ESTATES HEALTHCARE AND REHABILITATION CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from abuse for 3 of 6 residents (Resident #4, Resident #6, and Resident #7) reviewed for abuse.<BR/>1. The facility failed to ensure Resident #4 was free from emotional and mental abuse. Video footage identified CNA A antagonizing Resident #4 when she went to check on him on 02/18/25 . <BR/>The noncompliance was identified as past noncompliance (PNC). The noncompliance began on 02/18/25 and ended on 02/19/25. The facility had corrected the noncompliance before the investigation began.<BR/>2. The facility failed to ensure Resident #6, and Resident #7 were free from abuse on 03/11/25 when Resident #6 verbally abused Resident #7 which cause Resident #7 to physically abuse Resident #6 by hitting him on the face. <BR/>The noncompliance was identified as past noncompliance (PNC). The noncompliance began on 03/11/25 and ended on 03/14/25. The facility had corrected the noncompliance before the investigation began.<BR/>These failures could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and psychological harm.<BR/>Findings included:<BR/>1. Record review of Resident #4's Face sheet dated 05/01/25, revealed the resident was a [AGE] year-old male with an admission date of 04/15/24 and readmitted on [DATE]. <BR/>Record review of Resident #4's quarterly MDS, dated [DATE], reflected his diagnoses included anxiety disorder, vascular dementia, and mild cognitive impairment. Resident #4's BIMS score was 04 which indicated his cognition was severely impaired. The MDS Section E - Behaviors reflected Resident #4 did not exhibit any physical or verbal behaviors towards others. The MDS Section GG - Functional Abilities also reflected Resident #4 was dependent of staff to assist with ADLs. <BR/>Record review of Resident #4's Care Plan revised date 03/11/25, reflected Focus: The resident has a behavior problem r/t hx of stroke, resident will become difficult to manage. Resident yells out loudly and will use cursive language. Resident is very adament toward care, sports, etc and will yell out at staff and curse. Goal: The resident will have fewer episode by review date. Interventions: Anticipate and meet the resident's needs. Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by. Redirection techniques will include offering alternatives to the current activity. <BR/>Record review of the Provider Investigation Report dated 02/25/25 reflected, Resident responsible party had address to [Administrator] a concern of a staff member being rough with the resident when trying to readjust on the bed. When [Responsible party name], the resident's responsible party, entered [Administrator] office and informed [Administrator] of an incident that occurred the previous night, [Administrator] contacted the CNA [CNA A] to discuss the matter. [Administrator] informed her about the responsible party reported aggressive behavior toward the resident [Resident #4] and confirmed that she had indeed acted aggressively toward [Resident #4] due to [Resident #4] cussing at him and she was trying to correct him. [Administrator] informed her that she would be suspended until further notice. Safe surveys conducted no noted concern. Skin assessment completed and no noticed concerns, pain assessment no noted concerns, Trauma assessment no concerns noted. The Provider Investigation Report also reflected that the result of the investigation was inconclusive, but CNA A was terminated. <BR/>Record review of CNA A's Statement dated 02/29/25, reflected Went to resident's room cause he was hanging off the bed and yelling. [CNA A] told the resident to put his legs back in the bed before he ended up on the floor. That's when the resident call me a bitch and to leave him alone. [CNA A] told him not till he in bed right that if keeps hanging out the bed like that he was going to be on the floor and the floor hursts and wins every time. He then proceeded to call me a bitch again. [CNA A] told him to don't be disrespectful to me cause [CNA A] wouldn't do him like that and that I'm someone sister daughter and mother and that he wouldn't like it if [CNA A] called the women in his family that name. [CNA A] also asked him what was wrong with him.<BR/>Observation of Video Footage time stamped 02/18/2025 05:44:24 CST [5:44 AM] revealed: Resident #4 sitting at the edge of the bed. CNA A (who was a tall, heavy-set woman) entered Resident #4's room stating, What are you doing [Resident #4's name]. Resident #4 states What are you talking about bitch. CNA A stated what. Resident #4 stated What are you talking. CNA A standing in front of Resident #4. CNA A then proceed to tell Resident #4 twice to put those legs back in the bed. Resident #4 asked CNA A Why?''. CNA A tells Resident #4 you can't walk [you] will end up on the floor. Resident #4 tells her No I won't. CNA A responded, Okay bet, but I am going to put your legs back on the bed. Resident #4 asked why again. CNA A responded, I don't have to explain why. Resident #4 asked CNA A why are [you] going too and CNA A stated, because I am going too. Resident #4 stated you not going too. CNA A observed leaning forward and grabbed the control for the bed. Resident #4 stated Get your fucking hands of me bitch, I will fuck you up. CNA A asked resident What did [you] say? and Resident #4 stated, I will fuck you up, get your fucking hands off of me. CNA A observed to lean forward put her right hand on Resident #4's right knee. CNA A then stated My hand is on you. What are [you] going to do? Nothing, and [you] better quit calling me out of my name because [you] wouldn't like if [I] called your momma, sister, or anybody in your family out of their name, don't be disrespectful to [me] because I am not being disrespectful to [you], [you] understand. Resident #4 agreed with CNA A and CNA A removed her hand from Resident #4's knee. CNA A states I don't know where you get that being disrespectful from, that [ain't] going to get you nothing , that [ain't] going to get you no help, that is going to get you talk ed about, don't be disrespectful, and you wait until someone comes in here to help you, you got me? CNA A proceed to adjust Resident #4's legs on the bed. Resident #4 stated I hear that CNA A states Alright then, I am not about to play with you, cause you end up on the floor, you end up on the floor and the floor hurts and it wins every time. Resident #4 stated yeah right. CNA A states Yeah right, you got a real smart mouth, what is wrong with you, what is your problem tonight. Resident state I got a problem with you. CNA response No, I [ain't] your problem, Resident stated oh yeah. CNA A stated, I just came in here to help you. CNA A proceeded to walk out the room and stated, you better act like you got some sense. Video was about 2 minutes long. CNA A hand was on Resident #4's knee for about 32 second.<BR/>Interview on 04/30/25 at 11:14 AM, Resident #4 revealed he was doing well and feeling safe at the facility. Resident #4 was not a good historian; resident could not recall incident with CNA A. <BR/>Interview on 04/30/25 at 12:46 PM, Resident #4 Family Member revealed she reviewed the video footage a day after the incident and notified the Administrator. She stated the incident happened on 02/18/25, Resident #4 was sitting on his bed and the staff was observed entering the room. She stated on the video footage it was observed Resident #4 being disrespectful toward the staff; however, the staff was rude and antagonizing the situation. She stated on the video it was observed Resident #4 saying keep your hands off of me and then staff proceed to put her hand on his knee. Family Member stated she agreed with the staff redirecting and telling Resident #4 to stop cursing at her; however, the staff putting her hand on him was what concerned her. She stated the staff was antagonizing the situation by putting her hand on Resident #4. Family Member stated after the Administrator was notified, the facility investigated the incident and terminated the staff. <BR/>Interview by phone on 05/01/25 at 9:27 AM, CNA A revealed she was doing her last round, when she heard Resident #4 screaming. She stated she entered the room and observed Resident #4 was hanging on the side of the bed. She stated she asked Resident #4 what he was doing, and Resident #4 started to curse at her and got mad because she told him to get back in bed. CNA A stated Resident #4 was calling her a bitch and being disrespectful to her. She stated she told Resident #4 to stop, to not called her like that because he would not like for someone to call his mom, sister or daughter that. She stated Resident #4 stated he would not like that. She stated she only touched Resident #4 when repositioning him back to bed. CNA A stated she was not supposed to correct Resident #4. She stated she was wrong for telling him to stop being disrespectful because they were told residents were always right. CNA A stated she never touched the resident or disrespected the resident. CNA A stated she was suspended and then let go. <BR/>Interview on 05/01/25 at 2:16 PM, Corporate Compliance RN revealed she reviewed the video footage regarding CNA A and Resident #4. She stated CNA A should lose her license. She stated CNA A was verbally abusive towards Resident #4, she stated when CNA A put her hand on Resident #4' she was antagonizing the situation. She stated CNA A should had stepped away. Regional Compliance stated Resident #4 had no adverse effects from the incident. She stated CNA A was terminated. <BR/>Interview on 05/01/25 at 2:36 PM, the Administrator revealed Resident #4 family informed him about the incident and he immediately suspended CNA A. He stated skin assessment was completed on Resident #4 with no injuries, safe surveys and quality of life checks were completed with no concerns. The Administrator stated after reviewing the video footage it was determined CNA A was considered being verbally abusive and was terminated for abuse. He stated CNA A admitted to what she did wrong. He stated his expectations were for his staff to respect residents, care for them and to report any abuse and neglect allegations to him to protect the residents. <BR/>Record Review of CNA A's personnel file, reflected CNA A was suspended and terminated on 02/19/25.<BR/>Record review of facility Abuse/Neglect policy, revised 09/09/24, reflected the following: <BR/>The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility.<BR/>Prior to the HHSC investigation, the facility took the following actions to correct the noncompliance:<BR/>Record review of Resident #4's Skin assessment, Pain assessment and Trauma Assessment completed on 02/19/25, no concerns noted.<BR/>Record review of Safe surveys were completed on 02/19/25 with five residents with no issues noted.<BR/>Record review of facility In Service Training dated 02/19/25, provided by Administrator and Corporate Compliance RN reflected staff were In Serviced on Abuse and Neglect Policy to include - Arguing with, antagonizing, and touching a resident against their will is considered Abuse. If [you] see a staff member or resident engaging in this activity, the Administrator must be notified immediately. The Administrator is the abuse coordinator. If [you] can't get a hold of the administrator, notify the DON or ADON immediately. Staff should not continue to work their shift, they must be suspended immediately, Resident Rights <BR/>Record review of facility In Service Training dated 02/19/25, provided by Corporate Compliance RN reflected staff were In Serviced on Abuse and Neglect, Resident Rights.<BR/>Interviews on 04/30/25 from 1:21 PM through 05/01/25 to 3:45 PM with ADON Y, ADON U, BOM, FM, CNA B, LVN C, CNA D, CNA F, CNA H, CNA E, Van Driver, CNA I, CNA F, LVN G, LVN K, LVN L, CNA V, LVN X revealed the facility staff were able to verify education was provided to them. The nursing staff stated they were educated on different types of abuse/neglect and resident rights. Staff provided the types of abuse were physical, mental, financial, and verbal. Staff stated the three signs of abuse occur when the resident avoids eye contact, bruises, and the resident withdraws from care. Staff stated they would intervene if witness any type of abuse from a staff. Staff revealed they would report these and other signs to the Abuse Coordinator, the Administrator, immediately if they witness or observed any of these signs.<BR/>2. Record review of Resident #6's Face sheet dated 05/01/25, revealed the resident was a [AGE] year-old male with an admission date of 04/28/21 and readmitted on [DATE]. <BR/>Record review of Resident #6's quarterly MDS, dated [DATE], reflected his diagnoses included bipolar disorder, dementia, and cognitive communication deficit. Resident #6's BIMS score was 12 which indicated his cognition was moderately impaired. The MDS Section E - Behaviors reflected Resident #6 did not exhibit any physical or verbal behaviors towards others. The MDS Section GG - Functional Abilities also reflected Resident #6 needed substantial/maximal assistance with ADLs.<BR/>Record review of Resident #6's care plan, revised 03/11/25, reflected Focus: The resident has a history of trauma that may have a negative impact. The trauma is r/t: Resident with hx of physical altercation with another resident. Goal: Maintain resident's safety and integrity post trauma episode, using appropriate interventions. Interventions: Perform the following de escalation techniques as required: redirection, and deep breathing. Psychiatric services adjusted medication.<BR/>Record review of Resident #7's face sheet dated 05/01/25, revealed the resident was a [AGE] year-old male with an admission date of 12/24/21 and readmitted on [DATE].<BR/>Record review of Resident #7's admission MDS, dated [DATE], reflected his diagnoses included anxiety disorder, major depressive disorder, schizoaffective disorder, restlessness and agitation and cognitive communication deficit. Resident #6's BIMS score was 13 which indicated his cognition was cognitively intact. The MDS Section E - Behaviors reflected Resident #7 did not exhibit any physical or verbal behaviors towards others. The MDS Section GG - Functional Abilities also reflected Resident #7 was independent for ADLs.<BR/>Record review of Resident #7's care plan, revised 04/14/25, reflected Focus: The resident has potential to demonstrate physical behaviors related to paranoid schizophrenia, schizoaffective disorder as evidence by: Physical aggression demonstration due to being provoke when cussed at. Goal: The resident will seek out staff/caregiver when agitation<BR/>occurs through the review date. Interventions: If the resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately.<BR/>Record review of the Provider Investigation Report dated 03/18/25 reflected, [Speech and Language Therapist] witness [Resident #7] hit [Resident #6] due to an altercation they were having an immediately separate them both. During investigation, Resident #7 reported that Resident #6 was using inappropriate language to him and repeatedly told him to stop. When Resident #6 continued, Resident #7 became frustrated and end up hitting him. Upon witnessing the incident, [Speech Therapy] quickly intervene to separate the two residents and called for assistance. Both residents were promptly separated, and a 1:1 supervision was implemented until a psychiatric evaluation could be performed.<BR/>Record review of Witness Statement from Speech and Language Therapist dated 03/11/25 reflected, My name is [Name]. [Speech and Language Therapist ] am an employee at the [Facility Name]. [Speech and Language Therapist] am the speech language pathologist. At approximately 10:15 a.m., [Speech and Language Therapist] witnessed two residents [Resident #6 and Resident #7] in a physical altercation in the dining room. [Speech and Language Therapist] heard [Resident #7] say to [Resident #6] call me a bitch one more time. [Resident #6] responded and then [Resident #7] struck [Resident #6] about two times. Immediately, [Speech and Language Therapist] intervened to ensure both men were safe. [Resident #7] left the dining room. Once [Resident #7] left the dining room, [Speech and Language Therapist] asked [Resident #6] if he was okay and if he could tell me what happened. [Resident #6] replied, he's just mad because [Speech and Language Therapist] wouldn't give him a cigarette. Once both individuals were safe, [Speech and Language Therapist] immediately told [Administrator]. <BR/>Interview on 04/30/25 at 10:45 AM, Resident #6 stated he was doing well. Resident #6 stated he had an incident with Resident #7. Resident #6 stated Resident #7 got frustrated with him, and Resident #7 kept telling him to not say anything to him. Resident #6 stated he told Resident #7 that he was coming in and needed him to get out of the way, he stated Resident #7 got more frustrated and hit him on the side of the face. Resident #6 stated the police was called but he did not pressed charges. Resident #6 stated he was only hit once on the side of his face. Resident #6 stated he was not hurt. Resident #6 stated he never called Resident #7 any names. <BR/>Interview on 04/30/25 at 12:26 PM, Resident #7 stated he was doing well. Resident #7 stated he got into an altercation with Resident #6. Resident #7 stated for a week Resident #6 was messing with him and calling him out of his name. Resident #7 stated he never told anyone about it. Resident #7 stated on the day of the altercation Resident #6 called him a bitch and he asked Resident #6 to stop but he continued to call him a bitch. Resident #7 stated he got mad, and he hit him on the face once. Resident #7 stated he was tired of Resident #6 calling him a bitch. Resident #7 stated after the altercation, he keeps his distance from Resident #6. <BR/>Interview on 05/01/25 at 9:49 AM, the Administrator revealed Speech and Language Therapist was out on leave. <BR/>Interview on 05/01/25 at 1:38P PM, ADON Y stated Resident #6 and Resident #7 had an altercation in the dining room on 3/11/25. She stated it was a witnessed altercation by Speech Therapy. She stated she was not sure what started the altercation, but Resident #7 got upset and hit Resident #6 in the face. She stated there had been no previous incidents between them. She stated both residents were assessed with no injuries and placed on 1:1 monitoring until psych services consult. She stated the incident was considered abuse from Resident #7 hitting Resident #6. <BR/>Interview on 05/01/25 at 2:16 PM, Corporate Compliance RN revealed she was made aware of the incident between Resident #6 and Resident #7. She stated she was informed Resident #7 slapped Resident #6 on the face. She stated she was unsure what started the argument. She stated the incident was considered abuse from Resident #7 to Resident #6. She stated Resident #7 was placed 1:1 supervision, a psych services consult was completed, medications were adjusted, and Resident #7 was moved to another hall. Resident #6 had no injures to him and also received a psych service consult. <BR/>Interview on 05/01/25 at 2:36 PM, the Administrator revealed Speech and Language Therapist observed Resident #6 and Resident #7 talking and then observed Resident #7 slapped Resident #6 on the face. He stated the Speech and Language Therapist intervene and separated both residents. The Administrator stated the police was called, skin assessment, trauma and pain assessment completed on both residents with no concerns. He stated families were notified of the incidents. The Administrator stated Resident #7 was placed on 1:1 monitoring, and then Resident #7 requested to go home after the incident. He stated two weeks later Resident #7 returned to the facility and he got a new room in a different hall. The Administrator stated both residents used to get along and joke with each other, he stated he was not sure what happened between them. The Administrator stated a resident-to-resident altercation was considered abuse, and every resident had the right to be free from abuse and neglect. <BR/>Record review of facility Abuse/Neglect policy, revised 09/09/24, reflected the following:<BR/>The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. Resident to Resident - The above policy will apply to potential resident-to-resident abuse.<BR/>Prior to the HHSC investigation, the facility took the following actions to correct the noncompliance:<BR/>Record review Resident #6 progress notes dated 03/11/25 14:58 [2:58 PM] new order for busPirone HCL Oral tablet 15 mg (Buspirone HCl) Give 1 tablet by mouth every 12 hours for anxiety.<BR/>Record review of facility 15 Minute Monitoring dated 3/11/15, reflected Resident #7 was being monitored every 15 minutes starting at 10:15AM and ended at 11:45 AM. <BR/>Record review Resident #7 progress notes dated 03/11/25 15:24 [3:24 PM] Psych NP [Resident #7] telehealth with the resident. New order obtained for HydroXizne HLC tablet 25 MG give 1 tablet by mouth every 8 hours as needed for anxiety x 14 days and to monitor behaviors q shift.<BR/>Record review Resident #7 progress notes dated 03/11/25 15:55 [3:55 PM] reflected, [Resident #7] the Psych NP discontinued 1:1 resident stable with no behavior issues exhibited at the moment. <BR/>Record review of Resident #6 and Resident #7 Trauma Informed PRN Assessment, Skin Assessment and Pain Assessment completed on 03/11/25 with no concerns. <BR/>Record review of Safe surveys were completed with 10 residents with no issues noted.<BR/>Record review of facility In Service Training dated 03/11/25 and 3/13/25, provided by Administrator reflected staff were In Serviced on Abuse and Neglect, Resident Rights, Safe environment and De-escalation methods for residents with behaviors. <BR/>Record review of facility In Service Training dated 3/14/25, provided by Corporate Compliance RN reflected staff were In Serviced on Abuse and Neglect, Resident Rights, Notification of Changes.<BR/>Interviews on 04/30/25 from 1:21 PM through 05/01/25 to 3:45 PM with ADON Y, ADON U, BOM, FM, CNA B, LVN C, CNA D, CNA F, CNA H, CNA E, Van Driver, CNA I, CNA F, LVN G, LVN K, LVN L, CNA V, LVN X revealed the facility staff were able to verify education was provided to them. The nursing staff stated they were educated on different types of abuse/neglect, resident rights, notification of changes and de-escalation methods. Staff stated they monitor behaviors. Staff provided the types of abuse were physical, mental, financial, and verbal. Staff stated the three signs of abuse occur when the resident avoids eye contact, bruises, and the resident withdraws from care. Staff revealed they would report these and other signs to the Abuse Coordinator, the Administrator, immediately if they witness or observed any of these signs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that all alleged violations involving neglect were reported immediately, but not later than two hours after the allegation was made, if the events that caused the allegation involved neglect, to the State Survey Agency in accordance with State law through established procedures for one (Resident #1) of five residents reviewed for abuse.<BR/>The facility failed to immediately report an allegation of potential neglect to the abuse coordinator on 12/15/22 after Resident #1 sustained an unwitnessed fall with major injury. As a result, the incident was not reported to the State Survey Agency within the required timeframe.<BR/>This failure could place residents at risk for abuse and neglect. <BR/>Findings include:<BR/>Review of the facility's Abuse, Neglect, Misappropriation, Exploitation Policy, dated 01/2019, reflected, .Serious Bodily Injury: An injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; requiring medical intervention such as surgery, hospitalization, or physical rehabilitation; or an injury resulting from criminal sexual abuse . and .Alleged violations/violations will be reported to the Administrator, designee immediately . and Immediately reporting all alleged violations to the Administrator, designee, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframe .<BR/>Review of Resident #1's Face Sheet, dated 01/14/23, reflected she was a [AGE] year-old female, admitted to the facility on [DATE] with a readmission date of 12/15/22, with diagnoses including age-related cognitive decline, unsteadiness on feet, and muscle wasting and atrophy.<BR/>Review of Resident #1's MDS Assessment, dated 11/04/22, reflected she had severe cognitive impairment. The MDS Assessment reflected she had a history of falls, including a fall with injury.<BR/>Review of Resident #1's Care Plan, dated 08/03/21 with a revision date of 10/11/22, reflected Resident #1 had a history of falls and injury from falls due to poor balance, unsteady gait, and cognitive deficits.<BR/>Review of Resident #1's Progress Notes, dated 12/15/22 and written by LVN A (LVN/Charge Nurse), reflected, .CNA called this nurse into resident room. Resident noted laying on the floor on her back beside her bed. Resident noted with blood pooling underneath her head. Resident alert and talking, confused at baseline. First aid provided. Vital signs taken. 911 called. MD on call notified. Responsible Party notified. Paramedics arrived. Patient taken to [hospital] .<BR/>Interview with CNA B on 01/14/23 at 7:05PM revealed she was one of the individuals who responded to Resident #1's fall on 12/15/22. She stated she was at the Nurse's Station when a loud noise was heard coming from Resident #1's room. She and LVN A immediately went to Resident #1's room and saw Resident #1 lying on the floor next to her bed. CNA B stated she noted a large pool of blood coming from a gash in Resident #1's head. CNA B stated the gash on Resident #1's head was approximately the length of a finger. Resident #1's eye was also swollen. Resident #1 stated she was trying to get out of bed and fell to the floor. Resident #1 denied being in pain and said, this is nothing. Facility staff immediately called 911 for assistance; staff stayed with Resident #1 and applied pressure to her head until EMS arrived and transported her to the hospital. CNA B stated at the time of the incident, Resident #1's bed was in the lowest position, as required due to her history of falls.<BR/>During an interview with the Administrator on 01/14/23 at 7:40PM, she stated the incident occurred when the previous DON oversaw nursing care. She stated it would have been the previous DON's responsibility, as the head of nursing, to report this incident to her. She stated the previous DON did not report any injuries to Resident #1 as a result of her fall. Per the Administrator, the previous DON just said that Resident #1 was weak and had fallen, so she was sent out to the hospital for further evaluation and treatment. The Administrator said she had no idea Resident #1 had hit her head or was bleeding at the time of her fall. She stated occurrences such as this would typically be reported to HHSC and investigated by the facility to rule out abuse/neglect. The Administrator was able to verbalize the facility's policies and procedures related to abuse/neglect, including the various types of abuse/neglect, prevention methods, and response protocols.<BR/>Attempted interviews with LVN A on 01/14/23 at 8:30PM and 01/16/23 at 10:13AM were unsuccessful.<BR/>Attempted interviews with the previous DON on 01/14/23 at 8:56PM and 01/16/23 at 10:16AM were unsuccessful.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to incorporate the recommendations from the PASRR Level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for 2 of 4 residents reviewed (Residents #2 and #5) for PASRR assessments.1.The facility failed to submit a NFSS form, used to request specialized services for residents, request within 20 from interdisciplinary team meeting dated 03/18/25 for Resident #2. 2. The facility failed to submit a completed a NFSS in the LTC Online Portal within 20 business days of Resident #5's IDT meeting. This failure could place residents at risk of not receiving or benefiting from recommendations for services they may require. Findings included:1. Record review of Resident #2's most recent Quarterly MDS, dated [DATE], reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. Resident #2 had moderate cognitive impairment with a BIMS score of 8. The resident's diagnoses included anxiety disorder (condition that cause significant and uncontrollable feelings of anxiety and fear), depression (persistent feeling of sadness and loss of interest), and schizophrenia (severe mental disorder), bipolar disorder (mental health condition with extreme mood swings), unspecified intellectual disabilities (condition that limits intelligence and disrupts abilities necessary for living independently). Resident #2's MDS indicated he received Speech Therapy 3 days beginning 12/22/24, Occupational Therapy 2 days beginning 12/10/24, and Physical Therapy 3 days beginning 12/09/24. Resident #2 had impairment on both side of his lower extremities and utilized a wheelchair. Supervision or touching assistance with lower body dressing, partial/moderate assistance with showers, oral, personal, and toileting hygiene, with set up assistance with eating. Record review of Resident #2's care plan, undated revealed he has been identified as having PASRR positive status related to Mental Illness and Intellectual Disabilities. Goal: Resident #2 will have the specialized services recommended by local authority according to PASRR Specialized Services program as needed. Interventions included the Local Authority would be invited annually to the care plan meeting for review of Specialized Services. Record review of Active Residents with PASRR Positive PE reflected Resident #2 on the list. The list indicated Resident #2 status date was 12/14/24 due to mental illness and developmental disabilities and had special services. Record review of Resident #2's PASRR Level 1 Screening completed 12/05/24 indicated Yes to Mental Illness and Intellectual Disability. Record review of Resident #2's PASRR Evaluation completed 12/13/24 indicated Yes to Intellectual Disability and Development Disability. Record review of Resident #2's PASRR Comprehensive Service Plan Form dated 03/18/25 revealed recommended Nursing Facility Specialized Services included new: Customized Manual Wheelchair, Specialized Assessment Occupational Therapy, Specialized Assessment Physical Therapy, Specialized Assessment Speech Therapy, Specialized Occupational Therapy, Specialized Physical Therapy, Specialized Speech Therapy, Day Habilitation, Habilitation Coordination, Independent Living Skills Training. The above services have been accepted by Resident #2. Record review of Resident #2's PASRR Comprehensive Service Plan Form dated 06/19/25 reflected the recommended Nursing Facility Specialized Services included ongoing: Customized Manual Wheelchair, Specialized Assessment Occupational Therapy, Specialized Assessment Physical Therapy, Specialized Assessment Speech Therapy, Specialized Occupational Therapy, Specialized Physical Therapy, Specialized Speech Therapy, Habilitation Coordination. The above services have been accepted by Resident #2 except CMWC. Interview on 09/09/25 at 9:30 AM with Resident #2 revealed he had a wheelchair which he used daily. Resident #2 stated he received physical therapy, but he did not know if he received occupational or speech therapy. Interview on 09/09/25 at 12:00 PM with PASRR representative revealed there was an interdisciplinary team meeting on 03/18/25. The facility was required to have uploaded documentation from the meeting into the portal within 20 business days from the meeting. According to the PASRR representative, she saw Resident #2 during his Occupational Therapy and he was doing fine, however when she looked in the portal for the documents, they had not been uploaded from the 03/18/25 meeting. The PASRR representative stated she spoke with the Social Worker about the missing documents in the hopes of having the documents uploaded. Interview on 09/09/25 at 3:32 PM with the Social Services Director revealed she was not an employee during the 03/18/25 visit and was not aware of missing documents for Resident #2 until she spoke with PASRR representative on 09/08/25. The Social Services Director stated she just recently started getting the invite to PASRR meetings, and would pass the invitation to the Director of Rehabilitation along with letting the Director of Rehabilitation. Interview on 09/09/25 at 3:45 PM with the Director of Rehabilitation revealed she began working in the facility in November 2024 as the Director of Rehabilitation and coming to the nursing home the system was different from where she was before. The Director of Rehabilitation stated she only knew of two residents that were PASRR positive until recently when she began getting invites to the interdisciplinary team meetings. The Director of Rehabilitation stated she also recently started being notified by the MDS Coordinators that there were 8 PASRR positive residents in the facility . The Director of Rehabilitation stated all PASRR residents were receiving services, but she needed to upload all the documents such as the signature pages from the physician. The Director of Rehabilitation stated over time she had uploaded the required PASRR documents into the portal, but they were disappearing, so she reached out to her regional help. According to the Director of Rehabilitation, she and her regional help contacted the help line of the portal and were told there was a glitch in the system which would not allow them up successfully upload into the portal . The Director of Rehabilitation stated the incident was not documented, and further stated eventually the glitch was fixed and she was able to upload. The Director of Rehabilitation stated at this time there was such a back log due to her having to get new physician signature pages to upload. The Director of Rehabilitation revealed for Resident #2 she was currently waiting on the physician to sign off on the services so that she could upload the form. The Director of Rehabilitation stated she was responsible for ensuring the NFSS form and other documents were uploaded in a timely manner. According to the Director of Rehabilitation, PASRR positive residents were not at risk because residents were provided services once they admit to the facility, if they were not covered by their insurance or PASRR the facility will pay to ensure services are continued, so there was never a gap in services. Record review of Resident #2's NFSS forms for Occupational, Physical and Speech therapies revealed as of 09/10/25 - NFSS Form from interdisciplinary meeting completed on 03/18/25 was not submitted within 30 calendar days of the IDT meeting. Interview on 09/10/25 at 11:25 AM with the Administrator revealed she could not recall the exact date she was notified by the PASRR Coordinator resident's NFSS document had not been uploaded within 20 business days of their last interdisciplinary team meetings. The Administrator stated she was told by the Director of Rehabilitation there was glitch in the system which would not allow documents to be uploaded in the portal. The Administrator stated there were several people involved to ensure the issues were resolved. According to the Administrator the Director of Rehabilitation was responsible for ensuring all required documents were uploaded to the portal within an adequate time frame, not doing so placed residents at risk of delay in services. 2. Record review of Resident #5's Nursing Home Comprehensive MDS, dated , 09/07/25, reflected he was a [AGE] year-old male with an original admission date of 04/12/23 and re-admission date of 03/26/25. Record review of the MDS also reflected diagnoses that included cerebral palsy (a group of conditions that affect movement and posture caused by damage that occurs to the developing brain, most often before birth), scoliosis (side to side curve of the spine), and benign prostatic hyperplasia (nonmalignant growth of prostate tissue). Record review of Resident #5's Care Plan, dated 09/09/25, reflected: Focus: Resident has Mental Illness , ID, or DD and is PASRR positive Date initiated: 02/12/25 Goal: Resident will have the specialized services recommended by local authority per PASRR Specialized Services program as needed. Date initiated: 02/12/25 Revision 08/31/25 Target Date 08/31/25. Interventions: The LA will be invited Annually to the care plan meeting for review of Specialized Services. Date initiated: 02/12/25.Record review of Resident #5's initial IDT meeting revealed it was held on 04/23/25, and a customized wheelchair was recommended by the Habilitation Coordinator.Record review of Resident #5's PASRR evaluation on 04/23/25 revealed the resident was PASRR level II positive related to his diagnoses of development disability other than an intellectual disability that manifested before the age on 22. Interview with Resident #5 on 09/09/25 at 11:22 AM revealed interview was attempted. However, Resident #5 was unable to communicate verbally. Interview on 09/09/25 at 3:57 PM with the facility Social Services Director revealed she gets a calendar invite from the resident's case manager. The Social Services Director said that she could not recall if Resident #5 was eligible for specialized services. The Social Services Director stated that she made referrals for ancillary services for vision, dental, and podiatry. The Social Services Director said that she was not involved in any other part of the resident's PASRR or referral services. Interview on 09/10/25 at 10:30 AM with the MDS Coordinator revealed she was responsible for uploading the meeting notes into Simple. The MDS Coordinator stated there was a meeting on 04/24/25 that determined Resident #5 would be placed on physical and occupational therapy serviced as well as receive a customized wheelchair. The MDS Coordinator said that the Director of Rehabilitation was responsible for submitting the nursing facility specialized services forms after the meetings. Interview on 09/10/25 at 11:00 AM with the Director of Rehabilitation revealed she was responsible for submitting the nursing facility specialized services forms for Resident #5 for physical and occupational therapy as well as the customized wheelchair after the meeting on 04/23/25. The Director of Rehabilitation stated there was a period in which the forms in Simple would disappear after they were input. The Director of Rehabilitation said that she reached out to her regional leadership and asked for assistance with the issue, and they eventually reached out to the Simple information technology department to resolve the issue. The Director of Rehabilitation stated that Resident #5 still received physical and occupational services. The Director of Rehabilitation said that they attempted to set up an appointment with the third-party company for the customized wheelchair, but he did not state the date this was attempted. However, the company did not show up for the appointment, so they had to start the process over again. The Director of Rehabilitation revealed they are now waiting for another company to come and assess the resident for a customized wheelchair. The Director of Rehabilitation stated that after the 07/10/25 meeting, she submitted and received approval for the nursing facility specialized services form approved on 07/25/25 and on 08/01/25. The Director of Rehabilitation said that Resident #1 was only waiting on his customized wheelchair that would be molded to his contractures. The Director of Rehabilitation stated that the resident has a regular wheelchair. The Director of Rehabilitation said that she knew the nursing facility specialized services forms were supposed to be submitted within 20 days after the meeting date and that she was responsible for submitting them. The Director of Rehabilitation revealed if she did not submit the forms timely then the facility would be responsible for paying for the services. Interview on 09/10/25 at 12:05 PM with the Administrator revealed the facility had an issue with forms disappearing on the Simple website. The Administrator stated she was notified by the state that the form had not been uploaded into the state's system, so they attempted that same day on 06/20/25. The Administrator also stated that the Director of Rehabilitation's regional director assisted the Director of Rehabilitation by uploading the Simple forms and resolved the technical issue. The Administrator revealed it was the Director of Rehabilitation's responsibility to upload the forms in a timely manner because it created a risk of delay in care to residents when forms were not uploaded time. Record review of facility's PASRR Nursing Specialized Services Policy and Procedure, revised 03/06/19, reflected: Policy: It is the policy of Creative solutions in Healthcare facilities to ensure NFSS Forms are submitted timely and accurately. Procedure: .8. Therapy, CMWC DME or DME is notified ASAP after the IDT meeting. (You only have 3 days to enter PCSP Form after the PCSP meeting). 9. The facility only has 20 business days from the Date of the PCSP meeting to submit a completed and accurate NFSS Form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents.<BR/>CNA A failed to get assistance from another staff member when providing Resident #1, who required two staff for assistance with all ADLs, a bed bath on 12/05/24. During the bed bath, CNA A asked Resident #1 to turn to her side. When the resident turned she fell to the floor, which resulted in the resident sustaining a fracture of her right femur (thigh bone). <BR/>The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 12/05/24 and ended on 12/05/24. The facility had corrected the noncompliance before the survey began.<BR/>This failure could place residents at risk for serious injury or harm, decline in health, and decreased quality of life.<BR/>Findings included:<BR/>Record review of Resident #1's quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hypertension (high blood pressure), seizure disorder, cellulitis of right lower limb (bacterial infection that affects the skin and underlying tissue), fibromyalgia (chronic condition that causes widespread pain and tenderness in the body), and muscle wasting. The resident had a BIMS score of 9 which indicated her cognition was moderately impaired. The MDS further reflected Resident #1 was dependent for shower/bathing which indicated the helper did all the effort or the assistance of two or more helpers was required for the resident to complete the activity. <BR/>Record review of Resident #1's care plan revised on 12/16/24 reflected the resident had an ADL self-care performance deficit. Interventions included the resident required the assistance of two staff for bathing and bed mobility. <BR/>Record review of Resident #1's bathing status in the [NAME] system (documentation system used by reference key resident information for their nursing care plan) printed on 01/13/25 reflected the resident required the assistance of two staff members.<BR/>Record review of the facility's Provider Investigation Report dated 12/05/24 reflected the following:<BR/>The resident experienced a fall while in bed during care by the CNA [CNA A]. The CNA [CNA A] notified the nurse and had discovered the resident on the floor, resting against the bed. The resident has skin tears on both great toes, the let wrist, and beneath the right breast The resident reports generalized pain, with a particular emphasis on greater discomfort in her legs compared to other areas. When inquired about the incident, the resident explained 'I threw my foot over too far and fell.' The resident was transferred to the hospital due to experiencing pain the X-ray indicated a fracture in the left femur (left femur was facility documentation error; fracture was on the right leg). The resident subsequently underwent surgery to address the fracture <BR/>Record review of Resident #1's hospital records dated 12/05/24 reflected the resident was diagnosed with a comminuted distal femoral fracture (a broken bone that has been shattered into multiple pieces and are usually caused by severe trauma) of the right leg.<BR/>Observation and interview on 01/08/25 at 10:26 PM revealed Resident #1 in bed watching television. The resident was alert and oriented and able to recall the incident when she fell during care. The resident said CNA A was giving her a bed bath, and the aide asked her to turn to her side. The resident said she was turning over onto her side as she was holding on the repositioning bar and fell on the floor. She said CNA A was usually able to catch her when she rolled over, but this time she was not able to. Resident #1 said she was sent to the hospital and had surgery on her leg, as she pointed to her right leg. Resident #1 stated CNA A usually bathed her alone and never had a helper. The resident stated she preferred two people because she felt safer. Resident #1 said she was not experiencing much pain from her fracture but had discomfort due to the cellulitis in her legs. <BR/>Interview on 01/08/25 at 1:05 PM with CNA A revealed she was giving Resident #1 a bed bath and asked the resident to turn to her side. She stated the resident grabbed the repositioning bar on the bed, threw her leg over her left leg and that was when the resident fell over on to the floor. CNA A stated she then called for the nurse to assist, and the resident was assessed. CNA A stated Resident #1 was on an air mattress, and it was inflating at the time the resident was turning to her side. CNA A said she was aware Resident #1 required two staff for care, but she was not able to find someone to help her. CNA A said she asked another CNA, whose name she could recall, for help. She stated she did not get any help, so she bathed the resident alone. She stated she had bathed the resident alone in the past. The CNA said she felt safe bathing the resident alone because the resident was able to help turn in bed. <BR/>Interview on 01/13/25 at 1:23 PM with LVN B revealed she was called by CNA A to Resident #1's room and noticed the resident was on the floor. CNA A told her the resident was trying to turn in bed during a bed bath, and the resident fell. LVN B said during Resident #1's assessment, the resident was complaining of pain and noticed the resident's toes were bleeding and other areas of her body such as her side, so she was transferred to the hospital via EMS. LVN B stated Resident #1 required two staff member for care because she was a bariatric resident and for safety. The LVN said she did not know CNA A was caring for Resident #1 alone, and she did not recall the aide asking anyone for help during the bed bath. LVN B further stated the aides could look in the [NAME] system to verify if a resident required one or two staff members during care or ask a charge nurse.<BR/>Interview on 01/08/25 at 1:28 PM with CNA D revealed she had worked at the facility for about a year and cared for Resident #1. CNA D said Resident #1 was bed bound per choice and required two staff members for assistance for all care because the resident was bariatric and could not be care for by one staff member. <BR/>Interview on 01/08/25 at 2:07 PM with CNA E revealed she worked with Resident #1 and the resident was bed bound. CNA E said the resident required two staff members for all care including bed baths because she was bariatric and needed more support. CNA E further stated Resident #1 had never been a one-person care resident. <BR/>Interview on 01/08/25 at 2:39 PM with RN F revealed Resident #1 was bed bound and required two staff members for all care including bed baths because the resident was bariatric and one staff member could not adequately care or clean the resident up during ADL care. <BR/>Interview on 01/08/25 at 2:29 PM the ADON revealed Resident #1 was bed bound and rarely got out of bed. She said the resident was a two-person assist for all care at all times because she was on an air mattress and could easily roll out of bed and for overall safety. The ADON was made aware CNA A had bathed Resident #1 alone, but the aide was not able to explain why she had not requested for help but only stated she had not seen anyone else. The ADON stated it appeared to her that CNA A had not looked for anyone to help her with the resident. The ADON further stated they immediately began to re-in-service (training) for all nursing staff re-educating them on the importance of using two staff member if the resident required it. They also identified all the residents that required two staff members for care they were monitoring and making observations to ensure two staff were assisting when needed. The monitoring began after the incident with Resident #1 and would be on-going for six weeks to ensure safety. <BR/>Interview on 01/13/25 at 8:36 AM with the DON revealed she was told Resident #1 was getting a bed bath by CNA A and while the resident was turning to her left side with the assistance of the repositioning rail, Resident threw her leg over too far and continued to roll until she fell out of the bed. Resident #1 was assessed, and they noticed she had bruising to the top of her feet and was complaining of pain throughout her body but mostly to her right knee. The resident was transferred to the hospital where she was diagnosed with a right leg fracture. The DON said Resident #1 required two staff members for care due to being a bariatric resident and for safety. The DON stated CNA A admitted knowing Resident #1 required two staff members for care, but the aide told them she had not been able to find assistance but if she would asked her (DON) she would have assisted. The DON also said if aides did not know if a resident was a one or two person for care, they could look in their [NAME] computer system. After the incident, CNA A was suspended pending their investigation and had a 1:1 counseling and re-in-service (training) on resident care and the aide was pulled from working with Resident #1. The other nursing staff were re-educated on using the [NAME] computer system to ensure a resident required a one- or two-person assistance during care. The DON further stated they had identified all the residents that required two people and were going to monitor but watching care for those resident for 6 weeks. <BR/>Record review of the facility's Safe Patient Handling policy revised December 2005 reflected the following:<BR/>The facility has a program to promote and assure safe patient handling for both the resident and the employee. The policy includes identification, assessment and interventions to provide a comfortable, safer transfer, repositioning and resident movement. <BR/> .3. Nurses will be educated in the identification, assessment and control of risks of injury to resident and nurses during patient handling <BR/> .5. Nurses will be educated regarding correct safe handling procedures, to report concerns or the inability to perform resident handling or movement that the nurse believes in good faith will expose a resident or nurse to an unacceptable risk of injury <BR/>Record review of 1:1 in-service with CNA A dated 12/05/24 revealed she had been re-educated on using the [NAME] system to communicate the resident's needs and information to all the CNA's to ensure appropriate resident care. CNA was also re-educated on fall prevention strategies and safe patient handling and abuse and neglect policy. <BR/>Record review of in-services dated 12/05/24 with all direct nursing reflected the staff had been re-educated using the [NAME] system to communicate the resident's needs and information to all the CNAs to ensure appropriate resident care. CNAs were also re-educated on fall prevention strategies and safe patient handling and abuse and neglect policy. <BR/>Interview on 01/08/25 at 1:05 PM with CNA A revealed she had been re-in-serviced 1:1 on abuse and neglect, ensure to always use two staff members during care for residents that required it and using the [NAME] system to check the care of the residents if they were unsure. <BR/>Interviews on 01/08/25 from 11:12 AM to 5:14 PM and on 01/13/25 from 10:01 AM to 1:23 PM with nursing staff from various shifts to include LVN B, CNA C, CNA D, CNA E, RN F, LVN G, CNA H, CNA I, CNA J, and CNA K all revealed they have been in-serviced on abuse/neglect, using the [NAME] system to verify if a resident required one or two staff members for care, and fall prevention to avoid accidents. <BR/>Record review of the direct care monitoring sheets reflected it included to watch at least 10 episodes of incontinent care or assist with bed mobility weekly to ensure staff was performing correctly and the care-planned number of staff were assisting. The monitoring dates reviewed began 12/05/24 and would continue for 6 weeks, and end on 01/15/25. <BR/>Observation on 01/08/25 at 11:07 AM revealed Resident #2 was transferred from the bed to the chair via mechanical lift by two staff members. <BR/>Observation on 01/13/25 at 3:32 PM revealed Resident #3 was transferred to bed via mechanical lift by two staff members.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from abuse for 3 of 6 residents (Resident #4, Resident #6, and Resident #7) reviewed for abuse.<BR/>1. The facility failed to ensure Resident #4 was free from emotional and mental abuse. Video footage identified CNA A antagonizing Resident #4 when she went to check on him on 02/18/25 . <BR/>The noncompliance was identified as past noncompliance (PNC). The noncompliance began on 02/18/25 and ended on 02/19/25. The facility had corrected the noncompliance before the investigation began.<BR/>2. The facility failed to ensure Resident #6, and Resident #7 were free from abuse on 03/11/25 when Resident #6 verbally abused Resident #7 which cause Resident #7 to physically abuse Resident #6 by hitting him on the face. <BR/>The noncompliance was identified as past noncompliance (PNC). The noncompliance began on 03/11/25 and ended on 03/14/25. The facility had corrected the noncompliance before the investigation began.<BR/>These failures could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and psychological harm.<BR/>Findings included:<BR/>1. Record review of Resident #4's Face sheet dated 05/01/25, revealed the resident was a [AGE] year-old male with an admission date of 04/15/24 and readmitted on [DATE]. <BR/>Record review of Resident #4's quarterly MDS, dated [DATE], reflected his diagnoses included anxiety disorder, vascular dementia, and mild cognitive impairment. Resident #4's BIMS score was 04 which indicated his cognition was severely impaired. The MDS Section E - Behaviors reflected Resident #4 did not exhibit any physical or verbal behaviors towards others. The MDS Section GG - Functional Abilities also reflected Resident #4 was dependent of staff to assist with ADLs. <BR/>Record review of Resident #4's Care Plan revised date 03/11/25, reflected Focus: The resident has a behavior problem r/t hx of stroke, resident will become difficult to manage. Resident yells out loudly and will use cursive language. Resident is very adament toward care, sports, etc and will yell out at staff and curse. Goal: The resident will have fewer episode by review date. Interventions: Anticipate and meet the resident's needs. Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by. Redirection techniques will include offering alternatives to the current activity. <BR/>Record review of the Provider Investigation Report dated 02/25/25 reflected, Resident responsible party had address to [Administrator] a concern of a staff member being rough with the resident when trying to readjust on the bed. When [Responsible party name], the resident's responsible party, entered [Administrator] office and informed [Administrator] of an incident that occurred the previous night, [Administrator] contacted the CNA [CNA A] to discuss the matter. [Administrator] informed her about the responsible party reported aggressive behavior toward the resident [Resident #4] and confirmed that she had indeed acted aggressively toward [Resident #4] due to [Resident #4] cussing at him and she was trying to correct him. [Administrator] informed her that she would be suspended until further notice. Safe surveys conducted no noted concern. Skin assessment completed and no noticed concerns, pain assessment no noted concerns, Trauma assessment no concerns noted. The Provider Investigation Report also reflected that the result of the investigation was inconclusive, but CNA A was terminated. <BR/>Record review of CNA A's Statement dated 02/29/25, reflected Went to resident's room cause he was hanging off the bed and yelling. [CNA A] told the resident to put his legs back in the bed before he ended up on the floor. That's when the resident call me a bitch and to leave him alone. [CNA A] told him not till he in bed right that if keeps hanging out the bed like that he was going to be on the floor and the floor hursts and wins every time. He then proceeded to call me a bitch again. [CNA A] told him to don't be disrespectful to me cause [CNA A] wouldn't do him like that and that I'm someone sister daughter and mother and that he wouldn't like it if [CNA A] called the women in his family that name. [CNA A] also asked him what was wrong with him.<BR/>Observation of Video Footage time stamped 02/18/2025 05:44:24 CST [5:44 AM] revealed: Resident #4 sitting at the edge of the bed. CNA A (who was a tall, heavy-set woman) entered Resident #4's room stating, What are you doing [Resident #4's name]. Resident #4 states What are you talking about bitch. CNA A stated what. Resident #4 stated What are you talking. CNA A standing in front of Resident #4. CNA A then proceed to tell Resident #4 twice to put those legs back in the bed. Resident #4 asked CNA A Why?''. CNA A tells Resident #4 you can't walk [you] will end up on the floor. Resident #4 tells her No I won't. CNA A responded, Okay bet, but I am going to put your legs back on the bed. Resident #4 asked why again. CNA A responded, I don't have to explain why. Resident #4 asked CNA A why are [you] going too and CNA A stated, because I am going too. Resident #4 stated you not going too. CNA A observed leaning forward and grabbed the control for the bed. Resident #4 stated Get your fucking hands of me bitch, I will fuck you up. CNA A asked resident What did [you] say? and Resident #4 stated, I will fuck you up, get your fucking hands off of me. CNA A observed to lean forward put her right hand on Resident #4's right knee. CNA A then stated My hand is on you. What are [you] going to do? Nothing, and [you] better quit calling me out of my name because [you] wouldn't like if [I] called your momma, sister, or anybody in your family out of their name, don't be disrespectful to [me] because I am not being disrespectful to [you], [you] understand. Resident #4 agreed with CNA A and CNA A removed her hand from Resident #4's knee. CNA A states I don't know where you get that being disrespectful from, that [ain't] going to get you nothing , that [ain't] going to get you no help, that is going to get you talk ed about, don't be disrespectful, and you wait until someone comes in here to help you, you got me? CNA A proceed to adjust Resident #4's legs on the bed. Resident #4 stated I hear that CNA A states Alright then, I am not about to play with you, cause you end up on the floor, you end up on the floor and the floor hurts and it wins every time. Resident #4 stated yeah right. CNA A states Yeah right, you got a real smart mouth, what is wrong with you, what is your problem tonight. Resident state I got a problem with you. CNA response No, I [ain't] your problem, Resident stated oh yeah. CNA A stated, I just came in here to help you. CNA A proceeded to walk out the room and stated, you better act like you got some sense. Video was about 2 minutes long. CNA A hand was on Resident #4's knee for about 32 second.<BR/>Interview on 04/30/25 at 11:14 AM, Resident #4 revealed he was doing well and feeling safe at the facility. Resident #4 was not a good historian; resident could not recall incident with CNA A. <BR/>Interview on 04/30/25 at 12:46 PM, Resident #4 Family Member revealed she reviewed the video footage a day after the incident and notified the Administrator. She stated the incident happened on 02/18/25, Resident #4 was sitting on his bed and the staff was observed entering the room. She stated on the video footage it was observed Resident #4 being disrespectful toward the staff; however, the staff was rude and antagonizing the situation. She stated on the video it was observed Resident #4 saying keep your hands off of me and then staff proceed to put her hand on his knee. Family Member stated she agreed with the staff redirecting and telling Resident #4 to stop cursing at her; however, the staff putting her hand on him was what concerned her. She stated the staff was antagonizing the situation by putting her hand on Resident #4. Family Member stated after the Administrator was notified, the facility investigated the incident and terminated the staff. <BR/>Interview by phone on 05/01/25 at 9:27 AM, CNA A revealed she was doing her last round, when she heard Resident #4 screaming. She stated she entered the room and observed Resident #4 was hanging on the side of the bed. She stated she asked Resident #4 what he was doing, and Resident #4 started to curse at her and got mad because she told him to get back in bed. CNA A stated Resident #4 was calling her a bitch and being disrespectful to her. She stated she told Resident #4 to stop, to not called her like that because he would not like for someone to call his mom, sister or daughter that. She stated Resident #4 stated he would not like that. She stated she only touched Resident #4 when repositioning him back to bed. CNA A stated she was not supposed to correct Resident #4. She stated she was wrong for telling him to stop being disrespectful because they were told residents were always right. CNA A stated she never touched the resident or disrespected the resident. CNA A stated she was suspended and then let go. <BR/>Interview on 05/01/25 at 2:16 PM, Corporate Compliance RN revealed she reviewed the video footage regarding CNA A and Resident #4. She stated CNA A should lose her license. She stated CNA A was verbally abusive towards Resident #4, she stated when CNA A put her hand on Resident #4' she was antagonizing the situation. She stated CNA A should had stepped away. Regional Compliance stated Resident #4 had no adverse effects from the incident. She stated CNA A was terminated. <BR/>Interview on 05/01/25 at 2:36 PM, the Administrator revealed Resident #4 family informed him about the incident and he immediately suspended CNA A. He stated skin assessment was completed on Resident #4 with no injuries, safe surveys and quality of life checks were completed with no concerns. The Administrator stated after reviewing the video footage it was determined CNA A was considered being verbally abusive and was terminated for abuse. He stated CNA A admitted to what she did wrong. He stated his expectations were for his staff to respect residents, care for them and to report any abuse and neglect allegations to him to protect the residents. <BR/>Record Review of CNA A's personnel file, reflected CNA A was suspended and terminated on 02/19/25.<BR/>Record review of facility Abuse/Neglect policy, revised 09/09/24, reflected the following: <BR/>The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility.<BR/>Prior to the HHSC investigation, the facility took the following actions to correct the noncompliance:<BR/>Record review of Resident #4's Skin assessment, Pain assessment and Trauma Assessment completed on 02/19/25, no concerns noted.<BR/>Record review of Safe surveys were completed on 02/19/25 with five residents with no issues noted.<BR/>Record review of facility In Service Training dated 02/19/25, provided by Administrator and Corporate Compliance RN reflected staff were In Serviced on Abuse and Neglect Policy to include - Arguing with, antagonizing, and touching a resident against their will is considered Abuse. If [you] see a staff member or resident engaging in this activity, the Administrator must be notified immediately. The Administrator is the abuse coordinator. If [you] can't get a hold of the administrator, notify the DON or ADON immediately. Staff should not continue to work their shift, they must be suspended immediately, Resident Rights <BR/>Record review of facility In Service Training dated 02/19/25, provided by Corporate Compliance RN reflected staff were In Serviced on Abuse and Neglect, Resident Rights.<BR/>Interviews on 04/30/25 from 1:21 PM through 05/01/25 to 3:45 PM with ADON Y, ADON U, BOM, FM, CNA B, LVN C, CNA D, CNA F, CNA H, CNA E, Van Driver, CNA I, CNA F, LVN G, LVN K, LVN L, CNA V, LVN X revealed the facility staff were able to verify education was provided to them. The nursing staff stated they were educated on different types of abuse/neglect and resident rights. Staff provided the types of abuse were physical, mental, financial, and verbal. Staff stated the three signs of abuse occur when the resident avoids eye contact, bruises, and the resident withdraws from care. Staff stated they would intervene if witness any type of abuse from a staff. Staff revealed they would report these and other signs to the Abuse Coordinator, the Administrator, immediately if they witness or observed any of these signs.<BR/>2. Record review of Resident #6's Face sheet dated 05/01/25, revealed the resident was a [AGE] year-old male with an admission date of 04/28/21 and readmitted on [DATE]. <BR/>Record review of Resident #6's quarterly MDS, dated [DATE], reflected his diagnoses included bipolar disorder, dementia, and cognitive communication deficit. Resident #6's BIMS score was 12 which indicated his cognition was moderately impaired. The MDS Section E - Behaviors reflected Resident #6 did not exhibit any physical or verbal behaviors towards others. The MDS Section GG - Functional Abilities also reflected Resident #6 needed substantial/maximal assistance with ADLs.<BR/>Record review of Resident #6's care plan, revised 03/11/25, reflected Focus: The resident has a history of trauma that may have a negative impact. The trauma is r/t: Resident with hx of physical altercation with another resident. Goal: Maintain resident's safety and integrity post trauma episode, using appropriate interventions. Interventions: Perform the following de escalation techniques as required: redirection, and deep breathing. Psychiatric services adjusted medication.<BR/>Record review of Resident #7's face sheet dated 05/01/25, revealed the resident was a [AGE] year-old male with an admission date of 12/24/21 and readmitted on [DATE].<BR/>Record review of Resident #7's admission MDS, dated [DATE], reflected his diagnoses included anxiety disorder, major depressive disorder, schizoaffective disorder, restlessness and agitation and cognitive communication deficit. Resident #6's BIMS score was 13 which indicated his cognition was cognitively intact. The MDS Section E - Behaviors reflected Resident #7 did not exhibit any physical or verbal behaviors towards others. The MDS Section GG - Functional Abilities also reflected Resident #7 was independent for ADLs.<BR/>Record review of Resident #7's care plan, revised 04/14/25, reflected Focus: The resident has potential to demonstrate physical behaviors related to paranoid schizophrenia, schizoaffective disorder as evidence by: Physical aggression demonstration due to being provoke when cussed at. Goal: The resident will seek out staff/caregiver when agitation<BR/>occurs through the review date. Interventions: If the resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately.<BR/>Record review of the Provider Investigation Report dated 03/18/25 reflected, [Speech and Language Therapist] witness [Resident #7] hit [Resident #6] due to an altercation they were having an immediately separate them both. During investigation, Resident #7 reported that Resident #6 was using inappropriate language to him and repeatedly told him to stop. When Resident #6 continued, Resident #7 became frustrated and end up hitting him. Upon witnessing the incident, [Speech Therapy] quickly intervene to separate the two residents and called for assistance. Both residents were promptly separated, and a 1:1 supervision was implemented until a psychiatric evaluation could be performed.<BR/>Record review of Witness Statement from Speech and Language Therapist dated 03/11/25 reflected, My name is [Name]. [Speech and Language Therapist ] am an employee at the [Facility Name]. [Speech and Language Therapist] am the speech language pathologist. At approximately 10:15 a.m., [Speech and Language Therapist] witnessed two residents [Resident #6 and Resident #7] in a physical altercation in the dining room. [Speech and Language Therapist] heard [Resident #7] say to [Resident #6] call me a bitch one more time. [Resident #6] responded and then [Resident #7] struck [Resident #6] about two times. Immediately, [Speech and Language Therapist] intervened to ensure both men were safe. [Resident #7] left the dining room. Once [Resident #7] left the dining room, [Speech and Language Therapist] asked [Resident #6] if he was okay and if he could tell me what happened. [Resident #6] replied, he's just mad because [Speech and Language Therapist] wouldn't give him a cigarette. Once both individuals were safe, [Speech and Language Therapist] immediately told [Administrator]. <BR/>Interview on 04/30/25 at 10:45 AM, Resident #6 stated he was doing well. Resident #6 stated he had an incident with Resident #7. Resident #6 stated Resident #7 got frustrated with him, and Resident #7 kept telling him to not say anything to him. Resident #6 stated he told Resident #7 that he was coming in and needed him to get out of the way, he stated Resident #7 got more frustrated and hit him on the side of the face. Resident #6 stated the police was called but he did not pressed charges. Resident #6 stated he was only hit once on the side of his face. Resident #6 stated he was not hurt. Resident #6 stated he never called Resident #7 any names. <BR/>Interview on 04/30/25 at 12:26 PM, Resident #7 stated he was doing well. Resident #7 stated he got into an altercation with Resident #6. Resident #7 stated for a week Resident #6 was messing with him and calling him out of his name. Resident #7 stated he never told anyone about it. Resident #7 stated on the day of the altercation Resident #6 called him a bitch and he asked Resident #6 to stop but he continued to call him a bitch. Resident #7 stated he got mad, and he hit him on the face once. Resident #7 stated he was tired of Resident #6 calling him a bitch. Resident #7 stated after the altercation, he keeps his distance from Resident #6. <BR/>Interview on 05/01/25 at 9:49 AM, the Administrator revealed Speech and Language Therapist was out on leave. <BR/>Interview on 05/01/25 at 1:38P PM, ADON Y stated Resident #6 and Resident #7 had an altercation in the dining room on 3/11/25. She stated it was a witnessed altercation by Speech Therapy. She stated she was not sure what started the altercation, but Resident #7 got upset and hit Resident #6 in the face. She stated there had been no previous incidents between them. She stated both residents were assessed with no injuries and placed on 1:1 monitoring until psych services consult. She stated the incident was considered abuse from Resident #7 hitting Resident #6. <BR/>Interview on 05/01/25 at 2:16 PM, Corporate Compliance RN revealed she was made aware of the incident between Resident #6 and Resident #7. She stated she was informed Resident #7 slapped Resident #6 on the face. She stated she was unsure what started the argument. She stated the incident was considered abuse from Resident #7 to Resident #6. She stated Resident #7 was placed 1:1 supervision, a psych services consult was completed, medications were adjusted, and Resident #7 was moved to another hall. Resident #6 had no injures to him and also received a psych service consult. <BR/>Interview on 05/01/25 at 2:36 PM, the Administrator revealed Speech and Language Therapist observed Resident #6 and Resident #7 talking and then observed Resident #7 slapped Resident #6 on the face. He stated the Speech and Language Therapist intervene and separated both residents. The Administrator stated the police was called, skin assessment, trauma and pain assessment completed on both residents with no concerns. He stated families were notified of the incidents. The Administrator stated Resident #7 was placed on 1:1 monitoring, and then Resident #7 requested to go home after the incident. He stated two weeks later Resident #7 returned to the facility and he got a new room in a different hall. The Administrator stated both residents used to get along and joke with each other, he stated he was not sure what happened between them. The Administrator stated a resident-to-resident altercation was considered abuse, and every resident had the right to be free from abuse and neglect. <BR/>Record review of facility Abuse/Neglect policy, revised 09/09/24, reflected the following:<BR/>The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. Resident to Resident - The above policy will apply to potential resident-to-resident abuse.<BR/>Prior to the HHSC investigation, the facility took the following actions to correct the noncompliance:<BR/>Record review Resident #6 progress notes dated 03/11/25 14:58 [2:58 PM] new order for busPirone HCL Oral tablet 15 mg (Buspirone HCl) Give 1 tablet by mouth every 12 hours for anxiety.<BR/>Record review of facility 15 Minute Monitoring dated 3/11/15, reflected Resident #7 was being monitored every 15 minutes starting at 10:15AM and ended at 11:45 AM. <BR/>Record review Resident #7 progress notes dated 03/11/25 15:24 [3:24 PM] Psych NP [Resident #7] telehealth with the resident. New order obtained for HydroXizne HLC tablet 25 MG give 1 tablet by mouth every 8 hours as needed for anxiety x 14 days and to monitor behaviors q shift.<BR/>Record review Resident #7 progress notes dated 03/11/25 15:55 [3:55 PM] reflected, [Resident #7] the Psych NP discontinued 1:1 resident stable with no behavior issues exhibited at the moment. <BR/>Record review of Resident #6 and Resident #7 Trauma Informed PRN Assessment, Skin Assessment and Pain Assessment completed on 03/11/25 with no concerns. <BR/>Record review of Safe surveys were completed with 10 residents with no issues noted.<BR/>Record review of facility In Service Training dated 03/11/25 and 3/13/25, provided by Administrator reflected staff were In Serviced on Abuse and Neglect, Resident Rights, Safe environment and De-escalation methods for residents with behaviors. <BR/>Record review of facility In Service Training dated 3/14/25, provided by Corporate Compliance RN reflected staff were In Serviced on Abuse and Neglect, Resident Rights, Notification of Changes.<BR/>Interviews on 04/30/25 from 1:21 PM through 05/01/25 to 3:45 PM with ADON Y, ADON U, BOM, FM, CNA B, LVN C, CNA D, CNA F, CNA H, CNA E, Van Driver, CNA I, CNA F, LVN G, LVN K, LVN L, CNA V, LVN X revealed the facility staff were able to verify education was provided to them. The nursing staff stated they were educated on different types of abuse/neglect, resident rights, notification of changes and de-escalation methods. Staff stated they monitor behaviors. Staff provided the types of abuse were physical, mental, financial, and verbal. Staff stated the three signs of abuse occur when the resident avoids eye contact, bruises, and the resident withdraws from care. Staff revealed they would report these and other signs to the Abuse Coordinator, the Administrator, immediately if they witness or observed any of these signs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents.<BR/>CNA A failed to get assistance from another staff member when providing Resident #1, who required two staff for assistance with all ADLs, a bed bath on 12/05/24. During the bed bath, CNA A asked Resident #1 to turn to her side. When the resident turned she fell to the floor, which resulted in the resident sustaining a fracture of her right femur (thigh bone). <BR/>The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 12/05/24 and ended on 12/05/24. The facility had corrected the noncompliance before the survey began.<BR/>This failure could place residents at risk for serious injury or harm, decline in health, and decreased quality of life.<BR/>Findings included:<BR/>Record review of Resident #1's quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hypertension (high blood pressure), seizure disorder, cellulitis of right lower limb (bacterial infection that affects the skin and underlying tissue), fibromyalgia (chronic condition that causes widespread pain and tenderness in the body), and muscle wasting. The resident had a BIMS score of 9 which indicated her cognition was moderately impaired. The MDS further reflected Resident #1 was dependent for shower/bathing which indicated the helper did all the effort or the assistance of two or more helpers was required for the resident to complete the activity. <BR/>Record review of Resident #1's care plan revised on 12/16/24 reflected the resident had an ADL self-care performance deficit. Interventions included the resident required the assistance of two staff for bathing and bed mobility. <BR/>Record review of Resident #1's bathing status in the [NAME] system (documentation system used by reference key resident information for their nursing care plan) printed on 01/13/25 reflected the resident required the assistance of two staff members.<BR/>Record review of the facility's Provider Investigation Report dated 12/05/24 reflected the following:<BR/>The resident experienced a fall while in bed during care by the CNA [CNA A]. The CNA [CNA A] notified the nurse and had discovered the resident on the floor, resting against the bed. The resident has skin tears on both great toes, the let wrist, and beneath the right breast The resident reports generalized pain, with a particular emphasis on greater discomfort in her legs compared to other areas. When inquired about the incident, the resident explained 'I threw my foot over too far and fell.' The resident was transferred to the hospital due to experiencing pain the X-ray indicated a fracture in the left femur (left femur was facility documentation error; fracture was on the right leg). The resident subsequently underwent surgery to address the fracture <BR/>Record review of Resident #1's hospital records dated 12/05/24 reflected the resident was diagnosed with a comminuted distal femoral fracture (a broken bone that has been shattered into multiple pieces and are usually caused by severe trauma) of the right leg.<BR/>Observation and interview on 01/08/25 at 10:26 PM revealed Resident #1 in bed watching television. The resident was alert and oriented and able to recall the incident when she fell during care. The resident said CNA A was giving her a bed bath, and the aide asked her to turn to her side. The resident said she was turning over onto her side as she was holding on the repositioning bar and fell on the floor. She said CNA A was usually able to catch her when she rolled over, but this time she was not able to. Resident #1 said she was sent to the hospital and had surgery on her leg, as she pointed to her right leg. Resident #1 stated CNA A usually bathed her alone and never had a helper. The resident stated she preferred two people because she felt safer. Resident #1 said she was not experiencing much pain from her fracture but had discomfort due to the cellulitis in her legs. <BR/>Interview on 01/08/25 at 1:05 PM with CNA A revealed she was giving Resident #1 a bed bath and asked the resident to turn to her side. She stated the resident grabbed the repositioning bar on the bed, threw her leg over her left leg and that was when the resident fell over on to the floor. CNA A stated she then called for the nurse to assist, and the resident was assessed. CNA A stated Resident #1 was on an air mattress, and it was inflating at the time the resident was turning to her side. CNA A said she was aware Resident #1 required two staff for care, but she was not able to find someone to help her. CNA A said she asked another CNA, whose name she could recall, for help. She stated she did not get any help, so she bathed the resident alone. She stated she had bathed the resident alone in the past. The CNA said she felt safe bathing the resident alone because the resident was able to help turn in bed. <BR/>Interview on 01/13/25 at 1:23 PM with LVN B revealed she was called by CNA A to Resident #1's room and noticed the resident was on the floor. CNA A told her the resident was trying to turn in bed during a bed bath, and the resident fell. LVN B said during Resident #1's assessment, the resident was complaining of pain and noticed the resident's toes were bleeding and other areas of her body such as her side, so she was transferred to the hospital via EMS. LVN B stated Resident #1 required two staff member for care because she was a bariatric resident and for safety. The LVN said she did not know CNA A was caring for Resident #1 alone, and she did not recall the aide asking anyone for help during the bed bath. LVN B further stated the aides could look in the [NAME] system to verify if a resident required one or two staff members during care or ask a charge nurse.<BR/>Interview on 01/08/25 at 1:28 PM with CNA D revealed she had worked at the facility for about a year and cared for Resident #1. CNA D said Resident #1 was bed bound per choice and required two staff members for assistance for all care because the resident was bariatric and could not be care for by one staff member. <BR/>Interview on 01/08/25 at 2:07 PM with CNA E revealed she worked with Resident #1 and the resident was bed bound. CNA E said the resident required two staff members for all care including bed baths because she was bariatric and needed more support. CNA E further stated Resident #1 had never been a one-person care resident. <BR/>Interview on 01/08/25 at 2:39 PM with RN F revealed Resident #1 was bed bound and required two staff members for all care including bed baths because the resident was bariatric and one staff member could not adequately care or clean the resident up during ADL care. <BR/>Interview on 01/08/25 at 2:29 PM the ADON revealed Resident #1 was bed bound and rarely got out of bed. She said the resident was a two-person assist for all care at all times because she was on an air mattress and could easily roll out of bed and for overall safety. The ADON was made aware CNA A had bathed Resident #1 alone, but the aide was not able to explain why she had not requested for help but only stated she had not seen anyone else. The ADON stated it appeared to her that CNA A had not looked for anyone to help her with the resident. The ADON further stated they immediately began to re-in-service (training) for all nursing staff re-educating them on the importance of using two staff member if the resident required it. They also identified all the residents that required two staff members for care they were monitoring and making observations to ensure two staff were assisting when needed. The monitoring began after the incident with Resident #1 and would be on-going for six weeks to ensure safety. <BR/>Interview on 01/13/25 at 8:36 AM with the DON revealed she was told Resident #1 was getting a bed bath by CNA A and while the resident was turning to her left side with the assistance of the repositioning rail, Resident threw her leg over too far and continued to roll until she fell out of the bed. Resident #1 was assessed, and they noticed she had bruising to the top of her feet and was complaining of pain throughout her body but mostly to her right knee. The resident was transferred to the hospital where she was diagnosed with a right leg fracture. The DON said Resident #1 required two staff members for care due to being a bariatric resident and for safety. The DON stated CNA A admitted knowing Resident #1 required two staff members for care, but the aide told them she had not been able to find assistance but if she would asked her (DON) she would have assisted. The DON also said if aides did not know if a resident was a one or two person for care, they could look in their [NAME] computer system. After the incident, CNA A was suspended pending their investigation and had a 1:1 counseling and re-in-service (training) on resident care and the aide was pulled from working with Resident #1. The other nursing staff were re-educated on using the [NAME] computer system to ensure a resident required a one- or two-person assistance during care. The DON further stated they had identified all the residents that required two people and were going to monitor but watching care for those resident for 6 weeks. <BR/>Record review of the facility's Safe Patient Handling policy revised December 2005 reflected the following:<BR/>The facility has a program to promote and assure safe patient handling for both the resident and the employee. The policy includes identification, assessment and interventions to provide a comfortable, safer transfer, repositioning and resident movement. <BR/> .3. Nurses will be educated in the identification, assessment and control of risks of injury to resident and nurses during patient handling <BR/> .5. Nurses will be educated regarding correct safe handling procedures, to report concerns or the inability to perform resident handling or movement that the nurse believes in good faith will expose a resident or nurse to an unacceptable risk of injury <BR/>Record review of 1:1 in-service with CNA A dated 12/05/24 revealed she had been re-educated on using the [NAME] system to communicate the resident's needs and information to all the CNA's to ensure appropriate resident care. CNA was also re-educated on fall prevention strategies and safe patient handling and abuse and neglect policy. <BR/>Record review of in-services dated 12/05/24 with all direct nursing reflected the staff had been re-educated using the [NAME] system to communicate the resident's needs and information to all the CNAs to ensure appropriate resident care. CNAs were also re-educated on fall prevention strategies and safe patient handling and abuse and neglect policy. <BR/>Interview on 01/08/25 at 1:05 PM with CNA A revealed she had been re-in-serviced 1:1 on abuse and neglect, ensure to always use two staff members during care for residents that required it and using the [NAME] system to check the care of the residents if they were unsure. <BR/>Interviews on 01/08/25 from 11:12 AM to 5:14 PM and on 01/13/25 from 10:01 AM to 1:23 PM with nursing staff from various shifts to include LVN B, CNA C, CNA D, CNA E, RN F, LVN G, CNA H, CNA I, CNA J, and CNA K all revealed they have been in-serviced on abuse/neglect, using the [NAME] system to verify if a resident required one or two staff members for care, and fall prevention to avoid accidents. <BR/>Record review of the direct care monitoring sheets reflected it included to watch at least 10 episodes of incontinent care or assist with bed mobility weekly to ensure staff was performing correctly and the care-planned number of staff were assisting. The monitoring dates reviewed began 12/05/24 and would continue for 6 weeks, and end on 01/15/25. <BR/>Observation on 01/08/25 at 11:07 AM revealed Resident #2 was transferred from the bed to the chair via mechanical lift by two staff members. <BR/>Observation on 01/13/25 at 3:32 PM revealed Resident #3 was transferred to bed via mechanical lift by two staff members.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident on one of three medication carts (300) and 3 of 3 residents (Residents #7,#147, and #178) reviewed for pharmacy services.<BR/>1. The facility failed to ensure the 300 Hall nurses' medication cart contained accurate narcotic logs for Resident #7, #147 and #178 on 02/12/25. <BR/>2. The facility failed to ensure expired medications , 1 bottles of atropine 0.1% with expiration dates of August 2024 was removed and destroyed form 300 hall nurses cart on 02/12/25. <BR/>These failures could place residents at risk for medication errors, drug diversion, and ineffective drug therapy.<BR/>Findings included: <BR/>1. Record review of Resident# 7's Quarterly MDS Assessment, dated 12/10/24, reflected the resident was [AGE] year-old female readmitted to the facility on [DATE] with original admission on [DATE], with diagnoses that included anxiety (common mental health condition characterized by excessive worry, fear, and nervousness that can interfere with daily life). The resident had mild impaired cognition with a BIMS score of 11. <BR/>Record review of Resident #7's physician's orders dated 11/15/24 reflected an order for the resident to receive Lorazepam Oral Tablet 1 MG. Give 1/2 tablet to 2 tablets by mouth every 2 hours as needed related to anxiety disorder. <BR/>Record review of Resident # 47's Quarterly MDS assessment, dated 01/01/25, reflected the resident was [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included chronic pain syndrome (a condition characterized by persistent pain that lasts for at least 3-6 months and significantly impacts a person's life). The resident had intact cognition with a BIMS score of 15. <BR/>Record review of Resident #47's physician orders dated 12/12/24 reflected an order for the resident to receive Hydrocodone-Acetaminophen oral tablet 10-325 mg. Give 1 tablet by mouth every 8 hours, as needed for pain. <BR/>Record review of Resident# 178's entry MDS assessment, dated 02/07/25, reflected the resident was [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included pain. The resident BIMS score not completed Resident #178 was newly admitted . <BR/>Record review of Resident #178's physician orders dated 02/08/25 reflected an order for the resident to receive Hydrocodone-Acetaminophen oral tablet 10-325 mg. Give 2 tablet by mouth every 4 hours, as needed for pain.<BR/>Observation and record review on 02/12/25 at 2:12 PM of 300 Hall nurses' medication cart and the Narcotic Administration Record, with RN C, revealed Resident #7's Narcotic Administration Record for lorazepam 1 mg reflected a total of 13 pills remaining, while the blister pack count was 12 pills. It was last administered on 01/20/25 at 9:30 PM. It also revealed Resident#47's Narcotic Administration record Hydrocodone-Acetaminophen oral tablet 10-325 mg reflected a total of 7 pills remaining, while the blister pack count was 6 pills. Last administered on 02/10/25 at 07:41 AM. It also revealed Resident#178's Narcotic Administration record Hydrocodone-Acetaminophen oral tablet 10-325 mg reflected a total of 38 pills remaining, while the blister pack count was 36 pills. Last administered on 02/11/25 at 8:00 AM.RN C was observed to remove lorazepam 1mg &frac12; tablet in a cup covered with another cup that was not labelled in her pocket. <BR/>2. Observation on 02/12/25 at 2:45 PM of the 300 Hall medication cart with the RN C revealed 1 bottle of atropine 1 % with expiration date of 8/8/24 . <BR/>Interview with RN C on 02/12/25 at 2:45 PM revealed she popped Lorazepam 1mg &frac12; tablet put in a cup and she had not administered to Resident #7 before lunch because she had realized she had popped, and it was not meant for her. RN C stated she forgot to notify the other nurse for destruction. She took residents to dining for lunch and she forgot. She stated when she saw this surveyor checking the carts that was the time she removed from the cart and put it in her pocket. She stated she had administered Hydrocodone-Acetaminophen oral tablet 10-325 mg I (one) tablet, to Resident #47 as needed every 8 hours, and she had not signed off on the narcotic administration record log. She had also administered Hydrocodone-Acetaminophen oral tablet 10-325 mg 2 tablets to Resident #178 as needed every 8 hours, and she had not signed off on the narcotic administration record log. She stated she knew she was supposed to sign-out on the narcotic count sheet after administration and on the Medication Administration Record, but she did not. RN C stated the failure to log off could lead to overdose since the person that came after her would not be able to tell when the narcotic was administered. She stated failure to label the cup and keeping the medication in a cup could lead to missing a dose and administering to wrong resident leading to medication error. RN C also stated she was responsible of checking her cart every shift for the expired medications, but she forgot to check. She stated the risk of having expired medication in her cart was adverse effect if administered. She stated she had completed an in-service on Medication administration. <BR/>Interview on 02/13/25 at 9:44 AM, the ADON B stated her expectation was for staff administering narcotic medications to document the medications when they were given to the resident on the medication administration record and to sign on the narcotic log. She stated she also expected RN C to assess the Resident #7 before she popped Lorazepam 1mg &frac12; tablet and if she had made a mistake to call her or any other nurse they destroy and not to put in cup in her pocket. She stated it was her responsibility to audit the carts weekly and if there was an issue she audited daily. She stated she had last checked the cart on 02/4/25. The ADON stated failure to document after administration and destroying after refusal or popping by mistake could lead to drug diversion, missing of a dose, overdose and residents not getting therapeutic effects. She stated facility had done trainings on medication administration.<BR/>Interview on 02/13/25 at 1:34 PM, the DON revealed her expectation was for staff administering narcotic medications to document the medications when they were given to the resident on the medication administration record and to sign on the narcotic log. She stated nurses should not be pulling medications if the resident had not asked for it. She stated she asked RN C why she had not destroyed the medication that she had accidentally popped, and she did not give her a varied answer. She stated she expected RN C to label the cup, repull the right medication and then destroy the other one with a witness but not keeping in her pocket. DON stated failure to document could lead to overdose and effect on resident management. She stated ADONs were responsible for auditing the medication carts. She stated the facility had done training on medication administration and trainings dated 10/4/24 and 01/08/24 and RN C was not in attendance.<BR/>Record review of facility policy entitled Medication Administration procedures , dated 10/25/17, reflected the following: <BR/> 5. After the resident has been identified, administer the medication and immediately chart doses administered on the medication administration record. It is recommended that medication be charted immediately after administration, but if facility policy permits, medication may be charted immediately before administration.<BR/>17.If a controlled medication removed from its packaging and is not to be administered (resident refusal or contamination) the dose needs to be wasted to where the drug is unable to be used and /or destroyed and disposed of. If controlled medication is wasted, it must be documented on the controlled accountability sheet for the medication and witnessed by a nurse. Both staff members must sign on the accountability sheet verifying the drug was wasted.<BR/>Record review of the facility's Storage of Medications policy, dated 2003, reflected the following:<BR/>Did not address expired medications removal from the carts .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents.<BR/>CNA A failed to get assistance from another staff member when providing Resident #1, who required two staff for assistance with all ADLs, a bed bath on 12/05/24. During the bed bath, CNA A asked Resident #1 to turn to her side. When the resident turned she fell to the floor, which resulted in the resident sustaining a fracture of her right femur (thigh bone). <BR/>The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 12/05/24 and ended on 12/05/24. The facility had corrected the noncompliance before the survey began.<BR/>This failure could place residents at risk for serious injury or harm, decline in health, and decreased quality of life.<BR/>Findings included:<BR/>Record review of Resident #1's quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hypertension (high blood pressure), seizure disorder, cellulitis of right lower limb (bacterial infection that affects the skin and underlying tissue), fibromyalgia (chronic condition that causes widespread pain and tenderness in the body), and muscle wasting. The resident had a BIMS score of 9 which indicated her cognition was moderately impaired. The MDS further reflected Resident #1 was dependent for shower/bathing which indicated the helper did all the effort or the assistance of two or more helpers was required for the resident to complete the activity. <BR/>Record review of Resident #1's care plan revised on 12/16/24 reflected the resident had an ADL self-care performance deficit. Interventions included the resident required the assistance of two staff for bathing and bed mobility. <BR/>Record review of Resident #1's bathing status in the [NAME] system (documentation system used by reference key resident information for their nursing care plan) printed on 01/13/25 reflected the resident required the assistance of two staff members.<BR/>Record review of the facility's Provider Investigation Report dated 12/05/24 reflected the following:<BR/>The resident experienced a fall while in bed during care by the CNA [CNA A]. The CNA [CNA A] notified the nurse and had discovered the resident on the floor, resting against the bed. The resident has skin tears on both great toes, the let wrist, and beneath the right breast The resident reports generalized pain, with a particular emphasis on greater discomfort in her legs compared to other areas. When inquired about the incident, the resident explained 'I threw my foot over too far and fell.' The resident was transferred to the hospital due to experiencing pain the X-ray indicated a fracture in the left femur (left femur was facility documentation error; fracture was on the right leg). The resident subsequently underwent surgery to address the fracture <BR/>Record review of Resident #1's hospital records dated 12/05/24 reflected the resident was diagnosed with a comminuted distal femoral fracture (a broken bone that has been shattered into multiple pieces and are usually caused by severe trauma) of the right leg.<BR/>Observation and interview on 01/08/25 at 10:26 PM revealed Resident #1 in bed watching television. The resident was alert and oriented and able to recall the incident when she fell during care. The resident said CNA A was giving her a bed bath, and the aide asked her to turn to her side. The resident said she was turning over onto her side as she was holding on the repositioning bar and fell on the floor. She said CNA A was usually able to catch her when she rolled over, but this time she was not able to. Resident #1 said she was sent to the hospital and had surgery on her leg, as she pointed to her right leg. Resident #1 stated CNA A usually bathed her alone and never had a helper. The resident stated she preferred two people because she felt safer. Resident #1 said she was not experiencing much pain from her fracture but had discomfort due to the cellulitis in her legs. <BR/>Interview on 01/08/25 at 1:05 PM with CNA A revealed she was giving Resident #1 a bed bath and asked the resident to turn to her side. She stated the resident grabbed the repositioning bar on the bed, threw her leg over her left leg and that was when the resident fell over on to the floor. CNA A stated she then called for the nurse to assist, and the resident was assessed. CNA A stated Resident #1 was on an air mattress, and it was inflating at the time the resident was turning to her side. CNA A said she was aware Resident #1 required two staff for care, but she was not able to find someone to help her. CNA A said she asked another CNA, whose name she could recall, for help. She stated she did not get any help, so she bathed the resident alone. She stated she had bathed the resident alone in the past. The CNA said she felt safe bathing the resident alone because the resident was able to help turn in bed. <BR/>Interview on 01/13/25 at 1:23 PM with LVN B revealed she was called by CNA A to Resident #1's room and noticed the resident was on the floor. CNA A told her the resident was trying to turn in bed during a bed bath, and the resident fell. LVN B said during Resident #1's assessment, the resident was complaining of pain and noticed the resident's toes were bleeding and other areas of her body such as her side, so she was transferred to the hospital via EMS. LVN B stated Resident #1 required two staff member for care because she was a bariatric resident and for safety. The LVN said she did not know CNA A was caring for Resident #1 alone, and she did not recall the aide asking anyone for help during the bed bath. LVN B further stated the aides could look in the [NAME] system to verify if a resident required one or two staff members during care or ask a charge nurse.<BR/>Interview on 01/08/25 at 1:28 PM with CNA D revealed she had worked at the facility for about a year and cared for Resident #1. CNA D said Resident #1 was bed bound per choice and required two staff members for assistance for all care because the resident was bariatric and could not be care for by one staff member. <BR/>Interview on 01/08/25 at 2:07 PM with CNA E revealed she worked with Resident #1 and the resident was bed bound. CNA E said the resident required two staff members for all care including bed baths because she was bariatric and needed more support. CNA E further stated Resident #1 had never been a one-person care resident. <BR/>Interview on 01/08/25 at 2:39 PM with RN F revealed Resident #1 was bed bound and required two staff members for all care including bed baths because the resident was bariatric and one staff member could not adequately care or clean the resident up during ADL care. <BR/>Interview on 01/08/25 at 2:29 PM the ADON revealed Resident #1 was bed bound and rarely got out of bed. She said the resident was a two-person assist for all care at all times because she was on an air mattress and could easily roll out of bed and for overall safety. The ADON was made aware CNA A had bathed Resident #1 alone, but the aide was not able to explain why she had not requested for help but only stated she had not seen anyone else. The ADON stated it appeared to her that CNA A had not looked for anyone to help her with the resident. The ADON further stated they immediately began to re-in-service (training) for all nursing staff re-educating them on the importance of using two staff member if the resident required it. They also identified all the residents that required two staff members for care they were monitoring and making observations to ensure two staff were assisting when needed. The monitoring began after the incident with Resident #1 and would be on-going for six weeks to ensure safety. <BR/>Interview on 01/13/25 at 8:36 AM with the DON revealed she was told Resident #1 was getting a bed bath by CNA A and while the resident was turning to her left side with the assistance of the repositioning rail, Resident threw her leg over too far and continued to roll until she fell out of the bed. Resident #1 was assessed, and they noticed she had bruising to the top of her feet and was complaining of pain throughout her body but mostly to her right knee. The resident was transferred to the hospital where she was diagnosed with a right leg fracture. The DON said Resident #1 required two staff members for care due to being a bariatric resident and for safety. The DON stated CNA A admitted knowing Resident #1 required two staff members for care, but the aide told them she had not been able to find assistance but if she would asked her (DON) she would have assisted. The DON also said if aides did not know if a resident was a one or two person for care, they could look in their [NAME] computer system. After the incident, CNA A was suspended pending their investigation and had a 1:1 counseling and re-in-service (training) on resident care and the aide was pulled from working with Resident #1. The other nursing staff were re-educated on using the [NAME] computer system to ensure a resident required a one- or two-person assistance during care. The DON further stated they had identified all the residents that required two people and were going to monitor but watching care for those resident for 6 weeks. <BR/>Record review of the facility's Safe Patient Handling policy revised December 2005 reflected the following:<BR/>The facility has a program to promote and assure safe patient handling for both the resident and the employee. The policy includes identification, assessment and interventions to provide a comfortable, safer transfer, repositioning and resident movement. <BR/> .3. Nurses will be educated in the identification, assessment and control of risks of injury to resident and nurses during patient handling <BR/> .5. Nurses will be educated regarding correct safe handling procedures, to report concerns or the inability to perform resident handling or movement that the nurse believes in good faith will expose a resident or nurse to an unacceptable risk of injury <BR/>Record review of 1:1 in-service with CNA A dated 12/05/24 revealed she had been re-educated on using the [NAME] system to communicate the resident's needs and information to all the CNA's to ensure appropriate resident care. CNA was also re-educated on fall prevention strategies and safe patient handling and abuse and neglect policy. <BR/>Record review of in-services dated 12/05/24 with all direct nursing reflected the staff had been re-educated using the [NAME] system to communicate the resident's needs and information to all the CNAs to ensure appropriate resident care. CNAs were also re-educated on fall prevention strategies and safe patient handling and abuse and neglect policy. <BR/>Interview on 01/08/25 at 1:05 PM with CNA A revealed she had been re-in-serviced 1:1 on abuse and neglect, ensure to always use two staff members during care for residents that required it and using the [NAME] system to check the care of the residents if they were unsure. <BR/>Interviews on 01/08/25 from 11:12 AM to 5:14 PM and on 01/13/25 from 10:01 AM to 1:23 PM with nursing staff from various shifts to include LVN B, CNA C, CNA D, CNA E, RN F, LVN G, CNA H, CNA I, CNA J, and CNA K all revealed they have been in-serviced on abuse/neglect, using the [NAME] system to verify if a resident required one or two staff members for care, and fall prevention to avoid accidents. <BR/>Record review of the direct care monitoring sheets reflected it included to watch at least 10 episodes of incontinent care or assist with bed mobility weekly to ensure staff was performing correctly and the care-planned number of staff were assisting. The monitoring dates reviewed began 12/05/24 and would continue for 6 weeks, and end on 01/15/25. <BR/>Observation on 01/08/25 at 11:07 AM revealed Resident #2 was transferred from the bed to the chair via mechanical lift by two staff members. <BR/>Observation on 01/13/25 at 3:32 PM revealed Resident #3 was transferred to bed via mechanical lift by two staff members.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately consult with the physician of a significant change in the resident's health status; or a need to alter treatment significantly for 1 (Resident #168) of 4 residents reviewed for notification of change. <BR/>The facility failed to notify Resident #168's physician that the resident's insulin had been discontinued by the hospital or that the resident had returned from the hospital and failed to follow-up with the physician to obtain new orders. <BR/>The failure placed residents at risk of not having medical complications and deterioration. <BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated 01/05/24 indicated the resident was an [AGE] year-old female, initially admitted on [DATE], and readmitted on [DATE] with diagnoses that included pneumonia, diabetes mellitus with ketoacidosis (potentially life threatening complication of diabetes), dehydration, acute and chronic respiratory failure with hypoxia (not able to keep oxygen and carbon dioxide at normal levels), dementia, heart failure, acute kidney failure, chronic kidney disease stage 3, convulsions, chronic obstructive pulmonary disease, high blood pressure. <BR/>Record review of Resident #168's MDS dated [DATE] indicated Resident #168 had a BIMS of 5, indicating severe cognitive impairment. Resident #168 required supervision for oral hygiene and eating, and partial/moderate assistance with toileting. Active diagnosis included Type II Diabetes Mellitus with Hyperglycemia (indicating blood sugar too high).<BR/>Record review of Resident #168 care plan undated indicated Resident #168 has Diabetes Mellitus Type 2. The care plan revealed the resident was often noncompliant with blood sugar and medication/insulin. The care plan reflected: Goal: [Resident #168] will have no complications related to diabetes. Intervention: Diabetes medication as ordered by physician. Monitor and document for side effects and effectiveness. Educate importance of medications and importance of compliance. <BR/>Record review of Resident #168's hospital records dated 12/29/23 indicated he was admitted on [DATE] among active problems included Type 2 Diabetes Mellitus with complication, with long-term current use of insulin. Among discontinued medications were insulin lispro 100 unit/mL injection, insulin glargine 100 unit/mL (3mL), Freestyle Libre (glucose monitor) 10-day reader, Freestyle Libre 10-day sensor kit, blood-glucose meter.<BR/>Record review of Resident #168's January 2024 physician orders revealed he had no orders for administering insulin, no orders to monitor blood sugar levels. <BR/>Record review of progress note dated 12/29/23 at 5:34 PM written by LVN B, indicated Resident #168 returned to the facility via emergency services in stable condition, vitals are stable. Progress notes did not indicate discontinued medications or that the physician was notified of his return. <BR/>During an interview on 01/04/24 at 5:58 PM with ADON A, she stated Resident #168 had been placed on hospice since his return to the facility. She stated Resident #168 had a significant change of condition and was sent out to the hospital. ADON A stated when he returned, he was extremely weak and was only getting out of bed for a few hours, unlike what he was doing before. ADON A stated she was looking at his medications today (01/04/24) and realized he had returned with orders for tramadol and hospice evaluation. ADON A stated, We have not been checking his blood sugar because there were no orders for it. We were going to ask hospice care if they wanted to monitor it. When asked why she was not notified that the resident's insulin orders were discontinued, she replied, We knew it was discontinued from the hospital. According to ADON A Resident #168 was on both a long- and short-acting insulin; however, Resident #168 would like to instruct staff on how much insulin he would take, so they were very aware of him taking insulin prior to his hospital stay. ADON A stated Resident #168 went from medications including 10 pills and insulin down to only having order for tramadol and hospice and the doctor was aware. ADON A stated Resident #168's blood sugar was not being checked because the orders were discontinued from the hospital and he was placed on hospice, with the expectation of not making it; however, the resident was thriving quite well. She stated they would contact the doctor for an order to start checking his blood sugar again. According to ADON A, nursing staff were responsible for contacting the physician to alert him that Resident #168's order for insulin had been discontinued at his hospital discharge. ADON A stated not following up with the physician about Resident #168's insulin orders could place him at risk for further decline. ADON A stated it was her responsibility to review Resident #168's orders to ensure proper treatment was being provided. <BR/>Record review of Resident #168's progress notes on 01/04/24 at 6:29 PM written by ADON A reflected the following: Spoke with Physician informing him that resident's blood sugar checks and insulin was discontinued from the hospital and resident is on hospice, but he is not taking anything for his diabetes. New orders received to check blood sugar BID. Family Member called and informed.<BR/>Interview on 01/05/24 at 8:47 AM with Physician I revealed his policy for the facility was to contact him for sending residents out to the hospital, fall, change of condition and when the resident returned from the hospital. Physician I stated with that being said, he usually received a call from the facility with any changes in resident care or condition. Physician I stated his instruction to them was always to follow hospital discharge instructions they should have documented those instructions. According to Physician I, he was in the facility every Monday and at that time he would review discharge records and initial them once he had reviewed. Physician I stated he thought that he got two calls, one stating that Resident #168 had returned to the facility and another call either yesterday or the day before about the discontinued insulin orders. Physician I stated since Resident #168 was someone that was being administered insulin before the facility should be checking his blood glucose, hemoglobin A1C (test that measures average blood sugar of the past 2-3 months) and communicating those results to him. According to Physician I, not checking the resident's hemoglobin A1C could place the resident at risk of complications with his health, which could further his complications with which he was already dealing. <BR/>During an interview on 01/05/24 at 1:57 PM with LVN H, she stated she was not the admitting nurse when Resident #168 arrived from the hospital. According to LVN H, the protocol for returning orders from the hospital were to follow the instructions from the discharge paperwork, alert the physician, ADON, DON and family of any changes. LVN H stated after documenting the hospital orders they were placed in the mail box for the physician to review. LVN H stated it was the responsibility of the ADON to review resident orders in the system upon a resident's return to ensure the orders were entered correctly. LVN stated not have orders for residents who received insulin placed them at risk for missing treatments. She stated she had been off and had not completed care for Resident #168. <BR/>An interview was attempted with LVN B on 01/05/24 at 2:10 PM; however, she declined the interview stating she was off the clock. <BR/>On 01/05/24 at 5:00 PM, the Administrator was asked to provided the facility's policy regarding notification of changes; however, the policy was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 9 residents (Resident #1) reviewed for quality of care.<BR/>The facility failed to ensure hospital discharge orders were followed for Resident #1 to have a follow-up appointment with a primary care physician.<BR/>This failure could affect residents who receive care from the facility and place them at risk for worsening conditions.<BR/>Findings included: <BR/>Record review of Resident #1's face sheet, dated 01/30/24, reflected the resident was a [AGE] year-old female resident who was initially admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses of Alzheimer's disease, abnormalities of gait and mobility, cognitive communication deficit, muscle weakness, lack of coordination, history of falling, abnormal posture, muscle wasting and atrophy (loss of muscle tissue), dementia, and unsteady on feet. Resident #1's primary care physician was reflected as being also the facility's medical director. <BR/>Record review of Resident #1's Minimum Data Set, dated [DATE], reflected Resident #61 had a BIMS score of 4, which indicated the resident had severe cognitive impairment. Resident #1 required total dependence with 2 person assist for transfers.<BR/>Record review of Resident #1's care plan, undated, obtained 01/30/24, reflected the following problem area: Resident #1 has a history of falls related to impaired cognition, poor safety awareness, and is very impulsive. She is a risk for future falls and injury from falls. The care plan reflected: Goals: [Resident #1] will not sustain serious injury. Resident #1 will be free of minor injury. Intervention: Encourage resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Ensure that the resident wearing appropriate footwear when ambulating or mobilizing in wheelchair. Anticipate and meet the resident's needs. Dycem to wheelchair seat. Educate the resident/family/caregiver about safety reminders and wheat to do if a fall occurs. Keep furniture in locked position. Keep needed items, water. in reach. Mechanical lift with staff x2 to assist with transfers. Monitor resident per facility protocol when on the wheelchair. Physical therapy evaluate and treat as ordered or as needed. Put resident back in bed after each meal when not doing activities in the day room.<BR/>Record review of Resident #1's discharge recommendations from the hospital, obtained 01/30/24, reflected Resident #1 needed to follow-up with a primary physician or at the hospital clinic post discharge in 7-14 days (around 01/15/24).<BR/>Record review of resident admission dated 01/09/24 revealed Resident #1 was mobile with the use of a wheelchair, she had poor trunk control for balance, she required two-person assist with bed mobility, and she was transferred with a mechanical lift. No additional information related to mobility/safety indicated. <BR/>Record review of Resident #1's progress notes entered by LVN A, dated [late entry] dated 01/08/24 at 6:17 PM, revealed Resident #1 was transferred to the hospital on [DATE] at 6:15 PM related LVN A being told Resident #1 fell face forward out of her wheelchair while on her way to dinner. <BR/>Observation and interview on 01/30/24 at 9:51 AM with Resident #1 revealed the resident was in bed. She had a light scar on the left side of her forehead, but there were no current indications of bruising. A floor mat was folded up underneath the foot of the resident's bed, and the bed was not in the lowest position. Resident #1 was able to communicate; however, she not able to stay on task when asked if she had a fall, injury, or hospital visit. <BR/>Interview on 01/30/24 at 10:20 AM with CNA B revealed CNA B said she was not present during the fall, had not noted any signs and symptoms of a fall during her care. CNA B stated she had never known Resident #1 to have any falls or be a fall risk. According to CNA B, Resident #1 used a mechanical lift to transfer. She stated the resident was assisted out of bed three times a week. She stated the resident could be very combative during care and transfers. She stated Resident #1 had a hard time with sitting up straight for long periods of time whether in bed or in her wheelchair. CNA B stated it was not a surprise to see the floor mat underneath the bed, and not at the bedside. She stated the floor mat was used on days Resident #1 remained in bed. <BR/>Interview on 01/30/24 at 2:10 PM with LVN A revealed she did assist with Resident #1's admission back into the facility. LVN A did not recall any hospital discharge documents that came in with Resident #1. LVN A stated she was responsible for following up to notify the physician upon her return and enter any new orders, but there was no documentation at this time. LVN A stated either she or the ADON would contact the hospital to ensure Resident #1 proper care would be given once her return to the facility. LVN A stated she did not recall notifying the ADON or the hospital for Resident #1's hospital discharge documents. LVN A stated not following up for the hospital documents placed Resident #1 at risk for not receiving any follow up visits or proper care after her injury. <BR/>Interview on 01/30/24 at 3:05 PM with the Administrator revealed hospital records were retrieved when residents returned from the hospital and sometimes were requested by the admitting nurse. When the documentation were retrieved, the admitting nurse would review it, notify the physician, enter any new orders, update resident records, give a copy to social services for future appointments, and leave discharge documents for the physician to review and sign off on. The Administrator stated after the physician signed off that he reviewed the hospital documents, the documents were uploaded to the portal by the Medical Records staff. According to the Administrator, she did not observe hospital discharge documents uploaded to Resident #1's clinal records, and she would follow-up with the Medical Records staff. <BR/>Interview on 01/30/24 at 3:36 PM with the ADON revealed the admitting nurse would review hospital discharge documents and follow-up with the physician on any new orders. According to the ADON, she had not observed any discharge documents prior to this interview. According to the ADON, upon review of the resident's hospital discharge documents, Resident #1 was to have a follow-up visit with a primary physician within a week after discharge (around 01/15/24). The ADON stated she was not aware of this recommendation. The ADON stated the nurse admitting the resident back in the facility was responsible for contacting the hospital to retrieve discharge documents if they did not come in with the resident back to the facility. The ADON stated she did review records for hospital records received; however, this was missed. The ADON stated not doing so placed Resident #1 at risk of missing follow-up visits after her fall. The ADON stated the facility could have missed crucial instructions from the hospital leaving Resident #1 not receiving proper care. <BR/>Interview on 01/30/24 at 4:00 PM with the Administrator revealed Resident #1's primary physician was the Medical Director of the facility, and he visited the facility weekly. The Administrator stated having Resident #1 return to the hospital clinic for a follow-up visit would cause double billing. The Administrator stated the facility failed to retrieve Resident #1's discharge documents. The facility failed notify the physician of recommendations from the discharge documents. The Administrator revealed the documents were not retrieved upon Resident #1's return to the facility. The Administrator stated this failure could prevent proper healing and care. <BR/>Request of a facility policy on 01/30/24 at 4:30 PM regarding completing hospital discharge recommendations, follow-up visits, and to arrange for services that have been ordered by a physician was not available according to the Administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to prevent development of pressure ulcers for 1 (Resident #67) of 2 residents reviewed for pressure ulcers with use of a wound vacuum.<BR/>RN C failed to provide Resident #67 with wound care when he reported to her on 02/09/25 at approximately 7:30 AM that he was not feeling well and needed his dressing changed because his wound vac was leaking. RN C did not follow-up with Resident #67 for care until 5:30 PM at which time she discovered she did not have enough supplies to complete wound care. The wound care was not provided for approximately 10 hours after the resident had asked to have the dressing changed, which resulted in resident discomfort and wound drainage getting on the resident, his wheelchair, and bed linens. <BR/>An IJ was identified on 02/13/25. The IJ template was provided to the facility on [DATE] at 5:20 PM. While the IJ was removed on 02/14/25, the facility remained out of compliance at a scope of isolated and a severity level potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's need to implement corrective systems.<BR/>These failures placed residents with wounds at risk of wound deterioration, wound development, and infection. <BR/>Findings included:<BR/>Record review of Resident #67's face sheet reflected the resident was [AGE] years old male who admitted to the facility on [DATE] and readmitted on [DATE]. <BR/>Record review of Resident #67's quarterly MDS assessment, dated 11/28/24, reflected a BIMS score of 14, which indicated his cognition was intact. His diagnoses included paraplegia (the inability to voluntarily move the lower parts of the body), neurogenic bladder (the bladder muscles and nerves do not function properly), anxiety disorder, pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) of unspecified buttock, unspecified stage and need for assistance with personal care. The MDS further revealed Section M - Skin Conditions - Skin and Ulcer/Injury Treatment indicated the resident's required pressure ulcer/injury care and surgical wound care. <BR/>Record review of Resident #67's Care plan, revised date 01/29/25, reflected: Focus: [Resident #67] has a pressure at multiple sites. Please see physician orders and [MAR] for wound and treatment. Goal: [Resident #67] Pressure ulcer will show signs of healing and remain free form infection by/through review date. Interventions: Administer treatments as ordered and monitor for effectiveness. Replace loose or missing dressing PRN . Wound Vac ordered. <BR/>Record review of Resident #67's February 2025 MAR physician orders reflected: Clean the left hip and right ischial ulcer with N/S, Tap Dry, apply granular foam into the ulcer, cover with a drape, connect to Wound VAC with 125 MM mercury pressure, change Q Monday, Wednesday, Friday, and as Needed. In the morning every Mon, Wed, Fri for wound treatment.<BR/>Record review of Resident #67's February 2025 MAR physician orders reflected: If Wound VAC is not available, clean bilateral hip ulcer and hip ischial ulcer with normal saline, tap with dry dressing, apply silver alginate rope into all the ulcer, cover with multiple layers of 4 x 4s ABD, secure with medipore (cloth) tape, change the dressing every other day and as needed for wound discharge. Every 12 hours as needed for wound treatment related to Pressure Ulcer of Unspecified Buttock, Unspecified state. <BR/>Record review of Resident #67's physician orders revealed:<BR/>If wound vac is not available, clean bilateral hip ulcer and hip ischial ulcer with normal saline, tap with dry dressing, apply silver alginate rope into all the ulcer, cover with multiple layers of 4 x 4 s abdominal pads, secure with medipore (cloth) tape, change the dressing every other day and as needed for wound discharge.<BR/>Every 12 hours as needed for wound treatment related to pressure ulcer of unspecified buttock, unspecified stage 1/9/2025<BR/>Clean the left hip and right ischial ulcer with n/s, tap dry, apply granular foam into the ulcer, cover with a drape, connect to wound vac with 125 mm mercury pressure, change every Monday, Wednesday, Friday. and as needed. In the morning every Monday, Wednesday, Friday for wound treatment 1/9/2025<BR/>Record review of Resident #67's MAR, for the month of February 2025 (02/01/25 - 02/14/25) revealed Resident #67 was provided care to clean the left hip and right ischial ulcer with normal saline, tap dry, apply granular foam into the ulcer, cover with drape, connect to wound vac with 125MM mercury pressure, change every Monday, Wednesday, Friday, and as needed. In the morning every Monday, Wednesday, Friday for wound treatment on day 02/03/25, 02/05/25, 02/07/25 and did not indicate care was provided on 02/09/25, and care was not provided on 02/10/25. <BR/>Record review of Resident #67's Wound Evaluation and Management Summary dated 02/12/25 reflected: <BR/>Chief Complaint - Patient has wounds on his right hip; left hip; left ischium. <BR/>Focused Wound Exam (Site 1)<BR/>Stage 4 Pressure Wound of the Left Ischium Full Thickness <BR/>Etiology (quality) . Pressure<BR/>MDS 3.0 Stage . 4<BR/>Duration . Greater than 395 days<BR/>Objective . Healing/Maintain Healing <BR/>Wound Size (LxWxD): . 2 x 1.5 x 1.5 cm <BR/>Surface Area . 3.00 cm<BR/>Undermining . 4.2 cm at 3 o'clock<BR/>Exudate . Moderate Serous<BR/>Granulation tissue . 100 %<BR/>Wound progress . Improved evidenced by decrease in depth <BR/>Focused Wound Exam (Site 2)<BR/>Stage 4 Pressure Wound of the Left Ischium Full Thickness <BR/>Etiology (quality) . Pressure<BR/>MDS 3.0 Stage . 4<BR/>Duration . Greater than 345 days<BR/>Objective . Healing/Maintain Healing <BR/>Wound Size (LxWxD): . 4.5x 5 x 0.6 cm <BR/>Surface Area . 22.50 cm<BR/>Undermining . 3 cm at 9 o'clock<BR/>Exudate . Moderate Serous<BR/>Granulation tissue . 100 %<BR/>Wound progress . Not at Goal <BR/>Dressing Treatment Plan - Negative pressure wound therapy apply three times per week for 10 days; NPWT , Coarse (green) foam, 120 mmHg suction, continuous mode, change 3 x week and PRN; Irrigate and cleanse wound with &frac14; % Dakin's with wound vac dressing changes apply three times per week for 10 days<BR/>Focused Wound Exam (Site 3)<BR/>Stage 4 Pressure Wound of the Left Ischium Full Thickness <BR/>Etiology (quality) . Pressure<BR/>MDS 3.0 Stage . 4<BR/>Duration . Greater than 365 days<BR/>Objective . Healing/Maintain Healing <BR/>Wound Size (LxWxD): . 6 x 5 x 1 cm <BR/>Surface Area . 30.00 cm<BR/>Undermining . 2 cm at 6 o'clock<BR/>Exudate . Moderate Serous<BR/>Granulation tissue . 30 %<BR/>Wound progress . Improved evidenced by decrease in depth <BR/>Dressing Treatment Plan - Negative pressure wound therapy apply three times per week for 10 days; Continuous suction at 120 mmHg. Bridge dressing onto left anterior thigh; irrigate and cleanse wound with &frac14; % Dakin's with wound vac dressing changes apply three times per week for 10 days<BR/>Record review of Resident #67's progress notes dated 2/9/25 at 1:48 PM written by RN C revealed patient had come to nursing desk and stated he did not feel well, and that wound vac was not working right on left hip. Lips were pale, sclera pale. Went to patient room and discussed going to hospital. Discussed with patient removal of wound vac dressing and placement of wet to dry dressing. Patient refused wet to dry and said he was going to wait until he spoke with his wife and stated that he would let this writer know of his decision.<BR/>Record review of Resident #67's progress notes dated 02/9/25 at 1:55 PM written by RN C revealed This writer had gone to patient room to ask what his decision was. He stated that he wanted left hip wound dressing to be changed. He was informed that dressing would be changed as soon as possible. patient verbalized understanding<BR/>Record review of Resident #67's progress notes dated 2/9/25 at 7:58 PM written by RN C revealed wound vac dressing change had been done to left hip. patient then informed this writer that his right hip dressing needed to be changed. informed supplies would need to be gathered. Wife present at bedside and offered to change dressing. Wife changed dressing to demonstrate how was taught to change dressing. Pt tolerated well. <BR/>Record review of Resident #67's progress notes dated 2/10/25 at 12:19 AM written by RN C revealed Patient tolerated MN medications, pt alert, able to answer questions writer asked. Pt held water, accepted snack at this time. Fluids at bedside Gatorade and ice water. Wound vac on, dressing intact upon observation. Pt declined any needs that need to be addressed at this time. Care ongoing.<BR/>Interview on 02/11/25 11:37 AM with Resident #67 revealed the resident in bed, Resident #67 asked if he could include his Family Member and made a phone call. Resident #67 and Family Member stated there has been a lot of issues in regard to his wound care. Resident #67 stated he and his Family Member had been speaking with the Administrator and the DON to have consistent and timely wound care. According to the Family Member and Resident #67, nursing staff to include the LVN M were rude and lacked customer service and bedside manner, staff would not want to complete his wound care. Resident #67 stated when the LVN M was not available or had a day off wound care could not be completed because other nurses, they lack the proper training to assist him with administering the wound vacuum. Resident #67 stated he has a wound on each hip and one right below his right butt check. Resident #67 stated upon speaking with the Administrator, wound care and placement of the wound vacuum should be completed early in the mornings at the start of shift. Resident #67 stated on last Sunday (02/09/25) he alerted RN C about 7:30 - 7:45 AM that he did not feel well, and needed to have his wounds cleaned and vacuum replaced because the wounds were leaking all over his bed and wheelchair. Resident #67 stated RN C did not return to assess, clean, and connect the wound vacuum until 5:30 PM just prior to the end of her shift, at that time it was discovered RN C did not have enough supplies to complete care which resulted in a prolonged wait to get care. According to Resident #67 the vacuum machine was malfunctioning early in the morning hours, it was off and not working, the bandages were coming off allowing the wound to drain and leak all day which was disgusting. <BR/>Observation on 02/12/25 at 10:55 AM of Resident #67's wound care for Resident #67 with LVN M she explained the procedure was to wash her hands and put all the supplies together then donn PPE. Resident #67 was positioned, and the wound vacuum was disconnected. She removed the old dressings on the left hip and ischium. The wound looks clean no signs of swelling, redness, or bleeding was observed. She cleansed the area with gauze soaked with solution inside out with each swipe. She patted dry. The wound doctor measured the wound. She cleansed again and patted dry. She sprayed the edges with skin prep and waited to dry. She applied xeroform on an open area on the hip. She then applied the film to cover the hip. She cut the film to the size of the wound and applied the black foam. She doffed and washed hands and repeated the same procedure for the ischium. She doffed gloves and washed her hands. She applied the film to cover both areas and a bridge sponge was applied. She applied the tubing and then covered with film, and she anchored the tubing not to touch the body. She washed hands and donned gloves. She removed the old dressing on the right hip. The wound was observed, no swelling, no odor, and no bleeding was observed or redness. The same procedure was applied to the right hip. LVN M then connected both tubes from both hips and connected to a new canister and put it on. The pressure was at 125 mm mercury pressure. The wound vac was left working properly. <BR/>Observation and interview on 02/12/25 at 11:39 AM with the Wound Care Doctor revealed him stating both wounds are measuring about the same maybe a bit smaller in diameter (left ischium 2x1.5x1.5 cm, left hip 4.5x5x.06 cm, and right hip 6x5x1 cm). According to the Wound Care Doctor, he was not notified about the wound vacuum malfunctioning on 02/09/25. He further stated, Resident #67 left the facility a lot and that may have to do with the reason for the vacuum disconnecting, and I don't think they have staff over the weekend that is able to address that issue. The Wound Care Doctor stated therefore it has to be addressed on the following business day and Resident #67 would usually inform me when I come on Wednesday. The Wound Care Doctor stated he would like the wound to be cared for in a timely manner, and there should be staff trained to address the issue. The Wound Care Doctor stated not caring for the wound or replacing the dressing could place Resident #67 at risk of infection and needing to be sent to the hospital for sepsis. He further stated, I have no concerns with his care and the wound treatments .<BR/>Interview on 02/12/25 at 1:15 PM with the LVN M revealed she had been working with Resident #67 on wound care. She stated she was notified on 02/09/25 by RN C there were no supplies to complete wound care for Resident #67. LVN M stated she came to the facility to replenish supplies and left some in Resident #67's room. LVN M stated supplies were normally kept on the wound cart and the medication room located behind the nursing station. She stated that she could be contacted, if needed, to gather supplies out of her office if needed. LVN M stated when she arrived at the facility RN C asked her to provide care to Resident #67's wound, she said she responded No, today is my off day and she left the facility. According to the LVN M, Central Supply was responsible to keep supplies stocked, not doing so could place the residents at risk of not receiving timely care as needed. <BR/>Interview on 02/12/25 at 5:38 PM with RN C revealed she worked with Resident #67 on 02/09/25. She stated Resident #67 came to the nursing station around 7:30 - 7:45 AM. He stated, I'm not feeling good, I had been laying in this, I am leaking all over my bed, myself, and now my wheelchair. RN C stated Resident #67 looked pale, he looked sick (lips were pale, sclera pale). The wound looked like it was leaking, and it needed to be changed. RN C stated she then told Resident #67 to contact Family Member and discuss being sent out to the hospital because she did not want to complete the care with the new canister if he was going out. She stated, I needed to know which supplies to use, if he was going to the hospital, I would need to use wet to day supplies. RN C stated she was waiting on Resident #67 to come back to her with a response from Family Member, on what they had decided about going to the hospital. RN C stated when she got around to checking on Resident #67 it was after 5:00 PM, she stated I completed care on the right hip, and I did not know if you did one side you needed to do the other side as well, there was not enough supplies to complete the left side. I reached out to the DON, and she gave me the LVN M's number to contact her, she then came to the facility to bring me supplies, this was around 6:00 PM. RN C stated, I had other things going on and could not prioritize him, I did not intently neglect him. RN C stated she was responsible for ensuring wound care for Resident #67 was completed in a timely manner, not doing so placed him at risk of him being in sepsis and making wounds worst with no suction. RN C stated the Family Member entered Resident #67's room upset about him not receiving timely care and completed the wound care with RN C observing. According to RN C she received a video in-service on 02/10/25 and she was also expected to do one on one training with the LVN M on how to use wound vacuum. According to RN C she was trained on wound vacuum in prior positions however, not the way it was requested by Resident #67 and Family Member. <BR/>Interview on 02/13/25 at 12:28 PM with the DON revealed she received a call from RN C around 5:30 PM indicating there was no supplies available to complete wound care for Resident #67, that she thought the wound vacuum was messed up, According to the DON she instructed RN C to look at the vacuum and contact the LVN M for supplies. The DON stated she also called the LVN M to bring supplies and was on the phone with the LVN M when she entered the facility to deliver supplies. According to the DON only a limited number of supplies are put out on the wound cart or in the medication room, when additional supplies are needed, the LVN M was contacted so she can tell us where to get more or she will come to the facility to get them from her office. The DON stated she got confirmation from RN C that the vacuum was changed and working properly. According to the DON she was in communication with RN C throughout the day and she never reported Resident #67 was not feeling or did not look well. The DON stated she heard from Family Member that Resident #67 requested earlier in the day to have his wounds changed and machine inspected. The DON stated she would have expected RN C to address Resident #67's concerns with his wounds and wound care in a timely manner, not wait the entire shift to complete care. The DON stated she sent a you tube video to RN C on Monday and had been having all nursing staff to shadow one on one wound care with the LVN M that started weeks ago. The DON stated she started this process, so nurses were comfortable changing the wound vacuum and the supplies, and what to do when wound vacuums are beeping. The DON stated RN was responsible for addressing Resident #67's needs for his wounds, and reporting when residents have a change in condition to the physician, DON, and the Administrator. The DON further stated, not completing care in a timely manner placed Resident #67 at risk of sepsis, wound breakdown, hospitalization, and septic shock and because of that we took disciplinary action.<BR/>Interview on 02/13/25 at 4:27 PM with the Administrator revealed he received a call from the Family Member on 02/09/25 that RN C was refusing to replace the wound vacuum for Resident #67, that she was trying to send him out to the hospital instead. According to the Administrator the Family Member reported she saw supplies in the room. The Administrator stated, I don't know if the nurse knew what she was doing and that he expected the nursing staff to address any wound changes or resident needs in a timely manner. According to the Administrator the DON and ADONs were responsible for ensuring the nurses were trained to complete wound care. The Administrator stated it was reported back to him the dressings and wound care was completed that day. The Administrator stated he expected nurses to ensure they are following doctor orders, not doing so placed Resident #67 at risk of infections and having to be sent out to the hospital for not addressing his need for wound care. The Administrator stated he did not have the full story of events and he did not investigate the incident; he did not feel he needed to because the wound care was completed . The Administrator stated that he expected Resident #67's wound care to have been completed in the mornings at the beginning of the 6:00 AM shift. The Administrator stated not providing wound care, when the wound is leaking and Resident #67 stated he did not feel well, and not checking on Resident #67 for the entire shift would be a form of neglect.<BR/>Interview on 02/14/25 at 1:16 PM with the Physician revealed he was not made aware that Resident #67 had a change in condition, the Physician stated he expected to be notified by the facility if there was change in condition with residents. The Physician stated if the wound vacuum machine was beeping that indicated the wound vacuum needed to be checked. The Physician stated at that time the wound should be assessed with the possibility of the dressings to be changed . According the Physician waiting 10 hours could place the resident at risk of several things and the need to be sent to the hospital<BR/>Record review of facility policy revised 10/05/16 titled Skin Integrity Management reflected:<BR/>Wound care should be performed as ordered by the physician. Skin should be cleansed at the time of soiling and the routine intervals. The frequency of skin cleansing should be individualized according to need/and or resident preference. Minimize skin exposure to moisture due to incontinence, perspiration, or wound drainage. <BR/>Record review of facility policy dated 2015 titled Physician Orders reflected to monitor and ensure the accuracy and completeness of the medication orders, treatment orders, and activities of daily living order for each resident. <BR/>Record review of facility policy revised 03/11/23 titled Notifying the Physician of Change in Status reflected The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgement deem it necessary for immediate medical attention. <BR/>The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptom of signification change, time/date of call to physician, and intervention s that were implemented in the resident's clinical record. <BR/>This was determined to be an Immediate Jeopardy (IJ) on 02/13/25 at 5:25 PM. The Administration was notified. The Administrator was provided the IJ template on 02/13/25 at 5:26 PM and a plan of removal was requested. <BR/>The following plan of removal submitted by the facility was accepted on 02/14/25 at 1:40 PM and included the following:<BR/>Plan of Removal<BR/>Problem: F686 Failure to Prevent Pressure Ulcers<BR/>Interventions:<BR/>As of 2/13/25 resident #1 had a complete head to assessment performed by the Treatment Nurse<BR/>As of 2/13/25 the wound MD was notified. The wound MD assessed and measured all of resident #1 wounds. No additional orders were received. <BR/>All residents in the facility will receive a head-to-toe skin assessment. Wound treatments including wound vacs will be verified as completed according to MD orders by the Regional Compliance Nurse, DON, ADON. Completion date 2/13/25.<BR/>Treatment nurse was educated on checking daily, Monday-Friday, to ensure that all wound care supplies is readily available. Completion date 2/14/25.<BR/>All nurses were educated on the location of wound care supplies. If not available, they need to notify the DON and Administrator immediately. Completion date 2/14/25.<BR/>The DON and ADON were in-serviced 1:1 on following topics by the Regional Compliance Nurse. Completed 2/13/25.<BR/>Dressing Change Procedure- procedure to include wound vac dressings. <BR/>Abuse and Neglect: failure to complete a dressing change according to MD orders including wound vacs could be considered abuse and neglect. <BR/>Notification of Change in Condition: including notifying a MD for a change in a resident's condition. <BR/>Resident Rights: to respect a resident's right to request care including dressing changes. <BR/>The medical director was notified of the immediate jeopardy on 2/13/25. <BR/>An ADHOC QAPI meeting was completed on 2/13/25 with IDT team including the Medical Director to discuss the immediate jeopardy and plan of removal. <BR/>In-services:<BR/>All nursing staff will be in-serviced on 2/13/25 regarding the following topics below by the and ADO, Regional Compliance Nurse, Administrator, DON, and ADON. All staff not present will not be allowed to assume their duties until in-serviced. All PRN staff will be in-serviced prior to their next assignments. All new hires will be in-service on their date of hire, during facility orientation. All agency staff will be in-serviced prior to the start of their assignment. Completion date 2/14/25. <BR/>Dressing Change Procedure- procedure to include wound vac dressings. <BR/>Dressing Supplies- all supplies needed for treatment services are in the medication room. Notify the DON and Administrator if not available. <BR/>Abuse and Neglect: failure to complete a dressing change according to MD orders including wound vacs could be considered abuse and neglect. <BR/>Notification of Change in Condition: including notifying a MD for a change in a resident's condition. <BR/>Resident Rights: to respect a resident's right to request care including dressing changes. <BR/>Monitoring of POR:<BR/>Inservice Training Topic: <BR/>Dressing Change Procedure - Procedure to include wound vac dressings. <BR/>Abuse and Neglect: Failure to complete a dressing change according to MD order including wound vacs could be considered abuse and neglect. <BR/>Notification of Change in Condition: including notifying MD for a change in a resident's condition.<BR/>Resident Rights: to respect a resident's right to request care including dressing changes. <BR/>Date and Time Conducted: 2/13/24.<BR/>Instructor: Regional DON <BR/>Attendees: Administrator, ADON A, ADON B, DON<BR/>Inservice Training Topic:<BR/>Wound Care Supplies Being Readily Available <BR/>The wound nurse will ensure that all necessary wound care supplies are readily accessible for nursing staff. If staff encounter any difficulties in finding the supplies, she will guide them on where to locate the required items. From Monday to Friday, the wound nurse will verify that supplies are adequately stocked in the medication room, and on Fridays, she will also confirm that the supplies are prepared for the weekend. <BR/>Date Conducted: 02/13/25. <BR/>Instructor: Regional DON<BR/>Attendees: LVN M<BR/>Inservice Training Topic:<BR/>Notification of Changes - see attached policy regarding notification of changes. <BR/>Date Conducted: 02/13/25.<BR/>Instructor: Regional DON<BR/>Attendees to include MA P, MA EE, CNA F, CNA K, CNA N, CNA Q, CNA V, CNA X, CNA BB, RN D, RN GG, LVN H, LVN M, ADON A, CNA HH, CNA II, CNA JJ, CNA KK, CNA LL, CNA DD <BR/>Inservice Training Topic: <BR/>Abuse and Neglect Resident Rights <BR/>Date Conducted: 02/13/25.<BR/>Instructor: DON<BR/>Attendees to include: ADON B, LVN H, CNA X, LVN BB, MA CC, MA EE, RN GG, CNA F, CNA JJ, CNA HH, RN D, MA P, CNA K, CNA Q, Med Rec, LVN M, CNA LL<BR/>Inservice Training Topic:<BR/>Wound Dressing Care and Changes <BR/>Date Conducted: 02/13/25.<BR/>Instructor: Regional DON<BR/>Attendees to include: ADON B, LVN H, LVN BB, MA CC, CNA LL, MA EE, RN GG, RN D, CNA N, CNA Q, CNA T, LVN M, ADON B, CNA AA, CNA DD<BR/>Inservice Training Topic:<BR/>A resident request a change to the wound vac, immediately address the resident, do NOT delay treatment. <BR/>Call the DON and Wound Care Nurse if there are any issues in applying the wound vac. <BR/>Monitor the wound vac for changes to suction, taping, leakage, tubing kinked and any other concerns. <BR/>Operating Manual Revision Date: 2024-08-16 titled extriCARE 3000 Negative Pressure Wound Therapy System<BR/>Date Conducted: 02/13/25.<BR/>Instructor: DON<BR/>Attendees to include: LVN I, LVN BB, ADON B, ADON A, LVN H, MA CC, MA EE, RN D, RN GG, CNA Q, CNA T<BR/>Interviews conducted with the above staff indicated they had understanding to identify when a resident has a change of condition, signs of abuse/neglect, the need to honor resident rights. Nursing staff was able to reveal where wound care supplies were kept; how and who to notify to restock if items were low, and Nurses stated they understood how to complete wound care on residents with wound vacuums. <BR/>The Administrator was informed the Immediate Jeopardy was removed on 02/14/2025 at 7:10 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents.<BR/>CNA A failed to get assistance from another staff member when providing Resident #1, who required two staff for assistance with all ADLs, a bed bath on 12/05/24. During the bed bath, CNA A asked Resident #1 to turn to her side. When the resident turned she fell to the floor, which resulted in the resident sustaining a fracture of her right femur (thigh bone). <BR/>The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 12/05/24 and ended on 12/05/24. The facility had corrected the noncompliance before the survey began.<BR/>This failure could place residents at risk for serious injury or harm, decline in health, and decreased quality of life.<BR/>Findings included:<BR/>Record review of Resident #1's quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hypertension (high blood pressure), seizure disorder, cellulitis of right lower limb (bacterial infection that affects the skin and underlying tissue), fibromyalgia (chronic condition that causes widespread pain and tenderness in the body), and muscle wasting. The resident had a BIMS score of 9 which indicated her cognition was moderately impaired. The MDS further reflected Resident #1 was dependent for shower/bathing which indicated the helper did all the effort or the assistance of two or more helpers was required for the resident to complete the activity. <BR/>Record review of Resident #1's care plan revised on 12/16/24 reflected the resident had an ADL self-care performance deficit. Interventions included the resident required the assistance of two staff for bathing and bed mobility. <BR/>Record review of Resident #1's bathing status in the [NAME] system (documentation system used by reference key resident information for their nursing care plan) printed on 01/13/25 reflected the resident required the assistance of two staff members.<BR/>Record review of the facility's Provider Investigation Report dated 12/05/24 reflected the following:<BR/>The resident experienced a fall while in bed during care by the CNA [CNA A]. The CNA [CNA A] notified the nurse and had discovered the resident on the floor, resting against the bed. The resident has skin tears on both great toes, the let wrist, and beneath the right breast The resident reports generalized pain, with a particular emphasis on greater discomfort in her legs compared to other areas. When inquired about the incident, the resident explained 'I threw my foot over too far and fell.' The resident was transferred to the hospital due to experiencing pain the X-ray indicated a fracture in the left femur (left femur was facility documentation error; fracture was on the right leg). The resident subsequently underwent surgery to address the fracture <BR/>Record review of Resident #1's hospital records dated 12/05/24 reflected the resident was diagnosed with a comminuted distal femoral fracture (a broken bone that has been shattered into multiple pieces and are usually caused by severe trauma) of the right leg.<BR/>Observation and interview on 01/08/25 at 10:26 PM revealed Resident #1 in bed watching television. The resident was alert and oriented and able to recall the incident when she fell during care. The resident said CNA A was giving her a bed bath, and the aide asked her to turn to her side. The resident said she was turning over onto her side as she was holding on the repositioning bar and fell on the floor. She said CNA A was usually able to catch her when she rolled over, but this time she was not able to. Resident #1 said she was sent to the hospital and had surgery on her leg, as she pointed to her right leg. Resident #1 stated CNA A usually bathed her alone and never had a helper. The resident stated she preferred two people because she felt safer. Resident #1 said she was not experiencing much pain from her fracture but had discomfort due to the cellulitis in her legs. <BR/>Interview on 01/08/25 at 1:05 PM with CNA A revealed she was giving Resident #1 a bed bath and asked the resident to turn to her side. She stated the resident grabbed the repositioning bar on the bed, threw her leg over her left leg and that was when the resident fell over on to the floor. CNA A stated she then called for the nurse to assist, and the resident was assessed. CNA A stated Resident #1 was on an air mattress, and it was inflating at the time the resident was turning to her side. CNA A said she was aware Resident #1 required two staff for care, but she was not able to find someone to help her. CNA A said she asked another CNA, whose name she could recall, for help. She stated she did not get any help, so she bathed the resident alone. She stated she had bathed the resident alone in the past. The CNA said she felt safe bathing the resident alone because the resident was able to help turn in bed. <BR/>Interview on 01/13/25 at 1:23 PM with LVN B revealed she was called by CNA A to Resident #1's room and noticed the resident was on the floor. CNA A told her the resident was trying to turn in bed during a bed bath, and the resident fell. LVN B said during Resident #1's assessment, the resident was complaining of pain and noticed the resident's toes were bleeding and other areas of her body such as her side, so she was transferred to the hospital via EMS. LVN B stated Resident #1 required two staff member for care because she was a bariatric resident and for safety. The LVN said she did not know CNA A was caring for Resident #1 alone, and she did not recall the aide asking anyone for help during the bed bath. LVN B further stated the aides could look in the [NAME] system to verify if a resident required one or two staff members during care or ask a charge nurse.<BR/>Interview on 01/08/25 at 1:28 PM with CNA D revealed she had worked at the facility for about a year and cared for Resident #1. CNA D said Resident #1 was bed bound per choice and required two staff members for assistance for all care because the resident was bariatric and could not be care for by one staff member. <BR/>Interview on 01/08/25 at 2:07 PM with CNA E revealed she worked with Resident #1 and the resident was bed bound. CNA E said the resident required two staff members for all care including bed baths because she was bariatric and needed more support. CNA E further stated Resident #1 had never been a one-person care resident. <BR/>Interview on 01/08/25 at 2:39 PM with RN F revealed Resident #1 was bed bound and required two staff members for all care including bed baths because the resident was bariatric and one staff member could not adequately care or clean the resident up during ADL care. <BR/>Interview on 01/08/25 at 2:29 PM the ADON revealed Resident #1 was bed bound and rarely got out of bed. She said the resident was a two-person assist for all care at all times because she was on an air mattress and could easily roll out of bed and for overall safety. The ADON was made aware CNA A had bathed Resident #1 alone, but the aide was not able to explain why she had not requested for help but only stated she had not seen anyone else. The ADON stated it appeared to her that CNA A had not looked for anyone to help her with the resident. The ADON further stated they immediately began to re-in-service (training) for all nursing staff re-educating them on the importance of using two staff member if the resident required it. They also identified all the residents that required two staff members for care they were monitoring and making observations to ensure two staff were assisting when needed. The monitoring began after the incident with Resident #1 and would be on-going for six weeks to ensure safety. <BR/>Interview on 01/13/25 at 8:36 AM with the DON revealed she was told Resident #1 was getting a bed bath by CNA A and while the resident was turning to her left side with the assistance of the repositioning rail, Resident threw her leg over too far and continued to roll until she fell out of the bed. Resident #1 was assessed, and they noticed she had bruising to the top of her feet and was complaining of pain throughout her body but mostly to her right knee. The resident was transferred to the hospital where she was diagnosed with a right leg fracture. The DON said Resident #1 required two staff members for care due to being a bariatric resident and for safety. The DON stated CNA A admitted knowing Resident #1 required two staff members for care, but the aide told them she had not been able to find assistance but if she would asked her (DON) she would have assisted. The DON also said if aides did not know if a resident was a one or two person for care, they could look in their [NAME] computer system. After the incident, CNA A was suspended pending their investigation and had a 1:1 counseling and re-in-service (training) on resident care and the aide was pulled from working with Resident #1. The other nursing staff were re-educated on using the [NAME] computer system to ensure a resident required a one- or two-person assistance during care. The DON further stated they had identified all the residents that required two people and were going to monitor but watching care for those resident for 6 weeks. <BR/>Record review of the facility's Safe Patient Handling policy revised December 2005 reflected the following:<BR/>The facility has a program to promote and assure safe patient handling for both the resident and the employee. The policy includes identification, assessment and interventions to provide a comfortable, safer transfer, repositioning and resident movement. <BR/> .3. Nurses will be educated in the identification, assessment and control of risks of injury to resident and nurses during patient handling <BR/> .5. Nurses will be educated regarding correct safe handling procedures, to report concerns or the inability to perform resident handling or movement that the nurse believes in good faith will expose a resident or nurse to an unacceptable risk of injury <BR/>Record review of 1:1 in-service with CNA A dated 12/05/24 revealed she had been re-educated on using the [NAME] system to communicate the resident's needs and information to all the CNA's to ensure appropriate resident care. CNA was also re-educated on fall prevention strategies and safe patient handling and abuse and neglect policy. <BR/>Record review of in-services dated 12/05/24 with all direct nursing reflected the staff had been re-educated using the [NAME] system to communicate the resident's needs and information to all the CNAs to ensure appropriate resident care. CNAs were also re-educated on fall prevention strategies and safe patient handling and abuse and neglect policy. <BR/>Interview on 01/08/25 at 1:05 PM with CNA A revealed she had been re-in-serviced 1:1 on abuse and neglect, ensure to always use two staff members during care for residents that required it and using the [NAME] system to check the care of the residents if they were unsure. <BR/>Interviews on 01/08/25 from 11:12 AM to 5:14 PM and on 01/13/25 from 10:01 AM to 1:23 PM with nursing staff from various shifts to include LVN B, CNA C, CNA D, CNA E, RN F, LVN G, CNA H, CNA I, CNA J, and CNA K all revealed they have been in-serviced on abuse/neglect, using the [NAME] system to verify if a resident required one or two staff members for care, and fall prevention to avoid accidents. <BR/>Record review of the direct care monitoring sheets reflected it included to watch at least 10 episodes of incontinent care or assist with bed mobility weekly to ensure staff was performing correctly and the care-planned number of staff were assisting. The monitoring dates reviewed began 12/05/24 and would continue for 6 weeks, and end on 01/15/25. <BR/>Observation on 01/08/25 at 11:07 AM revealed Resident #2 was transferred from the bed to the chair via mechanical lift by two staff members. <BR/>Observation on 01/13/25 at 3:32 PM revealed Resident #3 was transferred to bed via mechanical lift by two staff members.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 2 residents (Residents #9 and #63) reviewed for dialysis.<BR/>The facility failed to ensure dialysis communication forms for Residents #9 and Resident #63 were received back from dialysis center after returning from dialysis treatment on the dates mentioned below.<BR/>The missing communication forms for Resident #9 totaling to 10 days on the following dates: 01/01/25, 01/03/25, 01/06/25, 01/08/25, 01/10/25, and 01/17/25, 02/03/25, 02/05/25, 02/07/25 and 02/10/25. <BR/>Resident #63 was missing communication forms totaling to 12 days on the following dates: 01/01/25, 01/03/25, 01/06/25, 01/08/25, 01/10/25, 1/20/25,1/24/25, 01/29/25, 02/03/25, 02/05/25, 02/07/25 and 02/10/25.<BR/>This failure could place residents at risk of inadequate communication between the facility and dialysis center. <BR/>Findings included: <BR/>1. Record review of Resident #9's quarterly MDS assessment, dated 11/13/25, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #9 had a diagnosis of end stage renal disease (a chronic condition that occurs when the kidneys can no longer filter waste from the blood and requires long-term dialysis). She had a BIMS score of 15, which indicated her cognition was intact. The MDS reflected Resident #9 received dialysis. <BR/>Record review of Resident #9's care plan, dated 01/25/25, reflected Resident #9 needed hemodialysis (medical procedure that filters blood to remove waste and extra fluid when the kidneys are no longer functioning properly). The care plan reflected the following goals: [Resident #9] would have immediate intervention should any signs and symptoms of complications from dialysis occur through the review date. The care plan interventions reflected: Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis. Monitor/document/report PRN any signs and symptoms of infection to access site: Redness, Swelling, warmth or drainage. <BR/>Record review of Resident #9's February 2025 physician's order reflected to monitor Arteriovenous shunt/fistula (a surgical procedure that creates a new pathway for fluid to flow) to (site) for thrill & bruit (A bruit is a sound and a thrill is a vibration that indicate a fistula is working properly) every shift notifies medical doctor/Nurse practitioner for any unusual/unexpected findings.<BR/>Record review of Resident #9's EHR on 02/13/24 reflected nursing documentation regarding Resident #9's pre- and post-dialysis vital signs but missed any communication from dialysis center. <BR/>Record review of Resident #9's dialysis communication forms for 01/01/25 to 01/31/25 reflected dialysis communication form dated 01/13/25, 01/15/25, 01/20/25, 01/22/25, 01/24/25, 01/27/25, 01/29/25 and 01/31/25, all the other dialysis dates of the month of January 2025 were missing communication forms totaling to 6 days in January 2025 on the following days: 01/01/25, 01/03/25, 01/06/25, 01/08/25, 01/10/25, and 01/17/25. <BR/>Record review of Resident #9's dialysis communication forms for 02/01/25 to 02/14/25 reflected dialysis communication form dated 02/12/25. All the other dialysis dates of the month of February 2025 were missing communication forms totaling to 4 days in February 2025 on the following days: 02/03/25, 02/05/25, 02/07/25 and 02/10/25.<BR/>2. Record review of Resident #63's admission MDS assessment, dated, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE] and a readmission of 01/18/2025. Resident #63 had a diagnosis of end stage renal disease (a chronic condition that occurs when the kidneys can no longer filter waste from the blood and requires long-term dialysis). He had a BIMS score of 05, which indicated his cognition was severely impaired. The MDS reflected Resident #63 received dialysis. <BR/>Record review of Resident #63's care plan, dated 08/30/24, reflected Resident #63 needed dialysis (medical procedure that filters blood to remove waste and extra fluid when the kidneys are no longer functioning properly) rule out renal failure. The goals reflected Resident #63 would have immediate intervention should any signs and symptoms of complications from dialysis occur through the review date. The resident will have no s/s of complications from dialysis through the review date. The care plan interventions included: Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis. Check and change dressing daily at access site. Monitor/document/report to MD PRN any signs and symptoms of infection to access site: Redness, Swelling, warmth or drainage.<BR/>Record review of Resident #63's February 2025 physician's order reflected to monitor Arteriovenous shunt/fistula (a surgical procedure that creates a new pathway for fluid to flow) to (site) for thrill & bruit (A bruit is a sound and a thrill is a vibration that indicate a fistula is working properly) every shift notifies medical doctor/Nurse practitioner for any unusual/unexpected findings. <BR/>Record review of Resident #63's EHR on 02/13/25 reflected nursing documentation regarding Resident #63's pre- and post-dialysis vital signs but missed any communication from dialysis center. <BR/>Record review of Resident #63's dialysis communication forms for 01/01/25 to 01/31/25 reflected dialysis communication form dated 1/22/25,1/27/25, and 01/31/25, all the other dialysis dates of the month of January 2025 were missing communication forms totaling to 8 days in January 2025 on the following days: 01/01/25, 01/03/25, 01/06/25, 01/08/25, 01/10/25, 1/20/25,1/24/25 and 01/29/25. <BR/>Record review of Resident #63's dialysis communication forms for 02/01/25 to 02/14/25 reflected dialysis communication form dated 02/12/25. All the other dialysis dates of the month of February 2025 were missing communication forms totaling to 4 days in February 2025 on the following days: 02/03/25, 02/05/25, 02/07/25 and 02/10/25.<BR/>Interview on 02/11/25 at 02:18 PM with Resident #9 revealed she went for dialysis Monday, Wednesday, and Friday. She stated she got a form that she took to dialysis and brought back to the facility. She stated she got checked for her vital signs when she left for dialysis and when she came back from dialysis. <BR/>Interview on 02/11/25 at 01:26 PM with Resident #63 revealed he went for dialysis Monday, Wednesday, and Friday. He stated he got a form that he took to dialysis and brought back to the facility. He stated his vital signs were checked when he left for dialysis and when he came back from dialysis.<BR/>Interview on 02/14/25 at 09:41 AM with RN D revealed she was aware Resident #9 and Resident#63 went for dialysis Monday, Wednesday, and Friday. She stated she was supposed to send Resident #9 and Resident #63 with the dialysis communication form when they left for dialysis and then collect the form when the resident's returned from dialysis. RN D stated she knew she was supposed to monitor the dialysis access site for the bruit thrill (a vibration caused by blood flowing through the fistula and can be felt by placing fingers just above incision line), dressing for bleeding and vital signs when Residents #9 and Resident #63 were back from dialysis which she does and document in the progress notes. She stated it was nurse's responsibility to collect the dialysis communication forms when Resident #9 and Resident #63 came back and filed them. RN D stated they were supposed to call the dialysis clinic and follow up if communication forms were not sent back with residents. She stated the importance of the dialysis communication forms was continuation of care between the dialysis and facility. Failure to follow up on the communication form after dialysis was completed could cause them to miss the orders and recommendations and treatments from dialysis center. She stated she had done trainings on dialysis communication form. <BR/>Interview on 02/14/25 at 9:54 AM with the ADON A revealed her expectation was, nurses were supposed to fill out the forms with the residents' pre-dialysis vitals, and the form would be taken to dialysis by Resident #9 and Resident #63. She stated she expected the nurses to collect the form after dialysis, perform vital signs, and document on communication forms and put the communication forms on the binders to be uploaded. She stated the importance of the communication form was communication between the facility and dialysis center on new orders, treatment given, and any change of condition. She stated she had checked on the binders and had noticed the communication forms were missing after the surveyor brought it to her attention. She stated she was responsible of ensuring nurses were completing the forms, monitoring vitals pre and post dialysis. She stated the last time she checked the binders, was on 02/14/25 after she was notified the communication forms were missing. She stated the risk of not having the communication form brought back from dialysis was omission of orders and not knowing what medications were administered at the dialysis center. <BR/>Interview on 02/14/25 at 2:27 PM with the DON revealed her expectation was for the nurses to check vitals before and after dialysis and document on the communication form. She stated she expected nurses to send Resident #9 and Resident #63 with a communication form and get it when back from dialysis and if forms are not sent back with Resident nurse should follow up with dialysis center. She stated the failure to collect the forms back from dialysis where they could miss important orders from dialysis and the treatment given at dialysis. She stated the ADON's were responsible of following up to ensure the staff were getting the communication forms back from dialysis. She stated the facility had done training with staff and provided a record dated 02/13/25 on dialysis policy that addressed dialysis monitoring of vitals before and after dialysis and documentation. <BR/>Record review of the facility's Dialysis policy, dated November 2023, reflected the following: <BR/> .19.This facility will monitor departures and returns from the dialysis center. The facility will document the resident vital signs, general appearance, orientation, and additional baseline data as needed. The resident's clinical record will be documented with this information. The date and time of the resident's return to the facility will be recorded by the nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to provide specialized rehabilitative services for 1 (Resident #2) of 3 residents reviewed for specialized rehabilitative services.<BR/>The facility failed to ensure Resident #2 received a speech therapy evaluation as per physician orders dated 01/28/25.<BR/>This failure could place residents with orders for therapy at risk of not meeting their highest practicable well-being. <BR/>Findings included:<BR/>Record review of Resident #2's Nursing Home Comprehensive Item Set MDS dated [DATE] reflected Resident #2's initial admission date of 07/27/21 and readmission date of 04/13/22. Resident #2's diagnoses were non-traumatic brain dysfunction, non-Alzheimer's dementia (common type of dementia), malnutrition, and aphasia (rare type of dementia where language is heavily affected). Resident #2's MDS also reflected that Resident #2 had severe cognitive impairment. MDS reflected that Resident #2 began receiving occupational therapy in 10/17/24 with no end date. MDS did not reflect that she received speech therapy or physical therapy.<BR/>Record review Resident #2's Care plan dated 02/14/25 reflect: Focus: Potential Risk for Malnutrition. Goals: Maintain Stable weight and nutritional parameters. Interventions: Monitor and document meal intake, monitor resident weights, Monitormonitor resident's labs, Notify the physician for any negative findings, abnormal labs, or resident non-compliance, Offer diet as ordered by the physician, Update food preferences as needed.<BR/>Record Review of Resident #2's Progress Note dated 01/24/25 by the Registered Dietician reflected Recommend speech evaluation. <BR/>Record Review of Resident #2's Physician's orders documented the following order: On 01/28/25 ST eval and treat as indicated. Dietician Recommended.<BR/>Interview on 02/14/25 at 3:26 PM with facility Speech Therapist revealed that she did not receive a referral from the facility for Resident #2. The Speech Therapist stated that the director of rehabilitation normally received the order for rehabilitation and passed it to her so that she could complete the initial screening after the facility's morning meeting. The Speech Therapist stated that normally if there was a conversation in the daily meeting, the director of rehab would inform her so that she could retrieve the facility communication form that the facility administration completes on a resident that would be receiving speech therapy. However, the Speech Therapist stated that she never received a communication form. And she was never informed by the director of rehabilitation that the resident had an order for speech therapy. The facility Speech Therapist stated that the resident's lost time in speech therapy could lead to a larger weight loss. <BR/>Interview on 02/14/25 at 4:27 PM with the DON revealed that the dietician would complete a communication order and send it to the DON with their recommendation. Then the DON would forward the recommendation to the doctor who would then approve (or not approve) the order. However, the DON stated that she never received the dietician's recommendation for Resident #2. The DON said that the regional compliance nurse put the doctor's order in the EHR on 01/28/25. The DON stated that she was unsure how the regional nurse received Resident #2's dietary order. The DON stated that it was possible for the resident to have continued poor nutrition, choking, etc. if she did not receive the speech screening as ordered by the doctor. <BR/>Interview on 02/14/25 at 5:52 PM with the Registered Dietician revealed that she wrote the dietary recommendation for Resident #2 on 01/24/25. The Registered Dietician stated that she emailed a copy of the recommendation to the Administrator, DON, ADON, Dietary Manager and MDS Coordinator. The Registered Dietician stated that without the recommended screening the resident was at risk for further weight loss. <BR/>The Administrator revealed there was no facility policy regarding therapists following physicians' orders. The Administrator stated in an email on 02/18/25 at 2:58 PM that the facility follows physician orders as the physician signs the orders for evaluation, clarification orders for frequency, as well as evaluations and recertifications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that all alleged violations involving neglect were reported immediately, but not later than two hours after the allegation was made, if the events that caused the allegation involved neglect, to the State Survey Agency in accordance with State law through established procedures for one (Resident #1) of five residents reviewed for abuse.<BR/>The facility failed to immediately report an allegation of potential neglect to the abuse coordinator on 12/15/22 after Resident #1 sustained an unwitnessed fall with major injury. As a result, the incident was not reported to the State Survey Agency within the required timeframe.<BR/>This failure could place residents at risk for abuse and neglect. <BR/>Findings include:<BR/>Review of the facility's Abuse, Neglect, Misappropriation, Exploitation Policy, dated 01/2019, reflected, .Serious Bodily Injury: An injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; requiring medical intervention such as surgery, hospitalization, or physical rehabilitation; or an injury resulting from criminal sexual abuse . and .Alleged violations/violations will be reported to the Administrator, designee immediately . and Immediately reporting all alleged violations to the Administrator, designee, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframe .<BR/>Review of Resident #1's Face Sheet, dated 01/14/23, reflected she was a [AGE] year-old female, admitted to the facility on [DATE] with a readmission date of 12/15/22, with diagnoses including age-related cognitive decline, unsteadiness on feet, and muscle wasting and atrophy.<BR/>Review of Resident #1's MDS Assessment, dated 11/04/22, reflected she had severe cognitive impairment. The MDS Assessment reflected she had a history of falls, including a fall with injury.<BR/>Review of Resident #1's Care Plan, dated 08/03/21 with a revision date of 10/11/22, reflected Resident #1 had a history of falls and injury from falls due to poor balance, unsteady gait, and cognitive deficits.<BR/>Review of Resident #1's Progress Notes, dated 12/15/22 and written by LVN A (LVN/Charge Nurse), reflected, .CNA called this nurse into resident room. Resident noted laying on the floor on her back beside her bed. Resident noted with blood pooling underneath her head. Resident alert and talking, confused at baseline. First aid provided. Vital signs taken. 911 called. MD on call notified. Responsible Party notified. Paramedics arrived. Patient taken to [hospital] .<BR/>Interview with CNA B on 01/14/23 at 7:05PM revealed she was one of the individuals who responded to Resident #1's fall on 12/15/22. She stated she was at the Nurse's Station when a loud noise was heard coming from Resident #1's room. She and LVN A immediately went to Resident #1's room and saw Resident #1 lying on the floor next to her bed. CNA B stated she noted a large pool of blood coming from a gash in Resident #1's head. CNA B stated the gash on Resident #1's head was approximately the length of a finger. Resident #1's eye was also swollen. Resident #1 stated she was trying to get out of bed and fell to the floor. Resident #1 denied being in pain and said, this is nothing. Facility staff immediately called 911 for assistance; staff stayed with Resident #1 and applied pressure to her head until EMS arrived and transported her to the hospital. CNA B stated at the time of the incident, Resident #1's bed was in the lowest position, as required due to her history of falls.<BR/>During an interview with the Administrator on 01/14/23 at 7:40PM, she stated the incident occurred when the previous DON oversaw nursing care. She stated it would have been the previous DON's responsibility, as the head of nursing, to report this incident to her. She stated the previous DON did not report any injuries to Resident #1 as a result of her fall. Per the Administrator, the previous DON just said that Resident #1 was weak and had fallen, so she was sent out to the hospital for further evaluation and treatment. The Administrator said she had no idea Resident #1 had hit her head or was bleeding at the time of her fall. She stated occurrences such as this would typically be reported to HHSC and investigated by the facility to rule out abuse/neglect. The Administrator was able to verbalize the facility's policies and procedures related to abuse/neglect, including the various types of abuse/neglect, prevention methods, and response protocols.<BR/>Attempted interviews with LVN A on 01/14/23 at 8:30PM and 01/16/23 at 10:13AM were unsuccessful.<BR/>Attempted interviews with the previous DON on 01/14/23 at 8:56PM and 01/16/23 at 10:16AM were unsuccessful.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to investigate and report allegation of neglect for 1 (Resident #67) of 3 residents reviewed for accidents and hazards. <BR/>The Administrator failed to investigate and report the results of the investigation to the state agency when Resident #67 fell backwards in his wheelchair (which had not anti-tippers or brakes), hitting his head on the floor of the van during takeoff in the facility parking lot. Resident #67 was sent to hospital resulting in initial encounter with head injury and contusion of right hand. Resident #67 stated his wheelchair was not strapped down correctly and stated he blacked out.<BR/>This failure could place residents at risk of harm and injuries related to neglect and a delay in investigating.<BR/>Findings include:<BR/>Record review of Resident #67's face sheet reflected the resident was [AGE] years old male who admitted to the facility on [DATE] and readmitted on [DATE]. <BR/>Record review of Resident #67's quarterly MDS assessment, dated 11/28/24, reflected a BIMS score of 14, which indicated his cognition was intact. His diagnoses included osteomyelitis (bone infection that causes inflammation and destruction of bone tissue), paraplegia (the inability to voluntarily move the lower parts of the body), neurogenic bladder (the bladder muscles and nerves do not function properly), anxiety disorder, pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time) of unspecified buttock, unspecified stage and need for assistance with personal care. The MDS further revealed Section M - Skin Conditions - Skin and Ulcer/Injury Treatment indicated the resident's required pressure ulcer/injury care and surgical wound care. <BR/>Record review of Resident #67's Care plan, revised date 01/29/25, reflected: Focus: [Resident #67] at risk for falls paraplegia. Goal: The resident will be free of falls through the review date. [Resident#67] will not sustain serious injury through the review date. Interventions: Anticipate and meet the resident's needs. Staff x 1 to assist with transfers.<BR/>Record review of Resident #67's progress notes written by RN GG dated 02/06/25 at 1:41 PM reflected Resident had a fall. Location: while on leave . Fall information: Hit Head. Cognition/Behavior at Time of Event: Oriented/no problem, Resident assisted to chair from the fall while in transport van, Resident stated hit his head, Resident stated blacked out, Physician Assistant on site, sent to emergency room for further evaluation. Appears and /or states to be in pain. Describes the pain as: continuous, chronic. Location of pain: head, right wrist pain relieving intervention used at this time: sent to emergency room for evaluation. Initial Treatment/New Orders: send to Emergency Room. Resident Statement: I hit my head and I want to go to the hospital. <BR/>Record review of Resident #67's progress notes written by RN GG dated 02/06/25 at 2:51 PM reflected Resident #67 was transferred to a hospital on [DATE] at 1:55 PM related to transport van patient had fallen backwards in wheelchair, hitting head. Sent to hospital for evaluation. <BR/>Record review of Resident #67's progress notes written by LVN G dated 02/06/25 at 10:58 PM reflected At 8:17 PM. Resident #67 come back from hospital on non-emergency transportation on diagnosis of fall encounter Head injury, contusion of right hand. Initial encounter. Blood pressure 121/69, pulse 67, respiratory 18 saturation 98 percent, Alert, and oriented x 4, able to voice needs and concerns, did head to toe skin assessment. Change hip dressing to Wet to Dry dressing, ongoing care, call light in reach. <BR/>Record review of Resident #67's after visit summary dated 02/06/25 reflected Reason for visit: Fall, Diagnoses: Fall, initial encounter, Head injury, initial encounter, Contusion of right hand, initial encounter, History of paraplegia. CT head without contrast, chest x ray, hand x ray. Medications given: Oxycodone-acetaminophen, Instructions: Follow up with provider in two weeks around 02/20/25 if symptoms worsen. <BR/>Record review of Resident #67's incident report dated 02/10/25 reflected Conclusion: resident in 3rd party transport van, his chair has no anti tippers or brakes. Resident fell backward due to inertia upon the driver taking off. Intervention: parts have been ordered for resident chair, and resident to use transport chair vs personal wheelchair. Therapy to screen.<BR/>Interview on 02/11/25 at 11:37 AM with Resident #67 revealed on 02/06/25 he had a urology appointment and after he was loaded on the van, he fell backwards hitting his head. According to Resident #67 he had a headache and pain in his right hand from the fall. Resident #67 stated it was not the facility van driver, but an outside provider that was taking him to his appointment. Resident #67 stated he took off like a race car driver in the parking lot and I fell backwards, hitting my head on the floor, and blacked out. Resident #67 stated the van driver did not strap me down correctly, so when he took off, I fell backwards and hit my head, and was sent to the hospital. <BR/>Interview on 02/13/25 at 12:28 PM DON revealed she knew Resident #67 was scheduled for urology appointment on 02/06/25, she stated the facility van had other appointments, so he was to be transported by an outside transport provider. The Social Worker stated she did not see Resident #67 exit the building for his appointment. The DON stated she was alerted to come outside, when she got outside, she saw Resident #67 still in his wheelchair; straps were still attached. According to the DON she jumped in the van and removed 2 straps, she stated Resident #67 had to be removed from the chair so they could get the wheelchair out the van. Once the wheelchair was removed from the van, Resident #67 was placed back in the wheelchair, assessed and was one on one with nurse until the emergency medical services arrived to take him to the hospital. The DON stated Resident #67 was delirious and not holding good truck control he was not his baseline, he complained of head pain and stated that he lost consciousness. The DON stated she did not speak to the Van Driver; she did not recall if an incident report was completed. According to the DON, the Administrator was present and would have handled any reporting, she was busy with Resident #6 ensuring he was ok. According to the DON drivers were responsible for entering the facility to transport residents out and back inside upon returning to the facility. The DON stated the Administrator was responsible for reporting all incidents to Health and Human Services, not doing so could place residents at risk of further injuries. <BR/>Interview on 02/13/25 at 2:47 PM with Social Worker revealed when residents require an outside appointment, they will leave notification for the Facility Transportation Driver to schedule the appointment with the provider and arrange transportation. According to the Social Worker, she was alerted by the Van Driver coming to the door saying, your patient has flipped out here on the van, the Social Worker stated at that point she alerted either the Administrator or the DON. The Social Worker stated when she got outside, she saw Resident #67 laying on his back yelling at the Van Driver you fucking dropped me, there was no way I was strapped in. According to the Social Worker Resident #67 and the Van Driver were going back and forth indicating Resident #67 was upset. The Social Worker stated she saw he was strapped in however could not tell if it was done correctly. She stated there was one strap on each front wheel but did not recall if the back wheels had any straps, she further stated there were straps caught in the wheels and it was a lot of trouble getting the straps out the wheelbase. According to the Social Worker she was responsible to alert the Administrator which was the Abuse Coordinator when there was an incident of neglect, not doing so placed residents at risk of further neglect and injury . According to the Social Worker, she was responsible for alerting the Administrator. The Social Worker stated any reporting to the state would be the responsibility of the Administrator. Not doing so placed residents at risk of possible harm. <BR/>Interview on 02/13/25 at 4:27 PM with The Administrator revealed he was alerted by Resident #67's family member that he fell in the van outside in the parking lot. The Administrator stated he went out front, saw Resident #67 laying on the floor of the van yelling and cursing, stating his head hurt. The Administrator stated the nursing staff assessed him and stayed with him until he was taken by emergency medical services to the hospital. The Administrator stated when he went outside, he observed all four points connected, he did not recall seeing the seat belt connected. The Administrator stated he contacted the transport company to provide a statement about the incident. The Administrator stated they were not contracted with the outsourced transportation company and was not responsible for residents once they were in the hands of the outside provider. The Administrator revealed when residents used an outsourced transportation company residents are picked up from the nursing station or the front door by the van driver. The Administrator stated the Van Driver of the transport company was responsible for ensuring residents were safely transported, not doing so placed residents at risk of injuries. The Administrator stated the Van Driver stated to him, he did not know what happened, had all four points secured. The Administrator stated he did not complete an investigation. He stated he did not report to Health and Human Services because the transportation company followed up with him, and advised they would be reporting the incident to Health and Human Services, so he did not feel like he needed to do so . The Administrator revealed he did not feel like he had to report this incident within 2 hours because Resident #67 was not within the care of the facility. According to the Administrator he had not planned to report the incident to Health and Human Services and not doing so place Resident #67 at risk of further accidents and injury.<BR/>Record review of the facility's undated policy titled Event Reporting reflected: The facility will complete an Event report on variances that occur within the facility. Variances include falls, skin tears, bruises, lacerations, fractures, choking, burns, elopement, or behaviors that affect others. All Events beyond immediate first aid must be reported immediately by the supervisor of the shift the Administrator/DON. All Events resulting in a change in status of a resident must be reported immediately to the attending physician and family member. Documentation of the notification and subsequent interventions and comments must be recorded. The Administrator and /or DON will be responsible for ensuring completion of documentation and notification of the physician and the family member as well as notification to the home office and to the State Survey Agency. The investigation should be completed by the DON/Administrator or designee. The investigation report documents a thorough investigation of the events of the reported Event including persons, equipment, and materials that were involved. The investigation report must include what actions were taken to prevent subsequent Events and signatures of the individuals as indicated on the form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident on one of three medication carts (300) and 3 of 3 residents (Residents #7,#147, and #178) reviewed for pharmacy services.<BR/>1. The facility failed to ensure the 300 Hall nurses' medication cart contained accurate narcotic logs for Resident #7, #147 and #178 on 02/12/25. <BR/>2. The facility failed to ensure expired medications , 1 bottles of atropine 0.1% with expiration dates of August 2024 was removed and destroyed form 300 hall nurses cart on 02/12/25. <BR/>These failures could place residents at risk for medication errors, drug diversion, and ineffective drug therapy.<BR/>Findings included: <BR/>1. Record review of Resident# 7's Quarterly MDS Assessment, dated 12/10/24, reflected the resident was [AGE] year-old female readmitted to the facility on [DATE] with original admission on [DATE], with diagnoses that included anxiety (common mental health condition characterized by excessive worry, fear, and nervousness that can interfere with daily life). The resident had mild impaired cognition with a BIMS score of 11. <BR/>Record review of Resident #7's physician's orders dated 11/15/24 reflected an order for the resident to receive Lorazepam Oral Tablet 1 MG. Give 1/2 tablet to 2 tablets by mouth every 2 hours as needed related to anxiety disorder. <BR/>Record review of Resident # 47's Quarterly MDS assessment, dated 01/01/25, reflected the resident was [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included chronic pain syndrome (a condition characterized by persistent pain that lasts for at least 3-6 months and significantly impacts a person's life). The resident had intact cognition with a BIMS score of 15. <BR/>Record review of Resident #47's physician orders dated 12/12/24 reflected an order for the resident to receive Hydrocodone-Acetaminophen oral tablet 10-325 mg. Give 1 tablet by mouth every 8 hours, as needed for pain. <BR/>Record review of Resident# 178's entry MDS assessment, dated 02/07/25, reflected the resident was [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included pain. The resident BIMS score not completed Resident #178 was newly admitted . <BR/>Record review of Resident #178's physician orders dated 02/08/25 reflected an order for the resident to receive Hydrocodone-Acetaminophen oral tablet 10-325 mg. Give 2 tablet by mouth every 4 hours, as needed for pain.<BR/>Observation and record review on 02/12/25 at 2:12 PM of 300 Hall nurses' medication cart and the Narcotic Administration Record, with RN C, revealed Resident #7's Narcotic Administration Record for lorazepam 1 mg reflected a total of 13 pills remaining, while the blister pack count was 12 pills. It was last administered on 01/20/25 at 9:30 PM. It also revealed Resident#47's Narcotic Administration record Hydrocodone-Acetaminophen oral tablet 10-325 mg reflected a total of 7 pills remaining, while the blister pack count was 6 pills. Last administered on 02/10/25 at 07:41 AM. It also revealed Resident#178's Narcotic Administration record Hydrocodone-Acetaminophen oral tablet 10-325 mg reflected a total of 38 pills remaining, while the blister pack count was 36 pills. Last administered on 02/11/25 at 8:00 AM.RN C was observed to remove lorazepam 1mg &frac12; tablet in a cup covered with another cup that was not labelled in her pocket. <BR/>2. Observation on 02/12/25 at 2:45 PM of the 300 Hall medication cart with the RN C revealed 1 bottle of atropine 1 % with expiration date of 8/8/24 . <BR/>Interview with RN C on 02/12/25 at 2:45 PM revealed she popped Lorazepam 1mg &frac12; tablet put in a cup and she had not administered to Resident #7 before lunch because she had realized she had popped, and it was not meant for her. RN C stated she forgot to notify the other nurse for destruction. She took residents to dining for lunch and she forgot. She stated when she saw this surveyor checking the carts that was the time she removed from the cart and put it in her pocket. She stated she had administered Hydrocodone-Acetaminophen oral tablet 10-325 mg I (one) tablet, to Resident #47 as needed every 8 hours, and she had not signed off on the narcotic administration record log. She had also administered Hydrocodone-Acetaminophen oral tablet 10-325 mg 2 tablets to Resident #178 as needed every 8 hours, and she had not signed off on the narcotic administration record log. She stated she knew she was supposed to sign-out on the narcotic count sheet after administration and on the Medication Administration Record, but she did not. RN C stated the failure to log off could lead to overdose since the person that came after her would not be able to tell when the narcotic was administered. She stated failure to label the cup and keeping the medication in a cup could lead to missing a dose and administering to wrong resident leading to medication error. RN C also stated she was responsible of checking her cart every shift for the expired medications, but she forgot to check. She stated the risk of having expired medication in her cart was adverse effect if administered. She stated she had completed an in-service on Medication administration. <BR/>Interview on 02/13/25 at 9:44 AM, the ADON B stated her expectation was for staff administering narcotic medications to document the medications when they were given to the resident on the medication administration record and to sign on the narcotic log. She stated she also expected RN C to assess the Resident #7 before she popped Lorazepam 1mg &frac12; tablet and if she had made a mistake to call her or any other nurse they destroy and not to put in cup in her pocket. She stated it was her responsibility to audit the carts weekly and if there was an issue she audited daily. She stated she had last checked the cart on 02/4/25. The ADON stated failure to document after administration and destroying after refusal or popping by mistake could lead to drug diversion, missing of a dose, overdose and residents not getting therapeutic effects. She stated facility had done trainings on medication administration.<BR/>Interview on 02/13/25 at 1:34 PM, the DON revealed her expectation was for staff administering narcotic medications to document the medications when they were given to the resident on the medication administration record and to sign on the narcotic log. She stated nurses should not be pulling medications if the resident had not asked for it. She stated she asked RN C why she had not destroyed the medication that she had accidentally popped, and she did not give her a varied answer. She stated she expected RN C to label the cup, repull the right medication and then destroy the other one with a witness but not keeping in her pocket. DON stated failure to document could lead to overdose and effect on resident management. She stated ADONs were responsible for auditing the medication carts. She stated the facility had done training on medication administration and trainings dated 10/4/24 and 01/08/24 and RN C was not in attendance.<BR/>Record review of facility policy entitled Medication Administration procedures , dated 10/25/17, reflected the following: <BR/> 5. After the resident has been identified, administer the medication and immediately chart doses administered on the medication administration record. It is recommended that medication be charted immediately after administration, but if facility policy permits, medication may be charted immediately before administration.<BR/>17.If a controlled medication removed from its packaging and is not to be administered (resident refusal or contamination) the dose needs to be wasted to where the drug is unable to be used and /or destroyed and disposed of. If controlled medication is wasted, it must be documented on the controlled accountability sheet for the medication and witnessed by a nurse. Both staff members must sign on the accountability sheet verifying the drug was wasted.<BR/>Record review of the facility's Storage of Medications policy, dated 2003, reflected the following:<BR/>Did not address expired medications removal from the carts .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that each resident who was incontinent of bladder with an indwelling catheter received appropriate treatment and services for 1 of 2 residents (Residents #1) reviewed for incontinent care and for indwelling urinary catheters.<BR/>The facility they failed to monitor and document signs and symptoms of dehydration, decreased or no urine output, for Resident#1.<BR/>This failure could place residents at risk of not having their individual needs met, not receiving necessary care and services, and a decreased quality of life. <BR/>Findings included:<BR/>Record review of Resident #1's admission record dated 10/04/24 reflected the resident was a [AGE] year-old male, who initially admitted to the facility on [DATE] with a readmission on [DATE]. Resident#1's diagnoses included intellectual disability, acquired absence of right leg below the knee, anemia chronic kidney disease, Type 2 diabetes mellitus with unspecified complications, protein calorie malnutrition and retention of urine. <BR/>Record review of Resident#1's discharged MDS dated [DATE] reflected the resident required substantial/maximal assistance, Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort, for toileting hygiene, shower/bathe self and lower body dressing. The MDS reflected Resident #1 was always continent of bladder.<BR/>Record review of Resident#1's Entry MDS dated [DATE] reflected Resident#1 had no BIMS assessment documented.<BR/>Record review of Resident#1's care plan dated 08/21/24 reflected: <BR/>Problem: The resident has potential fluid deficit r/t decreased mobility, recent admit to facility. Intervention: Monitor/document/report to MD PRN s/sx of dehydration: decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness on sitting/standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, dry/sunken eyes. <BR/>Record review of Resident#1's care task for the month of October 2024 reflected no care task related to monitoring, documenting, and reporting to the physician signs and symptoms of dehydration, such as decreased or no urine output, concentrated urine and strong odor.<BR/>Record review of Resident #1's October 2024 TAR/MAR reflected no care related to monitoring, documenting, and reporting to the physician signs and symptoms of dehydration, such as decreased or no urine output, concentrated urine and strong odor.<BR/>Record review of Resident #1's October eMAR reflected no care related to monitoring, documenting, and reporting to the physician signs and symptoms of dehydration, such as decreased or no urine output, concentrated urine and strong odor.<BR/>Record review of Resident#1's September and October 20234 eMAR reflected the resident had a 16 French urinary catheter 30 cc for a diagnosis of urine retention, for one time a day for urine retention. The facility staff placed a check mark in the AM (morning) box.<BR/>Record review of Resident#1's the progress notes from 09/10/24 to 10/03/24 reflected no care related to monitoring, documenting, and reporting to the physician signs and symptoms of dehydration, such as decreased or no urine output, concentrated urine and strong odor.<BR/>Record review of Resident#1's progress notes reflected no care related to monitoring, documenting, and reporting to the physician signs and symptoms of dehydration, such as decreased or no urine output, concentrated urine and strong odor.<BR/>Observation on 10/04/24 at 1:00 PM revealed Resident#1's catheter urine collection bag had no urine output.<BR/>Observation on 10/04/24 at 1:42 PM revealed Resident#1 had a case of water in his room.<BR/>Observation on 10/04/24 at 3:30 PM revealed Resident#1's catheter urine collection bag had no urine output.<BR/>Observation on 10/05/24 at 10:00 PM revealed Resident#1's catheter urine collection bag had no urine output.<BR/>Interview on 10/04/24 at 1:04 PM with MA F revealed Resident#1 just returned from the hospital today after being gone for about three weeks. She stated Resident#1 had a catheter and both his legs were amputated. She stated Resident#1 would call out if he needed help. <BR/>Interview on 10/04/24 at 1:42 PM with Resident #1 revealed staff had not emptied his catheter bag since early in the morning before breakfast. Resident#1 stated that he was doing okay, and he had just come back from the hospital.<BR/>Interview on 10/04/24 at 2:10 PM with the Treatment Nurse revealed Resident#1 was not on her wound care list, and he returned from the hospital today. She stated the resident's urine would need to be monitored if it was cloudy and had sediment in it. She stated Resident#1 kept bottled water in his room to drink. <BR/>Interview on 10/04/24 at 9:34 PM with MA C revealed Resident#1's urine output was monitored and the information was given to the charge nurse to put in the system. MA C revealed Resident#1 was one of the resident's, who were monitored for urine output, and he just returned from the hospital today.<BR/>Interview on 10/05/24 at 9:42 PM with RN D revealed Resident#1's urine output information was put in the resident's electronic record by her or the charge nurse by the end of each shift. RN D stated urine retention output monitoring was needed to be done to determine if the resident's medications were working or not. <BR/>Interview on 10/05/24 at 10:00 PM with LVN E revealed if the DON had not updated the eMAR with the resident urine output instructions, the information should have been put in the nurses' progress notes. LVN E stated if the urine output was not being monitored, the resident could have blockage, dehydration, or bladder issues. LVN E had not worked with Resident# 1 since he had returned from the hospital. <BR/>Interview on 10/05/24 at 10:15 PM with the ADON revealed the order on Resident #1's eMAR was to ensure staff checked the catheter bag. The ADON stated that was not for monitoring and measurements of urine retention. <BR/>Telephone interview on 10/06/24 at 12:05 AM with the Administrator and the DON revealed if the resident's urine outpoint was not being monitored, the resident could develop a UTI or be dehydrated. The DON stated all the nursing staff were responsible for ensuring urine output was monitored. The Administrator and DON stated Resident#1 was admitted to the hospital on [DATE] and returned to the facility on [DATE]. <BR/>Record review of the facility's current Nursing Policy and Procedure Manual reflected the following undated policy:<BR/>Comprehensive Care Plan <BR/>The comprehensive care plan will describe the following The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 10 residents (Resident #2) reviewed for call lights. <BR/>Resident #2's call light was not within reach. The call button was on the other side of the privacy curtain draped over a vacant bed. <BR/>This failure could place residents at risk of not having their needs and preferences met and a decreased quality of life.<BR/>Finding included:<BR/>Record review of Resident #2's Face Sheet dated 10/01/2024, reflected the resident was an [AGE] year-old female who was originally admitted to the facility at 07/16/2024. Diagnoses included: Unspecified dementia without behavioral disturbance (a group of symptoms that may affect, memory, thinking and interferes with daily life), lack of coordination, anemia (deficiency of healthy red blood cells in the blood), hypothyroidism (decreased productions of thyroid hormones), and dysphasia (impacts the ability to speak and understand spoken language). <BR/>Record review of Resident #2's Initial MDS Assessment, dated 07/24/2024, reflected a BIMS score of 11 which indicated moderately cognitively intact. She required maximum assistance for toileting and showers. She was frequently incontinent of bowel and bladder. <BR/>Record review of Resident #2's Care Plan dated 07/22/2024 reflected: Focus: [Resident #2] is risk for falls. Intervention: Anticipate and meet [Resident #2's] needs. Be sure [Resident #2's] call light is within reach and encourage the resident to use it or assistance as needed. Staff x 1 to assist with transfers. Focus: [Resident #2] has an ADL Self Care Performance Deficit. Interventions: Encourage [Resident #2] to use bell to call for assistance. <BR/>In an observation and interview on 10/01/2024 at 11:30 AM, Resident #2 was in her room resting on her bed, which was close to the window. The call button was observed draped over the A bed's headboard, which was closest to the door in the room. The privacy curtain covered the area between the two beds. Resident #2's wheelchair was beside her bed. Resident #2 said she did not know where her call light was. When asked about it, she looked around the room but was not able to find it. When asked how she called for staff if she needed assistance, she said she did no call for help. She said she did transfer herself and did have a fall about a month ago but did not hurt herself. She said she lost her balance when she was transferring to her wheelchair from her bed. <BR/>In an observation and interview on 10/01/2024 at 1:30 PM, the DON accompanied this state surveyor to Resident #2's room. The call button was observed draped over the A (closest to the door) bed's headboard in the room. The privacy curtain covered the area between the two beds. The DON said the call button should be accessible to Resident #2 so she could call for assistance if she needed to. She said Resident #2 did have a recent fall and required assistance to transfer and reminders to use her call light. <BR/>In an interview on 10/01/2024 at 1:40 PM, LVN A said she did not know Resident #2's call light was not in her reach. She said the call light should be accessible to all residents to ensure they can call for assistance if they need it.<BR/>In an interview 10/01/2024 at 2:06 PM, CNA B said she worked in all halls. She said she did not notice that Resident #2's call light was not accessible to her. She said it should be accessible to Resident #2 so she could call for assistance if she needed to. <BR/>In an interview on 10/01/2024 at 2:14 PM, the Regional Compliance Nurse said all residents needed to have a call light accessible to them to ensure they could call for assistance as needed. <BR/>In an interview on 10/01/2024 at 2:37 PM, CNA C said she was not aware that Resident #2's call light was not accessible to her. CNA C said she rounds constantly and typically checks to ensure call lights were placed. She said residents have a right to be able to call for assistance whenever they needed it. She said she did receive in-servicing on placing call lights but did not recall when the last time was. <BR/>In an interview on 10/01/2024 at 3:25 PM, the Administrator stated his managers completed Champion Rounds, every morning. She said they look at things like call lights, room condition, resident needs and the information was discussed in the facility's morning meeting for follow up. He said he expected all residents to have access to call lights for their safety and to ensure their needs were met. <BR/>Record review of the facility's Resident Rights policy, dated 2003, reflected: We believe each resident has a right to a dignified existence, self -determination, and communication with and access to persons and services inside and outside our facility . his facility complies with all applicable provisions of the Human Resources Code Title 2, Chapter 102.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents.<BR/>CNA A failed to get assistance from another staff member when providing Resident #1, who required two staff for assistance with all ADLs, a bed bath on 12/05/24. During the bed bath, CNA A asked Resident #1 to turn to her side. When the resident turned she fell to the floor, which resulted in the resident sustaining a fracture of her right femur (thigh bone). <BR/>The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 12/05/24 and ended on 12/05/24. The facility had corrected the noncompliance before the survey began.<BR/>This failure could place residents at risk for serious injury or harm, decline in health, and decreased quality of life.<BR/>Findings included:<BR/>Record review of Resident #1's quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hypertension (high blood pressure), seizure disorder, cellulitis of right lower limb (bacterial infection that affects the skin and underlying tissue), fibromyalgia (chronic condition that causes widespread pain and tenderness in the body), and muscle wasting. The resident had a BIMS score of 9 which indicated her cognition was moderately impaired. The MDS further reflected Resident #1 was dependent for shower/bathing which indicated the helper did all the effort or the assistance of two or more helpers was required for the resident to complete the activity. <BR/>Record review of Resident #1's care plan revised on 12/16/24 reflected the resident had an ADL self-care performance deficit. Interventions included the resident required the assistance of two staff for bathing and bed mobility. <BR/>Record review of Resident #1's bathing status in the [NAME] system (documentation system used by reference key resident information for their nursing care plan) printed on 01/13/25 reflected the resident required the assistance of two staff members.<BR/>Record review of the facility's Provider Investigation Report dated 12/05/24 reflected the following:<BR/>The resident experienced a fall while in bed during care by the CNA [CNA A]. The CNA [CNA A] notified the nurse and had discovered the resident on the floor, resting against the bed. The resident has skin tears on both great toes, the let wrist, and beneath the right breast The resident reports generalized pain, with a particular emphasis on greater discomfort in her legs compared to other areas. When inquired about the incident, the resident explained 'I threw my foot over too far and fell.' The resident was transferred to the hospital due to experiencing pain the X-ray indicated a fracture in the left femur (left femur was facility documentation error; fracture was on the right leg). The resident subsequently underwent surgery to address the fracture <BR/>Record review of Resident #1's hospital records dated 12/05/24 reflected the resident was diagnosed with a comminuted distal femoral fracture (a broken bone that has been shattered into multiple pieces and are usually caused by severe trauma) of the right leg.<BR/>Observation and interview on 01/08/25 at 10:26 PM revealed Resident #1 in bed watching television. The resident was alert and oriented and able to recall the incident when she fell during care. The resident said CNA A was giving her a bed bath, and the aide asked her to turn to her side. The resident said she was turning over onto her side as she was holding on the repositioning bar and fell on the floor. She said CNA A was usually able to catch her when she rolled over, but this time she was not able to. Resident #1 said she was sent to the hospital and had surgery on her leg, as she pointed to her right leg. Resident #1 stated CNA A usually bathed her alone and never had a helper. The resident stated she preferred two people because she felt safer. Resident #1 said she was not experiencing much pain from her fracture but had discomfort due to the cellulitis in her legs. <BR/>Interview on 01/08/25 at 1:05 PM with CNA A revealed she was giving Resident #1 a bed bath and asked the resident to turn to her side. She stated the resident grabbed the repositioning bar on the bed, threw her leg over her left leg and that was when the resident fell over on to the floor. CNA A stated she then called for the nurse to assist, and the resident was assessed. CNA A stated Resident #1 was on an air mattress, and it was inflating at the time the resident was turning to her side. CNA A said she was aware Resident #1 required two staff for care, but she was not able to find someone to help her. CNA A said she asked another CNA, whose name she could recall, for help. She stated she did not get any help, so she bathed the resident alone. She stated she had bathed the resident alone in the past. The CNA said she felt safe bathing the resident alone because the resident was able to help turn in bed. <BR/>Interview on 01/13/25 at 1:23 PM with LVN B revealed she was called by CNA A to Resident #1's room and noticed the resident was on the floor. CNA A told her the resident was trying to turn in bed during a bed bath, and the resident fell. LVN B said during Resident #1's assessment, the resident was complaining of pain and noticed the resident's toes were bleeding and other areas of her body such as her side, so she was transferred to the hospital via EMS. LVN B stated Resident #1 required two staff member for care because she was a bariatric resident and for safety. The LVN said she did not know CNA A was caring for Resident #1 alone, and she did not recall the aide asking anyone for help during the bed bath. LVN B further stated the aides could look in the [NAME] system to verify if a resident required one or two staff members during care or ask a charge nurse.<BR/>Interview on 01/08/25 at 1:28 PM with CNA D revealed she had worked at the facility for about a year and cared for Resident #1. CNA D said Resident #1 was bed bound per choice and required two staff members for assistance for all care because the resident was bariatric and could not be care for by one staff member. <BR/>Interview on 01/08/25 at 2:07 PM with CNA E revealed she worked with Resident #1 and the resident was bed bound. CNA E said the resident required two staff members for all care including bed baths because she was bariatric and needed more support. CNA E further stated Resident #1 had never been a one-person care resident. <BR/>Interview on 01/08/25 at 2:39 PM with RN F revealed Resident #1 was bed bound and required two staff members for all care including bed baths because the resident was bariatric and one staff member could not adequately care or clean the resident up during ADL care. <BR/>Interview on 01/08/25 at 2:29 PM the ADON revealed Resident #1 was bed bound and rarely got out of bed. She said the resident was a two-person assist for all care at all times because she was on an air mattress and could easily roll out of bed and for overall safety. The ADON was made aware CNA A had bathed Resident #1 alone, but the aide was not able to explain why she had not requested for help but only stated she had not seen anyone else. The ADON stated it appeared to her that CNA A had not looked for anyone to help her with the resident. The ADON further stated they immediately began to re-in-service (training) for all nursing staff re-educating them on the importance of using two staff member if the resident required it. They also identified all the residents that required two staff members for care they were monitoring and making observations to ensure two staff were assisting when needed. The monitoring began after the incident with Resident #1 and would be on-going for six weeks to ensure safety. <BR/>Interview on 01/13/25 at 8:36 AM with the DON revealed she was told Resident #1 was getting a bed bath by CNA A and while the resident was turning to her left side with the assistance of the repositioning rail, Resident threw her leg over too far and continued to roll until she fell out of the bed. Resident #1 was assessed, and they noticed she had bruising to the top of her feet and was complaining of pain throughout her body but mostly to her right knee. The resident was transferred to the hospital where she was diagnosed with a right leg fracture. The DON said Resident #1 required two staff members for care due to being a bariatric resident and for safety. The DON stated CNA A admitted knowing Resident #1 required two staff members for care, but the aide told them she had not been able to find assistance but if she would asked her (DON) she would have assisted. The DON also said if aides did not know if a resident was a one or two person for care, they could look in their [NAME] computer system. After the incident, CNA A was suspended pending their investigation and had a 1:1 counseling and re-in-service (training) on resident care and the aide was pulled from working with Resident #1. The other nursing staff were re-educated on using the [NAME] computer system to ensure a resident required a one- or two-person assistance during care. The DON further stated they had identified all the residents that required two people and were going to monitor but watching care for those resident for 6 weeks. <BR/>Record review of the facility's Safe Patient Handling policy revised December 2005 reflected the following:<BR/>The facility has a program to promote and assure safe patient handling for both the resident and the employee. The policy includes identification, assessment and interventions to provide a comfortable, safer transfer, repositioning and resident movement. <BR/> .3. Nurses will be educated in the identification, assessment and control of risks of injury to resident and nurses during patient handling <BR/> .5. Nurses will be educated regarding correct safe handling procedures, to report concerns or the inability to perform resident handling or movement that the nurse believes in good faith will expose a resident or nurse to an unacceptable risk of injury <BR/>Record review of 1:1 in-service with CNA A dated 12/05/24 revealed she had been re-educated on using the [NAME] system to communicate the resident's needs and information to all the CNA's to ensure appropriate resident care. CNA was also re-educated on fall prevention strategies and safe patient handling and abuse and neglect policy. <BR/>Record review of in-services dated 12/05/24 with all direct nursing reflected the staff had been re-educated using the [NAME] system to communicate the resident's needs and information to all the CNAs to ensure appropriate resident care. CNAs were also re-educated on fall prevention strategies and safe patient handling and abuse and neglect policy. <BR/>Interview on 01/08/25 at 1:05 PM with CNA A revealed she had been re-in-serviced 1:1 on abuse and neglect, ensure to always use two staff members during care for residents that required it and using the [NAME] system to check the care of the residents if they were unsure. <BR/>Interviews on 01/08/25 from 11:12 AM to 5:14 PM and on 01/13/25 from 10:01 AM to 1:23 PM with nursing staff from various shifts to include LVN B, CNA C, CNA D, CNA E, RN F, LVN G, CNA H, CNA I, CNA J, and CNA K all revealed they have been in-serviced on abuse/neglect, using the [NAME] system to verify if a resident required one or two staff members for care, and fall prevention to avoid accidents. <BR/>Record review of the direct care monitoring sheets reflected it included to watch at least 10 episodes of incontinent care or assist with bed mobility weekly to ensure staff was performing correctly and the care-planned number of staff were assisting. The monitoring dates reviewed began 12/05/24 and would continue for 6 weeks, and end on 01/15/25. <BR/>Observation on 01/08/25 at 11:07 AM revealed Resident #2 was transferred from the bed to the chair via mechanical lift by two staff members. <BR/>Observation on 01/13/25 at 3:32 PM revealed Resident #3 was transferred to bed via mechanical lift by two staff members.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents.<BR/>CNA A failed to get assistance from another staff member when providing Resident #1, who required two staff for assistance with all ADLs, a bed bath on 12/05/24. During the bed bath, CNA A asked Resident #1 to turn to her side. When the resident turned she fell to the floor, which resulted in the resident sustaining a fracture of her right femur (thigh bone). <BR/>The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 12/05/24 and ended on 12/05/24. The facility had corrected the noncompliance before the survey began.<BR/>This failure could place residents at risk for serious injury or harm, decline in health, and decreased quality of life.<BR/>Findings included:<BR/>Record review of Resident #1's quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hypertension (high blood pressure), seizure disorder, cellulitis of right lower limb (bacterial infection that affects the skin and underlying tissue), fibromyalgia (chronic condition that causes widespread pain and tenderness in the body), and muscle wasting. The resident had a BIMS score of 9 which indicated her cognition was moderately impaired. The MDS further reflected Resident #1 was dependent for shower/bathing which indicated the helper did all the effort or the assistance of two or more helpers was required for the resident to complete the activity. <BR/>Record review of Resident #1's care plan revised on 12/16/24 reflected the resident had an ADL self-care performance deficit. Interventions included the resident required the assistance of two staff for bathing and bed mobility. <BR/>Record review of Resident #1's bathing status in the [NAME] system (documentation system used by reference key resident information for their nursing care plan) printed on 01/13/25 reflected the resident required the assistance of two staff members.<BR/>Record review of the facility's Provider Investigation Report dated 12/05/24 reflected the following:<BR/>The resident experienced a fall while in bed during care by the CNA [CNA A]. The CNA [CNA A] notified the nurse and had discovered the resident on the floor, resting against the bed. The resident has skin tears on both great toes, the let wrist, and beneath the right breast The resident reports generalized pain, with a particular emphasis on greater discomfort in her legs compared to other areas. When inquired about the incident, the resident explained 'I threw my foot over too far and fell.' The resident was transferred to the hospital due to experiencing pain the X-ray indicated a fracture in the left femur (left femur was facility documentation error; fracture was on the right leg). The resident subsequently underwent surgery to address the fracture <BR/>Record review of Resident #1's hospital records dated 12/05/24 reflected the resident was diagnosed with a comminuted distal femoral fracture (a broken bone that has been shattered into multiple pieces and are usually caused by severe trauma) of the right leg.<BR/>Observation and interview on 01/08/25 at 10:26 PM revealed Resident #1 in bed watching television. The resident was alert and oriented and able to recall the incident when she fell during care. The resident said CNA A was giving her a bed bath, and the aide asked her to turn to her side. The resident said she was turning over onto her side as she was holding on the repositioning bar and fell on the floor. She said CNA A was usually able to catch her when she rolled over, but this time she was not able to. Resident #1 said she was sent to the hospital and had surgery on her leg, as she pointed to her right leg. Resident #1 stated CNA A usually bathed her alone and never had a helper. The resident stated she preferred two people because she felt safer. Resident #1 said she was not experiencing much pain from her fracture but had discomfort due to the cellulitis in her legs. <BR/>Interview on 01/08/25 at 1:05 PM with CNA A revealed she was giving Resident #1 a bed bath and asked the resident to turn to her side. She stated the resident grabbed the repositioning bar on the bed, threw her leg over her left leg and that was when the resident fell over on to the floor. CNA A stated she then called for the nurse to assist, and the resident was assessed. CNA A stated Resident #1 was on an air mattress, and it was inflating at the time the resident was turning to her side. CNA A said she was aware Resident #1 required two staff for care, but she was not able to find someone to help her. CNA A said she asked another CNA, whose name she could recall, for help. She stated she did not get any help, so she bathed the resident alone. She stated she had bathed the resident alone in the past. The CNA said she felt safe bathing the resident alone because the resident was able to help turn in bed. <BR/>Interview on 01/13/25 at 1:23 PM with LVN B revealed she was called by CNA A to Resident #1's room and noticed the resident was on the floor. CNA A told her the resident was trying to turn in bed during a bed bath, and the resident fell. LVN B said during Resident #1's assessment, the resident was complaining of pain and noticed the resident's toes were bleeding and other areas of her body such as her side, so she was transferred to the hospital via EMS. LVN B stated Resident #1 required two staff member for care because she was a bariatric resident and for safety. The LVN said she did not know CNA A was caring for Resident #1 alone, and she did not recall the aide asking anyone for help during the bed bath. LVN B further stated the aides could look in the [NAME] system to verify if a resident required one or two staff members during care or ask a charge nurse.<BR/>Interview on 01/08/25 at 1:28 PM with CNA D revealed she had worked at the facility for about a year and cared for Resident #1. CNA D said Resident #1 was bed bound per choice and required two staff members for assistance for all care because the resident was bariatric and could not be care for by one staff member. <BR/>Interview on 01/08/25 at 2:07 PM with CNA E revealed she worked with Resident #1 and the resident was bed bound. CNA E said the resident required two staff members for all care including bed baths because she was bariatric and needed more support. CNA E further stated Resident #1 had never been a one-person care resident. <BR/>Interview on 01/08/25 at 2:39 PM with RN F revealed Resident #1 was bed bound and required two staff members for all care including bed baths because the resident was bariatric and one staff member could not adequately care or clean the resident up during ADL care. <BR/>Interview on 01/08/25 at 2:29 PM the ADON revealed Resident #1 was bed bound and rarely got out of bed. She said the resident was a two-person assist for all care at all times because she was on an air mattress and could easily roll out of bed and for overall safety. The ADON was made aware CNA A had bathed Resident #1 alone, but the aide was not able to explain why she had not requested for help but only stated she had not seen anyone else. The ADON stated it appeared to her that CNA A had not looked for anyone to help her with the resident. The ADON further stated they immediately began to re-in-service (training) for all nursing staff re-educating them on the importance of using two staff member if the resident required it. They also identified all the residents that required two staff members for care they were monitoring and making observations to ensure two staff were assisting when needed. The monitoring began after the incident with Resident #1 and would be on-going for six weeks to ensure safety. <BR/>Interview on 01/13/25 at 8:36 AM with the DON revealed she was told Resident #1 was getting a bed bath by CNA A and while the resident was turning to her left side with the assistance of the repositioning rail, Resident threw her leg over too far and continued to roll until she fell out of the bed. Resident #1 was assessed, and they noticed she had bruising to the top of her feet and was complaining of pain throughout her body but mostly to her right knee. The resident was transferred to the hospital where she was diagnosed with a right leg fracture. The DON said Resident #1 required two staff members for care due to being a bariatric resident and for safety. The DON stated CNA A admitted knowing Resident #1 required two staff members for care, but the aide told them she had not been able to find assistance but if she would asked her (DON) she would have assisted. The DON also said if aides did not know if a resident was a one or two person for care, they could look in their [NAME] computer system. After the incident, CNA A was suspended pending their investigation and had a 1:1 counseling and re-in-service (training) on resident care and the aide was pulled from working with Resident #1. The other nursing staff were re-educated on using the [NAME] computer system to ensure a resident required a one- or two-person assistance during care. The DON further stated they had identified all the residents that required two people and were going to monitor but watching care for those resident for 6 weeks. <BR/>Record review of the facility's Safe Patient Handling policy revised December 2005 reflected the following:<BR/>The facility has a program to promote and assure safe patient handling for both the resident and the employee. The policy includes identification, assessment and interventions to provide a comfortable, safer transfer, repositioning and resident movement. <BR/> .3. Nurses will be educated in the identification, assessment and control of risks of injury to resident and nurses during patient handling <BR/> .5. Nurses will be educated regarding correct safe handling procedures, to report concerns or the inability to perform resident handling or movement that the nurse believes in good faith will expose a resident or nurse to an unacceptable risk of injury <BR/>Record review of 1:1 in-service with CNA A dated 12/05/24 revealed she had been re-educated on using the [NAME] system to communicate the resident's needs and information to all the CNA's to ensure appropriate resident care. CNA was also re-educated on fall prevention strategies and safe patient handling and abuse and neglect policy. <BR/>Record review of in-services dated 12/05/24 with all direct nursing reflected the staff had been re-educated using the [NAME] system to communicate the resident's needs and information to all the CNAs to ensure appropriate resident care. CNAs were also re-educated on fall prevention strategies and safe patient handling and abuse and neglect policy. <BR/>Interview on 01/08/25 at 1:05 PM with CNA A revealed she had been re-in-serviced 1:1 on abuse and neglect, ensure to always use two staff members during care for residents that required it and using the [NAME] system to check the care of the residents if they were unsure. <BR/>Interviews on 01/08/25 from 11:12 AM to 5:14 PM and on 01/13/25 from 10:01 AM to 1:23 PM with nursing staff from various shifts to include LVN B, CNA C, CNA D, CNA E, RN F, LVN G, CNA H, CNA I, CNA J, and CNA K all revealed they have been in-serviced on abuse/neglect, using the [NAME] system to verify if a resident required one or two staff members for care, and fall prevention to avoid accidents. <BR/>Record review of the direct care monitoring sheets reflected it included to watch at least 10 episodes of incontinent care or assist with bed mobility weekly to ensure staff was performing correctly and the care-planned number of staff were assisting. The monitoring dates reviewed began 12/05/24 and would continue for 6 weeks, and end on 01/15/25. <BR/>Observation on 01/08/25 at 11:07 AM revealed Resident #2 was transferred from the bed to the chair via mechanical lift by two staff members. <BR/>Observation on 01/13/25 at 3:32 PM revealed Resident #3 was transferred to bed via mechanical lift by two staff members.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents.<BR/>CNA A failed to get assistance from another staff member when providing Resident #1, who required two staff for assistance with all ADLs, a bed bath on 12/05/24. During the bed bath, CNA A asked Resident #1 to turn to her side. When the resident turned she fell to the floor, which resulted in the resident sustaining a fracture of her right femur (thigh bone). <BR/>The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 12/05/24 and ended on 12/05/24. The facility had corrected the noncompliance before the survey began.<BR/>This failure could place residents at risk for serious injury or harm, decline in health, and decreased quality of life.<BR/>Findings included:<BR/>Record review of Resident #1's quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included hypertension (high blood pressure), seizure disorder, cellulitis of right lower limb (bacterial infection that affects the skin and underlying tissue), fibromyalgia (chronic condition that causes widespread pain and tenderness in the body), and muscle wasting. The resident had a BIMS score of 9 which indicated her cognition was moderately impaired. The MDS further reflected Resident #1 was dependent for shower/bathing which indicated the helper did all the effort or the assistance of two or more helpers was required for the resident to complete the activity. <BR/>Record review of Resident #1's care plan revised on 12/16/24 reflected the resident had an ADL self-care performance deficit. Interventions included the resident required the assistance of two staff for bathing and bed mobility. <BR/>Record review of Resident #1's bathing status in the [NAME] system (documentation system used by reference key resident information for their nursing care plan) printed on 01/13/25 reflected the resident required the assistance of two staff members.<BR/>Record review of the facility's Provider Investigation Report dated 12/05/24 reflected the following:<BR/>The resident experienced a fall while in bed during care by the CNA [CNA A]. The CNA [CNA A] notified the nurse and had discovered the resident on the floor, resting against the bed. The resident has skin tears on both great toes, the let wrist, and beneath the right breast The resident reports generalized pain, with a particular emphasis on greater discomfort in her legs compared to other areas. When inquired about the incident, the resident explained 'I threw my foot over too far and fell.' The resident was transferred to the hospital due to experiencing pain the X-ray indicated a fracture in the left femur (left femur was facility documentation error; fracture was on the right leg). The resident subsequently underwent surgery to address the fracture <BR/>Record review of Resident #1's hospital records dated 12/05/24 reflected the resident was diagnosed with a comminuted distal femoral fracture (a broken bone that has been shattered into multiple pieces and are usually caused by severe trauma) of the right leg.<BR/>Observation and interview on 01/08/25 at 10:26 PM revealed Resident #1 in bed watching television. The resident was alert and oriented and able to recall the incident when she fell during care. The resident said CNA A was giving her a bed bath, and the aide asked her to turn to her side. The resident said she was turning over onto her side as she was holding on the repositioning bar and fell on the floor. She said CNA A was usually able to catch her when she rolled over, but this time she was not able to. Resident #1 said she was sent to the hospital and had surgery on her leg, as she pointed to her right leg. Resident #1 stated CNA A usually bathed her alone and never had a helper. The resident stated she preferred two people because she felt safer. Resident #1 said she was not experiencing much pain from her fracture but had discomfort due to the cellulitis in her legs. <BR/>Interview on 01/08/25 at 1:05 PM with CNA A revealed she was giving Resident #1 a bed bath and asked the resident to turn to her side. She stated the resident grabbed the repositioning bar on the bed, threw her leg over her left leg and that was when the resident fell over on to the floor. CNA A stated she then called for the nurse to assist, and the resident was assessed. CNA A stated Resident #1 was on an air mattress, and it was inflating at the time the resident was turning to her side. CNA A said she was aware Resident #1 required two staff for care, but she was not able to find someone to help her. CNA A said she asked another CNA, whose name she could recall, for help. She stated she did not get any help, so she bathed the resident alone. She stated she had bathed the resident alone in the past. The CNA said she felt safe bathing the resident alone because the resident was able to help turn in bed. <BR/>Interview on 01/13/25 at 1:23 PM with LVN B revealed she was called by CNA A to Resident #1's room and noticed the resident was on the floor. CNA A told her the resident was trying to turn in bed during a bed bath, and the resident fell. LVN B said during Resident #1's assessment, the resident was complaining of pain and noticed the resident's toes were bleeding and other areas of her body such as her side, so she was transferred to the hospital via EMS. LVN B stated Resident #1 required two staff member for care because she was a bariatric resident and for safety. The LVN said she did not know CNA A was caring for Resident #1 alone, and she did not recall the aide asking anyone for help during the bed bath. LVN B further stated the aides could look in the [NAME] system to verify if a resident required one or two staff members during care or ask a charge nurse.<BR/>Interview on 01/08/25 at 1:28 PM with CNA D revealed she had worked at the facility for about a year and cared for Resident #1. CNA D said Resident #1 was bed bound per choice and required two staff members for assistance for all care because the resident was bariatric and could not be care for by one staff member. <BR/>Interview on 01/08/25 at 2:07 PM with CNA E revealed she worked with Resident #1 and the resident was bed bound. CNA E said the resident required two staff members for all care including bed baths because she was bariatric and needed more support. CNA E further stated Resident #1 had never been a one-person care resident. <BR/>Interview on 01/08/25 at 2:39 PM with RN F revealed Resident #1 was bed bound and required two staff members for all care including bed baths because the resident was bariatric and one staff member could not adequately care or clean the resident up during ADL care. <BR/>Interview on 01/08/25 at 2:29 PM the ADON revealed Resident #1 was bed bound and rarely got out of bed. She said the resident was a two-person assist for all care at all times because she was on an air mattress and could easily roll out of bed and for overall safety. The ADON was made aware CNA A had bathed Resident #1 alone, but the aide was not able to explain why she had not requested for help but only stated she had not seen anyone else. The ADON stated it appeared to her that CNA A had not looked for anyone to help her with the resident. The ADON further stated they immediately began to re-in-service (training) for all nursing staff re-educating them on the importance of using two staff member if the resident required it. They also identified all the residents that required two staff members for care they were monitoring and making observations to ensure two staff were assisting when needed. The monitoring began after the incident with Resident #1 and would be on-going for six weeks to ensure safety. <BR/>Interview on 01/13/25 at 8:36 AM with the DON revealed she was told Resident #1 was getting a bed bath by CNA A and while the resident was turning to her left side with the assistance of the repositioning rail, Resident threw her leg over too far and continued to roll until she fell out of the bed. Resident #1 was assessed, and they noticed she had bruising to the top of her feet and was complaining of pain throughout her body but mostly to her right knee. The resident was transferred to the hospital where she was diagnosed with a right leg fracture. The DON said Resident #1 required two staff members for care due to being a bariatric resident and for safety. The DON stated CNA A admitted knowing Resident #1 required two staff members for care, but the aide told them she had not been able to find assistance but if she would asked her (DON) she would have assisted. The DON also said if aides did not know if a resident was a one or two person for care, they could look in their [NAME] computer system. After the incident, CNA A was suspended pending their investigation and had a 1:1 counseling and re-in-service (training) on resident care and the aide was pulled from working with Resident #1. The other nursing staff were re-educated on using the [NAME] computer system to ensure a resident required a one- or two-person assistance during care. The DON further stated they had identified all the residents that required two people and were going to monitor but watching care for those resident for 6 weeks. <BR/>Record review of the facility's Safe Patient Handling policy revised December 2005 reflected the following:<BR/>The facility has a program to promote and assure safe patient handling for both the resident and the employee. The policy includes identification, assessment and interventions to provide a comfortable, safer transfer, repositioning and resident movement. <BR/> .3. Nurses will be educated in the identification, assessment and control of risks of injury to resident and nurses during patient handling <BR/> .5. Nurses will be educated regarding correct safe handling procedures, to report concerns or the inability to perform resident handling or movement that the nurse believes in good faith will expose a resident or nurse to an unacceptable risk of injury <BR/>Record review of 1:1 in-service with CNA A dated 12/05/24 revealed she had been re-educated on using the [NAME] system to communicate the resident's needs and information to all the CNA's to ensure appropriate resident care. CNA was also re-educated on fall prevention strategies and safe patient handling and abuse and neglect policy. <BR/>Record review of in-services dated 12/05/24 with all direct nursing reflected the staff had been re-educated using the [NAME] system to communicate the resident's needs and information to all the CNAs to ensure appropriate resident care. CNAs were also re-educated on fall prevention strategies and safe patient handling and abuse and neglect policy. <BR/>Interview on 01/08/25 at 1:05 PM with CNA A revealed she had been re-in-serviced 1:1 on abuse and neglect, ensure to always use two staff members during care for residents that required it and using the [NAME] system to check the care of the residents if they were unsure. <BR/>Interviews on 01/08/25 from 11:12 AM to 5:14 PM and on 01/13/25 from 10:01 AM to 1:23 PM with nursing staff from various shifts to include LVN B, CNA C, CNA D, CNA E, RN F, LVN G, CNA H, CNA I, CNA J, and CNA K all revealed they have been in-serviced on abuse/neglect, using the [NAME] system to verify if a resident required one or two staff members for care, and fall prevention to avoid accidents. <BR/>Record review of the direct care monitoring sheets reflected it included to watch at least 10 episodes of incontinent care or assist with bed mobility weekly to ensure staff was performing correctly and the care-planned number of staff were assisting. The monitoring dates reviewed began 12/05/24 and would continue for 6 weeks, and end on 01/15/25. <BR/>Observation on 01/08/25 at 11:07 AM revealed Resident #2 was transferred from the bed to the chair via mechanical lift by two staff members. <BR/>Observation on 01/13/25 at 3:32 PM revealed Resident #3 was transferred to bed via mechanical lift by two staff members.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 9 residents (Resident #1) reviewed for quality of care.<BR/>The facility failed to ensure hospital discharge orders were followed for Resident #1 to have a follow-up appointment with a primary care physician.<BR/>This failure could affect residents who receive care from the facility and place them at risk for worsening conditions.<BR/>Findings included: <BR/>Record review of Resident #1's face sheet, dated 01/30/24, reflected the resident was a [AGE] year-old female resident who was initially admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses of Alzheimer's disease, abnormalities of gait and mobility, cognitive communication deficit, muscle weakness, lack of coordination, history of falling, abnormal posture, muscle wasting and atrophy (loss of muscle tissue), dementia, and unsteady on feet. Resident #1's primary care physician was reflected as being also the facility's medical director. <BR/>Record review of Resident #1's Minimum Data Set, dated [DATE], reflected Resident #61 had a BIMS score of 4, which indicated the resident had severe cognitive impairment. Resident #1 required total dependence with 2 person assist for transfers.<BR/>Record review of Resident #1's care plan, undated, obtained 01/30/24, reflected the following problem area: Resident #1 has a history of falls related to impaired cognition, poor safety awareness, and is very impulsive. She is a risk for future falls and injury from falls. The care plan reflected: Goals: [Resident #1] will not sustain serious injury. Resident #1 will be free of minor injury. Intervention: Encourage resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Ensure that the resident wearing appropriate footwear when ambulating or mobilizing in wheelchair. Anticipate and meet the resident's needs. Dycem to wheelchair seat. Educate the resident/family/caregiver about safety reminders and wheat to do if a fall occurs. Keep furniture in locked position. Keep needed items, water. in reach. Mechanical lift with staff x2 to assist with transfers. Monitor resident per facility protocol when on the wheelchair. Physical therapy evaluate and treat as ordered or as needed. Put resident back in bed after each meal when not doing activities in the day room.<BR/>Record review of Resident #1's discharge recommendations from the hospital, obtained 01/30/24, reflected Resident #1 needed to follow-up with a primary physician or at the hospital clinic post discharge in 7-14 days (around 01/15/24).<BR/>Record review of resident admission dated 01/09/24 revealed Resident #1 was mobile with the use of a wheelchair, she had poor trunk control for balance, she required two-person assist with bed mobility, and she was transferred with a mechanical lift. No additional information related to mobility/safety indicated. <BR/>Record review of Resident #1's progress notes entered by LVN A, dated [late entry] dated 01/08/24 at 6:17 PM, revealed Resident #1 was transferred to the hospital on [DATE] at 6:15 PM related LVN A being told Resident #1 fell face forward out of her wheelchair while on her way to dinner. <BR/>Observation and interview on 01/30/24 at 9:51 AM with Resident #1 revealed the resident was in bed. She had a light scar on the left side of her forehead, but there were no current indications of bruising. A floor mat was folded up underneath the foot of the resident's bed, and the bed was not in the lowest position. Resident #1 was able to communicate; however, she not able to stay on task when asked if she had a fall, injury, or hospital visit. <BR/>Interview on 01/30/24 at 10:20 AM with CNA B revealed CNA B said she was not present during the fall, had not noted any signs and symptoms of a fall during her care. CNA B stated she had never known Resident #1 to have any falls or be a fall risk. According to CNA B, Resident #1 used a mechanical lift to transfer. She stated the resident was assisted out of bed three times a week. She stated the resident could be very combative during care and transfers. She stated Resident #1 had a hard time with sitting up straight for long periods of time whether in bed or in her wheelchair. CNA B stated it was not a surprise to see the floor mat underneath the bed, and not at the bedside. She stated the floor mat was used on days Resident #1 remained in bed. <BR/>Interview on 01/30/24 at 2:10 PM with LVN A revealed she did assist with Resident #1's admission back into the facility. LVN A did not recall any hospital discharge documents that came in with Resident #1. LVN A stated she was responsible for following up to notify the physician upon her return and enter any new orders, but there was no documentation at this time. LVN A stated either she or the ADON would contact the hospital to ensure Resident #1 proper care would be given once her return to the facility. LVN A stated she did not recall notifying the ADON or the hospital for Resident #1's hospital discharge documents. LVN A stated not following up for the hospital documents placed Resident #1 at risk for not receiving any follow up visits or proper care after her injury. <BR/>Interview on 01/30/24 at 3:05 PM with the Administrator revealed hospital records were retrieved when residents returned from the hospital and sometimes were requested by the admitting nurse. When the documentation were retrieved, the admitting nurse would review it, notify the physician, enter any new orders, update resident records, give a copy to social services for future appointments, and leave discharge documents for the physician to review and sign off on. The Administrator stated after the physician signed off that he reviewed the hospital documents, the documents were uploaded to the portal by the Medical Records staff. According to the Administrator, she did not observe hospital discharge documents uploaded to Resident #1's clinal records, and she would follow-up with the Medical Records staff. <BR/>Interview on 01/30/24 at 3:36 PM with the ADON revealed the admitting nurse would review hospital discharge documents and follow-up with the physician on any new orders. According to the ADON, she had not observed any discharge documents prior to this interview. According to the ADON, upon review of the resident's hospital discharge documents, Resident #1 was to have a follow-up visit with a primary physician within a week after discharge (around 01/15/24). The ADON stated she was not aware of this recommendation. The ADON stated the nurse admitting the resident back in the facility was responsible for contacting the hospital to retrieve discharge documents if they did not come in with the resident back to the facility. The ADON stated she did review records for hospital records received; however, this was missed. The ADON stated not doing so placed Resident #1 at risk of missing follow-up visits after her fall. The ADON stated the facility could have missed crucial instructions from the hospital leaving Resident #1 not receiving proper care. <BR/>Interview on 01/30/24 at 4:00 PM with the Administrator revealed Resident #1's primary physician was the Medical Director of the facility, and he visited the facility weekly. The Administrator stated having Resident #1 return to the hospital clinic for a follow-up visit would cause double billing. The Administrator stated the facility failed to retrieve Resident #1's discharge documents. The facility failed notify the physician of recommendations from the discharge documents. The Administrator revealed the documents were not retrieved upon Resident #1's return to the facility. The Administrator stated this failure could prevent proper healing and care. <BR/>Request of a facility policy on 01/30/24 at 4:30 PM regarding completing hospital discharge recommendations, follow-up visits, and to arrange for services that have been ordered by a physician was not available according to the Administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Resident #61) of 17 residents reviewed for dignity. <BR/>The facility failed to ensure a WanderGuard device was not placed on Resident #61 when the resident was not an elopement risk. <BR/>The failure placed residents at risk of decreased quality of life and lowered self-esteem.<BR/>Findings included: <BR/>Record review of Resident #61's face sheet dated 01/07/24 revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included neuropathy (damaged nerves resulting in numbness, burning, or pain in relation to whichever part of the body is damaged), aphasia (language disorder affecting ability to communicate), and chronic kidney disease. <BR/>Record review of Resident #61's MDS assessment, dated 08/20/23, revealed the resident had moderately impaired cognitive abilities and exhibited zero wandering frequencies one week after admission and used a wander elopement alarm daily.<BR/>Record review of Resident #61's comprehensive care plan, revised 08/15/23, revealed the resident did not have a risk of elopement documented on his care plan as upon entry into the facility.<BR/>Record review of Resident #61's Elopement Risk Evaluation, dated 08/14/23, revealed Resident #61 was at a risk of elopement. Record review of an updated elopement risk dated 11/14/23 revealed Resident #61 was not at risk for elopement.<BR/>Record review of Resident #61's physician's orders revealed: <BR/>May have WanderGuard due to poor cognition and poor redirection. There was a start date of 11/30/2023 and no end date.<BR/>Monitor placement of WanderGuard bracelet q shift. There was a start date of 11/30/2023 and no end date.<BR/>Monitor for function of WanderGuard QD and prn. There was a start date of 11/30/2023 and no end date.<BR/>Assess skin under WanderGuard q shift every shift for preventative. There was a start date of 11/30/2023 and no end date.<BR/>Record review of Resident #61's EHR revealed an entry by the Social Worker on 08/16/23 reflected the Social Worker had spoken with the resident's family member and explained the need for the resident to use a WanderGuard; however, there was documented consent from the family member. <BR/>During an interview on 01/03/24 at 10:04 AM with Resident #61, he stated, I hate wearing the ankle monitor the facility has placed on me. If I ran away, where would I go? <BR/>Interview on 01/4/24 at 4:33 PM with Resident #61 revealed the resident was still wearing a WanderGuard device. Resident #61 stated, It's embarrassing. It goes off every time I even get near the door. <BR/>Observation on 01/05/24 at 11:08 AM with Resident #61 revealed the resident was still wearing his WanderGuard. He said he did not understand why he must wear the WanderGuard. Resident #61 stated he was embarrassed wearing the device. <BR/>Interview on 01/05/24 at 10:24 AM with CNA C, who had worked at the facility since 2011, revealed she had not observed the resident exit-seeking. CNA C stated the resident said he did not want the WanderGuard, and he was alert and oriented. <BR/>Interview on 01/05/24 at 10:33 AM with ADON A revealed when Resident #61 first came to the facility, the nurse said that he went to the front door and was standing next to it. ADON A stated the resident's family members were coming, and he went there to wait for them. She stated the resident did not try to go out, and he had not tried to exit-seek. She stated the resident did not have to wear a WanderGuard. She stated they took the WanderGuard off of him after they became familiar with him. ADON A asked if the resident was still wearing the WanderGuard, and she was informed the resident was still wearing it. She stated she would discontinue the WanderGuard immediately.<BR/>Observation and interview on 01/05/24 at 10:53 AM with ADON A revealed she had Resident #61's WanderGuard, which had been removed from the resident. She also had the physician order showing that the WanderGuard had been discontinued and the resident's elopement assessment had been updated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately consult with the physician of a significant change in the resident's health status; or a need to alter treatment significantly for 1 (Resident #168) of 4 residents reviewed for notification of change. <BR/>The facility failed to notify Resident #168's physician that the resident's insulin had been discontinued by the hospital or that the resident had returned from the hospital and failed to follow-up with the physician to obtain new orders. <BR/>The failure placed residents at risk of not having medical complications and deterioration. <BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated 01/05/24 indicated the resident was an [AGE] year-old female, initially admitted on [DATE], and readmitted on [DATE] with diagnoses that included pneumonia, diabetes mellitus with ketoacidosis (potentially life threatening complication of diabetes), dehydration, acute and chronic respiratory failure with hypoxia (not able to keep oxygen and carbon dioxide at normal levels), dementia, heart failure, acute kidney failure, chronic kidney disease stage 3, convulsions, chronic obstructive pulmonary disease, high blood pressure. <BR/>Record review of Resident #168's MDS dated [DATE] indicated Resident #168 had a BIMS of 5, indicating severe cognitive impairment. Resident #168 required supervision for oral hygiene and eating, and partial/moderate assistance with toileting. Active diagnosis included Type II Diabetes Mellitus with Hyperglycemia (indicating blood sugar too high).<BR/>Record review of Resident #168 care plan undated indicated Resident #168 has Diabetes Mellitus Type 2. The care plan revealed the resident was often noncompliant with blood sugar and medication/insulin. The care plan reflected: Goal: [Resident #168] will have no complications related to diabetes. Intervention: Diabetes medication as ordered by physician. Monitor and document for side effects and effectiveness. Educate importance of medications and importance of compliance. <BR/>Record review of Resident #168's hospital records dated 12/29/23 indicated he was admitted on [DATE] among active problems included Type 2 Diabetes Mellitus with complication, with long-term current use of insulin. Among discontinued medications were insulin lispro 100 unit/mL injection, insulin glargine 100 unit/mL (3mL), Freestyle Libre (glucose monitor) 10-day reader, Freestyle Libre 10-day sensor kit, blood-glucose meter.<BR/>Record review of Resident #168's January 2024 physician orders revealed he had no orders for administering insulin, no orders to monitor blood sugar levels. <BR/>Record review of progress note dated 12/29/23 at 5:34 PM written by LVN B, indicated Resident #168 returned to the facility via emergency services in stable condition, vitals are stable. Progress notes did not indicate discontinued medications or that the physician was notified of his return. <BR/>During an interview on 01/04/24 at 5:58 PM with ADON A, she stated Resident #168 had been placed on hospice since his return to the facility. She stated Resident #168 had a significant change of condition and was sent out to the hospital. ADON A stated when he returned, he was extremely weak and was only getting out of bed for a few hours, unlike what he was doing before. ADON A stated she was looking at his medications today (01/04/24) and realized he had returned with orders for tramadol and hospice evaluation. ADON A stated, We have not been checking his blood sugar because there were no orders for it. We were going to ask hospice care if they wanted to monitor it. When asked why she was not notified that the resident's insulin orders were discontinued, she replied, We knew it was discontinued from the hospital. According to ADON A Resident #168 was on both a long- and short-acting insulin; however, Resident #168 would like to instruct staff on how much insulin he would take, so they were very aware of him taking insulin prior to his hospital stay. ADON A stated Resident #168 went from medications including 10 pills and insulin down to only having order for tramadol and hospice and the doctor was aware. ADON A stated Resident #168's blood sugar was not being checked because the orders were discontinued from the hospital and he was placed on hospice, with the expectation of not making it; however, the resident was thriving quite well. She stated they would contact the doctor for an order to start checking his blood sugar again. According to ADON A, nursing staff were responsible for contacting the physician to alert him that Resident #168's order for insulin had been discontinued at his hospital discharge. ADON A stated not following up with the physician about Resident #168's insulin orders could place him at risk for further decline. ADON A stated it was her responsibility to review Resident #168's orders to ensure proper treatment was being provided. <BR/>Record review of Resident #168's progress notes on 01/04/24 at 6:29 PM written by ADON A reflected the following: Spoke with Physician informing him that resident's blood sugar checks and insulin was discontinued from the hospital and resident is on hospice, but he is not taking anything for his diabetes. New orders received to check blood sugar BID. Family Member called and informed.<BR/>Interview on 01/05/24 at 8:47 AM with Physician I revealed his policy for the facility was to contact him for sending residents out to the hospital, fall, change of condition and when the resident returned from the hospital. Physician I stated with that being said, he usually received a call from the facility with any changes in resident care or condition. Physician I stated his instruction to them was always to follow hospital discharge instructions they should have documented those instructions. According to Physician I, he was in the facility every Monday and at that time he would review discharge records and initial them once he had reviewed. Physician I stated he thought that he got two calls, one stating that Resident #168 had returned to the facility and another call either yesterday or the day before about the discontinued insulin orders. Physician I stated since Resident #168 was someone that was being administered insulin before the facility should be checking his blood glucose, hemoglobin A1C (test that measures average blood sugar of the past 2-3 months) and communicating those results to him. According to Physician I, not checking the resident's hemoglobin A1C could place the resident at risk of complications with his health, which could further his complications with which he was already dealing. <BR/>During an interview on 01/05/24 at 1:57 PM with LVN H, she stated she was not the admitting nurse when Resident #168 arrived from the hospital. According to LVN H, the protocol for returning orders from the hospital were to follow the instructions from the discharge paperwork, alert the physician, ADON, DON and family of any changes. LVN H stated after documenting the hospital orders they were placed in the mail box for the physician to review. LVN H stated it was the responsibility of the ADON to review resident orders in the system upon a resident's return to ensure the orders were entered correctly. LVN stated not have orders for residents who received insulin placed them at risk for missing treatments. She stated she had been off and had not completed care for Resident #168. <BR/>An interview was attempted with LVN B on 01/05/24 at 2:10 PM; however, she declined the interview stating she was off the clock. <BR/>On 01/05/24 at 5:00 PM, the Administrator was asked to provided the facility's policy regarding notification of changes; however, the policy was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 8 residents (Residents #166) reviewed for comprehensive care plans. <BR/>The ADON failed to ensure Resident #166's care plan was updated to include her use of a Life Vest. <BR/>This failure could place the residents at risk of deterioration and improper care. <BR/>Findings included:<BR/>Review of Resident #166's undated admission Record revealed Resident #166 was [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included heart failure, atrial fibrillation (irregular heartbeat), muscle wasting atrophy (decrease in size and muscle wasting), Type 2 Diabetes Mellitus, hypotension and hypertension (high and low blood pressure), unsteadiness on feet, lack of coordination. <BR/>Review of Resident #166's admission MDS assessment, dated 12/22/23, revealed the resident's BIMS score was blank. Her Functional Status indicated she substantially/ maximum dependent on staff for toileting, shower/bathing and for dressing. The MDS assessment indicated Resident #23 admitted with an indwelling catheter. For eating she required set-up assistance. <BR/>Review of Resident #166's care plan, last review dated 01/03/24, revealed no indication that Resident #166 had been out to the hospital and returned with a Live Vest that must be worn and not removed until doctor evaluation. <BR/>Review of Resident #166's January 2023 physician orders revealed:<BR/>1. Change and recharge battery QD, Remove battery before taking off system to shower or bathe Q shift, Change garment and if desired put lotion on round electrode Q shift, Check electrode placement -all electrodes against skin ends of belt fastened together, Centered in front Q shift, Every shift for Life Vest Care. <BR/>2. 24-hour help line [PHONE NUMBER] every shift for Life Vest Care<BR/>3. Always: Hold response buttons when you feel vibration or hear siren alert, Check display when you hear a [NAME] alert, Every shift for Life Vest Care. <BR/>Observation and interview on 01/03/24 at 1:37 PM revealed Resident #166 sitting at her bedside table with her lunch tray. Resident #166 stated she was ready to lay down. Staff entered the room to assist with the transfer, and Resident #166 stated she was itching under her breast. The staff stated they would be careful not to remove her vest. After her transfer, staff were observed making the resident comfortable and checking underneath her shirt for placement. <BR/>Interview on 01/04/23 at 3:00 PM with CNA D revealed he was new to the facility so he liked to discuss the shower process with residents to make them feel comfortable with him and the process. CNA D stated with Resident #166 she advised him that she was ready to shower and that he had to be careful not to remove her life vest. According to CNA D, he was not aware that Resident #166 wore a life vest, and he was waiting on his nurse to assist him. CNA D stated he used the care plan which gave him a reference to care for residents. CNA D stated the life vest was not on the care plan. He stated the resident recently returned from the hospital, so he was going to wait on the nurse to proceed with the shower. <BR/>Interview on 01/04/23 at 3:05 PM with LVN B revealed Resident #166 recently returned from the hospital with the life vest. According to LVN B, she saw Resident #166 with the vest on and saw orders in the system for the lfe vest. LVN B stated it was the responsible of the ADON or the MDS Coordinator to update the care plan. LVN B stated it was important to have the care plan updated so that staff would have the lastest information to care for the resident. <BR/>Interview on 01/05/23 at 1:57 PM with LVN H revealed Resident #166 has had two recent trips to the hospital and each time she had the vest once she returned to the facility. According to LVN H, the vest was required because the first time she returned from the hospital she had very low blood pressure and was not responding the way she would have liked so she contacted the physican and family and the resident was sent out. LVN H stated it was the responsibility of the ADON and the MDS department to ensure care plans were updated. LVN H stated if this was not done it could place risk to Resident #166 not receiving proper care, she could not have the vest removed. <BR/>Interview on 01/05/24 at 2:15 PM with ADON B revealed she received information on Resident #166 prior to her discharging from the hosptial. According to ADON B, Resident #166 was not wearing the life vest in the hospital so she was not sure why she was sent home with it. ADON B stated she entered what information that was given to her from the discharging nurse at the hospital and perhaps upon discharge additonal orders were added. ADON B further stated she was aware Resident #166 was wearing a life vest based on orders that were entered for her. <BR/>Interview on 01/05/24 at 2:30 PM with ADON A revealed she was aware Resident #166 had a life vest, and that she needed to check to see if she still needed to wear it. After review of Resident #166's clinical records, ADON A stated Resident #166 had a follow-up appointment with her primary care provider of cardiology and needed to wear the life vest until that appointment. ADON A stated resident use of the life vest should be included on her care plan, however it had not been updated to the care plan due to the survey beginning. ADON A stated she was responsible for including the life vest on the care plan. ADON A stated not updating the care plan could place residents at risk of goals and interventions to be dropped and it will not paint the whole picture of the residents. <BR/>Interview on 01/05/24 at 4:30 PM with the Administrator revealed the IDT was responsible for updating each departments goals and interventions. The Administrator stated if it was something clinical that needed to be updated it would be the DON and ADON's responsibilty to update resident care plans. Administrator stated not updating the programs would place residents at risk of not receiving individualized care based on their needs. <BR/>Review of the facility's current, undated Comprehensive Care Planning policy reflected:<BR/>The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the 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 comprehensive assessment. <BR/>The comprehensive care plan will describe the following - <BR/>The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. <BR/>The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented.<BR/>Prepared and/or contributed to by an interdisciplinary team, that includes but is not limited to-- The attending physician, A registered nurse with responsibility for the resident, A nurse aide with responsibility for the resident. <BR/>The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents received proper treatment and assistive devices to maintain vision abilities for 1 (Resident #45) of 23 residents reviewed for vision services.<BR/>The facility did not address Resident #45's vision loss and ensure Resident #45 was seen by an ophthalmologist.<BR/>This failure could place all residents with vision loss at risk of not receiving proper services, decreased ability to communicate and/or a decreased quality of life.<BR/>Findings included: <BR/>Record review of Resident #45's face sheet revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included stroke, congestive heart failure, and kidney failure.<BR/>Record review of Resident #45's MDS assessment dated [DATE] revealed resident had a BIMS score of 13 indicating the resident was cognitively intact and capable to discuss his own plan of care. Resident's MDS also revealed that Resident #45 requires supervision assistance by one person with activities of daily living. <BR/>Record review of Resident #45's Comprehensive Care Plan dated 07/03/23 revealed that resident has impaired visual function and requires ophthalmologist care as directed. Intervention stated .arrange consultation with eye practitioner as required.<BR/>Record review of Resident #45's Physician's Orders revealed an order for Referral to an ophthalmologist dated 11/2/2023.<BR/>Record review of Resident #45's Social Services Note dated 12/12/2023 at 09:35 AM reflected: <BR/>SW contacted ophthalmologist office via phone. SW informed the operator that the documents were faxed, and SW received a transmission verification report showing that the fax went through. The operator states that she will transfer me to the ophthalmologist number, and they might have more information. SW was transferred to the main menu, and no one answered the call. SW contacted the office again via phone. SW was transferred to the ophthalmologist office. The office stated that the referrals department should have scheduled the appointment by now, but they are not sure why it is not scheduled. The office states that they checked with the referral team, and they have not received it and stated to wait four more days and they should get through the referrals, and they will call us back or to call them back after 4 days. Social Services<BR/>Record review of Resident #45's Social Services Note dated 11/29/2023 at 10:37 AM reflected: <BR/>SW contacted the hospital via phone and was provided with a number to call to schedule an appointment. SW contacted the hospital, and they state they did not receive the referral on the 11/27/23. SW informed the hospital that SW has a transmission verification report, and it shows that the referral went through. The department states that they cannot find it and asked SW to email the referral, and someone will call the facility within a day or two to schedule the appointment. SW emailed the referral. Email was not received. SW contacted the hospital again. They state that it is best to fax the referral than to email it. They state that it takes them 48-72 hours to receive the referral and once they have received it, they will contact us. Social Services<BR/>Record review of Resident #45's Social Services Note dated 11/27/2023 at 1:58 PM reflected: <BR/>SW contacted ophthalmologist office and was informed that they do not accept the resident's insurance. SW contacted hospital and was informed that a referral from primary care physician is needed because the resident has not been seen at that hospital. SW contacted another hospital via phone and was informed that for Resident #45 to be seen, they need the order to be faxed, and someone will call me back as soon as they receive the order. At 16:38 [4:38 PM], SW faxed resident's referral order for ophthalmologist to hospital. Social Services <BR/>Interview on 01/03/2024 at 10:16 AM with Resident #45 revealed he needed an ophthalmologist appointment, but he had not yet been provided an appointment date. <BR/>Interview on 01/05/24 at 1:43 PM with the Administrator revealed the facility's Social Worker left on vacation on 12/15/23. The Administrator stated someone should have followed up on the referral, which that would have been transport. She stated she would follow-up on the referral immediately. The Administrator stated Resident #45 was not getting services that he needed. She stated the facility policy was to follow-up on referrals. <BR/>Record review of facility's Referrals From Other Disciplines for Social Services policy, dated 2003, reflected: <BR/> .4. The Social Service employee will respond to the referral by: <BR/>1. Contacting the referral source. <BR/>2. Seeing the resident and/or family member. <BR/>3. Providing the service or item. <BR/>4. Answering the question. <BR/>5. Reporting back to the referral source .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all mechanical, electrical, and patient care equipment was in safe operating condition for 1 (Resident #22) of 6 residents reviewed for safe, functional equipment.<BR/>The facility failed to ensure Resident #22's bed was in proper working condition. <BR/>This failure could place residents at risk for skin tears, injury, falls and discomfort during transfers. <BR/>Findings included:<BR/>Record review of Resident #22's face sheet dated 01/05/24 indicated Resident #22 was a [AGE] year-old male and originally admitted on [DATE], readmitted on [DATE] with diagnoses including acquired absence of right leg below the knee, age-related physical debility (affects the persons physical mobility), muscle weakness, lack of coordination, chronic pain, acute pyelonephritis (sudden and severe kidney inflammation due to bacterial infection) Hypertension (high blood pressure), Diabetes Mellitus (high sugar levels).<BR/>Record review of Resident #22's quarterly MDS assessment dated [DATE] indicated Resident #22 had a BIMS score of 15 which indicated cognition was intact. Resident #22 required the use of a wheelchair. The MDS indicated Resident #22 required extensive assistance with bed mobility with one person assist, limited assistance with transfers and toileting with one person assist. Resident was able to roll to the left and right, lying to sitting on the side of the bed independently. <BR/>Record review of Resident #22's last care plan review was completed 11/01/23 indicated Resident #22 had a physical functioning deficit related to: Mobility impairment, self-care impairment. Goal: improve current level of physical functioning. Intervention: Inspect skin with care, report reddened areas, rashes, bruising, or open areas to charge nurse. Observe and report changes in physical functioning ability, observe and report changes in ROM ability. Resident #22 had a skin tear, laceration, or abrasion Left Dorsal Foot, Left Distal Shin (left leg) Goal: resident's skin will resolve without complications Interventions: assess reason for skin injury occurrence, notify staff of cause; determine measures to prevent further skin injuries. Notify the nurse of any new skin issues, perform wound care as ordered.<BR/>Observation and interview on 01/03/24 at 10:56 AM revealed Resident #22 lying across his bed in a perpendicular position with his left foot on the wheelchair located at the side of his bed. Resident was observed with 2-3 pillows behind his head. Resident #22 stated he was having trouble getting the facility to switch out his bed. Resident #22 stated he had spoken with staff previously to have his bed replaced. Resident #22 stated he could not recall how it had been since his bed had not been able to lift up or down, head of bed does not elevate and when he is transferring in and out of bed, he would hit his knee which sometimes caused injury or pain. Resident #22 was noted with scabs at his left knee and shin. Observation of the bed revealed the head of the bed was not able to elevate or lift. The foot board of the bed was damaged with a hole and wood particles missing from the foot board. <BR/>Observation and interview on 01/03/24 at 1:00 PM revealed Resident #22 sitting in his wheelchair having lunch. Resident #22 stated in order to eat he had to relocate to his wheelchair and could not eat while in bed due to the head of bed could not be elevated. Observation of resident room revealed the bed moved away from the wall, bed rail on the floor near the door, bedding removed from the bed. Resident #22 stated that since he spoke with the surveyor, he was getting a new bed, so he moved the bed in preparation of getting a new bed placed in his room. Resident #22 stated he had spoken with maintenance, and they would come in and replace the bed. <BR/>Observation and interview on 01/03/24 at 1:10 PM revealed ADON A entered Resident #22's room and asked what was going on with his room, and why was the bed moved from the wall. Resident #22 stated he was getting a new bed today. He stated he moved the bed himself in anticipation of the bed change. Resident #22 stated the controls on the bed did not work, and he had requested several times to have a new bed. Resident #22 stated a nurse or maintenance had come in his room and told him he was getting a new bed. ADON A told Resident #22 not to move the bed, that she would have housekeeping come in and assist him. <BR/>Interview on 01/04/24 at 3:10 PM with CNA D revealed Resident #22 did communicate he wanted an electric bed. CNA D stated he then informed ADON B either yesterday (01/03/24) or the day before (01/02/24). CNA D stated Resident #22 had requested a different bed previously, due to the condition of the bed. CNA D stated it was his responsibility to alert the nurse or the ADON when residents make a complaint or feel uncomfortable about their care. CNA D stated not communicating with the nurse about resident care or request placed residents at risk of not getting their needs met. <BR/>Interview on 01/05/24 at 11:23 AM with the Maintenance Assistant revealed he was notified by an aide on the morning of 01/04/24 to change out the bed for Resident #22. The Maintenance Assistant stated the bed was thrown out when it was removed from Resident #22's room. He stated the bed was not any good, the foot board was broken, one of the springs were broken, there was no remote, and the motor was out. According to the Maintenance Assistant, this was his first time being alerted to the request for a bed change for Resident #22. He stated the beds were supposed to be checked on a regular basis by the maintenance department to prevent injury and so that residents had properly working beds. The Maintenance Assistant stated prior to the new Maintenance Director, beds were checked every two weeks; however, now they were checked at least once a month unless notified through the maintenance portal system or verbally that there was a problem or need to have the bed checked. <BR/>Interview on 01/05/24 at 3:00 PM with ADON B revealed she was told about Resident #22 requesting a new bed. She was not able to indicate which day or by whom. ADON B stated it was her expectation for the staff to inform her and also enter a request in the maintenance portal and alert the nurse. ADON B stated not responding to resident request could make them feel neglected and not heard. <BR/>Interview on 01/05/24 at 4:32 PM with the Administrator revealed all staff were responsible for notifying maintenance about issues with beds. The Administrator stated there was a new Maintenance Director, a new portal system linked directly to them, which they have access to any maintenance request, and they received requests quickly. According to the Administrator, not changing out the bed could place Resident #22 at risk for him getting hurt. The Administrator stated the bed was broken and the room in disarray was a complete hazard to him which jeopardized his health. The Administrator stated her expectation would be once a resident alerted any staff of maintenance concerns, that staff was to enter the concern in the maintenance portal and alert the nurse. <BR/>Record review of the facility's Resident Rights, Homelike Furniture policy reflected: <BR/>A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. <BR/>Safe Environment - the resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide-<BR/>1. <BR/>A safe, clean, comfortable, and homelike environment<BR/>2. <BR/>Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from abuse for 3 of 6 residents (Resident #4, Resident #6, and Resident #7) reviewed for abuse.<BR/>1. The facility failed to ensure Resident #4 was free from emotional and mental abuse. Video footage identified CNA A antagonizing Resident #4 when she went to check on him on 02/18/25 . <BR/>The noncompliance was identified as past noncompliance (PNC). The noncompliance began on 02/18/25 and ended on 02/19/25. The facility had corrected the noncompliance before the investigation began.<BR/>2. The facility failed to ensure Resident #6, and Resident #7 were free from abuse on 03/11/25 when Resident #6 verbally abused Resident #7 which cause Resident #7 to physically abuse Resident #6 by hitting him on the face. <BR/>The noncompliance was identified as past noncompliance (PNC). The noncompliance began on 03/11/25 and ended on 03/14/25. The facility had corrected the noncompliance before the investigation began.<BR/>These failures could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and psychological harm.<BR/>Findings included:<BR/>1. Record review of Resident #4's Face sheet dated 05/01/25, revealed the resident was a [AGE] year-old male with an admission date of 04/15/24 and readmitted on [DATE]. <BR/>Record review of Resident #4's quarterly MDS, dated [DATE], reflected his diagnoses included anxiety disorder, vascular dementia, and mild cognitive impairment. Resident #4's BIMS score was 04 which indicated his cognition was severely impaired. The MDS Section E - Behaviors reflected Resident #4 did not exhibit any physical or verbal behaviors towards others. The MDS Section GG - Functional Abilities also reflected Resident #4 was dependent of staff to assist with ADLs. <BR/>Record review of Resident #4's Care Plan revised date 03/11/25, reflected Focus: The resident has a behavior problem r/t hx of stroke, resident will become difficult to manage. Resident yells out loudly and will use cursive language. Resident is very adament toward care, sports, etc and will yell out at staff and curse. Goal: The resident will have fewer episode by review date. Interventions: Anticipate and meet the resident's needs. Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by. Redirection techniques will include offering alternatives to the current activity. <BR/>Record review of the Provider Investigation Report dated 02/25/25 reflected, Resident responsible party had address to [Administrator] a concern of a staff member being rough with the resident when trying to readjust on the bed. When [Responsible party name], the resident's responsible party, entered [Administrator] office and informed [Administrator] of an incident that occurred the previous night, [Administrator] contacted the CNA [CNA A] to discuss the matter. [Administrator] informed her about the responsible party reported aggressive behavior toward the resident [Resident #4] and confirmed that she had indeed acted aggressively toward [Resident #4] due to [Resident #4] cussing at him and she was trying to correct him. [Administrator] informed her that she would be suspended until further notice. Safe surveys conducted no noted concern. Skin assessment completed and no noticed concerns, pain assessment no noted concerns, Trauma assessment no concerns noted. The Provider Investigation Report also reflected that the result of the investigation was inconclusive, but CNA A was terminated. <BR/>Record review of CNA A's Statement dated 02/29/25, reflected Went to resident's room cause he was hanging off the bed and yelling. [CNA A] told the resident to put his legs back in the bed before he ended up on the floor. That's when the resident call me a bitch and to leave him alone. [CNA A] told him not till he in bed right that if keeps hanging out the bed like that he was going to be on the floor and the floor hursts and wins every time. He then proceeded to call me a bitch again. [CNA A] told him to don't be disrespectful to me cause [CNA A] wouldn't do him like that and that I'm someone sister daughter and mother and that he wouldn't like it if [CNA A] called the women in his family that name. [CNA A] also asked him what was wrong with him.<BR/>Observation of Video Footage time stamped 02/18/2025 05:44:24 CST [5:44 AM] revealed: Resident #4 sitting at the edge of the bed. CNA A (who was a tall, heavy-set woman) entered Resident #4's room stating, What are you doing [Resident #4's name]. Resident #4 states What are you talking about bitch. CNA A stated what. Resident #4 stated What are you talking. CNA A standing in front of Resident #4. CNA A then proceed to tell Resident #4 twice to put those legs back in the bed. Resident #4 asked CNA A Why?''. CNA A tells Resident #4 you can't walk [you] will end up on the floor. Resident #4 tells her No I won't. CNA A responded, Okay bet, but I am going to put your legs back on the bed. Resident #4 asked why again. CNA A responded, I don't have to explain why. Resident #4 asked CNA A why are [you] going too and CNA A stated, because I am going too. Resident #4 stated you not going too. CNA A observed leaning forward and grabbed the control for the bed. Resident #4 stated Get your fucking hands of me bitch, I will fuck you up. CNA A asked resident What did [you] say? and Resident #4 stated, I will fuck you up, get your fucking hands off of me. CNA A observed to lean forward put her right hand on Resident #4's right knee. CNA A then stated My hand is on you. What are [you] going to do? Nothing, and [you] better quit calling me out of my name because [you] wouldn't like if [I] called your momma, sister, or anybody in your family out of their name, don't be disrespectful to [me] because I am not being disrespectful to [you], [you] understand. Resident #4 agreed with CNA A and CNA A removed her hand from Resident #4's knee. CNA A states I don't know where you get that being disrespectful from, that [ain't] going to get you nothing , that [ain't] going to get you no help, that is going to get you talk ed about, don't be disrespectful, and you wait until someone comes in here to help you, you got me? CNA A proceed to adjust Resident #4's legs on the bed. Resident #4 stated I hear that CNA A states Alright then, I am not about to play with you, cause you end up on the floor, you end up on the floor and the floor hurts and it wins every time. Resident #4 stated yeah right. CNA A states Yeah right, you got a real smart mouth, what is wrong with you, what is your problem tonight. Resident state I got a problem with you. CNA response No, I [ain't] your problem, Resident stated oh yeah. CNA A stated, I just came in here to help you. CNA A proceeded to walk out the room and stated, you better act like you got some sense. Video was about 2 minutes long. CNA A hand was on Resident #4's knee for about 32 second.<BR/>Interview on 04/30/25 at 11:14 AM, Resident #4 revealed he was doing well and feeling safe at the facility. Resident #4 was not a good historian; resident could not recall incident with CNA A. <BR/>Interview on 04/30/25 at 12:46 PM, Resident #4 Family Member revealed she reviewed the video footage a day after the incident and notified the Administrator. She stated the incident happened on 02/18/25, Resident #4 was sitting on his bed and the staff was observed entering the room. She stated on the video footage it was observed Resident #4 being disrespectful toward the staff; however, the staff was rude and antagonizing the situation. She stated on the video it was observed Resident #4 saying keep your hands off of me and then staff proceed to put her hand on his knee. Family Member stated she agreed with the staff redirecting and telling Resident #4 to stop cursing at her; however, the staff putting her hand on him was what concerned her. She stated the staff was antagonizing the situation by putting her hand on Resident #4. Family Member stated after the Administrator was notified, the facility investigated the incident and terminated the staff. <BR/>Interview by phone on 05/01/25 at 9:27 AM, CNA A revealed she was doing her last round, when she heard Resident #4 screaming. She stated she entered the room and observed Resident #4 was hanging on the side of the bed. She stated she asked Resident #4 what he was doing, and Resident #4 started to curse at her and got mad because she told him to get back in bed. CNA A stated Resident #4 was calling her a bitch and being disrespectful to her. She stated she told Resident #4 to stop, to not called her like that because he would not like for someone to call his mom, sister or daughter that. She stated Resident #4 stated he would not like that. She stated she only touched Resident #4 when repositioning him back to bed. CNA A stated she was not supposed to correct Resident #4. She stated she was wrong for telling him to stop being disrespectful because they were told residents were always right. CNA A stated she never touched the resident or disrespected the resident. CNA A stated she was suspended and then let go. <BR/>Interview on 05/01/25 at 2:16 PM, Corporate Compliance RN revealed she reviewed the video footage regarding CNA A and Resident #4. She stated CNA A should lose her license. She stated CNA A was verbally abusive towards Resident #4, she stated when CNA A put her hand on Resident #4' she was antagonizing the situation. She stated CNA A should had stepped away. Regional Compliance stated Resident #4 had no adverse effects from the incident. She stated CNA A was terminated. <BR/>Interview on 05/01/25 at 2:36 PM, the Administrator revealed Resident #4 family informed him about the incident and he immediately suspended CNA A. He stated skin assessment was completed on Resident #4 with no injuries, safe surveys and quality of life checks were completed with no concerns. The Administrator stated after reviewing the video footage it was determined CNA A was considered being verbally abusive and was terminated for abuse. He stated CNA A admitted to what she did wrong. He stated his expectations were for his staff to respect residents, care for them and to report any abuse and neglect allegations to him to protect the residents. <BR/>Record Review of CNA A's personnel file, reflected CNA A was suspended and terminated on 02/19/25.<BR/>Record review of facility Abuse/Neglect policy, revised 09/09/24, reflected the following: <BR/>The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility.<BR/>Prior to the HHSC investigation, the facility took the following actions to correct the noncompliance:<BR/>Record review of Resident #4's Skin assessment, Pain assessment and Trauma Assessment completed on 02/19/25, no concerns noted.<BR/>Record review of Safe surveys were completed on 02/19/25 with five residents with no issues noted.<BR/>Record review of facility In Service Training dated 02/19/25, provided by Administrator and Corporate Compliance RN reflected staff were In Serviced on Abuse and Neglect Policy to include - Arguing with, antagonizing, and touching a resident against their will is considered Abuse. If [you] see a staff member or resident engaging in this activity, the Administrator must be notified immediately. The Administrator is the abuse coordinator. If [you] can't get a hold of the administrator, notify the DON or ADON immediately. Staff should not continue to work their shift, they must be suspended immediately, Resident Rights <BR/>Record review of facility In Service Training dated 02/19/25, provided by Corporate Compliance RN reflected staff were In Serviced on Abuse and Neglect, Resident Rights.<BR/>Interviews on 04/30/25 from 1:21 PM through 05/01/25 to 3:45 PM with ADON Y, ADON U, BOM, FM, CNA B, LVN C, CNA D, CNA F, CNA H, CNA E, Van Driver, CNA I, CNA F, LVN G, LVN K, LVN L, CNA V, LVN X revealed the facility staff were able to verify education was provided to them. The nursing staff stated they were educated on different types of abuse/neglect and resident rights. Staff provided the types of abuse were physical, mental, financial, and verbal. Staff stated the three signs of abuse occur when the resident avoids eye contact, bruises, and the resident withdraws from care. Staff stated they would intervene if witness any type of abuse from a staff. Staff revealed they would report these and other signs to the Abuse Coordinator, the Administrator, immediately if they witness or observed any of these signs.<BR/>2. Record review of Resident #6's Face sheet dated 05/01/25, revealed the resident was a [AGE] year-old male with an admission date of 04/28/21 and readmitted on [DATE]. <BR/>Record review of Resident #6's quarterly MDS, dated [DATE], reflected his diagnoses included bipolar disorder, dementia, and cognitive communication deficit. Resident #6's BIMS score was 12 which indicated his cognition was moderately impaired. The MDS Section E - Behaviors reflected Resident #6 did not exhibit any physical or verbal behaviors towards others. The MDS Section GG - Functional Abilities also reflected Resident #6 needed substantial/maximal assistance with ADLs.<BR/>Record review of Resident #6's care plan, revised 03/11/25, reflected Focus: The resident has a history of trauma that may have a negative impact. The trauma is r/t: Resident with hx of physical altercation with another resident. Goal: Maintain resident's safety and integrity post trauma episode, using appropriate interventions. Interventions: Perform the following de escalation techniques as required: redirection, and deep breathing. Psychiatric services adjusted medication.<BR/>Record review of Resident #7's face sheet dated 05/01/25, revealed the resident was a [AGE] year-old male with an admission date of 12/24/21 and readmitted on [DATE].<BR/>Record review of Resident #7's admission MDS, dated [DATE], reflected his diagnoses included anxiety disorder, major depressive disorder, schizoaffective disorder, restlessness and agitation and cognitive communication deficit. Resident #6's BIMS score was 13 which indicated his cognition was cognitively intact. The MDS Section E - Behaviors reflected Resident #7 did not exhibit any physical or verbal behaviors towards others. The MDS Section GG - Functional Abilities also reflected Resident #7 was independent for ADLs.<BR/>Record review of Resident #7's care plan, revised 04/14/25, reflected Focus: The resident has potential to demonstrate physical behaviors related to paranoid schizophrenia, schizoaffective disorder as evidence by: Physical aggression demonstration due to being provoke when cussed at. Goal: The resident will seek out staff/caregiver when agitation<BR/>occurs through the review date. Interventions: If the resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately.<BR/>Record review of the Provider Investigation Report dated 03/18/25 reflected, [Speech and Language Therapist] witness [Resident #7] hit [Resident #6] due to an altercation they were having an immediately separate them both. During investigation, Resident #7 reported that Resident #6 was using inappropriate language to him and repeatedly told him to stop. When Resident #6 continued, Resident #7 became frustrated and end up hitting him. Upon witnessing the incident, [Speech Therapy] quickly intervene to separate the two residents and called for assistance. Both residents were promptly separated, and a 1:1 supervision was implemented until a psychiatric evaluation could be performed.<BR/>Record review of Witness Statement from Speech and Language Therapist dated 03/11/25 reflected, My name is [Name]. [Speech and Language Therapist ] am an employee at the [Facility Name]. [Speech and Language Therapist] am the speech language pathologist. At approximately 10:15 a.m., [Speech and Language Therapist] witnessed two residents [Resident #6 and Resident #7] in a physical altercation in the dining room. [Speech and Language Therapist] heard [Resident #7] say to [Resident #6] call me a bitch one more time. [Resident #6] responded and then [Resident #7] struck [Resident #6] about two times. Immediately, [Speech and Language Therapist] intervened to ensure both men were safe. [Resident #7] left the dining room. Once [Resident #7] left the dining room, [Speech and Language Therapist] asked [Resident #6] if he was okay and if he could tell me what happened. [Resident #6] replied, he's just mad because [Speech and Language Therapist] wouldn't give him a cigarette. Once both individuals were safe, [Speech and Language Therapist] immediately told [Administrator]. <BR/>Interview on 04/30/25 at 10:45 AM, Resident #6 stated he was doing well. Resident #6 stated he had an incident with Resident #7. Resident #6 stated Resident #7 got frustrated with him, and Resident #7 kept telling him to not say anything to him. Resident #6 stated he told Resident #7 that he was coming in and needed him to get out of the way, he stated Resident #7 got more frustrated and hit him on the side of the face. Resident #6 stated the police was called but he did not pressed charges. Resident #6 stated he was only hit once on the side of his face. Resident #6 stated he was not hurt. Resident #6 stated he never called Resident #7 any names. <BR/>Interview on 04/30/25 at 12:26 PM, Resident #7 stated he was doing well. Resident #7 stated he got into an altercation with Resident #6. Resident #7 stated for a week Resident #6 was messing with him and calling him out of his name. Resident #7 stated he never told anyone about it. Resident #7 stated on the day of the altercation Resident #6 called him a bitch and he asked Resident #6 to stop but he continued to call him a bitch. Resident #7 stated he got mad, and he hit him on the face once. Resident #7 stated he was tired of Resident #6 calling him a bitch. Resident #7 stated after the altercation, he keeps his distance from Resident #6. <BR/>Interview on 05/01/25 at 9:49 AM, the Administrator revealed Speech and Language Therapist was out on leave. <BR/>Interview on 05/01/25 at 1:38P PM, ADON Y stated Resident #6 and Resident #7 had an altercation in the dining room on 3/11/25. She stated it was a witnessed altercation by Speech Therapy. She stated she was not sure what started the altercation, but Resident #7 got upset and hit Resident #6 in the face. She stated there had been no previous incidents between them. She stated both residents were assessed with no injuries and placed on 1:1 monitoring until psych services consult. She stated the incident was considered abuse from Resident #7 hitting Resident #6. <BR/>Interview on 05/01/25 at 2:16 PM, Corporate Compliance RN revealed she was made aware of the incident between Resident #6 and Resident #7. She stated she was informed Resident #7 slapped Resident #6 on the face. She stated she was unsure what started the argument. She stated the incident was considered abuse from Resident #7 to Resident #6. She stated Resident #7 was placed 1:1 supervision, a psych services consult was completed, medications were adjusted, and Resident #7 was moved to another hall. Resident #6 had no injures to him and also received a psych service consult. <BR/>Interview on 05/01/25 at 2:36 PM, the Administrator revealed Speech and Language Therapist observed Resident #6 and Resident #7 talking and then observed Resident #7 slapped Resident #6 on the face. He stated the Speech and Language Therapist intervene and separated both residents. The Administrator stated the police was called, skin assessment, trauma and pain assessment completed on both residents with no concerns. He stated families were notified of the incidents. The Administrator stated Resident #7 was placed on 1:1 monitoring, and then Resident #7 requested to go home after the incident. He stated two weeks later Resident #7 returned to the facility and he got a new room in a different hall. The Administrator stated both residents used to get along and joke with each other, he stated he was not sure what happened between them. The Administrator stated a resident-to-resident altercation was considered abuse, and every resident had the right to be free from abuse and neglect. <BR/>Record review of facility Abuse/Neglect policy, revised 09/09/24, reflected the following:<BR/>The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. Resident to Resident - The above policy will apply to potential resident-to-resident abuse.<BR/>Prior to the HHSC investigation, the facility took the following actions to correct the noncompliance:<BR/>Record review Resident #6 progress notes dated 03/11/25 14:58 [2:58 PM] new order for busPirone HCL Oral tablet 15 mg (Buspirone HCl) Give 1 tablet by mouth every 12 hours for anxiety.<BR/>Record review of facility 15 Minute Monitoring dated 3/11/15, reflected Resident #7 was being monitored every 15 minutes starting at 10:15AM and ended at 11:45 AM. <BR/>Record review Resident #7 progress notes dated 03/11/25 15:24 [3:24 PM] Psych NP [Resident #7] telehealth with the resident. New order obtained for HydroXizne HLC tablet 25 MG give 1 tablet by mouth every 8 hours as needed for anxiety x 14 days and to monitor behaviors q shift.<BR/>Record review Resident #7 progress notes dated 03/11/25 15:55 [3:55 PM] reflected, [Resident #7] the Psych NP discontinued 1:1 resident stable with no behavior issues exhibited at the moment. <BR/>Record review of Resident #6 and Resident #7 Trauma Informed PRN Assessment, Skin Assessment and Pain Assessment completed on 03/11/25 with no concerns. <BR/>Record review of Safe surveys were completed with 10 residents with no issues noted.<BR/>Record review of facility In Service Training dated 03/11/25 and 3/13/25, provided by Administrator reflected staff were In Serviced on Abuse and Neglect, Resident Rights, Safe environment and De-escalation methods for residents with behaviors. <BR/>Record review of facility In Service Training dated 3/14/25, provided by Corporate Compliance RN reflected staff were In Serviced on Abuse and Neglect, Resident Rights, Notification of Changes.<BR/>Interviews on 04/30/25 from 1:21 PM through 05/01/25 to 3:45 PM with ADON Y, ADON U, BOM, FM, CNA B, LVN C, CNA D, CNA F, CNA H, CNA E, Van Driver, CNA I, CNA F, LVN G, LVN K, LVN L, CNA V, LVN X revealed the facility staff were able to verify education was provided to them. The nursing staff stated they were educated on different types of abuse/neglect, resident rights, notification of changes and de-escalation methods. Staff stated they monitor behaviors. Staff provided the types of abuse were physical, mental, financial, and verbal. Staff stated the three signs of abuse occur when the resident avoids eye contact, bruises, and the resident withdraws from care. Staff revealed they would report these and other signs to the Abuse Coordinator, the Administrator, immediately if they witness or observed any of these signs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from abuse for 3 of 6 residents (Resident #4, Resident #6, and Resident #7) reviewed for abuse.<BR/>1. The facility failed to ensure Resident #4 was free from emotional and mental abuse. Video footage identified CNA A antagonizing Resident #4 when she went to check on him on 02/18/25 . <BR/>The noncompliance was identified as past noncompliance (PNC). The noncompliance began on 02/18/25 and ended on 02/19/25. The facility had corrected the noncompliance before the investigation began.<BR/>2. The facility failed to ensure Resident #6, and Resident #7 were free from abuse on 03/11/25 when Resident #6 verbally abused Resident #7 which cause Resident #7 to physically abuse Resident #6 by hitting him on the face. <BR/>The noncompliance was identified as past noncompliance (PNC). The noncompliance began on 03/11/25 and ended on 03/14/25. The facility had corrected the noncompliance before the investigation began.<BR/>These failures could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and psychological harm.<BR/>Findings included:<BR/>1. Record review of Resident #4's Face sheet dated 05/01/25, revealed the resident was a [AGE] year-old male with an admission date of 04/15/24 and readmitted on [DATE]. <BR/>Record review of Resident #4's quarterly MDS, dated [DATE], reflected his diagnoses included anxiety disorder, vascular dementia, and mild cognitive impairment. Resident #4's BIMS score was 04 which indicated his cognition was severely impaired. The MDS Section E - Behaviors reflected Resident #4 did not exhibit any physical or verbal behaviors towards others. The MDS Section GG - Functional Abilities also reflected Resident #4 was dependent of staff to assist with ADLs. <BR/>Record review of Resident #4's Care Plan revised date 03/11/25, reflected Focus: The resident has a behavior problem r/t hx of stroke, resident will become difficult to manage. Resident yells out loudly and will use cursive language. Resident is very adament toward care, sports, etc and will yell out at staff and curse. Goal: The resident will have fewer episode by review date. Interventions: Anticipate and meet the resident's needs. Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by. Redirection techniques will include offering alternatives to the current activity. <BR/>Record review of the Provider Investigation Report dated 02/25/25 reflected, Resident responsible party had address to [Administrator] a concern of a staff member being rough with the resident when trying to readjust on the bed. When [Responsible party name], the resident's responsible party, entered [Administrator] office and informed [Administrator] of an incident that occurred the previous night, [Administrator] contacted the CNA [CNA A] to discuss the matter. [Administrator] informed her about the responsible party reported aggressive behavior toward the resident [Resident #4] and confirmed that she had indeed acted aggressively toward [Resident #4] due to [Resident #4] cussing at him and she was trying to correct him. [Administrator] informed her that she would be suspended until further notice. Safe surveys conducted no noted concern. Skin assessment completed and no noticed concerns, pain assessment no noted concerns, Trauma assessment no concerns noted. The Provider Investigation Report also reflected that the result of the investigation was inconclusive, but CNA A was terminated. <BR/>Record review of CNA A's Statement dated 02/29/25, reflected Went to resident's room cause he was hanging off the bed and yelling. [CNA A] told the resident to put his legs back in the bed before he ended up on the floor. That's when the resident call me a bitch and to leave him alone. [CNA A] told him not till he in bed right that if keeps hanging out the bed like that he was going to be on the floor and the floor hursts and wins every time. He then proceeded to call me a bitch again. [CNA A] told him to don't be disrespectful to me cause [CNA A] wouldn't do him like that and that I'm someone sister daughter and mother and that he wouldn't like it if [CNA A] called the women in his family that name. [CNA A] also asked him what was wrong with him.<BR/>Observation of Video Footage time stamped 02/18/2025 05:44:24 CST [5:44 AM] revealed: Resident #4 sitting at the edge of the bed. CNA A (who was a tall, heavy-set woman) entered Resident #4's room stating, What are you doing [Resident #4's name]. Resident #4 states What are you talking about bitch. CNA A stated what. Resident #4 stated What are you talking. CNA A standing in front of Resident #4. CNA A then proceed to tell Resident #4 twice to put those legs back in the bed. Resident #4 asked CNA A Why?''. CNA A tells Resident #4 you can't walk [you] will end up on the floor. Resident #4 tells her No I won't. CNA A responded, Okay bet, but I am going to put your legs back on the bed. Resident #4 asked why again. CNA A responded, I don't have to explain why. Resident #4 asked CNA A why are [you] going too and CNA A stated, because I am going too. Resident #4 stated you not going too. CNA A observed leaning forward and grabbed the control for the bed. Resident #4 stated Get your fucking hands of me bitch, I will fuck you up. CNA A asked resident What did [you] say? and Resident #4 stated, I will fuck you up, get your fucking hands off of me. CNA A observed to lean forward put her right hand on Resident #4's right knee. CNA A then stated My hand is on you. What are [you] going to do? Nothing, and [you] better quit calling me out of my name because [you] wouldn't like if [I] called your momma, sister, or anybody in your family out of their name, don't be disrespectful to [me] because I am not being disrespectful to [you], [you] understand. Resident #4 agreed with CNA A and CNA A removed her hand from Resident #4's knee. CNA A states I don't know where you get that being disrespectful from, that [ain't] going to get you nothing , that [ain't] going to get you no help, that is going to get you talk ed about, don't be disrespectful, and you wait until someone comes in here to help you, you got me? CNA A proceed to adjust Resident #4's legs on the bed. Resident #4 stated I hear that CNA A states Alright then, I am not about to play with you, cause you end up on the floor, you end up on the floor and the floor hurts and it wins every time. Resident #4 stated yeah right. CNA A states Yeah right, you got a real smart mouth, what is wrong with you, what is your problem tonight. Resident state I got a problem with you. CNA response No, I [ain't] your problem, Resident stated oh yeah. CNA A stated, I just came in here to help you. CNA A proceeded to walk out the room and stated, you better act like you got some sense. Video was about 2 minutes long. CNA A hand was on Resident #4's knee for about 32 second.<BR/>Interview on 04/30/25 at 11:14 AM, Resident #4 revealed he was doing well and feeling safe at the facility. Resident #4 was not a good historian; resident could not recall incident with CNA A. <BR/>Interview on 04/30/25 at 12:46 PM, Resident #4 Family Member revealed she reviewed the video footage a day after the incident and notified the Administrator. She stated the incident happened on 02/18/25, Resident #4 was sitting on his bed and the staff was observed entering the room. She stated on the video footage it was observed Resident #4 being disrespectful toward the staff; however, the staff was rude and antagonizing the situation. She stated on the video it was observed Resident #4 saying keep your hands off of me and then staff proceed to put her hand on his knee. Family Member stated she agreed with the staff redirecting and telling Resident #4 to stop cursing at her; however, the staff putting her hand on him was what concerned her. She stated the staff was antagonizing the situation by putting her hand on Resident #4. Family Member stated after the Administrator was notified, the facility investigated the incident and terminated the staff. <BR/>Interview by phone on 05/01/25 at 9:27 AM, CNA A revealed she was doing her last round, when she heard Resident #4 screaming. She stated she entered the room and observed Resident #4 was hanging on the side of the bed. She stated she asked Resident #4 what he was doing, and Resident #4 started to curse at her and got mad because she told him to get back in bed. CNA A stated Resident #4 was calling her a bitch and being disrespectful to her. She stated she told Resident #4 to stop, to not called her like that because he would not like for someone to call his mom, sister or daughter that. She stated Resident #4 stated he would not like that. She stated she only touched Resident #4 when repositioning him back to bed. CNA A stated she was not supposed to correct Resident #4. She stated she was wrong for telling him to stop being disrespectful because they were told residents were always right. CNA A stated she never touched the resident or disrespected the resident. CNA A stated she was suspended and then let go. <BR/>Interview on 05/01/25 at 2:16 PM, Corporate Compliance RN revealed she reviewed the video footage regarding CNA A and Resident #4. She stated CNA A should lose her license. She stated CNA A was verbally abusive towards Resident #4, she stated when CNA A put her hand on Resident #4' she was antagonizing the situation. She stated CNA A should had stepped away. Regional Compliance stated Resident #4 had no adverse effects from the incident. She stated CNA A was terminated. <BR/>Interview on 05/01/25 at 2:36 PM, the Administrator revealed Resident #4 family informed him about the incident and he immediately suspended CNA A. He stated skin assessment was completed on Resident #4 with no injuries, safe surveys and quality of life checks were completed with no concerns. The Administrator stated after reviewing the video footage it was determined CNA A was considered being verbally abusive and was terminated for abuse. He stated CNA A admitted to what she did wrong. He stated his expectations were for his staff to respect residents, care for them and to report any abuse and neglect allegations to him to protect the residents. <BR/>Record Review of CNA A's personnel file, reflected CNA A was suspended and terminated on 02/19/25.<BR/>Record review of facility Abuse/Neglect policy, revised 09/09/24, reflected the following: <BR/>The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility.<BR/>Prior to the HHSC investigation, the facility took the following actions to correct the noncompliance:<BR/>Record review of Resident #4's Skin assessment, Pain assessment and Trauma Assessment completed on 02/19/25, no concerns noted.<BR/>Record review of Safe surveys were completed on 02/19/25 with five residents with no issues noted.<BR/>Record review of facility In Service Training dated 02/19/25, provided by Administrator and Corporate Compliance RN reflected staff were In Serviced on Abuse and Neglect Policy to include - Arguing with, antagonizing, and touching a resident against their will is considered Abuse. If [you] see a staff member or resident engaging in this activity, the Administrator must be notified immediately. The Administrator is the abuse coordinator. If [you] can't get a hold of the administrator, notify the DON or ADON immediately. Staff should not continue to work their shift, they must be suspended immediately, Resident Rights <BR/>Record review of facility In Service Training dated 02/19/25, provided by Corporate Compliance RN reflected staff were In Serviced on Abuse and Neglect, Resident Rights.<BR/>Interviews on 04/30/25 from 1:21 PM through 05/01/25 to 3:45 PM with ADON Y, ADON U, BOM, FM, CNA B, LVN C, CNA D, CNA F, CNA H, CNA E, Van Driver, CNA I, CNA F, LVN G, LVN K, LVN L, CNA V, LVN X revealed the facility staff were able to verify education was provided to them. The nursing staff stated they were educated on different types of abuse/neglect and resident rights. Staff provided the types of abuse were physical, mental, financial, and verbal. Staff stated the three signs of abuse occur when the resident avoids eye contact, bruises, and the resident withdraws from care. Staff stated they would intervene if witness any type of abuse from a staff. Staff revealed they would report these and other signs to the Abuse Coordinator, the Administrator, immediately if they witness or observed any of these signs.<BR/>2. Record review of Resident #6's Face sheet dated 05/01/25, revealed the resident was a [AGE] year-old male with an admission date of 04/28/21 and readmitted on [DATE]. <BR/>Record review of Resident #6's quarterly MDS, dated [DATE], reflected his diagnoses included bipolar disorder, dementia, and cognitive communication deficit. Resident #6's BIMS score was 12 which indicated his cognition was moderately impaired. The MDS Section E - Behaviors reflected Resident #6 did not exhibit any physical or verbal behaviors towards others. The MDS Section GG - Functional Abilities also reflected Resident #6 needed substantial/maximal assistance with ADLs.<BR/>Record review of Resident #6's care plan, revised 03/11/25, reflected Focus: The resident has a history of trauma that may have a negative impact. The trauma is r/t: Resident with hx of physical altercation with another resident. Goal: Maintain resident's safety and integrity post trauma episode, using appropriate interventions. Interventions: Perform the following de escalation techniques as required: redirection, and deep breathing. Psychiatric services adjusted medication.<BR/>Record review of Resident #7's face sheet dated 05/01/25, revealed the resident was a [AGE] year-old male with an admission date of 12/24/21 and readmitted on [DATE].<BR/>Record review of Resident #7's admission MDS, dated [DATE], reflected his diagnoses included anxiety disorder, major depressive disorder, schizoaffective disorder, restlessness and agitation and cognitive communication deficit. Resident #6's BIMS score was 13 which indicated his cognition was cognitively intact. The MDS Section E - Behaviors reflected Resident #7 did not exhibit any physical or verbal behaviors towards others. The MDS Section GG - Functional Abilities also reflected Resident #7 was independent for ADLs.<BR/>Record review of Resident #7's care plan, revised 04/14/25, reflected Focus: The resident has potential to demonstrate physical behaviors related to paranoid schizophrenia, schizoaffective disorder as evidence by: Physical aggression demonstration due to being provoke when cussed at. Goal: The resident will seek out staff/caregiver when agitation<BR/>occurs through the review date. Interventions: If the resident has physical behaviors toward another resident, immediately intervene to protect the residents involved and call for assistance. If intervening would be unsafe, call out for staff assistance immediately.<BR/>Record review of the Provider Investigation Report dated 03/18/25 reflected, [Speech and Language Therapist] witness [Resident #7] hit [Resident #6] due to an altercation they were having an immediately separate them both. During investigation, Resident #7 reported that Resident #6 was using inappropriate language to him and repeatedly told him to stop. When Resident #6 continued, Resident #7 became frustrated and end up hitting him. Upon witnessing the incident, [Speech Therapy] quickly intervene to separate the two residents and called for assistance. Both residents were promptly separated, and a 1:1 supervision was implemented until a psychiatric evaluation could be performed.<BR/>Record review of Witness Statement from Speech and Language Therapist dated 03/11/25 reflected, My name is [Name]. [Speech and Language Therapist ] am an employee at the [Facility Name]. [Speech and Language Therapist] am the speech language pathologist. At approximately 10:15 a.m., [Speech and Language Therapist] witnessed two residents [Resident #6 and Resident #7] in a physical altercation in the dining room. [Speech and Language Therapist] heard [Resident #7] say to [Resident #6] call me a bitch one more time. [Resident #6] responded and then [Resident #7] struck [Resident #6] about two times. Immediately, [Speech and Language Therapist] intervened to ensure both men were safe. [Resident #7] left the dining room. Once [Resident #7] left the dining room, [Speech and Language Therapist] asked [Resident #6] if he was okay and if he could tell me what happened. [Resident #6] replied, he's just mad because [Speech and Language Therapist] wouldn't give him a cigarette. Once both individuals were safe, [Speech and Language Therapist] immediately told [Administrator]. <BR/>Interview on 04/30/25 at 10:45 AM, Resident #6 stated he was doing well. Resident #6 stated he had an incident with Resident #7. Resident #6 stated Resident #7 got frustrated with him, and Resident #7 kept telling him to not say anything to him. Resident #6 stated he told Resident #7 that he was coming in and needed him to get out of the way, he stated Resident #7 got more frustrated and hit him on the side of the face. Resident #6 stated the police was called but he did not pressed charges. Resident #6 stated he was only hit once on the side of his face. Resident #6 stated he was not hurt. Resident #6 stated he never called Resident #7 any names. <BR/>Interview on 04/30/25 at 12:26 PM, Resident #7 stated he was doing well. Resident #7 stated he got into an altercation with Resident #6. Resident #7 stated for a week Resident #6 was messing with him and calling him out of his name. Resident #7 stated he never told anyone about it. Resident #7 stated on the day of the altercation Resident #6 called him a bitch and he asked Resident #6 to stop but he continued to call him a bitch. Resident #7 stated he got mad, and he hit him on the face once. Resident #7 stated he was tired of Resident #6 calling him a bitch. Resident #7 stated after the altercation, he keeps his distance from Resident #6. <BR/>Interview on 05/01/25 at 9:49 AM, the Administrator revealed Speech and Language Therapist was out on leave. <BR/>Interview on 05/01/25 at 1:38P PM, ADON Y stated Resident #6 and Resident #7 had an altercation in the dining room on 3/11/25. She stated it was a witnessed altercation by Speech Therapy. She stated she was not sure what started the altercation, but Resident #7 got upset and hit Resident #6 in the face. She stated there had been no previous incidents between them. She stated both residents were assessed with no injuries and placed on 1:1 monitoring until psych services consult. She stated the incident was considered abuse from Resident #7 hitting Resident #6. <BR/>Interview on 05/01/25 at 2:16 PM, Corporate Compliance RN revealed she was made aware of the incident between Resident #6 and Resident #7. She stated she was informed Resident #7 slapped Resident #6 on the face. She stated she was unsure what started the argument. She stated the incident was considered abuse from Resident #7 to Resident #6. She stated Resident #7 was placed 1:1 supervision, a psych services consult was completed, medications were adjusted, and Resident #7 was moved to another hall. Resident #6 had no injures to him and also received a psych service consult. <BR/>Interview on 05/01/25 at 2:36 PM, the Administrator revealed Speech and Language Therapist observed Resident #6 and Resident #7 talking and then observed Resident #7 slapped Resident #6 on the face. He stated the Speech and Language Therapist intervene and separated both residents. The Administrator stated the police was called, skin assessment, trauma and pain assessment completed on both residents with no concerns. He stated families were notified of the incidents. The Administrator stated Resident #7 was placed on 1:1 monitoring, and then Resident #7 requested to go home after the incident. He stated two weeks later Resident #7 returned to the facility and he got a new room in a different hall. The Administrator stated both residents used to get along and joke with each other, he stated he was not sure what happened between them. The Administrator stated a resident-to-resident altercation was considered abuse, and every resident had the right to be free from abuse and neglect. <BR/>Record review of facility Abuse/Neglect policy, revised 09/09/24, reflected the following:<BR/>The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. Resident to Resident - The above policy will apply to potential resident-to-resident abuse.<BR/>Prior to the HHSC investigation, the facility took the following actions to correct the noncompliance:<BR/>Record review Resident #6 progress notes dated 03/11/25 14:58 [2:58 PM] new order for busPirone HCL Oral tablet 15 mg (Buspirone HCl) Give 1 tablet by mouth every 12 hours for anxiety.<BR/>Record review of facility 15 Minute Monitoring dated 3/11/15, reflected Resident #7 was being monitored every 15 minutes starting at 10:15AM and ended at 11:45 AM. <BR/>Record review Resident #7 progress notes dated 03/11/25 15:24 [3:24 PM] Psych NP [Resident #7] telehealth with the resident. New order obtained for HydroXizne HLC tablet 25 MG give 1 tablet by mouth every 8 hours as needed for anxiety x 14 days and to monitor behaviors q shift.<BR/>Record review Resident #7 progress notes dated 03/11/25 15:55 [3:55 PM] reflected, [Resident #7] the Psych NP discontinued 1:1 resident stable with no behavior issues exhibited at the moment. <BR/>Record review of Resident #6 and Resident #7 Trauma Informed PRN Assessment, Skin Assessment and Pain Assessment completed on 03/11/25 with no concerns. <BR/>Record review of Safe surveys were completed with 10 residents with no issues noted.<BR/>Record review of facility In Service Training dated 03/11/25 and 3/13/25, provided by Administrator reflected staff were In Serviced on Abuse and Neglect, Resident Rights, Safe environment and De-escalation methods for residents with behaviors. <BR/>Record review of facility In Service Training dated 3/14/25, provided by Corporate Compliance RN reflected staff were In Serviced on Abuse and Neglect, Resident Rights, Notification of Changes.<BR/>Interviews on 04/30/25 from 1:21 PM through 05/01/25 to 3:45 PM with ADON Y, ADON U, BOM, FM, CNA B, LVN C, CNA D, CNA F, CNA H, CNA E, Van Driver, CNA I, CNA F, LVN G, LVN K, LVN L, CNA V, LVN X revealed the facility staff were able to verify education was provided to them. The nursing staff stated they were educated on different types of abuse/neglect, resident rights, notification of changes and de-escalation methods. Staff stated they monitor behaviors. Staff provided the types of abuse were physical, mental, financial, and verbal. Staff stated the three signs of abuse occur when the resident avoids eye contact, bruises, and the resident withdraws from care. Staff revealed they would report these and other signs to the Abuse Coordinator, the Administrator, immediately if they witness or observed any of these signs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that all alleged violations involving neglect were reported immediately, but not later than two hours after the allegation was made, if the events that caused the allegation involved neglect, to the State Survey Agency in accordance with State law through established procedures for one (Resident #1) of five residents reviewed for abuse.<BR/>The facility failed to immediately report an allegation of potential neglect to the abuse coordinator on 12/15/22 after Resident #1 sustained an unwitnessed fall with major injury. As a result, the incident was not reported to the State Survey Agency within the required timeframe.<BR/>This failure could place residents at risk for abuse and neglect. <BR/>Findings include:<BR/>Review of the facility's Abuse, Neglect, Misappropriation, Exploitation Policy, dated 01/2019, reflected, .Serious Bodily Injury: An injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; requiring medical intervention such as surgery, hospitalization, or physical rehabilitation; or an injury resulting from criminal sexual abuse . and .Alleged violations/violations will be reported to the Administrator, designee immediately . and Immediately reporting all alleged violations to the Administrator, designee, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframe .<BR/>Review of Resident #1's Face Sheet, dated 01/14/23, reflected she was a [AGE] year-old female, admitted to the facility on [DATE] with a readmission date of 12/15/22, with diagnoses including age-related cognitive decline, unsteadiness on feet, and muscle wasting and atrophy.<BR/>Review of Resident #1's MDS Assessment, dated 11/04/22, reflected she had severe cognitive impairment. The MDS Assessment reflected she had a history of falls, including a fall with injury.<BR/>Review of Resident #1's Care Plan, dated 08/03/21 with a revision date of 10/11/22, reflected Resident #1 had a history of falls and injury from falls due to poor balance, unsteady gait, and cognitive deficits.<BR/>Review of Resident #1's Progress Notes, dated 12/15/22 and written by LVN A (LVN/Charge Nurse), reflected, .CNA called this nurse into resident room. Resident noted laying on the floor on her back beside her bed. Resident noted with blood pooling underneath her head. Resident alert and talking, confused at baseline. First aid provided. Vital signs taken. 911 called. MD on call notified. Responsible Party notified. Paramedics arrived. Patient taken to [hospital] .<BR/>Interview with CNA B on 01/14/23 at 7:05PM revealed she was one of the individuals who responded to Resident #1's fall on 12/15/22. She stated she was at the Nurse's Station when a loud noise was heard coming from Resident #1's room. She and LVN A immediately went to Resident #1's room and saw Resident #1 lying on the floor next to her bed. CNA B stated she noted a large pool of blood coming from a gash in Resident #1's head. CNA B stated the gash on Resident #1's head was approximately the length of a finger. Resident #1's eye was also swollen. Resident #1 stated she was trying to get out of bed and fell to the floor. Resident #1 denied being in pain and said, this is nothing. Facility staff immediately called 911 for assistance; staff stayed with Resident #1 and applied pressure to her head until EMS arrived and transported her to the hospital. CNA B stated at the time of the incident, Resident #1's bed was in the lowest position, as required due to her history of falls.<BR/>During an interview with the Administrator on 01/14/23 at 7:40PM, she stated the incident occurred when the previous DON oversaw nursing care. She stated it would have been the previous DON's responsibility, as the head of nursing, to report this incident to her. She stated the previous DON did not report any injuries to Resident #1 as a result of her fall. Per the Administrator, the previous DON just said that Resident #1 was weak and had fallen, so she was sent out to the hospital for further evaluation and treatment. The Administrator said she had no idea Resident #1 had hit her head or was bleeding at the time of her fall. She stated occurrences such as this would typically be reported to HHSC and investigated by the facility to rule out abuse/neglect. The Administrator was able to verbalize the facility's policies and procedures related to abuse/neglect, including the various types of abuse/neglect, prevention methods, and response protocols.<BR/>Attempted interviews with LVN A on 01/14/23 at 8:30PM and 01/16/23 at 10:13AM were unsuccessful.<BR/>Attempted interviews with the previous DON on 01/14/23 at 8:56PM and 01/16/23 at 10:16AM were unsuccessful.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident on one of three medication carts (300) and 3 of 3 residents (Residents #7,#147, and #178) reviewed for pharmacy services.<BR/>1. The facility failed to ensure the 300 Hall nurses' medication cart contained accurate narcotic logs for Resident #7, #147 and #178 on 02/12/25. <BR/>2. The facility failed to ensure expired medications , 1 bottles of atropine 0.1% with expiration dates of August 2024 was removed and destroyed form 300 hall nurses cart on 02/12/25. <BR/>These failures could place residents at risk for medication errors, drug diversion, and ineffective drug therapy.<BR/>Findings included: <BR/>1. Record review of Resident# 7's Quarterly MDS Assessment, dated 12/10/24, reflected the resident was [AGE] year-old female readmitted to the facility on [DATE] with original admission on [DATE], with diagnoses that included anxiety (common mental health condition characterized by excessive worry, fear, and nervousness that can interfere with daily life). The resident had mild impaired cognition with a BIMS score of 11. <BR/>Record review of Resident #7's physician's orders dated 11/15/24 reflected an order for the resident to receive Lorazepam Oral Tablet 1 MG. Give 1/2 tablet to 2 tablets by mouth every 2 hours as needed related to anxiety disorder. <BR/>Record review of Resident # 47's Quarterly MDS assessment, dated 01/01/25, reflected the resident was [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included chronic pain syndrome (a condition characterized by persistent pain that lasts for at least 3-6 months and significantly impacts a person's life). The resident had intact cognition with a BIMS score of 15. <BR/>Record review of Resident #47's physician orders dated 12/12/24 reflected an order for the resident to receive Hydrocodone-Acetaminophen oral tablet 10-325 mg. Give 1 tablet by mouth every 8 hours, as needed for pain. <BR/>Record review of Resident# 178's entry MDS assessment, dated 02/07/25, reflected the resident was [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included pain. The resident BIMS score not completed Resident #178 was newly admitted . <BR/>Record review of Resident #178's physician orders dated 02/08/25 reflected an order for the resident to receive Hydrocodone-Acetaminophen oral tablet 10-325 mg. Give 2 tablet by mouth every 4 hours, as needed for pain.<BR/>Observation and record review on 02/12/25 at 2:12 PM of 300 Hall nurses' medication cart and the Narcotic Administration Record, with RN C, revealed Resident #7's Narcotic Administration Record for lorazepam 1 mg reflected a total of 13 pills remaining, while the blister pack count was 12 pills. It was last administered on 01/20/25 at 9:30 PM. It also revealed Resident#47's Narcotic Administration record Hydrocodone-Acetaminophen oral tablet 10-325 mg reflected a total of 7 pills remaining, while the blister pack count was 6 pills. Last administered on 02/10/25 at 07:41 AM. It also revealed Resident#178's Narcotic Administration record Hydrocodone-Acetaminophen oral tablet 10-325 mg reflected a total of 38 pills remaining, while the blister pack count was 36 pills. Last administered on 02/11/25 at 8:00 AM.RN C was observed to remove lorazepam 1mg &frac12; tablet in a cup covered with another cup that was not labelled in her pocket. <BR/>2. Observation on 02/12/25 at 2:45 PM of the 300 Hall medication cart with the RN C revealed 1 bottle of atropine 1 % with expiration date of 8/8/24 . <BR/>Interview with RN C on 02/12/25 at 2:45 PM revealed she popped Lorazepam 1mg &frac12; tablet put in a cup and she had not administered to Resident #7 before lunch because she had realized she had popped, and it was not meant for her. RN C stated she forgot to notify the other nurse for destruction. She took residents to dining for lunch and she forgot. She stated when she saw this surveyor checking the carts that was the time she removed from the cart and put it in her pocket. She stated she had administered Hydrocodone-Acetaminophen oral tablet 10-325 mg I (one) tablet, to Resident #47 as needed every 8 hours, and she had not signed off on the narcotic administration record log. She had also administered Hydrocodone-Acetaminophen oral tablet 10-325 mg 2 tablets to Resident #178 as needed every 8 hours, and she had not signed off on the narcotic administration record log. She stated she knew she was supposed to sign-out on the narcotic count sheet after administration and on the Medication Administration Record, but she did not. RN C stated the failure to log off could lead to overdose since the person that came after her would not be able to tell when the narcotic was administered. She stated failure to label the cup and keeping the medication in a cup could lead to missing a dose and administering to wrong resident leading to medication error. RN C also stated she was responsible of checking her cart every shift for the expired medications, but she forgot to check. She stated the risk of having expired medication in her cart was adverse effect if administered. She stated she had completed an in-service on Medication administration. <BR/>Interview on 02/13/25 at 9:44 AM, the ADON B stated her expectation was for staff administering narcotic medications to document the medications when they were given to the resident on the medication administration record and to sign on the narcotic log. She stated she also expected RN C to assess the Resident #7 before she popped Lorazepam 1mg &frac12; tablet and if she had made a mistake to call her or any other nurse they destroy and not to put in cup in her pocket. She stated it was her responsibility to audit the carts weekly and if there was an issue she audited daily. She stated she had last checked the cart on 02/4/25. The ADON stated failure to document after administration and destroying after refusal or popping by mistake could lead to drug diversion, missing of a dose, overdose and residents not getting therapeutic effects. She stated facility had done trainings on medication administration.<BR/>Interview on 02/13/25 at 1:34 PM, the DON revealed her expectation was for staff administering narcotic medications to document the medications when they were given to the resident on the medication administration record and to sign on the narcotic log. She stated nurses should not be pulling medications if the resident had not asked for it. She stated she asked RN C why she had not destroyed the medication that she had accidentally popped, and she did not give her a varied answer. She stated she expected RN C to label the cup, repull the right medication and then destroy the other one with a witness but not keeping in her pocket. DON stated failure to document could lead to overdose and effect on resident management. She stated ADONs were responsible for auditing the medication carts. She stated the facility had done training on medication administration and trainings dated 10/4/24 and 01/08/24 and RN C was not in attendance.<BR/>Record review of facility policy entitled Medication Administration procedures , dated 10/25/17, reflected the following: <BR/> 5. After the resident has been identified, administer the medication and immediately chart doses administered on the medication administration record. It is recommended that medication be charted immediately after administration, but if facility policy permits, medication may be charted immediately before administration.<BR/>17.If a controlled medication removed from its packaging and is not to be administered (resident refusal or contamination) the dose needs to be wasted to where the drug is unable to be used and /or destroyed and disposed of. If controlled medication is wasted, it must be documented on the controlled accountability sheet for the medication and witnessed by a nurse. Both staff members must sign on the accountability sheet verifying the drug was wasted.<BR/>Record review of the facility's Storage of Medications policy, dated 2003, reflected the following:<BR/>Did not address expired medications removal from the carts .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure it was free of a medication error rate of five percent (5%) or greater for one (MA D) of two staff observed for medication pass. There were two errors made with 28 opportunities for error which gave a 7% medication error rate.<BR/>MA D failed to administer Resident #61's Clonazepam 0.5 MG 1 PO BID and her Lyrica 25 MG 1 PO QD. <BR/>This failure could place residents at risk for not receiving the therapeutic effects of their medications, an exacerbation in their pain and anxiety and a decrease in their quality of life.<BR/>Findings included:<BR/>Review of Resident #61's admission MDS assessment, dated 10/18/22 reflected Resident #61 was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of congestive heart failure, hypertension, diabetes melittus, thyroid disorder, anxiety disorder, depression and chronic obstructive pulmonary disease unspecified pain and. She was able to understand and be understood, was oriented to person, time, and place, and was independent in daily decision-making. It also reflected she was on routine and as needed pain medications.<BR/>Review of Resident #61's care plans, dated 10/14/22 reflected Resident #61 had a diagnoses of depression, use/side effects of medications put her at risk of increased episodes. The goal was for her to remain free of symptoms of distress, symptoms of depression, anxiety or sad mood. The first intervention was to administer medications as ordered.<BR/>An observation on 11/02/22 at 8:47 AM, MA D prepared Resident #61's morning medications as follows:<BR/>- Artificial Tears, 1 drop both eyes; <BR/>- Atorvastatin (Treats high cholesterol and triglycerides) 40 MG (Milligram) 1 PO (By mouth) QD (Every Day); <BR/>- Buspirone (Treats Anxiety) 30 MG 1 PO BID (Two times a day); <BR/>- Duloxetine (Treats depression and anxiety) 60 MG 2 PO QD; <BR/>- Iron tab 325 MG 1 PO TID (Three Times a Day); <BR/>- Hydralazine (Treats Hypertension) 50 MG 1 PO TID, held; <BR/>- Magnesium Oxide (Treats Hypomagnessemia) 400 MG 1 PO QD; <BR/>- Miralax (Laxative) 17 GM PO QD; refused by resident; <BR/>- Tolterodine Tar (Treats Overactive Bladder) 1 MG PO BID; <BR/>- Certrizine (Antihistamine)10 MG 1 PO; <BR/>- Pregabalin (Treats Nerve and Muscle pain) 150 MG 1 PO BID; <BR/>- signed out in narc book Oxycodone (Treats Pain) 20 MG 2 PO BID. <BR/>MA D took all medications into Resident #61's room, gave her the portion cup and the resident took them all with water. <BR/>Review of Resident #61's MAR (Medication Administration Record) dated November 2022, for the date of 11/02/22, revealed two other medications MA D did not prepare or administer as follows: <BR/>Clonazepam (Treats Anxiety) 0.5 MG 1 PO BID and Lyrica (Treats Pain) Capsule 25 MG 1 PO. There was a code 7 then the MAs initials. Review of the MAR codes revealed that code 7 meant, Other/See Progress Notes.<BR/>Review of Resident #61's Order Summary Report with an order date range of 10/01/22 -11/30/22 revealed the following orders: Clonazepam tablet 0.5 MG Give one tablet by mouth two times a day for anxiety with the order date of 10/12 22. <BR/>It further revealed an order for: Lyrica Capsule 25 MG (Pregabalin) Give 1 capsule by mouth one time a day for Pain.<BR/>An interview on 11/02/22 at 10:51 AM with MA D, revealed she did not give the clonazepam or Lyrica medications because they were not available. She stated they had been ordered by the charge nurse as they were responsible for ordering. The medication cards have stickers and we give them to the nurse when it is time to reorder the medications. She also said LVN E was checking to see if have any in the E-kit (Emergency Medication Box). MA D said if they do have them in the E-kit she would administer them. MA D also stated she pulled the reorder sticker when there were at least 7 doses of the medication left. <BR/>An interview on11/02/22 at 3:59 PM, ADON C revealed the missing medications had been addressed. She stated the DON was the only one with clearance to order narcotics and she felt she had ordered them this morning but would go check to make sure. She went and asked the DON, came back and said yes, they were ordered that morning. The surveyor asked ADON C if Resident #61 would be getting either of the two medications this evening and she said she did not know. The surveyor asked if the facility had an emergency kit for medications and ADON C said she did not think they had one for narcotics, went and looked, came back and said they do not have an E-kit for narcotics.<BR/>Review on 11/03/22 of Resident #61's MAR for 11/02/22 revealed she still had not received the doses of the two medications because they were not available on 11/02/22 in the AM and had not received the PM dose of the Clonazepam. <BR/>An interview on 11/03/22 at 9:29 AM with ADON C revealed she explained they actually have two Narcotic E-Kits. She also said Resident #61 had received the medications as they came in last night. ADON C also stated a new E-kit for narcotics had been delivered as well. <BR/>An interview on 11/03/22 at 9:37 AM with the DON revealed she worked there since July of 2022. She stated they were doing an in-service with her nurse's and MA's about re-ordering medications and the E-kit. The DON said she did not know why the nurse or MA did not give Resident #61 the missing medications from the emergency kit on 11/02/22. She also stated if they run out of the pain medication it could cause an increase of their pain or anxiety.<BR/>An interview on 11/3/22 at 3:39 PM the Administrator revealed the DON had informed her about Resident #61's missed medications on 11/02/22. When asked how the nursing staff were to know about the emergency kit being available and she said the DON was conducting in-service's. The surveyor informed her about Resident #61's nursing note about her anxiety last night and she had not had 3 days doses of the clonazepam. When asked why the nurse's did not get them from the emergency kit she stated she did not know and wondered why the nurse did not get some for her then as well.<BR/>Review of the facility's policy and procedure General Dose Preparation and Medication Administration revised 01/01/13 revealed the following: Administer medications within the timeframes specified by Facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area for 1 (Resident #42) of 29 residents reviewed for resident call systems.<BR/>The facility failed to ensure Resident #42's call system was in working order, in order for him to request staff assistance. <BR/>This failure could place residents at risk of being unable to obtain assistance when needed.<BR/>Findings included:<BR/>Review of Resident #42's face sheet, dated 11/04/22, reflected he was admitted to the facility on [DATE], with diagnosis of Chronic Obstructive Pulmonary Disease, Dementia in other Diseases, Muscle Wasting and Atrophy, PTSD, Cerebral Infarction (resulting in an additional diagnosis of Attention and Concentration Deficit, Memory Deficit, and Frontal Lobe and Executive Function Deficit), Generalized Muscle Weakness, Difficulty in Walk, Unsteadiness on Feet, Other Lack of Coordination, Unspecified Convulsions, and History of Falling. <BR/>Review of Resident #42's MDS assessment, dated 10/18/2022, reflected he was understood by others, and able to understand others. He had a BIMS of 15, indicating intact cognition, and no psychosis or behaviors. Resident required set up help from one person for transfers, walking, and locomotion, and limited one-person supervision for bed mobility, toilet use, and hygiene. He required limited one-person assistance for dressing and help with part of his bathing activities. He was occasionally incontinent of bowel, and frequently incontinent of urine. He was noted to have had two falls in the period between this assessment, and the assessment prior. <BR/>Review of Resident #42's care plan, dated 10/29/21, reflected he had ADL self-care deficits related to his history of stroke, and required interventions of staff assistance, oversight, encouragement and cueing for various ADL activities, on order to maintain his current level of functioning. <BR/>Review of Resident #42's care plan, dated 12/04/21, reflected Resident #42 had limited physical mobility due to history of stroke, and had a goal of appropriate use of a wheelchair to increase mobility. <BR/>Review of Resident #42's care plan, dated 08/19/22, reflected Resident #42 had actual falls on 08/19/22, 08/28/22, and 09/15/22. <BR/>Review of Resident #42's care plan, dated 08/18/22, reflected the resident had fall risk related to impaired mobility, with a goal to be free of falls through the target date of 01/18/23, with the intervention of being sure the resident's call light was within reach, and encouraging him to use it as needed, and the resident needed prompt response to all requests for assistance. <BR/>Review of incident reports for Resident #42 reflected three falls:<BR/>- On 08/19/22 he had a fall in the bathroom, while attempting to use the toilet. No injuries observed.<BR/>- On 08/28/22 he had a fall in his room (exact location unknown), and was lying on his side, with his head under his wheelchair. Resident stated he had not been sitting in his wheelchair, and had been shaving, and just fell. No injuries observed. <BR/>-On 09/15/22 he fell in the bathroom, after sliding to the floor while holding onto the toilet. His wheelchair was still by his bed. No injuries observed. <BR/>An interview and observation on 11/01/22 at 11:53 AM with Resident #42 revealed his call button had not worked for over a month. He said he had reported it to the front desk person, and no one had done anything about it. He pressed his call button and the light outside the door did not turn on. At this time, his roommate pressed his call light and the light outside turned on. Resident #42 said he did not call for help when he needed it. He said he could get from his bed to his wheelchair, but it was difficult. He said he had fallen off the toilet a couple of times, and he did not think that call light worked either, and he had also reported it, but there was never any follow up. <BR/>An interview and observation on 11/01/22 at 12:02 PM revealed CNA A responded to Resident #42's roommate, Resident #70's, call light . She did a call light check for the bathroom light, and it did work. She was informed at this time, by the surveyor, that Resident #42's call light did not work. <BR/>An interview and observation on 11/02/22 at 12:30 PM with Resident #42 revealed when he pressed his call button, the light did not turn on. He said his only concern was his call light not working because he tended to fall, and he would use it to call for help. <BR/>An interview on 11/02/22 at 12:44 PM with LVN B revealed nursing staff entered maintenance issues, like call lights not working, in the computer, and the Maintenance Director could print a report from it. <BR/>An interview and record review on 11/02/22 at 1:04 PM with the Maintenance Director revealed they used a physical (paper) logbook in the past, but now it was all electronic. He said the staff entered it in the electronic medical record software, and it notified him through an app. He showed the surveyor his phone with the current list of pending tasks, and it did not include the call light for Resident #42. The Maintenance Director said that the hall staff (CNAs) would inform the nursing staff at the nurse's station if there was a maintenance issue, and they would enter it into the computer, where he would have access to it. <BR/>An interview on 11/02/22 at 1:25 PM with CNA A revealed she had gotten busy on 11/01/22 and forgotten to inform anyone about the non-functional call light. She said there was a book located at the nurse's station to report maintenance issues, and the resident had never said anything to her before about the call light not working. <BR/>An interview on 11/03/22 at 12:23 PM with the Maintenance Director, revealed he had worked in the facility for about three weeks. He said he he had not been informed about a call light not working, except he thought the DON had told him earlier that day that one in the 300 hall was not working, but they were not sure which light it was. He said it was important for staff to use the electronic system they had, to inform in him, so he would know immediately what needed to be done, and where. He said on 11/02/22 nobody said anything to him about a call light, and it might have been because he was busy with their Life Safety Code survey. The Maintenance Director explained that the call light checks were scheduled in the same electronic system where staff entered his work orders, so when it was time to test the lights, he was alerted in the app. He said he checked each individual light, and if it worked, it passed. If one did not work, or broke down in between tests, they put in a work order for the repair. He said there were no more paper logs, it was all electronic. If a light did not work, he would see it in his app, and he would check on it that day. He said sometimes he had what he needed to fix it, and sometimes they had to order parts, which could take a week or two. While the resident did not have a light, the staff would provide them a bell to ring, if they needed anything, until he was able to fix the call light. He said the Administrator, or a nurse would give them a bell. He said that sometimes the residents got the buttons sticky, or wet, and they would stick, and not work properly, and he would go check Resident #42's immediately. <BR/>An interview and observation on 11/03/22 at 12:31 PM with Resident #42 revealed his call light still did not work. He pressed the button, and the light in the hall did not come on. He said nobody ever gave him a bell, and if he needed something, he didn't' yell or anything but just waited until someone came, and he said, I even wait if I fall. He said if he had a call bell he could reach, he would use it, and the only time he hollered was to get his roommate's attention when he fell, and his roommate used his call light on his behalf. He said he thought he last fell and waited for staff to find him about three weeks prior to this interview. He said the light had not worked for over a month, and it might have been closer to two months, but he was not sure. <BR/>An interview and observation on 11/03/22 at 12:35 PM revealed the Maintenance Director checking on the call button for Resident #42. He said it did work, but the button was sticking, due substances from the resident's hands over time, as he had explained in the previous interview, and he just needed to replace the button part. He showed the surveyor that the light did come on in the hall . He said he had one of the parts he needed on hand and would fix it immediately.<BR/>An interview on 11/03/22 at 3:39 PM with the Administrator revealed the Maintenance Director had informed her that same day that a call light was sticking. She said he had replaced another call light, but she had not been aware of Resident #42's before today. She said all the CNA had to do was put it into the electronic system, which the staff had been trained to do. She said they all could do it if they had access to the electronic records software, or they could tell her, and she would put it in. <BR/>An interview on 11/03/22 at 4:52 PM revealed the DON had informed the Maintenance Director about a different call light in the same hall as Resident #42, but not his. She said she was not aware of Resident # 42's light until the day of this interview. She said staff was supposed to put a maintenance request in the software, which could be accessed through the electronic record software, or they could tell her, or the Administrator. She said the staff went through training to know how to put in maintenance requests. She said agency staff was instructed to tell her or the Administrator about any maintenance issues, and they would enter it into the system. She said if a resident's call light did not work, they might not get the help they needed. She said they could be having a stroke, or horrible chest pain, and nobody would know to go help them. She said going forward, they might need to educate the residents about who they needed to notify about maintenance issues. <BR/>Review of the printed maintenance work order list of open and in-progress work orders as of 11/02/2022 did not reflect an order to fix the call light for Resident #42 .<BR/>Review of an in-service training record, dated 07/14/22, reflected an in-service for the electronic system used to enter maintenance requests. Direct care and some administrative staff signed the document, but CNA A's name was not reflected in this training. <BR/>Review of a list of current staff reflected CNA A was hired on 04/25/2006.<BR/>Review of the Logbook Documentation provided by the Maintenance Director on 11/02/22 for the electronic system used for maintenance requests reflected the following:<BR/>1. For each department, notify the appropriate person in charge that the call system is being tested.<BR/>2. Check all devices transmitting to, and received from nurse call system, to include pull cords, pendants, and pagers. Repair as necessary.<BR/>3. Check call cords in bathrooms and shower rooms. Ensure call cord length is no more than 6 inches from the floor. Repair as necessary.<BR/>4. Notify the appropriate person in charge that the test has been completed and has been returned to operational status.<BR/>5. Check call light clips.<BR/>6. If system is capable, run report to identify equipment alerts, such as low battery.<BR/>This document included call system checks, including individual rooms, with checkboxes for each room (not for A and B beds) for:<BR/>- 04/16/22 (400 hall) with a pass (no components of test failed). <BR/>- 08/27/22 (300 hall) with 1 fail (one room failed) and a note to replace the call light for that room. <BR/>-09/14/22 (100 hall) with checks of six of eleven rooms on that hall completed and passed. Other rooms were not documented as checked on this document. <BR/>Review of the policy reflected: Nurse Call System. Monthly the nurse call system should be checked for proper function for the following: 1. Each call cord should be exercised to ensure that it activates the light in the corridor and the annunciation panel at the nurse's station. 2. Each cord needs to be visible and reachable by the resident to which it operates for. 3. Each pull cord in each restroom should be tested to verify that it activates the light in the corridor and the annunciation panel at the nurse's station. 4. Any component that does not function should be repaired as soon as practically feasible .

Based on interview, the facility failed to designate a registered nurse to serve as the director of nursing on a full time basis for 53 of 65 days (04/13/24-06/05/24) reviewed for DON coverage.<BR/>The facility failed to designate a RN to serve as DON on a full-time basis since 04/12/24.<BR/>The failure placed residents at risk of not receiving necessary care and services.<BR/>Findings included:<BR/>Interview on 06/05/24 at 3:15 PM with the Administrator revealed the last time the facility had a dedicated DON was on 04/12/24. She stated she had interviewed applicants, but she had not hired anyone yet. Currently the DON responsibilities were being divided up between the ADON, the MDS Coordinator, and the Regional Compliance Nurse. None of the three people were dedicated to the DON position 8 hours a day. The Administrator stated she did not have a policy about DON coverage.<BR/>Interview on 06/05/24 at 3:30 PM with the ADON revealed she and the MDS Coordinator and the Regional Compliance Nurse were covering for the DON. She stated they were also all performing their regular duties as well.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 (Resident #57) of 17 residents reviewed for drug storage. <BR/>LVN A left two medications at the bedside of Resident #57.<BR/>This failure could place residents at risk of taking medications not prescribed for them.<BR/>Findings included:<BR/>Review of Resident #57's undated admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included schizophrenia, emphysema, muscle weakness and heart attack.<BR/>Review of Resident #57's annual MDS, dated [DATE], revealed a BIMS score of 9 indicating she was mildly cognitively impaired. Her Functional Status indicated she required limited assistance with her ADLs. <BR/>Review of Resident #57's care plan, dated 1/03/24, revealed she was at risk of altered breathing status related to her emphysema, with interventions of administering her inhaled medications as prescribed. <BR/>Review of Resident #57's physician orders revealed she was prescribed Advair 250/50, 1 puff twice a day and Spiriva 18 mcg, 1 puff once a day. <BR/>Observation on 01/04/24 at 8:55 AM revealed Resident #57 had two inhalers, Advair and Spiriva, on her bedside table. <BR/>Interview on 01/04/24 at 8:55 AM with Resident #57 revealed the nurse had administered the two inhalers and left them at her bedside. Resident #57 stated staff do that all the time. The Resident stated she knew to only take Advair twice a day and Spiriva once a day. <BR/>Interview on 01/04/24 at 9:00 AM with LVN A revealed she had administered the inhalers to Resident #57 but was called away before she could put the inhalers back on her cart. LVN A stated some medications can be left at the bedside depending on who the patient was and if the doctor said it was ok. LVN A did not know if the physician had said it was ok to leave Resident #57's inhalers at her bedside. LVN A stated the risk of leaving any medication at the bedside was that a confused resident might take them. <BR/>Interview on 01/04/24 at 10:05 AM with ADON A revealed no medications were allowed to be at the bedside of any residents. She stated the facility had no residents that had been evaluated for self-administration of medications. <BR/>Review of the facility's Medication Administration policy, dated 10/25/17, revealed it did not address leaving medications at the bedside other than: <BR/> .8. After the medication administration process is completed, the medication cart must be completely locked, or otherwise secured

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 (Resident #57) of 17 residents reviewed for drug storage. <BR/>LVN A left two medications at the bedside of Resident #57.<BR/>This failure could place residents at risk of taking medications not prescribed for them.<BR/>Findings included:<BR/>Review of Resident #57's undated admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included schizophrenia, emphysema, muscle weakness and heart attack.<BR/>Review of Resident #57's annual MDS, dated [DATE], revealed a BIMS score of 9 indicating she was mildly cognitively impaired. Her Functional Status indicated she required limited assistance with her ADLs. <BR/>Review of Resident #57's care plan, dated 1/03/24, revealed she was at risk of altered breathing status related to her emphysema, with interventions of administering her inhaled medications as prescribed. <BR/>Review of Resident #57's physician orders revealed she was prescribed Advair 250/50, 1 puff twice a day and Spiriva 18 mcg, 1 puff once a day. <BR/>Observation on 01/04/24 at 8:55 AM revealed Resident #57 had two inhalers, Advair and Spiriva, on her bedside table. <BR/>Interview on 01/04/24 at 8:55 AM with Resident #57 revealed the nurse had administered the two inhalers and left them at her bedside. Resident #57 stated staff do that all the time. The Resident stated she knew to only take Advair twice a day and Spiriva once a day. <BR/>Interview on 01/04/24 at 9:00 AM with LVN A revealed she had administered the inhalers to Resident #57 but was called away before she could put the inhalers back on her cart. LVN A stated some medications can be left at the bedside depending on who the patient was and if the doctor said it was ok. LVN A did not know if the physician had said it was ok to leave Resident #57's inhalers at her bedside. LVN A stated the risk of leaving any medication at the bedside was that a confused resident might take them. <BR/>Interview on 01/04/24 at 10:05 AM with ADON A revealed no medications were allowed to be at the bedside of any residents. She stated the facility had no residents that had been evaluated for self-administration of medications. <BR/>Review of the facility's Medication Administration policy, dated 10/25/17, revealed it did not address leaving medications at the bedside other than: <BR/> .8. After the medication administration process is completed, the medication cart must be completely locked, or otherwise secured

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 (Resident #57) of 17 residents reviewed for drug storage. <BR/>LVN A left two medications at the bedside of Resident #57.<BR/>This failure could place residents at risk of taking medications not prescribed for them.<BR/>Findings included:<BR/>Review of Resident #57's undated admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included schizophrenia, emphysema, muscle weakness and heart attack.<BR/>Review of Resident #57's annual MDS, dated [DATE], revealed a BIMS score of 9 indicating she was mildly cognitively impaired. Her Functional Status indicated she required limited assistance with her ADLs. <BR/>Review of Resident #57's care plan, dated 1/03/24, revealed she was at risk of altered breathing status related to her emphysema, with interventions of administering her inhaled medications as prescribed. <BR/>Review of Resident #57's physician orders revealed she was prescribed Advair 250/50, 1 puff twice a day and Spiriva 18 mcg, 1 puff once a day. <BR/>Observation on 01/04/24 at 8:55 AM revealed Resident #57 had two inhalers, Advair and Spiriva, on her bedside table. <BR/>Interview on 01/04/24 at 8:55 AM with Resident #57 revealed the nurse had administered the two inhalers and left them at her bedside. Resident #57 stated staff do that all the time. The Resident stated she knew to only take Advair twice a day and Spiriva once a day. <BR/>Interview on 01/04/24 at 9:00 AM with LVN A revealed she had administered the inhalers to Resident #57 but was called away before she could put the inhalers back on her cart. LVN A stated some medications can be left at the bedside depending on who the patient was and if the doctor said it was ok. LVN A did not know if the physician had said it was ok to leave Resident #57's inhalers at her bedside. LVN A stated the risk of leaving any medication at the bedside was that a confused resident might take them. <BR/>Interview on 01/04/24 at 10:05 AM with ADON A revealed no medications were allowed to be at the bedside of any residents. She stated the facility had no residents that had been evaluated for self-administration of medications. <BR/>Review of the facility's Medication Administration policy, dated 10/25/17, revealed it did not address leaving medications at the bedside other than: <BR/> .8. After the medication administration process is completed, the medication cart must be completely locked, or otherwise secured

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 8 residents (Residents #166) reviewed for comprehensive care plans. <BR/>The ADON failed to ensure Resident #166's care plan was updated to include her use of a Life Vest. <BR/>This failure could place the residents at risk of deterioration and improper care. <BR/>Findings included:<BR/>Review of Resident #166's undated admission Record revealed Resident #166 was [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included heart failure, atrial fibrillation (irregular heartbeat), muscle wasting atrophy (decrease in size and muscle wasting), Type 2 Diabetes Mellitus, hypotension and hypertension (high and low blood pressure), unsteadiness on feet, lack of coordination. <BR/>Review of Resident #166's admission MDS assessment, dated 12/22/23, revealed the resident's BIMS score was blank. Her Functional Status indicated she substantially/ maximum dependent on staff for toileting, shower/bathing and for dressing. The MDS assessment indicated Resident #23 admitted with an indwelling catheter. For eating she required set-up assistance. <BR/>Review of Resident #166's care plan, last review dated 01/03/24, revealed no indication that Resident #166 had been out to the hospital and returned with a Live Vest that must be worn and not removed until doctor evaluation. <BR/>Review of Resident #166's January 2023 physician orders revealed:<BR/>1. Change and recharge battery QD, Remove battery before taking off system to shower or bathe Q shift, Change garment and if desired put lotion on round electrode Q shift, Check electrode placement -all electrodes against skin ends of belt fastened together, Centered in front Q shift, Every shift for Life Vest Care. <BR/>2. 24-hour help line [PHONE NUMBER] every shift for Life Vest Care<BR/>3. Always: Hold response buttons when you feel vibration or hear siren alert, Check display when you hear a [NAME] alert, Every shift for Life Vest Care. <BR/>Observation and interview on 01/03/24 at 1:37 PM revealed Resident #166 sitting at her bedside table with her lunch tray. Resident #166 stated she was ready to lay down. Staff entered the room to assist with the transfer, and Resident #166 stated she was itching under her breast. The staff stated they would be careful not to remove her vest. After her transfer, staff were observed making the resident comfortable and checking underneath her shirt for placement. <BR/>Interview on 01/04/23 at 3:00 PM with CNA D revealed he was new to the facility so he liked to discuss the shower process with residents to make them feel comfortable with him and the process. CNA D stated with Resident #166 she advised him that she was ready to shower and that he had to be careful not to remove her life vest. According to CNA D, he was not aware that Resident #166 wore a life vest, and he was waiting on his nurse to assist him. CNA D stated he used the care plan which gave him a reference to care for residents. CNA D stated the life vest was not on the care plan. He stated the resident recently returned from the hospital, so he was going to wait on the nurse to proceed with the shower. <BR/>Interview on 01/04/23 at 3:05 PM with LVN B revealed Resident #166 recently returned from the hospital with the life vest. According to LVN B, she saw Resident #166 with the vest on and saw orders in the system for the lfe vest. LVN B stated it was the responsible of the ADON or the MDS Coordinator to update the care plan. LVN B stated it was important to have the care plan updated so that staff would have the lastest information to care for the resident. <BR/>Interview on 01/05/23 at 1:57 PM with LVN H revealed Resident #166 has had two recent trips to the hospital and each time she had the vest once she returned to the facility. According to LVN H, the vest was required because the first time she returned from the hospital she had very low blood pressure and was not responding the way she would have liked so she contacted the physican and family and the resident was sent out. LVN H stated it was the responsibility of the ADON and the MDS department to ensure care plans were updated. LVN H stated if this was not done it could place risk to Resident #166 not receiving proper care, she could not have the vest removed. <BR/>Interview on 01/05/24 at 2:15 PM with ADON B revealed she received information on Resident #166 prior to her discharging from the hosptial. According to ADON B, Resident #166 was not wearing the life vest in the hospital so she was not sure why she was sent home with it. ADON B stated she entered what information that was given to her from the discharging nurse at the hospital and perhaps upon discharge additonal orders were added. ADON B further stated she was aware Resident #166 was wearing a life vest based on orders that were entered for her. <BR/>Interview on 01/05/24 at 2:30 PM with ADON A revealed she was aware Resident #166 had a life vest, and that she needed to check to see if she still needed to wear it. After review of Resident #166's clinical records, ADON A stated Resident #166 had a follow-up appointment with her primary care provider of cardiology and needed to wear the life vest until that appointment. ADON A stated resident use of the life vest should be included on her care plan, however it had not been updated to the care plan due to the survey beginning. ADON A stated she was responsible for including the life vest on the care plan. ADON A stated not updating the care plan could place residents at risk of goals and interventions to be dropped and it will not paint the whole picture of the residents. <BR/>Interview on 01/05/24 at 4:30 PM with the Administrator revealed the IDT was responsible for updating each departments goals and interventions. The Administrator stated if it was something clinical that needed to be updated it would be the DON and ADON's responsibilty to update resident care plans. Administrator stated not updating the programs would place residents at risk of not receiving individualized care based on their needs. <BR/>Review of the facility's current, undated Comprehensive Care Planning policy reflected:<BR/>The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the 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 comprehensive assessment. <BR/>The comprehensive care plan will describe the following - <BR/>The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. <BR/>The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented.<BR/>Prepared and/or contributed to by an interdisciplinary team, that includes but is not limited to-- The attending physician, A registered nurse with responsibility for the resident, A nurse aide with responsibility for the resident. <BR/>The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 (Resident #57) of 17 residents reviewed for drug storage. <BR/>LVN A left two medications at the bedside of Resident #57.<BR/>This failure could place residents at risk of taking medications not prescribed for them.<BR/>Findings included:<BR/>Review of Resident #57's undated admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included schizophrenia, emphysema, muscle weakness and heart attack.<BR/>Review of Resident #57's annual MDS, dated [DATE], revealed a BIMS score of 9 indicating she was mildly cognitively impaired. Her Functional Status indicated she required limited assistance with her ADLs. <BR/>Review of Resident #57's care plan, dated 1/03/24, revealed she was at risk of altered breathing status related to her emphysema, with interventions of administering her inhaled medications as prescribed. <BR/>Review of Resident #57's physician orders revealed she was prescribed Advair 250/50, 1 puff twice a day and Spiriva 18 mcg, 1 puff once a day. <BR/>Observation on 01/04/24 at 8:55 AM revealed Resident #57 had two inhalers, Advair and Spiriva, on her bedside table. <BR/>Interview on 01/04/24 at 8:55 AM with Resident #57 revealed the nurse had administered the two inhalers and left them at her bedside. Resident #57 stated staff do that all the time. The Resident stated she knew to only take Advair twice a day and Spiriva once a day. <BR/>Interview on 01/04/24 at 9:00 AM with LVN A revealed she had administered the inhalers to Resident #57 but was called away before she could put the inhalers back on her cart. LVN A stated some medications can be left at the bedside depending on who the patient was and if the doctor said it was ok. LVN A did not know if the physician had said it was ok to leave Resident #57's inhalers at her bedside. LVN A stated the risk of leaving any medication at the bedside was that a confused resident might take them. <BR/>Interview on 01/04/24 at 10:05 AM with ADON A revealed no medications were allowed to be at the bedside of any residents. She stated the facility had no residents that had been evaluated for self-administration of medications. <BR/>Review of the facility's Medication Administration policy, dated 10/25/17, revealed it did not address leaving medications at the bedside other than: <BR/> .8. After the medication administration process is completed, the medication cart must be completely locked, or otherwise secured

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 ice chests observed for infection control. <BR/>1. The facility failed to ensure the ice chests were maintained in a manner to prevent cross-contamination.<BR/>2. The facility failed to ensure staff personal food items were not stored in the facility's medication refrigerator in the facility's medication storage.<BR/>These failures placed residents at risk for the development and spread of infection. <BR/>Findings included:<BR/>Observation on 01/03/24 at 9:00 AM revealed the facility had three halls and a secured unit. The three halls each had an ice chest, with ice for the residents' drink cups, located where staff and residents had access to them. <BR/>Observation on 01/04/24 at 9:10 AM revealed Resident #29 filled his drink cup with ice from the 100 Hall ice chest, using the scoop provided, but placing the scoop into his cup in the process. <BR/>Interview on 01/04/24 at 9:11 AM with Resident #29 revealed he filled his drink cup himself several times a day. Resident #29 stated he had never been told staff had to get ice out of the ice chest. <BR/>Observation on 01/04/24 at 9:34 AM revealed Resident #33 filled his drink cup from the 300 Hall ice chest, using the scoop provided, but placed the scoop into the ice chest while he re-adjusted his grip on his cup before continuing to fill his cup. <BR/>Interview on 01/04/24 at 9:35 AM with Resident #33 revealed he always filled his own cup with ice. He stated he knew he was supposed to have staff do it but waiting on staff would take too long.<BR/>Observation on 01/04/24 at 11:40 AM revealed the refrigerator in the medication storage room contained one frozen dinner with a staff member name on it, one partial bottle of red soda with no name, and two cups of ice with staff members' names on them. The countertop contained a bag of fried chicken and a bottle of Ranch dressing. <BR/>Interview on 01/04/24 at 11:45 AM with LVN B revealed she was unaware staff food items could not be in the medication room and refrigerator. LVN B relocated all items to the staff breakroom. <BR/>Interview on 01/04/24 at 12:00 PM with ADON A revealed staff knew personal food items were not allowed to be in with resident medications. She stated the risk of contamination was too high. Residents also knew they were to have staff access the ice chests to ensure the ice or the scoop was not contaminated. <BR/>Review of the facility's Infection Control policy, dated March 2023, revealed it did not address placing personal food items with resident medications.