Every finding on record at Windsor Nursing and Rehabilitation Center of Raymo

Based on observation, interview, and record review the facility failed to provide reasonable accommodation for resident needs and preferences for one (Resident #1) of 8 residents reviewed for call light placement. The facility failed to ensure Resident #1's call light was within reach. This failure could place residents at risk of needs and accommodation being unmet. Findings included: Record review of a face sheet dated 4/29/2026 indicated Resident #1 was a [AGE] year-old female, re-admitted on [DATE] (initial admission date 5/7/2010), with diagnoses of Dementia (a condition characterized by progressive of persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), Schizophrenia (chronic, severe mental disorder characterized by disruptions in thought processes, perceptions, and emotional responsiveness, often involving hallucinations, delusions, and disorganized thinking), Type 2 Diabetes Mellitus (a chronic metabolic condition where the body cannot effectively use or produce enough insulin, leading to high blood sugar levels), Neurocognitive Disorder (decreased mental function due to acquired brain disease, injury, or medical conditions, rather than psychiatric illness), Cognitive Communication Deficit (communication impairment resulting from underlying cognitive issues rather than primary language or speech muscle dysfunction), and Arthritis (a general term for joint inflammation, pain, and stiffness). The face sheet reflected Resident #1 was also listed as her own resident representative. Record review of a quarterly MDS assessment, dated 4/13/2026, indicated Resident #1 had a BIMS score of 03 which indicated severe problems with thinking and memory. The MDS indicated Resident #1 was totally dependent on staff for toileting, showering, and dressing. The MDS also indicated Resident #1 used a wheelchair and was dependent on staff for locomotion. Record review of Resident #1's care plan, undated, revealed, a problem listed for Resident #1 revealed she was unable to use the call light due to her Dementia. Resident #1's goal for the problem was for the call light to be reachable for family or staff to request assistance with an intervention of monitoring and rounding frequently. During an observation on 4/28/2026 at 12:04 p.m., revealed Resident #1 was in her room wiggling in her bed and calling out. Resident #1 did not have a call light within reach. Resident #1's call light was on the floor beside her nightstand. During an interview on 4/28/2026 at 12:05 p.m., Resident #1 stated she wanted some cookies and milk. During an interview on 4/28/2026 at 12:07 p.m., the ADON stated CNA A must not have placed the call light in reach of when assisting Resident #1. The ADON stated call lights were to be in reach of all residents, including Resident #1. During an interview on 4/28/2026 at 12:30 p.m., CNA A stated he was unaware Resident #1's call light was not within her reach, but that it should be within her reach. CNA A stated Resident #1 moved a lot in the bed when repositioning the resident and the call light must have fallen. CNA A stated Resident #1 could have tried to get out of bed unassisted and hurt herself. During an interview on 4/29/2026 at 3:30 p.m., the DON stated it was expected that every time a staff member exited a resident's room, they needed to ensure all frequently used items are within reach, to include the call light, including Resident #1. The DON stated a resident may need something and staff wouldn't know or be able to meet their needs. The DON stated Resident #1would normally call out if she needed something, but the call light still needed to be within her reach. Record review of facility policy titled, Call Lights: Accessibility and Timely Response implemented on 10/13/2022, reflected 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. The policy also revealed 5. Staff will ensure the call light is within reach of resident and secured, as needed

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and help prevent the development and transmission of communicable and infections for 1 of 1 laundry room and 1 of 6 residents (Resident #1) reviewed or infection control in that:The facility failed to ensure textiles used for cleaning were stored properly to prevent contamination.The facility failed to ensure Resident #1 was provided tracheostomy care using sterile technique. These failures could result in the transmission of infection and illness. Findings included: 1. In an observation and interview on 2/24/2026 at 2:50 PM, the facility's only laundry room was observed to have textiles used for cleaning on an open rack near the washing machines. This area was separated from the space containing the dryers by a closed door. The textiles on the rack included rags, reusable mopping pads, and mop heads. The HSK said soiled linen was sorted and washed in this area before being moved to the other space for folding and storage. She said they used this method to prevent contamination of clothing and linen. She said the textiles on the wire rack were clean and used by her staff to clean the entire facility, and they had always stored these items in the area where soiled linen was processed. She said she was unaware of the potential for contamination of these items by storing them in this manner. In an interview with the ADON/Infection Preventionist on 02/25/2026 at 7:22 AM, she said she was unaware the items were being stored on the processing side of the laundry area. She said clean items should be stored away from that area to prevent contamination. Record review of the facility policy titled Infection Prevention and Control Program dated 5/13/2023 revealed the following: a. Laundry and direct care staff shall handle, store, process and transport linens to prevent spread of infection. b. Clean linen shall always be separated from soiled linen. 2. Record review of Resident #1's admission Record on 2/23/2024, revealed a [AGE] year-old male admitted on [DATE]. Resident #1's diagnoses include Tracheostomy Status ( presence of an artificial, temporary or permanent opening in the windpipe to assist with breathing), Persistent Vegetative State ( chronic condition of wakeful unconsciousness following coma, lasting over four weeks, where patients have sleep-wake cycles and automatic functions but no cognitive awareness), Dependence on Supplemental Oxygen ( prescribed, life-sustaining therapy for people unable to maintain adequate blood oxygen levels), Personal history of Traumatic Brain Injury ( recognized as a chronic, often life-long condition rather than a single event leading to long-term impairments). Record Review of Resident #1's Care Plan, dated 01/22/2026, revealed Resident #1 cannot utilize call light if in distress due to vegetative state, infection of the trachea, Trach collar and inner cannula changes as scheduled and as needed, oxygen humidification as indicated. Record Review of Resident #1's MDS, dated [DATE], revealed Persistent Vegetative State, BIMS 00, Dependence for all ADLs, Incontinence of bowel and bladder. Record review of a facility document titled [Corporate] Health Services- Respiratory Skills Checklist dated 1/27/2026 reflected LVN D had received an in-service and competency evaluation from the facility regarding care of tracheostomies. In an observation and interview on 2/26/2026 at 8:50 AM, LVN D was observed performing routine tracheostomy care for Resident #1. While wearing non-sterile gloves, LVN D opened the sterile, disposable tracheostomy care kit and placed it on the table. She then reached into the kit and handled the supplies inside of the kit without first donning the sterile gloves provided in the kit, thereby contaminating the contents of the kit. LVN then performed hand hygiene and donned the sterile gloves before using the contaminated supplies to perform care to the tracheostomy. LVN D said she did not don the sterile gloves until she was actually providing care to the resident in order to prevent the gloves from being contaminated. In an interview with the ADON/Infection Preventionist on 02/26/2026 at 10:43 AM, she said LVN D should have worn the sterile gloves when handling the contents of the kit in order to maintain sterility of the contents. She said using non-sterile gloves could result in contamination. Record review of the facility policy titled Infection Prevention and Control Program dated 5/13/2023 did not reveal findings related to donning sterile gloves or opening sterile kits.

Based on interview and record review, the facility failed to ensure each resident and staff member was offered the COVID-19 vaccine for 1 of 1 facility reviewed for infection prevention. The facility failed to offer residents and staff the 2025-2026 COVID-19 vaccination. This failure could lead to the contraction and transmission of respiratory illness. Findings included: Record review of the staff vaccination records for 2025 did not reveal documentation of COVID-19 vaccination administration or documentation for the facility. In an interview on 02/25/2026 at 7:22 AM, the ADON said she served as the Infection Preventionist for the facility. She said the facility did not offer COVID-19 vaccinations to residents or staff in fall 2025, and they only offered influenza (flu) and pneumococcal (pneumonia, or an infection of the lungs) vaccinations to eligible staff/residents. She said the facility did not offer COVID-19 vaccinations because it was not required by state regulations. In a subsequent interview with the ADON on 02/25/2026 at 11:20 AM, she said the language of the facility policy indicated the facility was only required to administer the COVID-19 vaccination when supplies were available, and she did not think the vaccination was available. She was unsure if the facility had attempted to procure the COVID-19 vaccine from their contracted pharmacy. In an interview with the DON on 02/25/2026 at 1:01 PM, she said she had contacted the pharmacy earlier that day by e-mail to request COVID-19 vaccinations for administration to staff and residents, and she was informed the pharmacy could not provide the vaccinations. She said they had not attempted to get a supply of vaccinations prior to that day. She said that the facility intended to assist all interested staff and residents with obtaining the COVID-19 vaccination through a local pharmacy going forward. She said previously staff members who wanted the seasonal COVID-19 vaccination were on their own to obtain it because the facility no longer mandated administration of the vaccination. Record review of the facility policy titled Infection Prevention and Control Program dated 5/13/2023 reflected the following:a. Residents and staff will be offered the COVID-19 vaccine when vaccine supplies are available to the facility.

Based on observation, interview and record review, the facility failed to maintain all mechanical, electrical and patient care equipment in safe operating condition for 1 of 1 facility's reviewed for safe and functioning equipment.The facility had 1 of 1 stand-up freezers inoperable. Based on observation on 2/23/2026 at 2:00 pm, the kitchen surveyor noted that the stand-up freezer was broken and inoperable. Based on interview with FSM on 2/23/2026 at 2:00 pm, FSM stated that the freezer has been broken for over a year and that they are storing food in a chest freezer. FSM stated that the work order has been placed in but they have not received a new one. FSM stated that he has to make changes to the menu as some of the food comes bulk from food service company and he does not have the space. Surveyor asked if they obtain food from other sources and FSM replied that they run to HEB for smaller packages of items like broccoli as an example. Based on interview on 2/24/2026 at 11:55 with FSM, FSM stated they were supposed to have baked ham for lunch, but he could not order the ham due to the size of the packaging. FSM stated that they changed the menu to chicken and rice for lunch and that the dietician was aware.Record review of policies revealed that facility does not have a policy for working, essential equipment, but follows CMS guidelines. Based on record review of work orders and emails, email from facility LNFA was sent regarding follow-up to freezer on 10/29/2025.

Based on interviews, and record reviews, the facility failed to ensure residents were free from significant medication administration errors for 1 of 6 Residents (Resident #18) reviewed for medication administration. Resident #18 was not administered his high blood pressure medication as prescribed. This failure could place residents at risk for not receiving the intended therapeutic effects of their prescribed medications.The findings include: A record review of Resident #18's admission record revealed an admission date of 10/12/2023 with diagnoses which included cerebral infarction (a blockage in an artery supplying blood to the brain, leading to the death of brain tissue due to lack of oxygen). A record review of Resident #18's quarterly MDS assessment dated [DATE] revealed Resident #18 was a [AGE] year-old male admitted for long term care related to Resident #18's needs with ADLs. Resident #18 was assessed with a BIMS score of 10 out of a possible 15 which indicated moderately impaired cognition. A record review of Resident #18's care plan dated 2/25/2026 revealed, (Resident #18) has altered cardiovascular status related to hypertension . administer medications as ordered. A record review of Resident #18's physician's orders dated 9/19/2025 revealed the Physician prescribed Resident #18 to daily receive a combined drug of lisinopril 20mg and hydrochlorothiazide 25mg called Zestoreic. The physician provided instructions when not to administer the medication, Hold if sbp<100 dbp<60 (SBP - systolic blood pressure; the top number in a reading (e.g., 120/80 mmHg), measures the pressure in your arteries when the heart contracts to pump blood and DBP - diastolic blood pressure is the bottom number in a reading and measures the pressure in your arteries when your heart muscle relaxes between beats.) further record review revealed no instructions regarding Resident #18 pulses. A record review of Resident #18 February 2026 medication administration record revealed resident #18's medication Zestoreic was not administered as per the physicians' orders. The medication was not administered on:2/2/2026 when MA C recorded Resident #18's Blood Pressure was recorded as 149/78.2/3/2026 when MA C recorded Resident #18's Blood Pressure was recorded as 126/62.2/4/2026 when MA C recorded Resident #18's Blood Pressure was recorded as 125/66.2/5/2026 when MA C recorded Resident #18's Blood Pressure was recorded as 150/80.2/6/2026 when MA C recorded Resident #18's Blood Pressure was recorded as 141/79.2/8/2026 when MA G recorded Resident #18's Blood Pressure was recorded as 122/67.2/9/2026 when MA C recorded Resident #18's Blood Pressure was recorded as 122/72.2/10/2026 when MA C recorded Resident #18's Blood Pressure was recorded as 135/65.2/16/2026 when MA C recorded Resident #18's Blood Pressure was recorded as 123/64.2/18/2026 when MA C recorded Resident #18's Blood Pressure was recorded as 145/75.2/19/2026 when MA C recorded Resident #18's Blood Pressure was recorded as 152/69.2/20/2026 when MA C recorded Resident #18's Blood Pressure was recorded as 154/70.2/23/2026 when MA C recorded Resident #18's Blood Pressure was recorded as 134/73. During an interview on 2/25/2026 at 8:40 AM MA C stated the medication Zestoreic was prescribed with instructions not to administer the medication if the systolic blood pressure was less than 100, or the diastolic blood pressure was lower than 60, or the pulse was lower than 60 pulses per minute. During an interview on 2/26/2026 at 11:50 AM LVN D stated she had not received reports from MA C that Resident #18 had not received his Zestoreic related to physicians' orders to hold the medication. LVN D reviewed Resident #18's medication administration record and Resident #18's physician orders and stated Resident #18 was to receive his Zestoreic if his blood pressure was above 100/60 regardless of his pulse. LVN D stated MA C should have reported the held medications and if she had LVN D stated she would have assessed Resident #18 and upon assessment of blood pressures above 100/200 she would have administered the medication. LVN D stated the potential risk for Resident #18 not receiving his medication as prescribed could be high blood pressure. During an interview on 2/26/2026 at 12:15 PM NP stated the expectation was for nursing to administer medications as ordered specific to the correct dosages and professional standards. NP stated Residents who were prescribed blood pressure medications with only parameters for SBP and DBP should receive their medications without consideration for the pulse rate. NP stated if the medication was held for prolonged periods she would have expected a communication with the assessments for the withheld medications. NP stated the potential risk for resident #18 not receiving his Zestoreic as prescribed could be a stroke. During a joint interview on 2/26/2025 at 4:00 PM the Administrator and the DON stated the expectations for Medication Aides and Nurses who administered medications was for the staff to follow physician's orders for medication administration. The DON stated and the Administrator concurred Resident #18 should have received his medications when he was recorded with blood pressures higher than the physicians' prescribed limits. The Administrator and the DON stated the potential negative outcome for residents could be they may not have received the intended therapeutic effects of their medications. A record review of the facility's policy titled Mediation Administration dated 10/24/2022 revealed, . Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physicians' prescribed parameters. Review medication administration record to identify medication to be administered. Compare medication source, bubble pack, vial, etcetera with medication administration record to verify resident name, medication name, form, dose, route, and time. Refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects.

Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment, including injuries of unknown source, are reported within established timelines to the administrator of the facility and to the SSA for 5 of 7 residents (Residents #8, #16, #26, #20, #32) reviewed for abuse. The facility failed to ensure unexplained bruises found on Resident #32's right arm and wrist on 12/16/2025 were reported to the SSA.The facility failed to ensure a physical altercation between Residents #16 and #26 on 1/3/2026, in which Resident #26 allegedly scratched Resident #16 on the arm after he attempted to grab her breast, was reported to the SSA.The facility failed to ensure a physical altercation between Residents #8 and #20 on 1/5/2026, in which Resident #20 allegedly scratched Resident #8 on the face after he yelled at her, was reported to the SSA.The facility failed to ensure a physical altercation between Residents #20 and #26 on 1/18/2026, in which Resident #20 allegedly scratched Resident #26 on the neck during a verbal altercation, was reported to the SSA.These failures could lead to lack of oversight and decreased quality of life for residents. Findings included: Record review of Resident #32's admission Record dated 2/26/2026 reflected a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included Alzheimer's disease (a progressive neurological condition affecting memory and behavior). Record review of Resident #32's quarterly MDS submitted 1/6/2026 reflected a BIMS score of 00, which indicated severely impaired cognitive function. Record review of Resident #32's progress notes reflected the following entry dated 12/16/2025 at 9:15 PM by LVN F:Skin Issue: #001: New skin Issue. Location: Right outer forearm. Laterality / Orientation: Superior. Issue type: Bruising. Progress: Unknown. Wound acquired in-house. It is unknown how long the wound has been present. Signs and symptoms of infection: None. Painful: No. Further record review of Resident #32's progress reflected an additional entry dated 12/16/2025 at 9:37 PM by LVN H:Sent photos and information to NP E on SBAR done for discolorations. NP E gave orders to do 2 view xrays [sic] of the two areas. Xrays [sic] ordered. Call to family placed but no answer and no voicemail available. Record review of the facility document titled Incidents By Incident Type dated 2/26/2026 for date range 8/1/2025 through 2/23/2026 did not reveal an incident on or around 12/16/2025 for Resident #32. In an observation of Resident #32 on 2/23/2026 at 3:25 PM, she was observed ambulating independently throughout the secured unit. She was mumbling unintelligible words to herself and did not respond when approached for interview. In an interview with LVN F on 2/25/2026 at 1:46 PM, she said she recalled minimal bruising located to the outside of Resident #32's lower forearm. She said she had not seen Resident #32 fall or have an injury in the period prior to the assessment documented on 12/16/2025. She said she thought it was possible the bruises were related to a laboratory blood draw, but she was unsure if Resident #32 had received the procedure around the time of the bruising. She said Resident #32 could not explain what caused the bruising. She said she didn't think that Resident #32 had been physically abused by anyone because she did not see finger shaped bruising in her assessment, but she said she had observed Resident #16 following Resident #32 and attempting to grab her shirt and arms on multiple occasions. She said she had not seen Resident6 #16 make physical contact with Resident #32. She said she notified NP E and Resident #32 received x-rays that were without negative findings. In an interview with the DON on 2/25/2026 at 2:20 PM, she said she recalled being told by the nursing staff that Resident #32 had bruising on her arm in December 2025, and she attributed the bruising to the laboratory blood draw Resident #32 had on 12/11/2025. She said when she saw the bruising, she observed a pinprick mark to the bruising, that she felt was confirmation of the cause of the bruising. She said she did not have suspicions that the bruising to Resident #32's arm was the result of abuse because the staff would have observed it. She was unsure why NP E would order x-rays for Resident #32's arm if the staff attributed the injury to a laboratory blood draw and not a fracture or other injury. She was unsure why the discoloration was noted 5 days after the procedure and not sooner, as is typical for laboratory blood draw bruising. She said she did not feel the bruising needed to be reported to the SSA because she felt like the bruise was related to the procedure. She was unsure if her investigation of the bruising included safe surveys of other residents, staff interviews, or an in-service, but she would consult her records and return any relevant documents. The DON did not return any documents related to this investigation prior to the end of survey. In an interview with NP E on 2/25/2026 at 3:56 PM, he said he ordered x-rays for Resident #32 as a preventative measure even though he was informed by the staff that Resident #32's bruising was likely related to a laboratory blood draw. He said Resident #32 had a history of difficulty with the procedure, and he did not find the injury to be suspicious of abuse or neglect, and the x-rays were to ensure there were no additional injuries. In an interview with the Administrator on 2/26/2026 at 7:20 AM, she said she was on leave when this incident occurred, and it was investigated by the DON and the regional leadership team. She was unsure of rationale to not report the incident to the SSA for potential abuse/neglect. 2. Record review of Resident #16's admission Record dated 2/23/2026 reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included personal history of other mental and behavioral disorders.Record review of Resident #16's quarterly MDS submitted 12/5/2025 reflected a BIMS score of 03, which indicated severely impaired cognition. Section E0200 of the MDS reflected Resident #16 did not exhibit physical, verbal, or other behavioral symptoms directed towards others during the assessment period. Record review of Resident #16's Care Plan Report printed 2/23/2026 revealed the following:[Resident #16] has history of inappropriately touching the women residents in the facility, pulling the fire alarm in the hallway which is close to his room, verbal/physical aggression r/t [disease processes] 1/3/26 [Resident #16] attempted to touch female residents [sic] breast, female resident scratched [Resident #16.]. new orders for [wound care] to scratch on right handDate Initiated: 01/03/2026Record review of Resident #26's admission Record dated 2/25/2026 reflected a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included unspecified dementia [a progressive disorder affecting memory and reasoning], severe, with psychotic disturbance. Record review of Resident #26's annual MDS submitted 2/4/2026 reflected a BIMS score of 03, which indicated severely impaired cognition. Section E0200 of the MDS reflected Resident #26 did not exhibit physical, verbal, or other behavioral symptoms directed towards others during the assessment period. Record review of Resident #26's Care Plan Report printed 2/25/2026, revealed the following:[Resident #26] is/has the potential to be physically aggressive r/t dementia, history of harm to others. Poor impulse control 11-26-24 resident slapped staff member. Date initiated 11/26/2024. Record review of Resident #26's progress notes reflected an entry dated 1/3/2026 at 12:30 PM by LVN D that read as follows:SN was notified by CNA that resident was sitting on the couch in TV room next to another resident, when the other resident attempted to touch her left breast. This resident reacted by scratching the other resident [sic] right hand. Resident was assessed, no injuries noted at this time. Resident was redirected successfully. [NP E] notified, [Family member]- no answer x 2, voice mail left.In an interview with CNA I on 2/24/2026 at 10:00 AM, she said she witnessed Resident #16 attempt to grab Resident #26 on 1/3/2026. She said Resident #26 responded to the behavior by becoming angry and intentionally scratching Resident #16, and she immediately separated the residents and notified the nurse. In an interview with LVN D on 2/25/2026 at 1:41 PM, she said she was notified by CNA I that Resident #16 had been scratched by Resident #26 after he attempted to grab Resident #16's breast. She said the scratch to Resident #16's arm was minor and required only basic wound care. She said she notified the DON, provider, and ADON after the incident, and there were no additional altercations between the residents.In an interview on 2/25/2025 at 2:09 PM, the DON said she was notified by staff of the altercation between Residents #16 and #26 after it occurred. She said she reviewed the incident with the regional leadership team, and they felt that the scratch happened accidentally while Resident #26 was waving her arms to deflect Resident #16's attempt to grab her breast. She said this incident was not reported to the SSA because the scratch was unintentional and because staff intervened before Resident #16 was able to make contact with Resident #16. She said the behaviors from Resident #16 were frequent and staff monitored him to ensure safety of other residents. She was unsure if the facility had conducted any further investigation of the incident, including resident/staff interviews, safe surveys, or an in-service. She said she would research her records and provide documentation. No additional documents were returned prior to survey exit.In an interview on 02/26/2026 at 7:20 AM with the Administrator, she said she was on leave when this incident occurred, and she was unsure of the rationale to not report the incident to the SSA. She was unsure if she felt it should have been reported for potential abuse after reviewing it.3. Record review of Resident #8's admission Record dated 2/24/2026 reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included Alzheimer's disease. Record review of Resident #8's annual MDS submitted 12/12/2025 reflected a BIMS score of 03, which indicated severely impaired cognition. Section E0200 of the MDS reflected Resident #8 did not exhibit physical, verbal, or other behavioral symptoms directed towards others during the assessment period. Record review of Resident #8's Care Plan Report printed 2/24/2026 revealed the following:[Resident #8] has a behavior problem r/t history of episodes of starting arguments with other residents and staff. Difficult to redirect at times. [Resident #8] has a tendency to urinate on the floor. Date initiated 11/10/2024[Resident #8] is physically/verbally aggressive toward staff and residents at times r/t Dementia [sic], Poor [sic] impulse control Date initiated 11/29/20241/5/26 Resident to ResidentResident became upset with another ressident because he thought she took his b ed [sic] and attempted to hit another resident.Staff to cont [sic] to redirect resident when he is in a confused stateCLEANSED WITH NS AND APPLIED TAO, LEFT OPEN TO AIR date initiated 1/05/2026 Record review of Resident #20's admission Record dated 2/26/2026 reflected a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included Alzheimer's disease. Record review of Resident #20's quarterly MDS submitted 12/9/2025 reflected a BIMS score of 03, which indicated severely impaired cognition. Section E0200 of the MDS reflected Resident #8 exhibited other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) for 1 to 3 days of the assessment period. Record review of Resident #20's Care Plan Report printed 2/24/2026 reflected the following:[Resident #20] has potential to be physically aggressive to others r/t Dementia, has history of being physically aggressive towards others. Date Initiated: 05/16/20241/5/25- resident to resident incident in which resident accidentally scratched another resident. Cont [sic] to monitor and redirect resident. Date Initiated: 01/05/2026 Record review of Resident #20's progress notes reflected an entry dated 1/5/20026 at 2:13 PM by LVN B that read as follows:RESIDENT WALKING DOWN THE HALL WHEN MALE RESIDENT WALKED OUT OF HIS ROOM AND NOTED AN EMPTY BED IN THE HALLWAY, MALE RESIDENT YELLED AT FEMALE RESIDENT AS TO WHY WAS SHE TAKING HIS BED, FEMALE RESIDENT THEN REACTED AND SCRATCHED RESIDENT BELOW LEFT EYE. RESIDENTS REDIRECTED AT THIS TIME. [NP E] NOTIFIED AND [family member], RESIDENTS DAUGHTER NOTIFIED, NO INJURIES NOTED. VERBALIZED UNDERSTANDING. V/S 136/77, 78,98.0, 97%, 18The progress note included a check mark that indicated the residents were unable to describe the incident. In an interview on 2/25/2025 at 2:09 PM, the DON said she was notified by staff of the altercation between Residents #8 and #20 after it occurred. She said she reviewed the incident with the regional leadership team, and they felt that the scratch happened accidentally while Resident #20 was waving her arms to distance herself from Resident #8. She said the incident was not reported to the SSA because she felt the scratch was unintentional and because both residents were confused at baseline and did not knowingly harm each other. In an interview on 02/26/2026 at 7:20 AM with the Administrator, she said she was on leave when this incident occurred, and she was unsure of the rationale to not report the incident to the SSA. She was unsure if she felt it should have been reported for potential abuse after reviewing it. 4. Record review of Resident #20's Care Plan Report printed 2/24/2026 reflected the following:1/18/26 resident to resident new order for tao to scratch on left lateral chin, psych consult, [laboratory testing]. Notify MD/NP if behaviors continue Date initiated 1/18/2026 Record review of Resident #20's progress notes reflected the following entry dated 1/18/2026 at 8:21 PM by LVN B:WAS CALLED TO UNIT, BOTH RESIDENTS HAD BEEN REDIRECTED BACK TO THEIR ROOMS WHEN THIS NURSE ARRIVED. PER CNA, RESIDENT WAS ON TOP OF ANOTHER FEMALE RESIDENT, FIGHTING ON THE FLOOR FULL HEAD TO TOE ASSESSMENT DONE, RESIDENT HAS SMALL SCRATCH TO LEFT LATERAL [side] CHIN. NO BUMPS TO HEAD NOTED AT THIS TIME. NO PAIN. An additional progress note dated 1/18/2026 at 8:50 PM by the DON read as follows:Clarification to follow up PN to include the following: Upon further investigation of incident. CNA present states she heard noise coming from this residents [sic] room. After proceeding to enter room, she noted other resident laying on the floor on her back, and this resident getting up from the floor. CNA states she did not see residents hitting each other. In speaking to other resident, she states that she and this resident were sitting at the edge of her bed having a conversation. She states that they disagreed on a certain topic. The other resident states that this resident reached towards her in which she got startled, at that time the other pulled back causing her and this resident to slide off the bed and land on the floor. Resident says as they slid off the bed, this resident inadvertently scratched the left side of the other residents [sic] neck.In an interview on 2/25/2025 at 2:09 PM, the DON said she was notified by staff of the altercation between Residents #20 and #26. She said when she arrived to the Residents' shared room, they denied a physical altercation. She was unsure why the nursing documentation reported a physical altercation. She said the incident was reviewed with the regional leadership team, and they determined the incident did not need to be reported to the SSA because the residents denied they had been in a physical altercation and because they were visualized laughing and behaving friendly towards each other immediately following the incident. In an interview with NP E on 2/25/2026 at 3:56 PM, he said he was notified by the facility that Residents #20 and #26 were observed engaged in a physical altercation resulting in a minor scratch to Resident #26's neck, and he instructed the staff to ensure the residents remained separated until they determined it was safe for them to be around each other.In an interview on 02/26/2026 at 7:20 AM with the Administrator, she said she was aware of the incident between Residents #20 and #26, and she was not concerned about possible abuse because both residents were laughing and behaving like friends after staff intervened. She said the DON spoke to both residents and determined the scratch was not intentional, so she did not feel it needed to be reported as potential abuse. In an interview on 02/26/2026 at 2:30 PM, the RRN said he had reviewed the incidents described above after being aware of the surveyors' concerns, and he felt that the facility should have reported them to the SSA as potential abuse. He said he did feel that any of the incidents resulted in harm or neglect to the residents involved but because there were initial suspicions of abuse, reports to the SSA were warranted. Record review of the facility policy titled Abuse, Neglect, and Exploitation dated 7/11/2025 revealed the following: 'Alleged violation' is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property . 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 .

Based on observation, interview, and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated and reported the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for 5 of 7 residents (Residents #8, #16, #26, #20, #32) reviewed for abuse. The facility failed to ensure unexplained bruises found on Resident #32's right arm and wrist on 12/16/2025 were thoroughly investigated and the results reported.The facility failed to ensure a physical altercation between Residents #16 and #26 on 1/3/2026, in which Resident #26 allegedly scratched Resident #16 on the arm after he attempted to grab her breast, was thoroughly investigated and the results reported.The facility failed to ensure a physical altercation between Residents #8 and #20 on 1/5/2026, in which Resident #20 allegedly scratched Resident #8 on the face after he yelled at her, was thoroughly investigated and the results reported.The facility failed to ensure a physical altercation between Residents #20 and #26 on 1/18/2026, in which Resident #20 allegedly scratched Resident #26 on the neck during a verbal altercation, was thoroughly investigated and the results reported.These failures could lead to lack of oversight, mistreatment of residents, and decreased quality of life. Findings included: Record review of Resident #32's admission Record dated 2/26/2026 reflected a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included Alzheimer's disease (a progressive neurological condition effecting memory and behavior). Record review of Resident #32's quarterly MDS submitted 1/6/2026 reflected a BIMS score of 00, which indicated severely impaired cognitive function. Record review of Resident #32's progress notes reflected the following entry dated 12/16/2025 at 9:15 PM by LVN F:Skin Issue: #001: New skin Issue. Location: Right outer forearm. Laterality / Orientation: Superior. Issue type: Bruising. Progress: Unknown. Wound acquired in-house. It is unknown how long the wound has been present. Signs and symptoms of infection: None. Painful: No. Further record review of Resident #32's progress reflected an additional entry dated 12/16/2025 at 9:37 PM by LVN H:Sent photos and information to NP E on SBAR done for discolorations. NP E gave orders to do 2 view xrays [sic] of the two areas. Xrays [sic] ordered. Call to family placed but no answer and no voicemail available. Record review of the facility document titled Incidents By Incident Type dated 2/26/2026 for date range 8/1/2025 through 2/23/2026 did not reveal and incident on or around 12/16/2025 for Resident #32. In an observation of Resident #32 on 2/23/2026 at 3:25 PM, she was observed ambulating independently throughout the secured unit. She was mumbling unintelligible words to herself and did not respond when approached for interview. In an interview with LVN F on 2/25/2026 at 1:46 PM, she said she recalled minimal bruising located to the outside of Resident #32's lower forearm. She said she had not seen Resident #32 fall or have an injury in the period prior to the assessment documented on 12/16/2025. She said she thought it was possible the bruises were related to a laboratory blood draw, but she was unsure if Resident #32 had received the procedure around the time of the bruising. She said Resident #32 could not explain what caused the bruising. She said she didn't think that Resident #32 had been physically abused by anyone because she did not see finger shaped bruising in her assessment, but she said she had observed Resident #16 following Resident #32 and attempting to grab her shirt and arms on multiple occasions. She said she had not seen Resident6 #16 make physical contact with Resident #32. She said she notified NP E and Resident #32 received x-rays that were without negative findings. In an interview with the DON on 2/25/2026 at 2:20 PM, she said she recalled being told by the nursing staff that Resident #32 had bruising on her arm in December 2025, and she attributed the bruising to the laboratory blood draw Resident #32 had on 12/11/2025. She said when she saw the bruising, she observed a pinprick mark to the bruising, that she felt was confirmation of the cause of the bruising. She said did not have suspicions that the bruising to Resident #32's arm was the result of abuse because the staff would have observed it. She was unsure why NP E would order x-rays for Resident #32's arm if the staff attributed the injury to a laboratory blood draw and not a fracture or other injury. She was unsure why the discoloration was noted 5 days after the procedure and not sooner, as is typical for laboratory blood draw bruising. She said she did not feel the bruising needed to be reported to the SSA because she felt like the bruise was related to the procedure. She was unsure if her investigation of the bruising included safe surveys of other residents, staff interviews, or an in-service for staff, but said she would consult her records and return any relevant documents. The DON did not return any documents related to this investigation prior to the end of survey. In an interview with the Administrator on 2/26/2026 at 7:20 AM, she said she was on leave when this incident occurred, and it was investigated by the DON and the regional leadership team. She was unsure of the extent of the investigation of the incident or the documentation of the investigation. 2. Record review of Resident #16's admission Record dated 2/23/2026 reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included personal history of other mental and behavioral disorders.Record review of Resident #16's quarterly MDS submitt4ed 12/5/2025 reflected a BIMS score of 03, which indicated severely impaired cognition. Section E0200 of the MDS reflected Resident #16 did not exhibit physical, verbal, or other behavioral symptoms directed towards others during the assessment period. Record review of Resident6 #16's Care Plan Report printed 2/23/2026 revealed the following:[Resident #16] has history of inappropriately touching the women residents in the facility, pulling the fire alarm in the hallway which is close to his room, verbal/physical aggression r/t [disease processes]1/3/26 [Resident #16] attempted to touch female residents [sic] breast, female resident scratched [Resident #16.]. new orders for [wound care] to scratch on right handDate Initiated: 01/03/2026Record review of Resident #26's admission Record dated 2/25/2026 reflected a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included unspecified dementia [a progressive disorder affecting memory and reasoning], severe, with psychotic disturbance. Record review of Resident #26's annual MDS submitted 2/4/2026 reflected a BIMS score of 03, which indicated severely impaired cognition. Section E0200 of the MDS reflected Resident #2 did not exhibit physical, verbal, or other behavioral symptoms directed towards others during the assessment period. Record review of Resident #26's Care Plan Report printed 2/25/2026, revealed the following:[Resident #26] is/has the potential to be physically aggressive r/t dementia, history of harm to others. Poor impulse control 11-26-24 resident slapped staff member. Date initiated 11/26/2024. Record review of Resident #26's progress notes reflected an entry dated 1/3/2026 at 12:30 PM by LVN D that read as follows:SN was notified by CNA that resident was sitting on the couch in TV room next to another resident, when the other resident attempted to touch her left breast. This resident reacted by scratching the other resident [sic] right hand. Resident was assessed, no injuries noted at this time. Resident was redirected successfully. [NP E] notified, [Family member]- no answer x 2, voice mail left.In an interview with CNA I on 2/24/2026 at 10:00 AM, she said she witnessed Resident #16 attempt to grab Resident #26 on 1/3/2026. She said Resident #26 responded to the behavior by becoming angry and intentionally scratching Resident #16, and she immediately separated the residents and notified the nurse. In an interview with LVN D on 2/25/2026 at 1:41 PM, she said she was notified by CNA I that Resident #16 been scratched by Resident #26 after he attempted to grab Resident #26's breast. She said the scratch to Resident #16's arm was minor and required only basic wound care. She said she notified the DON, provider, and ADON after the incident, and there were no additional altercations between the residents.In an interview on 2/25/2025 at 2:09 PM, the DON said she was notified by staff of the altercation between Residents #16 and #26 after it occurred. She said she reviewed the incident with the regional leadership team, and they felt that the scratch happened accidentally while Resident #26 was waving her arms to deflect Resident #16's attempt to grab her breast. She was unsure if the facility had conducted any further investigation of the incident, including resident/staff interviews, safe surveys, or an in-service. She said she would research her records and provide documentation. No additional documents were returned prior to survey exit.In an interview with the Administrator on 2/26/2026 at 7:20 AM, she said she was on leave when this incident occurred, and it was investigated by the DON and the regional leadership team. She was unsure of the extent of the investigation of the incident or the documentation of the investigation. 3. Record review of Resident #8's admission Record dated 2/24/2026 reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included Alzheimer's disease. Record review of Resident #8's annual MDS submitted 12/12/2025 reflected a BIMS score of 03, which indicated severely impaired cognition. Section E0200 of the MDS reflected Resident #8 did not exhibit physical, verbal, or other behavioral symptoms directed towards others during the assessment period. Record review of Resident #8's Care Plan Report printed 2/24/2026 revealed the following:[Resident #8] has a behavior problem r/t history of episodes of starting arguments with other residents and staff. Difficult to redirect at times. [Resident #8] has a tendency to urinate on the floor. Date initiated 11/10/2024[Resident #8] is physically/verbally aggressive toward staff and residents at times r/t Dementia [sic], Poor [sic] impulse control Date initiated 11/29/20241/5/26 Resident to ResidentResident became upset with another ressident because he thought she took his b ed [sic] and attempted to hit another resident.Staff to cont [sic] to redirect resident when he is in a confused stateCLEANSED WITH NS AND APPLIED TAO, LEFT OPEN TO AIR date initiated 1/05/2026 Record review of Resident #20's admission Record dated 2/26/2026 reflected a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included Alzheimer's disease. Record review of Resident #20's quarterly MDS submitted 12/9/2025 reflected a BIMS score of 03, which indicated severely impaired cognition. Section E0200 of the MDS reflected Resident #20 exhibited other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) for 1 to 3 days of the assessment period. Record review of Resident #20's Care Plan Report printed 2/24/2026 reflected the following:[Resident #20] has potential to be physically aggressive to others r/t Dementia, has history of being physically aggressive towards others. Date Initiated: 05/16/20241/5/25- resident to resident incident in which resident accidentally scratched another resident. Cont [sic] to monitor and redirect resident. Date Initiated: 01/05/2026 Record review of Resident #20's progress notes reflected an entry dated 1/5/20026 at 2:13 PM by LVN B that read as follows:RESIDENT WALKING DOWN THE HALL WHEN MALE RESIDENT WALKED OUT OF HIS ROOM AND NOTED AN EMPTY BED IN THE HALLWAY, MALE RESIDENT YELLED AT FEMALE RESIDENT AS TO WHY WAS SHE TAKING HIS BED, FEMALE RESIDENT THEN REACTED AND SCRATCHED RESIDENT BELOW LEFT EYE. RESIDENTS REDIRECTED AT THIS TIME. [NP E] NOTIFIED AND [family member], RESIDENTS DAUGHTER NOTIFIED, NO INJURIES NOTED. VERBALIZED UNDERSTANDING. V/S 136/77, 78,98.0, 97%, 18The progress note included a check mark that indicated the residents were unable to describe the incident. In an interview on 2/25/2025 at 2:09 PM, the DON said she was notified by staff of the altercation between Residents #8 and #20 after it occurred. She said she reviewed the incident with the regional leadership team, and they felt that the scratch happened accidentally while Resident #20 was waving her arms to distance herself from Resident #8. She said the incident was not reported to the SSA because she felt the scratch was unintentional and because both residents were confused at baseline and did not knowingly harm each other. She said her investigation concluded after interviewing the residents because she felt confident that there had not been an intentional physical altercation or potential for abuse. In an interview on 02/26/2026 at 7:20 AM with the Administrator, she said she was on leave when this incident occurred, and she was unsure of the rationale to not report the incident to the SSA. She was unsure if she felt it should have been reported for potential abuse after reviewing it. 4. Record review of Resident #20's Care Plan Report printed 2/24/2026 reflected the following:1/18/26 resident to resident new order for tao to scratch on left lateral chin, psych consult, [laboratory testing]. Notify MD/NP if behaviors continue Date initiated 1/18/2026 Record review of Resident #20's progress notes reflected the following entry dated 1/18/2026 at 8:21 PM by LVN B:WAS CALLED TO UNIT, BOTH RESIDENTS HAD BEEN REDIRECTED BACK TO THEIR ROOMS WHEN THIS NURSE ARRIVED. PER CNA, RESIDENT WAS ON TOP OF ANOTHER FEMALE RESIDENT, FIGHTING ON THE FLOOR FULL HEAD TO TOE ASSESSMENT DONE, RESIDENT HAS SMALL SCRATCH TO LEFT LATERAL [side] CHIN. NO BUMPS TO HEAD NOTED AT THIS TIME. NO PAIN. An additional progress note dated 1/18/2026 at 8:50 PM by the DON read as follows:Clarification to follow up PN to include the following: Upon further investigation of incident. CNA present states she heard noise coming from this residents [sic] room. After proceeding to enter room, she noted other resident laying on the floor on her back, and this resident getting up from the floor. CNA states she did not see residents hitting each other. In speaking to other resident, she states that she and this resident were sitting at the edge of her bed having a conversation. She states that they disagreed on a certain topic. The other resident states that this resident reached towards her in which she got startled, at that time the other pulled back causing her and this resident to slide off the bed and land on the floor. Resident says as they slid off the bed, this resident inadvertently scratched the left side of the other residents [sic] neck.In an interview on 2/25/2025 at 2:09 PM, the DON said she was notified by staff of the altercation between Residents #20 and #26. She said when she arrived to the Residents' shared room, they denied a physical altercation. She was unsure why the nursing documentation reported a physical altercation. She said the incident was reviewed with the regional leadership team, and they determined the incident did not need to be reported to the SSA because the residents denied they had been in a physical altercation and because they were visualized laughing and behaving friendly towards each other immediately following the incident. She said her investigation concluded after interviewing the residents because she felt confident that there had not been a physical altercation or potential for abuse.In an interview with NP E on 2/25/2026 at 3:56 PM, he said he was notified by the facility that Residents #20 and #26 were observed engaged in a physical altercation resulting in a minor scratch to Resident #26's neck, and he instructed the staff to ensure the residents remained separated until they determined it was safe for them to be around each other.In an interview on 02/26/2026 at 7:20 AM with the Administrator, she said she was aware of the incident between Residents #20 and #26, and she was not concerned about possible abuse because both residents were laughing and behaving like friends after staff intervened. She said the DON spoke to both residents and determined the scratch was not intentional, so the investigation was concluded at that time. She was unsure what documentation was maintained by the DON regarding the investigation. Record review of the facility policy titled Abuse, Neglect, and Exploitation dated 7/11/2025 revealed the following:A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.B. Written procedures for investigations include:1. Identifying staff responsible for the investigation;2. Exercising caution in handling evidence that could be used in a criminal investigation .;3. Investigating different types of alleged violations;4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations;5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and6. Providing complete and thorough documentation of the investigation.

Based on observation, interview and record review the facility failed to ensure that a medication error rate was not 5 percent or greater. The facility had a medication error rate of 18.51%, based on 5 errors out of 27 opportunities, which involved 3 of 6 residents (Residents #18, #43 and #49) and 3 of 4 staff (LVN A, LVN B, and MA C) reviewed for medication administration and medications errors. The facility failed to ensure the staff administered medications to Residents #18, #43 and #49 timely, according to physician orders, and professional standards. This failure could place residents at risk of not receiving therapeutic effects of their medications and possible adverse reactions.The findings include: A record review of resident #49's admission record dated 2/26/2026 revealed an admission date of 2/3/2025 with diagnoses which included Diabetes Mellitus type II (a chronic metabolic disease characterized by high blood sugar levels, occurring when the body cannot properly produce or use insulin). A record review of Resident #49's quarterly MDS assessment revealed Resident #49 was a [AGE] year-old male admitted for long term care related to Hemiplegia associated with a stroke (a severe or total paralysis affecting one vertical side of the body caused by brain damage, such as from stroke). Resident #49 was assessed with a BIMS score of 11 from a potential of 15 which indicated moderate cognitive impairment. Resident #49 was assessed with a history of strokes and needed assistance with ADLs. Resident #49 was assessed as receiving insulin injections for his diagnosis of diabetes (Insulin is a hormone that allows cells to use glucose for energy. Without enough insulin, glucose builds up in the blood, leading to serious health issues like heart disease, blindness, and nerve damage). A record review of Resident #49's care plan, dated 2/26/2026, revealed, (Resident #49) Has diabetes mellitus requires insulin use . diabetes medication as ordered by doctor. A record review of Resident #49's physician's orders, dated 2/26/2026 revealed the physician prescribed for Resident #49 to receive:Insulin glargine solution 100 units per ml. inject 12 units subcutaneously (below the skin) one time a day for diabetes.Novolin (insulin regular human) injection pen, injection solution 100 units per ml. inject per sliding scale:If (blood sugar) 0 = 0 units.151 - 200 = 2 units.201 - 250 = 4 units.251 - 300 = 6 units. A record review of the insulin injection pen's website title FlexPens:https://www.novonordisk.com/our-products/pens-and-needles/flexpen.htmlaccessed 2/26/2026 revealed, Novolin(R) N FlexPen may contain a small amount of air. To prevent an injection of air and make certain insulin is delivered, an air shot must be done before each injection.Directions for performing an air shot are provided on the reverse side of this insert. FlexPen prefilled insulin syringe directions for use: . Giving The air shot Before Each Injection:Small amounts of air may collect in the needle and insulin reservoir during normal use.To avoid injecting air and to ensure proper dosing, hold the syringe with the needle pointing up and tap the syringe gently with your finger so any air bubbles collect in the top of the reservoir. Remove both the plastic outer cap and the needle cap.e. Dial 2 units.f. Holding the syringe with the needle pointing up, tap the reservoir gently with your finger a few times. Still with the needle pointing up, press the push button as far as it will go and see if a drop of insulin appears at the needle tip. If not, repeat the procedure until insulin appears. Before the first use of each Novolin N FlexPen prefilled insulin syringe you may need to perform up to 6 air shots to get a droplet of insulin at the needle tip. If you need to make more than 6 air shots, do not use the syringe, and return the product to (name of manufacturer). During an observation and interview on 2/26/2026 at 6:38 AM revealed LVN B assessed Resident #49 with a blood sugar of 258. LVN B prepared and administered to Resident #49:The Insulin glargine by attempting to draw the medication from a vial which was not Resident #49's insulin glargine vial of medication. Surveyor intervention caused LVN B to recognize the vial was not Resident #49's medication and discovered Resident #49's medication and then prepared and administered Resident #49's insulin glargine 12 units.The Novolin regular insulin 6 units injection without priming the injection pen.LVN B stated she had not recognized someone else's insulin vial was in Resident #49's insulin glargine box when she retrieved the vial for administration, but she did search and discovered Resident #49's insulin glargine vial in another Residents box. LVN B stated she had not primed Resident #49's Novolin injection pen prior to administering Resident #49 his 6 units and could have possibly underdosed Resident #49. LVN B stated Resident #49 could potentially have an adverse reaction to the insulin administration. A record review of Resident # 43's admission record dated 2/26/2026 revealed an admission date of 2/12/2026 with diagnoses of gangrene (a serious, potentially life-threatening condition involving the death of body tissue due to a severe bacterial infection. It commonly affects extremities like fingers, toes, and limbs) and acquired absence of left great toe. A record review of Resident #43's admission MDS assessment dated [DATE] revealed Resident #43 was a [AGE] year-old male admitted for care related to his amputated left great toe and infection. Resident #43 was assessed with a BIMS score of 14 out of a possible 15 which indicated no cognitive impairment. A record review of Resident #43's care plan dated 2/25/2026 revealed, (Resident #43) has infection of the skin . administer antibiotic as per MD orders. A record review of Resident #43's physicians orders dated 2/25/2026, revealed the physician prescribed for Resident #43 to receive:Fluticasone 100mg, Umeclidinium 62.5mg, Vilanterol 25mg inhalation aerosol powder. 1 puff inhale orally one time a day for heart failure. (Fluticasone 100mg, Umeclidinium 62.5mg, Vilanterol 25mg is a once-daily, single-inhaler triple therapy medication used for long-term maintenance treatment of asthma in adults).Piperacillin 3mg, Tazobactam 0.375mg (a potent, intravenous combination antibiotic used to treat severe bacterial infections), use 1 application intravenously every 8 hours for Resident #43's toe amputation (intravenously - administering fluids, nutrients, or medications directly into a vein via a needle or tube, allowing for immediate bloodstream entry). A record review of the manufacturer's website for Fluticasone 100mg, Umeclidinium 62.5mg, Vilanterol 25mg inhalation aerosol powder; https://www.trelegy.com/ ; accessed 2/26/2026 revealed, (brand name of medication) can cause serious side effects, including: fungal infection in your mouth or throat (thrush). Rinse your mouth with water without swallowing after using (brand name of medication) to help reduce your chance of getting thrush. During an observation and interview on 2/25/2026 at 9:30 AM revealed LVN A prepared and administered Resident #43 medications:Fluticasone 100mg, Umeclidinium 62.5mg, Vilanterol 25mg inhalation aerosol powder without educating, suggesting, and directing Resident #43 to rinse out his mouth with water and spitting out the water after inhaling the medication.Piperacillin 3mg, Tazobactam 0.375mg by not administering Resident #43's full dose when she primed the intravenous line by dumping most of the medication into a waste basket. Surveyor intervention caused LVN A to recognize a small amount left in the medication bag after LVN A primed the intravenous supply line.LVN A stated she did not ask Resident #43 to rinse out his mouth after his oral inhalation of the aerosolized medication due to his potential refusal of rinsing out his mouth. LVN A stated she had not recognized the small amount of intravenous antibiotic in the medication bag after she primed the intravenous supply line until the State Surveyor had intervened. LVN A stated the potential outcome for Resident #43 was an underdose of antibiotic and oral infections without rinsing the mouth. A record review of Resident #18's admission record revealed an admission date of 10/12/2023 with diagnoses which included cerebral infarction (a blockage in an artery supplying blood to the brain, leading to the death of brain tissue due to lack of oxygen). A record review of Resident #18's quarterly MDS assessment dated [DATE] revealed Resident #18 was a [AGE] year-old male admitted for long term care related to Resident #18's needs with ADLs. Resident #18 was assessed with a BIMS score of 10 out of a possible 15 which indicated moderately impaired cognition. A record review of Resident #18's care plan dated 2/25/2026 revealed, (Resident #18) has altered cardiovascular status related to hypertension . administer medications as ordered. A record review of Resident #18's physician's orders dated 9/19/2025 revealed the Physician prescribed Resident #18 to daily receive a combined drug of lisinopril 20mg and hydrochlorothiazide 25mg called Zestoreic. During an observation and interview on 2/25/2026 at 8:40 AM revealed MA C prepared and administered Resident #18 medications except for the Zestoric. MA C stated the medication was not on the cart nor was the medication available in house. MA C stated she would report the missed administration to Resident #18's nurse. During an interview on 2/26/2026 at 11:50 AM LVN D stated she had received a report from MA C that Resident #18 missed his daily dose of Zestoreic and the medication was not available in house. LVN D stated she called the pharmacy late afternoon 2/25/2026 and ordered a refill from the pharmacy which arrived today (2/26/2026). LVN D stated she did not know why the medication was not re-filled earlier. LVN D stated the potential adverse reaction to Resident #18 not receiving the daily dose of Zestoric was high blood pressure. During an interview on 2/26/2026 at 12:15 PM NP stated the expectation was for nursing to administer medications as ordered specific to the correct dosages and professional standards. NP stated the failure to prime an insulin injection pen could be underdosing of insulin and continued elevated blood sugar levels. NP stated the failure to improperly prime an intravenous supply line for antibiotic intravenous administration could be underdosing of the antibiotic and ineffective antibiotic therapy. NP stated missing a daily dose of the Zestoreic could be high blood pressure. During a joint interview on 2/26/2025 at 4:00 PM the Administrator and the DON stated the expectations for Medication Aides and Nurses who administered medications was for the staff to follow physician's orders and manufactures recommendations for medication administration. The DON stated and the Administrator concurred the insulin vials should be kept in their respective boxes segregated by residents to ensure each resident received their medication from their vial; insulin injection pens should be primed to ensure accurate dosage administration; intravenous lines should be primed in a manner to ensure no medication was wasted and the resident would receive their intended dose; and for medications to be monitored for timeliness of refills to ensure residents received their medications without missing a dose. The Administrator and the DON stated the potential negative outcome for residents could be they may not have received the intended therapeutic effects of their medications. A record review of the facility's policy titled Mediation Administration dated 10/24/2022 revealed, . Review medication administration record to identify medication to be administered. Compare medication source, bubble pack, vial, etcetera with medication administration record to verify resident name, medication name, form, dose, route, and time. Refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects. Administer medication as ordered in accordance with manufacturer specifications.

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 (Kitchen 1) of 1 kitchen reviewed for food safety requirements. The facility failed to store food preparation equipment in sanitary area.The facility failed to store and maintain drink dispensing guns between and during meal services in a sanitary method during survey of facility. This failure could place residents at risk for the spread of infections, food contaminations, food-borne illnesses, and diminished quality of life. 1.Based on observation on 2/23/2026 at 1:45 pm surveyor noted that facility was storing two crockpots in their kitchen chemical closet. Above the crockpots were gallons of degreaser for kitchen use.During an interview with FSM on 2/23/2026 at 1:45 pm, the FSM stated that the crockpots belonged to the Activities Department and they kept them in the chemical closet in-between uses. Surveyor asked what the policy was for storing items in the chemical closet and the FSM stated he would have to check. During interview with FSM on 2/24/2026 at 1:20 pm, Surveyor asked FSM if maybe there was a better place to store the crockpots when FSM verified that degreaser was sitting above the crockpots and FSM responded with yes, probably.Record review of Food Storage policy for the facility stated that facility is not to use or store cleaning materials or other chemicals where they might contaminate foods and to store chemicals in a locked area away from food products.Record review of degreaser product in MSDS in kitchen on 2/25/2026 at 8:49 am revealed that the degreaser is harmful if swallowed, harmful if comes into contact with skin, and causes severe burns and eye damage. MSDS states 'do not taste or swallow. Wash thoroughly after handling and before eating. MSDS states can cause burns to mouth, throat, and stomach. 2.Based on observation on 2/23/2026 at 1:55 pm surveyor noted two drink dispensing guns were not secured in the holders from the manufacturer but were hanging from the cart they were attached to about two inches from the floor. During an observation on 2/24/2026 at 12:20 pm surveyor noted that DA was filling coffee containers on the rolling cart next to the drink dispensing guns. Surveyor noted that one of the guns was up against the cart the coffee was on. During an observation on 2/26/2026 at 2:30 pm surveyor noted that the drink dispensing guns were secured in the manufacturer holders on the cart.During an interview with FSM on 2/23/2026 at 1:55 pm, FSM stated that they drink dispensing guns do not stay in the holders that came with them because the holders were not secured to the cart. FSM also stated that the guns had been this way for a while. FSM stated that they do not have an issue with the guns and contamination. During an interview on 2/24/2026 at 12:15 pm, cook stated that the guns had been like that and she never rubs against them when moving around kitchenDuring an interview with DA on 2/24/2026 at 12:25 pm, DA stated that it is not an issue with the guns. Surveyor asked if they pick the guns up when they mop and DA responded with, they tried to. Facility stated they do not have a policy on the drink dispensing guns but will follow state approved guidelines. F812 Appendix PP states that improper sanitation of equipment could cause food-born illnesses.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care (including tracheostomy care), was provided such care, consistent with professional standards of practice for 1 resident (Resident # 1) of 1 resident with a tracheostomy reviewed for respiratory and tracheostomy care.The facility failed to ensure that Resident #1's Tracheostomy humidification with air compressor was at 20 PSI per physician order. The facility also failed to ensure Resident #1's inner canula daily change was completed using sterile technique per medical guidelines for procedure.This failure could affect residents with oxygen therapy and tracheostomy status and could lead to respiratory distress, infection control issues, and even death. Record review of Resident #1's admission Record on 2/23/2026, revealed a [AGE] year-old male admitted on [DATE]. Resident #1's diagnoses include Tracheostomy Status ( presence of an artificial, temporary or permanent opening in the windpipe to assist with breathing), Persistent Vegetative State ( chronic condition of wakeful unconsciousness following coma, lasting over four weeks, where patients have sleep-wake cycles and automatic functions but no cognitive awareness), Dependence on Supplemental Oxygen ( prescribed, life-sustaining therapy for people unable to maintain adequate blood oxygen levels), Personal history of Traumatic Brain Injury ( recognized as a chronic, often life-long condition rather than a single event leading to long-term impairments). Record review of Resident #1's Order Summary Report reviewed on 2/23/2026, revealed orders for changing of disposable trach (Shiley size 6) inner canula one time a day, Trach humidification with air compressor at 20 PSI every shift, Trach care cleaning every shift. Record review of Resident #1's Care Plan, dated 01/22/2026, revealed Resident #1 cannot utilize call light if in distress due to vegetative status, infection of the Trachea, Trach collar and inner canula changes as scheduled and as needed, oxygen humidification as indicated. Record review of Resident #1's MDS, dated [DATE], revealed Persistent Vegetative State, BIMS score of 00 indicating severe cognitive impairment, Dependence for all ADL's, and Incontinence of bowel and bladder.In an observation on 2/26/2026 at 08:50 am, trach care observation revealed that trach humidification was at 19, versus the 20 PSI that was ordered. Surveyor observed LVN D attempt to adjust the pressure. LVN D then stated to LVN F that the knob was stuck and could LVN F assist LVN D. In an observation on 2/26/2026 at 08:50 am, LVN D was noted to wear non-sterile gloves and set up sterile supplies for inner canula change. LVN D touched sterile items in it with non-sterile gloves. In an observation on 2/26/2026 at 09:25 am revealed PSI for Resident #1 was at 20.Interview on 2/26/2026 at 08:50 am with LVN D revealed the order for tracheostomy humidification was for 20 PSI. LVN D stated she checked the PSI when she did trach care, which was once per shift. LVN D stated that she checked after the tracheostomy care was completed. Interview with ADON on 2/26/2026 at 10:43 am revealed that ADON's expectation when performing tracheostomy care was to use the sterile gloves in the kit to maintain the sterility of supplies.

Based on observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial need that were identified in the comprehensive assessment for 1 of 3 residents (Resident #1) reviewed for comprehensive person-centered care plans.1.The facility failed to ensure Resident #1's care plan included he was under EBP (refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloved use during high contact resident care activities) due to having an Indwelling/foley catheter.2.The facility failed to ensure Resident #1 had an order for EBP (refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloved use during high contact resident care activities).This deficient practice could place residents at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs. The findings included:Record review of Resident#1's admission sheet, dated 01/21/26, revealed a [AGE] year-old male with an admit date of 12/15/25 and an original admission date of 05/29/24. His relevant diagnoses included; dementia (a progressive aging condition involving significant cognitive decline-memory loss, impaired language, and behavioral changes), bladder-neck obstruction (blockage where the bladder's opening to the urethra doesn't open properly during urination, hindering urine flow),urinary incontinence (involuntary loss of bladder control, resulting in the unintentional leakage of urine), and cognitive communication deficit (an impairment in communication caused by underlying, disruptive cognitive process such as memory loss, attention, organization, and reasoning).Record review of Resident's #1's quarterly MDS assessment dated [DATE], reflected a BIMS score of 09, which indicated his cognition was moderately impaired. It was also noted Resident #1 had an indwelling/foley catheter (a flexible tube (often a foley catheter) inserted into the bladder to continuously drain urine into an external bag).Record review of Resident #1's quarterly care plan dated 12/26/25 failed to include he required EBP due to his indwelling/foley catheter.In an observation on 01/21/26 at 12:47 p.m., Resident #1 had EBP signage on his door, gloves and gowns were available outside his room and a trash can inside his room near the exit. Resident #1 was observed lying in bed awake. He had an indwelling/foley catheter and his drainage bag had a privacy cover. In an interview on 01/21/26 at 1:20 p.m., RN B/MDS said Resident #1 had an indwelling/foley catheter which required him to be under EBP. She said if a resident required to be under EBP, it needed to be care planned. She was observed as she reviewed Resident #1's electronic medical record and said she did not see where EBP had been care planned nor an order for EBP. RN B/MDS said a negative outcome for Resident #1 not having his EBP care planned could be that staff would not know to take precautions when they conducted high-contact care to him. In an interview on 01/21/26 at 4:00 p.m., the DON said the facility's protocol regarding EBP was that an order was required and it needed to be care planned. She said that would ensure staff would know what precautions to take when providing high-contact care. The DON said a negative outcome to Resident #1 not having his EBP care planned could be that staff might not take the necessary precautions when providing care. The DON said the facility did not have a policy related to physician's orders. Record review of the facility's Comprehensive Care Plans policy dated 10/24/22, reflectedPolicy: 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, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines:3. 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.

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 2 residents reviewed for accuracy and completeness of clinical records. The facility failed to ensure Resident #1 had an order for EBP (refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloved use during high contact resident care activities). 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 01/21/26, revealed a [AGE] year-old male with an admit date of 12/15/25 and an original admission date of 05/29/24. His relevant diagnoses included; dementia (a progressive aging condition involving significant cognitive decline-memory loss, impaired language, and behavioral changes), bladder-neck obstruction (blockage where the bladder's opening to the urethra doesn't open properly during urination, hindering urine flow),urinary incontinence (involuntary loss of bladder control, resulting in the unintentional leakage of urine), and cognitive communication deficit (an impairment in communication caused by underlying, disruptive cognitive process such as memory loss, attention, organization, and reasoning). Record review of Resident's #1's quarterly MDS assessment dated [DATE], reflected a BIMS score of 09, which indicated his cognition was moderately impaired. It was also noted Resident #1 had an indwelling/foley catheter (a flexible tube (often a foley catheter) inserted into the bladder to continuously drain urine into an external bag). Record review of Resident #1's quarterly care plan dated 12/26/25 failed to include he required EBP due to his indwelling/foley catheter.In an observation on 01/21/26 at 12:47 p.m., Resident #1 had EBP signage on his door, gloves and gowns were available outside his room and a trash can inside his room near the exit. Resident #1 was observed lying in bed awake. He had an indwelling/foley catheter and his drainage bag had a privacy cover. In an interview on 01/21/26 at 1:20 p.m., RN B/MDS said Resident #1 had an indwelling/foley catheter which required him to be under EBP. She said if a resident required to be under EBP, an order was needed. She was observed as she reviewed Resident #1's electronic medical record and said she did not see an order for EBP. RN B/MDS said a negative outcome for Resident #1 not having an order for EBP could be that staff would not know to take precautions when they conducted high-contact care to him. In an interview on 01/21/26 at 4:00 p.m., the DON said the facility's protocol regarding EBP was that an order was required. She said that would ensure staff would know what precautions to take when providing high-contact care. The DON said a negative outcome to Resident #1 not having an order for EBP could be that staff might not take the necessary precautions when providing care. The DON said the facility did not have a policy related to physician's orders.

Based on observations, interviews and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 (Resident #1) residents reviewed for EBP.The facility failed to ensure CNA A wore proper PPE during peri-care for Resident #1 who required enhanced barrier precautions (EBP). This failure could place residents at risk of MDRO contamination. The findings included: Record review of Resident#1's admission sheet, dated 01/21/256, revealed a [AGE] year-old male with an admit date of 12/15/25 and an original admission date of 05/29/24. His relevant diagnoses included; dementia (a progressive aging condition involving significant cognitive decline-memory loss, impaired language, and behavioral changes), bladder-neck obstruction (blockage where the bladder's opening to the urethra doesn't open properly during urination, hindering urine flow), and urinary incontinence (involuntary loss of bladder control, resulting in the unintentional leakage of urine).Record review of Resident's #1's quarterly MDS assessment dated [DATE], reflected a BIMS score of 09, which indicated his cognition was moderately impaired. It was also noted Resident #1 had an indwelling catheter (a flexible tube (often a foley catheter) inserted into the bladder to continuously drain urine into an external bag).Record review of Resident #1's quarterly care plan dated 12/26/25 reflected a problem of [Resident #1] has an indwelling catheter r/t bladder neck obstruction, other obstructive and reflux uropathy, date initiated 12/15/25 and revised on 01/20/26. His interventions in part included a 16 French indwelling catheter. Position catheter bag and tubing below the level of the bladder and away from entrance room door, check tubing for kinks each shift, Monitor and document intake and output as ordered, and monitor for s/sx of discomfort on urination and frequency.In an observation on 01/21/25 at 12:45 p.m., there was an EBP signage on Resident #1's door along with gowns and gloves available outside his room. This surveyor observed CNA A walking out of Resident #1's room. She had a clear plastic bag that contained a soiled brief and gloves only. This surveyor observed Resident #1's room and the trash can positioned inside his room near the exit for discarding PPE after removal was empty. This surveyor did not observe a used gown in the clear plastic bag nor in the trash can inside Resident #1's room.In an interview on 01/21/25 at 12:47 p.m., CNA A said she had transferred Resident #1 from the living room back to his room and performed peri-care. CNA A was asked if she had gowned up when she had performed peri-care and she said no. CNA A said she was in hurry and had forgotten to gown up, she said she had only worn gloves. CNA A said the negative outcome of not gowning up could be the possibility of cross-contamination. CNA A said she had been regularly in-serviced on the topic of infection control which included enhanced barrier precautions. In an interview on 01/21/25 at 1:20 p.m., RN B/MDS said she was covering Resident #1's floor during the lunch hour. She said Resident #1 was under EBP due to having an indwelling/foley catheter. She said EBP guidelines should be followed when performing peri-care or any other high contact activities. She said CNA A should have worn gloves and a gown when she performed peri-care on Resident #1. RN B/MDS said the negative outcome of not following EBP could be cross-contamination.In an interview on 01/21/25 at 4:00 p.m., the DON said Resident #1 was under EBP due to having an indwelling/foley catheter. She said CNAs and nursing staff should follow EBP guidelines when they conducted high contact activities which included peri-care. The DON said the negative outcome when CNAs and/or nursing staff do not follow EBP guidelines was an increased risk of cross-contamination. Record review of the facility's Enhanced Barrier Precautions policy dated 11/24/25 reflected:Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.Definition: enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organism that employs targeted gown and gloves use during high contact resident care activities.Policy Explanation and Compliance Guidelines: 3. Implementation of Enhanced Barrier Precautions:b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities.4. High-contact resident care activities include:f. changing briefs or assisting with toileting.

Based on interviews and record reviews, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (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. CNA A failed to report an allegation of abuse to the Administrator involving Resident #1 being tucked into bed with a blanket tucked behind her shoulders sometime in March of 2025. This failure could place residents at risk for undetected abuse and neglect, and a decline in feelings of safety and well-being. The findings included: 1. Record review of Resident #1's face sheet, dated 08/22/25, revealed the resident was a [AGE] year-old female who was initially admitted to the facility on [DATE] with diagnoses that included: Alzheimer's disease (progressive brain disorder that gradually destroys memory and thinking skills) unspecified dementia (a group of thinking an social symptoms that interferes with daily functioning), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety and need for assistance with personal care (ADLs) Record review of Resident #1's annual MDS assessment, dated 06/05/25, revealed Resident #1 had a BIMS score of 00, indicating her cognition was severely impaired. Resident #1's MDS reflected she had unclear speech, was rarely/never understood, and rarely/never understood others. Resident #1's MDS reflected she required supervision or touching assistance to roll left or right in bed, to go from lying to sitting on the side of the bed, to sit to stand and to complete chair/bed to chair transfers. Record review of Resident #1's care plan with an initiation date of 11/21/19 reflected a problems of [Resident #1] has an ADL self -care performance deficit r/t Alzheimer's, impaired balance. Requires a lot of encouragement and guidance to complete a task. With an initiation date of 08/03/23 and intervention of, BED MOBILITY: The resident requires assistance by 1 staff to monitor for safety in bed as necessary. and TRANSFER: The resident requires assistance by 1 staff to move between surfaces necessary. with an initiation date of 08/03/23. During an attempted interview with Resident #1 on 08/06/25 at 2:35pm, she would not respond to any introduction or question. Record review of Resident #1's medical chart from March to May did not reveal any verbiage related to the allegation of Resident #1 being tucked in except for a note written by the DON on 06/18/25 when the facility received a compliance call that mentioned the incident with Resident #1. The note written by the DON stated, A head to toe assessment was performed with no open areas noted. Resident was noted to have red scratch marked to right buttock and right upper thigh with no broken skin. During n interview with CNA A on 08/08/25 at 3:31pm, he said he was no longer employed at the facility as of July, 2025. CNA A stated that sometime in March of 2025 around 3:00am or 4:00am, he was completing his rounds and noticed that Resident #1 was asleep and had 3 or 4 blankets in use and was restrained with some type of blanket. CNA A initially stated it was a blanket with a knot and then stated it was not a knot, but two ends of the blanket were tied, and the blanket was on top of Resident #1's shoulders with the corners crossed in back of her on her back but not in a knot just crossed. CNA A stated the blanket was tucked behind her shoulder blades. CNA A stated, at the time he found Resident #1, he removed the blanket. CNA A stated he did not know who placed the blanket like that and did not know if there was anyone else working with Resident #1 at that time. CNA A stated he never showed a photo of Resident #1 and never had a photo of Resident #1. CNA A stated he had completed 2 prior rounds on her during his shift and had checked her brief each time and did not see a blanket tucked behind her shoulder blades during those rounds. CNA A stated Resident #1 would not have been able to remove the blanket and stated his initial thought was that Resident #1 looked restrained. CNA A stated he considered restraints as a form of abuse. CNA A stated after he removed the blanket from Resident #1, he reported it to LVN B as a safety precaution. CNA A stated he did not report to the Administrator because he did not have her number. CNA A stated he had previously been trained over immediately reporting allegations of abuse to the abuse coordinator who was the Administrator but could not recall who provided him with that training or when. CNA A stated the facility policy stated he needed to report allegations like this one to the administrator immediately, and stated he felt he did not follow the facility policy. CNA A stated not reporting allegations of abuse or restraints to the Administrator could negatively impact residents mentally and could be considered neglect. Record review of a written statement dated 08/08/25 by the DON revealed, This statement is regarding a concern voiced in March. The resident in question was assessed by a licensed nurse who based on their professional experience, voiced that after his thorough assessment, the resident did not have any indication of abuse or neglect as defined by THHS. According to the Licensed Nurse, the resident was not in any immediate danger, her safety was in no way at risk, and the resident was noted to freely move all extremities along with being noted to get out of bed without any form of resistance or signs of distress. During an interview with LVN B on 08/11/25 at 12:43pm, he stated he didn't remember when, but thought maybe in April or May 2025 at around 5:00am in the morning, he was called over by CNA A and LVN C and was shown an undated photo without timestamp that CNA A had of Resident #1. LVN B stated Resident #1 appeared to be tucked in but was not tied. LVN B stated with the way Resident #1 was tucked in she would have been able to break out of and remove. LVN B stated CNA A did not say anything about Resident #1 being restrained or tucked in, and stated he told CNA for them to go look at Resident #1. LVN B stated he went back to see Resident #1 and found her sitting in bed with a smile with blankets at her feet. LVN B stated Resident #1 did not have any markings or signs of abuse or anything. LVN B stated he did not know if CNA A had removed the blankets from Resident #1 prior to him seeing her. LVN B stated Resident #1 had problems with mobility and would have been able to get the blanket off of her without any problems and stated when he saw the photo of Resident #1, she was smiling and had the blanket up to her chest and it was tied or wrapped it was lightly pushed in on the sides. LVN B stated he did not see any abuse or neglect, did not see anything wrong with Resident #1. LVN B stated he had nothing to report, and he did not document anything because there was nothing to document. LVN B stated he had called the DON about an hour after he was shown the photo of Resident #1, and stated she did not call him back until a little later but was not sure what time. LVN B stated at that time, he let the DON know that he was shown an undated, photo without a timestamp of Resident #1, but when he went to check her, he found her with her blankets at her feet and stated she was smiling and was unable to tell him what happened. LVN B stated he didn't think he needed to tell the Administrator because there was nothing there, he did not know when the photo was taken, and he did not see anything or suspect any abuse or neglect . LVN B stated he thought telling the DON was good. LVN B stated he had been trained over abuse and reporting requirements on their annual trainings and monthly trainings, and stated if he suspected or witnessed abuse, he had to report to the abuse coordinator, who was the Administrator, immediately. LVN B stated the Administration was responsible for reporting any allegation of abuse to HHSC and they only had 2 hours to report. LVN B stated he did not consider tucking in a resident as abuse, but if they were wrapped like a burrito, then yes, he would. LVN B stated the facility policy stated they had to report allegation of abuse to their abuse coordinator, and he did not suspect abuse from the photo he saw of Resident #1. LVN B stated he followed the facility's policy and felt like he did what needed to be done at that time. LVN B stated not reporting allegation of abuse to the Administrator, and not reporting to HHSC within the appropriate time frame, could negatively impact the residents because whatever type of abuse could be happening, could also be happening to other residents. During an interview with the DON on 08/11/25 at 3:08pm, she stated the Administrator was the abuse coordinator and responsible for reporting allegation of abuse to HHSC. The DON stated the Administrator provided monthly in-services to staff over abuse which included examples of abuse and what was considered abuse. The DON stated staff were educated on reporting to the Administrator, herself, and the ADON, if they suspected or witnessed any abuse. The DON stated, sometime in March, LVN B had gotten word from CNA A that Resident #1 was tucked in bed, but according to his assessment, she was freely able to move around and get out of bed and he did see anything impeding her from getting out of bed. The DON stated LVN B stated Resident #1 was not scared or afraid, and had no signs that would warn him that something had occurred. The DON stated she was not made aware until a couple days later, when LVN B called her at 7:00am or 8:00am a couple days after to notify her of what he had been told by CNA A. She stated she told LVN B to notify staff of doing things how they should be done with residents, and they completed an In-service with whatever staff was available at that time. The DON stated they did not document or do any investigation at that time, but did complete an in-service. The DON stated they did not do an investigation, because based on LVN B's clinical judgment ,Resident #1 was fine, and LVN B stated there was nothing to report because Resident #1 was free to move around and was safe with no signs or symptoms of abuse. The DON stated if a resident was tucked in tightly to where they could not move or get themselves out, then it would be considered restraints, and restraints would be consider abuse. The DON stated after LVN B reported to her, she called the Administrator who had also just been made aware, and after they spoke about it, there was nothing to report because LVN B said there were no signs or symptoms of abuse that was noted. The DON stated CNA A and LVN B should have reported these allegations to the Administrator at the time they occurred. The DON stated they had a 2-hour time frame to report to HHSC, but did not report anything until they received a compliance call in June 2025 that mentioned the incident. The DON stated the facility's policy stated they had to make a report to the state within 2 hours if they were told of any abuse. The DON stated herself and staff followed the facility's policy and they went by the information they received from the nurses, what they saw, and the findings on their assessments. The DON stated not reporting allegations of abuse to the Administrator, or HHSC within 2 hours, could negatively impact residents with harm if there was actual abuse. The DON stated, in this case, there was nothing. During an interview with the Administrator on 08/11/25 at 4:37pm, she stated she was not aware of the exact date or time that CNA A notified LVN B of Resident #1 being tucked in, but stated CNA A asked LVN B if he could go look at Resident #1 and see how she was tucked in. The Administrator stated LVN B went to assess Resident #1, did not see any signs or symptoms of abuse or anything, and as per his clinical judgement, felt it was nothing to be concerned about. The Administrator stated the DON notified her, she did not remember at what date or time she was notified ,but it was later that same morning. The Administrator stated they did not do anything else in response and did not report it because based on the information provided to them from LVN B, Resident was stable, there was nothing to report, and had not been reported as abuse. The Administrator stated CNA A could have reported to her, but he felt safe with LVN B so he reported to him, the Administrator stated LVN B did not report to her and could have so that she could have been aware as to what was going on. The Administrator stated If LVN B had found something then he should have reported to it to her. The Administrator stated she was the abuse coordinator and was responsible for reporting any allegation of abuse to HHSC. The Administrator stated herself and staff had been trained over reporting abuse at least monthly, and staff should report to her as soon as possible because she only had 2 hours to report. The Administrator stated she considered restraints as abuse, but with being tucked in, it depended. The Administrator stated their facility's policy stated if staff saw, suspected, or even if they were not sure of it, they had to report any abuse to her. She stated, in this situation, she felt her and the staff followed that policy. The Administrator stated they monitored facility incidents to ensure they identified reportables and their appropriate time frame by reviewing documentation, rounding, and providing in-services to staff on what should be reported. The Administrator stated not reporting allegations of abuse to the Administrator and HHSC within a 2-hour time frame could negatively impact the residents because they would not be investigating or following protocols, and if they were not aware, then they were not doing interventions. Record review of the facility's in-service dated 02/13/25 that was provided by the Administrator covered abuse and neglect, and the 3 R's (recognize, remove, report) revealed CNA A, LVN B and the DON had received the training. Record review of the facility's policy with an implemented date of 07/11/25 and titled, Abuse, Neglect and Exploitation included a section titled, V. Investigation of Alleged Abuse, Neglect, and Exploitation that included verbiage stating, An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. VII. Reporting/Response.1.Reporting of all alleged violation to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hour after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 (Resident #161, Resident #33, Resident #53, and Resident #15) of 8 residents observed for infection control. 1. The facility failed to post the enhanced barrier precaution sign and no PPE gowns noted in the room or nearby Resident #161's room. 2. During Gtube medication administration for Resident #33, RN K did not sanitize hand after touching the privacy curtain. Then while wearing gloves, he touched the bed remote and with the same pair of gloves, he proceeded to touch the residents Gtube. 3. CNA F failed to wash her hands or use hand sanitizer between glove changes during wound care for Resident #53. 4. The facility failed to change gloves and perform hand hygiene when moving from a clean to a dirty area during wound care for Resident #15. 5. The facility failed to ensure Resident #33 was identified for and had implemented Enhanced Barrier Precautions. These deficient practices could place residents at-risk for healthcare associated cross contamination and the spread of infection due to improper care practices. Findings included: 1. Record review of Resident #161's face sheet dated 12/02/2024 revealed the resident was an [AGE] year-old male admitted on [DATE] with the following diagnoses: Urinary tract infection- ESBL(bacteria resistant to most antibiotics), Metabolic Encephalopathy (a disorder that affects brain function), Type 2 Diabetes Mellitus, Transient Cerebral Ischemic Attack (mini stroke), Chronic Kidney Disease, Stage 4, and Cystitis (infection in the urinary bladder). Record review of Resident #161's BIMS dated 11/30/2024 revealed he scored of 08, which indicated he had moderately cognitive impairment. Record review of Resident #161's comprehensive care plan, dated 12/02/2024, reflected Resident #161 was on antibiotic therapy (Meropenum) r/t ESBL UTI. Interventions: Monitor/document/report as needed signs and symptoms of secondary infection r/t antibiotic therapy . Observation on 12/02/24 at 10:22 a.m. Resident #161 sitting in a wheelchair in his room with IV lock on right forearm. There were no EBP signs or any indication that the resident was on EBP. No PPE gowns noted in the room or nearby. In an interview on 12/02/24 at 2:45 p.m. with LVN J stated that the person responsible for posting the EBP sign outside of Resident #161 room was the admitting nurse. If the admission was done at night, then the ADON puts it up, but the floor nurse can put it up as well. She stated she has no idea what Resident #161 was being treated for nor half of the residents she was assigned to because they are all new residents to her. LVN J stated she has not had a chance to look at Resident #161 because he was in physical therapy. She stated that it was important to have the EBP signage to keep infection from spreading. LVN J stated in service for infection control was done about 2-3 months ago. In an interview on 12/02/24 at 3:00 p.m. with the ADON, stated that the nurses and him were responsible for putting up the EBP sign on the outside of the resident rooms if they know the resident needs it. He stated that he rounds when he comes in and makes sure the EBP signs are there. The ADON stated that they had a lot of admits last week. He stated that he was not sure why the nurse did not catch that the EBP sign was not posted. He stated they have infection control trainings via online through health stream. In an interview on 12/02/24 at 3:10 p.m. with the DON, stated that when new admissions come in then the floor nurses are responsible for putting up the EBP sign if needed but the infection preventionist should follow up as well as the treatment nurse. She stated they are all responsible for posting the EBP sign. The DON stated that it was important for the EBP sign to be posted for the staff to be made aware of any type of precaution regarding the infection that a resident has. She stated she was not sure when the most recent in service for infection control was done. 2. Record review of Resident #33's face sheet dated 12/04/2024 revealed the resident was a [AGE] year-old female admitted on [DATE], initial admitting date of 10/12/24 with the following diagnosis: Gastrostomy (which was a surgical opening in the stomach that can be used for nutritional support or to decompress the stomach), Cerebral Infarction (stroke), Type 2 Diabetes Mellitus, Muscle wasting and Atrophy (loss of muscle tissue), Dysphagia (difficulty swallowing), Psoriasis (chronic skin disease). Record review of Resident #33's quarterly MDS dated [DATE] revealed BIMS score of 00, which indicated he had severely cognitive impairment and his nutritional approaches via feeding tube. Record review of Resident #33's Comprehensive Care Plan, dated 12/03/2024, revealed Resident #33 requires tube feeding r/t Dysphagia. Interventions: Monitor/document as need any signs and symptoms of .infection at tube site. Record review of Resident #33's physician order summary dated 12/04/2024 revealed Resident #33 Enteral Feed Order every shift flush feeding tube with 10mls of water before and after medication administration. Observation on 12/03/24 at 11:36 a.m. RN K touched privacy curtain, then donned gloves without sanitizing hands. He then touched the bed remote to adjust the height of the bed to working level, and with the same pair of gloves he proceeded to touch the residents Gtube prior to medication administration. In an interview on 12/03/24 at 11:55 a.m. with RN K, stated he did well during the Gtube medication administration. RN K stated he was to sanitize hands in between glove changes. He stated that they are to wash their hands before anything they do prior to patient care. RN K stated he did not think he needed to change his gloves after touching bed remote. He stated that they are to sanitize hands in between glove changes because hands can be contaminated from sweat. He stated that he was supposed to sanitize hands after touching privacy curtain prior to putting on gloves. RN stated sanitizing hands was important to prevent transmission of bacteria. In service for infection control was done maybe like 2 weeks ago. He stated in services for infection control are done often. In an interview on 12/03/24 at 12:01 p.m. LVN C, was present with RN K when doing the Gtube medication administration for Resident #33. She stated that they are to sanitize hands all the time before patient care, after patient care and in between glove changes. She stated this was important, so they do not pass infection and germs to other residents, to prevent infection. In service for infection control training was done online on the computer, maybe 2 weeks ago. In an interview on 12/03/24 at 12:05 p.m. with the ADON, stated staff was trained to sanitized hands in between glove changes and if they touch a resident's surrounding surfaces to where they break barrier. If they touched any surface that was not the resident, then they cannot touch the resident again with the same pair of gloves. Staff was to sanitize hands prior to putting a new pair of gloves. This was important to make sure not to pass any infection or introduce any pathogens to other residents with EBP. In an interview on 12/03/24 at 12:09 p.m. with the DON, stated staff was trained to sanitized hands right before working with a resident, before administrating medication, or if they touch any surface like the bed. They are to remove their gloves and either sanitize or wash their hands. If they touch a surface prior to touching the resident, they must re-sanitize. The DON stated that this was important, so they do not introduce any microbes or bacteria to the residents. 3. Record review of Admission Record, dated 12/4/2024, reflected Resident #53was a [AGE] year-old male, originally admitted [DATE]. Diagnosis include Acute Kidney Failure with medullary necrosis (a severe condition where the kidneys suddenly lose function due to damage specifically to the inner part of the kidney, called the medulla, resulting in cell death (necrosis) in that region, often leading to significant complications like decreased urine output and fluid buildup in the body), Orthostatic Hypotension (a condition where a person experiences a sudden drop in blood pressure when standing up from a sitting or lying position, often causing dizziness or lightheadedness due to reduced blood flow to the brain), and need assistance with personal care. Record review of the quarterly MDS assessment dated [DATE], reflected Resident #53 did not have a BIMS assessment conducted. Record review of the Care Plan reflected Resident #95 was at risk for impaired skin integrity related to Impaired mobility Date Initiated: 10/03/2024. During an observation on 12/3/24 at 10:30 AM, of incontinent care performed on Resident # 53 CNA F and CNA G prepared all supplies, while performing incontinent care CNA F failed to wash her hands or use hand sanitizer between glove changes during wound care for Resident #53, no handwashing or hand sanitized used throughout the incontinent care. During an interview on 12/3/24 at 11:20AM CNA F said that she knew she was supposed to wash her hands or use hand sanitizer in between gloves change but she said she was nervous and forgot. CNA F said that the last inservice on infection control was done last week. CNA F said that was very important to wash hands or use hand sanitizer because failed to do that would put resident at risk for getting an infection. During an interview on 12/3/24 at 11:30AM CNA G said she was supposed to use hand sanitizer between change of gloves and failing to do that the resident would be at risk for infection or urinary tract infection. CNA G said that the last in-service on infection control was done a week ago. During an interview on 12/3/24 at 11:45 AM ADON said that handwashing or hand sanitizer should be used in between every glove changes or when gloves comes visible contaminated. ADON said that by doing handwashing would prevent any infection. ADON said that he tried to do an in-service on infection control at least every month. ADON said that staff skilled check off were done twice per year. During an interview on 12/4/24 at 12:00PM DON said that was important to practice handwashing to prevent spreading any germs from resident to resident because that would put the residents at risk for infection. 4. Record review of Resident #15's Face sheet, dated 12/3/2024, revealed Resident #15 was a 57 -year-old male, with an admitted [DATE]. Diagnoses included Type 2 diabetes (adult-onset diabetes), Cerebral infraction (a general term for a range of neurological conditions that cause a decline in mental ability and interfere with daily life), Gastrostomy status (was the presence of a gastrostomy, which was a surgical opening in the stomach that can be used for nutritional support or to decompress the stomach). Record review of Resident #15's Quarterly MDS assessment, dated 8/26/2024, revealed Resident #15's BIMS score was 2 meaning he was unable to complete the Brief Interview for Mental Status. Record review of Resident #15's care plan initiated 5/24/23 revealed Resident's#15 has a stage III pressure ulcer to his Sacrum area r/t Immobility and contractures. The resident's #15 Pressure ulcer will show signs of healing and remain free from infection by/through review date. Record review of physician's orders revealed Resident #15 had has a stage III pressure ulcer to his Sacrum area r/t Immobility and contractures. Orders were Medi honey Wound &Burn Dressing External Paste (Wound Dressings) Apply to sacrum topically one time a day for stage III sacral wound Cleanse with NS, pat dry with dry gauze, apply medihoney and cover with foam bordered dressing. During observation on 12/3/2024 at 9:10AM of wound care, the Wound Care Nurse cleanse the wound with Normal Saline and failed to maintain infection control prevention by using contaminated gloves when going from dirty to clean area. In an interview on 12/03/2024 at 9:55AM Wound Care Nurse stated she forgot to perform hand hygiene and changing gloves between cleaning and pat dry wound. The Wound Care Nurse stated not washing hands and changing gloves at the appropriate intervals could put residents at risk of getting their wounds infected or slow the healing process. The Wound Care Nurse stated she was nervous and did not realize she had skipped a step. The WCN could not state when the last in-service on performing hand hygiene was. In an interview on 12/4/2024 at 12:00PM the DON stated all staff are expected to wash hands for at least 20 seconds or greater to maintain infection control measures and stop the spread of germs. The DON stated not performing hand hygiene and wearing gloves as recommended could cause the resident's wounds to get infected. The DON stated she was going to conduct a one-on-one training with the Wound Care Nurse and in-service all staff on hand washing and changing gloves. DON stated the nurses are to follow Wound Care procedure with regards to infection control. 5. Record review of Resident #33's face sheet dated 12/04/2024 revealed the resident was a [AGE] year-old female admitted on [DATE], initial admitting date of 10/12/24 with the following diagnosis: Gastrostomy (which is a surgical opening in the stomach that can be used for nutritional support or to decompress the stomach), Cerebral Infarction (stroke), Type 2 Diabetes Mellitus, Muscle wasting and Atrophy (loss of muscle tissue), Dysphagia (difficulty swallowing), Psoriasis (chronic skin disease). Review of Resident #33's Care Plan revealed: Revised on 11/15/24 Focus: The resident requires tube feeding r/t DYSPHAGIA, ORAL PHASE Goal: The resident will maintain adequate nutritional and hydration status aeb weight stable, no s/sx of malnutrition or dehydration through review date. Interventions included the resident needs the HOB elevated 45 degrees during and thirty minutes after tube feed. Check for tube placement and gastric residual volume and record. Hold feed if greater than 100 cc aspirate. (There was nothing about Enhanced Barrier Precautions either as its own focus or as an intervention for the gastrostomy status). Review of Resident #2's Order Summary Report, dated 12/4/24, revealed active enteral feedings (Glucerna 1.5 bolus feeding via peg tube. 1 carton per feeding at 0500,1100,1700,2300. There were no orders about enhanced barrier precautions. Observation on 12/2/24 at 3:37 PM revealed Resident #33 in bed facing up. There was nothing posted at the door or at Resident #33's bedside notifying anyone of Resident #33's Enhanced Barrier Precaution status. LVN B entered the room without PPE and gave resident #33 her scheduled feeding bolus. Interview o 12/2/24 at 3:45PM LVN B said that she was not aware that she needed to use PPE with resident that had a G-Tube. LVN B said that she thought she was supposed to use EBP only if she got close to the resident. Interview on 12/2/24 at 3:50 PM the ADON said he was the ICP. The ADON stated for EBP, there was PPE on the linen carts. The ADON said staff were supposed to wear them for chronic wounds, catheter, ostomy care. The ADON stated the staff knew and had been in-serviced the gowns were on the linen carts. ADON said the last in-service on EBP was in November 2024. The ADON it was important to use PPE to prevent introduce any infection to the body through the open wounds or the ostomy. Interview on 12/4/24 at 11:55AM LVN C said that it was important to use the EBP to protect residents from whatever microorganisms that she could carry and to protect other residents. LVN C said residents could be at risk of infection. In an interview on 12/2/24 at 12:26 AM, DON stated EBP was staff needed to wear gown and gloves for individuals with a urinal, feeding tube, or wounds. DON said that it was important to use PPE to prevent introducing any kind of infection to residents, DON said that by not using EBP could put residents at higher risk for infection. Record review of RN K, Hand Hygiene Competency Assessment was completed on 12/03/24, revealed he performed and passed the hand washing procedure in accordance with the facility's standard of practice. Record Review of the facility's Infection Prevention and Control Program dated 05/13/23 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: 2. All staff are responsible for following all policies and procedures related to the program. Record review of the facility's Enhanced Barrier Precautions Policy dated 04/05/24 revealed Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions: Enhanced barrier precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. Policy Explanation and Compliance Guidelines: 2. Initiation of Enhanced Barrier Precautions: i.Indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. 3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the resident's room. 50487

Based on observation, interview and record review, the facility failed to store all drugs and biologicals in a locked compartment under proper temperature controls and permit only authorized personnel to have access to the keys for one (Resident #53) of seven residents reviewed for medications. Resident #53 had an unidentified medicated cream in a small plastic cup sitting on his nightstand. This failure could put residents at risk of unauthorized use of medication and accidental ingestions/use of an unprescribed medication. The findings were: Record review of Resident #53's Admission Record dated 12/02/24 revealed Resident #53 was admitted to the facility on [DATE] with diagnoses of acute kidney failure with medullary necrosis (a severe condition where the kidneys suddenly lose their ability to filter waste products from the blood, specifically caused by damage and cell death in the inner part of the kidney), essential (primary) hypertension (high blood pressure that has no identifiable cause), other specified malignant neoplasm of skin (the most common type of skin cancer, usually developing in areas exposed to the sun). Record review of Resident #53's physician's orders dated 12/02/24 revealed orders for Betadine External Solution 5% (Povidone-Iodine), apply to right heel topically one time a day for arterial ulcer to right heel. Cleanse with NS, pat dry, apply betadine, cover with dry dressing, and wrap with kerlix. Venelex External Ointment ([NAME]-[NAME] Oil) Apply to sacrum topically four times a day for redness to sacrum. Record review of Resident #53's physician's orders did not reveal orders for zinc oxide. Record review of Resident #53's Admission MDS dated [DATE] revealed Resident #53 able to understand others, was understood by others, and was cognitively intact. Record review of Resident #53's care plan initiated on 10/03/24 and revised on 10/04/24 revealed Resident #53 has risk for impaired skin integrity related to impaired mobility with interventions to administer medications as ordered to address medical diagnosis/conditions, monitor for effectiveness and adverse effects, conduct skin inspections/examinations weekly and as needed, document findings, and educate and reinforce on risk factors associated with resident and/or family's choice to not adhere to IDT recommendations per the plan of care. Observation on 12/02/24 at 10:21 a.m. revealed Resident #53 in bed, in a semi-sitting position. Surveyor observed a small plastic cup with white cream and a wooden stick sticking up from the center of the cup on resident's nightstand. In an interview on 12/02/24 at 10:21 AM Resident #53 said he had spots, and they used the cream to treat them. Resident #53 said he could not recall the nurse that placed the cream on the nightstand. In an interview on 12/02/24 at 11:22 a.m., LVN A said she did not do the wound treatment for Resident #53 . LVN A said she did not do the wound treatment because they have a wound treatment nurse. LVN A said she did not leave the cream in the room and did not know who might have left the cream in the resident's room. In an interview on 12/02/24 at 11:33 a.m., LVN B said she was the wound treatment nurse, but she did not leave the cream in the room for Resident #53. LVN B said Resident #53 does have wounds on his back and he has a wound on his heel, but he does not use the barrier cream zinc oxide. The resident uses Venelex, and it was not white. LVN B said she has not provided the wound care to Resident #53 today yet. In an interview on 12/02/24 at 04:11 p.m., the ADON said they do not use the zinc oxide in the nurse's carts, it was only kept in the treatment cart. The ADON said it could have been the weekend treatment nurse that left the zinc oxide in Resident #53's room. The ADON said he did not think any of the staff were going to confess to leaving the cup with the zinc oxide in the resident's room. The zinc was not used frequently it was only used for wounds. The key was kept at the nurse's station so that it could be used by other nurses. The ADON said there were no adverse effects if a resident uses it on their skin. The nurse would hand the zinc oxide to the CNA and the responsibility was the floor nurses to make sure the CNA did not leave the zinc oxide in the resident's room. Resident #53 did not have an order for the zinc oxide. Resident #53 was alert but did have some forgetfulness. Resident #53 was alert and oriented times two. The ADON said they do not have residents that wander, the residents that wander were in the memory unit. There were residents with dementia in the other halls, but they do not wander or go into other residents' rooms. In an interview on 12/04/24 at 08:11 a.m., the DON said only the nurses had access to the zinc oxide. The nurses were supposed to apply the zinc oxide to the resident and not the CNAs. The nurses should not give the zinc oxide to the CNAs to apply to the resident's skin because it was a medication, and the CNAs should not administer medications. The DON said the zinc oxide was only used for residents with wounds. Resident #53 did have a wound to his heel, but he did not have orders for the zinc oxide. Resident #53 had orders for the Venelex. The DON said the nurses should not be applying zinc oxide to Resident #53 because zinc oxide was a medication and there should be orders for the nurse to apply it onto the resident. The DON said she questioned the nurses for that hall and the wound care nurse, but they all said they had not used the zinc oxide. The DON said they do not have residents that wander into other residents' room. The facility has a memory unit. The DON said the only side effect to using the zinc oxide without an order would be dry skin. In an interview on 12/04/24 at 02:00 p.m., the ADON and DON revealed the wound care nurse had done Resident #53's wound care and did not see any zinc oxide on Resident #53 skin. Record review of the facility's Medication Administration policy dated 10/24/22 revealed: Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 11. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. 14. Administer medication as ordered in accordance with manufacturer specifications. 15. Observe resident consumption of medication. Record review of facility's Bedside Medication Storage dated 10/01/19 revealed: 6. All nurses and aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage and to give unauthorized medications to the charge nurse for return to the family or responsible party.

Based on interviews and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care plan and provide a summary of their baseline care plan to residents for 1 (Resident #161) of 8 residents reviewed for care plan completion. The facility failed to complete a baseline care plan that addressed enhanced barrier precautions for Resident #161 within the required 48-hour timeframe of admission. This deficient practice could place newly admitted residents at risk of not being provided with the necessary care and having personalized plans developed to address their specific needs. Findings included: Record review of Resident #161's face sheet dated 12/02/2024 revealed the resident was an [AGE] year-old male admitted on [DATE] with the following diagnoses: Urinary tract infection- ESBL(bacteria resistant to most antibiotics), Metabolic Encephalopathy (a disorder that affects brain function), Type 2 Diabetes Mellitus, Transient Cerebral Ischemic Attack (mini stroke), Chronic Kidney Disease, Stage 4, and Cystitis (infection in the urinary bladder). Record review of Resident #161's BIMS dated 11/30/2024 revealed he scored of 08, which indicated he had moderately cognitive impairment. Record review of Resident #161's medical record on 12/02/2024 revealed no evidence of the completion of a baseline care plan for enhanced barrier precautions. In an interview on 12/04/2024 at 11:09 a.m. with the ADON, stated there should be a baseline care plan in place for the enhanced barrier precautions. He stated the care plan was in place because it was the picture of what the nurses are doing for the resident. It was what the nurses follow to adequately care for their residents. He stated that he can add to the care plan, but the DON was the one who completes the baseline care plan. ADON stated that Resident #161 was admitted over a holiday weekend and maybe that was why it got overlooked. In an interview on 12/4/24 at 11:20 a.m. with the DON stated that she was responsible for completing the baseline care plan for the enhanced barrier precautions as well as the admitting nurses. She stated when they do the baseline care plan, it was a quick assessment, and they did not look at the ESBL and E. coli information. The DON stated that Resident #161 was admitted over the weekend, and it got overlooked. She stated that it was important to have the enhanced barrier precaution care planned because that was how they know how they will work with the resident. The care plan was what they follow for what care they are providing for the resident. Record review of facility policy titled, Baseline Care Plan date reviewed/revised 10/05/2023, revealed Policy: The facility will level and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Policy Explanation and Compliance Guidelines: a. Be developed within 48 hours of a resident's admission.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 2 of 8 residents (Resident #157 and Resident #27), staff, and the public in that: The facility failed to ensure bathroom sinks hot water temperatures were below 110 degrees Fahrenheit in occupied room for Resident #157 and Resident #27. This failure could affect residents by placing them at risk for diminished quality of life and at risk for burn injuries. Findings Included: Record review of Resident #157's , electronic face sheet dated 12/04/2024 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Unspecified Dementia, Mixed Receptive Expressive Language Disorder (problems with speaking), Muscle wasting and Atrophy (loss of muscle tissue), Hyperlipidemia (high cholesterol), and Polyosteoarthritis (arthritis that affects five or more joints at the same time). Record review of Resident #157's comprehensive MDS assessment, dated 11/20/2024 revealed a BIMS score of 05, indicating Resident #157 was severely cognitive impaired. Minimal assistance for mobility. Record review of Resident #157's care plan revised dated 11/29/24 revealed she had Dementia. Intervention included the resident was able to ambulate with supervision. Record review of Resident #27's, electronic face sheet dated 12/04/2024 revealed the resident was an [AGE] year-old female admitted to the facility on [DATE], with original admitted [DATE]. Her diagnoses included Alzheimer's Disease, Type 2 Diabetes Mellitus, Muscle wasting and Atrophy (loss of muscle tissue), Anxiety Disorder, Bipolar Disorder, and schizoaffective disorder, and Dysphasia (communication disorder). Record review of Resident #27's comprehensive MDS assessment, dated 11/14/2024 revealed a BIMS score of 00, indicating Resident #27 was severely cognitive impaired. Supervision for mobility. Record review of Resident #27's care plan revised dated 08/07/24 revealed she had Alzheimer's and ambulates in hallway most of the day. Observation on 12/02/24 at 4:15pm with the Maintenance Director and using the maintenance director's digital thermometer revealed the bathroom sink hot water temperature on 12/02/24 at 4:15 PM were: room [ROOM NUMBER]- bathroom sink was 114 degrees Fahrenheit for Resident #157 and Resident #27. In an interview on 12/02/24 at 4:20pm the Maintenance Director at time of observation stated he did rounds every day in the morning. The Maintenance Director stated he checks at least one room in each hall every day and the last time he checked them was this morning (12/02/24) but he checked the rooms furthest in the hall. The Maintenance Director stated that he documented the temperature readings in the logbook. The Maintenance Director stated the temperature should be between 100-110 degrees Fahrenheit. He stated that he moved the water heater temperature this morning to make sure the temperature was good. The Maintenance Director stated the negative outcome of the water temperature being too hot in the resident's restroom was that the residents can burn themselves. In an interview on 12/04/24 at 11:40a.m. with the Administrator, stated that she was not sure on what the procedure was for how often the maintenance director checks water temperatures. She stated that it might be done daily but maybe one room from each hall. She stated they have a system in place called TELS (a platform designed to help maintenance teams' efficiency). The administrator stated she usually gets an alert if something was not completed on time. She stated the hot water temperature should be at 110 degrees Fahrenheit. She stated if the hot water was too hot then it can be dangerous for the residents when they wash their hands and/or their face. Record Review of the Logbook documentation dated 12/02/24 revealed room [ROOM NUMBER] was 119 degrees F. Further review of Logbook for month of November revealed minimal variation of temperature between 106 to 108 degrees F. Review of facility's incident and accidents logs dated 10/2024, 11/2024, and 12/2024 did not reveal any injuries to residents due to hot water. Review of the facility's Grievance logs dated 10/2024, 11/2024, and 12/2024 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. Record results in the water temperature log. 2. Adjust water heater setting as required. 3. Retest as necessary

Based on observation, interview 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 promotes enhancement of his or her quality of life, recognizing each resident's individuality for 2 of 7 Residents (Resident #5 and Resident #12) who were observed for ADL care. 1. CNA D stood while feeding Resident #5 her lunch meal on 12/2/24. 2. CNA D stood while feeding Resident #12 her lunch meal on 12/2/24. These deficient practices could affect dependent residents and contribute to feelings of shame or feeling uncomfortable and could place residents at risk of embarrassment, lack of privacy, and loss of dignity. The findings were: Review of Resident #5's face sheet, dated 12/3/24, revealed she was initially admitted to the facility on [DATE] with diagnosis including Alzheimer's Disease (A progressive disease that destroys memory and other important mental functions), Chronic Obstructive Pulmonary Disease (A group of lung diseases that block airflow and make it difficult to breathe), Chronic Kidney Disease (a condition where the kidneys are damaged and can't filter blood properly, which can lead to a buildup of waste and fluid in the body), Need for assistance with personal care, all dated 8/11/2021. Review of Resident #5's quarterly MDS assessment, dated 11/13/24, revealed her BIMS was 3 meaning she was unable to complete the Brief Interview for Mental Status. Further review revealed she had a diagnosis of Alzheimer's Disease and required assistance with eating. Review of Resident #5's Care Plan, initiated on 11/12/23, revealed she had an ADL self-care performance deficit r/t General Weakness, Decreased Mobility, ALZHEIMER's, and the resident requires assistance by 1 staff to eat. Observation on 12/2/24 at 12:30PM to 1:00 PM revealed CNA D standing while feeding Resident #5. Resident #5 was eating all of her food while periodically looking up at CNA D. 2. Review of Resident #12's face sheet, dated 12/3/24, revealed she was admitted to the facility on [DATE] with diagnoses including Dementia (a general term for a range of neurological conditions that cause a decline in mental ability and interfere with daily life) and Cerebral infraction (a general term for a range of neurological conditions that cause a decline in mental ability and interfere with daily life). Review of Resident #12's quarterly MDS assessment, dated 09/7/24, revealed her BIMS was 2 meaning she was unable to complete the Brief Interview for Mental Status. Review of Resident #12's Care Plan, initiated on 12/29/2017, revealed she had has an ADL self-care performance deficit r/t Activity Intolerance, Dementia, Limited Mobility and the resident requires assistance by 1 staff to eat. Observation on 12/2/24 at 12:30PM to 1:00 PM revealed CNA D standing while feeding Resident #12. Resident #12 was eating all of her food while periodically looking up at CNA D. Interview on 12/2/24 at 1:00 PM with CNA D revealed that he knew that he had to be sitting down, and he said that today his back was hurting and that was why he was standing up while feeding the residents. He said that he had training but was not able to recall when the training took place. Interview on 12/2/24 at 4:10PM with ADON said that feeding the residents standing up is not respectful to the residents. He said that by sitting down while feeding residents shows dignity and respect to the residents. Interview on 12/4/24 at 12:00 PM with the DON revealed staff should be sitting down while feeding residents because it shows respect and to prevent violating the resident's dignity. DON said that managers on duty are responsible to make sure staff is sitting down when feeding the residents. Review of a facility policy, Promoting/Maintaining Resident Dignity During Mealtimes, implemented on 1/13/23 read: 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 protect the rights of each resident. All staff will be seated, if possible, while feeding a resident.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standard or food service safety for 1 of 1 kitchen reviewed for food service safety in that: The facility failed to ensure all food items were labeled and dated in the refrigerators and in the dry storage. This failure could place residents at risk of foodborne illnesses. The findings included: An observation and interview during the initial tour of the facility's #2 refrigerator on 12/02/24 at 8:53 a.m. revealed on opened one gallon container of Dijon honey mustard salad dressing with the dates of 04/23 and 05/17 on the lid. The Dietary Manager said they do not use the Dijon dressing that often. An observation of the facility's #1 refrigerator on 12/02/24 at 8:54 a.m. revealed a 17 oz container of Siracha hot chili sauce without a date. An observation of the facility's dry storage on 12/02/24 at 8:56 a.m. revealed six loaves of bread that were not dated. In an interview on 12/02/24 at 8:56 a.m. the Dietary Manager said all the staff were responsible for receiving food items form vendors and have been trained to label and date all foods items in the refrigerator, freezer, or dry storage. In an interview on 12/03/24 at 11:40 a.m., the Consultant Dietician said he sent in in-services monthly for the Dietary Manager to conduct with the staff. The Consultant Dietician said he also did monthly sanitation reviews where he observed different areas such as hand hygiene, safe food handling and temperature control. The Consultant Dietician said all staff knew to date and label all food items when received and stocked. It is important to date and label all food items to prevent food expiration or spoilage or food contamination and prevent the residents from getting sick. In an interview on 12/03/24 at 12:56 p.m., Dietary Aide H said all staff were responsible for receiving and stocking food items. Once they received the items they had to date and label all merchandise. Dietary Aide H said they had an in-service two months ago on that. Dietary Aide H said it is important to date items so they can know if the food is still good to use. Dietary H said they did not want the residents to get sick from food they provided. In an interview on 12/03/24 at 1:09 p.m., Dietary Aide I said everyone is responsible for storing food and other items. Dietary Aide I said they [NAME] to write the date before storing the food in the refrigerator, freezer, or pantry. In an interview on 12/04/24 at 4:15 p.m., the Administrator said the Dietary Manager oversees the kitchen staff and the staff have trainings and should be following policies. Record review of facility's policy titled Policy: Food Storage date revised: June 1, 2019, stated: Policy: 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. 1. Dry Storage g. Use the first-in, first-out (FIFO) rotation method. Date packages and place new items behind existing supplies, so that the older items are use first. 2. Refrigerators d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent covered containers that are approved for food storage.

Based on observation, record review, and interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being, in accordance with the comprehensive assessment for one Resident (R#2) with pain of eight residents reviewed for pain management. R#2's pain to her self-inflicted wounds to the gluteus and thighs were not assessed and R#2 did not receive medication to prevent pain. Failure to provide the necessary care and services likely caused unnecessary pain and discomfort for R#2 and could put 22 residents on a pain management program at risk for unnecessary pain and discomfort. The findings were: Face Sheet dated 06/10/2011 revealed R#2 was admitted to the facility on [DATE] with diagnoses of Dementia with Behavior Disturbance, [MEDICAL CONDITION], Nonspecific Skin Eruptions, Anxiety State, Diabetes, Mood Disorder, [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. The Face Sheet indicated R#2's Father and Mother's name was unknown. Emergency notification name listed a friend with a phone number. Significant Change Minimum Data Set (MDS) assessment dated [DATE] indicated R#2: -had moderately impaired cognitive skills for daily decision making (decisions poor, cues/supervision required), -had [MEDICAL CONDITION] with [MEDICAL CONDITION] (misconceptions or beliefs that are firmly held, contrary to reality), -had not received any pain medications, -could not be interviewed for pain due to resident rarely/never being understood, -required extensive assistance for all Activities of Daily Living (ADLs) for bed mobility, transfer, locomotion on and off the unit, dressing, personal hygiene and bathing, -was totally dependent on two staff for transfers, dressing, toilet use, and personal hygiene, and, -used a wheelchair for mobility. Quarterly MDS assessment dated [DATE] revealed R#2: -had moderately impaired cognitive skills for daily decision making, -had [MEDICAL CONDITION] with [MEDICAL CONDITION], -had not received any pain medications, and, -could not be interviewed for pain due to resident rarely/never being understood. R#2's May 2012 physician's orders [REDACTED]. -administer [MEDICATION NAME] 650 milligrams (mg), one tablet by mouth as needed (PRN) every six hours for pain, start date 8/30/11. -apply [MEDICATION NAME] (used in treatment of [REDACTED]. -cleanse right thigh wounds with saline, pat dry with gauze and apply zinc oxide with [MEDICATION NAME] (used to treat skin infections) 1:1 mixture BID (twice daily) and after "stooling". Apply thick and leave open to air until healed. -cleanse left thigh wounds with saline, pat dry with gauze and apply zinc oxide with [MEDICATION NAME] 1:1 mixture BID (twice daily) and after "stooling". Apply thick and leave open to air until healed. -apply zinc oxide ointment to right thigh BID, start date 8/30/11. -apply zinc oxide ointment to left thigh BID, start date 8/30/11. -cleanse left gluteal wound with saline, pat dry with gauze and apply zinc oxide with [MEDICATION NAME] 1:1 mixture BID and after "stooling". Apply thick and leave open to air until healed, start date 08/30/11. Review of Non-Pressure Skin Condition Record dated 01/02/12 revealed self-inflicted scratches to right and left gluteal and thighs to be continued with current treatment. The Psychiatrist's last two progress notes dated 06/09/11 and 01/12/12 revealed no [DIAGNOSES REDACTED]. Review of R#2's Pain Evaluation dated 01/13/12 revealed R#2 had not been on a scheduled pain management regime or received PRN pain medications between 01/08/12 and 01/13/12. R#2 had received non-medication intervention for pain including reassurance and assistance with positioning with positive results. In the resident interview area of the Pain Evaluation, the interview revealed R#2, "had a rambling response, not related to question when asked if she had any pain in the last 5 days (between 01/08/12 and 01/13/12)." R#2 had no response when asked the questions, "how much of the time have you experienced pain or hurting over the last 5 days, had pain made it hard for you to sleep at night and over the past 5 days, have you limited your day-to-day activities because of pain?" Review of the Head to Toe Skin Checks for the months of January, February, and March and April 2012 revealed skin was not intact due to self-inflicted wounds to buttocks, thighs, and sometimes to face and arms. Wound Care Progress Notes dated 12/09/11, 12/23/11, 01/06/12, 01/13/12 and 05/03/12 were reviewed. All notes revealed R#2's wounds were treated by the Wound Care Physician. Pain Evaluation dated 04/09/12 revealed R#2 had not been on a scheduled pain management regime or received PRN pain medications for the last five days. In the resident interview area of the Pain Evaluation, the interview revealed R#2 was unable to answer the questions, "How much of the time have you experienced pain or hurting over the last 5 days, over the past 5 days, had pain made it hard for you to sleep at night and over the past 5 days, have you limited your day-to-day activities because of pain? " R#2's Medication Administration Records (MARs) dated April and May 2012 revealed [MEDICATION NAME] 650 mg one tablet to be administered for pain PRN every 6 hours. See pain flow sheet. The PRN Pain Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The record revealed one [MEDICATION NAME] dosage was administered on 04/10/12. The PMAR for May 2012 revealed no dosages of [MEDICATION NAME] had been administered as of 05/09/12 at 3:00 p.m. Nursing Weekly/Monthly Summary dated May 2012 revealed comments in the pain section that R#2, "denies pain. PRN Tylenol. Trial of [MEDICATION NAME] for week of 02/12/12 with zero [MEDICATION NAME] positive results." Comments in the pain section of Nursing Weekly/Monthly Summary for April and March 2012 revealed R#2, "denies pain." Interview with Licensed Vocational Nurse (LVN) "B" during initial tour on 05/07/12 at 7:25 a.m. revealed R#2 had no family, had behaviors of yelling, and was very confused. LVN "B" said R#2 had self-inflicted wounds to her buttocks and both thighs, made with her hands and fingernails. Surveyor observed R#2 was lying in bed. After noticing surveyor and LVN "B" in room, R#2 began to ask surveyor questions about unknown persons or facts. Interview with Certified Nurse Aide (CNA) "P" on 05/08/12 at 9:15 a.m. revealed that R#2 required assistance with her showers, dressing, grooming, incontinent care and transfers from bed to wheelchair and wheelchair to bed. CNA "P" said she always got another staff member to assist her with transferring R#2 from her bed to her wheelchair and back to bed. R#2 could bear weight, but usually two staff would assist her because the pain from the scratches to R#2's buttocks was so great. CNA "P" said R#2 could get up from bed by herself, but R#2 did not want to get up unassisted due to the pain in her buttocks. CNA "P" said she would usually get another staff member to assist her in dressing R#2 because R#2 would moan and grimace as if in pain when she was dressed. CNA "P" said R#2 would usually moan and grimace as if in pain when R#2 was assisted in transfers from bed to wheelchair and back to bed. Interview with LVN "B" on 05/08/12 at 9:45 a.m. revealed that R#2 used her fingernails to scratch her thighs and buttocks. The wound care doctor told her and staff that R#2's problem with her scratching herself was a "psychiatric" problem. After telling R#2 that she was going to look at her thighs, LVN "B" exposed R#2's wounds to the right thigh for observation. R#2's right thigh had approximately eight long scratches with excoriation (scratched or abrased skin). R#2 moaned, grimaced, and said, "get me up." LVN "B" covered R#2's thigh with a blanket. R#2 immediately started asking surveyor questions, "Hey, do you know how to make cookies, do you know if they still make bread in Matamoros, do you know how to make bread, do you know Maria from Matamoros?" On 05/08/12 at 1:25 p.m. prior to the incontinent care for R#2 provided by CNA "L" and CNA "M", R#2 was observed sitting in her wheelchair in her room. CNA "L" and CNA "M" lifted R#2 from the wheelchair into her bed. As CNA "L" lifted R#2, CNA "L" touched R#2's left hip area with her arm and R#2 yelled out in pain. R#2's pajama bottom was observed with two large dry blood stains from the buttocks area. CNA "L" and CNA "M" assisted R#2 to bed. Both CNAs removed R#2's diaper, which was saturated with urine. CNA "L" cleaned R#2's buttocks area with a dry wipe cloth. CNA "L" began to use a dry wipe cloth to rub R#2's buttocks and R#2 started to moan as if in pain. CNA "L" said R#2 was always in pain when they changed her diaper. Surveyor observed both of R#2's buttocks were extremely excoriated, appearing like raw meat, with red skin peeling and bleeding. R#2's buttocks, backs of both thighs and skin folds under buttocks were completely red and bleeding. CNA "L" applied zinc oxide to R#2's entire excoriated areas. R#2 moaned as if in pain. CNA "M" said R#2, "always has pain when we clean her or change her diapers." On 05/08/12 at 4:45 p.m. R#2 was observed exiting the shower room in her wheelchair followed by CNA "I ". CNA "I" took R#2 to the dining room. Interview with CNA "I" on 05/08/12 at 4:45 p.m. revealed that R#2 did not express pain when she was showered, while she sat in the shower chair. CNA "I" said she would change R#2's diaper by herself since she was the only one that worked on her hall on the 2:00 p.m. to 10:00 p.m. shift. CNA "I" said sometimes R#2's diaper had a little bit of blood on the buttocks area. CNA "I" said she knew R#2 had pain from the wounds on her buttocks and thighs because R#2 would moan and her face would grimace, even if R#2 did not verbally say so. R#2 would not verbally tell her that she had pain but she thought R#2 did not know pain. CNA "I" said she thought R#2 could not verbally express pain because R#2 had mental problems. Review of R#2's care plans revealed no evidence R#2's ADLs were care planned. Interview with Assistant Director of Nurses (ADON) "A" on 05/09/12 at 9:05 a.m. revealed she had reviewed R#2's care plans and could not find R#2's care plan that addressed R#2's ADLs. The care plan for pain for R#2, last date reviewed on 04/11/12, revealed a problem of actual pain related to chronic disease process. Goal checked off in the care plan for pain was that R#2 would have reduced pain as measured by verbal expression and/or decrease in behaviors associated with pain. Approaches included to: - redirect R#2 with coloring and reassurance, - administer [MEDICATION NAME] as ordered, - implement pain management flow sheet, - observe resident for signs and symptoms of pain, including verbal expressions and nonverbal expressions (facial grimacing, bracing, restlessness, rubbing, other). Frequency of monitoring was every shift, -notify R#2's Physician if interventions were not consistently effective, and, -administer [MEDICATION NAME] ([MEDICATION NAME] pain medication) 50 mg (milligrams), one tab twice a day for two weeks start date 02/02/12. During wound treatment for [REDACTED]. LVN " B " said R#2's skin condition was improving. LVN "B" said the doctor had tried different treatments and she felt the Zinc and Lotrim mixture was the best one that was working. LVN "B" said CNAs would change R#2's diaper every two hours. If R#2 had a bowel movement, the CNAs were supposed to let her know and LVN "A" would come in and apply the Zinc with Lotrim. LVN "B" would do the wound treatment in the morning and another nurse would do a second wound treatment in the afternoon. If R#2 did not have a bowel movement, CNAs would apply zinc oxide only. After preparing the bedside table with wound treatment supplies, LVN "B" had CNA "N" assist R#2 to stand up and lean against the bed. CNA "N " and LVN "B" removed R#2's clothes and diaper, which was very wet. LVN "B" used 4 x 4 sponge gauze saturated with saline and squeezed saline onto R#2's buttocks and both thighs. LVN "B" applied the [MEDICATION NAME] ointment with a wooden spoon. R#2 moaned "Ay" and face was grimacing. After the application of ointment, a diaper was placed on R#2 and she was transferred onto her wheelchair, all the time conversing incoherently. On 05/09/12 at 12:15 p.m. surveyor attempted to interview R#2. R#2 began to ramble with questions about unknown persons. Interview with the ADON "A" on 05/09/12 at 2:30 p.m. revealed no staff had informed her that R#2 had pain during transfers, dressing or incontinent care. R#2 had never verbally expressed or otherwise to her that she was in any pain. ADON "A" asked R#2 if she was in any pain but only when R#2 was in bed or sitting in her wheelchair. When asked if she was in pain, R#2 would say, "No" and instantly start other conversations with random questions. On 05/09/12 at 2:50 p.m. CNA "I" said she told Registered Nurse "Q" on 05/08/12 that R#2 had expressed pain and she had also told other nurses on other days. On 05/09/12 at 3:00 p.m. LVN "R" said she asked R#2 if she was in any pain before her wound treatments. R#2 would say "No" when asked if she was in pain. LVN "R" said she did not think R#2 would be able to verbally express if she was in any pain. R#2 would not express pain verbally or non-verbally, only continuing to talk "rambling." R#2's rambling conversations made her think that R#2 could not make any type of decisions. Interview with the Interim External Director of Nurses (DON) on 05/09/12 at 3:35 p.m. revealed several interventions for R#2 had been implemented for her self-inflicted wounds to her buttocks, thighs, face, and arms. R#2 was treated for [REDACTED]. After removing R#2's urinary catheter some time ago, the scratching had lessened. The DON said she believed R#2's self-inflicted wounds were related to her [DIAGNOSES REDACTED].#2. R#2 had received an evaluation by the facility psychiatrist. On 05/09/12 at 5:45 p.m. during the exit conference with the Administrator and the DON, surveyor asked if the facility had any additional information to present regarding pain management. No additional information was provided. The CMS (Center for Medicare & Medicaid Services) form 802 documented 22 residents on a pain management program.