN "C." -01/21/14 to 01/24/14 on the evening shift (2:00 p.m. to 10:00 p.m.), and, -01/20/14 to 01/25/14 on the night shift (10:00 p.m. to 6:00 a.m. shift). In a telephone interview on 01/30/14 at 10:55 a.m., surveyor asked LVN "C" about initialing R#3's TAR, indicating a bed alarm was being placed on R#3's bed daily. LVN "C" said those entries had been a, "mistake", and that there were no bed alarms in use on 600 hall. In an interview on 01/30/14 at 10:33 a.m., CNA/Team Leader "D" said she was instructed to place a bed and chair alarm on R#3's bed and wheelchair only after R#3 was found on the floor on 01/25/14. In an interview on 01/30/14 at 1:25 p.m., the Director of Nurses (DON) said she found out during her investigation the bed alarm was not on R#3's bed. The DON said that was why she immediately reported the incident to the state. The DON said R#3 was in another room, but was transferred to a room closer to the nurse's station. During the transfer to the other room, the bed alarm was not put on the bed R#3 was going to use. The DON said she did not remember the exact date R#3 move to another room. Surveyor did not interview R#3 as she was in the hospital during the investigation. Surveyor reviewed the facility's policy dated 11/01/09, "Investigating Allegations of Neglect." Under the subtitle "Policy Interpretation and Implementation" it included the following: "Neglect is repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical or psychological injury or a substantial risk of death. When conducting an investigation of neglect, implement the following protocol: -determine what goods or services were not provided, -determine if physical harm, mental anguish, mental illness or deterioration in the resident's physical or mental conditions resulted from the failure of the facility to provide goods or services and -determine if the intent of the negligence was willful. During the exit conference on 01/30/14 at 4:10 p.m., the facility was given the opportunity to provide additional information related to neglect. No other information was presented. On 01/30/14 at 3:50 p.m., the DON said the facility had 45 residents with bed alarms.

Based on interview and record review, the facility failed to implement their written policy and procedures that prohibited neglect, for one Resident (R#3) of 13 residents reviewed for neglect. The facility failed to ensure R#3's bed alarm was in place. R#3 suffered an undetected fall which resulted in a fixated comminuted [MEDICAL CONDITION] proximal femur with lateral displacement of a segment of the proximal femur (shattered upper part of the femur). This failure could place 45 residents with bed alarms at risk for injuries. Findings were: Surveyor reviewed the facility's policy dated 11/01/09, "Investigating Allegations of Neglect." Under the subtitle "Policy Interpretation and Implementation" it included the following: "Neglect is repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical or psychological injury or a substantial risk of death. When conducting an investigation of neglect, implement the following protocol: -determine what goods or services were not provided, -determine if physical harm, mental anguish, mental illness or deterioration in the resident's physical or mental conditions resulted from the failure of the facility to provide goods or services and -determine if the intent of the negligence was willful. Face Sheet dated 01/22/14 revealed R#3 was an [AGE] year-old female, admitted on [DATE]. R#3's admitting [DIAGNOSES REDACTED]. R#3's January 2014 computerized physician's orders [REDACTED]. Same orders documented: -to clean left hip incision with wound cleanser and leave open to air BID (twice a day), order date of 01/17/14, and, -may apply bed alarm to alert staff when resident is attempting to self-transfer unassisted, due to high risk for falls, order date 01/17/14. R#3's clinical record did not contain a Minimum Data Set (MDS) assessment as R#3 had only been at the facility for one week at the time of R#3's fall in the facility. R#3's Care Plans dated 01/20/14 revealed: -R#3 was admitted for rehabilitation due to a left hip ORIF (open reduction and internal fixation - surgery to fix repair [MEDICAL CONDITION]). -R#3's intervention: "need to have a bed alarm and chair alarm and call light available at all times." Incident/Accident Report dated 01/25/14 documented the following: "Nurse called to Pt (patient) room. Observed Pt on floor, lying on her right side. Questioned pt what she was doing trying to get up. Passive/active ROM (range of motion) done on all extremities. Complaining of left hip pain. Pt then states she did fall on her left side. 2:1 assist with transfer to wheelchair. Call light was in place. Physician notified and ordered a stat x-ray of left hip and left leg. Pt denies hitting head." Same report documented under, "Interventions implemented: Personal alarm", that a personal alarm was not present. The report indicted there was evidence of abuse, or neglect or exploitation and counseling was needed. R#3's Physician Communication and Progress Note for New Symptoms, Signs and other Changes in Condition form dated 01/25/14 documented the following:-R#3's x-ray dated 01/25/14 of left hip/knee, was positive for fracture, -R#3 in the nursing facility due to an ORIF of left hip, -R#3 fell on [DATE] at 7:00 a.m., and complaining of pain to left hip, and, -R#3 was transferred to the hospital. In an interview on 01/30/14 at 9:14 a.m., Housekeeper "A" said on 01/25/14 she was walking down hall 600 when she heard someone yelling, "Llevante me (get me up)." Housekeeper "A" said she went to R#3's room and saw R#3 on the floor. Housekeeper "A" said R#3 said she was going to the bathroom and fell down. Housekeeper "A" went to get help for R#3. Housekeeper "A" said she saw Certified Nurse Aide (CNA) "B" coming down the hall and informed CNA "B" that R#3 was on the floor. CNA "B" went to R#3's room. Housekeeper "A" then informed Licensed Vocational Nurse (LVN) "C" that R#3 was on the floor. Housekeeper "A" she did not hear a bed alarm activated in the room, only R#3's voice. In an interview with 600 hall CNA "B" on 01/30/14 at 9:20 a.m., CNA "B" said she had taken R#3's vital signs in the morning. R#3 was in her bed. CNA "B" said that, sometime around 7:00 a.m., Housekeeper "A" told her that R#3 was on the floor. CNA "B" went into R#3's room. R#3 was yelling, "Ayudame (help me) me calli (I fell )." CNA "B" said R#3 was on the floor on her back, by the foot of her bed. CNA "B" said she asked R#3 why R#3 had not used the call light. R#3 said she did not want to bother staff. CNA "B" said R#3 did not have a bed alarm on her bed at the time. CNA "B" said she had never been informed that R#3 needed a bed alarm. CNA "B" said then LVN "C" came into R#3's room. LVN "C" assessed R#3, then transferred R#3 to the wheelchair. In a telephone interview on 01/30/14 at 9:47 a.m., 600 hall CNA "E" said he could not remember if R#3 ever used a bed alarm while in bed. In a telephone interview on 01/30/14 at 10:25 a.m., LVN "C" said Housekeeper "A" informed her that R#3 was on the floor. LVN "C" went to R#3's room. R#3 was on her right side. LVN "C" said she assessed R#3. R#3 could move all extremities and did not complain of pain. LVN "C" said she and CNA "B" transferred R#3 to the wheelchair and took her to the toilet. R#3 grabbed the hand rails and sat on the toilet. LVN "C" said later R#3 complained of pain to her left hip. R#3's Physician was in the facility and ordered x-rays of R#3's left hip and leg. LVN "C" said a bed alarm was not in place on R#3's bed or wheelchair at the time of the fall. LVN "C"said R#3 was in the facility due to a left hip replacement. R#3's Treatment Administration Record (TAR) dated January 2014 documented: -may apply bed alarm to alert staff when resident is attempting to self-transfer unassisted, due to high risk for falls every shift, order date: 01/17/14. The TAR documented R#3 had the bed alarm on from: -01/21/14 to 01/25/14 on the day shift (6:00 a.m. to 2:00 p.m.), initialed by LVN "C." -01/21/14 to 01/24/14 on the evening shift (2:00 p.m. to 10:00 p.m.), and, -01/20/14 to 01/25/14 on the night shift (10:00 p.m. to 6:00 a.m. shift). In a telephone interview on 01/30/14 at 10:55 a.m., surveyor asked LVN "C" about initialing R#3's TAR, indicating a bed alarm was being placed on R#3's bed daily. LVN "C" said those entries had been a, "mistake", and that there were no bed alarms in use on 600 hall. In an interview on 01/30/14 at 10:33 a.m., CNA/Team Leader "D" said she was instructed to place a bed and chair alarm on R#3's bed and wheelchair only after R#3 was found on the floor on 01/25/14. In an interview on 01/30/14 at 1:25 p.m., the Director of Nurses (DON) said she found out during her investigation that the bed alarm was not on R#3's bed. The DON said that was why she immediately reported the incident to the state. The DON said R#3 was in another room, but was transferred to a room closer to the nurse's station. During the transfer to the other room, the bed alarm was not put on the bed R#3 was going to use. The DON said she did not remember the exact date R#3 changed rooms. Surveyor was unable to interview R#3 as she was in the hospital during the investigation. During the exit conference on 01/30/14 at 4:10 p.m., the facility was given the opportunity to provide additional information related to implementation of policies to prevent neglect. No other information was presented. On 01/30/14 at 3:50 p.m., the DON said the facility had 45 residents with bed alarms.

Based on observation, record review, and interview, the facility failed to provide the necessary care and services to promote healing and prevent new pressure ulcers from developing for one Resident (R#10) of nine Residents reviewed with pressure ulcers. On 11/29/11, R#10 was assessed for, and received, a gel cushion to relieve pressure from a Stage 2 pressure ulcer to the coccyx. As of 01/10/12, R#10 did not have a gel cushion while up to wheelchair. On 01/10/12, R#10 was noted with two Stage 2 pressure ulcers between the buttocks near the coccyx. Failure to provide services to prevent development of pressure ulcers could likely affect the health status of all 12 residents with pressure ulcers. The findings were: R#10's Quarterly MDS assessment dated [DATE] indicated R#10: - required extensive assistance from staff for bed mobility and transfers, eating, and toilet use, - was totally dependent on staff for locomotion, dressing, eating, toilet use, and personal hygiene, - was incontinent of bowel and bladder, - had [DIAGNOSES REDACTED]. - was at risk for developing pressure ulcers, and, - had a Stage 2 pressure ulcer since 10/19/11 (Stage 2 - partial thickness loss of dermis presenting as a shallow open ulcer with a red -pink wound bed without slough - dead tissue separating from living tissue). R#10's care plan, last reviewed 11/20/11, included the following approaches for healing of pressure ulcers: -Turn and reposition Q2H (every two hours) and PRN (as needed). Try not to do any shearing of skin when lifting in bed (shearing - an applied force that tends to cause an opposite but parallel sliding motion. Such motions cause tissues and blood vessels to move in such a way that blood flow may be interrupted, placing the patient at risk for pressure ulcers.) -Treatment to be done as ordered. -Weekly assessment to be done and notify MD (Medical Doctor) if no improvement noted or if any new problems arise. R#10's Nursing Notes dated 11/21/11 at 10:30 (no a.m or p.m. indicated) documented the following: "received call from R#10's Physician giving orders for OT (occupational therapy) to evaluate and recommend pressure relief devices while up to wheelchair due to Stage II to coccyx (tailbone), order noted and carried out." R#10's Occupational Therapy (OT) Evaluation and Discharge Summary assessment dated [DATE] documented, "Summary/Rationale- Pt (patient) is [AGE] years old female who presents with wheelchair sitting position difficulties as Pt has developed Stage II to coccyx, Pt referred to skilled OT for evaluation of positioning and recommendations for devices. R#10's Occupational Therapy Evaluation and Discharge Summary Assessment also documented, "Initial Evaluation -PT received gel wedge cushion to relieve pressure from stage II to coccyx ulcer." This assessment was signed by R#10's Physician on 12/06/11. R#10's Telephone Order dated 11/29/11 (no time) documented the following "OT clarification order- skilled OT evaluation completed. PT not a candidate for skilled services at this time." This order signed by R#10's Physician on 12/06/11. R#10's Telephone Order dated 12/14/11 (no time) documented the following: -D/C (discontinue) Tx (treatment) to pressure ulcer to coccyx -ulcer stage II, healed well. R#10's name did not appear on the facility's Weekly Pressure Ulcer QI (Quality Indicator) log dated 01/05-11/12. During the initial tour with Certified Nurse Aide (CNA) "E" on 01/09/12 at 9:50 a.m., CNA "E" said R#10 had no pressure ulcers. On 01/09/12 at 5:30 p.m., 5:45 p.m., 6:00 p.m., 6:15 p.m. and 6:30 p.m., surveyor observed R#10 in the dining room sitting in her wheelchair with no gel cushion in place on the wheelchair. On 01/10/12 at 9:10 a.m., 10:10 a.m., 10:40 a.m., 11:00 a.m., 11:45 a.m., and 12:25 p.m., surveyor observed R#10 in the dining room sitting in a wheelchair with no gel cushion in place. On 01/10/12 at 2:10 p.m. and 3:10 p.m., surveyor observed R#10 in front of the west nurse's station sitting in a wheelchair with no gel cushion in place. On 01/10/12 at 3:12 p.m., surveyor asked Assistant Director of Nurses (ADON) "G" if R #10 was going to be put back to bed. ADON "G" said she had just told the nurse aides to put R#10 back to bed. On 01/10/12 at 3:20 p.m. both CNA "R" and CNA "S" said R#10 had no pressure ulcers at this time. At 3:25 p.m. CNA "R" and CNA "S" were observed putting R#10 to bed. Surveyor asked CNAs "R" and "S" to check R#10's buttocks. Surveyor observed R#10 had two wounds between her buttocks by the coccyx. One of the wounds was approximately one centimeter (cm) and beefy red. The other wound was approximately 0.5 cm, beefy red wound. At this time surveyor observed there was no gel cushion on R#10's wheelchair. Surveyor did observe a non-gel cushion covered with a blanket on the wheelchair. At 3:30 p.m., the CNAs notified the charge nurse about R#10 skin breakdown. R#10's Nursing Notes dated 01/10/12 at 3:53 p.m. documented, "left message at (R#10's) Physician regarding Stage II to coccyx, Lt (left) buttocks (upper) and left buttocks (lower), wound measurements as follows: - coccyx 1.8 cm x 0.7 cm x 0.1 -Lt buttocks (upper), 1.5 cm. x 0.8 cm -Lt buttocks (lower) 0.4 cm x 0.4 cm Wound beds pink and red with no drainage noted" In an interview with the Director of Nurses (DON) on 01/11/12 at 11:00 a.m., the DON said an order was not needed for a gel cushion, it would be a nursing judgment to use one. The DON said she did not know why the gel cushion was not mentioned on the telephone order dated 11/29/11. The DON said when nursing staff got an Evaluation and Discharge Summary Assessment from the Rehabilitation (Rehab) department, nursing staff reviewed and communicated the evaluation to the Physician. If Rehab made recommendations then the nursing staff transcribed the recommendations onto a telephone order for the Physician to agree or disagree. The DON did not know what happened in this case. In an interview with Licensed Vocational Nurse (LVN) "F" on 01/12/11 at 10:10 a.m., LVN "F" said that when nursing staff got a signed Evaluation and Discharge Summary Assessment (Rehab) from the Physician, they needed to review the form. If there were any recommendations from the Rehab department, a telephone order was sent to the Physician for signature or clarification. LVN "F" said she could not remember if R#10 had a gel cushion while up to wheelchair. LVN "F" said R #10 had a previous pressure ulcer that had healed sometime in December 2011. LVN "F" said that there was a now a treatment order for R#10's pressure ulcers. During the exit conference on 01/12/12 12:45 p.m., the Administrator and DON were given the opportunity to provide additional information regarding pressure ulcers. No additional information was provided. The Centers for Medicare & Medicaid Services (CMS) Resident Census and Conditions of Residents form (672) identified 12 residents with pressure ulcers.